Every finding on record at Village Care Center Inc

Based on interviews and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services. This failure had the potential to affect 29 residents who received food from the kitchen. The facility census was 29.Review of the facility job description, Dietary Manager, (DM) undated, showed:- Position reports to the Administrator and Director of Nursing (DON).- Dietary Manager (DM) is responsible for the overall operation of the dietary department, ensuring the provision of safe, nutritious, and appealing meals in accordance with physician orders, resident preferences, and regulatory requirements. - Collaborate with the dietitian to ensure nutritional needs are met and special diets are followed.- Maintain appropriate inventory levels, temperature logs, cleaning schedules and sanitation audits.- Maintain a safe working environment for staff and residents.- Ensure compliance with fire, safety, and emergency procedures.- Report hazards and incidents promptly.- Qualifications: high school diploma, completion of a Dietary Manager certification program, prior experience in food service management, preferably in long-term care.- Licensure/Certification: Certified Dietary Manager (CDM) preferred or required per state regulations or must be obtained within one year of hire.- Food Safety Certification required.Request for Human Resources hiring documentation for the Dietary Manager was not provided. Written statement from facility showed DM was hired on 5/1/25 as the Dietary Manager. Review of personnel records, dated 5/8/25, showed that the DM had successfully completed the standards for ServSafe Food Protection Manager Certification Examination administered by the American National Standards Institute (ANSI). During an interview on 4/7/26 at 1:10 P.M., the DM said:- She had completed ServSafe training and certification. She was currently working on getting her Certified Dietary Manager certification through an online course from North Dakota. She had a few weeks to go before she could take the examination. Her background in food service came from working as an employee at Sonic Drive-in. The Administrator had asked her if she wanted to apply for the position shortly after starting employment at the facility and she applied and was hired as the DM about a year ago. - She would receive training from the part time Registered Dietician (RD) whenever she came to the facility. She would not normally have any contact with the RD other than those occasions and did not have the RD's phone number. - She was responsible for doing all deep cleaning in the kitchen and no specific dietary staff reporting to her were assigned any of these functions other than day-to-day cleaning. The month of April cleaning schedule had not been updated or posted yet in the kitchen. During an interview on 4/7/6 at 2:30 P.M., the Administrator said the current DM hired as interim and the facility is actively looking for a qualified individual to fill the role. The current DM is performing well and is pursing CDM certification. She has been in the role for almost a year now.

Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly store and monitor food items for expiration dates, failed to maintain safety and cleanliness standards in the kitchen area, and failed to properly hand sanitize when hot water was not available. This affected all residents in the facility. The facility census was 29.Review of facility policy, Food Receiving and Storage, revised July 2014, showed:- Food Services, or other designated staff, will maintain clean food storage areas at all times;- Food in designated dry storage areas shall be kept off the floor (at least 18 inches);- Dry foods that are stored in bins will be removed from original packaging, labeled and dated with use by dates;- All foods stored in the refrigerator or freezer will be covered, labeled and dated with use by dates;- Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded;Request for facility policy on leftovers in the Kitchen was not provided;Review of facility policy, Sanitization, revised October 2008, showed:- The food service area shall be maintained in a clean and sanitary manner;- All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish;- All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions;- Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime;- The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas;Review of facility policy, Water Temperature Management, undated, showed:- The purpose of this policy is to ensure safe water temperatures throughout the facility to prevent scalding injuries while reducing the risk of waterborne pathogen growth;- The facility will maintain hot water between 105 degrees Fahrenheit (dF) and 120 dF and must not exceed 120 dF to prevent scalding;- Monitoring schedule is done monthly at Kitchen sinks;- If temperatures are too hot (>120 dF) immediately restrict use and adjust mixing valves or system controls;1.Observation in the Kitchen on 4/6/26 at 9:11 A.M., showed:- Hand washing station hot water was unbearable to the touch;Stand-up Refrigerator:- Plastic jug with tea had no label or use by date;- Pink liquid in a plastic jug had no label or use by date;- Seven plastic jugs with unknown liquid had no labels or use by dates;- Orange juice dated 4/1/25 in plastic jug with no use by date;- Cranberry juice dated 4/2/25 in plastic jug with no use by date;- Tomato juice unlabeled in plastic jug with no use by date;- four-ounce individual serving of juice in drinking cup unlabeled;Under the Coffee Station- Sleeve of plastic cups on the floor;- Broken plate and a ball of tin foil on the floor;Observation in the Kitchen on 4/6/26 at 9:25 A.M., showed:- Cleaning list posted but incomplete from March 2026. Evening cleaning not initialed, no dates listed. Morning [NAME] cleaning not completed. - Monthly cleaning schedule posted with no month indicated, incomplete assignments and initials with no staff assignments on the schedule. Double Door Refrigerator:- Overloaded with items restricting access and air flow;- Plastic container of celery dated 2/3/26 with wilted celery and no use by date;- Individual sized servings of jello leftovers dated 3/30/26, expired;- Four individual sized servings of pears dated 4/2/26 no use by date;- Bag of raw carrots, no received date or use by date;- Bag of raw green onions no received date or use by date;- Leftover Brussel sprouts use by 4/5/26 in container, expired;- Two leftover blueberry muffins wrapped in plastic wrap, no label or dates;- Bottom shelf of refrigerator in front of fresh eggs has entire surface area covered in light dusting of crumbs and food debris;- Beef base 16 ounces, no open date, best used by 3/26/26, expired;- Eight bags of sealed cabbage and one bag of sealed shredded carrots with no labels or use by dates;- Two bags of coleslaw and two bags of lettuce air sealed dated 3/31/26 with no use by date;Stand-up Freezer in Kitchen Area:- Two large bags of frozen egg patties unlabeled and falling out of overfilled freezer, one bag not sealed;- Frozen meat stacked on top of ice cream containers, various items wedged into freezer with no air flow;Kitchen Area:- Broken plate on the ground under the right side of the stand-up freezer;- Behind ice machine on the ground was a paperback manual, six-inch diameter plastic lid cover, plastic ice scoop, plastic pill cup, and pieces of paper trash;- Dust on top of the ice machine;- Standing water and dirt on the inside bottom lip of the ice machine where the access cover meets the metal lip when it is closed;- Dust build up on the wall air conditioning unit fins louvers;- Four foot high fan at the center of the kitchen next to the food preparation table was operating with no blade guard attached to the fan;Dry Storeroom:- Case of variety muffin mix stored on the floor;- Case of six #10 size cans of vegetables stored on the floor;- One one-gallon jug of Worcestershire sauce with no open date, one eighth full, expired 5/7/25;- One one-gallon jug of unsulphured molasses, no open date, one eighth full, expired July 2025;Stand-up Freezer:- 16 packs of frozen deli meat no received dates or labels on packaging;- Five bags of frozen vegetables had no label or received dates;- One bag of frozen corn opened and re-sealed with no open date, received date or use by date;- Virginia frozen ham with no received by date;- Four bags of [NAME] sprouts no received date;- Freezer overfilled with food items restricting air flow around products;Observation in the kitchen on 4/7/26 at 9:35 A.M., showed:- Hand washing station hot water measured at 138 dF which was scalding to the touch and within 60 seconds it dropped to 66 dF which was cold to the touch;- Bench freezer in center of the kitchen had six bags of frozen lima beans with no labels or dates;- Bench freezer is overfilled, is able to be shut when force is used on the lid crushing the items inside;- Stand-up refrigerator had leftover pears in syrup in a plastic container dated 4/2/26 and a use by date of 4/10/26 which was 9 days after opening;- Plastic 24 oz container on spice rack was labeled as containing Bran and also labeled as containing baking powder;- Leftover green beans in the refrigerator labeled 4/6 with a use by date of 4/13 (8 days);- Leftover cooked carrots in the refrigerator labeled 4/2 with a use by date of 4/9 (8 days);- 11:22 A.M. Dietary Aide (A) said there was no hot water to wash his/her hands;- 11:31 A.M. Dietary Aide (A) said there was no hot water to wash his/her hands;- Built up grease film and dust on surface area of shelfing holding pots and pans located next to the bench freezer in the kitchen;- 11:43 A.M. Dietary Aide (A) said there was no hot water to wash his/her hands;During an interview on 4/7/26 at 11:58 A.M., the DM said:- The water is currently ice cold at the hand washing station, it oftentimes bounces from hot to cold depending on if the laundry is operating.- She has informed the Maintenance Supervisor about the situation. During an interview on 4/7/26 at 1:30 P.M., the DM said:- The leftover policy for cooked foods is three days. If something was cooked on 4/1/26 it would have to be discarded at the end of the day on 4/3/26;- Canned fruit has a seven-day limit for leftovers once opened;- Uncooked vegetables has a seven-day limit for leftovers;- Jello made on 3/30/26 would have to be discarded by the end of day seven;- Everything should be labeled in the refrigerator and freezer with use by dates for opened items;- A bag of lettuce that is opened must be sealed with the date opened and should be used by the next day;- Deep cleaning assignments are not given to the kitchen staff, the DM does all of the deep cleaning;- Beverage plastic jugs need to be labeled and dated with a use by date in the refrigerator, which is three days;- Food items should not be stored on the ground in the dry storeroom;During an interview on 4/7/26 at 3:10 P.M., Dietary [NAME] (A) said that the refrigerators and freezers in the kitchen area are overloaded, and they needed more space to store their food items;During an interview on 4/7/26 at 4:14 P.M., the Maintenance Supervisor said:- He was aware of the temperature issues in the kitchen and the low water temperature that was being supplied to the hot water faucets. He was not aware that measurements of 138 dF had been taken at the hot water faucet. He has a valve ordered which will be delivered in a week which he feels might solve the problem. During an interview on 4/7/26 at 4:30 P.M., the Administrator said:- Kitchen staff should have access to hot water when they are washing their hands;- Food items received should be labeled with a receipt date;- Food items that are opened and re-sealed should be labeled, dated and have a discard date;- Food items that are expired should be discarded immediately;- She has not been informed that the refrigerators and freezers are overloaded and while she does inspect the kitchen she has not seen inside the refrigerators or freezers for a while;- There should be an ongoing cleaning program with accountability in place in the kitchen;- There should not be paper trash, broken dishes, plastic cups and utensils on the floor in the kitchen;- There should not be grease and dust build up on the storage racks in the kitchen;- Staff should not have a fan in the kitchen without a blade guard installed;- Stocked food items should not be stored on the floor;- Jugs of juice in the refrigerator should be labeled and have a use by date;

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. The facility also failed to ensure appropriate hand hygiene was performed during food handling. Both of these deficient practices had the potential to affect all residents. The facility census was 29.Review of the facility policy Legionella Water Management Program, dated July 2017, showed:- As part of the infection prevention and control program our facility has a water management program which is overseen by the water management team;- The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease;- The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing water management program;- The program includes a detailed description and diagram of the water system in the facility including receiving, cold water distribution, heating, hot water distribution, and waste;- The program also includes the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains and medical devices such as CPAP machines;- The program also includes the identification of situations that can lead to Legionella growth, such as construction, water main breaks, changes in municipal water quality, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection;- Specific measures used to control the introduction and/or spread of legionella;- The control limits or parameters that are acceptable and that are monitored;- A diagram of where control measures are applied;- A system to monitor control limits and the effectiveness of control measures;- A plan for when control limits are not met and/or control measures are not effective;- Documentation of the program;- The water management program will be reviewed at least once a year, or sooner if needed. Review of the facility policy Food Preparation and Service, dated April 2019, showed:- Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices;- Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness;- Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plated and food waste prior to handling food trays;- Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use;- Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food;- Staff do not handle ice with bare hands 1.Review of the facility's current maintenance binder, showed the following:- No testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility was present;- There were no facility-specific interventions or action plans for when control limits are not met;- There was no documentation included in the maintenance binder with any dated cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 04/07/2026 at 1:25 P.M., the Maintenance Director said:- They don't have a water management plan but are currently writing the Legionella/water pathogen plan now;- He's making a map;- He does check drains but doesn't write it down, and he knows from other things that if you don't write it down it didn't happen. During an interview on 04/08/2026 at 7:57 A.M., The Administrator said:- They have a water management Performance Improvement Plan (PIP) in place since a mock survey recently and they were given a water management tool kit that they are working with;- They are using a CDC program and just started March 31st;- They have had no cases of Legionnaires; - They had a plan in place on flushing drains and checking water temperatures which should have been documented. If it's not documented, it didn't happen. 2. Observation of the Dining Room on 4/6/26 at 12:04 P.M., showed:- DON came out of the kitchen with a cart of covered food trays for the residents eating in the dining room. DON delivered two meals to residents placing plates and dishes in front of each resident. DON put her hands in her pocket. Then touched the back of a resident's chair and continued to get trays from the meal cart and serve the rest of the residents at the table without sanitizing her hands. DON then touched a resident's drink glass, put her hands back in her pocket, wiped her hands on her pants and served another resident their meal without hand sanitizing. DON then touched another chair to move it out of the way, served a resident, put her hands in her pockets, got another meal from the cart to serve a resident and helped another resident with their food bib without hand sanitizing between residents. - 12:13 P.M. CMT (A) picks up a biscuit from a resident's plate without wearing gloves and butters the biscuit in the palm of his/her hand with a knife and then returns the biscuit to the resident's plate. During an interview on 4/7/26 at 2:52 P.M., the Administrator said:- She would expect staff to not touch a resident's food with their bare hands and would not expect them to butter a biscuit in their ungloved hand and hand the biscuit back to the resident.- She would expect staff to sanitize hands between serving residents in the dining room after touching a non-sanitary surface. - She would expect staff sanitize their hands after putting their hands in their pockets before serving a resident meal.

Based on observation, interview and record review, the facility staff failed to provided proper respiratory care when staff failed to date the oxygen tubing when replaced for one of the 12 sampled residents, (Resident #26), failed to change and date oxygen tubing for Resident #29 and failed to change and date nebulizer tubing for Resident #5 and #29, and additionally, when staff failed to properly clean oxygen concentrator filters for two residents (Resident #16 and #29), The facility census was 29. Review of facility Oxygen, Respiratory Therapy, and Nebulizer Management Policy, undated, showed:- The facility will provide oxygen therapy and respiratory treatments in a safe, effective, and sanitary manner;- All staff will follow physician orders, manufacturers guidelines, and infection prevention standards to ensure optimal resident outcomes and safety;- Ensure all equipment is clean, functional, and in good working order;- Oxygen tubing, cannulas, and masks must be clean;- Equipment must be dated upon opening or placement;- Change guidelines unless otherwise ordered are nasal cannula every 14 days and as needed, oxygen tubing every 30 days and as needed, nebulizer kits every 14 days and as needed, and humidifier bottles cleaned and changed per manufacturer guidelines and as needed;- Nebulizer equipment must be rinses after each use, air dried completely, and stored in a clean, dry container or bag;- Nebulizer equipment must be labeled with resident name and date. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/16/26 showed: - Cognitive skills intact. - Required assistance with set up and clean up for transfers. - Diagnoses included anemia (a condition where your blood does not have enough healthy red blood cells or hemoglobin to carry oxygen to your body), atrial fibrillation (A-fib, an irregular, often fast heart rhythm where the upper chambers of the heart (atria) beat in a chaotic way instead of a steady rhythm), and Coronary Artery Disease (CAD, a condition where the blood vessels that supply the heart become narrowed or blocked Review of the resident's Physician Order Sheet (POS), dated March 2026 showed: - Start date: 3/12/26: Ipratropium - albuterol solution for nebulization, 0.5 milligrams (mg.) - 3 mg./ 3 milliliters (ml.), inhalation every six hours as needed for shortness of air or wheezing. - Start date: 3/12/26: budesonide suspension for nebulization; 0.5 mg./2 ml., one vial inhalation in the morning and at bedtime. Rinse mouth with water after use to reduce after taste and incidence of candidiasis. Do not swallow. Give for shortness of breath. - The POS did not have an order to indicate when the nebulizer tubing should be changed or dated. Review of the resident's Medication Administration Record (MAR) dated March 2026 showed:- Budesonide suspension for nebulization; 0.5 mg./2 ml., one vial inhalation in the morning and at bedtime. Rinse mouth with water after use to reduce after taste and incidence of candidiasis. Do not swallow. Give for shortness of breath. Staff documented it was administered as ordered. - Ipratropium - albuterol solution for nebulization, 0.5 milligrams (mg.) - 3 mg./ 3 milliliters (ml.), inhalation every six hours as needed for shortness of air or wheezing. Staff did not document the medication as administered since the resident did not require the as needed medication. - The MAR did not indicate when the nebulizer tubing should have been changed and dated. Review of the resident's POS, dated April 2026 showed: - Start date: 3/12/26: Ipratropium - albuterol solution for nebulization, 0.5 milligrams (mg.) - 3 mg./ 3 milliliters (ml.), inhalation every six hours as needed for shortness of air or wheezing. - Start date: 3/12/26: budesonide suspension for nebulization; 0.5 mg./2 ml., one vial inhalation in the morning and at bedtime. Rinse mouth with water after use to reduce after taste and incidence of candidiasis. Do not swallow. Give for shortness of breath. - The POS did not have an order to indicate when the nebulizer tubing should be changed or dated. Review of the resident's MAR, dated April 2026 showed: - Budesonide suspension for nebulization; 0.5 mg./2 ml., one vial inhalation in the morning and at bedtime. Rinse mouth with water after use to reduce after taste and incidence of candidiasis. Do not swallow. Give for shortness of breath. Staff documented it was administered as ordered. - Ipratropium - albuterol solution for nebulization, 0.5 milligrams (mg.) - 3 mg./ 3 milliliters (ml.), inhalation every six hours as needed for shortness of air or wheezing. Staff did not document the medication as administered since the resident did not require the as needed medication. - The MAR did not indicate when the nebulizer tubing should have been changed and dated. Review of the resident's care plan revised 4/1/26 showed it did not address the use of nebulizer therapy. Observation on 4/6/26 at 10:23 A.M., showed the nebulizer tubing and mask was dated 3/12 and was placed on top of the resident's compressor unit and was not stored in a plastic bag. Observation on 4/7/26 at 8:10 A.M., showed the nebulizer tubing and mask was dated 3/12 and was placed on top of the resident's compressor unit and was not stored in a plastic bag. 2. Review of Resident #29's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact. - Independent with transfers. - Diagnoses included cancer, Congestive Heart Failure (CHF, accumulation of fluid in the lungs and other parts of the body), PVD, anxiety, depression, Chronic Obstructive Pulmonary Disease (COPD, obstruction of air flow that interferes with normal breathing) and respiratory failure. Review of the resident's care plan, revised 2/4/26 showed: - The resident had COPD and respiratory failure, so the resident used oxygen at all times. The resident used oxygen at 4 liters (L) via nasal cannula (NC), titrate to keep oxygen saturation (amount of oxygen in the blood) above 92%. The resident had been re-educated on the importance of adhering to prescribed breathing treatments as ordered per care plan. Discussed risks of non-compliance and benefits of consistent use. The resident managed his/her own oxygen tubing. Has been educated on keeping it off the floor and understood the reason but did not always put the tubing where it belonged. Review of the resident's POS, dated March 2026 showed: - Start date: 6/24/25 - Ipratropium - albuterol solution for nebulization; 0.5 mg.-3 mg./3 ml. three times daily for acute and chronic respiratory failure with shortness of air. - Start date: 4/17/25 - (Friday night shirt) every two weeks: change oxygen tubing and nebulizer tubing (if applicable). Date and initial tubing with small piece of medical tape. Clean oxygen concentrator and rinse/dry filters. Clean oxygen humidification reservoir with soap and water, rinse with diluted vinegar water. - Start date:10/4/24 - Titrate oxygen as needed to maintain saturation greater than 92% for COPD. Review of the resident's MAR dated March 2026 showed: - Ipratropium - albuterol solution for nebulization; 0.5 mg.-3 mg./3 ml. three times daily for acute and chronic respiratory failure with shortness of air. Staff documented the breathing treatment was administered as ordered except on 3/2/26 at 9:31 A.M. the resident refused. On 3/2/26 at 1:10 P.M., the resident was asked multiple times if he/she was going to take the breathing treatment and the resident replied, I will do it later. On 3/5/26 the resident was unavailable. The resident refused the breathing treatment on 3/7/26, 3/8/26, 3/11/26, 3/12/26, 3/16/26, 3/17/26, 3/20/26, 3/25/26, and on 3/27/26. Review of the resident's Treatment Administration Record (TAR) dated March 2026 showed: - (Friday night shirt) every two weeks: change oxygen tubing and nebulizer tubing (if applicable). Date and initial tubing with small piece of medical tape. Clean oxygen concentrator and rinse/dry filters. Clean oxygen humidification reservoir with soap and water, rinse with diluted vinegar water. Staff documented the tubing had been changed on 3/6/26 and 3/20/26. - Titrate oxygen as needed to maintain saturation greater than 92%. Review of the resident's POS, dated April 2026 showed:- Start date: 6/24/25 - Ipratropium - albuterol solution for nebulization; 0.5 mg.-3 mg./3 ml. three times daily for acute and chronic respiratory failure with shortness of air.- Start date: 4/17/25 - (Friday night shirt) every two weeks: change oxygen tubing and nebulizer tubing (if applicable). Date and initial tubing with small piece of medical tape. Clean oxygen concentrator and rinse/dry filters. Clean oxygen humidification reservoir with soap and water, rinse with diluted vinegar water.- Start date:10/4/24 - Titrate oxygen as needed to maintain saturation greater than 92% for COPD. Review of the resident's MAR dated April 2026 showed: - Ipratropium - albuterol solution for nebulization; 0.5 mg.-3 mg./3 ml. three times daily for acute and chronic respiratory failure with shortness of air. Staff documented the treatment as administered except the resident had refused the treatment on 4/1/26 and 4/5/26. Review of the resident's TAR dated April 2026 showed: - Titrate oxygen as needed to maintain saturation greater than 92% for COPD. - (Friday night shirt) every two weeks: change oxygen tubing and nebulizer tubing (if applicable). Date and initial tubing with small piece of medical tape. Clean oxygen concentrator and rinse/dry filters. Clean oxygen humidification reservoir with soap and water, rinse with diluted vinegar water. Staff documented the tubing had been changed on 4/3/26. Observation and interview on 4/6/26 at 10:36 A.M., showed: - The resident had oxygen on at 3L/NC. - The filters on both sides of the oxygen concentrator were covered in gray lint. - The oxygen tubing was dated 3/7. - The nebulizer tubing was dated 2/20 and it had 3 ml. of clear liquid in the chamber. The resident said the nurses just set it up for him/her to do. He/She did not remember when it was set up. Observation and interview on 4/7/26 9:19 A.M., showed: - The resident still had 3 ml. of clear liquid in the nebulizer chamber, and the tubing was still dated 2/20. - LPN A was passing medication and asked the resident if he/she wanted the nebulizer treatment and the resident said maybe later. - LPN A did not put medication in the nebulizer chamber and did not check to see if it had any medication in it. - The oxygen tubing was still dated 3/7 and the filters were covered in gray lint. During an interview on 4/7/26 at 11:10 A.M., Licensed Practical Nurse (LPN) A said:- The night shift Charge Nurse (CN) checks and changes the oxygen tubing and the nebulizer tubing every other Friday. It does not populate for all the residents on Friday; it's for different residents every Friday. - Oxygen tubing and the nebulizer tubing should be dated and initialed when changed and the night shift CN cleans the oxygen filters every other Friday. There should not be any medication left in the nebulizer chamber. During an interview on 4/7/26 at 11:45 A.M., Registered Nurse (RN) A said the oxygen and nebulizer tubing is changed and initialed by the nigh CN every other Friday night. The oxygen filters should be cleaned at the same time. The nebulizer tubing should be placed in a bag if it is not in use. There should not be any medication left in the nebulizer chamber. Staff should have emptied it out and rinsed it out and left it to air dry. During an interview on 4/8/26 at 7:57 A.M., the Director of Nursing (DON) said: - The oxygen tubing and the nebulizer tubing is changed by the night CN on different days. - The oxygen tubing and the nebulizer tubing should be dated and initialed when it is changed. - The filters on the oxygen concentrator should be cleaned every two weeks on different days. - The humidified water bottle should be cleaned with vinegar water every two weeks. - The nebulizer tubing should be changed the same as the oxygen tubing. - There should not be any medication left in the nebulizer chamber. The nebulizer mask should be rinsed out and left to air dry. 3. Review of the Resident 26's comprehensive care plan, dated 02/04/26, showed:- The Resident required supplemental oxygen to maintain adequate oxygen levels and prevent shortness of breath;- The Resident would allow staff to inspect oxygen tubing and equipment routinely;- The Resident would keep oxygen equipment on and functioning properly with staff assistance. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 02/19/26, showed:- The Resident was cognitively intact;- The Resident required staff assistance with showering and dressing;- The Resident diagnoses: dementia, heart failure, and renal failure. Review of the resident's physician orders, dated 01/30/26, showed:- The nursing staff were to change nebulizer tubing and date weekly;- The nursing staff were to change oxygen tubing and date weekly;- The nursing staff were to date and initial tubing with small piece of medical tape;- The nursing staff were to clean the oxygen concentrator and rinse and dry the filters. An observation of the resident's room, on 04/06/26 at 2:18 P.M., showed:- The oxygen tubing had not been dated;- The Resident was sitting up in his/her recliner, with oxygen applied and the oxygen concentrator running at two and a half liters. During an interview on 04/06/26 at 2:18 P.M., the resident's family member said He/She would expect the nursing staff to maintain the resident's oxygen supplies properly. 4. Review of Resident #16's Quarterly MDS, dated [DATE], showed:- The Resident was cognitively intact;- The Resident required substantial assistance from staff for toileting, showering, and dressing;- The Resident diagnoses: chronic respiratory failure, heart disease, and depression. Review of the resident's comprehensive care plan, dated 02/06/26, showed:- The Resident required substantial assistance with bathing, transfers, and dressing;- The Resident required supplemental oxygen to maintain adequate oxygen levels and prevent shortness of breath;- The nursing staff were required to monitor the resident's blood pressure, pulse, and oxygen and check oxygen level if the resident became short of breath or confused. Review of the resident's physician orders, dated 04/17/25, showed:- The nursing staff were to change nebulizer tubing and date weekly;- The nursing staff were to change oxygen tubing and date weekly;- The nursing staff were to date and initial tubing with small piece of medical tape;- The nursing staff were to clean the oxygen concentrator and rinse and dry the filters. An observation of the resident's room, on 04/06/26 at 9:32 A.M., showed:- The oxygen tubing had been dated but the oxygen concentrator filter was dirty;- The Resident was sitting upright in his/her bed, with oxygen applied and the oxygen concentrator running at one and a half liters. An observation of the resident's room, on 04/07/26 at 11:10 A.M., showed:- The oxygen concentrator filter was dirty;- The Resident was resting in his/her bed, with oxygen applied and the concentrator running at one and a half liters. During an interview on 04/07/26 at 8:39 A.M., Registered Nurse (RN) A said:- The night nurses were to change the oxygen tubing every two weeks and should be dated;- There should be a bag on the concentrator to store the tubing and the nebulizer bags were kept in the drawers;- The tubing on portable oxygen tanks should also have dates and be changed properly. During an interview on 04/08/26 at 7:57 A.M., the Director of Nursing (DON) said Oxygen concentrator humidifier bottles are cleaned with vinegar and water every two weeks, the oxygen concentrator filters should be cleaned at the same time.

Based on interview and record review, the facility failed to ensure services were provided in accordance with accepted professional standards of practice, when the Administrator performed nursing services despite not holding an active nursing license. Specifically, the Administrator performed TB (tuberculosis) testing on facility staff and administered a rectal suppository to one resident (Resident #1) without qualifications or authorization to perform licensed nurse functions. The facility census was 33. Review of the facility's undated job description for a licensed nurse (Registered Nurse (RN)/ Licensed Practical Nurse (LPN) showed:-Reports to the Director of Nursing (DON). -Regulatory compliance: Follow all facility policies and procedures. Maintain compliance with Missouri State regulations and CMS guidelines. -Qualifications: current Missouri RN or LPN license in good standing. Review of the facility's undated policy for Employee Tuberculosis (TB) Screening and Testing showed TB skin tests shall be administered by a licensed nurse who has been trained in proper placement and reading techniques. Review of the facility's policy for Administering Medications, revised April 2019, showed:-Medications are administered in a safe and timely manner and as prescribed. -Only persons licensed or permitted by this state, to prepare, administer and document the administration of medications may do so.-The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. -The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. -As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. Review of the Quick Confirm License Verification Report for the Administrator showed:-Registered Nurse (RN) license issued on 06/06/18.-License Status - voluntary surrender.-License Expiration date of 03/14/23. Review of the Employee Vaccine Record for Certified Nurse Aide (CNA) A showed:-The TB test was administered in February 2026 and was administered by the Administrator whose signature appeared on the form. During an interview on 06/02/26 at 1:34 P.M., CNA A said his/her TB test was administered in February by the Administrator. Review of the Employee Vaccine Record for Staff Member A showed:-The first step TB test was administered on 02/01/26. The second step was administered by the Administrator whose signature appeared on the form. Review of the Employee Vaccine Record for LPN B showed:-The TB test was administered on 02/15/26. The test was administered by the Administrator whose signature appeared on the form. Review of the Employee Vaccine Record for the Dietary Supervisor showed:-The TB test was administered on 02/11/26. The test was administered by the Administrator whose signature appeared on the form. During an interview on 06/02/26 at 2:14 P.M., the DON said:-A licensed nurse should administer the TB tests and read them. -She just recently found out the Administrator did not have a nursing license. During an interview on 06/02/26 at 3:57 P.M., the Administrator said:-She acknowledged the TB tests should have been administered by licensed nursing personnel and she should not have administered them. -A licensed nurse should read the TB tests. Review of Resident #1's Physician Order Sheet (POS), dated 03/23/26 - 05/04/26, showed an order with a start date of 04/06/26 for Bisacodyl suppository 10 milligrams (mg) as needed rectally after no reported bowel movement for three days. Review of the resident's MAR, dated April 2026, showed:-An order for Bisacodyl suppository 10 mg as needed rectally after no reported bowel movement for three days.-There was no documentation to indicate the suppository had been administered by staff. Review of the resident's MAR, dated May 2026, showed:-An order for Bisacodyl suppository 10 mg. as needed rectally after no reported bowel movement for three days.-There was no documentation to indicate the suppository had been administered by staff. During an interview on 06/02/26 at 9:54 A.M., RN A said the Administrator administered a suppository to the resident in April 2026 and the resident passed away in May 2026. During an interview on 06/02/26 at 1:49 P.M., the MDS/Care Plan Coordinator said:-He/She witnessed the Administrator administer a suppository to the resident. -At the time, he/she did not know the Administrator did not have a nursing license. During an interview on 06/02/26 at 2:14 P.M., the DON said:-He/She administered the suppository to the resident with the Administrator in the room. -When asked why the Administrator was in the room, if that was normal practice, the DON shook his/her head no and said he/she did not administer the suppository to the resident, the Administrator administered the suppository to the resident. -At the time, he/she did not know the Administrator did not have a nursing license. During an interview on 06/02/26 at 3:57 P.M., the Administrator said:-She surrendered her RN license about two or three years ago.-She acknowledged that she had administered the suppository to Resident #1. She was aware she should not have performed the administration of the suppository; however, the resident refused to allow any other staff member to administer the suppository. -She did not remember when she administered the suppository, but it should have been documented on the MAR. -She did not have a nursing license and should not have administered any medication. During an interview on 06/02/26 at 3:25 P.M., the Corporate Officer said:-The Administrator has been in the current position since 2022 or 2023.-She did not know who administered the TB tests to the staff but thought it was the pharmacy or a floor nurse.-Whoever administered the TB tests should be the one to sign the forms.-Medications are administered by the CMTs, nurses or the DON. It must be a licensed nurse or CMT.-Whoever administered the medication, should also sign the MAR/TAR. -The Administrator does not have an RN license; she surrendered it a year or two ago.-The Administrator should not be performing any nursing duties, and she was not aware the administrator was performing nursing duties. During an interview on 06/02/26 at 3:39 P.M., the Medical Director said:-She expected medications to be administered by a licensed nurse or CMT. -She was not for sure if a licensed nurse should administer the TB tests to the staff.-A resident is more worrisome than a staff member getting nursing services from a non-clinical nurse. -Administration should be done by a properly licensed person. Intake 3001993

Based on interview and record review, the facility failed to protect one resident's right to be free from mental and physical abuse when during care, as three staff were providing cares, RN A forcefully pushed the residents wheelchair forward and pulled it back and told the resident something to the effect of Ride'em cowgirl, verbally threatened to shame/humiliate the resident publicly for his/her behavior of taking off his/her clothes in public, when the resident resisted cares and made a biting motion, RN A told the resident babies bite. The resident was reported to be visibly upset and crying and when an aide offered to stay with the resident so the resident could calm down, RN A said no and that the resident needed to go to the dining room so others could see how he/she was acting and they would know what RN A has to deal with. The facility census was 28. On 3/23/26, the Administrator was notified of the past noncompliance which began on 3/3/26. On 3/3/26, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include; assessment of the resident, suspension of RN A, interviews with other residents for indications of abuse, implementation of daily auditing of staff interactions with residents, QAPI (Quality Assurance and Performance Improvement) tracking initiated, and mandatory in-service training for all staff on abuse prevention, treating residents with dignity and respect and safe handling of residents. The noncompliance was corrected on 3/19/26. Review of facility policy, Facility Policy and Procedure: Abuse, dated 7/18/23, showed:- Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual caretake of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being;- All personnel must promptly report any incident of resident abuse, including injuries of an unknown source; - Mandatory reporting of adult abuse is any person who, in the course of employment, examines, attends, counsels, or treats a dependent adult and reasonably believes the dependent adult has suffered abuse;- Mental Abuse includes humiliation, harassment, threats of punishment, or deprivation;- Any person witnessing or suspecting abuse or neglect of a resident shall immediately remove the resident from a harmful environment and report the suspected abuse to the charge nurse;- Employees of the facility that have been accused of resident abuse will be placed on suspension pending investigation. Review of Resident #1's Face Sheet showed:- Resident is cognitively impaired;- Diagnoses: chronic kidney disease, anemia, diabetes, dementia, and anxiety disorder.Review of facility investigation, dated 3/3/26, included: - On March 3,2026 at around 1:15P.M. the facility received an allegation that RN A used demeaning language toward the resident while the resident was agitated and attempting to remove clothing and that RN A forcefully handled the resident and jerked the wheelchair while the resident was seated. The allegation involved potential verbal abuse, mental abuse, and inappropriate physical handling. - Upon notification, the facility ensured resident safety, completed full head-to-toe assessment, interviewed resident (as cognitively able), removed accused staff member from direct resident care pending investigation, initiated internal abuse investigation per facility policy, implemented increased monitoring of resident. -No visible bruising, redness, new swelling, or injury noted on assessment. Vital signs stable. - Witnesses reported resident was agitated and resistant during transfer. - Statements indicate RN A used a firm and elevated tone directing resident to sit down, Resident reportedly stated, You're hurting my foot., RN A reportedly responded, Pick up your feet then. Witnesses' statements describe the RN's tone as raised and firm. - While assisting resident onto the commode resident was crying and repeatedly attempting to remove her shirt. Resident verbally resisted assistance, yelling No, No, No. Witness reported RN A stated, Do you want me to call your spouse and tell him/her you're trying to be naked in front of everyone. RN A reportedly grabbed resident's forearm while instructing her to Stop and Knock it off. Witness described RN's tone as harsher and louder than usual. - A witness reported RN A stated she wanted to take resident to dining room so they could see how she acted. The witness expressed discomfort transporting resident publicly while she was attempting to disrobe. During hallway transport, the resident again attempted to remove clothing. Witness reported RN A jerked the wheelchair forward and backward several times. RN A reportedly stated, Hold on, it's a bucking bronc. - Resident assessed immediately following the incident with no bruising, swelling, redness, or injury identified, no complaints of pain at time of assessment, vital signs stable. The resident was upset during the event but later returned to baseline affect. Due to cognitive impairment (dementia), resident was unable to provide a reliable detailed account. No ongoing fear expressed following the incident. - RN A provided a written statement via text message regarding the incident. In his/her statement, RN A indicated he/she did not agree with the characterization of events. RN A reported that while attempting to transport the resident through the doorway, one leg of the wheelchair became caught on the door frame. He/she stated that she moved the wheelchair forward and backward in an effort to free it from the doorway.RN A reported that CNA A and CMT A were present, both speaking to the resident during the interaction. RN A stated that she was attempting to maneuver the wheelchair and gain space to open the door. He/She acknowledged making a statement similar to [NAME]-[NAME], ride'em cowgirl, which he/she described as an attempt to redirect the situation and communicate her difficulty maneuvering the wheelchair. -RN A denied intent to harm the resident and indicated he/she was attempting to manage a challenging behavioral situation involving disrobing. - During follow-up interview with the Administrator and DON, RN A clarified that RN A did not call the resident a baby. He/She stated that while the resident was biting her during the interaction, he/she said, Don't bite, babies bite. RN A denied directly labeling the resident as a baby. She stated the comment was made in response to being bitten and was intended as redirection.- Determination: multiple consistent witness statements, staff acknowledgement of raised voice, demeaning and threatening statements, grabbing of resident's forearm, and jerking of wheelchair while resident was seated. Although no physical injury occurred, the conduct included demeaning and humiliating language, unnecessary public exposure risk, physical handling inconsistent with safe and respectful standards, and created emotional distress.- The facility implemented removal of staff member from direct resident care, disciplinary action per HR policy, mandatory abuse prevention and re-education for nursing staff, facility wide in-service training on abuse, dignity, respectful communication, and safe resident handling. - The facility substantiated verbal abuse and inappropriate physical handling and terminated RN A. Review of facility after action documentation, showed:- 3/3/26 random sample of 12 residents interviewed regarding any abuse witnessed or experienced by the resident at the facility. There were no concerns reported.- 3/9/26 through 3/19/26 Daily Auditing tool used for monitoring of staff interactions regarding, communication, behavioral responses, physical interactions, dignity, and privacy with residents. There were no concerns reported. - QAPI Tracking initiated on 3/6/26 covering: Abuse Prevention, Resident Rights, and Staff Performance. - Mandatory Staff in-service, dated 3/3/26 for Abuse Prevention, Dignity, and Safe Resident Handling. 27 staff members attended.- Staff Abuse Training, dated 3/3/26, 27 staff members attended.Review of the Resident's Care Plan, updated 3/17/26, showed:- Resident had behavioral symptoms which required staff to approach resident slowly, calmly and with clear instructions. - Staff are directed, that if the resident shows signs of being overwhelmed or upset to give the resident space, perform cares later, use gentle reassurance, reduce noise and distractions and keep his/her routine consistent.- Resident has chronic back pain that can come and go, pain is not always spoken, watch for behaviors. Resident's pain may increase with movement or certain positions.- Resident has dementia and has been recently hospitalized for altered mental status. Resident had increased confusion which required staff to keep environment quiet and not overwhelming for resident. Staff are to monitor for acute changes from baseline dementia behaviors. During an interview on 3/23/26 at 12:10 P.M., RN A said: - Around 11:30 A.M. the resident started to try and disrobe and would not take his/her medicine. RN B and RN A were able to put the resident in his/her wheelchair and CNA A and CMT A took the resident to his/her room. - RN A, CNA A and CMT A were all present when the resident was placed into the bathroom for toileting. The resident's brief was changed, and fresh clothes were placed on the resident. It was hard to get the resident dressed since he/she was yelling. - CMT A was making threats to the resident that he/she was going to call his/her spouse about his/her behavior. Once the staff got the resident back into his/her wheelchair, RN A started brushing the resident's hair. - When RN (A) tried to wheel the resident out of the room in his/her wheelchair the foot pedal got caught on the wall. While this was going, he/she did say Ride em cowgirl! while he/she was trying to get the wheelchair unstuck. Both CNA A and CMT A were present at this time. - When they left the room with the resident, the resident tried to disrobe and tried to bite his/her and at that point he/she told the resident, Biting is what babies do, don't bite me. -Due to low staffing, it wasn't feasible for CMT A to just sit with the resident and try to calm the resident down during lunch time.- Once they were in the dining room, food and drink was brought to the resident, the resident would only drink and would not take his/her medications. The DON came to help but still the resident was resistive. - Later in the breakroom he/she was approached by the Administrator and DON and asked about abuse allegations regarding the way he/she provided care to Resident #1. - He/she told the DON and administrator the only reason his/her voice was raised in the bathroom was because it was a small space and hard to hear each other. - He/she told the administrator he/she never touched the resident other than to dress the resident. - He/she was terminated over the incident. During an interview on 3/23/26 at 9:50 A.M., Certified Medical Technician CMT A said:- On 3/3/26 around 12:30 P.M., he/she witnessed the resident in the facility living room trying to disrobe. Registered Nurse RN A and RN B we're trying to get the resident into his/her wheelchair to transport the resident back to his/her room. Once the resident was in the wheelchair, RN A and Certified Nursing Assistant CNA A took the resident to his/her room.- CMT A arrived shortly thereafter and stood in the doorway and, due to the cramped space did not provide care but did observe the two staff members with the resident. - RN A and CNA A assisted the resident to stand and transfer to the toilet. - CMT A observed RN A being rude to the resident calling the resident a baby because the resident was crying. - RN A threatened the resident that RN A would tell his/her spouse that he/she was trying to disrobe in front of other residents. - RN A made the statement in a loud and harsh voice and the resident cried even more. - The resident continued to cry after he/she got off the toilet and continued trying to disrobe. -CMT A offered to stay with the resident and attempt to calm him/her down while the other staff members attended to other duties. -He/she did not feel that the resident was mentally ready to be in the dining room because he/she was still crying. - RN A declined CMT A's offer to stay with the resident and said the resident needed to go to the dining room so management could see what bad behaviors he/she had to deal with. - RN A, with the resident in a wheelchair, started to shake the wheelchair back and forth and said the resident was a bucking bronco. - He/she felt RN A s actions were intentional to torment the resident. - RN A and CMT A transported the resident to the dining room while the resident was still crying. - The resident continued to be upset while in the dining room and continued to try and disrobe. - RN A tried to keep the resident's hands away from his/her clothes so to prevent him/her from disrobing. - CMT A went to the kitchen to get food and drink for the resident. When CMT A came back with the resident's meal, the Director of Nursing (DON) had arrived to help administer the resident's medication. - Since RN A and the DON were there CMT A went directly to the Administrator to report what had occurred. CMT A felt RN As actions were abuse. During an interview on 3/23/26 at 10:25 A.M., CNA A said:- CMT A was present as well. - He/she did not stay long in the room and doesn't know exactly when the alleged abuse occurred. If he/she would have seen anything he/she would have reported it immediately administration.- The facility recently had abuse and neglect training for the staff earlier this month. During an interview on 3/23/26 at 2:15 P.M. the Administrator and DON said: - RN A should have backed off a bit from the resident as he/she was being overly verbally aggressive towards the resident.- The facility has sufficient staffing, and it would have been appropriate for CMT A to stay with the resident to help calm him/her rather than bringing him/her to the dining room while visibly upset. - Their investigation substantiated verbal abuse and inappropriate physical handling of the resident and RN A was terminated.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a record of the dishwasher temperature and chemical tests, failed to cease using dishwasher when temperatures did not meet requirements, failed to keep a daily record of refrigerator temperatures, failed to wash hands in between tasks and in between glove changes, failed to label and date all foods upon receiving and upon opening, failed to ensure kitchen was clean and in good repair, and failed to ensure dishwasher temperature reached minimum temperatures. The facility census was 35. 1. Review of the facility's Food Handling policy, dated 7/2014, showed: -Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized; -All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. The facility's Employee Hygiene and Sanitary Practices policy, dated 10/2017, showed: -Employees must wash their hands: a) Whenever entering or re-entering the kitchen; b) Before coming into contact with any food surfaces; c) After handling soiled equipment or utensils; d) During food preparation, as often as necessary to remove soil ad contamination and to prevent cross contamination when changing tasks, or; e) After engaging in other activities that contaminate the hands; -Contact between food and bare (ungloved) hands is prohibited; -The use of disposable gloves does not substitute for proper handwashing. Observation on 3/26/25 from 11:07 A.M. to 12:01P.M. showed: -Cook A used gloved hands to turn on the faucet to fill a measuring cup with water; -Cook A added spaghetti noodles to the boiling water with the same gloved hands that were used to turn on the faucet to fill the measuring cup with water with no handwashing was done in between tasks. - [NAME] A used gloved hands to turn on faucet to fill water pitcher. - [NAME] A cut up chicken with same gloved hands that were used to fill the water pitcher at 11:19 A.M. with no handwashing since filling the pitcher. Observation on 3/26/25 at 11:41 A.M. showed Dietary Aid B washed the workstation by the coffee maker with a dishcloth, did not wash hands before pulling pre-poured drinks from the refrigerator to pass out to residents in dining room. Observation on 3/26/25 at 12:01 P.M. showed: -Cook A removed gloves, did not wash hands and put on oven mitts to remove the garlic bread from the oven; -Cook A did not wash hands before putting on new gloves on to remove garlic bread from the pan. During an interview on 3/27/25 at 9:26 A.M., Dietary Aid A said: -Hands should be washed before handling food; -Hands should be washed before handling food or clean dishes if a dietary aid touches any dirty dishes. During an interview on 3/27/25 at 9:42 A.M., the dietary manager said hands should be washed when switching tasks. During an interview on 3/28/25 at 2:30 P.M., the Administrator said he/she expects staff to wash hands upon entry into the kitchen, if hands are visibly contaminated, and before/after donning gloves; 2. Review of the facility's Sanitization policy, dated 10/2008, showed; - All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water/and/or chemical sanitizing solutions. Observation on 3/25/25 at 10:09 A.M. showed: -Missing baseboard behind steam table and unpainted patched areas 3x3 inches; -Garbage can next to the stove was covered with spills and grime; -Dirty fan next to handwashing sink was covered in dirt and grime; -Dirty air purifier next to the oven was covered in spills on the front; -Grills on the bottom of upright refrigerator doors and freezer were covered in grime and spatters. During an interview on 3/27/25 at 9:26 A.M., Dietary Aid A said: -The outside of garbage cans and refrigerator grills should be free of spatters and grime and should cleaned twice a day and in between if there was something that recently spilled; -The walls and ceiling in the kitchen should be in good repair. During an interview on 3/27/25 at 9:42 A.M., the Dietary Manager said: -The outside of garbage cans, refrigerator grills, and fans should be cleaned twice a week and be free of spatters and grime; -Kitchen walls and ceiling should be in good repair and painted. During an interview on 3/28/25 at 2:30 P.M., the administrator said: -He/She expects the outside of garbage cans, refrigerator grills, and items used in the kitchen to be clean and free of spatters and grime; -He/She expects the walls and baseboards in the kitchen to be in good repair. 3. Review of the facility's Food Receiving and Storage policy, dated 7/2014, showed: -All foods stored in the refrigerator or freezer will be covered, labeled and dated; -Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager and documented. The facility's Refrigerators and Freezers policy, dated 12/2014, showed: -Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures; -Food service supervisors will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening; -All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Continuous observation on 3/25/25 at 10:09 A.M. to10:40 A.M. showed: -No received date or best by date on frozen peas in pantry upright freezer; -No best by date or received date on brussel sprouts in pantry upright freezer; -No best by or received date on 12 packages of unbranded frozen lunch meat in pantry upright freezer; -No open date on two packages of broccoli in pantry upright freezer; -Two packages of opened, unsealed, undated, wilted and browning cabbage in refrigerator; -sliced white cheese in the refrigerator with no opened date; -Opened and unsealed 5 lbs. shredded mild cheddar cheese in the refrigerator; - Butter in the refrigerator with no received date; -No dates on frozen breadsticks in deep freezer; -No dates on frozen dinner rolls in deep freezer; -Temperature logs missing for evening refrigerator temperatures for the two-door refrigerator from 3/22-3/24; from 3/22 to 3/24; -Temperature logs missing for the white freezer from 3/22-3/24; -Temperature logs missing for the white chest freezer from 3/22 - 3/24; -Temperature logs missing for the drink refrigerator from 3/22 - 3/24. Observation of the two-door freezer on 3/25/25 at 10:40 A.M. showed: -No opened date and unsealed frozen peas; -No opened date on 4 Lb. bag of frozen vegetables; -No opened date, received date, or best by date on frozen sausage links; -No opened date received date, or best by date on frozen chicken drumsticks; -No opened date, received date, or best by date on frozen chicken cordon blue; -No opened date or received date on a bag of frozen sausage patties; -No received or opened date on frozen eggs. During an interview on 3/27/25 at 9:26 A.M., Dietary Aid A said: -All opened food packages must be wrapped in plastic or placed in a sealed tub; -Frozen vegetables should be folded over and clipped; -Bagged dry goods should be folded and clipped; -Refrigerator and freezer temperatures should be recorded in the morning and in the evening; -Freezer burned food and browned product should be thrown away; -Foods should be dated when received and dated again once opened. During an interview on 3/27/25 at 9:42 A.M., the Dietary Manager said: -Opened food should be sealed when in storage; -Opened food packages should be clipped to seal the bag; -When food is received, it should be dated and then dated again when opened; -Refrigerator and freezer temperatures should be recorded when staff arrives in the morning and evening; -Browning produce or freezer burned foods should be thrown away. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -Opened food should be sealed for storage; -Foods should be labeled with a received date and an opened date when opened; -Opened food should be sealed for storage; -Foods should be labeled with a received date and an opened date when opened. -He/She expects the refrigerator and freezer temperatures be recorded every shift; 4. Facility did not provide the requested dishwasher user manual. Review of the facility's Dishwashing Machine Use policy, dated 2/2010, showed: -Dishwashing machines that use hot water to sanitize must contain the following wash solution temperatures: a) 150 degrees Farenheit for stationary rack, dual temperature machines or multi-tank, conveyor, multi-temperature machines; b) 160 degrees Fahrenheit for single tank, conveyor, dual temperature machines; c) 165 degrees Fahrenheit for stationary rack, single temperature machines. -Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degrees Fahrenheit, or less than: a) 165 degrees Fahrenheit for stationary rack, single temperature machines; b) 180 degrees Fahrenheit for all other machines. -The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log; -Inadequate temperatures will be reported to the supervisor and corrected immediately; -If hot water temperatures or chemical sanitization concentration do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. -Dishwasher temperature log missing readings for 3/3-3/4; 3/7-3/10; 3/13-3/14; 3/17-3/18; 3/20-3/24. Observation on 3/25/25 10:09 A.M. showed: -Dishwasher temperature recordings were below the required temperature (in Fahrenheit) on: -3/1/25 Breakfast: wash temperature was 95 degrees, rinse temperature was 100 degrees; Lunch: wash temperature was 95 degrees, rinse temperature was 100 degrees; -3/2/25 Breakfast: wash temperature was 90 degrees; Lunch: wash temperature was 90 degrees and rinse temperature was 90 degrees; Dinner: wash temperature was 90 degrees; lunch temperature was 90 degrees; -3/5/25 Breakfast: wash temperature was 90 and rinse temperature was 95 degrees; Lunch wash temperature was 90 degrees and rinse temperature was 95 degrees; -3/6/25 Breakfast: wash temperature was 100 degrees, and the rinse temperature was 100 degrees; Lunch temperature was 100 degrees and lunch temperature was 100 degrees; -3/11/25 Breakfast: wash temperature was 95 degrees, and the rinse temperature was 100 degrees; -3/12/25 Breakfast: wash temperature was 90 degrees, and the rinse temperature was 95 degrees; Lunch: was temperature was 90 degrees and the rinse temperature was 95 degrees; -3/15/25 Breakfast: wash temperature was 90 degrees, and the rinse temperature was 90 degrees; Lunch: wash temperature was 90 degrees, and the rinse temperature was 95 degrees; -3/16/25 Breakfast: wash temperature was 90 degrees, and the rinse temperature was 90 degrees; Lunch: wash temperature was 90 degrees, and the rinse temperature was 95 degrees; -3/19 Breakfast: wash temperature was 100 degrees, and the rinse temperature was 100 degrees; Lunch: wash cycle was 100 degrees, and the rinse temperature was 100 degrees; -3/25 Breakfast: wash temperature was 100 degrees, and the rinse temperature was 100 degrees; Lunch: wash temperature was 100 degrees, and the rinse temperature was 100 degrees. During an interview on 3/27/25 at 9:26 A.M., Dietary Aid A said: -Temperatures for the wash cycle were done twice at breakfast: once for a wash cycle and once for the rinse cycle; -Wash cycle and rinse cycle test should read 120 degrees Fahrenheit at a minimum; -If the dishwasher temperatures were not high enough, the dietary staff may run dishes through the dishwasher again; -If the dishwasher temperature was too low then the dishes must be hand washed; -If the dishwasher temperature was too low, then the dietary staff would notify maintenance; -The water heater ran low on hot water when laundry and showers were being done at the same time the dishwasher was running; -The dietary staff has not been hand washing dishes recently; -The administrator was made aware of the low dishwasher temperatures and was working with the maintenance supervisor to correct the issue; During an interview on 3/27/25 at 9:42 A.M., the Dietary Manager said: -The facility had a low temperature, chemical dishwasher; -The dishwasher temperatures should be at 100 degrees Fahrenheit; -Dishes should be washed again if the dishwasher temperature reading is too low; -Maintenance supervisor has been notified that the dishwasher has been running low temperatures; -Dishwasher wash/rinse cycle temperatures should be recorded first thing in the morning and during the evening shift. During an interview on 3/28/25 at 9:48 A.M., the Maintenance Supervisor said: -Last December, the kitchen staff said they were having troubles getting dishwasher to an acceptable temperature; -He/She believes the dishwasher does not reach a high enough temperature due to the hot water heater; -He/She has been in touch with an HVAC company to request some warranty work on the water heater; -Food distributing company A checked the dishwasher a week ago and determined the dishwasher is working properly. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -The facility had a low temperature, chemical dishwasher; -He/She expects the dishwasher wash/rinse cycle temperatures to be recorded according to the facility policy; -He/She expects the dishwasher temperatures to be within the range according to the facility policy and dishwasher manual; -He/She expects staff to wash dishes using the three-sink method if the dishwasher temperature levels are unsafe.

Based on observation and interviews, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 35. 1. The facility did not provide a policy for the Dietary Manager qualifications. During an interview on 3/27/25 at 9:42 A.M., Dietary Manager said: -He/She has worked at the facility for ten years; -He/She has been the Dietary Manager for a year; -He/She did not have any dietary manager certifications; -He/She did not know what certifications were required for a dietary manager; -He/She was not currently enrolled in classes for dietary manager certifications; -He/She needed to make a plan with the dietician about enrolling in dietary certification classes. -The facility dietician was contracted to come in once a month. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -The dietary manager needed to take the dietary management course to obtain the required certifications; -The dietary manager was an interim dietary manager; -He/She had been advertising to fill the dietary manager position for a while; -He/She said they would have to look at the regulation to determine the deadline for the dietary manager to obtain the required certifications.

Based on observations, interviews and record review, the facility failed to ensure staff wore the proper personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to workplace hazards that can cause serious injuries or illnesses) which affected one of the 12 sampled residents, (Resident #18), failed to wear gloves when obtaining Resident #19's blood sugar, and failed to clean the port of the insulin pen prior to attaching the needle for Resident #1, #5, and #21. The facility census was 35. Review of the facility's policy titled, Infection Prevention and Control Manual, showed:- Enhanced Barrier Precautions, (EBP), are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes; - EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices); - EBP can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO; - Examples of indwelling medical devices include: central line, urinary catheter (sterile tube inserted into the bladder to drain urine) , feeding tube and tracheostomy (an artificial opening into the wind pipe to aid breathing)/ventilator (a device that supports or takes over the breathing process, delivering breaths to a person who is unable to breathe adequately on their own or who is breathing insufficiently); - Examples of high contact resident care activities include: dressing, bathing or showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting , device care or use, and wound care; - Process: identify residents with wounds or indwelling medical devices, who have active MDRO infection or known to have MDRO colonization, and those at risk for MDROs due to wounds or indwelling medical devices; set up a room with Enhanced Barrier Precautions PPE supplies; use gown and gloves while providing high contact care activities; post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; gowns and gloves should be available outside of each resident room, and alcohol based hand rub should be available for every resident room (ideally both inside and outside of the room); do not need to wear gowns and gloves if transferring residents in dining room and /or commons area; a trash can (or laundry bin) large enough to dispose of multiple gowns should be available for each room; - Residents are not restricted to their rooms and do not require placement in a private room. Review of the facility's undated policy titled, Handwashing/Hand Hygiene, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - Wash hands with soap and water for the following situations: when hands are visible soiled and after contact with a resident with infectious diarrhea; - Use an alcohol-based hand rub containing at least 62% alcohol, or soap and water for the following situations: - Before and after direct contact with residents, before performing any non-surgical invasive procedures, before and after handling an invasive device (urinary catheters, intravenous (IV) sites), before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, and before and after entering isolation precaution settings; - Hand hygiene is the final step after removing and disposing of PPE; - The use of gloves does not replace hand washing/hand hygiene; - Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1. Review of Resident #18's Significant Change in Status Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/25 showed: - Cognitive skills severely impaired; - Upper extremities impaired on both sides; - Lower extremities impaired on one side; - Dependent on the assistance of staff for oral care, personal hygiene, transfers and toilet use; - Had a Suprapubic catheter (a catheter surgically inserted through the wall of the abdomen); - Always incontinent of bowel; - Diagnoses included obstructive uropathy (condition where urine flow is blocked in the urinary tract, preventing the body from properly eliminating waste products), Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), psychotic disorder (a mental illness characterized by a significant disconnect from reality, often involving symptoms like delusions (false beliefs) and hallucinations (seeing or hearing things that aren't there), and dementia ( inability to think). Review of the resident's care plan, revised 3/26/25 showed: - The resident required maximum assist for daily care tasks needs; - He/she was dependent on staff for toileting needs. He/she was incontinent of bowel and had a supra pubic catheter; - He/she required substantial assistance of two staff for bed mobility. Observation on 3/26/25 at 7:53 A.M., showed: - Certified Medication Technician (CMT) B and Certified Nurse Aide (CNA) A entered the resident's room to get him/her up for breakfast; - CMT B and CNA A did not wash their hands and applied gloves and did not have on personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to workplace hazards that can cause serious injuries or illnesses); - The resident had an undated dressing on his/her coccyx (tailbone); - CMT B and CNA A provided incontinent care to the resident; - CMT B sanitized, applied gloves and a gown; - CMT B emptied the resident's drainage bag (a medical device, typically connected to a catheter, that collects urine or other fluids from the body); - CMT B removed the gown and gloves, sanitized hands and donned new gloves; - CMT B and CNA A dressed the resident and placed the lift sling under the resident; - CMT B and CNA A removed gloves and did wash their hands; - CMT B and CNA A used the mechanical lift and transferred the resident from the bed to his/her wheelchair; - Without gloves on, CMT B passed the drainage bag under the resident's wheelchair to CNA A who did not have gloves on and placed the drainage bag in the dignity bag ( a bag used to cover and hold the catheter drainage bag so it is not visible); - CMT B propelled the resident to the dining room for breakfast. During an interview on 3/27/25 at 1:15 P.M., CMT B said: - He/She should wash hands anytime when providing cares for a resident, after providing resident cares and after cleaning fecal material. Should wash hands or sanitize between glove changes; - He/She thought you only had to wear PPE if you were emptying the drainage bag; - He/She was told to only gown up when providing wound care or catheter care. During an interview on 3/27/25 at 1:54 P.M., CNA A said: - He/she should wash his/her hands before and after cares, sanitize hands between glove changes and if cleaning fecal material, should remove gloves and wash hands; - We only have to wear a gown and gloves when providing wound care or catheter care to residents. Observation and interview on 3/27/25 at 9:37 A.M., showed: - Nurse Aide (NA) B entered the resident's room and did not wash hands or apply gloves; - NA A brought the Direct Supply mechanical lift into the resident's room and did not wash his/her hands or apply gloves; - NA A and NA B used the mechanical lift and transferred the resident from his/her wheelchair to the bed; - NA A placed the resident's drainage bag on the resident's lap; - After the resident was in bed, NA B placed the drainage bag in the dignity bag on the side of the bed. During an interview on 3/27/25 at 1:37 P.M., NA B said: - He/She thought you were supposed to wear gown and gloves anytime you were providing any type of cares; - He/She should wash hands when entering the resident's room, between glove changes and before leaving the room and should wash hands after cleaning fecal material. During an interview on 3/28/25 at 11:44 A.M., NA A said: - Should wash hands before and after entering a resident's room, anytime you touch a surface that could be contaminated and after using hand sanitizer three times. Between glove changes should either wash hands or sanitize; - He/She was not for sure what EBP meant and was not for sure what PPE should be worn or when it should be worn. During an interview on 3/28/25 at 2:30 P.M., the Director of Nursing (DON) said: - Staff should wash hands before donning gloves, before providing cares and between glove changes; - For EBP, there should be signs posted outside the resident's door; - Staff should wear gown and gloves when coming into contact with bodily fluids. 2. Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, revised January 2011, showed: - The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level (the concentration of glucose (a type of sugar) in your blood); - Wear clean gloves; - Assess the resident's fingertips for good blood supply; - Wash the selected fingertip with warm and water and soap. If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. Review of the resident's Annual MDS, dated [DATE] showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Independent with eating and transfers; - Diagnoses included diabetes mellitus. Review of the resident's care plan revised 1/22/25 showed the resident was on a therapeutic diet for diabetes to control the resident's blood sugar. Review of Resident #19's Physician Order Sheet (POS), dated 2/26/25 - 3/26/25 showed the staff did not have an order to obtain blood sugar levels. Review of the resident's MAR, dated 3/1/25 - 3/26/25 showed the resident did not have a physician's order to obtain blood sugars. Observation on 3/27/25 at 7:24 A.M., showed:- CMT B entered the resident's room and did not wash his/her hands or apply gloves; - CMT B cleaned the resident's fingertip with an alcohol wipe, let it air dry and obtained the resident's blood sugar. During an interview on 3/27/25 at 1:15 P.M., CMT B said he/she was not taught to wear gloves when obtaining blood sugars. During an interview on 3/28/25 at 2:30 P.M., the DON said staff should wear gloves when obtaining blood sugars. 3. Review of the facility's undated policy titled, Insulin Pen Device, showed: - To attach the safety pen needle: remove the blue cap from the insulin pen; wipe the rubber seal with an alcohol pad; twist open and remove outer cover from the safety pen needle; screw the pen safety needle securely onto the insulin pen. Review of Resident #5's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Diagnoses included diabetes mellitus, anxiety and depression. Review of the resident's POS dated 2/26/25 - 3/26/25 showed: - Order start date: 3/19/25 - Novolog (fast acting) Insulin Flex Pen, 18 units three times a day for diabetes mellitus. Review of the resident's MAR,dated 3/1/25 - 3/26/25 showed: - Novolog Insulin Flex Pen, 18 units three times a day for diabetes mellitus. Observation on 3/26/25 at 11:44 A.M., showed: - CMT A removed the cap from the Novolog insulin pen, did not clean the port with an alcohol wipe and attached the needle; - CMT A primed the insulin pen with two units, dialed to 18 units and administered the insulin to the resident. 4. Review of Resident #21's Quarterly MDS, dated [DATE], showed;- Cognitive skills intact; - Lower extremity impaired on both sides; - Diagnoses included diabetes mellitus, depression, anxiety, and renal insufficiency (RI, a condition where the kidneys are unable to effectively filter waste products and excess fluid from the blood). Review of the resident's POS dated 2/27/25 - 3/27/25 showed: - Start date: 11/8/24 - Fiasp (fast acting) Flex Touch Insulin Pen per sliding scale. Blood sugar 316. For blood sugar range 301 - 350 - give 14 units with meals for diabetes mellitus. Review of the resident's MAR, dated 3/1/25 - 3/27/25 showed: -FiaspFlex Touch Insulin Pen per sliding scale. Blood sugar 316. For blood sugar range 301 - 350 - give 14 units with meals for diabetes mellitus. Observation and interview on 3/26/25 at 11:51 A.M., showed: - CMT A removed the cap from the Fiasp insulin pen, did not clean the port with an alcohol wipe and attached the needle; - CMT A primed the insulin pen with four units, he/she said there was not enough insulin and the resident would need a new insulin pen; - CMT A dialed the Fiasp insulin pen to 11 units and administered it to the resident; - CMT A removed the cap from a new Fiasp insulin pen, did not clean the port with an alcohol wipe and attached the needle; - CMT A primed the Fiasp insulin pen with three units, dialed the Fiasp insulin pen to three units and administered it to the resident. During an interview on 3/28/25 at 9:43 A.M., CMT A said he/she should have cleaned the insulin ports with an alcohol wipe before attaching the needle. During an interview on 3/28/25 at 2:30 P.M., the DON said staff should clean the insulin ports with an alcohol wipe before attaching the needle.

Based on interview and record review, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of the 12 sampled residents, (Resident #20 and #25). The facility census was 35. The facility did not provide a policy for ABN's. 1. Review of Resident #20's medical records showed: - Notice of Medicare Non-coverage (NOMNC) CMS - 10123 showed the last date of coverage was [DATE]. The resident signed it on [DATE]; - The facility used an outdated ABN form CMS - R-131 (expired [DATE]) and was signed by the resident on [DATE]. 2. Review of Resident #25's medical records showed: - NOMNC CMS - 10123 showed the last date of coverage was [DATE]. The resident signed it on [DATE]; - The facility used an outdated ABN form CMS - R-131 (expired [DATE]) and was signed by the resident on [DATE]. During an interview on [DATE] at 2:30 P.M., the Administrator said:- Social Services was new to the position; - They should be using the correct forms.

Based on observation, interview, and record review, the facility failed to ensure staff obtained physicians' orders and assess residents for safe administration of medication to be kept at the bedside for two of 12 sampled residents (Resident #19 and #25). The facility census was 35. Review of the facility's policy for Resident Self-Administration of Medication, dated 12/2016, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe to do so; -In addition to general evaluation of decision-making capacity, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; -The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications; -For self-administering residents, the nursing staff will determine who will be responsible (the resident or nursing staff) for documenting that medications were taken; -Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. 1. Review of Resident #19's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/25, showed: -Resident is cognitively intact; -Resident is independent with activities of daily living (ADL's). -Diagnoses included: anemia (low red blood cell count), heart disease, high blood pressure, gastroesophageal reflux disease (stomach contents to back up into the esophagus), thyroid disorder, dementia (a disease that affects memory and reasoning), depression, diabetes, kidney disease, and debility (general state of weakness and decline). Observation and interview on 3/27/25 at 8:21 A.M. showed a 3.53 oz. tube of diclofenac sodium topical gel arthritis pain reliever and a bottle of Latanoprost drops, .005%, eye drops on the resident's bedside table. The resident said staff told him/her that they can keep the topical gel and eye drops in their room for self-administration. Review of the resident's care plan, dated 1/23/25, showed the care plan did not reflect the resident's ability to administer diclofenac sodium topical gel and eye drops and did not reflect the resident's ability to keep these medications at bedside. Review of the resident's physician order sheet (POS), dated 2/26/25 through 3/26/25, showed: -Diclofinac gel, 1%, four grams, topical. Apply to the affected area in the morning and at bedtime; -Latanoprost drops, .005%, one drop in the eye at bedtime; -No physician's orders for keeping diclofenac or eye drops at bedside for self-administration. 2. Review of Resident #25's MDS, dated [DATE], showed: -Resident is cognitively intact; -Diagnoses included: heart failure, anxiety, depression, asthma, and respiratory failure; -Resident was independent with ADL's. Observation and interview on 3/25/25 at 11:56 A.M. showed three pills in a cup (two white and one green) and Scalpicin cream (hydrocortisone) on the resident's bedside table. The resident said the white pills were probiotics, the green pill was Ropinerol and the Scalpicin cream was to relieve itching on the resident's scalp. The resident said the nurse left the items on his bedside table but didn't know why. Review of the resident's care plan, dated 1/13/25 showed the care plan did not reflect the resident's ability to administer Scalpicin cream and medications. Review of the resident's POS, dated 2/26/26 to 3/26/25 showed: -No orders for Scalpicin cream -No orders for keeping medications or Scalpicin cream at bedside for self-administration. During an interview on 3/28/25 at 10:17 A.M., CNA B said: -If he/she saw medications, eye drops, or ointments in a resident's room, he/she would report it to the charge nurse; -If there were no orders for the medications, then the resident should not have them in their room. During an interview on 3/27/25 at 2:15 P.M., Registered Nurse (RN) B said: -If a resident wanted to keep medications in their room, there would need to be doctor's orders; -Nursing staff would need to monitor the medications in a resident's room; - The administering nurse should watch the residents take the medications rather than leave them in a cup in the resident's room; -If he/she sees saw medications in a resident's room, he/she would take it and put in the treatment cart, unless there were orders for self-administration. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -If a resident wanted to self-administer medications, the facility should perform an assessment to ensure safety; -The facility should obtain physician's orders for self-administration; -The facility should update the resident's care plan to reflect self-administration of specific medications. -Medications should not be left in a cup on a resident's bedside table; -The administering nurse should watch the resident take the medications.

Based on observation, interview and record review, the facility failed to ensure nurse aides met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 35. Review of the facility's policy titled, Nurse Aide (NA) Qualifications and Training Requirements, revised May, 2019 showed: - Nurse Aides must undergo a state-approved training program; - In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; - Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in 483.150 (a) and (b) of the Requirements of Participation; - Nursing assistants failing to successfully completed the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of facility employee list showed;- Nurse Aide A was hired on 8/14/24; - Nurse Aide B was hired on 10/17/24; - Nurse Aide C was hired on 9/28/23; - Nurse Aide D was hired on 9/11/18. During an interview on 3/28/25 at 2:30 P.M., the Administrator said the nurse aides should be enrolled in Certified Nurse Aide (CNA) classes within four months of their hire date.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent. Facility staff made three medication errors out of 25 opportunities for error, which resulted in a medication error rate of 12%, which affected two of the 12 sampled residents, (Resident # 19 and #27). The facility census was 35. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Drug and biological orders must be recorded on the Physician Order Sheet (POS) in the resident's chart; - All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; - Orders for medications must include: name and strength of the drug; number of doses, start and stop date, and/or specific duration of therapy; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed. Review of the facility's policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frames. Review of the facility's policy titled, Administering Topical Medications, revised October 2010, showed: - The purpose of this procedure is to provide guidelines for the safe administration of topical medications; - Verify that there is a physician's medication order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - Perform hand antisepsis by either washing with soap and water or applying alcohol-based rub; - Place the Medication Administration Record (MAR) within easy viewing distance; - Check the label on the medication and confirm the medication name and dose with the MAR; - Calculate the medication dose; - Prepare the correct dose of medication; - Apply glove to your dominant hand; - Remove tongue blade from sterile wrapper; - Place medication on the tongue blade and transfer to gloved hands; - Warm the medication in gloved hands and apply gently to the skin in the direction of hair growth; - Remove gloves. Wash and dry hands thoroughly. 1. Review of Resident #19's POS, dated 2/26/25 - 3/26/25 showed: - Start date: 9/23/24 - Diclofenac Sodium over the counter (OTC) gel 1%, 4 grams topically, apply to affected area in the A.M., and at bedtime for arthritis. Review of the resident's MAR, dated 3/1/25 - 3/26/25 showed: - Diclofenac Sodium OTC gel 1%, 4 grams topically, apply to affected area in the A.M., and at bedtime for arthritis. Observation on 3/27/25 at 7:24 A.M., showed: - Certified Medication Technician (CMT) B did not wash his/her hands and applied gloves; - CMT B applied an unknown amount of Diclofenac gel to his/her gloved hands and applied across the resident's shoulders, removed gloves and did not wash his/her hands. During an interview on 3/27/25 at 1:15 P.M., CMT B said the Diclofenac gel should be measured but he/she can not always find the measuring device. During an interview on 3/28/25 at 2:30 P.M., the Director of Nursing (DON) said staff should measure the Diclofenac gel. 2. Review of the facility's policy titled, Instillation of Eye Drops, revised January 2014, showed: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - To steady the eye dropper during the instillation process, rest your hand on the bridge of the resident's nose or on his/her forehead; - Wash and dry your hands thoroughly and don gloves; - If the resident is sitting up, tilt his/her head backward slightly; - Gently pull the lower eyelid down, instruct the resident to look up; - Drop the medication into the mid lower eyelid. (Do not touch the eye or eyelid with the dropper); - Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops; - Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye. Review of the website, www.webmd.com for administration of artificial tears showed: - Tilt the head back, look up and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one or two minutes; - Place one finger at the corner of the eye near the nose and apply gently pressure. This will prevent the medication from draining away from the eye. Review of the manufacture's guidelines for Flonase nasal spray (used to treat allergies) showed: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #27's POS, dated 2/27/25 - 3/27/25, showed: - Start date: 6/7/24 - Flonase Allergy Relief spray 50 micrograms (mcg.) one spray in each nostril as needed for rhinitis (inflammation of the nasal mucous membranes); - Start date: 3/25/25 - Artificial tears 1.0 - 2.0, 2% one drop in both eyes as needed for dry eyes. Complete hand hygiene. Tilt head back, gently pull down lower eyelid to create a pocket, and instill one drop into both eyes in the pocket, avoid touching the dropper tip to your eye or surrounding areas. Review of the resident's MAR, dated 3/1/27 - 3/27/25, showed: - Flonase Allergy Relief spray 50 mcg. one spray in each nostril as needed for rhinitis; - Artificial tears 1.0 - 2.0, 2% one drop in both eyes as needed for dry eyes. Observation on 3/27/25 at 7:49 A.M., showed: - CMT B had the resident blow his/her nose. He/She shook the bottle and gave one spray in each nostril and did not close one side of the nostril; - CMT B gave one drop of Visine in the right eye and touched the tip of the eye dropper to the resident's eye lashes, then gave one drop in the resident's left eye and touched the tip of the eye dropper to the resident's eye lashes. He/She did not apply lacrimal pressure to either eye. During an interview on 3/27/25 at 1:15 P.M., CMT B said: - He/She should have used artificial tears instead of the Visine; - He/She should not have touched the tip of the eye dropper to the resident's eyelid; - He/She was never taught to apply lacrimal pressure; - Should follow the manufacturer's guidelines for administering nasal spray and should close each side of the nostril. During an interview on 3/28/25 at 3: 20 P.M., the DON said;- The tip of the eye dropper should not touch the resident's eye lashes and staff should apply lacrimal pressure; - Staff should follow the manufacturer's guidelines for administration of the nasal spray; - Staff should administer the correct eye drop.

Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of the 12 sampled residents, (Resident #18 and #21) during the use of a mechanical lift. The facility census was 35. Review of the facility's policy titled, Using a Mechanical Lifting Machine, revised July 2017, showed: - The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; - It is not a substitute for manufacturer's training or instructions; - At least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the undated manufacturer's guidelines for the Direct Supply lift showed: - When lifting and lowering the resident, ensure legs on the adjustable base are in the maximum open position for optimal stability. 1. Review of Resident #18's Significant Change in Status Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/25 showed: - Cognitive skills severely impaired; - Upper extremities impaired on both sides; - Lower extremities impaired on one side; - Dependent on the assistance of staff for oral care, personal hygiene, transfers and toilet use; - Had a Suprapubic catheter (a catheter surgically inserted through the wall of the abdomen); - Always incontinent of bowel; - Diagnoses included obstructive uropathy (condition where urine flow is blocked in the urinary tract, preventing the body from properly eliminating waste products), Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), psychotic disorder (a mental illness characterized by a significant disconnect from reality, often involving symptoms like delusions (false beliefs) and hallucinations (seeing or hearing things that aren't there), and dementia ( inability to think). Review of the resident's care plan, revised 3/26/25 showed: - The resident required maximum assist for daily care tasks needs; - He/She was dependent on staff for toileting needs. He/She was incontinent of bowel and had a supra pubic catheter; - He/She required substantial assistance of two staff for bed mobility. Observation on 3/26/25 at 7:53 A.M., showed: - Certified Medication Technician (CMT) B and Certified Nurse Aide (CNA) A entered the resident's room to get him/her up for breakfast and brought the mechanical lift into the resident's room; - CMT B and CNA A did not wash their hands and applied gloves and did not have on personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to workplace hazards that can cause serious injuries or illnesses); - CMT B and CNA A provided incontinent care and dressed the resident; - CNA B placed the wheelchair by the resident's bed and locked the brakes; - CMT B placed the mechanical lift under the resident's bed with the legs in the closed position; - CMT B raised the resident up in the mechanical lift and backed away from the bed with the legs of the lift closed then opened the legs of the lift to go around the resident's wheelchair and lowered the resident into the wheelchair. During an interview on 3/27/25 at 1:15 P.M., CMT B said the legs of the mechanical lift should be open when raising or lowering the resident. During an interview on 3/27/25 at 1:54 P.M., CNA A said when he/she is raising or lowering a resident in the mechanical lift, the legs of the lift should be in the open position. Observation and interview on 3/27/25 at 9:37 A.M., showed: - Nurse Aide (NA) A brought the mechanical lift into the resident's room; - NA A opened the legs of the lift and went around the resident's wheelchair; - NA A and NA B hooked the lift sling up to the lift; - NA A raised the resident up in the lift and backed away from the resident's wheelchair; - NA A closed the legs of the mechanical lift and moved across the room and placed the legs of the lift under the resident's bed with the legs of the lift closed and lowered the resident onto the bed; - NA A and NA B unhooked the lift sling from the mechanical lift. 2. Review of Resident #21's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Required set up and clean up with oral care; - Dependent on the assistance of staff for toilet use and transfers; - Required substantial to maximum assistance for personal hygiene; - Always incontinent of bowel and bladder; - Diagnoses included anxiety, depression, Congestive Heart Failure (CHF, accumulation of fluid in the lungs and other areas of the body), Chronic Obstructive Pulmonary Disease, (COPD, obstruction of air flow that interferes with normal breathing), diabetes mellitus and renal insufficiency (RI, a condition where the kidneys are unable to effectively filter waste products and excess fluid from the blood). Review of the resident's care plan, revised 3/26/25 showed: - The resident required substantial assistance with all of his/her ADLs; - The resident was incontinent of bowel and bladder; - The resident was maximum assistance with transfers of two staff and the mechanical lift. Observation on 3/25/25 at 2:36 P.M., showed: - CNA C placed the mechanical lift under the resident's bed with the legs of the lift closed; - CNA C and CNA D hooked the lift sling up to the mechanical lift; - CNA C raised the resident up in the mechanical lift with the legs of the lift closed; - CNA C backed away from the bed with the legs of the lift closed and moved across to the floor to the resident's recliner; - CNA C opened the legs of the lift to go around the resident's recliner and lowered the resident into the recliner; - CNA C and CNA D unhooked the lift sling from the mechanical lift. During an interview on 3/28/25 at 11:27 A.M., CNA D said the legs of the mechanical lift should be open when raising or lowering the resident. During an interview on 3/38/25 at 2:12 P.M., CNA C said the legs of the mechanical lift should always be open when raising or lowering a resident. Observation on 3/27/25 at 9:01 A.M., showed: - NA A and NA B gave the resident a bed bath; - NA A and NA B dressed the resident; - NA A placed the Direct Supply mechanical lift under the resident's bed with the legs of the lift closed; - NA A and NA B hooked the lift sling up to the lift; - NA A raised the resident up in the lift with the legs of the lift closed; - NA A backed away from the bed with the legs of the lift closed, turned the lift around with the legs closed and moved to the resident's wheelchair; - NA A opened the legs of the lift to go around the resident's wheelchair and lowered the resident into his/her wheelchair; - NA A and NA B unhooked the lift sling from the wheelchair. During an interview on 3/27/25 at 1:37 P.M., NA B said: - The legs of the mechanical lift should be closed when raising or lowering the resident; - The legs of the mechanical lift should be closed because of the way the beds are made; - The legs of the lift should be open when moving across the floor to the wheelchair or the bed. During an interview on 3/28/25 at 11:44 A.M., NA A said the legs of the mechanical lift should be closed when raising or lowering the resident and opened to go around the wheelchair. During an interview on 3/28/25 at 2:30 P.M., the Director of Nursing (DON) said the legs of the mechanical lift should be open when staff are raising or lowering the residents.

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary serviced to maintain good personal hygiene when staff did not provide complete perineal care which affected two of the 12 sampled residents, (Resident #18 and #21). Additionally, the staff failed to provide A.M. care to Resident #18. The facility census was 35. Review of the facility's policy titled, Supporting Activities of Daily Living, revised March 2018 showed: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, rooming and oral care). Review of the facility's policy titled, Perineal Care, revised February 2018 showed: - The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation , and to observe the resident's skin condition; - Wash and dry hands thoroughly and put on gloves; - Wash the perineal area, wiping from front to back; - Separate the skin folds and wash the area downward from front to back; - Continue to wash the skin folds moving from inside outward to the thighs; - Turn the resident on their side; - Wash the rectal area thoroughly, wiping from the base of the skin folds towards and extending over the buttocks. 1. Review of Resident #18's Significant Change in Status Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/25 showed: - Cognitive skills severely impaired; - Upper extremities impaired on both sides; - Lower extremities impaired on one side; - Dependent on the assistance of staff for oral care, personal hygiene, transfers and toilet use; - Had a Suprapubic catheter (a catheter surgically inserted through the wall of the abdomen); - Always incontinent of bowel; - Diagnoses included obstructive uropathy (condition where urine flow is blocked in the urinary tract, preventing the body from properly eliminating waste products), Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), psychotic disorder (a mental illness characterized by a significant disconnect from reality, often involving symptoms like delusions (false beliefs) and hallucinations (seeing or hearing things that aren't there), and dementia ( inability to think). Review of the resident's care plan, revised 3/26/25 showed: - The resident required maximum assist for daily care tasks needs; - He/She was dependent on staff for toileting needs. He/She was incontinent of bowel and had a supra pubic catheter; - He/She required substantial assistance of two staff for bed mobility. Observation on 3/26/25 at 7:53 A.M., showed: - Certified Medication Technician (CMT) B and Certified Nurse Aide (CNA) A entered the resident's room to get him/her up for breakfast; - CMT B and CNA A did not wash their hands and applied gloves; - CMT B did not separate and clean all the skin folds; - CMT B removed gloves, washed his/her hands and applied new gloves; - CMT B and CNA A turned the resident on his/her side; - The resident had an undated dressing on his/her coccyx (tailbone); - CNA A used the same area of the wipe and cleaned different areas of the buttocks; - CNA A removed gloves, sanitized and applied new gloves; - CMT B and CNA A turned the resident to the other side and removed the soiled brief and placed a clean brief under the resident; - CMT B and CNA dressed the resident and used the mechanical lift and transferred the resident from the bed to his/her wheelchair; - CMT B propelled the resident to the dining room for breakfast and did not offer or provide oral care, or wash the resident's face and hands. During an interview on 3/27/25 at 1:15 P.M., CMT B said: - We should not use the same area of the wipe to clean different areas of the skin; - He/She should have separated and cleaned all areas of the skin folds; - We should have washed the resident's face and hands and provided oral care. During an interview on 3/27/25 at 1:54 P.M., CNA A said: - When providing peri care, should separate and clean all the skin folds; - He/She should not have used the same area of the wipe to clean different areas of the skin; - Before taking the resident to breakfast, we should have provided oral care and washed the resident's face and hands; - Should wear a gown and gloves when providing would care or catheter care. 2. Review of Resident #21's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Required set up and clean up with oral care; - Dependent on the assistance of staff for toilet use and transfers; - Required substantial to maximum assistance for personal hygiene; - Always incontinent of bowel and bladder; - Diagnoses included anxiety, depression, Congestive Heart Failure (CHF, accumulation of fluid in the lungs and other areas of the body), Chronic Obstructive Pulmonary Disease, (COPD, obstruction of air flow that interferes with normal breathing), diabetes mellitus and renal insufficiency (RI, a condition where the kidneys are unable to effectively filter waste products and excess fluid from the blood). Review of the resident's care plan, revised 3/26/25 showed: - The resident required substantial assistance with all of his/her ADLs; - The resident was incontinent of bowel and bladder; - The resident was maximum assistance with transfers of two staff and the mechanical lift. Observation on 3/27/25 at 9:01 A.M., showed: - Nurse Aide (NA) A and NA B gave the resident a bed bath; - NA A and NA B turned the resident on his/her side; - The resident urinated; - NA A and NA B did not separate and clean all the areas of the skin where urine had touched; - NA A and NA B dressed the resident and used the mechanical lift and transferred the resident from the bed to his/her wheelchair. During an interview on 3/27/25 at 1:37 P.M., NA B said he/she should have separated and cleaned all areas of the skin where urine or feces had touched. During an interview on 3/28/25 at 11:44 A.M., NA A said he/she should have separated and cleaned all areas of the skin where urine or feces had touched. During an interview on 3/28/25 at 2:30 P.M., the Director of Nursing (DON) said:- Staff should wash the residents face and hands, brush their hair and offer oral care before taking the resident to breakfast; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all areas of the skin where urine or feces had touched.

Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to keep oxygen tubing off the floor for three residents (Resident #22, #25, and #134), failed to date oxygen tubing for one resident (Resident #134), and failed to fill humidifier bottle with distilled water for one resident (Resident #134), resulting in possible exposure to bacteria and discomfort during oxygen usage. This affected three of 12 sampled residents. The facility census was 35. Review of the facility's Oxygen Administration policy, dated 10/2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as the oxygen flows through; -Periodically recheck water level in humidifying jar; -Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. 1. Review of Resident #134's Face Sheet, undated, showed diagnoses included: skin cancer, anemia (low red blood cell count), kidney disease, lung disease, and kidney disease. Review of baseline care plan, dated 3/17/2025, directed staff to administer oxygen as ordered. Observation on 3/26/25 at 7:59 A.M. showed: -No date on oxygen tubing; -Excess oxygen tubing was coiled on the floor; -Water bottle was empty. Observation on 3/26/25 at 12:27 P.M. showed: -Excess oxygen tubing was coiled on the floor; -No date on oxygen tubing; -Water bottle was empty; -No date on oxygen tubing. Observation on 3/27/25 at 9:01 A.M. showed: -Excess oxygen tubing was coiled on the floor; -No date on oxygen tubing. 2. Review of Resident #25's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/25, showed: -Resident is cognitively intact; -Diagnoses included: heart failure, anxiety, depression, asthma, and respiratory failure; -Resident is independent with ADL's. Review of care plan, dated 1/28/2025, showed the resident wears oxygen continuously. Review of physician's orders, dated 10/2/2024 and 10/4/2024 showed: -Change oxygen tubing and clean oxygen filter every two weeks on Friday night shift; -Titrate oxygen, as needed, to maintain saturation greater than 92%, every shift. Observation on 3/25/25 at 11:56 A.M. showed excess oxygen tubing was coiled on the residents floor. 3. Review of Resident #22's Quarterly MDS, dated [DATE] showed: -Resident was cognitively intact; -Active diagnoses include: debility (general weakness), anemia, high blood pressure, peripheral vascular disease (circulation disorder), anxiety, asthma, and respiratory failure. Review of care plan, dated, 12/18/2024, showed no information regarding oxygen use. Review of physician's orders, dated 6/20/2023. showed to change oxygen and nebulizer tubing every two weeks on Friday night shift, date and initial tubing with small piece of medical tape. Observation on 3/25/25 at 4:40 P.M. showed excess oxygen tubing was coiled on the floor in the reisdent's room. Observation on 3/27/25 at 8:40 A.M. showed excess oxygen tubing was coiled on the floor in the residents room. During an interview on 3/28/25 at 10:17 A.M., CNA B said: -Oxygen tubing should not be touching the floor; -Oxygen tubing should be stored in a bag on the resident's concentrator; -The oxygen humidifier bottle should be filled to the line, about halfway. During an interview on 3/27/25 at 2:15 P.M., RN B said: -If there is excess oxygen tubing, it should be coiled and stored on the concentrator; -Oxygen tubing should not be coiled on the floor; -The oxygen humidifier bottle should be half full and should be checked daily. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -Oxygen tubing should be neatly coiled and kept off the floor; -The humidifier bottle for the oxygen concentrator should not be empty.

Based on observation, interview, and record review, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to ensure the bed's dimensions were appropriate for the resident's size, (for resident #134). Additionally the facility failed to obtain physicians orders and care plan the use of bed rails for three residents (Resident #23, #19 and #134). This included three of 12 residents sampled (Residents #23, #19, and #134). The facility census was 35. Review of facility policy, Proper Use of Side Rails, revised 12/2016, showed: -The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medial symptoms; -An assessment will be made to determine if the resident's symptoms, risk of entrapment, and reason for using siderails; -When used for mobility, or transfer, an assessment will include a review of the residents: a) Bed mobility; b) Ability to change positions, transfer to and from bed or chair; c) Risk of entrapment from the use of siderails; d) That the bed's dimensions are appropriate for the resident's size and weight; -The use of side rails as an assistive device will be addressed in the resident care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative after reviewing risks and benefits; -The resident will be checked periodically for safety relative to side rail use; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. 1. Review of resident #23's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/11/25, showed: -He/She is cognitively intact; -He/She had impairment on both sides of lower extremities; -He/She required substantial assistance to move from sitting to lying and to move from lying to sitting; -He/She required total assistance for toileting, lower body dressing, and to move from sitting to standing; -He/She required partial/moderate assistance for upper body dressing; -Diagnoses included debility (general weakness), cardiorespiratory conditions, high blood pressure, and asthma. Observation on 3/25/25 at 1:58 P.M. showed U-shaped bed rails on the left and right side of the resident's bed. Review of physician's orders, dated 2/4/25 through 3/27/35, showed no orders for the use of side rail or assist bars. Review of resident's care plan, dated 2/24/25, showed: -Resident uses positioning wand (bedrail) on both sides of the bed to pull himself/herself over in bed; -Resident has been assessed for safety in using the positioning devices; -Resident has reviewed the risks and benefits of using the positioning wand and, despite the risk, he/she was able to maintain mobility independence by using the device. Review of positioning device assessment, dated 2/25/25 showed: -He/She was assessed for side rails to use to assist with transfers and bed mobility; -Positioning wands to be used; -No box was checked to indicate which side(s) of the bed the rail would be used on; -Resident's family signed for consent; -No bed measurements or height and weight of the resident noted. During an interview on 3/25/25 at 1:58 P.M., the resident said: -He/She uses the side rail to get in and out of bed. 2. Review of Resident #19's Annual (MDS), dated [DATE], showed: -Resident is cognitively intact; -Resident is independent with activities of daily living (ADL's). -Impairment on one side of the upper extremity; -Diagnoses included: anemia (low red blood cell count), heart disease, high blood pressure, gastroesophageal reflux disease (stomach contents to back up into the esophagus), thyroid disorder, dementia, depression, diabetes, kidney disease, and debility (general state of weakness and decline). Observation on 3/25/25 at 3:29 P.M. showed U-shaped rail on the left side of the resident's bed. Review of physician's orders, dated 2/26/25 to 3/26/25, showed no order for bed rails. Review of care plan, dated 9/30/24, showed the Resident requested a handrail on the left side of the bed to have something to grab onto when getting out of bed. Review of positioning device assessment, dated 10/2/24, showed: -He/She was assessed for side rails to use to assist with transfers and bed mobility; -Positioning wand to be used on the left side of the bed; -No bed measurements or height and weight of the resident noted. During an interview on 3/25/25 at 3:29 P.M., the resident said he/she used the rail to get out of bed because he/she cannot use their right arm. 3. Review of Resident #134's face sheet showed: -Resident was admitted on [DATE]; -Diagnoses included: skin cancer, anemia (low red blood cell count), kidney disease, lung disease, and kidney disease. Observation on 3/26/25 at 7:59 A.M. showed U-shaped rail on the left side of the resident's bed. Review of resident's care plan, dated 3/18/25 did not include the use of or staff direction regarding the use of positioning bar. Review of resident's physician's orders dated 2/27/25 to 3/37/35 showed no order for positioning rails. During an interview on 3/26/25 at 7:59 A.M., resident #134 said he/she used the bed rail to keep himself/herself on the bed. During an interview on 3/27/25 at 2:15 P.M., RN B said physical therapy is responsible for requesting and placing the bedrails for residents. During an interview on 3/28/25 at 10:42 A.M., Physical Therapist A said: -Transfer bars were used to help residents to get in and out of bed; -If a resident was being seen by physical therapy, and the therapist deemed the resident needed a positioning bar, they will make a recommendation to the DON (director of nursing) and the administrator; -Physical therapy does not perform any assessments or measurements for positioning rails. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -Positioning rails should be provided when a resident requests one or when therapy recommends one; -An assessment that includes bed measurements should be completed and reviewed by the interdisciplinary team; -There should be physician's orders for positioning rails; -The use of positioning rails should be care planned.

Based on observation, record review and interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe and when they did not maintain the only drinking fountain. The facility census was 28. The facility did not provide an environmental policy. 1. Observations beginning on 4/23/24 at 9:24 A.M. showed: -room [ROOM NUMBER] door had scuff marks, the frame had chipped paint with exposed wood; -The exit door's frame was chipped, exposing wooden frame underneath; -The fan heater below the handrail, had a bent metal frame, causing a sharp protrusion of metal at knee/calf height; -Sliding bathroom door of room [ROOM NUMBER] had molding loose on one side, with a 2 inch screw exposed; -Sliding bathroom door of room [ROOM NUMBER] had molding loose on one side, with 2 screws, measuring 1.5 inches and 1 inches, exposed; -room [ROOM NUMBER] door frame had chipped paint with exposed wood; -room [ROOM NUMBER] door frame had chipped paint with exposed wood; -room [ROOM NUMBER] had large gouges and chips in the sheet rock behind the resident's bed. The door frame was chipped with exposed wood; -200 hall fire door laminate was chipped with exposed wood; -The mattress in room [ROOM NUMBER] plastic, protective coating was peeling with foam exposed; -room [ROOM NUMBER] had large gouges and scrapes into the sheetrock behind the resident's chair. During an interview on 4/24/24 at 12:15 P.M. the Maintenance Supervisor said: -He started working at the facility about eight months ago; -He was aware there are areas that need to be fixed; -He was working on a schedule of repairs and audits. During an interview on 4/25/24 at 9:36 A.M. the Administrator said: -She was aware that there are door frames that need repaired; -She had a list by room for needed repairs; -There is a performance improvement plan (PIP) for building repairs; -The new maintenance man had made major strides in completing tasks; -Once a week housekeeping should wash resident's beds and notify her if there are any rips, tears or reason to replace the mattress. 27584 2. Observation on 4/23/24 at 1:07 P.M., showed the only water fountain in the facility, by the nurse's station near room [ROOM NUMBER], did not dispense water when pushed. Observation on 4/23/24 at 1:10 P.M. showed a hydration station by the activity room. Observation on 4/24/24 at 9:38 A.M., showed no exception posted for the hydration station in lieu of a water fountain. During an interview on 4/24/24 at 11:30 A.M., the Administrator said the Director of Nursing had worked at the facility for five years and the water fountain had not worked since she worked at the facility. They thought it may have been disconnected due to COVID-19. They set up a hydration center near the activity room and thought they did not need the water fountain. They did not realize a State tag existed that said the water fountain needed to be maintained and in good repair. They had not received or submitted approval for an exception to the regulation.

Based on observation, interview and record review, the facility failed to ensure residents had a complete, accurate and individualized care plan, to address the specific needs for three of the 12 sampled residents (Residents #1, #13 and #22). The facility census was 28. Review of the facility's 2018 policy on Resident's Plan of Care., showed: -Every resident will have a formal plan of care within 48 hours of admission. The care plan team is responsible for periodic review and updating of care plans. -Care plans should be updated when there is a significant change in the resident's condition, with a readmission from the hospital, and at least quarterly. Review of Resident #22's Admission MDS (Minimum Data Set) A federally mandated comprehensive assessment completed by facility staff. Completed on 3/26/24., showed: - Not Cognitively Intact - History of behaviors and wondering in the last 7 day look back period. - Limited supervision with activities of daily living. - Independent with mobility and meals. - Diagnoses: Right femur fracture, dementia with mood disturbances, anxiety, heart failure. - Admission 3/20/24 - Not Cognitively Intact Review of Physicians Orders for the month of March 2024., showed: -Lorazepam 0.5 mg by mouth three times a day as needed for anxiety. -Antibiotics for Urinary Tract Infection- Cephalexin 500 mg by mouth four times a day from 4-11-24 through 4-18-24 -Hydrocodone 5-325 mg by mouth every 8 hours as needed for pain. -Lorazepam 0.5 mg by mouth four times a day at 8 A.M. 12 Noon, 4 P.M. and 8 P.M. routinely. -Zoloft 50 mg by mouth daily. - Up ad lib ( Up when the resident wants to be and independently ) -No orders for any positioning alarms in the physician orders. Review of March 2023 medication administration records., showed: - 4/17/24 at 6:00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 10:30 A.M. - 4/17/24 at 8: 00 A.M. Hydrocodone 5-325 mg given for pain- Resident fell at 4/17/24 at 10:30 A.M. - 4/20/24 at 6 :00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 8:20 A.M. - 4/20/24 at 8:00 A.M. Zoloft 50 mg given- Resident fell on [DATE] at 8:20 A.M. - 4/20/24 at 6:30 A.M. Hydrocodone 5-325 mg given for pain- Resident fell at 8:20 A.M. - 4/24/24 at 6:00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 7:15 A.M. - 4/24/24 at 6:21 A.M. Hydrocodone 5-325 mg given for pain- Resident fell on [DATE] at 7:15 A.M. Review of progress notes in the medical record for the month of March, 2023., showed: - 4/17/24 at 10:30 A.M., witnessed fall that resident fell while ambulating with only one shoe on and without walker in resident's room. Resident expressed pain to the back of his/her head. Daughter notified and neurological checks started. Pupils documented as sluggish. No other interventions. - 4/20/24 at 8:20 A.M., unwitnessed fall in the resident's room. Resident expressed moderate pain in the back with abrasion and bruising to arm. Found by staff lying on side between the bed and wall. Note does not indicate who found the resident, which side resident was lying on the floor, or where the area of bruising was located. Linens on the floor indicated resident fell due to linens around feet. Resident was placed in bedside chair with an alarm. -4/24/24 at 7:15 A.M., unwitnessed fall in the resident's room. Resident expressed pain at tailbone area. No injury noted in the progress notes. Resident was found sitting on the floor with pajama bottoms and brief at the resident's knees. Assisted to toilet with max assist of two certified nursing assistants. Physician and daughter notified. Request to the physician for body alarm was the first intervention. - There was no documentation in the clinical record to support any changes to the care plans or interventions related to medication usage. Review of the resident's care plan prior to 4/24/24., showed: - Supervision needed with ambulation and that resident used a four wheeled walker with a seat. - Resident is at risk for falls. Interventions are to monitor the resident's activity. and provide non-slip footwear. - Pain associated with previous hip fracture, to monitor for pain and medicate as needed. - No care plan related to Urinary Tract Infection and increase fall risk. - No care plan related to personal alarms. - No care plan related to moving the resident closer to the nurses station. During an interview on 4/24/24 at 4:00 P.M. the Director Of Nursing (DON) said; - She and the Administrator had spoken with the family of the resident regarding the possibility of moving the resident into a room closer to the nurses station that morning. - The DON is currently completing the MDS and Care Plans for the facility and the nurses can also update the care plans. - The resident's physician will order and provide whatever the family's wishes are. - Care plans should be updated with a change in the residents routine or needs. During an interview on 4/24/24 at 4:10 P.M., the Administrator said: - A fall risk assessment was not re-assessed for the resident, since the resident was already a high risk for falls. - Changes in residents conditions should be care planned. - She would consider a hematoma an injury and neurological assessments have been every 15 minutes. - They were working on other interventions and met with family this morning. - The goal would be to have the resident moved closer to the nurses station. - She would expect personal alarms and positioning devices to have a physician order. 44395 2. Review of Resident #1 Quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 14, indicated no cognitive loss; -Able to understand and make self understood; -Independent for Activities of Daily Living (ADL's: fundamental skills required to care for oneself, such as eating, bathing, and mobility); -No limits in range of motion; -Diagnoses included: Atrial Fibrilliation (irregular and often very rapid heart rhythm), diabetes (a condition that affects how your body turns food into energy), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and macular degeneration (disease that affects a person's central vision and can result in a severe loss of vision). Review of the resident's April 2024 physician order sheet showed: -Azelastine aerosol spray; 137 micrograms (mcg), one spray each nostril twice a day as needed for seasonal allergic rhinitis. (May keep at bedside and self administer) -Flonase allergy relief 50 mcg, two sprays once a day as needed for seasonal allergic rhinitis (may keep at bedside) Review of the resident's comprehensive Care Plan dated 2/2/24 showed: -No care plan for keeping medications at bedside. Review of Resident #1's Self Administration Assessment completed 1/31/24 showed: -The resident was alert and oriented; -He/she was able to make needs and decisions; -He/She was capable and able to administer own medications of Flonase, and Azelastine. Observation on 4/22/24 at 3:25 P.M. showed the resident had Azelastine nasal spray and Flonase nasal spray sitting out on his/her over the bed table. During an interview on 4/22/24 at 3:25 P.M. the resident said: -He/She takes the sprays once a day when he/she needed them for allergies. 3. Review of Resident #13 Annual MDS dated [DATE] showed: -BIMS of 11, indicated some cognitive loss; -Rejection of care 1-3 days; -Substantial to maximum assistance with ADL's; -Therapeutic Diet; -Diagnoses of : Dementia, Congestive Heart Failure (a weakened heart that causes fluid buildup in the feet, arms, lungs, and other organs), cardiac pacemaker (a small device, implanted in the chest, to treat irregular heartbeats) and respiratory failure (a condition where the blood does not have enough oxygen) Review of the resident's April physician order sheets showed: -Diet: Regular/No Added Salt (NAS: a diet that limits the amount of salt intake); -2500 milliliter (ml) fluid restriction in 24 hours. Review of Resident #13's Comprehensive Care Plan showed: -No care plan for fluid restriction and NAS diet. Observation on 4/22/24 at 12:16 P.M. showed: -He/She requested salt for his/her meal; -Certified Nurse Aide (CNA) A gave the salt shaker to the resident; -He/She liberally salted his/her food. During an interview on 4/25/24 at 8:45 A.M. CNA A said: -He/she did not know if any resident was on a no added salt diet; -Resident #13 was on a fluid restriction; the resident does not follow it. 4. During an interview on 4/25/24 at 8:38 A.M. CNA B said: -He/She was not aware of residents with medications at bedside; -Resident #13 is on a fluid restriction, but is non complaint and gets his/her own water and soda; -He/She tries to limit the resident's fluid but is not always able, since the resident can get it him/herself; -The care plan is used to tell what care a resident needs; -There is a communication book to notify staff of any changes to the care plan. 5. During an interview on 4/25/24 at 9:08 A.M. RN A said: -He/She started work at the facility about a week ago; -He/She was not sure if anyone was on a fluid restriction or no added salt diet; -He/She was not sure about medication at bedside; -He/She can update care plans as needed, then would notify the Director of Nursing of updates. 6. During an interview on 4/25/24 at 9:36 AM the DON said: -There was a care plan book at the desk with a working copy of the care plan; -The computer care plan is updated quarterly; -Residents who have keep at bedside orders should have a care plan. 7. During an interview on /25/24 at 9:56 AM the Administrator said: -She was not aware there was a resident with medication at bedside; -Care plans are updated as needed, then computer updates are completed quarterly; -Any changes in a care plan are passed on in report from the nurse to the CNA's; -New staff are educated about care plans in New Employee Orientation; -A CNA communication/report book was at the nurse's station for any changes.

Based on observation, interview, and record review, the facility failed to ensure systems and interventions were put in place for one resident to ensure the resident's safety, (Resident #22), This resident had a urinary infection, severely impaired cognition, medication use daily for anxiety as well as narcotic use and had sustained three falls with in a week's time resulting in a hematoma (a collection for blood outside of the broken blood vessel, causing swelling and bruising) to the back of the head, without additional interventions put into place. This effected one resident (Resident #22), of 12 sampled residents. The facility census was 28. Review of the facility policy on Fall Clinical Protocol, dated March of 2018., showed: - The nursing staff will help identify individuals with a history of falls and risk factors for falling. - Those individuals with repeated falls often have an underlying cause. - Staff will identify medical conditions affecting fall risk, complications of falls, and risks for bleeding associated with a fall. - Appropriate interventions will be put into place to prevent further falls. 1. Review of Resident #22's Admission MDS (Minimum Data Set) A federally mandated comprehensive assessment completed by facility staff. Completed on 3/26/24., showed: - Not Cognitively Intact; - History of behaviors and wondering in the last 7 day look back period; - Limited supervision with activities of daily living; - Independent with mobility and meals; - Diagnoses: Right femur fracture, dementia with mood disturbances, anxiety, heart failure; - Admission 3/20/24. Observation on 4/22/24 at 12:30 P.M., showed: - Resident sitting in the dining room with elbow on table, resting his/her head in the palm of his/her hand and eye closed with lunch tray uneaten; - Resident had purple, raised bump the size of a golf ball to the back of his/her head and small bruises to bilateral hands and forearms. Observation on 4/22/24 at 1:45 P.M., showed: -Resident's room is the last room at the end of the hallway, and farthest from the nurses station; - The resident is alone in this room and is without a roommate; - Resident is unable to utilize a call light related to severe cognitive impairment, even though the call light is in close proximity to the resident's reach. Observation on 4/23/24 at 8:30 A.M., showed: - Resident sitting at the dining room table rest his/her head on right arm, sleeping, with breakfast meal sitting in front of him/her, and untouched. Observation on 4/23/24 at 12:15 P.M., showed; -Resident sitting in the front living room, holding head, and appears sleepy. Observation on 4/24/24 at 10:11 A.M., showed: - Resident walking alone with walker after morning fall, outside of the resident's room. - Once staff saw the resident walking alone, a gait belt was then applied to the resident's waist. - There was no alarm sounding to indicate the resident was up and walking alone. Review of Physicians Orders for the month of March 2024., showed: -Lorazepam 0.5 mg by mouth three times a day as needed for anxiety. -Antibiotics for Urinary Tract Infection- Cephalexin 500 mg by mouth four times a day from 4-11-24 through 4-18-24 -Hydrocodone 5-325 mg by mouth every 8 hours as needed for pain. -Lorazepam 0.5 mg by mouth four times a day at 8 A.M. 12 Noon, 4 P.M. and 8 P.M. routinely. -Zoloft 50 mg by mouth daily. - Up ad lib ( Up when the resident wants to be and independently ) -No orders for any positioning alarms in the physician orders. Review of March 2023 medication administration records., showed: - 4/17/24 at 6:00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 10:30 A.M. - 4/17/24 at 8: 00 A.M. Hydrocodone 5-325 mg given for pain- Resident fell at 4/17/24 at 10:30 A.M. - 4/20/24 at 6 :00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 8:20 A.M. - 4/20/24 at 8:00 A.M. Zoloft 50 mg given- Resident fell on [DATE] at 8:20 A.M. - 4/20/24 at 6:30 A.M. Hydrocodone 5-325 mg given for pain- Resident fell at 8:20 A.M. - 4/24/24 at 6:00 A.M. Lorazepam 0.5 mg given- Resident fell on [DATE] at 7:15 A.M. - 4/24/24 at 6:21 A.M. Hydrocodone 5-325 mg given for pain- Resident fell on [DATE] at 7:15 A.M. Review of progress notes in the medical record for the month of March, 2023., showed: - 4/17/24 at 10:30 A.M., witnessed fall that resident fell while ambulating with only one shoe on and without walker in resident's room. Resident expressed pain to the back of his/her head. Daughter notified-Neurological checks started. Pupils documented as sluggish. No other interventions. - 4/20/24 at 8:20 A.M., unwitnessed fall in the resident's room. Resident expressed moderate pain in the back with abrasion and bruising to arm. Found by staff lying on side between the bed and wall. Note does not indicate who found the resident, which side resident was lying on the floor, or where the area of bruising was located. Linens on the floor indicated resident fell due to linens around feet. Resident was placed in bedside chair with an alarm. -4/24/24 at 7:15 A.M., unwitnessed fall in the resident's room. Resident expressed pain at tailbone area. No injury noted in the progress notes. Resident was found sitting on the floor with pajama bottoms and brief at the resident's knees. Assisted to toilet with max assist of two certified nursing assistants. Physician and daughter notified. Request to the physician for body alarm was the first intervention. Review of the resident's care plan prior to 4/24/24., showed: - Supervision needed with ambulation and that resident used a four wheeled walker with a seat. - Resident is at risk for falls. Interventions are to monitor the resident's activity. and provide non-slip footwear. - Pain associated with previous hip fracture, to monitor for pain and medicate as needed. - No care plan related to Urinary Tract Infection and increase fall risk. - No care plan related to personal alarms. - No care plan related to moving the resident closer to the nurses station. During an interview on 4/23/24 at 10:45 A.M. Certified Medication Tech (CMT) A said the resident had shown a decline in the last week with more falls, more sleepiness, and less of a desire to participate in meals with feeding his/her self. CMT said the resident get Lorazepam four times a day and narcotics for pain. During an interview on 4/24/24 at 11:30 A.M. Restorative Aid (RA) A said the he/she had noticed in the last week that the resident is much slower, needing more assistance with daily care, and had another fall that morning. RA said he/she had not considered the possibility of moving resident closer to the nurses station. During an interview on 4/24/24 at 3:45 P.M. the resident's family member said he/she was aware that recent infection, use of anxiety medications and narcotics, placed the resident at risk for more falls. He/She spoke with facility administrator regarding the possibility of moving the resident to a room closer to the nurses station. Family member said that the resident had a hip fracture at home resulting from a fall which is why he/she was now at the nursing home. The family member said keeping the resident sedated is better than having resident upset with behaviors. During an interview on 4/24/24 at 4:00 P.M. the Director Of Nursing (DON) said; - She and the Administrator had spoken with the family of the resident regarding the possibility of moving the resident into a room closer to the nurses station that morning. - The DON is currently completing the MDS and Care Plans for the facility and the nurses can also update the care plans. - The resident's physician will order and provide whatever the family's wishes are. During an interview on 4/24/24 at 4:10 P.M., the Administrator said: - A fall risk assessment was not re-assessed for the resident, since the resident was already a high risk for falls. - Changes in residents conditions should be care planned. - She would consider a hematoma an injury and neurological assessments have been every 15 minutes. - They were working on other interventions and met with family this morning. - The goal would be to have the resident moved closer to the nurses station. - She would expect personal alarms and positioning devices to have a physician order.

Based on observation, interviews and record reviews, the facility failed to provide the necessary care and services for one sampled resident (Resident #1) to attain their highest practicable mental and physical well being when staff failed to notify the appropriate physician, in a timely manner, of Resident #1's change in mental status and abnormal laboratory results, failed to follow the facility's protocol to contact the physician when they did not receive a response to abnormal laboratory results, and failed to assess and document assessments when the resident had a change in mental status and abnormal laboratory results. The resident suffered a fall and sustained a [MEDICAL CONDITION]. The facility census was 29. 1. Review of the undated, Change in a Resident's Condition or Status policy and procedure showed the nurse supervisor will notify the resident's attending physician when: - There is a significant change in the resident's physical, mental or psychosocial status; - There is a need to alter the resident's treatment significantly; - Deemed necessary or appropriate in the best interest of the resident. 2. During an interview on 7/1/15 at 9:40 A.M., the new director of nursing (DON), said: - The facility's protocol allowed nurses to write a telephone order (TO) for a urinalysis (UA, a test to identify the contents of urine and aid in diagnosing an infection) for any resident with a change in mental status or increased falls. The nurse should send the UA to the laboratory, put the TO on the clipboard, and the physician or nurse practitioner (F-NP) signed the TO on their next rounds. - If the UA results are abnormal staff should fax them to the physician then contact the physician to assure he/she received them. - Each shift, staff should document, on the 24 hour report to show staff faxed the labs to the physician and if they received an order or not. If the lab results arrived after office hours staff should follow up with the physician the next morning. If the labs arrived on a weekend or holiday staff should contact the on-call physician for orders. Staff should either check the on-call physician list or call the hospital for the on-call physician. 3. During an interview on 7/2/15 at 12:55 P.M., Family Member (FM) A, said: - Physician B was Resident #1's physician prior to admission to the facility. - When the facility admitted the resident, in 2011, the resident switched to Physician A because Physician B did not make rounds at the facility. - Physician A was still the resident's physician. Review of the resident's care plan, dated as reviewed on 3/25/15, showed: - Problem: at risk for falls due to pain and unsteady gait; - Goal: the resident will remain free from injury; - Approaches included encourage resident to assume a standing position slowly, independent with transfers, and self propelled his/her wheelchair. Review of the resident's quarterly Minimum Data Sets (MDS), a federally mandated assessment completed by facility staff, dated 5/29/15, showed: - Moderately impaired cognitive ability; - Independent for transfers and locomotion with no setup or physical assistance; - Steady at all times while moving from a seated to standing position, transferring to and from the bed to a chair or wheelchair, moving on and off the toilet, and turning and facing the opposite direction when walking; - No falls; - [DIAGNOSES REDACTED]. During an interview on 7/2/15 at 10:13 A.M., Licensed Practical Nurse (LPN) A said: - On 6/3/15, he/she worked from 6:00 P.M. to 10:00 P.M. - The resident had increased confusion, did not know where his/her room was, and asked a lot of questions that did not make sense. - Because of the resident's increased confusion, he/she wrote UA and increased confusion on the 24 hour report sheet and told LPN B, the night nurse, that staff needed to get an UA. Review of the undated TO, showed: - UA with culture and sensitivity (C&S, a test that identified the type of bacteria and the effective antibiotics) if indicated for increased confusion. Review of the nurses' notes, showed: - No staff documented the resident's increased confusion or any assessment from 6/3/15 through 6/8/15. Review of the facility's 24 hour report sheets, showed: - On 6/3/15, LPN A wrote the resident had increased confusion and needed a UA. During an interview on 6/30/15 at 2:55 P.M., and 7/1/15 at 12:40 P.M., LPN C said: - On 6/4/15 he/she worked from 6:00 A.M. to 10:00 P.M. - He/she obtained a UA because the resident had increased confusion. - He/she did not assess the resident because he/she was busy; although there was no excuse to not assess a resident, as charge nurse you are busy. - He/she faxed the UA results to Physician B and then left a voice message because staff should not just fax abnormal labs to a physician's office. - By 10:00 P.M., Physician B had not called so he/she passed on in report that staff needed to follow up with the physician for an antibiotic order. - He/she faxed the UA results to Physician B because he/she thought that was the resident's physician. - He/she did not work again until 6/9/15. Review of the UA, dated 6/4/15, showed: - Abnormal results included cloudy urine, protein of 1+, positive for [MEDICATION NAME] (indicative of bacterial growth), contained blood, and 3+ leukocyte (a white blood cell that helps the body fight infection). - LPN C's notation that, on 6/4/15 at 3:30 P.M., he/she faxed the results to Physician B, left a voice mail for Physician B, and the resident's allergy to [MEDICATION NAME] (an antibiotic). Review of the facility's 24 hour report sheets, showed: - On 6/4/15, LPN C wrote that the UA was positive (abnormal results). He/she faxed the UA to Physician B, called Physician B, and staff needed to follow up with the physician for an antibiotic order. - On 6/4/15, LPN B wrote UA and increased confusion. During an interview on 7/2/15 at 12:55 P.M., FM A said: - Facility staff never told him/her the resident had increased confusion; not being able to find his/her room was not normal for the resident. - Increased confusion was a sign of a urinary tract infection [MEDICAL CONDITION] for the resident. - No staff told him/her the resident had an abnormal UA on 6/4/15. During an interview on, 7/2/15 at 10:13 A.M., LPN A said: - He/she did not work on 6/4/15; the next day, in report, LPN B said staff faxed the UA to the physician. - He/she thought LPN B wrote waiting for C&S, on the UA results. - The UA was on the physician's clipboard for the physician's next rounds. Review of the UA results, dated 6/4/15, showed no documentation directing staff to wait for the C&S results. During interviews on, 7/1/15 at 10:01 P.M., and 7/3/15 at 10:00 P.M., LPN B said: - He/she worked 6:00 P.M., to 6:00 A.M., or 10:00 P.M., to 6:00 A.M. - He/she did not fax information, such as lab results, to physicians' offices during his/her shifts. Physician A did not want staff to fax information unless he/she was in the office. - When he/she wrote fax sent to physician it meant staff previously faxed that information to the physician. - He/she did not call physicians during the night shift to follow up on labs or orders. - If there was an emergency, a fall, or injury that needed attention, he/she paged the on-call physician, but not for routine follow ups. - Staff should contact physicians during the physicians' office hours to follow up on labs and orders. - He/she never told LPN A to wait for the resident's C&S results. Review of the facility's 24 hour report sheets, showed: - On 6/5/15, LPN A wrote urine bad. LPN B wrote UA bad, allergic to [MEDICATION NAME], no orders, and fax sent to Physician B. - On 6/6/15, LPN A wrote the resident had increased confusion and LPN B wrote no antibiotic yet and increased confusion. - On 6/7/15, LPN A wrote okay and LPN B wrote diarrhea. During an interview on 7/2/15 at 10:13 A.M., and 12:10 P.M., LPN A said: - He/she thought about it and no staff wrote to wait for the C&S results. - No, there was not an order to wait for C&S. - He/she worked several 12 hour shifts and doubles during that week (6/3/15 to 6/8/15) and did not assess the resident because it was a very busy week. - He/she did not contact any physician or FN-P about the resident's increased confusion or the UA results. - He/she knew the physician would make rounds on 6/8/15, so he/she kept the UA and C&S on the clipboard and gave them to him/her during rounds on 6/8/15. Review of the C&S, dated 6/8/15 at 8:14 A.M., showed: - Abnormal results of greater than 100,000 colony-forming units per milliliter (CFU/ml, used to estimate the number of bacteria or fungal cells, capable of reproducing, in the sample) of Staphylococcus aureus (a gram-positive bacteria). - FN-P B wrote an order for [REDACTED]. Review of the facility's 24 hour report sheets, showed: - On 6/8/15, staff wrote encourage fluids, incontinent, and started [MEDICATION NAME] twice a day for UTI. Review of the Medication Administration Record, [REDACTED].M. During an interview on 6/30/15 at 2:55 P.M., LPN C said: - On 6/9/15 the resident fell and it looked like he/she tried to transfer from the bed to the wheelchair. - He/she called the ambulance and sent the resident to the emergency room (ER) because the resident's right leg appeared rotated (a possible sign of [MEDICAL CONDITION]). Review of LPN C's nurse's note, dated 6/9/15 at 5:15 P.M., showed: - Called to room by Certified Nurse Aide (CNA) and found the resident on the floor, on his/her right side, and next to the bed. Hip rotation noted and the resident complained of pain of a ten (rated on a scale of one to 10). Called 911 for ambulance transport to hospital and obtained verbal order from Physician C to transport to ER for evaluate and treatment. - Voice message left for FM A. - Ambulance staff arrived at 5:25 P.M. and transported the resident to the ER. During an interview on 7/2/15 at 12:55 P.M., FM A said: - The facility sent the resident to the ER after he/she fell on [DATE]. - The ER staff said they noticed the resident's urine had an odor, an off color, and with his/her confusion they questioned a UTI. - He/she thought the ER found the UTI. - He/she did not understand why the physician, at the facility, did not immediately order an antibiotic when the resident had increased confusion and a positive UA. Review of the emergency room Department records, dated 6/9/15, showed: - The resident complained of right hip pain after a fall from the wheelchair. - No prior injuries to the area. - A right femoral intertrochanteric fracture (a fracture in the upper part of the long thigh bone). - [MEDICATION NAME] 1 gram intravenous (IV, medication given into a vein to treat an infection). - Orthopedic surgery consult; - [MEDICATION NAME] injection 30 milligrams (mg, pain medication injected into the muscle); - [MEDICATION NAME] injection 0.5 mg (narcotic pain medication). Observation and interview on 6/30/15, at 4:10 P.M., provided the following information: - The resident in bed on his/her back. - He/she gently padded the right hip and said he/she fractured the hip in a fall. - He/she did not remember what caused the fall. - He/she said the medication helped relieve the pain. During an interview on 7/1/15 at 9:40 A.M., and 2:40 P.M., the new DON said: - Staff should have called Physician B's office the next shift, if the office was still open. If Physician B's office had closed, staff should have called the physician's office the next morning and continued to call the office until they received an order. - Staff should inform the DON if they did not receive an order by the next day. - She thought Physician B was the resident's physician. During an interview on 7/2/15 at 1:25 P.M., FN-P A said: - He/she and Physician A were out of the office at that time (6/4/15). - When they are out of the office staff should contact the on-call physician with abnormal laboratory results. - Staff should not just fax labs to a physician because they do not know where the labs go or if they ever arrived. - Staff should do an assessment and contact the physician with the UA results when a resident was not his/her norm or had increased confusion. - Staff should absolutely do assessments when a resident had a change in condition, but staff seemed to wait until they started the antibiotic to do the assessments. - Staff should start assessments as soon as they identify a change in a resident, no exception. How will staff know if the resident became septic (if untreated, a localized infection, such as a UTI, can lead to infection in the bloodstream, wide spread inflammation, and septic shock) if they do not assess them. - There is a positive correlation between a resident's increased confusion, UTI, and increased risk of falls. During an interview on 7/3/15 at 11:05 A.M., the administrator said: - When the resident had any change in condition, she expected staff to assess the resident and document the assessment. - Staff should continue to assess the resident until the issue resolved. - The facility's protocol allowed the nurses to use nursing judgment and obtain a UA prior to contacting the physician. - She expected staff to fax abnormal UA results to the resident's physician and follow up with the physician, during office hours, to assure they received the lab. - If a physician did not respond, she expected staff to contact their office during the next shift, unless it was after office hours. - After office hours, she expected staff to contact the physician's office the next morning. - On holidays, weekends, or if the physician was out of the office she expected staff to contact the on-call physician.

Based on interviews and record reviews, the facility failed to provide the necessary care and services for two of two sampled residents (Residents #1 and #2) to attain their highest practicable mental and physical well being when staff failed to give Resident #1's [MEDICAL CONDITION] medication as ordered, failed to notify the pharmacy of medication dose changes, failed to notify the physician, in a timely manner, of the resident's [MEDICAL CONDITION], and failed to notify the physician of the resident's missed doses of [MEDICAL CONDITION] medications and/or refusal to take the [MEDICAL CONDITION] medications. The resident suffered a [MEDICAL CONDITION] that resulted in a subdural hematoma (a collection of blood between the outer layer and middle layer of brain covering, most often caused by a blow to the head). Staff failed to notify Resident #2's physician, in a timely manner, of elevated blood pressures and a fall resulting in injury, failed to notify the pharmacy of the resident's admission, and failed to obtain and give a high blood pressure medication as ordered. The facility census was 34. 1. Record review of Resident #1's care plan, dated 6/19/14, showed: - Problem - Resident had a risk of injury related to [MEDICAL CONDITION] disorder. - Goal - Resident will not injure himself/herself secondary to [MEDICAL CONDITION] disorder. - Approaches included - Administer medications as ordered. Review of a physician's orders [REDACTED]. - Increase [MEDICATION NAME] [MEDICATION]) 125 milligrams (mg) to three capsules in the A.M. and continue two capsules in the P.M. During an interview on 10/3/14 at 10:30 A.M., Pharmacy Technician (PT) A, who worked at Pharmacy A, said: - The pharmacy was open Monday through Friday, from 9:00 A.M. to 9:00 P.M., Saturday from 9:00 A.M. to 7:00 P.M., and Sunday from 10:00 A.M. to 6:00 P.M. - The pharmacy dispensed medications in bottles not bubble packs (a pre-packaged card of individual dose medications contained in clear plastic bubbles). - Staff called in the prescription number on the medication bottle and if that prescription had refills they dispensed the medication according to that prescription's instructions. - When a physician changed the dosage of medication the pharmacy needed a new prescription. - On 6/10/14 the pharmacy dispensed a thirty day supply of [MEDICATION NAME] 125 mg three capsules in the A.M. and two capsules in the P.M. (total of 150 capsules). Review of Registered Nurse (RN) B's nurses' notes, dated 6/20/14, showed: - At 7:00 A.M., staff found the resident on the floor. When RN B went to the unit the resident was up and walking, no injuries noted, and no signs or symptoms of pain. - At 4:00 P.M., staff found the resident on the floor with his/her back against the wall and called RN B to the unit. The resident stared straight ahead, would not speak, and was incontinent of urine. - At 4:10 P.M., received orders to send the resident to the emergency room (ER). - At 4:40 P.M., emergency medical services (EMS) transported the resident to the ER. Review of Hospital A's ER visit information, dated 6/20/14, showed: - [DIAGNOSES REDACTED]. - Increase [MEDICATION NAME] 125 mg to three capsules three times a day (TID). During an interview on 10/3/14 at 10:30 A.M., PT A said: - Facility staff did not inform the pharmacy staff of the 6/20/14 order that increased the [MEDICATION NAME] dosage. - On 6/30/14 staff called in a prescription number for a [MEDICATION NAME] refill. - The pharmacy dispensed a 30 day supply of [MEDICATION NAME] 125 mg take two capsules twice a day (BID), as those were the instructions associated with that prescription number, (120 capsules). Record review of the physician's orders [REDACTED]. - [MEDICATION NAME] 125 mg take three capsules (375 mg) TID, at 8:00 A.M., 12:00 noon, and 8:00 P.M., for [DIAGNOSES REDACTED]. - [MEDICATION NAME] solution 100 mg/ milliliter (ml) give 7.5 ml (750 mg) BID, at 8:00 A.M. and 6:00 P.M., for [DIAGNOSES REDACTED]. - [MEDICATION NAME] 50 mg once a day at 8:00 A.M., for [DIAGNOSES REDACTED]. During an interview on 9/26/14 at 5:50 P.M., the facility's consultant pharmacist said: - [MEDICATION NAME] had a narrow therapeutic range. - If the [MEDICATION NAME] level went over 100 it became toxic. - Physicians usually started residents on just [MEDICATION NAME] and if it did not control the [MEDICAL CONDITION] the physicians ordered other medications to augment (increase the effect) the [MEDICATION NAME]. The [MEDICATION NAME] and [MEDICATION NAME] increased the effectiveness of the [MEDICATION NAME]. - The fact that the resident was on three [MEDICAL CONDITION] medications indicates he/she needed them to control the [MEDICAL CONDITION]. Review of the resident quarterly Minimum Data Sets (MDS), a federally mandated assessment completed by facility staff, dated 8/4/14, showed: - Short- and long-term memory problems; - Moderately impaired cognitive skills for daily decision-making; - Clear speech, usually makes self understood and usually understands others; - Independent and did not require supervision for transfers, walking, dressing, eating, and personal hygiene; - Steady at all times while moving from a seated to standing position, walking, and transferring. - One fall with no injury since prior assessment; - [DIAGNOSES REDACTED]. During an interview on 9/25/14 at 12:40 P.M. Certified Medication Technician (CMT) A said: - Staff initialed the Medication Administration Record [REDACTED]. - Staff circled their initials to show they did not give a medication and wrote the reason on the back of the MAR. - At times the resident refused medications but that depended on the day and the staff giving the medications. Review of the MAR, dated 7/5/14 through 8/4/14, showed: - On 7/23/14 staff circled their initials for the 8:00 A.M., and 12:00 noon doses of [MEDICATION NAME]. Staff did not document a reason on the MAR. During an interview on 10/3/14 at 10:30 A.M., the PT A said: - On 7/23/14 the pharmacy dispensed 150 capsules of [MEDICATION NAME] 125 mg three capsules in the A.M. and two capsules in the P.M. - On 7/23/14, at 6:37 P.M., someone signed for and picked up the medication. Review of the MAR, dated 7/5/14 through 8/4/14, showed: - On 7/29/14 staff circled their initials for the 8:00 A.M. and 6:00 P.M., doses of [MEDICATION NAME]. Staff documented, on the MAR, the [MEDICATION NAME] was not available. - On 7/30/14 staff circled their initials for the 12:00 noon and 6:00 P.M., doses of [MEDICATION NAME] and the 8:00 A.M. dose of [MEDICATION NAME]. Staff did not document the reason on the MAR. - On 7/31/14 staff circled their initials for all three doses of [MEDICATION NAME] and did not document a reason on the MAR. Review of the nurses' notes, dated 7/23/14 through 7/31/14, showed: - No staff documented they notified the physician of the missed doses of [MEDICAL CONDITION] medication. Review of the Licensed Practical Nurse (LPN) A's nurse's note, dated 7/31/14, at 8:30 P.M., showed the resident's [MEDICATION NAME] was not available, he/she called Pharmacy A, sent someone to pick up the [MEDICATION NAME]. Review of the July 2014, For Your Information (FYI) letters showed no staff notified the physician or the family nurse practitioner (FN-P) that the resident did not receive the ordered doses of [MEDICAL CONDITION] medications. Review of the MAR, dated 7/5/14 through 8/4/14, showed: - On 7/31/14 no staff initialed to show they gave the 8:00 P.M., dose of [MEDICATION NAME]. - On 8/3/14 staff circled their initials for the 8:00 A.M. dose of [MEDICATION NAME]. On the MAR indicated [REDACTED].M. but did not circle their initials for the 8:00 A.M., doses of [MEDICATION NAME] and [MEDICATION NAME]. Review of the POS [REDACTED] - [MEDICATION NAME] 125 mg take three capsules at 8:00 A.M., 12:00 noon, and 8:00 P.M. - [MEDICATION NAME] solution 7.5 ml twice a day, at 8:00 A.M. and 6:00 P.M. - [MEDICATION NAME] 50 mg at 8:00 A.M. Review of the MAR, dated 8/5/14 through 9/4/14, showed: - On 8/5/14 staff circled their initials for the 12:00 noon and 8:00 P.M., doses of [MEDICATION NAME]. Staff documented the resident refused the 8:00 P.M., medications, but no staff documented why they did not give the 12:00 noon dose. Review of nurses' notes showed: - On 8/5/14 at 8:00 P.M., the resident spit the medications out and refused to take them. - No staff documented they notified the physician that the resident refused the [MEDICAL CONDITION] medication. Review of the MAR, dated 8/5/14 through 9/4/14, showed: - On 8/6/14 staff circled their initials for the 8:00 A.M., doses of [MEDICATION NAME], and [MEDICATION NAME]. Staff documented they could not wake the resident. - On 8/7/14 staff did not initial to show they gave the 12:00 noon dose of [MEDICATION NAME]. - On 8/8/14 staff circled their initials for all doses of [MEDICATION NAME], and [MEDICATION NAME]. Staff documented they could not wake the resident for the 8:00 A.M. medications and the resident refused the 12:00 noon and 8:00 P.M. medications. - On 8/9/14 staff circled their initials to show they did not give the 8:00 A.M. dose of [MEDICATION NAME]. No staff documented, on the MAR, why they did not give the medication. Review of nurses' notes showed: - On 8/9/14 at 3:30 A.M., the resident refused the 8:00 P.M. medications. - No staff documented they notified the physician that the resident refused the [MEDICAL CONDITION] medications from 8/6/14 to 8/9/14. During an interview on 10/1/14 at 5:41 P.M., LPN A said: - He/she worked as the charge nurse on the night shift. The night shift started on 8/9/14 and ended on 8/10/14 so the date on the FYI and nurses' note are different. - The resident had two [MEDICAL CONDITION] during the shift. He/she wrote the FYI and put it on the nurses' clipboard. Since 8/9/14, was a Saturday he/she knew staff could not fax it to the office on Sunday so just left it for Physician A or the FN-P to address on their next rounds. - FN-P- A made rounds, at the facility, on Monday, Tuesday, and Friday. - Staff cannot call Physician A or the FN-P after 5:00 P.M. on office days or at all on weekends and holidays. - The nurses are supposed to call the hospital for the assigned on-call physician after 5:00 P.M. on weekdays and all hours on weekends and holidays. - Physician A did not want staff to fax the FYI to the office after office hours. -The hospital on-call physicians do not know the residents so unless he/she needed to send a resident to the ER he/she just put the FYI on the clipboard. - If he/she needed to send a resident to the ER he/she called the hospital on-call physician. Review of the LPN A's nurse's note, dated 8/10/14, at 3:30 A.M., showed: - The resident had two [MEDICAL CONDITION] that shift. During the second [MEDICAL CONDITION] the resident's head hit the wall and caused him/her to go limp. No signs of pain or injury noted. Resident in bed for a couple of hours then resumed pacing with intermittent rest periods, and then finally went to bed at 2:30 A.M. Review of an LPN A's FYI letter, dated 8/9/14, showed: - The resident had a [MEDICAL CONDITION] while walking that caused him/her to fall to the floor, denied pain, no injuries noted, neuro checks (a brief neurological assessment of vital signs, level of consciousness, pupil response, and movement of extremities). - The FYI did not show any fax stamps. - On 8/11/14 FN-P B ordered a [MEDICATION NAME] level. - RN B noted the order on 8/11/14. Review of the MAR, dated 8/5/14 through 9/4/14, showed: - On 8/10/14 staff circled their initials for the 8:00 A.M. doses of [MEDICATION NAME], and [MEDICATION NAME] and documented the resident refused the medications. Staff circled their initials for the 6:00 P.M., dose of [MEDICATION NAME] and did not document a reason on the MAR. Review of nurses' notes, dated 8/10/14, showed: - No staff documented they notified the physician that the resident refused the [MEDICAL CONDITION] medication. During an interview on 9/26/14 at 3:53 P.M., the resident's guardian said: - He/she had several clients and did not recall any conversation with any staff that the resident missed or refused doses of [MEDICAL CONDITION] medications. - He/she noted when staff called and documented the information. - He/she read the documentation aloud and it did not show that staff notified him/her of the resident's missed or refused [MEDICAL CONDITION] medications. - He/she may have missed making a note but felt he/she would remember something that important and would ask for a [MEDICATION NAME] level. - On 8/10/14 RN B called and said the resident fell and hit his head and he/she asked if the resident needed a [MEDICATION NAME] level. Review of RN B's nurse's note, dated 8/10/14, at 2:10 P.M., showed he/she notified the resident's guardian of the fall. Review of RN B's FYI letter, dated 8/11/14, showed: - Resident had [MEDICAL CONDITION] activity yesterday. Could we get an order for [REDACTED]. - A fax stamp shows staff faxed it to Physician A's office on 8/11/14 at 6:23 A.M. - The physician wrote yes, and faxed the response on 8/11/14 at 3:00 P.M. - The FYI showed RN B noted the order on 8/11/14. Review of RN B's nurse's note, dated 8/11/14, showed: - New order for [MEDICATION NAME] level and notified the guardian of the new orders. - At 2:10 P.M. called to the unit and resident was on the floor leaning on CMT A. CMT A was in the dining room, heard the resident fall, and found the resident on the floor in front of the couch. No injuries noted, pupils reactive, and hand grasps equal. Three staff transferred the resident to the couch. Noticed resident's right eye and right side of mouth drooping. - At 2:15 P.M. called FN-P B and orders to send to ER. - At 2:20 P.M. called EMS and called report to ER. - At 2:35 P.M. EMS staff transported resident to hospital. Review of the facility's August 2014, FYI letters, showed no staff notified the physician or FN-P that the resident did not receive the ordered doses of [MEDICAL CONDITION] medication. Review of the resident's discharge assessment MDS, dated [DATE], showed: - One fall with major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma). Review of Hospital B's history and physical, dated 8/11/14, showed: - The nursing home nurse told EMS he/she was pretty sure the resident had a [MEDICAL CONDITION] and some facial droop. The nurse aide said the resident was very lethargic, which was not normal as he/she usually got up immediately and was hyper after a [MEDICAL CONDITION]. - EMS transported the resident to Hospital A, where they did labs and a computed tomography scan of the head (CT, computerized cross sectional images of the brain). The [MEDICATION NAME] level was 78.2 microgram/milliliter (ug/ml) with a reference range of 50-100 ug/ml. The CT showed subfalcine herniation (a prolapse of part of the brain caused when the brain is under high pressure). - The resident was transferred to Hospital B and underwent burr hole drainage (a surgery to remove blood clots near the brain) of the left side subdural hematoma and monitored in the intensive care unit. During a joint interview on 9/29/14 at 2:20 P.M., the administrator and director of nursing (DON) said: - Staff should fax or call the medication prescription number to the pharmacy for a refill when the resident had seven doses left - The DON did not know if staff told her the resident ran out of [MEDICATION NAME] in July 2014. She expected staff to order the medications so they do not run out. If staff ran out of a medication they should send someone to the pharmacy to pick up the medication. Staff should make attempts to resolve medication problems with the pharmacy and if they are unable to resolve the problem they should inform her. Staff told her they had problems getting the resident to take medications but not specific medications. She did not tell the physician the resident refused medications. She did not know if staff informed the physician the resident refused medications. - The administrator expected staff to notify the physician if a resident missed or refused consecutive doses of any medication. - Both said if staff informed the physician of the missed or refused medications they should document it in the nurses' notes or on a FYI. - Physician A made rounds each week, but just saw each resident quarterly unless a specific issue warranted seeing the resident. If staff wanted the physician to see a resident for a specific issue staff documented the issue on an FYI. FN-P A made rounds twice a week. - Staff should notify the physician if a resident had a significant change in status, an injury, abnormal vital signs, or abnormal laboratory results; otherwise it is a nursing judgment for staff to either notify the physician or write out an FYI. - Staff should write an FYI and put it in the physician's folder and either FN-P or Physician A reviews the FYI on rounds. If a resident required immediate attention staff should call the physician / FN-P or the hospital on-call physician. - Staff should have contacted the hospital on-call physician on 8/9/14 about the resident's [MEDICAL CONDITION]. During an interview on 9/26/14 at 4:35 P.M., Physician A said: - He/she did not understand how staff determined when to notify the physician. - It seemed the facility left it to each nurse's discretion whether or not to notify the physician. - The facility has a problem with their system for notifying physicians. Staff did not seem to know when to notify him/her. - Staff should inform the DON about each issue, she should direct staff on how to handle those issues. - [MEDICATION NAME] is a primary medication you cannot just run out of it. - If staff ran out of [MEDICATION NAME] in July, the facility has a pharmacy system problem. - Staff should have notified her/her when the resident missed doses of the [MEDICAL CONDITION] medication. If staff had notified him/her of missed or refused [MEDICAL CONDITION] medication doses he/she would have ordered a [MEDICATION NAME] level. If staff did not document notifying him/her it was not done. - He/she increased the dosage of [MEDICATION NAME] in June because the resident's level was low. - He/she checked the [MEDICATION NAME] level on 7/9/14 and it had increased to 78.2 ug/ml; and it was not checked again until 8/11/14 and it was also 78.2 ug/ml. If the MAR indicated [REDACTED]. 2. Review of Resident #2's admission MDS, dated [DATE], showed: - admitted [DATE]; - Brief interview for mental status score of 13 (a score of 13-15 indicated a resident as cognitively intact); - Clear speech, makes self understood and understands others; - Required assist of one staff for transfers and supervision with ambulation; - Falls prior to admission; - Two or more falls since admission with no injury; - One fall with injury since admission; - [DIAGNOSES REDACTED]. Review of the POS [REDACTED] - [MEDICATION NAME] ER (extended release medication to treat high B/P) 240 mg capsule daily at 8:00 A.M.; - [MEDICATION NAME] 40 mg daily (high B/P medication) at 8:00 A.M.; - [MEDICATION NAME] 50 mg (high B/P medication) twice a day at 8:00 A.M., and 8:00 P.M., - Notify primary care physician (PCP, Physician A) if the systolic blood pressure (S B/P, the top number in the blood pressure reading) is less than 80 millimeters of mercury (mmHg) or greater than 180 mmHg, diastolic blood pressure (D B/P, the bottom number in the blood pressure reading) is less than 30 mmHg or greater than 110 mmHg. During an interview on 10/1/14 at 8:04 P.M., LPN B said: - On 9/3/14 (Wednesday), at 6:30 P.M., the resident fell . - He/she wrote an FYI about the fall and put it on the nurses' clipboard for Physician A or FN-P A to see on their next rounds. - He/she always filled out an FYI and put it on the clipboard for rounds unless a resident had an injury, needed to go to the ER for stitches, or the family wanted the resident sent to the ER. - PCP notified meant he/she wrote a FYI and put it on the clipboard. Review of LPN B's nurse's note, dated 9/3/14, at 6:30 P.M., showed: - Resident fell , B/P 190/76 mmHg, and no injury noted at this time. - Neuro checks within normal limits (WNL). - Resident said he/she lost his/her balance. - PCP notified, DON notified, and family notified. Review of the neurological assessments showed: - On 9/3/14, at 6:30 P.M., a B/P of 190/76 mmHg and at 6:45 P.M., a B/P of 170/80 mmHg. - On 9/4/14, at 11:00 P.M., a B/P of 210/106 mmHg. During a telephone interview on 10/1/14 at 8:04 P.M., LPN B said: - On 9/4/14 at 11:00 P.M., he/she documented the resident's B/P as 210/106 mmHg and WNL because his/her B/P ran high. - On 9/5/14 at 3:00 A.M., he/she checked the resident's B/P and documented it on the neuro sheet, and 218/112 mmHg sounded correct. - He/she did not notify anyone of the B/P because he/she thought the physician had increased the resident's B/P medication. He/she checked the resident's chart, during the interview, and said the physician had not just increased the medication. - He/she wrote an FYI and put it on the clipboard because that was the facility's protocol. Staff did not call the resident's physician after office hours. - If he/she needed to send a resident to the hospital he/she called the hospital on-call physician. Review of the LPN B's nurse's note, dated 9/5/14 at 2:30 A.M., showed: - The resident remained on neuro checks due to a fall, B/P 210/106 mmHg, neuro checks WNL. Review of the neurological assessments showed: - On 9/5/14, staff documented they took the resident's B/P five times, at 3:00 A.M., a B/P of 218/112 mmHg, at 7:00 A.M., a B/P of 159/85 mmHg, at 11:00 A.M. a B/P of 188/96 mmHg, at 3:00 P.M. staff documented they could not obtain a B/P, and on the 10:00 P.M. to 6:00 A.M., shift staff recorded a B/P 209/107 mmHg. Review of the nurses' notes, dated 9/6/14, at 1:45 A.M., showed staff documented a B/P of 209/107 mmHg. Review of the neurological assessments, dated 9/6/14, showed: - On the 6:00 A.M., to 2:00 P.M., staff documented a B/P of 141/89 mmHg. - On the 2:00 P.M., to 10:00 P.M., shift staff documented the resident fell again and restarted neuro checks. During an interview on 10/1/14 at 5:41 P.M., LPN A said: - He/she wrote the 9/6/15 (Saturday), FYI because he/she was concerned about the resident's high B/P. - He/she called the DON, either during the night or the next morning, for advice and to let her know that the hospital on-call physician would not know the resident. He/she told the DON if the resident had any complication he/she would send her to the ER and call the on-call physician. The DON agreed that he/she should just monitor the resident. - He/she checked on the resident, did neuro checks and wrote the FYI. - He/she told the certified nurse aides (CNA) to check on the resident each time they passed the room and during any down time. - Staff cannot send faxes to the physician's office during the night. - He/she did not call a physician, he/she wrote physician notified, in the nurse's note, because he/she wrote an FYI and put it on the clipboard for the physician's or FN-P's rounds. - Staff cannot call the physician after 5:00 P.M. so since he/she worked the night shift, he/she always wrote concerns on a FYI, and told the oncoming nurse. - He/she would call the ER if he/she saw the resident had one sided weakness, face droop, and any signs of a [MEDICAL CONDITION]. - On 9/7/14 (Sunday), he/she told RN B, the oncoming nurse, about the resident's B/P, that he/she was in line for a stroke or [MEDICAL CONDITION], to continue monitoring him/her, and to get the FYI to the physician on Monday (9/8/14), even if the B/P went down. Review of the LPN A's nurse's note, dated 9/7/14 at 3:00 A.M., showed: - The resident fell at the beginning of the shift at 6:45 P.M. (9/6/14), B/P 210/130 mmHg and denied pain. - The resident complained of being dizzy, B/P high, and physician notified. - Checked resident every 30 minutes to check for dizziness, offer fluids and toileting. Review of LPN A's FYI, dated 9/6/14, showed: - B/P of 210/130 mmHg. - Resident fell , stated he/she slipped out of the chair, and complained of dizziness. - Denied pain and no injuries noted. - Neuro checks started and B/P's high at 200/108 mmHg, 192/99 mmHg, 200/99 mmHg, 194/102 mmHg, 179/93, and 122/107 mmHg. - On 9/8/14 FN-P documented the B/P as 195/85 mmHg and ordered to increase the [MEDICATION NAME] to 100 mg in the A.M., and 50 mg in the P.M. Review of the neurological assessments, dated 9/6/14, showed: - At 6:45 P.M., a B/P of 210/130 mmHg; - At 7:00 P.M. a B/P of 200/108 mmHg; - At 7:15 P.M. a B/P of 192/99 mmHg; - At 7:30 P.M. a B/P of 200/99 mmHg; - At 8:00 P.M. a B/P of 194/102 mmHg; - At 8:30 P.M. a B/P of 179/93 mmHg; During an interview on 10/1/14 at 7:52 P.M., RN B said: - He/she did not remember that staff said anything about the resident the weekend of 9/6/14. - The facility did not use 24 hour report sheets so he/she could not check to see what staff told him/her in report. - He/she checked the resident's B/P every morning, before he/she gave the B/P medications, and the resident's B/P ran high every morning. - The staff put FYIs on a clipboard and the physician or FN-P addressed them on rounds. Review of the neurological assessments, dated 9/7/14, showed: - At 12:30 A.M., a B/P of 192/67 mmHg; - At 4:30 A.M. a B/P of 198/92 mmHg; Review of the RN B's nurse's note, dated 9/7/14 at 8:30 A.M., showed: - Resident continues on fall follow-up with neuro checks, B/P 181/90 mmHg WNL for resident. - Resident denied pain, nausea, and dizziness. - Will continue to monitor. Review of the neurological assessments, dated 9/7/14, showed: - At 8:30 A.M. a B/P of 181/90 mmHg; - At 12:30 P.M. a B/P of 152/80 mmHg; - At 4:30 P.M. a B/P of 176/88 mmHg; - On the 10:00 P.M. to 6:00 A.M. shift B/P of 179/79 mmHg. Review of the neurological assessments, dated 9/8/14, showed: - On the 6:00 A.M. to 2:00 P.M. shift a B/P of 185/95 mmHg; - On the 2:00 P.M. to 10:00 P.M. shift a B/P of 170/90 mmHg; - Staff wrote the resident fell at 6:30 P.M. Review of a nurses' note, dated 9/8/14, showed: - At 2:00 A.M., the resident complained of ankle pain and B/P of 179/77 mmHg. - At 10:30 A.M. a B/P of 185/95 mmHg, no complaints of pain, nausea, or dizziness, and will continue to monitor. - At 1:40 P.M., new order received to discontinue the [MEDICATION NAME] 50 mg and start [MEDICATION NAME] 100 mg in the A.M. and 50 mg in the P.M. - At 7:00 P.M., the resident fell at 6:30 P.M., sustained a left eye bruise and goose egg. B/P 180/90, neuro checks WNL. Ice pack applied to left eye bruise and goose egg. Moves extremities without difficulty, will monitor. Family member, DON, and PCP all notified. Review of the MAR, dated 9/5/14 to 10/4/14, showed: - Staff circled their initials for the A.M. dose of [MEDICATION NAME] and documented on the back that the medication was not available and they ordered it from Pharmacy A. During an interview on 10/3/14 at 10:30 A.M., PT A said: - The facility did not notify the pharmacy when they admitted a resident that used that pharmacy. - Physician ordered a certain number of refills with each prescription. The resident's prescription for [MEDICATION NAME] 50 mg twice a day ended on 8/30/14. - On 9/5/14 Physician A's office called in a prescription for [MEDICATION NAME] 50 mg twice a day. The pharmacy filled the prescription on 9/5/14. The pharmacy staff did not notify the facility because the facility did not notify them they admitted the resident. - The facility did not send them any information for the 9/8/14 increased [MEDICATION NAME] dose. - On 9/9/14 at 10:20 A.M., someone picked up the [MEDICATION NAME] 50 mg twice a day. During an interview on 10/1/14 at 8:04 P.M., LPN B said: - The resident fell on [DATE] at 6:30 P.M., and had a bruised left eye and goose egg. - He/she had a B/P of 180/90 mmHg. - When he/she wrote PCP notified it meant he/she wrote a FYI and put it on the nurses' clipboard Review of LPN B's fall report, dated 9/8/14 at 6:30 P.M., showed: - Staff found the resident on the floor with his/her walker turned on its side. - The resident said he/she lost his/her balance and fell . - The resident had a bruised face and eye. - B/P 180/90 mmHg; - In response to the question, "Was the physician notified?" Staff circled yes, and entered Physician A's name, 9/8/14, at 6:30 P.M. - In response to the question, "If not, please explain." Staff wrote FYI. Review of LPN B's FYI, dated 9/8/14, showed: - Resident fell at 6:30 P.M., and sustained a left eye bruise and goose egg, no other injuries noted. - B/P 180/90 mmHg; - On 9/9/14 FN-P A wrote an order for [REDACTED]. Review of nurses' note, dated 9/9/14 at 5:00 P.M., showed: - Staff sent the resident to the ER for high blood pressure. - At 4:30 P.M. the resident's B/P was 162/95 mmHg and a 4:35 P.M., a B/P of 196/131 mmHg. - Received telephone order to send resident to ER per family's request. - Family transported the resident to the ER. Review of LPN A's nurse's note, dated 9/9/14 at 9:00 P.M., showed: - ER staff called and said they admitted the resident for observation, the resident had a stroke sometime in the last seven to ten days, and his/her B/P is down. During an interview on 10/2/14 at 2:00 P.M., FN-P A said: - He/she had concerns that staff did not know when to notify him/her. - Staff should call him/her if a resident had an elevated blood pressure. - If a resident with a [DIAGNOSES REDACTED]. - The staff had his/her phone number and he/she told staff to call him/her with questions. - If he/she was out of town staff should call the hospital on-call physician. - He/she told staff if something was important enough to fax him/her then they should call him/her. - He/she told staff when he/she ordered a medication, it did not mean to wait until tomorrow to start the medication. - When staff wrote PCP notified, it looked like they called him/her and he/she did not give any orders. - When staff put an FYI in the folder or on the clipboard that is not notifying me at the time of the incident. During an interview on 10/2/14 at 3:10 P.M., the administrator said: - The pharmacy was a little over a mile away. - She expected staff to order medication and send someone to pick it up in time to give the ordered dose. - Staff should have called the on-call physician when the resident's blood pressure was elevated. - She thought when staff documented PCP notified they actually called the physician and she wondered why the physician did not give orders. Review of the physician's discharge summary, dated 9/12/14, showed: - Discharge Diagnoses: [REDACTED]. - admitted through ER for increased frequency of falls, high blood pressure, and intermittent confusion. - A CT scan showed a sub acute/chronic right frontal (front part of the brain) stroke. MO

Based on observation, interview and record review, the facility failed to ensure staff implemented interventions to prevent falls and failed to update interventions on the care plan for one of nine sampled residents (Resident #3) who sustained injuries from a fall when staff left him/her alone in the bathroom. This had the potential to affect all residents at risk for falls. The facility census was 40. 1. Review of the facility's undated policy entitled, "Resident Care Plan," showed: -The results of the comprehensive assessment are used to develop, review and revise residents' comprehensive plans of care. -Sources of concerns or problems include, but are not limited to: problems related to diagnoses, physician orders, mental deficits, behavior and mood state, physical deficits, preventative care, provision of safety, and all problems identified on all assessments. -Individualize care for the unique needs of the resident. -Communicate vital information to all staff providing direct resident care. -List safety measures. -List preventative measures. -The care plan must be reviewed and revised (updated) as necessary, but at least every three months. Problems, goals and approaches must be reviewed and revised when appropriate and necessary, three months is the maximum time limit for care. Three months may be too long and not reasonable for certain short-term goals. Care plans may need to be revised when new orders are obtained. -Note: Remember the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consonant with the physician's plan of care for the resident. Review of the instructions for the facility's Fall Risk Assessment form showed: -Assess the resident status upon admission and quarterly (at a minimum) thereafter; -A prevention protocol should be initiated immediately and documented on the care plan. 2. Review of the resident's care plan for falls updated 7/25/12, by staff showed: -Problem: At risk for falls, adverse reactions and/or injury due to [DIAGNOSES REDACTED]. -Goal: Will remain free of injury and/or adverse reactions through next review; -Approaches included: Personal body alarm on at all times, Medications as ordered, Pharmacy consult, Encourage to lay down between meals as resident will allow, Mobile per wheelchair as desired; Fall risk assessment, mini mental and depression scale quarterly and as needed, Falling leaf program, Encourage activities, Staff to monitor for side effects and/or adverse reactions to Haldol (an antipsychotic medication) and notify physician of changes; -Staff drew a line through the following intervention: Ambulates short distances with one assist and use of gait belt. Staff then documented: Stand-by assist; -No other interventions or changes added. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/10/12, showed: -Long- and short-term memory impairment; -Severely impaired decision-making skills; -Behaviors included wandering; -Required supervisory assistance of one for ambulation in the room; -Supervisory assistance of one for ambulation in the hall; -Frequently incontinent of bowel and bladder; -Received antipsychotic medication; -Had no falls. The resident's Fall Risk Assessment for 10/10/12, showed: -Disoriented at all times; -No history of falls; -Ambulatory/Incontinent; -Had a balance problem while standing and walking; -Had decreased muscular coordination; -Jerking or unstable when making turns; -No drops in blood pressure between lying and standing; -Took 3-4 of the following medications within the last 7 days: anesthetics, antihistamines, antihypertensives, anti-seizure, benzodiazepines, cathartics, diuretics, hypoglycemic, narcotics, psychotropics, sedatives/hypnotics; -Total score of 14 (Total score above 10 represents High Risk). Review of Resident #3's Post Fall Investigation Report dated 1/4/13, showed: -No falls in past 12 months; -Identified on care plan as high risk for falls; -Postural hypotension or dizziness listed as a contributing factor; -Fall was witnessed with no injury; -Resident lost his/her balance when stood up from the couch in the main dining room, stumbled and fell ; -Received psychotropic and antihypertensive medication; -Preventative measures at the time of the fall included a low bed, no body alarm; -Initial and follow-up assessments initiated; -Fall Risk Reassessment completed-Staff marked "yes;" -Plan of care for falls completed-Staff marked "yes;" -Findings (Summarize factors identified as contributing to and/or causing the fall(s). Then describe planned systemic interventions/changes): Resident lost his/her balance getting up from the couch in the dining room and fell on to the floor. No injuries found. Orthostatic blood pressures completed and there was a drop in blood pressure. Physician notified of fall and blood pressure drop. The resident's Fall Risk Assessment for 1/8/13, showed the same information as the 10/10/12, assessment and also included: -Had a change in gait pattern when walking through doorway; -Total score of 15. - Further review of the residents Fall Risk Assessments showed staff documented no Fall Risk Assessments after 1/8/13. Review of the resident's Post Fall Investigation Report dated 1/18/13, showed: -Falls in the past 12 months: 1/4/13; -Identified on care plan as high risk for falls; -Contributing factors included postural hypotension or dizziness, call light off, improper footwear; -Occurred in resident's room, un-witnessed; -Received psychotropic and antihypertensive medications; -Had issues with orthostatic hypotension and the physician was adjusting medications; -Fall un-witnessed; -Staff heard a door hit the wall and heard the resident holler; -Found resident on his/her back on the floor in his/her doorway; -Assessment and neuro checks initiated; -No injury found; -Preventative measures in place at the time of the fall included a low bed, no body alarm; -Fall Risk Reassessment completed-Nothing marked; -Plan of care for falls completed-Nothing marked; -Findings: Believed the resident got up from the bed and his/her blood pressure dropped and he/she fell . Orthostatic blood pressures (blood pressures taken while lying, the sitting, then standing to see if, and how much, the person's blood pressure drops) reported to the physician and medication was being adjusted. Resident also did not have proper foot wear on. We will continue to work with the physician pertaining to the drop in blood pressure. Review of the resident's Post Fall Investigation Report dated 1/25/13, showed: -Falls in the past 12 months included: 1/4/13 and 1/18/13; -Identified on the care plan as high risk for a fall; -Contributing factors included need for bathroom and legs gave out; -Occurred in the hallway accompanied by staff who lowered resident to the floor with a gait belt; -No injury; -Received psychotropic and antihypertensive medications; -Fall Risk Reassessment completed-Nothing marked; -Plan of care for falls completed-Nothing marked; -Resident health care status change prior to this fall-mass found in lungs; -Findings: Resident's legs gave out during ambulation. Resident lowered to floor by CNA with gait belt. No injuries noted, put in wheelchair. Review of the resident's Post Fall Investigation Report dated 2/17/13, showed: -Falls in the past 12 months included: 1/4/13, 1/18/13, and 1/25/13; -Identified on the care plan as high risk for a fall; -Contributing factors included need for bathroom, call light off, non-compliant resident, and left alone in the bathroom; -Fall un-witnessed; -Resident fell on his/her face in his/her bedroom trying to transfer self from bathroom to bed; -Received psychotropic and antihypertensive medications; -Health care status changes prior to fall included placed on hospice for mass in lungs; -Safety measures or fall prevention interventions in place prior to the current fall- Staff marked "yes;" -Were measures/interventions carried out as per the care plan- Staff marked "no" with explanation that the resident was left in the bathroom alone; -Preventative measures at the time of the fall included: a low bed and mattress on floor, nothing marked related to an alarm; -Fall Risk Reassessment completed-Marked "yes;" -Nothing marked for Plan of Care for Falls Completed; -Initiated assessment, including neuro checks, and follow-up assessments; -Had a laceration to the cheek; -Notified physician and family and called the ambulance and sent to the emergency room ; Findings: Believed leaving the resident alone in the bathroom was a contributing factor in the fall. Staff disciplined. Review of Certified Nurse Aide (CNA) C's written statement related to Resident #3's fall on 2/17/13, dated 2/17/13, showed: -He/she took the resident to the bathroom; -Left to assist another resident to the bathroom, and before he/she returned, the resident got off the toilet and attempted to take him/herself to bed; -The CNA heard the resident hit the ground; -Went immediately to the resident and found him/her laying prone on the right side of his/her face; -Paged for assistance, the nurse assessed the resident, then the CNA and nurse assisted the resident into a wheelchair; -They cleaned the resident, took vital signs, and stayed with the resident until the ambulance arrived. Review of the resident's nurse's notes dated 2/17/13, showed: -2:20 P.M.-Assistant Director of Nurses (ADON) answered a call from the Special Care Unit (SCU) related to a fall with a resident bleeding; -Found the resident on the floor at the foot of his/her bed with feet toward the room door; -He/she was lying face down with the right side of his/her face on the floor; -CNA C and the ADON assisted the resident to his/her knees then to a wheelchair; -The resident had blood all over his/her face and she noted a moderate sized pool of blood on the floor; -She found a large laceration to the right cheek and moderate amount of bleeding from the cheek, eyebrow area and nose; -Another nurse initiated first aid while the ADON contacted the ambulance to transport to the emergency room ; -CNA C reported he/she was attempting to re-direct another resident who was attempting to exit SCU, and on return, found Resident #3 on the floor; -Incident occurred around 1:30 P.M. -4:45 P.M.-Nurse received report from the emergency room nurse that the resident sustained [REDACTED]. -Resident was on hospice and family chose not to treat; -emergency room nurse said the next 72 hours were the most critical to monitor for change in condition; -Resident had sutures on the right cheek and temporal (side of head near eyebrow) area; -6:00 P.M.-Resident returned to the facility transported by family; -Resident had bruising on the right shoulder, left thumb, left upper arm and bruising throughout arms with sutures to right cheek and temporal area and dressing intact. Review of the resident's significant change MDS, dated [DATE], showed: -Long- and short-term memory impairment; -Moderately impaired decision-making skills; -Supervision assistance of one staff for ambulation in the room; -Limited assistance of one for ambulation in the hall; -Frequently incontinent of bowel and bladder; -No falls; -Received antipsychotic medication. Review of the resident's nurse's notes dated 2/22/13, showed staff received an order to discontinue Lisinopril (a blood pressure medication). Review of the resident's Post Fall Investigation Report dated 3/4/13, showed: -Occurred at 12:30 P.M. in resident's room; -Falls in the past 12 months included: 1/4/12, 8/11/12, 1/18/13, 1/25/13, and 2/17/13; -Identified on the care plan as high risk for a fall; -Do you see any patterns with falls?-Marked Not Applicable; -Contributing factors-Non-compliant resident-Confusion; -Found on floor beside bed, appeared to have bumped head/face on dresser; -Preventative measures included: Mattress on floor, Call light off, Alarm-Sounding; Low bed-No; -Gave resident food and fluids at noon and put to bed at 12:15 P.M.-Did not indicate that the resident was toileted before he/she went to bed; -Injury showed as skin tear right upper arm and re-opened right cheek laceration; -Resident assessed, ice pack applied, neuro checks initiated, cleansed and dressed wounds, and placed in bed; -Ordered a hi/low bed and re-arranged room so resident couldn't hit anything; -Other contributing factors: Need to offer toilet before lying down due to resident asked to use the bathroom while nurse dressed arm; -Resident received psychotropic medications; -Witness stated he/she just laid the resident down after eating; -Were safety measure or fall prevention interventions in place prior to the fall?-Staff marked "yes;" -Were measures/interventions in the care plan?-Staff marked "yes;" -Were the measures/interventions carried out as per the care plan?-Staff marked "yes;" -Findings: Resident had advanced dementia, non-compliant with calling for assistance with transfers. High-low bed ordered, re-arranged furniture. Review of the resident's care plan showed no new updates for fall interventions since 7/25/12. Observation on 3/12/13, at 11:12 A.M., showed the following: -Resident #3 lay in bed on his/her back with eyes closed; -Personal alarm on; -Hi/lo bed in low position with the right side against the wall; -Fall mats on the floor from the head of the bed to the foot of the bed; -Above the resident's bed hung a sign entitled "Care Plan Communication" that said: Please take to the bathroom before bed, Fall mat X2 while in bed, Lower bed completely, and Check fall alarm and place under shoulder; -Dressing dry and intact to right cheek. During an interview on 3/13/13, at 11:50 A.M., CNA C said staff should do the following to prevent resident falls: -Toilet frequently, at least every 2 hours; -If restless, offer fluids and toilet; -Talk with and interact with residents. Don't ignore them; -Ask residents what they need; -Assist with seating changes, such as from the wheelchair to the couch During an interview on 3/14/13, at 7:30 A.M., the ADON verified the information in her nurse's note from 2/17/13, and said: -Thought CNA C told her he/she left Resident #3 in the bathroom because another resident was at the exit door trying to leave the unit; -Didn't remember if she heard the door alarm sound. During an interview on 3/14/13, at 10:40 AM, CNA C said the following related to Resident #3's fall on 2/17/13: -The resident never tried to walk out of the bathroom before; -He/she occasionally tried to stand up in the bathroom; -While he/she assisted Resident #3 in the bathroom, CNA C heard a body alarm sound down the hall and left to check that resident who was trying to self transfer in his/her bathroom; -CNA C assisted the second resident to the toilet and gave him/her the call light, as he/she knew this resident would use it; -CNA C started back to Resident #3's bathroom when he/she saw a third resident at the double door exit holding on to the door handles, trying to pull him/herself up from his/her wheelchair; -CNA C assisted the third resident back into the wheelchair to prevent him/her from falling and took this resident to his/her room; -As CNA C returned to Resident #3, he/she heard the resident hit the floor; -These activities occurred around 1:30 P.M., right after meal time when residents tended to need increased assistance to the bathroom and to bed; -He/she was the only staff in the SCU; -He/she didn't have time to call staff outside the SCU as each incident happened so quickly; -Each of the other residents he/she assisted was also at risk for falls; -He/she never received any instruction related to how staff should handle multiple resident needs that occurred at the same time with only one staff available; -Since the 2/17/13, fall the DON instructed him/her never to leave a resident in the bathroom unattended, even if another resident's body alarm sounded; -Staff tried walkie-talkies to communicate between SCU and other facility staff in the past, but for one reason or another, they quit using them; -He/she understood that the facility would start staffing two persons in the SCU soon. 3. During an interview on 3/13/13, at 5:00 P.M., the Director of Nurses (DON) said: -No resident who had a cognitive deficit, especially if on the Alzheimer's SCU, should be left alone in the bathroom; -It surprised him that CNA C left Resident #3 in the bathroom unattended as he/she worked at the facility [AGE] years without any past problems with care; -The facility did a weekly QA (Quality Assurance) meeting and reviewed each fall from the previous week; -Staff present from each department discussed potential interventions to implement; -He didn't realize or know why the resident's fall care plan contained no updated interventions. During an interview on 3/14/13, at 6:15 A.M., the DON said: -He remembered one fall intervention staff implemented was to check orthostatic blood pressures, which they did, and found the resident's blood pressures decreased when he/she stood; -They obtained an order to hold the blood pressure medication, and the physician later discontinued it; -Not sure why not documented on the resident's care plan. The facility provided no policy specific to falls and fall prevention. MO

"This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 3/14/13." Based on observation, interview and record review, the facility failed to ensure staff monitored nine of ten residents who resided on the special care unit (SCU-a locked unit specialized in the care of residents diagnosed with [REDACTED]. The facility failed to supervise one resident (Resident #18) who the facility identified at risk for falls. This had the potential to affect 10 of 10 residents who reside on the SCU. The facility census was 39 residents. 1. During an interview on 5/1/13 at 2:30 P.M., the acting administrator said the facility did not have a policy to address staffing needs on the special care unit (SCU). She said if SCU staff needed to go into a resident's room to provide care, then before going into the room, they should call for someone to come to the SCU to watch the other residents who also live on the SCU. 2. Review of Resident #18's current care plan dated 1/23/13 showed the resident was at risk for injury related to falls. The goal was the resident would remain free of fall related injury by the next review date. The approaches included the following: - 1/23/13: Maintain room free of clutter; ensure well fitting shoes are on when resident is ambulating, monitor for changes in ambulation status and report to MD immediately, administer medications per order, and monitor for side effects/adverse reactions to medications - 2/1/13: Offer to assist resident to bed after meals. - 4/4/13: Body alarm applied, fall mat on floor, orthostatic blood pressures (blood pressure checked lying down, sitting and standing) every shift for 24 hours. - 4/5/13: Two hour toileting schedule.. - 4/12/13: Helmet to keep from getting injured - 4/17/13: Hip protectors, Restorative aide (RA) program three times a week - 4/16/13: Pressure alarm applied to bed. Observation and interview on 4/30/13 at 11:15 A.M. through 11:30 A.M., showed no staff monitoring seven residents who were located in the lounge/dining room and corridor areas of the SCU. Resident #18 wore a helmet (head injury protection device) while seated in his/her chair in front of the dining room table. Resident #19 held several plastic ice cream cups and spoons in his/her hands and positioned one of the cups on the hand rail of the corridor. Resident #20 wandered from one resident room to another. Resident #15 sat in a wheelchair in the lounge. Resident #21 said he/she was bored, wanted something to do, and wanted to get out of the confined area of the SCU. Family Member (FM) A had a dog attached to a leash that he/she held while sitting at the dining room table. Resident #23 opened and closed an ice cooler on the dining room counter, then took a cup and dug around with his/her hands in the ice contained in the cooler. Resident #22 came out of his/her room with an unsteady gait and said he/she was dizzy and grabbed the corridor hand rail. FM A left the SCU and Resident #22 responded by going to his/her room and slamming the door. At 11:30 A.M., Certified Nurse Aide (CNA) C and Nurse Aide (NA) B came out of Resident #17's room. CNA C said he/she was sorry he/she could not come out of Resident #17's room sooner, but was in the middle of something he/she could not leave. Observation of the locked special care unit day room, on 4/30/13 at 12:00 P.M. showed: - Several ambulatory residents in the day room; - Resident #18 sat in a tilt wheelchair; - Resident #17, wearing a leather helmet, sat in a wheelchair; - CNA C and NA B left the residents in the day room to provide care, behind closed doors, for Resident #3. - Staff left the residents in the day room unsupervised for 15 minutes. In an interview on 4/30/13 at 11:32 A.M., CNA C said: - Resident #17 required two-assist with transfers and it took time to provide the care required. - When staff was in resident rooms providing resident care, there was no way they were able to monitor the other residents on the SCU. - There was no communication system set up to obtain additional staff to come to the SCU to monitor resident care needs during the times SCU staff went behind closed doors. In the past, they attempted to utilize Walkie Talkies (hand held communication device), but it did not work. - Resident #18 had a fall history, required assistance with transfers, and normally attempted to stand on his/her own at least once a day. - Staff kept ice in the cooler on the dining room counter to provide ice to residents. Residents should not be in the ice cooler as it was not sanitary. When staff was not in the unit dining room there was no way to monitor if residents were getting into the ice. - Resident #22 gets upset when FM A leaves. Resident #22 had a history of [REDACTED]. 3. Observation of the SCU day room, on 5/1/13 from 2:10 P.M. to 2:20 P.M. showed: - Four residents (including Residents #17, #18) in the day room; - No facility staff were present during this time. During an interview, on 5/1/13 at 2:20 P.M., CNA H and CNA I said: - They were both packing a resident's room; - A staff member should be in the day room with residents; - They should have called the floor staff to supervise the day room. During an interview, on 4/30/13 at 10:00 A.M., CNA C said: - He/She worked on the locked special care unit; - The facility staffed the locked unit with two CNAs on the day shift, two CNAs on the evening shift, and one CNA on the night shift; - Could only communicate with the rest of the facility by using an intercom located in the SCU day room; - Could not contact other staff from resident rooms if they needed assistance. During an interview, on 5/1/13 at 2:00 P.M., the Director of Nurses (DON) said: - Residents, placed in the locked special care unit, were at risk for elopement, falls, and other behaviors; - One staff member should always be in the locked special care unit day room if residents were in the room; - Staff should call the floor staff on the day room intercom when staff needs to leave the day room; - Staff could not call for help from resident rooms; - The facility did not have a policy requiring a staff member to remain in the day room with residents. During an interview, on 5/1/13 at 2:30 P.M., Nurse Practitioner (NP) A said: - He/she provided medical care for some residents on the locked special care unit; - Expected the residents to have a staff member with them at all times when in the day room; - Expected the staff to be able to call for needed help from resident rooms. During an interview, on 5/1/13 at 2:45 P.M., the acting administrator said: - Staff should always chaperone residents in the day room; - Staff could not call for help from resident rooms; - Staff should be able to call for help from resident rooms. During an interview on 5/1/13, FM A said: - He/she visited Resident #22 on the SCU daily. - Limited staff on the SCU created a problem when staff had to assist residents behind closed doors. - Resident #20 and Resident #15 get belligerent and should not be left alone. - Resident #18 constantly falls trying to get out of his/her wheelchair. By the time Resident #18's chair alarm goes off, he/she is on the floor. - Within the past two months during the late morning, he/she observed staff leave the common area of the SCU to go behind a closed door and attend to a resident. During this time, Resident #18 fell while attempting to get up out of his/her wheelchair. FM A notified staff of the fall by shouting. He/she was pretty concerned and felt that this could happen to any of the residents being left unattended. - During the past two weeks for 10 to 15 minute at a time, he/she observed staff leave residents in the common area of the SCU to assist other residents in their rooms. In an interview on 5/1/13 at 1:45 P.M., FM B said: - He/she visited Resident #1 on the SCU daily. - One to two times a week around 11:00 A.M. and 1:00 P.M. for 10 to 15 minutes each time, he/she observed staff leaving residents unattended in the common area of the SCU to attend to other residents in their rooms. He/she was concerned that residents left unattended could fall and be hurt. - A month ago while staff was in another resident's room, he/she observed Resident #18 fall and holler out. He/she thought the resident bruised him/herself from the fall. If staff is not available to prevent falls, he/she believed Resident #18 could fall again. Resident #18 was not strong enough to be left alone. - Last night at 5:30 P.M., there was only one staff person on the SCU and they were busy with another resident. Resident #1 needed staff to assist him/her with toileting and no staff was available. He/she was afraid Resident #1 would fall. Resident #1 could not wait for staff to be available so FM B assisted him/her to the bathroom to get on and off the toilet. FM B was not supposed to assist Resident #1 due to health limitations and both he/she and the resident could have been hurt. Staff had told him/her not to help the resident due to the risk involved for both of them. He/she complained to the staff person who responded that he/she was busy with someone else. Review of Resident #1's current care plan dated 7/9/12 and updated 3/23/12 showed the resident had an activities of daily living self care deficit and required assistance in transfers, dressing, showers, and meal set-up. One of the interventions showed the resident required one staff to assist with transfers as needed..

Based on interview and record review, the facility failed to assure staff provided care to attain or maintain the highest practicable physical, mental and psychosocial well-being when they failed to perform neurological assessments (neurochecks) for one of two sampled residents (Resident #23) who fell , striking his/her head and failed to perform neurochecks following a fall per facility policy for a second sampled resident (Resident # 9). The facility also failed to obtain and administer ordered pain medication for two of two sampled residents with pain (Residents #23 and #25). The facility identified eight residents with a history of falls in the last 30 days and 15 residents with pain. The facility census was 44. 1. Review of the facility policy entitled "Neurological Assessments for Head Injury" dated ,[DATE] showed: - The objective was to identify signs and symptoms of increased intracranial pressure (pressure inside the brain which can be life threatening). - Neurochecks are to include complete vital signs (blood pressure, pulse, respirations and temperature), pupil checks using a light, level of consciousness, (assessment for) headache, vomiting and decreased motor responses (hand grip). - Staff were to perform neurochecks (after a head injury) every fifteen minutes for the first hour, every thirty minutes for the next hour, then every four hours for the next 22 hours and then twice a day for the next 48 hours. 2. Review of Resident #23's hospital A progress note dated [DATE], showed: - The hospital admitted the resident on [DATE], with [DIAGNOSES REDACTED]. - The physician noted the necrosis of the resident's left hand finger tips was likely a result of the myeloproliferative disorder (related to myeloid [MEDICAL CONDITION]). - The physician noted the hospital would discharge the resident when the necrosis stopped progressing. Review of the resident's hospital A discharge medication list, dated [DATE], showed: - Aspirin (helps prevent blood clots) 325 milligrams (mg) one tablet by mouth daily. - [MEDICATION NAME] (pain reliever) 5 mg one tablet by mouth every two hours as needed for pain. - [MEDICATION NAME] ([MEDICATION NAME] - helps prevent blood clots) 60 mg inject 0.5 milliliter (ml) as directed twice daily. - [MEDICATION NAME] ([MEDICATION NAME] - [MEDICAL CONDITION] hormone replacement) 25 microgram (mcg) one tablet by mouth daily. - [MEDICATION NAME] (antihypertensive) 25 mg take one-half tablet by mouth daily. - [MEDICATION NAME] (diuretic) 20 mg tablet by mouth daily. - Potassium chloride SR (K-Dur - potassium replacement) 20 milliequivalents (meq) tablet by mouth daily. Review of the resident's admission nurse's notes dated [DATE], at 3:30 P.M., showed Licensed Practical Nurse (LPN) B documented the following: - The resident arrived at the facility at that time. - The resident was up ad lib with a walker. - The resident was pleasant with cares and had no complaints of pain. During an interview on [DATE], at 2:30 P.M., the administrator said the resident's family member (FM) A was walking with the resident down the hall on [DATE], at 5:15 P.M. He/she turned away and the resident fell , striking his/her face on the medication cart in the hallway. Review of the resident's nurses' notes dated [DATE], at 5:15 P.M., showed staff documented "Res (resident) observed on floor in hallway, upon assessment complained of left arm pain, all extremities all WNL (within normal limits) - family request send Res to ER 911 notified - transfer paperwork completed V/S (B/P),[DATE], (pulse) 96, (respirations/minute) 16, (temperature) 98.1?, (oxygen saturation/measure of oxygen in the blood) 97% RA ( on room air) will monitor. " Review of the facility Occurrence Report, dated [DATE], at 5:30 P.M., showed staff listed injuries after the occurrence as head trauma, rule out fracture, and skin tear. During an interview on [DATE], at 8:20 A.M., FM A said: - He/she was walking down the hall with the resident when he/she said he/she needed to go to the toilet. - He/she turned away from the resident to look for staff to assist him/her and the resident fell face forward and hit his/her right arm on a medication cart parked nearby. - The resident tried to catch him/herself with his/her left arm, but fell face forward onto the carpeted floor. - The resident's face and front of the body hit the floor. During an interview on [DATE], at 10:40 A.M., Certified Medication Technician (CMT) A said: - He/she was standing at the medication cart in front of the nurses station when he/she noticed the resident coming up the hall with FM A. - He/she heard the resident talking with his/her family member. - He/she turned back to the medication cart. - The resident was by another medication cart. - He/she heard a crash, turned around and saw the resident lying face down, flat on the floor. - He/she told the resident not to move and went to the administrator's office and summoned the Director of Nurses (DON), the administrator and Licensed Practical Nurse (LPN) C. - When they returned to the resident, he/she had turned to his/her back. - The first thing he/she noticed was the resident's nose was red. The resident also had a skin tear on one hand. - The resident said (his/her) shoulder hurt. During an interview on [DATE], at 11:02 A.M., Certified Nurse Aide (CNA) G said: - He/she saw the resident walk down the hall with FM A. As they got near the nurses' station, the resident slipped out of his/her right slipper. - He/she fell face first into the medication cart. It made a noise. - The resident landed face first on the floor. - The resident said his/her shoulder hurt. He/she had a small "nick" on her nose - it was red. - CMT A was nearby and got the DON. LPN B and C also came to the resident's side. During an interview on [DATE], at 11:40 A.M., LPN B said: - He/she was charge nurse for the resident that evening, but was in the "back" (locked unit) in the facility at the time the resident fell . - Someone came to her and told her that someone had fallen. - When he/she approached the resident, he/she was lying on his/her back and complained of left arm pain. - The DON, LPN C and CMT A were with the resident. - The DON and LPN C assessed the resident for injuries to his/her arms and legs. - No one told him/her the resident had hit his/her face as he/she fell . - He/she could not see anything wrong with the resident's face. - He/she talked to the resident and FM A. - FM A wanted resident sent to emergency room (ER). - He/she prepared paperwork to send with the resident to the hospital. - He/she thought he/she probably gave report to the ambulance crew when they arrived, but didn't remember what he/she said. Review of the resident's facility transfer report, dated [DATE], (no time given) completed by LPN B showed staff documented under Remarks and Pertinent Information Fall-new resident at facility. Complained of left arm pain. Family request to be seen at ER. LPN B did not document that the resident fell face first to the floor on the transfer form. Review of the ambulance report dated [DATE], (onset time) 5:28 P.M., written by Paramedic A, showed the following: - The resident was walking in the carpeted hallway when he/she tripped and fell on to his/her left shoulder on the vinyl floor. - The resident also struck his/her left cheek and nose. - There was only a slight redness on her cheek and nose, no bruising or bleeding. - He/she splinted the resident's left shoulder and transferred him/her to the hospital. During an interview on [DATE], at 9:10 A.M., Paramedic A said: - Facility staff (did not know who) reported to him/her that the resident had fallen face forward onto the floor as he/she was walking to the dining room. - He/she reported to the hospital that the resident fell face forward to the floor and complained of left arm and shoulder pain. Review of the resident's Emergency Department (ED) notes dated [DATE], showed: - The resident's chief complaint was of left shoulder pain after tripping on carpet and falling, landing on his/her left shoulder. - History of the fall was provided by the patient and the nursing home. The fall occurred walking (tripped on carpet while walking at the nursing home). He/she fell from a height of one to two feet and landed on carpet. The point of impact was the left side. The injury/pain location is left arm. The pain is moderate. There was no loss of consciousness. - Clinical impression was fall and closed fracture (break) of the left humerus (upper arm bone). Review of the resident's hospital discharge information, dated [DATE], showed: - The hospital discharged the resident back to the facility. - Directions for the resident to see an orthopedic surgeon in one week. - Directions to continue previous medications and to take [MEDICATION NAME] 50 milligrams (mg) injected into muscle every four hours as needed for pain. - Care instructions for the fractured humerus. - No directions to perform neurochecks. During an interview on [DATE], at 11:40 A.M., LPN B said: - On [DATE], at 6:00 P.M., another nurse, LPN D, took over care of the residents on Resident #23's hall. - The resident came back to the facility later that evening. - He/she did not know the resident had hit his/her head with the fall and did not report that to LPN D. During an interview on [DATE], at 2:35 P.M., LPN D said: - The resident was going out to the hospital when he/she came to work that evening ([DATE]) at about 6:00 P.M. - LPN B told him/her the resident had fallen. - CMT A told him/her the resident fell face down on the floor. - He/she thought the resident returned to the facility at about 8:20 P.M. with FM A in his/her private car. - He/she helped the resident out of the car, obtained a meal tray and allowed the resident time to eat. Then he/she helped the resident to bed. - The hospital discharge orders did not direct him/her to do neuro checks on the resident. - He/she went by the hospital discharge orders and did not do neuro checks. - The report from the hospital was that the resident had a fractured humerus. - Facility policy directs staff to do neuro checks when a resident hits their head. - He/she took the resident's vital signs after he/she ate. He/she did not know why they were not charted in the resident's nurses' notes, but said that was the only place in the resident's record he/she would have recorded the vital signs. - The resident was very coherent that night, but afraid and wanted to feel safe. As a result he/she was in the resident's room a lot that night because he/she could not put on the call light. He/she gave the resident a bell. Review of the resident's nurses' notes by LPN D dated [DATE] at 8:20 P.M. showed staff documented: - Returned to facility via private car accompanied by FM A and (another family member). - Wheelchair transport provided, taken to dining room, evening meal consumed. - Pleasant and cooperative. - Bedside commode in place and used prior to settling in bed. - Able to move fingers, left hand warm dt touch, pillow in place to support elbow. - Call light at hand. - Body Alarm applied and functional. - Ice bag applied to elevate arm to provide comfort. - Will monitor. - LPN D didn't document any neurochecks or vital signs. During an interview on [DATE] at 12:20 P.M., Registered Nurse (RN) A said: - He/she was the charge nurse for the resident from about 6:00 A.M. until 6:00 P.M. on [DATE]. - LPN D told him/her that staff had just admitted the resident, then he/she had fallen, gone to the hospital and received treatment for [REDACTED]. - No one told him/her the resident had fallen and hit his/her head or face. - He/she did not do neurochecks for the resident. - Normally staff performed neurochecks for residents that have fallen and hit their head or for a resident with an unwitnessed fall. Review of the resident's nurses' notes dated [DATE] (first entry untimed), written by RN A, showed the following: - Resident continued on 72 hour admit/after fall follow up vital signs. (Temperature) -97.8? (pulse)- 123, (respirations)-18, (blood pressure)- ,[DATE] and (oxygen saturation)- 93% on RA (room air). - Denies complaints at this time. - Up in wheelchair for meals, (son) in to visit at lunch. - Resident returned to bed after meals per resident request. - Left upper extremity immobilizer on, circulation (checks) OK, capillary refill less than three seconds. - Will continue to monitor. - RN A didn't document any other neurocheck assessments. Review of the resident's nurse's notes dated [DATE] (second entry untimed) written by RN A showed: - Resident complained of pain, medications not available; contacted pharmacy. Unable to fill [MEDICATION NAME] related to out of supply, unable to fill [MEDICATION NAME] related to need written prescription. - Request E-kit (emergency medication kit) withdrawel approved, but no [MEDICATION NAME] in E- kit. - Contacted (Physician B) who gave new order (to) DC (discontinue) [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] (see physician's order). - RN A didn't document any neurocheck assessments. During an interview on [DATE] at 4:35 P.M., RN B said: - He/she was the facility's charge nurse on [DATE] at 6:00 P.M. through 6:00 A.M. on [DATE]. - RN A told him/her in report that the resident had fallen while ambulating and had a fractured arm. - The resident seemed OK that evening but tired. - He/she awoke the resident for medications at bedtime (could not give exact time). - He/she gave [MEDICATION NAME] (medication given to decrease the risk of blood clots, will increase risk of bleeding) to the resident that evening. - Staff took the resident's vital signs at 4:00 A.M. (on [DATE]) and found his/her temperature was 100?. - He/she went to give the resident Tylenol, but could not awaken him/her. - He/she called the resident's FM A who requested staff send the resident to the ER. Review of the resident's nurses' notes dated [DATE] at 4:00 A.M. showed: - Resident unresponsive in bed. - Small amount of green vomit on corner of mouth. - Vital signs - temperature 100.1?, pulse- 94, respirations 22, blood pressure ,[DATE] and oxygen saturation 92% on room air. - Resident sent to (hospital B) ER by resident's (son's) request. - Resident transferred by ambulance. - DON (Director of Nurses) notified. Review of the resident's hospital B ER records dated [DATE] showed: - The resident arrived at the ER at 4:52 A.M. - ER staff obtained a CT (computed tomography/specialized type of x-ray) of the resident's head which showed a large right intracranial (within the skull) bleed with significant mid line shift (movement of the brain due to the bleeding). - ER staff transferred the resident to another hospital for further evaluation. Review of the receiving hospital's (hospital C's) admission history and physical dated [DATE] showed the physician's impression was terminal condition secondary to cerebral (largest part of the brain) bleed plus subdural (below the outer covering of the brain) bleed. The resident had a midline shift and showed signs of focal herniation (structures of the brain were moved to one side due to the accumulation of blood). The resident's terminal condition was also secondary to prior [DIAGNOSES REDACTED]. After a thorough discussion with the resident's family the resident was made "Do Not Resuscitate" and comfort care measures provided. During an interview on [DATE] at 8:20 A.M., FM A said the resident expired on [DATE]. During an interview on [DATE] at 2:55 P.M., the DON said: - We do neurochecks when we know a resident hit their head, with a fall or otherwise or if they have an unwitnessed fall. - However, he would not have expected facility staff to do neurochecks unless the hospital directed that. He assumed the hospital would have "checked out" the resident and determined whether staff should do that. - If the resident had not been sent to the hospital following this fall, staff would have done neurochecks. On [DATE] at 2:55 P.M., this surveyor called Physician A's office and asked to speak with the physician. The physician's office staff provided a fax number for the physician. This surveyor left a message for Physician A asking if he/she could respond to questions regarding this resident. This surveyor faxed those questions to the physician's fax number. On [DATE] at 10:45 A.M. this surveyor called Physician A's office and asked to speak with the physician/or his/her nurse regarding the questions faxed on [DATE]- connected with voicemail, message left. As of [DATE] at 2:30 P.M., Physician A had not responded to this surveyor's calls or faxed questions. 3. Review of Resident #9's care plan dated [DATE] showed staff had determined the resident was at risk for falls, injury and/or adverse reactions due to balance problems, [DIAGNOSES REDACTED]. Review of the resident's nurses' notes dated [DATE] (no time given) showed: - Staff found the resident on his/her back, leaned to the right side, on the floor in his/her room, in front of the recliner. The resident's head was against the wall. - The resident said he/she hit his/her head. Staff noted a small bump to the right "crown" on the back of the head where the resident indicated he/she hit his/her head. - Neurochecks within normal limits. Review of the resident's neurological assessment record showed staff failed to document performing complete neurochecks for five sets of scheduled neurochecks in the first 24 hours following the resident's fall. During an interview on [DATE] at 2:55 P.M., the DON said: - He had checked that staff had begun doing neurochecks per policy after this resident's fall, but did not monitor to see that all were completed. - He did not not know why staff did not document completing all the scheduled neurochecks. - The resident had no complications from this fall. 5. Review of "Charge Nurse's Admissions or Re-Admissions, no date, not labeled as policy, provided by the DON showed directions to the admitting nurse to "phone the physician and verify orders-finish the POSs (physician's order sheets)." The form did not specify a time frame in which staff were to contact the physician, however, the form directed the "following nurse" to review the POS, MAR (medication administration record) and treatment record against the transfer sheet to verify accuracy. 6. Review of Resident #23's hospital (hospital A) progress note dated [DATE] showed: - The hospital admitted the resident on [DATE] with [DIAGNOSES REDACTED]. - The hospital admitting physician noted the necrosis of the resident's left hand finger tips was likely a result of the myeloproliferative disorder. - On admission, the physician noted the hospital would discharge the resident when the necrosis stopped progressing. - The physician planned to continue the order for [MEDICATION NAME] (a narcotic pain reliever for moderate to severe pain, a schedule II medication) for pain control. Review of the resident's discharge instructions from hospital A, showed: - Hospital A discharged the resident to the facility on [DATE]. - Discharge orders included the order for [MEDICATION NAME] five milligrams (mg), one tablet by mouth every two hours as needed for pain. During an interview on [DATE] at 12:10 P.M., the DON said; - When the facility learned the resident was being discharged from the hospital on [DATE] to their facility, he called hospital A and asked staff there to fax the resident's discharge orders. - He faxed those orders to the pharmacy. - He felt it was his fault the facility did not have a written prescription for the [MEDICATION NAME] from the physician at hospital A when the facility admitted the resident. Review of the resident's nurses' notes showed: - The facility admitted the resident on [DATE] at 3:30 P.M. - On [DATE] at 5:15 P.M. staff observed the resident on the floor in the hallway. Upon assessment, the resident complained of left arm pain. The resident's FM A requested transfer to the ER. Staff called 911. - On [DATE] at 5:45 P.M. the ambulance arrived to transport the resident to hospital B. - On [DATE] (time not given) staff received a call from the ER. The ER staff reported the resident had a fractured right humerus (upper arm bone). Hospital B staff had applied an immobilizer (device to stabilize the fracture) and sling. Review of the resident's hospital B discharge information, dated [DATE], showed: - Hospital B discharged the resident back to the facility. - Directions for the resident to see an orthopedic surgeon in one week. - Directions to continue previous medications and [MEDICATION NAME] (a narcotic pain reliever used to treat moderate to severe pain, schedule II) 50 milligrams (mg) injected into muscle every four hours as needed for pain. - Care instructions for the fractured humerus. Review of the resident's facility nurses' notes showed: - On [DATE] at 8:20 P.M. the resident returned to the facility. Staff applied an ice bag to the upper arm for comfort. - On [DATE] at 10:00 P.M., pharmacy staff contacted the facility and said they would send the resident's medications out in the morning, but needed to know the resident's physician before sending them. During interviews on [DATE] at 2:55 P.M., [DATE] at 12:10 P.M., and [DATE] at 9:50 A.M.the DON said: - He was new in looking at potential new resident admissions and accepting them. - The resident did not have a primary (or attending) physician in the facility, but had indicated he/she wanted Physician A. - He did not know if staff contacted Physician A and notified him/her of the resident's admission. - Physician A was the facility medical director and it was facility policy that the medical director would accept any resident admitted who did not have another physician. - He faxed the hospital A's discharge orders to the pharmacy and said they accept them because they have a physician's signature. - He did not know when he faxed the resident's medication orders to the pharmacy that they required a written prescription for a Schedule II medication. - He knew now that the pharmacy must have a written prescription to fill a narcotic. They must have the prescription signed by the physician in hand before they fill. - That was why the pharmacy could not fill the order for [MEDICATION NAME]. During an interview on [DATE] at 2:35 P.M., LPN D said: - He/she was the resident's charge nurse from 6:00 P.M. on [DATE] until 6:00 A.M. on [DATE]. - The facility did not receive any of the resident's ordered medications from the pharmacy on his/her shift, including pain medications. - The resident did not complain of pain during this shift. - He/she would have contacted the physician if the resident had a problem, for example if the resident had pain and pain medication was not available. - The resident was content all night and he/she did not call the physician. Review of the resident's Temporary Care Plan dated [DATE] showed: - Staff determined the resident had an actual risk for pain related to his/her left humerus fracture. - Approaches for staff to take related to this risk included assess his/her characteristics of pain: location, severity on a scale of ,[DATE], frequency, precipitating factors and relief factors every four hours while awake. Offer resident [MEDICATION NAME], according to physician's orders. Teach resident to request [MEDICATION NAME] before his/her pain became too severe. Offer resident non-pharmacological methods for reducing pain/promoting comfort - such as back rubs, repositioning and diversions. During an interview on [DATE] at 12:20 P.M., Registered Nurse (RN) A said: - He/she was the facility charge nurse on [DATE] from 6:00 A.M. to 6:00 P.M. - LPN D reported to him/her that the resident had fallen and been sent out for a fractured humerus. LPN D reported the resident did not complain of pain on the night shift. - The resident did not complain of pain, during the first part of this shift, but by the afternoon the resident did have pain with his/her left arm. - He/she remembered talking with the pharmacy at about 12:00 P.M., because the facility had not received the resident's medication for pain. - The pharmacy said [MEDICATION NAME] was back ordered until [DATE]. - The pharmacy was not able to deliver the resident's [MEDICATION NAME] (part of original admission orders [REDACTED]. - He/she called the "on-call" physician (Physician B) who asked him/her what the facility had in their emergency kit. - He/she told the physician the facility stocked [MEDICATION NAME] (narcotic pain reliever used for mild to moderate pain). - Physician B ordered [MEDICATION NAME] until the pharmacy filled the original order for [MEDICATION NAME]. Review of the resident's nurses' notes written by Registered Nurse (RN) A on [DATE] (no time given) showed: - Admit/after fall follow up vital signs were temperature - 97.8?, pulse -123, respirations 18, blood pressure ,[DATE] and oxygen saturation (percentage of oxygen carried in the blood) 93%. - Denies complaints at this time. - Up in wheelchair for meals. - Resident returned to bed after meals per resident request. - Upper extremity immobilizer on. Review of U. S. National Library of Medicine, Medline Plus Medical Encyclopedia states a normal pulse rate for the average healthy adult while resting is 60 - 100 (beats per minute). During an interview on [DATE] at 9:50 A.M., RN A said he/she did not know what time of day he/she took the resident's vital signs. He/she thought the resident's pulse rate of 123 beats per minute was due to some right shoulder discomfort. He/she said the resident was kind of fidgety. Review of a second nurses' note by RN A on [DATE] (no time given), showed: - The resident complained of pain, his/her medications were not available. - He/she contacted the pharmacy. - The pharmacy said they were unable to fill the [MEDICATION NAME] because they were out of a supply. - The pharmacy said they were unable to fill the [MEDICATION NAME] because they needed a written prescription. - Requested emergency kit withdrawal approved, but there was no [MEDICATION NAME] in the emergency kit. - Contacted Physician B, who discontinued the [MEDICATION NAME] and [MEDICATION NAME] and ordered [MEDICATION NAME]. Review of the physician's order dated [DATE] (no time given) showed: - [MEDICATION NAME] 7XXX,[DATE] milligrams (mg) one by mouth every four hours prn (as necessary) not to exceed six per day. - Discontinue [MEDICATION NAME] and [MEDICATION NAME]. During an interview on [DATE] at 12:20 P.M., RN A said: - At about 2:00 P.M. to 3:00 P.M., he/she called the pharmacy and informed them, he/she had the order for [MEDICATION NAME]. He/she explained the resident had a fractured arm and needed something for pain. He/she said he/she could fax the order for [MEDICATION NAME] and a request to use a certain number of [MEDICATION NAME] tablets from the emergency kit. Pharmacy staff said don't send the request to use [MEDICATION NAME] from the emergency kit, because they would send [MEDICATION NAME] that evening. - The pharmacy had not delivered the [MEDICATION NAME] by 6:00 P.M. that evening when he/she ended her shift. During an interview on [DATE] at 3:00 P.M. the DON said: - RN A called him about not having pain medication available to give the resident on [DATE]. The resident did not have a primary physician in the facility yet. The resident had requested Physician A, but he did not know if staff had notified Physician A of that. He told him/her to call the on call physician (Physician B) at the hospital. - Although Physician B ordered [MEDICATION NAME], the pharmacy would not give permission for staff to give that from the emergency kit without a signed prescription. - He could not say what staff should have done beyond this. - These were the first residents the facility had admitted since he began as DON. He did not know the the physician's needed to send a signed prescription for staff to obtain narcotic. During an interview on [DATE] at 12:50 P.M., CNA D said: - He/she cared for the resident on [DATE] from 6:00 A.M. to 6:00 P.M. - The resident complained of arm pain all day. He/she did not want anyone to touch it. - He/she seemed tired and did not want to eat much. - He/she was in a lot of pain with his/her arm - the charge nurse was trying to get (his/her) pain medication. - The resident's arm was painful - more so if staff touched the arm. During an interview on [DATE] at 4:35 P.M., RN B said: - He/she was the charge nurse in the facility from 6:00 P.M. on [DATE] until 6:00 A.M. on [DATE]. - RN A told him/her that the resident had fallen and fractured his/her arm. - RN A told him/her, that he/she had trouble getting medication for pain for the resident. - In the early part of the shift, in the evening, he/she met the resident and talked with him/her and FM A. - The resident was OK, seemed tired. - The pharmacy delivered some of the resident's ordered medications that evening. He/she could not remember, but thought they delivered a narcotic pain medication. - He/she did not administer any pain medication to the resident, because he/she did not complain of pain. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - The orders for [MEDICATION NAME] five mg one by mouth every two hours prn (as necessary) for pain, [MEDICATION NAME] 50 mg/ml (give) one ml IM (intramuscularly) every four hours prn pain and [MEDICATION NAME] 7XXX,[DATE] mg one by mouth every four hours prn for pain not to exceed six tablets per 24 hours. Staff documented they discontinued the orders for [MEDICATION NAME] and [MEDICATION NAME] on [DATE]. - No staff documented giving the resident any pain medication. During an interview and review of the resident's record on [DATE] at 3:30 P.M., the DON confirmed there was a signed physician's prescription dated [DATE], for [MEDICATION NAME] five milligrams every two hours as needed for pain. He did not know hospital A had sent that with the resident's discharge orders on [DATE]. He should have faxed that to the pharmacy when he faxed the original orders on [DATE]. During an interview on [DATE] at 10:00 A.M., RN A said he/she did not know the facility had a physician's prescription for [MEDICATION NAME] from admission. He/she thought staff found this the next day ([DATE]). He/she thought the prescription got mixed up with the other paperwork sent by hospital A. Review of the list of medications stocked in the facility emergency kit showed both [MEDICATION NAME] and [MEDICATION NAME] in the kit. 4. Review of the facility's undated Emergency Supply of Medications policy showed: - As permitted by applicable law, the pharmacy may provide the facility with an emergency supply of medications (E-Kit). - The E-Kit of medications is the property of the pharmacy. - The medication supply should be stored in a known, secure location per facility policy with access only by authorized facility personnel. - The facility should not administer any E-Kit medications without a valid physician's order. - The facility should complete the E-Kit withdrawal form to report for which resident the medication was withdrawn. - Scheduled II Controlled Substances: Before a facility staff may access a medically necessary Schedule II Controlled Substance from the E-Kit, facility staff should receive authorization from the pharmacy confirming that the pharmacy received a valid written prescription for a Schedule II Controlled Substance by a physician/prescriber; or in an emergency situation, an oral authorization for a Schedule II Controlled Substance directly from the physician/prescriber. - Scheduled III Controlled Substances use the same process as stated above or a faxed written prescription for a Scheduled III-V Controlled Substance transmitted by a physician/prescriber to the pharmacy. - In order to request authorization from the pharmacy to remove a Scheduled II-V Controlled Substance from the E-Kit, the facility staff should complete the Request for Remov