Every finding on record at Wilshire at Lakewood Rehab Center

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; the facility failed to ensure appropriate barrier placement when checking one supplemental resident's (Resident #66) blood glucose (sugar) level, failed to ensure appropriate hand hygiene was completed for one supplemental resident (Resident #39), and failed to ensure appropriate infection control measures were taken prior to the use of an insulin (a hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose in the blood) pen for two supplemental residents (Resident #142 and #151) out of five supplemental residents. The facility census was 122 residents with a licensed capacity for 170 residents at the time of the survey.1. Observation on 9/16/25 between 8:47 A.M. and 9:27 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, a chemical dish-washing machine, a hand-washing sink, an ice machine, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state). Observation on 9/17/25 between 11:21 A.M. and 12:53 P.M. during the initial facility LSC walk-through inspection with the Director Plant Operations (DPO) showed:-The municipal water main supply entered the facility at the front of the building. -The building was equipped with a complete fire sprinkler system with sprinkler heads located throughout the facility. -There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water), water heaters, water softeners, and hot/cold water piping throughout the facility.-There were numerous resident rooms with private and/or shared bathrooms and sinks throughout the eight resident hallways.-There were commercial clothes washers in the laundry area.-There were eight shower rooms in the facility. -There was a Beauty Shop with a sink. -There was a large unused fountain in the atrium (in architecture, it is a central, sky-lit space within a building, often covered by a glass roof, that can serve as a lobby or communal area).-There were two dining rooms with sinks.-Public restrooms were located on the front administrative office hall with additional restrooms in the west Employee Breakroom. Review of the facility's untitled, undated, and unreviewed Legionella paperwork, held together with a binder clip and provided by the Administrator, showed the following:-There was a 31-page (pg.) Centers for Disease Control (CDC) toolkit including a completed brief eight question assessment on page 2, with the rest consisting of educational guidelines for creating a water management program with control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.-There was a 14-pg. CDC Legionella Environmental Assessment Form that was filled out up to the 19th question on page 5 and continued incomplete through the following 9 pages without notations on whether they were applicable or not.-Another similar 13-pg. CDC Legionella Environmental Assessment Form with some pages that were partially or completely filled out, and others that were left blank.-There was a 5-pg. facility-specific review of their own management plan that began and ended with the same facility layout map that only showed locations of water heaters, two sprinkler rooms, and utility shut-offs.-There was a Glossary, a 3-pg. explanation of Controlling Legionella in Decorative Fountains, and another 1-pg. assessment left blank.-A generic 8-pg. educational Communicable Disease Investigation Reference Manual from the Missouri Department of Health and Senior Services was included.-There was an additional 2 pages of CDC guidelines taken from a 241-page document.-A 2-pg. list of water test results from January 2024 through September 2025 was also provided. During an interview on 9/19/25 at 9:32 AM the Administrator said:-The water management program was created by using the assessments they follow.-He/She assumed they had all been finished.-He/She actually oversaw the program. During an interview on 9/19/25 at 10:37 AM the Director Plant Operations said:-Their water management program was based off a TELS (a computerized maintenance building management system and suite of services designed for Senior Living communities) review in June of this year.-If there were assessments that should have been completed by the Maintenance Director but were not, he/she actually did not catch that. Review of the facility's policy titled Subcutaneous Injection/ Insulin or Heparin dated 10/24/22 showed no mention of insulin pens within the policy. Review of the facility's policy titled Blood Glucose Monitoring dated 10/24/22 showed no policy for barrier use while checking a resident's blood glucose level. Review of the facility's policy titled Medication Administration dated 10/24/22 showed staff were to wash their hands before and after medication administration. 2. Review of Resident #66's admission Record showed he/she was admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Observation on 9/15/25 at 12:10 P.M. showed:-Licensed Practical Nurse (LPN) D entered the resident's room.-LPN D informed the resident that he/she was going to check the resident's blood sugar.-LPN D set the blood sugar supplies on the resident's sink area without a barrier in place.-LPN D checked the resident's blood sugar, gathered the supplies from the resident's sink area and left the resident's room. During an interview on 9/19/25 at 9:34 A.M. LPN D said:-He/She would not have done anything differently from how she performed the resident's blood sugar check.-He/She could not remember if he/she had used a barrier during the resident's blood sugar check.-He/She had never been taught that he/she needed to use a barrier when setting down blood sugar supplies in resident care areas. 3. Review of Resident #39's admission Record showed he/she admitted to the facility with the following diagnoses:-DM II.-Acute Kidney Failure. Observation on 9/19/25 at 9:03 A.M. of the resident's medication administration completed by Certified Medication Technician (CMT) B showed:-He/She did not wash or sanitize his/her hands prior to taking all of the resident's medication out of the packets.-He/She entered the resident's room without washing or sanitizing his/her hands.-He/She exited the resident's room without washing or sanitizing his/her hands.-He/She began the next resident's medication administration without washing or sanitizing his/her hands. During an interview on 9/19/25 at 9:16 A.M. CMT B said he/she would not have done anything differently. During an interview on 9/23/25 at 12:18 P.M. CMT B said:-He/She was unsure if he/she had sanitized his/her hands before he/she passed Resident #39's medications.-He/She thought he/she had not sanitized his/her hands after he/she passed Resident #39's medications.-Hand hygiene should be performed before and after each resident during medication administration. 4. Review of Resident #142's admission Record showed he/she admitted to the facility with a diagnosis of DM II. Review of the resident's Order Summary Report dated September 2025 showed an order for Humalog (Insulin Lispro- short acting insulin) Solution 100 unit/milliliters (ml), inject per sliding scale: if 251-300 give 14 units. Observation on 9/19/25 at 11:45 A.M. of the resident's Humalog administration completed by LPN E showed:-LPN E went into the resident's room and checked the resident's blood sugar.-LPN E then exited the resident's room and prepared the resident's insulin via a pen injector.-LPN E placed the needle on the pen without sanitizing the hub of the pen.-LPN E then primed the insulin pen and dialed the insulin pen to 14 units.-LPN E walked into the resident's room and administered the resident's insulin. 5. Review of Resident #151's admission Record showed he/she admitted to the facility with a diagnosis of DM II. Review of the resident's Order Summary Report dated September 2025 showed an order for Insulin Lispro Injection Solution, inject as per sliding scale: if 250-299 inject six units. Observation on 9/19/25 at 12:04 P.M. of the resident's Insulin Lispro administration completed by LPN E showed:-LPN E went into the resident's room and checked the resident's blood sugar.-LPN E then exited the resident's room and prepared the resident's insulin via a pen injector.-LPN E placed the needle on the pen without sanitizing the hub of the pen.-LPN E then primed the insulin pen and dialed the insulin pen to six units.-LPN E walked into the resident's room and administered the resident's insulin. During an interview on 9/19/25 at 12:15 P.M. LPN E said he/she would not have done anything differently during Resident #142's and Resident #151's insulin administration. 6. During an interview on 9/22/25 at 2:12 P.M. the Director of Nursing (DON) said:-He/She expected staff to perform hand hygiene before and after each resident during medication administration.-CMT B had not performed correct hand hygiene during Resident #39's medication administration.-A barrier needed to be in place when setting any medical equipment down in a resident care area to include blood sugar monitoring supplies.-Blood sugar monitoring was on a recent skills check-off that LPN D would have been a part of.-LPN D had not performed correct infection control measures during Resident #66's blood glucose check.-All insulin pens needed to be sanitized with the manufacturer's recommendation of sanitation prior to each use.-LPN E had not performed correct infection control measures during Resident #142's and Resident #151's insulin administration. During an interview on 9/23/25 at 12:18 P.M. CMT B said:-He/She was insulin administration certified.-When checking a resident's blood sugar, he/she would normally bring all of the supplies into the room and place a barrier down if he/she were setting down the supplies.-The staff person should have used a barrier when checking Resident #66's blood sugar.-Without a barrier in place, then the supplies could have been contaminated.-He/She was unsure if the hub of an insulin pen needed to be sanitized prior to use. During an interview on 9/23/25 at 12:35 P.M. the Assistant Director of Nursing (ADON) said:-Hand hygiene needed to be performed before and after each resident during medication administration. -CMT B had not performed appropriate hand hygiene during Resident #39's medication administration.-A barrier needed to be used when placing any medical equipment in resident care areas which included blood sugar monitoring equipment.-When a barrier is not in place then it puts residents at an increased risk of infection.-LPN D had not performed appropriate infection control measures during Resident #66's blood sugar check.-All insulin pens needed to be sanitized before each use.-LPN E had not performed appropriate infection control measures during Resident #142's and Resident #151's insulin administration.

Based on observation, interview, and record review, the facility failed to meet professional standards for one sample resident (Resident #5) when staff taped the resident's ileostomy (a surgical procedure that creates an opening in the abdominal wall through which the last part of the small intestine, called the ileum, is brought to the surface of the body) bag shut instead of using a clip and for one sampled resident (Resident #70) when staff failed to correct an order entry error related to weighing the resident daily and documenting the daily weights out of 31 sampled residents. The facility census was 122 residents.Review of the facility's policy titled Nutrition/Hydration Management dated 10/24/22 showed:-Residents were weighed upon admission and re-admission and then at least weekly for four weeks and then monthly if weight is stable.-Based on clinical judgement licensed nurses weigh residents as needed based on clinical presentation.Review of the facility's policy titled Ileostomy Care dated 10/24/22 showed:-When emptying the ostomy pouch staff were to drain the contents of the pouch into the toilet or bed pan, wipe the bottom of the pouch, and reapply the closure clamp.1. Review of Resident #5's admission Record showed he/she was admitted to the facility with a diagnosis of Ileostomy Status.Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/26/25 showed:-The resident was cognitively intact.-The resident did not have any type of ostomy present.Review of the resident's undated care plan showed the resident had an alteration in gastrointestinal status and had an ileostomy with no interventions in place related to the care or supplies the resident needed for his/her ileostomy care.During an interview on 9/15/25 at 2:19 P.M. the resident said:-He/She had an ileostomy.-The facility was not good about keeping the needed supplies in his/her room.During an interview on 9/22/25 at 11:09 A.M. the resident said:-He/She was upset because the staff that did his/her ostomy care had to tape up the bag because they could not find a clamp in his/her room.-He/She had been learning how to do his/her own ileostomy care and was frustrated that he/she could not empty his/her ileostomy bag because it was taped shut.Observation on 9/22/25 at 11:09 A.M. showed the resident's ileostomy bag had been taped shut. During an interview on 9/22/25 at 11:16 A.M. Licensed Practical Nurse (LPN) E said:-He/She could not find a clamp or closure device when doing the resident's ileotomy care earlier in the morning, so he/she had to tape it shut.-When the resident was first admitted to the facility, the staff had trouble keeping a good seal of the bag to the residents ostomy and staff had been blowing through supplies.-He/She was unsure of why the clamps to the ostomy pouches kept disappearing.-He/She had forgotten that he/she had taped the pouch shut and still needed to find a closure device for the resident's ileostomy pouch.During an interview on 9/22/25 at 2:12 P.M. the Director of Nursing (DON) said:-He/She had been made aware that LPN E had taped the resident's ileostomy pouch up because they could not find a closure device for the resident's pouch.-The facility had plenty of ostomy supplies.-All nursing staff had access to central supply, so finding extra supplies would not be difficult.During an interview on 9/23/25 at 12:35 P.M. the Assistant Director of Nursing (ADON) said:-There had been a lot of issues with the resident's ileostomy care when the resident first admitted to the facility.-When he/she had cared for the resident, he/she found it difficult to find the appropriate closure device for the resident.-Ostomy pouches should never be taped shut.-LPN E should have laid the pouch on a towel instead of taping the pouch shut.-After laying the pouch on a towel LPN E should have immediately gone to central supply to find a closure device for the resident.-By taping the ileostomy bag shut, LPN E hindered the resident's independence with performing his/her own ileostomy care.2. Review of Resident #70's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis (a medical procedure that replaces the function of the kidneys by filtering water products and excess fluid from the blood through a machine). -Dependance of Renal Dialysis.Review of the resident's undated care plan showed the resident had renal insufficiency related to his/her diagnosis of ESRD and had dialysis treatments every Monday, Wednesday, and Friday.Review of the resident's Order Summary Report dated September 2025 showed:-An order for the resident to be weighed daily and staff were to call the facility doctor if the resident had a two or more-pound weight gain in 2 days or if the resident had a five-pound weight gain in a week.-The order was dated 8/11/25 but had a start date on 9/1/25.Review of the resident's weight's dated August 2025 and September 2025 showed:-The resident had only two weights documented in the Electronic Medical Record (EMR) for August 2025.-The resident did not have daily weight's put into the EMR eight times out of 21 opportunities.Review of the resident's dialysis communication forms dated August 2025, and September 2025 showed:-The facility had been faxed seven of the resident's communication forms on 9/19/25.-Only two dialysis communication forms were uploaded into the resident's EMR.-The resident was only getting weighed on his/her dialysis days in the month of August 2025.Review of the resident's Treatment Administration Record dated September 2025 showed:-Eight missing weights in the record.-Of the eight missing weights, staff marked drug refused six times.During an interview on 9/22/25 at 9:25 A.M. the Regional Nurse and the ADON said that they would expect staff to document in a progress note if the resident refused to be weighed and not use the drug refused option.During an interview on 9/22/25 at 12:46 P.M. the facility's Medical Director said:-Residents who received dialysis treatments were normally put on daily weights.-He/She was unsure of why the order had a start date of 9/1/25.-He/She thought the person who put in the order must have made an order entry error.-If the resident was refusing to be weighed, it needed to be documented.-The resident should have been getting weighed daily since admission to the facility.During an interview on 9/22/25 at 2:12 P.M. the DON said:-He/She was unsure of the resident's current weight order.-He/She assumed the resident's weight order was for the resident to be weighed three times a week, before and after dialysis.-He/She would expect a progress note to be made by staff every time the resident refused to be weighed.-The staff should have been clicking the progress note option on the TAR, this would automatically create a pop-up box for staff to type a note into the EMR.-It was not sufficient documentation for the staff to mark drug refused on the TAR.-The resident's weight order should have been clarified upon review of the orders.During an interview on 9/23/25 at 12:18 P.M. Certified Medication Technician (CMT) B said:-He/She was unsure of the resident's current weight order.-If the resident refused to be weighed it needed to be documented somewhere in the chart.-It was appropriate for staff to use the drug refused option on the TAR to indicate that the resident refused to be weighed.During an interview on 9/23/25 at 12:35 P.M. he ADON said:-The resident's current weight order was for the resident to be weighed before and after each dialysis treatment.-If the resident refused to be weighed it needed to be documented.-There was an option in the TAR for staff to be able to make a progress note.-He/She was unsure of why the resident's daily weight order had a start date of 9/1/25.-He/She assumed that it was an order entry error.

Based on interview and record review the facility failed to ensure one sampled resident's (Resident #147) physician's order for no cardiopulmonary resuscitation (CPR - any medical intervention used to restore circulatory and/or respiratory function that has ceased) was followed when the resident was found not breathing and having no heart beat out of 31 sampled residents. The facility census was 122 residents.1. The Administrator was notified on [DATE] of past non-Compliance which occurred on [DATE]. The facility had completed an internal investigation and had in-serviced all staff on [DATE]. The past non-compliance was corrected on [DATE]. Review of the facility Cardiopulmonary Resuscitation (CPR) policy dated [DATE], showed:-CPR is instituted (started) in cases of recognized cardiac arrest (the heart has stopped) and/or pulmonary arrest (breathing has stopped) to sustain or support a resident's cardiac and/or breathing function until medical emergency personnel are available to take over the resuscitation efforts.-CPR is instituted on all residents except those designated as No Code or No CPR. Review of Resident #147's physician order dated [DATE] showed:-Do not resuscitate (DNR - a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest.Review of the resident's licensed nurse progress note dated [DATE] showed:-At approximately 4:00 A.M. on [DATE] the licensed nurse making rounds found the resident in his/her room not breathing and without a pulse.-The licensed nurse yelled Code Blue (an announcement that an adult is having a medical emergency, usually cardiac or respiratory arrest) and for help to come.-CPR was started.-911 was called.-Emergency Medical Services (EMS) arrived at the facility at approximately 4:20 A.M. Review of the resident's Fire Department Prehospital Care Report dated [DATE], showed:-Emergency Medical Services (EMS -a system of pre-hospital care and transport for patients with urgent medical needs) was dispatched to the facility at 4:22 A.M. on [DATE]/ 2024 for a resident having cardiac arrest and not breathing with CPR in progress. cardiac arrest-The resident's medical history was obtained from facility health care personnel.-The resident had cardiac arrest (his/her heart was not beating) and respiratory arrest (he/she was not breathing).-He/she had no advance directives.-On arrival, EMS found the resident unresponsive, lying on his/her back with his/her face and torso pointing up on his/her bed (NOTE: For chest compressions to be effective, they must be delivered with enough force to compress the chest by at least 2 inches (5 cm) for adults. When performed on a soft, flexible surface like a bed mattress, a significant amount of the force is absorbed by the surface, preventing adequate chest compression.)-Facility staff reported CPR had been started approximately 15 minutes before EMS arrival.-The resident was pale, with lividity (the bluish-purple discoloration of skin after death) starting to form on the dorsal (back) side of his/her arms, near his/her shoulders.-He/she was not breathing, rigor (stiffness that occurs shortly after death) was absent and he/she was warm to touch.-His/her eyes were non-reactive (the pupils did not change size in response to light - a sign of serious neurological damage in the brain stem that controls automatic body functions of breathing, heartbeat and blood pressure).-His/her breastbone was soft and flexible, in conjunction with CPR.-Facility staff reported the resident to be a full code (a healthcare directive indicating that all life-saving measures, such as CPR, should be used if a patient's heart stops beating or they stop breathing) and were in the process of contacting the resident's family upon EMS arrival.-Chest compressions were immediately taken over by EMS; pulse and breathing were found to be absent.-EMS moved the resident from his/her bed to the floor and continued chest compressions.-An oropharyngeal airway (ORA - a medical device used to maintain an open airway in persons who are unconscious or have difficulty breathing) was inserted and Bag-valve-mask (BVM - ventilation is a manual resuscitation technique that provides positive pressure ventilation to patients with inadequate or absent breathing) ventilation was initiated.-A nasal capnography was also placed (a non-invasive technique that monitors ventilation and airway integrity during procedures and critical care measures).-He/she was placed on a heart monitor and was found to be in asystole (the most serious form of cardiac arrest when the heart's electrical system fails entirely, which causes the heart to stop pumping and is usually irreversible); throughout EMS care, he/she never left asystole.-Possible Intravenous (IV) access was not found; intraosseous (IO - vascular access procedure used in emergencies to provide rapid, temporary access to the blood stream by inserting a needle into bone marrow allowing administration of fluids and medications). -The [NAME] device (a mechanical device that provides consistent and high-quality chest compressions during CPR) was placed.-Epinephrine (a medication used to increase blood flow to the heart and brain, which can increase the chances of a return of spontaneous circulation) three times with no change.-Normal saline (intravenous fluid with salt concentration of human blood) was administered.-An endotracheal tube (ET tube - a flexible, hollow plastic tube inserted into the windpipe through the mouth, serving to secure a definitive airway and facilitate breathing when a patient cannot do so sufficiently on their own, such as during critical illness).-Throughout EMS resuscitation the resident's lividity did not improve, and he/she remained pale through CPR.-After 25 minutes of Advanced Cardiovascular Life Support (ACLS - evidence-based clinical guidelines for the urgent treatment of life-threatening cardiovascular conditions, such as cardiac arrest; it incorporate advanced procedures, medications, airway management, and defibrillation, preparing healthcare providers to manage patients in critical medical emergencies) CPR, the resident's condition did not improve and no change in heat rhythm was found.-Facility staff had made contact with the resident's family who were comfortable terminating recessive efforts.-Per protocol, resuscitation was discontinued at 4:56 A.M. and the resident was left in the care of facility staff.During an interview on [DATE] at 12:33 P.M. the resident's physician said:-He/she believed the facility did everything correctly regarding CPR for the resident.-For CPR to have been successful, it had to have been started when the resident was found unresponsive warm.-The facility informed EMS of the resident's DNR and EMS said they could not stop resuscitation.-He/she felt EMS should have stopped resuscitation at that time.-In his/her view the facility staff were not wrong to have started CPR, but EMS should have stopped CPR once the resident's code status was communicated to EMS. During an interview on [DATE] at 9:59 A.M. Licensed Practical Nurse (LPN) A said:-He/she was the charge nurse on the resident's hall on the night shift on [DATE].-A Certified Nursing Assistant (CNA) had come to ask him/her about the resident's positioning in his/her bed - at that time the resident was alert and talking.-A few minutes later, he/she went to check on the resident and found him/her unresponsive, without a pulse, not breathing, but warm to touch.-He/she called a code (summoned staff for a life-threatening emergency) and started CPR.-EMS was called to come to the facility.-Facility staff confirmed that the resident was a DNR but by that time EMS had arrived and had taken over CPR.-Facility staff informed EMS that the resident was a DNR and EMS told facility staff they had to continue CPR and could not stop.-EMS worked on the resident for a while; their efforts were not successful, and they eventually stopped.-Afterward he/she was trained individually and with a group of facility staff to look in the facility electronic medical record (EMR) system to confirm a resident's code status before starting CPR.-He/She now knew to confirm code status in the EMR before starting CPR. During an interview on [DATE] 10:52 AM the resident's family member and Designated Power of Attorney (person named in writing as a decision-making agent in the when a person can no longer make decisions for themself) said:-He/she appreciated that the facility did CPR because he/she preferred they err on the side of caution when they found the resident not breathing and without a pulse.-He/she was not upset because the resident was in a better place now.Complaint 2619701

Based on observation, interview, and record review the facility failed to ensure staff were adequately documenting supplement usage for one sampled resident (Resident #5) out of 31 sampled residents. The facility census was 122 residents.Review of the facility policy titled Nutrition/Hydration Management dated 10/24/22 showed:-A resident was assessed for nutrition/hydration status by nursing during the admission process.-A comprehensive care plan would be developed by the interdisciplinary team that addressed nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed needs. -The nutrition/hydration management program may address the following:--The factors contributing to actual or potential causes for inadequate nutrition or hydration status.--Specific modification in the resident's meal plan including food from outside of the facility and/or special food activities.--Use of supplemental vitamins and/or minerals.--Weight frequency.1. Review of Resident #5's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) Due to Unspecified Occlusion (blockage) or Stenosis (the narrowing of a passageway that prevents certain substance or structure from passing through as easily as it should) of Right Carotid Arteries.-Encounter for Surgical Aftercare Following Surgery on the Digestive System.-Unspecified Protein-Calorie Malnutrition.-Ulcerative Colitis (a chronic inflammatory bowel disease that affects the large intestine), Unspecified With Other Complication.-Diverticulosis (a condition where small, bulging pouches called diverticula form in the walls of the large intestine) of Large Intestine Without Perforation [NAME] a hole in) Or Abscess (a swollen area within body tissue) Without Bleeding.Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning) dated 8/26/25 showed:-The resident was cognitively intact.-The resident had no known weight loss prior to admitting to the facility.Review of the resident's undated care plan showed:-The resident had a nutritional problem or potential nutritional problem related to a mechanically altered diet.-The following interventions were in place:--Monitor weight notifying Medical Doctor (MD)/Registered Dietitian (RD) of gain/loss per protocol.--Occupational Therapy (OT) to screen and provide adaptive equipment for feeding as needed.--Provide and serve diet as ordered.--RD to evaluate and make diet change recommendations Pro re nata (PRN- as needed).Review of the resident's RD Note dated 9/11/25 showed:-The resident was being seen due to a weight warning with a decrease in weight.-The resident had lost 6.3 percent (%) of his/her weight since admission.-The RD recommended the resident be put on the supplement Boost (nutritional supplement) or an equivalent supplement three times a day.Review of the resident's Order Summary Report dated September 2025 showed:-An order for a regular diet, with a regular texture and regular consistency.-An order for Boost or Boost Breeze three times a day that was ordered on 9/13/25.During an interview on 9/15/25 at 2:18 P.M. the resident said:-He/She had lost some weight since being admitted to the facility.-He/She was unsure of the exact amount of weight that he/she had lost.Observation on 9/17/25 at 10:58 A.M. showed the resident was drinking an eight ounce Ensure (nutritional supplement) supplement drink.Review of a nurse note dated 9/18/25 showed:-All parties had been notified of the resident's weight loss including the Medical Director, RD, and Director of Nursing (DON).-Refer to the RD note dated 9/11/25.-Staff were to continue current Plan of Care (POC).-No further recommendations at that time.During an interview on 9/22/25 at 1:14 P.M. the resident said:-His/Her family brought his/her supplements up to the facility and they were stored in his/her mini fridge.-He/She had already had two Ensure drinks that day because he/she did not like the breakfast that was served.-He/She had liked the meals the day prior and had one Ensure drink the entire day.-He/She had been drinking the Ensure drinks since admission to the facility and was unaware that the facility had ordered different supplements for him/her.-Staff had not been asking him/her the amount of supplement he/she was drinking. During an interview on 9/22/25 at 2:12 P.M. the DON said:-The resident had lost weight since being admitted to the facility.-The Assistant Director of Nursing (ADON) and the DON were responsible for reviewing the RD recommendations.-He/She was unsure if supplements had been recommended by the RD for the resident.-If a supplement was ordered for the resident, then he/she would expect the staff to document when the resident received his/her supplement and the amount the resident drank.-He/She was unaware that the resident had been drinking his/her own supplements brought from home since admission.-He/She would need to talk with the RD to see if his/her recommendation would still be the same since the resident had already been drinking a nutritional supplement.Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated September 2025 showed:-Staff had not been documenting that the resident had been given his/her Boost Supplement or documenting the amount he/she drank as of 9/23/25.During an interview on 9/23/25 at 11:42 A.M. Licensed Practical Nurse (LPN) E said:-He/She was unsure if the resident had an order for a supplement.-He/She was unsure if the resident had lost weight.-Usually nursing staff would document when a supplement was given and the amount the resident drank.-He/She was unsure why staff were not documenting on the supplement order.During an interview on 9/23/25 at 12:18 P.M. Certified Medication Technician (CMT) B said:-The resident was on a supplement.-The kitchen staff or nursing staff could give residents supplements.-Regardless of who were to give the resident his/her supplement, staff would need to document when the supplement was given and how much the resident drank if indicated.-He/She was unaware that the resident was bringing in his/her own nutritional supplements.-The staff would need to store the resident's supplements in order to ensure the resident was getting the correct amount.-If the resident preferred a different supplemental drink to the one that the RD recommended, then the RD would need to be contacted to ensure that the preferred supplement was appropriate.

Based on observation, interview, and record review the facility failed to ensure two sampled residents (Resident #17 and #149) who were fed by enteral (a form of nutrition that is delivered into the digestive system as a liquid) means received the appropriate treatment and services to prevent complications of enteral feeding by failing to assess the percutaneous endoscopic gastrostomy tube (PEG tube) a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) for placement out of 31 sampled and five supplemental residents. The facility census was 122. Review of facility policy entitled Feeding Tube-Administration of Medication revised 10/24/22 showed:-Check for tube placement by checking residual.--If residual is greater than 100 milliliters (ml), withhold medications.--Reattempt administration of medications in one hour.--If residual of 100 ml or greater is obtained, hold medications and notify Attending Physician for further instructions. -Re-instill any gastric content obtained back into the tube. -If no gastric content appears, the tube may be against the lining of the stomach or the tube may be obstructed. Reposition the resident and repeat above steps. -If you continue to meet resistance as you aspirate for stomach content, stop the procedure. Notify the Attending Physician promptly. 1. Review of Resident #17's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Dysphagia (inability or difficulty swallowing) following Cerebral Infarction (stroke).-Hemiplegia and Hemiparesis (paralysis/weakness affecting one side of the body) following Cerebral Infarction affecting left non-dominate side.-Cerebral Infarction. -Encounter for surgical aftercare following surgery on the digestive system. Review of the resident's Care Plan dated 5/27/25 showed: -The resident required tube feeding related to NPO (nothing by mouth) status. -Check for tube placement and gastric contents/residual volume per facility protocol and record. -Monitor/document/report any signs/symptoms of aspiration-fever, shortness of breath, tube dislodgement, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, abdominal distension, abdominal tenderness, constipation, diarrhea, nausea, and vomiting.-Obtain and monitor lab/diagnostic work as ordered. Report results to Medial Doctor (MD) and follow up as indicated. -Provide local care to PEG-Tube site as ordered and monitor for signs and symptoms of infection.-Registered Dietician (RD) was to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. -Speech Therapy (ST) evaluation and treatment as ordered. Review of the resident's Order Summary Report dated 5/31/25 showed:-Enteral Feed Order every shift Fibersource HN (brand of enteral feed) 1.2 at 75 milliliters (ml) per hour continuous. -Enteral Feed Order every day and night shift ensure that head of bed was always up to 30-45 degrees. -NPO (nothing by mouth) diet NPO texture, NPO consistency.-Enteral Feed Order every day shift wash tube site with warm soap and water, dry thoroughly and place T sponge daily. -Flush peg tube with 150 ml of water every four hours for hydration. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/14/25 showed:-The resident had a feeding tube. -The resident's mental status was severely cognitively impaired. Observation on 9/16/25 at 1:34 P.M. showed: -Tube feeding was running at 75 ml/hour and was dated 9/15/25.-PEG tube site showed no redness or open areas. Observation on 9/18/25 at 2:32 P.M. showed: -Tube feeding was running at 75 ml/hour and was dated 9/18/25.-PEG tube site showed no redness or open areas. Observation on 9/19/25 at 1:02 P.M. of Licensed Practical Nurse (LPN) B showed:-LPN B picked up a syringe and injected 10 ml of air into the PEG tube and listened with his/her stethoscope.-LPN B then pulled back and checked residual which was zero ml of residual. During an interview on 9/19/25 at 1:10 P.M., LPN B said: -The PEG tube would be assessed for signs of infection or complications each shift. -The PEG tube would be assessed for placement by auscultation (the act of listening for sounds within the body) and residual. -This was the way he/she was taught to assess PEG tubes in nursing school.-The facility had not taught any other ways to assess PEG tube placement.-He/She followed the facility policy. During an interview on 9/23/25 at 8:30 A.M., Certified Medication Technician (CMT) A said that giving medications through a PEG tube was not in his/her scope of practice and he/she did not do anything with PEG tubes. During an interview on 9/23/25 at 8:35 A.M., LPN C said:-He/She would check PEG tube placement by auscultation, residual, and if there were numbers on the PEG tube, he would verify those. -This was how he/she has assessed PEG tubes as he was taught in nursing school. 2. Review of Resident #149's admission Record showed the resident was admitted to the facility with a diagnosis of gastrostomy (G-tube: surgical procedure that creates an opening in the stomach through the abdominal wall) Review of the resident's undated care plan showed no focus, goal, or interventions in place for the resident's G-Tube. Review of the resident's Order Summary Report dated September 2025 showed:-An order for staff to check residual and measure every shift if over 50 ml during feeding, medication administration, or flushes, then staff were to call the physician.-An order for staff to flush the G-tube with 30 ml of water before and after medication administration, flush with five to ten ml water in between medications.-An order for Gabapentin (a medication used to treat seizures and nerve pain) capsule 400 milligrams (mg), give one tablet via G-tube two times a day for Neuropathy (damage or dysfunction of the peripheral nerves, which can cause pain, burning, or prickling sensations).-An order for Ibuprofen (used to treat pain and inflammation) tablet 200 mg, give one tablet four times a day for inflammation. Observation on 9/17/25 at 2:45 P.M. of the resident's G-tube medication administration completed by LPN E showed:-LPN E prepared the Ibuprofen 200 mg tablet and Gabapentin 400 mg capsule for G-tube administration.-LPN E then went into the resident's room and placed the supplies down on a barrier.-LPN E then used a syringe to check the resident's residual.-LPN E did not get any residual into the syringe.-LPN E did not use any other way to check the placement of the G-tube.-LPN E then preceded to give the resident his/her medication. During an interview on 9/17/25 at 3:22 P.M. LPN E said he/she would not have done anything differently related to how he/she checked the placement of the resident's G-tube. 3. During an interview on 9/22/25 at 2:12 P.M. the DON said:-He/She had recently found out that the facility was not assessing PEG tubes correctly and the facility was coming up with a new policy.-Prior to the survey the expectation for assessing PEG tubes placement was to auscultate and check residual.-LPN E had not checked Resident #149's G-tube placement correctly.-If LPN E had not gotten any residual back from the G-tube, then LPN E should have contacted the facility's physician to get an order for a Kidney, Ureter, and Bladder (KUB- an x-ray that visualizes these organs) to check the G-tube placement. During an interview on 9/23/25 at 11:42 A.M. LPN E said:-Staff were to check the placement of G-tubes using two different methods.-Staff could check placement using the residual with a pH (a figure to express the acidity of a liquid) strip (a small strip of paper or other material containing a pH indicator that changes color when dipped into a liquid).-Staff could also check for placement of the G-tube by measuring the resident's G-tube.-Staff could check for placement by auscultating (listening) via a stethoscope.-He/She had not remembered how he/she had checked the resident's placement of his/her G-tube prior to the resident's medication administration. During an interview on 9/23/25 at 12:35 P.M. the Assistant Director of Nursing (ADON) said:-Staff were expected to check the placement of G-tubes by using pH strips after getting residual from the resident's G-tube.-The facility's policy was getting updated to reflect the current standard of practice when checking G-tube placement.-The policy previously stated that staff could check placement by checking for residual and auscultating.-There could be difficulty in checking G-tube placement by measurement of the tube if the facility did not have the correct measurement upon admission.-If staff were to check the placement of a G-tube by checking the pH of the residual and there was no residual, then staff were to call the provider.-The staff person had not administered the medications appropriately if/she had not checked for appropriate placement.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent (%) for one supplemental resident (Resident #149) out of five supplemental residents. Two medication errors were detected out of 28 observed opportunities resulting in an error rate of 7.14 %. The facility census was 122 residents.Review of the facility's policy titled Feeding Tube-Administration of Medication dated 10/24/22 showed staff needed to verify that medication cups were clear of any remnants of crushed pills or liquid medication. 1. Review of Resident #149's admission Record showed the resident was admitted to the facility with a diagnosis of gastrostomy (G-tube: surgical procedure that creates an opening in the stomach through the abdominal wall).Review of the resident's Order Summary Report dated September 2025 showed:-An order for staff to check residual and measure every shift if over 50 milliliters(ml) during feeding, medication administration, or flushes, then staff were to call the physician.-An order for staff to flush the G-tube with 30 ml of water before and after medication administration, flush with five to ten ml water in between medications.-An order for Gabapentin (a medication used to treat seizures and nerve pain) capsule 400 milligrams (mg), give one tablet via G-tube two times a day for Neuropathy (damage or dysfunction of the peripheral nerves, which can cause pain, burning, or prickling sensations).-An order for Ibuprofen (used to treat pain and inflammation) tablet 200 mg, give one tablet four times a day for inflammation. Observation on 9/17/25 at 2:45 P.M. of the resident's G-tube medication administration completed by Licensed Practical Nurse (LPN) E showed:-LPN E placed the Ibuprofen 200 mg tablet into a medication cup and opened the Gabapentin 400 mg capsule and poured the contents into the same cup.-LPN E then placed the contents of the medication cup into a small bag in order for medications to be crushed together.-LPN E then put the crushed medications back into the medication cup and poured 30 ml of water into the cup in order for the medications to be mixed together.-LPN E then went into the resident's room and placed the supplies down on a barrier.-LPN E then used a syringe to flush the G-tube with 30 ml of water, poured the resident's medications into the syringe, and flushed the G-tube with 30 ml of water.-LPN E did not ensure all of the medication was given to the resident. Observation on 9/17/25 at 2:52 P.M. of the resident's medication cup showed there was medication remnants left over in the cup. During an interview on 9/17/25 at 3:22 P.M. LPN E said he/she would not have done anything differently during the resident's medication administration. During an interview on 9/22/25 at 2:12 P.M. the Director of Nursing (DON) said:-LPN E had not administered the resident's medications appropriately.-He/She would have expected LPN E to put additional water into the medication cup and looked for any medication remnants to ensure the resident received the full dosage of medication. During an interview on 9/23/25 at 11:42 A.M. LPN E said:-He/She would normally fill the medication back up with water and mix it to ensure that the resident was given the full dose of medication.-He/She could not remember if he/she had done that during the resident's medication administration. During an interview on 9/23/25 at 12:35 P.M. the Assistant Director of Nursing (ADON) said:-LPN E had not administered the resident's medication appropriately.-LPN E should have ensured that the resident was given the full dosage of medication by putting more water into the medication cup and looking for any additional medication remnants.

Based on observation and interview, the facility failed to properly contain waste and refuse in outdoor dumpsters, to prevent the harboring and/or feeding of pests. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility and/or ate food from the kitchen. This facility had a census of 122 residents with a licensed capacity of 170 residents at the time of the survey.1. Observation on 9/15/25 between 11:43 A.M. and 2:41 P.M. during the initial Life Safety Code (LSC) facility outer perimeter inspection showed the following:-The south lid of the south dumpster outside the Service Hall was flipped back completely open.-The facility itself had large, wooded areas on the north and west sides. Observation on 9/17/25 at 11:44 A.M. during the LSC facility walk-through inspection with the Director Plant Operations (DPO) showed outside the Service Hall the south dumpster had both its lids flipped back open and the north dumpster had its north lid flipped back. Observation on 9/17/25 at 1:09 P.M. during the follow-up LSC facility outer perimeter inspection showed the south dumpster was overflowing with boxes and had both lids flipped back open and the north dumpster had its north lid flipped back. Observation on 9/19/25 at 8:23 A.M. during a concluding LSC facility outer perimeter inspection showed the north lid of the north dumpster was flipped back open. During an interview on 9/19/25 at 9:32 AM the Administrator said the following:-Dumpster lids should be kept closed at all times. -All departments use the dumpsters. During an interview on 9/19/25 between 10:37 A.M. and 12:59 P.M. the DPO said the following:-The housekeeping, dietary, and maintenance departments frequently use the dumpsters, but activities or nursing use was seldom.-He/She knew the lids should not be left open.-They even closed them yesterday morning in the rain.-He/She thought they had done that at least eight times during this survey.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary food preparation equipment; to keep trash dumpsters lidded; to follow correct hair hygiene practices; and to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 123 residents with a licensed capacity for 170 residents at the time of the survey. 1. Observation on 11/13/23 between 9:01 A.M. and 10:57 A.M. during the initial kitchen inspection showed the following: -There was a sticky substance on the manual can opener blade by the microwave and also on the one by the Dry Storage (DS) room. -A black handled knife in the holder by the microwave had a broken tip and two reddish stains on the blade. -There were numerous crumbs underneath the conveyer toaster unit on a food preparation table. -There were two large pieces of plastic and cardboard under the racks in the walk-in freezer. -There was plastic, cardboard, a plastic lid and foil under the racks in the walk-in refrigerator. -There was an open 1-gallon jug of teriyaki sauce in the DS room approximately (app.) 1/2 full with a label which read refrigerate after opening. -A transport cart in the DS room with snacks on the top shelf had loose Fritos around the snack packages. -A kitchen aide's hairnet only covered the hair bun on top of his/her head. Observation on 11/13/23 at 11:17 A.M. during the Life Safety Code (LSC) outer perimeter inspection with the Director of Maintenance (DOM) showed the left lid of the south dumpster in a brick walled enclosure was flipped back open. Observation on 11/14/23 at 1:25 P.M. during the LSC facility walk-through inspection with the DOM showed there was an ice machine with an ice scoop in it in the kitchenette next to the Auxiliary Dining Room. Observation on 11/15/23 at 1:58 P.M. during the follow-up LSC outer perimeter inspection showed the right lid of the south dumpster in a brick walled enclosure was propped open app. 1.5 feet (ft.) by a black trash bag. Observation on 11/16/23 at 12:17 P.M. showed there was a sign on the service hall door on the south side of the kitchen leading to the dumpsters in a brick walled enclosure which read, You MUST place the trash INSIDE the dumpster and ensure the lid is CLOSED when you're finished. During an interview on 11/17/23 at 9:31 A.M. the Dietary Manager said the following: -Food preparation areas are constantly cleaned with sanitizer after each use. -Foodstuffs should be stored at their correct temperatures. -The walk-in floors are cleaned three times a week and as needed. -Food preparation items are cleaned every day and after each use. -Damaged food preparation items are immediately thrown away. -The dietary staff have weekly re-education meetings on hygiene standards.

Based on interview and record review, the facility failed to obtain written authorizations from residents or their representatives to hold, manage, safeguard, and account for their funds for 6 sampled residents (Residents #17, #45, #51, #59, #65, and #87) out of 44 residents who had an account in the Resident Trust Fund (RTF) in accordance with standard accounting practices and principles, as required by Federal regulations and the State of Missouri statutes. This deficient practice had the potential to affect all residents who held an account in the facility's resident trust. The facility census was 123 residents with a licensed capacity for 170 residents at the time of the survey. Review of the facility's 4-page RTF policy entitled Resident Funds - Handling & Recording, revised 5/1/23 and provided by the Business Office Manager (BOM), showed at point II.A., under the heading Procedure, that When a resident elects to have the Facility manage the resident's personal funds, the resident or resident representative must sign a written statement authorizing the Facility to manage the resident's funds. 1. Review of the facility's 1-page Authorization and Agreement to Handle Resident Funds forms provided by the BOM, showed that the forms for Residents #17, #45, #51, #59, #65, and #87 were unsigned. Review of the facility's Trial Balance Sheet, dated as of 11/13/23 and provided by the BOM, showed the following: -There were 44 residents with accounts in the RTF. -The sampled residents' accounts all had positive balances. During an interview on 11/16/23 at 2:51 P.M., the BOM said: -He/she had been employed at the facility for a little over two months. -They had found the residents' Authorization and Agreement to Handle Resident Funds forms this month and began reviewing them. -As soon as he/she found that some were unsigned they knew they would have to start working on getting them signed.

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL), bathing/showering, for two sampled residents (Resident #107 and #64) and to provide bathing for for one sampled resident (Resident #37) out of 25 sampled residents by not providing scheduled baths or showers, causing poor hygiene. The facility census was 125 residents. Review of the facility's Showering a Resident policy, dated 10/24/22, showed: -A bath/shower was given to the residents to provide cleanliness, comfort and to prevent body odor. -Residents were offered a shower a minimum of once weekly and given per resident request. -Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. -Update the resident's care plan as needed. -Note: No procedure for documentation of bathing/showering and/or resident refusal was noted. 1. Review of Resident #107's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/14/23, showed: -The resident was diagnosed with traumatic spinal cord dysfunction (an injury from external physical impact that damaged the spinal cord). -The resident required a motorized wheel chair. -The resident required a mechanical lift for transfers. -The resident scored a 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. -The resident required maximum assistance for bathing/showering. Review of the shower schedule, located in the 200 hall Certified Nursing Assistant (CNA) Binder, showed the resident was scheduled for a shower on Wednesday evenings. Review of the resident's Comprehensive CNA Shower Reviews (shower sheet), showed: -On 9/11/23 the sheet was marked refused by the resident. --There was no signature of the resident present. --There was no signature of a nurse present. -On 9/22/23 the resident refused a shower. --There was no signature of the resident present. --There was no signature of a nurse present. -On 9/25/23 the sheet was marked refused by the resident. --There was no signature of the resident present. --There was no signature of a nurse present. -On 10/2/23 the sheet was marked bed bath given by a student CNA. --The sheet was signed by the CNA. --There was no signature of a nurse present. -On 10/10/23 the sheet was marked refused by the resident. --There was no signature of the resident present. --There was no signature of a nurse present. -On 10/13/23 the sheet was marked refused by the resident. --There was no signature of the resident present. --There was no signature of a nurse present. -On 10/16/23 the sheet was marked bed bath given by a student CNA. --The sheet was not signed by the CNA. -On 10/30/23 the sheet was marked bed bath given. --The sheet was not signed by the nurse. -On 11/10/23 the sheet was marked refused by the resident. --There was no signature of the resident present. --There was no signature of a nurse present. During an interview on 11/13/23 at 9:38 A.M., the resident said: -He/she could not remember when the last it was he/she had a shower or bath. -He/she was offered bed baths from time to time but preferred a shower. During an interview on 11/15/23 10:49 A.M., CNA A said: -Residents were offered a bath/shower once a week. -The facility did not employ a bath aide. -CNA's were responsible for giving baths. -There was a bath schedule at the nurse's desk. -Resident's signed bath sheets if they refused. -The resident did not refuse baths very often. During an interview on 11/15/23 at 11:10 A.M., CNA B said: -Residents received baths/showers two days a week. -If a resident refused they signed the bath sheet that said refused on it. -The resident usually did not refuse. -The resident preferred showers over bed baths. -Shower sheets were completed when residents received or refused the showers. -The shower schedule was located in the cares binder at the nurse's desk. During an interview on 11/15/23 at 11:58 A.M., the Administrator said: -Bath schedules were located in the CNA cares binder at the nurse's desk. -Bath sheets were completed by the CNA and turned into the evening shift supervisor. -The sheets had only been implemented for a week or so. During an interview on 11/16/23 at 9:29 A.M., Registered Nurse (RN) A said: -There was a book somewhere at the nurse's desk that said when residents were scheduled for a bath/shower. -He/She was unaware of a bath/shower tracking system prior to the one in the CNA cares binder. -The resident sometimes refused showers. On 11/20/23 at 12:15 P.M., the resident's bath/shower sheets were reviewed with the resident. During an interview on 11/20/23 at 12:15 P.M., the resident said he/she would not have refused that many baths/showers in a row, especially if he/she only had a bed bath in between. During an interview on 11/21/23 at 2:03 P.M., the Director of Nursing (DON) said: -The goal for resident baths/showers was to offer them twice weekly. -The company policy was once a week. -He/she could not recall if the policy took into consideration resident preference. -Shower sheets had documentation if the resident refused. -They should offer more than once if the resident refused. -CNA's and nurses both should have signed the shower sheet. -It was not the expectation to have residents sign the shower sheet but it was suggested to be a good measure. -Bed baths should be offered if the resident was ill, if they refused the bath house, in between regular showers, isolation issues, or health concerns. -Bed baths should not be offered in place of a shower. -Day to day the charge nurse, Assistant DON (ADON), DON and unit manager were responsible to ensure baths were completed. 22727 2. Review of Resident #37's comprehensive CNA shower review sheets dated September 2023 showed: -On 9/2/23, the resident received a bed bath. -On 9/30/23, the resident received a shower. Review of the resident's comprehensive CNA shower review sheets dated October 2023 showed: -On 10/2/23, the resident refused a shower and a nurse did not sign the sheet. -On 10/13/23, the resident received a bed bath. -On 10/23/23, the resident refused a shower and a nurse did not sign the sheet. -On 10/27/23, the resident received a bed bath. Review of the resident's care plan dated as revised on 11/2/23 showed the resident required total assistance of two staff with bathing/showering twice a week and as necessary. Review of the resident's comprehensive CNA shower review sheets dated November 2023 (through the morning of 11/21/23) showed the resident received a shower on 11/3/23. Review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident: -Moderately impaired cognitive skills. -Did not reject cares. -Totally dependent on staff for shower/bathing. -Used a motorized scooter. -Could not stand. -Was frequently incontinent of urine and always incontinent of bowel. -Some of his/her diagnoses included kidney failure, stroke, hemiplegia (paralysis of one side of the body) or hemiparesis (a slight paralysis or weakness on one side of the body) and respiratory failure. -Was on dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein). During an interview on 11/21/23 at 1:30 P.M., the resident said: -He/she wanted two showers per week. -He/she was not getting two showers per week. -The facility staff wanted him/her to take a shower at 6:00 P.M. but he/she was thinking about bed time by then and would rather have a shower in the morning. During an interview on 11/21/23 at 2:00 P.M., the DON said: -The resident was supposed to be bathed twice a week. -Tuesday and Saturday were his/her shower days. -The resident was scheduled for evening showers. -He/she was not aware of the resident not wanting evening showers. -The resident had refused showers in the shower house sometimes because he/she had severe motion sickness. -They identified there were problems with the residents getting showers but now he/she saw some additional areas they needed to work on. 39469 3. Review of Resident #64's Annual MDS dated [DATE] showed he/she was admitted on [DATE] with the following diagnoses: -Stroke (damage to the brain from interruption of its blood supply). -Alzheimer's (a progressive disease that destroys memory and other important mental functions). -Aphasia (loss of ability to understand or express speech, caused by brain damage). -His/Her Brief Interview for Mental Status (BIMS) was a 6 out of 15 indicating he/she was severely cognitively impaired. -He/She was dependent on staff for showers. Observation on 11/13/23 at 10:37 A.M. showed: -The resident was sitting in his/her room. -His/her nails were long and dirty. -There were crumbs on his/her sweatshirt. -His/her hair was matted down. Observation on 11/14/23 at 2:00 P.M. showed the resident was wearing the same dirty clothes. -There were the same stains on his/her sweatshirt . -His/her nails were long and dirty. -His/her hair was matted down in the back. During an interview on 11/15/23 Licensed Practical Nurse (LPN) E said: -The resident had refused showers. -The CNA's were to check the shower book at the nurses' station to see who was scheduled for a bath that day. -The CNA's were to fill out a shower sheet and give it to the nurse. -The residents were to have been offered a shower twice a week. -If the resident refused then it should have been written on the shower sheet. -Cutting the resident's nails should have been documented on the bath sheet as it was part of getting a shower. -The resident's nails were long and should have been cut. -The resident had been resistant to showers. -The resident could get physically abuse during cares. Record review of the CNA shower book showed the resident was scheduled for a shower on Sundays during the day shift. Observation on 11/16/23 at 8:00 A.M. showed: -The resident had the same clothes on with the stains on them. -His/her hair was matted down. -His/her nails were long and dirty. During an interview on 11/16/23 at 10:24 A.M. LPN F said: -They don't always have a shower aid. -The CNA's usually have to help with the baths. -The CNA's look in the book to see who needed a bath on that day. -The nurse verified the resident was only scheduled for one bath a week on Sundays. -He/she had said the resident sometimes would refuse cares but that should be documented on the computer. -The resident should have been scheduled for two a week but he/she had changed rooms and for some reason he/she was scheduled for only one shower a week. -It had slipped through the crack. During an interview on 11/16/23 at 11:00 A.M. CNA H said: -They look at the notebook at the nurses's station to see who needed a bath or shower that day. -If the resident refused it was documented on the shower sheet. -The shower sheet went to the charge nurse. -The residents should have two showers a week including cutting toe nails and finger nails or would be put on the list to see the Podiatrist. Review of the shower notebook at the nurses' station on 11/17/23 showed the resident was scheduled in the shower/bath book for one day (Sunday) only. Review of the shower sheets dated November 2023 showed: -The resident was offered showers on the following days:--11/2/23, 11/6/23, 11/10/23, 11/13/23, and 11/16/23. -None of the days he/she was offered a shower were a Sunday. -The resident refused each day. -There was no documentation the resident had a shower the first 17 days of November. -The charge nurse had not signed the shower sheets. -There was no documentation the resident had been offered a shower on a different time. Review of the bathing sheet on the computer dated November 2023 showed: -The resident was to have a bath or shower on Mondays and Thursdays. -The sheet showed the resident had a refused a bath or shower on the following days: --11/2/23, 11/6/23, 11/9/23, 11/13/23, and 11/15/23. -None of those dates were a Sunday. During an interview on 11/20/23 at 1:15 P.M. CNA H said: -He/she looked in the shower book at the nurses' station and the resident was to have a shower on Sundays. -He/she could not find a second day the resident was to receive a shower. -He/she saw the resident looked like he/she needed a shower so offered it on a different day. -The resident could be aggressive at times. -The resident had not received a shower during the month of November except for last Friday 11/17/23. -He/she did not cut the resident's fingernails. -He/she had not had the charge nurse sign the shower sheets when the resident refused a shower. -Maybe he/she should have taken a second CNA in the resident's room to help get him/her into the shower. -He/she had not tried a second time to get the resident into the shower. During an interview on 11/20/23 at 1:20 P.M. LPN H said: -The resident's nails were long and dirty. -The resident only had one bath this month. -The resident should have been offered a bath a second time. -The charge nurse should have been notified that he/she had refused the shower and signed the sheet. -His/Her nails should have been cut and cleaned. During an interview on 11/21/23 at 2:00 P.M. the DON said: -The company policy said the residents were to have been offered one bath a week. -The resident's clothes should have been changed daily. -If a resident had refused a shower it should have been documented on the computer and the shower sheet. -Staff should have tried more than once to get the resident to take a shower. -Other attempts to have the resident shower also should have been documented. -The nurse and the CNA both should have signed the shower sheet if the resident refused to take a shower. -The charge nurse was responsible to ensure the residents had a shower. -The shower sheets were sent to the ADON and from there to the DON. -There was a task bar on the computer that popped up to remind staff when a resident was scheduled for a shower. -There was a notebook at the nurses' station that the CNA's looked at to see who needed a shower on that date. -The Unit Manager and ADON were responsible to ensure new residents were included in the shower rotation.

Based on observation, interview, and record review, the facility failed to ensure the narcotic count was correct by not ensuring two nurses were counting the narcotic medications at the beginning and end of each shift, and signing at the time the nurses counted the medications; to ensure nurses were not pre-signing the medication count sheet before counting with the second nurse; to ensure the two nurses verified the amount in the medication container was the same amount that was on the medication sheet for three sampled residents, (Resident #109, #19, and #114), and to ensure there were no expired medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Medication Storage-Controlled Medication storage dated 11/'17 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. -The Director of Nursing (DON) and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. -only authorized licensed nursing and pharmacy personnel have access to controlled medications. -A controlled medication accountability record is prepared when receiving inventory of a Schedule II (controlled) medication and the following information is completed: --Name of resident. --Prescription number. --Name, strength (if designated), and dosage form of medication. --Date received. --Quantity received. --Name of person receiving medication. -At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. -The nursing care center may elect to count all controlled medications at shift change. -Any discrepancy in controlled substance medication counts is reported to the DON immediately. -The DON or designee investigates and makes every reasonable effort to reconcile all reported discrepancies while nurses remain on duty. -The DON, in a report to the administrator, documents irreconcilable discrepancies. -If a major discrepancy or a pattern of discrepancies occurs or if there is apparent criminal activity, the DON notifies the administrator, pharmacy manager, and consultant pharmacist immediately. -If diversion is discovered and substantiated, timely notifications must be made to appropriate agencies, such as: --Local law enforcement. --DEA. --State Board of Nursing. -Current controlled medication accountability records are kept in the Medication Administration Record (MAR) or narcotic book. -When completed, accountability records are submitted to the DON and maintained on file at the nursing care center. -The consultant pharmacist, or pharmacy designee, routinely reviews a sampling audit of controlled medication storage, records and expiration dates during the medication storage inspections. Review of the facility's Medication Storage-Storage of Medications policy dated 01/21 showed: -Medications and biological's (therapeutic substance, such as a vaccine or drug) are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. -The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements. -Medications are to remain in these containers and stored in a controlled environment which may include such containers as: --Medication carts. --Medication rooms. --Medication cabinets. --Or other suitable containers. -Controlled medications must be stored separately from non-controlled medications. -The access system (key, security codes) used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. -Schedule II medications and preparations must be stored in a separately locked permanently affixed compartment. -In order to limit access to prescription medications, only licensed nurse, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. -Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by person with authorized access. -Potentially harmful substances (such as household poisons, cleaning supplies, and disinfectants) are clearly identified and stored in an area separate from medications. -Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures foe medication disposal. -Medication storage should be kept clean, well lit, organized and free of clutter. -Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. 1. Observation on 11/15/23 at 5:18 A.M. of the East side medication room overstock storage cupboard showed the following expired medications: -Albuterol Sulfate (a medication used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases) inhalation (breathing in) Solution 0.083% 2.5 mg/3 ml. 11 packages of five vials each with the expiration date of September 2023. -Licensed Practical Nurse (LPN) C removed the expired medications. During an interview on 11/15/23 at 5:18 A.M. LPN C said he/she would destroy the medications with Registered Nurse (RN) B. 2. Review on 11/15/23 at 5:35 A.M., of the East side Nurses narcotic count sheet dated 10/31/23 11:00 P.M. to 11/15/23 7:00 A.M., showed: -On 11/4/23 the day shift nurse did not sign off at 7:00 P.M. for the off going shift. -On 11/6/23 the night shift nurse did not sign off at 7:00 A.M. for the off going shift. -On 11/11/23 the night shift nurse did not sign off at 7:00 A.M. for the off going shift. -On 11/12/23 the night shift nurse did not sign off at 7:00 A.M. for the off going shift. -On 11/12/23 the day shift nurse did not sign off at 6:00 P.M. for the off going shift. -On 11/15/23 the night shift nurse pre-signed for the off going shift when he/she signed on 11/14/23. Review on 11/15/23 at 5:35 A.M., of the East side Certified Medication Technician (CMT) narcotic count sheet dated 10/31/23 11:00 P.M. to 11/15/23 7:00 A.M. showed: -On 11/3/23 the night shift nurse did not sign on at 11:00 P.M. for the oncoming shift. -On 11/4/23 the night shift nurse did not sign off at 7:00 A.M. for the off going shift. -On 11/4/23 the night shift nurse did not sign on at 11:00 P.M. for the oncoming shift. -On 11/5/23 the night shift nurse did not sign off at 7:00 A.M. for the off going shift. -On 11/6/23 the night shift nurse did not sign off at 8:00 A.M. for the off going shift. -On 11/7/23 no times noted and only one entry with no oncoming signature. -On 11/8/23 the day shift nurse did not sign on at 8:00 A.M. for the on-coming shift. -On 11/15/23 the night shift nurse pre-signed for the off going shift when he/she signed on 11/14/23 for the night shift on-coming. During an interview on 11/15/23 at 6:00 A.M., RN B said: -The narcotic count was done at the begging of each shift change. -The narcotic count sheet should not be pre-signed for any shift. -He/She had pre-signed for 11/15/23 before the end of shift. During an interview on 11/15/23 at 6:05 A.M., LPN C said: -The narcotic count sheet should not be pre-signed before the count was done. -Signing the narcotic count sheet was verifying the count was correct. During an interview on 11/15/23 at 6:15 A.M., LPN D said: -The narcotic count sheet should not be pre-signed. -There were times when he/she had come on and the night nurse had pre-signed the narcotic count sheet sheet. -At times there were no signatures on the narcotic count sheet for a shift. -Each nurse should always sign at the time of the count for either coming on or going off. 3. During an interview on 11/21/23 at 2:00 P.M., the DON said: -Medications should be checked for expiration dates monthly in both the medication carts and the overstock cupboards. -The nurses should be checking expiration dates when administering the medications. -The nurse managers should be checking the expiration dates when doing the audits of the medication carts and the medication rooms. -The expired medications should be removed and destroyed with two nurses and documented on the destruction form. -Narcotic medications should be counted at each shift change or when the narcotic keys are transferred from one nurse to another nurse. -The narcotic medications were recorded on the narcotic count sheet. -The oncoming and the off going nurses count the narcotics together and sign that it was correct. -The nurses should not pre-sign in the off going space on the narcotic count sheet when they sign as oncoming. 39469 4. Observation and review on 11/15/23 at 4:55 A.M. of the 600 Hallway medication cart, narcotic count sheet with LPN A showed: -The directions on the top of the narcotic count sheet showed; a count should have occurred anytime the keys were exchanged. -Any discrepancies should have been reported to the DON immediately. -The narcotic sheet was not signed by the nurse when he/she came on shift. During an interview on 11/15/23 at 4:55 A.M. LPN A said: -He/she had counted the narcotics but did not sign the narcotic count sheet. -The narcotics should have been counted then signed by the two nurses who counted them when they came on shift or left the shift. Review of the medication count sheet on 11/15/23 at 5:05 A.M. of the 400 Hall medication cart dated 11/10/23 to 11/15/23 with LPN A showed: -On 11/10/23 evening shift, the oncoming nurse did not sign. -On 11/12/23 there was no documentation for the A.M. shift. -On 11/12/23 there was no documentation for the P.M. shift. -On 11/13/23 night shift the number of cards was blank. -On 11/13/23 night shift only one signature. -On 11/14/23 no documentation for the evening shift. -On 11/15/23 the night nurse pre-signed the day shift before the day nurse came on shift. During an interview on 11/15/23 at 5:05 A.M. LPN A said: -He/she had pre signed the medication count sheet. -He/she knew he/she was not supposed to pre sign the sheet before the day nurse arrived to count with him/her. Review of the medication count sheet on 11/15/23 at 5:10 A.M. of the 200 Hall CMT cart dated 10/23/23 to 10/31/23 with LPN B showed: -On 10/24/23 evening shift the number of cards at the end of the shift was blank. -On 10/24/23 there was no documentation for the P.M. shift. -On 10/25/23 there was no documentation for the P.M. shift. -On 10/26/23 day shift the number of cards at the end of the shift was blank. -On 10/27/23 day shift the number of cards at the end of the shift was blank. -On 10/27/23 night shift there was no documentation. -On 10/28/23 day shift there was no documentation. -On 10/28/23 night shift there was no documentation. -On 10/29/23 day shift there was no documentation. -On 10/29/23 night shift there was no documentation. -On 10/31/23 day shift the number of cards at the beginning and end of the shift was blank. -On 10/31/23 day shift there was no on coming signature. Review of the medication count sheet on 11/15/23 at 5:10 A.M. of the 200 Hall CMT cart dated 11/1/23 to 11/15/23 with LPN B showed: -On 11/1/23 day shift the number of cards at the end of the shift was blank. -On 11/1/23 night shift the number of cards at the end of the shift was blank. -On 11/1/23 night shift there was no signature for the oncoming shift. -On 11/2/23 day shift the number of cards at the end of the shift was blank. -On 11/2/23 day shift there was no off going signature. -On 11/2/23 night shift there was no documentation. -On 11/3/23 day shift the number of cards at the end of the shift was blank. -On 11/3/23 day shift there was no signature for the oncoming shift. -On 11/3/23 night shift the number of cards for the on coming and off going shift was blank. -On 11/3/23 night shift there was no signature for the off going shift. -On 11/4/23 day shift the number of cards for the oncoming and off going shift was blank. -On 11/4/23 day shift there was no signature for the oncoming shift -On 11/4/23 night shift there was no documentation. -On 11/5/23 day shift there was no documentation. -On 11/5/23 night shift there was no documentation. -On 11/6/23 night shift there was no signature for the oncoming shift. -On 11/7/23 day shift the number of cards at the end of the shift was blank. -On 11/7/23 day shift there was no signature for the off going shift. -On 11/7/23 night shift there was no documentation. -On 11/8/23 day shift there was no signature for the oncoming shift. -On 11/8/23 night shift there was no documentation. -On 11/9/23 day shift there was no signature for the off going shift. -On 11/10/23 day shift there was no signature for the off going shift. -On 11/10/23 day shift there was no signature for the off going shift. -On 11/11/23 day shift there was no documentation. -On 11/22/23 night shift there was no documentation. -On 11/13/23 night shift there was no signature for the oncoming shift. -On 11/14/23 day shift there was no documentation. -On 11/14/23 night shift there was no documentation. During an interview on 11/15/23 at 5:10 A.M. LPN B said: -The narcotics had not been counted since the morning of 11/13/23. -There was only one signature on that day. -There were many blanks on the medication count sheet. -He/she had pre-signed the narcotics count sheet before counting the narcotics with the oncoming nurse. -The narcotics should have been counted with the oncoming nurse, and both nurses should have signed at that time. Review of the narcotic count sheet of the 300 hall CMT cart dated 10/3/23 to 10/31/23 showed: -Directions on the narcotic count sheet showed the count was to have been done at the beginning and end of each shift. -On 10/3/23 day shift showed an end of shift count was blank. -On 10/3/23 day shift the off going signature was blank. -On 10/4/23 day shift was blank except an off going signature. -On 10/4/23 night shift was blank except an oncoming signature. -On 10/5/23 day shift showed the end of shift count was blank. -On 10/5/23 day shift did not show an oncoming signature. -On 10/6/23 day shift there was no documentation. -On 10/6/23 night shift there was no documentation. -On 10/7/23 day shift the oncoming signature was blank. -On 10/8/23 day shift there was no documentation. -On 10/8/23 night shift there was no documentation. -On 10/9/23 day shift there was no documentation. -On 10/9/23 night shift there was no documentation. -On 10/10/23 day shift there was no documentation. -On 10/10/23 night shift there was no documentation. -On 10/11/23 day shift the oncoming signature was blank. -On 10/12/23 day shift the start count was blank. -On 10/12/23 day shift there was no off going signature. -On 10/12/23 night shift there was no documentation. -On 10/13/23 day shift there was no documentation. -On 10/13/23 night shift there was no documentation. -On 10/14/23 day shift there was no documentation. -On 10/14/23 night shift there was no documentation. -On 10/15/23 day shift there was no documentation. -On 10/15/23 night shift there was no documentation. -On 10/16/23 day shift there was no end count. -On 10/16/23 day shift there was no oncoming or off going signatures. -On 10/16/23 night shift there was no documentation. -On 10/17/23 day shift there was no documentation. -On 10/17/23 night shift there was no documentation. -On 10/18/23 day shift there was no documentation. -On 10/18/23 night shift there was no documentation. -On 10/19/23 day shift there was no documentation. -On 10/19/23 night shift there was no documentation. -On 10/20/23 day shift there was no end count. -On 10/20/23 day shift there was no off going signature. -On 10/20/23 night shift there was no documentation. -On 10/22/23 day shift there was to oncoming signature. -On 10/22/23 night shift there was no documentation. -On 10/23/23 day shift there was no documentation. -On 10/23/23 night shift there was no documentation. -On 10/24/23 day shift there was no documentation. -On 10/24/23 night shift there was no documentation. -On 10/25/23 day shift there was no documentation. -On 10/25/23 night shift there was no documentation. -On 10/26/23 day shift there was no start count. -On 10/27/23 day shift there was no documentation. -On 10/27/23 night shift there was no documentation. -On 10/28/23 day shift there was no oncoming signature. -On 10/27/23 night shift there was no documentation. -On 10/29/23 day shift there was no documentation. -On 10/29/23 night shift there was no documentation. -On 10/30/23 day shift there was no start count. -On 10/30/23 there was no off going or oncoming signatures. -On 10/31/23 day shift there was no documentation. -On 10/31/23 night shift there was no documentation. Review of the narcotic count sheet of the 300 hall CMT cart dated 11/1/23 to 11/14/23 showed: -On 11/1/23 day shift there was no documentation. -On 11/1/23 night shift there was no documentation. -On 11/2/23 day shift there was no documentation. -On 11/2/23 night shift there was no documentation. -On 11/3/23 day shift there was no documentation. -On 11/3/23 evening shift there was no off going or oncoming signatures. -On 11/4/23 day shift there was no oncoming signature. -On 11/4/23 night shift there was no documentation. -On 11/5/23 day shift there was no documentation. -On 11/5/23 night shift there was no documentation. -On 11/6/23 day shift there was no documentation. -On 11/6/23 night shift there was no documentation. -On 11/7/23 day shift there was no oncoming signature. -The next entry did not have a date, time, or beginning count, it had an ending count and the off going and on coming signatures. -On 11/8/23 day shift there was no documentation. -On 11/8/23 night shift there was no documentation. -On 11/9/23 day shift there was no documentation. -On 11/9/23 night shift there was no documentation. -On 11/10/23 day shift there was no documentation. -On 11/10/23 night shift there was no documentation. -On 11/11/23 day shift there was no on coming signature. -On 11/12/23 day shift there was no documentation. -On 11/12/23 night shift there was no documentation. -On 11/13/23 day shift there was no documentation. -On 11/13/23 night shift there was no documentation. -On 11/14/23 day shift there was no documentation. -On 11/14/23 night shift there was no documentation. Observation and interview on 11/15/23 at 7:50 A.M. of the 300 hall CMT cart with the ADON showed: -The total Narcotic card count sheet showed 13 cards there were 14 cards. -The ADON verified the count was 14 cards. -The narcotic cards had not been counted since 11/11/23 many dates did not have the two required signatures. -The cards should be counted at the every shift. -He/she said there should be two signatures per shift counted by the ongoing and off going nurses and signed when they count together. -The charge nurse was responsible for ensuring two nurses were counting at the beginning and end of the shift. -The charge nurse should have looked to ensure the narcotic count was correct. Review of the Narcotic count sheet on 11/15/23 at 8:00 A.M. showed: -On 10/30/23 the night shift showed the end card count to have been 14 cards. -The date may have been 10/29/23. -On 10/30/23 day shift the beginning count should have been 14 cards, it showed 13 cards. -They received three cards which should have equaled 17 cards. -On 11/3/23 evening shift received two cards and two cards were removed for a total of 17 cards. -On 11/7/23 day shift removed one card for a total of 16 cards. -On 11/11/23 day shift added two cards and removed one card for a total of 17 cards. -There were 14 cards verified by the ADON. 5. Review of Resident #109's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Epilepsy (a disorder in which nerve cell activity in the brain was disturbed, causing seizures (a burst of uncontrolled electrical activity between brain cells that cause temporary abnormalities in muscle tone or movement). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 9/21/23 showed: -His/Her Brief Interview for Mental Status (BIMS) score was 00 out of 15 indicating he/she was not able to complete the test. -He/She had a seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain). Review of the resident's Physician Order Sheet (POS) dated November 2023 showed the following order for Vimpat (Lacosamide - a medication used to treat seizures), oral solution 10 milligram (mg)/milliliter (ml) give 10 ml by mouth morning and evening daily. Review of the resident's Medication Administration Record (MAR) dated November 2023 showed the medication had been signed off as given every morning and evening as ordered. Review of the narcotic count of the 200 hall nurses cart on 11/15/23 at 6:30 A.M. with the DON showed: -The resident had a 200 ml bottle of Lacosamide prescribed by the physician. -There were 37 mls in the bottle. -There should have been 10 mls in the bottle according to the count sheet. Review of the resident's Controlled Drug Record for Lacosmide showed: -The count sheet showed there should have been 10 mls in the bottle. -The DON confirmed that there was 37 ml in the bottle. 6. Review of Resident #19's face sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses: -Wedge compression fracture of T11-T12 vertebra (collapsing of the bone in front of the spine and leaving the back of the same bone unchanged, resulting in the vertebra taking on a wedge shape). -Age related osteoporosis without current pathological fracture (a condition in which the bones become weak and brittle). -The resident was receiving Hospice (care focused on the care, comfort, and quality of life for a person with a serious illness who was approaching the end of life) services. Review of the resident's Significant change MDS dated [DATE] showed: -His/her BIMS score was 6 out of 15 indicating he/she was severely impaired. -He/she had pain. Review of the resident's undated care plan showed: -He/she had chronic neck pain. -He/she had a terminal prognosis (a person who may only have a short time to live) related to Cardiovascular Disease (Heart). Review of the resident's POS dated November 2023 showed an order for Morphine Sulfate 20 mg/0.5 ml to give 1.0 ml. every two hours as needed for pain. Review of the narcotic count sheet of the 200 hall nurses cart on 11/15/23 at 6:30 A.M. with the DON showed: -The resident had a 30 ml bottle of Morphine. -15.5 ml had been administered. -There was 18 ml in the bottle. -There should have been 14.5 ml left in the bottle. -The DON verified there was 18 ml left in the bottle. During an interview on 11/15/23 at 6:35 A.M. the DON said: -He/She did not know how this had happened. -He/She took the bottles to his/her office to investigate more. 7. Review of resident's #114's face sheet showed the resident had been admitted to the facility on [DATE] with the following diagnosis of benign neoplasm of the meniges (tumors from the membrane that covers the brain and spinal cord). Review of the resident's quarterly MDS dated [DATE] showed: -He/She had a medically complex assessment. -His/Her BIMS score was 00 out of 15 indicating he/she was not able to complete the test. -He/She had communication problems. -He/She had Stage III pressure ulcers (Full thickness skin loss that extended through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Review of the resident's POS dated November 2023 showed the following order Oxycodone (Narcotic pain medication) 5 mg/5 ml via tube every six hours as needed for pain. Review of the Controlled Drug Receipt sheet on 11/15/23 at 7:30 A.M. sheet showed: -The resident had two 60 ml bottles of medication, bottle #1 and bottle #2. -Bottle #1 had 25 ml in it. -The count sheet showed there should have been 15 ml in bottle #1. -The entry on 11/5/23 had been crossed out, the total should have been 20 ml. -Bottle #2 had 50 ml in it. -The count sheet showed there should have been 55 ml in bottle #2. -The amounts in bottles #1 and #2 were verified by the Assistant Director of Nursing (ADON). Review of the 300 hall medication cart on 11/15/23 at 7:30 A.M. with the ADON showed the ADON verified the amounts of medication in the resident's bottles of Oxycodone was not correct. Review of the resident's MAR dated November 2023 showed: -The medication had not been signed off as administered in November. -Comparing the MAR to the controlled drug receipt sheet, 5 ml from bottle #2 was signed off as administered on 11/6/23. -Comparing the MAR to the controlled drug receipt sheet, 5 ml from bottle #1 was signed off as administered on 11/11/23. -During an interview on 11/15/23 at 7:35 A.M. the ADON said: -He/she did not know how the amounts could be off on the counts. -He/she was taking the bottles to the DON to notify him/her of the issues. -The charge nurse should have been auditing the narcotics and the narcotic count sheets to verify the amounts were correct. 8. During an interview on 11/15/23 at 9:00 A.M. the ADON said: -There should have been two nurses signing the medication sheets at the beginning and end of their shifts. -There should not have been any blank spaces where they had not signed. -There was always a little extra medication in the liquid medications. -You could not count what amount was in the neck of the bottle above the measuring line. -He/She didn't worry about that he/she just subtracted the amount from what was on the count sheet. -If the count was off he/she would have told the DON. -The Pharmacy came every month and looked at the medications. The Hospice Pharmacy was attempted to call twice with a message left, they did not return the phone call. During an interview on 11/20/23 at 1:30 P.M. the Medical Director said: -The narcotics count should be signed by the two nurses who counted them at the time they were counted. -There have been issues at the facility in the past regarding there were less medications than what was on the count. -If the medication count was off the staff should have more education. During an interview on 11/21/23 at 9:20 A.M. the Pharmacist said: -Some liquid medications were poured into a bottle like the Lacosomide there might be four to five extra mls in the bottle. -They did not measured the medicine before they pour it into the bottle, They eyeball it. -The extra was not accounted for when sent to the facility. -If the prescription was for 30 mls and 35 mls was sent the facility or resident was not charged for the extra 5 mls. -He/she did not know how the facility dealt with the extra 5 mls or so that was sent. -Oxycodone was sent in a bottle sealed at the factory and usually had an extra 2 mls to 3 mls in the bottle. -Someone from their pharmacy came out to the facility to look at the medications. -He/she was not sure if they did a verification of the narcotics. During an interview on 11/21/23 at 9:40 the Pharmacy Director said: -There was a group of their Pharmacists that went out to the facilities to consult. -They would have done a medication review, chart audits, and check the narcotics to ensure the count was correct. -They poured the medication into the bottles and eyeball the amount. -There should not be more than a 3 ml difference. -He/she was not aware of any issues at the facility. During interview on 11/21/23 at 2:00 P.M. the DON said: -The on coming and off going nurse was responsible for counting the narcotics and ensuring the count was correct at the start and end of each shift or whenever the keys to the medication cart was handed off. -Staff was expected to sign with a second nurse at the same time they count together. -They should not pre sign the narcotic sheets. -If staff found the count was off they first should verify it was off. -If the count was off the ADON or DON should have been notified immediately. -The unit manager and ADON were supposed to have been doing audits. -The Pharmacy came in monthly and would look at the carts. -They should have been looking for expired medications in the cart. -The Registered Nurse (RN) consultant came in monthly and did a more thorough audit. -The RN watched the medication pass. -The RN would provide education. -The RN was at the facility in August 2023.

Based on observation, interview, and record review, the facility failed to ensure the medication carts were locked when staff was not in attendance of them, to ensure the keys to the medication cart which contained narcotics were not accessible to anyone walking by the medication cart, to ensure cleaning supplies were not in with the residents medications, to ensure other objects were not in with the residents medications, to ensure the residents prescribed medication had a date written on them after opening, and to have a policy of how to open the automated medication machine if the power went out. The facility census was 123 residents. Review of the facility's policy, Medication Storage, Controlled Medication Storage, dated 11/17 showed: -The Director of Nursing (DON) and the consultant pharmacist monitored for compliance with the federal and state laws and regulations in the handling of controlled medications. -Only authorized licensed nursing and pharmacy personnel would have access to controlled medications. -The medication nurse on duty maintained possession of the key to controlled medication storage areas. -The DON would keep back-up keys to all medication storage areas, including those for controlled medications. Review of the facility's policy, Storage of Medications, dated 01/21 showed: -The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Schedule II medications (drugs with a high abuse risk, but also have safe and accepted medical uses) must be stored in a separately locked permanently affixed compartment. -Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. -Potentially harmful substances (such as cleaning supplies) were to have been clearly identified and stored in an area separate from medications. -Medication storage should have been kept clean, organized and free of clutter. -Medication storage conditions were to have been monitored on a regular basis as a random quality assurance check. 1. Observation on 11/15/23 at 4:55 A.M. of the 600 Hallway medication cart showed: -The medication cart was unlocked without a nurse in sight. -The keys to the medication cart which included the keys to the locked narcotic drawer inside of the medication cart was on top of the unlocked cart. -One resident walked by within two feet of the cart. Observation on 11/15/23 at 5:05 A.M. of the 400 Hall medication cart showed: -The keys to the medication cart and narcotic drawer were on top of the unlocked cart. -There was no nurse in attendance of the medication cart for 10 minutes. -One resident went by the medication cart within two feet of the cart. During an interview on 11/15/23 at 5:20 A.M. Licensed Practical Nurse (LPN) B said: -The medication cart should have been locked if staff were not in front of it. -The keys should not have been on top of the cart. 2. Continuous observation on 11/15/23 from 6:00 A.M. to 6:30 A.M. of the nurses medication carts at the nurses station showed: -The 200 hall medication cart was unlocked. -The 400 hall medication cart was unlocked. -There were six residents sitting in front of the nurses station within an arms reach of two of the unlocked medication carts. -LPN B left the nurses' station for three minutes then returned to the nurses' station. -LPN B left the nurses' station for four minutes then returned to the nurses' station. -LPN B left the nurses' station for six minutes with the kitchen manager to see where to get food supplies. Observation on 11/15/23 at 6:30 A.M. with the Director of Nursing (DON) showed: -There were four nurses' medications carts sitting at the nurses's station that were unlocked with no nurses in attendance. -There were six residents sitting at the nurses' station within reach of the unlocked medication carts without a nurse present. 3. Observation on 11/15/23 at 5:40 A.M. of the 400 hall nurses' medication cart with LPN A showed: -There was a container of bleach wipes in the same compartment as residents prescribed medications. -A resident's prescribed medication, Levetiracetam (medication used to treat seizures - a burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities in muscle tone or movement) 100 gram (gm) 5 milliliter (ml) bottle was opened with no date on it. -There was a used butter knife in with the residents' prescribed medications. -A resident's Lacosamide (medication used to treat seizures) 300 ml give 5 ml was opened without the date opened written on it. -A resident's prescribed medication Morphine Sulfate (pain medication) a 30 ml bottle was opened without the date opened written on it. During an interview on 11/15/23 at 5:45 A.M. LPN A said: -There should not have been a butter knife in the the residents' medications. -Medication that had been opened should have had the date that it had been opened written on it. -Bleach wipes should not have been in with the medications. Observation on 11/15/23 at 7:30 A.M. of the 300 hall medication cart with the Assistant Director of Nursing (ADON) showed: -There were bleach wipes in the same compartment with a resident's prescribed medication Cyclosporine (medication used to treat dry eyes) eye drops (gtts). Observation on 11/15/23 at 7:50 A.M. of the 300 hall Certified Medication Technician (CMT) cart with the ADON showed: -There were bleach wipes in with a resident's prescribed Restasis (medication used to treat dry eyes) 0.05 % eye gtts. 4. During an interview on 11/15/23 at 7:15 A.M. the Administrator and DON said: -They had two pyxis (automated medication dispensing machines) in the building. -They did not know what to do if the electricity went out. -The facility did not have a generator. -If the pyxis machine went down they did not have a key to open it for emergency medications. -They did not think there was a policy for that issue. 5. During an interview on 11/15/23 at 8:00 A.M. the ADON said: -Said there should not have been bleach wipes in with the resident's medications. -There should not have been a butter knife in with the residents' medications. -Medications that had been opened should have the date they were opened written on them. -The medication carts should never have been left unlocked without a nurse in front of it. -The nurse should never have left the keys on top of the unlocked medication cart and walked away. -Whoever had used the cart was responsible for ensuring it was clean, did not have any foreign objects in it, was responsible to ensure medications that had been opened had the date opened written on it, and was responsible to ensure cleaning agents like bleach wipes were not in the same drawer as the medications. During an interview on 11/22/23 at 2:00 P.M. the DON said: -Bleach wipes and silver ware should not have been in the medication cart with the residents' medications. -The medication carts should have been locked if the nurse was not in front of them. -The keys to the cart should not have been left on top of the medication cart. -The nurse manager should have been doing random audits during their daily rounds to ensure the medication carts were locked.

Based on observation, interview and record review, the facility failed to ensure urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was kept off of the floor for one sampled resident (Resident #60) out of four residents sampled for urinary catheters and to properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Residents #10 and #218) out of five residents sampled for TB screening. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 123 residents. Review of the facility's policy titled Tuberculosis - Screening dated as revised on 10/24/22 showed: -The facility screened referrals for admission and readmission for information regarding exposure to, or symptoms of TB and checks results of recent (within 12 months) TB skin tests (TST). -Any resident without documented negative TST within the previous 12 months received a baseline (two-step) TST. -When the first TST was negative, a follow-up TST was administered one to three weeks after the initial test was read. -No instructions on when to read the TSTs. -No instructions on where to document the administration and results of the TSTs. 1. Review of Resident #10's entry tracking record showed the resident admitted to the facility on [DATE]. Review of the resident's immunization record showed: -No documentation of when the resident's step one TST was administered. -The resident's step one TST was read on 7/21/23 and the results were negative (0 mm). Review of the resident's Medication Administration Record (MAR) dated July 2023 showed: -A physician's order to give the resident a step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The TST was administered on 7/31/23 and the location was left. Review of the resident's MAR dated August 2023 showed: -A physician's order to read the resident's step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The step one TST was read on 8/1/23 and the result was 0 (11 days after 7/21/23 and one day after 7/31/23). Review of the resident's immunization record showed the resident's step two TST was read on 8/4/23 (one day late if it was administered on 7/31/23) and the result was negative (0 mm). Review of the resident's MAR dated August 2023 showed: -A physician's order to give the resident a step two TST seven to 21 days after the first step, one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The TST was administered on 8/9/23 and the location was left forearm. -There was no date the second TST was read and there was no result documented. 2. Review of Resident #218's Minimum Data Set (MDS-a federally mandated assessment tool completed by staff for care planning) showed: -An entry tracking record showed the resident admitted to the facility on [DATE]. -A discharge assessment showed the resident discharged from the facility on 10/14/23 with the resident's return not anticipated. -An entry tracking record showed the resident admitted to the facility on [DATE]. Review of the resident's immunization record showed: -No documentation of when the resident's first TST was administered. -The resident's first TST was read on 10/4/23 and the result was negative (0 mm). -No documentation of when the resident's second TST was administered. -The resident's second TST was read on 10/24/23 and the result was negative (0 mm). -Another TST was documented on 10/30/23 as historical with no information regarding administration or reading. Review of the resident's MAR dated October 2023 showed: -A physician's order to give the resident a step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The first TST was administered on 10/4/23 on the resident's right arm. -A physician's order to read the resident's step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The first TST was read on 10/6/23 and the result was 0. -A physician's order to give the resident a step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The second TST was administered on 10/10/23 (too early) on the resident's right forearm. -A physician's order to read the resident's step one (should have been step two) TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The result on 10/12/23 was 0 mm. -A physician's order to give the resident a step one TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The third TST was administered on 10/24/23 on the resident's right forearm. -A physician's order to read the resident's TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The result of the third TST on 10/26/23 was 0 mm. -A physician's order to give the resident a TST one time only for three days, read in 48-72 hours and document it in the resident's immunization record. -The fourth TST was administered on 10/30/23 in the right arm. -There was no date the fourth TST was read and there were no results documented. Review of the resident's MAR dated November 2023 showed a physician's order for a second step TST one time only for three days, read in 48-72 hours and there was no documentation of it being administered or read. During an interview on 11/21/23 at 11:26 A.M., Registered Nurse (RN) A said: -Residents should get a two-step TST when admitted to the facility. -The evening shift charge nurse was usually the person responsible for administering the first TST and entering it onto the MAR. -They were also supposed to document the TSTs under the vaccination tab. -The TST should be read after two days and documented in the electronic health record system. -The electronic health record system automatically triggered the second TST which should be done seven to 14 days after the first TST. During an interview on 11/21/23 at 2:00 P.M., the Director of Nursing (DON) said: -The admitting nurse was responsible for administering the first TST upon admission either during the first shift the resident was admitted or the next shift. -The first TST administration should be documented on the MAR and it should also include when to read it, which is 48-72 hours from administration. -Nursing should document the TST result on the MAR. -The Assistant Director of Nursing (ADON) entered the order for the second TST which should be administered 14-21 days after the first TST. 3. Review of the facility's catheter care policy dated as revised 10/24/22 showed it did not include instructions to ensure the catheter tubing was positioned so that it would be off of the floor. Review of Resident 60's care plan dated 9/22/23 showed the resident had a urinary catheter. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Cognitively intact. -Had an indwelling catheter. -Had a diagnosis of neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Used a wheelchair. Observation on 11/14/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) E and Certified Nursing Assistant (CNA) D showed: -LPN E and CNA D transferred the resident from his/her wheelchair to his/her bed. -The resident's catheter tubing was on the floor after the transfer. -Wound care was performed on the resident's multiple wounds. -The resident's catheter tubing was on the floor until the LPN E and CNA D moved the resident back to his/her wheel chair. -LPN E told CNA D to clean the catheter tubing. -CNA D cleaned the catheter tubing. -The catheter tubing was still touching the floor. -LPN E and CNA D said the catheter tubing should not have been on the floor. During an interview on 11/21/23 at 2:00 P.M., the DON said urinary catheter tubing should not be touching the floor.

Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review [PASRR- a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed. A level I was required for all residents and a level II if the resident tested positive for any MI or ID] for two sampled residents (Residents #29 and #40) out of 25 sampled residents. The facility census was 123 residents. Record review of the facility's PASRR policy dated October 24, 2022 showed: -The Facility, as a Medicaid certified nursing facility, ensures that Level I of the PASRR is completed either by the transferring facility, upon admission, or as soon as practicable thereafter, by the Facility for all applicants, regardless of payer, to determine if they have a Mental Disorder (D) or ID. -The Facility also conducts Level I screen for current residents who have a MI or ID and experience a significant change in their condition based on Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) 3.0 guidelines. -A negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious MD or ID arises later. -A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II, which must be conducted prior to admission to a nursing facility. -A record of the prescreening should be retained in the resident's medical record. 1. Review of Resident #29's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Schizoaffective disorder (a mental health condition including schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] and mood disorder symptoms) dated 7/7/21. -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) dated 7/7/21. -Unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated 7/7/21. -Vascular dementia (is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated 9/16/21. Review of the resident's Physician Order Summary (POS) dated November 2023 showed: -Donepezil HCl (medication that treats symptoms of Alzheimer's disease like memory loss and confusion) Tablet 10 Milligrams (mg), Give 10 mg by mouth at bedtime for Dementia dated 7/7/21. -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) monitoring Monitor for signs/symptoms of depression, sadness, tiredness, trouble focusing or concentrating, unhappiness, anger, irritability, frustration loss of interest in pleasurable activities and complete progress note every shift dated 1/9/23. -Behaviors- Assess for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing cares. If resident has behaviors document and complete progress note every shift dated 1/9/23. -Escitalopram Oxalate (used to treat depression and anxiety) Tablet 10 mg, Give 10 mg by mouth in the morning for major depressive disorder dated 7/28/23. -There were no orders for the resident receiving any medications for the diagnosis of Schizophrenia at this time. Review of the resident's care plan dated 10/30/23 showed: -He/she had impaired cognitive function and has been declared incompetent by two physicians. -He/she had a potential psychosocial well-being problem. -Used antidepressant medication related to Depression. -Did not have a care plan that addressed the resident's diagnoses of: --Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) or mood behaviors. --Dementia. Review of the resident's Quarterly MDS dated [DATE] showed the resident had the following diagnoses: -Cognitive Loss/Dementia. -Schizophrenia. Review of the resident's medical record on 11/14/23 at 12:02 P.M., showed no PASRR. During an interview on 11/17/23 at 2:05 P.M., the Administrator said he/she had contacted the Central Office Medical Review Unit (COMRU) on Tuesday 11/14/23 for getting a PASRR and was waiting to hear back from them. During an interview on 11/20/23 at 12:55 P.M., the Administrator said: -He/she received an email from COMRU on 11/14/23 at 2:53 P.M., it showed: --Nothing came up with the Social Security Number (SSN) for the resident. -He/she double checked the resident's SSN and at 1:13 P.M., COMRU still did not find anything for the resident. 2. Review of Resident #40's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Schizoaffective disorder bipolar type (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs) dated 2/15/23. -Cognitive (involving conscious intellectual activity) Communication Deficit (problems with communication that have an underlying cause in a cognitive deficit such as: attention, memory, organization, problem solving/reasoning, rather than a primary language or speech deficit) dated 2/15/23. -Bipolar disorder, unspecified dated 2/15/23. -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, mild dated 2/15/23. -Unspecified Psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition dated 3/2/22. -Bipolar disorder, current episode manic without psychotic features, unspecified dated 3/2/22. -Anxiety Disorder due to known physiological condition dated 7/1/22. Review of the resident's care plan dated 9/15/23 showed: -He/she used antidepressant medication related to Depression. -He/She had a potential psychosocial well-being problem. -Had diagnoses of: --Schizophrenia. --Bipolar. --Anxiety. --Depression. Review of the resident's Quarterly MDS dated [DATE] showed the resident had the following diagnoses: -Anxiety. -Depression. -Manic Depression (bipolar type). -Psychotic disorder (other than Schizophrenia). -Schizophrenia. Review of the resident's medical record on 11/14/23 at 1:30 P.M., showed no PASRR. During an interview on 11/14/23 at 1:30 P.M., the DON said the resident was private pay and admitted from another facility. During an interview on 11/17/23 at 2:05 P.M., the Administrator said he/she had contacted COMRU on Tuesday 11/14/23 for getting a PASRR and was waiting to hear back from them. During an interview on 11/20/23 at 12:55 P.M., the Administrator said: -He/she received an email from COMRU on 11/14/23 at 2:53 P.M., it showed: -For the resident: --they cannot provide copies because the Level 2 was more than a year old. --A new application would need to be submitted. 3. During an interview on 11/21/23 at 2:00 P.M., the DON said: -If a resident was coming from a hospital or other facility they were responsible to start the PASRR DA124 form. -If a resident was coming from home the facility was responsible to start the DA124 form. -The Administrator, at this time, was responsible for seeing that a PASRR DA124 form was started or that a resident had a PASRR completed. -The PASRR should be done pre-admit from a hospital or another facility. -If a resident was coming from home the facility admission coordinator should do it on admission. -The PASRR should be found in the electronic record in the Census pro (an admissions program) program and saved in the documents section on the computer. -Psych diagnoses would trigger for a PASRR, but not necessarily trigger for a Level II PASRR it would depend on how the diagnosis affected the resident's life and social interactions. -There should be a Level I PASRR screening for all residents.

Based on interview, and record review, the facility failed to ensure a Comprehensive Care Plan (a document describing agreed goals of care, and outlining planned medical, nursing and allied health activities for a patient) was developed and implemented for one sampled resident (Resident #29) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's care plan policy dated October 24, 2022 showed: -The facility's Interdisciplinary Team (IDT) will develop a Comprehensive Care Plan for each resident. -The IDT may include the following individuals: --The attending Physician. --The Resident Assessment Coordinator. --The Director of Nursing (DON). -The Care Plan will include measurable objectives and time tables to meet a resident's medical, nursing, mental and psychosocial needs. -Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. -The IDT will revise the Comprehensive Care Plan as needed at the following intervals: --Per the Resident Assessment Instrument (RAI). --As dictated by changes in the resident's condition. --To address changes in behavior and care. 1. Review of Resident #29's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) dated 7/7/21. -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) dated 7/7/21. -Unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated 7/7/21. -Vascular Dementia (is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated 9/16/21. Review of the resident's Physician Order Summary (POS) dated November 2023 showed: -Donepezil HCl (medication that treats symptoms of Alzheimer's disease like memory loss and confusion) Tablet 10 Milligrams (mg), Give 10 mg by mouth at bedtime for Dementia dated 7/7/21. -Depression Monitoring: Monitor for signs/symptoms of depression, sadness, tiredness, trouble focusing or concentrating, unhappiness, anger, irritability, frustration loss of interest in pleasurable activities and complete progress note every shift dated 1/9/23. -Behaviors- Assess for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing cares. If resident has behaviors document and complete progress note every shift dated 1/9/23. -Escitalopram Oxalate (used to treat depression and anxiety) Tablet 10 mg, Give 10 mg by mouth in the morning for major depressive disorder dated 7/28/23. -There were no orders for the resident receiving any medications for the diagnosis of Schizophrenia at this time. Review of the resident's care plan dated 10/30/23 showed: -He/She had impaired cognitive function and has been declared incompetent by two physicians. -He/She had a potential psychosocial well-being problem. -Used antidepressant medication related to Depression. -Did not have a care plan that addressed the resident's diagnoses of: --Schizophrenia or mood behaviors. --Dementia. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 11/2/23 showed: -Cognitive Loss/Dementia. -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). During an interview on 11/21/23 at 1:28 P.M., the MDS Coordinator said: -He/she had been at the facility for 10 weeks. -Care Plans were built off of the MDS admission and annual assessments and the Care Area Assessments (CAA- a problem-oriented framework for arranging MDS information and additional clinically relevant information about an individual's health problems or functional status). -The MDS Coordinator had 14 days to complete the admission MDS and seven days to complete the comprehensive Care Plan. -The care plans were update as needed, they were a work in progress. -Care plans were reviewed during the care plan meeting or when there were changes in medications or diagnoses, or a change in code status. -The diagnoses of Schizophrenia, dementia, anxiety, or depression should be specific in a care plan. -The MDS Coordinator looked at resident's diagnoses and section I on the MDS to update the care plan. -The diagnosis of Schizophrenia and Dementia should be care planned. -He/She was unaware that the resident had a diagnosis of Schizophrenia or Dementia. During an interview on 11/21/23 at 2:00 P.M., the DON said: -The MDS Coordinator was responsible for the updates to the comprehensive care plan. -The comprehensive care plan should be completed within 14 days of a resident's admission and updated as needed with any changes that may occur. -The diagnoses of Schizophrenia and Dementia should be care planned. -The diagnoses do not need to be listed by themselves specifically but: --The symptoms to monitor for due to the diagnoses should be listed as a care plan if not listed specifically. --If a resident used a medication due to a diagnoses, the medication should be care planned if the diagnoses is not listed specifically.

Based on interview and record review, the facility failed to include and document participation of the resident and/or the resident's representative(s) regarding care plan development for two sampled residents (Resident #70 and Resident #61) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Care Planning policy, dated 10/24/2022, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. -The Care Plan served as a course of action where the resident, resident's family and/or guardian or other legally authorized representative, resident's attending physician, and the Interdisciplinary Team (IDT) worked to help the resident move toward resident-specific goals that addressed the resident's medical, nursing, mental and psychosocial needs. -The Comprehensive Care Plan was prepared by the IDT team, which included: --The resident and/or his/her family or legal representative. --Attending physician. --Resident Assessment Coordinator. --The nurse who was responsible for the resident. --The Dietary Supervisor and/or the Registered Dietician. --Social Service staff member responsible for the resident. --The Director of Nursing (DON). --Therapists as applicable. --A Certified Nursing Assistant (CNA) responsible for the resident's care. -If the resident and his/her resident representative participation was determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record. -The facility invited the resident and their family to care planning meetings. -Care plan meetings were scheduled at the convenience of the resident as best as possible. 1. Review of Resident #70's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 11/17/23 showed: -The resident scored a 14 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). -This indicated the resident was cognitively intact. Review of the resident's Electronic Health Record (EHR) document section showed: -The resident received a Notice of Care Plan Meetings dated May 2022. -There were no other Notice of Care Plan Meetings available in the document section of the EHR after May 2022. Review of the resident's progress notes located in the resident's EHR showed not notes were entered indicating the resident and/or their representative or family member were invited to or declined to attend any care plan meetings. During an interview on 11/13/23 at 9:19 A.M., the resident said: -He/she had not been invited to a care plan meeting in a long time. -He/she received letters in the past notifying him/her of when the care plan meeting was scheduled. -He/she believed they had a meeting and did not invite him/her. During an interview on 11/15/23 at 10:49 A.M., CNA A said: -He/she was unaware of the care plan meeting process. -He/she was informed of when care plan meetings were and he/she got the resident up and ready for the meeting. -He/she was unaware of where care plan meetings were held or how residents were informed. -He/she was unaware if the resident was invited to a care plan meeting. During an interview on 11/15/23 at 11:10 A.M., CNA B said: -Residents were invited to their care plan meetings. -He/she was unaware of how that happened. -Some resident's liked to go to their meetings and some chose not to. -All residents had the option to go or not. -He/She was unaware of how the process worked. During an interview on 11/17/23 at 9:49 A.M., Registered Nurse (RN) A said: -Residents were invited to care plan meetings. -He/She was unaware of the process. During an interview on 11/17/23 at 1:03 P.M., the Social Services Designee (SSD) said: -He/she had been working at the facility for a couple of months. -He/she received a calendar from the corporate office with the names of the residents due for a care plan update. -He/she was unaware of how care plan meetings were scheduled prior to him/her taking the position. -He/she documented care plan meetings under the assessments tab in the EHR. During an interview on 11/20/23 at 11:29 A.M., the MDS Coordinator said: -He/she had been in this position for a couple of months. -Social Services notified families, representatives and residents of care plan meetings. -They sent out a letter, possibly electronic notification, such as a text message or email. -He/she was unaware of the process prior to his/her employment at the facility. -He/she was unaware if invites were uploaded to the EHR. 39469 2. Review of Resident #61's face sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses: -Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time). -Dysphagia (difficulty swallowing foods or liquids). -Chronic Obstructive Pulmonary Disease (COPD - when lungs become inflamed causing a shortness of breath). -Cerebral infarction (a disruption of blood flow to the brain) -Abnormal posture (rigid body movements and chronic abnormal positions of the body). -Schizoaffective disorder (Schizophrenia a disorder that affects a person's ability to think, feel, and behave clearly and mood disorders such as depression or bipolar a mental health disorder that involves extreme mood swings). -Dementia (a group of thinking and social symptoms that interferes with daily function). -Dysarthria (weakness in the muscles used for speech which often causes slowed or slurred speech) and Anarthria (a complete loss of speech). Review of the resident's quarterly MDS dated [DATE] showed: -His/Her Brief Interview for Mental Status (BIMS) score was 00 out of 15 indicating he/she was not able to complete the test. -He/She had progressive Neurological (diseases of the brain, nerves, spinal column and muscles)conditions. During a family interview on 11/13/23 at 9:34 A.M. the resident's spouse said: -The resident did not talk well. -The resident had Huntington's Disease which was very rare. -He/she came to the facility almost every day. -He/she was very involved with his/her spouse's care. -The facility did not have a Social Service or a MDS person for a while. -The resident had not had a care plan meeting for at least six months. -He/she would have went to the care plan meeting. Review of the resident's medical record showed the last documented care plan meeting was on April 26, 2023. During an interview on 11/21/23 at 10:30 A.M. the MDS Cordinator said: -He/she had only been in this job for 10 weeks. -He/she was not able to find any documentation that there had been a care plan meeting with the resident and family since April 26, 2023. -There was no documentation the family or resident was sent a letter for the care plan meeting for July or October 2023. -There should have been a care plan meeting with the resident and or family every three months. -There should have been a letter sent to the family and resident two to four weeks before the meeting and it was not done. -There had not been care plan meetings for the last six months. During an interview on 11/21/23 at 2:00 P.M. the DON said: -There should have been care plan meetings every quarter with the family and the resident. -The family and resident if appropriate should have received a letter from the MDS coordinator notifying them of the upcoming meeting. -They also use a Blast system - multi email to inform families when needed. -The MDS coordinator or SSD could call the family members to inform them of the upcoming care plan meetings or put them on speaker phone for the meeting. -The invitation to the care plan meeting should have been documented on the computer system. -The MDS coordinator was responsible for the care plan meetings and the invitations to the families. -The Administrator and DON were ultimately responsible to ensure there were quarterly care plan meetings and that the residents and family were invited to them. -Invites should have been documented in the EHR. -The electronic system did not automatically populate to the each resident's EHR.

Based on observation, interview and record review, the facility failed to address one sampled resident's motion sickness (Resident #37) and to ensure one sampled resident (Resident #92) took his/her prescribed medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's policy, Medication Administration, dated October 24, 2022 showed: -Medications may be administered one hour before or after the scheduled mediation administration time. -Medications would not be left at the bedside. 1. Review of Resident #37's progress notes dated September 2023, October 2023 and November 2023 showed no documentation regarding any nausea or vomiting. Review of the resident's comprehensive Certified Nursing Assistant's (CNA) shower review sheets dated September 2023 showed: -On 9/2/23, the resident received a bed bath. -On 9/30/23, the resident received a shower. Review of the resident's Medication Administration Record (MAR) dated September 2023 showed: -A physician's order for Zofran four milligrams (mg) every six hours as needed for nausea and vomiting. -No Zofran was administered during the month. Review of the resident's comprehensive CNA shower review sheets dated October 2023 showed: -On 10/2/23, the resident refused a shower. -On 10/13/23, the resident received a bed bath. -On 10/23/23, the resident refused a shower. -On 10/27/23, the resident received a bed bath. Review of the resident's MAR dated October 2023 showed: -A physician's order for Zofran four mg every six hours as needed for nausea and vomiting. -Zofran was administered on 10/10/23 at 3:50 P.M. and on 10/19/23 at 2:30 P.M. and both marked effective. Review of the resident's care plan dated as revised on 11/2/23 showed: -The resident required total assistance of two staff with bathing/showering twice a week and as necessary. -No additional instructions related to showers or bed baths. -Nothing regarding the resident having nausea, vomiting or motion sickness. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/8/23 showed the following staff assessment of the resident: -Moderately impaired cognitive skills. -Did not reject cares. -Totally dependent on staff for shower/bathing. -Used a motorized scooter. -Could not stand. -Was frequently incontinent of urine and always incontinent of bowel. -Some of his/her diagnoses included kidney failure, stroke, hemiplegia (paralysis of one side of the body) or hemiparesis (a slight paralysis or weakness on one side of the body) and respiratory failure. -Was on dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein). Review of the resident's comprehensive CNA shower review sheets dated November 2023 (through the morning of 11/21/23) showed the resident received a shower on 11/3/23. During an interview on 11/14/23 at 10:13 A.M., the resident said: -He/she had motion sickness with bathing. -Staff gave him/her a bed bath instead of a shower sometimes because sometimes he/she threw up when they gave him/her a shower due to his/her motion sickness. -During bed baths, they rolled him/her around a lot which also made him/her nauseous. -He/she thought they should give him/her something for nausea before a shower or bed bath. -He/she thought he/she had an order for something for nausea. -Sometimes they gave him/her the anti-nausea medicine after a shower but he/she thought they should give it to him/her before he/she got sick from a bed bath or shower. Review of the resident's MAR dated November 2023 (through 11/15/23) showed: -A physician's order for Zofran four mg every six hours as needed for nausea and vomiting. -No Zofran was administered during the month. During an interview on 11/20/23 at 10:48 A.M., CNA E said: -The resident had severe motion sickness. -The resident's nausea was the worst when they did his/her showers or bed baths. -The resident had Zofran as needed for nausea. -The resident was scheduled for evening showers. -He/she told CNA F, who worked evening shifts, to make sure to ask to give the resident his/her Zofran 30 minutes prior to a shower or bed bath. During an interview on 11/20/23 at 3:30 P.M., the Director of Nursing (DON) said: -The resident had severe motion-sickness. -He/she thought the resident was receiving Meclizine (an antihistamine used to treat nausea/vomiting from motion sickness) for nausea/vomiting. During an interview on 11/21/23 at 9:53 A.M., CNA F said: -He/she gave the resident showers sometimes. -The resident had asked for medication for nausea in the evenings sometimes. -The resident said he/she had an order for medication for nausea. -He/she always told the nurse when the resident got nauseated or threw up. -The resident got nauseous and vomited maybe a couple times a week. -The resident had less nausea when two staff members worked with him/her so there was less rolling the resident around in the bed during cares, transfers and showers. -They did not always have two people to do cares with the resident. -No one told him/her to ask the nurse for the medicine before the resident's shower. During an interview on 11/21/23 at 12:48 P.M., the MDS Coordinator said: -He/she wasn't aware of the resident's motion sickness. -He/she would talk to the resident and care plan it if appropriate. During an interview on 11/21/23 at 1:30 P.M., the resident said: -He/she had not thrown up this week. -He/she threw up last week from motion sickness. -He/she thought if the staff would give him/her something for nausea before his/her showers that he/she would not get sick. During an interview on 11/21/23 at 2:00 P.M., the DON said: -The resident had refused showers in the shower house sometimes because he/she had severe motion sickness. -Zofran was typically given after the symptom appeared. -He/She would have to talk to the doctor about giving the resident something for nausea prior to showers/bed baths. During an interview on 11/29/23 at 9:57 A.M., Primary Care Physician A said: -The resident did not get nauseous all the time so his/her Zofran was ordered for as needed. -There were always risks associated with taking scheduled medicine so he/she thought it was best to have it as needed to start with. -He/she talked to the facility staff and went ahead and scheduled the medicine for his/her motion sickness. 39469 2. Review of Resident #92's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizoaffective disorder (a mental health condition which was a combination of schizophrenia {a disorder that affects a person's ability to think, feel, and behave clearly} and a mood disorder). -Myocardial infarction (heart attack). -Diabetes. -Heart disease. -Depression (loss of pleasure of activities for long periods of time). -Anxiety (Intensive, excessive, and persistent worry and fear about every day situations). -Gout (pain and inflammation occurring when too much uric acid crystallizes in the joints). -Benign prostatic hyperplasia (enlargement of the prostate gland causing urinary difficulty). Review of the resident's Quarterly MDS dated [DATE] showed: -His/her Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he/she was cognitively intact. -He/she had hallucinations (an experience involving the apparent perception of something not present). -He/she had delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions). -He/she rejected care such as taking medications daily. Review of the resident's undated care plan showed: -He/she has a self care deficit. -He/she had a behavior problem. -He/she had hoarding tendencies. -He/She would refuse treatments. -Staff was to administer medications as ordered. Observation on 11/16/23 at 1:27 P.M. during wound care with Licensed Practical Nurse (LPN) E showed: -The resident had a medication cup full of pills at his/her bedside. -The resident did not have a room mate. -LPN E verified the medications in the cup was the resident's morning medications. During an interview on 11/16/23 at 1:30 P.M. LPN E said: -They were not supposed to leave medications at the bedside unless they had a physician's order. -The nurse verified that the resident did not have an order to leave the medication at the resident's bedside for him/her to take when they were ready to. -The medications were from the morning medication pass and should have been administered when the resident woke up. During an interview on 11/16/23 at 1:35 P.M. the resident said: -The Certified Medication Technician (CMT) had left the medication so he/she could take them when he/she was ready to. -The CMT had left the medications before lunch maybe at 11:00 A.M. Observation on 11/16/23 at 1:40 P.M. showed: -LPN E took the cup full of medications out of the resident's room, verified they were his/her morning medications, then threw them in the trash. -The following medications were left at the resident's bedside in a cup: --Aspirin (medication used as a blood thinner to help reduce the risk of heart attacks) 81 milligram (mg). --Buspar (medication used to treat anxiety) 5 mg. --Plavix (medication used as a blood thinner to help reduce the risk of heart attacks) 75 mg. --Depakote (medication used to treat bipolar disease) 125 mg. --Jardiance (medication used to help stabilize diabetes) 10 mg. --Multi Vitamin. --Flomax (medication used to treat urinary retention) 0.4 mg. --Allopurinol (medication used to treat gout) 50 mg. --Amlodipine (medication used to treat high blood pressure)10 mg. --Vitamin C 500 mg. --Isobride (medication used for heart related chest pain or heart failure) 30 mg. --Linzess (medication used to treat bowel problems) 72 microgram (mcg). --Protonix (medication used to treat stomach issues) 40 mg. Review of the resident's Physician Order Sheet dated November 2023 showed the following orders: -There was no order for the resident to self administer his/her own medications. -Aspirin 81 mg give one tablet by mouth in the morning for anticoagulation, dated 8/19/23. -Buspar 5 mg give one tablet by mouth two times a day for anxiety. -Plavix 75 mg give one tablet by mouth in the morning related to myocardial infarction. -Depakote 125 mg give one tablet by mouth two times a day for seizures. -Jardiance 10 mg give one tablet by mouth in the morning for diabetic. -Multi Vitamin give one tablet by mouth for supplementation. -Flomax 0.4 mg give one tablet by mouth in the morning for benign prostatic hyperplasia. -Allopurinol 50 mg give 50 mg by mouth in the morning for gout. -Amlodipine 10 mg give one tablet by mouth in the morning for hypertension. -Vitamin C 500 mg give one tablet by mouth for supplementation. -Isobride 30 mg give on tablet by mouth in the morning for hypertension. -Linzess 72 mcg give one tablet by mouth in the morning for bowels, hold if loose stools. -Protonix 40 mg give one tablet by mouth in the morning for GERD. During an interview on 11/16/23 at 2:04 P.M. CMT A said: -He/she had left the resident's morning medications at bedside. -The resident said he/she was not ready to take the medications. -He/she had education during orientation about not leaving medications at bedside. Review of the resident's CMT MAR on 11/16/23 showed the CMT had charted that the resident had refused all of his/her morning medications. During an interview on 11/21/23 at 2:00 P.M. the Director of Nursing (DON) said: -Staff should never have left a resident's medications at bedside. -In order for a resident to self administer their own medications there would have to have a physician's order. -The resident did not have an order to self administer his/her own medications. -The charge nurse should have educated the CMT's not to leave medications for the residents to take on their own. -He/she was ultimately responsible to ensure the residents were given their mediations correctly.

Based on observation, interview and record review, the facility failed to provide toenail care or an appointment with a podiatrist for one sampled resident (Resident #60) out of 25 sampled residents who had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) which posed a risk to foot health. The census was 123 residents. Review of the facility's policy titled Grooming care of fingernails and toenails revised 10/24/22 showed: -Residents who had diabetes would not have their toenails trimmed by Certified Nursing Assistants (CNA). -High risk residents who had toenail issues such as thick toenails or toenails with a fungal infection would be referred to a podiatrist. 1. Review of Resident #60's medical record showed no podiatry progress notes. Review of the resident's care plan dated 9/22/23 showed the resident had a diagnosis of diabetes and required limited assistance of one staff member with personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 10/4/23 showed the following staff assessment of the resident: -Cognitively intact. -Had a diagnosis of diabetes. Observation and interview on 11/14/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) E and CNA D showed: -The resident's toe nails were long and thick. -The second toenail on the resident's right foot was so long it wrapped around to the bottom of the toe, pressing into his/her skin. -The resident said he/she did not know when his/her toe nails were last trimmed and they needed to be clipped. -LPN E said the resident should have been seen by the podiatrist. -LPN E said the podiatrist was at the facility twice in the last three months and the resident was not currently on the list to be seen by the podiatrist. During an interview on 11/21/23 at 2:00 P.M., the Director of Nursing (DON) said: -Staff should notify a nurse if a resident with diabetes had long toe nails. -The nurse should make sure the residents with long toe nails who had a diagnosis of diabetes were seen by podiatry. -The podiatrist came to the facility on ce a month.

Based on observation, interview and record review, the facility failed to ensure urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was in a safe place during a transfer for one sampled resident (Resident #60) out of four residents sampled for urinary catheters. The facility census was 123 residents. Review of the facility's catheter care policy dated as revised 10/24/22 showed instructions to ensure the catheter tubing was properly anchored to prevent urethral tear. 1. Review of Resident 60's care plan dated 9/22/23 showed the resident had a urinary catheter. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/4/23 showed the following staff assessment of the resident: -Cognitively intact. -Had an indwelling catheter. -Had a diagnosis of neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Used a wheelchair. Observation and interview on 11/14/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) E and Certified Nursing Assistant (CNA) D showed: -LPN E and CNA D were getting ready to transfer the resident from his/her bed to his/her wheelchair. -The resident's catheter tubing was wrapped around his/her legs. -If the resident had stood up, it would have pulled the catheter tubing down and potentially out of the resident's urethra. -The transfer was stopped by the surveyor due to the risk of harm to the resident. -LPN E and CNA D said the catheter tubing should have been unwrapped from the resident's leg prior to transferring the resident. During an interview on 11/21/23 at 2:00 P.M., the Director of Nursing(DON) said: -The catheter tubing should not have been wrapped around the resident's legs. -The catheter bag should be taken where the resident was going. -The catheter bag should have been put on the wheelchair first and then the resident could have been transferred to his/her wheelchair.

Based on interview, and record review, the facility failed protect two sampled residents (Resident #3 and #2) from a physical altercation between each other, when Resident #2 tapped Resident #3 on the shoulder with his/her reacher (an instrument used to pull things toward a person that was out of reach) and when Resident #3 hit Resident #2 on the back of his/her head then scratched Resident #2's face, out of 10 sampled residents. The facility census was 107 residents. On 2/24/23 the Administrator was notified of the past noncompliance which occurred on 2/11/23. On 2/11/23 the facility administration was notified of the incident and the investigation was started. Staff were educated on the resident behaviors, interventions were in place at the time of the resident to resident incident. The facility staff immediately separated Resident #2 and Resident #3. The deficiency was corrected on 2/13/23. Record review of the facility's policy Violence between Residents dated October 24, 2022 showed: -The purpose was to protect the health and safety of residents by ensuring that altercations between residents were promptly reported, investigated, and addressed by the facility. -Facility staff monitored residents for aggressive or inappropriate behavior toward other residents. -Any occurrences of such behavior were promptly reported to the Charge Nurse, the Director of Nursing (DON), and the Administrator. -Response to an altercation. --Separate the residents, and institute measures to calm the situation. --Determine what happened, including what might have led to aggressive conduct on the part of one or more of the residents involved in the altercation. --Notify each resident's representative and Physician of the incident. --Review the events with the Charge Nurse and DON including interventions staff could take to prevent additional incidents. --Consult with the Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. --Make any necessary changes in the care plan for any or all of the involved residents as necessary. --Document the resident's interventions and there effectiveness in the resident's medical record. --Consult with psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management necessary or as may be recommended by the Physician or Interdisciplinary Team. --Document the incident, findings, and any corrective measures taken in the resident's medical record. -If after carefully evaluating the situation, it was determined that care could not be readily given within the Facility, transfer the resident. 1. Record review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Generalized muscle weakness. -Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucination or delusions, and mood disorder symptoms, such as depression or mania.) -Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -He/she was his/her own responsible person. Record review of Resident #2's Pre Admission Screening and Resident Review (PASRR a federally mandated program that required all states to prescreen all people, regardless of payer source or age, seeking admission to a Medicaid certified nursing facility) dated 2/15/23 showed: -He/she did not have a guardian. -He/she did not show any signs of a major mental illness. -He/she did have a current, suspected, or history of a major mental illness that included Anxiety, Schizoaffective disorder, and Depressive disorder. -He/she did not have any impairment due to serious mental illness. -He/she had not experienced a psychiatric treatment episode that was more intensive than routine follow-up care in the last two years. -He/she did not have a substance related disorder. -He/she did not have a diagnosis or history of an Intellectual disability or related condition. -He/she was not currently a danger to self or others. -Physician's Signature, Discipline, and License number was blank. -Diagnosis list was not attached. -History and Physical was not attached. -He/she had stable mental condition and no mood or behavior symptoms observed and no reported psychiatric conditions. -He/she was oriented to person, place, and time. -He/she had to issues with memory or recall ability. -Level of supervision was two hour checks. -He/she had severe difficulty with vision. Record review of Resident #2's Admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 12/20/22 showed: -His/her Brief Interview for Mental Status (BIMS) score was 15 which indicated he/she was cognitively intact. -He/she had no behaviors. -It was very important to him/her to take care of personal belongings. -It was very important to him/her to have a place to lock up his/her things. Record review of Resident #2's undated care plan showed: -The problem identified: --He/she had the potential to be verbally aggressive related to mental and emotional illness, poor impulse control and hoarding. --He/she did not like having people mess with his/her things. -The desired outcome: --He/she would verbalize understanding of the need to control verbally abusive behavior through the review date. (there was no review date documented). -Interventions included: --Staff would monitor the resident's behaviors per shift. --Staff would document any observed behaviors and attempted interventions. --When the resident became agitated staff would intervene before agitation escalated. --Staff would guide him/her away from the source of distress. Record review of Resident #2's weekly skin observation dated 2/11/23 showed: -He/she had scratches under his/her eyes and by the bridge on his/her nose related to resident to resident altercation. Record review of Resident #2's Trauma Informed Care assessment dated [DATE] documented by Social Services Designee showed: -He/she was in an altercation with Resident #3. -He/she was not afraid of the other resident as he/she trusted staff would take care of him/her. Record review of Resident #2's Physical Therapy Treatment Encounter dated 2/15/23 showed: -He/she demonstrated safe and independent use of a reacher in his/her room. -Education provided on the safe use of the reacher. Record review of Resident #3's PASRR dated 12/16/22 showed: -He/she had signs or symptoms of a major mental illness; aggressive behavior including hitting and kicking. -He/she had a current, suspected or history of a major mental illness; Major Depressive Disorder and Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -He/she had impairment due to serious mental illness; difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, self-injurious, self-mutilation suicidal, physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or required intervention by mental health or judicial system. -He/she had a diagnosis of Major Neurocognitive Disorder with Lewy Bodies (a disease associated with abnormal deposits of a protein in the brain called Lewy bodies which affects chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood). -He/she was not currently a danger to self or others. -The diagnosis list was not attached. -History and Physical was not attached. -He/she was minimally aggressive. -He/she had an unstable mental condition monitored by a physician or licensed mental health professional at least monthly or behavior symptoms were currently exhibited or psychiatric conditions were recently exhibited. -He/she was oriented to person, place and situation. -He/she had impaired short term memory. -Level of supervision was two hour checks. Record review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition such as a viral infection or toxins in the blood). -Bipolar disorder -Major depression. -Neurocognitive disorder -He/she was his/her own responsible person. Record review of Resident #3's Care plan dated 2/2/22 showed: -The problem identified: --He/she had a behavior problem related to a diagnosis of bipolar disorder and Lewy Body Dementia. -He/she had hoarding tendencies. -He/she yelled at staff if they were touching his/her stuff. -He/she wandered into other resident's rooms and took their things. -He/she had an altercation with Resident #2 dated 2/11/23. -The desired outcome: --He/she would have fewer episodes of behavior. -Interventions included: --He/she was introduced to Resident #2 and moved into the room. --He/she was moved into a room by himself/herself dated 2/11/23. --He/she was placed on 1:1 prior to being sent out to the hospital for evaluation dated 2/11/23. --Staff were to educate the resident on successful coping and integration strategies. Record review of Resident #3's Admission MDS dated [DATE] showed: -His/her BIMS score was 11 which indicated he/she was moderately cognitively impaired. -He/she had hallucinations (an experience involving the apparent perception of something not present). -He/she had behavior symptoms directed toward others. -He/she had verbal behaviors directed toward others. -He/she was at significant risk for physical illness or injury. -He/she significantly interfered with other residents' participation or social activities. -He/she put others at significant risk for physical injury. Record review of the Resident #3's Psychiatric evaluation dated 2/9/23 showed: -Staff recommended the resident be seen due to increased anxiety, agitation, manic, aggressive behavior, and paranoid delusion thinking people were after him/her. -He/she presented with anxiousness, irritability, maniac, hyperverbal, and periods of agitation. -He/she reported he/she was bipolar and was very anxious. -He/she had not slept for the last three days. -He/she had just been discharged from the hospital where he/she had been in a coma (a state of prolonged unconsciousness) for three days. -His/her spouse verified that he/she had just been discharged from the hospital and had been in a coma for three days. -The resident was having paranoid delusions. -His/her medications were reviewed. Record review of Resident #3's Nurses' Progress note date 2/10/23 showed: -The nurse spoke with Resident #3 about getting a roommate. -Resident #2 and Resident #3 were introduced to one another, spoke, and agreed to room move. Record review of the facility's Abuse Investigation Timeline showed: -The investigation was started on 2/11/23 at 5:00 A.M. -Resident #2 and Resident #3 were involved in a resident to resident altercation. -The DON was notified on 2/11/23 at 4:10 A.M. -The Administrator was notified on 2/11/23 at 4:20 A.M. -The State was notified on 2/11/23 at 7:44 A.M. -The Physician for both Resident #2 and Resident #3 was notified on 2/11/23 at 8:48 A.M. -Resident #3's spouse was notified on 2/11/23 at 8:48 A.M. -The abuse checklist was completed. -Resident #2's statement, taken by the nurse said: --He/she was on his/her side of the room drinking milk, when Resident #3 came into the room. --Resident #3 asked if he/she could look in his/her refrigerator, he/she told the resident no. --Resident #3 thought all of Resident #2's things belonged to him/her. --When he/she went to put the milk back in the refrigerator when Resident #3 attacked him/her. --Resident #3 grabbed at his/her eyes and started to hit him/her. --Staff came in to break it up. -Resident #3's statement, taken by the nurse said: --He/she was in the room mopping the floor up because he/she had spilled water on accident. --Resident #2 started to yell and tell him/her to hurry up and told him/her to pick up his/her clothes off of the floor. --He/she told Resident #2 that he/she was moving as fast as he/she could. --Resident #2 started to hit him/her with his/her reacher across his/her back and head because he/she was not moving fast enough. --He/she told Resident #2 to stop hitting him/her but Resident #2 kept hitting him/her. -He/she had to fight back to get away from Resident #2. --Resident #2 would not stop so he/she kept pushing Resident #2 towards the door to get out. --A staff member came in to break it up. --Staff brought Resident #3 to the nurses' station. -Education was provided to the staff by 2/13/23. Record review of facility Abuse training dated 2/13/23 showed all staff had been trained by 2/13/23. During an interview on 2/23/23 at 10:45 A.M. Resident #2 said: -He/she was in his/her room watching TV when his/her roommate (Resident #3) came into their room. -Resident #3 had just moved in that day. -Resident #3 asked him/her for a bottle of water out of his/her refrigerator. -He/she gave Resident #3 a bottle of water from his/her refrigerator. -Resident #3 took the bottle of water and poured the water on the floor. -He/she tapped Resident #3 on the shoulder with his/her reacher and told Resident #3 to clean up the spill. -Resident #3 then hit him/her on the back of his/her head four or five times with his/her hand. -Resident #3 stuck his/her thumbs in his/her eyes and scratched his/her face just below his/her eyes. -A staff member heard the altercation and came into the room and took Resident #3 out of the room. -They were separated and he/she had not seen Resident #3 since then. -He/she felt the staff could keep him/her safe in the facility. Record review of the resident roster dated 2/23/23 showed Resident #3 was not listed as a current resident in the facility. During an interview on 2/23/23 at 2:20 P.M. the Administrator and DON said: -Resident #3 was with a different resident who had a lot of belongings in the room so staff wanted to move him/her in with someone who had less stuff in their room. -On 2/10/23 Resident #2 and Resident #3 met each other and they seemed to get along. -Resident #3 was moved into Resident #2's room. -On 2/11/23 about 4:00 A.M. there was a physical altercation between Resident #2 and Resident #3. -Staff heard the altercation and went into the room to break it up. -Staff took Resident #3 out of the room to the Nurses' desk where he/she sat with the Nurse. -Resident #3's family and physician were notified of the altercation. -Resident #2 was placed on 1 on 1 observation. -The physician wanted Resident #3 sent out to the hospital. -Resident #3 was sent to the hospital. -Resident #3 came back from the hospital later that same day. -Resident #3 was placed on 1 on 1 observation. -Resident #3 was moved to a different room in the facility. -Resident #2 and Resident #3 had different stories as to what happened. -Resident #3 said he/she had stumbled into the room and then stumbled into the other resident. -Resident #3 had scratched Resident #2 in his/her eyes. -Resident #2 said he/she was drinking milk when Resident #3 scratched him/her in the eyes. -After 48 hours Resident #2 had no further behaviors and the 1 on 1 was discontinued. -Resident #3 had his/her Geodon (medication used to treat bipolar disease) increased. -Resident #3 was still on 1 on 1 observation. -Resident #3 was upset and was sent out to the hospital a second time on 2/20/23 for medication management. -The facility was not aware of any previous issues with Resident #3. -On 2/15/23 Resident #3's spouse said the resident had anger issues, which the facility had not known about. -Resident #3 was currently at the hospital awaiting placement at a Geriatric Psychiatric facility. -The Social Worker had been looking for placement for Resident #3. -Resident #2 was seen by the facility physician. -Head to toe assessment was completed on both residents. -Residents were separated. -State was notified. -Investigation was completed. -All staff was in-serviced on the facility's abuse policy. During an interview on 2/23/23 at 3:00 P.M. Registered Nurse (RN) A said: -He/she was working the night of the altercation from 11:00 P.M. to 7:00 A.M. -He/she did not see the altercation. -Resident #2 and Resident #3 were separated immediately. -Resident #3 was in his/her wheelchair and moved to the Nurses' station where he/she was put on a 1 on 1. -Resident #3 had attacked Resident #2. -Resident #2 had scratches underneath his/her eyes and was bleeding. -He/she directed staff to keep the two residents separated. -Resident #2 was also put on 1 on 1 in his/her room. -He/she did a head to toe assessment and took vital signs on Resident #2. -He/she cleansed Resident #2's scratches on his/her face. -He/she asked Resident #2 if he/she wanted to go to the hospital and he/she declined. -He/she asked Resident #2 if he wanted her to call the police and he/she declined. -He/she did a head to toe assessment and vital signs on Resident #3. -He/she asked him/her if he/she wanted to call the police and he/she declined. -He/she asked Resident #3 if he wanted to go to the hospital and he/she did. -Resident #3 told the nurse, he/she was hit by Resident #2 with his/her grabber, when he/she was mopping up water on the floor. -Resident #2 said he/she was in their room drinking milk, when Resident #3 pushed and hit him/her. -Resident #2 had been in the room by himself/herself. -Resident #3 had moved in with Resident #2 less than 12 hours before the altercation took place. -Resident #2 could be anxious but was easy to redirect. -Resident #2 did not have any behaviors that he/she was aware of. -Resident #3 was in a different room with a roommate and to his/her knowledge had not had any behaviors. -He/she did not know why Resident #3 was moved in with Resident #2. -He/she had notified the physician, family, Administrator, and DON of the incident. -He/she stayed with Resident #3 until he/she went out to the hospital. -One of the Certified Nursing Assistants stayed with Resident #2 who was tearful. -Staff calmed Resident #2 down. -Resident #3 returned to the facility from the hospital later that day. -He/she had training on abuse during orientation and since the incident. -Staff were to separate the residents and make sure they were safe. -Staff were to call the Administrator. -Resident #2 was his/her own person and said he/she would call his/her family to notify them of the incident. -Resident #2's physician should have been notified. -Administration would call the State. -Since the incident on 2/11/23 he/she had worked with Resident #3 and he/she has had behaviors. -Resident #3 was on 1 on 1 observation. -Resident #3 had trash talked to staff. -Resident #3 had been sexually inappropriate to staff. -Resident #3 had delusional thinking that someone was in his/her chair. -Resident #3 had been sent out to the hospital a second time and was still in the hospital. -Resident #2's eyes were red after the altercation and had scratches underneath both eyes after the altercation. MO00213894

Based on interview and record review, the facility failed to contact Emergency Medical Services (EMS), check code status, initiate and provide continuous cardiopulmonary resuscitation (CPR) for one sampled resident (Resident #1) who had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Agency Licensed Practical Nurse (LPN) A, Agency LPN B, and Agency Certified Medication Technician (CMT) A failed to verify the resident's code status and provide CPR. The facility census was 108 residents. On [DATE] at 12:57 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE] the facility administration was notified of the incident and the investigation was started. No employees were allowed to work prior to reeducation. The IJ was corrected on [DATE]. Record review of the facility policy for CPR, revised February 2018, showed: -If a resident was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR was to have initiated CPR unless the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -If the resident's DNR status was unclear, CPR was to be initiated until it was determined that there was a DNR order, or there were obvious signs of irreversible death, such as rigor mortis-(stiffening of the joints and muscles of a body a few hours after death). -If the resident had an absence of breathing, the staff was to begin CPR and have someone call 911. -Another staff member was to verify the resident's code status if unknown while CPR continued. -CPR with chest compressions was to have been started after the initial assessment that the resident was not breathing and had no pulse. -If the resident was to have been a DNR, physician's orders must have been signed by the attending physician and kept in the resident's medical record. -A DNR order form must have been completed and singed by the attending physician and the resident or the resident's legal surrogate as permitted by State law, and placed in the medical record. 1. Record review of Resident #1's facility Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Stoke with [CONDITION(S)] (the loss or ability to produce or comprehend language due to a [CONDITION(S)]). -Acute kidney failure (a recent onset of the inability for the kidneys to filter out waste, concentrate urine and conserve electrolytes). -Non-pressure ulcer with bone necrosis (a wound, not created by pressure which is deep enough to cause a portion of the bone to die). Record review of the resident's Physician's Order Sheet (POS), dated [DATE], showed the resident was a full code and admitted to hospice (end of life) care. Record review of the facility and hospice Admission, Readmission and Intake Report Sheet showed had no code status listed for the resident. Record review of the resident's progress notes, dated [DATE] at 6:32 P.M., and completed by Agency (LPN) B showed: -The resident's family member approached the nurse's station at 1:55 P.M., requesting a nurse to come to the resident's room once someone was available. Agency LPN B stated he/she would come down as soon as he/she finished getting report for that hall. -The family member came back to the nurse's station approximately five minutes later and stated that the resident was short of air. -Upon entering the resident's room, Agency LPN B observed the resident having difficulty breathing. -He/she made sure the resident was seated upright in bed. -Agency CMT A then attempted to get an O2 saturation level and Agency LPN B administered [MEDICATION(S)] 0.25 milliliters (mls) (a narcotic used for sever pain and to treat shortness of air) to the resident as ordered. -The resident's temperature was obtained and was 96.7 degrees F. -The resident's family member then gave the resident some water and Agency LPN B went to get an O2 concentrator and tubing. -Agency LPN B placed O2 on the resident. -The resident continued to look around the room and the resident's family members were present and talking with the resident. -Agency CMT A stayed in the room the entire time. -The resident's nails were very long so Agency LPN B obtained permission from the resident's family to clip his/her nails to better apply the O2 saturation measuring device. -Agency LPN B and Agency CMT A were still unable to get an oxygen level. -The resident continued to have difficulty breathing. -The resident's eyes remained open and he/she had an occasional cough. -LPN B remained in the room with the resident to monitor him/her. -The resident was then noted to have respiration less than ten per minute and at 2:20 P.M., his/her respirations were approximately three per minute. -At 2:42 P.M., the resident was noted to have stopped breathing and Agency LPN B was unable to hear any heartbeat via stethoscope. During an interview on [DATE] at 1:50 P.M., Agency LPN B said: -He/she was getting report from Agency LPN A between 2:00 P.M., and 2:30 P.M., on [DATE]. -Someone had come to the nurse's station asking if someone could come to the resident's room when they had time to. -Soon after, the person came back to the nurse's station and said the resident was having trouble breathing and they needed help now. -Agency LPN A pointed to him/her to go to the room. -He/she had not even gotten report on the resident yet, but he/she and Agency CMT A ran to the resident's room. -When he/she and Agency CMT A got to the resident's room, the resident was visibly short of air. -The resident's nails were long and the machine was not reading, so he/she went to get nail clippers and an O2 concentrator, which Agency LPN A had given him/her and he/she went back into the room. -He/she placed O2 on the resident and Agency CMT A clipped the resident's fingernail to try and get a better O2 saturation reading, but still was unable to get a reading. -A resident family member then gave the resident a drink of water. -He/she was trying to get the resident to breathe through his/her nose instead of mouth as the O2 was coming in through his/her nose. -All of a sudden the resident's respirations dropped to about ten per minute. -It had only been about seven to ten minutes after the staff got into the resident's room. -After another minute or two, the resident took two breaths and then stopped breathing. -He/she tried to get a heartbeat with his/her stethoscope and got no heartbeat. -A family member then asked if the resident had passed, to which he/she replied the resident had. -He/she then asked if the family wanted to spend some time with the resident. -The family members replied that they did. -He/she and Agency CMT A left the room. -He/she went to log in to his/her computer to call the physician, hospice and facility Administrative staff and that was when he/she discovered the resident was a full code. Record review of Agency CMT A's written statement, dated [DATE], showed: -The incident took place between 2:00 P.M., and 2:15 P.M. -The nurses were giving and receiving report when a family member of Resident #1 came to the nurse's station and asked if Agency LPN B could come to the resident's room. -Agency LPN B stated he/she was getting report and could the resident wait for just a few minutes. -The family member stated that would be fine, so Agency LPN B continued receiving report. -Approximately two to three minutes later, while still getting report, the resident's family member came back stating that the resident was having shortness of air. -He/she grabbed the oxygen (O2) saturation measuring device and a thermometer and ran with Agency LPN B to the resident's room. Agency CMT A placed the O2 saturation measuring device on the resident's finger and obtained his/her temperature. -The resident's temperature was 96.7 Fahrenheit (F) (normal body temperature ranges from 97 F to 99 F), but the O2 saturation measuring device was not reading at all. -While he/she continued to attempt to get a reading on the resident's O2 saturation, Agency LPN B went and got nail clippers and an O2 concentrator. -He/she then grabbed the nail clippers, as the resident's nails were very long and could have been interfering in the measuring of his/her O2 saturation. -The O2 saturation measuring device still did not read the resident's O2 level. -While he/she was clipping the resident's nail and attempting to get an O2 saturation reading, Agency LPN B placed O2 on the resident. -The O2 saturation was still not reading, so Agency LPN B attempted to get a heartbeat with his/her stethoscope. -Agency LPN B stated there was no heart beat and the resident had passed. -They notified the Assistant Director of Nursing (ADON) and the weekend supervisor. During an interview on [DATE] at 10:46 A.M., Agency CMT A said: -He/she had taken care of the resident that day as well as the day before. -The resident did not show any difference in his/her status throughout the entire shift. -The resident continued to talk and had no issues in breathing all day. -He/she did have some pain and was treated with pain medication earlier in the day. -He/she saw the resident around 2:00 P.M., on [DATE] and there was no change in the resident's status. -At around 2:00 P.M., a family member of the resident came to the nurse's station asking if a nurse could come down to the resident's room. -The nurses were in report, but said would be there soon. -Before any nurse could get to the resident's room, the family member came back and said the resident was having trouble breathing. -Agency LPN B grabbed some equipment and he/she ran down the hallway to the resident's room. -Agency LPN B placed O2 on the resident after sitting him/her upright and he/she attempted to get an O2 saturation level on him/her. -The resident's fingernails were very long and the O2 saturation measuring device was not reading, so he/she clipped the resident's fingernails and tried to get an O2 saturation again but still got nothing. -The resident continued to talk with family in the room and did not show a drastic change in his/her status. -Agency LPN B was checking for a heartbeat with his/her stethoscope and after a little while was not able to get a heartbeat. -Agency LPN B then asked the family if they would like to spend some time with the body to which they said they did, so he/she left the room and Agency LPN B went to call the physician, facility Administrative staff and hospice. -He/she thought the resident was a DNR. -He/she thought that since the resident was under hospice care that he/she was dying so was a DNR. -No one in the room said anything about the resident having been a Full Code. Record review of Agency LPN A's written statement, dated [DATE], showed: -The resident had been stable during the morning shift, with no signs or symptoms of a declining status. -The resident showed discomfort during a gown change, so he/she gave him/her the ordered [MEDICATION(S)] (a narcotic used to treat severe pain) and [MEDICATION(S)] (a medication used to treat anxiety) at noon on [DATE]. -The resident showed no difficulty swallowing his/her mediations and water. -Later in the shift, another staff member and him/her changed the resident's wound dressing and Agency CMT A assisted with rolling and repositioning the resident during the dressing change. -During that time, he/she did not witness any respiratory complaints or at any time during the shift, the resident showed no signs of distress. -The resident ate his/her lunch with no issues. -Beginning at 1:50 P.M., he/she counted narcotics and began giving report to the oncoming nurse, Agency LPN B. -At 2:00 P.M., a family member came to the nurse's station and asked who the resident's nurse was. -He/she told the family member that Agency LPN B was going to be the resident's nurse, asking if he/she could come down to the resident's room. -The family member then walked away. -He/she then began to do some documentation and the family member came back to the nurse's station just a few minutes later, stating the resident was having a hard time breathing. -He/she then went to central supply to get an O2 concentrator and brought it to Agency LPN B. -He/she did not see the resident at that time as he/she was preparing to go home for the day. -Agency CMT A then notified him/her that Agency LPN B was looking for him/her. -Agency LPN B then notified him/her that the resident had died at 2:30 P.M. During an interview on [DATE] at 1:42 P.M., Agency LPN A said: -He/she was not in the resident's room after he/she began giving report to Agency LPN B. -He/she had assisted Agency LPN B in getting the O2 concentrator so Agency LPN B could take it to the resident's room. -The resident had been fine all day long with no medical issues. -He/she did not know the resident was a Full Code. -He/she assumed that since the resident was under hospice care, he/she was a DNR. -He/she found out later that the resident had passed away and was a Full Code. During an interview on [DATE] at 11:30 A.M., the Nurse Practitioner (NP) said: -The physician saw the resident on [DATE]. -He/she was aware the resident was to have been a Full Code, however, only O2 was used on him/her when he/she began to have issues with his/her breathing. -There were notes from the physician showing that he/she had discussed making the resident a DNR, however, the resident and family had never made that decision so the resident should have been resuscitated. -It was the NP's expectation that the resident have been resuscitated once he/she quit breathing and there was no heartbeat detected. During an interview on [DATE] at 5:10 P.M., the Physician said: -He/she saw the resident on [DATE]. -The resident was able to make his/her needs known. -The physician did discuss code status with the resident and with one family member, however, no final decision was made to change his/her code status to DNR, the record showed he/she remained a Full Code. -He/she also spoke with the hospice representative to make sure that they also discussed code status with the resident and the family, which they communicated back to physician that they had spoken with both the resident and the family, but no decision was made to become a DNR. -He/she would have expected the facility staff to know the resident's code status. -He/she would have expected the facility staff to have done CPR on the resident as soon as there was no heartbeat or respirations detected. During an interview on [DATE] at 1:45 P.M., the resident's Family Member A said: -He/she was not present when the resident passed away, but came to the facility after he/she got the word. -When the resident was in the hospital, he/she and the family spoke with the hospice company representatives and told them that the resident wanted to be a Full Code. -He/she thought that since it was the same hospice company, they would have relayed that information to the facility. -The family spoke with someone from the hospice company after the resident was admitted to the facility and told them the resident's wishes to be resuscitated. -He/she thought they relayed that information to the nursing staff that he/she was supposed to be resuscitated. -He/she just assumed the facility staff knew the resident's wishes. -He/she felt as though the facility should have followed the resident's wishes and was upset that the facility staff did not take the resident's wishes into account. During an interview on [DATE] at 2:30 P.M., Family Member B said: -The resident absolutely wanted CPR to be done. -They had told the hospice company that the resident wanted to be resuscitated. -He/she was in the room when the resident began to have trouble breathing and until he/she passed away. -He/she asked for someone to help and a person who gave the mediations came to the room and tried to get something on the resident's finger to measure his/her O2 level. -He/she cut the resident's finger nails to try and get a reading. -It seemed like it took a long time for the nurse to put O2 on the resident. -The resident kept gasping for air and then it seemed like he/she just quit breathing. -No one did anything other than give him/her some [MEDICATION(S)] in his/her mouth and O2 towards the very end. -Then the nurse said the resident had passed away. -The whole family was very upset that no CPR was done. During an interview on [DATE] at 11:15 A.M., the Director of Nursing (DON) said: -He/she would have expected the staff know the code status of all the residents in their care. -The resident code status could be found by all nursing staff on the resident physician order in the electronic medical record. -He/she would have expected the staff to look up the code status in the electronic medical record. -He/she would have expected Agency LPN B to have begun CPR as soon as he/she detected no respirations or heartbeat. During an interview on [DATE] at 11:20 A.M., the Administrator said: -He/she expected the staff to perform CPR on any resident who had a Full Code status. -He/she expected the staff know the code status of all the residents in their care. -He/she expected the nursing staff to perform CPR on the resident as soon as they could not detect a heartbeat. MO 660

Based on observation, interview and record review, the facility failed to complete fall investigations and put individualized interventions in place for one sampled resident (Resident #20) who sustained a cervical fracture (a broken bone in the neck region of the spine) from a fall on 1/22/22; and to complete fall investigations and put individualized interventions in place for one sampled resident (Resident # 87) who sustained a left first (big) toe fracture (broken) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Falls- Clinical Protocol policy, revised March 2018 showed: -The physician will help identify residents with a history of falls and risk factors for falling. -Staff will ask the resident and the caregiver or family about a history of falling. -The staff and physician will document in the medical record a history of one or more recent falls (for example within 90 days). -While many falls are isolated resident incidents, a few residents fall repeatedly; those residents often have an identifiable underlying cause. -In addition, the nurse shall identify vital signs (temperature, heart rate, breathing rate, blood pressure) recent injury, especially fracture or head injury, musculoskeletal function (ability to move muscles and bones), observing for change in normal range of motion (ability to move joints), weight bearing (ability to bear one's own weight while standing), change in cognition (thinking) or level of consciousness (alertness), neurological status (Assessment of overall condition of nervous system function), pain, frequency and number of falls sine last physician visit, precipitating (cause an event or situation, typically one that is bad or undesirable, to happen suddenly) factors, details on how the fall occurred, all current medications, especially those associated with dizziness or lethargy (tiredness), and all active diagnoses. -The staff and practitioner will review each resident's risk factors for falling and document in the medical record. -Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral [CONDITION(S)] (conditions that result when nerves that carry messages to and from the brain and spinal cord to the rest of the body are damaged or diseased), gait ( manner of walking) and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment (difficulty seeing), [CONDITION(S)] (low blood pressure), and medical conditions affecting to central nervous system (the the brain and spinal cord). -After a first fall, the staff (and physician if possible) should watch the resident rise from a chair without using his/her arms, walk several paces and return to sitting.; if the resident has difficulty or is unsteady in performing this test, additional evaluation should occur. -The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or [CONDITION(S)]) and the risk for significant complications of falls (for example, increased fracture risk or increased risk of bleeding). -Falls offer have medical causes, they are not just a nursing issue. -The staff will evaluate and document falls that occur, for example when and where they happen and any observations of the event. -Falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. -Falls should also be identified as witnessed or unwitnessed events. -For a resident who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. -Often multiple factors contribute to a falling problem. -If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR - unwanted, uncomfortable, or dangerous effects that a drug may have), or if the resident continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. -After a fall, the physician should review the resident's gait, balance, and current medication that may be associated with dizziness or falling. -Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. -Based on the assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of significant consequences of falling. -If underlying causes cannot be readily identified or corrected staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. -Staff with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as fracture (broken bone) or subdural hematoma (bleeding next to the brain) have been ruled out or resolved. -Delayed complications may occur hours or days after a fall, while sighs of a subdural hematoma or other intracranial (inside the skull) bleeding could occur up to several weeks after a fall. -The staff and physician will monitor and document the resident's response to interventions intended to reduce falling or the consequences of falling. -Frail elderly residents are often at greater risk for serious adverse (harmful, unfavorable) consequences of falls. -Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. -If interventions have been successful in fall prevention, the staff will continue with current. -If interventions have been successful in fall prevention, staff will continue with current approaches and will discuss periodically whether these measures are still needed. -If the resident continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 1. Record review of Resident #20's Admission Record showed he/she admitted to the facility on [DATE] and had the following diagnoses: -Non-displaced fracture (a crack or break in a bone in which the bone retains its proper alignment) of fourth cervical vertebra (C4 - the fourth neck bone away from the skull), onset date 1/25/22. -Personal history of [CONDITION(S)] (TIA - a brief stroke-like episode during which parts of the brain do not receive enough blood) and stroke ( the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen). -Difficulty walking. -Unsteadiness on feet. -Muscle weakness, generalized. -Other lack of coordination. Record review of the residents Order Summary Report showed [MEDICATION(S)]-[MEDICATION(S)] (a medication that can cause dizziness and weakness) tablet 25-100 milligrams (mg), give two tablets by mouth four times a day for [CONDITION(S)] (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), start date 11/10/21. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated tool required to be completed by facility staff for care planning) dated 12/25/21 showed he/she: -Had unclear speech. -Was moderately cognitively impaired. -Had no behavioral symptoms. -Received one staff person assistance for transfer. -Had [CONDITION(S)] disease. Record review of the resident's Incident Note dated 1/22/22 at 12:30 P.M. showed: -He/she fell out of his/her wheelchair head first and his/her head hit the floor. -The licensed nurse was called to the resident's room by the caregiver who witnessed the fall and assessed the resident for injury. -He/she was alert and confused, was moving his/her arms and legs. -He/she had an abrasion (an area of scraped away skin) on his/her forehead. -He/she was assisted into his/her bed. -His/her physician was notified and gave an order for him/her to be transported to hospital. Record review of the resident's Witnessed Fall report dated 1/22/22 at 12:30 P.M. showed: -The incident location was the resident's room. -The person preparing the report was the Assistant Director of Nursing (ADON). -The incident description showed: Resident was sitting in wheelchair, staff was in with the resident; he/she fell on floor hitting his/her head; an abrasion was noted on his/her head; resident was assisted to his/her bed; his/her primary care physician (PCP) was called and notified and ordered to send the resident to emergency room (ER) to evaluate and treat him/her; the resident's family was notified of his/her fall and ER transfer. -Resident Description: The resident was unable to give a description. -Immediate Action: He/she was taken to local hospital. -Injuries observed at the time of the incident: No injuries observed at time of incident (Note: the Incident Description included that he/she had an abrasion noted on his/her forehead). Level of Pain: Total score - 4: Breathing: Occasional labored breathing (abnormal increased effort to breathe), short period of hyperventilation (rapid or deep breathing, usually caused by anxiety or panic) (score = 1); Negative (unhappy) Vocalization: Occasional moan or groan, low level of speech (score = 1); Facial Expression: Sad frightened, frown (score = 1); Body Language: Relaxed (score = 0); Consolability - Distracted or reassured by voice or touch (score = 1). -Level of consciousness (a medical term that describes a state of awareness, alertness, and wakefulness.): Lethargic (drowsy). -Mental Status: Withdrawn (a sign of mental status change). -Injuries Report Post incident: No Injuries observed post incident (Note: the Incident Description section included that he/she had an abrasion noted on his/her forehead). Predisposing (to make someone inclined to something in advance) Environmental Factors: Boxes to check for 16 listed factors including None and Other (describe) had no boxes checked. -Predisposing Physiological (the way the body functions) Factors: 19 boxes with factors to check - boxes checked for drowsy, gait imbalance, recent change in cognition (thinking ability), and weakness. -Predisposing Situation Factors: Boxes to check for 17 listed factors including None and Other (describe) had no boxes checked. -Other Information: Blank. -Witnesses: No witnesses found (Note: The Incident Description section included that staff was in with the resident). -Agencies/People Notified: Director of Nursing (DON), Assistant Director of Nursing (ADON), Physician. Record review of the resident's Nursing Note dated 1/22/22 at 12:48 P.M. showed: -He/she was sent to a local hospital at approximately 12:40 P.M. -His/her family member called back regarding him/her and was given an update at that time. Record review of the resident's hospital Trauma Progress Note dated 1/23/22 showed: -He/she had a fall from his/her wheelchair. -He/she had a frontal scalp hematoma (an abnormal collection of blood outside of a blood vessel). -He/she had a history of receiving a blood thinner. -He/she had a non-displaced of his/her posterior (back) spinous process (part of the spine) of C4. Record review of the resident's Re-Admission assessment dated [DATE] showed he/she was admitted from the hospital ER via stretcher at 6:00 P.M. Record review of the resident's Order Summary Report showed an order for his/her bed to be kept in low position when he/she was in bed and mats on the side of the bed regarding falls, dated 1/25/22. Record review of the resident's care plan showed the following with a revision date of 3/7/22: -He/she was at risk for falls. -Ensure his/her call light was in reach, encourage him/her to use his/her call light for assistance as needed. -Follow the facility falls protocol. -There was no other mention of or interventions for falls in the resident's care plan. Observation on 3/16/22 showed the resident: -Was lying in his/her bed in the lowest position and mats next to his/her bed. -Was alert but did not answer questions. Observation on 3/17/22 at 8:46 A.M. showed the resident: -Was in his/her room seated in his/her wheelchair with upright posture. -Was alert. -Mumbled with nonsensical (having no understood meaning) speech when asked questions. Observation on 3/18/22 at 11:14 A.M. showed the resident: -Was at the sink with the faucet on and his/her hands under the flowing water. -He/she was alert. -He/she mumbled with nonsensical speech when asked questions. During an interview on 3/22/22 at 11:14 A.M. ADON said: -The resident's Witnessed Fall report dated 1/22/22 showed he/she had completed the form however he/she did not recall that investigation. -He/she did not recognize it as his/her investigation, it was not how he/she documented; there were no witness statements, if it had been him/her who did the resident's 1/22/22 fall investigation, he/she could say he/she did get witness statements when he/she did falls investigations. -There was no documentation of an investigation of the root cause of the resident's fall on 1/22/22. -He/she would have to say the resident fell forward out of his/her wheelchair cause was that the investigation of his/her fall on 1/22/22 did not have documentation that would show an investigation of the root cause of the resident's fall. -Items that were missing from the residents 1/22/22 Witnessed Fall report/falls investigation included the resident's vital signs, the root cause of the resident's fall, the size of his/her abrasion, his/her baseline neuro check immediately following his/her fall, how (the method, i.e. number of staff, gait belt/assisted/total lift/mechanical lift) he/she was transferred to his/her bed, how he/she went to the hospital (i.e. by Emergency Medical Services - EMS). -The DON at that time was no longer employed at the facility. -His/her care plan should have had interventions specific to preventing him/her from having further falls from his/her wheelchair. -He/she had not participated in care plan meetings at the facility. -There should have been witness statements documented with his/her falls investigation. -Falls had been routinely discussed every Friday in Risk Meetings. During an interview on 3/22/22 at 11:42 A.M. ADON A said: -Certified Nursing Assistant (CNA) was the caregiver with the resident in his/her room when he/she fell forward out of his/her wheel chair. -He/she did not know who the CNA was, it was not noted of the Witnessed Fall report. -The resident in general leans forward in his/her wheelchair. -He/she did not know of any other falls the resident had. During an interview on 3/22/22 at 12:30 P.M. the DON, ADON and Corporate Nurse Consultant B said: -The root cause of the resident's fall was not included in the investigation information regarding his/her 1/22/22 fall with a major injury of a cervical fracture. -Following the resident's 1/22/22 fall he/she was put on therapy services and safe wheelchair positioning was the reason for therapy. -Care plan interventions for him/her would have been therapy services, having his/her call light in reach, and monitoring/checking on him. -If no root cause of the resident's fall was determined, it was known that he/she leaned forward in his/her wheelchair. -All the facility had regarding the resident's 1/22/22 fall was the incident report and the hospital report that he/she had a cervical fracture. During a telephone interview on 3/25/22 at 9:43 A.M. the resident's physician said: -The resident had [CONDITION(S)] and had some behaviors of being adamant of doing things only his/her way and sometimes got agitated and stubborn with staff and had some unpredictable behaviors. -It was always good to look at the root cause of a fall; with him/her, because of his/her [CONDITION(S)], his/her personality traits, and his/her behavior it would be difficult to eliminate all risk of falls but the facility was doing the best they could with him/her. -Facility staff were attentive with the resident. -He/she was notified of the resident's fall; the resident was promptly transferred to hospital and did have the fracture. -Measures were put in place to keep his/her bed low and to have mats next to his//her bed; methods of keeping him/her from falling from his/her wheelchair were difficult because he/she needed as much independence as possible and because he/she was unpredictable; putting him/her in a reclined wheelchair was a restraint for him/her so that was not done. 2. Record review of Resident #87's Admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: -Spinal Stenosis, Cervical Region (narrowing of the spine in the neck region, which can compress the spinal cord and/or nerves, often causing pain, numbness and/or weakness). -Expressive Language Disorder (a disorder in which a person has difficulty expressing ideas/thoughts). -Stroke. -[CONDITION(S)] Disease. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Had borderline cognitive impairments. -Needed assistance with walking and transfers. -Had one non-injury fall since the last assessment. -Started Physical Therapy (PT) on 12/8/21 and Occupational Therapy (OT) on 12/13/21. Record review of the resident's Nursing note, dated 2/20/22 at 12:18 P.M. showed: -Around 12:00 noon, this nurse was notified by the Certified Medication Technician (CMT) that the resident fell on the floor. -The CNA witnessed the resident falling and said the resident did not hit his/her head. -The resident said he/she did not hit his/her head. The resident said he/she was walking from the bathroom to his/her chair when his/her legs gave out. -The resident was able to move all four extremities. Neurological checks (assessments of neurological functions including mental status, motor exam and reflexes, sensory exam, eye responses), blood pressure, and vital signs (temperature, respirations, and pulse) were normal. -The resident's primary contact was notified and the concern was written in the electronic system for the physician. Record review of the resident's Fall Report, dated 2/20/22 showed: -The fall was witnessed. -The location of the incident was the resident's room. -A description of the incident showed: At around 12:00 noon the nurse was notified by the CMT that the resident fell . The resident was found lying on his/her back on the floor. The CNA witnessed the fall and stated the resident did not hit his/her head. The resident was walking to his/her chair from the bathroom when he/she fell on the floor. Neuro checks and vital signs were done and were all within normal limits. The resident was able to move all four extremities. No injuries noted. The resident had no complaints of pain or discomfort. The resident's responsible party was notified and the concern was written by electronic communication for the physician. The resident said he/she was walking from the bathroom to his/her chair when his/her legs gave out and said he/she did not hit his/her head. -Immediate actions taken were the resident's skin was checked and vital signs were taken. The resident did not go to the hospital. -The resident was described as oriented to person, place and time. -There were no predisposing environmental or situational factors. A predisposing physiological factor was weakness. -There were no witnesses found (this contradicted the earlier description in which a CNA witnessed the fall). -Persons notified were the resident's primary contact, the DON, and the physician. -A weekly DON report, for the week of 2/16/22 through 2/22/22 showed the resident had one fall with a major injury and the intervention was for PT and OT to evaluate the resident. Further review of the resident's Fall Report, dated 2/20/22 showed the following information was missing: -The names of the CNA and CMT were not mentioned in the report and there were no witness statements. -There was no information as to whether or not the CNA was assisting the resident at the time of the fall, and if so, whether or not the CNA was using a gait belt while the resident walked from the bathroom to his/her chair. -There was no documentation as to whether or not the resident was using his/her walker at the time of the fall. -There was no documentation of details about what the witness observed such as any changes in how the resident walked, whether or not the resident had just risen from a seated to a standing position, what footwear he/she was wearing, or if any resident body part was observed hitting or scraping against an object. -There was no mention of any medications that could have possibly contributed to the resident's fall. -The report did not show whether or not the CNA followed the resident's care plan related to transfers/ambulation needs or if any education was provided to either the resident or the CNA. Record review of the resident's Nursing Health Status Note, dated 2/21/22 at 2:07 P.M. showed: -The resident had an abrasion to his/her left great toe and said he/she sustained the abrasion when he/she fell on [DATE]. -An order was received to apply Vaseline dressing and cover with a dry dressing daily. -The wound nurse was to follow up on 2/23/22. Record review of the resident's Nursing Health Status Note, dated 2/22/22 at 2:00 P.M. showed: -A change of mental status was noted by the nurse while he/she was doing the resident's ordered dressing change. The resident was very lethargic and his/her voice was noted to be weak. -The Nurse Practitioner (NP) was face-timed and an order was obtained to send the resident to the hospital for evaluation and treatment to rule out a stroke as the resident had a witnessed fall on 2/20/22. -The resident's primary contact was notified of the order to transfer. -A report was called to the hospital ER. -The Administrator was notified of the transfer. Record review of the resident's acute care hospital Discharge Summary, dated 2/25/22 showed: -The patient (the resident) presented to the hospital 2/22/22 after a fall at the nursing home with altered mental status. There were concerns he/she may have had a stroke. -The patient was disoriented and lethargic at presentation. His/her Lactic acid was elevated (higher than normal lactic acid can result in lactic acidosis which can lead to muscle weakness, confusion and sleepiness). -The patient had a subtle fracture of the left big toe. Orthopedics recommended postop shoe and follow-up as outpatient. -The patient was admitted and sedating medications were held. [MEDICATION(S)] (a diuretic which can treat fluid retention and high blood pressure) was held. He/She was treated with intravenous (IV) fluids. -Computerized tomography (CT combines a series of X-ray images taken from different angles around your body and uses computer) scans of the head were negative and Magnetic Resonance Imaging (MRI procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body) of the brain was negative for stroke. -CT of the thoracic (near the rib cage) and lumbar spine (lower part of the back) were negative for fractures. -His/her Ammonia (a waste product made by your body during the digestion) was slightly elevated and the resident was treated with [MEDICATION(S)] (a medication used to lower ammonia levels in the blood). -Neurology was consulted and thought his/her mental status changes was likely from multiple sedating medications in the setting of [CONDITION(S)] (poor functioning kidneys). -The patient's [MEDICATION(S)] (an anti-[CONDITION(S)] medication) dose was decreased and [MEDICATION(S)] (a muscle relaxer) was discontinued. -The patient was difficult to mobilize due to back pain. -His/Her mental status was improved and likely back to baseline. -The patient will be discharged back to the nursing home with PT and OT. -The Orthopedic Consult on 2/24/22 showed: --Swelling, slight bruising, and tenderness as well as an abrasion to the left big toe with no calf tenderness. There were no signs of infection. The patient could move his/her toes. --X-ray, two views of the toes and comparison with radiographs from 9/9/21, showed subtle non-displaced lucencies involving the lateral base of the first distal phalanx (fracture on outside portion of bone near the joint closest the toenail). --Recommendations for follow up radiographs in seven to ten days; keep heels off-loaded while in bed; pain medications as needed; Wound care to the left great toe abrasion; weight bearing with post-op shoe as tolerated; elevate and ice the left lower extremity as much as possible; and follow up with orthopedics in two weeks. No orthopedic surgical intervention was needed. Record review of the facility's Non-Pressure Injury Reports, for March, 2022 showed the resident had facility-acquired trauma to the great left toe, including an abrasion requiring on-going treatment. Record review of the resident's Fall Report, dated 2/26/22, showed: -The fall was unwitnessed. -The resident was found on his/her bottom with his/her back against the toilet on 2/26/22 at 10:41 A.M. -The nurse and another staff tried to get the resident up, but was unable to do so. Additional staff were called. -Staff tried to get the resident up with a mechanical lift and sling, but there was insufficient room to use it so a sit to stand mechanical lift was tried. -The resident didn't have enough strength to hold himself/herself up long enough to be cleaned or transferred so he/she had to be lowered before he/she slipped out. -Staff ended up rolling the resident on a couple of blankets and pulling him/her out of the bathroom to his/her room and using a mechanical lift with sling to get the resident safely into his/her recliner. -The resident said he/she had been having some loose stool and didn't want to wait. His/Her legs gave out when he/she was getting ready to sit down. He/She reported having his/her usual pain in his/her back. -No injuries were observed at the time of the incident. -Pain level was at a six out of 10 with 10 being the most severe. -The resident was oriented to self, place, time and situation. -Predisposing environmental, physiological or situational factors were not indicated on the form. -The resident was educated to use the call light when he/she needed help. -People notified were the resident's primary contact, DON, and physician. Further review of the resident's Fall Report, dated 2/26/22 showed information was limited such as the following: -Other than the nurse, the names of staff assisting the resident prior to and following his/her fall were not mentioned. -The report did not indicate whether or not the resident had used his/her call light, and if so, how long the resident said he/she had been waiting for staff assistance. -There was no information as to whether or not the resident's loose stools were being or would be addressed. -The report did not show whether or not the resident had taken his/her walker into the restroom. Record review of the resident's Fall Care Plan, most recently amended 2/28/22, showed interventions that included: -Educated resident to use his/her call light when needing to be repositioned in his/her recliner, added 2/23/20. -Provide assistance of one staff for wheelchair and rolling walker every one to two hours for skin integrity and fall risk reduction, added 3/24/20. -Staff to encourage resident to use his/her call light and wait for assistance before trying to self-transfer from restroom, added 6/13/20. -Nonskid tape to be reapplied to floor, added 9/10/21. -OT and PT to work with the resident on strengthening and walking to and from the restroom, added 2/20/22. -Resident to wear a soft boot anytime he/she is out of the recliner and walking, added 2/28/22. During an interview on 3/14/22 at 12:40 P.M. the resident said: -He/she fell approximately two weeks ago and broke his/her left big toe. -He/she went to the hospital following the fall and was given a special shoe to wear when he/she was out of his/her recliner. -Staff was with him/her when he/she fell . -He/she turned and lost his/her balance. -He/she didn't think staff held onto a gait belt and didn't remember wearing a gait belt. During an interview on 3/16/22 at 5:43 A.M. agency CNA A said the resident gets up by himself/herself and does not require any staff assistance for transfers or staff to check on him/her while in the restroom or any other time. During an interview on 3/16/22 at 6:45 A.M. CNA B said: -The resident's recliner assists him/her in getting up and he/she usually went to the toilet on his/her own. -The resident sometimes needed help lifting up from the toilet. -The resident would put on the call light if he/she wanted help. -Staff doesn't help him/her every time he/she uses the restroom. During interview on 3/17/22 at 10:08 A.M. the Rehabilitation Director/Physical Therapist Assistant (PTA) A said: -The resident started ST on 2/26/22 which was discontinued on 3/10/22. -He/She started OT and PT on 2/28/22 and was still receiving OT and PT services. -The resident was working on walking in his/her room. The surgical shoe throws him/her a little off-balance. -Therapy communicates with CNAs, nurses, and the MDS Coordinator about each resident's assistance needs. -When ambulating in his/her room he/she needed assistance of one staff and the use of his/her walker. During an interview on 3/21/22 at 11:38 A.M. CNA B said: -The resident was not always compliant with putting on his/her call light, but would tell staff he/she knows he/she was supposed to put the call light on when using the restroom. -When he/she assisted the resident, the resident used his/her walker and he/she holds onto the resident's gait belt. (In an interview on 3/16/22 CNA B said staff didn't necessarily help the resident in the restroom if the resident did not put on his/her call light). During an interview on 3/21/22 at 12:08 P.M. CNA E said: -If the resident was having a good day he/she would put on his/her call light. If the resident hasn't put on his/her call light within a couple of hours he/she would ask the resident if he/she needed to go to the restroom. -The resident was supposed to use his/her walker when walking to and from the restroom and staff were supposed to use and hold onto a gait belt in the event the resident should lose his/her balance. 3. During an interview on 3/22/22 at 8:36 A.M. Registered Nurse (RN) A said: -When a resident falls the charge nurse interviews the resident and the CNA or other witnesses. What they report to the nurse goes in the report. The physician was always notified. The CNA or other witnesses do not write a statement of anything they witnessed to his/her knowledge. -A progress note should be written in the resident's chart. -An immediate intervention might be needed such as a fall mat or changing the resident's footwear. -The Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward a common goal fo

Based on observation, interview and record review, the facility staff failed to prevent an avoidable fall by not using a gait belt during transfers, resulting in the resident hitting his/her head and fracturing both bones in their forearm, and resulting in his/her being transferred to the hospital, for one sampled resident (Resident #12); to provide protective oversight for one sampled resident (Resident #3) who required total care and supervision and was left unattended in their room and sustained a fall that was avoidable; to implement the resident's fall interventions to reduce the hazard and risk for falls for one sampled resident (Resident #16) who had recent fall on 2/29/16 in a timely manner; to update the resident's care plan to show all post interventions for two sampled residents (Resident #3 and #12); to ensure medication carts were locked when unattended; and to ensure care plans were updated to show current fall interventions for one sampled resident (Resident #21) out of 24 sampled residents. The facility census was 144 residents. 1. Record review of Resident #12's Admission Record dated 3/9/16, showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-A fracture of the wrist, and in the thinner and longer of the two bones in the human forearm, on the side opposite to the thumb; -Muscle weakness; -Difficulty in walking; -Cognitive communication deficit; -Dysphagia (difficulty with swallowing); -Pain in the left hip; -A history of falling; -Glaucoma (a condition of increased pressure inside the eye which could lead to blindness); -[DIAGNOSES REDACTED](abnormal heart rhythm); -Chronic obstructive pulmonary disease (COPD; a disease process that decreases the ability of the lungs to perform ventilation); and -Shortness of breath. Record review of the undated Certified Nurses Aide (CNA) Care Sheet showed he/she: -Was a full code; -Used a wheelchair for mobility; -Was a gait belt (a canvass belt used to aide in resident transfer) transfer with the assist of one staff member; -Had pneumonia; -Needed assistance with toileting every two hours; -Had a fracture of the left wrist with a cast; -Was non-weight bearing on his/her upper left extremity; and -Was able to wear a sling on his/her left arm for comfort. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) dated 2/16/16, showed he/she: -Was cognitively intact; -Received extensive assist with one staff person during bathing, for toileting and transfers; and -Received limited assistance with one staff person for walking in his/her room, the corridor, with locomotion on or off the unit and with dressing. Record review of the resident's Progress Note dated 2/20/16 at 7:22 A.M., and written by a Registered Nurse (RN), showed: -The resident lost his/her balance and fell against the wall during a transfer with the CNA. The resident hit his/her head and left wrist during the fall. The resident had a large hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) to the left forehead upon assessment, and complained of pain to the left wrist. The physician and the resident's child was notified of the incident and then the resident was transported to the hospital; -The fall was to be reported on the shift report and the 24 hour report. Record review of the resident Fall Investigation dated 2/20/16, reviewed with the DON at 2:00 P.M., showed: -The fall had occurred between 5:00 A.M. and 5:30 A.M.; -The CNA reported the resident fell to the floor when he/she lost his/her balance when the CNA turned to get the resident's pillow off the resident's bed for the resident's recliner. The resident fell to his/her left side and hit the wall, when trying to stop the fall with his/her left hand; -The fall was witnessed; -The resident was an assist of one staff member; -The fall resulted in an injury; -The resident was assessed with [REDACTED]. -The resident was sent to the hospital; -Interventions before the fall included providing standby assist; the resident was to be checked every two hours and educated to use the call light for assistance; -Interventions post fall included to educate the resident to call out when assistance was needed, and the aides were educated to encourage the resident to sit and wait while gathering the resident's requested items; -Notifications were made to the resident's physician and adult child; and -A gait belt was not used at the time of the incident. Record review of CNA F's statement regarding the resident's fall dated 2/21/16, showed: -After toileting the resident wanted to sit in his/her chair; -The resident stated he/she could not sit without his/her pillow; -The CNA went to the bed to get the resident's pillow, and on the way back the resident lost his/her balance and fell to the floor while hitting his/her head on the wall. He/she may have broken his/her wrist when trying to catch his/her balance. Record review of the resident Care Plan dated 2/23/16, showed a focus area where he/she required assistance with Activities of Daily Living (ADL's) and was at risk for falls, with interventions that he/she: -Required one staff person assist for transfers; -Was not weight bearing to his/her left upper extremity; -Used a wheelchair for mobility; -Used a quad cane when walking with therapy; and -No care plan intervention for staff to use a gait belt while transferring. Record review of the resident's physician order [REDACTED]. -Functional level was up with the assist of one staff to their wheelchair; and -Was non-weight bearing to his/her left upper extremity. During an observation and interview on 3/9/16, the resident said he/she: -Had a hematoma on his/her left forehead with bruising; -Had a cast on his/her right forearm wrist area; -Had broken his/her wrist when he/she was going to sit down and the staff person reached to get his/her pillow and let go of him/her; -He/she then fell and hit the wall hard; -His/her face was black, two bones were broken in his/her wrist, he/she had a bump on his/back which had gone down, and the bump on the left side of his/her forehead would not go down; and -He/she should have sat down while waiting for the pillow. During an interview on 3/10/16 at 11:24 A.M., MDS Licensed Practical Nurse (LPN) B said: -Care plans were developed from the MDS Care Area Assessments; -Post interventions should be placed on the care plan after a fall; -When a resident falls a fall assessment is completed; -Preventative interventions are found on the care plan; -For falls the care plan should have if the resident were found to be at risk for falls a goal and preventions; -He/she did not say a gait belt should have been used for the resident. During an interview on 3/11/16 at 9:18 A.M., LPN D said: -The resident should transfer with a gait belt with hands on by the staff during the transfer. During an interview on 3/11/16 at 8:50 A.M., the Physical Therapy (PT) Program Director said: -The fall was the result of the resident multi-tasking, asking the aide to grab a pillow before sitting; -The resident was a stand by assist of one, contact guard for transfer meaning the resident should have been transferred with a gait belt; -He/she was an active participant of the fall committee; -All resident falls were reviewed weekly in the fall committee; and -Therapy's role in the fall committee was to discuss need, intervention, possible adjustment to assistive device and or nursing interventions. During an interview on 3/11/16 at 10:08 A.M., the Administrator said: -All resident falls within a week of the incident were reviewed weekly with all disciplines present; -The investigation of the resident fall did not have a statement as to whether or not a gait belt was used or not. During an interview on 3/11/16 at 11:00 A.M., CNA F said he/she: -Had assisted the resident to the restroom and dressing before assisting the resident to a chair when the resident had asked for him/her to grab a pillow, when the pillow was reached for the resident lost his/her balance; -Did not use a gait belt for the transfer, and the resident was a standby assist; -When the resident hit the wall, the resident had put his/her hand down to stop the fall and broke his/her wrist; -The previous shift report, the chart and or the nurse educated to him/her when there was a gait belt needed. During an interview on 3/11/16 at 12:10 P.M., the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) said: -Interventions from the falls should be in the care plan within a week of the incident or a week of the fall committee meeting's follow up discussion; -If the intervention is found on another focus area it is not always added to the fall focus area; -CNAs are able to find interventions for each resident form their task list or care sheets which are completed by the MDS Coordinator; -The MDS Coordinator pulls from the MDS and the care plan to create the CNA care sheets; -The care plan should be reflective of the resident and ongoing; and -The resident fall was avoidable. The CNA should have used a gait belt and the resident was a stand-by assist of one staff member. During an interview on 3/23/16 at 3:48 P.M., the resident's facility physician said: -The facility made timely notification of the resident's fall; -An extensive evaluation of the fall had taken place; -The resident did have initial physician's orders [REDACTED]. -Physician orders [REDACTED]. -He/she was unable to speak directly to the transfer order without the resident's chart; -He/she was unable to say the use of gait belt would have or have not prevented the resident fall; and -The resident was a fall risk, presented debilitated, was weak and on oxygen. The incident was unfortunate. 2. Record review of Resident #3's Admission Record dated 6/2/15, showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Osteoarthritis (a degenerative disease of the bones and joints); -Senile dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function); -Personal history of falls; -Tremors (an involuntary quivering movement); -Debility (weakness); -Difficulty in walking; -Muscle weakness; -Retention of urine; -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus); and -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's undated CNA Care Sheet showed he/she was: -In a Broda chair (a specialized wheelchair that can recline back); -A transfer assist with a gait belt of one to two staff persons; -Was weight bearing as tolerated; and -Was to have his/her bed in the low position with a fall mat. Record review of the resident's fall investigation dated 11/10/15 and reviewed with the DON at 2:00 P.M., showed he/she: -Had a fall 11/10/15 at 10:05 A.M.; -The Certified Medication Technician (CMT) found the resident in a sitting position on the floor in front of his/her chair and was able to report he/she had fallen out of the chair; -Was in a Broda chair; -Was able to lean forward and slid out; -Had enough muscle strength to pull himself/herself up and to lean forward when reclining; -The fall was avoidable as the resident was left unattended in his/her room; -Interventions prior to the fall included frequent checks, bed and wheelchair alarms, he/she had a catheter (a tube from the bladder to drain urine), and he/she was to be laid down after meals; -Interventions post fall was to educate the staff about not leaving the resident unattended in his/her Broda chair in his/her room and to keep the resident in view of the staff; -The fall was non-injury and unwitnessed; -Notifications were made to the physician and the adult child; and -A prior fall was 2/22/15. Record review of the resident's care plan dated 1/20/16, showed he/she was: -At risk for falls and had a history of [REDACTED].>-To have activities that minimize the potential for falls while providing diversion and distraction; -To be monitored closely for whereabouts in the facility due to being a high risk for falls; and -To have bed and chair alarms in place. During an observation on 3/8/16 at 8:35 A.M., showed the resident was: -In his/her room in their Broda chair and had his/her eyes open; -Facing the doorway; and -Alone. During an observation on 3/8/16 at 9:55 A.M., showed the resident was: -In his/her room up in his/her Broda chair and had his/her eyes shut; -Covered and his/her right foot was hanging off the foot rest; -Facing the doorway; and -Alone. During an observation on 3/10/16 at 12:53 P.M., showed the resident was: -In his/her room sitting in his/her Broda chair with his/her eyes open; -Facing the doorway; and -Alone. During an interview on 3/11/16 at 8:50 A.M., the PT Program Director said: -Resident #3 was not involved with specialized rehabilitation services; -Therapy was not part of Resident #3's transition to a Broda chair from a wheelchair; -Therapy would educate staff about positioning the resident in a Broda chair if requested; however therapy preferred modifications of the wheelchair to be attempted first before moving to a Broda chair; -If a resident were found unsafe to be alone in a Broda chair a review would need to be done to determine if the Broda chair continued to be appropriate. During an interview on 3/11/16 at 11:50 A.M., CNA K said: -When the resident was up in the Broda chair he/she should be in view at the nurses station, television room or in a group activity; -He/she had not been educated of the expectations when the resident was up in his/her Broda chair, and was just thinking safety; -The care sheet did not identify where the resident should be when up in the Broda chair; -If he/she had questions related to care he/she would go to the charge nurse. During an interview on 3/11/16 at 12:10 P.M., the DON and the ADON said: -The resident's care plan was not updated to reflect the change in care needs nor was the CNA care sheet. The care plan should have had the resident was not to be left alone in his/her Broda chair in his/her room; -The resident fall was avoidable since the resident should not have been left alone in his/her room up in the Broda chair; -They were not aware that the staff had been leaving the resident unattended in his/her room while sitting up in the Broda chair. 3. Record review of the facility's undated Medication Administration policy and procedure showed: -The medication cart shall be locked or under the direct supervision of the responsible nurse or Certified Medication Technician (CMT) at all times. During an observation on 3/7/16 at 6:30 A.M., showed: -The medication cart used to store resident medications was left unlocked on the 400 hall by the CMT from 6:30 A.M. to 6:50 A.M.; -The CMT had walked up and down the hall while the cart was unlocked to pass medications to residents in their rooms; -The medication cart was out of sight and out reach of the CMT on five occasions for at least three minutes each time; -The computer with resident information was left up, open and showing; -Three residents were seen propelling themselves past the unlocked medication cart; -Two different staff members walked past the unlocked medication cart; -One staff member was seen pushing a resident past the unlocked medication cart; -The medication cart was locked during the interview with the CMT at 6:50 A.M. During an interview on 3/7/16 at 6:50 A.M., CMT C said he/she: -Upon arrival makes sure the medication cart is fully stocked with resident medications so he/she would not have to return to the nurses station for refills; -Does not lock the medication cart when he/she was not going long distances; -Was aware the policy and best practice was to lock the medication cart and to close the computer screen each time he/she was to step away from the medication cart. During an interview on 3/10/16 at 11:24 A.M., MDS Coordinator LPN B said: -The medication carts should be locked anytime the CMT or Nurse is away from the medication cart and it is not in direct eyesight; -The expectation and policy is to lock the medication cart when the medication cart is not in eyesight and in direct reach. During an interview on 3/11/16 at 12:10 P.M., the DON and the ADON it was said: -Medication carts should be and were expected to be locked when not in eyesight or within reach. 4. Record review of Resident #21's Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's physician's orders [REDACTED].>-Bed and wheelchair alarms to be checked for placement and functioning status every shift for fall risk (initiated on 12/1/15); -Bed in the lowest position with a floor mat on the floor at the bedside with the resident in bed (initiated on 12/1/15); -Half side rails to assist with bed mobility and transfers, and a trapeze bar above his/her bed to assist with bed mobility (initiated on 2/9/16). Record review of the resident's significant change MDS dated [DATE], showed he/she: -Was moderately cognitively impaired and exhibited verbal behaviors that were directed at others; -Used a wheelchair for mobility and needed the assistance of two staff persons to transfer; -Was unable to stabilize to transfer without assistance; and -had a history of [REDACTED]. Record review of the resident's Fall Risk assessment dated [DATE], showed a score of 26, which was considered to be at high risk for falling. Record review of the resident's Care Plan showed he/she had a self-care performance deficit related to his/her right leg below the knee amputation, risk for falls, skin integrity and immobility. It showed the resident needed extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene, and was dependent on facility staff for locomotion on and off of the unit, but the resident was able to self-propel in his/her wheelchair short distances. Interventions showed staff was to: -Be sure the call light is within reach and to encourage/remind him/her to use it for assistance (initiated 10/26/15); -Ensure bed alarms and wheelchair alarms are on for safety (initiated 10/26/15); -Ensure the resident wore appropriate footwear with transfers (initiated 10/26/15); -Encourage the resident to use his/her call light for assistance (initiated 10/26/15); -Follow facility fall protocol and review information on past falls and attempt to determine the cause of the resident's falls (initiated 10/26/15). Record review of the resident's Nursing Notes showed: -On 1/7/16, the nurse heard the resident's alarms going off and upon approach with the CNA, saw the resident in his/her room sitting on the floor on his/her bottom between the bed and wheelchair. The resident said he/she was trying to transfer himself/herself from his/her bed to his/her wheelchair without assistance. The nurse assessed the resident and with staff assistance, placed the resident back in his/her bed (the resident began cussing at staff during his/her transfer). The nurse stepped outside of the resident's room to get his/her medications and heard the resident's alarms going off again. When he/she came back into the resident's room, the resident was sitting on the edge of his/her bed, nearly on the floor again. The nurse and CNA staff transferred the resident into his/her wheelchair. The resident's spouse was notified; -Notes showed nursing staff started neurological checks from 1/7/16 to 1/11/16; -Notes did not show any additional post fall new or added fall interventions implemented to prevent further falls. Record review of the resident's Post Fall assessment dated [DATE], showed he/she was transferring himself/herself without any assistance from his/her bed to his/her wheelchair and fell . The CNA (unidentified) heard the alarm sounding and found the resident on the floor in his/her room beside his/her bed. The nursing staff last saw the resident laying in his/her bed (no time documented). His/her alarms were in place and working. The resident's call light was within reach and his/her bed was in a locked position. He/she had no injuries and his/her physician and responsible party were notified. The intervention was to re-educate the resident to use his/her call light. Record review of the resident's Care Plan showed there were no updated interventions showing the resident fell on [DATE], and there were no added interventions or change in current interventions documented. Record review of the resident's Nursing Notes showed: -On 1/30/16 at 3:36 P.M., the CNA (unidentified) responded to a sounding alarm and informed the nurse that he/she found the resident sitting on the floor next to his/her bed. The resident said he/she was caught in his/her blanket and fell out of his/her bed. The resident had no apparent injury upon assessment. The resident's range of motion was intact and he/she was transferred back into his/her bed without difficulty. The resident denied hitting his/her head. Nursing staff initiated neurological checks. The intervention showed the resident was reminded and encouraged to use his/her call light for assistance; -Notes showed nursing staff started neurological checks on 1/30/16 for 72 hours after his/her fall; -Notes did not show any additional post fall new or added fall interventions implemented to prevent further falls. Record review of the resident's Post Fall assessment dated [DATE], showed the CNA (unidentified) heard the resident's alarm sounding and observed the resident sitting on the floor next to his/her bed. The resident was last observed in his/her bed (no time documented). The resident's call light was within reach and his/her bed was in a locked position. He/she had no injuries and his/her physician and responsible party were notified. The intervention was that staff reminded and re-educated the resident to use his/her call light for assistance. Record review of the resident's Care Plan showed there was no documentation showing the resident fell on [DATE], and no updated interventions or documentation showing the facility reviewed his/her falls to try to determine interventions based on the circumstances of each fall (time, location, etc.) that may further prevent falls. Record review of the resident's Nursing Notes showed: -On 2/3/16 at 4:00 A.M., the resident's bed alarm was sounding and when the CNA (unidentified) arrived, the resident was found sitting on the floor beside his/her bed. He/she said he/she was trying to transfer himself/herself from his/her bed to his/her wheelchair. There were no injuries noted upon assessment and the resident denied pain. The nurse and CNA assisted the resident back into his/her bed and reminded the resident not to try to transfer himself/herself, and to use his/her call light for assistance. The nurse was to inform the resident's physician and responsible party. -Notes showed nursing staff started neurological checks on 2/3/16 for 72 hours after his/her fall. -Notes did not show any additional post fall new or added fall interventions implemented to prevent further falls. Record review of the resident's Post Fall assessment dated [DATE] showed the CNA (unidentified) heard the resident's alarm sounding and upon entering his/her room, found the resident sitting on the floor beside his/her bed. The nursing staff last saw the resident in his/her bed (no time documented). The resident's bed was not in a low position but the brakes were locked and side rails were up. The resident's physician and responsible party were notified. The intervention was that the resident was educated not to try to transfer himself/herself and to use his/her call light for assistance. Record review of the resident's Care Plan showed there was no documentation showing the resident fell on [DATE]. There was an updated intervention dated 2/3/16, showing staff would check the resident more frequently. Record review of the resident's Nursing Notes showed: -On 2/6/16 at 4:11 P.M., the CMT (unidentified) was passing by the resident's room and saw the resident slide out of his/her wheelchair to the floor under the sink. The CMT was trying to get to the resident but was unable to reach him/her before the resident reached the floor. The resident did not hit his/her head. The resident said he/she was trying to reach for something and fell . There were no injuries noted at this time. The resident was assisted back into his/her wheelchair. Within 10 minutes of assisting the resident back into his/her wheelchair, staff saw the resident sliding down in his/her wheelchair again. The nurse notified the resident's physician and responsible party. -Notes showed no new or added post fall interventions were added to the resident's care plan. Record review of the resident's Post Fall assessment dated [DATE], showed: -The CMT (unidentified) was walking by the resident's room and watched him/her sliding out of his/her wheelchair onto the floor. The resident was last seen at the sink in his/her room. The intervention showed the resident was reminded to use his/her call light for assistance. Record review of the resident's Care Plan showed there was no documentation showing the resident had another fall and there were no updated post fall interventions. Observation on 3/11/16 at 10:28 A.M., the resident was laying in his/her bed asleep. The resident had a quarter side rail up on one side of his/her bed and a triangle above his/her bed for mobility. The resident's call light was within reach and the resident's tray table was within reach for his/her personal items that were on it. The resident's wheelchair was across the room by the sink. There was a bed alarm on his/her bed and a chair alarm on his/her wheelchair. During an interview on 3/11/16 at 10:34 A.M., CNA E said: -Since the resident only had one leg, nursing staff needed to assist the resident to transfer. -The resident had recently declined in his/her ability to assist with transferring and ambulating so they now transfer the resident using a mechanical lift (a full body hydraulic lift used to transfer a person from one location to another). -The resident had confusion and thinks that he/she can still transfer himself/herself independently without assistance. -The resident tries to get up without calling for help (using his/her call light). -They have to always remind the resident to use his/her call light but he/she will not use it. -They noticed that if the resident's wheelchair was close to him/her, he/she was more inclined to try to transfer himself/herself without assistance. -He/she said he/she thought this had contributed to the resident's falls, though he/she did not how many times the resident had fallen. During an interview on 3/11/16 at 11:40 A.M., LPN C said: -He/she was the charge nurse on the resident's unit and was familiar with the resident and his/her falls. -Several of the resident's falls had occurred on his/her shift. -They tried to keep the resident active in activities or at the nursing station to try to better monitor the resident and prevent him/her from falling as much. -The resident had confusion and still thought that he/she had both legs and could walk at times. -The resident also did not think he/she needed assistance and tries to get up on his/her own. -The resident often refused to accept assistance from staff and could become combative with staff. -He/she would not use the call light to request for help. -The resident also had a bed and chair alarm, but they found the resident at times would remove the alarm or turned it off, especially the alarm on his/her bed. -The alarm on the resident's wheelchair was more difficult for the resident to reach so he/she could not remove or turn it off as easily. -The resident's family also visited frequently and that helped to keep the resident from trying to get up independently and also helped with managing his/her behaviors. They always put the resident's call light within reach and have educated him/her several times to use it when he/she needed assistance but he/she had not used his/her call light (refused to use it to request help). -The nursing staff are supposed to check the resident at least every two hours, but they try to check on the resident every 15 to 20 minutes since the resident would not use his/her call light and tried to get up independently. -He/she also said some of the resident's falls were not actual falls, but were due to the resident deliberately putting himself/herself on the floor (behaviors). -The resident has had several medication changes regarding his/her psychotropics, to try to better control his/her behaviors and the resident's behaviors have started to improve some. -The resident had declined in his/her physical ability and more care was needed from staff for his/her transfers and mobility. -The resident's intervention to use the call light was not appropriate because he would not use the call light and it was ineffective. -The interventions they are using are more frequent monitoring, activities and keeping him/her at the nursing station for monitoring for as long as possible so they can more closely monitor him/her. During an interview on 3/11/16 at 1:13 P.M., the DON said: -They would not be able to allow the surveyors to look at the investigations, but he/she would answer questions about them. -The resident's fall on 1/7/16 was unwitnessed, his/her alarms were going off and he/she was found on the floor by his/her bed without injury. Neurological checks were initiated and the resident's physician and responsible party were notified (he/she read the description of the incident as stated in the nursing note). He/she said the resident said he/she tried to transfer himself/herself and fell . He/she said nursing staff did not document when they had last seen the resident or assisted him/her with toileting. The intervention was to re-educate the resident on using the call light to request assistance. -The fall committee (that met weekly) re-evaluated the resident's fall and determined that the reason the resident was falling was because he/she would not use his/her call light or ask for assistance. He/she said the resident only had one leg, did not have a prosthesis, and would forget that he/she could not walk. He/she said the resident also did not like to ask for assistance and they had referred him/her for psychiatric services. -The resident's fall on 1/30/16 was unwitnessed, his/her alarms were going off and he/she was found on the floor sitting next to his/her bed without injury. The resident said he/she became tangled in his/her