Every finding on record at Villages of Jackson Creek

Based on interview and record review the facility staff failed to notify one sampled resident's (Resident #4) representative out of 14 sampled residents after a fall with injury. The facility census was 102 residents.The Administrator was notified on 1/22/26 of Past Non-Compliance, which occurred on 12/8/25. Nursing staff completed in-service training on when and who to notify after a change in condition on 12/8/25. The nurse who failed to notify the resident's family after a fall was individually counselled and educated on his/her failure to follow the facility's fall policy on 12/11/25. The deficiency was corrected 12/11/25. Review of the facility's policy titled Assessing Falls and Their Causes, revised 3/2018, showed that staff was to notify the resident's family when a resident fell. Review of the facility's policy titled Change in a Resident's Condition or Status, revised 2/2021, showed:-The facility promptly notified the resident's representative of changes in the resident's' medical/mental condition and/or status.-Unless otherwise instructed by the resident, a nurse would notify the resident's representative when the resident was involved in any accident or incident that resulted in an injury, there was a significant change in the resident's physical, mental, or psychosocial status, or when it was necessary to transfer the resident to a hospital/treatment center. 1.Review of Resident #4's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 11/15/25 showed:-The resident had moderate cognitive impairment.-The resident had the diagnoses of Huntington's Disease (HD- an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die. The disease attacks areas of the brain that help to control voluntary (intentional) movement, as well as other areas. -Cognitive Communication Deficit (difficulty with talking, understanding, or interacting due to impaired cognition). Review of the resident's admission Record, dated 1/22/26 showed:-The resident's Durable Power of Attorney (DPOA) with contact information. -The resident's DPOA was the resident's emergency contact #1. -The resident's DPOA was the resident's responsible party. Review of the resident's fall incident report, dated 12/8/25 at 12:25 A.M., showed:-The nurse was alerted by the resident's roommate that the resident fell out of bed.-When the nurse entered the room, the resident was on the floor with blood on his/her mouth.-The resident had a red mark on the back of his/her head. -The nurse called an ambulance, the DON (Director of Nursing), and the resident's doctor to notify them of the resident's fall and injuries.-The resident was transported to the hospital by the ambulance at 1:08 A.M. Review of the resident's change of condition, post fall review, dated 12/8/25 at 1:28 A.M., showed the reason for the assessment was due to a recent fall. During an interview on 1/22/26 at 2:00 P.M., Licensed Practical Nurse (LPN) C said:-He/She was the charge nurse on duty when the resident fell on [DATE].-He/She sent the resident to the hospital due to injuries that the resident received from the fall.-He/She notified the doctor and the DON of the resident's fall. -He/She did not notify the resident's DPOA when the resident fell and was sent to the hospital.-He/She was aware that the resident had a responsible party and was not his/her own person.-He/She knew that he/she was supposed to contact the resident's DPOA about the fall and transfer to the hospital but forgot to do so.-He/She received education after the incident from the facility and was told to always notify a resident's DPOA or representative when a resident fell.-The resident returned to the facility from the hospital after receiving sutures for a laceration he/she sustained from the fall.-The resident's DPOA went to facility after the resident was transferred back to the facility from the hospital and was upset about not being notified about the resident's fall and injuries at the time of the fall. During an interview on 1/22/26 at 2:30 P.M. the resident's DPOA said:-He/She was not notified when the resident fell on [DATE] by the charge nurse on duty.-He/She was notified of the resident's fall by a family friend who worked at the facility eight hours after the fall occurred. -The family friend was not a nurse and was not the person who was responsible for notifying him/her of the resident's fall and injuries. -The family friend notified him/her of the fall inadvertently when they asked the DPOA if the resident was okay.-He/She was not aware of what happened so he/she questioned the family friend of the reasoning that they would ask if the resident was okay and that's how he/she found out about the fall and injuries. -He/She would have liked to have known about the resident's fall and injuries so that he/she could have gone to the hospital and been with the resident while they were receiving care at the hospital.-The resident had a laceration on his/her mouth that required sutures.-The resident's face was bruised up and swollen after the fall. -The resident had injuries to his/her legs after the fall. During an interview on 1/22/26 at 2:55 P.M. the DON said:-The DPOA was not notified when the resident fell on [DATE].-LPN C who was responsible for notifying the resident's DPOA was counselled and educated on the facility's fall and notification policies. During an interview on 1/22/26 at 3:30 P.M. the Administrator said:-The charge nurse was expected to notify the resident representative promptly or immediately with a fall and or a change in condition. -The resident's DPOA was not notified by LPN C when the resident fell.-All staff have been educated on the facility's fall and notification of change policies. Complaint #2687129

Based on observation, interview and record review, the facility failed to maintain the walk in cooler ceiling, fans, and floors; failed to maintain the cleanliness of the floors under the cooking equipment area; failed to maintain the cleanliness of the knife holder by the dish machine area; failed to sanitize the counter surface after a thermometer was placed on it after it fell on the floor; failed to ensure utensils were washed and sanitized; and a facility staff member working in the kitchen failed to wash their hands providing a risk of cross contamination between objects and food. Facility census was 108 residents. Review of the facility's Sanitization Policy revised dated 2022 showed:-The food area service area is maintained in a clean and sanitary manner.-All kitchens, kitchen areas and dining areas were kept clean, free from garbage and debris, and protected from rodents and insects. -All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use of proper cleaning.-All equipment, food contact surfaces and utensils were cleaned and sanitized using heat or chemical sanitizing solutions. -When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are:--Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air dried and sprayed with sanitizing solution (at the effective concentration).--The equipment was reassembled and any food contact surfaces that had been contaminated during the process area re-sanitized (according to the manufacturer's instructions).-Areas used for garbage disposal were to be free from odors waste fats and maintained to prevent pests. 1. Observation on 12/1/25 at 9:47 A.M. during the initial kitchen walk through showed:-The walk-in cooler had dust on the ceiling and on the fans.-The knife holder by the dish machine had food debris on it and droppings of food residue right below the holder on the ledge of the wall that connects to the dish machine area. Observation on 12/4/25 from 9:18 A.M. to 1:00 P.M. during the lunch meal preparation showed:-The walk-in cooler had dust on the ceiling and on the fans.-The walk-in cooler had a slick slimy brown substance in between the shelves by the wheels on the left-hand side. -Debris under the shelves in the walk-in cooler.-Six individual tubs of butter spread out on the floor under the shelves on the left side of the walk-in cooler. -Dietary Assistant A, dropped a probe thermometer on the floor picked it up and put it on the table then grabbed the scrapper and scrapped the top of the griddle, then moved the spatula, then moved the tongs, and then finally grabbed the thermometer and wiped it down with sanitizer wipes before probing the hot dogs. -Dietary Assistant A never washed his/her hands or changed gloves after picking up the thermometer off the floor. -Dietary Assistant A did not sanitize the thermometer right away therefore any floor debris that was on the thermometer was now on the counter and the counter did not get wiped down or sanitized and neither did all the utensils that the assistant touched. -Dietary Assistant A, walked into the kitchen and put gloves on, grabbed a cooked hamburger patty and put a slice of cheese on it, then put it in the microwave, then went to the walk-in cooler and came out of the walk-in cooler with lettuce and a tomato slice in his/her hand, and then gave it to the cook to put on the cheeseburger. Then took his/her gloves off and grabbed the empty tomato soup and chicken noodle soup cans on the counter. -Dietary Assistant A never washed his/her hands before entering the kitchen area. -Dietary Assistant A never performed proper hand hygiene in between touching nonfood contact surfaces and food contact with ready to eat foods. During an interview on 12/5/25 at 10:20 A.M. the Dietary Manager (DM) said:-Staff cleaned the kitchen daily.-Staff should wash their hands and change their gloves whenever they drop something on the floor or touch a surface that was not food related before touching food. -Staff should wash their hands when they enter the kitchen area.

Based on observation, interview and record review, the facility failed to maintain the hot water at the handwashing faucets in resident rooms 334, 333, 310, 402, 403, 414, 322, 326, 329, 312, 310, 308, 302, 301, 305, at a temperature at or below 120 F (degrees Fahrenheit); failed to maintain the hot water temperature in the following rooms (resident rooms [ROOM NUMBERS]) at a temperature of at least 105 F. This practice potentially affected at least 21 residents who resided in those rooms. The facility also failed to maintain the laminate sections in resident rooms [ROOM NUMBERS], firmly attached to the subfloor; failed to maintain the floor in a non-resident area free of a buildup of dust and debris; and failed to maintain the drainage area around the dish machine causing the drain itself to have a black residue on it and the area of the drain to release a foul odor potentially a sewage smell. The facility census was 108 residents.** All water temperatures were recorded after the hot was allowed to flow for at least two minutes in accordance with Department Policy Item 311.00 paragraph 3 revised on 2/18/16. Review of the undated facility's policy showed plumbing fixtures that require hot water and are resident accessible, shall be supplied with water thermostatically controlled to provide a water temperature of between one hundred five degrees (105 degrees F) to one hundred twenty degrees (120 degrees F) at the fixture or faucet 1. Observation on 12/1/25 showed the following hot water temperatures which were above 120 degrees F in the following resident's rooms:-At 10:04 A.M., the hot water temperature in room [ROOM NUMBER], was 124.3 degrees F.-At 10:07 A.M., the hot water temperature in room [ROOM NUMBER], was 124.3 degrees F.-At 10:23 A.M., the hot water temperature in room [ROOM NUMBER], was 128.4 degrees F.-At 10:45 A.M., the hot water temperature in room [ROOM NUMBER], was 123.6 degrees F.-At 10:47 A.M., the hot water temperature in room [ROOM NUMBER], was 125.5 degrees F.-At 10:52 A.M., the hot water temperature in room [ROOM NUMBER], was 123.4 degrees F. Observation on 12/1/25 showed the following hot water temperatures which were below 105 degrees F in the following resident's rooms:-At 10:11 A.M., the hot water temperature in room [ROOM NUMBER], was 66.8 degrees F.-At 12:00 P.M., during a recheck, the hot water temperature in room [ROOM NUMBER] was 66.3 degrees F. Observation on 12/2/25 showed the following hot water temperatures which were above 120 degrees F in the following resident's rooms:-At 10:19 A.M., the hot water temperature in room [ROOM NUMBER], was 128.4 degrees F.-At 10:27 A.M., the hot water temperature in room [ROOM NUMBER], was 125.0 degrees F.-At 11:03 A.M., the hot water temperature in room [ROOM NUMBER], was 125.9 degrees F.-At 11:09 A.M., the hot water temperature in room [ROOM NUMBER], was 125.9 degrees F.-At 11:11 A.M., the hot water temperature in room [ROOM NUMBER], was 125.0 degrees F.-At 11:21 A.M., the hot water temperature in room [ROOM NUMBER], was 126.6 degrees F.-At 11:25 A.M., the hot water temperature in room [ROOM NUMBER], was 126.8 degrees F.- At 11:30 A.M., the hot water temperature in room [ROOM NUMBER], was 125.5 degrees F. Observation on 12/2/25 showed the following hot water temperatures which were below 105 degrees F in the following resident's rooms:-At 10:51 A.M., the hot water temperature in room [ROOM NUMBER], was 67.2 degrees F.-At 10:52 A.M., the hot water temperature in room [ROOM NUMBER] was 66.0 degrees F. During an interview on 12/2/25 at 3:34 P.M., the Maintenance Director said:-The temperature of the hot water heaters was set between 138 degrees F and 140 degrees F.-On 12/2/25 (prior to this interview) he/she reset the temperature to 135 degrees F.-The hot water for the section of 300 Unit where rooms 319, 320, 321, and 322 were located could get hot, but it could take 5 minutes or longer.-He/she was not sure how the plumbing for the 300 Hall was arranged, but the circulating pump was working. 2. Observation on 12/1/25 at 11:16 A.M., showed a 2 feet (ft.) long arched section of the floor that was peeled away from the subfloor underneath in resident room [ROOM NUMBER]. During an interview in 12/1/25 at 11:16 A.M., the Maintenance Director said he/she did not know about that area of damage. 3. Observation on 12/2/25 at 11:25 A.M., showed a 10 ft. long by 6 ft. 5 inches (in.) wide section of laminate flooring which peeled away from the floor in resident room [ROOM NUMBER]. During an interview on 12/2/25 at 11:25 A.M., the Maintenance Director said no one had told him/her about the damaged floor in the resident room [ROOM NUMBER]. During an interview on 12/3/25 at 2:10 P.M., the Housekeeping Supervisor said:-Housekeepers should report damaged floors to the Maintenance Director.-In the past, housekeepers had reported damaged floors to the Maintenance department.-Housekeepers were used to seeing damaged carpet not necessarily damaged laminate flooring. 4. Observation on 12/2/25 at 1:19 P.M., showed a heavy buildup of debris between the fridge and the wall in the employee breakroom. During a phone interview on 12/9/25 at 10:37 A.M., the Housekeeping Supervisor said it was the housekeeping department's job to clean the breakroom floor, but the housekeeping staff needed help in moving the refrigerator to reach certain areas on the floor. Review of the facility's Sanitization Policy and procedure revised dated 2022 showed:-The food area service area is maintained in a clean and sanitary manner.-All kitchens, kitchen areas and dining areas were kept clean, free from garbage and debris, and protected from rodents and insects. -All equipment, food contact surfaces and utensils were cleaned and sanitized using heat or chemical sanitizing solutions. -Areas used for garbage disposal were to be free from odors waste fats and maintained to prevent pests. 5. Observation on 12/1/25 at 9:47 A.M. during the initial kitchen walk through showed:-Black residue on the drain under the dish machine.-A foul odor coming from the dish machine area. Observation on 12/4/25 from 9:18 A.M. to 1:00 P.M. during the lunch meal preparation showed:-Black residue on the drain under the dish machine.-A foul odor coming from the dish machine area. During an interview on 12/5/25 at 10:20 A.M. the Dietary Manager (DM) said:-The odor had been noticed for a couple of months. -The dish machine water was dumped after every meal. -The drain was cleaned every night with soap and water.-He/She knew maintenance had dumped an enzyme down the drain to help keep gnats away but couldn't remember how often that was done. -He/She thought the smell could be coming from the grout, the wall, and a little bit of the drain.-Had plans to get the wall and grout replaced but no current plans for the drain.

Based on observation, interview, and record review, the facility failed to ensure infection control practices to prevent cross-contamination with proper placement of medical devices to include indwelling foley catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain the urine) drainage tube that was placed underneath a wheelchair and the tubing was dragging on the floor for one sampled resident (Resident #29) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system); and for a wound vacuum device (negative pressure wound vac, removes this pressure over the area of the wound. This can help a wound heal in several ways) that was not on a protective barrier or hung on the side of the bedframe for one sampled resident (Resident #118) who was being treated for a bone infection; and failed to ensure handwashing and glove changing was completed to prevent cross contamination during incontinence and treatment care for one sampled resident (Resident #58) out of 22 sampled residents. The facility census was 108 residents. The facility catheter care and wound vacuum policy were requested and not received at the time of exit. 1. Review of Resident #29's admission Face Sheet showed he/she admitted with the following diagnoses: -End stage renal disease (ESRD, is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant). -Neuromuscular Dysfunction of the bladder (is nerve damage that keeps the bladder from working properly to include loss of bladder control and retaining urine). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/27/25, showed he/she:-Was moderately cognitively impaired.-He/she was able to understand others and make his/her needs known.-Required total assistance from staff for toileting.-admitted with an indwelling catheter. Review of the resident's Physician Order Sheet (POS) dated 12/1/25 showed:-Nursing staff were to provide foley catheter care every shift was ordered on 10/8/25.-Nursing staff were to change the indwelling foley catheter (use an 18 French (Fr, a measure of the outer diameter of a catheter) tip with a 10 centimeters (cc) bulb attached to gravity drainage bag, change every month on the 27th and as needed if plugged, leaking or dislodged, related to diagnosis of urinary retention, was ordered on 11/28/25. Review of the resident's nursing progress noted dated 11/28/25 at 5:28 P.M. showed: -The resident complained of his/her genital area hurting. -His/her foley catheter was changed to an 18 Fr catheter with a 10 ml bulb. The resident tolerated the catheter change well. -An order for a Urinalysis (UA) would be collected on Sunday, 11/30/25 and was to be sent for testing on Monday morning 12/1/25. -The resident's family member was notified. Observation on 12/2/25 at 1:11 P.M., of the resident showed:-He/She had just returned from dialysis clinic sitting in a wheelchair by the nursing station. -The resident's catheter tubing was dragging on the ground underneath his/her wheelchair. -The resident was moaning in pain, and he/she said over and over that he/she wanted to go to the hospital. -He/she had complaints of severe pain in the groin area and lower back pain. -At 1:16 P.M., an unknown charge nurse informed the resident he/she would contact the resident's physician related to his/her complaint of pain and with no relief from the pain medications that was given. -The resident told the nurse he/she did not want just pain medication that he/she wanted treatment to fix the issue causing the pain. Review of the resident's Nursing Note dated 12/2/25 at 2:18 P.M., showed: -The resident told the nurse he/she was in pain after returning to the facility from dialysis. -He/she was given as needed (PRN) pain medication and pain patch to left side of his/her back near kidneys. -The resident said his/her pain was a 7/10 on the pain scale (10 worst), when he/she moved, he was hurting more. -The resident's family member voiced concerns about the resident's catheter and UA that was done on Friday. The nurse addressed family concerns, and no further questions were asked. -Per resident request he/she was sent to the hospital for severe uncontrolled pain. Nurse notified unit manager and physician. Review of the resident's follow-up nursing note dated 12/2/25 at 2:18 P.M., the resident had returned from the emergency room with a diagnosis of UTI and new orders for an antibiotic. Review of the resident's POS dated 12/3/25 at 9:00 A.M. showed a new order for Cephalexin (antibiotic) tablet 500 milligrams (mg) Give one tablet by mouth every 12 hours for urinary tract infection for five days. Observation on 12/3/25 at 12:51 P.M. of the resident showed: -He/she was sitting in a wheelchair next to the nursing station. -Underneath his/her wheelchair noted the catheter tubing dragging on the ground. During an interview on 12/5/2025 at 9:00 A.M., Certified Nursing Assistant (CNA) A and CNA B said: -The catheter drainage bag should be below the bladder.-The catheter tubing should be secured underneath the wheelchair and not dragging on the ground. During an interview on 12/5/25 at 9:16 A.M., Licensed Practical Nurse (LPN) A said he/she would secure catheter tubing under the resident's wheelchair and ensure the catheter tubing was not dragging on the ground underneath the wheelchair. During an interview on 12/5/25 at 10:00 A.M., Unit Manager A said he/she would expect care staff to ensure the resident's foley catheter tubing was placed secure underneath the wheelchair and the tubing was not dragging or touching the ground. During an interview on 12/5/25 at 1:45 P.M. the Director of Nursing (DON) said:-He/she would expect care staff to ensure the catheter tubing was secured underneath the wheelchair and the tubing should not be dragging or laid on ground. -When catheter tubing was found touching the ground he/she would expect nursing staff to change the catheter drainage system. 2. Review of Resident #118's admission Face Sheet showed he/she was admitted to the facility with the following diagnoses:-Osteomyelitis (bone infection) of the right ankle. -Cognitive communication deficit.-He/she was his/her own responsible person. Review of the resident's MDS showed it had not been completed at the time of review. Review of the resident's nursing progress note dated 11/29/25 at 6:48 P.M. showed the resident readmitted with a right heel wound and would have a wound vac that would be put in place as soon as the wound vac arrived at the facility. Review of the resident's POS dated 12/1/25 to 12/3/25 showed:-Piperacillin Sod-Tazobactam So (antibiotic) Solution Reconstituted 4-0.5 grams (gm), use 4.5 gram intravenously (IV) every six hours, infuse at 4.5g at 200 milliliters (ml) per hour over 30 minutes, for Osteomyelitis for seven days, was ordered on 11/30/25.-Monitor wound vac every two hours for proper function. If malfunctioning, remove and place a wet-to-dry dressing on wound, was ordered on 12/1/25. -Cleanse right heel with normal saline, then apply skin prep to peri wound area and pack wound with black foam attach to the wound vac, set at 125 millimeter of Mercury (mm Hg) continuous flow; change wound vac dressing on Monday, Wednesday and Friday for surgical wound care was ordered on 12/3/25. Review of the resident's Wound Care Plan dated on 12/1/25 showed:-He/she was admitted to the facility with unstageable pressure injury to the right heel.-Wound vac to right heel, setting at 125 mm Hg continuously. -Wound vac therapy as ordered. Observation on 12/1/25 at 11:38 A.M., of the resident showed:-On the right side of his/her bed on the floor was a black carrying case with a wound vac device running inside the case.-There was no protective barrier under the wound vac carrying case. Observation on 12/2/25 at 11:46 A.M. of the resident in bed showed:-His/her the wound vac was on the ground on the right side of his/her bed. -There was no barrier under the wound vac device inside the black carrying case bag. Observation on 12/3/25 at 2:00 P.M, of the resident in bed showed: -The wound vac device was on the ground next to the resident's bed. -There was no barrier under the medical wound vac device. Observation on 12/4/25 at 10:43 A.M. of the resident's wound care showed:-His/her wound vac machine was on the ground on top of a barrier.-The wound nurse placed the wound vac canister and storage bag on top of the resident's bed to change out the old drainage canister. -The resident had a right heel wound about the size soft ball.-The outer wound area had staples all around and a few on the inner wound bed. -The inner wound bed had two areas that had purplish red tissue. -Wound care was completed following the orders. -The wound nurse hung the wound vac machine on right side of the bed prior to leaving the resident room. During interview on 12/4/25 at 10:50 A.M., the wound nurse said:-The resident had surgical debridement of the wound in the hospital and returned with the wound vac device and staples in and around the wound bed. -The resident's wound vac device should be hung off his/her bed rail and not touch the floor.- He/she would not have placed the wound vac device directly on the ground. -The wound vac pump and drainage system would also cause a tripping hazard if it was on the ground. During an interview on 12/5/2025 at 9:00 A.M., Certified Nursing Assistant CNA A and CNA B said: -He/she would have hung the resident's wound vac in the storage bag on the resident's bed rail, so it was not tugging on the wound. -If the wound vac device was placed on ground, there should be a barrier underneath the wound vac device. During an interview 12/5/2025 at 1:45 P.M., the DON said:-He/She would expect the wound vac device to be hung on the back of the wheelchair or on the resident's bedframe-The wound vac device could be placed on the floor because the black carrying case bag would protect it as it was a closed system. -All care staff would be responsible for ensuring the proper placement of the wound vac during any interaction with the resident and monitored during care. A policy on hand hygiene was requested but not provided by the time of exit. 3. Review of Resident #58's Face Sheet showed he/she was admitted with the following diagnoses:-Post Polio Syndrome (a condition that causes gradual muscle weakness and muscle atrophy (loss) that can affect people who've had polio).-Palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness).-Paraplegia (the inability to voluntarily move the lower parts of the body). Review of the resident's admission MDS dated [DATE] (in progress), showed:-He/She was moderately cognitively impaired.-He/She needed extensive assistance with bed mobility, transfers, dressing, eating, hygiene and toileting.-He/She had impaired mobility to lower extremities. Review of the resident's Care Plan dated 11/18/25 showed he/she:-Was at risk for skin breakdown related to impaired Activities of Daily Living (ADL) ability, impaired mobility and bowel incontinence.-Had limited mobility and was dependent on staff for personal hygiene care.-Had paraplegia.-Had a catheter. Observation on 12/2/25 at 10:48 A.M., showed:- LPN E performed hand hygiene prior to entering room, donned (put on) a gown and gloves then entered the room. -Hospice CNA G was already in the room and gloved at the resident's bedside. -CNA G opened the resident's unsoiled brief and held the resident in place on his/her right side using the left hand and used wet wipes to clean the resident's buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk) and peri area (region between the anus and the external genitalia) with the right hand. After cleaning the resident, without discarding gloves or sanitizing his/her hands, CNA G continued holding the resident on his/her side.-LPN E cleaned the resident's peri area with a wet wipe in the left hand and alternately applied Cavalon (A liquid that dries to a breathable, waterproof film, protecting skin from body fluids, adhesives, friction, and shear) with the right hand to the resident's coccyx (a small triangular bone at the base of the spinal column) and buttock areas. -CNA G and LPN E, with the same gloves on reapplied the resident's brief. -LPN E with the same gloves on, re-adjusted the resident's nasal cannula, picked up the resident's water pitcher and held the straw in place while resident drank from pitcher, attached resident's call light to the resident's covers.-LPNE and CNA G pulled the resident up in bed and pulled covers over resident.-LPN E used the bed remote to adjust the resident's bed position and moved the bedside tray table close to the bed.-LPN E discarded the gloves and gown then performed hand hygiene before leaving the room. During an interview on 12/5/25 at 9:21 A.M., CNA H said:-He/She should sanitize or wash his/her hands before and after resident care, before meals, before and after handling linen, after toileting, after peri care, after caring for one route of the body before moving to another.-Hand hygiene should be performed, and gloves should be changed after performing peri care.-Gloves should be changed and hand hygiene should be performed after peri care and before touching anything else in the room such as the resident's items, room items and the resident themselves.-He/She had received hand hygiene training. During an interview on 12/5/25 on 11:47 A.M., LPN E said:-Times to perform hand hygiene were before entering and exiting the resident's room, before and after patient contact, after toileting, after eating, and whenever needed.-The process when performing cares for a resident on EBP were to put on a gown, perform hand hygiene, put on gloves, do cares, remove gown and gloves then perform hand hygiene.-Gloves should be changed and hand hygiene should be performed before going from one route/area on a resident's body to another.-Gloves should be changed and hand hygiene should be performed after peri care and before touching anything else in the room such as the resident's items, room items and the resident themselves. During an interview on 12/5/25 at 1:50 P.M., the DON said:-Hand hygiene should be performed, and gloves should be changed after performing peri care on residents.-Gloves should be changed and hand hygiene should be performed after peri care and before touching anything else in resident's room.-Concerning hand hygiene, training for staff was done every two weeks and as needed. -Skills checks for staff were done annually.

Based on interview and record review, the facility failed to transcribe detailed physician's orders for Hospice (end of life care) services that included supporting diagnosis and the name of the Hospice provider on the Physician's Order Sheet for four sampled residents (Resident #32, #92, #58, and #42) out of 22 sampled residents. The facility census was 108 residents.The facility physician's order policy was requested and not received at the time of exit. Review of the facility's Hospice Program policy revised January 2014 showed there was no guidance on transcription of a detailed physician order for Hospice care services. 1. Review of Resident #32's Face Sheet showed the resident was admitted to the facility with the following diagnoses:-Cerebral Palsy (a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination.-Cognitive communication deficit.-Dysphagia (a condition that affects your ability to produce and understand spoken language).-Aphasia (difficulty swallowing).-Hemiplegia (paralysis that affects only one side of your body), and muscle weakness. Review of the resident's Nursing Note dated 9/29/25, showed:-The resident had been refusing meals, ate at most 25 percent, refused to get up, primarily in pain, Nurse Practitioner was aware. Called the resident's Durable Power of Attorney in a conference call, discussed the resident's status, and agreed with admitting the resident back into the same Hospice services. Notified the Hospice provider and waiting for a call back.-Nursing Notes did not show when Hospice services actually started. Review of the resident's Hospice Medical Record showed Hospice Notification dated 10/1/25 showed Hospice was initiated with a diagnosis of senile degeneration of the brain starting 10/1/25. Review of the resident's Physician's Order Sheet (POS) dated December 2025, showed physician's orders:-Hospice to assess and evaluate the resident (order dated 9/29/25).-There was no physician's order showing Hospice services were ordered that also identified the Hospice provider. During an interview on 12/5/25 at 11:09 A.M., Unit Manager A said there should be a physician's order for Hospice services on the resident's physician's order sheet. 2. Review of Resident #92's admission Face sheet showed: -An admitting diagnosis of Malignant Neoplasm (cancer) of prostate and Encounter of palliative care (improves the quality of life of patients and their families by relieving the pain, symptoms and stress of a serious or debilitating illness).-Had Hospice provider name and phone number. -Under the diagnosis section it did not indicate which supporting diagnosis for his/her Hospice admission. Review of the resident's care plan dated 6/2/25 showed the name of the Hospice provider and admitting to Hospice services with a diagnosis of prostate cancer. Review of the resident's POS and Medication Administration Record (MAR) dated December 2025 showed: -An order for the Hospice provider to evaluate with phone number listed in order dated 5/31/25. -There was no detailed admission to Hospice services order that included the supporting diagnosis documented in the order. During an interview on 12/5/25 at 9:16 A.M., Licensed Practical Nurse (LPN) A said:-He/She reviewed the resident's electronic medical record and noted there was a special instruction banner that had the resident's Hospice company name, phone number, and supporting diagnosis.-He/She was not able to find a detailed physician's order transcribed to the resident's POS for admission to Hospice that included the name of the Hospice provider and supporting diagnosis. During an interview on 12/5/25 at 10:00 A.M., Unit Manager A said: -He/she would expect to have a detailed Hospice order to include admit to Hospice services with a supporting diagnosis documented and the name of Hospice provider. 3. Review of Resident #58's Face Sheet showed the resident was admitted with the following diagnoses:-Post Polio Syndrome (a condition that causes gradual muscle weakness and muscle atrophy (loss) that can affect people who've had polio).-Encounter for Palliative Care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness).-Paraplegia (the inability to voluntarily move the lower parts of the body). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 11/17/25 (in progress), showed:-He/She was moderately cognitively impaired.-He/She needed extensive assistance with bed mobility, transfers, dressing, eating, hygiene and toileting.-He/She had impaired mobility to lower extremities.-Was receiving Hospice services. Review of the resident's Care Plan dated 11/18/25 showed the resident:-Was End of Life.-Was receiving Hospice services through a local Hospice service. Review of the resident's Hospice records showed the resident:-Was admitted to a local Hospice service on 11/7/25 with a diagnosis of Cerebral Vascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain).-Had regular visits logged by Hospice staff including Certified Nursing Assistants (CNA) and nurses.-Hospice last visited on 11/26/25. Review of the resident's POS dated December 2025 showed there was no physician's order for Hospice services. During an interview on 12/3/25 at 12:53 P.M., LPN D said:-The resident had been receiving Hospice care since he/she was admitted .-Hospice visited twice a week to give resident showers.-The resident did not have a physician's order for Hospice services in his/her chart.-There should be a physician's order for Hospice that included the resident's diagnosis in the resident's chart. 4. Review of Resident #42's admission Sheet dated 2/28/25 showed the following diagnoses:-Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) with Dyskinesia (involuntary, uncontrolled muscle movements, ranging from fidgeting to writhing, often affecting limbs, face, or tongue) with Fluctuations (the changes in motor and non-motor symptoms that occur as medication levels in the body change, leading to periods of improvement (on) and worsening (off)).-Dysphagia oropharyngeal phase (inability or difficulty swallowing)-Unspecified Dementia, moderate with psychotic disturbance (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations).-Alzheimer's Disease Unspecified (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).-Heart Failure. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was not cognitively intact.-He/She was on Hospice. Review of the resident's POS dated December 2025 showed the resident did not have orders listed for Hospice. Review of the resident's care plan dated 12/3/25 showed the resident had been on Hospice since 3/4/25. During an interview on 12/5/25 at 10:30 A.M., CNA E said he/she thought there should be orders for a resident to be on Hospice. During an interview on 12/5/25 at 10:45 A.M., LPN D said there should be Hospice orders along with the Hospice company's name on the residents POS. During an interview on 12/5/25 at 1:44 P.M., the Director of Nursing (DON) said: -They had a Hospice banner in the computer that showed the nurse whether the resident was on Hospice services.-They had a physician's order for a referral to Hospice for evaluation, but this order dropped off of the physician's order sheet eventually.-The charge nurse typically received the physician's order for Hospice services.-He/she would expect the resident's physician's orders for Hospice to include admitted to Hospice with the name of the provider and supporting diagnosis. -The resident's detailed Hospice orders would also be documented in the electronic medical record under the special instruction banner.-The resident's special instruction banner remained even if the physician's orders dropped off. -The physician's order audit should be completed by the Unit Manager within 24 hours of new admissions and reviewed during the daily Interdisciplinary team's morning meeting.-He/She would expect physician's order to be reviewed every month to ensure orders were accurate and up to date.-Orders sometimes fall off, but the banner was permanent.-The charge nurse, unit manager, or whomever received the order was responsible for entering the order into the resident's chart.

Based on observation and interview, the facility failed to maintain two ceiling fans in the 400 Unit lobby free from a buildup of dust; failed to ensure the floors in resident rooms [ROOM NUMBERS] were maintained free from dust and debris buildup; and failed to maintain the ceiling vent in the beauty shop, free from a buildup of dust. This practice potentially affected an unknown number of residents who used or reside in those areas. The facility census was 108 residents.1. Observation on 12/1/25 at 10:39 A.M. with the Maintenance Director showed a buildup of dust on two ceiling fans in the 400 Unit lobby area where about seven residents were sitting.During an interview on 12/1/25 at 10:39 A.M., the Maintenance Director said he/she did not know the last time the fans were cleaned.During an interview on 12/3/25 at 2:01 P.M., the Housekeeping Supervisor said it was the responsibility of the maintenance department to clean the ceiling fans, and the ceiling fans should be cleaned once per month.2. Observation on 12/1/25 at 11:36 A.M., showed a buildup of dust and debris under the beds in resident room [ROOM NUMBER].Observation on 12/1/25 at 11:38 A.M., showed a buildup of dust and debris under the bed in resident room [ROOM NUMBER].During an interview on 12/3/25 at 2:06 P.M., the Housekeeping Supervisor said:-During regular mopping and sweeping the housekeeping staff should get under the beds to clean them.-The space under the beds in resident rooms [ROOM NUMBERS] should not have dust and debris.3. Observation on 12/2/25 at 1:16 P.M. showed a heavy buildup of dust on the ceiling vent in the beauty salon.During an interview on 12/2/25 at 1:16 P.M., the Maintenance director said it was the responsibility of the housekeeping department to clean the vent in the beauty salon.During a phone interview on 12/9/25 at 10:38 A.M. the Housekeeping Supervisor said it is normally the Maintenance Director's duty to clean the vent in the beauty salon.

Based on observation, interview, and record review, the facility failed to provide a choice of food for three days for one sampled resident (Resident #9) out of 22 residents who received room trays. The facility census was 108 residents.Review of the facility's Food and Nutrition Services Policy revised dated 2017 showed:-Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. -A resident-centered diet and nutrition plan will be based on this assessment.-Reasonable efforts will be made to accommodate resident choices and preferences.-Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.--If an incorrect meal is provided to a resident, or a meal does not appear to be palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. 1. Review of Resident #9's face sheet showed the following diagnoses:-Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) without Dyskinesia (involuntary, uncontrolled muscle movements, ranging from fidgeting to writhing, often affecting limbs, face, or tongue) without mention of Fluctuations (the changes in motor and non-motor symptoms that occur as medication levels in the body change, leading to periods of improvement (on) and worsening (off)).Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 9/24/25, showed:-He/She was cognitively intact.-He/She was dependent on a wheelchair for mobility. -He/She was independent for upper body motions. During an interview on 12/1/25 at 9:47 A.M. the Dietary Manager (DM) said:-The cook and the servers were responsible for checking what was on the meal tickets.-They were in the process of getting a new food software program and at this time the residents that ate in their rooms were not able to order ahead of time but once they got their food, they could refuse any item and get something else. -The residents were supposed to let whoever was passing trays know if they needed something. During an interview on 12/3/25 at 8:48 A.M. the resident said:-He/She did not receive his/her oatmeal or milk this morning, and he/she had told the nursing staff but still did not receive anything. -Not getting items happened frequently in the morning at breakfast time. -He/She had started circling the items on the meal ticket so they could see he/she was not getting them.Observation on 12/3/25 at 8:48 A.M. of the resident's meal ticket showed milk and oatmeal were listed to be served in the morning at breakfast. During an interview on 12/4/25 at 8:47 A.M. the resident said:-He/She did not receive his/her oatmeal or milk this morning, and he/she had told the nursing staff. -He/She had circled the items on the meal ticket again.Observation on 12/4/25 at 8:47 A.M. of the resident's meal ticket showed milk and oatmeal were listed to be served in the morning at breakfast. During an interview on 12/5/25 at 8:51 A.M. the resident said:-He/She did not receive his/her oatmeal or milk this morning, and he/she had told the nursing staff -He/She had items circled the objects on the meal ticket again.Observation on 12/5/25 at 8:51 A.M. of the resident's meal ticket showed milk and oatmeal were listed to be served in the morning at breakfast. During an interview on 12/5/25 at 10:30 A.M., Certified Nursing Assistant (CNA) E said:-If a resident didn't get an item that was on their meal ticket or if they wanted something else the resident would tell whoever was passing out the trays. -The staff was moved around so much, and he/she had not passed trays these last few days in the morning.-The resident had let him/her know in the past that he/she had not received something.-He/She would go to the dining room and let the kitchen staff know and bring the item back to the resident. During an interview on 12/5/25 at 10:45 A.M., Licensed Practical Nurse (LPN) D said:-He/She had delivered trays but had not passed them out the last few days in the morning. -He/She would ask the resident what they wanted.-If he/she noticed a resident hadn't eaten something then he/she would ask why and if they wanted an alternative. -If he/she noticed something wasn't on the tray that was listed on the meal ticket, he/she would ask the resident if they wanted that item or something different.-He/She would go to the kitchen and get the missing item or the additional item for the resident. During an interview on 12/5/25 at 1:44 P.M. the Director of Nursing (DON) said:-The CNA's were supposed to double check the meal tickets before giving the residents their food. -If a resident did not receive something or wanted to make a change the CNA should notify the kitchen and then the CNA would take the item back to the resident's room.

Based on interview and record review, the facility failed to ensure monthly medication regimen reviews (MRR) were reviewed and recommendations were followed within a timely manner for two sampled residents (Resident #15 and #59) out of 22 sampled residents. The facility census was 108 residents.Review of the facility's policy titled Medication Regimen Reviews dated May 2019 showed:-The Consultant Pharmacist performed a MRR for every resident in the facility receiving medication.-MRRs were done upon admission and at least monthly thereafter, or more frequently if indicated.-The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.-The MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication problems, medication errors and other irregularities.1. Review of Resident #15's admission Record showed he/she was admitted to the facility with the following diagnoses:-Chronic Pain Syndrome (pain that lasts over three months).-Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified.Review of the resident's Electronic Medical Record showed:-Pharmacy Recommendations were made in April 2025 and May 2025.-There was no documentation to indicate MRRs were completed from June 2025 through October 2025.Review of the Physician Recommendations dated August 2025 completed by the Consultant Pharmacist showed:-A 14-day stop date needed to be added to the resident's Morphine Sulfate order.-A specific number of days pro re nata (PRN- as needed) use for the resident's Lorazepam order needed to be added to the order or the medication needed to be discontinued.Review of the resident's Treatment Administration Record (TAR) dated August 2025 showed:-The resident's Morphine Sulfate order remained unchanged.-The resident's Lorazepam order remained unchanged.Review of the Physician Recommendations dated September 2025 completed by the Consultant Pharmacist showed:-A 14-day stop date needed to be added to the resident's Morphine Sulfate order.-A specific number of days PRN use for the resident's Lorazepam order needed to be added to the order or the medication needed to be discontinued.Review of the resident's TAR dated September 2025 showed:-The resident's Morphine Sulfate order remained unchanged.-The resident's Lorazepam order remained unchanged.Review of the resident's Consultant Pharmacist Recommendation to Physician dated October 2025 completed by the Consultant Pharmacist showed a specific number of days PRN use for the resident's Lorazepam order needed to be added to the order or the medication needed to be discontinued.Review of the resident's MRRs received on 12/4/25 showed:-No documentation was received for the recommendations made in April 2025.-No documentation was received for the recommendations made in May 2025.-No documentation was received to indicate that an MRR was completed for June 2025.-No documentation was received to indicate that an MRR was completed for July 2025.Review of the resident's Order Summary Report dated December 2025 showed:-An order for Lorazepam (a medication used to treat anxiety) Oral Concentrate two milligrams (mg)/milliliters (ml), give 0.25 ml by mouth every four hours as needed for anxiety, which was ordered on 8/5/25.-An order for Morphine Sulfate (a medication used to treat pain) Oral Solution 20 mg/ml, give 0.25 ml by mouth every four hours as needed for shortness of air (SOA)/pain, which was ordered on 8/5/25.Review of the Resident's Clinical Physician Orders on 12/4/25 at 12:45 P.M. showed:-The resident's Morphine Sulfate order dated 8/5/25 had been discontinued on 12/4/25.-The resident's Lorazepam order dated 8/5/25 had been discontinued on 12/4/25.2. Review of Resident #59's admission Record showed he/she admitted to the facility with the following diagnoses:-Hypertensive Heart (problems with your heart that can develop if you have high blood pressure).-Chronic Kidney Disease (a long-standing kidney disease based on kidney damage or decreased kidney function for three or months) with Heart Failure (a complex clinical syndrome characterized by the heart's inability to pump blood effectively due to structural or functional impairments) and Stage One through Four Chronic Kidney Disease, or Unspecified Chronic Kidney Disease.Review of the resident's Electronic Medical Record showed:-Pharmacy Recommendations were made in April 2025 and May 2025.-There was no documentation to indicate MRRs were completed from June 2025 through October 2025.Review of the resident's MRRs received on 12/4/25 showed:-No documentation was received for the recommendations made in April 2025.-No documentation was received for the recommendations made in May 2025.-No documentation was received to indicate that an MRR was completed for June 2025.-No documentation was received to indicate that an MRR was completed for July 2025.-No documentation was received to indicate that an MRR was completed for August 2025.3. During an interview on 12/5/25 at 9:35 A.M. Licensed Practical Nurse (LPN) D said:-The wound nurse and the unit managers were responsible for the management of the MRRs.-He/She was unsure when the MRRs were completed.-The Director of Nursing (DON) would ensure the recommendations were reviewed and follow-up was completed.-He/She thought there were Pharmacists who came to the building to share pertinent findings with the nurses and nurse management.-The facility changed pharmacies approximately two months prior, which could be a part of the problem.During an interview on 12/5/25 at 9:53 A.M. the wound nurse said:-Unit managers were responsible for completing the MRRs.-He/She was unsure when MRRs were completed.-The facility changed pharmacies about three months ago.-The new pharmacy the facility utilized did not do monthly reviews.-To his/her knowledge the new pharmacy would do the MRRs throughout the month and would send an email with any residents that were completed.-It was very likely that the change in pharmacies contributed to the issues that were found with the MRRs.-At one point in time there was an issue with the previous pharmacy not completing the MRRs.-The DON would be responsible for ensuring that the MRRs were reviewed and completed within a timely manner.During an interview on 12/5/25 at 10:56 A.M. Unit Manager A said:-The unit managers and the wound nurse were responsible for completing the MRRs.-The facility had changed pharmacies around June 2025.-All the recommendations completed by the old pharmacy were sent via email.-The new pharmacy utilized their own website, and the facility would have to log on to the website to get the recommendations.-There had been inconsistencies in the MRRs completion by the pharmacies.-He/She had looked up Resident #15 and Resident #59 and could not find any MRRs that had been completed by the new pharmacy.-He/She was unsure why Resident #15's recommendations were not completed.-Any recommendations that were made by the Consultant Pharmacist needed to be followed up within 24 to 48 hours of receiving the recommendation.During an interview on 12/5/25 at 1:45 P.M. the DON said:-The unit managers were responsible for completing the MRRs.-The facility switched pharmacies in June.-The main difference between the two pharmacies were how the MRRs were provided to the facility.-Unit Manager A would split the recommendations by doctors and then by units so the appropriate unit manager could follow up on the recommendations.-He/She was responsible for ensuring completion of the MRRs.-He/She was unsure why Resident #15 had the same recommendations made multiple months in a row.-There was no back-up system to ensure all MRRs were completed when the facility switched pharmacies.-When the MRRs were completed by the Consultant Pharmacist the facility needed to immediately follow up with any recommendations that were made.

Based on observation, interview, and record review, the facility failed to accurately assess a resident's Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they were unable to eat) for proper placement while administering medications; failed to ensure liquid nutrition was received as prescribed daily; failed to label the tube feeding bags accurately according to accepted nursing standards of practice; failed to document and monitor the amount of nutrition and water that was provided daily to ensure physician's orders were followed; facility failed to ensure liquid nutrition was received as prescribed daily; failed to label the tube feeding bags accurately according to accepted nursing standards of practice; failed to document and monitor the amount of nutrition and water that was provided daily to ensure physician's orders were followed; and failed to check for residual fluids in the resident's stomach while administering medications for one sampled resident (Resident #6) out of 22 sampled residents. The facility census was 108 residents. Review of the facility's Enteral Tube Feeding Via Continuous Pump Policy Revised November 2018 showed:-If anything suggested improper tube positioning, do not administer feeding or medications, and notified the charge nurse or physician.-When correct tube placement has been verified, flush tubing with at least 30 milliliters (ml) of warm water (or prescribed amount).-The person that performed the procedure would have recorded verification of tube placement in the residents' medical record. -NOTE: The policy did not explain the procedure on how to verify PEG tube placement. 1. Review of Resident #6's admission Record showed he/she was admitted to the facility with the following diagnoses: -Encounter for surgical aftercare following surgery on the digestive system. -Dysphagia (inability or difficulty swallowing) following cerebral infarction (stroke).-Dysphagia, oropharyngeal (mouth and pharynx) phase. Review of the resident's Comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/28/25 showed he/she:-Had severe cognitive impairment.-Had a feeding tube upon admission. -Received over 51 percent (%) of his/her nutrition through tube feeding.-Required total staff assistance for transfers, bed mobility, dressing, and eating.-Required total staff assistance for bathing and toileting. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated October 2025 showed:-Check for gastric residual every eight hours from the resident's PEG.-There were no PEG placement checks specified and no directions on how to check for PEG placement. Review of the resident's care plan revised on 11/4/25 showed he/she:-Was dependent on staff for all cares. -Enteral Nutrition/Medications: Resident had a PEG tube and was at risk for enteral nutrition complications related to aspiration pneumonia, clogged tubing, excessive residual, infection, and stoma irritation. With the following interventions:--Check for residual as ordered.--Check for tube placement as ordered.--Check lung sounds for signs and symptoms of fluid overload as needed.-NOTE: The care plan did not specify how to check for PEG tube placement or how often to check for PEG tube placement and for gastric residual. Review of the resident's Order Summary Report (OSR) dated November 2025 showed:-Check for gastric residual every eight hours, if residual was greater than 100 ml, hold feeding and inform the resident's physician every shift. -Flush the PEG tube with 30 ml pre and post medication administration. -No direction of how to check placement. -No measurements listed of PEG tube length. Review of the resident's MAR and TAR dated November 2025 showed:-Check for gastric residual every eight hours from the resident's PEG.-There were no PEG placement checks specified and no directions on how to check for PEG placement. Review of the resident's MAR and TAR dated December 2025 showed:-Check for gastric residual every eight hours from the resident's PEG.-There were no PEG placement checks specified and no directions on how to check for PEG placement. Observation on 12/3/24 at 9:31 A.M. showed Licensed Practical Nurse (LPN) A:-Unplugged the tube feeding from the PEG tube and inserted a syringe into the PEG Tube.- Flushed the PEG tube with 30 ml of water. -Poured a medication dissolved in water into the syringe. -Waited for the liquid in the syringe to drain into the PEG tube.-Poured another medication cup of medications mixed with water into the PEG tube.-Poured more water into the medication cup and swirled it around to get all the medication dissolved and poured that in the PEG tube. -Flushed the tube with another 30 ml of water. -Put the cap on the PEG tube. -Did not assess the PEG tube for placement before giving medications. -Did not check residual before giving medications. During an interview on 12/3/25 at 9:43 A.M., LPN A said: -He/She did not assess the PEG tube before giving medications because the tube feeding was running. -He/She did not check residual before giving meds because he/she forgot.-He/She should have assessed the PEG tube placement by listening with a stethoscope on the abdomen and pushing air through the PEG tube using the syringe (auscultation). -When asked if he/she would have verified the PEG tube placement any other way he//she said no just by auscultation. -He/She did not know the PEG tube placement should not be verified by auscultation anymore, that was what he/she was taught in school.-No one at the facility had explained how to correctly assess the PEG tube placement. -He/She did not know facility policy on checking the PEG tube placement. -He/She did not remember seeing anywhere in any resident chart what the external length of tubing should be for the residents PEG tube.-He/She did not know what the length of the PEG tube was supposed to be for the resident. During an interview on 12/3/25 at 12:25 P.M., the Director of Nursing (DON) said:-Staff should have verified placement of a resident's PEG tube by aspiration of gastric contents and length.-The facility policy was to verify placement by length and residual of gastric contents. -He/she expected staff to follow the physician's order on how to assess a PEG tube.-He/she expected the care plan to include how to assess the resident's PEG tube to include length and aspiration of gastric contents.-The unit managers were responsible to ensure staff assessed PEG tubes correctly.-He/She was ultimately responsible to ensure the PEG tube placement was done correctly. -Anytime medications were given by a PEG tube, placement of the PEG tube should have been verified before medications were given even if the tube feed was going before medications were given. -Residual would always be checked before medications were given to ensure that there was not too much residual in the stomach to give the medications.-The PEG tube placement assessment should be done prior to any nurse using the PEG tube. 2. Review of the resident's weight record showed he/she was on weekly weights. The monthly weight showed:-On 10/30/25 he/she weighed 165.0 pounds-On 11/26/25 he/she weighed 165.0 pounds -Documentation showed the resident has had no significant weight loss. Review of the resident's Dietary Notes showed the Registered Dietician (RD) documented:-On 11/3/25 the resident was currently on nocturnal continuous feeding of Jevity 1.2. Rate & schedule was 4:00 P.M.to 10: A.M. or 18 hours at a rate of 70 milliliters (ml)/hour. This provided daily: 1260 ml of Jevity 1.2 or 1512 kilocalories (Kcal-the unit used to express the energy value of food), 75.6 grams (g) protein, 1008 ml free water. In addition, he/she was getting 150 ml water flush 4 times daily or 600 ml water daily. The total water he/she was getting was 1608 ml daily. In addition, they would give water with medication. Speech Therapy was working with the resident to try mechanically soft foods and nectar thickened liquids during the 6 hours (between 10:00 A.M. to 4:00 P.M.) he/she was not receiving the Jevity 1.2 continuous feed. Speech therapy was monitoring his/her tolerance to the oral feeding.-On 11/13/25 He/She discussed with the Unit Manager and Rehabilitation the resident's tube feeding plan for Saturday and Sunday since therapy was not available to supervise weekend oral feedings when the resident was not on tube feedings. The Registered Dietician showed the resident received Jevity 1.2, at 70ml/hour, given 4:00 P.M.to 11:00 A.M. only and 1or 2 bottles of 237ml Jevity 1.2 could be given as needed if the resident expressed hunger. Jevity 1.2 at 70 ml/hour from 4:00 P.M. to 11:00 A.M. provided: 1330 ml Jevity 1.2, 1596 kcal, 79.8 g protein, 1064 ml water. The resident received an additional 600 ml water from water flushes to total water=1664ml water daily. So far, the resident was tolerating the tube feeding and doing well with therapy's progressive feedings. The RD would continue to follow. The resident's weight on 11/5/25 was 166.8 pounds, up from 165 pounds upon admission on [DATE]. Review of the resident's MAR and TAR dated November 2025 to December 2, 2025, showed:-November and December showed physician's orders for resident to be on nocturnal tube feeding for 8 hours between 9:00 P.M. to 5:00 A.M.-Staff documented when the tube feeding was initiated and removed but the times of initiation and discontinuation varied. -The documentation on the MAR/TAR did not show the residents daily intake or how staff were monitoring whether he/she received the physician ordered daily amount of nutrition. Review of the resident's Fluid Intake record from 11/4/25 to 12/3/25 showed there were options to document the date, time and amount of fluid intake. There were also options to document if the resident refused, if the resident was not available or was not applicable. Documentation showed:-The nursing staff did not document daily fluid intake amounts and the times of documented fluid intake varied.-The nursing staff did not document actual fluid intake amounts on 17 out of 30 days.-On the 13 dates when fluid intake was documented, the fluid intake documentation was more than 600 ml only on 5 days. All other documented fluid intakes were between zero and 400 ml. Review of the resident's medical record showed there was no documentation showing how nursing staff monitored the resident's daily liquid nutrition (tube feeding) amounts. Review of the resident's Physician's Order Sheet (POS) dated December 2025, showed physician's orders for:-Regular diet mechanical soft nectar thickened liquids for dysphasia (11/26/25)-Jevity 1.2 (liquid nutrition) two times a day for nutrition 70 ml/hour from 4:00 p.m. to 10:00 a.m. (11/26/25). Review of the resident's annual Nutritional assessment dated [DATE], showed the resident:-Was alert with aspiration precautions, chewing and swallowing problems, needed assistance with feeding and received tube feeding.-Had no significant weight loss or gain.-The resident's nutritional intake showed he/she was doing well with continuous tube feeding at 70 ml/hour from 4:00 P.M. to 10:00 A.M. along with his/her current diet as ordered. The resident was ready to progress to a regular diet. -The RD recommended reducing the resident's tube feeding to 9:00 P.M. to 5:00 A.M. for 8 hours of Jevity 1.2 continuous feeding at 70 ml/hour. He/She would continue with water flushes of 150 ml four times daily. This tube feeding regimen provided 560 ml of Jevity 1.2, 672 kcal, 448 ml water plus the 600ml water flushes-33.6 grams of protein. -He/She would also receive a half cup of cottage cheese and one carton of Greek yogurt for an additional 30 grams of protein.-The new diet order showed regular mechanical soft texture with nectar thickened liquids and Jevity 1.2 continuous feeding at 70 ml/hour with water flushes of 150 ml four times daily. Crushed medications with 30 ml water flush via feeding tube before and after medication administration. Review of the resident's POS dated December 2025 showed a physician's order for:-Jevity 1.2 two times a day for nutrition 70/ml/hour from 9:00 P.M. to 5:00 A.M. (order revised on 12/2/25). Observation on 12/1/25 at 11:08 A.M., showed the resident was laying in his/her bed dressed for the weather with call light within reach. His/her tube feeding machine had both a water and a liquid nutrition bag hanging. The water bag was empty, and the nutrition bag had less than 250 ml of liquid nutrition inside. The date on the bag showed 12/1/25 with no time hung or who hung it. The machine was turned off. The residents' spouse was in the room and said:-The resident had aphasia and received tube feeding from 4:00 P.M., to 10:00 A.M. and then it was turned off.-The resident also was now eating orally and ate a pureed (food is macerated to a baby food consistency) diet and was doing very well so far.-The resident had a stroke that affected his/her right side, and he/she was unable to feed himself/herself and needed to be fed. Observation and interview on 12/2/25 at 11:42 A.M., showed the resident was sitting up in a high-backed wheelchair with tray table in front of him/her with noodles, broccoli and ground meat with gravy. The tube feeding machine was turned off. The nutrition bag showed a date of 12/2/25 and had 450 ml liquid nutrition on the bag. There was no time showing when it was hung or who hung it. The water flush bag showed a date of 12/1/25 and there was 150 ml inside of the bag. The bag did not show the time it was hung or who hung it. The resident's spouse was preparing to feed the resident at this time. He/She said therapy came in to work with the resident this morning so the nurse disconnected the tube feeding and said he/she would reconnect it at 2:00 PM. Observation on 12/3/25 at 9:23 A.M., showed the resident was sitting up in bed. His/her tube feeding was on and running at 70ml/hour. The nutrition bag was dated 12/2/25 without a time hung and had 300 ml of liquid nutrition and the water bag was dated 12/2/25 without a time hung and had 600 ml of water. The resident's spouse said that the resident had biscuits with gravy this morning. Observation on 12/3/25 at 12:27 P.M., showed the resident was not in his/her room. His/her feeding tube machine was off. The liquid nutrition bag showed it was dated 12/2/25 and hang time was 5:00 P.M. It showed there was 300 ml of liquid nutrition inside. The water flush bag showed a date of 12/2/25 and there was 600 ml of water in the bag. The resident was receiving rehabilitation at this time. Observation and interview on 12/4/25 at 8:56 A.M., showed the resident was sitting up in bed with breakfast in front of him/her. His/her tube feeding bag was turned off. The liquid nutrition bag was dated 12/3/25 without the time hung documented or who hung it. There was 500 ml inside. The water flush bag was dated 12/3/25 without a time hung or who hung it documented. There was 1100 ml water inside (full). Family Member B, who was feeding the resident said:-The nurse hung the nutrition and water flush bags last night at 9:00 P.M. and turned them off at 5:00 A.M. this morning. During an interview on 12/4/25 at 9:02 A.M. agency Registered Nurse (RN) A said:-The documentation he/she was given at shift change showed the resident's tube feeding was started at 4:00 P.M. and stopped at 10:00 A.M. -He/She was getting ready to turn the resident's tube feeding off. -He/She had not seen the resident yet, and did not know if the nurse had documented the time the feeding was hung and said he/she had not seen the resident yet. During an interview on 12/4/25 at 9:06 A.M., Unit Manager A said:-They changed the resident's tube feeding order on 12/2/25 for the resident to receive the tube feeding at 70 ml/hour from 9:00 P.M. to 5:00 A.M. with water flushes of 150 ml four times daily.-The resident's prior order showed they were feeding the resident manually four times daily, but after the resident came back from the hospital (on 10/26/25) the order showed continuous tube feeding at 70 ml/hour for 16 hours from 4:00 P.M. to 10:00 A.M. with 150 ml water flushes four times daily.-Once the resident began eating oral food the RD reassessed the resident's tube feeding and it changed to 70 ml/hour tube feeding from 9:00 P.M. to 5:00 A.M. (8 hours) with 150 ml water flush four times daily.-The physician's order was changed to reflect the new order on 12/2/25. During an interview on 12/5/25 at 10:24 A.M., the Registered Dietician said:-He/She expected the nursing staff to follow the nutritional orders for tube feeding and water flushes.-The staff seem to document that they gave the supplement or not, but it was key to know how much the resident consumed. -Regarding the resident, the resident was receiving manual tube feeding four times daily then he/she went to the hospital and came back to the facility (11/26/25) on continuous tube feeding for 16 hours daily from 4:00 PM to 10:00 A.M.-Once they introduced food to the resident and he/she began eating successfully, he/she recommended changing the continuous tube feeding to 8 hours nocturnally so the resident could eat orally during the day.-He/She came into the facility on [DATE] and spoke with the family, resident and Unit Manager and they reduced her tube feedings to 8 hours continuous feeding at 70ml/hr. from 9:00 P.M. to 5:00 A.M. with water flushes four times daily at 150 ml per flush to keep from filling up the resident with liquid nutrition.-When he/she came into the facility on [DATE], the nursing staff said the resident had not received his/her tube feeding overnight on 12/1/25 and that the tube feeding had been started late so they had to run it longer in order for the resident to receive the amount of tube feeding he/she was supposed to receive.-He/She was aware that sometimes mistakes occur, but he/she assumed that most of the time his/her recommendations/orders for the tube feeding and flushes were being followed. -The nursing staff do not document the number of flushes the resident receives or the amount of tube feeding the resident receives daily, but he/she has been checking the resident's weights and worked closely with speech therapy regarding the resident's oral intake and the resident was doing okay so far.-He/She expected the nurse who was hanging the formula was documenting the rate, time and amount when the tube feeding was turned off and the bag should show the date and time the feeding was hung. -The resident was to receive 150 ml water flushes every 4 hours which is given automatically while the tube feeding machine was on, but when they turned the machine off, the water flushes were automatically turned off as well, so the staff had to provide those flushes during the time the machine was off. -He/She was not sure that was occurring, and he/she had not seen it documented in the resident's medical record. During an interview on 12/5/25 at 11:09 A.M., Unit Manager A said:-He/She expected staff to follow physician's orders regarding following the resident's tube feeding and water flush orders.-The tube feeding bag should show the residents name, the date, time it was hung and name of the staff that hung the bag for both the feeding and water flush bag. -The nurses had been labeling the bags this way prior to the resident going to the hospital and they had labels that go on the bags.-Prior to 12/2/25, the Jevity was supposed to be hung at 4:00 P.M. and turned off at 10:00 A.M.-On 12/2/25 the nutrition was hung late by the night shift nurse, and the nurse asked if he/she could extend the time of the resident's tube feeding for 2 hours and he/she agreed to this.-The orders for tube feeding and water flushes were changed on 12/2/25 to show they were supposed to start the tube feeding at 9:00 P.M. and stop it at 5:00 A.M. (for 8 hours of feeding) with 150 ml water flush 4 times daily. -The tube feeding machine showed how much tube feeding and water flushes the resident had received daily during the time the resident was receiving tube feeding and flushes.-There should be supplemental documentation showing the total amount (how many ml) of the flushes given and the total amount of the feeding the resident received every day in the resident's medical record.-The department heads, nurses and Registered Dietician should be monitoring to ensure the amount of tube feeding and water flushes prescribed was the amount the resident was receiving daily. -The charge nurse should inform the physician if the resident was not receiving the prescribed amount of nutrition/water flushes, or if the resident had a residual and did not receive all of the feeding or flush, he/she was supposed to receive. The nurse should inform the physician and document this in the resident's nursing notes. During an interview on 12/5/25 at 2:00 P.M. the DON said:-The resident's tube feeding nutrition bag and the water flush bag should be labeled with the resident's name, date hung, time hung, and what the physician's order is for the feeding and flush. -The physician's order should match the order on the nutrition and water flush bags.-Any change in physician's orders should be documented on the physician's order sheet and passed along correctly at the shift change.-He/She expected the nurse to document how much nutrition and water was given at the time the nurse turned the feeding tube machine off in the nursing notes in the resident's medical record.-He/She expected to see a nursing note showing whether the resident's tube feeding and or water flush was accepted and any additional information regarding the tube feeding and flush that was pertinent should be in the nursing notes.-If there were any concerns, such as the staff not hanging the bag timely or the resident not receiving all the tube feeding amount or flush amount for whatever reason the tube feeding was not completed or interrupted, the nurse should document an explanation in the nursing notes of why the feeding was not given as ordered.-When administering medications through the tube, the nurse should listen to the resident's bowel sounds, check the tube for placement and ensure the placement was there prior to giving any medication.

Based on observation, interview and record review, the facility failed to follow physician's orders for giving the nutritional supplement per the physician's order, and failed to ensure the consumption amount of nutritional supplements were documented for one sampled resident (Resident #32) who was dependent on staff for eating, received nutritional supplements and was a high risk for weight loss out of 22 sampled residents. The facility census was 108 residents.1. Review of Resident #32's Face Sheet showed the resident was admitted to the facility with the following diagnoses:-Cerebral Palsy (a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).-Cognitive communication deficit.-Dysphagia (a condition that affects your ability to produce and understand spoken language).-Aphasia (difficulty swallowing).-Hemiplegia (paralysis that affects only one side of your body).-Muscle weakness.Review of the resident's monthly Weight Record showed:-On 7/9/25 the resident weighed 115.8 pounds.-On 8/6/25 the resident weighed 112.0 pounds.-On 9/3/25 the resident weighed 110.4 pounds.-On 10/2/25 the resident weighed 109.0 pounds.-On 11/21/25 the resident weighed 108.2 pounds.-The weight record showed a gradual weight loss over the past three and five months that was not significant weight loss.Review of the resident's Dietary Notes showed:-On 9/22/25 the resident's weight on 9/3/25 was 110.4 pounds, on 8/6 was 112.0 pounds for a 30-day weight loss of 1.4 percent. On 7/9/25 the resident's weight was 115.8 and showed a weight loss of 5 percent in 60 days. He/She was on a regular, mechanical soft-ground meat diet, with thin liquids. He/She was getting Greek Yogurt at breakfast, MedPass supplement, 7 ounces three times daily and magic cup at lunch and dinner. The resident needed assistance eating and sat at the assisted dining table in the dining room. Recommend continue plan of care and continued assistance with eating.-On 10/20/25 the resident was now on Hospice (end of life care). His/her diet was regular, mechanical soft-ground meat diet with thin liquids. He/She received magic cup at noon and in the evening. MedPass supplement, 7 ounces had been ordered three times daily with meals. He/She was to have assistance with his/her meals in the assisted dining area of the dining room. He/She rarely communicated and continued to eat 25 to 50 percent of his/her meals and occasionally more. He/She had family support. Supplement and assistance orders were in place for this Hospice patient.Review of the resident's comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/23/25, showed the resident:-Was alert with significant cognitive impairment.-Had upper and lower extremity impairment and needed moderate to total assistance with dressing, grooming, bathing and mobility.-Needed moderate to extensive assistance with eating.-Had difficulty swallowing.-Had significant weight loss.-Received a mechanically altered diet.-Did not show the resident received supplemental nutrition.Review of the resident's Care Plan, updated on 11/8/25, showed the resident was cognitively incapacitated, was on hospice services and was at risk of rapid decline, altered nutrition and weight loss. The resident preferred to get out of bed for lunch and eat in the assisted dining area when out of bed. Staff was to feed the resident while in bed (at other meals). Interventions showed staff would:-Provide food preferences per resident choice.-Provide nutrition related medications per physician's order.-Provide house supplements as ordered.-Evaluate the need for assistance while eating and drinking as needed.-Offer substitutes for refused fluids and meals.Review of the resident's Dietary Notes showed:-On 11/25/25 Follow up for weight loss. The resident's weight was down 5.6 percent in 90 days. The resident was on Hospice and had leg wounds. He/She moved with difficulty due to pain, so getting in a safe position to eat and drink was challenging for him/her. The resident was monitored for pain. The resident was on a regular, mechanical soft with ground meat/gravy diet with thin liquids. Had Med Pass supplement, 7 ounces with meals three times daily as ordered. Observed the resident drink cranberry juice, without difficulty, through a straw, helped by the nurse. Since 11/22/25 he/she had been eating 0 to 25 percent at meals. Some days he/she ate more. Nursing and Hospice were overseeing his/her care. Dietician was available as needed. --NOTE: The note did not show whether the med pass supplement was a successful nutritional intervention.Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated November 2025 showed:-Physician's orders for the resident to receive MedPass (supplement), 7 ounces three times daily at meals.-The MAR showed a checkmark that the MedPass was provided at each meal.-There was no documentation showing how much MedPass the resident consumed at each meal.Review of the resident's Meal Consumption Record dated 11/5/25 to 12/5/25 showed:-The form was to record alternate meal/nourishments provided to the resident.-The task showed staff was to document on the form if the resident consumed 50 percent or less of a meal or refusal.-Options to document daily consumption included the different supplements that could be offered and space to document the percentage consumed, whether the resident refused, whether the resident was not available or was not applicable.-The record showed no data was documented over 30 days (maximum documentation capacity). Review of the resident's Physician's Order Sheet (POS) dated December 2025, showed physician's orders:-Regular diet, mechanical soft texture (foods were soft and meat was ground).-Medpass 7 ounces with meals three times a day (5/29/25).-There were no physician's orders for Magic Cup.Review of the resident's MAR and TAR dated December 2025, showed:-The physician's orders for the resident to receive MedPass, 7 ounces three times daily at meals. -The MARs showed a checkmark showing the med pass was provided at each meal, but there was no documentation showing how much the resident consumed at each meal. Review of the resident's Medical Record showed:-There was no documentation showing how the facility was monitoring the consumption of nutritional supplement. -There was no documentation showing how much of the supplement the resident consumed daily or at each meal.Review on of the resident's Meal Ticket (undated), showed:-The resident was to receive a mechanical soft diet. -It did not show that the resident was to have MedPass 7 ounces three times daily at every meal.Observation on 12/3/25 at 12:00 P.M., showed:-The resident was sitting up in a high-backed wheelchair in the dining room at the assisted dining table. He/She was served mashed potatoes, carrots, ground chicken and a dinner roll with a cranberry juice beverage. -The resident did not receive a MedPass supplement with his/her meal. -Nursing staff was trying to get the resident to eat bites of potatoes and chicken, but the resident would not open his/her mouth for the staff to feed him/her. Staff continued to encourage eating during the meal period. -The resident drank cranberry juice through a straw while assisted by staff but continued to refuse eating. The resident drank all of his/her cranberry juice.-At 12:19 P.M. Certified Nursing Assistant (CNA) C continued to try to feed the resident a chocolate mousse dessert and the resident would not open his/her mouth. CNA C took the resident back to his/her unit.During an interview on 12/3/25 at 12:10 P.M., CNA C said:-The resident did not really eat and had very poor intake at all meals. -If the resident received supplements, it was during the medication pass and the Certified Medication Technician (CMT) or nurse gave it to him/her. -The resident did not receive the supplement with his/her meal.During an interview on 12/3/25 at 12:15 PM CNA F said:-The resident usually did not eat well at any meal. -When his/her sisters visited, they could get him/her to eat a little bit. -The resident would drink the nutritional supplements, but they did not provide the supplement with the resident's meals. -When the resident's sisters visited, they got the supplement from the nurse or CMT and gave it to the resident.Observation on 12/3/25 showed:-At 12:20 P.M. CNA C informed the nurse that the resident had not received his/her nutritional supplement. -At 12:23 P.M., the nurse approached the resident with a banana flavored nutritional supplement and the resident refused to open his/her mouth to drink it. The nurse approached the resident once more and the resident again refused to drink it.Observation and interview on 12/4/25 at 11:33 A.M., showed the resident was lying in his/her bed on a low airloss mattress. There was a container of nutritional supplement on a small dresser with a straw. Family Member A was in the resident's room and said:-The resident had always been a picky eater, but he/she could get him/her to eat at times during his/her visits.-The resident did not eat as much anymore, but he/she would drink the nutritional supplement when it was given to him/her. -Staff were supposed to give the resident the supplement at all three meals. -He/She visited on Tuesday and was able to get the resident to drink a full container of nutritional supplement. -He/She was going to try to get the resident to drink the supplement today while he/she is visiting.During an interview on 12/4/25 at 2:29 P.M., Registered Nurse A (agency) said: -If the physician's order said the resident was to receive nutritional supplement at meals, then he/she should have received it at meals.-Nursing staff should not only document that they provided the supplement, but they should document how much of the supplement the resident was consuming or if the resident refused it.-At this facility, the Certified Medication Technicians (CMT) gave the resident supplements.-The CMT should document on the MAR that he/she gave the supplement, and they should document the amount of supplement the resident drank.-He/She did not know where they were supposed to document the resident consumption in the resident's medical record, but there should be somewhere to document it. Observation on 12/5/25 at 8:20 A.M., showed the resident was lying in bed with his/her eyes closed resting comfortably. There was no one in the room with him/her, and he/she did not have a food tray or supplement in his/her room. Breakfast was being served at this time. During an interview on 12/5/25 at 9:57 A.M., CMT A (agency) said:-He/She gave the resident his/her supplement today, but he/she only drank half of it.-Once he/she offered the supplement using a straw, the resident drank more so he/she documented that the resident drank the supplement on the resident's MAR.-He/She was not able to document how much of the supplement he/she drank. -In the computer system, they could only document if the resident drank the supplement or not. -In other computer systems there was an area to document how much/percentage of supplement the resident drank.During an interview on 12/5/25 at 9:58 A.M., Licensed Practical Nurse (LPN) A said:-The CMT staff give the nutritional supplements.-They documented if they give it or offered it to the resident or if he/she refused it, but they did not document how much of the supplement he/she drank. -The resident was on Hospice and had not been eating any food, though they tried to give the supplement if he/she would accept it.-The resident had not been drinking the supplement either, but they still offered it to him/her.-This week the resident had not been eating or drinking.-The resident had several family members who came in and visited and they tried to get him/her to drink and eat and sometimes they could encourage him/her to eat and drink and other times they could not.During an interview on 12/5/25 at 10:24 A.M., the Registered Dietician said:-His/Her expectation was for staff to document how much of the nutritional supplement the resident drank because he/she needed to know whether it was an effective intervention for this resident and any other residents who received supplements. -The staff seemed to only document that they gave the supplement or not, but it was key to know how much the resident consumed.-Regarding the resident, he/she was on Hospice, and he/she had not been taking food well. -Recently he/she had increasingly not been eating and drinking as much. -His/her family members were concerned, and they tried to encourage him/her to eat and take the supplement, but the resident continued to decline and may be in the process of dying.-He/She did not expect the staff to force the resident to eat/drink.-Even though the resident seemed to be declining, he/she still expected staff to give the resident the supplement as ordered and to document the amount he/she drank if he/she was drinking any of the supplement.During an interview on 12/5/25 at 11:09 A.M., Uniti Manager A said:-He/She expected staff to follow physician's orders regarding providing nutritional supplements. -The CMT was responsible for giving the supplement and documenting whether the resident received it or not.-If the CMT entered a checkmark on the MAR, it meant that they gave the entire supplement. -If the resident did not consume all of the supplement prescribed, they could still show they gave the supplement, but there was a comment section where they could document how much the resident drank.-He/She expected the CMT to notify the nurse that the resident was not drinking all of the supplement, and the nurse should notify the physician. This should also be documented in the resident's progress notes. -The CMT should document the amount the resident received to ensure they were successful in providing the supplement or not and the reason why (maybe he/she did not like the type of supplement).-It was okay that the resident did not receive the supplement at the time of the meal because the resident could receive it before or after mealtime, as long as it was within the parameter of the mealtime.During an interview on 12/5/25 at 1:49 P.M., the Director of Nursing (DON) said:-Nursing staff should follow orders for providing the resident's nutritional supplement. -They were able to add supplemental documentation on the MAR showing what the resident actually drank and not just a checkmark showing that staff gave the supplement.-He/She expected staff to document how much of the supplement the resident consumed. -The option was available in the electronic record.

Based on observation, interview, and record review, the facility failed to obtain and transcribe a physician order to provide own indwelling foley catheter self-care and failed to ensure to have a nursing assessment completed for the residents ability to perform any or all foley catheter care for one sampled resident (Resident #5) who was at risk for Urinary Tract Infections (UTI - an infection of one or more structures in the urinary system) out of 22 sampled residents. The facility census was 108 residents.The facility Self-Care policy and Catheter Care policy were requested and were not received at the time of exit. 1. Review of Resident #5's admission Face sheet showed the resident admitted to the facility with following diagnoses: -Neuromuscular Dysfunction of the bladder (is nerve damage that keeps the bladder from working properly to include loss of bladder control and retaining urine).-History of UTI.Review of the resident's foley catheter care plan dated 5/16/25 showed: -The resident had a foley catheter due to urinary retention, obstructive uropathy (a blockage in the urinary tract) and history of stroke. --He/she had a history of refusal of catheter care and changes. --Facility staff were to provide catheter care every shift. --Monitor for signs and symptoms of infections and report to his/her physician. -He/she did not have a care plan for providing his/her own catheter care and no nursing assessment was completed to assess the resident's ability and knowledge to perform his/her own catheter care to include emptying the foley catheter drainage bag. Review of the resident's Bladder and Bowel assessment dated [DATE] showed the resident had no documentation he/she was assessed to provide his/her own catheter care. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 11/11/25, showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known.-Required total assistance from staff for toileting.-admitted with an indwelling catheter. During interview on 12/2/25 at 10:02 A.M., the resident said:-He/she had a foley catheter since 2023.-He/she provided most of his/her own personal care with minimal assistance from care staff. -He/she did complete some of his/her own catheter care to including emptying the catheter drainage bag as needed. -The facility nursing staff monitored his/her catheter site and provided catheter care as needed. -He/she had recently been treated for a UTI.Review of the resident's Physician Order Sheet (POS) active order as of 12/3/25 showed:-Nursing staff and care staff were to provided Foley catheter care with soap and warm water, rinse, pat dry and check for urine output every shift, was ordered on 5/14/25. -Change indwelling foley catheter (s a soft, plastic or rubber tube that is inserted into the bladder to drain the urine) use a 18 French (Fr, a measure of the outer diameter of a catheter) tip with a 10 centimeters (cc) bulb attached to gravity drainage bag, change every month on the 17th and as needed if plugged, leaking or dislodged. Diagnosis of urinary retention and order dated 7/17/25.-NOTE: There was no physician order (PO) for the resident to provide his/her own catheter care to include emptying the drainage bag and personal catheter care. -NOTE: There was no physician order for the licensed staff to assess the resident's ability to provide his/her own catheter care to include emptying the drainage bag. Observation on 12/3/25 at 2:16 P.M., of the resident showed he/she had a foley catheter drainage bag located under his/her wheelchair. During an interview on 12/4/25 at 9:27 A.M., Certified Nursing Assistant (CNA) C said:-The resident tried to complete his/her own catheter care.-The CNA assigned would complete the catheter care to include emptying the catheter drainage bag and document the output of urine. During an interview on 12/4/25 at 9:36 A.M., CNA A and CNA B said: -The resident required assistance with personal care after bowel movements. -The resident normally would empty the catheter bag by himself/herself.-The CNA's tried to encourage the resident to inform staff the amount of output and any concerns he/she had with the catheter. During an interview and record review of the resident POS on 12/4/25 at 9:43 A.M., Agency Registered Nurse (Agency RN) A said:-He/She had worked with the resident in the past and the resident had refused care and medications. -The resident's POS showed a physician order for facility nursing staff to provide catheter care every shift. -He/she was not aware the resident provided some of his/her own catheter care. -He/She did not find a physician's order for the resident to perform his/her own catheter care. -The licensed nursing should be providing catheter care every shift and monitoring insertion site every shift for proper placement and signs of infections. During an interview on 12/4/25 at 9:46 A.M., Licensed Practical Nurse (LPN) B said:-He/she was not aware the resident provided his/her own catheter care.-He/she was unsure if a physician's order was required for a resident to provide his/her own catheter care.-Nursing should have completed a self-care assessment if the resident was providing his/her own care. -He/she would have to check with unit manager to get clarification on the facility policy for self-catheter care. During an interview on 12/5/25 at 9:05 A.M., CNA D said: -He/she provided showers for the residents.-The resident provided most of his/her own care with standby assist from care staff. -The resident preferred to complete his/her own personal cares including some catheter care such as emptying the drainage bag. During an interview on 12/5/25 at 9:16 A.M., LPN A said: -The resident provided some of his/her own personal care, due to refusing staff to assist with cares. -The resident did empty his/her own catheter drainage bag, but he/she needed assistance with personal hygiene. -The resident would tell the nurse the amount of urine emptied during the shift. -Staff would check on the resident's catheter every shift. During an interview on 12/5/2025 at 10:00 A.M., Unit Manager A said: -He/she would expect the care staff to be present and assist with the resident's catheter care.-Nursing staff should provide catheter care and monitoring every shift and ensure to document the urine output every shift. During an interview on 12/5/2025 at 1:45 P.M., the Director of Nursing (DON) said: -He/she would expect to have a physician's order, and a nursing assessment completed for the resident who wished to provide any part of his/her own personal catheter care. -He/she would expect nursing staff to have assess the resident for self-care, documented the assessment and any education that had been provided to the resident related to self-catheter care

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for one sampled resident (Resident #32) by not providing palm grips to maintain the resident's range of motion and failed to ensure soft (bunny) boots (provide pressure relief to the heel, ankle and lower calf) were worn to prevent skin breakdown for with limited range of motion in upper and lower extremities, who needed total assistance with bed mobility and was at high risk for skin breakdown out of 22 sampled residents. The facility census was 108 residents.1. Review of Resident #32's Face Sheet showed the resident was admitted to the facility with the following diagnoses:-Cerebral Palsy (a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).-Cognitive communication deficit.-Dysphagia (a condition that affects your ability to produce and understand spoken language), aphasia (difficulty swallowing).-Hemiplegia (paralysis that affects only one side of your body), and muscle weakness.Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/23/25, showed the resident:-Was alert with significant cognitive impairment.-Had upper and lower extremity impairment.-Needed moderate to total assistance with dressing, grooming, bathing and mobility.-Did not receive any restorative treatments or services. Review of the resident's Braden Scale dated 10/18/25, showed score of 11 (a score of 10-12 showed high risk for developing wounds). Review of the resident's Physician's Order Sheet (POS) dated December 2025 showed:-Palm guard (acts as a barrier between fingers and palmar skin to help prevent finger contractures and skin breakdown in the palm) don (to put on) the right hand daily and doff (to remove) at night every shift (ordered 11/3/25).-There were no physician's orders for the resident to wear soft boots (bunny boots).-There was a physician's order dated 4/24/25, to wear bunny boots to (his/her) feet at all times every day and night shift for prevention. This order showed it was discontinued on 11/17/2025.Review of the resident's Care Plan dated 11/8/25, showed the resident was at risk for skin breakdown related to impaired mobility, incontinence and impaired activity of daily living ability (bathing, dressing, toileting, eating, mobility and hygiene). Interventions showed staff would:-Assist to turn and reposition as tolerated (3/20/25).-Check skin during daily care provisions (3/20/25). -Keep skin clean and dry to the extent possible (3/20/25).-Notify the physician and/or responsible party of non-compliance with treatment interventions (3/20/25).-Pressure reduction mattress (3/20/25).-Bunny boots to both feet at all times as tolerated (5/9/25).-Right hand palm guard (5/9/25).Review of the resident's Nursing Note dated 11/11/25 showed:-Second order Restorative Nursing Aide Splinting and Bracing Program Task: If not wearing, already place on the resident's right hand. Resident was able to open (his/her) fingers slightly to allow placement with less pain, 5 times a week.-Review of the resident's Nursing Notes showed there was no documentation showing the resident refused to wear the hand splints.Review of the resident's Task form showed:-Restorative Nursing Aide Splinting and Bracing Program Task: If not wearing already place on right hand. Resident was able to open (his/her) fingers slightly to allow placement with less pain, 5 times a week. -There was no documentation showing the resident refused to wear the palm guard.-There was no documentation showing when the palm guard was applied to the resident.Observation on 12/1/25 at 12:20 P.M., showed the resident was lying in bed on a low airloss mattress (a medical-grade mattress designed to prevent and treat wounds by reducing moisture and heat buildup). His/her legs and feet were elevated on pillows, and he/she was not wearing a palm guard on his/her hands or bunny boots on his/her feet. The resident was awake but was not verbalizing. The resident's bunny boots were sitting on his/her tray table across from his/her bed. There was a sign on the wall that said to keep the palm guard in his/her left hand per physician. Observation on 12/2/25 at 10:07 A.M., showed the resident was in his/her bed on a low airloss mattress. The resident's eyes were closed, and he/she was resting comfortably. His/her feet and legs were elevated on pillows. The resident's bunny boots were laying on top of his/her tray table that was beside her bed but not within reach. There was nothing in or on the resident's hands. Observation on 12/3/25 at 9:07 A.M., showed the resident was laying in his/her bed on a low airloss mattress. The resident's bunny boots were on the resident's tray table beside his/her bed, and not within reach. His/her feet were not elevated or on pillows. The resident had nothing in or on his/her hands. The resident's eyes were closed, and he/she was resting comfortably. Observation on 12/3/25 at 10:57 A.M., showed the resident was laying on her left side on his/her low airloss mattress. His/her call light was within reach. His/her bunny boots were on the tray table beside his/her bed. [NAME] did not have anything in or on his/her hands.Observation on 12/3/25 at 12:00 P.M. showed the resident was sitting up in a high-backed wheelchair in the dining room. He/She was dressed for the weather and was wearing a palm guard with a soft lining in his/her right hand. The resident was also wearing his/her bunny boots on both feet while sitting at the assisted dining table.Observation on 12/4/25 at 8:50 A.M., showed the resident was laying in his/her bed turned to the left side on the low airloss mattress. He/She was wearing his/her bunny boots in bed. He/She did not have anything in or on his/her hands.Observation and interview on 12/4/25 at 11:33 A.M., showed the resident was in his/her bed on a low airloss mattress. He/She was wearing bunny boots in bed, but he/she was not wearing a palm guard or anything in/on her hands. The palm guard was laying on the resident's dresser. Family Member A was in the room and said:-Sometimes the staff place the palm grips on the resident and sometimes they do not.-He/She did not know exactly how long the resident was to wear them or when, but therapy would know. -The resident was supposed to wear his/her bunny boots at all times to protect his/her heels, because he/she was in bed so much and was at risk for skin breakdown.-The resident was prone to skin breakdown, which was why they were ordered, and they should not be discontinued.-He/she was not aware they were discontinued. During an interview on 12/4/25 at 12:18 P.M., the Wound Care Nurse said:-The resident was supposed to wear the bunny boots at all times he/she usually had them on when in bed. -Hospice (end of life care) provided the bunny boots.-He/She would check to see if there was a physician's order but there should have been an order for them. -He/She tried to check every week to ensure the hospice orders for equipment they provided was also documented on the resident's POS.During an interview on 12/4/25 at 12:25 P.M., the Rehabilitation Director said:-The resident was supposed to wear the palm grip daily and they were to be put on in the morning and removed in the evening. -The resident would often refuse to wear them, but his/her family members were in the building daily and when they came in, they were able to help to encourage the resident to wear them. -There should be documentation showing whether the resident refused to wear the palm grips, and the Restorative Aide would be responsible for that documentation.During an interview on 12/4/25 at 12:26 P.M., the Restorative Aide said:-He/She was new to the facility and had a list of residents that he/she was responsible for range of motion or applying splints, braces etc. on.-He/She worked with the resident who was supposed to wear palm grip to his/her right hand.-The resident was supposed to wear palm grips in the morning then he/she would remove them.-Most of the time the resident refused to wear the palm grips.-Sometimes he/she would wait until one of the family members came in and they helped to encourage the resident to wear it. -He/She or the family would put it on around lunch time and the resident would wear it 2 to 3 hours then he/she would remove it. -He/She was supposed to document in the resident's medical record if the resident wore the palm grip, but he/she documented it on paper first then transferred it to the medical record later.-He/She documented the resident's refusals on the paper he/she used while performing his/her restorative duties, but this document was not part of the resident's record.-He/She did not remember where in the resident's medical record he/she documented the resident's restorative tasks. During an interview on 12/4/25 at 12:58 P.M., the Wound Nurse said:-The physician's order for the resident's bunny boots was not on the POS and he/she added the order. -The resident's bunny boots were part of his/her care plan. During an interview on 12/4/25 at 2:29 P.M. Agency Registered Nurse (RN) A said:-Physician's orders for soft bunny boots or hand grips should also be on the resident's POS with the dates they were ordered, and they should also be on the resident's care plan.-Anytime a resident refused any treatment, medication, restorative care or cares, he/she would expect the nursing staff to notify the charge nurse, and it should be documented that the care was refused in the resident's medical record.-If the resident refused restorative care, he/she expected the Restorative Aide to notify the charge nurse.During an interview on 12/5/25 at 11:09 A.M., Unit Manager A said:-The physician's orders should be followed for placing and removing the resident's palm guard. -If the resident refused to allow them to put the palm guard on, they should document that in the resident's medical record and notify the nurse.-Regarding the bunny boots, there should be an order for the bunny boots on the POS and they should have been putting the bunny boots on daily. -The resident usually wore the bunny boots at all times, especially while in bed. -The nurse was responsible to check to ensure the resident is wearing those and the palm grip.-He/She would follow up and complete an in-service on this area.During an interview on 12/5/25 at 1:49 P.M., the Director of Nursing (DON) said:-He/She expected staff to follow the physician's orders for the resident to wear palm grips.-There should have been a physician's order for the resident to wear bunny boots for prevention of skin breakdown.-It was possible the order was discontinued by mistake.

Based on observation, interview and record review, the facility failed to maintain the cleanliness of a resident's wheelchair potentially affecting his/her dignity for one sampled resident (Resident #42) out of 22 sampled residents. The facility census was 108 residents. 1. Review of Resident #42's face sheet showed the following diagnoses:-Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) with Dyskinesia (involuntary, uncontrolled muscle movements, ranging from fidgeting to writhing, often affecting limbs, face, or tongue) with fluctuations (the changes in motor and non-motor symptoms that occur as medication levels in the body change, leading to periods of improvement (on) and worsening (off)).-Dysphagia oropharyngeal phase (inability or difficulty swallowing)-Unspecified Dementia, moderate with psychotic disturbance (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations).-Alzheimer's Disease Unspecified (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 9/29/25 showed: -He/She was not cognitively intact.-He/She needed a wheelchair for mobility.-He/She needed substantial/maximal assistance for feeding.-He/She needed substantial/maximal assistance for all activities of daily living.Observation on 12/2/25 at 12:55 P.M. showed:-The resident was sitting in the community room in his/her wheelchair with other residents. -There was white and brown dried, spilled food debris that was in a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest.Observation on 12/2/25 at 2:00 P.M. showed:-The resident was sitting in the community room in his/her wheelchair while other residents and staff worked on the community room Christmas tree. -There was brown and white dried, spilled food debris a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest.Observation on 12/2/25 at 2:30 P.M. showed there was brown and white dried, spilled food debris in a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest. Observation on 12/3/25 at 9:15 A.M. showed:-The resident was sitting in the community room in his/her wheelchair with other residents. -There was brown and white dried, spilled food debris in a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest.Observation on 12/3/25 at 11:04 A.M. showed:-The resident was sitting in the community room in his/her wheelchair with other residents. -There was brown and white dried, spilled food debris in a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest. Observation on 12/4/25 at 9:06 A.M. showed:-The resident was sitting in the community room in his/her wheelchair with other residents. -There was brown and white dried, spilled food debris in a dripping formation all over the left side of the resident's arm rest and down the outside of the wheelchair below the resident's arm rest. During an interview on 12/5/25 at 10:30 A.M., Certified Nursing Assistant (CNA) E said:-He/She believed it was night shifts responsibility to clean the residents' wheelchairs.-He/She didn't know what the policy was for cleaning the wheelchairs. -He/She had verbally said something a couple of times to the daytime charge nurses about the wheelchair.-He/She said the resident's wheelchair needed to be scrubbed.-The resident would vomit daily and believed it was always vomit on his/her chair. During an interview on 12/5/25 at 10:45 A.M., Licensed Practical Nurse (LPN) D said: -It was night shifts responsibility to clean the residents' wheelchairs. -There used to be a list staff would put the name of the resident who needed their wheelchair cleaned but didn't know what happened to the list and thought it was just on an as needed basis as to when the wheelchair needed cleaned. -He/She had no idea as to how often the wheelchairs should be cleaned. -The resident vomited every day his/her family would bring food, and he/she would eat too much. -The chair hadn't been cleaned in days. During an interview on 12/5/25 at 1:44 P.M., the Director of Nursing (DON) said: -Night shift was responsible for cleaning the wheelchairs.-Night shift had a schedule to clean all wheelchairs at least once a week and on an as needed basis. -He/She did not know why there was debris on the resident's chair.

Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #1) refusal of medications, omission of and late administration of medications was correctly documented and communicated to facility management; and failed to revise the resident's care plan to address the resident's refusal of medications, out of seven sampled residents, and failed to have a policy to address sliding scale insulin. The facility census was 99 residents. Review of the facility Insulin Administration policy dated 2001 showed: -Rapid-acting insulin has an onset of 10-15 minutes, a peak of 30 minutes to one hour and a duration of 3-6 hours. -The policy did not address sliding scale insulin. Review of the facility Administering Medications policy dated 2001 showed: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication administration times are determined by resident need including enhancing optimal therapeutic effect of the medication. -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes. -Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, has its most significant effect on lowering blood sugar levels in about 1 hour, and keeps working for 2 to 4 hours) Subcutaneous (under the skin) solution cartridge 100 units/milliliter (ml) inject per sliding scale (a method to determine how much insulin to give based on a person's current blood sugar) including for a blood sugar of 401 to 450 give 12 units after meals. -Sevelamer (medication used to control high blood levels of phosphorus in people who are on dialysis) 800 milligrams (mg), give two tablets with meals for dialysis. Observation and interview with the resident on 4/8/25 at 12:35 P.M. showed: -The resident had finished eating his/her lunch. -He/she said he/she was to take two large capsules with each meal, and no one had brought in that medication. During an interview on 4/8/25 at 1:58 P.M. the resident said: -No one had checked his/her blood sugar, and no one had given him/her any insulin after his/her lunch meal and also had never given him/her the two capsules that he/she was to take with his/her lunch. -He/she had not been taking the large binder capsules because of an increase in the dose to three capsules with meals, that was too much to swallow, but the dose had recently been changed to two capsules and he/she had decided he/she would take it, but no one brought the medication to him/her at lunch. During an interview on 4/8/25 at 2:07 P.M. Certified Medication Technician (CMT) A said: -The resident was very emotional that morning and had refused to take his/her Sevelamer with his/her breakfast. -He/she knew the resident would not take the Sevelamer at lunch because he/she had refused it at breakfast. -He/she did not offer the Sevelamer to the resident with the resident's lunch. -He/she marked that the resident had taken the Sevelamer at breakfast and at lunch. -He/she had not told the charge nurse that the resident had refused the Sevelamer at breakfast. -He/she had not told the charge nurse that he/she had not offered the Sevelamer to the resident with his/her lunch meal. -He/she knew the medication the resident was to take with meals was very important for him/her to take. -The resident was often emotional and usually did not take the Sevelamer for him/her and he/she would document that he/she had given the medication to the resident. -He/she knew he/she should tell the charge nurse if a resident refused a medication or if he/she did not give a resident a medication to a resident. -He/she knew that he/she should not document that he/she gave a medication that had not been given. During an interview on 4/8/25 at 2:55 P.M. Agency Registered Nurse (RN) A said: -He/she had not done the resident's lunch time blood glucose monitoring (the test system includes a handheld meter and test strips to measure how much glucose is in a small sample of blood) and had not administered any sliding scale insulin to the resident after his/her lunch meal. -He/she had not had time to do the resident's blood glucose monitoring because of other resident care he/she had been doing. -He/she had not had time to talk to anyone about the resident's lunch time blood glucose monitoring and sliding scale insulin. -CMT A had not told him/her that the resident had refused his/her Sevelamer with breakfast or that he/she had not given the resident his/her Sevelamer with lunch. During an interview on 4/8/25 at 3:05 P.M. Unit Nurse Manager A said: -He/she was not aware the resident had not had his/her Sevelamer with his/her breakfast and lunch. -CMT A should have told the charge nurse, or him/her that the resident refused his/her breakfast dose of Sevelamer. -Agency RN A had not told him/her that he/she had not done the resident's after lunch blood glucose monitoring and sliding scale insulin. -He/she had been available and could have helped RN A if he/she had notified him/her that he/she needed help. -The resident's blood glucose monitoring and sliding scale insulin should have been completed as soon as possible after he/she finished his/her lunch. -The resident's lunch was typically served by noon. During an interview on 4/10/25 at 2:25 P.M. the Care Plan Coordinator said: -He/she had not previously known that the resident sometimes refused his/her dialysis medications, and the residents care plan had not addressed refusal of medications. -The resident's care plan should have addressed the refusal of medications. During an interview on 4/10/25 at 3:16 P.M. Nurse Unit Manager A said: -If a resident did not receive a medication, it was to be documented correctly on the resident's Medication Administration Record (MAR), there were codes for showing reasons a medication was not administered. -CMT A had documented that the resident's Sevelamer had been given at breakfast and at lunch on 4/8/25. -CMT A should have correctly documented the resident did not take the medication and the reason. -Any refusal of his/her medications needed to have been communicated to him/her and the care plan coordinator so the resident's care plan would address his/her refusal of medications. -The resident's MAR showed his/her 4/8/25 after lunch sliding scale insulin was administered at 3:44 P.M. -The resident's noon meal sliding scale should have been given as close to him/her finishing his/her lunch meal as possible. During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said: -The CMT should have correctly documented the resident had not taken medications and the reason the resident did not take the medications. -The CMT should have told the charge nurse or the Unit Manager that the resident had refused medications. -The resident's after meal blood glucose monitoring and sliding scale insulin should have been completed as close to the end of his/her meal as possible. -The licensed nurse should have told the Unit Manager that he/she had missed administering the resident's after lunch blood glucose monitoring and sliding scale insulin. MO00252435

Based on observation, interview and record review, the facility failed to notify one sampled resident's (Resident #1) physician of the resident's refusal of his/her dialysis medication and late administration of the resident's sliding scale insulin, out of seven sampled residents. The facility census was 99 residents. Review of the facility Change in a Resident Condition or Status policy dated 2001 showed: -The facility was to promptly notify the resident's attending physician of changes in the resident's medical/mental condition and/or status. -The licensed nurse would notify the resident's attending physician or physician on call when a resident refused treatment or medications at least two consecutive times. 1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes. -Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, has its most significant effect on lowering blood sugar levels in about 1 hour, and keeps working for 2 to 4 hours) Subcutaneous (under the skin) solution cartridge 100 units/milliliter (ml) inject per sliding scale (a method to determine how much insulin to give based on a person's current blood sugar) including for a blood sugar of 401 to 450 give 12 units after meals. -Sevelamer (medication used to control high blood levels of phosphorus in people who are on dialysis) 800 milligrams (mg), give two tablets with meals for dialysis. Observation and interview with the resident on 4/8/25 at 12:35 P.M. showed: -The resident had finished eating his/her lunch. -He/she said he/she was to take two large capsules with each meal, and no one had brought in that medication. During an interview on 4/8/25 at 2:07 P.M. Certified Medication Technician (CMT) A said: -The resident was very emotional that morning and had refused to take his/her Sevelamer with his/her breakfast. -He/she knew the resident would not take the Sevelamer at lunch because he/she had refused it at breakfast. -He/she did not offer the Sevelamer to the resident with the resident's lunch. -He/she marked that the resident had taken the Sevelamer at breakfast and at lunch. -He/she had not told the charge nurse that the resident had refused the Sevelamer at breakfast and had not told the charge nurse that he/she had not offered the Sevelamer to the resident with his/her lunch meal. -He/she knew the medication the resident was to take with meals was very important for him/her to take. -The resident was often emotional and usually did not take the Sevelamer for him/her and he/she would document that he/she had given the medication to the resident. -He/she knew he/she should tell the charge nurse if a resident refused a medication or if he/she did not give a resident a medication to a resident. During an interview on 4/8/25 at 2:55 P.M. Agency Registered Nurse (RN) A said: -He/she had not done the resident's lunch time blood glucose monitoring (the test system includes a handheld meter and test strips to measure how much glucose is in a small sample of blood) and had not administered any sliding scale insulin to the resident after his/her lunch meal. -He/she had not had time to talk to anyone about the resident's lunch time blood glucose monitoring and sliding scale insulin. -CMT A had not told him/her that the resident had refused his/her Sevelamer with breakfast or that he/she had not given the resident his/her Sevelamer with lunch. During an interview on 4/10/25 at 3:16 P.M. Nurse Unit Manager A said: -The resident's physician should have been notified when the resident refused or did not receive medications. -He/she did not see progress notes that the resident's physician had been notified regarding any refused or missed medications. -If a resident did not receive a medication, it was to be documented correctly on the resident's Medication Administration Record (MAR), there were codes for showing reasons a medication was not administered. -The resident's MAR showed his/her 4/8/25 after lunch sliding scale insulin was administered at 3:44 P.M.; there was no progress note that the resident's physician had been notified. During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said: -The CMT should have told the charge nurse, or the Unit Manager that the resident had refused medications. -Then the charge nurse or the Unit Manager should have notified the resident's physician the resident had refused or did not receive medications. -Agency RN A should have told the Unit Manager that he/she had missed administering the resident's after lunch sliding scale insulin. -Either Agency RN A or the Unit Manager should have notified the resident's physician that the resident's after lunch sliding scale insulin had not been done after his/her lunch and these were not done until later that afternoon that way the resident's physician could decide if he/she wanted to give any additional orders. MO00252435

Based on observation, interview and record review, the facility failed to ensure infection control measures when applying a dressing over one sampled resident's (Resident #1's) central venous catheter (CVC - a tube inserted into a large vein, often in chest, or groin, and used for various purposes, including hemodialysis - dialysis a procedure that uses a machine to filter blood when the kidneys were no longer able to do so), out of seven sampled residents. The facility census was 99 residents. Review of the facility Central Venous Catheter Care and Dressing Changes policy dated 2001 showed: -The purpose of the procedure was to prevent associated complications including catheter-related infections associated with contaminated (exposed to germs, bacteria, or other foreign particles), loosened, soiled (dirty, regardless of the source of the dirt), or wet dressings. -Perform site care and dressing change immediately if the integrity of the dressing is compromised- damp loosened or visibly soiled. -Open sterile dressing kit. -Apply mask. -Apply sterile gloves. -Clean catheter insertion site with approved antiseptic solution. -Apply sterile dressing. Review of the facility Enhanced Barrier Precautions (EBPs - extended use of infection control measures that extends use personal protective equipment - PPE, like gowns and gloves) policy dated 2001 showed: -EBPs are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDRO) to residents. -EBPs employ targeted gown and glove use in addition to standard precautions (basic infection prevention practices used in healthcare settings for all patients, regardless of their suspected or confirmed infection status) during high contact resident care activity, including central line care. Review of the Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO-24-08-NH, posting date - effective date 4/1/24 showed: -CMS issued new guidance for long term care (LTC) facilities on the use of (EBP) to align with nationally accepted standards. -EBP recommendations now include use of EBP for residents with indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. -For residents for whom EBP are indicated, EBP is employed when performing central line care. 1. Review of Resident #1's care plan dated 2/4/25 showed: -He/she required hemodialysis related to end stage renal failure and had an implanted port to his/her right chest. -His/her dialysis center was to provide dialysis catheter access site care. -May change the dressing if it became soiled or fell off. Review of the resident's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease and dependence on renal dialysis. -Change central line dressing every seven days and as needed for infection prevention and accidental dressing removal. Observation on 4/8/25 at 2:05 P.M. showed: -Unit Nursing Manager A entered the resident's room without first putting on a gown or mask, put a prepackaged dressing on a surface without first putting a barrier (a disposable cover placed on frequently touched surfaces to prevent contamination and reduce the need for frequent cleaning and disinfection), washed his/her hands and put the gloves. -He/she then picked up the packaged dressing, opened the dressing and without first cleansing the resident's dialysis access site on his/her right chest applied an adhesive dressing over the resident's dialysis site. Observation on 4/9/25 of the contents of the facility Central Line Dressing Kit showed the kit included: -Two masks. -Gloves. -Alcohol wipe. -Dressing. During an interview on 4/9/25 Nurse Manager B said: -The Central Line Dressing Kits had two masks. -One of the masks was for the nurse and one was for the resident to use during the dressing change. During an interview on 4/10/25 at 2:10 P.M. Unit Nurse Manager A said: -He/she should have cleansed the resident's central line site before applying the dressing. -He/she should have worn a mask and gown. -He/she should have used a barrier for the resident's dressing before placing it on a surface. -He/she could have reached out to see if there was a central line dressing kit on the other nursing unit. During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said: -He/she expected licensed nurses to follow EBP, when having direct contact with dialysis residents. -When applying dressings to central lines he/she expected the licensed nurses to wear the appropriate PPE that included a mask and gown and to provide a mask for the resident. -He/she expected all residents with central lines to have their own Central Line Dressing Kit available. -If a resident did not have a Central Line Dressing Kit, he/she expected the licensed nurse to reach out to other nurses to see if a kit was available. -A barrier should be used for any supplies used for dressing changes. -The resident's central line insertion site should have been cleansed with an alcohol wipe prior to application of the new dressing. MO00252435

Based on interview and record review, the facility failed to ensure communication between the facility and dialysis (a procedure that uses a machine to filter blood when the kidneys were no longer able to do so) provider to provide coordinated and consistent care for one sampled resident (Resident #1) with end stage renal disease (permanent kidney failure that requires a regular course of dialysis) out of seven sampled residents. The facility census was 99 residents. Review of the facility End-Stage Renal Disease policy dated 2021 showed: -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. -There would be communication between the dialysis clinic and the facility. 1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease, dependence on renal dialysis. -Dialysis Monday, Tuesday, Wednesday and Friday. During an interview on 4/9/25 at 2:20 P.M. the resident's dialysis clinic nurse said: -For about two months there had been no written communication between the facility before or after the resident's dialysis. -The facility had not provided a form for the dialysis clinic to provide information to the facility regarding the resident's dialysis treatments. -The facility also had not called the facility to get a verbal report regarding the resident's dialysis treatments. During an interview on 4/9/25 at 2:50 P.M. Licensed Practical Nurse (LPN) B said: -There used to be a paper that came back with the resident from dialysis but for at least four weeks there had been not written communication returned from his/her dialysis appointments. -He/she had not called the resident's dialysis provider to get a report on the resident and to ask that the dialysis provider send a written report back to the facility with the resident. During an interview on 4/10/25 at 1:40 P.M. the resident said: -Facility nurses put a form in a bag on the back of his/her wheelchair with his/her weight and vital signs. -The dialysis nurses had stopped looking in his/her bag for the form and he/she had gotten tired of telling them to get the form out of his/her bag a couple of months ago. -The dialysis nurses hadn't given any information back to the facility after his/her dialysis treatments for a long time. -He/she had gotten tired of telling everyone about the form and stopped saying anything about the dialysis papers. During an interview on 4/10/25 at 3:50 P.M. the Director of Nursing (DON) said: -He/she expected licensed nurses to fill out and send a report sheet with the resident to his/her dialysis appointments. -He/she expected licensed nurses to print a sheet for the dialysis provider to use an provide a written report back to the facility following dialysis. MO00252435

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #1) who required dialysis three times a week, received physician ordered dialysis services on 10/22/24 and 10/24/24. On 10/26/24, the resident was sent to dialysis and dialysis staff noticed a significant change in condition and sent the resident to the hospital. The resident was admitted to the hospital on 10/26/24 for weight gain, abdominal pain, acute encephalitis (a neurological condition), end stage renal disease, hyponatremia (low sodium), hyperkalemia (elevated potassium), and his/her hemoglobin was low- requiring an immediate blood transfusion before the resident could receive dialysis. The facility census was 91 residents. The Administrator was notified on 10/29/24 at 3:38 P.M., of an Immediate Jeopardy (IJ) which began on 10/26/24. The IJ was removed on 10/30/24 as confirmed by surveyor onsite verification. Review of the facility's Care of a Resident with End-Stage Renal Disease Policy, dated September 2010, showed: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. -Education and training of staff in the care of ESRD/dialysis residents may be managed by the contracted dialysis facility or by a clinician with special training in ESRD and dialysis care. -Agreement between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed. -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the Coordination of Care Policy, dated 5/20/24, showed: -The Purpose of the policy was to establish a framework for effective coordination of care for the residents in the facility. -The policy aims to enhance communication among interdisciplinary team members, ensure continuity of care, and improve health outcomes for residents. -Upon admission, a comprehensive assessment of each resident's medical, physical, emotional, and social needs will be conducted by the interdisciplinary team. -Regular interdisciplinary (IDT) team meetings will be held at least weekly to discuss resident care plans, progress, and any necessary adjustments to treatment. -The IDT will regularly monitor the resident's progress toward care plan goals. -Staff member will receive training on the principles of care coordination, effective communication, and the roles of different team members in the coordination process. -Feedback from residents, families, and staff will be solicited to enhance care coordination efforts continually. Review of the facility Transportation Policy, dated 10/1/22, showed the facility will contract with licensed medical transportation vendors for the purpose of transporting patients, either by wheelchair or stretcher, for admission, to and medical appointments or to and from dialysis. Review of the facility's undated Admissions Coordinator (Director) job responsibilities showed: -Responsible for managing the admissions process for new residents and ensuring a smooth transition into the facility. -Would involve coordinating with prospective residents, their families, and healthcare providers to facilitate the admission process. -Responsibilities include helping communicate and install transportation schedules and norms for the facility and ensuring compliance with all regulatory requirement relation to admission and documentation. 1. Review of Resident #1's Admission Record showed the resident readmitted on [DATE], with diagnoses including ESRD, chronic kidney disease, and dependence on renal dialysis. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/1/24, showed the resident severely cognitively impaired. Review of the resident's undated Care Plan showed: -The resident had a diagnosis of ERSD and was on dialysis Tuesday, Thursday and Saturday at the dialysis center, chair time from 6:30 A.M. to 10:00 A.M. -Monitor hemodialysis (a medical procedure that filters a patient's blood to remove waste and excess fluid when their kidneys are no longer functioning properly) access site for signs and symptoms of complications and report abnormal findings to physician and/or dialysis center. -Dialysis: Resident required hemodialysis related to end stage renal failure and was at risk for deficient/excess fluid volume, edema (swelling), high blood pressure and infection. Review of the resident's Nurse's Note, dated 10/20/24 at 3:30 P.M., showed the resident readmitted from the hospital with no medication changes, continue current level of care. Review of the resident's Order Summary Report for October 2024 showed: -Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis, ordered 4/26/24. -Dialysis Center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, ordered 4/30/24. -Dialysis pre weight one time a day every Tuesday, Thursday and Saturday, ordered 4/26/24. -Dialysis post weight one time a day every Tuesday, Thursday and Saturday, ordered 4/26/24. Review of the resident's Treatment Administration Record (TAR) for October 2024 showed: -Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis- not documented as completed on 10/22/24. -Dialysis Center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, resident was to be picked up at 5:45 A.M. by a third party transportation company on dialysis days. -Dialysis pre weight one time a day every Tuesday, Thursday and Saturday- not documented as completed on 10/22/24. -Dialysis post weight one time a day every Tuesday, Thursday and Saturday- documented as other, see nurse's notes on 10/22/24 and 10/24/24. Review of the resident's Nurse's Note, dated 10/22/24 at 2:04 P.M., showed dialysis post weight one time a day every Tuesday, Thursday, and Saturday for weight- no additional notes and signed by Licensed Practical Nurse (LPN) A. Review of the resident's Nurse's Note, dated 10/24/24 at 8:15 P.M., showed dialysis post weight one time a day every Tuesday, Thursday and Saturday for weight- patient did not go to dialysis and signed by LPN A. Review of the resident's Neurological Assessment Flow Sheet, dated 10/26/24, showed facility staff documented resident's blood pressure (B/P) as 211/92 (120/80 normal) on 10/26/24 at 4:15 A.M., pupil assessment normal, and hand grasps were greater on the left than the right. Resident transferred to the hospital from dialysis on 10/26/24, signed by the Unit Manager. Review of the resident's Nurse's Note, dated 10/26/24 at 10:50 A.M., showed the resident left for dialysis at this time transported by a third-party transport company, signed by LPN A. Review of the resident's Nurse's Note, dated 10/26/24 at 7:09 P.M., showed: -Resident transferred from dialysis this morning to the hospital. -Resident admitted to the hospital for elevated potassium and low hemoglobin. -Family aware. During an interview on 10/29/24 at 10:47 A.M., Hospital Registered Nurse (RN) A said: -The resident was admitted to the hospital on 10/26/24 with weight gain, abdominal pain, acute encephalitis, ESRD, anemia, and hyponatremia. -The resident received a transfusion due to low hemoglobin, before receiving dialysis on 10/26/24. -The resident received dialysis on 10/26/24 and 10/27/24. -There were additional complications on 10/29/24 and the resident was unable to receive dialysis. During an interview on 10/28/24 at 4:03 P.M., LPN A said: -He/She was the charge nurse for the resident on 10/22/24. He/She knew the resident did not go to dialysis on 10/22/24. -He/She spoke to the dialysis center on 10/22/24 and was told it was too late for the resident to go to dialysis and to resume on the next scheduled dialysis day, 10/24/24. -He/She did not notify or report to anyone the resident had missed dialysis on 10/22/24. -Admissions or Social Services usually set up transportation for dialysis. -He/She was the charge nurse for the resident on 10/24/24. -On 10/24/24, the night nurse had informed the on-call nurse the resident was not picked up for dialysis. -He/She did not notify or report to anyone about the resident not being picked up on 10/24/24 since the on-call nurse had already been contacted. -He/She spoke with Family Member A on 10/24/24, but did not notify him/her the resident had missed dialysis on 10/22/24 and 10/24/24. During an interview on 10/28/24 at 5:38 P.M., Certified Nursing Aide (CNA) A said: -On 10/25/24 he/she could tell the resident was not feeling well and asked to be taken back to his/her room. -On 10/25/24 at 10:30 A.M. he/she found the resident in his/her room on the floor. -He/She notified the nurse of the resident on the floor, the nurse assessed the resident and he/she assisted getting the resident to bed. During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said: -He/She was unsure who called the dialysis center to inform the center the resident was not coming to dialysis on 10/22/24 and 10/24/24. -The charge nurse was responsible for ensuring the resident went to dialysis. -He/She observed the resident was in his/her room on 10/26/24, had not had breakfast at that time, and appeared to be sleepy. -During his/her engagement with the resident on 10/26/24, the resident stood with minimal assist to place a Hoyer pad under him/her with no issues. -On 10/26/24, he/she observed some swelling around the resident's eyes. During an interview on 10/28/24 at 4:58 P.M., LPN B said: -On 10/26/24 he/she was the charge nurse for the resident. -During report on 10/26/24 at 6:45 A.M., he/she noticed the resident had not left for dialysis. -He/She was told the resident had not been to dialysis all week. -He/She reviewed the resident's chart and noted the resident had returned to the facility on [DATE], ordered dialysis three times per week on Tuesday, Thursday and Saturday. -The resident was to go to dialysis on 10/22/24 and 10/24/24, but transportation was not set up. -He/She notified the DON of the resident not being picked up for dialysis and was instructed to set up transportation and schedule a new chair time with the dialysis center. -He/She was able to arrange a new chair time for 10/26/24 at 11:30 A.M. as well as set up transportation. -The resident was tired after breakfast, but was aware he/she was going to dialysis. -About 30 minutes after the resident left for dialysis, he/she received a call from the dialysis center to inform the facility the resident was not stable enough for dialysis and was sent to the hospital. -When he/she noticed the resident had not been to dialysis, he/she felt it was a priority to get the resident to dialysis. -When he/she spoke to the hospital she was informed the resident had elevated potassium and low hemoglobin which required a blood transfusion before the resident had dialysis. -The resident had been in the facility for some time and everyone knows his/her dialysis schedule. -The resident's admission to the hospital was due to missing dialysis. -The Admissions Director was responsible for setting up all dialysis transportation at admission. During an interview on 10/28/24 at 2:10 P.M., Dialysis Center Staff A said: -On 10/22/24 and 10/24/24 the facility called the dialysis center stating transportation did not show up for the resident and they were not sending the resident to dialysis on those days. -When the facility called the dialysis center on 10/26/24, the facility left a message that the resident was not coming due to no transportation. -He/She called back to the facility on [DATE] and spoke to LPN B to inform him/her it was not ok for the resident to not come to dialysis. -He/She advised LPN B on 10/26/24 the resident either needed to come to dialysis or go to the hospital for dialysis treatment. -He/She took care of the resident on 10/26/24. -Upon arrival the resident was out of it when he/she was weighing the resident. -Once the resident was taken back to the dialysis chair, the resident was not responding and his/her face was swollen. -Due to the resident's change in level of consciousness, his/her tongue hanging out of his/her mouth and drooling, emergency medical services (EMS) was called to take the resident to the hospital. -He/She assessed the resident and it was determined the resident was too unstable to receive dialysis at the dialysis center. During an interview on 10/28/24 at 11:38 A.M., the Administrator said: -He/She was made aware of the resident not making it to dialysis on 10/26/24 by LPN B. -The new Admissions Director was not aware he/she was supposed to set up transportation for the resident when the resident was readmitted on [DATE]. -The Admissions Director was still learning his/her position and had only been working in the facility for about a week and a half. During an interview on 10/28/24 at 11:50 A.M., the Director of Nursing (DON) said: -He/She was notified on 10/26/24 the resident was not picked up for dialysis. -They tried to locate transportation once he/she was notified. -They were able to get the resident to dialysis. -The resident was sent to the hospital from dialysis due to altered mental status. -The resident missed dialysis on 10/22/24 and 10/24/24. -He/She was not notified of the resident missing dialysis on 10/22/24 and 10/24/24. -The resident last had dialysis before leaving the hospital on 10/20/24. -Transportation had been canceled when the resident was in the hospital from 10/15/24 through 10/20/24. -He/She said the ball was dropped and the transportation was not set up after the resident returned on 10/20/24. -The facility had an in-house driver for transport, but the staff failed to notify the driver or supervisors the resident was in need of transport services for dialysis. -The resident had been in the facility for a lengthy amount of time and staff should have known the resident needed to go to dialysis. During an interview on 10/28/24 at 12:09 P.M., Family Member A said: -He/She had a meeting at the facility on 10/28/24 related to the resident not being transported to dialysis. -He/She was not aware of the resident missing dialysis on 10/22/24 and 10/24/24. -He/She was contacted by another patient at the dialysis center on 10/26/24 asking why the resident was not at dialysis. -He/She contacted the dialysis center on 10/26/24 and was told the resident did not come to dialysis for the third consecutive scheduled time. -The last time the resident had a dialysis treatment was prior to being discharged from the hospital on 10/20/24. -He/She contacted the facility on 10/26/24 at approximately 8:00 A.M., at which time he/she was told the resident was at the desk and the staff was arranging transport to dialysis. -The resident arrived at the dialysis center on 10/26/24 at approximately 11:00 A.M. -He/She was concerned that upon arrival at the dialysis center the resident was unresponsive and was sent to the hospital. -He/She was told there had been a change in management and the transportation got confused. -This was the first time anything like this has happened at the facility. -He/She was upset that no phone calls were made to him/her and he/she was not aware the resident had missed dialysis. -If he/she had known the resident was in need of transportation to dialysis, he/she would have taken the resident him/herself. During an interview on 10/28/24 at 12:35 P.M., the Admissions Director said: -He/She started at the facility on 10/10/24. -He/She was not aware it was his/her responsibility to set up transportation for new admissions or readmissions until 10/26/24. -When a resident is admitted /readmitted he/she is supposed to review the admission documentation within a timely manner. -He/She reviewed admission documents and was aware of the resident's dialysis, but was not aware at that time it was his/her job to set up the transportation for dialysis. -If he/she would have known it was his/her responsibility to schedule the transportation, he/she would have set it up when the resident readmitted to the facility on [DATE]. - The resident missing dialysis on 10/22/24 and 10/24/24 could have been prevented had he/she been made aware it was his/her responsibility to set up transportation. -He/She was made aware the resident had missed dialysis on 10/22/24 and 10/24/24 on 10/26/24 when the charge nurse initiated an alert to administrative staff about the resident not having transportation for dialysis. -He/She was aware there was a driver in-house for transportation needs. During an interview on 10/28/24 at 1:37 P.M., the Nurse Practitioner said: -He/She was aware the resident readmitted and did see the resident for readmission on 10/21/24. -Was not aware the resident had missed dialysis on 10/22/24 and 10/24/24. -He/She expected the resident to resume dialysis and staff to communicate with transportation to ensure the residents were getting to dialysis. -The nurses and nurse managers should have ensured the resident was getting dialysis. -The resident's hospital admission was a result of not receiving dialysis for six days. -Missing dialysis had a significant impact on the resident's health status. -The resident had dementia and would not have known whether or not he/she missed or needed to go to dialysis. During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said: -He/She was notified on 10/26/24 prior to getting to the facility about the resident not being picked up for dialysis. -It was reported to him/her the resident either needed to go to dialysis or to the hospital for dialysis due to missing dialysis on 10/22/24 and 10/24/24 due to no transportation. -He/She had not been made aware the resident had not been to dialysis since the resident returned to the facility on [DATE]. -On 10/26/24 he/she spoke to Family Member A to discuss the resident not being at dialysis since return and reassured him/her that transportation would be set up for the resident to get to dialysis as ordered. -Dialysis transportation was usually set up by the Admission Director at the time a resident was admitted /readmitted to the facility. -He/She was not aware of any checks and balances to ensure transport was in place. -Dialysis appointments were set to populate on the TAR for residents who required dialysis to include the date, time and transportation company. -He/She expected to be informed of the resident not being transported to dialysis. -Although the IDT meets daily, he/she did not recall the resident being discussed related to missing dialysis for any reason. During an interview on 10/28/24 at 3:37 P.M., LPN C said: -He/She was the on-call nurse from 10/21/24 through 10/27/24. -On 10/24/24 he/she was notified the resident did not go to dialysis due to no transportation by the charge nurse, he/she advised to give transport a little more time as they could be running late and to pass the information on to LPN A. -Upon arrival at the facility on 10/24/24 LPN A was aware of the transportation concerns, therefore he/she did not pursue any follow up at that time. -He/She was not informed of the resident missing dialysis on 10/22/24 until 10/26/24. -The resident had been at the facility prior to readmission on 10/20/24 with dialysis transportation in place. -There had not been prior concerns about the resident not making it to dialysis due to transportation in the past. -The Admissions Director was responsible for setting up transportation to dialysis upon admission/readmission of the resident on 10/20/24. -The resident's admission to the hospital could have been prevented if the transportation concern had been resolved or set up at admission. -The resident has had several hospitalization s related to dialysis. During an interview on 10/29/24 at 11:51 A.M., the Dialysis Center Staff said: -The resident's increased potassium level was a direct result of missing dialysis. Missing dialysis resulted in increased toxins in the body and altered mental status. -He/She had never seen the resident with altered mental status. -The resident had been very compliant with dialysis and had never missed dialysis consistently in the past. -The resident had a recent repair of his/her fistula (dialysis access). -Complications of the fistula could result if not used, causing clotting and/or stenosis (a narrowing of a tubular structure or blood vessel). -The resident's low hemoglobin was a result of missing dialysis due to not receiving the iron and Mircea (a medication to promote red blood cell production) while at dialysis. The resident did not receive the routine laboratory monitoring and medications while at dialysis. During an interview on 10/29/24 at 1:11 P.M., the Medical Director said: -He/She was aware the resident was admitted to the hospital on 10/26/24. -He/She was not informed the resident missed dialysis on 10/22/24 and 10/24/24. -He/She was not aware of the resident's fall on 10/25/24, therefore was not aware of the resident's potential decline due to missing dialysis on 10/22/24 and 10/24/24. -He/She believed the resident's fall on 10/25/24 and admission to the hospital 10/26/24 was the result of missing dialysis on 10/22/24 and 10/24/24. -There was no reason for him/her to not be notified as he/she is at the facility every Tuesday and Thursday. -He/She did not understand why the staff did not ensure the resident was transported to dialysis. During an interview on 10/29/24 at 3:10 P.M., the Administrator said: -He/She was not made aware of the resident missing dialysis on 10/22/24 or 10/24/24. -He/She was not aware of the potential change in condition on 10/25/24. -He/She was not aware there were concerns related to transportation to dialysis until 10/26/24 when LPN B initiated the alert to department heads. -The resident fall and hospitalization was preventable and the staff should have alerted him/her, the Medical Director, the DON, the Unit Manager, Social Services, in-house transportation, the Admissions Director and/or the family. During an interview on 10/31/24 at 11:29 A.M., LPN A said: -He/She were responsible for the resident on 10/22/24 and 10/24/24. -The relevance of dialysis was life or death. -If he/she had notified someone of transportation concerns, the resident may not have missed dialysis which resulted in the resident's admission to the hospital on 10/26/24. During an interview on 10/31/24 at 12:26 P.M., the Social Services Designee said he/she would have been notified of the resident needing transportation to dialysis, he/she would have assisted with arranging transport. During an interview on 10/31/24 at 12:49 P.M., the DON said if the staff had notified the physician, family, DON or any other department head in real time the resident would not have missed dialysis which resulted in the resident's admission to the hospital. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00244188

Based on interview and record review, the facility failed to ensure nursing staff notified the next of kin, physician, and department heads when one sampled resident (Resident #1) missed dialysis on 10/22/24 and 10/24/24, had increased blood pressure, and had a fall on 10/25/24. The resident was hospitalized on [DATE]. The facility census was 91 residents. Review of the facility Coordination of Care Policy, dated 5/20/24, showed: -The purpose of the policy was to establish a framework for effective coordination of care for the residents in the facility. -The policy aims to enhance communication among interdisciplinary team members, ensure continuity of care, and improve health outcomes for residents. -Care coordination will be facilitated through effective communication, shared decision-making, and the involvement of residents and their families in the care planning process. -Regular interdisciplinary (IDT) team meetings will be held at least weekly to discuss resident care plans, progress, and any necessary adjustments to treatment. -All team members must document relevant communication in the resident's medical record to ensure continuity of care and shared understanding. -A designated staff member will be responsible for communicating any significant changes in a resident's condition to all relevant team members promptly. 1. Review of Resident #1's Admission Record showed the resident readmitted on [DATE] with diagnoses including End-Stage Renal Disease (ESRD), dependence on renal dialysis, and hemiplegia and hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain), following cerebral infarction (stroke) affecting right dominant side. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/1/24, showed the resident severely cognitively impaired. Review of the resident's undated Care Plan showed: -The resident had a diagnosis of ESRD and was on dialysis Tuesday, Thursday and Saturday at the dialysis center, chair time from 6:30 A.M. to 10:00 A.M. --Monitor hemodialysis access site for signs and symptoms of complications and report abnormal findings to physician and/or dialysis center. -Dialysis: Resident required hemodialysis related to end stage renal failure and was at risk for deficient/excess fluid volume, edema, high blood pressure and infection. -Falls: Resident at risk for fall with or without injury related to altered balance while standing and/or walking, altered mental status, antihypertensive medication, diuretic medication, history of falls, seizure disorder, and unsteady gait. --Monitor for changes in condition affecting risk for falls and notify physician if observed. -Resident had an unwitnessed fall and is at risk for recurring falls, 6/17/24. --Monitor for complications related to the fall and notify physician promptly if observed. Review of the resident's Order Summary Report for October 2024 showed: -Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis, ordered 4/26/24. -Dialysis center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, ordered 4/30/24. -Dialysis pre-weight one time a day every Tuesday, Thursday, and Saturday, ordered 4/26/24. -Dialysis post weight one time a day every Tuesday, Thursday, and Saturday, ordered 4/26/24. Review of the resident's Treatment Administration Record (TAR) for 10/1/24 through 10/31/24 showed: -Dialysis: Complete observation tab, print and send with patient to dialysis, also collect once patient returns and place in the medical records bin to be scanned to the patient chart, one time a day every Tuesday, Thursday and Saturday for dialysis- not documented as completed on 10/22/24. -Dialysis center days and times of treatment, Tuesday, Thursday, and Saturday and name of transportation, resident was to be picked up at 5:45 A.M. by a third party transportation company on dialysis days. -Dialysis pre-weight one time a day every Tuesday, Thursday and Saturday- not documented as completed on 10/22/24. -Dialysis post weight one time a day every Tuesday, Thursday and Saturday- documented as other, see nurse's notes on 10/22/24 and 10/24/24. Review of the resident's Nurse's Note, dated 10/22/24 at 2:04 P.M., showed dialysis post weight one time a day every Tuesday, Thursday, and Saturday for weight, no additional notes were signed by Licensed Practical Nurse (LPN) A. Review of the resident's Nurse's Note, dated 10/24/24 at 8:15 P.M., showed dialysis post weight one time a day every Tuesday, Thursday and Saturday for weight- patient did not go to dialysis, signed by LPN A. No further nurse's notes for 10/25/24. Review of the resident's medical record showed no documentation the physician, family, or department heads were notified of the missed dialysis on 10/22/24 or 10/24/24 until 10/26/24 Review of the resident's un-witnessed fall report, dated 10/25/24 at 9:30 A.M., showed: -The nurse alerted by Certified Nurse Aide (CNA) A that the resident had fallen. -The resident was laying on his/her right side in a fetal position. -No injuries noted. -Predisposing factors, recent change in cognition. -Notifications: Director of Nursing (DON), Family Member A, and Medical Director on 10/25/24 at 10:10 A.M. Review of the resident's Rehab-Status Post-Fall Screen, dated 10/25/24 at 10:16 A.M., showed: -The resident had a non-injury fall in room. -No injury noted. -Information reported to IDT at Stand-up Meeting by: no therapist noted, no notes for reporting. Review of the resident's Neurological Assessment Flow Sheet, dated 10/26/24, showed facility staff documented the resident's blood pressure (B/P) was as high as 211/92 (normal 120/80), pupil assessment was normal and hand grasps were greater on the left than the right. The resident was transferred to the hospital from dialysis on 10/26/24 signed by the Unit Manager. Review of the resident's medical record showed staff did not notify the physician of the resident's blood pressure of 211/92 on 10/26/24, prior to being sent to dialysis. Review of the resident's Nurse's Note, dated 10/26/24 at 10:50 A.M., showed the resident left for dialysis at this time transported by a third-party transport company, signed by LPN A. Review of the resident's Nurse's Note, dated 10/26/24 at 7:09 P.M., showed: -Resident admitted to the hospital for elevated potassium and low hemoglobin. -Resident transferred from dialysis this morning to the hospital. During an interview on 10/28/24 at 11:50 A.M., the DON said: -The resident missed dialysis on 10/22/24 and 10/24/24. -He/She was not notified of the resident missing dialysis on 10/22/24 and 10/24/24. -The facility had an in-house driver for transport, but the staff failed to notify the driver or supervisors the resident was in need of transport services for dialysis. -The resident had been in the facility for a lengthy amount of time and staff should have known the resident needed to go to dialysis. During an interview on 10/28/24 at 12:09 P.M., Family Member A said he/she had not been notified of the resident's missed dialysis or the resident's fall. During an interview on 10/28/24 at 1:37 P.M., the Nurse Practitioner said: -He/she was not aware the resident had missed dialysis on 10/22/24 and 10/24/24. -He/she was not notified of the resident fall. -He/she would of expected notification of the fall. During an interview on 10/28/24 at 2:10 P.M., Dialysis Center Staff A said: -On 10/22/24 and 10/24/24, the facility called the dialysis center stating transportation did not show up for the resident and they were not sending the resident to dialysis on those days. -When the facility called the dialysis center on 10/26/24, the facility left a message that the resident was not coming due to no transportation. -He/She called back to the facility on [DATE] and spoke to LPN B to inform him/her it was not ok for the resident to not come to dialysis. -He/She advised LPN B on 10/26/24 the resident either needed to come to dialysis or go to the hospital for dialysis treatment. -He/She took care of the resident on 10/26/24. -Upon arrival the resident was out of it when he/she was weighing the resident. -Once the resident was taken back to the dialysis chair, the resident was not responding and his/her face was swollen. -Due to the resident's change in level of consciousness, his/her tongue hanging out of his/her mouth and drooling, emergency medical services (EMS) was called to take the resident to the hospital. -He/She assessed the resident and felt the resident was too unstable to receive dialysis at the dialysis center. During an interview on 10/28/24 at 2:41 P.M., the Unit Manager said: -It was reported to him/her the resident either needed to go to dialysis or to the hospital for dialysis due to missing dialysis on 10/22/24 and 10/24/24 due to no transportation. -He/She had not been made aware the resident had not been to dialysis since the resident returned to the facility on [DATE]. -He/She expected to be informed of the resident not being transported to dialysis. -Although the IDT meets daily, he/she did not recall the resident being discussed related to missing dialysis for any reason. -He/she was not notified of the resident fall. During an interview on 10/28/24 at 3:37 P.M., LPN C said: -He/She was the on-call nurse from 10/21/24 through 10/27/24. -On 10/24/24 he/she was notified the resident did not go to dialysis due to no transportation by the charge nurse, he/she advised to give transport a little more time as they could be running late and to pass the information on to LPN A; -Upon arrival at the facility on 10/24/24 LPN A was aware of the transportation concerns, therefore he/she did not pursue any follow up a that time. -He/She was not informed of the resident missing dialysis on 10/22/24 until 10/26/24. During an interview on 10/29/24 at 1:11 P.M., the Medical Director said: -He/She was aware the resident was admitted to the hospital on 10/26/24. -He/She was not informed the resident missed dialysis on 10/22/24 and 10/24/24. -He/She was not aware of the resident's fall on 10/25/24, therefore was not aware of the resident's potential decline due to missing dialysis on 10/22/24 and 10/24/24. -There was no reason for him/her to not be notified as he/she is at the facility every Tuesday and Thursday. During an interview on 10/29/24 at 2:06 P.M., the DON said: -He/She was not notified of the resident's fall until 10/28/24 during morning meeting. -He/She was not sure if anyone else had been notified, such as the physician and the family. -He/She expected to be notified immediately to begin an investigation. During an interview on 10/29/24 at 3:10 P.M., the Administrator said: -He/She was not made aware of the resident missing dialysis on 10/22/24 or 10/24/24. -He/She was not aware of the resident's fall or potential change in condition on 10/25/24. -He/She was not aware there were concerns related to transportation to dialysis until 10/26/24 when LPN B initiated the alert to department heads. -He/She feels this was preventable and the staff should have alerted him/her, the Medical Director, the DON, the Unit Manager, Social Services, in-house transportation, the Admissions Director, and the family. During an interview on 10/31/24 at 10:16 A.M., LPN D said the expectation is to notify the family, physician, and administrative staff any time there was a change with a resident such as a fall or missed appointment. During an interview on 10/31/24 at 11:29 A.M., LPN A said: -He/She was the nurse for 10/22/24 and 10/24/24. -The relevance of dialysis was life or death. -If he/she had notified someone of transportation concerns, the resident may not have missed dialysis which resulted in the resident's admission to the hospital on 10/26/24. During an interview on 10/31/24 at 12:13 P.M., the Unit Manager said: -He/She expected staff to notify the physician, family, unit manager, DON and any other relevant parties in a timely manner about any changes such as a fall, missing dialysis or any other changes pertaining to a resident. -He/She expected LPN A to make the necessary notifications about the resident not being picked up for dialysis on 10/22/24 and 10/24/24 by 7:30 A.M. on those dates. -He/She felt there was no reason for LPN A to not make the notifications on 10/22/24 and 10/24/24 as there were no emergencies and there was a provider in the building Monday through Friday. During an interview on 10/31/24 at 12:26 P.M., the Social Services Designee said if he/she would have been notified of the resident needing transportation to dialysis, he/she would have assisted with arranging transport. During an interview on 10/31/24 at 12:49 P.M., the DON said if the staff had notified the physician, family, DON or any other department head in real time the resident would not have missed dialysis which resulted in the resident's admission to the hospital. MO00244188

Based on observation and interview, the facility failed to remove grime from the top of the garbage disposal (a device, installed under a kitchen sink between the sink's drain and the trap used to shred food waste into pieces small enough--less than 2 mm -- in diameter, to pass through plumbing); to remove a buildup of grime and debris including drinking cups from under the ice machine; to remove debris from around the nozzles of the juice machine; to ensure that Dietary Aide's (DA) A's hair was fully covered; to place a label to identify an unknown substance that was in a bottle on the shelf above the stove; to label a white powdery substance in a container in a dry goods' storage to identify that item; and to maintain the milk at 400 Hall kitchenette at a temperature of 41 F (degrees Fahrenheit) or colder. This practice potentially affected all residents. The facility census was 105 residents. 1. Observation on 4/29/24 from 9:11 A.M. through 9:36 A.M., during the initial kitchen observations, showed: -A buildup of grime under the dishwasher. -A small leak from the garbage disposal. -A buildup of grime and debris including cups and dust under the ice machine. -The presence of grime around nozzles of juice machine. 2. Observations on 5/2/24 from 6:25 A.M. through 8:37 A.M., showed: -A buildup of grime under the dishwasher. -A small leak from the garbage disposal. -A buildup of grime and debris including cups and dust under the ice machine. -The presence of grime around nozzles of juice machine. -The presence of dust on light fixtures above the steam table. -DA A's hair was not completely covered by a hair restraint. -The temperature of the milk that was in a tub was 48.3 F (degrees Fahrenheit). During an interview on 5/2/24 at 7:43 A.M., DA A said he/she did not know the lower part of his/her hair was not covered by the hair net. During an interview on 5/2/24 at 8:39 A.M., DA B said he/she did not check the temperature of the milk before that day and the tub that the container of milk was in did not have ice in it. During interviews on 5/2/24, from 8:49 A.M. through 8:57 A.M., the Dietary Manager (DM) said: -He/She had not scraped off the debris from the outside of the garbage disposal and that in the past, maintenance tried to repair it. -The Maintenance Director attempted to fix garbage disposal about 2-3 weeks prior to the survey. -He/She was not sure why they did not label the sugar. -The bottle with the unidentified liquid on the shelf above the stove was filled with water.

Based on observation, interview and record review, the facility failed to safely provide a two person assist sit-to-stand lift (is a device that assists a patient to rise from the seated position but does not support the patient's entire body weight, a sling is attached to the lift) transfer by Agency Certified Nursing Assistant (CNA) A, for one sampled resident (Resident #1) that resulted in a major injury of deep tissue laceration (deep cut or tear in the skin or flesh) to his/her right lower leg, out of four sampled residents. The failure has the potential to affect the safety of residents who require assistance with transfers. The facility census was 101 residents. On 6/14/23, the Administrator was notified of the past noncompliance which occurred on 6/3/23. Facility staff were educated on 6/5/23 related to providing safe mechanical lift transfers with two person assist, to include review of policy for Safe Lifting and Movement of the Resident and updated the Agency CNA's Orientation Information Acknowledgement Sheet to include the use of two person lifts on 6/6/23 and updated the CNA shift-to-shift report sheet as well as the CNA assignment sheet to include the instruction all lift transfers are to be done with two people. The deficiency was corrected as of 6/6/23. 1. Review of Resident #1's Admission Face Sheet showed he/she had the following diagnoses: -Laceration without a foreign body, to his/her right lower leg. -Dementia. -Rheumatoid Arthritis -Long term use of steroids. Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/22/23, showed he/she: -Was severely cognitively impaired and had short term and long term memory problems. -He/she was able to understand others and make his/her needs known. -Required limited assistant of one staff member for all cares and transfer. Review of the facility's undated CNA Report Sheet for resident on the 400 hallway showed: -The resident required transfer with a gait belt and assist of two staff members. -Sit-to-Stand and mechanical lifts always required two person assistant. Review of the resident's Nursing Event Report dated 6/3/23 at 11:42 P.M. showed: -The resident had a deep irregular shape laceration on right side of his/her lower leg, was about the size of fist. -The resident's wound had a moderate amount of controlled bleeding. -The resident had pain rated of 10 out of 10 on the pain scale, indicating excruciating pain. -The injury happened while transferring the resident. -Facility staff had applied direct pressure to the wound and applied a bandage, Emergency Medical Services (EMS) were notified. -Staff notified the resident's physician and family member on 6/4/23 at 12:00 A.M. -The event note remained open. Review of the resident's Nursing Note dated 6/4/23 at 12:03 A.M., showed: -Attached to event note dated 6/3/23 at 11:42 A.M. -The nurse was notified that assistance was needed due to a serious injury observed by Agency CNA A. --Upon arrival to the resident's room to assess the resident, it was observed that the resident has a laceration the size a fist on the right outer side of his/her right leg. Blood could be seen on the pants and bed of the resident. --The wound was not actively bleeding. A pressure bandage was put in place and EMS were called, along with resident's emergency contact and physician. --When asked what happen, Agency CNA A said the resident was being transferred from his/her wheelchair to the bed. When Agency CNA A removed the resident's pants, he/she observed the wound. Agency CNA A did not see blood on the lift or on the resident's wheelchair. -Resident was transferred to the hospital by EMS. Review of the resident's nursing note dated 6/6/23 at 4:54 P.M., showed: -The resident arrived back at the facility with a nine centimeter (cm) by nine cm dressing to right lower calf area. He/she had a Wound Vacuum Assisted Closure (Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) attached, the dressing had about 25% covered with blood colored (reddish brown) drainage. Review of the resident's Hospital Discharge Summary dated 6/6/23 showed: -The resident had a traumatic wound of a large avulsion (is a forcible tearing off of skin, and when any time layers of skin have been torn off, can expose muscles, tendons and tissue) to his/her right lower extremity tissue, with muscle exposure. -It was unclear of the circumstances regarding the cause of the injury. -Applied a wound vac to right lower leg. -Referred to a wound clinic and primary care physician for follow-up. -No description of the wound was documented in the summary. Review of the Facility Administrator Summary and Investigation dated 6/6/23 showed: -He/she had spoken with Agency CNA A who was assigned to the resident. -On 6/3/23 at approximately 9:15 P.M., the Agency CNA A had arrived to facility for his/her shift, had received report from another staff member and completed walking rounds on assigned residents. -He/she had transferred the resident to bed with a sit-to-stand lift. -While Agency CNA A was placing the lifts back sling strap around the resident waist, Resident #1 had complained of pain with movement, but could not communicate where the pain was. The resident repeatedly said he/she felt like he/she was falling. The resident was securely in the sling. -Agency CNA A provided reassurance throughout the transfer and at no time did Resident #1 scream out suddenly or give any indication that an injury was in progress. -Agency CNA A and the nurse both looked at the resident's wheelchair and lift and did not see any blood on either, nor was anything sticking out that would have obviously caused the injury. -Agency CNA A had notified the unit nurse and when the unit nurse saw the resident's injured leg, he/she had requested another nurse to help with resident care. -Agency CNA A did not ask for assistance with transfer, he/she said No, the sit-to-stands in most places are a one person assist, unlike the Hoyer lift (a mechanical lift) which requires a two person assist. Review of the resident's care plan revised on 6/13/23 (after the resident injury) showed: -The resident requires a two person assist for transfers with gait belt. -He/she was unable to use mechanical lift including the sit to stand. -Note: The facility were not able to provide documentation of the resident's prior care plan before the incident. The facility electric medical record system does not save past care plans. Observation on 6/14/23 at 1:10 P.M. of the resident's transfer showed: -The resident had pink tube covering left side leg rest pegs (to protect from injury to lower left leg) area and had a full leg rest on the right side of the wheelchair. -Resident said he/she was afraid of falling and reported that several times during the transfer. -CNA B and Agency CNA C placed the gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move)around the resident's waist and then lifted the resident as they pivoted the resident to his/her bed. The resident's right knee bent and had a difficult time flex out flat. -The resident had an intact dressing to his/her right lower leg with a small amount of brownish drainage noted. -The resident was not interviewable. During an interview on 6/14/23 at 9:25 A.M., Restorative Aide (RA) A said: -He/she was not working the evening of resident incident. -He/she was in-serviced on proper transfer with a sit-to-stand and all mechanical lifts were to be a two person assist. -He/she was informed that the resident's injury happen during a transfer. -Prior to the resident's incident, the resident would be a either a gait belt transferred or two person sit to stand. He/she was not always a two person transfer with the gait belt, it depended on the resident ability to assist during the transfer that day. During an entrance interview on 6/14/23 at 9:35 A.M., Administrator said: -The resident's injury occurred during a one person transfer with a sit-to-stand. -After the final investigation was completed, the root cause was the resident tends to pull his/her right leg backwards while in a wheelchair and during transfers, it was possible he/she had pressed his/her back calf area against the wheelchair leg rest pegs as he/she was being lifted. -Was noted the resident had a half moon shape wound that was same shape at the leg rest pegs. -The resident's history of complaints pain were due to a diagnosis of rheumatoid arthritis (an inflammatory disease that may lead to serious joint damage and disability). -The resident's skin very frail and thin. During an interview on 6/14/23 at 10:30 A.M. the resident's Family Member said: -He/she was notified by facility staff on 6/3/23 that the resident was being sent to the hospital due to an injury from a fall. -The resident required to be sent to a trauma center due to the severity of the wound. -emergency room physician and EMS said they had never seen anything like the trauma injury to resident's lower right leg. -He/she had obtained photos of the resident's right leg from hospital. The photos showed an irregular shaped long split of the skin and tissue with exposed yellow fatty tissue, and red-pink muscle tissue. No drainage was noted in the pictures. -The facility provided the family with a demonstration on how they thought the injury happened. The resident tends to pull his/her right leg backwards and possibly caught his/her pant leg and skin on the wheelchair's leg rest pegs and his/her leg was torn during the lifting of the resident. -The resident should been transfer lift with a two person assist. -The resident is being seen by the wound clinic. The hospital could not surgically repair the injury due to the resident's frail skin. -The resident left hand was contracted and he/she has difficulty holding on to any items and he/she felt the resident could not be able to help support himself/herself during the transfer with a sit-to-stand. -The resident was fearful of falling due to a history of falling at home. During an interview on 6/14/23 at 11:50 A.M., CNA B said: -He/she had worked the day-shift and part of the evening shift on 6/3/23. -The resident had no skin tears noted at that time. -The resident required a two person assist with a gait belt for transfers after the incident. -CNA B had never used a sit-to-stand for the resident. -He/she would have stopped to see why the resident was in pain before completing the transfer. -Sit-to-stand transfers should always be a two person assist. -He/she had been in-served on safe transfers and to always use two people assist with all mechanical lifts after the incident. -He/she was not aware of the facility sit-to-stand lift having leg straps. During an interview on 6/14/23 at 1:40 P.M., Director of Rehabilitation Services (DRS) said: -The resident was being seen by Occupational Therapy (OT) after he/she had returned from the hospital. -Prior to his/her injury, the resident was a two person sit-to-stand or a two person gait belt transfer. -The resident has been reevaluated and was now a two person gait belt assist, with a lift pivot and turn. -He/she and the facility administration staff had established the cause of the resident's injury by recreating how it could have happened during the transfer. --The resident tended to pull his/her right leg backwards and his/her pant leg and skin could have been caught as the resident was being lifted with the sit to stand. During an interview on 6/14/23 at 1:40 P.M., Registered Nurse (RN) B and Wound Nurse said: -The hospital picture of the resident's leg wound made it look bigger then it was. -The resident was fearful of falling prior to the injury. -The resident was, most of the time, a two person sit to stand transfer. -The resident's skin very frail and tears easily. -The facility staff were provided with in-services on safe transfer and all mechanical lift are a two person transfer after the incident. -Had updated the agency orientation sheet and CNA shift to shift reports on how to transfer the resident. -All Hoyer and sit-to-stand transfers require two person assist. During an interview on 6/14/23 at 2:30 P.M., Director of Nursing (DON) said: -The finding of the investigation was the Agency CNA A provided a one person sit-to-stand transfer which had caused the injury to the resident's right lower leg. -The facility administration were continuing to educate care staff on how to safely provide a two person sit-to-stand lift transfer and Hoyer lift transfers. -The nursing staff and therapy would determine the safest means to transfer a resident and it should be documented in the resident's care plan and CNA care sheets. -The care plans are updated and the facility was unable to review past care plan interventions if they had been removed. During an interview on 6/14/23 at 4:11 P.M., Agency CNA A said: -Another unknown CNA had briefed him/her on care of the residents. -It was reported to him/her, that the resident was known to yell out in pain often so he/she should not be alarmed. -During the transfer, the resident was yelling out in pain, but he/she could not express to him/her where the pain was. -He/she had locked the resident's wheelchair and attached the sling around the resident then secured to the sit-to-stand lift. He/she started to lift the resident and resident voiced he/she was in pain, again he/she could not say where. -He/she transferred the resident to the bed with the lift. -He/she was removing the resident's pants and as he/she was lifting the resident's leg, he/she noticed a lot of blood. -There was no blood trail from the lift to the bed. -The resident's skin was frail and maybe received a skin tear. -He/she went to get the nurse, a dressing was applied, and EMS was called. -When EMS arrived, they said the resident need more care than a regular emergency room visit, he/she needed trauma care due to the type of injury wound. -Report was given to EMS, it was unknown how the resident was injured during the transfer. -The wound was pretty bad and was the size of fist, appeared his/her leg may had scrapped on something. -He/she was briefed on the facility policy for safe transfer with a sit to stand lift and required two person assistance the next day after the incident. -He/she was informed the next day that the facility had an Agency Orientation Sheet at nursing station to be read signed prior to shift. -He/she was not made aware on 6/3/23 of Agency Orientation Sheet at nursing station when he/she started his/her shift. Complaint # MO00219627

Based on observation, interview, record review, and recorded video footage review, the facility staff failed to ensure that a resident remained free from mental abuse, that could demean or humiliate a resident regardless of the resident's cognition or consent, when a staff member videotaped a confused and vulnerable resident, without consent, while the staff member could be heard laughing in the background, then uploaded the video of the resident to a social media page for the staff member's friends to view for entertainment purposes, for one sampled resident (Resident #1) out of eight sampled residents. The facility census was 111 residents. Record review of the facility's Cellular Phone/Camera-Equipped Mobile Device Policy, undated, found in the facility employee handbook on page 44, showed: -The use of personal cellular phones and personal electronic devices during working time was strictly prohibited, unless: --The employee took an authorized break and in an area of the facility restricted to employee use only; -When performing job duties, the personal cellular phone or electronic device must be kept in a bag or locker, and turned off; -Employees may not take digital or still photos or record audio or video footage with cellular phones, for personal use while on the facility premises; -Camera-equipped or audio/video-equipped recording devices were strictly prohibited from use anywhere on the facility property. Record review of the facility's Patient Protection and Response for Allegations of Abuse Policy, revised 9/1/16, showed: -Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation, and staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate, regardless of consent or cognitive status; -Any resident event that is reported to an employee will be considered an allegation of abuse, neglect, or misappropriation of resident property, if the event meets the following criteria: --Any complaint of humiliation, harassment, threats of punishment or deprivation, including staff taking, keeping or using photographs or recordings in any manner that would demean or humiliate regardless of the resident's cognitive status or consent; -The center will train all partners through orientation and ongoing in-services, on the prevention, identification, investigation, and reporting of resident abuse or neglect; Training will include: --Consequences of substantiated and willful abuse allegations; and --Appropriate interventions to deal with aggressive behaviors. Record review of an In-service Training Report, dated 8/22/16, showed: -An in-service was conducted by the Administrator In-Training (AIT) at the facility for all facility staff members; -Printed information was given to the staff members regarding regulatory changes in regard to photo and video recordings of any resident in a long term care facility; -Signatures of all staff members that attended the required in-service. 1. Record review of Resident #1's Admission Record showed the resident: -admitted to the facility on [DATE]; -Medical [DIAGNOSES REDACTED].>--Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) or a condition characterized by a chronic decline in cognitive functions contrasted with a person's usual state of functioning) without behaviors; -History of a stroke; and -High blood pressure. Record review of the resident's Informed Consent for Photos, Videos, and Audio Recordings, dated 10/24/16, showed the resident: -Gave consent for his/her photos/videos to be sent to his/her family members; -Gave consent for his/her photo to be posted within the facility for birthday notification, bulletin board information, and on the picture board in the facility; -Did not consent to his/her picture made for release to the general public, inside or outside of the facility; -Did not consent for his/her picture to be made for release digitally through the facility's controlled social media page. Record review of the resident's Interim Care Plan, dated 10/24/16, showed: -Behavioral interventions revised on 11/6/16, included: --The resident yells out at times and has increased agitation; --[MEDICATION NAME] 1 milligram (mg) by mouth as needed for increased agitation was ordered by the Physician; --Assess the resident for external and internal contributory factors for behaviors; --Assess the resident for [MEDICAL CONDITION] (a sudden onset of increased delusions and mental instability). Record review of the resident's Initial Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 10/31/16, showed the resident: -Cognitively impaired; -Rarely made decisions about daily tasks; -Was assessed to have clear speech and adequate hearing; -Could make his/her needs known to others; -Never refused care from the staff; -Required limited assistance from staff to perform bed mobility, transfers, ambulation, and dressing; -Used a walker and wheelchair for mobility devices; and -Was assessed to have no behaviors observed by the staff. Record review of the resident's physician's orders [REDACTED]. -A physician's orders [REDACTED]. Record review of a self-report made to the State Agency on 11/9/16 at 1:43 P.M., showed: -The Director of Nursing (DON) reported a facility employee brought to her attention a video recording that was posted to a social media application on the evening of 11/8/16, by Certified Nursing Assistant (CNA) A; -The DON reported the alleged video recording showed the resident in a confused mental state, who could not have given consent for the video recording or for the footage to be uploaded to a social media application for public viewing; -The DON reported the video recording showed the resident using racial epithets and yelling at CNA A; -The CNA engaged the resident in inappropriate conversation of a non-therapeutic nature rather than seeking assistance from other nursing staff members to de-escalate the resident's aggressive behavior; -The CNA annotated (added a note, comment, or explanation) the video recording with visual enhancements that could be construed as ridicule; -The video recording also showed another employee's presence, CNA B, who was performing his/her job duties, but did not show his/her face; -The video also showed footage of the resident in his/her room, and a third employee, CNA C, who was in training as a new facility employee, was present in the resident's room, but not observed in the video recording; -CNA A, CNA B, and CNA C had been removed from the staff schedule until an investigation could be conducted; -The resident's family would be contacted after making the self-report to the State Agency. Record review of CNA A's Personnel File, showed: -Worked at the facility since August 2016; -No previous incidents or prior disciplinary action documented since being hired; -Completed orientation at the facility, which included being informed of resident confidentiality with health information and acknowledgement of the facility policies that prohibited staff from taking photos and video recordings on the facility premises. An observation and interview on 11/10/16 at 11:30 A.M., showed the resident: -Participating in Physical Therapy (PT) services; -Responded appropriately to yes or no questions; -Had no response when asked if a staff member had videotaped footage of him/her and sat in his/her wheelchair with eyes closed; -Had no combative behaviors towards any staff member; -Repeatedly closed his/her eyes for frequent rest periods while seated in his/her wheelchair; -Had no response when asked if his/her photo or video could be taken. During an interview on 11/10/16 at 12:35 P.M., the DON said: -Two unsuccessful attempts to contact the resident's family were made on 11/9/16; -An in-service was conducted with all facility staff present in the building on the morning of 11/10/16; -The in-service included review of the facility's printed policy of prohibited cellular phone usage, camera-enable cellular phone usage, and audio/video recordings on facility premises; -CNA A was requested to arrive to the facility early to speak with the DON before his/her scheduled work shift at 3:00 P.M.-11:00 P.M. During an interview on 11/10/16 at 2:20 P.M., CNA A said: -He/she had no recorded audio/video footage of the resident; -He/she worked the 3:00 P.M.-11:00 P.M. shift on 11/8/16; -He/she had taken care of the resident in the past; -The resident refused to let the CNA touch him/her on 11/8/16 when the CNA tried to assist the resident with bedtime tasks; -CNA B and the CNA A would assist one another with job duties and were friends outside of work; -The resident was in the hallway near his/her room and exhibited combative behaviors at approximately 9:30 P.M. that lasted approximately two hours on 11/8/16; -The resident was confused and thought CNA A had taken items from his/her room; -The charge nurse, Licensed Practical Nurse (LPN) A was notified of the resident's confusion and refusal of care; -LPN A and CNA A attempted to assist the resident with a transfer to the bed and the resident began to swing his/her call light at the staff members; -LPN A instructed him/her to continue checking on the resident for safety and LPN A would notify the resident's Physician; -Had assisted with new employment training for CNA C on 11/8/16; -Had no knowledge of any staff member taking video footage of the resident's behaviors on 11/8/16; -Had been oriented on the facility's policy not to have his/her cellular phone on their person during working hours; -If he/she witnessed any staff member taking photos or video footage of any resident, he/she would report it to their charge nurse; -The resident repeatedly referred to CNA A using a derogatory racial term; -He/she told the resident, that behavior was not nice and asked the resident not to say that; -The resident continued to use that term, which didn't bother the CNA because he/she was aware that the resident was confused; -The resident was later assisted to bed by LPN A and CNA A and later fell asleep; -Denied having any recording of the resident in his/her phone; -The DON emphasized the seriousness of the matter and informed CNA A that she had actually seen the video recording, which included CNA A's face being shown; -He/she could not explain how that would be possible and denied videotaping the resident; -CNA B and CNA C would not have videotaped the resident on 11/8/16; -He/she confirmed having a social media page, but denied posting any video to the page. During an interview on 11/10/16 at 2:40 P.M., CNA C said: -He/she was in new employee orientation and had been recently hired at the facility; -Had not witnessed any employee recording video of any resident; -He/she would report an incident to his/her charge nurse or DON; -Confirmed the resident had combative behaviors and refusal of care on 11/8/16; -He/she said some employees did have their cellular phones in their possession while working; -He/she had been oriented and educated on the facility policies which banned cellular phone use and photo/video recordings to be taken of any resident. Observation on 11/10/16 at 4:00 P.M., of the videotaped footage that CNA B brought to the DON for viewing on 11/9/16, showed: -The videotaped footage was approximately 13 seconds in length and contained two separate video clips; -The first clip showed the resident seated in a wheelchair, fully clothed, in an open hallway not far from a nurse's desk, where CNA B was briefly shown documenting on a computer and CNA A was heard on the video saying, There's my bestie; -CNA A then shows his/her face on the video, smiling and giggling at the camera; -The resident is then shown seated in a wheelchair, fully clothed, in his/her room, yelling at CNA A; -Each time that the resident refers to CNA A, using a racial derogatory term, an added graphic of a brass horn appeared on the video screen; -An explosion of multi-colored confetti pieces was synchronized with the resident's wording, that showered down over the resident seated in his/her wheelchair; -CNA A could be heard in the video background laughing loudly when the confetti exploded and showered down over the resident who sat facing forward; -CNA A added the choreographed graphics to the recording using the social media application, to emphasize the resident's verbiage. A phone interview on 11/10/16 at 3:30 P.M., with CNA B was attempted, but he/she was unavailable. A return phone call was requested. A phone interview on 11/10/16 at 4:30 P.M. with LPN A was attempted, but he/she was unavailable. A return phone call was requested. During a phone interview on 11/10/16 at 5:10 P.M., the resident's family member said: -He/she had limited time to speak on the phone; -After being told of the resident being videotaped, he/she replied by saying, Oh, really?; -The resident would get out of hand at times during the evening hours due to Dementia; -He/she did not believe the resident could give consent and fully understand what he/she was consenting to, regarding photos/videos to be taken of him/her self. During a phone interview, conducted by the DON, on 11/10/16 at 6:00 P.M., LPN A allegedly said: -He/she was not aware that CNA A had recorded the resident; -He/she would have immediately reported the incident to the nursing supervisor, DON, and Administrator, if he/she had knowledge of the recording; -Frequent monitoring of the resident for safety and notification to the resident's Physician of the resident's agitation was implemented the evening of 11/8/16. Record review of the resident's PRN (as needed) Medication Administration Record [REDACTED] -[MEDICATION NAME] 1 mg by mouth was administered to the resident on 11/11/16 at 3:10 A.M. due to increased agitation and was documented as effective in reducing the resident's agitation. During an interview on 11/14/16 at 11:00 A.M., the CNA A said: -He/she had additional information about the incident on 11/8/16; -He/she normally doesn't lie; -He/she didn't know that CNA B and CNA C were also suspended until the investigation could be completed; -The resident's behaviors were funny at first, which was why he/she recorded the resident; -He/she had uploaded the recorded video to his/her social media page, that 25-30 friends could access for approximately three to four hours; -He/she was trying to increase the number of people that followed him/her on the social media application; -He/she thought the resident would not have wanted his/her video recorded or shared on a social media page; -He/she understood how the resident and resident's family could be embarrassed or humiliated from others viewing the video recording; -He/she acknowledged that he/she had violated the facility policy regarding cellular phone use during working hours; -He/she acknowledged that he/she had violated the facility policy regarding photo/video recordings taken on the facility premises. During a phone interview on 11/14/16 at 1:15 P.M., CNA B said: -He/she worked the evening shift on 11/8/16; -He/she remembered CNA A called his/her name, but chose not to look at CNA A and continued to document on the computer that evening; -He/she confirmed the resident exhibited combative behaviors that evening; -He/she was aware that CNA A was trying to either take a photo or video of him/her, but had no knowledge that CNA A recorded the resident; -CNA A showed him/her the recorded video of the resident later that evening on 11/8/16; -He/she told CNA A that residents were not to be videotaped or have any of their personal information recorded or shared, and told CNA A to delete the video; -He/she said CNA A replied by saying, I know; -He/she did not report the incident to a supervisor on 11/8/16, due to being unsure who to report the incident to; -He/she didn't think to call the DON at home since it was so late in the evening; -He/she reported the incident to the DON, the next morning on 11/9/16 and brought the DON video footage that CNA A posted on his/her social media page; -He/she had been educated on the facility's policy that prohibited the use of cellular phone and camera-equipped devices on the facility premises during orientation and in-serviced in August 2016. A second phone interview on 11/14/16 at 1:40 P.M. with LPN A was attempted but he/she was unavailable. A return phone call was requested. During a phone interview on 11/14/16 at 2:15 P.M., the resident's Physician said: -He had been notified on 11/9/16 of the resident being videotaped by CNA A; -He felt the resident did not experience mental harm or anguish from the incident; -He felt the resident probably had no recollection of the entire incident; -He felt that additional education and in-servicing with the facility staff about facility policies and resident privacy would be the best way to prevent incidents such as this from occurring in the future. During an interview on 11/14/16 at 2:30 P.M., the facility Social Worker said: -She felt the incident had no impact on the resident due to the resident's cognitive status; -She felt that this was an isolated incident and poor decision by CNA A; -She had been in-serviced and educated on the facility policies that prohibited cellular phone use and photos/videos taken of any resident in the facility; -She felt the resident was unable to give his/her consent for a video/photo to be taken. During an interview on 11/14/16 at 3:30 P.M., the Administrator and DON said: -Facility staff are educated on all facility policies, resident privacy, cellular phone usage and video/audio recording of any kind on the facility premises, during orientation and annually; -Facility staff were promptly educated on the regulation changes associated with photography and video recordings, with social media websites when released for long term care facilities; -Felt that the incident was an isolated incident that involved poor decisions made by CNA A; -The facility would complete its full investigation of the incident and would terminate CNA A from employment at the facility; -Felt they were proactive in preventing this type of incident from occurring to residents in the facility and felt their actions were prompt and appropriate when this incident was brought to their attention by CNA B; -All facility staff will be re-educated on the facility policy for cellular phone use and audio/video recordings, and photography that is prohibited on the facility premises; -The resident was discharged to his/her home, from the facility on 11/14/16. # MO 995