Every finding on record at Webco Manor

Based on observation, interview, and record review, the facility failed to have a system in place to ensure each resident's code status preference was clear and accurate when staff failed to update a full code (every possible measure, including cardiopulmonary resuscitation (CPR - an emergency procedure that is done when a person stops breathing or heart stops, to save a person's life)) to a do not resuscitate (DNR - an order that instructs providers not to start CPR if a person stops breathing or heart stops) for one resident (Resident #1). The facility census was 61. On [DATE], Social Services Director (SSD) notified the Administrator that staff provided CPR to Resident #1, who wished to be a DNR. On [DATE], the facility completed an audit of all residents' code status. On [DATE] the facility implemented a new process and in-serviced all staff. The non-compliance was corrected on [DATE]. Review of the facility's Advanced Directive Policy, revised [DATE], showed the following information:-Upon admission, the resident will be provided with written information regarding the right to refuse or accept medical treatment and to formulate an advance directive if he or she chooses to do so;-If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives;-The resident will be given the option to accept or decline assistance;-Nursing staff will document in the medical record;-The resident has the right to refuse treatment, whether or not he or she has an advance directive;-A resident will not be treated against his or her own wishes.Review of the facility's Do Not Resuscitate Order Policy, revised [DATE], showed the following information:-The facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a DNR order in effect;-DNR orders must be signed by the physician, on the physician's order sheet maintained in the resident's medical record;-A DNR order form must be completed and signed by the physician and resident and placed in front of the resident's medical record.1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of [DATE];-Resident expired on [DATE];-Resident was a full code;-Diagnoses included atrial fibrillation (irregular heart rate and rhythm), cardiac disease, stroke, and lung disease.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the resident had normal cognition.Review showed staff did not provide a care plan for the resident. Review of the resident's Physician Order Sheet (POS) showed an order, dated [DATE], for full code.Review of resident's Outside Hospital Do-Not-Resuscitate (OHDNR) Order, dated [DATE], showed the order signed and dated by the resident and the physician.Review of the resident's progress notes showed the following information:-On [DATE], at 9:56 P.M., the resident was found unresponsive. The nurse was immediately called to the room. Staff initiated CPR and called 911;-On [DATE], at 10:04 P.M., emergency medical services (EMS) arrived and took over CPR for over an hour;-On [DATE], at 11:00 P.M., staff notified the family and physician of the code.Review of the admission Director's handwritten statement, undated, showed the following: -He/she went to the resident's room on [DATE] to complete the admission paperwork;-After completion, all forms were put in a folder on his/her desk. He/she left the facility for the weekend;-He/she returned to the facility on [DATE] and gave the folder to the Social Services Director (SSD);-It did not occur to him/her to make copies for the nursing charts;-It was his/her responsibility to ensure all admissions paperwork was completed and the next steps taken care of before leaving for the weekend.During an interview on [DATE], at 9:35 A.M., the Admissions Director (AD) said the following information:-The resident admitted from the hospital to the facility on [DATE] around 5:00 P.M.;-On [DATE], he/she completed the admission paperwork with the resident;-After completing the admission paperwork, he/she normally gave the paperwork to the SSD, however, he/she had already left the facility for the weekend;-On [DATE], staff found the resident unresponsive and CPR was initiated;-On [DATE], the admission packet was given to the SSD;-He/she said he/she realized the mistake of not letting nursing staff know that the resident changed his/her code status.Review of the Social Services Director (SSD) handwritten statement, undated, showed the following: -The resident admitted on [DATE];-When the resident was accepted to the facility, the SSD created a profile in electronic medical records (EMR) and listed the resident as a full code;-The facility's policy is to default to full code until staff have spoken to the resident and/or family to determine preferred code status;-On [DATE], the admission Director gave the SSD signed admission paperwork;-On [DATE], the SSD began reviewing the admission packet to scan into the EMR when he/she discovered a signed DNR form;-The SSD immediately notified the Administrator.During an interview on [DATE], at 10:00 A.M., the SSD said the following:-The resident admitted to the facility on [DATE] in the evening;-On [DATE], the AD completed the admission paperwork;-On [DATE], the resident and the physician signed the DNR paperwork;-The SSD didn't receive the admission paperwork, including the DNR until [DATE];-All residents are admitted as a full code, that is the facility's default;-The resident's orders had not been up-dated in the hard chart, EMR , or the green/red sticker outside the resident's door prior to his/her death;-On [DATE], the SSD seen the DNR order in the admission paperwork and notified the Administrator.During an interview on [DATE], at 10:53 A.M., Licensed Practical Nurse (LPN) A said the following:-Resident code status can be found in the code book. This is where the resident's DNR OHDNR order form is located;-Code status can also be found on the resident's face sheet;-Red or green sticker outside the resident's door on the resident's name tag;-The resident was a full code.During an interview on [DATE], at 11:03 A.M., Certified Nursing Assistant (CNA) B said the following:-A resident's code status is on the resident's door. [NAME] sticker means full code and red sticker means DNR;-A resident's code status is also in the EMR, on the face sheet;-He/she would get the nurse if the resident appeared to need CPR.During an interview on [DATE], at 11:44 A.M., the Director of Nursing (DON) said the following information:-The resident admitted on [DATE] in the evening;-The Admissions Director completed the admission packet on [DATE] and included signing contracts, going over vaccination records and code status;-Normally the AD will give the code status paperwork to the DON to update in the EMR and the SSD will up-date the red and green stickers out-side the door. That did not happen this time;- The DON said that he/she did not receive any DNR paperwork on the resident prior to the resident coding on [DATE];-Staff called the DON when the resident coded;-The DON came to the facility and contacted family that the resident was coding;- EMS also arrived at the facility and took over CPR.During an interview on [DATE], at 1:30 P.M., the Administrator said the following information:-The resident admitted late on [DATE];-The Admissions Director completed the resident's admission paperwork on [DATE];-The resident changed his/her wishes from a full code to a DNR. DNR paperwork was completed and signed by the resident and the physician;-The Admissions Director did not pass that DNR paperwork onto the SSD or the DON to in-put into the medical record, therefore, nursing staff were not aware that the resident wanted to be a DNR.#2788102

Based on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated, and steps were taken to protect all residents during the investigation, when staff did not begin an immediate investigation into an allegation staff to resident (Resident #1) abuse and the staff member continued to work independently with residents. The facility census was 64.Review of the facility's Abuse and Neglect Policy, undated, showed the following information:-Types of abuse include physical, verbal, sexual, mental, and financial exploitation;-The Administrator or Director of Nursing (DON) or designee must begin an internal investigation immediately and report to DHSS. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of 02/02/24;-Diagnoses included multiple sclerosis (an autoimmune disease disrupting brain to body communication). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/15/25, showed minimal cognitive impairment. Review of the resident's care plan, last reviewed on 12/01/25, showed the following information:-Communication problems related to diagnoses;-Provide resident with supportive care and services. Review a written statement by Certified Nurse Aide (CNA) A's statement dated 01/18/26, between 2:00 A.M. and 2:25 A.M., showed the following: -He/she went into the resident's room to change the resident's brief when the resident reported to her that CNA B came into his/her room, turned on the bright light;-The resident yelled hey at CNA B;-The resident said he/she was upset that CNA B turned on the bright light because he was sleeping;-The resident said that CNA B has a bad temper and was being very rough while attempting to change the resident;-The resident told CNA B to stop. CNA B then punched the wall three times above his/her head and walked out of the room;-The resident told CNA A that he/she was fearful of CNA B and did not want him/her back in his/her room;-CNA A immediately reported the incident to Registered Nurse (RN) C;-On 01/18/26, at 2:54 A.M., CNA A sent a picture of his/her written statement to the Director of Nursing (DON) via text message. CNA A did not receive a response;-On 01/18/26, at 2:56 A.M., CNA A attempted to call the DON, and then the Administrator. Neither answered their phone;-On 01/18/26, at 3:04 A.M., CNA A sent a picture of his/her written statement to the Administrator.During an interview on 01/21/26, at 2:15 P.M., CNA A said the following: -On 01/18/26, at approximately 2:00 A.M., he/she entered the resident's room, and the resident told him/her that CNA B came in his/her room, turned on the bright light, and was rough with cares. The resident told CNA B to stop. CNA B became upset and hit the wall three times above the resident's head before leaving his/her room; -CNA A immediately reported the incident to RN C;-CNA A then wrote out his/her statement; -CNA A tried to call the DON and the Administrator. Neither party answered their phone; -CNA A took a picture of her written statement and sent it to both the DON and the Administrator via text message;-On 01/18/26, at 9:00 A.M., the Administrator called CNA A back regarding the allegation;-CNA A said that if a resident states that staff was rough with cares that is an allegation of abuse. Review of a written statement by RN C dated 01/18/26, no time noted, showed the following information:-On 01/18/26, between 2:00 A.M. to 3:00 A.M., CNA A reported to him/her that the resident was upset with CNA B because CNA B was rough during cares;-The resident told CNA B to stop. CNA B backed off, apologized to the resident, and left the room;-CNA B became upset and punched the wall in the hallway outside of the resident's room;-RN C told CNA B to not enter the resident's room for the remainder of the shift and assigned CNA A to the resident's room for the remainder of the shift;-RN C reported the incident to the day shift nurse during shift report.During an interview on 01/21/26, at 1:15 P.M., RN C said that on 01/18/26, between 2:00 A.M. to 3:00 A.M., CNA A reported to him/her that the resident complained that CNA B was rough when providing cares, then CNA B punched the wall in the hall outside of the resident's room;-RN C reassigned CNA A to the resident's room and told CNA B to not go back in the resident's room;-RN C did not go into the resident's room nor did he/she interview the resident;-RN C said that rough with cares was not an allegation of abuse and did not report the allegation to the DON or the Administrator.During an interview on 01/21/26, at 12:27 P.M., CNA B said the following: -On 01/18/26, at approximately 2:00 A.M., he/she entered the resident's room, turned on the bathroom light, and proceeded to change the resident;-The resident yelled at CNA B because he/she didn't like the way he/she was being rolled;-CNA B finished peri care and left the room;-CNA B told CNA A that the resident was upset. CNA A told CNA B that he/she would check on the resident;-Approximately 20 minutes later, RN C told him/her not to go back in the resident's room;-CNA A was reassigned to that room;-On 01/18/26, at approximately 11:00 A.M., CNA B received a telephone call from the Administrator suspending him/her pending an investigation.During an interview on 01/21/26, at 11:40 A.M., RN D said the following: -Abuse could be verbal, sexual, physical, emotional, or financial;-For any allegation of abuse, staff should ensure resident safety and report to the DON or Administrator immediately;-If a resident reported rough cares and he/she didn't feel safe, that should be considered an abuse allegation. During an interview on 01/21/26, at 3:00 P.M., the DON said the following: -On 01/18/26, at 2:54 A.M., he/she received a written statement via a text message from CNA A;-On 01/18/26, at 2:56 A.M., he/she had a missed call from CNA A;-The DON did not respond to either the text message or the telephone call because he/she was sleeping and did not hear his/her telephone;-On 01/18/26, at 09:00 A.M., the Administrator called the DON informing him/her of the allegation;-The DON said that rough with cares and punching a wall was abuse. During an interview on 01/21/26, at 3:20 P.M., the Administrator said the following:-On 01/18/26, at 2:56 A.M., he/she received a written statement via text message from CNA A;-On 01/18/26, at 2:56 A.M., he/she had a missed call from CNA A;-The Administrator did not respond to either the text message or the telephone call because he/she was sleeping and did not hear the telephone;-On 01/18/26, at 9:30 A.M., the Administrator called CNA A and confirmed the incident and started an investigation;-An allegation of rough cares is considered an abuse allegation and an investigation should be started immediately. #2719698

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported timely to State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when staff failed to report an allegation of staff to resident abuse within the required two hours of the facility staff becoming aware of the allegation involving one resident (Resident #1). The facility census was 64. Review of the facility's Abuse and Neglect Policy, undated, showed the following information:-Types of abuse include physical, verbal, sexual, mental, and financial exploitation;-All employees are mandated reporters;-Any suspicion or knowledge of abuse, neglect, or misappropriation must be reported immediately to the Administrator and charge nurse;-The Administrator or Director of Nursing (DON) or designee must begin an internal investigation immediately and report to DHSS;-Reports must be made to the Missouri DHSS within two hours if allegation alleges serious injury or 24 hours if it does not allege serious injury.1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of 02/02/24;-Diagnoses included multiple sclerosis (an autoimmune disease disrupting brain to body communication).Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/15/25, showed minimal cognitive impairment.Review of the resident's care plan, last reviewed on 12/01/25, showed the following information:-Communication problems related to diagnoses;-Provide resident with supportive care and services.Review a written statement by Certified Nurse Aide (CNA) A's statement dated 01/18/26, between 2:00 A.M. and 2:25 A.M., showed the following: -He/she went into the resident's room to change the resident's brief when the resident reported to her that CNA B came into his/her room, turned on the bright light;-The resident yelled hey at CNA B;-The resident said he was upset that CNA B turned on the bright light because he/she was sleeping;-The resident said that CNA B has a bad temper and was being very rough while attempting to change the resident;-The resident told CNA B to stop. CNA B then punched the wall three times above his head and walked out of the room;-The resident told CNA A that he/she was fearful of CNA B and did not want him/her back in his/her room;-CNA A immediately reported the incident to Registered Nurse (RN) C;-CNA A then asked CNA B what had happened in the resident's room. CNA B told CNA A that the resident yelled at him/her for being rough during cares and he/she left the resident's room;-CNA A wrote out a statement regarding the incident;-On 01/18/26, at 2:54 A.M., CNA A sent a picture of his/her written statement to the DON via text message. CNA A did not receive a response;-On 01/18/26, at 2:56 A.M., CNA A attempted to call the DON, and then the Administrator. Neither answered their phone;-On 01/18/26, at 3:04 A.M., CNA A sent a picture of his/her written statement to the Administrator.During an interview on 01/21/26, at 2:15 P.M., CNA A said the following: -On 01/18/26, at approximately 2:00 A.M., he/she entered the resident's room;-The resident told him/her that CNA B came in his/her room, turned on the bright light, and was rough with cares. The resident told CNA B to stop. CNA B became upset and hit the wall three times above the resident's head before leaving his/her room; -He/she immediately reported the incident to RN C;-He/she wrote out his/her statement; -He/she tried to call the DON and the Administrator, however neither party answered their phone; -CNA A took a picture of his/her written statement and sent it to both the DON and the Administrator via text message;-If a resident stated that staff was rough with cares that was an allegation of abuse and should be reported immediately to the charge nurse, DON, or the Administrator. The facility had two hours to report abuse allegations to the State. Review of a written statement by RN C's, dated 01/18/26, no time noted, showed the following information:-On 01/18/26, between 2:00 A.M. and 3:00 A.M., CNA A reported to him/her that the resident was upset with CNA B because CNA B was rough during cares;-The resident told CNA B to stop. CNA B backed off, apologized to the resident and left the room;-CNA B became upset and punched the wall in the hallway outside of the resident's room;-RN C told CNA B to not enter the resident's room for the remainder of the shift and assigned CNA A to the resident's room for the remainder of the shift;-RN C reported the incident to the day shift nurse during shift report.(The RN did not document reporting the allegation of possible abuse to management or DHSS.)During an interview on 01/21/26, at 1:15 P.M., RN C said the following:-On 01/18/26, between 2:00 A.M. and 3:00 A.M., CNA A reported to him/her that the resident complained that CNA B was rough when providing cares and then CNA B punched the wall in the hall outside of the resident's room;-Rough with cares was not an allegation of abuse and did not report the allegation to the DON or the Administrator.Review of the written statement by the DON, no date or time noted, showed the following information:-The DON interviewed CNA B regarding the allegation;-CNA B said that he/she entered the resident's room and turned on the light;-The resident did not like the light on;-The resident became upset with how CNA B was rolling the resident and told CNA B to stop;-CNA B stepped back and left the room;-CNA B denied punching anything in the building.Review of the Administrator's written statement dated 01/18/25, no time noted, showed the following:-On 01/18/26, the Administrator called RN C to discuss the occurrence between the resident and CNA B;-The Administrator asked RN C to write a statement for the investigation;-On 01/18/26, the Administrator spoke with CNA A regarding the investigation;-The Administrator educated CNA A that texting him/her an abuse or neglect allegation was not an appropriate way to notify him/her of an allegation, and he/she expected to be called for any future abuse or neglect allegations;-On 01/21/26, the Administrator spoke with CNA B regarding the incident;-The Administrator educated CNA B that all abuse or neglect allegations must be reported, even when the allegation was against oneself;-On 01/18/26, at 9:54 A.M., family was notified of the allegation of abuse;-On 01/18/26, at 9:59 A.M., the physician was notified of the allegation of abuse.Review of the resident's progress notes showed staff did not document information pertaining to the allegation of abuse.Review of DHSS records showed an online report was made regarding the allegation of abuse on 01/18/26, at 9:58 A.M. (over seven hours after staff became aware of the allegation of possible abuse.)During an interview on 01/21/26, at 11:40 A.M., RN D said the following: -Abuse can be verbal, sexual, physical, emotional, or financial;-Any allegation of abuse should be reported to the DON or Administrator immediately. -The facility has two hours to report an abuse allegation to state;-If a resident reported rough cares and he/she didn't feel safe, that should be considered an abuse allegation and reported immediately.During an interview on 01/21/26, at 11:45 A.M. CNA E said the following: -Abuse should be reported to the charge nurse immediately;-The facility had two hours to report to State;-He/she would consider rough cares abuse.During an interview on 01/21/26, at 11:50 A.M., Certified Medication Technician (CMT) F said the following: -Abuse could be verbal, physical, sexual, mental, and financial;-He/she would notify his/her charge nurse immediately of any allegation of abuse. -The facility had two hours to report abuse to State.During an interview on 01/21/26, at 11:54 A.M., CNA G said the following: -Abuse could be financial, verbal, physical, emotional and sexual;-He/she would notify the charge nurse or the Administrator of any allegation of abuse;-The facility has two hours to report abuse to the State;-If a resident reported rough cares he/she would consider that an abuse allegation and would report it immediately.During an interview on 01/21/26, at 11:59 A.M., CMT H said the following: -Abuse could be verbal, physical, mental, sexual and financial;-He/she would notify his/her charge nurse, DON, or the Administrator immediately of an allegation of abuse;-The facility had two hours to report abuse allegation to State;-An allegation of rough cares should be reported.During an interview on 01/21/26, at 3:00 P.M., the DON said the following: -On 01/18/26, at 2:54 A.M., he/she received a written statement via a text message from CNA A;-On 01/18/26, at 2:56 A.M., he/she had a missed call from CNA A;-The DON did not respond to either the text message or the telephone call because he/she was sleeping and did not hear his/her telephone;-On 01/18/26, at 9:00 A.M., the Administrator called the DON and informed him/her of the allegation;-The DON said that rough with cares and punching a wall was abuse and should be reported to the State within two hours. During an interview on 01/21/26, at 3:20 P.M., the Administrator said the following: -On 01/18/26, at 2:56 A.M., he/she received a written statement via text message from CNA A;-On 01/18/26, at 2:56 A.M., he/she had a missed call from CNA A;-The Administrator did not respond to either the text message or the telephone call because he/she was sleeping and did not hear the telephone;-On 01/18/26, at 9:30 A.M., the Administrator called CNA A and confirmed the incident;-On 01/18/26, at 9:58 A.M., the Administrator reported the allegation to DHSS;-An allegation of rough cares was considered an abuse allegation and should be reported to DHSS within two hours. #2719698

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to facility management and within two hours to the State Survey Agency (Department of Health and Senior Service (DHSS) when the facility failed to report one resident's (Resident #1) allegation of abuse by a staff member in a timely fashion. The facility census was 56.Review of the facility's policy titled. Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021 showed the following:-All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported;-If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law;-The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident's representative; adult protective services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's attending physician; and the facility medical director;-Immediately is defined as within two hours of an allegation involving abuse or resulting in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 02/16/21.-Diagnoses included altered mental status, peripheral vascular disease (a condition that affects the blood vessels), heart failure, depression, high blood pressure, dementia, and Alzheimer's (irreversible brain disorder that causes memory loss, cognitive decline and changes in behavior and personality). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/08/25, showed the following:-Resident had severe cognitive impairment.-Resident required total assistance from staff for activities of daily living.Review of the facility's investigation, dated 10/07/25, showed the following:-On 10/01/25, approximately 6:30 P.M., the resident was yelling out and Certified Nurse Aide (CNA) A attempted to calm and redirect the patient. CNA B saw this and was concerned with the calming/redirection style the CNA A used; -CNA B was interviewed and reported she/he witnessed CNA A cover the mouth of the resident while saying for her to be quiet. This took place in the resident's room while two of them were putting the resident to bed.-On 10/02/25, CNA B told CNA C that CNA A had put his/her hand over the resident's mouth and told the resident to shut the fuck up. CNA C told CNA B that he/she needed to report this to the Director of Nursing (DON) and/or the Administrator. CNA B said no, so CNA C reported the alleged abuse to the DON and the Administrator.(Staff did not document reporting the allegation of abuse to DHSS.) Review of the resident's nurses' note showed did not document reporting the allegation of abuse to DHSS.Review of DHSS records showed the facility reported the allegation of possible abuse involving the resident and CNA A on 10/02/25 at 7:39 P.M. (the day after the alleged abuse was observed by facility staff). During an interview on 10/09/2, at 1:58 P. M., CNA A said the following:-If he/she saw abuse he/she would intervene and report the abuse to the charge nurse;-Allegations of abuse are reported to the state within two hours.During an interview on 10/09/25, at 3:07 P.M., CNA B said the following:-If he/she saw abuse he/she would report the abuse to the charge nurse and the DON if needed;-On 10/01/25, he/she [NAME] he/she did observe abuse. He/she saw an CNA A place his/her hand over the resident's mouth and yelled at the resident to shut up. The resident was crying;-He/she did not report it that day, but the next day, on 10/02/25, he/she told CNA C and CNA C reported the abuse to the DON;-He/she should have reported the abuse immediately; -All abuse has to be reported to the state within 2 hours.During an interview on 10/09/25, at 11:55 A.M., CNA C said the following:-All abuse should be reported immediately to the charge nurse, DON, and/or the Administrator;-All abuse should be reported to the state within two hours.During an interview on 10/09/25, at 12:15 A.M., CMT D said the following:-If he/she witnessed any abuse he/she would report to the charge nurse and would go to the DON and administrator if necessary;-All abuse should be reported immediately and has to be reported to the state within two hours.During an interview on 10/09/25, at 2:33 P.M., Registered Nurse (RN) E said the following:-He/she would report all allegations of abuse to the DON and the Administrator;-All allegations of abuse should be reported to the state within two hours.During an interview on 10/09/25, at 9:40 A.M., the Administrator said the following:-All allegations of abuse need to be reported immediately;-CNA B should have reported the alleged abuse immediately to the charge nurse or to the DON and/or the Administrator;-All allegations of abuse should be reported to the state within two hours. #2633764

Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when staff did not ensure physicians' orders and pharmacy dosage directions matched resulting in staff administering incorrect dosages of Paxlovid (oral antiviral medication used to treat coronavirus disease 2019 (COVID-19) disease (an infectious disease caused by the SARS-CoV-2 virus)) to four residents (Resident #1, Resident #2, Resident #3 and Resident #4) out of 9 sampled residents. The facility census was 55.Review of the facility's policy titled Medication Orders, revised 11/2014, showed the following:-The purpose of the procedure was to establish uniform guidelines in the receiving and recording of medication orders;-When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. A placebo is considered a medication and must also have specific orders.Review of the facility's policy titled Telephone Orders, revised 02/2014, showed the following:-Verbal telephone orders may be accepted from each resident's attending physician;-Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record;-The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Review of the facility's policy titled Verbal Orders, revised 02/2014, showed the following:-Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols;-Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record;-If a treatment, test, or another intervention is included in a written protocol that has been reviewed and approved by the Medical Director, then a verbal order may be written for a situation that is covered by the protocol. Otherwise, a verbal order will not be written that is not based on a conversation with the practitioner.Review of the facility's policy titled Administering Medications, revised 12/2012, showed the following:-Medications shall be administered in a safe and timely manner, and as prescribed;-The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions;-Medications must be administered in accordance with the orders, including any required time frame;-If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns;-The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medicationReview of the Paxlovid prescribing information, revised 07/2025, showed the following:-Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death;-The 5-day treatment course of Paxlovid should be initiated as soon as possible after a diagnosis of COVID-19 has been made, and within 5 days of symptom onset even if baseline COVID-19 symptoms are mild. Should a patient require hospitalization due to severe or critical COVID-19 after starting treatment with Paxlovid, the patient should complete the full 5-day treatment course per the healthcare provider's discretion;-If the patient misses a dose of Paxlovid within 8 hours of the time it is usually taken, the patient should take it as soon as possible and resume the normal dosing schedule. If the patient misses a dose by more than 8 hours, the patient should not take the missed dose and instead take the next dose at the regularly scheduled time. The patient should not double the dose to make up for a missed dose;-The recommended dosage for Paxlovid is 300 milligrams (mg) nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) with all 3 tablets taken together orally twice daily in the morning and at bedtime for 5 days.1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 04/26/24;-Diagnoses included COVID-19 and contact with and/or (suspected) exposure to COVID-19.Review of the resident's care plan, revised 08/22/25, showed the following:-He/she remained at risk for COVID-19 and its multiple variances;-He/she tested positive for COVID-19 on 08/13/25;-Administer his/her medications as ordered;-Monitor him/her for side effects.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 07/11/25, showed the resident was cognitively intact.Review of the resident's August 2025 Physician's Order Sheet (POS) showed an order, dated 08/14/25, for Paxlovid (nirmatrelvir-ritonavir) tablets dose pack, 300 mg (150 mg x 2) - 100 mg. (Dose pack instructions state medication should be administered twice daily.) Review of the resident's August 2025 Medication Administration Record (MAR) showed the following:-On 08/15/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/16/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/17/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/18/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/19/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.Review of the resident's August 2025 POS showed an order, dated 08/28/25, for Paxlovid tablets dose pack (300 mg (150 mg x 2) - 100 mg), give 2 x 150 mg = 300 mg with 100 mg tablets twice daily for five days for COVID-19.Review of the resident's August 2025 MAR showed on 08/28/25, staff did not administer Paxlovid to the resident. Review of the resident's nurses' progress notes, dated 08/01/25 through 08/28/25, showed staff did not document related to the resident's Paxlovid not given per physician's order or pharmacy recommendation, contact with the physician related to the Paxlovid not given per physician's order or pharmacy recommendation, or notification of the resident or resident's responsible party related to the Paxlovid not given per physician's orders or pharmacy recommendation.During an interview on 08/28/25, at 12:40 P.M., Licensed Practical Nurse (LPN) A said the following:-The resident was originally placed on a generic order per the Infection Preventionist (IP) and the order was supposed to be changed when the pharmacy delivered the medication to the dose pack instructions;-The resident received the medication once daily from 08/15/25 through 08/19/25, but was supposed to receive the medication twice daily;-The resident had five doses left after the initial five doses were given;-A certified medication technician (CMT) noticed this and informed him/her. He/she (the LPN) put a new order in the resident's medical record. He/she was not instructed to do this but assumed the resident would need to complete the course of the medication;-He/she notified the IP, and the IP gave no other direction to him/her;-He/she did not contact the physician, but should have to get direction from the physician;-He/she did not notify the resident or their responsible party;-The resident did not receive the medication per the dose pack instructions.During an interview on 08/28/25, at 2:55 P.M., the IP said the resident did not receive his/her Paxlovid per the physician orders or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the Director of Nursing (DON) said the resident did not receive his/her Paxlovid per the physician orders or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the Administrator said the following:-The resident did not receive his/her Paxlovid per physician orders or at a therapeutic level;-The charge nurse should have notified the physician, resident or resident's responsible party, and the DON and documented this in the resident's nurses' progress notes.2. Review of Resident #2's face sheet showed the following:-admission date of 03/22/23;-Diagnoses included COVID-19 and contact with and/or (suspected) exposure to COVID-19. Review of the resident's care plan, revised 08/15/25, showed the following:-He/she tested positive for COVID-19 on 08/14/25;-Administer his/her medications as ordered;-Monitor him/her for side effects.Review of the resident's quarterly MDS, dated [DATE], showed the resident had had mild cognitive impairment.Review of the resident's August 2025 POS showed an order, dated 08/14/25, for Paxlovid tablets dose pack, 300 mg (150 mg x 2) - 100 mg. Administer per pack dosing, orally, once daily. (Dose pack instructions state medication should be administered twice daily.)Review of the resident's August 2025 MAR showed the following:-On 08/15/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/16/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/17/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/18/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/19/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;Review of the resident's August 2025 POS showed an order, dated 08/24/25, for Paxlovid tablets, dose pack; 150 mg (6) - 100 mg (5), give 1 tablet 150 mg and 1 tablet 100 mg tablets by mouth twice daily for five days for COVID-19. Review of the resident's MAR, dated 08/2025, showed the following:-On 08/24/25, Paxlovid administered once between 2:00 P.M. and 6:00 P.M.;-On 08/25/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. and once between 2:00 P.M. and 6:00 P.M.;-On 08/26/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. The P.M. dose was marked drug/item unavailable;-On 08/27/25, staff marked the drug/item unavailable for A.M. and P.M. doses;-On 08/28/25, staff marked the drug/item unavailable for the A.M. dose.Review of the resident's nurse's progress notes, dated 08/01/25 through 08/28/25, showed staff did not document related to the resident's Paxlovid not given per physician's order or pharmacy recommendation, contact with the physician related to the Paxlovid not given per physician's order or pharmacy recommendation or notification of the resident or resident's responsible party related to the Paxlovid not given per physician's orders or pharmacy recommendation.During an interview on 08/28/25, at 12:40 P.M., LPN A said the following:-A CMT noticed the resident's PO and medication did not match and informed him/her. He/she (the LPN) put a new order in the resident's medical record. He/she was not instructed to do this but assumed the resident would need to complete the course of the medication;-He/she notified the IP, and the IP gave no other direction to him/her;-He/she did not contact the physician, but should have to get direction from the physician;-He/she did not notify the resident or their responsible party;-The resident did not receive the medication per the dose pack instructions.During an interview on 08/28/25, at 2:55 P.M., the IP said the resident did not receive his/her Paxlovid per the PO or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the DON said the resident did not receive his/her Paxlovid per the physician orders or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the Administrator said the following:-The resident did not receive his/her Paxlovid per physician orders or at a therapeutic level;-The charge nurse should have notified the physician, resident or resident's responsible party, and DON and documented this in the resident's nurse's progress notes. 3. Review of Resident #3's face sheet showed the following:-admission date of 12/20/23;-Diagnoses included contact with and/or (suspected) exposure to COVID-19 and COVID-19.Review of the resident's care plan, revised 08/22/25, showed the following:-He/she tested positive for COVID-19 on 08/14/25;-Administer his/her medications as ordered;-Monitor him/her for side effects.Review of the resident's quarterly MDS, dated [DATE], showed they had moderate cognitive impairment.Review of the resident's August 2025 POS showed an order, dated 08/14/25, for Paxlovid tablets, dose pack; 300 mg (150 mg x 2) - 100 mg. Amount to administer per pack dosing, orally, once daily. (Dose pack instructions state medication should be administered twice daily.)Review of the resident's August 2025 MAR showed the following:-On 08/15/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/16/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/17/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/18/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/19/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/20/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/21/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/22/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.Review of the resident's August 2025 POS showed an order, dated 08/23/25, for Paxlovid tablets, dose pack; 300 mg (150 mg x 2) - 100 mg, give 2 x 150 mg = 300 mg with 100 mg tablets twice daily for five days for COVID-19.Review of the resident's MAR, dated 8/2025, showed the following:-On 08/23/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. and once between 2:00 P.M. and 6:00 P.M.;-On 08/24/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. The P.M. dose was marked drug/item unavailable;-On 08/25/25, staff marked the drug/item unavailable for A.M. and P.M. doses;-On 08/26/25, staff marked the drug/item unavailable for A.M. and P.M. doses;-On 08/27/25, staff marked the drug/item unavailable for A.M. and P.M. doses.Review of the resident's nurse's progress notes, dated 08/01/25 through 08/28/25, showed staff did not document related to the resident's Paxlovid not given per physician's order or pharmacy recommendation, contact with the physician related to the Paxlovid not given per physician's order or pharmacy recommendation or notification of the resident or resident's responsible party related to the Paxlovid not given per physician's orders or pharmacy recommendation.During an interview on 08/28/25, at 12:40 P.M., LPN A said the following:-A CMT noticed the resident's PO and medication did not match and informed him/her. He/she (the LPN) put a new order in the resident's medical record. He/she was not instructed to do this but assumed the resident would need to complete the course of the medication;-He/she notified the IP and the IP gave no other direction to him/her;-He/she did not contact the physician, but should have to get direction from the physician;-He/she did not notify the resident or their responsible party;-The resident did not receive the medication per the dose pack instructions.During an interview on 08/28/25, at 2:55 P.M., the IP said the resident did not receive his/her Paxlovid per the physician orders or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the DON said the resident did not receive his/her Paxlovid per the physician orders or at a therapeutic dose. During an interview on 08/28/25, at 3:35 P.M., the Administrator said the following:-The resident did not receive his/her Paxlovid per physician orders or at a therapeutic level;-The charge nurse should have notified the physician, resident or resident's responsible party and DON and documented this in the resident's nurse's progress notes. 4. Review of Resident #4's face sheet showed the following:-admission date of 01/02/24;-Diagnoses included contact with and/or (suspected) exposure to COVID-19 and COVID-19.Review of the resident's care plan, revised 08/22/25, showed the following:-He/she remained at risk for COVID-19 and it's multiple variances;-He/she tested positive for COVID-19 on 08/12/25;-Administer his/her medications as ordered;-Monitor him/her for side effects.Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.Review of the resident's August 2025 POS showed an order, dated 08/14/25, for Paxlovid tablets dose pack, 300 mg (150 mg x 2) - 100 mg, per dose pack once daily in A.M. (Dose pack instructions state medication should be administered twice daily.)Review of the resident's August 2025 MAR showed the following:-On 08/15/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/16/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/17/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/18/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.;-On 08/19/25, Paxlovid administered once daily between 6:00 A.M. and 10:00 A.M.Review of the resident's August 2025 POS showed an order, dated 08/24/25, for Paxlovid tablets dose pack, 300 mg (150 mg x 2) - 100 mg according to box, oral, give 2 x 150 mg tablets = 300 mg with 100 mg tablet twice daily for 5 days for COVID.Review of the resident's MAR, dated 08/2025, showed the following:-On 08/24/25, Paxlovid administered once daily between 2:00 P.M. and 6:00 P.M.;-On 08/25/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. and once between 2:00 P.M. and 6:00 P.M.;-On 08/26/25, Paxlovid administered once between 6:00 A.M. and 10:00 A.M. and once between 2:00 P.M. and 6:00 P.M.;-On 08/27/25, staff marked the drug/item unavailable for A.M. and P.M. doses;-On 08/28/25, staff marked the drug/item unavailable for the A.M. dose. Review of the resident's nurses' progress notes, dated 08/01/25 through 08/28/25, showed staff did not document related to the resident's Paxlovid not given per physician's order or pharmacy recommendation, contact with the physician related to the Paxlovid not given per physician's order or pharmacy recommendation or notification of the resident or resident's responsible party related to the Paxlovid not given per physician's orders or pharmacy recommendation.During an interview on 08/28/25, at 12:40 P.M., LPN A said the following:-A CMT noticed the resident's physician order and medication did not match and informed him/her, he/she (the LPN) put a new order in the resident's medical record. He/she was not instructed to do this but assumed the resident would need to complete the course of the medication;-He/she notified the IP, and the IP gave no other direction to him/her;-He/she did not contact the physician, but should have to get direction from the physician;-He/she did not notify the resident or their responsible party;-The resident did not receive the medication per the dose pack instructions. During an interview on 08/28/25, at 2:55 P.M., the IP said the resident did not receive his/her Paxlovid per the physician order or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the DON said the resident did not receive his/her Paxlovid per the physician order or at a therapeutic dose.During an interview on 08/28/25, at 3:35 P.M., the Administrator said the following:-The resident did not receive his/her Paxlovid per physician order or at a therapeutic level;-The charge nurse should have notified the physician, resident or resident's responsible party and DON and documented this in the resident's nurse's progress notes.5. During interviews on 08/28/25, at 11:46 A.M. and 12:40 P.M., LPN A said the following:-He/she administered residents' medications per physician's orders;-A CMT notified him/her that some of the Paxlovid orders were put in for once daily when they should have been twice daily;-He/she changed the orders when the CMT brought this to his/her attention;-He/she notified the IP when the discrepancy was noticed;-He/she understood the residents had a generic order placed for once daily and the physician wanted the pharmacy to determine the dosing;-The charge nurse on duty when the Paxlovid came in was responsible for changing the order to the pharmacy's recommended dosing instructions;-The IP was responsible for notification of the residents' responsible parties to get authorization for the medication and for following through on ensuring the residents' orders were updated when the medication was delivered to the facility;-He/she should notify the physician, DON, and resident or their responsible party when there was a discrepancy between the physician's order in the electronic record and the medication in the medication cart. During an interview on 08/28/25, at 1:52 P.M., CMT B said the following:-If he/she noticed a medication package label and the order in the MAR were different, he/she notified the charge nurse and the charge nurse compared the two and if they did not match, the charge nurse sent the medication back to the pharmacy;-When medications arrived at the facility, CMTs and charge nurses signed them in;-When administering medications, he/she was supposed to look at the package and the MAR to ensure they matched every time he/she administered the medication;-He/she was instructed to administer Paxlovid according to the resident's order in the MAR;-If the order read to administer once daily, he/she administered it once daily;-He/she noticed residents' Paxlovid package instructions were different than the orders in their MAR and notified LPN A.During an interview on 08/28/25, at 2:13 P.M., the Assistant Director of Nursing (ADON) said the following:-When staff passed medications they should follow right route, right dose, right frequency, right medication, and right resident;-The physician gave an order, and the charge nurses entered physician's orders into residents' electronic chart;-When staff administered medications, they look at the MAR and the medication to ensure they matched. If they did not match, the CMT notified the charge nurse, and the charge nurse checked the medication and the MAR. If they confirmed the medication and the MAR did not match, the charge nurse should notify the physician to clarify the order;-The charged nurse was not allowed to change an order without the physician being notified and clarification received;-Paxlovid did not have a standard dosing, and the pharmacy provided the recommended dosing for the resident;-The physician gave orders for Paxlovid per the pharmacy's recommendation;-Staff put a generic order for Paxlovid in the residents' electronic record and when the medication arrived the charge nurses were supposed to update the physician's order to the instructions on the label of the medication;-Both charge nurses and CMTs received and checked medications in from the pharmacy;-He/she did not know if the CMTs were instructed to notify the charge nurse when the Paxlovid came in;-The CMTs were not aware there was a generic order for the Paxlovid, and he/she was not sure all the charge nurses were aware;-If the CMTs did not notice the discrepancy between the order and the medication and they were not administering the medication per the physician's orders;-If the Paxlovid was given once daily and the medication was supposed to be given twice daily, the medication was not given per physician orders;-Once the charge nurse was made aware of the discrepancy between the residents' physician orders and the medication label, they should have filled out a medication error form and given this to the CMT supervisor and notified the residents' physician, the resident or their responsible party, the DON, and Administrator;-The nurse should not have placed a new order in without contacting the physician because this was out of a nurse's scope of practice;-The IP was responsible for ensuring the charge nurses knew the process related to the Paxlovid orders and the charge nurses were responsible for ensuring the CMTs notified them when Paxlovid arrived from the pharmacy;-The Administrator was responsible for ensuring the IP completed the education with the charge nurses related to the Paxlovid orders.During an interview on 08/28/25, at 2:36 P.M., the CMT Supervisor said the following:-He/she trained new CMTs and charge nurses on the facility's policy and procedure related to medication orders and administration within the first two weeks. The DON, Administrator or human resources set this training up upon hire. He/she had not trained the IP;-CMTs should read the resident's medication card and compare the medication to the resident's MAR to ensure the right medication, resident, dose, route, and time;-If the medication and the MAR did not match, the CMTs notified the charge nurse and the charge nurse and CMT checked them together;-CMTs and charge nurses checked medication in when the medication arrived from the pharmacy;-The CMTs were not instructed to notify the charge nurse when Paxlovid was received from the pharmacy;-On 08/21/25, a CMT noticed a discrepancy between a Paxlovid order, and the medication box and alerted LPN A and LPN A said he/she would fix the order in the computer;-The physician gave orders to the IP for Paxlovid to be given per the pharmacy's dosage instructions and the IP wrote the initial order for the Paxlovid to be given once daily for all of the residents whose physician prescribed the medication;-The IP was new to the facility and did not know to alert the charge nurses to change the orders to the pharmacy's recommended dosing instructions when the medication arrived;-He/she did not know if the IP instructed the charge nurses about the Paxlovid orders;-When the discrepancies between the orders and the medication were found, the charge nurse should have contacted the physician for clarification and notified the resident or their responsible party.During an interview on 08/28/25, at 2:55 P.M., the IP said the following:-Staff should ensure right resident, dose, medication, route, and time when they administered medications;-The CMTs knew what medication was to be given when they looked at the MAR and should match the medication in the MAR to the medication package;-If a CMT noticed a discrepancy, they notified the charge nurse, and the charge nurse investigated it and then notified the physician for clarification if the medication and the MAR did not match;-Nurses should not write an order without notification of the physician;-If the nurse was alerted that medication was not given per the physician orders they notified the physician, DON, Administrator, and resident or the resident's responsible party and filled out a medication error form;-The original order from the physician said to give Paxlovid per the pharmacy recommendations;-The pharmacist at the pharmacy said the dose was 300 mg - 100 mg dosing once daily for five days so he/she wrote the order per the pharmacist instructions but also put to administer per the dose pack instructions in the special instructions section of the physician's order;-When the pharmacy sent the medications, they were 150 mg - 100 mg dosing instead of the 300 mg - 100 mg and a CMT brought that to the ADON's attention on 08/20/25;-The ADON said he/she fixed the orders of Paxlovid for the residents on the COVID-19 hall;-He/she did not instruct the CMTs to notify the nurses when Paxlovid arrived from the pharmacy and did not instruct the charge nurses to update the Paxlovid orders per the pharmacy's dosing recommendation;-He/she was not aware that LPN A did not contact the residents' physician when the discrepancy was found between the MAR and the Paxlovid packaging instructions;-LPN A should not have written the new orders without the physician's notification and clarification;-He/she was responsible for ensuring the residents' Paxlovid orders were correct in their MAR because he/she wrote the original generic order;-He/she had worked at the facility since 03/2025 and had not received training from the CMT Supervisor related to medication orders.During an interview on 08/28/25, at 3:35 P.M., the DON said the following:-He/she expected the CMTs to follow the orders as written by the physician and if they noticed a discrepancy to alert the charge nurse;-The physician gave direction to administer Paxlovid per the pharmacy's recommendations;-Once the Paxlovid arrived from the pharmacy, the charge nurses were to take the dosing instructions from the label and update the physician's order to match;-The CMTs should have checked the Paxlovid label on the box with the PO in the MAR and then take the medication to the charge nurse;-The generic orders placed in the residents' MAR for Paxlovid were for once daily and if the CMTs following procedure properly they would have noticed the discrepancy and notified the charge nurse immediately;-He/she should have been clearer in his/her communication about Paxlovid to the CMTs and the charge nurses;-LPN A should have notified the physician, Administrator, and DON of the medication errors;-LPN A should not have written new orders without notification and clarification from the residents' physician because that was not in the LPN's scope of practice;-The residents' Paxlovid was not given per physician's orders or at a therapeutic level since the residents did not receive the medication twice daily;-He/she sent new nurses to the CMT Supervisor for training and did practice in the electronic medical record program when they were hired;-He/she should have scheduled the IP for the training;-He/she was responsible for ensuring staff were aware of the medication administration process and what to do in the case of a medication error.During an interview on 08/28/25, at 3:35 P.M., the Administrator said the following:-He/she expected staff to follow the five rights (right resident, medication, route, dose and time) when they administered medications;-If a CMT noticed a discrepancy between the medication and the order they notified the charge nurse, and the charge nurse contacted the physician for clarification;-Writing an order without notification of the physician was not within a nurse's scope of practice.Complaint #2601210

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for six staff members (Certified Nursing Assistant (CNA) E, Certified Medication Technician (CMT) F, Licensed Practical Nurse (LPN) G, CMT K, LPN G, and Dietary Aide (DA) I) of ten sampled staff members. The facility census was 57.Review of the facility's policy titled Tuberculosis, Employee Screening, revised July 2010, showed the following:-All employees shall be screening for tuberculosis (TB), infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment;-Each newly hired employee is screened for TB infection and disease after an employment offer has been made, but prior to the employee's duty assignment;-The employee health coordinator (or designee) will accept documented verification of two-step TST or BAMT results within the preceding 12 months. If the TST or BAMT result was negative, the employee will not be given another skin test prior to beginning employment. If the previous skin test result was positive or unavailable, the employee must have additional verification of absence of the TB;-The facility's Employee Health Coordinator will administer a TST to all newly hired employees except those who have a documented positive TST or BAMT results, and those who provide documented verification of having had a negative TST or BAMT within the preceding 12 months;-The initial TB testing will be a two-step TST performed by injecting 0.1 mL (5 tuberculin units) of purified protein derivative intradermally (under the skin). If the reaction to the first skin test is negative, the facility will administer a second skin test one to two weeks after the first test. The employee may begin duty assignments after the first skin test, if negative;-If the reaction to the TST is positive, the employee will be referred for a chest X-ray and symptom screening, which must be completed prior to employment. Review of 19 CSR 20-20.100 showed the following:-Long-term care facilities shall screen their staff for tuberculosis;-Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained for all employees and volunteers;-All long-term care facility employees and volunteers who work ten or more hours per week are required to a complete a TB test within one month prior to starting employment in the facility;-If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins;-Employees and volunteers with an initial negative two-step TB test shall be one-step tested annually and the results recorded in a permanent record.1. Review of CNA E's personnel file showed the following:-Hire and start date of 03/06/24;-The first TST was administered on 03/04/24 and with no results documented; -The second TST was administered on 05/22/24 (79 days after the first test was administered) and read on 05/24/24 with a result of 0 mm. During an interview on 07/25/25, at 12:31 P.M., the Human Resource Staff (HR) reviewed CNA E's file and said he/she did not know why the first two step TST wasn't read, or why the second two step TST wasn't done timely. During an interview on 07/25/25, at 2:00 P.M., the Director of Nursing (DON) said he/she was not aware CNA E's first TST test was not read, and that staff did not have a second TST test timely. During an interview on 07/28/25, at 10:12 A.M., the Administrator said he/she was not aware that CNA E's first TST skin test was not read, and that CNA E did not have a second TST test timely. During an interview on 07/28/25, at 2:30 P.M., the Assistant Director of Nursing (ADON) said he/she was not aware that CNA E's first TST skin test was not read, and that CNA E did not have a second TST test timely prior to working the floor. 2. Review of CMT F's personnel file showed the following:-Hire and start date of 11/06/24;-The first TST was administered on 11/06/24 with no results documented; -The second TST was administered on 01/12/25 (67 days after the first TST test was administered) and read on 01/15/25 with no redness. Staff did not document the induration or the size. During an interview on 07/25/25, at 12:31 P.M., HR reviewed CMT F's file and indicated the facility ran out of serum during the time the second TB test was to be administered. The staff probably did continue working the floor. During an interview on 07/25/25, at 2:00 P.M., the DON said he/she was not aware CMT F's first TST test was not read and that CMT F did not have a second TST test timely. During an interview on 07/28/25 at 10:12 A.M., the Administrator said he/she was not aware that CMT F's first TST skin test did not have a size and that CMT F did not have a second TST test timely. During an interview on 07/28/25 at 2:30 P.M., the ADON he/she was not aware that CMT F's first TST skin test did not have a size and that CMT F did not have a second TST test timely. 3. Review of LPN G''s personnel file showed the following:-Hire and start date of 06/09/25;-The first TST was administered on 06/09/25 (the LPN's start date) and staff documented reading the results with no induration or redness, but did not document the size;-The second TST was administered on 07/17/25 (38 days after the first TST test was administered) and read on 07/19/25 with no redness or induration. Staff did not document the size. During an interview on 07/25/25, at 12:31 P.M., HR reviewed LPN G's file and said he/she did not know why the second TB test was not administered timely. During an interview on 07/25/25, at 2:00 P.M., the DON said he/she was not aware LPN G's first TST test did not have a size, and that LPN G did not have a second TST test timely. During an interview on 07/28/25, at 10:12 A.M., the Administrator said he/she was not aware that LPN G's first TST skin test did not have a size, and that LPN G did not have a second TST test timely. During an interview on 07/28/25, at 2:30 P.M., the ADON said he/she was not aware that LPN G's first TST skin test did not have a size, and that LPN G did not have a second TST test timely. 4. Review of CMT K's personnel file showed the following:-Hire and start date of 09/04/24;-The first TST was administered on 09/04/24 and staff documented reading the results on 09/06/24 (two days after the CMT's start date), but did not document the induration, site redness or the size;-The second TST was administered on 11/19/24 (66 days after the first TST test was administered) and read on 11/22/24, with no redness, induration, or size. During an interview on 07/25/25, at 12:31 P.M., HR reviewed CMT K's file and said the facility ran out of serum during the time the second TB test was to be administered. The staff probably did continue working the floor. During an interview on 07/25/25, at 2:00 P.M., the DON said he/she was not aware CMT K's first TST test did not have the induration, site redness, or size, and that CMT K did not have a second TST test timely. During an interview on 07/28/25, at 10:12 A.M., the Administrator said he/she was not aware that CMT K's first TST skin test did not have the induration, redness, or size, and that CMT K did not have a second TST test timely. During an interview on 07/28/25, at 2:30 P.M., the ADON he/she was not aware CMT K's first TST skin test did not have the induration, skin redness, or size, and that CMT K did not have a second TST test timely. 5. Review of LPN H's personnel file showed the following:-Hire and start date of 07/31/24;-The first TST was administered on 07/31/24 with no documentation the TST was read;-The second TST was administered on 01/12/25 (67 days after the first TST test was administered) and read on 01/15/25 with no redness. Staff did not document the induration or the size. During an interview on 07/25/25, at 12:31 P.M., HR reviewed LPN H's file and said the LPN H was hired for an as needed position and had worked elsewhere. The staff was supposed to bring in the prior TB test, but never provided that to the facility. The staff probably did continue working the floor. During an interview on 07/25/25, at 2:00 P.M., the DON said he/she was not aware LPN H's first TST test was not read, and that LPN H did not have a second TST test completed timely. During an interview on 07/28/25, at 10:12 A.M., the Administrator said he/she was not aware that LPN H's first TST skin test was not read, and that LPN H did not have a second TST test timely. During an interview on 07/28/25, at 2:30 P.M., the ADON he/she was not aware that LPN H's first TST skin test was not read, and that LPN H did not have a second TST test timely. 6. Review of DA I K's personnel file showed the following:-Hire date of 11/06/24 and start date of 11/08/24;-The first TST was administered on 11/05/24 and staff documented reading the results 24 hours later, with documentation of no site redness, no induration and 0 mm;-The second TST was administered on 01/14/25, (67 days after the first TST test was administered) and read on 01/17/25 with documentation of no site redness, no induration, and 0 mm. During an interview on 07/25/25, at 12:31 P.M., HR reviewed DA I's file, and said the facility ran out of serum during the time the second TB test was to be administered. The staff probably did continue working the floor. During an interview on 07/25/25, at 2:00 P.M., the DON said he/she was not aware DA I's first TST test was read within 24 hours after being administered, or why DA I did not have a second TST test timely. During an interview on 07/28/25, at 10:12 A.M., the Administrator said he/she was not aware DA I's first TST test was read within 24 hours after being administered, or why DA I did not have a second TST test timely. During an interview on 07/28/25, at 2:30 P.M., the ADON he/she was not aware DA I's first TST test was read within 24 hours after being administered, or why DA I did not have a second TST test timely. 7. During an interview on 07/25/25, at 12:31 P.M., HR said the following:-He/she begins the new hire process, and the staff TB tests are part of that process;-Once the new hire accepts a position, he/she brings the new staff to whichever nurse is working the floor, and they complete the TB test;-New hires do not begin working the floor until they have the test administered;-The TB test is administered the first day, or sometimes before if they're hired at the interview;-The TB test must be read 48 hours after administered. The nurses have a form they document the test on and the results that include the skin appearance, induration, swelling, and size;-The second TB test should be completed in 21 day and it's the same as the first two-step process;-He/she has a spreadsheet where the tests are tracked for each staff, along with calendar reminders.During an interview on 07/28/25, at 2:00 P.M., LPN J said the following:-He/she was not sure who is responsible for administered or reading the TB tests;-He/she had not administered any TB tests;-He/she knows the TB tests should be read 48 to 72 hours after administered and the documentation should include the induration, size, and if positive;-A second two-step should be completed two weeks later.During an interview on 07/28/25, at 2:30 P.M., the ADON said the following:-The staff are to administer the first two-step TB test when they go through orientation;-The first Tb test should be administered and read before the staff work the floor;-The first TB test is completed at orientation and read 48 to 72 hours later. The reading should include the redness, induration, and size. The next two-step is completed within 14 days and should be the same process;-HR is the one that brings nursing the paperwork and HR should be tracking when the TB test should be read and the next one administered;-They had an RN supervisor, that was responsible for completing the TB tests and tracking them and it wasn't being done;-He/she would expect the tests to be administered timely, read within the 48 to 72 hours, and to be documented;-He/she would also expect the next two step test to be done within 14 days and the same process. During an interview on 07/25/25, at 2:00 P.M., the DON said the following:-The first TB two-step, or chest x-ray should be administered and read prior to staff working the floor;-Whoever the nurse is that's working the floor is responsible for administering the TB test to the new hire;-They did have a weekend nurse that was responsible for completing this task but he/she was not doing it;-The new IP that's taking over is going to be responsible for ensuring this is completed timely;-He/she expected the first TB test to be administered before the staff worked the floor, and it should be read withing 48 to 72 hours after. Staff should be documenting the induration, redness, and size;-He/she would expect the next two step test to be done within 21 days and the same process. During an interview on 07/28/25, at 10:12 A.M., the Administrator said the following:-All new hires should have a negative TB result or chest Xray before working the floor;-HR and the DON are responsible for ensuring this gets done and tracking them;-The first TB Test is administered before working the floor and should be ready in 48 to 72 hours. The documentation should include if the skin is raised or reddened, and the size;-The second two step TB test should be administered and read within 21 days after the first two step.

Based on observation, interview, and record review, the facility staff failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent and treat urinary tract infections when staff failed to notify the physician of and provide treatment for suspected urinary tract infections (UTI) two residents (Resident #17 and #51). The facility also failed to ensure proper catheter (a thin, flexible tube inserted into the body to drain fluid) use for residents when staff failed to obtain appropriate physician orders to place a catheter, to provide catheter care, and to change the catheter for one resident (Resident #43) with an indwelling urinary catheter. The facility census was 57.Review of the facility policy titled, “Urinary Tract Infections (UTI)/Bacteriuria-Clinical Protocol,” revised June 2014, showed the following:-The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI;-The physician will help nursing staff interpret the significance of signs, symptoms, and lab test results;-The physician will order appropriate treatment for verified or suspected UTIs based on pertinent assessment. 1. Review of Resident #17’s face sheet showed:-admission date of 07/26/24;-Diagnoses included of Alzheimer’s disease, urinary tract infection, urinary incontinence, and congestive heart failure. Review of the resident’s quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff). dated 04/15/25, showed the following:-Severe cognitive impairment;-Resident ambulated with walker and independent with mobility and transfers;-Required partial to moderate assistance of staff with toileting hygiene, personal hygiene, upper and lower body dressing;-Frequently incontinent of bowel and bladder. Review of the resident’s physician orders showed an active order, dated 07/26/24, to straight catheterize as needed (PRN) to obtain urinalysis (UA), if unable to obtain by clean catch method. Review of the resident’s care plan, dated 08/06/24, showed the following:-Resident needs staff assistance with his/her activities of daily living (ADL) due to diagnosis of dementia;-Observe resident for signs or symptoms of a UTI, foul or strong urine, pain or burning with urination, or dark colored urine;-Report any symptoms to the charge nurse. Review of the resident’s nurse progress note dated 06/25/25, at 6:53 P.M., showed Registered Nurse (RN) Q documented a new order for UA with culture and sensitivity due to increased confusion. Review of the resident’s physician orders showed staff did not document a specific order for a urinalysis on 06/25/25. Review of the resident’s nurse progress note dated 06/26/25, at 5:21 A.M., showed a nurse documented UA obtained by clean catch and in fridge awaiting lab pick up. Review of the resident’s final urine culture results, reported on 06/29/25, showed the following:-Result of 10,000-49,000 colony-forming units (CFU)/milliliter (mL) of Proteus Mirabilis (a bacteria commonly associated with infections of the urinary tract);-An accompanying list of antibiotics for the bacteria with sensitivity and resistance listed. Review of the resident’s medical record, dated 06/29/25 to 07/10/25, showed staff did not document notification of the physician regarding the urine culture results. Review of the resident’s nurse progress note dated 07/11/2025, at 9:09 P.M., showed RN Q documented new orders for antibiotics. Resident started on Cefdinir (an antibiotic) 300 milligrams (mg) two times a day (BID) for a urinary tract infection (UTI). The resident received his/her first dose of therapy at 9:05 P.M. The resident will receive therapy for 7 days. Review of the resident’s physician orders showed the following orders:-An order, dated 07/11/25, for Cefdinir, capsule 300 mg, amount of 300 mg, oral twice a day for 7 days;-An order, dated 07/11/25, for acidophilus (a probiotic) capsule give 2 capsules with meals, orally two times per day, while the resident is on antibiotics. During an interview on 07/22/25, at 12:11 P.M., the Director of Nursing (DON) said the following: -The resident's urinalysis with culture and sensitivity, dated 06/29/25, was the most recent urinalysis completed on the resident;-The facility's laboratory was supposed to call the facility with critical lab results including the positive culture results, but they did not do so in this situation;-The lab results were reported to the facility via a computer portal;-The facility nurses must then print and scan a paper copy into each resident's electronic health record and place a paper copy in the physician's book for the physician to review when he/she made resident rounds at the facility;-If a culture result shows bacteria in the urine, the nurse should call the physician with the positive culture results;-The facility had an issue with the nurses not being able to view the portal results;-The issue was with laboratory portal access;-He/she was currently working on the issue;-The DON was printing the lab results off the lab portal and reviewing all results two times per week. During an interview on 07/25/25, at 1:07 P.M., Certified Medication Technician (CMT) U/Medical Records said the following:-He/she thought the facility had some issues with not being able to access the laboratory results;-For a time, only the DON and Assistant Director of Nursing (ADON) could access the laboratory results from the portal;-The facility had a few urinalysis results that nursing needed to address with the physician, but the results were delayed;-When the facility contacted the lab about the delays, the lab said the results had been sent to the facility, but he/she was unsure if the facility received those results;-The laboratory calls the facility with critical laboratory results, but he/she was unsure if the laboratory was calling urinalysis culture and sensitivity results to the facility. During an interview on 07/25/25, at 2:16 P.M, the ADON said the following:-The facility had experienced delays in obtaining urinalysis culture and sensitivity results from the laboratory;-The laboratory should call abnormal culture results to the facility;-He/she was unsure where the disconnect occurred, but the facility did not notify the physician timely of the laboratory results.-Nurses should notify the physician of culture and sensitivity results right away and the resident should be started on antibiotics within two hours of receiving the physician’s order for treatment. During an interview on 07/28/25, at 9:40 AM, the Administrator said the following:-The facility had an issue with nurses not reviewing laboratory results daily, which included urinalysis and urine culture and sensitivity results;-He/she informed the Director of Nursing (DON) he/she needed to review laboratory results at the morning meetings (Monday to Friday) to ensure timely reporting of results to the physician;-Reporting results timely to the physician, would help prevent delays in residents starting on antibiotics for infections. 2. Review of Resident #43’s face sheet showed the following:-admission date of 06/21/25;-Diagnoses included urinary retention, unspecified symptoms and signs involving the genitourinary system (two kidneys, two ureters, one urinary bladder, and one urethra), type 1 diabetes mellitus, and amputation or right lower leg. Review of the resident’s admission MDS, dated [DATE], showed the following:-Cognitively intact;-Rejected care one to three days in last week;-Required partial to moderate assistance of staff with toileting hygiene, showers, upper and lower body dressing, and transfers;-Presence of an indwelling urinary catheter;-Always incontinent of bowel and bladder. Review of the resident’s nurse progress note dated 07/01/25, at 6:32 P.M., showed CMT U/Medical Records documented the following:-Family Nurse Practitioner (FNP) here and saw the resident;-Received an order to discontinue the resident’s Foley catheter;-Resident aware of the new order. Review of the resident’s physician orders showed the following: -A previous order for Foley catheter (an indwelling urinary catheter) care every shift and as needed. The order was discontinued on 07/02/25;-No current order for a urinary foley catheter or catheter care. Review of the resident’s nurse progress note dated 07/02/25, at 1:02 P.M., showed the following:-The resident was refusing to allow the licensed practical nurse (LPN) to discontinue his/her Foley catheter as ordered by the physician at this time;-The resident said the physician did not talk with him/her about discontinuing his/her catheter and he/she would like to speak to the physician first;-Placed a request for the physician to talk with the resident about discontinuing the resident’s Foley catheter in the physician’s book. Observation and interview on 07/21/25, at 11:30 A.M., showed the following:-The resident on his/her bed;-The resident said he/she had an indwelling urinary catheter;-The resident said he/she completed his/her own catheter care;-The resident’s catheter drainage bag with yellow urine present was attached to the resident’s bed frame, suspended off the floor. During an interview on 07/25/25, at 1:43 P.M., CMT U/Medical Records said the following:-The physician gave an order to discontinue (remove) the resident’s urinary catheter, but the resident refused to allow staff to remove the catheter;-The resident wanted to speak with the physician about the pros and cons of the catheter and the physician encouraged the resident to allow nursing to remove the catheter, but the resident refused;-The resident had a diagnosis of neurogenic bladder (a condition where the nerves that control the bladder do not function properly, leading to difficulty with urination), so the physician agreed to allow the resident to keep his/her catheter. The physician told the resident nursing would change his/her catheter monthly;-Any resident with a catheter should have a physician’s order for the catheter to include size and changing frequency;-The CMT viewed the resident’s medical record and said he/she could not find a current physician’s order for the resident’s catheter or an order to change the catheter. During an interview on 07/28/25, at 2:18 P.M., RN Q said the following:-The physician or nurse practitioner discontinued the resident’s urinary catheter, but the resident refused to allow the catheter to be removed;-The resident did have a diagnosis of neurogenic bladder which qualified him/her to keep the catheter;-The nurse notified the Administrator and the resident’s physician;-The physician said the resident could keep due the indwelling urinary catheter due to his/her diagnosis a neurogenic bladder;-The nurse did not realize the resident did not have a current catheter order;-The resident should have an order for his/her indwelling urinary catheter;-The order should include catheter size, [NAME] size, and frequency of change;-The nurse said he/she thought the facility policy was for monthly changes of a urinary catheter. did not have an order, the order should include catheter size, balloon and frequency of change. During an interview on 07/28/25, at 9:40 AM, the Administrator said the following:-Nursing should obtain a physician’s order for any resident with a catheter. The order should include size of catheter and [NAME] and frequency of changing the catheter;-The physician gave staff an order to discontinue the resident’s catheter, but the resident refused removal of the catheter;-A nurse discontinued the catheter order and failed to request a new physician’s order for the catheter. 3. Review of Resident #51's face sheet showed the following:-admission date of 08/07/24;-Diagnoses included essential hypertension (HTN-high blood pressure), major depressive disorder, and chronic kidney disease stage III (moderate kidney damage). Review of the resident's progress note dated 05/07/25, at 1:01 A.M., showed a nurse documented the resident complained to the nurse that he/she voided excessively. The resident was incontinent. The resident stated that his/her bladder was low but not prolapsed. The resident would like to speak to the doctor to see if anything could be done. The resident was concerned about his/her voiding excessively. The resident did not complain of pain due to this. Review of the provider's note, dated 05/07/25, showed the provider documented urinary frequency per nursing staff and history of bladder prolapse. Check with urinalysis. Review of the resident's progress note dated 05/08/25, at 5:39 P.M., showed a nurse documented the laboratory called the facility with the urinalysis results. The white blood count was greater than 100. The nurse practitioner ordered to wait on the culture results. Review of the resident's laboratory results showed the following:-On 05/08/25, the lab was ordered;-On 05/14/25, the laboratory was verified;-Result of greater than 100,000 CFU/ml of Proteus mirabilis. Review of the resident's nurse practitioner's note, dated 05/20/25, showed the following:-Follow up on dysuria (a medical term for pain, discomfort, or a burning sensation during urination) and lab results;-Urine culture positive for proteus;-Cefdinir 300 mg twice a day for five days;-Diagnosis of UTI. Review of the resident's May 2025 Physician Order Sheet (POS) showed an order, dated 05/20/25, for Cefdinir 300 mg twice a day. (Staff documented the antibiotic order six days after the urine culture results were received.) Review of the resident's May 2025 Medication Administration Record (MAR) showed the following:-An order, dated 05/20/25, for Cefdinir 300 mg twice a day;-On 05/20/25 on the 10:00 P.M. to 10:00 A.M., shift staff administered the medication to the resident. Review of the resident's progress note dated 05/21/25, at 1:58 A.M., showed a nurse documented as a late entry for 10:00 P.M. at 05/20/25 a new order for an antibiotic for Cefdinir 300 mg to be started for treatment of a UTI. Staff administered initial dose at this time tonight. The resident had no complaints of dysuria or flank pain but did complain of urinary frequency. Review of the resident's quarterly MDS assessment, dated 05/29/25, showed the following:-Cognitive skills intact;-Substantial/maximal assistance required with toileting;-Frequently incontinent with urinary continence. Review of the resident's care plan, revised 06/03/25, showed the following:-The resident was at risk for skin breakdown and odor due to bowel and bladder incontinence;-Monitor for incontinence frequently. During an interview on 07/24/25, at 02:00 P.M., the ADON said the following:-The resident's UA culture did not result until 05/14/25 and the results were greater than 100,00, so the resident had a UTI. Staff should had called the physician right away;-The laboratory did not notify the facility of the resident's UA results and he did not think the nurses were checking the laboratory results. During an interview on 07/24/25, at 4:04 P.M., the DON said the following:-The resident's UA results were on 05/08/25, and the NP wanted to wait for results of the urine culture which was on 05/14/25. The lab should had called the facility with the resident's abnormal culture results. The resident's urine culture was in the lab portal and staff would have to search the resident in the lab portal for the culture results. Staff should had started the resident's antibiotic before 05/20/25. During an interview on 07/25/25, at 9:41 A.M., the resident said a few months ago, he/she thought in May 2025, he/she had a UTI. Staff sent the UA and he/she asked a staff member what the results were. The staff member said nothing was wrong. He/she knew there was something wrong because he/she had to urinate a lot and it burned. The physician got involved and staff sent another UA out for a culture he/she thought. It was decided he/she had a UTI and the antibiotic helped. He/she was concerned for how long the results did not come back. During an interview on 07/28/25, at approximately 04:00 P.M., CMT U/Medical Record Staff said he/she did not find the physician order for the resident's 05/08/25 UA. 4. During an interview on 07/24/25, at 02:00 P.M., the ADON said the following:-Signs and symptoms of a UTI include frequency of urination, lethargy, temperature, and strong foul-smelling urine;-Staff should call the physician for an order for a UA;-Nurses complete a lab requisition, place it in the laboratory binder, collect the UA, and the laboratory staff pick up the UA the next morning;-The laboratory company comes to the facility Monday through Friday and checks the binder for lab requisitions;-The facility receives UA results pretty quickly;-Staff find the laboratory results on the laboratory portal;-He started checking the laboratory portal every day to find results; -The nurses just quit looking for the laboratory results and they did not know how to do it and had not been showed how;-A UA culture and sensitivity report usually takes about three days for the results to come back; -Nurses should check the urine culture along with the UA on the laboratory requisition form;-Nurses notify the physician of the UA and/or culture results who orders an antibiotic if needed;-Nurses enter the antibiotic order into the computer and informs the CMTs who go to the machine and see if it is in the emergency kit. Staff should call the pharmacy if it is not in the emergency kit;-Nurses call the pharmacy for an antibiotic which is delivered within a two-hour window. During an interview on 07/28/25, at 11:30 A.M., the physician said he expected staff to inform him of the laboratory results for urinalysis and culture and sensitivity results. During an interview on 07/24/25, at 10:58 A.M., CMT K said the following:-Signs of a UTI include confusion and odors;-Staff should notify the nurse if a resident has signs of a UTI;-Nurses enter orders for labs. During an interview on 07/24/25, at 2:43 P.M., CMT U/Medical Records said the following:-Staff enter an order for a UA in the computer;-Staff collect the urine and give it to the nurse who documents clean catch in the computer;-Nurses complete a laboratory requisition form and place it in the binder and on the calendar;-The laboratory company comes to the facility Monday through Friday and take out the requisition form for the requested lab;-The facility usually receives the UA results that evening or the next morning;-A urine culture takes five days;-The laboratory company calls the facility if it is a critical lab;-If there is just slightly infection, the lab will do a culture before they send it, if it shows high in bacteria, the lab will call the facility;-Bacteria shows on the culture and not on the UA;-Nurses check the lab portal every day for results;-The facility had a lot of change in staff over the years and had with new nurses understanding the lab process;-The ADON and DON check the lab portal;-He/she rounds with the physician and places the lab results in his book;-The physician and NP signs every lab order and it is placed in the paper chart along with the lab results;-Nurses should notify the physician of a urine culture results;-Nurses place the lab results in a folder at the nurses’ desk which is taken on weekly rounds with the provider;-The physician and NP review the lab results and initial it;-Nurses should document critical level lab results, notification of the physician, and any medication change in the resident medical record;-Nurses should administer an antibiotic within two hours of receiving the order;-If an antibiotic is not in the emergency kit, they should notify the pharmacy to have it delivered with two hours. During an interview on 07/24/25, at 04:04 P.M., the DON said the following:-Signs of a UTI include a change in behaviors, mental status, and/or a change in activities of daily living;-The nursing staff should notify the physician of a possible UTI;-Nurses complete a lab requisition and place in the binder at the nurses' desk;-Nurses enter a lab order in the computer which triggers the MAR for staff to check each shift for the lab to be completed and continues until it is discontinued;-Nursing staff collect the UA and place it in the refrigerator;-The lab company comes to the facility Monday through Friday;-The lab company enters the lab results in the lab portal;-The nursing staff are supposed to check the lab portal daily for results;-Staff print off the lab results and report anything abnormal to the provider;-Staff should enter the physician order for an antibiotic, fax the order sheet to the pharmacy and pull it from the emergency kit and wait for the pharmacy to deliver it. During an interview on 07/28/25, at 9:20 A.M., the Administrator said the following:-Staff should monitor residents for signs of a UTI;-She expects staff to notify the physician with lab results and obtain the ordered antibiotic timely. Complaint 2562350

Based on interview and record review the facility failed to ensure all resident care plans were completed and current when staff failed to care plan related to a relationship and restrictions involving two residents (Resident #20 and #2) and when the staff failed to care plan new falls and new interventions for one resident (Resident #50). A sample of 20 residents was reviewed in a facility with a census of 57. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process;-Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making;-When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers;-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions changes. 1. Review of Resident #20's face sheet showed the following:-admission date of 05/18/22;-Diagnoses included essential hypertension (HTN-high blood pressure), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and major depressive disorder. Review of the resident's progress note dated 06/17/25, at 3:15 P.M., showed the Social Service Director (SSD) documented a care conference with the resident's legal guardian. The interdisciplinary team spoke with the guardian regarding the relationship between the resident and Resident #2. Resident #2 expressed his/her desire to relocate to another state and asked for the resident (Resident #20) to move with him/her. The residents have requested permission to spend time together in one another's rooms, which staff advised is not permitted. The guardian confirmed his/her support for the interventions staff put in place and expressed willingness to speak with the resident regarding the importance of guardianship and the legal procedures involved should he/she wish to pursue its revocation. Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 06/25/25, showed the following-Moderately impaired cognitive skills;-No behaviors. Review of the resident's revised care plan, dated 06/26/25, showed staff did not update the care plan of the resident's relationship with another resident and the restrictions of not able to be in each other's rooms. 2. Review of Resident #2's face sheet (resident's information at a quick glance) showed the following: -admission date of 09/17/21;-Diagnoses included post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing a terrifying or traumatic event), major depressive disorder (persistent feelings of sadness), cognitive communication deficit, muscle weakness, and anxiety disorder (worrying constantly and cannot control the worrying). Review of the resident's nurses' progress notes showed on 04/25/25, at 11:53 A.M., SSD met with Resident #2 to discuss appropriate boundaries during interactions between him/her and another resident (Resident #20). The importance of maintaining public settings for conversations. SSD advised he/she should refrain from entering the room of the resident, emphasizing that discussions should take place in common areas to ensure comfort, mutual respect, and the avoidance of misunderstandings. Review of the resident's annual MDS, dated [DATE], showed the following information: -Adequate vision and hearing;-Clear speech, makes self understood and understands others;-Responds adequately to simple, direct communication only;-No cognitive impairment. Review of the resident's care plan, revised on 07/07/25, showed the following:-Independent with activities, and can be manipulative with staff at times to get his/her way;-History of mood problems. Establish trusting relations, verbalize feelings, concern and fears;-Identify relationships he/she can draw on and explore with me past effective and ineffective coping mechanisms.(Staff did not care plan related to the resident's current relationship with another resident, or the restrictions on the relationship.) 3. During an interview on 07/24/25, at 9:50 A.M., Certified Nurse Aide (CNA) T said the following:-Nurses state the residents cannot be in each other's rooms and he/she did not know why;-Staff monitor the residents daily. Resident #2 and Resident #20 usually sit by the sunroom. During an interview on 07/24/25, at 1:53 P.M., the MDS Coordinator/Assistant Director of Nursing (ADON) said the following:-The residents should not be in the same room together;-During the last care plan meeting, Resident #20's guardian informed staff of his/her view of things and the relationship. The guardian stated Resident #20 did not have the capacity to consent to sex;-Resident #20's guardian was ok with the residents in public together;-The restrictions of the residents not in each other's rooms should be included on the care plan. During an interview on 07/24/25, at 2:43 P.M., Certified Medication Tech (CMT) U said Resident #2 and Resident #20's care plans should include them to not be in the same room together. Resident #20's guardian stated Resident #20 is not able to make decisions of his/her personal care. During an interview on 07/28/25, at 2:08 P.M., the SSD said Resident #20's guardian said it is ok for both residents to be in public but did not want them in a room in private and if the court deemed Resident #20 not capable, he/she was not capable to consent to make decisions for intimacy. During an interview on 07/24/25, at 04:04 P.M., the Director of Nursing (DON) said the following:-Resident #20 has restrictions to not be in the same room together with Resident #2 and it should be on both of the residents' care plan;-Resident #20's guardian states the resident is not capable of maintaining a safe environment. During an interview on 07/28/25, at 9:20 A.M., the Administrator said the following:-She spoke with Resident #20's guardian who said the resident is not capable of making his/her own decisions and cannot consent to sex and did not want the resident placed in that situation;-Resident #20's guardian had concerns with Resident #2 being manipulative with Resident #20;-She expected staff to update the residents' care plans of not allowed in each other's rooms. 4. Review of Resident #50's face sheet showed the following:-admission date of 05/08/25;-Diagnoses included heart failure, hypotension (low blood pressure), respiratory failure (lungs can't adequately provide oxygen to the blood), kidney failure (kidneys can no longer adequately filter waste and excess fluid from the blood), use of coagulants (medication that thins the blood), and conversion disorder with seizures or convulsions (episodes of weakness, difficulty walking and loss of muscle control). Review of the resident's entry MDS, dated [DATE], showed the following information:-Severe cognitive impairment;-Required partial assistance with toileting, showers, upper and lower body dressing, personal hygiene, lying to sitting and chair to chair transfer;-Used wheelchair;-Did not use bed rail. Review of the resident's progress note dated 06/01/25, at 7:06 P.M., showed the nurse was called to resident room by CNA. CNA had answered call light and found resident sitting on the floor, leaning against the wall. The nurse entered to find the resident in this position with the CNA at his/her side. Resident denied pain, interacted appropriately, and functioned at baseline status. Resident assisted to seated position on edge of bed with three staff assisting. No injuries noted at this time. Neuros initiated and resident placed in provider book for next visit. Review of the June 2025 Facility Event Reports showed an event report started on 06/01/25 and included documentation of unwitnessed fall in room and neurological assessments. Review of the resident's care plan showed staff did not update the care plan with the falls and new interventions put in place after the fall. Review of the resident's progress note dated 06/07/25, at 9:07 A.M., showed writer alerted to resident room by CNA. Resident found lying on right side in the floor next to his/her bed, wheelchair behind him/her. The nurse asked resident what happened, and resident stated he/she fell. When asked if he/she was trying to get back into bed, resident shook his/her head yes. Resident rubbed his/her right elbow and when asked if he/she has any pain resident stated that his/her elbow is hurting. Noted redness and nickel size bruise to right elbow. No further injuries noted. Range of motion intact to extremities times four. No outward rotation or shortening noted. Resident denied striking head. Neuro checks initiated with no deviation from baseline. Vitals obtained. Resident assisted out of the floor with three staff assisting into bed. Call light within reach. Nurse reminded resident to use his/her call light and wait for staff to assist before transferring. Will continue to monitor per facility protocol. Review of the June 2025 Facility Event Reports showed an event report, dated 06/07/25, included documentation of an unwitnessed fall and neurological assessments. Review of the resident's care plan showed staff did not update the care plan with the falls and new interventions put in place after the fall. Review of the resident's progress note dated 06/28/25, at 8:45 P.M., showed the resident's roommate came into the hall to tell staff the resident was on the floor. Resident was found to have stripped all clothes off, attempted to stand, urinated on the floor, and then slipped in the urine. Bed was saturated and changed. No apparent injuries noted. Resident cleaned and assisted back into bed. Vitals obtained. Call placed to nurse practitioner and informed of event with no new orders. More frequent toileting will be necessary. Will continue to monitor. Review of the June 2025 Facility Event Reports showed an event report, dated 06/28/25, included documentation of fall with neuros, and neurological assessment. Review of the resident's care plan showed staff did not update the care plan with the falls and new interventions put in place after the fall. Review of the resident's care plan, revised 07/23/25, showed the following information:-The resident required limited assistance for ambulation, bathing, bed mobility, dressing, grooming, hygiene, locomotion, toileting, and transfers;-Observe for safe ambulation and remind resident to not ambulate without assistance until therapies approve him/her to do so;-At risk for falling;-Keep bed in the lowest position, keep personal items within reach, fall risk assessment at least quarterly, and verbal reminders not to ambulate/transfer without assistance;-Assist rails (one to two) as needed to enable bed mobility;-Give resident verbal reminders not to ambulate or transfer without assistance. Encourage resident to use environmental devices such as hand grips, hand rails, etc.(Staff did not update the care plan to reflect falls and new interventions from falls on 06/01/25, 06/07/25 and 06/28/25.) During an interview on 07/24/24, at 9:53 A.M., the SSD said the following:-Prior administration had been updating care plans when the resident would have a fall;-The care plans should have the falls listed and any new interventions;-The resident is a fall risk. He/she doesn't know if the resident's care plan has been updated with new interventions. During an interview on 07/24/25, at 1:54 P.M., CNA A said the following:-When a resident falls, they add new interventions;-The resident has fallen multiple times; -They have the resident on a low bed, making sure his/her wheelchair is near the bed, and toileting resident more often;-The falls are discussed during weekly meetings and care plan meetings. He/she believed they would update the care plan with the falls and new interventions. During an interview on 07/24/25, at 1:00 P.M., CMT C said falls are documented in the care plans and new interventions are added, such as low bed, fall mats, toileting before laying down. During an interview on 07/24/25, at 1:58 P.M., the CMT Supervisor said the following:-Residents have a fall risk assessment completed upon admission;-When a resident falls they go over them in morning meetings. The meetings include the administrator, DON, SSD, Activities Director, and MDS Coordinator;-The interventions are discussed and the MDS Coordinator is supposed to update the care plan with the information. During an interview on 07/24/25, at 2:40 P.M., Registered Nurse (RN) D said when residents have falls, nursing completes a fall assessment and the MDS Coordinator should update the fall interventions for the care plans. During an interview on 07/24/25, at 3:42 P.M., the ADON said the following:-He/she has updated several care plans but did not know if the resident's care plan has been updated recently;-Falls should be listed in the care plan and updated as falls occur with new interventions. During an interview on 07/25/25, at 10:19 A.M., CNA B said the following:-They do have interventions for falls, such as ensuring the floor is clean, low bed, and fall mats;-The resident likes to self-transfer, so they have his/her bed in the low position;-He/she believed the care plan should be updated with falls. During an interview on 07/25/25, at 2:00 P.M., the DON said the following:-When a resident falls the nurse completes a fall report, fall investigation, and should place immediate interventions;-Staff have weekly meetings will all upper staff present to discuss falls;-The MDS Coordinator should be updating the care plan with falls and new interventions;-He/she was not sure if the resident's care plan had been updated to reflect the three falls from June 2025. During an interview on 07/28/25, at 10:12 A.M., the Administrator said they have daily morning meetings with all department head attending. They review falls and whose at risk. Interventions are discussed and the MDS Coordinator is in the meeting and responsible for updating the care plan with falls and the discussed interventions. He/she is not sure if the resident's care plan had been updated to reflect any of the falls from June 2025. 5. During an interview on 07/24/25, at 9:50 A.M., CNA T said the following:-The MDS Coordinator/ADON completed the care plans;-If there is a change that needed to be made to the care plan, staff should notify the nurse;-Staff find care plans in the care plan books and/or computer;-Care plans include how a resident transfers, diagnosesm or restrictions. During an interview on 07/24/25, at 1:53 P.M., the MDS Coordinator/ADON said the following:-He/she completed the MDS assessments and care plans; -Care plans should include behaviors, medications, fall interventions, and assistive devices. During an interview on 07/24/25, at 4:04 P.M., the DON said the following:-The interdisciplinary team meets weekly, morning stand up meetings, and in clinical meetings;-Staff conduct care plan meetings with residents and family;-The interdisciplinary team includes the Administrator, DON, ADON, medical records, SSD, Dietary Manager, activities, business office, and human resources;-The ADON is the current care plan coordinator.

Based on interview and record review, the facility failed to ensure all residents were offered, and received if requested, the pneumococcal vaccine when one resident (Resident #55) requested the vaccine, but staff failed to administer the vaccine and when facility staff failed to offer one resident (Resident #17), or his/her responsible party, the vaccine. The facility census was 57.Review of the facility policy titled, Pneumococcal Vaccine, revised August 2016, showed the following:-All residents will be offered pneumococcal vaccines to aid in preventing pneumonia and pneumococcal infections;-Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated of the resident has already been vaccinated;-Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record;-Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the vaccination. 1.Review of Resident #55's face sheet showed the following:-admitted [DATE] and re-admitted [DATE];-Diagnoses included Parkinson's disease, Alzheimer's disease, and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/12/25, showed the resident was cognitively intact. Review of the resident's vaccination consent form showed the following:-The resident checked declination of the Covid-19 and the influenza vaccine;-The resident checked yes to consent of the pneumonia vaccine (PSV20). Review of the resident's vaccination list showed staff did not document administration of a pneumonia vaccine. 2. Review of Resident #17's face sheet showed:-admission date of 07/26/24;-Diagnoses included Alzheimer's disease, urinary tract infection, urinary incontinence, and congestive heart failure.Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment.Review of the resident's vaccination consent form showed the following:-The resident's responsible party checked yes to consent of the influenza vaccine;-The resident's responsible party did not complete the consent or declination portion of the pneumococcal consent form. Review of the resident's vaccination list showed staff did not document administration of a pneumonia vaccine. 3. During an interview on 07/28/25, at 2:46 P.M., the Director of Nursing (DON) said he/she was unsure if facility staff administered pneumococcal vaccines to the residents or not. During an interview on 07/28/25, at 2:47 P.M., the Assistant Director of Nursing (ADON) said the following:-Facility staff did not offer residents and did not administer pneumococcal vaccines last year (2024) to the residents;-After the former DON resigned, staff were not able to locate resident pneumonia vaccine consents, therefore the facility did not administer the vaccinations to the residents. During an interview on 07/28/25, at 3:00 P.M., the facility Administrator said the following:-He/she was recently made aware that the facility staff had not offered pneumonia vaccines to all residents on admission in the past;-He/she had not yet had the opportunity to complete an audit to determine which residents were affected by the failure.

Based on interview and record review, the facility failed to ensure all residents were free from possible chemical restraints when staff failed to implement a physician approved pharmacy recommendation to decrease an antipsychotic in a timely fashion for one resident (Resident #4) out of a sample of five residents. The facility census was 57. Review showed the facility did not provide a policy regarding pharmacy consultations or pharmacy recommendations. 1. Review of Resident #4's face sheet (resident's information at a quick glance) showed the following:-admission date of 12/08/22;-Diagnoses included cognitive communication deficit, unspecified dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/12/25, showed the following:-Severe cognitive impairment;-No behaviors;-The resident took antipsychotic medication. Review of the resident's care plan, revised 05/20/25, showed the following:-The resident was at risk for adverse reactions to psychotropic medications as evidenced by receiving antianxiety, antidepressant, and antipsychotic medications;-Pharmacy consultant review at least monthly;-Attempt to give the lowest dose possible unless contraindicated;-Attempt a gradual dose reduction per pharmacy recommendation and/or as clinically needed per provider.Review of the resident's Physician Order Sheet (POS), dated 07/23/24, showed an order for Zyprexa (an antipsychotic) 5 milligrams (mg) once a day. The order did not indicate a diagnosis for administration of Zyprexa. Review of the resident's pharmacy recommendation, created between 12/09/24 and 12/11/24, showed the following:-The following psychotropic medication was due for a gradual dose reduction consideration for the resident;-Zyprexa 5 mg once daily for dementia with agitation;-Recommendation to reduce Zyprexa to 2.5 mg in the evening was marked;-The provider signed on 12/26/24.Review of the resident's medical record showed staff did not document a reduction in the resident's Zyprexa as approved by the physician. Review of the resident's pharmacy recommendation, dated 05/13/25, showed the following:-The following psychotropic medication was due for a gradual dose reduction consideration for the resident;-Zyprexa 5 mg once daily for dementia with agitation;-Recommendation to reduce Zyprexa to 2.5 mg in the evening was marked;-Prescribers comments: Trial the resident's reduction to see how it goes;-The provider signed on 05/16/25. Review of the resident's POS, dated 05/19/25, showed an order for Zyprexa 2.5 mg once a day. The order did not indicate a diagnosis for administration of Zyprexa. Review of the resident's May 2025 Medication Administration Record (MAR) showed an order, dated 05/19/25, for staff to administer Zyprexa 2.5 mg once a day. During interviews on 07/24/25, at 3:46 P.M., and on 07/25/25, at 10:52 A.M., the Assistant Director of Nursing (ADON) said the resident's Zyprexa should had been decreased per the December 2024 pharmacy recommendation. During an interview on 07/24/25, at 2:43 P.M., the Certified Medication Technician (CMT) U/Medical Records staff said the following:-Staff give the provider a list of medications that are recommended to be changed;-The nurse contacts the resident and/or representative of a medication change and documents in the progress notes. During an interview on 07/25/25, at 10:30 A.M., Licensed Practical Nurse (LPN) J said the following:-Staff give the pharmacy recommendations to the physician;-If the physician changes a medication, the nurses should notify the resident and/or representative and enter the new order in the computer. During interviews on 07/24/25, at 3:46 P.M., and on 07/28/25, at 11:18 A.M., the ADON said staff the following:-Staff should have called the physician and pharmacy to clarify the recommendation of the reduction of the Zyprexa to 2.5 mg that he signed 12/26/24; -The pharmacy comes to the facility monthly and emails the completed monthly medication reviews and recommendations;-The medical records staff and the Director of Nursing (DON) review the recommendations and places them in a folder for the physician to review who comes to the facility weekly;-The physician decides to agree with the recommendation or not;-The physician checks the box on the pharmacy recommendation and signs if he agrees for any medication changes;-Some nurses who no longer work at the facility placed the pharmacy recommendation in the medical record staff box and did not say anything. Facility staff found out a few months ago some recommendations did not get addressed. During an interview on 07/28/25, at 1:06 P.M., the physician said the following:-He said if he signed the resident's pharmacy recommendation on 12/26/24 to reduce the Zyprexa, it should had been reduced;-The diagnosis for the medication is dementia with agitation;-Staff give him the pharmacy recommendations when he comes to the facility;-Staff tell him if a resident is stable on current regimen;-He reviews the pharmacy recommendation;-Staff inform him if a resident has any behaviors or issues. During an interview on 07/28/25, at 2:00 P.M., the DON said the following:-Staff should had reduced the resident's Zyprexa to 2.5 mg per the December 2024 pharmacy recommendation;-The pharmacy recommendation must had been overlooked;-The pharmacy emails him the monthly medication reviews and he prints them off to review;-He places the recommendations on the physician's desk;-The physician comes to the facility weekly;-The physician reviews the pharmacy recommendations and gives them to the nurses with his decision and nurses enter the order. During an interview on 07/28/25, at 9:20 A.M., the Administrator said staff should follow pharmacy recommendations if the physician agrees and signs it.

Based on interview, observation, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion when facility staff failed to obtain an order for the use of a brace, failed to document use of a brace, failed to monitor the use of a brace, and failed to care plan the use of brace to the right-hand brace for one resident (Resident #8) with a contracture. The facility census was 57.Review of a facility policy titled Assistive Devices and Equipment, dated July 2017, showed the following:-The facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents;-Devices and equipment that assist with resident mobility, safety, and independence are provide for residents;-Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan;-Staff will be trained and demonstrate competency on the use of devices;-The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents: appropriateness for resident condition; personal fit measured to resident's size and weight; devices will be maintained on a schedule and defective or worn devices will be discarded or repaired; and staff competency on the device in use. Review of a facility policy titled Medication Orders, dated July 2017, showed the following:-A current list of orders must be maintained in the clinical record of each resident;-Orders must be written and maintained in chronological order;-When recording treatment orders, specify the treatment, frequency, and duration of the treatment. 1. Review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 06/06/25;-Diagnoses included cerebral infarction (sudden loss of brain function that occurs when blood flow to the brain is interrupted), hemiplegia (paralysis of one side of the body) of right side, muscle weakness, and aphasia (language disorder that affects a person's ability to communicate).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/06/25, showed the following:-Severe cognitive impairment;-Dependent on staff for transfers, mobility, dressing, and showering;-Resident was not receiving restorative services;-Resident did not use splint or a brace. Review of the resident's care plan, revised on 06/19/25, showed the resident had impaired function and requires staff assistance with self-care and mobility.Observation on 07/22/25, at 10:11 A.M., showed the resident resting in bed. The resident had a blue splint on the dresser next to his/her bed. Observation on 07/22/25, at 10:55 A.M., showed the resident wearing a blue splint on his/her right hand and wrist. Observation on 07/23/25, at 12:53 P.M., showed the resident sitting up in a chair watching television with a blue brace on his/her right hand and with a gauze roll in the palm of his/her right hand. Observation on 07/24/25, at 2:48 P.M., showed the resident sitting in a chair watching tv with a blue brace on the dresser. Observation on 07/25/25, at 9:27 A.M., showed the resident resting in bed with no brace on his/her right hand. A blue brace was observed on the dresser next to the bed.Review of the resident's July 2025 Physician Order Sheet (POS) showed no order to apply or monitor a right-hand brace. Review of the resident's nursing progress notes showed staff did not document regarding a right-hand brace of monitoring of the brace. Review of the resident's July 2025 Treatment Administration Record (TAR) showed no order for application or monitoring of right-hand brace.Review of the resident's current care plan showed staff did not care plan the use of a right hand brace. During an interview on 07/25/25, at 10:00 A.M., Certified Medication Technician (CMT) L said resident wears a brace to his/her right hand. The brace should be applied during the day and taken off at night. He/she did not know if the resident was admitted to the facility with the brace or acquired it during stay. There should be an order for a brace and it should be included in the care plan. There should also be an order to assess the skin under a brace due to possible skin breakdown.During an interview on 07/28/25, at 9:57 AM Licensed Practical Nurse (LPN) J said a resident should have an order for brace which should include times of application. Therapy would be responsible for ordering a resident a brace. The resident had a right-hand brace, but did not have an order for it. The CNA's were responsible for applying and removing braces. The nurses were responsible for monitoring skin under brace and ensuring the brace is on and off at designated times. A resident brace should be on the care plan.During an interview on 07/28/25, at 10:08 A.M., Certified Nurse Assistant (CNA) M said he/she would know if a resident required a brace during orientation. The trainer would educate the new employee on resident needs. Therapy will advise CNA's of any new assistive equipment or braces for residents. The resident care plan informed CNA's on how to take care of the resident. A resident with a brace should be included in the care plan. CNA's apply and remove the brace for the resident. He/she knew about the brace due to communication between the aides. There was no documentation that he/she does that indicate the brace had been applied or removed. There are no orders or charting required for the resident's brace.During an interview on 07/28/25, at 10:20 A.M., Certified Occupational Therapy Assistant (COTA) O said occupational therapy is responsible for hand braces. A resident will be recommended a brace while on therapy. A brace required an order and nursing obtained the order from the physician. He/she was not aware of the resident having a wrist brace. The resident came to the facility as a long-term resident and had not had occupational therapy. The resident was admitted to the facility with a blue arm brace from another facility. Nursing can obtain an order to continue a brace if a resident was admitted with one. An order was required for a resident to use a brace, and the nurse was responsible for the brace to be applied and removed.During an interview on 07/28/25, at 11:09 A.M., CNA N said he/she knew if a resident should wear a brace if they were wearing it or it was near them during cares. Therapy or the nurse will show aides how to apply a brace. The resident had a brace for his/her right arm. The resident has had a brace to the right arm as long as he/she had been caring for them. The use of a brace should be included in the care plan. The care plan showed staff what the resident needs are.During an interview on 07/28/25, at 11:46 A.M., the Assistant Director of Nursing (ADON) said a brace should have been included in the care plan and have an order. The order should indicate times of use and should include observation of skin under brace. He/she had never seen the resident wear a wrist brace. The resident does not have an order for a wrist brace. During an interview on 07/28/25, at 2:43 P.M., the Director of Nursing (DON) said there should be an order for a wrist brace. Therapy was responsible for assessing the resident and obtaining an order. The order should contain when to apply and remove the brace, to assess skin under the brace, and to check placement throughout day. Nurses or therapy should be applying any brace. A resident that used a brace should have it indicated in the care plan.During an interview on 07/28/25, at 2:35 P.M., the Administrator said residents should have an order for a brace and for the skin to be assessed under a brace. The brace should also be included on the care plan.

Based on observation, record review, and interview, the facility failed to ensure residents who required colostomy (a surgical procedure that creates an opening, or stoma, in the abdominal wall to allow the colon to pass waste through the body) services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences when staff failed to obtain an order for a colostomy, colostomy care, and colostomy monitoring, failed to assess resident for ability to provide self-care for the colostomy, and failed to care plan self-care of the colostomy for one resident (Resident #49). The facility census was 57. Review of the facility's policy titled Colostomy/Ileostomy Care, revised October 2010, showed the following:-The purpose of the procedure was to provide guidelines that would aid in preventing exposure of the resident's skin to fecal matter;-Review the resident's care plan to assess for any special needs of the resident;-The following information should be recorded in the resident's medical record: the date and time the colostomy/ileostomy care was provided; the name and title of the individual(s) who provided the colostomy/ileostomy care; any breaks in resident's skin, signs of infection or excoriation of skin; how the resident tolerated the procedure, if the resident refused the procedure, the reasons(s) why and the interventions taken; and the signature and title of the person recording the data. 1. Review of Resident #43's face sheet (admission data) showed the following:-admission date of 02/01/25;-Diagnoses included acute cholecystitis (inflammation of the gallbladder), generalized anxiety disorder, and colostomy. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment completed by facility staff), dated 05/29/25, showed the following:-Cognitive skills intact;-No behaviors;-Impairment on both sides of upper extremity;-Independent with toileting and hygiene. Review of the resident's care plan, last revised on 06/29/25, showed the following:-Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) due to the resident has a colostomy;-Staff to use EBP (gloves, gowns) during bathing/showers/performing activities of daily living and hygiene tasks.(The care plan did not have the resident's self-care of his/her colostomy) Review of the resident's medical record showed staff did not document physician orders for the resident's colostomy, assessment of the resident for self-care of his/her colostomy, or skin assessments related to his/her colostomy. Observation and interview on 07/23/25, at 12:45 P.M., showed the resident sat in his/her recliner in his/her room. The resident said he/she had a colostomy, and the nurses did not look at it. It is red and sore. He/she emptied the colostomy bag two to three times a day. The colostomy bag was supposed to last a week and blows up (gets too full he/she explained) at times and he/she had to change it. Staff asked if he/she has changed the colostomy bag and if he/she had a bowel movement. Observation and interview on 07/25/25, at 10:20 A.M., showed the resident sat on the toilet in his/her bathroom. The resident changed his/her own ostomy wafer and bag. Upon removal, the skin around the stoma was reddened and excoriated to approximately one-inch surrounding area. Additionally, there was 1 1/2 area of excoriation to an area two inches below and lateral to the resident's stoma. The resident said he/she had stoma powder and stoma paste, but when he/she tried to use it the adhesive on the wafer it did not stick. The resident said he/she had not told anyone about the issue. Licensed Practical Nurse (LPN) J said he/she would follow up with the physician for other possible options to alleviate excoriation/leaking. LPN J stated due to the resident's self-care, he/she did not know of the issues with the skin areas. During an interview on 07/25/25, at 10:30 A.M., LPN J said he/she had not seen the resident's stoma area and did not know what nursing staff did with it. The resident performed his/her own colostomy care. The nurses should monitor for odor and irritation around the area. Nurses should look at the resident's skin around the stoma weekly if not more, when he/she changes the bag to see if it is irritated. It was irritated and he has an area on his/her left side. It looks like it is from the adhesive from the wafer. During an interview on 07/24/25, at 09:32 A.M., Certified Medication Technician (CMT) K said the following:-Nurses inform staff of which residents have a colostomy;-The resident was able to perform his/her own colostomy care;-The resident emptied his/her colostomy bag. The resident prepped his/her skin and applied a new colostomy bag;-The resident appeared to perform his/her colostomy care ok;-The resident did not complain of pain or redness with his/her colostomy;-Staff asked the resident each day of how much he/she emptied out of the colostomy bag;-Staff find care plans in the computer;-If a resident performs his/her own colostomy care, it should be on the care plan. During an interview on 07/24/25, at 09:50 A.M. Certified Nurse Aide (CNA) T said the following: -The resident performed his/her own colostomy care;-Staff ask the resident daily if he/she emptied the colostomy bag;-The resident had not complained of pain or redness with his/her colostomy. During an interview on 07/25/25, at 9:46 A.M., CNA S said the resident changes his/her own colostomy. He/she asks the resident if he/she had a bowel movement per shift and if he/she has emptied the colostomy bag. The resident asks for staff assistance at times. During an interview on 07/25/25, at 10:10 A.M., CNA B said the resident completed his own colostomy care and changed his/her bag. The resident at times may need assistance with the wafer. One time it was too full, and he/she needed help with the cleanup and placing the colostomy bag on with the wafer the right angle. The resident needed help lining up the wafer at the correct angle. During an interview on 07/24/25, at 2:43 P.M., CMT U said the following:-The resident informed staff if he/she needed assistance with his/her colostomy care;-The nurses observe him/her, and the aides watched him/her to make sure he/she handled the colostomy properly;-He/she did not know if it was documented;-Staff assist residents with a bath twice a week and perform a skin assessment from head to toe;-If staff notice redness around the resident's colostomy site, they should report to the charge nurse;-The resident did not say anything about his/her colostomy site being sore or red;-The resident sometimes lets the colostomy bag get full, and he/she asks the staff for assistance;-The resident's self-care of his/her colostomy should be care planned. During an interview on 07/28/25, at 2:18 P.M., Registered Nurse (RN) Q said the following:-He/she did not know for sure if there should be orders for the resident's colostomy;-If the resident has an issue with his/her colostomy, he/she thought the resident would tell the nurses;-The resident should have a diagnosis of the colostomy;-The resident should have a weekly skin assessment and that should include an assessment of his/her colostomy site.-Last weekend (07/23/25 or 07/24/25), he/she saw the resident's site and it did not look bad at that time, but he/she looked at the site yesterday, (07/27/25) and it looked red and excoriated; -On 07/27/25, he/she contacted the provider about the condition of the resident's stoma site and the provider said to monitor the site and encourage the resident to use stoma powder;-The resident has not changed the type of appliances/wafers that he/she uses, so he/she is not sure why the resident's site is excoriated;-The resident's self-care of his/her colostomy should be on the care plan. During interviews on 07/24/25, at approximately 2:00 P.M., on 07/25/25, at 10:52 A.M., and on 07/28/25, at 2:12 P.M., the Assistant Director of Nursing (ADON) said the following:-He did not see an order for the resident's colostomy; -When the resident was first admitted , he/she did not let him/her observe his/her colostomy because the resident said he/she did his/her own colostomy care;-The resident's colostomy care should be on the TAR for nurses to monitor every day;-Nurses catch observations when the resident changes the colostomy bag;-The resident did not say anything about the site being red;-The weather was hot outside, and the resident goes to work outside of the facility;-Nurses complete weekly skin assessments and should document on forms or in the progress notes; -The resident should have an order for colostomy and the colostomy self-care; -At times, the resident had a problem letting the bag overfill;-The resident was admitted from an assisted living facility. The former DON should had assessed the resident for his/her self-care of the colostomy;-The resident has his/her own colostomy supplies. The resident informed the staff when he/she needed more supplies for his/her colostomy;-Staff should make sure the colostomy is on correctly and no breakdown of the resident's skin;-The resident informed the CMTs and aides the amount he/she emptied out of the colostomy bag; -Staff should have care planned the resident for self-care of his colostomy;-Nurses should look at the resident's skin to make sure the skin is not macerated. Nurses should make sure the stoma is beefy red and the peri wound areas is not macerated. Nurses should make sure the resident is not constipated. Nurses should make sure the consistency of the resident's stools are good;-Nurses should complete weekly skin assessment on residents and check their skin;-Nurses add physician orders in the computer which triggers on the MARs to assess residents daily;-He did not find documentation for the resident of an assessment for self-care of his/her colostomy;-He did not find a physician order for the resident's colostomy or physician orders on the resident's treatment administration record for staff to monitor the resident's colostomy. During an interview on 07/24/25, at 4:04 P.M., the Director of Nursing (DON) said the following:-The resident informed staff upon admission that he/she performed his/her own colostomy care;-Staff educated the resident on caring for his/her colostomy the proper way and staff should had documented it in a progress note;-Staff should have care planned the resident managing his/her own colostomy care;-Nurses should monitor the resident's colostomy with general interaction;-If an order is entered in the computer to check the colostomy, it would trigger on the resident's MAR for the nurses to check it;-Nurses should monitor the resident's colostomy supply usage, stoma, and output;-Nurses should monitor for signs of infection around the resident's stoma. During an interview on 07/28/25, at 9:20 A.M., the Administrator said the following:-Nurses should complete an assessment at the time of request to perform self-care of a colostomy;-Nurses should complete skin assessments for a resident with a colostomy;-She expects staff to monitor the resident for his/her colostomy care;-Staff should obtain a physician's order for a resident's colostomy;-Staff should have a care plan for the resident's self-care of his/her colostomy;-The staff did not complete an assessment for the self-care of his/her colostomy.

Based on observation, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation,; and failed to obtain physician orders for side rail usage, for one resident (Resident #50). The facility's census was 57. Review of the resident's quarterly fall risk assessment, dated 11/27/17, showed the resident to was a moderate risk with diminished safety awareness and poor recall and judgment.Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/08/25, showed the following information:-Severe cognitive impairment;-Partial assistance with toileting, showers, upper and lower body dressing, personal hygiene, lying to sitting and chair to chair transfer.Review of the facility records showed on 05/12/25, staff completed a bed rail safety check. Review of the resident's care plan, last revised on 07/23/25, showed the following information:-The resident required limited assistance for ambulation, bathing, bed mobility, dressing, grooming, hygiene, locomotion, toileting, and transfers;-At risk for falling. Staff to keep bed in the lowest position and keep personal items within reach;-Assist rails (one to two) as needed to enable bed mobility (start date of 05/20/25);-Give verbal reminders not to ambulate or transfer without assistance. Encourage resident to use environmental devices such as hand grips, hand rails, etc.Observations showed the following:-On 07/22/25, at 10:18 A.M., the resident was in bed. The resident's bed had two quarter size side rails (one on each side) in the up position;- On 07/24/25, at 10:40 A.M., the resident was in bed. The resident's bed had two quarter size side rails (one on each side) in the up position;-On 07/25/25, at 1:05 P.M., the resident was in bed. The resident's bed had two quarter size side rails (one on each side) in the up position. Review of the resident's July 2025 Physician's Order Sheet (POS) showed staff did not have documentation of a physician's order for the side rail use. Review of the resident's medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, or routine ongoing assessments to ensure the side rails were appropriate for use. During an interview on 07/24/25, at 9:53 A.M., the Maintenance Director said the following:-The side rails were ordered by the doctor, and he/she waited for the nurses to let him/her know when to install the bars;-He/she just begun checking the side rails monthly in July;-He/she checked certain areas of the rail to ensure it's a certain distance, and he/she checked the headboard and mattress;-He/she had done a couple on the resident. During an interview on 07/24/25, at 1:00 P.M., Certified Medication Technician (CMT) C said the following:-The side rails are placed on a resident's bed to assist the resident with turning, or pulling themselves over;-He/she believed there was supposed to be a signed consent form by the resident or the representative and the doctor;-He/she didn't know anything about the assessment or measurements;-He/she believed the resident had the side rails to assist him/her in rolling over when he/she was being changed. Duirng an interview on 07/24/25, at 1:54 P.M., Certified Nurse's Aide (CNA) A said the following:-Residents use side rails to assist them in turning, rolling, and pulling up;-He/she didn't know the process for having side rails installed;-The resident did use the side rails to pull up, or help him/her get out of bed.During an interview on 07/25/25, at 10:19 A.M., CNA B said the following:-The residents use the side rails on their stronger side to assist with turning, it's resident specific;-He/she not seen the resident use the side rails;-He/she believed the side rails require a consent from the resident or the durable power of attorney;-He/she would go to maintenance if the resident requested a side rail. During an interview on 07/24/25, at 1:58 P.M., the CMT Supervisor said the following:-The resident had a risk assessment completed, This tells the pros and cons and whether it's safe or not;-If a resident or representative insists on having side rails, the facility obtains consent from the resident or representative, and the doctor also signs the consent;-The residents used the side rails for turning over;-The documents are uploaded into the resident's electronic record;-He/she didn't know if the resident has a signed consent or risk versus benefits;-He/she did not find a signed consent. During an interview on 07/24/25, at 3:42 P.M., the Assistant Director of Nursing (ADON) said the following:-The prior administration felt all residents should have side rails, and they sent in work orders to have them installed;-They've removed several of the side rails that weren't needed;-Two assessments are completed on the residents, and they're saved in the file under observation. The assessments explain risks versus benefits and the consent;-The consent would need to be signed by the resident or the representative and the doctor;-They don't put the rails on unless the resident or representative is adamant;-The resident is his/her own person, staff should have a signed consent by the resident somewhere;-Maintenance is responsible for doing measurements on the bed and he/she is not sure how often this is done. During an interview on 07/25/25, at 2:00 P.M., the DON said the following:-The side rails have been an ongoing issue;-Prior to the DON coming on board, the prior Registered Nurse (RN) consultant went from resident to resident to add them;-The resident was required to have an assessment completed that's located under the observations;-The assessment had the risk versus benefits and requires the resident or representative's signature and the doctor;-Each resident should have the risk versus benefits and the consent prior to the side rails being installed on the resident's bed;-He/she was not sure if the resident signed a consent or if risk vs. benefits was completed. During an interview on 07/28/25, at 10:12 A.M., the Administrator said the following:-Residents should only be using the side rails for mobility improvements;-The resident should be assessed for other alternatives, and if the side rails are the method used, there should be a consent signed by the resident and/or representative prior to placing the rails on the bed;-Maintenance does the measurements when the rails are installed and checks them monthly or when a new bed or mattress is installed.

Based on observation, interview, and record review, the facility failed to prepare all food in a form designed to meet each resident's needs when staff failed to appropriately prepare thickened liquids to nectar consistency for one resident (Resident #27) in a selected sample of 20 residents. The facility census was 57. Review of the facility's policy titled 'Thickened Liquids, dated 2022, showed the following:-Liquids are categorized as thin - Level 0 (regular), mildly thick - Level 2 (nectar-like), moderately thick-Level 3 (honey-like), and extremely thick - Level 4 (pudding-like) for the purposes of this manual;-If liquids are to be thickened by nursing or dining service staff, proper training on the use of the thickening product and specific product instructions should be conducted by the Dining Services Manager, Speech Language Pathologist, or Registered Dietitian;-Proper preparation of thickened liquids improves acceptance and safety for individuals requiring thickened liquids;-The type of thickener, temperature of the liquid being thickened, and amount of thickening product used in the liquid will affect the rate of thickening;-It is imperative to follow the manufacturer's instructions carefully to understand how much of the thickener product to use, type of missing method necessary, and time required to reach the maximum thickness and desired consistency. Review of the instant food thickener container for mildly thick nectar consistency showed instructions to add one tablespoon to four ounces of liquid (water, clear juices, coffee, tea). Process for several seconds or until the thickener is thoroughly mixed. Allow four minutes to reach desired thickness. 1. Review of Resident #27's face sheet (a quick summary of important information) showed the following:-admission date of 01/31/25;-Diagnoses included dementia and aphasia (a language disorder that affects a person's ability to communicate).Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/30/25, showed the following:-Severe cognitive impairment;-Required set up with eating;-Swallowing loss of liquids and solids from mouth;-Mechanically altered diet.Review of the resident's care plan, revised 07/28/25, showed the following:-The resident had nutritional problems as evidenced by the need for mechanically altered diet;-The resident was on a puree diet with nectar thick liquids as ordered and to receive fortified foods.Review of the resident's May 2025 Physician Order Sheet (POS) showed an order, dated 05/02/25, for nectar-thickened liquids.Review of the resident's progress note dated 05/12/25, at 8:25 A.M., showed the Dietary Manager (DM) documented the resident received a puree texture with nectar thick liquids. Foods were presented in bowls and continued to receive double portions at his/her request. The resident sat on the assistance side of the dining room, and he/she was an aspiration risk. The resident ate large bites at a time and often gets choked on them.Observations on 07/22/25, at 11:56 A.M., showed the following:-The resident sat in his/her wheelchair in the main dining room with two cups. One cup contained a chocolate drink and one contained water (8-ounce cup);-The cup of water had thickener settled 1/4 way down of the cup with no thickener from 1/4 halfway up the cup of the water;-The resident coughed when he/she drank the water and chocolate drink;-The Assistant Director of Nursing (ADON) sat down beside the resident and talked to the resident. The ADON did not stir the water in the resident's cup. The ADON asked the resident if he/she had trouble swallowing. During observations and interview on 07/23/25, at 11:02 A.M., Dietary [NAME] R said the following:-He/she prepared breakfast and lunch in the morning;-He/she prepared a nectar thick liquid for another resident on thickened liquids and said the glass was a six-ounce glass;-He/she poured tea in the glass and added one tablespoon of thickener, stirred it and it dissolved fairly quickly. It did thicken some, but still appeared thin;-He/she said it thickens better in room temperature and lets the liquid sit for a minute;-He/she prepared the resident's water for lunch and prepared it the same way she did the other resident's tea this morning;-He/she placed one tablespoon in the six-ounce glass.(The directions on the container said to use one tablespoon for four ounces of liquid.) Observations on 07/23/25, at approximately 11:35 A.M., showed the following:-The resident sat in his/her wheelchair in the main dining room for lunch;-The resident had cup of water with the top half of the glass clear and the bottom half of the glass with the thickener at the bottom of the glass;-The resident drank the liquid and coughed. During an observation and interview on 07/23/25, at 11:35 A.M., the Speech Therapist (ST) said the following:-The resident's water on his/her table should be stirred;-The resident is not good with swallowing drinks;-The resident was admitted from his/her home and started having aspiration signs and symptoms after admission;-The resident was on a regular diet upon admission. He/she downgraded the resident's diet to puree and nectar thickened liquids;-The resident has a six-ounce glass of water on his/her table;-The resident drinks four glasses of those at meals;-Nurses request an evaluation if a resident has issues with swallowing;-The physician gives an order for a swallowing evaluation;-Therapy completes the evaluation and gives the recommendations to nursing and dietary staff for puree or thickened liquids;-Nurses document the orders in the computer;-He/she educates the aides for nectar thickened liquids or if the resident needs cues to slow the rate of eating or drinking;-The registered dietician and he/she monitors the resident;-Nectar is consistent of tomato juice, syrup. (like the syrup in can goods);-Nectar thick liquids should drip off a spoon;-If nectar thick liquids sit in the refrigerator, staff should stir it;-Staff should follow directions on the container to prepare the thickened liquids for a six-ounce glass of water;-Dietary staff prepares the drinks for the aides;-The aides prepare thickened liquids if the resident requests more to drink. Review on 07/24/25, at 10:03 A.M., showed the resident's current nutritional diet card showed for staff to provide the resident with nectar thick liquids. During an interview on 07/23/25, at 12:12 P.M., the DM said the following:-The facility had two residents on thickened liquids;-The dietary staff prepared the thickened liquids;-The dietary staff usually prepare the liquids at least two hours before each meal so they can refrigerate and get to the proper temperature;-The registered dietician, speech therapist, and herself trains the dietary staff on preparing thickened liquids;-Staff should follow the instructions on the thickener can;-The water, tea, and chocolate milk glasses are all eight-ounce cups;-For every four ounces of water, juice, or tea, it is one tablespoon of thickener per four ounces;-Staff should use two tablespoons of thickener for eight ounces of water for nectar thick liquids;-Staff should shake the thickened liquids before serving the resident because it can settle.During an interview on 07/28/25, at 10:00A.M., the Registered Dietician said the following:-She expected staff to follow directions on preparing thickened liquids, but it also depends on if the thickener was a gel or powder;-The directions are a guide and staff should use their own judgment;-The thickener depends on the temperature and the amount of acidity will make a difference with the thickening;-She expects staff to stir the thickened liquid if it settles. During an interview on 07/23/25, at 12:45 P.M., the ADON said the following:-Kitchen staff are responsible for making the thickened liquids for residents;-Staff should stir the liquids if the thickener settles to the bottom of the glass;-He/she thought the resident's water looked too thin since it ran too fast off the spoon;-The nectar thick liquids appeared too runny today for the resident, if it's runny, staff should inform the dietary manager. During an interview on 07/24/25, at 9:32 A.M., Certified Medication Technician (CMT) K said the following:-The resident eats too fast and staff have to remind him/her to slow down. The resident chokes on his/her drinks and puree at times;-He/she did not know if the resident was at high risk for aspiration;-Speech therapy staff evaluates residents to determine if they need thick liquids or dietary modifications;-Dietary staff or aides can make the thickened liquids;-Staff should follow the directions are on top of the canister for how many tablespoons per ounce to make thick liquids;-Nectar thick should be the consistency of pudding;-Residents have colored diet cards for their diet. An orange diet card is for a resident for puree;-Staff should stir liquids if the thickener settles on the bottom of the glass. During an interview on 07/24/25, at 9:50 A.M., Certified Nurse Aide (CNA) T said the following:-The resident had issues with choking, it worried him/her when he/she drank liquids;-Staff remind the resident to slow down with eating and drinking;-The resident's thickened liquids should be the correct consistency;-Staff should follow directions with preparing the thickened liquids for residents. During an interview on 07/23/25, at 12:40 P.M., CNA S said the following:-Nurses inform them of residents on thickened liquids;-Dietary staff prepare the thickened liquids for residents;-Staff should put two tablespoons in eight ounces of water;-Staff inform the kitchen staff if the nectar thick liquids did not look correct;-Staff should stir the liquids if the thickener settles to the bottom of the glass. During an interview on 07/24/25, at 4:04 P.M., the Director of Nursing (DON) said the following:-The resident was at high risk for aspiration;-The resident shoves food in his/her mouth and drinks liquids fast and did not care if he/she choked or not and could aspirate;-Staff should follow the directions on the container to prepare the thickened liquids;-Staff should stir the liquids if the thickener settles to the bottom of the glass. During an interview on 07/28/25, at 09:20 A.M., the Administrator said staff should follow the directions on the package to prepare a glass of thickened liquids and should stir the thickened liquids if it settles in the glass.

Based on interview, observation, and record review, the facility failed to maintain a complete call light system accessible to all residents when staff failed to consistently place the call light within the reach of one resident (Resident #8). The facility census was 57.Review of the facility policy titled Answering the Call Light, dated October 2010, showed the following:-The purpose of the procedure was to respond to the resident requests and needs;-Be sure the call light is plugged in at all times;-When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident;-Answer the resident's call as soon as possible. 1. Review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 06/06/25;-Diagnoses included cerebral infarction (sudden loss of brain function that occurs when blood flow to the brain is interrupted), hemiplegia (paralysis of one side of the body) of right side, muscle weakness, and aphasia (language disorder that affects a person's ability to communicate). Review of the resident's care plan, revised on 06/19/25, showed the following:-Resident had impaired function and required staff assistance with self-care and mobility;-Resident was at risk for falls related to unsteady balance and a history of falls;-Staff to keep frequently used items within reach;-Required staff assistance for ambulation, bathing, bed mobility, dressing, grooming,hygiene, locomotion, toileting, and transfers;-Staff to keep call light within reach. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/06/25, showed the following:-Severe cognitive impairment;-Dependent on staff for transfers, mobility, dressing, and showering. Observation on 07/21/25, at 10:03 A.M., showed the resident resting in bed with the call light clipped to a curtain and out of reach of the resident.Observation on 07/23/25, at 12:45 P.M. showed the resident awake and sitting in a chair watching television. He/she held the television remote in his/her left hand and was pressing buttons to forward the playing television show. The call light was observed placed over the bedside table which was behind the resident out of reach.Observation on 07/24/25, at 2:51 P.M. showed the resident sitting in a chair with the call light resting on top of the chair out of the resident's reach.Observation on 07/25/25, at 9:28 A.M. showed the resident resting in bed with the call light draped over the head of the bed out of the resident's reach. During an interview on 07/28/25, at 11:09 A.M., the Certified Nurse Assistant (CNA) N said call lights should be within easy access to the resident. A call light should not be clipped to a curtain because the resident would be unable to reach it. The resident can use one of his/her hands. The resident should be able to use a call light if he/she is able to use a television remote. The resident had been known to yell out if help was needed.During an interview on 07/25/25, at 10:00 A.M., Certified Medication Technician (CMT) L said call lights should always be within reach of the resident. Call lights should not be clipped to a curtain. The resident could use a call light and should have one. During an interview 07/28/25, at 9:57 A.M., Licensed Practical Nurse (LPN) J said call lights should be within the resident's reach. Call lights should not be clipped to a curtain. The resident should be able to use a call light if he/she is able to use a television remote.During an interview on 07/28/25, at 10:08 A.M., CNA M said call lights should be within reach. Aides will clip the call light to a pillow or on a bed rail to allow residents easy access. The resident had occasionally used the call light. Staff should not clip a resident's call light to a curtain or out of reach.During an interview on 07/28/25, at 11:46 A.M., the Assistant Director of Nursing (ADON) said call lights should be within resident reach. Call lights should not be clipped to a curtain. The resident can use a call light and should have it placed within reach.During an interview on 07/28/25, at 2:43 P.M., the Director of Nursing (DON) said call lights should be within the reach of residents. Staff should place call lights right on chest where they can be reached. The call light should not be placed on a curtain out of reach. The resident can use a call light.During an interview on 07/28/25, at 2:35 P.M., the Administrator said call lights should be within the resident's reach.

Based on interviews and record review, the facility failed to ensure all residents' families or representatives were notified of all significant changes and potential changes in care when staff did not notify two residents' (Resident #1 and #2) family/representative after a change in condition/allegation of abuse. The facility census was 54. Review showed the facility did not provide a policy regarding notification of resident representatives. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality, and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems as evidenced by his/her impaired hearing. He/she usually understands; -The resident had mood problems; -Staff to establish trusting relationship with resident and encourage resident to verbalize feelings, concerns, fears, and clarify misconceptions; -Staff to notify the physician as needed if mood problems become worse; -Resident at risk for delirium as evidenced by signs and symptoms of inattention and disorganized thinking; -Cognitive loss/dementia as evidence by signs and symptoms of inattention and disorganized thinking. Resident has a diagnosis of dementia. Review of the resident's progress note dated 12/23/24, at 9:10 P.M., showed Registered Nurse (RN) G documented the resident exhibited inappropriate touching of residents of the opposite sex this shift. Staff observed resident putting hands in crotch of pants of another resident. Staff intervened and removed the resident to another table. Staff will continue to monitor. (Staff did not document notification of the resident's family/representative regarding the change of condition/abuse allegation.) 2. Review of the facility's investigation, dated 12/26/24, showed the following: -During the manager's meeting on the morning of 12/26/24, documentation from RN G dated 12/23/24 and timed at 9:10 P.M., was noted by manager and brought to the attention of those present for discussion. The nurse's note in question stated inappropriate touching of other residents this shift. Resident observed putting hands in crotch of another resident (Resident #2). Staff intervened and removed the resident to another table. Staff will continue to monitor; -Interim administrator phoned DHSS office to report the incident; -Neither the interim administrator, or the DON were notified of the incident. (Staff did not document notification of the either residents' family/representative regarding the change of condition/allegation of abuse.) 3. Review of Resident #2's face sheet showed the following: -admitted [DATE], readmitted [DATE]; -Diagnoses included acute kidney failure (kidneys lost their ability to filter waste products from the blood), major depression, dementia, cognitive communication deficit, weakness, and acute respiratory disease (lungs are damaged making it difficult to exchange oxygen). -The resident had durable power of attorney invoked. Review of the resident's medical record showed staff did not notify the durable power of attorney of the change of condition/potential abuse. During interviews on 12/31/24, at 2:45 P.M., and on 01/02/25, at 1:35 P.M., the NOK for the resident said the MDS Coordinator called him/her a day or two before Christmas, about a wound on the resident's heal and also mentioned another resident was following Resident #2 around. Staff did not call the NOK related to the incident that occurred on 12/23/24. 4. During interviews on 12/31/24, at 11:07 A.M., and on 01/02/25, at 10:25 A.M., Licensed Practical Nurse (LPN) B said the family should be notified of the incident on 12/23/24. He/she didn't know if the families were notified of the situation with Resident # 1 and Resident #2. During an interview on 12/31/24, at 11:22 A.M., LPN E said the if the residents are not their own person, or have the capacity to consent, he/she would notify the next of kin or guardian of sexual behavior. He/she doesn't believe Resident #1 understands his/her behavior. During an interview on 01/02/25, at 10:12 A.M., LPN K said when a resident touches another resident's private parts, the residents should be separated and they would do an investigation and families are notified. During an interview on 12/31/24, at 3:11 P.M., RN G said he/she did not notify the resident's (Resident #1 and Resident #2) families of the incident on 12/23/24. During interviews on 12/31/24, at 12:09 P.M., and on 01/02/25, at 11:30 A.M., the Social Services Director said he/she was told in the care plan meeting on 01/02/25, Resident #1's family was notified over the weekend, either 12/28/24 or 12/29/24, of the incident that occurred on 12/23/24. During interviews on 12/31/24, at 11:35 A.M., and on 01/02/25, at 11:33 A.M., the Director of Nursing (DON) said the following he/she did not notify the families of Resident #1 or Resident #2 regarding the incident on 12/23/24. During interviews on 12/31/24, at 12:50 P.M., and on 01/02/25, at 11:37 A.M., the Interim Administrator said the families of the residents should be notified of allegations regarding potential abuse. He/she didn't know if Resident #1's or Resident #2's families had been notified. During interviews on 01/02/25, at 8:55 A.M. and 11:50 A.M., the RN Consultant, Administrator, and DON said the following: -When a resident-to-resident incident occurred, social services, the nurse, DON, or Administrator should notify the families of all residents; -They did not believe the families were notified of the incidents involving Resident #1 and Resident #2. During an interview on 01/02/25, at 10:48 A.M., with the Administrator said the following; -Resident to resident incidents should be reported to the charge nurse and the charge nurse should tell the DON. The nurse should notify the NOK of the incident. MO00247124

Based on interview and record review, the facility staff failed to immediately begin an investigation of possible abuse when staff witnessed one resident (Resident #1) touch another resident (Resident #3) in the groin area. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse; -Sexual abuse is defined as non-consensual contact of any type with a resident; -Staff, with the physician's input as needed, will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Review of the facility's policy titled, Abuse Prevention Program, revised December 2021, showed the following: -Purpose to protect residents from abuse by anyone, including but not necessarily limited to, facility staff, other residents; -Identify and assess all possible incidents of abuse; -Investigate and report any allegations of abuse within timeframes as required by federal requirements; -Protect residents during abuse investigations. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality), and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems due to impaired hearing, He/she usually understands; -The resident had activities of daily living (ADL) functional problems. Balance wasn't always steady, but he/she was able to stabilize without staff assistance; -Resident had mood problems; -Staff to establish trusting relationship with resident. Staff to encourage resident to verbalize feelings, concerns, fears and clarify misconceptions; -Resident at risk for delirium; -Resident had cognitive loss/dementia. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure, major depressive disorder, chronic pain, dementia, cognitive communication, and deficit. Review of the resident's care plan, last revised on 10/28/24, showed the following: -Resident was at risk for delirium; -Resident had mood problems; -Resident had ADL functional problems; -Resident at risk for remembering past trauma events. 3. During interviews on 12/31/24, at 3:39 P.M., and 01/02/24, at 10:57 A.M., the Activities Assistant said the following: -He/she was not completely certain of the date, but believed it was 12/11/24, or one day close to this date; -He/she was close the Administrator's door, in the common area, writing down the names of residents participating in the activity; -He/she heard another resident yell at Resident #1, that's not your spouse. When he/she looked at Resident #1, the resident had his/her hand on Resident #3's groin, and the resident had laid his/her head in Resident #3's lap; -He/she told Resident #1 that Resident #3 was not his/her spouse and Resident #1 said it was his/her spouse; -He/she moved Resident #1 close to the nurses' station and the MDS Coordinator asked why the Activities Assistant brought Resident #1 to the nurses' station. He/she told the MDS Coordinator what happened; -The Activities Assistant and MDS Coordinator went to the RN Consultant and told the RN Consultant what happened between Resident #1 and Resident #3. 4. Review of Resident #1 and Resident #3's records showed staff did not document investigating the allegation of possible abuse. Review of DHSS records showed the facility did not provide an written investigation of the allegation of possible abuse. 5. During an interview on 12/31/24, at 11:13 A.M., Nurse Aide (NA) C said the following: -If he/she sees a resident touch another resident's private parts, he/she would separate the two residents and tell his/her charge nurse; -If a resident touches another resident's private area this would be considered abuse. During an interview on 12/31/24, at 11:01 A.M., Certified Nurse's Aide (CNA) A said the following: -If he/she witnessed a resident putting their hands on another resident's private area, he/she would separate the residents and tell his/her charge nurse; -If a resident puts their hand on another resident's private area, this could be abuse. During interviews on 12/31/24, at 11:07 A.M., and on 01/02/25, at 10:25 A.M., Licensed Practical Nurse (LPN) B said the following: -If he/she saw a resident put their hands on another resident's private parts, he/she would separate the residents and if the residents don't understand their actions, or if its not mutual, the incident should be reported to the supervisor; -The facility does an investigation on allegations of abuse. He/she believes the Director of Nursing (DON) or Administrator completes the investigation. During an interview on 12/31/24, at 11:22 A.M., LPN E said if he/she sees a resident touch another resident's private parts, he/she would separate the two residents and notify the DON, ensure the Administrator knows as well and they do an investigation. During interviews on 12/31/24, at 11:35 A.M., and on 01/02/25, at 11:33 A.M., the DON said the following: -If staff see a resident touching another resident in their private area, the staff should separate and notify the DON and the Administrator immediately; -Investigations are completed on allegations of abuse. He/she was not aware of the incident between Resident #1 and Resident #3 and an investigation was not completed. During interviews on 12/31/24, at 12:09 P.M., and on 01/02/25, at 11:30 A.M., Social Services Director said the following: -If a resident touched another resident's body parts, he/she would separate the residents and notify his/her supervisor; -The facility does investigate allegations of abuse. He/she has assisted in these in the past but usually doesn't anymore. During interviews on 01/02/25, at 10:17 A.M., and on 01/03/25, at 10:45 A.M., with the MDS Coordinator said the following; -In resident to resident incidents, with inappropriate touching, he/she would separate the residents, notify the DON, and there would be an investigation completed; -He/she is not aware of an incident between Resident #1 and Resident #3. During interviews on 12/31/24, at 12:50 P.M., and on 01/02/25, at 11:37 A.M., the Interim Administrator said the following: -He/she expected staff to intervene if a resident was touching another resident inappropriately; -He/she expected staff to investigate incidents of abuse; -He/she was not aware of the incident between Resident #1 and Resident #3 until today; -He/she was not aware Resident #1 touched Resident #3's groin. This incident should've been reported to the charge nurse, DON, and/or Administrator, and an investigation completed. During an interview on 01/02/25, at 10:48 A.M., the Administrator said resident to resident incidents should be reported to the charge nurse. The charge nurse should tell the DON, and the DON should begin the investigation. MO00247124

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegation of sexual abuse involving three residents (Resident #1, #2, and #3) to management and DHSS in a timely fashion. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Sexual abuse is the non-consensual contact of any type with a resident. Review of the facility's policy titled, Abuse Prevention Program, revised December 2021, showed the following: -Purpose to protect residents from abuse by anyone, including but not necessarily limited to, facility staff, other residents; - Investigate and report any allegations of abuse within timeframes as required by federal requirements. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality), and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -He/she had communication problems as evidenced by his/her impaired hearing, He/she usually understands; -He/she had activities of daily living (ADL) functional problems as evidenced by the need for staff assistance with ADLs. Resident balance wasn't always steady, but he/she was able to stabilize without staff assistance; -He/she had mood problems; -Staff to establish trusting relationship with resident. Staff to encourage resident to verbalize feelings, concerns, fears, and clarify misconceptions; -Staff to notify the physician as needed if mood problems become worse; -Resident at risk for delirium as evidenced by signs and symptoms of inattention and disorganized thinking; -Resident had cognitive loss/dementia. Review of the resident's progress note dated 12/23/24, at 9:10 P.M., showed Registered Nurse (RN) G documented inappropriate touching of other residents this shift. Resident observed putting hands in crotch of pants of another resident. Staff intervened and removed him/her to another table. Staff will continue to monitor. (The RN did not document notification of facility administration or DHSS of the allegation of abuse.) 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure (kidneys lost their ability to filter waste products from the blood), major depression, dementia, cognitive communication deficit, weakness, and acute respiratory disease (lungs are damaged making it difficult to exchange oxygen). Review of the resident's care plan, last revised on 11/22/24, showed the following: -He/she did not always remember he/she was in the nurse facility; -He/she has cognitive loss/dementia; -At risk for psychosocial well being problems as evidenced by previously admitting that he/she had little interest of pleasure in doing things. Review of the resident's medical record showed staff did not document regarding the incident with Resident #1 on 12/23/24, or notification of manage or DHSS of the incident. 3. Review of the facility's investigation, dated 12/26/24, showed the following: -During the managers' meeting on the morning of 12/26/24, documentation from RN G, dated 12/23/24 and timed at 9:10 P.M., was noted by manager and brought to the attention of those present for discussion. The nurse's note in question stated inappropriate touching of other residents this shift. Resident observed putting hands in crotch of another resident. Staff intervened and removed Resident #1 to another table and staff will continue to monitor; -Interim Administrator phoned DHSS office to report the incident; -Neither the Interim Administrator, or the Direct of Nursing (DON) were notified of the incident. 4. Review of DHSS records showed the facility self-reported the allegation of possible abuse between Resident #1 and Resident #2 on 12/26/24, at 2:58 P.M. (three days after staff became aware of the allegation of possible abuse). 5. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure, major depressive disorder, chronic pain, dementia, and cognitive communication deficit. Review of the resident's care plan, last revised on 10/28/24, showed the following: -Resident at risk for delirium as evidenced by his/her inattention, disorganized thinking; -Resident had mood problems and diagnosis of major depressive disorder; -Resident had ADL functional problems as evidenced by the need for staff to assist with ADLs; -At risk for remembering past trauma events; -Resident at risk for psychosocial well being problems as evidenced by previously admitting that he/she has little interest of pleasure in doing things. During interviews on 12/31/24, at 3:39 P.M., and on 01/02/24, at 10:57 A.M., the Activities Assistant said the following: -He/she was not completely certain of the date, but believes it was 12/11/24, or one day close to this date; -He/she was close the Administrator's door in the common area writing down the names of residents participating in the activity; -He/she heard another resident yell at Resident #1, that's not your spouse. When he/she looked at Resident #1, the resident had his/her hand on Resident #3's groin, and the resident had laid his/her head in Resident #3's lap; -He/she told Resident #1 that Resident #3 was not his/her spouse and Resident #1 said it was his/her spouse; -He/she moved Resident #1 close to the nurses' station and the MDS Coordinator asked why the Activities Assistant brought Resident #1 to the nurses' station. He/she told the MDS Coordinator what happened; -The Activities Assistant and the MDS Coordinator went to the RN Consultant and told the RN Consultant what happened between Resident #1 and Resident #3; -He/she considered inappropriate touching possible abuse and he/she was supposed to report this to the charge nurse and it's then reported to the state within 24 hours. Review of Resident #3's medical record showed no documentation of the incident with Resident #1. Review of DHSS records showed the home did not self-report the allegation of possible abuse between Resident #1 and Resident #3. 6. During an interview on 12/31/24, at 11:13 A.M., Nurse Aide (NA) C said the following: -If he/she saw a resident touch another resident's private parts, he/she would separate the two residents and tell his/her charge nurse; -If a resident touches another resident's private area this would be considered abuse and it should be reported within two hours to the state. During an interview on 12/31/24, at 11:01 A.M., Certified Nurse's Aide (CNA) A said the following: -If he/she witnessed a resident putting their hands on another resident's private area, he/she would separate the residents and tell his/her charge nurse; -If a resident puts their hand on another resident's private area, this could be abuse and should be reported to the state within two hours. During an interview on 12/31/24, at 11:19 A.M., CNA D said if he/she saw a resident touching another resident's private area, and it's unwanted, he/she would separate the residents and report it to the charge nurse. He/she would write out a statement and ensure it's reported to the state in less than two hours. During an interview on 12/31/24, at 3:24 P.M., CNA I said the following: -On 12/23/24, around 4:30 P.M. or 4:45 P.M., Resident # 1 and Resident #2 were both in the common area close to the time for the staff to begin bringing the residents into the dining room to eat dinner; -He/she walked into the common area and saw Resident #1 leaning forward in in his/her wheelchair, and Resident #1's hand was on Resident #2's inner left thigh with the fingertips touching Resident #2's groin; -He/she separated the two residents; -He/she said two other residents had told another aide that Resident #1 had Resident #2's jogging pants at the top stretched out, and was reaching into Resident #2's pants; -He/she reported the incident to RN G; -He/she was told by Activities Assistant that Resident #1 had inappropriate behaviors with two other residents, one of which was Resident #3; -He/she would consider this potential abuse, that should be investigated and reported to the state within two hours. He/she doesn't believe it was reported to the state. During an interview on 01/02/25, at 10:08 A.M., CNA J said the following; -If He/she saw a resident touching another resident's private area, he/she would separate the residents and notify the charge nurse; -Depending on the situation, if the residents are able to consent or not, would determine if it's abuse and needs to be reported to the state in two hours. During interviews on 12/31/24, at 11:07 A.M., and on 01/02/25, at 10:25 A.M., Licensed Practical Nurse (LPN) B said the following: -If he/she saw a resident put their hands on another resident's private parts, he/she would separate the residents and if the residents don't understand their actions, or if its not mutual, the incident should be reported to the supervisor and it should be reported to the state within 2 hours. During an interview on 12/31/24, at 11:22 A.M., LPN E said the following: -If he/she saw a resident touch another resident's private parts, he/she would separate the two residents and notify the DON and ensure the Administrator knew as well; -If the resident's can't consent, it could be abuse and should be reported to the state within two hours. During an interview on 01/02/25, at 10:12 A.M., LPN K said when a resident is touching another resident's private parts, the residents should be separated and the State is notified within two hours. During an interview on 12/31/24, at 3:11 P.M., RN G said the following: -He/she said an aide, he/she is not certain which aide, said Resident #1 was acting up again. The resident grabbed another resident's crotch; -He/she didn't know whose crotch Resident #1 grabbed; -He/she did not notify the DON, Administrator, or the resident's families; -He/she knows that in these types of situations it would be considered abuse and he/she should've called the DON and the Administrator; -He/she knew the state was supposed to be notified of abuse within two hours. During interviews on 12/31/24, at 12:09 P.M., and on 01/02/25, at 11:30 A.M., the Social Services Director (SSD) said the following: -If a resident was touching another resident's body parts, he/she would separate the residents and notify his/her supervisor; -He/she knew an allegation of abuse should be reported in two days. During interviews on 01/02/25, at 10:17 A.M., and on 01/03/25, the MDS Coordinator, said the following; -In resident to resident incidents, with inappropriate touching, he/she would separate the residents, notify the DON and there would be an investigation completed; -The State was notified in two hours. During interviews on 12/31/24, at 11:35 A.M., and on 01/02/25, at 11:33 A.M., the DON said the following: -If staff see a resident touching another resident in their private area, the staff should separate and notify the DON and the Administrator immediately; -He/she didn't find out until 12/26/24 when it was read in Resident #1's medical record that Resident #1 touched Resident #2 inappropriately; -He/she knows these incidents are supposed to be reported to the state within two hours and this incident was not reported within two hours; -He/she would have expected RN G to notify him/her and or the Administrator of the incident between Resident #1 and Resident #2. It should have been called into the state within two hours. During interviews on 01/02/25, at 8:55 A.M. and 11:50 A.M., the RN Consultant, Administrator and DON said the following; -They were not aware of other incidents with Resident #1 being inappropriate; -An incident with Resident #1 touching Resident #3 in the groin area was not reported to management. During interviews on 12/31/24, at 12:50 P.M., and on 01/02/25, at 11:37 A.M., the Interim Administrator said the following: -He/she expected staff to intervene if a resident was touching another resident inappropriately; -He/she expected staff to investigate the incident and report to the state within two hours; -The incident between Resident #1 and Resident #2 happened on 12/23/24, but he/she wasn't aware until 12/26/24 so it was not reported timely to the state; -He/she was not aware Resident #1 touched Resident #3's groin. This incident should've been reported to the charge nurse, DON, and or Administrator and the state called in two hours. -Resident is touching another resident in the private area He/she would expect staff to separate the two residents, notify the Administrator and DON, and begin and investigation; -The incident was to be reported to the state in two hours of being made aware of the incident; -He/she was not aware of the incident between Resident #1 and Resident #3 until today; -The incident between Resident #1 and Resident #3 should've been reported to the state within two hours of occurrence. During an interview on 01/02/25, at 10:48 A.M., the Administrator said resident to resident incidents should be reported to the charge nurse and the charge nurse should tell the DON, and the DON should begin the investigation. The state should be notified in two hours; MO00247124

Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #1) to include two incidents of the resident touching other residents inappropriately. The facility's census was 54 Review showed the facility did not provide a policy on updating care plans. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality), and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems as evidenced by his/her impaired hearing. He/she usually understands; -The resident had activities of daily living (ADL) functional problems as evidenced by the need for staff assistance with ADLs due to my diagnosis of (nothing added). Balance wasn't always steady, but he/she was able to stabilize without staff assistance; -The resident had mood problems; -Staff to establish trusting relationship with resident and encourage resident to verbalize feelings, concerns, fears, and clarify misconceptions; -Staff to notify the physician as needed if mood problems become worse; -At risk for delirium as evidenced by signs and symptoms of inattention and disorganized thinking;; -Cognitive loss/dementia as evidenced by signs and symptoms of inattention and disorganized thinking. Resident had diagnosis of dementia. Review of the resident's progress note dated 12/23/24, at 9:10 P.M., showed Registered Nurse (RN) G documented the resident exhibited inappropriate touching of residents of the opposite sex this shift. Staff observed resident putting hands in crotch of pants of another resident. Staff intervened and removed him/her to another table. Staff will continue to monitor. Review of the resident's care plan showed staff did not update the care plan following the incident on 12/23/24. During interviews on 12/31/24, at 3:39 P.M., and on 01/02/24, at 10:57 A.M., the Activities Assistant said the following: -He/she was not completely certain of the date, but believes it was 12/11/24, or one day close to this date, he/she was close the Administrator's door, in the common area, where he/she was writing down the names of residents participating in the activity. He/she heard another resident yell at Resident #1, that's not your spouse. When he/she looked at Resident #1, the resident had his/her hand on Resident #3's groin, and the resident had laid his/her head in Resident #3's lap; -He/she told Resident #1 that Resident #3 was not his/her spouse and he/she moved Resident #1 away from Resident #3; -He/she moved Resident #1 close to the nurses' station and told the MDS Coordinator what just happened; -The Activities Assistant and the MDS Coordinator went to the RN Consultant and told the RN Consultant what happened between Resident #1 and Resident #3. Review of the resident's care plan showed staff did not update the care plan after the incident between Resident #1 and #3. During an interview on 12/31/24, at 11:13 A.M., Nurse Aide (NA) C said he/she has seen Resident #1 rub Resident #2's arm. During interviews on 12/31/24, at 11:07 A.M., and on 01/02/25, at 10:25 A.M., Licensed Practical Nurse (LPN) B said the following: -He/she has seen Resident #1 and Resident # 2 sitting by each other and Resident #1 will pat Resident #2 on the shoulder; -If he/she sees a resident put their hands on another resident's private parts, he/she would separate the residents; -If a resident has sexually inappropriate behavior it should be documented somewhere. The MDS Coordinator does the care plans and he/she would also add that to the care plan; -The MDS Coordinator would learn of changes in resident's behaviors by looking at the charting and attending daily meetings. During an interview on 12/31/24, at 3:11 P.M., RN G said he/she was not aware of Resident #1 having inappropriate touching in the past (prior to 12/23/24). During an interview on 12/31/24, at 3:19 P.M., CNA H said the following: -He/she has witnessed Resident #1 holding Resident #2's hands in the lobby area the day of 12/23/24; -He/she was on his/her way into the dining room when the incident occurred; -CNA I witnessed the incident between Resident #1 and Resident #2; -CNA I said Resident #1's hand was going towards Resident #2's crotch area. During an interview on 12/31/24, at 3:24 P.M., CNA I said the following: -On 12/23/24, around 4:30 P.M. or 4:45 P.M., Resident # 1 and Resident #2 were both in the common area close to the time for the staff to begin bringing the residents into the dining room to eat dinner; -He/she walked into the common area and saw Resident #1 leaning forward in his/her wheelchair, and Resident #1's hand was on Resident #2's inner left thigh and Resident #1's fingertips were on Resident #2's groin. He/she separated the two residents; -He/she said two other residents had told another aide that Resident #1 had Resident #2's jogging pants at the top pulled out and was reaching into Resident #2's pants; -He/she was told by Activities Assistant that Resident #1 had inappropriate behaviors with two other residents. During an interview on 01/02/25, at 10:08 A.M., CNA J said he/she had access to resident's care plans and inappropriate behavior would be put in there by the nurses. During an interview on 01/02/25, at 10:12 A.M., LPN K said resident behaviors are in the care plans. The MDS Coordinator puts information into the care plans but he/she didn't know how the MDS Coordinator would receive information about residents when they have a change in behavior. During interviews on 12/31/24, at 12:09 P.M., and on 01/02/25, at 11:30 A.M., Social Services Director said if a resident had inappropriate behaviors, it would be care planned. They go over residents with changes during morning meetings and the interdisciplinary meetings that are held weekly. If a resident is having sexually inappropriate behaviors it should be on the care plan. The MDS coordinator is responsible for updating the care plans as needed. During interviews on 01/02/25, at 10:17 A.M., and on 01/03/25, the MDS Coordinator said the following; -He/she is in charge of updating the resident's care plans; -He/she attends the morning stand up meetings held Monday through Friday, as well as PAR (Patients at Risk) and IDT meetings to obtain information about changes on residents that needs to be added to the care plan; -Last week, he/she saw the note in Resident #1's medical record, and during a stand up, stating the inappropriate behavior with another resident; -The behavior probably should be put in the care plan, along with interventions; -He/she is responsible for updating the care plans and he/she did not update Resident #1's care plan to reflect the changed behavior. During interviews on 12/31/24, at 11:35 A.M., and on 01/02/25, at 11:33 A.M., the Director of Nursing (DON) said the following: -He/she was not aware Resident #1 having inappropriate behaviors prior to the incident on 12/23/24; -The MDS Coordinator was responsible for updating the care plans when there are changes in resident's behaviors; -Inappropriately touching another resident, would be a behavior that should be in the care plan; -The MDS Coordinator attends the PAR and IDT meetings, as well as stand up; -The MDS Coordinator was made aware of the inappropriate behaviors of Resident #1 on 12/26/24; -The care plan should have been updated. During interviews on 12/31/24, at 12:50 P.M., and on 01/02/25, at 11:37 A.M., with the Interim Administrator, said the following; -He/she said the incident with Resident #1 and Resident #2 occurred around dinnertime on 12/23/24, but He/she was not made aware until 12/26/24; -He/she was not aware of the incident between Resident #1 and Resident #3, until today; -The MDS Coordinator is responsible updating the resident's care plans; -The MDS Coordinator is aware of resident changes by reading the documentation, and there should be communication between staff on changes in resident behaviors; -The MDS Coordinator also attends PAR meetings weekly; -The MDS Coordinator was made aware of the incident on 12/26/24 and was told to update the care plan to reflect the incident between Resident #1 and Resident #2. During an interview on 01/02/25, at 10:48 A.M., with the Administrator, said the following; -Sexually inappropriate behaviors would be discussed at the PAR meetings and the IDT; -The MDS Coordinator is involved in the PAR meetings and is responsible of updating the care plan when residents have changes in behavior; -He/she is not sure if Resident #1's care plan has been updated, but it should have been. MO00247124

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, follow-up on effectiveness of pain medication, failed to try additional steps when pain was not relieved, and failed to notify the physician of the pain, ineffectiveness of the current pain medication regimen, and when an order for a new pain medication was not received from the pharmacy for one resident (Resident #1) in a review of four sampled residents. The facility census was 52. Review of the facility's policy titled 'Pain Assessment and Management, revised March 2015, showed the following: -The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -Pain management is multidisciplinary care process that includes the following: assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of intervention, and modifying approaches as necessary; -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -Document the resident's reported level of pain with adequate detail (enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program; -Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record; -Report the following information to the physician or practitioner: significant changes in the level of the resident's pain, adverse effects from pain medications and prolonged, unrelieved pain despite care plan interventions. 1. Review of Resident #1''s face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included cognitive communication deficit, rheumatoid arthritis (a chronic autoimmune disease that causes inflammation in the joints, resulting in pain, swelling, stiffness, and loss of function), osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), and chronic pain syndrome. Review of the resident's care plan, initiated 03/16/23, showed the following: -The resident has activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) functional problems as evidenced by the need for staff assistance with his/her ADLs due to diagnosis of arthritis. -The resident's balance is not always steady and the resident is only able to stabilize with staff assistance. -The resident required extensive assistance for ambulation, bathing, mobility, dressing, grooming, hygiene, locomotion, toileting and transfers. -Remind the resident to not transfer without assistance. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/16/24, showed the following information: -Moderately impaired cognitive skills; -No impairment to upper and lower extremities; -Supervision required with toileting hygiene and showers; -Pain with pain intensity of 5 on a 1 to 10 pain scale. Review of the resident's October 2024 Physician Order Sheet (POS) showed the following: -An order, dated 03/08/23, for staff to ask the resident every shift if if he/she has any pain and document the pain number on a pain scale of 0 to 10; -An order, dated 03/08/23, for acetaminophen suppository 650 milligrams (mg) rectal every four hours as needed (PRN) for general discomfort, restlessness, or temperature above 100.5 degrees Fahrenheit (F). Do not exceed 3,000 mg acetaminophen per 24 hours for chronic pain syndrome; -An order, dated 03/08/23, for acetaminophen tablet 325 mg two tablets oral every four hours PRN for general discomfort, restlessness, or temperature above 100.5 degrees F. Do not exceed 3,000 mg acetaminophen per 24 hours for chronic pain syndrome; -An order, dated 11/02/23, for fentanyl patch (medication used to treat severe pain) 25 micrograms (mcg) transdermal (application of a medicine through the skin) once a day every three days for chronic pain syndrome; -An order, dated 11/03/23, for staff to apply Hempvana (a brand of pain relief creams and posture correctors that use hemp seed oil and other ingredients to provide temporary relief from pain and other issues) cream two times per day (BID) to effected areas (hands and/or knees and or back and or shoulders); -An order, dated 05/17/24, for acetaminophen over the counter (OTC) 325 mg two tablets oral once a day. Do not exceed 3,000 mg acetaminophen per 24 hours for chronic pain; -An order, dated 09/18/24, for duloxetine capsule (can be used to treat osteoarthritis pain) delayed release 40 mg oral once a day. Review of the facility's communication form for the physician to review upon visit, dated 10/28/24, showed Registered Nurse (RN) A documented the resident had increased pain in his/her legs/knees and was unable to transfer for four days related to pain. The resident stated he/she twisted it (right knee). Review of the resident's medical record showed staff did not document related to the resident's increased pain or inability to transfer himself/herself the prior four days (10/23/24 to 10/27/24). Review of the resident's October 2024 Medication Administration Record (MAR) showed the following: -On 10/28/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 3 on a pain scale of 0 to 10. -On 10/28/24, on the 6:00 A.M. to 4:00 P.M. shift, staff documented administration of the Hempvana to the resident's right knee. (Staff did not document follow-up on the resident's pain and effectiveness of the pain medications.) -On 10/28/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 10/28/24 on the 4:00 P.M. to 10:00 P.M. shift, staff documented administration of the Hempvana to the resident's right knee; -On 10/28/24 on the 7:00 P.M. to 10:00 P.M. shift, staff documented administration of the acetaminophen; -On 10/28/24, on the 10:00 P.M. to 6:00 A.M. shift, staff documented the resident had pain level of a 10 on a pain scale of 0-10. Staff documented PRN medication given and cream. (Staff did not document follow-up on the resident's pain and effectiveness of the pain medications.) Review of the resident's nurse practitioner's (NP) progress note, dated 10/29/24, showed the NP saw the resident for leg pain at the request of the nursing staff. The resident did not have injuries or falls. The resident had issues with chronic pain. The NP assessed for full range of motion to all extremities. The resident used a wheelchair. The resident had significant arthritic changes in all joints. All of the resident's joints painful with decreased range of motion. The resident was alert and oriented with cognitive deficits noted. Staff to increase duloxetine to 60 milligrams (mg) and trial Lyrica (a controlled substance that can be used to treat pain) as well. The resident also had a fentanyl patch. NP reviewed the resident's medications, progress notes, and treatment plan. Review of the resident's October 2024 MAR showed the following: -On 10/29/24, at 4:10 A.M., staff administered acetaminophen 325 mg two tablets as needed medication for right knee pain. Staff documented on 10/29/24 at 8:40 A.M. somewhat effective results. (Staff did not document additional steps taken to address continued pain.) -On 10/29/24, on the 6:00 A.M. to 02:00 P.M. shift, staff documented the resident had pain level of a 8 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) -On 10/29/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 5 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) -On 10/29/24, at 6:44 P.M., staff documented did not administer as other/not completed of the Hempvana. -On 10/29/24, on the 7:00 P.M. to 10:00 P.M. shift, staff administered the acetaminophen 325 mg two tablets. (Staff did not document follow-up on the resident's pain and effectiveness of the pain medications.) -On 10/29/24, on the 10:00 P.M. to 06:00 A.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10. Review of the resident's medical record showed staff did not document notification of the resident's physician or NP of the increased pain. Review of the resident's progress note dated 10/30/24, at 3:08 A.M., showed RN A documented new orders to increase duloxetine back to 60 mg and to start Lyrica 50 mg three times per day for chronic pain. The resident's right knee was swollen, red, and warm to touch. The resident required two staff for assistance at this time. Review of the resident's October 2024 POS showed the following: -An order, dated 10/30/24 for duloxetine capsule delayed release 40 mg; amt: 60 mg oral once a day; -An order, dated 10/30/24, for Lyrica capsule 50 mg oral three time a day. Review of the resident's October 2024 MAR showed the following: -On 10/30/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 10/30/24, on the 6:00 A.M. to 4:00 P.M. staff documented administration of the Hempvana to the resident's neck/shoulder; -On 10/30/24, on the 6:00 A.M. to 3:30 P.M. shift, staff administered fentanyl patch to the resident's right upper back; -On 10/30/24 at 8:22 A.M., Certified Medication Technician (CMT) I documented the Lyrica was not administered due to the drug/item unavailable; -On 10/30/24, at 11:40 A.M., CMT I documented the Lyrica not administered due to the drug/item unavailable; -On 10/30/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 6 on a pain scale of 0-10 (Staff did not document follow-up on the resident's pain.); -On 10/30/24, on the 4:00 P.M. to the 10:00 P.M., staff documented administration of the Hempvana to the resident's right knee; -On 10/30/24, on the 7:00 P.M. to 10:00 P.M. shift, staff administered the duloxetine; -On 10/30/24, at 7:05 P.M. CMT J documented the Lyrica not administered due to the drug/item unavailable; -On 10/30/24, on the 07:00 P.M. to 10:00 P.M. shift, staff documented administration of the acetaminophen tablet 325 mg two tablets; -On 10/30/24, on the 10:00 P.M. to 6:00 A.M. shift, staff documented the resident had pain level of a 4 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) Review of the resident's medical record showed staff did not document notifying the physician or NP of the Lyrica not being available. Review of the facility's document titled 'Medication Unavailable, dated 10/30/24, showed the following: -The resident's name; -Date discovered: 10/30/24; -Medication and dose unavailable: Lyrica; -What date was the medication ordered?-left blank; -CMT I signed the form; -To be completed by charge nurses of why was the medication unavailable for administration? Charge nurse did not state the reason, document a signature or date; -Medication has been received and is ready for administration with date and DON signature - not completed. Review of the resident's October 2024 MAR showed the following: -On 10/31/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0 to 10; -On 10/31/24, on the 6:00 A.M. to 4:00 P.M., staff administered the Hempvana cream to the resident's neck and shoulders; -On 10/31/24, at 8:30 A.M., staff administered acetaminophen 325 mg two tablets as needed medication. Staff documented somewhat effective results; -On 10/31/24, at 8:39 A.M., CMT I documented the Lyrica not administered due to the drug/item unavailable; -On 10/31/24, at 11:14 A.M., CMT I documented the Lyrica not administered due to the drug/item unavailable; -On 10/31/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 6 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) -On 10/31/24, on the 4:00 P.M. to 10:00 P.M. shift staff administered the Hempvana cream to the resident's knees; -On 10/31/24, on the 7:00 P.M. to 10:00 P.M., staff documented administration of the acetaminophen tablet 325 mg two tablets; -On 10/31/24, on the 7:00 P.M. to 10:00 P.M., staff administered the duloxetine; -On 10/31/24, on the 10:00 P.M. to 6:00 A.M. shift, staff documented the resident had pain level of a 5 on a pain scale of 0-10 (Staff did not document follow-up on the resident's pain.); -On 10/31/24, at 7:35 P.M. CMT K documented the Lyrica not administered due to the drug/item unavailable. Review of the facility's document titled 'Medication Unavailable, dated 10/31/24, showed the following: -The resident's name; -Date discovered: 10/30/24; -Medication and dose unavailable: Lyrica; -What date was the medication ordered?-left blank; -CMT I signed the form; -To be completed by charge nurses of why is this medication unavailable for administration? Staff marked pharmacy had not delivered; -RN F signed and dated the form; -Medication has been received and is ready for administration with date and DON signature - not completed. Review of the resident's medical record showed staff did not document notification of the NP or physician of the resident's increased pain and the Lyrica not received from the pharmacy. Review of the resident's November 2024 MAR showed the following: -On 11/01/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 11/01/24, on the 6:00 A.M. to 4:00 P.M. shift, staff administered Hempvana cream to the resident's neck and shoulders; -On 11/01/24, at 9:55 A.M., showed staff administered acetaminophen for general discomfort and documented the medication was effective; -On 11/01/24, on the 4:00 P.M. to 10:00 P.M shift, staff administered Hempvana cream to the resident's left knee; -On 11/01/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 11/01/24, on the 10:00 P.M. to 6:00 A.M. shift, staff documented the resident had pain level of a 9 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.); -On 11/01/24, at 9:48 A.M., staff documented Lyrica was not administered due to the medication was unavailable; -On 11/01/24, at 11:49 A.M., staff documented Lyrica was not administered due to the medication was unavailable; -On 11/01/24, at 9:51 P.M., staff documented Lyrica was not administered due to the medication was unavailable. Review of the resident's progress note dated 11/01/24, at 3:29 P.M. (recorded as a late entry on 11/03/24 at 1:42 P.M.), showed Licensed Practical Nurse (LPN) D documented the resident continued to complain of right knee pain. The resident's right knee was swollen, slightly red, and warm to touch. The resident required more assistance for ADLs than his/her baseline. The resident's order for Lyrica continued to be unavailable. The resident's doctor was aware. (Staff did not specify if the physician was aware of the increased pain or Lyrica not received. Staff did not document when the physician was made aware.) Review of the resident's November 2024 MAR showed the following: -On 11/02/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 11/02/24, at 7:05 A.M., staff documented Lyrica was not administered due to the medication was unavailable;. -On 11/02/24, at 11:38 A.M., staff documented Lyrica was not administered due to the medication was unavailable;. -On 11/02/24, on the 6:00 A.M. to 3:30 P.M. shift, staff administered a fentanyl patch to the left resident's left shoulder; -On 11/02/24, on the 6:00 A.M. to 4:00 P.M. shift, staff administered Hempvana cream to the resident's knee. -On 11/02/24, on the 4:00 P.M. to 10:00 P.M. shift, staff administered Hempvana cream to the resident's knees; -On 11/02/24, at 9:20 P.M., staff documented Lyrica was not administered due to the medication was unavailable;. -On 11/02/24, on the 2:00 P.M. to 10:00 P.M. shift, staff documented the resident had pain level of a 0 on a pain scale of 0-10; -On 11/02/24, on the 10:00 P.M. to 06:00 A.M. shift, staff documented the resident had pain level of a 4 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) Review of the resident's progress note dated 11/02/24, at 9:05 A.M. (recorded as late entry on 11/03/24 at 12:31 P.M.), showed Registered Nurse (RN) E documented a certified nurse aide called him/her to the resident's room. The resident stated he/she wanted to request a second opinion for his/her knee. The resident stated he/she made more than one request to be seen by his/her doctor for his/her knee pain and swelling. The resident felt his/her knee was not being treated with sufficient urgency. RN E informed the resident that was his/her right to request and receive a second medical opinion and he/she would forward his/her request to the Social Service Director and Director of Nursing (DON) to follow up on. The resident verbalized understanding and appreciation. At this time the resident's knee was swollen as compared to his/her left knee. The resident's right knee was reddened and warm to the touch. The resident screamed in pain from passive range of motion to his/her right leg. A CNA reported the resident was unable to bear weight and his/her ability to participate in transfers had declined this shift. RN E offered the resident hot/cold packs which the resident declined. The resident repositioned and verbalized slight alleviation of pain. (Staff did not document notification of the resident's physician or NP of the resident's increased pain, request for a second opinion, resident response to the range of motion to the right leg, and decline in ADLs.) Review of the resident's progress note dated 11/02/24, at 1:01 P.M. (edited by RN F on 11/02/24 at 01:09 P.M. due to more data available), showed RN F documented staff replaced the resident's fentanyl patch which was currently on his/her left shoulder and verified by two nurses. The resident complained of pain to his/her right knee. The resident's knee was red, warm, and swollen at this time. Today the resident was upset with the current physician and voiced he/she would like a second opinion and would like a physician to see him/her in the building due to he/she did not feel he/she could make it to see a physician in the office. (Staff did not document notification of the resident's physician or NP of the resident's increased pain, request for a second opinion, or resident's concern of inability to go to a physician's office.) Review of the resident's November 2024 MAR showed the following: -On 11/03/24, on the 6:00 A.M. to 2:00 P.M. shift, staff documented the resident had pain level of a 6 on a pain scale of 0-10; -On 11/03/24, on the 6:00 A.M. to 4:00 P.M. shift, staff administered Hempvana cream to the resident's right knee; -On 11/03/24, at 7:41 A.M., staff administered acetaminophen and documented the medication was effective; -On 11/03/24, at 7:41 A.M., staff documented Lyrica was not administered due to the medication was unavailable; -On 11/03/24, at 11:09 A.M., staff documented Lyrica was not administered due to the medication was unavailable; -On 11/03/24, on the 2:00 P.M. to 8:00 P.M. shift, staff documented the resident had pain level of 8 on a pain scale of 0-10. (Staff did not document follow-up on the resident's pain.) Review of the resident's progress note dated 11/03/24, at 10:28 A.M., showed RN E documented the resident's scheduled Lyrica was unavailable. RN E called the pharmacy and left a message and requested a call back to discuss current status. At last known update, the pharmacy waiting for the provider to sign for the controlled medication. (Staff did not document notification of the NP or physician of the resident's Lyrica not received from the pharmacy) Review of the resident's progress note dated 11/03/24, at 12:40 P.M., showed RN E documented a CNA called him/her to the resident's room this morning at the resident's request to speak with a nurse. The resident reported pain to his/her right knee which had increased a lot since yesterday. The resident was tearful and sat in his/her wheelchair and stated he/she just wanted to know what was going on in reference to his/her knee pain. The resident's knee remained hot to touch, reddened, and swollen compared to his/her left knee. The CNA reported the resident was unable to bear weight and this morning required two staff with maximum assistance with a third CNA as standby for safety. RN E left a message with the pharmacy earlier this morning in regard to the Lyrica order. The medication was ordered on 10/29/24, but the pharmacy did not deliver the medication yet. RN E notified the provider and obtained an order to transfer at the resident's request and status as his/her own decision for medical. The resident requested for RN E to call his/her family member and discuss before he/she made a final determination. RN E called the resident's family member with an update and the family member verbalized agreement and insisted the resident needed to be seen if he/she experienced that much pain and unable to transfer. The resident stated he/she was ready. Staff notified the non-emergency transfer and emergency services transferred the resident at 12:17 P.M. Review of the resident's orthopedic consultation dated 11/03/24, at 3:45 P.M., showed the resident presented to the emergency department with complaints of severe knee pain. The resident stated he/she believed the pain started on Monday (10/28/24) and had not gotten better. The resident denied any fall or trauma to his/her knee, though there was some underlying dementia. The resident described the pain as a sharp shooting pain, particularly with movement. Review of the resident's progress note dated 11/03/24, at 4:51 P.M., showed RN E documented he/she received an update from the emergency room . The resident was diagnosed with a fracture of the right patella (a small, plate-shaped bone located in front of the knee joint) and scheduled for surgical repair or soonest or availability. Review of the resident's hospital history and physical dated 11/03/24, at 4:58 P.M., showed the following: -The resident had right knee pain for one week and unable to bear weight. The resident denied a fall. Bruising noted to right side. The resident's right knee was hot, swollen, and reddened. The resident was alert and oriented times three; -The resident had a history of rheumatoid arthritis. The resident noted to have right knee pain and swelling. The resident denied a fall, but is confused. The resident had evidence of falls based on bruising on his/her chest as well as deformed knee and patellar fracture. The resident's knee is painful and difficult to move with some swelling. During an observation and interview on 12/05/24, at 9:12 A.M., the resident lay in bed with his/her eyes open and closed at times during the interview. The resident said he/she did not know what happened to his/her knee it just got that way. He/she may have twisted it. He/she told the nurse it hurt and they looked at it a few times. It was a few days that it hurt and he/she needed help. He/she informed the staff his/her knee was painful and on a scale from one to ten was a nine. He/she told the nurse and aides that his/her knee hurt. During an interview on 12/05/24, at approximately 10:45 A.M., Certified Medication Technician (CMT) G said the following: -The resident required standby by assistance and limited one assistance before his/her fracture. The resident could stand and pivot and sometimes did not ask for help. He/she noticed the resident's right knee was swollen, red and fumigating heat; -He/she informed LPN D who stated the staff were aware and obtained Lyrica for pain; -He/she was unable to pull the Lyrica from the emergency kit and administered Tylenol to the resident; -The resident was very uncomfortable and reported pain to all staff; -The resident was more dependent and more confused; -Staff should review the resident's medications, offer a snack, hydration and report to the nurse if a resident complaints of pain. During an interview on 12/05/24, at 11:00 A.M., CNA H said the following: -He/she did not know the exact date, but heard in shift change report that the resident had a lot of pain in his/her right knee and did not transfer himself/herself. It was a weekend he/she heard about it. -On 11/02/24, the resident was already up in his/her wheelchair and dressed. He/she took the resident to the bathroom after breakfast with a gait belt and two staff. The resident was dead weight and did not bear weight on his/her right side. The resident said it hurt and ow when staff assisted the resident on the toilet and back in his/her chair. -CNA H informed RN E and RN F who assessed the resident. He/she informed the nurse the resident could not stand anymore and the resident did not want to bear weight on that leg. It took him/her another aide and RN E to place the resident in bed. The resident voiced he/she was not able to do on his/her own. -Staff should inform the charge nurse or CMT if a resident complains of pain. During interviews on 12/05/24, at 11:29 A.M., and on 12/06/24, at 8:10 A.M., CNA B said the following: -He/she worked on the floor a few days before the resident's shower on 10/31/24; -The resident's right knee was red, but the resident stood and said it hurt a little bit; -On 10/31/24, he/she gave the resident a shower and the resident could not stand. It took two aides to stand the resident up and one aide pulled the resident's pants down; -The resident's right knee was red and hot to touch. He/she informed the charge nurse; -The charge nurse said the resident saw the physician and staff put the resident back on the physician list; -The nurse said the physician wanted to lay the resident down and rest; -Several days after he/she gave the resident a shower on 10/31/24, the resident's right knee was so red and swollen it was hard to see anything. The resident did not scream out in pain, but could not move his/her right knee and it was difficult to get the resident on the toilet. The resident got more confused; -On 10/31/24, he/she documented the resident's right knee was reddened and hot to touch on the shower sheet; -He/she turned the shower sheet into a nurse who reviewed it; -The nurse said the resident was on the doctor list; -He/she contacted LPN C one day, about the resident's knee and LPN C said the resident was on the doctor list; -On 10/30/24, a day before the resident's 10/31/24 shower, the resident's right knee was red, swollen and hot to touch; -Staff left the resident in bed due to the resident hurt with his/her knee. The resident did not want to get up; -Staff should inform the charge nurse of any signs of pain. During an interview on 12/06/24, at 11:31 A.M., CMT I said the following: -He/she called the pharmacy on the resident's Lyrica. The pharmacy said they needed the doctor to sign the prescription; -He/she did not know if the nurses called the physician to try something different from the Lyrica; -Staff informed the former DON who said the NP looked at the resident's right knee; -Staff asked the nurses about the resident's pain and medication and the nurses said the NP saw the resident. -Staff fill out a form if a medication is unavailable and give to the supervisor or charge nurse; -Staff fill out a medication unavailable form every shift a medication is unavailable. During an interview on 12/06/24 at 11:50 A.M. CMT J said the following: -He/she called the pharmacy twice in a row and was informed a prior authorization was needed. It was an insurance issue; -He/she assisted the resident one evening, (Tuesday or Wednesday 10/29/24 or 10/30/24) in the bathroom and pulled the resident's pants down. The resident's right knee was red and swollen. He/she felt heat on the resident's right knee. He/she asked the resident if he/she had done something to it and the resident said it was just like that; -CMT J informed the nurse who said he/she was aware the the physician saw it the beginning of the week; -Staff complete a form if a medication is unavailable and give to the nurse. During an interview on 12/06/24 at 11:59 P.M. CMT K said the following: -He/she called the pharmacy after 10/30/24 or 10/31/24 who needed a pre authorization. He/she submitted the preauthorization under the physician; -On 11/13/24, the medication was not covered unless approved by insurance. The preauthorization was sent on 10/30/24 or 10/31/24 and was denied on 11/04/24. The form said can request an appeal and the resident was in the hospital at the time and was not sure if he/she would come back to the facility on the Lyrica. The resident returned from he hospital on 11/07/24 and the NP wrote an order to hold the Lyrica on 11/08/24 until it was available from the pharmacy. During interviews on 12/06/24, at 11:50 A.M. and 1:08 P.M., CMT K said the following: -The facility physician was at the facility on 10/28/24 and the NP was at the facility on 10/29/24; -Staff should complete a form if a medication is not available and give to the nurse. The nurse should follow up and then the DON gives to him/her to file in medical record. During interviews on 12/05/24, at 11:49 A.M. and 12:07 P.M., RN F said the following: -On 11/02/24 an aide called him/her to the resident's room. The resident complained of pain. He/she uncovered the resident's leg; -The resident was in bed. The resident's right knee was swollen, red, and tender to touch; -The resident was in his/her bed and stated his/her leg hurt; -The resident did not want his/her right leg moved and barely wanted it touched; -RN E notified the physician; -The resident was up for breakfast and was not tearful. The resident said he/she was in pain; -He/she did not know about the Lyrica or why it was not available; -Staff use a pain scale and if the resident cannot communicate pain, staff assess for facial grimacing and body movement; -Staff should check for scheduled and PRN pain medication; -Staff should call the physician if a resident has pain and obtain an order for a pain medication; -Staff should send the order to the pharmacy which usually is delivered that day or a few hours; -The physician signs the order for narcotics; -The physician signs for Lyrica; -The pharmacy handles the order if it is an insurance issue; -Staff should document in the progress notes when the physician is notified. During interviews on 12/05/24, at 1:32 P.M., and on 12/06/24, at 12:07 P.M., LPN C said the following: -The resident complained of pain to his/her right knee prior to 10/29/24; -He/she did not know when the resident's knee started hurting, but knew it was before 10/29/24 because staff placed the resident on the list for the NP to see; -The resident's Lyrica did not come in due to insurance reasons. -He/she did not receive reports of pain from the other nurses; -He/she did not know if the physician was aware of

Based on observations, interviews and record review the facility failed to ensure that two residents at risk for impaired nutritional status and dependent on staff for all nutrition and hydration received adequate food and or supplementation to maintain their weight and promote healing of open pressure ulcers. The deficient practice effected two of 15 residents selected for review. Resident #3 had unintentional weight loss of 31.5 pounds, representing 20.6% of usual body weight, and Resident #7 had unintentional weight loss of 16 lbs., representing 18.8% of usual body weight. Resident #3 and Resident #7 each had an open pressure ulcer that increased his/her nutrient needs for protein, kilocalorie (kcal) and micronutrients. According to the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcers are defined as: Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. According to the 2016 Becky Dorner Diet and Nutrition Care Manual the Body Mass Index (BMI) is utilized as an indicator of body fatness and/or ideal body weight. Data suggest that a higher BMI range may be protective in older adults and the standards for ideal weight (BMI of 18.5 to 25) may be too restrictive in the elderly. A lower BMI may be considered detrimental to older adults due to association with declining nutrition status, potential pressure ulcers, infection and other complications. A BMI of 19 or less may indicate nutritional depletion, while a BMI of 30 or above indicates obesity. BMI = weight (kg) / height (meters squared). According to an article in the Advances in Skin and Wound Care dated June 2002, titled Estimating Caloric Needs to Promote Wound Healing by Nancy Collins, PHD, RD, LD/N, Patients with wounds have elevated caloric needs. If caloric needs are not met, the patient may lose weight and wound healing may be impaired. 1. Record review of Resident #3's recent five day assessment Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by facility staff, dated 10/06/16, showed the following information: -Severely impaired cognition; -admitted to the facility on [DATE]; -The [DIAGNOSES REDACTED]. -Extensive assistance needed for bed mobility, transfers, dressing, toilet use and hygiene; -Adequate hearing and vision; -Clear speech and usually makes self-understood; -The resident is at risk for developing a pressure ulcer; -The resident did not have unhealed pressure ulcers, stage I or higher at the time of MDS. Review of the resident's care plan, dated 1/4/17, showed the following: -Offer a variety of fluids and encourage the resident to drink; -Encourage food and fluids to the resident; -Ice cream with lunch and supper; -Leave resident sitting at the dining table and make conversation until the certified nursing assistant (CNA) is prepared to take care of her needs immediately; -Give cues and supervision with meals; -Weekly weights; -Hospice; -Give reassurance and TLC; -Praise resident for each attempt at completion of a task. Record review of the resident's most recent comprehensive nutritional assessment dated [DATE] and completed by the facility's consulting registered dietitian (RD), showed the following information. The resident weighed 126 pounds (lbs.); The resident laboratory [MEDICATION NAME] level reflected mild depletion of protein stores; The resident did not have a pressure sore present; The resident's daily estimated energy needs was 1528 to 1728 kcal; The resident's daily estimated protein needs was 68 grams (gm); The RD used the resident's current weight of 126 lbs. and height of 62 inches and calculated the resident's BMI at 23 (an acceptable level); The RD estimated that the meals the facility served to the resident provided approximately 2600 kcal and 98 gm of protein, if the resident ate 100 percent of the meal; The RD wrote the resident had fair ability with both chewing and swallowing; The RD did not observe [MEDICAL CONDITION] (fluid retention that may increase the weight) in the resident; The resident had adequate comprehension and was able to make his/her needs known; The resident was [AGE] years old; The resident had returned to the facility following a hospitalization for aspiration pneumonia; The facility provided a mechanical soft diet with super cereal (a kcal dense food produced by facility dietary staff) at breakfast; a magic cup (a nutrient dense commercially produced food or pudding for the noon and evening meals; Dietary will continue efforts to please and encourage; Medication included 2 cal HN (nutritional supplement that is very dense in both kcal and protein) four ounces twice per day; The RD wrote a goal for the resident to maintain weight and have good meal intake. Record review of residents five day scheduled MDS dated [DATE] showed the resident had an unstageable pressure ulcer having eschar (black, brown, tan tissue that adheres firmly to the wound bed on the ulcer edges) measuring 1.2 centimeters (cm) in length by 1.4 cm in width and 0.0 cm in depth. Record review of the resident's [MEDICATION NAME] lab ([MEDICATION NAME] tests for a liver protein, that aids in assessing the severity of illness resulting from malnutrition), dated 11/3/16 showed the residents [MEDICATION NAME] level at 20 milligrams (mg) per deciliter (dl). the normal range for this laboratory value is between 20 and 40 ml/dL. Record review of the resident's physician order [REDACTED]. Observation on 1/25/17 at 1035 A.M., showed Registered Nurse (RN) E performed a clean dressing change on the resident. The nurse said the wound was not open the last time he/she changed the dressing; the physician would need to be notified. The nurse described the wound as a Stage II pressure area, dark red in color and open. However, he/she also said the wound was tunneling. RN E did not measure the wound. The observed area was open, with full thickness loss of skin, tunneling and with an approximate diameter the size of a nickel and marble-sized depth. Record review of progress notes from the facility's consulting RD, dated 12/29/16, showed the resident's current weight was 106 pounds (lbs.), down from 110 lbs. on 12/21/16 and 115 lbs. on 11/30/16. The RD recommended house shakes twice a day with meals. The dietitian recommended the staff to continue to encourage intake and monitor the resident's weights. Record review of the facility's significant weight loss documentation, presented to the surveyors on 1/24/17, showed the resident had a 7.7 percent weight loss in the last 30 days. Record review of the resident's weekly weights provided by the facility on 1/26/17 at 3:30 P.M., showed on 5/1/16 the resident weighed 133 lbs. On 1/25/17, the resident weighed 101.5 lbs., representing a 20.6 percent decline in the resident's usual body weight. Using the formula the RD used in the above clinical nutritional assessment and identified in the Diet and Nutrition Care Manual, the resident's weight of 101.5 lbs. reflected a BMI of 18.6 that may indicate nutritional depletion for an elderly person. Record review of the resident's daily meal intake provided by the facility on 1/27/17 at 10:20 A.M., showed the following: -From 12/16/17 through 1/26/17 the resident had 120 opportunities for meals (breakfast, lunch, and dinner); -The facility recorded the resident's intake for 24 of the 120 opportunities; -The resident's record showed the resident consumed 0 % five times, 1-25 % 12 times, 26-50 % six times, 76-100 % one time. Observation on 1/24/17 beginning at 11:37 A.M., showed the following: -Four CNAs and two dietary aides were present in the dining room; -12:03 P.M. The resident arrived at the dining room, smiling and talking to other resident's at lunch time; -12:07 P.M. Staff moved the resident to another table, the resident conversed with other residents near him/her; -12:20 P.M. A nurse brought the resident his/her lunch tray and instructed the resident to try and eat it; -12:28 P.M. The dining room staff consisted of one nurse, two kitchen aides (one serving out and one delivering trays to the residents) and two CNAs; -12:40 P.M. The resident had taken two bites of taco meat, consumed half of a piece of cake, and had taken two drinks of coffee, with no assistance from staff. The resident pushed him/herself away from the dining room table and told the restorative aide (RA) that he/she was done eating. The restorative aide did not respond to the resident and did not provide meal assistance; -12:57 P.M. The resident remained in the dining room with no meal assistance provided. Observation beginning on 1/25/17 at 11:20 A.M., showed the following: -The dining room had 21 residents in attendance with two dietary aides and one restorative aide RA C present; -12:25 P.M. Staff brought the resident to the dining room, but did not deliver any food at that time; -12:35 P.M. The resident received his/her lunch. The resident took a bite and spit out his/her food. A dietary aide asked the resident if he/she would like something else, and the resident responded Yes, and smiled at the aide; -12:42 P.M. The dietary aide brought the resident creamed style corn in a bowl, but did not assist the resident with eating his/her meal; -1:00 P.M. The resident ate one bite of corn and one bite of pudding, with no assistance provided by the facility staff. During an interview on 1/25/17 at 12:23 P.M., Dietary Aide G said he/she is the one who tracks the amounts in percentages that the residents eat for their meals. The aide said he/she writes down the percentage and turns it into the nurses. The aide said, I am not good with numbers, but I try my best. During an interview on 1/26/17, at 1:10 P.M., RA C said if a resident needs help with meals, it is in the resident's care plan. The RA said if a resident is just sitting at the table and not eating, they are offered assistance regardless. The RA was not familiar with Resident #3's care plan regarding meal assistance. During an interview on 1/26/17 at 1:33 P.M., Certified Medication Technician (CMT) I said if staff observe a resident not eating, the staff should help the resident. During an interview on 1/30/17 at 9:48 A.M., the Assistant Director of Nursing (ADON) said the staff refers to a resident's care plan to determine if the resident needs assistance with meals. The ADON said regarding Resident #3, the staff should attempt to try and assist him/her with meals. During an interview on 1/30/17, at 10:26 A.M., the Director of Nursing (DON) said residents who need meal assistance are determined by the facility looking at the meal intake percentages to see if the resident needs assisting. The DON said the meal charting for the residents was not being done daily. The DON said Resident #3 should get meal assistance and she would expect the restorative aides, CNAs or nurses to assist him/her. 2. Record review of Resident #7's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility 9/12/16; -[DIAGNOSES REDACTED].); -Severely impaired cognition; -Required supervision for eating. Record review of the resident's POS for January 2017, showed orders dated 11/9/16 for a nutritional shake at each meal, protein: one scoop three times daily with meals, Super cereal at breakfast, and ice cream at lunch and supper. Record review of the resident's progress notes showed the following entries: -12/29/16: registered dietitian nutritionist (RDN) documented the resident's weight graph was updated, with no new recommendations; -1/1/17: Open area noted to upper left back; new treatment orders obtained and initiated; -1/12/17: RDN documented the resident's weight graph was updated, with no new recommendations; -1/15/17: Charge nurse documented the resident required limited assistance with all activities of daily living (ADLs) including meals; did occasionally attempt to feed self. Record review of the resident's care plan, last updated 1/1/17, showed the following problems and approaches, dated 11/9/16: -Dehydration/Fluid Maintenance: At risk due to receiving routine diuretic and laxative. Encourage fluids; -Nutritional Status: Poor cognition with frequent cue needed to stay on task to eat. Max assist at most times at meals. Continues to show weight loss. Assist at meal time as needed; encourage food and fluid intake; intermittent supervision and cueing during meals; monitor intake and weight records; nutritional shake at meals; super cereal at breakfast and ice cream at lunch and supper. Record review of the resident's weight report showed the resident weighed 85 pounds (lbs) on his/her admitted , 9/13/16. Record review of the resident's intake report showed staff did not document the intake percentage for each meal. Of 408 meals served to the resident since his/her admission, staff documented an intake percentage on 129 occasions. Of the 129 documented occasions, the resident consumed the following percentages: -Less than 25% = 43 meals (33% of the documented meals); -26% - 50% = 55 meals (43% of the documented meals); -51% - 75% = 14 meals (11% of the documented meals); -76% - 100% = 17 meals (13% of the documented meals). Record review of the resident's most recent comprehensive nutritional assessment, dated 9/19/16, and completed by the facility's consulting RD, showed the following information: -The resident weighed 85 pounds (lbs.); down from 91 pounds (lbs.) on the admission date of [DATE]; -The resident's laboratory [MEDICATION NAME] level reflected mild depletion of protein stores; -Daily estimated energy need was 1370 to 1570 kcal; -Daily estimated protein need was 48 to 58 gm; -The RD used the resident's current weight of 85 lbs. and height of 55 inches and calculated the resident's BMI at 19.81 (80.95% of ideal body weight - IBW); -The RD estimated that the meals the facility served to the resident provided approximately 2400 kcal and 80 gm of protein, if the resident ate 100 percent of the meal; -The RD wrote the resident had problems with chewing; -The resident was alert and able to make needs known; -The resident was [AGE] years old; -The resident had a good appetite; -The facility provided a mechanical soft diet; -The RD wrote that weight loss was evident since admission and recommended they provide super cereal at breakfast, and ice cream with lunch and dinner to address the resident's needs; Record review of the resident's weight report showed the following information: -10/12/16 = 71.5 lbs (down 15%); -11/15/16 = 70 lbs (down 2%); -12/15/16 = 72.5 lbs (up 3%); -1/12/17 = 69 lbs (down 4%; representing a total (severe) weight loss of 18.8% in four months. Using the formula the RD used and identified in the Diet and Nutrition Care Manual, the resident's weight of 69 lbs. on 1/12/17, reflected a BMI of 16. Record review of the nurse's note dated 1/15/17, showed RN E wrote the resident required limited assistance with activities of daily living (ADLs) and the resident occasionally attempts to feed his/her self. During an interview on 1/30/17 at 11:15 A.M., the Assistant Director of Nursing (ADON) said Resident #7 needed to be fed by staff or provided with one-on-one meal assistance and encouragement to eat. Observation on 1/23/17 beginning at 5:12 P.M., showed the resident sat at a dining table with several bowls of food and two drink cups in front of him/her, but did not eat or drink anything. CNA F sat at the same table alternating eating assistance to two other residents. At 5:40 P.M. a visitor arrived and stood next to Resident #7 to speak to him/her. CNA F then assisted Resident #7 to eat several bites of food. Staff did not serve ice cream to the resident and did not document an intake percentage for the meal. Observations made on 1/24/17, starting at 11:52 A.M., in the 500 dining hall showed Resident #7 sitting in a wheelchair at a dining table. The resident had three bowls of pureed food in front of him/her. The resident started to feed him/herself, but then informed staff that one of the foods was too thick in consistency. The resident continued to attempt to feed self, but appeared to struggle and do so with difficulty. Staff started assisting resident #7 at 12:20 P.M. Observations made prior to Resident #7 attempting to feed his/herself showed that staff took the food cart from the main kitchen at 11:22 A.M. to the 500 dining hall. Staff took all the pureed meals for the 500 dining hall from the main kitchen and placed them on trays in individual bowls with a foil cover. At no time during the observation were the pureed foods placed on the steam table, nor were they reheated prior to being served to residents. Fifty eight minutes had elapsed from the warm food left the steamtable with any way to keep it hot and the time the staff started assisting the resident with feeding. Observation on 1/25/17 beginning at 12:37 P.M., showed the following: -Resident #7 sat at a dining table with three bowls of food and a health shake in front of him/her. The food and shake appeared to be untouched, and the resident did not attempt to eat or drink anything; -At 12:42 P.M., CNA D sat down at the table between Resident #7 and another resident. The CNA spoke to both residents, but did not offer assistance to either one. CNA D asked Resident #7 is he/she wanted something different, to which the resident responded No, and told him/her to try the shake. The resident did not pick up the shake; -At 12:49 P.M., CNA D left the table briefly and returned to assist another resident with cleaning his/her face. The CNA did not assist Resident #7 to eat or drink anything; -At 1:00 P.M., RA C spoke to the resident and told him/her to drink the shake even if he/she wasn't going to eat anything. The resident played with the straw in the shake for several minutes, but did not drink any of the shake; -At 1:05 P.M., staff members did not assist the resident to eat or drink anything and did not serve ice cream to the resident. Staff did not document an intake percentage for the observed meal. Observation on 1/25/17 at 2:40 P.M., showed the resident had an open wound to his/her left upper back. RN E measured the wound during treatment and said the size was 3.8 centimeters (cm) x 1.5 cm. Observation on 1/26/17 at 12:33 P.M., showed the resident sat at a dining table and ate part of a bowl of pureed cake, but not the other food items served with his/her meal only; he/she did not drink the health shake on the table. Staff did not assist or encourage the resident to eat and did not serve ice cream with or after the meal. Staff did not document an intake percentage for the meal. Observations made on 1/27/17 at 12:05 P.M. showed that staff placed a lunch tray with pureed food in bowls in front of Resident #7. One staff asked another Do you feed (Resident #7)? and staff replied that they do not assist the resident with meals. 3. During an interview on 1/27/17 at 2:20 P.M., the dietary manager said the following: -For residents who require assistance with eating, their food should remain on the steam table until staff take the resident's order. Staff should not take orders or give trays to residents requiring meal assistance until staff is ready to assist the resident with his or her meal; -For lunch and evening meal in the 500 hall dining hall, facility staff should have residents with puree meal orders up and ready in the dining hall (for when food comes from the main kitchen). Staff should then be able to immediately assist residents with pureed meal orders; -For residents who require assistance with eating, there are additional facility staff trained and able to assist those residents. However, those staff members are not currently assigned to assist residents at meal times. 4. During an interview on 1/30/17, starting at 3:07 P.M., the facility administrator said the following: -For residents who require meal assistance, staff should get resident orders and sit down with each resident as soon as staff obtain the meal tray; -For each of the two facility dining halls, there should be two CNAs and one bath aide available to help residents who need assistance with meals; -If with either of the dining areas are short staffed, additional staff from activities, transportation, MDS, and other staff should be pulled to assist residents with meals; -In both dining areas, staff should first serve and help those residents who require meal assistance and have mechanically-altered meals (such as pureed); -Staff are informed of residents who require meal assistance through memos from Restorative and reports from the kitchen. The DON and floor nurses should be aware of residents who require assistance with meals.

Based on record review and interview, the facility failed to implement interventions to decrease the risk of falls for three residents (Resident #2, #7, and #8) out of three residents sampled regarding falls. One resident (Resident #2) fell and sustained a hip fracture. The facility census was 92. 1. Record review of Resident #2's quarterly minimum data set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 05/22/14, showed the following information: -BIMS of 9 (moderate cognitive impairment); -Required extensive assistance from the facility staff for transfers and dressing; -History of falls; -Alzheimer's disease (the most common cause of dementia in older adults); -Debility (loss of strength). Record review of the care plan, dated 05/02/12, and reviewed on 05/27/14, showed the following information: -At risk for falls due to inability to transfer safely on own; -History of falls; -Functional decline; -Goal: Will have no major injuries due to falls; -On 05/02/12, staff added the interventions of keep bed in the lowest comfortable position for ease with transfers, keep requested personal items within reach, wheelchair for primary mode of locomotion, ambulate when agreeable with assist of one using roller walker; -On 07/18/12, staff added the intervention of encourage resident to use call light and wait for assistance with transfers; -On 01/09/13 the resident had an anti roll back locking device added to the wheelchair; -On 09/17/13 the facility added the resident to the walk list; -Staff did not document any additional changes in interventions on the care plan after 09/17/13 related to fall risk; -On 05/27/14, staff documented on the care plan the resident had met the goal of no recent falls with major injuries. Continue plan. Record review of the progress notes showed the following information: -On 05/04/14, at 8:35 A.M., the facility staff found the resident sitting on the floor in the bathroom with knees bent and his/her feet out in front of him/her. The resident said he/she was "trying to go from the toilet to (his/her) wheelchair". The resident did not use the call light for assistance; -On 05/04/14, at 1:00 P.M., the nurse documented the family of the resident's roommate advised the nurse that Resident #2 had taken him/herself to the bathroom. When the nurse entered the bathroom, the resident sat on the toilet. When questioned why the resident did not use the call light, the resident said he/she forgot where it was. The nurse showed the resident the call light and the resident verbalized understanding of its use. -On 05/04/14, at 1:05 P.M., the nurse notified the resident's responsible party of the fall. The nurse explained the resident had taken him/herself to the bathroom that morning twice without using the call light. The nurse explained the resident said he/she forgot where the call light was located. Staff to remind the resident of the location of the call light frequently; -On 05/09/14, the fall team reviewed the resident that morning due to the recent fall. The facility will continue with current fall interventions. The facility failed to implement new interventions; -On 06/16/14, at 8:30 P.M., a certified nursing assistant (CNA) reported a witnessed fall. The aide said the resident tried to get up on his/her own. The resident fell on his/her right side. The resident sustained [REDACTED]. The resident complained of pain to the right knee, hip, and shoulder. The nurse called the physician's answering service; -On 06/16/14, at 9:29 P.M., the nurse called the physician's answering service; -On 06/16/14, at 9:37 P.M., the physician called with new order for X-ray of right knee, right hip, and right shoulder. The resident to be non-weight-bearing until after the x-ray results received; -On 06/17/14, at 10:00 A.M., x-rays results obtained and showed acute right hip fracture. The nurse called the physician and obtained orders to send resident to hospital of choice. an x-ray was completed. The x-ray showed an acute hip fracture; -On 06/17/14, at 2:09 P.M., fall team reviewed the resident in the fall meeting that morning due to recent fall. The medication technician documented the facility would continue with current fall interventions. During an interview on 07/16/14, at 12:15 P.M., CNA A said the resident would get up by him/herself and staff would remind him/her to wait for help. He/she had not been made aware of any changes to the plan of care for the resident regarding falls. During an interview on 07/16/14, at 12:23 P.M., CNA B said the resident would not remember to use his/her call light and the staff would remind him/her to use the light. He/she had not been made aware of any changes to the plan of care for the resident. 2. Record review of Resident #7's annual MDS, dated [DATE], showed the following information: -BIMS score of 4 (severe cognitive impairment); -Required supervision with transfers, walking, and toilet use; -Required limited assistance for dressing and personal hygiene; -Occasionally incontinent of urine; -Continent of bowel; -History of falls, including one fall with non-major injury. Record review of the care plan, dated 04/03/12, and reviewed on 04/15/14, showed the following information: -At risk for falls; -Recent falls; -Had unsteady gait at times and loses balance; -Wanders; -Functional decline; -Assist with ambulation as needed, monitor for unsteady gait; -Keep bed in low position for ease with transfers; -Keep pathways clear, well-lit, and free of clutter; -Up as desired; -Goal: no major injures due to falls; -On 10/01/13, falling leaf program; -On 11/05/13, monitor for wearing proper fitting footwear; -On 04/15/14 new interventions added to encourage rest periods due to frequent wandering and offer and assist with toileting when the resident had increased wandering and confusion as the resident allowed. Monitor for urine in floor. -On 04/15/14, staff documented goal not met. The resident had falls with bruise/skin tear. Staff trying to monitor more, offer to toilet, and encourage rest periods. Record review of the resident progress notes showed the following information: -On 04/16/14, the staff found the resident in the floor; -On 04/17/14, the fall team reviewed the resident during fall meeting. He/she remained on the falling leaf program, which is used to identify residents at high risk for falls and who need increased monitoring, and continued with the current fall interventions. The current interventions included proper fitting footwear, staff to assist with walking as needed, bed in low comfortable position, and keep pathways clear and free of clutter. The facility staff failed to implement new interventions for the resident; -On 04/23/14, the fall team reviewed the resident in the fall meeting on 04/22/14. He/she will remain on the falling leaf program and continue with current fall interventions. The facility staff failed to implement new interventions for the resident; -On 04/26/14, the staff found the resident sitting on the floor next to his/her bed; -On 05/02/14 (six days after the fall), the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with current fall interventions. The facility staff failed to implement new interventions for the resident; -On 05/09/14, the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 05/14/14, the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 05/14/14, the staff found the resident on the floor of his/her room, lying at the end of the bed with the shower curtain wrapped around him/her; -On 05/21/14 (seven days after the fall), the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 05/23/14, staff found the resident on the floor in the bathroom with his/her back towards the wall; -On 05/25/14, the resident's roommate notified the nursing staff that the resident was on the floor; -On 06/03/14 (11 days after the first fall, 9 days after the second fall), the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 06/04/14, the staff found the resident lying on the floor in the main lobby; -On 06/11/14 (seven days after the fall), the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 06/17/14, the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident; -On 07/02/14, the resident fell in his/her room at the foot of the bed in a sitting position; -On 07/02/14, the resident continued on the falling leaf program. The facility staff failed to implement new interventions for the resident; -On 07/02/14, the staff found the resident on the floor on his/her back; -On 07/03/14, the staff found the resident on the floor by the door of his/her room; -On 07/03/14, the resident fell at the nurse's station; -On 07/03/14, the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility removed the foot pedals from the resident's wheelchair and put an anti-roll back on the wheelchair; -On 07/05/14, at 1:15 A.M., the aide called the nurse to the room. The resident lay on his/her back by the bed. The resident sustained [REDACTED]. -On 07/05/14, at 9:45 A.M., the aide reported the resident got up out of bed unassisted and sat down in the floor; -On 07/09/14, the fall team reviewed the resident during the fall meeting. He/she remained on the falling leaf program and continued with the current fall interventions. The facility staff failed to implement new interventions for the resident. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Short and long term memory problems; -Severely impaired decision-making skills; -Required extensive assistance from the facility staff for transfers, ambulation, dressing, eating, and hygiene; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Debility (loss of strength); -Dementia; -History of falls, including two falls with non-major injuries. Record review of the progress notes showed the following information: -On 07/11/14, the staff found the resident sitting in the floor. The resident was in bed sleeping prior to being found in the floor. The resident could not say how he/she got to floor; -On 07/14/14, the fall team reviewed the resident during the fall meeting. Encourage the staff to ambulate the resident often for restlessness. The facility staff failed to implement new interventions for the resident. During an interview on 07/16/14, at 12:15 P.M., CNA A said the resident began falling more recently and the staff would watch him/her closely. The resident came back from the hospital recently and just had the new geri chair added for positioning while out of bed. He/she had not been made aware of any changes in the plan of care for the resident. During an interview on 07/16/14, at 12:23 P.M., CNA B said the resident got the new chair about a week ago, after being in the hospital. He/she said the staff will keep a close eye on the resident, and assist him/her with walking when he/she wants to walk. He/she had been aware to keep the resident with staff when agitated but not aware of any other changes in the plan of care for the resident. During an interview on 07/16/14, at 12:30 P.M., licensed practical nurse (LPN) C said staff would assist the resident with walking and try to keep the resident busy. He/she said the resident had experienced a change in condition since his/her hospital stay. He/she was aware of the new chair for the resident in the last week, but not aware of any other changes in the plan of care for the resident. During an interview on 07/16/14, at 1:40 P.M., the RCA (restorative care) supervisor said the resident had been discussed during fall meetings. The fall team discussed the possibility of using a walker for the resident but were concerned the resident would not remember to use it or he/she might fall over it so they decided against it. 3. Record review of Resident #8's quarterly MDS, dated [DATE], showed the following information: -BIMS of 8 (shows moderate cognitive impairment); -Required limited assistance from facility staff for transfers and dressing; -Alzheimer's dementia; -Alteration of awareness; -History of falls. Record review of the progress notes, dated 04/04/14, showed the following information regarding his/her quarterly review: -Alert and oriented to place and name. The resident has confusion at times with a [DIAGNOSES REDACTED]. -Vision and hearing impairment. The resident wears glasses; -Toilets self most of time, one staff stand by assist at times; -Stand by assist with transfers and walking at times. The resident often walks by self to bathroom with the roller walker; -At risk for falls due to unsteady gait, functional decline, and arthritis in knees. Staff assist the resident as he/she allows. The resident did not have any recent falls. Record review of the care plan, dated 01/15/14, and reviewed on 04/09/14, showed the following information: -History of falls due to unsteady gait; -Functional decline; -Weakness and increased confusion at times; -Arthritis in the knees; -Goal: To have no injuries due to falls; -On 03/26/12, staff implemented the following interventions: -Assist with ambulation and transfers as the resident allowed; -Gait with roller walker at resident request and stand by assist; -Keep physician informed; -Wheelchair as needed; -On 09/05/12, staff added the resident to the "walk" list; -After 09/05/12, staff did not document any additional interventions or changes in interventions related to fall risk to the care plan; -On 04/09/14, staff documented the resident met goal and continue with plan. Staff documented the resident did not have any falls with injuries. Record review of the progress notes showed the following information: -On 05/04/14, an aide reported that staff were across the hall and saw the resident ambulating out of his/her bathroom and heading back to bed. The resident used his/her roller walker. The resident got to the end of the bed and his/her left knee gave out and the aide saw the resident sit down on the floor. -On 05/09/14 (five days after the fall), staff reviewed the resident in the fall meeting. He/she will continue with current fall interventions. The facility staff did not implement any new interventions for the resident; -On 06/21/14, staff found the resident sitting on the floor next to his/her bed. Staff documented the resident was alert and oriented to self. No apparent injuries. Staff assisted the resident back to bed; -On 06/26/14 (five days after the fall), staff reviewed the resident in the fall meeting. He/she will continue with current fall interventions. The facility staff failed to implement new interventions for the resident; -On 07/09/14, staff found the resident sitting on the floor with legs straight out and arms down to his/her side. Staff documented the resident as alert and oriented. When questioned what happened, the resident said he/she "missed the bed". The resident could not get up without assistance; -On 07/09/14, staff reviewed the resident in the fall meeting. He/she will continue with current fall interventions. The facility staff failed to implement new interventions for the resident. During an interview on 07/16/14, at 12:15 P.M., CNA A said he/she would walk with the resident for added safety. He/she said the resident is able to get him/herself up and about. He/she had not been made aware of any changes in the plan of care for the resident. During an interview on 07/16/14, at 12:23 P.M., CNA B said the staff keep the resident's walker next to his/her bed and he/she checks on the resident frequently. He/she had not been made aware of any changes in the plan of care for the resident. During an interview on 07/16/14, at 12:30 P.M., LPN C said the resident will normally have falls when getting out of bed and the facility staff will remind him/her to ask for help. He/she had not been made aware of any changes in the plan of care for the resident. 4. During an interview on 07/16/14, at 1:20 P.M., registered nurse (RN) D said the fall team tries to meet weekly and discuss all residents that have had a fall. He/she said the care plans will be updated with all changes or new interventions. If a resident had two falls in a short period of time, the resident is placed on the falling leaf program for closer monitoring. During an interview on 07/16/14, at 2:15 P.M., the Director of Nursing (DON) said when a resident falls, the nurse is expected to assess the resident, notify family and physician and document the event in the computer system. The fall team usually meets once a week to discuss interventions. The discussion is documented in the resident's progress notes with new interventions. The facility has a separate notebook with all the interventions in it. The care plan is updated with all new interventions and it is communicated to the CNAs by the communication book at the desk. 5. Record review of the fall team notebook showed the last intervention for the residents reviewed for falls (Resident #2, #7, and #8) was in 2010. Refer to complaint number MO 142.