Every finding on record at Villa at Blue Ridge, The

Based on interviews and record review, facility staff failed to ensure five Nurse Aides (Na's) (NA C, NA D, NA E, NA F, and NA G) out of five NA's completed the nurse aide training program within four months (120 days) of their employment in the facility. The facility's census was 91.1. Review of the facility's policies showed staff did not provide a policy for NA training and requirements.Review of the facility's Job Description for Certified Nursing Assistant (CNA), undated, showed a minimum qualification is to be licensed as a CNA in accordance with the requirements of the state governing the facility.2. Review of NA C's personnel file showed a hire date of 04/02/25, and he/she began work as an NA in 09/2025. The file did not contain documentation he/she completed the NA training program.During an interview on 04/22/26 at 11:53 A.M., NA C said he/she started working on the floor as an aide in 10/2025, but he/she has not been able to pass all the testing required to become certified.NA C said he/she was told he/she had 120 days to become certified, or he/she would not be able to continue to work the floor, and he/she passed the skills test, so is still allowed to work the floor but is usually paired with a CNA when working. NA C said he/she is scheduled to retake the written test on 04/28/26.During an interview on 04/22/26 at 10:05 A.M., the ADON said NA C transferred from another department to the nursing department in 09/2025.3. Review of NA D's personnel file showed a hire date of 07/29/25. The file did not contain documentation that the NA completed an NA training program.During an interview on 04/22/26 at 1:52 P.M., NA D said he/she started working on the floor as an aide in 08/2025, completed the NA classwork back in 01/2026 and passed the written test, but he/she does not have a date scheduled to take the required skills test to become certified, and did not provide a reason as to why it was not scheduled4. Review of NA E's personnel file showed a hire date of 10/03/25. The file did not contain documentation the NA completed the NA training program.During an interview on 04/22/26 at 10:05 A.M., the ADON said the NA had just completed the classes in the past week and is scheduled to take the written test 05/04/26. The ADON said a few months ago, NA E had a delay getting his/her pink sheets which is a requirement for the classes signed off timely. 5. Review of NA F's personnel file showed a hire date of 10/20/25. The file did not contain documentation the NA completed the NA training program.During an interview on 04/22/26 at 10:05 A.M., the ADON said NA F was scheduled to take the written test 04/22/26 and should have the results by the end of day.6. Review of NA G's personnel file showed a hire date of 12/02/25. The file did not contain documentation the NA completed an NA training program.During an interview on 04/22/26 at 10:05 A.M., the ADON said NA G failed the written test about a week prior and is scheduled to retake the test on 05/01/26.7. During an interview on 04/22/26 at 10:05 A.M., the ADON said the five NAs are on the current schedule to assist residents with care needs and are allowed to perform the skills they have been signed off for competency, but they are usually scheduled to work with a CNA.During an interview on 04/22/26 at 3:45 P.M., the administrator said NAs should be certified within 120 days of hire, and if not certified in the timeframe, they should be removed from the floor and offered to work in a different department, or perform duties like passing ice water, making beds, etc. The administrator said he/she, the DON and ADON share the responsibility to monitor the NAs for compliance, but they have faced several challenges to have the NAs certified timely. The administrator said he/she is aware the NAs are still scheduled to work the floor to assist with resident care. He/She said the facility had started to wait for NAs to work at least 30 days before paying for them to attend the classes. He/She said the testing sites they previously used are not currently allowed/able to facilitate the skills test/evaluations, the NAs are having difficulty finding a testing site closer than one to two hours from the facility to test, and with transportation to the available sites, so some have just have not scheduled the skills test in fear of not making it to the testing site.Complaint #2963123

Based on observation, interview and record review, facility staff failed to perform hand hygiene and/or wash hands to prevent the spread of infection during incontinence care for three residents (Resident #1, # 2 and #3) out of three sampled residents. Facility staff failed to wear appropriate personal protective equipment (PPE) during care or place appropriate PPE within proximity of the rooms for two residents (Resident #1 and #2) out of two sampled residents with wounds, who required Enhanced Barrier Precautions (EBP) (an infection control intervention). The facility's census was 91. 1. Review of the facility's Hand Cleanser policy, undated, showed the purpose is to cleanse the hands between resident contacts during care and to prevent the spread of infection.Review of the facility's Handwashing policy, undated, showed the purpose of handwashing is to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff.Review of the facility's policy, Perineal Care, undated, showed the purpose is to cleanse the perineum (area between genitals and anus), and to prevent infection and odor. Staff were directed to provide male and female perineal care, put on disposable gloves, remove gloves and wash hands.Review of the facility's policy, Gloves, undated, showed it did not contain direction for staff to perform hand hygiene between glove changes.Review of the facility's policy, Enhanced Barrier Precautions to Infection Control Guidance, dated 03/2024, showed:-The purpose is to prevent broader transmission of MDRO (multidrug-resistance organisms) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed;-Use EBP when providing high-contact resident care activities such as when transferring resident from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, and performing wound care;-Staff should use gown and gloves;-Residents that are placed on EBP should have PPE in close proximity outside the door and a trash can in resident's room for disposal prior to leaving the room.2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/26/26, showed staff assessed the resident as severely cognitively impaired and dependent on staff with transfers, personal hygiene and toileting.Review of the resident's weekly skin assessment completed by a nurse, dated 04/22/26 at 3:08 A.M., showed staff documented skin breakdown to coccyx and surrounding skin.Observation on 04/22/26 at 1:26 P.M., showed a medical sign outside the room to alert staff EBP required. The resident's room did not have PPE within proximity. Nursing Assistant (NA) D and Certified Nursing Assistant (CNA) H entered the resident's room, applied gloves, transferred the resident by mechanical lift from his/her chair to bed to perform incontinence care, and Licensed Practical Nurse (LPN) I entered the room to assess the resident's buttock. CNA H assisted with turning and removing the resident's clothing, while NA D performed incontinence care, and LPN I applied gloves and assessed a wound to the resident's left buttock and right gluteal fold (below the buttock). NA D, CNA H and LPN I did not wear a gown. NA D did not perform hand hygiene between gloves changes during peri-care or after providing peri-care to prevent the spread of infection.During an interview on 04/22/26 at 1:52 P.M., NA D said he/she was aware the resident had a small open area to his/her buttock, and the EBP sign meant staff should wear gown and gloves for transfers and incontinence care. NA D said gowns were on a bedside table down the hall, and other PPE might be on the linen cart or at a station somewhere in the hallway, but he/she does not always have time to search for PPE to use and just forgot to grab a gown. NA D said he/she should have used hand sanitizer or washed his/her hands after glove changes and before he/she left the room, but he/she was busy, felt overwhelmed and forgot.During an interview on 04/22/26 at 2:11 P.M., LPN I said he/she should have worn a gown to perform the wound assessment, but the aides did not have to wear a gown since they did not know the resident had the new open areas to his/her buttock.3. Review of Resident #2's annual MDS, dated [DATE], showed staff assessed the resident as requiring setup or clean-up assistance from staff with lower body dressing and putting on/taking off footwear and did not have any other ulcers, wounds or skin problems.Review of the resident's Physician Order Summary (POS), dated 01/01/26 through 04/23/26, showed an order to apply barrier cream to coccyx every shift and as needed and an order to cleanse the left shin with wound cleanser, pat dry, apply a sterile, non-adherent, petrolatum-based wound dressing to base of wound, cover with medical dressing and wrap daily.Observation on 04/22/26 at 1:58 P.M., showed CNA A entered the resident's room to provide care. CNA A put on gloves, without performing hand hygiene, and did not put on a gown. CNA A dressed the resident in his/her underwear and pants up to his/her buttocks and then put his/her shoes (touching the bottom of the shoes). CNA A assisted the resident with repositioning and put on his/her shirt with the same gloves. CNA A attempted to transfer the resident, but was unable to, so he/she left the room to find assistance. CNA A did not perform hand hygiene before leaving the room. CNA A and CNA B entered the resident's room. CNA A and CNA B did not perform hand hygiene upon entering the resident's room or put on a gown. CNA B applied gloves out of his/her pocket and gave CNA A a pair of gloves from his/her pocket. CNA B removed the resident's dirty clothing and incontinence pad, bagged up the items, then removed gloves. CNA B removed new gloves from his/her pocket and put on gloves without performing hand hygiene and assisted CNA A with pulling up the residents pants and underwear. CNA A and CNA B left the resident's room without performing hand hygiene.Observation on 04/22/26 at 2:17 P.M., showed a sticker on the resident's door to let staff know the resident on EBP and PPE not in proximity of the resident's room.3. Review of Resident #3's annual MDS, dated [DATE], showed staff assessed the residents as cognitively intact and required substantial to maximal assistance from staff with toilet transfers;Observation on 04/22/26 at 11:06 A.M., showed CNA A and CNA B entered the resident's room to provide care. CNA A and CNA B put on gloves, without performing hand hygiene and assisted the resident to the toilet. CNA A removed the resident's brief and assisted the resident to sit on the toilet. CNA A grabbed a clean brief with the same gloves and brought it into the bathroom. CNA B wiped the resident's buttock with a disposable wipe, then grabbed the clean brief before removing gloves and putting on new gloves without performing hand hygiene. CNA A and CNA B assisted with putting on a new brief. CNA A and CNA B put on put on the resident's pants and slippers and transferred the resident to the wheelchair with the same gloves. CNA B removed his/her gloves and left the resident's room without performing hand hygiene.4. During an interview on 04/22/26 at 2:19 P.M., CNA A said staff are directed to perform hand hygiene any time they are putting on/off or changing gloves. He/She said he/she did miss hand hygiene opportunity. He/She said he/she did not know why he/she did not perform hand hygiene between glove changes or why he/she did not wear a gown when providing care to a resident who is on EBP. He/She said staff identify resident's on EBP by a sticker on the resident's door.During an interview on 04/22/26 at 2:19 P.M., CNA B said staff are educated to use hand hygiene when entering the resident room, between going through clean and dirty task and upon exiting the room. He/She said he/she did know he/she missed a hand hygiene opportunity. He/She said a resident on EBP had a sticker on the door letting staff know to wear a gown and gloves. He/She said he/she was not thinking about hand hygiene between changing gloves or wearing a gown when providing care. He/She said there was not a set spot for staff to get PPE and it was not convenient.During an interview on 04/22/26 at 2:11 P.M., LPN I, the facility's Infection Preventionist (IP), said staff are educated on the EBP policy/process during orientation and staff meetings, and PPE are stored in credenzas in the hallways. LPN I said the medical symbol next to a residents name is to alert staff to wear at least gown and gloves for EBP during cares to prevent the spread of infection.During an interview on 04/22/26 at 3:09 P.M., the assistant Director of Nursing (ADON) said he/she expects staff to wash hands before and after care, when soiled, and after glove changes. The ADON said the nurses should spot check the NAs and CNAs for proper hand hygiene during cares. The ADON said staff are educated on the EBP policy during orientation and in-services, the medical sign by a resident's name indicates EBP is required for transfers, incontinence care and wound care, PPE are stored in the utility room cabinets, and the aides are expected to place PPE on the linen carts to use on the halls.During an interview on 04/22/26 at 3:45 P.M., the administrator said he/she expects staff to wear gloves during resident care, change gloves between dirty & clean tasks, and when switching residents. The administrator said staff should wash hands before and after cares, after they remove gloves, and when hands are visibly soiled to prevent infection. He/She said staff are educated on EBP during orientation and in-services, the medical sign by a resident's name indicates EBP is required for transfers, incontinence care and wound care. He/She said PPE should be stored in the credenzas and on linen carts on each hall, and should be within proximity to residents that require EBP. The administrator said the IP has only been in the role for about two weeks, but he/she will be responsible to ensure PPE is available and within proximity to the rooms of residents who require EBP.Complaint # 2963123

Based on observation, interview, and record review, facility staff failed to ensure the safety of one resident (Resident #8) when facility staff turned off door alarm to exit door located on 200 hall and resident exited the facility. Staff failed to notify the physician and/or hospice to inform them resident found outside unattended. The resident was outside unattended for approximately one hour and 49 minutes. The facility census was 88.The administrator was notified on 05/05/26 of past noncompliance that occurred on 04/23/26 when resident's family contacted RN K to report the resident had not been seen in his/her room for a while on his/her camera. Registered Nurse (RN) K and Certified Medication Technician (CMT) M found the resident outside, assessed for injuries, and brought him/her back inside. Administrator began an investigation and identified the door alarm had been turned off by staff. Staff in-serviced staff to not turn the door alarm off.1. Review of the facility's Elopement, Missing Resident policy, undated, showed it did not provide direction for staff in regard to what to do when an alarm sounds. Staff are directed to notify the physician and once the resident is located, notify all appropriate agencies/people.2. Review of the facility investigation, dated 04/23/26, showed RN K reported to the administrator the resident got out of the building and he/she and CMT M assisted the resident back in the building and assessed for injuries, and no injuries identified. RN K informed administrator the door alarm was not working. The administrator checked and the alarms were turned off at the nurse station. RN K said he/she did not know the alarms could be turned off.Review of the facility's video footage without sound, dated 04/23/26, showed the resident left his/her room at 8:24 P.M. Review showed at 9:09 P.M., staff looked in the resident's room and down the hall for the resident. Reviewed showed at 10:13 P.M. the resident found and taken to his/her room.3. Review of Resident #8's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/20/26, showed staff assessed the resident as severely cognitively impaired and did not exhibit behaviors of wandering.Review of the resident's progress notes, dated 04/23/26 at 10:12 P.M., showed RN K documented resident's family contacted the facility when they did not see the resident on the camera and he/she said he/she would check on the resident and call them back. He/She documented he/she checked the resident's room and hall, but the resident was not in either location. He/She documented he/she saw the door alarm on short wing was blinking and apparently the resident had gone out the door. He/She documented he/she did not realize it was an alarm as it was not audible because of the hall lights going off. RN K documented he/she and a Certified Medication Technician (CMT) M assisted the resident back inside the building. Review of the resident's elopement risk assessment, dated 03/20/26, showed the resident at risk for wandering related to cognitive impairment, restlessness, agitation and takes medication that suppress thought process.Observation on 05/05/26 at 11:58 AM, observation showed the door by the resident's room opened after fifteen seconds and the alarm sounded. The alarm continued until the code was entered at the nurse station.During an interview on 05/05/26 at 9:21 A.M., the administrator said the family contacted the facility after the resident was not in his/her room for about thirty to forty-five minutes. He/She said RN K went to check on the resident in his/her room, but he/she was not in the room. He/She said the resident was located outside. He/She said the resident got out the side door for about thirty to forty-five minutes. He/She said he/she did not know if the alarm on the door went off. He/She said RN K said he/she thought the alarm was not working. He/She said on 04/24/26 between 7:00 A.M. and 8:00 A.M. he/she went to check the alarms at the nurse station and found the alarm for the hall had been turned off. He/She said he/she did not know how long the alarm was turned off or by who. The administrator said he/she expected staff to notify the hospice agency and the resident's physician after a resident was found outside. He/She couldn't find documentation the nurse notified the physician or hospice agency.During an interview on 05/05/26 at 10:16 A.M., the hospice nurse said staff did not contact him/her after the resident was found outside unattended. He/She said he/she visited the resident on 04/24/26 and was told the resident was found outside the facility, so he/she completed a physical assessment and found bruising on the bottom right part of his/her right foot, most likely from standing for a long period of time. He/She said he/she could not confirm the bruise was or was not there prior to the resident being found outside by staff.During an interview on 05/05/26 at 1:56 P.M., RN L said if the door was opened, an alarm at the nurse station would blink, so staff would be notified. He/She said there have been no issues with the alarm system. He/She said staff reported the resident had gone out the door located by his/her room. He/She said the area where the resident was located was not enclosed. RN L said if a resident was located outside, staff should complete an assessment and contact the family, physician and hospice.During an interview on 05/06/26 at 7:31 A.M., Certified Nurse Aide (CNA) N said CMT M told him/her the resident was found outside. He/She said RN K had informed CMT M that he/she turned off the alarm because his/her child was bringing him/her food and did not want the alarm to go off.During an interview on 05/06/26 at 8:59 A.M., CMT M said RN K walked past him/her and said the family called him/her to let staff know the resident had not been in his/her room for a while. He/She said he/she looked down the hall and in the resident's room but did not see him/her. He/She said RN K looked up, the light above the exit door was blinking, but there was no sound, so they looked outside and found the resident down the sidewalk. He/She said the resident was down past the door, with his/her walker stuck in the mud and the resident couldn't get the walker out of the mud. He/She said there was no alarm sound at the nurse station and assumed the alarm was turned off because there was a loud noise when the alarms went off. He/She said RN K said the alarm was turned off and he/she didn't know by who.29988342994176

Based on interview and record review, facility staff failed to update the Facility Assessment (a facility-wide assessment completed by facility staff to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) at least annually. The facility's census was 91. 1. Review of the facility's Sample Process for Conducting the Facility Assessment, dated 09/18/17, showed staff were directed to review the facility assessment requirements and guidance at F838 (a federal regulation), and establish a process for updating the assessment in one year or earlier if there are substantive changes.2. Review of the facility's Facility Assessment, dated 08/12/24, showed:-The assessment was reviewed with the Quality Assurance and Performance Improvement (QAPI) committee at the January 31st Quality Assurance (QA) meeting;-The facility is licensed to provide care for 97 residents;-The average daily census is 80-90;-The staffing plan identified the total number of staff needed or average is based on 70 residents;-The assessment did not contain documentation staff updated the Facility Assessment at least annually and did not contain staffing data to reflect the total number of staff needed to care for the average daily census of 80-90 residents.During an interview on 04/22/26 at 3:45 P.M., the Administrator said the facility assessment should be reviewed quarterly by facility staff at QAPI meetings and updated at least annually. He/She said the facility assessment should be updated if there is a change in administration and should reflect staffing requirements for resident acuity and average census. He/She said the administrator listed on the facility assessment left the facility in 10/2024, so he/she does not know why the facility assessment had not been updated since 08/2024. The administrator said he/she assumed the role on 03/01/26 and has it on his/her list to complete the facility assessment at the next QAPI meeting.Complaint # 2963123

Based on interviews and record review, facility staff failed to meet professional standards of care when licensed staff failed to complete and document a fall assessment as directed by the facility policy for one resident (Resident #1) out of three sampled residents, after staff reported the resident had an unwitnessed fall. The facility census was 90. 1. Review of the facility's Event Investigation policy, undated, showed the purpose is to identify any injuries after a resident sustains an event, and staff were directed:-Complete a Report of Event Form as soon as possible whenever there is an unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely affects or has the potential to adversely affect a resident or visitor;-An example of when a form should be completed includes a fall or person found on the floor;-Document the location and type of event, such as a fall, complete vital signs (heart rate, blood pressure, respirations, body temperature), a mental/neurological status, range of motion (how far and in what direction you can move a joint or muscle), and pain assessment after the event. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment, dated 12/11/25, showed staff assessed the resident with moderate cognitive impairment, and had two or more non-injury falls since admission. Review of the video footage from the resident's room, dated 03/01/26 showed Certified Nursing Assistant (CNA) A entered the resident's room twice at approximately 1:21 A.M. and 1:27 A.M., both times with the resident's lower body on the fall mat/mattress next to his/her bed. Review of the resident's Electronic Medical Record (EMR), dated 03/01/26, did not contain documentation Licensed Practical Nurse (LPN) B completed a Report of Event Form or assessed the resident's vital signs, mental/neurological status, range of motion, and pain as directed by the facility policy. During an interview on 03/04/26 at 12:32 P.M., CNA A said he/she reported to the nurse twice that the resident was seated on the fall mat/mattress next to his her/her bed. During an interview on 03/04/26 at 12:52 P.M., LPN B said CNA A reported to him/her the resident was on the fall mat/mattress in his/her room, but he/she was busy and did not immediately go to assess the resident. The LPN said about 10 minutes after CNA A made the report of the unwitnessed fall to him/her, the resident's family arrived at facility, went to the resident's room, and assisted the resident back to his/her bed. The LPN said he/she did not enter the resident's room until after the resident's family left over an hour later. The LPN said when he/she went to the resident's room, the resident was asleep in bed and he/she obtained the resident's vital signs, but did not initiate any neurological checks or range of motion checks and thought he/she documented his/her assessment in a progress note. During an interview on 03/04/26 at 1:57 P.M., the administrator said since the resident had an unwitnessed fall, he/she expected the nurse to complete an event form and post-fall assessments per the facility policy, and document a progress note regarding the incident.During an interview on 03/04/26 at 3:42 P.M., the DON said if a resident has an unwitnessed fall, he/she expects the nurse to assess the resident's vital signs, neurological status (on paper), range of motion, pain, apply first aid if needed, and document a progress note in the computer, along with an event form.During an interview on 03/05/26 at 12:18 P.M., the resident's responsible party said he/she arrived at the resident's room on 03/01/26 at approximately 1:45 A.M., assisted the resident from the fall mat/mattress to bed, stayed with the resident for about an hour and a half and did not see any facility staff enter the resident's room or assess the resident. Intake# 2791204 and complaint # 2791413

Based on interviews and record review, facility staff failed to ensure one resident (Resident #1) remained free from verbal abuse when Certified Nursing Assistant (CNA) A verbally abused the resident and repeatedly yelled at the resident. The facility census was 90.The administrator was notified on 03/04/26 of past Non-Compliance, which occurred on 03/01/25 when the resident's family reported to facility staff that CNA A was observed on camera as he/she yelled and verbally abused the resident by mocking and ridiculing the resident. Staff immediately started an investigation, suspended CNA A pending the results of the investigation, assessed the resident for physical and psychological harm, notified the required state agency, re-educated staff on the abuse and neglect policy, and terminated CNA A on 03/02/26. Staff completed an additional in-service on communication with residents with a diagnosis of Dementia on 03/04/26. 1. Review of the facility's Abuse Prohibition Protocol Manual, undated, showed it is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, physical abuse, misappropriation of resident property and exploitation, corporal punishment and involuntary seclusion. Review of the facility's investigation, dated 03/01/26, showed Resident #1's responsible party reported to facility staff he/she watched a video footage, dated 03/01/26, and heard CNA A verbally abuse by mocking and ridiculing the resident. The administrator reported the allegations of verbal abuse to the required agencies and suspended CNA A. The administrator documented CNA A was terminated on 03/02/26 an employee handbook violation of failure to maintain care of residents on 03/01/26. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment, dated 12/11/25, showed staff assessed the resident with moderate cognitive impairment, diagnoses to include Unspecified dementia, unspecified severity, without behavioral disturbance, Psychotic Disturbance (symptoms of hallucinations, delusions, disorganized thoughts), and anxiety. Review of the resident's care plan, dated 02/11/26, showed staff assessed the resident has impaired decision making related to dementia, and staff were directed to calm the resident if signs of distress develop during the decision making process by giving him/her time to make the decisions, talk slower and calmer, offer to call family if needs their support, ask him/her what he/she needs to calm down. Review of the video footage, dated 03/01/26 at 1:27 A.M., showed CNA A entered the resident's room, CNA A is heard yelling at the resident I wish you would really leave stuff alone, what are you in here doing? The resident said, we are fixing to go kill an animal. CNA A yelled, aint no animal in here to kill, give it here as he/she pulled something from the resident's hand. The resident pointed across the room and said, you better quit acting dumb now, the animal is laying right there watching you, and CNA A yelled aint no animal in here, leave stuff alone! You need to leave stuff alone. The resident said what? and CNA A said, because, you have no freaking clue what you're doing, where are you at right now? The resident said, what are you talking about? Where am I at right now? CNA A said yes, exactly, aint no animal in here. The resident said, tell me what's gonna happen in the morning when all this, and CNA A yelled NOTHING! You need to leave drawers alone .followed by inaudible words CNA A then yelled Go to sleep! and slammed the door shut as he/she exited the room. During an interview on 03/04/26 at 9:15 A.M., the administrator said after staff reported the allegations to him/her, he/she immediately suspended CNA A pending the investigation. The administrator said after he/she reviewed the video footage, he/she determined CNA A verbally abused the resident, and he/she terminated CNA A. During an interview on 03/04/26 at 12:32 P.M., CNA A said his/her voice is naturally loud, and he/she only told the resident to go to sleep, but did not think he/she yelled at the resident and was not mean towards the resident. CNA A said he/she received in-services on abuse and neglect and denied any verbal abuse towards the resident. CNA A said there were no witnesses to his/her interaction with the resident inside the room. During an interview on 03/04/26 at 3:42 P.M., the DON said after he/she reviewed the video footage, he/she determined CNA A verbally abused the resident. During an interview on 03/05/26 at 11:48 A.M., Police Officer E said he/she received a report from the facility on 03/01/26 with allegations that CNA A had verbally abused the resident. He/She said CNA A was arrested on 03/04/26 on one charge relating to Elder Abuse and Neglect. During an interview on 03/05/26 at 12:18 P.M., the resident's responsible party said he/she reviewed the video footage in real time and did not appreciate how CNA A yelled at the resident and was demeaning towards the resident. The resident's responsible party said he/she watched the video again, then went to the facility later that morning and showed the video to facility staff. The resident's responsible party said after he/she spoke to the administrator, he/she agreed that CNA A was verbally abusive to the resident. Intake# 2791204 and complaint # 2791413

Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to complete shiftily controlled drug counts with two staff members and administer medications as ordered, when medications were unavailable for three residents (Residents #1 #2 and #3) out of three sampled residents. The facility census was 90.1. Review of the facility's Narcotic Count policy, undated, showed staff are directed to complete a physical inventory of narcotics at each shift change to identify discrepancies.-Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse.-After the supply is counted and justified, the nurse/Certified Medication Technician (CMT) records the date and his/her signature, verifying that the count is correct.Review of the facility's Medication Ordering and Receiving from Pharmacy policy, dated 04/2017, showed staff are directed to reorder medication four days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special processing, such as VA medications or specialty medications, order at least seven days in advance of need.Review of the facility's Medication, Administration Guidelines policy, undated, showed-It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies.-Each facility should institute and follow a policy and procedure for regular counting of Class III and IV drugs. 2. Review of the Shift Verification of Controlled Substance Count, dated 12/08/25 through 12/31/25 showed the control substance count did not contain documentation of two staff signatures:-On 12/08/25, one staff signature for 10:00 P.M.;-On 12/13/25, one staff signature for 6:00 A.M. and 2:00 P.M.;-On 12/15/25, one staff signature for 10:00 P.M.;-On 12/16/25, one staff signature for 6:00 A.M. and 2:00 P.M.;-On 12/17/25, one staff signature for 6:00 A.M.;-On 12/18/25, one staff signature for 6:00 A.M. and 2:00 P.M.;-On 12/19/25, one staff signature for 10:00 P.M.;-On 12/20/25, one staff signature for 7:00 A.M.;-On 12/21/25, one staff signature for 10:00 P.M.;-On 12/22/25, one staff signature for 6:00 A.M., no signatures at 7:00 P.M. and one signature at 10: P.M.;-On 12/23/25, one staff signature for 10:00 P.M.;-On 12/25/25, one staff signature for 6:00 P.M.;-12/27/25, one staff signature for 2:00 P.M, and 6:00 P.M.;-On 12/28/25, one staff signature for 6:00 A.M. no signature at 2:00 P.M and one signature at 10:00 P.M.;-On 12/29/25, no staff signatures for 6:00 A.M.;-On 12/30/25, one staff signature for 10:00 P.M.;-On 12/31/25, one staff signature for 6:00 A.M., 2:00 P.M. and 10:00 P.M. During an interview on 01/08/26 at 12:12 P.M., Licensed Practical Nurse (LPN) A said staff are directed to count narcotic medication when coming on shift and off shift by two staff members and document on the form. He/She said the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible to ensure staff documented they counted narcotic medication each shift. He/She said the concern with not completing a narcotic medication count each shift was the potential someone was stealing the medication.During an interview on 01/08/25 at 3:13 P.M., the administrator said staff are required to count narcotics at the beginning of each shift by two staff. He/She said staff should be documenting the narcotics count on the narcotics count form and signed off by both staff showing they completed the count. He/She said the Assistant Director of Nursing (ADON) or Director of Nursing (DON) were responsible to audit the form to verify staff are counting the narcotics. He/She said the concern with staff not completing the narcotic count on each shift, was the potential for the medication count to be off and unable to determine who could be responsible for the missing medication. During an interview on 1/16/26 at 9:49 AM, the ADON said staff are directed to complete count of the narcotic medication at the beginning and end of shift, or when another staff takes over the cart, by two staff members. He/She said staff would document in on the Shift Verifcation of Controlled Substance Count sheet once the count is completed by two staff members. He/She said the concern if staff did not count the narcotic medication on each shift, would make it more difficult to determine why the medication count was not corrected.During an interview on 01/16/26 at 9:50 A.M., the DON said the narcotic medications should be counted at the beginning and end of each shift or before another staff takes over the cart and should be counted by two staff members. He/She said staff are directed to document a count was completed by two staff member on the Shift Verifcation of Controlled Substance Count form. He/She said if the narcotic medications were not counted each shift, it would make it difficult for staff to determine why the narcotic medication count was not correct. #2709624

Based on interviews and record reviews, facility staff failed to prevent misappropriation of resident funds for one resident (Resident #4) out of six sampled residents. The facility census was 90.1. Review of the facility's, Abuse Prohibition Protocol Manual, undated, showed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident' medical symptoms. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to thoroughly investigate the alleged violations and take appropriate corrective action, as a result of investigation findings. The facility must have evident (documentation forms) of a thorough investigation including resident statements, witness statement, staff statements, environmental review, resident physical assessment, etc., including a timeline of events.2. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's funds account showed it did not contain a deposit of $1700 between the dates of 1/23/25 and 1/10/26. Review of the facility's investigation, dated 01/10/26, showed staff reported to the Director of Operations (DOP) Resident #4 missing $1700.00, and he/she began an investigation. Staff documented staff initially reported to the facility administrator in September 2025 the resident was missing $1700. Staff documented Registered Nurse (RN) A who completed the resident's admission to the facility confirmed the resident had $1700.00. RN A said he/she witnessed the resident give the $1700 to facility staff but was unable to recall who the staff member was. Police report made for the missing money by staff. Facility requested a replacement check to return the money to the resident. During an interview on 01/15/26 at 8:30 A.M., the DOP said the administrator was on vacation 01/05/26 through 01/09/26 so when he/she returned they started the investigation, suspended him/her, and terminated him/her. and he/she was at the facility overseeing it. The DOP said during the week Department of Health and Senior Services (DHSS) investigated a complaint which then stemmed him/her to speak with all the residents to ensure there were no further concerns. The DOP said he/she completed resident interviews on 01/10/26 as part of the investigation because the administrator never did when it was first reported in September 2025. and he/she was approached by Social Service Director (SSD) D in regard to the resident's missing money. The DOP said SSD D reported to him/her the resident and his/her family had reported to him/her on more than one occasion the resident was missing $1700.00 in cash. The DOP said SSD D reported to him/her that he/she had previously told the administrator about the missing money, but nothing had been done about it. The DOP said he/she immediately started an investigation for the missing money and notified DHSS the same day. The DOP said he/she has determined through his/her investigation the resident did have $1700.00 in cash when he/she admitted to the facility, and the resident did give the cash to a staff member and the date of his/her admission. The DOP said he/she notified the police of the missing money, and their report will be ready in seven business days. The DOP said he/she expects the facility to complete a detailed investigation if they receive a report of missing money. The DOP said the administrator did not complete an investigation at the time he/she was notified of the missing money and should have. The DOP said he/she expects the administrator to notify DHSS of any missing money. The DOP said the administrator did not notify DHSS of the missing money and should have. During an interview on 01/15/26 at 12:45 P.M., the corporate financial representative said he/she along with the Business Office Manager (BOM) spoke with the resident regarding his/her missing money. The corporate financial representative said the resident reported he/she had $1700.00 in cash when he/she was admitted to the facility. The corporate financial representative said the resident reported he/she took the money to the office and gave it to a staff member but did not recall his/her name. The corporate financial representative said the resident provide a description of the staff member and based on that he/she showed the resident pictures of staff to assist and identify who it may have been. The corporate financial representative said the resident was not able to identify the staff member. The corporate financial representative said the BOM took the resident and had him/her point out the office the resident took the money to. The corporate financial representative said the resident was able to identify the office. During an interview on 01/15/26 at12:58 P.M., the Assistant Director of Nursing (ADON) said he/she was aware the resident had reported missing money several months ago. The ADON said he/she asked the administrator at that time if there was anything he/she needed to do to assist with the missing money and the administrator told him/her no, the less you know the better. The ADON said he/she thought the administrator was completing an investigation at that time and he/she did not hear anything else about the missing money. The ADON said all staff are educated upon hire and annually to report any abuse, neglect, and misappropriation immediately. The ADON said if something is reported the facility is expected notify DHSS within two hours for abuse and complete an investigation. The ADON said the administrator is responsible to complete the investigation. During an interview on 01/15/26 at 1:12 P.M., SSD D said he/she started at the facility in September 2025. SSD D said right after he/she started the resident's family member came to him/her and inquired about the $1700.00 that was missing. SSD d said because he/she was new and not aware of this he/she spoke with a former staff member who told him/her and the resident's family member the facility was investigating it. SSD D said the resident's family member inquired about the missing money again in October 2025. SSD D said at that time he/she and the resident's family member spoke with the administrator in front of the receptionist about it. SSD D said he/she assumed the administrator would complete and investigation, but he/she does not know if the administrator did. SSD D said he/she received abuse, neglect, misappropriation education and knows if missing money is reported to him/her he must report it to the administrator immediately. During an interview on 01/15/26 at 1:24 P.M., the receptionist said he/she witnessed the SSD and resident's family member tell the administrator about the resident's missing money in October 2025. The receptionist said the administrator had been made aware of the missing money prior to that but he/she did not recall the timeframe. The receptionist said he/she does not know if the administrator completed an investigation or who the money was given to. The receptionist said an investigation should have been completed. The receptionist said he/she received abuse, neglect, misappropriation education and knows if missing money is reported to him/her he must report it to the administrator immediately. During an interview on 01/15/26 at 2:05 P.M. RN A said he/she was the nurse who admitted the resident. RN A said the day of admission the resident told him/her of the money, and it was $100 bills in cash. RN A said he/she took the resident to the BOM office but does not recall the staff member's name. RN A said he/she was a new employee and did not know everyone yet. RN A said he/she witnessed the resident give the staff member the money. RN A said the staff member told the resident he/she would put it in an account for him/her to use when he/she wanted it. RN A said the resident agreed to that. RN A said he/she is no longer an employee at the facility and does not know anything about the money missing. During an interview on 01/15/26 at 2:30 P.M., the administrator said he/she was told about the missing money but was not told how much was missing. The administrator did not recall the date he/she was told. The administrator said he/she did not speak with the resident's family about the missing money. The administrator said he/she did not do an investigation for the missing money or report it to DHSS when it was reported to him/her in September 2025. The administrator said he/she should have completed an investigation and notified DHSS of the missing money when he/she learned about it. The administrator said he/she did not do an investigation in September 2025 because he/she did not know how much money was missing. During an interview on 01/15/26 at 4:10 P.M., the Activity Director (AD) said he/she was gone on medical leave when the resident was admitted in July 2025. The AD said he/she returned to work the first week in August 2025. The AD said he/she was completing his/her admission activity assessment with the resident and inquired how the resident would like to pay for haircuts. The AD said the resident told him/her about giving the staff member $1700.00 in cash the day he/she was admitted to the facility, and he/she did not know what happened to the money after. The AD said the resident expressed he/she wanted to use that money for haircuts. The AD said he/she spoke with the administrator about the money and informed him/her the resident was concerned that he/she did not know what happened to his/her money at that time. The AD said he/she does not know if the administrator completed an investigation or not. During an interview on 01/15/26 at 4:33 P.M., SSD E said he/she left the facility around the end of September 2025. SSD E said he/she does not remember the resident and did not receive any cash from the resident that he/she recalls. SSD E said if he/she had received any money from a resident he/she would have got a witness and made sure it was locked up in the facility safe. Complaint #2713313

Based on interviews and record reviews, facility staff failed to initiate and complete a thorough investigation of alleged misappropriation of one resident (Resident #1) narcotic medication. The facility census was 90.1. Review of the facility's, Abuse Prohibition Protocol Manual, undated, showed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident' medical symptoms. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to thoroughly investigate the alleged violations and take appropriate corrective action, as a result of investigation findings. The facility must have evident (documentation forms) of a thorough investigation including resident statements, witness statement, staff statements, environmental review, resident physical assessment, etc., including a timeline of events.Review of the facility's Narcotic Count policy, undated, showed if the count is not accurate, the nurse going off duty is to remain on duty unto the count is reconciled and the Director of Nursing (DON) must be notified for further instruction. The Director of Nursing will initiate an investigation to determine the cause of the discrepancy and contact the pharmacist for assistance as needed.2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/25/25, showed staff assessed the resident as:-Moderately cognitively impaired;-Received a pain medication as needed during the seven day look back period;-Used an opioid medication.Review of the resident's Physician Order Summary (POS), dated 10/01/25 through 10/31/25, showed an order for 100 milligram(mg)/5 milliliter (ml) Morphine concentrate solution administered every four hours as needed for pain. Review of the resident's medical record, dated 09/01/25 through 10/31/25, showed it did not contain documentation the facility investigated the allegation of misappropriation of the resident's liquid Morphine.3. During an interview on 01/08/26 at 1:11 P.M., License Practical Nurse (LPN) C said he/she staff are directed to report missing narcotic medications to the charge nurse or upper management. He/She said upper management would investigate the missing narcotics. He/She said he/she was completing a narcotic count in October and discovered the resident's liquid Morphine medication seal was broken and the liquid appeared to be clear in color, even though it should have been a pink color and believed the bottle was full of water. He/She said the medication was received in June. He/She said the seal should not have been broken, since it was never administered from June until October. He/She said he/she reported the incident to the Assistant Director of Nursing (ADON).During an interview on 01/08/26 at 2:39 P.M., the pharmacist said the facility did contact him/her about the potential of missing doses of the resident's liquid morphine. He/She said the color of the liquid morphine was pink. He/She said even if the morphine solution was not used for a long period of time, the color would not change to clear, so shaking the morphine solution wouldn't change the color. He/She said If water got into the bottle, it would dilute the color.During an interview on 01/08/26 at 3:13 P.M., the administrator said he/she and the ADON were responsible to complete a thorough investigation after an allegation of misappropriation of property. He/She said the ADON conducted the investigation related to resident's missing medication and unsubstantiated the allegation.During an interview on 01/16/26 at 9:49 A.M., the ADON said staff are directed to report abuse and neglect immediately to the supervisor or administrator. He/She said he/she would conduct a thorough investigation. He/She said LPN C reported to him/her the resident's liquid Morphine was potentially missing doses. He/She said he/she did complete an investigation but was unable to locate the paperwork related to the investigation of the potential misappropriation of the resident's liquid Morphine.Complaint #2709624

Based on interview, and record review, facility staff failed to report an allegation of misappropriation of property for one resident (Resident #1) within 24 hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 90.1. Review of the facility's, Abuse Prohibition Protocol Manual, undated, showed the Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than twenty four hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident' medical symptoms. The intent is for the facility to develop and implement policies and procedures that ensure reporting of crimes against a resident or individual receiving care from the facility occurring in nursing homes within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Act;2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/25/25, showed staff assessed the resident as:-Moderately cognitively impaired;-Received a pain medication as needed during the seven day look back period;-Used an opioid medication.Review of the resident's Physician Order Summary (POS), dated 10/01/25 through 10/31/25, showed an order for 100 milligram(mg)/5 milliliter (ml) Morphine concentrate solution administered every four hours as needed for pain.During an interview on 01/08/26 at 1:11 P.M., License Practical Nurse (LPN) C said he/she staff are directed to report missing narcotic medications to the charge nurse or upper management. He/She said upper management would investigate the missing narcotics. He/She said he/she was completing a narcotic count in October and discovered the resident's liquid Morphine medication seal was broken and the liquid appeared to be clear in color, even though it should have been a pink color, and believed the bottle was full of water. He/She said the medication was received in June. He/She said the seal should not have been broken, since it was not administered from June until October. He/She said he/she reported the incident to the Assistant Director of Nursing (ADON).During an interview on 01/08/26 at 2:39 P.M., the pharmacist said the facility did contact him/her about the potential of missing doses of the resident's liquid morphine. He/She said the color of the liquid morphine was pink. He/She said even if the morphine solution was not used for a long period of time, the color would not change to clear, so shaking the morphine solution wouldn't change the color. He/She said If water got into the bottle, it would dilute the color.During an interview on 01/08/26 at 3:13 P.M., the administrator said he/she and the Assistant Director of Nursing (ADON) would be responsible to complete an investigation of misappropriation of property and report the allegation to DHSS within 24 hours. He/She said he/she did not remember if DHSS was contacted.During an interview on 01/16/26 at 9:49 A.M., the ADON said staff are directed to report abuse and neglect immediately to the supervisor or administrator. He/She said the administrator would be responsible to report an allegation of misappropriation of property to DHSS within 24 hours. He/She said LPN C reported to him/her the resident's liquid Morphine was potentially missing doses. He/She said he/she reported to the administrator the potential of misappropriation on the resident's liquid morphine. He/She said he/she did not know if the administrator reported the allegation to DHSS.During an interview on 01/16/26 at 9:50 A.M., the Director of Nursing (DON) said staff are directed to report abuse and neglect immediately to the supervisor or administrator. He/She said the administrator would be responsible to report an allegation of misappropriation of property to DHSS within 24 hours. He/She said he/she was not employed at the facility when the incident occurred.#2709624

Based on interview, and record review, facility staff failed to notify the physician for three resident's (Resident #1, #2 and #3) out of three sampled residents when medications were not available. The facility census was 90. 1. Review of the facility's Medication Orders policy, dated 04/2017, showed the prescriber is contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not or will not be available.2. Review of Resident #1's quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired.Review of the resident's Physician Order Summary (POS), dated 09/01/25 through 09/30/25, showed the physician directed staff to administer hydrochlorothiazide (to treat essential hypertension) 25 milligrams (mg) once a day by mouth and MiraLAX (to treat constipation) 17 grams once a day by mouth.Review of the resident's Medication Administration Record (MAR), dated 09/01/25 through 09/30/25 showed staff documented the following as not available:-9/1/25 Hydrochlorothiazide;-9/2/25 Hydrochlorothiazide;-9/24/25 MiraLax;-9/29/25 MiraLax.Review of the nurse notes, dated 09/01/25 through 09/30/25, did not contain documentation staff contacted the physician or the pharmacy when the resident medication was not available to administer. 3. Review of Resident #2's quarterly MDS dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's POS, dated 12/01/25 through 12/31/25, showed the physician directed staff to administer:-Hydrochlorothiazide 25 mg once a day by mouth;-Cyclobenzaprine (to treat muscle spasms) 5 mg one time a day by mouth;-Boost (to treat weight loss) three times a day by mouth:-Lemon drops (to treat localized enlarged lymph nodes) three times a day by mouth;-Ferrous Gluconate (to treat anemia) 324 mg one time a day by mouth:-Rosuvastatin (to treat long term drug therapy) 10 mg one time a day by mouth;-Mecobalamin (Vitamin B 12) (to treat a vitamin deficiently) 5000 mcg (microgram) one time a day by mouth.Review of the resident's MAR, dated 12/01/25 through 12/31/25 showed staff documented the following medications as not available:-On 12/02/25 Ferrous Gluconate 324 and Vitamin B12;-On 12/22/25, Cyclobenzaprine;-On 12/24/25 Lemon drops and Rosuvastatin;-On 12/25/25 Rosuvastatin and Cyclobenzaprine;-On 12/26/25 Cyclobenzaprine, Boost, Vitamin B12 and Rosuvastatin;-On 12/27/25 Vitamin B.Review of the nurse notes, dated 12/01/25 through 12/31/25, did not contain documentation staff contacted the physician when the resident medication was not available. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired.Review of the resident's POS, dated 12/01/25 through 12/31/25, showed the physician directed staff to administer:-Colestipol (used to treat hyperlipidemia) 1 gram two times a day by mouth;-Donepezil (to treat unspecified dementia) 10 mg one time a day by mouth;-Eliquis (to treat acute embolism and thrombosis of unspecified deep veins of lower extremities) 5 mg two times a day by mouth;-Potassium Chloride (to treat hypokalemia) 40 mEq (milliequivalent) one time a day by mouth;-Methenamine Hippurate (used to treat acute cystitis with hematuria) 1 gram twice a day by mouth;-Ascorbic Acid (Vitamin C) (to treat a vitamin deficiency) two times a day by mouth.Review of the resident's MAR, dated 12/01/25 through 12/31/25, showed staff documented the following medications as not available:-On 12/02/25 Methenamine Hippurate;-On 12/03/25 Colestipol and Methenamine Hippurate;-On 12/04/25 Methenamine Hippurate and Potassium Chloride;-On 12/05/25 Methenamine Hippurate and Potassium Chloride;-On 12/06/25 Methenamine Hippurate and Potassium Chloride;-On 12/07/25 Methenamine Hippurate;-On 12/08/25 Methenamine Hippurate and Potassium Chloride;-On 12/09/25 Methenamine Hippurate and Potassium Chloride;-On 12/10/25 Methenamine Hippurate;-On 12/11/25 Methenamine Hippurate;-On 12/12/25 Methenamine Hippurate;-On 12/13/25 Methenamine Hippurate and Potassium Chloride;-On 12/14/25 Potassium Chloride;-On12/15/25 Eliquis;-On 12/16/25 Eliquis;-On 12/17/25 Eliquis and Ascorbic Acid;-On 12/18/25 Eliquis;-On 12/19/25 Eliquis;-On 12/20/25 Eliquis and Potassium Chloride;-On 12/21/25 Ascorbic Acid, Potassium Chloride and Eliquis;-On 12/22/25 Eliquis and Potassium Chloride;-On 12/23/25 Eliquis;-On 12/25/25 Donepezil;-On 12/26/25 Donepezil;-On 12/29/25 Potassium Chloride;-On 12/30/25 Potassium Chloride;-On 12/31/25 Potassium Chloride.Review of the nurse notes, dated 12/01/25 through 12/31/25, did not contain documentation staff contacted the physician when the resident did not receive his/her medication.5. During an interview on 01/08/25 at 10:11 AM, Certified Medication Technician (CMT) B said staff would report to the charge nurse if a resident did not receive his/her medication.During an interview on 1/16/26 at 9:49 AM, the ADON said the nurse should contact the physician and pharmacy if a resident's medication is not available to see if there is an alternative medication to administer. During an interview on 1/16/26 at 9:50 A.M., the DON said staff should contact the physician and pharmacy to see if another medication could be used to replace the missing medication.#2709624

Based on observation, interview, and record review, facility staff failed to review and update the plan of care with changes in the residents' care needs for four residents (Residents #1, #2, and #3) out of five sampled residents, and failed to update the plan of care on a quarterly basis for two resident (Resident #2 and #3) out of five sampled residents. The facility census was 80. 1. Review of the Facility's Care Plan Comprehensive policy, undated, showed staff are directed as follows: -The purpose of an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set); -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when: a significant change in the resident's condition has occurred, at least quarterly; and when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/17/25, showed staff assessed the resident with severe cognitive impairment. Review showed staff did not asses as the resident with a fall since admission. Review of the resident's medical record, dated 05/04/25, showed staff documented the resident fell and sent him/her to the emergency room for evaluation. Review of the resident's care plan, dated 04/16/25, showed staff assessed the resident at risk for falls due to weakness and cognitive impairment. The care plan did not contain documentation of new interventions after the fall on 05/04/25. 3. Review of Resident #2's significant change MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review showed staff did not assess the resident with a five percent weight loss in the past month or ten percent or more in the past six months. Review of the Physician Order Summary (POS), undated, did not contain documentation of an order to monitor or address the resident's weight loss. Review of the resident's medical record, dated 05/08/25, showed a 5.7% weight loss from the prior month. Review of the resident's care plan, dated 01/22/25, did not contain documentation the care plan was updated on a quarterly basis. The care plan did not contain documentation of a weight loss intervention until 06/20/25. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did have two or more injury falls since admission. Review of the resident's medical record, dated 03/22/25, showed the resident had a fall. Review of the resident's care plan, last revised 02/08/25, showed the care plan did not contain documentation the care plan was updated on a quarterly basis. The care plan did not contain documentation of a new intervention of a fall after 01/31/25. 5. During an interview on 6/20/25 at 12:14 P.M., the administrator said the care plans should be updated when there was a significant change, quarterly and annually. He/She said there should be a new intervention after each fall and when there is a significant change in weight with new interventions. He/She said nurses and the MDS Coordinator would update the care plan. He/She said a new MDS Coordinator was recently hired. He/She said the Director of Nursing (DON) would be responsible to verify care plans are updated when a resident experienced a change in condition or quarterly and annually. During an interview on 6/20/25 at 12:14 P.M., the DON said the MDS Coordinator and nurses should update the care plans after a significant change, quarterly and annually. He/she said there should be a new intervention after each fall and when there is a significant change in weight. He/She said the MDS Coordinator is new to his/her position. He/She said he/she was responsible to audit to ensure care plans have been updated or revised. He/She said he/she did not have an excuse for the oversight of not verifying care plans were updated after a significant changed or quarterly and annually. MO00255965 and MO00255753

Based on observation, interview, and record review, facility staff failed to notify three resident's (Resident #1, #3 and #4) out of five sampled resident's representative and/or physician after a change in condition. The facility census was 80. 1. Review showed the facility did not provide a policy for notifying family or physician after a change in condition. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/17/25, showed staff assessed the resident as severely cognitively impaired and did not assess the resident with a fall since admission. Review of the facility's event report, dated 05/04/25 at 2:32 A.M., showed staff documented the resident fell. The report did not contain documentation staff notified the physician or the family related to the fall. The report contained documentation, dated 05/04/25 at 2:57 P.M., the resident's family member reported staff did not contact him/her of the fall or that he/she was sent to the hospital. Review of the facility's event report, dated 05/16/25, showed the resident had a fall. The report did not contain documentation staff notified the physician or family was notified of the fall. Review of the resident's progress notes, dated 05/15/25, showed staff documented the resident's family expressed concerns about lack of communication by facility staff in regards to one of the falls during a care plan meeting. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact staff did not assess the resident with two or more injury falls since admission. Review of the resident's progress notes, dated 03/22/25, showed staff documented the resident fell. Review of the progress notes showed did not contain documentation the physician or family were notified of the fall. Review of the facility's event report, dated 03/22/25, showed the report did not contain documentation the physician or family was notified of the fall. 4. Review of Resident #4's annual MDS, dated [DATE], showed staff did not assess the resident's Brief Interview for Mental Status (BIMS), and Did not assess the resident with a five percent weight loss in the past month or ten percent or more in the past six months. Review of the resident's weight chart, dated 03/10/25, showed staff assessed the resident's weight 105 pounds (lbs). Review of the resident's weight chart, dated 04/25, showed staff documented the resident's weight 97 lbs (7.62% weight loss from 03/10/25 through 04/25). Review of the resident's medical record did not contain documentation staff notified the resident's family and/or representative of the weight loss. 5. During an interview on 06/20/25 at 3:30 P.M., Licensed Practical Nurse (LPN) B said if a resident exhibited a change in condition, the aide would notify the nurse and the nurse would assess the resident, contact the physician if necessary and the family or guardian. During an interview on 6/20/25 at 12:14 P.M., the administrator said staff are directed to contact the resident's physician and responsible party if a resident experienced a change in condition. During an interview on 6/20/25 at 12:15 P.M., the Director of Nursing (DON) said if resident experienced a change in condition, staff should notify the resident's physician and responsible party. MO00255965 and MO00255753

Based on observation, interviews and record review, facility staff failed to ensure residents' environment remained free of accident hazards, when staff failed to ensure residents did not retain smoking materials while in the facility for two residents (Resident #2 and #4) of two sampled residents. The facility's census was 88. 1. Review of the facility's admission Packet, Resident Rules and Regulations, showed residents may not retain matches or lighters. Review of the facility's Smoking-Residents policy, undated, showed staff are directed as follows: -The facility shall establish and maintain safe resident smoking practices; -Any smoking related privileges, restrictions, and concerns (example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; -Smoking shall not be permitted in living/sleeping area; -This facility may check periodically to determine if residents have smoking articles in violation of our smoking policies. Staff shall confiscate any such articles and shall notify the charge nurse. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/20/25, showed staff assessed the resident as cognitively intact. Review of the resident's smoking assessment, dated 03/29/25, showed staff documented the resident as a safe smoker. Review of the resident's care plan, updated 04/14/25, showed staff did not document any interventions for smoking privileges, restrictions, or concerns. Review of the resident's nurses' note, dated 04/26/25 at 11:31 A.M., showed staff documented the resident lit a cigarette in the dining room, and was observed with smoke coming from his/her mouth, tried to educate him/her on the smoking policy, took the two lighters he/she had, checked his/her room for more lighters and did not see any. Review of the resident's nurses' note, dated 04/27/25 at 2:11 A.M., showed staff documented the resident was a direct threat to his/her own safety and other residents because he/she lit cigarettes in public gathering such as dining room and activity, knowing that there are multiple peers using oxygen around him/her. During an interview on 05/09/25 at 6:08 A.M., Certified Medication Technician (CMT) F said the resident was allowed to keep his/her cigarettes and lighter, but should not be allowed anymore for safety reasons. He/She said he/she did not know if the resident still had his/her cigarettes and lighter with him/her because the management staff takes care of that. During an interview on 05/09/25 at 8:04 A.M., the resident said he/she kept his/her cigarettes and lighter in his/her room. During an interview on 05/09/25 at 8:51 A.M., the Social Services Director (SSD) said he/she reviewed the smoking rules with the resident on admission, the resident was assessed as a safe smoker by the nursing staff and was allowed to keep his/her smoking materials. He/She said he/she was aware the resident was observed smoking in the building, which is not safe, and the resident should no longer be allowed to keep cigarettes or a lighter with him/her in the building. He/She said staff had removed the smoking supplies from the resident's room after he/she lit the cigarette in the building, and the resident did not have money to buy more smoking supplies, but he/she would check the resident's room to see if he/she had any smoking supplies inside the room. During an interview on 05/09/25 at 12:31 P.M., the Care Plan Coordinator (CPC) said he/she is responsible to ensure interventions for smoking are included on the resident's care plan, update the care plan quarterly or with changes to the resident's health conditions, and was not sure how he/she missed the smoking interventions. He/She said he/she was not aware the resident was observed smoking in the building, which is a risk for fire and potential injury to the resident and other residents in the facility. He/She said the resident was previously assessed as a safe smoker and was allowed to keep his/her smoking materials. During an interview on 05/09/25 at 1:10 P.M., the administrator said the CPC is responsible to ensure the resident has appropriate interventions for smoking on his/her care plan, and the interdisciplinary team (CPC, SSD, Director of Nursing, etc.) should have identified at each care plan meeting that smoking interventions were missing from the resident's care plan. He/She said the resident was previously assessed as a safe smoker and was allowed to keep his/her smoking materials. The administrator said he/she was not aware the resident was observed smoking in the building which is a safety risk for all residents, and the resident should no longer be allowed to keep his/her cigarettes and lighter inside his/her room. The administrator said she was not aware of the incident prior to this interview, or what staff did. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as cognition not assessed. Review of the resident's smoking assessment, dated 01/22/25, showed staff documented the resident as a safe smoker. Review of the resident's care plan, updated 04/14/25, showed the resident will have supervised smoking in designated areas, will smoke safely, cigarettes and lighters are kept at nursing station. Observation on 05/09/25 at 12:47 P.M., showed the resident in his/her wheelchair in the dining room with a pack of cigarettes and a lighter protruding from his/her opened waist pouch. During an interview on 05/09/25 at 12:47 P.M., the resident said he/she kept his/her cigarettes and lighter in his/her room but needed assistance to go outside to smoke. During an interview on 05/09/25 at 1:15 P.M., the administrator said the resident is a safe smoker, but if his/her care plan directs that cigarettes and lighters are to be kept at the nursing station, then the resident should probably not retain his/her cigarettes inside his/her room for safety reasons. 4. During an interview on 05/09/25 at 5:58 A.M., Registered Nurse (RN) D said residents who are assessed by staff as safe smokers are allowed to keep their cigarettes and lighter with them, and some residents are required to keep their smoking supplies at the nurses' station, but he/she did not know all the residents who are required to leave their smoking supplies at the nurses' station. During an interview on 05/09/25 at 6:08 A.M., CMT F cigarettes and lighters are kept for some residents at the nurses' station, but he/she did not know the exact residents who are required to leave their cigarettes and lighters at the nurses' station. During an interview on 05/09/25 at 1:10 P.M., the administrator said residents who are assessed by staff as safe smokers are allowed to keep their cigarettes and lighter with them, but if the resident violates the smoking policy, then he/she should not be allowed to retain his/her cigarettes and lighter. He/She said residents with cognitive impairments, could potentially smoke in their rooms, and place other residents and staff at risk from fire hazards or an explosion in the facility. MO00253882

Based on interview and record review, facility staff failed to ensure the facility did not employ or engage one of four sampled employees prior to employment who had a class A Felony First Degree Assault - Serious Physical Injury or Special Victim which is a disqualifying factor for employment in a long term care facility. The facility census was 84. 1. Review of the facility's Abuse Prohibition Protocol Policy , dated 2017, showed the facility cannot employ individuals who have been found guilty of abuse or have an abuse violation against their professional license. Abuse is defined as willful infliction of injury with resulting harm, pain or mental anguish. Review of facility's Hiring Process Policy, undated, directs staff to conduct an Employee Disqualification List (EDL) and a Family Safe Care Registry check (FSCR) on any potential newly hired staff. 2. Review of CNA A's personnel file showed a hire date of 06/20/2023. Review of the CNA's CBC, dated 04/22/25, showed a Class A Felony in the First Degree Assault - Serious Physical Injury or Special Victim. During an interview on 04/24/2025 at 9:40 P.M., the receptionist said he/she is responsible for conducting CBC's on all prospective employees prior to employment. He/She said at the time of CNA A's employment the facility used a private investigation firm for conducting CBC's and they did not identify any disqualifying crimes. The receptionist said when he/she submitted a request on 04/22/25, he/she learned CNA A did have a disqualifying crime and should not have been employed by the facility. During an interview on 04/24/2025 at 10:30 A.M., the Administrator said CBC's are conducted by the receptionist on behalf of the Business Manager. He/She stated CNA A's employment occurred prior to his/her employment October, 2024, so he/she was not aware the Family Safe Care Registry was not used to conduct the CBC. He/She was informed a CBC was conducted on 4/22/25 and CNA A flagged with a disqualifying crime on the report. MO00252853

Based on interview and record review, facility staff failed to provide written notification to the resident and/or the resident's representative of the facility bed hold policy at the time of transfer to the hospital for three residents (Resident #2, #3, and #4) out of four sampled residents. The facility's census was 88. 1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/20/25, showed staff assessed the resident as cognitively intact. Review of resident's medical record showed staff documented the resident: -discharged from the facility on 04/11/25 and readmitted to the facility on [DATE]; -discharged from the facility on 04/26/25 and readmitted to the facility on [DATE]; -Voluntarily agreed to transfer to the hospital for psychological evaluation on 05/01/25 and returned to the facility on [DATE]; -The medical record did not contain documentation staff issued a bed hold notice upon discharge with the resident on 04/11/25, 04/26/25, or 05/01/25. During an interview on 05/07/25 at 12:42 P.M., the resident said staff did not provide him/her with a bed hold notice when he/she was transferred or discharged to the hospital on [DATE], 04/26/25, or 05/01/25. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of resident's medical record showed the resident discharged from the facility on 04/19/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold notice upon discharge with the resident and/or the resident's responsible party. During an interview on 05/07/25 at 11:24 A.M., the resident said staff did not provide him/her with a bed hold notice when he/she was discharged to the hospital on [DATE]. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as cognition not assessed. Review of the resident's medical record showed the resident with a responsible party, the resident discharged from the facility on 04/24/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold notice upon discharge with the resident's responsible party. 5. During an interview on 05/07/25 at 12:37 P.M., the Assistant Director of Nursing (ADON) said the nurse who does the discharge is responsible to give the bed hold notice to the resident, have him/her sign the written notice if able, or call the resident's representative to discuss and obtain a verbal consent. He/She said he/she was not aware the nurses had not issued some of the bed hold notices. During an interview on 05/07/25 at 12:55 P.M., the Social Services Director (SSD) said the nurse is responsible to issue the bed hold policy to the resident or the resident's representative at the time of each hospital transfer or discharge, and eventually he/she verifies that a written notice was issued. He/She said he/she checks the bed hold notices monthly but had not yet checked the discharges for April. During an interview on 05/07/25 at 2:23 P.M., the Director of Nursing (DON) said the charge nurse is responsible to issue the bed hold policy to the resident or the resident's representative at the time of each hospital transfer or discharge and place the signed notice in either the DON or SSD's inbox. The DON said he/she gives any notices placed in his/her inbox to the SSD who follows up with filing the notice. During an interview on 05/07/25 at 2:30 P.M., the administrator said the charge nurse is responsible to issue the bed hold policy to the resident or the resident's representative at the time of each hospital transfer or discharge, and the SSD follows up with filing the notice. The administrator said he/she was not sure if anyone double checks that the bed hold notices are issued to residents or their representatives upon each discharge to the hospital. MO00253604

Based on interview and record review facility staff failed to ensure one resident (Resident #1) received his/her pain medications as ordered when staff failed to obtain a physician's order to resume medications that were on hold for surgery after notification of surgery cancellation, and failed to administer his/her pain medication as ordered when staff documented the medication as not available. Facility staff failed to complete smoking risk assessments to re-assess smoking privileges for two residents (Resident #2 and #4), of two sampled residents who smoke. The facility census was 84. 1. Review of the Medication Administration policy, revised 02/07/2013, showed medications are given to benefit the resident's health as ordered by the physician. The policy did not address medication holds or unavailable medications. Review of Medication, Holding policy, dated March 2012, showed staff are directed as follows: -The resident's medical record must indicate that medications are being held and the entry must be signed and dated by the staff/charge nurse entering the data; -Staff/charge nurse record the following data in the resident's medical record: name and strength of the medication, reason the medication is being held, when the thirty day period will expire, and other information as necessary or appropriate. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/07/2025, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosed with Parkinson's Disease; -Received scheduled and prn (as needed) pain medication; -Pain assessment interview should be conducted; -Pain frequency was Frequently, pain intensity over the past five days rated seven; -Opioids given since admission. Review of the resident's care plan, dated 11/19/2024, showed staff assessed the resident as diagnosis of left knee replacement related to osteoporosis, (a disease of progressive bone loss associated with an increased risk of fractures) and staff directed to assess, monitor and record pain. Review of the resident's Physician Order Sheets' (POS'), dated 4/23/25, showed staff did not document an order for medication holds due to surgery scheduled 04/21/25 or an order to resume previously held medications due to postponement of surgery on 04/11/25. Review of the resident's electronic Medication Administration Record (eMAR), dated 04/22/25 at 3:40 P.M., showed staff documented the following: -Tizanidine two milligram (mg) three times per day as needed. Staff documented the medication as not administered on 04/20 for day or night shift -Hydrocodone/acetaminophen 5/325 mg every six hours. Staff documented the medication as not administered on 04/18/25 at 4 P.M. and 10 P.M. due to not available; -Hydrocodone/acetaminophen 5/325 mg every six hours. Staff documented the medication as not administered on 04/19/25 at 10 A.M., due to unavailable; -Folic acid one mg, one tab daily. Staff documented on 04/20/25 not administered on hold; -Cyanocobalamin (B-12) 1000 mcg one tab daily. Staff documented not administered on 4/13/25 through 4/21/25 due to on hold; -Losartan 50 mg daily. Staff documented not administered on 04/20/25 due to on hold. Review of the resident's eMAR, dated 04/22/25 at 4:00 P.M. showed staff assessed the resident's pain scores as follows: -4/17/25 Day 0/10; Night 9/10; -4/18/25 Day 5/10; Night 2/10; -4/19/25 Day 9/10; Night 0/10; -4/20/25 Day 0/10; Night 0/10; -4/21/25-Day 7/10; Night 0/10. During an interview on 04/22/25 at 1:00 P.M., resident said he/she was scheduled for knee surgery on 04/21/25 and received a schedule of medication holds from the anesthesiologist. The schedule included a hold on day of surgery for Tizanidine (muscle relaxant) 2 mg, two tabs three times per day as needed, and hydrocodone/ acetaminophen (narcotic analgesic used for pain) 325 mg/5 mg one tab every six hours was to continue as scheduled. The surgery was postponed on 04/11/25 pending cardiac clearance. The resident said he/she talked to the charge nurses on 04/18 and 04/19 to ensure his/her medications would not be stopped after cancellation of the procedure. The resident said he/she feared having to play catch up on pain management due to an interruption in his/her pain medications as he/she had experienced in the past. He/She was assured by the two charge nurses there were no medications on hold. On 4/18 the resident's family also called the charge nurse on duty and was told there were no medications on hold for the resident. The resident said her pain baseline is eight out of 10 before medication and five out of 10 after medication. The resident said he/she was told on night of 04/20 by the Certified Medication Technician (CMT) administering medications that his/her Tizanidine was on hold. The resident said he/she woke up in pain that night and could not get back to sleep. The resident became increasingly concerned that staff were unaware of the procedure cancellation when he/she was reminded on the evening of 04/20/25 to take a pre-operative shower. During an interview on 04/23/25 at 2:10 P.M., the resident said he/she thought he/she had received Hydrocodone/Acetaminophen and Tizanidine on 04/18. He/She reported only requesting Tizanidine in the morning and at night. The resident said he/she was not told the hydrocodone was not available on 04/18 and 04/19, that she assumed it was in the cup of medications given to her. He/She said the CMT's don't tell him/her she is getting and get annoyed or don't respond when asked. The resident said he/she is asked to rate her pain every 7-10 days and he/she would never rate his/her pain zero out of 10 on the scale. He/She said sometimes he/she cannot stay awake late enough to ask for Tizanidine since staff pass medications between 9:30 P.M. and 10:00 P.M. Staff do not want to make extra trips for prn (as needed) medication requests. 3. During an interview on 04/22/25 at 2:25 P.M., CMT B said he/she only works two shifts per week and does not recall if the resident had medications on hold for surgery, he/she would have to check the eMAR. He/She did recall hearing the resident's surgery had been canceled. During an interview on 04/22/25 at 3:40 P.M., the Assistant Director of Nursing (ADON) said the resident must not have asked for Tizanidine on the opportunities it was available since it is a prn order. He/She said the pain score documentation is concerning since the resident's unmedicated baseline is eight out of 10 and that staff are probably not waking her up for medications. He/She said she did not understand why the daytime pain score on 04/17 and 04/20 would be zero. The ADON did not know why medication holds had not been resumed after surgery cancellation. He/She said the nurse who entered the holds no longer works at the facility and that is why it was missed. The ADON said he/she does not know why Hydrocodone/Acetaminophen was not available on 04/18 and 04/19 for the resident since it could have been obtained from the STAT box (a box of emergency medications) that all nursing staff can access. During an interview on 04/23/25 at 2:26 P.M., Licensed Practical Nurse (LPN) C said changes to medication holds are communicated during shift report. He/She said the nurse who put the resident's medications on hold no longer works at the facility and he/she would not think to see if the holds or continuations were correct. LPN C said residents should be asked their pain levels every shift or as directed and the eMAR requires documentation of a pain score prior to administration of pain medications. During an interview on 04/23/25 at 3:00 P.M., the Director of Nursing (DON) said when he/she was passing medications on the morning of 04/21/25 the resident requested Tizanidine, he/she realized there were holds on her medications that should have been removed after surgery cancellation. He/She fixed the eMAR so all medications were released from hold. The DON said they do not require a physician order for medications holds prior to surgery or to resume them if the procedure is canceled. He/She stated the information is usually passed on during sift change report or communicated in a note. He/She said if hydrocodone/acetaminophen is not available for residents in the medication cart, they can be obtain doses from the STAT box. During an interview on 04/24/25 at 10:30 A.M., the Administrator stated there should be a physician order to hold medications and an order should be obtained to resume held medications after hold is lifted. He/She said the Transporter is very good about communicating procedure changes and the information could be found in progress notes and communicated during report. 4. Review of the facility's Smoking-Residents policy, undated, showed the facility shall establish and maintain safe resident smoking practices, and staff will review the status of a resident's smoking privileges periodically, and consult as needed with the DON and the attending physician. 5. Review of Resident #2's annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and did not use tobacco products. Review of resident's smoking assessment, dated 03/29/25, showed staff documented the resident as a safe smoker. Review of resident's nurses' notes, dated 04/26/25 at 11:31 A.M., showed staff documented the resident lit a cigarette in the dining room, and was observed with smoke coming from his/her mouth. Review of resident's nurses' notes, dated 04/30/25 at 9:31 P.M., showed staff documented the resident yelled at Resident #4 to return his/her cigarette from earlier, and snatched a cigarette from Resident #4's hand. Review of resident's electronic medical record (EMR), dated 04/26/25 through 05/07/25, showed the EMR did not contain documentation staff reviewed or re-assessed the resident's smoking privileges. During an interview on 05/09/25 at 12:31 P.M., the Care Plan Coordinator (CPC) said the nurse who documented he/she observed the resident smoking inside the building should have completed a new smoking assessment for the resident or notify the CPC to assist with the assessment. During an interview on 05/09/25 at 1:10 P.M., the administrator said he/she would expect the nurse who documented he/she observed the resident smoking in the building, to re-assess the resident and complete a new smoking assessment. 6. Review of Resident #4's annual MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and did not use tobacco products. Review of resident's smoking assessment, dated 01/22/25, showed staff documented the resident as a safe smoker. Review of resident's nurses notes, dated 04/30/25 at 9:31 P.M., showed staff documented the resident was advised not to go outside to smoke when Resident #2 was outside smoking. Review of residents EMR dated 01/23/25 through 05/07/25, showed the EMR did not contain documentation staff reviewed or re-assessed the resident's smoking privileges. 7. During an interview on 05/07/25 at 2:30 P.M., the DON said the nurses are responsible to complete smoking assessments on admission and quarterly. During an interview on 05/09/25 at 5:58 A.M., Registered Nurse (RN) D said he/she was unsure, but thinks either the SSD or the CPC is responsible to complete smoking assessments for residents who smoke. During an interview on 05/09/25 at 8:51 A.M., the SSD said the CPC is responsible to complete smoking assessments on admission and quarterly for residents who smoke. During an interview on 05/09/25 at 12:31 P.M., the CPC said the nurses are responsible to complete smoking assessments on admission and quarterly for residents who smoke, but they have not been completing the assessments, so he/she has completed some assessments if he/she notices one missing. During an interview on 05/09/25 at 1:10 P.M., the administrator said the nurses are responsible to complete smoking assessments on admission and quarterly, and the CPC and DON should double check they are completed. MO00253049/MO00253882

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 84. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program, showed the program did not contain policies related to water management. Review showed the program did not contain control measures or corrective actions. Review showed the facility will not test the water or the resident's water unless there is a positive case of Legionnaire's disease within the facility. Review of the facility's water system description showed eight water heaters were identified as temperature permissive areas where Legionella could grow and special considerations for healthcare. Review of the annual water management checklist showed the monitoring procedure for water heaters was to maintain temperatures at 110-120 degrees Fahrenheit (F) and observe for signs of biofilm or sediment. Review showed the water heaters were cleaned on 12/12/23. Review of the facility's water system description showed sinks and showers were identified as areas of possible stagnation. Review showed the system description did not identify system dead legs (areas where water may pool). Review showed the water management plan did not include policies, control measures or corrective actions related to areas of possible stagnation. Review of Water Management Program Meeting minutes for June, July, August and September of 2024 showed the minutes included educational topics monthly. Review showed the minutes did not include information related to facility specific water systems or facility specific monitoring. Review of the Bureau of Environmental Health Services Sanitation Observation, dated 10/10/24, showed the facility does not have a water management plan specific to the facility addressing the facility's water distribution system and controls. The water temperature at the water heaters were approximately 117 degrees F. Thermometers at water heaters were observed to be nonfunctional and/or painted to cover the face. Cold water lines were run to resident rooms and capped and not actively in use which result in multiple dead leg cold water lines throughout the facility. During an interview on 10/08/24 at 3:15 P.M. the administrator said he/she was just notified the resident in room [ROOM NUMBER], who was sent to the hospital on 10/06/24 with respiratory distress, tested positive for Legionella. During an interview 0n 10/08/24 at 2:45 P.M., the maintenance director said he/she tested the facility water for coliform every March. The maintenance director said he/she did not document the results of the March 2024 test. The maintenance director said he/she never tested the water for Legionella. The maintenance director said he/she checked water temperatures weekly to ensure the temperature was kept between 105 and 120 degrees Fahrenheit (F). During an interview on 10/10/24 at 9:20 A.M., Housekeeper Q said housekeepers clean the bathrooms daily and run water for about 15 seconds every other day. Housekeeper Q said when he/she cleaned a shower head he/she would hang the head up which created a hanging loop in the shower hose. Housekeeper Q said he/she never performed water flushing beyond routine daily cleaning. During an interview on 10/10/24 at 2:00 P.M., the maintenance director said the administrator or corporate staff were responsible for writing policy. The maintenance director said he/she was not aware of any specific water management policies. The maintenance director said he/she cleaned the exterior and flushed the water heaters annually. The maintenance director said housekeeping staff runs the water in resident rooms but he/she did not know how long. The maintenance director said the facility did not have a policy related to flushing resident use sinks or showers. The maintenance director said he/she created the facility's water system description on his own based on a model in the CDC Toolkit. The maintenance director said he/she did not know what the term temperature permissive meant. The maintenance director said he was unsure what special consideration for healthcare facilities meant. The maintenance director said the facilities water management control measures were water temperature and visual inspections. The maintenance director said he/she did not document corrective actions. During an interview on 10/10/24 at 3:00 P.M., the Infection Preventionist (IP) said he/she was not really familiar with the water management program but there should be policies. The IP said water management education was reviewed during monthly department head meetings. The IP said he/she thought the water heaters were repaired in the previous month but he/she did not know what work was done. During an interview on 10/10/24 at 4:45 P.M., the administrator said he/she was aware of the requirements for a water management program. The administrator said the facility's control measures included water temperatures and he/she could not think of anything else. The administrator said maintenance and housekeeping flush sinks for three to five minutes every couple of weeks but he/she had never seen documentation of flushing. The administrator said he/she had not looked in depth at the water management program. The administrator said he/she was not aware the water management plan did not include facility specific policies, control measures or corrective actions. 50432

Based on interview and record review, facility staff failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for 19 residents (Resident #6, #9, #12, #20, #26, #28, #29, #31, #32, #33, #41, #44, #46, #51, #57, #63, #69, #70, and #71) out of 20 sampled. The facility census was 83. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Review of Resident #6's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 2. Review of Resident #9's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 3. Review of Resident #12's medical record showed a admission MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 4. Review of Resident #20's medical record showed a admission MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 5. Review of Resident #26's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 6. Review of Resident #28's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in July 2024. 7. Review of Resident #29's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 8. Review of Resident #31's medical record showed a admission MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 9. Review of Resident #32's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 10. Review of Resident #33's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 11. Review of Resident #41's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 12. Review of Resident #44's medical record showed a quarterly MDS dated [DATE]. Staff did not document a annual MDS in August 2024. 13. Review of Resident #46's medical record showed a annual MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 14. Review of Resident #51's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 15. Review of Resident #57's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 16. Review of Resident #63's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 17. Review of Resident #69's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 18. Review of Resident #70's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in July 2024. 19. Review of Resident #71's medical record showed a quarterly MDS dated [DATE]. Staff did not document a quarterly MDS in August 2024. 20. During an interview on 10/10/24 at 2:52 P.M., the MDS Coordinator said the previous MDS Coordinator was gone a lot and got behind on MDS's so he/she is now trying to catch up. He/She said if the MDS says In progress that means it is one he/she is actively working on. During an interview on 10/10/24 at 4:37 P.M., the Assistant Director of Nursing (ADON) said the previous MDS Coordinator was supposed to have them completed, but they were not, so the current MDS trying to get caught up. The ADON said the Director of Nursing (DON) is responsible for oversite on MDS. During an interview on 10/10/24 at 5:19 P.M., the administrator said she would expect the DON to help MDS if needed. The DON however has had to work the floor to cover RN hours, so he/she has not been available much. The administrator said she was not aware they were far behind and the corporate who over sees the facility hasn't reported anything about this to her.

Based on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for employee prior to hire to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) for five employees (Dietary Aide D, Nurse Aide E, Housekeeping F, Dietary [NAME] G, and Registered Nurse H) out of a sample of ten employees. Facility staff failed to complete a thorough investigate of an injury of unknown origin for one resident (Resident #61) out of one sampled resident. The facility census was 83. 1. Review of the Facility's Screening Abuse and Neglect Manual, undated, showed: -The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; or who has a finding in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has had a disciplinary action in effect taken against his/her professional license; -The Certified Nurse Assistant (CNA) Registry- ALL applicants must be checked before hire; -Keep a copy of the result page in the employee's personnel file. 2. Review of Dietary Aide D's employee file showed a hire date of 01/05/24. The employee file did not contain documentation of the Dietary Aide's CNA's registry check. 3. Review of Nurse Aide E's employee file showed a hire date of 08/26/24. The employee file did not contain documentation of the Nurse Aide's CNA's registry check. 4. Review of Housekeeping F's employee file showed a hire date of 10/01/24. The employee file did not contain documentation of the Housekeeping's CNA's registry check. 5. Review of Dietary [NAME] G's employee file showed a hire date of 11/19/23. The employee file did not contain documentation of the Dietary Cook's CNA's registry check. 6. Review of Registered Nurse H's employee file showed a hire date of 05/20/24. The employee file did not contain documentation of the Registered Nurse's CNA's registry check. During an interview on 10/10/24 at 10:05 A.M., the assistant business office manager (ABOM) said it is his/her responsibility to do background checks prior to hiring. He/She said he/she was not aware he/she should be running the nurse aide registry checks on all staff. He/She said he/she was recently educated on the CNA registry checks and he/she was only running them on CNA's to check for certification. During an interview on 10/10/24 at 4:36 P.M., the Assistant Director of Nursing (ADON) said it is the responsibility of the ABOM to run all background checks prior to hire including nurse aide registry. He/She said the nurse aide registry should be done prior to hire and quarterly. He/She was not aware they were not being done. He/She said he/she recently educated the ABOM and he/she must have only ran the CNA's instead of all staff. He/She said they should be done so the facility can ensure no one is hired who has charges against them. During an interview on 10/10/24 at 5:19 P.M., the Administrator said it is the responsibility of the ABOM to run all background checks prior to hire including nurse aide registry. He/She was not aware they were not being done. He/She said they should be ran prior to hire and quarterly. He/She is not sure why he/she was not doing them. He/She said it is important for the CNA registry checks to be completed to ensure all employees hired are free from charges of abuse and neglect. 7. Review of the Facility's Reporting Abuse and Neglect Manual, undated, showed: -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source and misappropriation of resident property by facility employees, contracted employees, volunteers, contract services, consultants, physicians, visitors, family members, or other individuals will be reported immediately but no later than the following timeframes. If the abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within 2 hours after the allegation was made. If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24 hours after the allegation was made. Review of the Facility's Event Investigation, undated, showed: -To investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. To identify any injuries after a resident sustains an event; -Complete a Report of Event Form as soon as possible whenever there is an unusual, unexpected and/or unidentified event that si not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor. Examples of when a form should be completed: -Bruises/skin tear of unknown origin; -The charge nurse is responsible for completion of the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. 8. Review of Resident #61's Annual Minimum Data Set (MDS), a federally mandated assessment tool used by staff, dated 06/15/24, showed staff assessed the resident as follows: -Cognition intact; -Substantial assistance with lower body dressing; -Upper extremity impairment on one side; -Diagnoses of Parkinson's disease; -Used wheelchair. Observation on 10/08/24 at 9:24 A.M., showed the resident in his/her recliner. He/She had a red left cheek, small amount of swelling under the left eye and on his/her left brow, laceration to the right forehead in his/her hairline, and resident's left wrist and hand appeared swollen. Resident was unable to answer questions, but grimaced and guarded left wrist when touched. Review of the resident's medical record, showed the record did not contain documentation staff investigated the injuries to the resident. During an interview on 10/10/24 at 4:36 P.M., the Assistant Director of Nursing (ADON) said he/she was called to the resident's room because the resident had a redden cheek, scratch to his/her forehead and a swollen wrist. He/She said when he/she asked the resident if he/she fell the resident nodded yes but was unable to answer any other questions. He/She said he/she asked dayshift staff if they knew where the resident got the injuries and staff were unsure. He/She said he/she never contacted night shift about the injuries. He/She said he/she told the charge nurse to contact the doctor and get an order for an X-ray, which came back clear. He/She said he/she is supposed to investigate when there is an injury of unknown origin. He/She said there was no proof that there was an injury, and that the resident didn't injury himself/herself. He/She said he/she did not do a formal investigation or fill out a report on the situation. During an interview on 10/10/24 at 5:19 P.M., the administrator said he/she expects the charge nurse who finds an injury of unknown origin to initiate the investigation, notify the physician, notify the responsible party, notify the ADON or DON and then he/she should notify the administrator. He/She would expect there to be an investigation that narrows down time frames and has staff interviews. He/She said he/she would expect there to be documentation of what was investigated. He/She was not made aware of the injury of unknown origin and he/she is not sure why it was not investigated and documented.

Based on observation, interview, and record review, the facility failed to implement dietary recommendations and follow physician's orders for one resident (Resident #18) who had a significant weight loss, which resulted in additional weight loss. The facility census was 70. 1. Review of the facility's Nutrition Policy, dated March 2015, showed the facility will provide nutrition as determined by a physician and in cooperation with a dietician for all residents according to State and Federal guidelines. Review of the facility's Supplements for Weight Loss Policy, dated March of 2015, showed when a resident was in need of a supplement, the charge nurse will obtain an order from the physician. The nurse will write the order on the Medication Administration Record (MAR). All supplements will be recorded on the MAR. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/25/23, showed staff assessed the resident as: -Cognitively intact; -Weight of 103 pounds (lbs); -No significant weight loss; -Diagnosis of Malnutrition. Review of the resident's Care Plan, revised 2/8/23, showed it did not contain direction for staff in regard to the resident's nutrition. Review of the resident's weights showed staff documented: -3/6/23: 103.2 lbs; -4/5/23: 91 lbs, a 12.2 lb significant weight loss. Review of the Dietitian Consult, dated 4/14/23, showed the Registered Dietitian (RD) documented the resident lost 12 lbs in one month. No vitamin D in place. Resident refusing to go to the dining room for meals. Further review showed the RD recommended the following: -Encourage the dining room; -Multivitamin/Minerals every day; -Medical Doctor (MD) to consider vitamin D supplement; -Boost (nutritional supplement) or house supplement three times a day (TID) at medication pass; -Make MD and family aware. Review of the resident's progress notes, dated 4/14/23, showed the RD documented he/she recommended a multivitamin/minerals every day, MD to consider Vitamin D supplement, and Boost or house supplement TID with medication pass. Review of the resident's Physician Order Sheet (POS), dated 4/20/23, showed the physician directed staff to monitor weekly weights until no weight loss for weeks. Further review showed it did not contain an order for a multivitamin/mineral, Vitamin D supplement, or Boost or house supplement. Review of the resident's MAR, dated 4/1/23, showed it did not contain a Multivitamin/Mineral, Boost or house supplement, Vitamin D Supplement or weekly weights. Review of the resident's Treatment Administration Record (TAR), dated 4/1/23, showed it did not contain a Multivitamin/Mineral, Boost or house supplement, Vitamin D Supplement, or weekly weights. Review of the resident's MAR, dated 5/1/23, showed it did not contain a Multivitamin/Mineral, Boost or house supplement, Vitamin D Supplement or weekly weights. Review of the resident's TAR, dated 5/1/23, showed it did not contain a Multivitamin/Mineral, Boost or house supplement, Vitamin D Supplement, or weekly weights. Observation on 5/3/23 at 1:32 P.M., showed Licensed Practical Nurse (LPN) G weighed the resident. The resident's weight read as 86.5 lbs. (significant weight loss). During an interview on 5/3/23 at 5:38 P.M., CMT M said they do not provide supplements to the resident. During an interview on 5/4/23 at 11:52 A.M., Licensed Practical Nurse (LPN) G said the resident's RD recommendations were not implemented because they were not given to him/her. The LPN said he/she did not know if the resident was supposed to have Boost or house shakes, he/she thinks Boost needs a doctor's order and house shakes do not. He/she said he/she did not know the resident had an order for weekly weights. He/she said the weights are not listed on the TAR, so staff did not complete them. The LPN said there was a lack of communication. The LPN said he/she needed to contact the doctor to get an order for the supplements. The LPN said the resident's weight loss should be on the care plan and it was not. During an interview on 5/4/23 at 3:20 P.M., the RD said he/she discovered the resident's weight loss when at the facility on 4/14/23. He/She said no one from the facility contacted him/her in regard to the resident's significant weight loss. The RD said a copy of the recommendations were made and sent to the DON and Administrator. He/she said staff should follow the recommendations but they did not and the resident has lost more weight. The RD said a significant weight loss should be documented right away. During an interview on 5/4/23 at 3:39 P.M., the MDS Coordinator said he/she was behind on updating care plans, because he/she worked on the floor and trained staff on the facility's electronic system. The MDS coordinator said he/she should have marked significant weight loss on the resident's MDS and the care plan should have been updated, but he/she had not had time to work on the care plans. The MDS Coordinator said the RD recommendations should be on the resident's care plan. During an interview on 5/4/23 at 4:31 P.M., the DON said staff should notify him/her and the charge nurse if a resident had a significant weight loss. The DON said the physician should be notified as soon as weight loss was noticed. The DON said he/she did not know why the physician or RD were not notified, but they should have been. The DON said the RD gave copies of his/her recommendations to the charge nurses and then staff contacted the physician for approval. The DON said the RD's recommendations should have been started, and he/she doesn't know why they weren't. The DON said a resident's weight loss should be on the MDS and care plan. The DON said if the resident had an order to obtain weekly weights he/she would expect staff to obtain them. The DON did not know why the weekly weights weren't obtained, and did not know why the RD's recommendations were not followed up on. On 5/4/23 at 10:04 A.M., attempted to contact the resident's physician without success. As of 06/02/23, the physician had not returned a call for interview.

Based on observation, interview, and record review, facility staff failed to appropriately identify, assess, monitor, and provide treatment as the physician directed for two resident (Residents #1 and #2), out of three sampled residents reviewed for pressure ulcers. The facility census was 64. 1. Review of the facility's Wound Care and Treatment policy, dated 3/2015, showed the policy directed staff as follows: -Purpose: It is the purpose of this facility to prevent and treat all wounds; -Wound care and Treatment: -Document the treatment immediately after completing the treatment; -The care plan should reflect the current status of the wound and appropriate goals and approaches. -Incontinence Management: -If the resident is extremely high risk, (score < 12 on Braden Scale(measures skin breakdown risk)) or has existing pressure ulcers, clean perineal area according to facility guidelines. Protect perineal area with moisture barrier cream with zinc oxide or anti fungal cream. -Positioning and Pressure Reduction: -Low risk (score of 15-16 if under [AGE] years; 15-18 if over [AGE] years on Braden Scale) does not require pressure-relieving device. Continue to assess need for pressure reduction devices; -Moderate Risk (13-15 on Braden Scale) and does not have a pressure ulcer: Pressure-reduction mattress or overlay; -High Risk and has pressure ulcers: Consult with Quality Assurance Nurse; -The policy did not show any directives for residents assessed at severe risk for development of pressure ulcers. -Wound Dressings: -Stage I (redness only, no break in skin): Cover with house [MEDICATION NAME] (waterproof dressing to promote wound healing) dressing. Change every 7 days or as needed. Other treatment as directed by physician; -Stage II (Partial full thickness, skin loss involving damage of the subcutaneous tissue): -Low exudate (drainage) - Apply house [MEDICATION NAME] dressing. Change every three days and as needed. Other treatment as directed by physician. -Medium exudate - House [MEDICATION NAME] or transparent dressing. Change every three days or as needed. Other treatment as directed by physician. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/1/16, showed staff assessed the resident as follows: -Severely impaired cognitive skills for daily living; -Rarely understood or understands; -Non-verbal; -Non-ambulatory; -Bed bound; -Required extensive, two person assistance with bed mobility and transfers; -Required total one person assistance with dressing, eating, toilet use, and personal hygiene; -Loss of functional use of all extremities; -[DIAGNOSES REDACTED]. -Gastrostomy tube (feeding tube) for all nutritional needs; -At risk for pressure ulcers due to limited mobility; -No current pressure ulcer or skin issues identified; -Identified need for interventions to minimize risk of pressure ulcers. Review of the resident's Braden Scale (prediction of pressure ulcer risk) dated 6/15/16 showed facility licensed staff assessed the resident at a score of 9, which placed the resident at a severe risk for pressure ulcer development. Review of resident's care plan, dated 6/13/16, showed staff assessed the resident was at high risk for pressure ulcers due to bedfast/mobility. Staff set a goal of intact skin without evidence of redness, irritation, maceration (softening and breaking down of skin resulting from prolonged exposure to moisture), or open areas for the next 90 days. Interventions included: -Notify the physician of any alteration in skin integrity; -Complete a skin assessment and inspection every week and as need, with close inspection to heels; -Turn/Reposition every two hours; -Assist with frequent small shifts of body weight; -Position with pillows to elevate pressure points off of bed; -Position prone if appropriate or elevate head of bed no more than 30 degrees. Review of nurses notes dated 7/14 - 8/3/16 showed staff did not document any skin issues for the resident. Review of Skin monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review sheet, dated 8/3/16, showed CNA B circled areas of the upper back and chest, and documented little red on back. red over upper chest. The charge nurse signed and documented under Charge nurse assessment no new skin issues. Staff documented N/A (not applicable) for the intervention. Staff documented they forwarded the form to the Director of Nursing (DON), but the DON did not sign to show he/she reviewed it. Review of the resident's care plan showed staff did not add any new interventions for the reddened area staff identified on 8/3/16. Review of nurses notes dated 8/3-8/9/16 showed staff did not document any skin issues for the resident. Review of Skin monitoring: CNA Shower Review sheet, dated 8/10/16, showed the CNA B circled an area of the mid-back, and documented sore on back. The CNA documented no new skin problems. The charge nurse signed and documented under Charge Nurse Assessment: small open area. Further review showed staff did not document any further assessment/description of the open area they identified. Staff documented they applied [MEDICATION NAME] (protective/barrier cream). Review showed staff did not document they forwarded the form to the Director of Nursing (DON), and the DON did not sign to show he/she reviewed it. Review of nurses notes dated 8/10-8/13/16 showed staff did not document any skin issues for the resident. Staff did not document they notified the physician of the open area on back documented by both the CNA and Charge nurse on 8/10/16. Review of the Physician order sheet (POS) dated 8/2016 showed no physician orders for the care and treatment of [REDACTED]. Review of the resident's plan of care showed staff did not add any new interventions for open area staff identified on 8/10. Review of Skin monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review sheet, dated 8/13/16, showed CNA B circled the area of the mid-back, and documented red area on back. The CNA documented no new skin problems. The charge nurse signed the form and did not document any further assessment or interventions for the red area. Staff did not document they forwarded the form to the Director of Nursing (DON), and the DON did not sign to show he/she reviewed it. During an interview on 8/19/16 at 1:40 A.M. CNA B said he/she had worked at the facility for [AGE] years and was familiar with the resident. The CNA said he/she worked with the resident on 8/13/16 until 2:00 P.M., and gave the resident a shower on 8/13. The CNA said the resident had red and open areas on his/her back visible when he/she assisted the resident to shower. The CNA said one of the open areas you could see white, I don't know if it was bone or what. The CNA reported the areas had been present for a couple weeks, I don't know if they were dressing it or anything, but I told the charge nurse about it. The CNA reported the resident was bed bound, only got up for showers, using a shower bed. The CNA after consulting with LPN C and environmental services reported the resident had not been on an low air loss mattress. The CNA reported the resident was on a two hour turn and reposition schedule. Review of the resident's nurses notes showed staff did not document on 8/13/16. Review of the resident's plan of care showed staff did not add any new interventions regarding the red area on the resident's back staff assessed on 8/13/16. Review of the resident's nurses notes dated 8/14/16 at 10:45 P.M. showed Licensed Practical Nurse (LPN) A documented staff notified the physician at 11:10 P.M. regarding copious amounts of brownish liquid and phlegm from [DEVICE] site and [MEDICAL CONDITION]. Staff sent the resident to hospital for evaluation and treatment as ordered. The LPN documented the resident's face and neck were red, no open areas noted, the resident's coccyx (tailbone) was free of redness and open areas, the resident's heels were intact, and the area around [DEVICE] site was excoriated (reddened). During an interview on 8/24/16 at 12:00 P.M. LPN A said the he/she assessed the resident when they sent him/her out on the evening of 8/14/16. The LPN said he/she completed a skin assessment and only assessed a blanchable area below the shoulder blade. Review of the emergency room note for admitted [DATE] (no time)showed hospital staff documented the following: -Integumentary (skin) assessment: Skin warm and dry, midline low back has four pressure ulcers present on admission: 1 x 1 centimeter (cm) unstageable ulcer, one 2 x 1 cm stage II pressure ulcer, three deep tissue injuries (pressure-related injury to subcutaneous tissues under intact skin) measuring 0.5 x 0.5 cm. Review of the multimedia manager images taken from the hospital admission showed the open areas identified above, including an open area with a slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy at times) covered wound base and multiple deep tissue injuries. Further review of images showed excoriation around the resident's [DEVICE] site. Observation on 8/19/16 at 1:15 P.M. showed resident's facility bed with a regular pressure reducing mattress and positing wedge in bed. The resident was currently in the hospital. Review of the resident's Admission Nursing History and Evaluation sheet dated 8/22/16 (no time) showed facility licensed staff documented four open areas to the resident's mid-back on re-admission to the facility. Review of nurses note dated 8/22/16 (no time) showed staff documented they placed the resident on an air mattress with directions to turn the resident every two hours. Review of the resident's nurses note dated 8/22/16 at 2:00 P.M. showed the ADON (wound nurse) completed a head to toe assessment and identified the following four areas on the resident's mid-back: - 0.9 cm x 0.5 cm, 0.9 cm x 0.9 cm, 0.6 cm x 0.5 cm, 0.3 cm x 1.5 cm. The ADON did not document any further description of the areas. Review of the resident's POS, dated 8/23/16 showed a new order for hydrogel and foam to areas on mid-back every Monday and Thursday and as needed. Observation on 8/24/16 at 10:12 A.M. showed the resident lay on a low air loss mattress. The observation showed open areas to the mid-back, the larger of which had visible slough in the wound base. During an interview on 8/19/16 at 1:55 P.M. the DON said the ADON should review shower sheets daily for skin issues. The DON said when staff identified a wound, they should complete an assessment of the wound, notify the physician, initiate wound care, and notify the wound nurse so they could complete follow-up and monitoring. The DON said he did not know the resident well enough to determine if it would have been appropriate for the bed bound resident that facility staff assessed at severe risk for pressure ulcer development, to have a low air loss mattress. 3. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/1/16, showed staff assessed the resident as follows: -Severely impaired cognitive skills for daily living; -Rarely understood or understands; -Non-ambulatory; -Required extensive, two person assistance with bed mobility and transfers; -Required extensive, one person assistance with dressing, eating, toilet use, and personal hygiene; -Urinary catheter; -Loss of functional use of all extremities; -[DIAGNOSES REDACTED]. -Gastrostomy tube (feeding tube) for all nutritional needs; -At risk for pressure ulcers due to limited mobility; -One stage III pressure ulcer (full thickness skin loss involving damage of subcutaneous tissue, which may extend down to, but not through, underlying fascia); -Identified need for interventions to minimize risk of pressure ulcers. Review of the resident's Braden Scale (prediction of pressure ulcer risk) dated 8/18/16 showed facility licensed staff assessed the resident at a score of 12, which places the resident at a high risk for pressure ulcer development. Review of resident's care plan, last reviewed 7/14/16, showed staff assessed/planned the following: -The resident had stage IV (Full thickness skin loss with extensive destruction, tissue dead tissue or damage to muscle, bone or supporting structures such as tendon or joint capsule) pressure ulcer on his/her coccyx (acquired in 2014). Staff set a goal for the resident to provide care so the resident had no signs/symptoms of infection to pressure ulcers, and current wounds will show improvement in healing in the next 90 days. Interventions included: -Low air loss mattress; -Coccyx- follow recommendations of wound nurse; -Wound care as specified by wound nurse; -Cushion to wheelchair. Review of nurses notes wound report dated 7/27/16 at 6:00 P.M. showed staff documented the resident had an open area on his/her coccyx measuring 3 cm x 0.6 cm x 0.2 cm., and open area on the right great toe measuring 0.9 cm x 0.4 cm x 0.1 cm with moderate drainage, and a red wound bed. Staff documented to continue with skin prep every shift. Review of the resident's Physician Order Sheet (POS) dated 8/1/16 showed the physician directed staff to complete the following treatments: -Change the toe wound treatment to [MEDICATION NAME] (product used for the management of wounds and burns) with a foam dressing and change Monday/Wednesday and as needed; -Apply skin prep to finger wound. Review of nurses notes wound report dated 8/2/16 at 11:00 A.M. showed staff documented the resident had a wound on his/her coccyx measuring 3 cm x 1.5 cm x 1 cm, and one on his/her right great toe measuring 0.9 cm x 1 cm x 0.1 cm, with odor present. The physician gave a new order for for skin prep daily for a newly identified deep tissue injury (pressure-related injury to subcutaneous tissues under intact skin) on the left buttock that measured 2 cm x 2.5 cm with minimal drainage. During an interview on 9/8/16 at 11:00 A.M. the ADON said the Deep tissue injury with minimal drainage he/she documented was a red/purple area with slight drainage. He/She said there was no visible open area, but there could have been a pin point area not visible which caused drainage. Review showed staff did not document they notified the physician of changes in the coccyx wound depth and odor to toe. Review of the resident's nurses note dated 8/7/16 (no time) showed staff sent the resident to the hospital at 1:37 A.M. due to a change in his/her medical condition. Review of nurses note dated 8/11/16 at 12:40 P.M. showed the resident was readmitted to the facility from the hospital. Review showed staff documented the resident had no new skin issues. Staff documented the resident had wounds they previously assessed on his/her coccyx, left great toe, and right finger. Staff did not document they assessed any new wounds. Review of the resident's Admission Nursing History and Evaluation sheet dated 8/11/16 (no time) showed staff documented the resident had open areas on his/her coccyx, right finger, and left great toe. Review of the resident readmission POS dated 8/11/16 showed physician orders to treat the area on the resident's coccyx with hydrogel and foam, change every Monday/Thursday and as needed. Further review showed no treatment order for areas identified on right finger and left great toe. Review of Skin monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review sheet, dated 8/15/16, showed the CNA documented the resident did not have any skin issues. The charge nurse signed and dated the sheet under Charge nurse assessment. Review of the resident's wound report dated 8/15/16 at 2:00 P.M. showed the ADON documented the resident's coccyx wound measured 2.5 cm x 0.8 cm x 0.5 cm with moderate drainage, no odor present with a new order for [MEDICATION NAME], calcium alginate, and foam to the area every Monday/Thursday and as needed. The ADON documented he/she assessed a newly identified wound on the left buttocks with a scattered wound 7 cm x 2.5 cm with 75 % slough (a layer of dead tissue that obscures the wound bed) present. The ADON documented the physician directed staff to apply skin prep around the wound bed and duoderm ([MEDICATION NAME] dressing) to the wound every Monday/Thursday, and as needed. During an interview on 9/8/16 at 11:00 A.M. the ADON said that the scattered wound on left buttocks consisted of the 7 cm x 2.5 cm open area with slough present, and had multiple pinprick areas which were immeasurable surrounding the wound. Review of the resident's wound report for the week of 8/14/16 showed the following: -Coccyx wound, stage IV pressure ulcer measuring 2.5 x 0.8 x 0.5 cm. Previous measurement 3.0 x 0.6 x 0.2 cm. 8/15/16 order to treat with [MEDICATION NAME], calcium alginate and foam; -Right great toe wound, unstageable pressure ulcer measuring 1.0 x 1.5 x unknown. Previous measurements are 0.9 x 0.4 x 0.1 cm. Treatment identified as hydrogel and foam, change every Monday/Thursday and as needed; -Left buttocks wound, stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer identified on 8/15/16 measuring 7.0 x 2.5 x 0.1 cm with 75% slough in wound bed. Acquired in house. Review of POS dated 8/15/16 showed the following: -Discontinue previous orders for wounds. Treat coccyx wound with [MEDICATION NAME] and foam, change Monday/Thursday; -Treat left buttocks with skin prep to macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) areas cover with duoderm, Change Monday/Thursday; -Further review showed no order for treatment of [REDACTED]. Review of the resident's Treatment Administration Record (TAR) dated 8/11 - 8/19 showed staff did not document they provided any treatment for [REDACTED]. Review of Skin monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review sheet, dated 8/18/16, showed the CNA identified a blister area on the resident's right inner knee and no other skin issues. The charge nurse signed and documented under Charge nurse assessment. Staff did not document anything further. Observation/interview on 9/19/16 at 10:05 A.M. showed the resident had no treatment to the blackened/scabbed over area on the great left toe. The ADON/wound nurse said staff should treat the area with [MEDICATION NAME] and foam. The ADON reviewed the TAR and found staff did not transcribe the treatment on the TAR and staff did not document they provided any treatment to the toe since admission on 8/11/16. The ADON transcribed the order onto the TAR and provided the treatment to the left great toe. Further observation showed the ADON provided the physician ordered treatment to a stage IV pressure ulcer on the resident's coccyx and the previously area identified area on the left buttock. A newly identified open area was found on the left buttocks measuring 0.8 x 1.5 cm. The ADON covered the area with foam until a physician order to treat could be obtained. The ADON said she was not previously aware of the area. During an interview on 8/19/16 at 10:05 A.M. the ADON said staff should have treated the area on the great right toe upon returning from the hospital, but staff did not transcribe the order to the TAR. During an interview on 8/19/16 at 1:55 P.M. the DON said part of the admission process was to complete a skin assessment and obtain orders for all identified areas. He said the staff should have contacted the physician and obtained treatment orders for the area identified on the right great toe. He said he would expect CNAs to identify all skin issues, even previously identified areas, to ensure areas are being addressed. MO 992

Based on interview and record review, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) and/or call [DATE] for one resident (Resident #1) with a written directive for full code status when they found the resident without pulse or respirations. Additionally, staff failed to notify the resident's physician of the resident's change in condition. The facility's census was 62. 1. Review of the facility's CPR policy/procedure, dated [DATE], showed staff are directed to check the resident's medical record for CPR or NO CPR, call paramedics, attending physician, and administrative personnel when they find a resident without pulse or respirations. A physician pronounces the resident dead. During an interview on [DATE] at 11:15 A.M., Licensed Practical Nurse (LPN) E said the facility's normal practice to identify code status is to check for the green or red forms in the front of a resident's chart. Red means No Code and green means Full Code. LPN E said if in doubt staff should start CPR and call [DATE]. Review of Resident #1's medical record showed the resident was admitted to the facility on [DATE], following a motor vehicle accident, which resulted in a fractured femur (thigh bone) with subsequent hospitalization and surgical repair of the fracture in an acute care hospital. Review of the resident's Initial Nursing History and Assessment, dated [DATE], showed staff documented the resident's initial vital signs (blood pressure, temperature, pulse and respirations) were within normal limits. The resident's medical [DIAGNOSES REDACTED]. Review of the resident's medical record showed a Resident Code Status Form, dated and signed by the resident's parent/guardian on [DATE]. The form stated: If I am found without a heartbeat or pulse: My wish is to have Cardiopulmonary Resuscitation (CPR). I understand that CPR consists of chest compressions and artificial breathing. Risks of CPR include broken ribs, severe bruising, punctured lungs, but I am willing to accept these risks if the effort may save my life. Review of the resident's medical record showed an undated CNA Care Card with a check mark indicating the resident's Full Code status. Review of LPN A's written statement (which is part of the facility's investigation), dated [DATE], showed LPN A documented the following: -At approximately 10:20 P.M. Certified Nurse Aide (CNA) B called nursing staff to Resident #1's room. The resident had a black colored emesis on face, ears, nose, sheets and on floor. They did not detect any vital signs. LPN A documented he/she last saw the resident at approximately 7:30 P.M. and he/she was awake without any signs/symptoms of distress. The previous shift reported the resident threw his/her dinner plate and water each time they gave him/her water. The off-going nurse reported he/she administered the resident's pain medication. No other information was passed on to me. During a telephone interview on [DATE] at 2:00 P.M., LPN A said on [DATE] his/her shift started at 6:00 P.M. and he/she first saw the resident at about 7:30 P.M. The CNA called him/her to the resident's room at about 10:20 P.M. to 10:30 P.M., and the resident was really dead. He/she had been dead a while. He/she did not find a red or green sheet in the resident's chart. He/she said later he/she found the Resident Code Status Form with the Code Status instructions. He/she did not recall when that was. When asked what he/she was expected to do when he/she found someone without vital signs and unknown Code Status, he/she replied, I guess I could do CPR, but the resident was dead a long time. He/she said he/she thought of doing CPR or calling [DATE], but it was such a mess and he/she wanted to clean the resident up first. LPN A said, he/she was not sure he/she called the resident's physician and thought LPN C did. LPN A said he/she did not notify the resident's family because he/she could not find the family's phone number. He/she called another staff person who helped him/her by phone to find the contact information. LPN A said LPN C notified the family. During an interview on [DATE] at 2:30 P.M. Social Services Director (SSD) S said LPN A called him/her on [DATE] at 11:05 P.M. LPN A told him/her of the resident's passing and SSD S explained how to find the contact information. He/she also asked LPN A if he/she performed CPR and called [DATE], and LPN A said no. SSD S said he/she told LPN A the resident was a full code. SSD S said they did not put the green sheet indicating full code on the chart because the resident came in late on [DATE] and died the following night. Review of CNA B's written statement, showed CNA B documented the following: -He/she came in to work at 10:00 P.M., and after attending to the residents that needed care, he/she passed ice. When he/she got to Resident #1's room to pass ice, he/she immediately knew that the resident was deceased . He/she called for both of the charge nurses, LPN A and LPN C, who ran to the room. The resident was positioned in the middle of the bed, covered in brown vomit. It looked like the resident had been deceased for some time because of the color and temperature of his/her body. During a telephone interview on [DATE] at 12:54 P.M., CNA B said on [DATE] he/she entered the facility at about 10:00 P.M. He/she noticed a distinctive, bad smell when she entered the building. The odor was throughout the building. When he/she finally entered the resident's room, the resident lay on top of the bed, in the middle, cold, covered with brown vomit. He/she checked for a pulse and did not find a pulse, the resident's skin color was yellow. CNA B said, he/she found the resident at about 10:20 P.M. and went to get LPN A. Both LPN A and LPN C entered the room at the same time. LPN A did not check vital signs and LPN C just entered the room and left again to make phone calls. CNA D also responded and LPN A directed them both to clean the resident and LPN A helped. CNA B said he/she asked LPN A if the resident was a full code and nobody knew. LPN A did not ask him/her to get the chart. CNA B said he/she did not know if LPN A or LPN C checked the resident's chart for the resident's code status. CNA B said he/she did not start CPR because he/she felt the resident was very dead and had been for a while. He/she called LPN A, who was just down the hall, to make the decision. CNA B said the resident showed no indications of not feeling well the night before. During a telephone interview on [DATE] at 2:55 P.M., LPN A said he/she last saw the resident at about 7:30 P.M., and he/she was okay. LPN A said LPN C took care of all phone calls after they found the resident deceased . When he/she checked with LPN C in the middle of the night, he/she found out LPN C did not call the resident's physician. He/she called the resident's physician at about 5:00 A.M. regarding Resident #1's death. Review of CNA D's written statement, dated [DATE] at 2:10 A.M., showed CNA D documented the following: -When he/she went into the resident's room between 7:30 P.M. and 8:00 P.M., he/she was sitting up in bed. He/she had this attitude all day. He/she threw his/her water bottle twice and his/her urinal. He/she assumed it was normal, no one said otherwise in report. Staff reported the resident kept asking for water. Shortly after staff gave him/her water, it would wind up all over his/her half of the room. At approximately 10:20 P.M., staff found the resident in his/her bed. He/she had passed away. His/her sheets were wet with black spots on them around the resident's head. The other CNA cleaned it out of his/her ears, and LPN A cleaned it off his/her arms. The area around the resident's eyes was black mixed with a dark yellow. As of [DATE], CNA D could not be reached by phone to confirm this statement. During a telephone interview on [DATE] at 3:40 P.M., LPN C said on Saturday [DATE] at about 10:30 P.M., the CNA making rounds called him/her and LPN A to the resident's room. LPN C said the resident was dead and we found him/her without breaths. He/she said they checked for a pulse and found none. When asked if either of the the nurses called [DATE], he/she said he/she left his/her cell phone at the desk. He/she is from another city and knew how [DATE] worked there but did not know how it worked here. He/she said LPN A said something about calling the physician, but LPN C told LPN A no need to call the doctor, he/she can't do nothing at this time of night. LPN C said he/she did not know the facility's protocol for a death. LPN C said LPN A did not have the resident's medical record during this incident. LPN C said he/she called the resident's family two or three times. LPN C said he/she called [DATE] but was told [DATE] would not come to the facility but would respond to the family's home and it would be up to the family. LPN C then clarified he/she called the County Sheriff's Office via [DATE] not Emergency Medical Services. He/she asked the Sheriff's Office to go to the family's home regarding the resident's death. During a telephone interview on [DATE] at 8:46 A.M., the resident's family member said local police officers came to the home, notified them of the resident's death and told them facility staff had been unable to reach them by phone. The family member said the resident could say some words, but one had to interpret his/her facial expressions. He/she would express pain with his/her eyes and did not have behaviors such as throwing objects. The family member said the resident's sibling went to the facility on [DATE] at about 8:00 P.M. to see the resident and provide clothing. During a telephone interview on [DATE] at 1:57 P.M. the resident's sibling said he/she went to the facility on Saturday [DATE] at about 8:,[DATE]:30 P.M. to bring the resident clothing. He/she did not see the resident because he/she did not want to get the resident excited at this hour in case he/she was already settled in for the night. He/she gave the clothing to an employee to place in the resident's room. He/she said the resident expressed not feeling well or pain by getting aggravated and yelling. He/she may have thrown things, but mostly just yelled. Review of the resident's nurse's note, dated [DATE] at 2:00 A.M., showed LPN A documented at 7:30 P.M. the resident lay in bed awake. At approximately 10:20 P.M., staff found the resident without pulse or other vital signs. The Medical Examiner and the resident's sibling were notified, and the body was released to the Medical Examiner at approximately 12:20 A.M. LPN A did not document staff started CPR, called [DATE], and/or notified the physician. During a telephone interview on [DATE] at 4:45 P.M., the resident's physician said staff did not call him/her regarding the resident's death until about ten hours later when he/she received a follow-up call from the facility's administrator. He/she expected staff to initiate CPR and call [DATE] in such a situation and expected to be notified immediately. Please note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. At the time of exit, based on record review and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. Facility staff completed an audit of all medical charts for the presence of the green/red code status sheets and implemented the policy that all Code Status forms will be placed in the front of the medical charts at the time of admission by the Social Services Director or her designee. The Director of Nursing has conducted in-services of all licensed staff regarding Code Status, green/red forms and their meaning. Staff were also instructed if Code Status cannot be determined, licensed staff shall initiate CPR and call [DATE] immediately if a resident is without vital signs. The facility will continue in-services on Code Status upon hire before assuming patient care and at least quarterly. The Administrator will monitor all new hire licensed nursing orientation, nursing in-services and monthly Code Status audits for compliance. The Administrator will report monthly to the Quality Assurance Committee on compliance for six months and then as determined by the committee on results. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D grid 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 the Class I violation. MO 5709