Every finding on record at Windsor Estates of St Charles

Based on record review and interview, the facility failed to implement procedures to accurately acquire and administer prescribed medications for one resident (Resident #1) upon admission, in a review of seven sampled residents. On admission, the facility involved a third-party provider, a group of physicians and nurse practitioners who review and issue orders after hours, to review the resident's medications listed on the resident's hospital discharge orders. The third-party provider placed medications to treat the resident's pain, anxiety, migraine headaches, and attention deficit hyperactivity disorder (ADHD, a disorder causing persistent patterns of inattention, hyperactivity, and impulsivity) on hold until the resident's physician reviewed and approved the orders. The facility failed to ensure the resident's physician was aware the third-party provider placed the resident's medications on hold. The resident, who was recovering from a fractured leg, did not receive as needed (PRN) pain medication for approximately 22 hours and complained of throbbing pain that affected his/her sleep. The resident did not receive prescribed medications to treat ADHD, anxiety and headaches for six days following admission to the facility. The resident reported headaches, anxiety, depression symptoms and difficulty focusing as a result of not receiving the medications. The facility census was 75.Review of the facility policy, Admission, dated 12/2024, showed prior to or at the time of the admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering medication orders, including (as necessary) a medical condition or problem associated with each medication. The facility did not provide a policy addressing the third-party provider system and the services they were expected to provide the facility. Review of Resident #1's undated Face Sheet showed the resident was admitted to the facility on [DATE]. The resident's diagnoses included fractured upper left tibia (larger bone in the lower leg), anxiety, and major depressive disorder (a severe mental health condition causing persistent sadness, hopelessness, and loss of interest in life). Review of the resident's hospital physician's discharge orders, dated 06/09/26, showed the following:-Oxycodone-acetaminophen (Percocet, a narcotic pain medication used to treat severe pain) 10 milligrams (mg)-325 mg every four hours as needed (PRN) for pain. The medication was circled and a note on hold was handwritten next to the medication;-Alprazolam (an antianxiety medication) 0.25 mg two times a day as needed (PRN) for anxiety. The medication was circled and a note on hold was handwritten next to the medication;-Butalbital-acetaminophen-caffeine (a medication used to treat migraine headaches) 50-325-40 mg every six hours PRN. The medication was circled and a note on hold was handwritten next to the medication;-Mydayis (a stimulant medication) 37.5 mg daily for ADHD. The medication was circled and a note on hold was handwritten next to the medication. Review of the resident's progress note, written by a facility contracted physician and nurse practitioner third-party provider, dated 06/09/26 at 5:55 P.M., showed the following:-Available documentation reviewed;-Orders and medications approved until resident is evaluated by primary team;-Obtain and review current/relevant hospital documentation and orders with primary team when available;-Notify a clinician of any change in condition; -Hold pending primary provider review - controlled substances. The following medications are held pending provider rounds or contact with authorizing/primary provider: 1. Oxycodone-acetaminophen (Percocet)10-325 mg one tablet by mouth (PO) every four hours as needed (PRN) for pain HOLD; 2. Alprazolam 0.25 mg one tablet two times a day (BID) PRN for anxiety HOLD; 3. Mydayis 37.5 mg ER (extended release) 24 hour one capsule PO daily HOLD; 4. Butalbital-acetaminophen caffeine 50-325-40 mg one tablet PO every six hours PRN for headache/migraine HOLD. -All other transfer orders received and noted. Provider notification pending. During a telephone interview on 06/29/26 at 5:30 P.M., a representative of the third-party provider said the following:-The facility contracted them to review medications and issue orders when the primary provider was not available;-They communicated with facility nurses via a computer and video conference if needed. They did not actually see the residents;-The resident's medical record was integrated through their system, so when Resident #1 was admitted to the facility after hours, they reviewed his/her medications. Due to the number of medications containing acetaminophen, the Percocet and butalbital-acetaminophen-caffeine were placed on hold for the physician to review before a prescription could be issued;-The Mydayis and alprazolam were narcotic medications. The physician should review before issuing a prescription;-The nurse with the third-party provider, who reviewed the resident's medications, communicated this with the facility nurse, Registered Nurse (RN) D, and documented it in a progress note; -The third-party provider did not follow up to see if physician orders were obtained; that was the facility's responsibility. During an interview on 07/06/26 at 2:05 P.M., RN D said the following:-Since the resident was admitted after hours (on 06/09/26), the third-party provider reviewed the resident's medications;-The third-party provider put Percocet, alprazolam, Mydayis and butalbital-acetaminophen-caffeine on hold since the resident's physician needed to review the orders for these medications; -He/She passed this information on to the night shift nurse (Licensed Practical Nurse (LPN) E). During an interview on 07/06/26 at 2:30 P.M., LPN E said the following:-He/She worked the night shift the day the resident was admitted (06/09/26). He/She remembered being told the third-party provider placed the pain medication (Percocet) and the alprazolam on hold pending the nurse practitioner's or physician's review;-He/She documented for the next shift to inform the NP or the physician; If the -The resident was very upset he/she did not have any pain medication;-The resident's family member got a prescription for the Percocet from the hospital, but the facility could not use it since the third-party provider placed the medication on hold. During an interview on 06/26/26 at 2:32 P.M., the resident said the following:-He/She fell and fractured his/her lower left leg and was in extreme pain;-The pain was a throbbing pain and woke him/her at night;-Upon admission [DATE]), the hospital did not send the handwritten prescription for the Percocet, so his/her family member went to the hospital to get the prescription;-When his/her family member brought the prescription to the facility, staff told them an NP reviewed the medication, and they could not give the Percocet until a physician reviewed the medication the next day;-He/She took acetaminophen for the pain every four hours, but it did not help. Review of the resident's progress note, dated 06/10/26 at 7:00 A.M., signed by Nurse Practitioner (NP) A showed the resident was seen for post-admission follow-up for fracture of upper end of left tibia. The resident reported significant pain in both legs and stated his/her pain was not adequately controlled with Tylenol. The resident reported he/she did not sleep well due to the pain. The resident and family reported concerns the pain medication was placed on hold or not available despite prior order and prescription. The resident reported the last pain medication dose was around 1:30 P.M. on 06/09/26. The Director of Nursing (DON) and pharmacy follow-up was discussed to clarify pain medication availability and status of medications. The resident reported anxiety and depression. (NP A's progress note did not address the resident's medications, alprazolam, butalbital-acetaminophen caffeine or Mydayis, which the third-party provider placed on hold on 06/09/26 awaiting the resident's physician's review.) During an interview on 06/29/26 at 10:47 A.M., NP A said she had not been made aware the third-party provider placed the orders for the resident's Percocet, alprazolam, Mydayis or the butalbital-acetaminophen-caffeine on hold. She assessed the resident who reported he/she had not had any pain medication since admission and said he/she was in extreme pain. She reviewed the chart on 06/10/26 and found the order for the Percocet and notified the physician and received an order for the Percocet. The resident did not mention he/she had not received any other medications. During an interview on 06/26/26 at 3:00 P.M., the Director of Nursing (DON) said the resident's physician could not issue a prescription for narcotic medications without seeing a resident and utilized NP A to screen the resident for the narcotic use and communicate with the physician. She did not know if NP A made the physician aware the medications were placed on hold. On 06/10/26, she made the physician aware of the prescription for the Percocet from the hospital and received permission to have the medication be given, the first dose was administered from the facility emergency kit on 06/10/26. The pharmacy then sent a medication card containing nine tablets of Percocet. Review of the resident's Physician Order Sheet (POS), dated 06/2026, showed a new order, dated 06/10/26, for Percocet (oxycodone with acetaminophen) 10-325 mg, give one tablet every four hours PRN. (The resident did not have active orders for alprazolam, butalbital-acetaminophen caffeine or Mydayis.) Review of the resident's Medication Administration Record (MAR), dated June 2026, showed staff administered Percocet on 06/10/26 at 11:29 A.M. for a pain level of six out of 10 (pain level of 0 being no pain and a pain level of 10 being extreme pain). During an interview on 06/29/26 at 11:25 A.M., LPN B said the following:-He/She received an order for the resident's Percocet on 06/10/26 and pulled the medication from the facility emergency kit. Percocet was delivered from the pharmacy later that day;-The third-party provider, who reviewed the medications, reviewed any orders received after hours when the NP or the physician is was not available;-The third-party provider did not actually see the resident; the nurses communicated with them via a computer;-When the third-party provider made a recommendation to put a medication on hold, staff should communicate this to the resident's NP or the physician. Review of the resident's progress note, dated 06/11/26 at 8:00 A.M., signed by NP A, showed the resident was assessed for post-admission fracture follow-up, pain management concern, chronic pain, anxiety and depression. (NP A's progress note did not address the resident's medications, alprazolam, butalbital-acetaminophen caffeine or Mydayis, which the third-party provider placed on hold on 06/09/26 awaiting the resident's physician's review.) Review of the resident's progress note, dated 06/12/26, signed by NP A, showed follow-up for a headache yesterday, chronic pain and orthopedic recovery, anxiety, depression history and medication review. The resident said he/she had a headache throughout the day and slept much of the day. The resident reported an anxiety level rated five out 10 (0 being none and 10 being severe) and denied feeling very depressed. Review of the medication orders did not show any orders for alprazolam, butalbital-acetaminophen-caffeine or Mydayis ordered or reviewed from admission. Review of the resident's Controlled Drug Receive/Record/Disposition Form for Percocet 10-325 mg showed the resident received the last dose (the last of the nine tablets received on 6/10/26) on 6/14/26 at 3:50 P.M. During an interview on 06/26/26 at 3:00 P.M., the Director of Nursing (DON) said staff administered the last dose (the last of the nine tablets received on 6/10/26) of the resident's Percocet on 06/14/26 and a new physician script needed to be obtained. The physician was scheduled to come to the facility to see the resident on 06/15/26, however the resident continued to complain of pain. She did not know anything about the resident's orders for alprazolam, Mydayis or the butalbital-acetaminophen-caffeine medications. During an interview on 06/26/26 at 3:00 P.M., Family Member (FM) A said the following:-After a couple of days at the facility, the resident ran out of pain medication (Percocet), and staff told the resident he/she would have to wait until a physician wrote another prescription for the Percocet;-It was at that point, he/she and the resident realized the facility had not given the resident any anxiety medication or medication for ADHD;-No one reviewed the medications after they were placed on hold on 06/09/26. During an interview on 06/26/26 at 2:32 P.M., the resident said the following:-A couple of days after admission, he/she had difficulty focusing and became depressed and had a lot of anxiety due to the pain;-He/She asked for a medication list and realized he/she had not received Mydayis for ADHD or alprazolam for anxiety. He/She also did not have an order for his/her migraine medication;-When he/she asked about this, staff said the physician had not reviewed the medication, so they had not been ordered. During an interview on 07/06/26 at 2:33 P.M., LPN F said the following:-He/She took care of the resident for the first time on 06/15/26;-On 06/15/26, the resident was in a lot of pain and did not have any pain medication;-The resident said he/she had not received any of the medication for ADHD, anxiety or headaches;-He/She reviewed the resident's medical record and found the medications were put on hold at admission;-He/She called the pharmacy to get a prescription. The DON told him/her the medications were put on hold and were waiting for the physician to review; -The resident and his/her family member were so upset the resident had not received the medication, they discharged the resident from the facility (on 06/15/26). Review of the resident's medical record, dated 06/09/26 through 06/14/26, showed no documentation the resident's physician reviewed the resident's medications that were on hold to ensure the resident received prescribed medications to treat anxiety, ADHD, and headaches. Review of the resident's progress note, dated 06/15/26 at 7:30 A.M., signed by NP A, showed the resident was seen on 06/15/26 for follow-up regarding medication concerns and post-admission orthopedic recovery. The resident reported he/she has been without pain medication since yesterday afternoon. The resident reported chronic pain related to left tibia fracture. The resident requested follow up with the attending physician for pain medication script and when it would be available from pharmacy. The resident also reported his/her long-standing ADHD treatment had not been given. The resident reported feeling less focused and questioned why he/she had not received the medication. During an interview on 06/29/26 at 10:47 A.M., NP A said on 06/15/26, when the resident told her about the ADHD and anxiety medications, she was told the DON was aware those medications had not been ordered. She notified the physician the medications were on hold for review. The physician said he would be in to see the resident later that day to review those medications. If she had been made aware those medications were on hold she would have communicated with the physician to get the medications approved and ordered. During an interview on 06/29/26 at 1:44 P.M., Physician C said the following:-He was the Medical Director for the facility and the resident's attending physician; -He was not aware the third-party provider placed the resident's Percocet, alprazolam, Mydayis, and the butalbital-acetaminophen-caffeine on hold until 06/15/26, when NP A contacted him for a prescription for the Percocet;-He expected staff to notify him/her the day after the medications were placed on hold. During an interview on 6/29/26 at 3:30 P.M., the DON said NP A was responsible for communicating the orders that were placed on hold to the resident's physician. NP A was made aware the medications were placed on hold the day after the resident was admitted . She expected NP A to communicate the resident's medications were on hold to the physician;She did not think the nursing staff should have had to call the physician regarding the resident not receiving his/her medications because the NP was the go to person for the physician and had access to the medical record. She thought it should have been the NPs responsibility. During an interview on 06/29/26 at 3:30 P.M., the Administrator said he expected the nurses and the nurse practitioner to communicate with the physicians to ensure the residents had the medications as ordered. 3045508

Based on interview and record review, facility employees and service providers failed to provide services to a resident (Resident #79) that were necessary to avoid physical harm. Facility staff failed to follow facility policy and procedures, and physician orders for monitoring upon admission and when the resident, who had cardiac-related diagnosis, experienced a change in condition. Staff failed to follow physician's order to check the resident's blood pressure prior to administering blood pressure medication and failed to initiate orders for a muscle relaxer. The facility failed to use nursing judgement and knowledge to advocate for further medical evaluation when the resident expressed possible cardiac-related symptoms, including a feeling of something sitting on their chest on [DATE] and [DATE]. Staff failed to notify the resident's power of attorney, per facility policy, when the resident had a change in condition. The resident's power of attorney reported he/she would have wanted the resident evaluated at the hospital if made aware of the resident's condition on [DATE] and [DATE]. On [DATE], staff found the resident unresponsive and without respirations. The facility failed to ensure the resident's preferred code status, Do Not Resuscitate, was accurately reflected in the resident's medical record. Staff initiated life-saving measures when the resident was found without a pulse and respirations, which was against the resident's wishes. The facility census was 72.The administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 04:31 P.M. which began on [DATE]. The IJ was removed on [DATE] as confirmed by the surveyor onsite verification. Review of the facility policy, Abuse, Prevention and Prohibition, dated 11/2025, showed the facility defined neglect as a failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy, Significant Condition Change and Notification, dated 12/2024, showed the following:-Purpose: To ensure the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: -An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention; -A significant change in the resident's physical, mental or psychosocial status (see below for examples):Chest pain;-Procedure: When any of the above situations exist, the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner, the nurse will complete the SBAR (situation, background, assessment, recommendation) assessment (a structured communication to quickly and safely convey critical resident information);-Calls will be made to the resident's representative until they are reached;-The medical practitioner will be contacted;-Each attempt will be charted as to the time the call was made, who was spoken to and what information was given;-Documentation: -All significant changes will be recorded in the residents electronic health record; -Charting will include an assessment of the resident's current status as it relates to the change in condition; -Charting will be done each shift for 72 hours for residents with change of condition; -Change of condition is reviewed by the Director of Nursing or designee for the continued need for additional documentation. Review of the facility policy, Advanced Directive, dated 12/2024, showed the following:Procedure:-Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her representative, about the existence of any written advance directives;-Information about whether or not the resident has executed an advance directive shall be placed in the medical record;-The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive;-The resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes;-In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to:-Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated;-Durable Power of Attorney for Health Care (i.e., Medical Power of Attorney) - a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated;-Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used;-Life-Sustaining Treatment - treatment that, based on reasonable medical judgment, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures;-The Interdisciplinary Team will review for changes to the resident's cognitive status and communicate significant changes to the resident's representative. Such changes will be documented in the care plan and medical record;-The Interdisciplinary Team will review at regular intervals with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Staff will assist the resident or representative to make changes to advanced directives in accordance with state law. Changes and/or revocations will be added to the clinical record. The care plan will be updated to reflect the change. Review of the facility policy, Cardiopulmonary Resuscitation, dated 03/2025, showed the following:Policy: Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). The goal of early delivery of CPR is to try to maintain life until the emergency response team arrives to deliver Advanced Life Support (ALS);-Policy interpretation and implementation:-If a resident is found unresponsive and not breathing normally, a clinical staff member will verify code status using the medical record;-If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR until the emergency response team arrives;-If the resident is a DNR, per the medical record, notify the attending provider. Review of the American Heart Association website showed a sensation of something sitting on the chest is classic symptom of chest pain/discomfort and the action needed advised to call 911 immediately as it may be a medical emergency. 1. During an interview on [DATE] at 2:55 P.M., the Assistant Director of Nursing (ADON) said the following:-The facility did not have a policy specific to new admissions or the admission process, but expected staff to complete an admission assessment, monitoring each shift (nurses worked 12 hour shifts), including documentation of nursing assessments and vital signs (VS) for 72 hours for newly admitted residents;-The Nurse Communication Book at each nursing station detailed these procedures. Review of a Nurse Communication Book showed the following:-The binder contained a page titled, What to do if I get an admission/re-admit. The form instructed staff to obtain VS, enter in all orders, including code status, and to complete nursing admission/re-admission data collection;-The binder contained a page titled, What to do if a resident has a change in condition. The form instructed staff to complete an SBAR, make family/POA notification, call Director of Nursing (DON)/ADON on call. If non-emergency, please send text. On day one, two and three, in the electronic health record, write a short progress note description of the resident's mood/behavior during your shift. A change in condition included pain of any kind. During an interview on [DATE] at 4:00 P.M., the DON said the facility administration was to conduct a 24-hour record review of all residents. Administration completed the review Monday through Friday during clinical meetings. Administration completed the Saturday and Sunday reviews on Monday during the clinical meeting. The review consisted of a review of various things, including new admits/readmits, residents with a change of condition and any new orders. 2. Review of Resident #79's face sheet showed the following:-admitted to the facility on [DATE];-His/Her family member was listed as his/her responsible party and emergency contact;-He/She was a full code, indicating the resident wanted full life-saving measures. Review of the resident's admission agreement showed the following:-An active Power of Attorney (POA) document, uploaded into the resident's medical record on [DATE];-The resident's elected Authorized Representative was his/her family member;-The Durable Power of Attorney for Health Care and/or Health Care Directive showed if the resident was persistently unconscious or there was no reasonable expectation of his/her recovery from a seriously incapacitating or terminal illness or condition, he/she directed that all of the life-prolonging procedures, including heart-lung resuscitation (CPR) be withheld or withdrawn. The resident initialed the selection;-The resident signed the document on [DATE]. Review of the resident's diagnoses page from his/her electronic medical record showed he/she was admitted with known cardiovascular diagnoses of complete AV block (irregular heart beat/rhythm), cardiac pacemaker (an medically implanted device to keep the heart beating at a normal rate), congestive heart failure (impaired heart function), and hypertension (high blood pressure), as well as pulmonary diagnoses of chronic obstructive pulmonary disease (lung disease) and history of respiratory failure with hypoxia (low level of oxygen in blood stream), and he/she was a full code status. Review of the resident's progress notes, dated [DATE] at 5:21 P.M. (documented as a late entry), showed the resident arrived at the facility, was alert and oriented, and able to make his/her needs known. Review of the resident's electronic health record. showed the following:-Staff took the resident's VS on [DATE];-Staff began data collection for the Nursing admission on [DATE] at 7:45 P.M. and data collection was still in progress (not complete). (Review on [DATE] at 10:00 A.M., showed the data collection was still in progress.) Review of the resident's care plan, dated [DATE], showed the following:-Advanced Directive/End of Life Care Plan: the resident is not at or approaching end of life at this time. The resident elected a full code status and his/her wishes would be honored (initiated by the Minimum Data Set (MDS) Coordinator);-The resident had a pacemaker. Monitor VS as ordered/per facility protocol and record. Monitor/Document/Report to provider any signs and symptoms of lower than baseline blood pressure. During an interview on [DATE] at 2:00 P.M., the MDS Coordinator said the following:-She thought she uploaded the resident's admission paperwork, including his/her health care directive, in the resident's electronic medical record, but she wasn't sure;-She completed the resident's care plan and would have entered the information related to code status based off the record review and what she saw as the resident's elected code status;-To her knowledge, she entered the resident's code status correctly. Review of the resident's [DATE] physician order sheet (POS) showed the following:-The resident was a full code;-The resident was prescribed midodrine HCI (medication to treat orthostatic hypotension (a sudden drop in blood pressure upon standing)) 10 milligrams three times daily; hold for systolic pressure (the top number of a blood pressure) over 130 (normal is less than 120). Review of the resident's electronic health record for [DATE] showed the following:-No documentation staff completed nursing assessments for the day shift (6:00 A.M. to 6:30 P.M.) and the night shift (6:00 P.M. to 6:30 A.M.) on [DATE], as directed in facility procedure for 72 hours following admission;-No documentation staff checked the resident's blood pressure as ordered before administering his/her scheduled midodrine at 4:00 P.M. on [DATE]. Review of the resident's electronic health record for [DATE] showed the following:-No documentation staff completed nursing assessments or VS for the day shift and the night shift on [DATE], as directed in facility procedure for 72 hours following admission;-No documentation staff checked the resident's blood pressure before administering his/her scheduled midodrine at 8:00 A.M., 12:00 P.M., and 4:00 P.M. on [DATE]. Review of the resident's progress notes, dated [DATE] at 7:00 A.M., showed Nurse Practitioner (NP) #1 conducted a routine round assessment of the resident. The resident required close monitoring to prevent respiratory or cardiac decompensation. At that time, the resident denied chest pain and was negative for anxiety. The NP documented the resident remained medically complex, requiring ongoing monitoring due to risk of respiratory compromise and cardiac instability. The plan was to continue cardiac monitoring and assess for arrhythmia (heart palpitations, chest pain, dizziness, shortness of breath and fatigue) symptoms and continue blood pressure monitoring. Review of the resident's electronic health record for [DATE] showed the following:-No documentation staff completed nursing assessments or VS for day shift on [DATE], as directed in facility procedure for 72 hours following admission;-No documentation staff checked the resident's blood pressure as ordered before administering his/her scheduled midodrine on [DATE] at 8:00 A.M., 12:00 P.M. or 4:00 P.M. Review of the resident's progress note, dated [DATE] at 7:00 A.M., showed NP #2 conducted a telehealth visit where the resident reported anxiety and a feeling of something sitting on his/her chest. The resident was ordered and administered hydroxyzine (a medication for itching and anxiety) 25 milligrams (mg) with instructions to follow up in 30 - 60 minutes if symptoms persist or sooner if needed. Review of the resident's progress notes, dated [DATE], showed no documentation who contacted NP #2 for the telehealth visit, the reason for the visit and the information provided to NP #2, per the facility's change in condition and notification policy. Review of the resident's electronic health record showed no documentation staff checked the resident's blood pressure before administering his/her scheduled midodrine at 8:00 A.M. or 12:00 P.M. on [DATE]. Review of the resident's [DATE] medication administration record (MAR) showed Licensed Practical Nurse (LPN) OO administered the resident the hydroxyzine 25 mg on [DATE] at 2:54 P.M. (approximately eight hours after the order was received). (Review showed no documentation staff followed up on the resident's condition as NP #2 directed following administration of the hydroxyzine.) Review of the resident's electronic health record showed the following:-No documentation staff completed an SBAR; no documentation staff notified the resident's POA, the DON, or ADON of the resident's change in condition; and no documentation staff completed a short progress note of the resident's condition during the shift on [DATE] when the resident had a change in condition, as directed in the Nursing Communication Book;-No documentation to show staff checked the resident's blood pressure before administering his/her scheduled midodrine at 4:00 P.M. on [DATE]. During an interview on [DATE] at 5:18 P.M., Licensed Practical Nurse (LPN) OO, the resident's charge nurse on [DATE] during the day shift, said the following:-He/She could not really recall the resident;-He/She could not recall how the telehealth visit on [DATE] came about;-He/She could not recall completing any assessments on the resident or administering him/her any medications;-If a resident required a physician or provider visit, the charge nurse was responsible to notify the family of any concerns or changes; he/she could not recall doing any of that. During an interview on [DATE] at 1:30 P.M., the contact with the medical group confirmed LPN OO called with the resident's concern of a feeling of something sitting on his/her chest. This was the reason for the telehealth visit on [DATE]. During an interview on [DATE] at 3:44 P.M., NP #2 said the following:-She could not speak to the resident and the specific visit at that time;-If a resident had a known cardiac history and was complaining of something sitting on his/her chest, it could indicate a cardiac event and possible evaluation in an emergency room;-She thought the system prompted her to order hydroxyzine due to anxiety, but could not recall. Review of the resident's electronic health record showed the following:-No documentation staff documented on the resident's condition during the night shift on [DATE] through the night shift on [DATE]. (The facility's change in condition policy directed staff to document on the resident for 72 hours following a change in condition.)-No documentation staff checked the resident's blood pressure before administering his/her scheduled midodrine at 8:00 A.M., 12:00 P.M., and 4:00 P.M. on [DATE]. (The facility did not provide evidence of a 24-hour record review for [DATE]. The facility did not provide documentation to show the DON or designee reviewed the resident's change of condition for the continued need for additional documentation as directed in the facility's policy for change in condition.) Review of the resident's electronic health record showed the following:-No documentation staff documented on the resident's condition during the day and night shifts on [DATE], per the facility's change in condition policy; -No documentation to show staff checked the resident's blood pressure before administering his/her scheduled midodrine at 8:00 A.M. and 12:00 P.M. on [DATE]. Review of the resident's [DATE] MAR showed staff did not administer the resident's scheduled midodrine on [DATE] at 4:00 P.M. Review of the resident's progress note, dated [DATE], showed staff did not administer the 4:00 P.M. dose of midodrine as the medication was not available. Review of the resident's electronic health record showed no documentation staff checked the resident's blood pressure at 4:00 P.M. on [DATE] and no documentation staff notified the resident's physician when staff did not administer the resident's midodrine. (The facility did not provide evidence of a 24-hour record review for [DATE]. The facility did not provide documentation to show the DON or designee reviewed the resident's change of condition on [DATE] for the continued need for additional documentation as the facility policy for change of condition instructed.) Review of the resident's progress note, dated [DATE] at 7:00 A.M., showed NP #1 conducted a visit with the resident and documented the chief complaint as anxiety episode with chest pressure sensation in a resident with chronic respiratory failure and advanced cardiopulmonary disease requiring evaluation and medication adjustment. The resident was evaluated for anxiety and complaint of a sensation described as something sitting on his/her chest. Nursing reports VS stable. The hydroxyzine administered to the resident resulted with only partial relief of symptoms. Due to underlying respiratory disease and cardiac co-morbidity, symptoms required careful evaluation to differentiate anxiety from cardiopulmonary decompensation. The resident was on a monitoring plan. Medication adjustment was initiated with tizanidine (a muscle relaxer) for muscle tension and discomfort with blood pressure precautions. Nursing staff were educated to monitor respiratory status, anxiety symptoms, blood pressure parameters, and sedation risk related to the new medication. Review of the resident's progress notes, dated [DATE], showed no documentation who contacted NP #1 for the telehealth visit, the reason for the visit and the information provided to NP #1, per the facility's change in condition and notification policy. During an interview on [DATE] at 11:15 A.M., NP #1 said the following:-She believed her visit on [DATE] was a follow up to the telehealth visit of [DATE];-She did not realize the visit was for a complaint of something sitting on the resident's chest for a second time in three days;-She could only go with what was documented and could not recall specifics about the resident;-If she instructed staff to complete careful monitoring. The resident was on a monitoring plan, which should have included monitoring the resident's VS per the facility policy and/or as ordered. Staff were to monitor and follow up on any voiced concerns and new medication orders;-She wasn't aware the facility was not monitoring the resident's VS.-She could not recall ordering the tizanidine, but if she did, she would have expected staff to administer it;-A resident with cardiac history who reports a feeling of something sitting on their chest could require further evaluation. During an interview on [DATE] at 5:00 P.M., the DON said a resident reporting a feeling of something sitting on their chest would be considered a cardiac symptom. She spoke with NP #1 who said anxiety can mimic cardiac symptoms. She did not agree with NP #1, but did nothing further to question her. She was not aware of the resident's cardiac history. If she had been, she would have sent the resident out for evaluation. Review of the resident's electronic health record for [DATE] through [DATE] showed the following:-No evidence the DON conducted an assessment or directed staff to conduct on-going monitoring of the resident after she became aware of the resident's reported possible cardiac symptoms and potential cardiac emergency;-No documentation of a physician order for tizanidine with a dose to be given or how often;-No documentation of blood pressure precautions or documentation staff monitored the resident's blood pressure before the administration of his/her midodrine at 8:00 A.M., 12:00 P.M. and 4:00 P.M. on [DATE];-No documentation to support staff monitored the resident's respiratory status, anxiety symptoms, and blood pressure parameters as NP #1 directed in his/her progress note, dated [DATE]. Review of the resident's progress note, dated [DATE] at 7:37 P.M. (documented as a late entry), showed staff alerted LPN I the resident was not breathing. The resident was in his/her room in severe respiratory distress with labored breathing and unresponsiveness. Staff assessed the resident immediately; no spontaneous respirations and no palpable pulse detected. Staff initiated emergency response and started CPR/compressions per facility protocol. Staff assisted and notified emergency medical services (EMS). Chest compressions continued as indicated. Despite resuscitation efforts, the resident remained unresponsive with no pulse and no respirations. EMS announced the resident's time of death at 8:57 A.M. The family was at the resident's bedside. Review of the EMS ticket of [DATE] showed nursing staff on scene reported the resident having shortness of breath in which he/she was denying oxygen or nebulizer treatments in which they called the family who was in route to the facility. On arrival, the resident was found unresponsive, apneic (a person has stopped breathing) and without a pulse with nursing staff standing around the bed not performing compressions. Nursing staff reports they did chest compressions for approximately one to two minutes prior to the EMS crew's arrival. Nursing staff reported the resident was a full code, therefore, compressions were initiated, and the paramedic took over before family member, who has power of attorney over the resident's medical decisions, asked for resuscitation measures be stopped. During an interview on [DATE] at 10:02 A.M., LPN OO, who worked on the day shift on [DATE], said the following:-He/She could recall assisting LPN I when staff found the resident in cardiac arrest;-Upon entering the room, LPN I was doing chest compressions on the resident;-He/She took over compressions at some point;-He/She did not look for the resident's code status and figured LPN I had;-He/She usually checked for a resident's code status on a report sheet and the electronic health record, specifically the physician's orders or face sheet, to determine a resident's code status;-He/She could not recall any facility staff checking the resident's vital signs. During an interview on [DATE] at 12:44 P.M., the resident's power of attorney (POA) said the following:-Staff did not make him/her aware of the resident's complaints of something sitting on his/her chest on [DATE] and [DATE] or of any medication adjustments;-He/She would have wanted the resident evaluated at the hospital.-He/She told the facility at the resident's admission the resident was a DNR (do not resuscitate, no CPR is to be initiated);-When he/she arrived at the facility on [DATE] and found staff and EMS performing CPR on the resident, he/she demanded they stop. During an interview on [DATE] at 4:18 P.M., Certified Medication Technician (CMT) BB said the following:-He/She really couldn't recall the resident, but could see his/her initials on the MAR showing he/she administered the resident's midodrine during his/her shifts;-The instructions with the medication order were to take the resident's blood pressure before administering the medication;-He/She could not see where he/she took the resident's blood pressure before administering the medication;-If he/she had taken the blood pressure, he/she would have documented it under the VS tab in the electronic medical record since there was no specific place to document it on the MAR. During an interview on [DATE] at 3:00 P.M., the ADON said she expected staff to monitor and document assessments of the resident per facility procedure and as ordered or directed by the medical provider. Nursing staff were to use their nursing judgement and knowledge. She would consider a resident reporting something sitting on their chest as cardiac related and would have sent the resident to the hospital for evaluation. She was not previously aware of the resident's complaint and had only just now become aware. During an interview on [DATE] at 2:00 P.M., the Administrator said the following:-Staff were to follow all facility policies and procedures and physician orders;-Staff should meet all residents' needs, through assessment and care. Staff should not neglect the residents;-The care the facility provided should reflect the resident's wishes and this information should be accurate throughout the resident's medical record. NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). 2973690

Based on observation, interview, and record review, the facility failed to reorder an antianxiety medication timely for one resident (Resident #62), in a review of 28 sampled residents, to ensure the medication was available for administration. Resident #62 missed six doses of antianxiety medication. The resident had a panic attack (a sudden surge of overwhelming fear and physical discomfort), experienced withdrawal symptoms, and expressed feelings of hopelessness and not wanting to live. The facility census was 72. Upon request, the facility did not provide a policy regarding re-ordering controlled medications.Review of Resident #62's care plan, revised on 11/04/23, showed the following:-Diagnoses included anxiety disorder;-The resident had mood problems due to major depressive disorder, anxiety, and insomnia; -Give anti-anxiety medications as ordered. Monitor/document side effects and effectiveness. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/01/26, showed the following:-Cognitively intact;-Mood: minimal depression;-The resident had been feeling down, depressed or hopeless for several days;-Diagnosis of anxiety disorder;-He/She took antianxiety medication.Review of the resident's April 2026 physician order sheet showed the resident had an order for alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M. Review of the resident's controlled drug record/disposition form for alprazolam showed staff administered the last dose from the resident's supply on 04/05/26 at 8:00 A.M. Review of the facility's automated medication dispensing system showed the machine contained alprazolam 0.25 mg tablets available for emergency use. Review of the resident's April 2026 treatment administration record (TAR) showed the following: -Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/05/26 at 12:00 P.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/05/26 at 11:40 A.M., showed staff documented they reordered the resident's alprazolam 1 mg.Review of the resident's April 2026 TAR showed the following:-Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/05/26 at 9:00 P.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/05/26 at 10:49 P.M., showed the following:-Alprazolam oral tablet 1 mg, give one tablet three times a day for anxiety;-Medication out at this time.(Review showed no documentation staff notified the resident's physician or the pharmacy regarding the resident's medication.)Review of the resident's April 2026 TAR showed the following:-Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/06/26 at 8:00 A.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/06/26 at 8:53 A.M., showed the following:-Alprazolam oral tablet 1 mg, give one tablet three times a day for anxiety;-Medication on order and was not available.(Review showed no documentation staff notified the resident's physician or the pharmacy regarding the resident's medication.)Review of the resident's April 2026 TAR showed the following:-Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/06/26 at 12:00 P.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/06/26 for approximately 12:00 P.M.,showed no progress note related to the resident's alprazolam 1 mg tablet. Review of the resident's April 2026 TAR showed the following:-Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/06/26 at 9:00 P.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/06/26 at 9:47 P.M., showed no documentation why staff did not administer the resident's alprazolam, and no documentation staff notified the resident's physician or the pharmacy about the resident's medication. Review of the resident's April 2026 TAR showed the following:-Alprazolam 1 mg tablet, give one tablet three times a day for anxiety, scheduled for 8:00 A.M., 12:00 P.M., and 9:00 P.M.;-On 04/07/26 at 8:00 A.M., staff did not administer the medication. Review of the resident's progress notes, dated 04/07/26 at 8:34 A.M., showed the following:-Alprazolam oral tablet 1 mg, give one tablet three times a day for anxiety;-Medication unavailable; awaiting signed script from physician. During an interview on 05/21/26 at 1:43 P.M., the pharmacist said the following:-The resident had a future fill prescription on file for alprazolam, and 120 pills were available on 04/05/26; -The facility did not notify the pharmacy they needed the resident's alprazolam until 04/07/26;-The pharmacy did not automatically refill prescriptions for controlled medications. The facility had to refill the medications by calling, faxing, or requesting the medication from the pharmacy through the facility's electronic health management system; -Staff could contact the pharmacy for access to the medication in the facility's automated medication dispensing system.During an interview on 05/11/26 at 2:05 P.M., the resident said he/she ran out of his/her medication, and he/she had withdrawals which led him/her to have a panic attack while at a scheduled appointment (on 04/07/26). His/Her physician sent him/her to the hospital.During an interview on 05/20/26 at 3:10 P.M., the registered medical assistant at the resident's physician's office said the following:-The resident attended a scheduled cardiology appointment on 04/07/26 at 1:10 P.M.-The resident was upset he/she had not received his/her scheduled medications (alprazolam) because he/she was awaiting the prescription refill;-The resident was having some withdrawal symptoms including being red, sweating and shaking before his/her appointment;-The resident said he/she felt off and was tearful;-The physician thought the resident was having withdrawals and was visibly withdrawing from his/her medication;-The resident said he/she did not want to live anymore, and the physician wanted the resident to be sent to the hospital.Review of the resident's hospital admission record, dated 04/07/26 at 1:14 P.M., showed the chief complaint was panic attack (from physician's office). The resident did not have alprazolam for three days.Review of the resident's ambulance patient care report, dated 04/07/26 at 6:22 P.M., showed the following:-Non-emergent transport from the hospital to the facility;-Chief concern: anxiety;-History: The resident presented to the hospital for a panic attack. The registered nurse (RN) reported the resident was at the physician's office today when he/she expressed feelings of hopelessness and felt like he/she did not have a reason to go on. The RN reported the resident had been out of his/her prescribed alprazolam and was given some in the hospital until the resident was able to have his/her prescribed alprazolam refilled. The resident denied any thoughts of suicidal ideations (SI) or homicidal ideations (HI). The resident was cleared for discharge. Review of the resident's mental status exam, dated 04/27/26, showed the following:-Problem list: anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable fear or worry);-The resident said he/she had been on alprazolam for 10 years.During an interview on 05/11/26 at 9:40 A.M., Licensed Practical Nurse (LPN) J said the following:-Staff were to reorder a controlled medications when the resident had approximately 10 doses remaining;-If a resident ran out of a medication, the facility had an automated medication dispensing machine they could use;-Staff should call the pharmacy to check on the availability of the medication in the automated medication dispensing system, and the pharmacy could open up the drawer where the medication was located;-Staff may have to contact the physician for a new prescription order.During an interview on 05/21/26 at 5:09 P.M., the Assistant Director of Nursing (ADON) said she did not know the resident did not receive his/her alprazolam.During an interview on 05/19/26 at 6:12 P.M., the Director of Nursing (DON) said the following:-Nursing staff should re-order controlled medications when the medication card was half empty;-She did not know the resident did not receive his/her alprazolam from 04/05/26 through 04/07/26;-She did not know the resident went to the emergency room on [DATE];-The resident should have received his/her alprazolam;-Nursing staff were responsible to ensure the resident received his/her controlled medications;-Staff did not report the resident was out of alprazolam to her.During an interview on 05/19/26 at 6:56 P.M., the Administrator said he expected residents to receive their medications as ordered.2979788

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, when the facility staff failed to follow facility policy during a manual transfer for one resident (Resident #51), in a review of 28 sampled residents, when staff failed to use a gait belt (device used to transfer residents from one position to another) and lock the resident's wheelchair brakes when assisting the resident to transfer from his/her wheelchair to the common area couch. The facility failed to propel one resident (Resident #18) safely when staff transported the resident in his/her wheelchairs without foot pedals. The resident's right foot was bent backwards and dragged against the floor underneath the wheelchair. The facility failed to utilize a sit-to-stand lift (a transfer device that helps partially-weight bearing individuals transition between sitting and standing positions) per the owner's manual for one resident (Resident #9), when staff used the lift as a transport device to transport the resident from his/her bed to the bathroom. The facility census was 72. Review of the facility's policy, Safe Lifting and Movement of Residents, dated 12/2024, showed the following:-Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Manual lifting of residents shall be eliminated when feasible;-Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices;-Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.(The facility policy did not address when to use a gait belt and did not address locking wheelchair wheels during a transfer.) Review of an on-line source from Medline Plus (.gov), Moving a Resident, showed the standard of practice is to lock both wheelchair wheels before any transfer. Never assume the chair will stay in place due to body weight or a short pivot. 1. Review of Resident #18's undated diagnosis sheet showed his/her diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. Review of the resident's care plan, revised on 01/19/26, showed the resident was at risk for falls: staff educated on gait belts, transfers, and pivoting. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/16/26, showed the following:-No documented cognitive status;-Impairment in one of his/her lower extremities;-Used a wheelchair for mobility;-Required substantial to maximum assistance from staff wheeling 50 feet. Observation on 05/11/26 at 12:20 P.M., showed the following:-The Staffing Coordinator pushed the resident down the 300 hall to the main living area. The resident's right foot was bent backwards and dragged against the floor underneath the wheelchair; -The wheelchair did not have food pedals attached;-The Staffing Coordinator left the resident to assist other residents on the hall; -The resident sat in his/her wheelchair and was crying;-The MDS Coordinator asked the resident what was wrong. The resident said, I don't know;-The MDS Coordinator asked the resident if he/she was in pain. The resident said, Yes;-The MDS Coordinator asked the resident where he/she was hurting. The resident said, I don't know; -The MDS Coordinator pushed the resident closer to the nurse's station. The resident's right foot was bent backwards and dragged on the floor; -The resident was still crying;-The MDS Coordinator pushed the resident back down the 300 hall. The resident's right foot dragged on the floor. During an interview on 05/19/26 at 6:25 P.M., the Staffing Coordinator said the following:-She should not push the resident without foot pedals;-Pushing the resident without food pedals could cause an accident or injury. 2. Review of Resident #51's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment;-Limited range of motion upper extremity, one side only;-Required substantial/maximum assistance for transfers from sitting to standing position.-Has had two or more non-injury falls and one fall with injury since last assessment. Review of the resident's care plan, updated on 05/05/26, showed the following: -Encourage the resident to ask for assistance with transfers while in the common area;-Staff education on gait belts, transfers, and pivoting. Observation on 05/11/26 at 12:30 P.M., showed the following: -The resident sat in his/her wheelchair in the common area near a couch. The resident scooted his/her bottom in the wheelchair closer to the front part of the wheelchair seat, placed his/her hands on the wheelchair arm rests and attempted to stand up from the wheelchair. The resident was partially standing; -Licensed Practical Nurse (LPN) N placed both of his/her arms up under the resident's arms, lifted under the resident's armpits/shoulders, and pivot transferred the resident from his/her wheelchair to the couch in the common area; -LPN N did not use a gait belt during the transfer and did not lock the wheels on the wheelchair prior to the transfer. During an interview on 05/19/26 at 11:00 A.M., LPN N said the following:-The resident began to transfer himself/herself, and he/she quickly went to assist him/her;-The resident had a history of falls and was unsteady when standing. He/She should have sent someone to get a gait belt before he/she transferred the resident; -He/She could have asked the resident to sit back down, and he/she then obtained and used a gait belt to transfer the resident; then the gait belt could have been obtained and used. During an interview on 05/19/26 at 3:03 P.M., the Director of Nursing (DON) said the following:-Staff should not manually lift residents under the arm/shoulder; -Staff should use a gait belt with all manual transfers. 3. Review of the owner's manual for the facility's sit-to-stand lift, showed the following:-The manufacturer strictly states the device is not a transport device;-The lift should be used solely for transferring a resident from one utility (e.g., bed, chair, wheelchair, or toilet) to another;-No room-to-room transport: It is not designed or intended to be used for transporting or moving residents across rooms or over longer distances;-Transfer proximity: Transfers should normally take place within the same resident room or bathroom. Review of the operating parameters for the sit-to-stand lift device showed the following:-Stand-up lifts (stand assists) are not transport devices. They are designed strictly to assist a resident from one resting surface to another (e.g., bed to wheelchair, or wheelchair to commode);-Safety Warnings & Use Cases: -Not for Room-to-Room Transport: You should not use a standing lift to wheel a resident over long distances, down hallways, or in lieu of a wheelchair or gurney; -Safe Transfer Limit: They should solely be used for short, direct transfers to a commode, shower chair, or wheelchair; -Patient Requirements: To use the lift, the resident must have partial weight-bearing capacity, be able to sit up, and have the upper-body strength to hold onto the lift's handles. 4. Review of Resident #9's face sheet showed the resident's diagnoses included muscle weakness, lack of coordination, Parkinson's disease (brain disorder causing unintended or uncontrolled movements) with dyskinesia (a category of movement disorders characterized by involuntary, erratic, and uncontrollable muscle movements), abnormalities of gait and mobility, unsteadiness on feet, and foot drop (inability to lift the front part of the foot due to weakness or paralysis) of the left foot. Review of the resident's care plan, dated 01/08/25, showed the following:-The resident was at risk for falls;-The resident required partial to moderate assistance with transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Uses wheelchair for locomotion;-Required partial to moderate assistance to transfer from bed to chair and to the toilet and to walk. Observation on 05/13/26 from 9:13 A.M through 10:10 A.M., showed the following:-Certified Nurse Assistant (CNA) M and CNA Q assisted the resident to sit on the side of his/her bed;-CNA M and CNA Q assisted the resident to a standing position using the sit-to-stand lift; -The CNAs transported the resident across the room, approximately 15 to 20 feet, to the bathroom, using the sit-to-stand lift as a transport device while the resident stood suspended and attached to the lift with the sling; -After the resident finished using the toilet, staff transported the resident from the bathroom across the room to his/her bedside, using the sit-to-stand lift as a transport device; -Staff lowered the resident to a sitting position in his/her wheelchair using the sit-to-stand lift. During interviews on 05/12/26 at 9:30 A.M., 05/13/26 at 10:10 A.M., and 10:35 A.M., the resident said the following:-Staff usually transported him/her to the bathroom using the sit-to-stand lift if he/she was not already in his/her wheelchair. -He/She preferred for staff to transport him/her from his/her bed to the bathroom in the sit-to-stand lift; -CNA M and CNA Q had cared for him/her before 5/13/26 and were aware of what he/she liked. During an interview on 05/13/26 at 10:20 A.M., CNA M said the following:-He/She did not know how staff usually transported the resident to the bathroom because he/she worked for an agency and it was his/her first day at this facility;-He/She should not transport residents any distance further than required to move from bed to chair, chair to bed, or chair to chair; -He/She used the sit-to-stand lift to transport the resident to the bathroom because it was the resident's preference. During an interview on 05/13/26 at 10:28 A.M., CNA Q said the following:-He/She did not know how staff usually transported the resident to the bathroom because he/she worked for an agency and it was his/her first day at this facility; -He/She should not transport residents any distance further than required to move from bed to chair, chair to bed, or chair to chair; -He/She used the sit-to-stand lift to transport the resident to the bathroom because it was the resident's preference;-He/She should have transported the resident to the bathroom using the resident's wheelchair. During an interview on 05/13/26 at 4:45 P.M., LPN C said staff should not transport residents to the bathroom using a sit-to-stand lift. 5. During interviews on 05/13/26 at 5:05 P.M. and 05/19/26 at 3:03 P.M., the DON said the following:-CNA M and CNA Q have worked shifts at that facility many times prior to 05/13/26;-Staff should not transport residents to the bathroom using any mechanical lifting device;-Staff should not push a resident in a wheelchair without foot pedals;-Staff pushing a resident without foot pedals could cause injuries. 3001665

Based on observation, interview, and record review, the facility failed to follow physician orders for three residents (Residents #81, #36, and #42), in a review of 28 sampled residents. Staff failed to administer medications as ordered on admission for Resident #81 and failed to obtain blood tests as ordered for Residents #36 and #42. The facility census was 72. Review of the facility's policy, Medication Administration, dated May 2019, showed the following: -Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. During an interview on 05/13/26 at 2:55 P.M., the Assistant Director of Nursing (ADON) said a check list in the nursing communication book gave directions to staff on what to do when a resident was admitted . The facility did not have a specific policy related to the process to follow for new admissions. Review of the undated nursing communication book, What to do if I get an admission/re-admit, showed the following:-Call physician to verify medications;-Enter all orders. During an interview on 05/15/26 at 12:40 P.M., the Administrator said the facility did not have a specific policy for following physician's orders or obtaining blood tests. 1. Review of Resident #81's face sheet showed the following: -admitted to the facility on [DATE];-Diagnoses include anxiety disorder (a mental health condition that causes fear and dread), hypertension (high blood pressure), hyperlipidemia (high cholesterol), stroke, gastroesophageal reflux disease (GERD/stomach contents leak backwards into the esophagus), depression (a mental health condition that includes a persistent feeling of sadness and loss of interest), glaucoma (a group of eye diseases that damage the optic nerve causing increased pressure inside the eye) and seizure disorder. Review of the resident's progress note, dated 05/11/26 at 7:47 P.M., showed the resident was admitted to the facility from a local hospital via emergency medical services. Review of the resident's hospital transfer/discharge paperwork, dated 05/11/26, showed physician orders for the following:-Cosopt (glaucoma eye drops) ophthalmic solution 2-0.5 percent (%), instill one drop in left eye two times a day for ocular hypertension (last administered at the hospital on [DATE] at 8:51 A.M.);-Depakote delayed release 125 mg, give three tablets, three times a day for seizures (last administered at the hospital on [DATE] at 8:47 A.M. and 2:09 P.M.);-Latanoprost ophthalmic solution (glaucoma eye drops) 0.005 percent (%), instill one drop in left eye at bedtime for ocular hypertension (no record this was administered at the hospital);-Trazodone hydrochloride/HCL (antidepressant) 100 mg, two tablets at bedtime for depression (no record this was administered at the hospital);-Potassium chloride (supplement) extended release (ER) 20 milliequivalents (meq) one time a day for minerals and electrolytes (no record this was administered at the hospital);-Amlodipine besylate (heart medication) 10 milligrams (mg) one time a day for elevated blood pressure. (last administered at the hospital on [DATE] at 8:46 A.M.);-Vitamin D-3 (supplement) oral table 25 mcg one time a day for vitamin deficiency (last administered at the hospital on [DATE] at 8:46 A.M.);-Acetaminophen (pain reliever) 325 mg, give two times a day for pain (no record this was administered at the hospital). Review of the resident's pharmacy electronic transmission report showed on 05/12/26 between 7:54 A.M. and 7:56 A.M., the resident's orders for potassium chloride, amlodipine besylate, Depakote, Cosopt ophthalmic solution, Latanoprost ophthalmic solution, Lipitor, vitamin D-3 and trazodone HCL were created and processed. During an interview on 05/12/26 at 9:53 A.M., the resident said he/she did not think he/she received any medications last night and was not sure if he/she received any medications yet today. Review of the resident's pharmacy electronic transmission report showed the following: -On 05/12/26 at 11:31 A.M, the resident's order for acetaminophen was created and processed;-On 05/12/25 at 5:22 P.M., the resident's order for Depakote was created and processed. Review of the resident's May 2026 medication administration record showed the following:-Cosopt ophthalmic solution 2-0.5% instill one drop in left eye two times a day for ocular hypertension. Staff first administered the medication in the evening on 05/12/26. (The resident did not receive the medication as ordered in the evening on 05/11/26 and in the morning on 5/12/26); -Depakote delayed release 125 mg, give three tablets, three times a day for seizures. Staff first administered the medication on 05/12/26 at 4:00 P.M. (The resident did not receive the medication as ordered in the evening on 05/11/26 and for the morning and noon dose on 05/12/26); -Latanoprost ophthalmic solution 0.005 %, instill one drop in left eye at bedtime for ocular hypertension. Staff first administered the medication in the evening on 05/12/26. (The resident did not receive the medication as ordered in the evening on 05/11/26;-Trazodone hydrochloride/HCL 100 mg, two tablets at bedtime for depression. Staff first administered the medication as ordered in the evening on 05/12/26. (The resident did not receive the medication as ordered in the evening on 05/11/26); -Potassium chloride ER 20 meq one time a day for minerals and electrolytes. Staff first administered the medication as ordered in the morning on 05/13/26. (The resident did not receive the medication as ordered on 05/12/26); -Amlodipine besylate 10 mg one time a day for elevated blood pressure. Staff first administered the medication as ordered in the morning on 05/13/26. (The resident did not receive the medication as ordered on 05/12/26); -Vitamin D-3 oral table 25 mcg one time a day for vitamin deficiency. Staff first administered the medication as ordered in the morning on 05/13/26. (The resident did not receive the medication as ordered on 05/12/26); -Acetaminophen 325 mg, give two times a day for pain. Staff first administered the medication as ordered in the evening on 05/12/26. (The resident did not receive the medication as ordered on 05/11/26 and in the morning on 05/12/26). Review of the facility provided medication list for the emergency medication kit showed the following medications were available:-Amlodipine besylate 5 mg;-Potassium chloride 10 meq;-Trazodone 50 mg,-Divalproex sodium (Depakote) 125 mg;-Acetaminophen 325 mg;-Vitamin D-3 25 mcg. During an interview on 06/03/26 at 2:58 P.M., Licensed Practical Nurse (LPN) PP said the following:-Resident #81 was admitted to the facility at the same time as another resident, toward the end of his/her shift;-He/She completed the resident's admission assessment and let the ADON know he/she still had medications to administer to other residents and had to administer a tube feeding for another resident. He/She asked the ADON if she could help since there were two admissions at the same time;-The ADON said she did not have time to help. The ADON said he/she (LPN PP) could pass it on to the next shift to complete the physician orders for the resident;-He/She was unsure who the staff member was who took over the next shift, but he/she shared the only thing he/she completed for the resident was the admission assessment and he/she had not had time to get to the physician orders. During an interview on 05/15/26, at 3:33 P.M., the Director of Nursing (DON), said the following: -She expected staff to administer medications as ordered;-Staff should enter orders for newly admitted residents as soon as possible, so staff could order the medications from the pharmacy as soon as possible;-Staff should not take 24 to 36 hours to enter physician orders for newly admitted residents.-She expected staff to check the emergency medication kit to check if any of the ordered medications were available to administer before the facility received the resident's medication supply from the pharmacy. During an interview on 05/12/26, at 2:30 P.M., the Medical Director said the following: -He expected staff to enter physician orders for new admissions in a timely manner. A resident should not miss 24 to 36 hours of medication;-Staff should contact the pharmacy for direction if a medication was unavailable in the emergency stock. 2. Review of Resident #36's April 2026 POS showed the resident had orders for a complete blood count (CBC; a blood test that determines general health status and screens for and monitors for a variety of disorders, including anemia), comprehensive metabolic panel (CMP; a blood test that measures blood sugar, electrolytes, fluid balance, kidney and liver function), A1C (a blood test to screen, diagnose or monitor diabetes) to be drawn every three months for chronic obstructive pulmonary disease (lung disease), type II diabetes (metabolic disease) with hyperglycemia (elevated amount of sugar in the blood) and hypertension (high blood pressure), starting on the last day of the month, starting 01/30/26. Review of the resident's electronic medical record showed results for a CMP and A1C dated 04/17/26. (Review showed no documentation a CBC was obtained. Review showed no documentation staff reviewed the blood test results.) Review of the resident's April 2026 treatment administration record (TAR) showed staff documented a code of 6 in the blood test administration box for 04/30/26. Review of the code definitions showed a code of 6 instructed to see progress notes. Review of the resident's progress note, dated 04/30/26 at 12:21 P.M., showed the only documentation was a copy of the order for the blood tests, including the CBC. Review of the resident's electronic medical record showed no evidence a CBC was obtained in April 2026 through the review date of 05/19/26. During an interview on 05/19/26 at 2:26 P.M., the DON said the following:-An outside lab company drew all ordered blood tests;-Staff were to document on the TAR to acknowledge the blood tests were obtained;-When staff received the blood test results, staff should document on the result form or at least in the progress notes that staff received and reviewed the results and made the physician aware. Part of that review would be to ensure all ordered blood tests were obtained and a result received; -There was no official tracking to ensure blood tests orders were obtained as ordered;-She did not see results of a CBC in the resident's medical record;-A CBC was not drawn as ordered. 3. Review of Resident #42's April 2026 POS showed the resident had orders for a CBC, CMP, thyroid stimulating hormone (TSH; a blood test to monitor treatment of hypothyroidism), lipids (laboratory test that measures cholesterol level in the blood) and vitamin-D every six months, starting on the first Monday of April/October, order date of 09/26/24. Review of the resident's April 2026 TAR showed a checkmark documented in the blood test administration box of 04/01/26. Review of the code definitions showed a checkmark indicated administered. LPN N's identifier was noted in the administration box with the checkmark. Review of the resident's electronic medical record showed blood tests results for a CMP, CBC, TSH and vitamin-D dated 04/02/26. (Review showed no documentation lipid blood test was obtained. Review showed no documentation staff reviewed the blood test results.) Review of the resident's electronic medical record showed no evidence a lipid blood test was obtained in April 2026 through the review date of 5/19/26. During an interview on 05/19/26 at 11:00 A.M., LPN N said the following:-A laboratory company drew the blood tests as ordered; -He/She documented in the administration box on the TAR that he/she knew the laboratory company was on-site to draw the blood, but did not confirm what they drew. During an interview on 05/19/26 at 2:26 P.M., the DON said the following:-She did not see results of a lipid blood test in the resident's record;-A lipid blood test was not drawn as ordered. 3007792

Based on observation and interview, the facility failed to provide residents with a safe, clean, and homelike environment, including providing housekeeping and maintenance services necessary to maintain an orderly, odor free, and comfortable interior. The facility census was 72. 1. During an interview on 05/19/26 at approximately 1:30 P.M., the Regional Nurse Consultant said the facility did not have a specific policy related to homelike environment. 2. Observation on 05/11/26 at 3:50 P.M. showed the shared closet door in occupied resident room [ROOM NUMBER] was off the track and dragged on the floor. During an interview on 05/11/25 at 3:50 P.M., the resident who resided in room [ROOM NUMBER] said the closet door dragged on the floor and got off the track. Staff would fix it and then it would break again. 3. Observation on 05/11/26 at 4:05 P.M., showed bed A in occupied resident room [ROOM NUMBER] would not lower to a low position and bed B was difficult to raise up and down. During interviews on 05/11/26 at 4:05 P.M. and 4:06 P.M., both residents who resided in room [ROOM NUMBER] voiced concerns about their beds not working correctly. One resident said his/her bed was broken and would not lower. He/She reported it numerous times to numerous staff and it still was not fixed. The resident was unaware if staff completed a maintenance request. The other resident said he/she used to have an electric bed that quit working so staff changed beds. The current bed he/she had was also broken and would not raise or lower and was not electric. He/She was unable to manually raise and lower the bed. The resident said the staff were aware he/she could not manipulate a manual bed. 4. Observations on 05/11/26 at 4:15 P.M. and 05/19/26 at 11:15 A.M., showed the door to the shared closet in occupied resident room [ROOM NUMBER] was off the track and difficult to open. During an interview on 05/19/26 at 11:15 A.M., the resident who resided in room [ROOM NUMBER] said his/her family member fixed the closet door every time he/she brought in clean laundry and the door didn't stay fixed for very long. He/She was sure the facility knew about it, because his/her family member reported it numerous times. 5. Observation on 05/12/26 at 8:05 A.M., showed the following:-A strong urine odor throughout the 100 hall;-A full, soiled linen receptacle was parked in the 100 hallway. 6. Observation on 05/13/26 at 5:05 A.M., showed the following: -A strong urine odor throughout the 100 hall;-A full soiled linen receptacle was parked in the hall outside room [ROOM NUMBER]; -An open bag of trash containing soiled incontinence supplies lay on the floor next to the soiled linen receptacle;-A strong urine odor on the 200 hall;-A full soiled linen receptacle was parked outside room [ROOM NUMBER];-An open bag of soiled linens lay on the floor in room [ROOM NUMBER];-Two incontinence briefs, soiled with urine, lay in a wheelchair parked at the foot of Resident #42's bed on the 200 hall. 7. Observation on 05/13/26 at 6:14 A.M. of the 200 hall shower room showed the following:-A foul, pungent odor upon entering the shower room;-The shower room was not in use;-Used gloves, soiled with a tan colored filmy substance, were on the floor inside the door;-Used paper towels, wrinkled and formed into a loose wad, were on the sink;-A shower chair (a specialized, waterproof chair used a shower) was soiled with a brown substance on the braces beneath the seat of the chair in one stall;-A folded, wet, medicated patch, dated 5/12 and 7 AM, lay on the floor under the shower chair;-Feces was on the floor under the shower chair;-A water-soaked towel was on the floor under the shower chair;-An approximately 5 feet long by 3 feet wide and 0.5 inch deep area of standing water on the floor around the drain;-Two wet towels lay on the counter beside the sink; -Used gloves, soiled with a white powdery substance, lay on the counter beside the sink; -Two soiled linen receptacles full of soiled and odorous linens and clothing;-A sit-to-stand lift (a mobility device that helps individuals transition from a seated to a standing position) was soiled at the base with hair, dirt and grime;-Used gloves lay on a wheelchair pedal beside a trash can;-Used gloves lay on a shower chair;-A sign on the inside of the door read, Please clean shower stall room after use. 8. During interviews on 05/11/26 at 3:45 P.M. and on 05/13/26 at 12:57 P.M., Resident #68 said the following:-He/She went to the Administrator at least three times complaining of odors;-The facility smelled of odors and it was totally disgusting;-The body odor and urine odors are so offensive he/she sprayed cologne to mask the odor; -The shower room had hair balls, feces, and standing water in it and it smelled like a sewer; -Staff didn't clean or sanitize the shower rooms or equipment in between residents. During an interview on 05/13/26 at 9:05 A.M., the Assistant Director of Nursing (ADON) said staff should clean the shower rooms after each use. During an interview on 05/19/26 at 7:26 P.M., the Administrator said the following: -He expected all equipment and furniture to be in good working order;-If something needed fixed or addressed, staff filled out a work order in the electronic maintenance system. This was the preferred alert system for requests as it went directly to the maintenance department;-He expected staff to conduct routine cleaning to control the odors in the facility, but this could be a challenge, because the incontinent episodes were unpredictable;-He expected staff to clean the shower rooms after each resident;-Housekeeping also cleaned the shower rooms every shift;-Staff should not leave soiled linens in any resident areas. 2973690

Based on observation, interview, and record review, the facility failed to provide eight residents (Residents #2, #9, #18, #29, #42, #45, #52, and #64), who required staff assistance for activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 72. Review of the facility's policy, Activities of Daily Living,( ADLs), dated 09/24/25, showed the facility provided each resident with care, treatment, and services according to the resident's individualized care plan. The facility did not provide a policy related to oral care. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 03/16/26, showed the resident was dependent on staff for oral hygiene. Review of the resident's care plan, revised 04/06/26, showed the following:-Diagnoses included need for assistance with personal cares;-The resident had a feeding tube;-The resident had a swallowing problem and was to have nothing by mouth (NPO; instruction that restricts a resident from consuming any food, beverages or oral medications);-The resident had an ADL self-care performance deficit;-The resident required one staff to assist with his/her oral care. Observation on 05/11/26 at 4:40 P.M., showed the following:-The resident had debris on his/her teeth;-The resident had debris on his/her lips, and his/her lips were dry; Observation on 05/12/26 at 10:00 A.M., showed the following:-The resident had debris on his/her lips, and his/her lips were dry;-His/Her teeth were coated with white-colored debris. Observation on 05/13/26 at 8:19 A.M., showed the following:-The resident sat in his/her wheelchair in the common area;-The resident had thick, discolored secretions flowing out of his/her mouth and onto his/her shirt; -The resident had debris on his/her lips;-His/Her teeth were coated with white-colored debris. During an interview on 05/13/26 at 8:13 A.M., the resident shook his/her head side to side when asked if any staff brushed his/her teeth. During an interview on 05/13/26 at 3:03 P.M., Certified Nurse Assistant (CNA) K said the following:-He/She was responsible for the resident's care on 05/13/26;-He/She washed the resident's face with a washcloth during morning cares; -He/She did not perform oral care for the resident during his/her shift. During an interview on 05/15/26 at 9:40 A.M., Licensed Practical Nurse (LPN) J said the following:-The resident required staff to perform oral care;-Staff should perform oral care once per day for the resident. 2. Review of Resident #9's care plan, dated 02/14/25, showed the resident required one staff to assist him/her with personal hygiene and oral care. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition intact;-Required partial to moderate assistance with oral hygiene. Observation on 05/11/26 at 12:30 P.M., showed the resident had a significant tremor, (unintentional, rhythmic muscle contraction causing shaking movements) in both of his/her hands. Observation on 05/12/26 at 9:30 A.M., showed the following:-The resident had debris on his/her teeth;-He/She had supplies needed for oral care in his/her room. During an interview on 05/12/26 at 9:10 A.M., the resident said the following:-He/She had his/her natural teeth;-He/She was unable to perform oral care without assistance due to his/her hands shaking;-Staff did not provide him/her with oral care on a regular basis. Observation on 05/13/26 at 9:13 A.M., showed the following:-The resident was in bed;-He/She had debris on his/her teeth;-Staff assisted the resident to eat his/her breakfast. Staff did not offer to provide oral care after the resident finished eating and before leaving the resident's room. Observation on 05/13/26 at 2:10 P.M., showed the resident had debris on his/her teeth. During interviews on 05/13/26 at 9:30 A.M. and 2:10 P.M., the resident said staff did not provide him/her with oral care today. Observation on 05/14/26 at 3:12 P.M., showed the resident had debris on his/her teeth. During an interview on 05/14/26 at 3:13 P.M., the resident said staff did not provide oral care for him/her today. Review of the resident's electronic health record, task section, showed no documentation staff provided oral care for the resident from 05/11/26 through 05/15/26. 3. Review of Resident #52's MDS, dated [DATE], showed the following:-Cognition intact;-Required supervision or touch assistance with oral care. Review of the resident's care plan showed the resident required assistance for personal hygiene and oral care. During an interview on 05/11/26 at 2:40 P.M., the resident said the following:-He/She had his/her natural teeth;-He/She was able to brush his/her own teeth if staff assisted him/her with set-up of the supplies;-He/She asked staff for assistance with oral care, but they did not assist him/her with oral care. Observation on 05/11/26 at 2:40 P.M., showed an emesis basin containing oral care supplies, including toothpaste and a toothbrush, on a shelf in the resident's room, out of the resident's reach. Observation on 05/12/26 at 9:51 A.M., showed the resident had debris on his/her teeth. Observation on 05/13/26 at 2:21 P.M., showed the resident had debris on his/her teeth. Observation on 05/14/26 at 3:13 P.M., showed the resident had debris on his/her teeth. During interviews on 05/12/26 at 9:50 A.M., 05/13/26 at 2:20 P.M. and 05/14/26 at 3:12 P.M., the resident said staff did not give him/her oral care supplies and did not assist him/her with oral care since he/she returned from the hospital on [DATE]. Review of the resident's electronic health record, task section, showed no documentation staff provided oral care for the resident from 05/11/26 through 05/15/26. 4. Review of Resident #42's care plan, dated 09/13/24, showed he/she required staff assistance for personal hygiene and oral care. Review of the resident's MDS, dated [DATE], showed the following:-Cognitively impaired;-Required partial to moderate assistance with oral care. Observation on 5/12/26 at 9:00 A.M., showed the following:-The resident sat in the common area in his/her wheelchair;-He/She had debris on his/her teeth. Observation on 05/13/26 from 5:10 A.M. through 5:50 A.M., showed the following:-Staff assisted the resident to dress and transferred the resident from the bed to the wheelchair;-An electric toothbrush and toothpaste sat on a shelf in the resident's room;-Staff did not provide oral care for the resident; -Staff took the resident to the common area in his/her wheelchair. Observation on 05/13/26 at 8:35 A.M., showed staff assisted the resident to the common area after the resident ate breakfast. Staff did not offer or provide oral care for the resident after breakfast. During interview on 05/13/26 at 9:50 A.M., Resident #52, the resident's roommate said the following:-He/She had not left his/her room since he/she returned from the hospital on [DATE];-He/She had not witnessed staff provide Resident #42 assistance with oral care at any time during the past two days. Review of the resident's electronic health record, task section, showed no documentation staff provided oral care for the resident from 05/11/26 through 05/15/26. 5. During an interview on 05/13/26 at 2:42 P.M., Certified Nursing Assistant (CNA) M said the following:-Staff should provide residents with oral care in the morning and after meals;-He/She was responsible for Residents #9, #42, and #52's care that day;-He/She did not assist Residents #9, #42, or #52 with oral care. During an interview on 05/13/26 at 2:57 P.M., CNA Q said the following:-Staff should provide residents with oral care at least one time per day;-He/She was responsible for Residents #9, #42, and #52's care that day and did not provide oral care for the residents;-Staff documented in the electronic health record when they provided oral care. During an interview on 05/13/26 at 4:45 P.M., LPN C said staff should provide oral care for dependent residents at least daily. During an interview on 05/14/26 at 7:32 P.M., LPN S said CNA staff should perform oral care for the residents. During an interview on 05/13/26 at 5:05 P.M., the Assistant Director of Nursing (ADON) said the following:-Staff should provide oral care at least in the morning and at bedtime during routine cares;-Staff should provide set-up assistance for oral care for residents who were able to perform the task independently after set-up;-Staff should document in the resident's electronic medical record when staff provide oral care for the resident. During an interview on 05/13/26 at 5:06 P.M., the Director of Nursing (DON) said the following:-Staff should provide oral care every day as part of routine morning and bedtime care; -Staff should provide set-up assistance with oral care for residents who require set-up assistance. 6. Review of Resident #29's care plan, revised on 09/17/24, showed the following:-Encourage the resident to ask for assistance prior to toileting;-He/She had bladder incontinence;-Check the resident as required for incontinence; wash, rinse, and dry perineum. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Intact cognition;-Frequently incontinent of bladder and always incontinent of bowel;-Required partial to moderate assistance for toileting hygiene. Observation on 05/13/26 at 6:10 A.M. showed the following:-CNA A removed the resident's urine-saturated incontinence brief and the urine-saturated incontinence pad underneath the resident;-CNA A provided perineal care for the resident;-The resident's buttocks was red. During an interview on 05/13/26 at 1:20 P.M., the resident said the following:-Staff didn't change him/her all night;-Staff let him/her lay wet all night and had to change his/her bedding, because he/she was soaked all the way through;-He/She used his/her call light, but no one came in, or they came in and turned it off, and didn't come back;-He/She was supposed to call for assistance because he/she loses his/her balance;-He/She has asked staff to take him/her to the bathroom and they wouldn't help, so he/she asked his/her roommate to help him/her get to the bathroom or to get staff when needed. During an interview on 05/13/26 at 1:20 P.M., Resident #68, the resident's roommate, said the following:-Staff left Resident #29 wet all night every night;-He/She assisted Resident #29 to go to the bathroom and got staff's attention when staff didn't respond to the resident's call light. 8. Review of Resident #45's care plan, revised on 06/29/25, showed the following:-He/She had potential impairment to skin integrity related to decreased mobility, cognition impairment and occasional incontinence; redness to left buttock;-He/She had an ADL self-care performance deficit and required assistance from one staff for bed mobility, toilet use and personal hygiene. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Intact cognition;-Frequently incontinent of bladder and always incontinent of bowel;-Required substantial to maximum assistance for toileting hygiene. Observation on 05/13/26 at 5:30 A.M., showed the following:-CNA A entered the resident's room and turned on the overhead light above the bed;-The resident asked CNA A for the time. CNA A told the resident it was 5:30 in the morning; -The resident said, Can you please help me? I'm wet and it's been a while. You see I need help. Please help me. It's been a long wait since 10:00 P.M.-CNA A pulled down the resident's blanket. The resident's incontinence brief was heavily saturated with urine. The skin on the resident's genitalia and buttocks was red. CNA A provided incontinence care for the resident. -The resident said, Thank you for the help I am receiving. I'm thankful now. During an interview on 05/13/26 at 5:30 A.M., the resident said the following:-Staff did not check or change him/her since 10:00 P.M.;-That was a long time to wait and to be left wet. 9. Review of Resident #64's care plan, revised on 06/29/25, showed the following:-He/She was totally dependent on staff for personal hygiene and toilet use; -He/She was incontinent of bladder; -Check the resident frequently and as required for incontinence;-Wash, rinse, and dry perineum. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severely impaired cognition;-Occasionally incontinent of bladder and always incontinent of bowel;-Required substantial/maximum assistance from staff for personal hygiene. Observation on 05/13/26 at 5:45 A.M., showed the following:-CNA A entered the resident's room and began performing morning cares;-The room had a very strong urine odor that permeated into the hallway;-CNA A pulled down the resident's heavily urine-saturated incontinence brief, -CNA A provided incontinence care for the resident;-The resident's buttocks were white and heavily wrinkled from moisture. During an interview on 05/13/26 at 5:20 A.M., CNA A said the following: -He/She worked on the night shift;-He/She was to check and change Resident #45 every two hours. The other residents on his/her assigned hall (Residents #29 and #64) were independent and used their call light if they needed assistance;-Staff gave him/her this information in report. 10. During an interview on 05/19/26 at 7:26 P.M., the DON said the following:-Staff should check and change the residents every two hours and as needed;-Residents should not have to depend on their roommate to get staff's attention to provide care. 29797883001665

Based on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for six of six sampled residents (Residents #1, #2, #3, #4, #5 and #6). The facility withdrew back room and board without the resident and/or financial guardian's written authorization or after the resident expired. The facility census was 72.1. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #3 expired on [DATE].Review of Resident #3's Ledger showed $8,119.01 held in the Resident Trust Account on [DATE]. Funds in the amount of $3,904.41 were reported to the Department of Social Services Third Party Liability (TPL) Unit on [DATE] and did not include the full balance of the resident's funds. The remaining funds in the amount of $3,311.00 was withdrawn for 09/2025's room and board in the amount of $1,051.00 and back room and board in the amount of $2,260.00 on [DATE] and an additional withdrawal for $51.60 on [DATE]. The remaining $2,311.60 funds were not reported to the Department of Social Services TPL Unit as of [DATE], 206 days after he/she expired. Review showed the facility continued to receive and hold interest in the amount of $2.22 as of [DATE] and did not submit a Personal Funds Account Balance Report until [DATE], 64 days after the initial interest deposit date of [DATE].2. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #6 expired on [DATE].Review of Resident #6's Ledger showed $1,073.37 was deposited into the Resident Trust Account on [DATE]. Review of the resident trust account documentation provided by the previous facility where Resident #6 resided showed $1,073.37 was money from the resident trust account and not room and board money. Review of Resident #6's Ledger showed an unauthorized $690.00 was withdrawn for room and board on [DATE]. Review also showed cremation services due in the amount of $837.00 and $383.48 was paid on [DATE] from the resident's funds. The unauthorized funds withdrawn for room and board held in the resident trust account in the amount of $690.00 were not submitted for cremation services or to the Department of Social Services TPL Unit as of [DATE], 38 days after he/she expired. During an interview on [DATE] at 3:06 P.M., the previous facility's Business Office Manager said the funds sent for Resident #6 was personal spending money from the resident trust account and not for room and board.3. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #4 expired on [DATE].Review of Resident #4's Ledger showed $2,792.85 held in the Resident Trust Account on [DATE] and a direct deposit credited to the account in the amount of $2,064.00 on [DATE]. Funds in the amount of $2,618.55 were reported to the Department of Social Services TPL Unit on [DATE], 41 days after he/she expired. The $2,618.55 did not include the full balance of the resident's funds. The remaining funds in the amount of $2,058.60 were withdrawn for 03/2026 room and board on [DATE] and were not reported to the Department of Social Services TPL Unit as of [DATE], 41 days after he/she expired. 4. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #2 expired on [DATE].Review of Resident #2's Ledger showed $51.30 held in the Resident Trust Account was withdrawn on [DATE] for back room and board and was not reported to the Department of Social Services TPL Unit as of [DATE], 337 days after he/she expired. Review showed the facility continued to receive and hold interest in the amount of $0.04 as of [DATE] and did not submit a Personal Funds Account Balance Report as of [DATE], 305 days after the initial interest deposit date of [DATE].5. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #1 expired on [DATE].Review of Resident #1's Ledger showed $1,295.84 held in the Resident Trust Account on [DATE] was not reported to the Department of Social Services TPL Unit until [DATE], 81 days after he/she expired. Review showed the facility continued to receive and hold interest in the amount of $1.15 as of [DATE] and did not submit a Personal Funds Account Balance Report until [DATE], 248 days after the initial interest deposit date of [DATE].6. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #5 expired on [DATE].Review showed the facility continued to receive and hold interest in the amount of $3.46 as of [DATE] and did not submit a Personal Funds Account Balance Report until [DATE], 217 days after the initial interest deposit date of [DATE].7. During an interview on [DATE] at 10:15 A.M., the Administrator said the facility had some turnover in the Business Office Manager (BOM) position last year. The BOM said he/she started the position in 11/2025, was trying to catch up paperwork and was not sure why the refunds/paperwork were not submitted within 30 days prior to him/her starting the position. The BOM also said the following:-he/she was still looking over Resident #2's account;-he/she was trying to clean up Resident #4 and #5's account; -he/she will need to check with the supervisor on what to do about the remaining interest in the accounts;-he/she did not know Resident #6's money from the previous facility was from the resident's trust account; -thought he/she had 60 days to complete the Personal Funds Balance Report and/or submit refunds.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of six sampled residents, received treatment and care in accordance with professional standards of practice when staff failed to assess Resident #1 following the report of a fall, failed to obtain treatment for two days following the fall, and failed to implement and follow physician orders for treatment following identification of the fall with injury. The resident sustained a fractured left wrist. The facility census was 73.Review of the facility Fall policy dated May 2025 showed the following:-Each resident of the community who experiences a fall will be treated and assessed to adequately treat any current injuries, either physical or psychosocial and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. After each fall, an occurrence report will be completed, root cause will be determined, and interventions will be implemented;-A fall is defined as unintentional change in position coming to rest on the ground, floor or onto the next lower surface, (such as onto a bed, chair, or beside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. During an interview on 12/11/25 at 3:00 P.M. the administrator said the facility did not have a policy regarding following physician orders. He expected staff to implement and follow physician orders. 1. Review Resident #1's Care Plan, dated 2/25/25, showed the following:-Diagnoses of heart disease, macular degeneration (deteriorating eye disease causing progressive blindness), muscle weakness, lack of coordination, and need for assistance with personal care;-The resident was at risk for falls. Staff should ensure the resident's call light was within reach and encourage the resident to use the call light. Provide a low bed and fall mats on the floor beside the bed when the resident was in bed. Provide a scoop mattress (mattress with raised edges providing support);-The resident had difficulty with Activities of Daily Living. Staff should provide assistance with bathing, bed mobility, dressing, personal hygiene, oral care, toileting and transfers. Review of the resident' quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/12/25, showed the following:-Moderately impaired cognition;-Required a wheelchair for mobility;-Required partial to moderate staff assistance (Staff does less than half the effort. Staff lifts, holds, or supports trunk or limbs, but provides less than half the effort) with dressing upper body;-Required substantial/maximal staff assistance (staff does more than half the effort and staff lifts or holds trunk or limbs and provides more than half the effort) with dressing lower body, putting on and taking off footwear, personal hygiene, toileting hygiene, bathing, transfers from sitting to lying in bed, lying to sitting on the side of the bed, transfers from chair to bed and transfers from sitting to standing;-Dependent on staff (helper does all the effort) with transfers to the toilet and to the shower;-No falls since the previous assessment. Review of the resident's progress note, dated 11/24/25 at 7:00 A.M., showed the Nurse Practitioner (NP) documented the resident self-reported a fall two days prior which was previously unreported to nursing staff. The resident now complained of pain, swelling, and bruising to the left arm. Given the mechanism and new symptoms, the immediate priority was to rule out a fracture. Therefore, the plan was to immediately obtain x-rays of the left arm to evaluate for any acute bony injury. The arm should be immobilized and managed with RICE (Rest, Ice, Compression, Elevation) pending radiographic results. Updated care team for follow up. Review of the resident's nurses' notes showed staff did not enter any documentation regarding the resident's fall, referenced in the 11/24/25 Nurse Practitioner's progress note Review of the resident's Physician Order Sheet (POS), dated 11/24/25, showed an order to obtain x-ray (images of the body's internal structures, bones, tissues and organs) of the left arm to evaluate for any acute bony injury. Immobilize the arm and manage with RICE pending x-ray results Review of the resident's left forearm x-ray report, dated 11/24/25, showed the following:-Examination date of 11/24/25 at 7:19 P.M. and reported on 11/25/25 at 5:00 A.M.;-Left upper extremity arm pain, bruising post unwitnessed fall, new fall;-Findings of acute distal radial metaphysis fracture with no evidence of displaced ends (fractured left forearm bone at the wrist). Review of the resident's nurses' notes showed staff did not enter any documentation regarding the resident's fall on 11/24/25, including provision of assessments or RICE treatments to the left arm. Review of the resident's Nurse Practitioner progress note, dated 11/25/25 at 7:00 A.M., showed the chief complaint was evaluation of the left arm pain, swelling and bruising after a self-reported fall. An x-ray obtained and revealed a fracture of the left arm. The resident presented with left arm pain, swelling and visible bruising, prompting evaluation. Based on the x-ray findings, resident sent to emergency room for further evaluation and management. Resident returned to the facility a few hours later. Review of the resident's nurses' note, dated 11/25/25, showed staff documented the following:-At 9:45 A.M. x-ray results reported to physician. Resident sent to hospital emergency room by ambulance with fracture of the left forearm;-At 2:01 P.M. resident returned from the hospital with a splint to the left arm. Review of the resident's emergency room Summary, dated 11/25/25, showed the following:-Resident presented with fractured left arm, resident fell on Saturday and x-ray was taken at facility;-Resident reported on Sunday he/she reached forward when a cord was too short, and it caused him/her to fall backwards landing on his/her left arm. The resident reported his/her pain was only in his/her left arm;-X-ray report showed comminuted (a severe break where the bone shattered into three or more pieces, usually from high impact trauma like falls) distal radius fracture (end of one of two bones in the forearm at the wrist);-Splint applied along with sling;-Follow-up with orthopedic (bone specialist);-Discharge diagnosis of closed fracture of the left wrist. Review of the resident's nurses' notes, dated 11/25/25 through 12/9/25, showed staff did not enter any documentation regarding the resident's fall, assessments or documentation of treatments to the left arm or the splint and sling provided. Review of the resident 's orthopedic physician orders, dated 12/9/25, showed the following:-The resident was seen in the office for a left wrist fracture and was given a brace for comfort. The brace could be removed for daily skin checks and should be removed for showers and hand washing. The resident could bear weight less than four ounces for self-care;-Six weeks from the injury (1/3/26) the brace may be discontinued and worn only upon the resident's request. At that time the resident could resume activities as tolerated. Review of the resident's POS, dated 12/10/25, showed wear brace to left arm for comfort. The brace could be removed for daily skin checks, showers and hand washing. Discontinue the brace 1/3/26 and then wear when the resident requested. Review of the resident's nurses' note, dated 12/10/25, showed no documentation regarding the resident's fall, including assessments or provision of treatment to the arm or the left wrist brace. Observation on 12/11/25 at 9:00 A.M. showed the resident sat in a wheelchair in the common area holding his/her left arm, elbow bent against his/her body with right hand supporting his/her left forearm/wrist area. The resident was not wearing a splint or immobilizer. The resident's left hand was clenched in a fist. During an interview on 12/11/25 at 10:10 A.M. the resident said he/she fell out of bed one night and laid on the floor. A nurse came in, picked him/her up, put him/her back into bed, and asked if the resident was okay. The resident told the staff member his/her arm hurt. The resident's arm continued to hurt and much later, he/she was sent to the hospital, had an x-ray and his/her left arm was broken. The hospital put a sling on his/her arm, and he/she was supposed to wear the sling. The resident did not know where the sling was, he/she just held and supported his/her left arm with his/her right hand. His/Her left arm hurt all the time. No one helped him/her until he/she went to the hospital. During an interview on 12/11/25 at 8:45 A.M. Resident #6 said Resident #1 was his/her roommate. Resident #6 saw Resident #1 on the floor when he/she got up to use the bathroom sometime in the night on Saturday 1/22/25 to 11/23/25. Resident #6 called for help. An unknown Certified Nurse Assistant (CNA) answered the call light. Resident #6 told the CNA he/she saw Resident #1 on the floor. The CNA picked Resident #1 up and put the resident back in bed. Two days later staff sent Resident #1 to the emergency room. During an interview on 12/11/25 at 9:45 A.M. the administrator said the resident's roommate (Resident #6) found Resident #1 on the floor during the night and called for help. Resident #6 said staff picked him/her up and put him/her back in bed. Staff did not tell the charge nurse the resident fell. Staff missed an opportunity to get the charge nurse to assess the resident before moving the resident after the fall. Staff should have assessed the resident before moving the resident back to bed. Staff learned later the resident had a fractured left arm. During an interview on 12/11/25 at 10:12 A.M. CNA B said the resident no longer had a sling. He/She did not know what happened to the sling. Observation on 12/11/25 at 10:13 A.M. showed a black wrist brace lay on the resident's bed. The resident sat in the wheelchair and supported his/her left forearm and wrist with his/her right hand with no brace or sling in place. During an interview on 12/11/25 at 10:15 A.M. Licensed Practical Nurse (LPN) A said he/she was the resident's charge nurse. He/She was aware the resident had a fractured arm. He/She did not know the current treatment for the resident's fractured arm. He/She did not know if the resident had a sling or immobilizer. LPN A checked the physician orders and said the resident's POS included and order to wear a brace to the left arm for comfort, remove for showers only, may discontinue on 1/3/26 and then use the brace as needed. During an interview on 12/11/25 at 10:25 A.M. the resident said he/she did not have the brace on when he/she went to bed the previous night and was without it all night. A staff member took the brace off and put it on the table the previous night and no one put the resident's brace back on. Observation on 12/11/25 at 10:26 A.M. showed LPN A asked the resident if he/she had pain. The resident rated his/her pain at 5 on a scale of 0-10 (with 10 the highest level of pain) LPN A notified physical therapy. The physical therapist applied the resident's left wrist brace and secured it in place. During an interview on 12/11/25 at 10:30 A.M. the resident's roommate (Resident #6) said Resident #1 did not have the wrist brace on all morning. During an interview on 12/11/25 at 11:00 A.M. the Assistant Director of Nursing (ADON) said the resident reported his/her arm hurt on 11/24/25, an x-ray was obtained on 11/24/25, and staff transferred the resident to the hospital emergency room on [DATE]. During an interview on 12/11/25 at 11:05 A.M. the Director of Nursing (DON) said the morning of 11/24/25, Administrative Assistant F, reported to Registered Nurse (RN) C the resident's arm was hurting, swollen and red. RN C brought the resident to the DON's office. The resident's left arm was red, swollen and warm to touch. The resident grimaced with movement. There was no bruising at the time. The resident said he/she fell out of bed and an unknown staff member picked the resident up from the floor and placed him/her back in bed. Mobile x-ray came on 11/24/25 to the facility. No ice or any treatment was provided on 11/24/25. The x-ray report received on 11/25/25 showed a fractured left wrist. Staff notified the resident's physician and transferred the resident to the emergency room for evaluation and treatment. The DON did not know if the resident received any pain medication on 11/24/25. During an interview on 12/11/25 at 11:07 A.M. RN C said on the morning of 11/24/25, Administrative Assistant F said the resident's arm was hurt. RN C took the resident to the DON's office. The resident's left arm was red, swollen and painful. The resident said he/she fell out of bed two days prior. RN C assessed the resident, notified the physician and received orders for x-rays. No treatment was provided to the resident's left arm on 11/24/25 during the day shift. Mobile x-ray arrived about 5:30 P.M. RN C did not see the results of the x-ray before leaving the facility at the end of his/her shift at 6:00 P.M. During an interview on 12/11/25 at 11:30 A.M. Administrative Assistant F said he/she saw the resident on 11/24/25 in the hallway near the common area. The resident had not been to the dining room for breakfast yet and seemed to have something wrong. Administrative Assistant F asked the resident what was wrong and if the resident was hungry. The resident said his/her arm hurt. The resident's left arm was red, swollen and bruised. Administrative Assistant F told RN C, the charge nurse, about the resident's arm. RN C assessed the resident's arm and took the resident to the DON's office. The resident said he/she fell Saturday night (night of 11/22/25). During an interview on 12/11/25 at 2:15 P.M. CNA D said he/she worked on Sunday 11/23/25 on day shift. He/She noticed the resident's left arm was bruised and swollen. The resident said he/she fell out of bed during the night, and someone picked him/her up and put him/her back into bed. No ice or immobilizer was put on the resident's left arm on 11/23/25. CNA D thought the charge nurse saw the resident's left arm was swollen and bruised. Night shift did not report the resident fell during the night. CNA D did not report the resident's left arm was bruised and swollen, he/she thought someone else had already reported it. During an interview on 12/11/25 at 3:15 P.M. CNA E said the following:-He/She worked the night shift and got Resident #1 up and dressed every morning. On 11/22/25 he/she worked the resident's hall on the night shift. The resident's roommate (Resident #6) pushed the call light during the night and said Resident #1 was on the floor and needed help. CNA E did not find Resident #1 on the floor. He/She did not pick the resident up off the floor and place the resident into bed during the night. CNA E did not tell the charge nurse, or any other staff the resident's roommate said Resident #1 was on the floor;-The following morning (Sunday 11/23/25), CNA E got Resident #1 up and dressed for the day. The resident did not complain of pain when CNA E transferred or dressed the resident. Resident #1 was a fall risk and staff placed fall mats on the floor. The resident's bed did not go all the way to the floor but was placed in the lowest position it would go while the resident was in bed. The resident required staff assistance with transfers and dressing;-CNA E returned to work on 11/23/25 at 2:00 P.M. and worked a double shift (2:00 P.M. to 6:00 A.M. on 11/24/25) on the resident's hall. The resident did not complain of left arm pain and CNA E did not notice any bruising, swelling or redness of the left arm. On 11/23/25 CNA E undressed and put the resident to bed. On 11/24/25 CNA E got the resident up for the day and dressed the resident. CNA E did not notice any change in the resident's left arm or any change in the resident's behaviors. CNA E did not know how the resident broke his/her arm;-He/She should have reported to the charge nurse when the resident's roommate said Resident #1 fell out of bed. During an interview on 12/15/25 at 8:45 A.M. the Assistant Director of Nursing (ADON) said the following:-CNA E should have reported the resident's roommate said the resident fell out of bed to the charge nurse. CNA E did not report the incident, and staff did not complete an assessment of the resident. No staff reported the resident fell out of bed to the charge nurse;-Staff did not provide the resident any treatment as directed by the physician. Staff did not provide RICE on 11/23/25 or 11/24/25 as the NP directed;-Staff should follow the physician's orders and provide the sling or brace as ordered. The brace should be on except for showers and assessments through 1/3/26. The brace would help alleviate pain. The resident was holding his/her left arm, supporting the arm when staff did not apply the brace as ordered;-Administrative Assistant F noted the resident's left arm was swollen and bruised Monday morning, 11/24/25. The resident went all day and night without the RICE treatment and no immobilizer in place until staff transferred the resident to the emergency room on [DATE]. During an interview on 12/15/25 at 10:30 A.M. the DON said staff should inform the charge nurse of any reported fall. The charge nurse should assess the resident and provide treatment as needed. Staff did not provide the resident treatment following the fall and did not implement the RICE treatment. The DON was not aware the roommate reported the resident was on the floor during the 11/22/25 night shift. He/She became aware on the morning of 11/24/25. Staff should follow physician orders and document assessments and treatments provided. During an interview on 12/15/25 at 8:40 A.M. the Administrator said staff should report any falls or reported falls to the charge nurse. The charge nurse should complete an assessment and implement treatment as directed. Staff should follow physician's orders.Staff did not report the resident was seen on the floor by the roommate. Staff did not complete an assessment and did not provide treatment as ordered. 2678587

Based on observation, interview and record review, the facility failed to provide protective oversight and prevent falls for one resident (Resident #2) in a review of six residents when staff failed to ensure the resident's bed was always in the lowest position while the resident was in bed. The facility also failed to ensure the resident's low air loss mattress (a specialized, medical, mattress with inflatable air cells that continuously circulate ai and provides pressure redistribution) was at the appropriate weight setting to prevent falls from bed. The facility census was 73.Review of the facility Fall Policy, dated May 2025, showed the following:-The purpose of the fall program was to develop, implement, observe and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life. The fall program promotes safety, prevention and education of both staff and residents;-The community shall ensure the fall program is maintained to reduce the occurrence of falls, reduce risk of injury and promote independence and safety. Each resident residing at the facility will be provided services and care that ensure the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors for falling at the time of admission/readmission, change of condition, quarterly and after every fall. Each resident of the community who experiences a fall will be treated and assessed to adequately treat any current injuries, either physical or psychosocial and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. After each fall, an occurrence report will be completed, root cause will be determined, and interventions will be implemented;-A fall is defined as unintentional change in position coming to rest on the ground, floor or onto the next lower surface, (such as onto a bed, chair, or beside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. During an interview on 12/15/25 at 10:35 A.M. Registered Nurse (RN)/Corporate Nurse H said the facility should follow the low air loss mattress manufacturer's instructions for use. Review of the ProActive Protekt Aire 4000 DX/5000DX Low Air Loss Mattress (the mattress in place for Resident #2) operation manual showed the following:-The mattress system was designed for prevention, treatment and management of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction);-Individual customized setting capability;-Select the correct resident weight (weight settings of 80, 120, 160, 200, 240,280,340 and 400 pounds);-Weight/pressure set up, adjust air mattress to a desired firmness according to the resident's weight. 1. Review of Resident #2's Care Plan, dated 10/25/25, showed the following:-Diagnoses of end stage renal disease (end of life kidney disease), heart failure, muscle weakness, need for assistance with personal care and right, above the knee amputation (loss of right leg above the knee);-The resident was at risk for falls. Staff should ensure the resident's call light was in reach and encourage the resident to use it for assistance as needed. Place fall mats on the floor on each side of the bed when in bed. Ensure personal items are within reach. Anticipate if resident wanted to get out of bed or transfer to avoid resident attempts at getting up on his/her own. Provide low to the floor bed;-The resident had inability to complete Activities of Daily Living. Staff should assist the resident with bathing, bed mobility, dressing, eating, personal hygiene, toileting, transfers to and from the bed with a mechanical lift (a mechanical device used to safely transfer resident's with limited mobility between surfaces such bed, chair or toilet by using a sling and a hydraulic pump) to a wheelchair. Review of the resident's Fall Risk Assessment, dated 10/25/25, showed staff documented the following:-Resident had a history of falls;-Received medication that increased the risk of falls;-Incontinent;-Unable to come to a standing position;-Score of 28, which indicated a high fall risk (score above 10 indicated high fall risk). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/7/25, showed the following:-Cognitively intact;-Required staff supervision or touching assistance (staff provides verbal cues and/ortouching/steadying and/or contact guard assistance as resident completes activity.Assistance may be provided throughout the activity or intermittently) for eating, oral hygiene, personal hygiene and rolling left and right in the bed;-Required partial/moderate staff assistance (staff did less than half the effort. Staff lifts, holds, or supports trunk or limbs, but provides less than half the effort) with mobility from sitting to lying and lying to sitting on the side of the bed;-Required substantial/maximal staff assistance (staff does more than half the effort. Staff liftsor holds trunk or limbs and provides more than half the effort) with showers and upper body dressing;-Dependent on staff (staff does all the effort, resident did none of the effort to complete the activity or the assistance of two or more staff was required to complete the activity) with toileting hygiene, lower body dressing, putting on/taking off footwear, chair to bed and bed to chair transfers, and toileting transfers;-The resident was unable to stand, used a wheelchair for mobility with staff assistance;-Required an indwelling urinary catheter and was frequently incontinent of bowel;-Weight was 268 pounds;-No falls since the prior assessment;-Required a pressure reducing (equipment that aims to relieve pressure away from areas of high risk for skin breakdown) device for the bed. Review of the resident's nurses' note, dated 11/8/25 at 2:41 A.M., showed staff documented the resident was on the floor between his/her bed and the roommate's bed. The resident said he/she tried to sit on the side of the bed and slid out. The bed was in the lowest position. Review of the resident's care plan showed no documentation staff implemented new fall risk interventions following the fall on 11/8/25. Review of the resident's medical record dated 11/10/25 showed staff documented the resident weighed 268 pounds. Review of the resident's nurses' note, dated 11/18/25, showed staff documented the following:-At 10:48 A.M. the resident was on the floor between the resident's bed and his/her roommate's bed. New intervention to add a bolster (supportive raised edges on the sides of the mattress) to the resident's mattress;-At 5:10 P.M. the resident was on the floor. He/She fell out of bed while reaching for a phone. The resident said his/her phone fell and he/she reached for the phone and slid off the bed. Staff assisted the resident back to bed. Staff provided education on calling for assistance when items were out of reach. Review of the resident's medical record showed no documentation staff applied bolsters to the resident's mattress on 11/18/25. Review of the resident's care plan, updated 11/18/25, showed add bolsters to the mattress. Review of the resident's care plan, updated 12/3/25, showed Call Don't Fall sign was added in the resident's room. Review of the resident's nurses' note, dated 12/4/25 at 2:07 P.M., showed staff documented the resident was on the floor. The resident said he/she reached for the tray and fell out of bed. Staff helped the resident back into bed with a mechanical lift. Review of the resident's care plan showed no documentation staff implemented new fall risk interventions following the fall on 12/4/25. Review of the resident's nurses' note, dated 12/9/25 at 9:45 P.M., showed staff documented the resident was on the floor. The resident said he/she rolled out of bed. Skin tear noted to the left knee and back of the right forearm. Review of the resident's care plan, updated 12/9/25, showed add enabler bar (a grab bar used for positioning) to the resident's bed to assist with safe transfers and staff should provide frequent rounds (monitoring). Review of the resident's Fall Risk Assessment, dated 12/9/25, showed the following:-Resident had history of falls;-Received medication that increased the risk of falls;-Incontinent;-Unable to come to a standing position;-Score of 29 which indicated a high fall risk (score above 10 indicated high fall risk). Review of the resident's nurses' note, dated 12/10/25 at 2:29 A.M., showed staff documented the resident was on the floor, face down on the floor mat beside the bed. Noted a skin tear to the resident's left knee and back of the right forearm. The resident said he/she rolled out of bed. Staff helped the resident back into bed with bed in lowest position and floor mats on each side of the bed. Review of the resident's care plan showed no documentation staff implemented new fall risk interventions following the fall on 12/10/25. Review of the resident's nurses' note, dated 12/11/25 at 5:51 A.M., showed staff documented the resident was on the floor, lying face down on the floor mat beside the bed. The resident said he/she rolled out of bed. Staff helped the resident back into bed with bed in lowest position for safety with floor mats on each side of the bed. Review of the resident's care plan showed no documentation staff implemented new fall risk interventions related to the fall on 12/11/25. Observation on 12/11/25 at 9:40 A.M. showed the resident lay in bed with a low air loss mattress set at 340 pounds (70 pounds more than the resident's weight as documented by staff on 11/10/25). The mattress had bolsters on each side, the length of the mattress and a grab bar (positioning device attached to the bed frame) in place. The resident had scooted down in the bed with his/her left foot and ankle resting directly on the wooden foot board. A mechanical lift pad (sling used for transfers with a mechanical lift) extended under the resident. Fall mats were noted on the floor on each side of the bed and the bed was in the normal height, not in the lowest position to the floor. During an interview on 12/11/25 at 9:41 A.M. the resident said he/she rolled out of the bed earlier that morning and landed on the fall mat when he/she reached for something and rolled out of the bed onto the floor. He/She went to dialysis three days per week but did not go to dialysis today. He/She did not plan to get out of bed today. Staff used the mechanical lift pad to reposition him/her in the bed and left the lift pad under him/her all the time. He/She scooted down in the bed frequently and his/her foot hung off the bottom of the mattress or rested on the foot board. It was not comfortable lying in the scooted down position. Observation on 12/11/25 at 4:00 P.M. showed the resident lay in bed with the low air loss mattress set at 340 pounds. Review of the resident's medical record, dated 12/13/25, showed staff documented the resident weighed 268 pounds. Observation on 12/15/25 at 7:20 A.M. showed the resident sat in a wheelchair preparing for dialysis. The resident's low air loss mattress was set at 340 pounds. During an interview on 12/15/25 at 10:15 A.M. Licensed Practical Nurse (LPN) G said he/she was responsible for monitoring resident's low air loss mattress settings. The weight setting should be set for the resident's weight. During an interview on 12/15/25 at 8:45 A.M. the Assistant Director of Nursing (ADON) said he/she reset the resident's low air loss mattress at the appropriate setting for the resident's weight, which was the 280 pound setting. Setting the weight too high on the low air loss mattress could contribute to the resident rolling out of bed. The mattress was filled with too much air for the resident's weight. The resident reached for the grab bar, rolled over and out of the bed onto the floor. During an interview on 12/15/25 at 10:30 A.M. the Director of Nursing (DON) said the following:-Staff should assess the resident following a fall and implement new fall prevention interventions after each fall;-Staff should monitor and set low air loss mattresses at the correct settings for the resident's weight;-The resident's mattress was set too high for his/her weight;-Staff should not leave the mechanical lift sling under the resident all the time while the resident was in bed. The mechanical lift sling was not a repositioning device; -Staff should keep the bed in the lowest position when the resident was in bed. During an interview on 12/15/25 at 8:40 A.M. the Administrator said staff should report any falls or reported falls to the charge nurse. The charge nurse should complete an assessment and implement treatment as directed. Staff should evaluate for new appropriate fall prevention interventions. Staff should follow the low air loss mattress manufacture directions for use. 2683848

Based on interview and record review, the facility failed to ensure one resident (Resident #9) of ten sampled residents, with a history of pressure ulcers received the necessary care and services, when staff failed to identify the presence of, history or risk of pressure ulcers including a pressure ulcer on admission on the resident's sacrum. The resident was identified eight days following admission [DATE]) with a Stage III pressure ulcer on his/her sacrum with an old dressing prior to the resident's transfer to a hospital. The facility had no documentation to show prior identification of the ulcer, assessment, treatment or a care plan to address the pressure ulcer. The facility census was 72.Review of the facility's policy, Wound Prevention, dated August 2023 showed the following:-Educate residents, their families, and staff members about wound prevention techniques and best practices;-Implement regular assessments and screening to identify residents at risk of developing wounds;-Create personalized service plans for residents with specific wound prevention needs;-Provide ongoing staff training and education on wound care prevention and management;-Encourage open communication and collaboration among staff, residents and health care providers to address any concerns or issues related to wound prevention promptly;-Conduct a comprehensive assessment upon admission to identify any existing wounds, skin conditions, or risk factors for wound development;-Perform routine skin assessments on all residents during regular monthly assessments;-Document and review the assessed information to establish appropriate wound prevention measures for each resident;-Provide good hygiene practices, including regular showering, and regular changing of soiled garments or incontinence products;-Encourage residents to change positions as necessary;-Educate staff about proper body alignment techniques, especially for residents with limited mobility;-Provide initial and ongoing training to all clinical staff members on wound prevention techniques, early identification of wounds, and appropriate care interventions;-Document all wound prevention measures, assessments, and interventions in resident's service plans and medical records;-Promptly report any new wounds, changes in skin conditions, or concerns related to wound prevention to appropriate healthcare personnel. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions:-Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed;-Deep Tissue Pressure Injury (DTI) is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. 1. Review of Resident #9's hospital history and physical, dated 7/14/25 at 1:01 P.M., showed the following: -The resident lived alone, had a history of dementia and was brought in by emergency medical services after a fall;-Wound care note/reason for consult: Sacrum (a triangular bone in the lower back formed from vertebra situated between the two hip bones of the pelvis) and deep tissue injury;-Pressure injury location: sacrum;-Site assessment: Black; purple/red;-Shape: circular;-Peri wound (the skin area extending from the wound's edges outwards) fragile;-Dressing: foam with a protective barrier. Review of the resident's Post Acute Discharge Instructions from the hospital, dated 8/22/35 at 2:00 P.M., showed recapitulation of the resident stay included mobility and positioning assistance, skin management and wound care. There were no orders included for wound care. Review of the resident's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-Diagnoses included dementia, urinary tract infection and repeated falls. During an interview on 9/2/25 at 2:30 P.M. the resident's family member said the following:-The resident recently admitted to the facility;-He/She thought the resident had a sore on his/her bottom when he/she admitted to the facility on [DATE]. Review of the resident's physician order sheets dated August 2025 showed no orders for treatment of pressure ulcers. Review of the resident's admission Assessment form, dated 8/22/25 at 5:02 P.M., showed the following:-The resident was understood and understands others;-The resident was alert to person and place;-The resident required one staff assistance with transfers, dressing, toilet use, personal hygiene, bathing, and with locomotion on and off the unit;-The resident required set up help with bed mobility;-The resident did not have impaired skin integrity;-The resident used incontinent briefs to control his/her bladder;-The resident used incontinent briefs to control bowel incontinence. Review of the resident's Braden scale (scale used to predict pressure ulcer risk) dated 8/22/25 at 6:15 P.M. showed the following:-Sensory perception: the resident was very limited on sensory perception, responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of the body;-Moisture/very moist: the skin was often moist but not always. Linen must be changed at least once a shift;-Activity: Chairfast. Ability to walk was severely limited or nonexistent. Cannot bear weight and/or must be assisted into chair or wheelchair;-Nutrition: Was probably inadequate. Rarely eats a complete meal and generally eats only 1/2 of what was offered;-Friction/Shear: Potential problem, moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices;-The resident was at moderate risk for pressure ulcer development. Review of the resident's daily skilled nursing note, dated 8/23/25 at 1:34 A.M., showed staff documented skin issues were not applicable. Review of the resident's daily skilled nursing note dated, 8/25/25 at 7:21 P.M., showed staff documented skin issues were not applicable. Review of the resident's care plan, dated 8/25/25, showed the following:-Check resident every two hours and assist with toileting;-Provide peri care with each incontinent episode;-The resident has impaired cognitive function related to dementia;-The resident required standby assistance of one staff member to reposition and turn in bed;-The resident required assistance of one staff member to dress, with personal hygiene, to use the toilet and with transfers;-The care plan did not address care of pressure ulcers or interventions for prevention of pressure ulcers. Review of the resident's Skin Monitoring: Comprehensive Shower Review Sheet, dated 8/27/25, showed the resident refused his/her shower. Review of the resident's daily skilled nursing note dated 8/28/25 at 3:42 P.M. showed staff documented the resident had no skin issues. Review of the resident's Skin Monitoring: Comprehensive Shower Review Sheet, dated 8/30/25, showed staff provided the resident with a bed bath and noted no skin issues. Review of the resident's progress note, dated 8/31/25 at 5:11 A.M., showed the following:-The nurse was called to the resident's room at 4:50 A.M. and the resident was noted on the floor mat, on his/her right side with a hematoma (when an injury causes blood to collect and pool under the skin) and laceration to the back side of the head;-The resident was sent to the hospital for evaluation and treatment. During an interview on 9/2/25 at 11:46 A.M., Certified Nurse Aide (CNA) H said the following:-He/She cared for the resident when he/she was at the facility. The resident had no pressure ulcers;-The resident had some redness on his/her bottom. The resident could turn and reposition in bed;-CNA H did not observe a dressing on the resident's bottom. During an interview on 9/2/25 at 4:05 P.M., CNA E said the following:-He/She did not recall providing care for this resident and was unaware of any residents at the facility that had pressure ulcers or who were at risk of developing pressure ulcers;-He/She checked incontinent residents every couple of hours and changed the residents, if necessary, but he/she did not reposition them. During an interview on 9/3/25 at approximately 9:30 A.M., CNA A said he/she was unaware of any residents with pressure ulcers or specific interventions in place for pressure ulcers. During an interview on 9/2/25 at 3:35 P.M., Licensed Practical Nurse (LPN) C said the following:-He/She completed the resident's admission assessment; -He/She worked with the resident a lot;-The resident's skin was intact, and he/she had no skin issues or dressings in place;-He/She was unaware of any history of pressure ulcers. During an interview on 9/2/25 at 3:50 P.M., Wound Nurse/LPN D said the following:-He/She was responsible to complete a skin assessment on all new admissions;-He/She completed a skin assessment of the resident upon admission but forgot to chart it;-The resident did not have any pressure ulcers or any dressings in place. During an interview on 9/2/25 At 6:07 P M., LPN B said the following:-He/She was worked at the facility on 8/31/25 when the resident fell and hit his/her head;-The resident was incontinent of bowel. He/She assisted the aide with cleaning the resident up before the resident was sent out to the hospital for evaluation;-While cleaning the resident up, he/she saw a soft foam type dressing on the resident's sacral area that was rolled up with no date visible on the dressing. The resident had a deep pressure ulcer probably a stage III or higher to his/her sacral area;-He/She had worked with the resident two days since the resident's admission to the facility and was unaware the resident had a pressure ulcer;-He/She cleaned the area and covered it with another dressing before the resident was sent to the hospital;-He/She looked at the resident's medical record and could not find any documentation of wounds or dressing changes;-He/She was going to speak with the Director of Nursing (DON) about the issue, but he/she had not been back to work since 8/31/25;-He/She did not complete a transfer assessment which included a skin assessment before the resident went out to the hospital. During an interview on 9/10/25 at 1:15 P.M., Hospital Wound Nurse F said the following:-He/She was assigned the resident's wound consultation upon admission to the hospital on 8/31/25;-The resident had a Stage III pressure to the sacral area and the area measured 3 centimeters (cm) x 3 cm x 1 cm with tunneling;-The resident also had DTI to both heels. The left heel DTI measured 1 cm x 3 cm, and the right heel DTI measured 3 cm x 4 cm. During an interview on 9/2/25 at 4:20 P.M. and 9/3/25 at approximately 11:45 A.M., the DON said the following:-The nurse responsible for completing an admission to the facility was to complete a head-to-toe skin assessment of the resident;-The admitting nurse did not complete a head-to-toe assessment on the resident and the assessment that was documented was not accurate;-She would expect the Wound Nurse/LPN D to complete a head-to-toe skin assessment on any new admissions also and document the assessment in the resident's medical record. The wound nurse was more experienced with pressure ulcers and deep tissue wound assessments;-The Wound Nurse/LPN D did not complete a head-to-toe skin assessment on the resident;-Staff were to follow any pressure ulcer interventions that had been put place. If a resident refused a specific intervention staff should continue to offer or have another staff attempt to provide the care;-Residents at risk for pressure ulcers should be encouraged to reposition every two hours for pressure redistribution;-LPN B did not complete the transfer assessment before he/she sent the resident out to the hospital which should have included any documentation of wounds a resident had;-She would expect staff to follow the Wound Prevention policy. During interview on 9/3/25 at 11:30 A.M., the Administrator said the following:-The facility relied on the nursing staff for accuracy of skin assessments;-The assessments completed on Resident #9 were not completed accurately;-He would expect the nursing staff to follow the Wound Prevention policy. Intake 2604410

Based on observation, interview and record review, the facility failed to ensure four residents (Resident #1, #3, #4, and #6), of eight sampled residents, who required assistance with Activities of Daily Living (ADL's) received the necessary care and services to maintain good grooming when staff failed to provide nail care. The facility census was 63.Review of the undated facility policy for Activities of Daily Living showed this facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Review of the undated facility policy for Foot Care showed the following:-This community will ensure that all residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment in accordance with professional standards or practice including prevention of complications from a resident's medical condition and assisting the resident in making appointments with a qualified person and arranging for transportation to and from podiatry appointments;-All foot care and treatment will be provided within professional standards of practice and state of practice as applicable;-Toenail clipping for residents without complicating disease processes will be provided by direct care staff who have received training and in-service and have demonstrated competency in toenail clipping at the time of each bathing experience as needed;-If a resident has any contributing disease process including but not limited to diabetes, peripheral vascular disease, neuropathy, or immobility affecting foot condition, a podiatrist will perform toenail clipping. 1. Review of Resident #1's face sheet showed the resident admitted on [DATE] with diagnosis of Alzheimer's disease. Review of the resident's care plan dated 4/25/23 showed no care plan to address nail care. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 6/26/25 showed the following:-Unable to make decision;-Required staff assistance with ADL's. During interview on 8/7/25 at 2:00 P.M. Family Member A said the following:-He/She had just cut Resident #1's fingernails and cleaned them;-He/She had taken pictures of the resident's fingernails prior to cutting them and showed the surveyor the pictures. The pictures showed the resident's fingernails on both hands were long and jagged, with black debris noted around the nails and thick black debris under the nails.Observation on 8/7/25 at 6:45 P.M. with the assistance of Licensed Practical Nurse (LPN) B showed the following:-The resident's toenail on the right foot, big toe was short and jagged with black debris around the edges of the nail;-The second, third and fourth toenails were long and curved toward the other toes with the nail touching the other toes; there was black debris under the nails;-The toenails on the left foot were long and curved toward the other toes with a black debris under the nails. During an interview on 8/7/25 at 6:45 P.M. LPN B said the following:-The resident was seen by a contracted podiatrist who comes every other month;-Nursing could cut and clean the resident's toenails between visits;-Nursing should clean under the residents fingernails as needed. During an interview on 8/15/25 at 4:00 P.M. FM A said it was obvious by the looks of Resident #1's toenails on 8/7/25 that the resident was not seen by podiatry in July. 2. Review of Resident #3's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses of fracture of left arm and Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement). Review of the resident's care plans dated 6/16/25 showed no care plan to address nail care. Review of the resident's comprehensive MDS dated [DATE] showed the following:-Able to make self understood and understands others;-Alert and oriented and able to make some decisions;-Requires assistance with ADL's. Observation on 8/7/25 at 3:00 P.M. showed the resident's toenails on both feet were long, thick with gray debris under the big toenail. During an interview on 8/7/25 at 3:00 P.M. the resident said he/she would like to have his/her toenails cut, they were too long and hurt in some of his/her shoes. 3. Review of Resident #4's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses of diabetes. Review of the resident's care plan for diabetes dated 3/13/25 showed the following:-The resident has diabetes;-The resident will have no complications related to diabetes;-There were no interventions to address nailcare for the resident with diagnosis of diabetes. Review of the resident's quarterly MDS dated [DATE] showed the following:-Able to make self understood and usually understands others;-Alert and oriented and able to make some decisions;-Required assistance with ADL's. During an interview on 8/7/25 at 2:50 P.M. the resident said:-His/Her toenails were long and he/she would like to see a podiatrist. Observation on 8/7/25 at 2:50 P.M. showed the resident's toenails on both feet were thick and long with gray debris under the nails. 4. Review of Resident #6 face sheet showed:-admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS- a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord). Review of the comprehensive MDS dated [DATE] showed:-Sometimes able to make self understood and usually understands others;-Alert and oriented and able to make decisions;-Dependent upon staff for ADL's. Review of the care plans dated 5/1/25 showed no care plan for nail care or how staff are to care for the resident's toenails. Observation on 8/7/25 at 4:15 P.M. showed the resident's fingernails were long with black debris under the nails. During an interview on 8/7/25 at 4:15 P.M. Family Member B said he/she tried to keep the resident's nails trimmed and clean but felt nursing staff should take care of them when they provide the resident care. During an interview on 8/7/25 at 7:00 P.M. the Administrator and Assistant Director of Nursing (ADON) said the following:-If a resident was diabetic, the nurse could trim the resident's nails on shower days and as needed;-For residents who were not diabetic, staff should clean and trim the resident's nails (hand and toes) on shower days and as needed;-The facility had a contracted podiatrist that saw residents at least every 60 days;-The Social Services Director (SSD) usually sets up the appointments;-The facility had not had an SSD for several weeks. During an interview on 8/15/25 at 2:00 P.M. the Administrator said the following:-The contracted podiatry company provided nail care to most of the residents every 60 days;-A nurse could cut a residents toenails if they were not diabetic, otherwise they would encourage the resident to be seen by podiatry.

Based on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 68. Review of the undated facility policy for Monitoring Food Temperatures for Meal Service showed:-Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures;-Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper servicing temperatures. Any food item not found at the correct holding/serving temperature will not be served unless appropriate action is taken, such as reheating;-If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit (F) or higher (check state specific regulations) when checked prior to meal service, the item will be reheated to at least 165 degree F for a minimum of 15 seconds-If the serving/holding temperature of a cold food item or beverage is not at 41 degree F or below (for less than four hours in duration) when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degree F (or less) before service;-Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degree F or greater to promote palatability for the resident.;-All room trays are sent to the room with a meal card and documentation of the time the meal was delivered when it should be served to assure the tray is delivered to the correct resident and to assure that it is not held longer than needed for palatability and safety.1. During an interview on 8/7/25 at 2:30 P.M. Resident #4 said he/she eats meals in his/her room, the food was not hot when served.2. During an interview on 8/7/25 at 2:40 P.M. Resident #3 said he/she ate in his/her room. The food was not hot when served.3. During an interview on 8/7/25 at 2:50 P.M. Resident #5 said he/she ate meals in his/her room, and the food was not hot when served. 4. During an interview on 8/7/25 at 4:30 P.M. Resident #7 and Resident #8 said the following:-They prefer to eat their meals in the assist dining room;-The food was usually not hot when served.5. Observation on 8/7/25 at 4:45 P.M. showed staff began the evening meal service from the steam table to the main dining room which included roast pork, mashed potatoes, and corn. Observation on 8/7/25 at 5:03 showed staff begin to prepare room trays for the 200 hall. Staff plated meals to include roast pork, mashed potatoes, and corn, then covered the plate with plastic film and placed the completed trays on an open metal cart with no covering. -There was a metal pan with approximately a half inch of water on the bottom of the cart with several cartons of milk, tea, and juice for service;-Dietary staff pushed the cart out into the hallway;-At 5:16 P.M. nursing staff received the cart, took it to the 200 hall and began delivering the meal trays to residents;-Staff delivered the last meal tray at 5:34 P.M.Observation on 8/7/25 at 5:34 P.M. of the test tray, after the last resident was served, showed the following food temperatures:-Roast pork was 110 degrees F and cool to taste;-Mashed potatoes were 89.1 degrees F and cool to taste;-Corn was 118 degrees F and warm to taste;-Milk from a carton was 51.4 degrees F and warm to taste.During an interview on 8/7/25 at 6:15 P.M. [NAME] A said the following:-The meat should be at 199-200 degrees, the potatoes and should be at 178 degrees when served;-He/She usually takes the temperature of the food before he/she puts the food on the steam table;-At the steam table the dietary aides should take the food temperatures, but they did not;-There were two wells on the steam table that were not currently working to keep the food warm, and that could be the difference in the food temperatures;-The dietary aides set up the drinks, the drinks should be kept on ice.During an interview on 8/7/25 at 5:45 P.M. the Dietary Manager said the following:-The facility did not have any insulated plate covers to help keep the food warm;-Dietary was dependent upon when staff were available to begin serving the room trays;-The hot foods should be at 160 degrees when served;-The beverages, especially milk should be kept on ice to keep cool.During an interview on 8/7/25 at 7:00 P.M. the Administrator said he would expect the food to be at the proper temperature when served to the residents.Complaint #2566328

Based on observation and interview, the facility failed to maintain the main parking lot. The facility census was 68. Observation on 8/7/25 at 12:45 P.M. and again at 7:30 P.M. showed the facility front driveway and parking lot with a large area of damaged asphalt. The area was approximately ten feet in diameter and approximately 8-10 inches in depth at the center. This area was at the end of the visitor parking area and would affect any vehicle using the area for travel. During an interview on 8/15/25 at 2:00 P.M. the Administrator said he was aware the area needed repair, there were several projects in the works; he would expect the area to be repaired. Complaint #2566328

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) of 10 sampled residents when the resident fell out of bed while receiving care, sustained injuries and required treatment at a local hospital. The resident required staff assistance for bed mobility and care. The resident's bed had a mattress overlay that reportedly shifted on the bed. Staff rolled the resident to his/her side, turned away from the resident to get supplies, and the resident fell out of the bed to the floor. The resident sustained a laceration to the right side of the forehead, a skin tear to the right outer eyebrow area, a skin tear to the right forearm, and bruising to the right elbow. The resident was sent to a local hospital and required staples to close the laceration to the forehead. The facility census was 62. Upon request, the facility said they did not have a policy for monitoring of residents utilizing air mattresses or mattress overlays. 1. Review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with diagnoses of respiratory failure, dementia and stroke. Review of the Physical Therapy (PT) evaluation dated 11/8/23 showed the following: -Reason for referral - the resident currently uses a mechanical lift for transfers. The facility has requested a PT evaluation to determine an emergency transfer status in the event of an emergency where the mechanical lift is unavailable; -Functional Mobility Assessment: bed mobility: substantial/maximal assistance with rolling left and right, sit to lying position, lying to sitting on side of bed; -Transfers: sit to stand - dependent upon staff, chair/bed-to-chair transfer, toilet transfer - dependent upon staff; -Ambulation not applicable; -Resident uses a manual wheelchair; -Resident does not sit unsupported for 30 seconds, not able to sit on the side of the bed unsupported, or stand without upper extremity support; -Clinical assessment: resident needs assistance of two staff to pivot transfer; -The PT evaluation does not address or indicate the number of staff members needed for bed mobility. Review of the resident's Care Plan for Activities of Daily Living (ADL's), revised 7/22/24 showed the following: -The resident required one staff to reposition and turn in bed; -The resident was totally dependent upon staff for dressing; -The resident required one staff for personal hygiene care. Review of the Fall Risk Data Collection (an assessment completed by staff to determine if the resident is at risk for falls) dated 1/23/25 showed the resident was at low risk for falls. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 3/28/25 showed the following: -Usually able to understand others and able to make self understood; -Impairment of one side of the lower extremities; -Dependent upon staff for lower body dressing, bathing and personal hygiene; -Substantial assistance (helper does more than half of the assistance) with rolling left and right; -Incontinent of bowel and bladder; -Received hospice services. Review of the resident's undated visual/bedside [NAME] report showed the following: -Personal hygiene/oral care: the resident required one staff participation with personal hygiene; -Mobility: the resident required one staff for repositioning and turning in bed. Review of the resident's nurses notes dated 4/23/25 at 10:00 P.M. signed by Licensed Practical Nurse (LPN) D showed the following: -This writer called to resident's room by Certified Nurse Aide (CNA) E. Upon entering room CNA said the resident accidentally hit the floor during peri care. Resident observed on the floor in the area between the resident's bed and roommate's bed. Resident observed on his/her back with head pointed toward head of bed and bilateral feet pointed towards foot of bed. Resident observed with bilateral arms down to sides, while attempting to keep head off of floor. Resident was bleeding coming from right side of forehead, right outer eyebrow and right top of forearm. Resident head propped and pressure applied to laceration to right side of forehead to stop bleeding. Laceration to right side of forehead red and light purple in color with swelling observed measuring 3.5 x 0.3 x 0.3 centimeters (cm). Area cleansed with normal saline (NS) and dry dressing lightly applied. 2) Skin tear to right outer eyebrow red in color measuring 0.5 x 0.1 x 0.1 cm, area cleansed with NS and dry dressing lightly applied. 3) Skin tear to top of right forearm red and pink in color with minimal bleeding area measures 2.5 x 2.0 x 0.1 cm, area cleansed with NS and dry dressing lightly applied. 4) Right outer elbow observed with bruising dark red in color measuring approximately. 3.0 x 2.0 cm. Call placed to primary provider who gave the order to send to emergency room (ER) for possible sutures if okay with hospice. Call placed to responsible party to make aware of fall, injuries and possible need for sutures, stated he/she was okay with all interventions he/she just wanted to be updated, made aware this writer would update. At 11:20 P.M. call placed to 911 to make aware of need to transport resident without lights and sirens. At approximately 9:30 P.M. emergency personnel in to transport resident to local hospital ER. Review of the nurses notes dated 4/24/2025 at 5:40 A.M. showed the resident returned to facility from local hospital. Resident observed with five staples to the right side of forehead and dark purple bruising to the right eye. During an interview on 5/1/25 at 7:15 P.M. Certified Nurse Aide (CNA) E said the following: -The resident was a one person assist with bed mobility; -The resident was easy to take care of and he/she would not move in the bed; -The resident was also on hospice and had an air mattress on the bed. The air mattress was on top of the regular mattress and would shift at times; he/she had not reported the issue with the air mattress to anyone; -He/She had to put the air mattress back in the center of the bed two times on the shift; -Towards the end of the shift, he/she went to check on the resident and the resident needed to be changed, he/she rolled the resident on to his/her right side; -He/She thought the resident was positioned in the center of the bed, but the air mattress seemed like it was too big and was shifting on the bed, so the resident could have been more toward the right edge of the bed; -He/She needed more wipes, so he/she turned away from the resident to get some more wipes off the bedside table. The bedside table was behind him/her and when he/she turned back towards the resident, the resident was sliding off the bed and landed on the floor; -He/She yelled for the nurse; -The resident was hurt with blood coming from his/her head, but he/she was still talking with him/her and the nurse; -After the nurse assessed the resident, they got the resident off the floor and put him/her back in the bed; -The nurse called 911 and the resident went to the hospital; -He/She should have had all of the supplies he/she needed at the bedside and should not have turned away from the resident; -He/She should have gotten more help to turn and change the resident, but did not elaborate why she should have had more help. During an interview on 5/1/25 at 7:15 P.M. Licensed Practical Nurse (LPN) D said the following: -He/She heard Nurse, help! and when he/she went into the resident's room, the resident was on the floor beside the bed on his/her right side. There was a laceration above the resident's right eye on the forehead and bruising to the elbow with a skin tear; -CNA E stood over the resident, visibly shaken saying, I tried to turn him/her by myself and he/she hit the floor. CNA E said something about the mattress not staying on the bed, but the mattress was on the bed; -He/She assessed the resident, and then with assistance from several staff, got the resident back in the bed, treated the resident's injuries then began calling the physician and the hospice provider to get the resident sent to the hospital for evaluation; -The resident was normally cooperative with care and did not move much; -He/She was surprised to see the resident on the floor as the resident could not move without help; -The resident returned from the hospital with staples to the laceration on the right side of the forehead. There was bruising on the resident's face from the fall. During an interview on 5/2/25 at 7:55 A.M. LPN A/Assistant Director of Nurses (ADON) said the following: -He/She had began the investigation into the resident rolling out of the bed; -CNA E said he/she did not have all of the supplies needed to provide care, and when he/she turned to get the supplies then back toward the resident, the resident was falling out of the bed; -The resident could use his/her arms and bend his/her knees, but did not move his/her body. The resident could not help staff when they turned and repositioned him/her. During an interview on 5/2/25 at 7:55 A.M. the Director of Nursing said the following: -She would expect staff to have the supplies they need at the bedside before providing care; -She would expect staff to ask for help to provide care if needed. During an interview on 5/1/25 at 3:00 P.M. the Administrator said the following: -The resident's fall was investigated and it was determined that CNA E had turned the resident onto his/her side, then turned away from the resident. When CNA E turned back to the resident, the resident was sliding off the bed and onto the floor; -The resident was a one person assist with bed mobility; -Therapy assessed the resident for bed mobility and will make recommendations on how many people are needed for cares; the resident was last evaluated in 2023. During an interview on 5/14/25 at 2:45 p.m. the Medical Director said the following: -She would have expected staff to have the mattress overlay secured to the bed, to prevent it from sliding; -Staff should monitor and ensure that any mattress was stable and secured; -She would expect therapy to assess the resident for bed mobility and the number of staff members needed to provide care in the bed and if a resident has a change of condition, or a decline in condition, the evaluation should be redone; -She would expect staff to ask for additional help with residents as needed for cares. MO253244

Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition services. This practice effected all residents in a facility. The facility census was 62. The facility did not have a policy regarding training or competency requirements for the Dietary Manager. 1. Review of the Food Establishment Inspection Report from the local county health department dated 2/12/25 showed: -Foodborne Illness Risk Factors and Public Health Interventions: Supervision: Certified Food Protection Manager out of compliance; -2-102 in accordance with Section 2-102-11, the person in charge must successfully complete a program that is approved by the Department for food protection manager certification and have posted in the food establishment a current certificated of training issued by the program; During an interview on 5/1/25 at 10:30 A.M. the DM said the following: -He had been the dietary manager for a couple of years; -He was enrolled in an online dietary manager course with a college and had not completed the course; -He began the course about mid last year, he could not remember the month that he started the course; -He reviewed a module or two with the Registered Dietician when he/she came to the facility each week; -He did not know how long it would be before he completed the course; -He had not taken any other classes for being a dietary manager. During an interview on 5/1/25 at 11:00 A.M. the Administrator said the following: -The facility's DM hire date was 8/30/23. The DM started as a cook/supervisor and was promoted to DM on 9/11/23; -The DM was enrolled in a dietary manager's course; -He did not know how much of the course the DM had completed or know how long it would take the DM to complete the course; -He was not aware the DM has been enrolled in the course since mid last year; -He would have expected the DM to have completed the course by now. MO253574

Based on observation, interview and record review, the facility failed to properly label food for expiration date, failed to discard food that has passed the expiration date as identified on the food label, failed to maintain one refrigerator to be free of rust and ice build up and failed to ensure a thermometer was present in the refrigerator. The facility failed to label and date when a food item was opened and refrigerated. The facility census was 62. Review of the undated facility policy for Food storage (Dry, Refrigerated, and Frozen) showed the following: -Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discharged ; -Discard food that has passed the expiration date; -Keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit (F ) to 135 degrees F , or per state specific regulations; -Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees F or lower. Place hanging thermometer in the warmest part of the refrigerator; -Conduct random temperature checks of food items. Review of the undated facility policy for Labeling and Dating Foods (Date Marking) showed the following: -All stored foods will be properly labeled according to the following guidelines: -Date marking for refrigerated storage food items: unopened cases of refrigerated times will be dated with the date the item was received into the facility; -Prepared food or opened food items should be discarded when: the food item is left over for more than 72 hours; the food item is older than the expiration date. 1. Observation on 5/1/25 at 10:20 A.M. of the refrigerator in the main dining room showed the following: -A a half empty large stainless steel pan of Jello with fruit covered with plastic wrap with a date of 4/25/25 written in black marker with no use by date; -A stainless steel pan containing eight individually wrapped ham sandwiches with a date of 4/26/25 and a discard date of 4/29/25 written on the label; -A plastic container from a local grocery store that was half full of potato salad with no date when the container was opened or when to discard the container; -A plastic container from half full of [NAME] slaw with no date when the container was opened or when to discard the container; -An opened container of prepackage thickened lemon water dated 4/3/25 with no discard date; -A three quarter full gallon of milk that was not dated when opened and the container had a use by date of 4/27/25 on the container; -A plastic container of an assortment of cut up melon, grapes and pineapple with a label dated 4/23/25 with no discard date. The melon was dried with white around the edges and the pineapple was dried with black edges; -No hanging thermometer in the refrigerator; -Small reddish/brown, rusty looking spots on the inside of the walls of the refrigerator with a buildup of ice at the back of the refrigerator. Observation of the refrigerator/freezer of the refrigerator in the kitchen prep/storage area on 5/1/25 at 10:45 A.M. showed the following: -In the freezer five individually wrapped pieces of cake on a plate covered with plastic wrap that was not dated; -The back of the freezer was had a build up of food; -No hanging thermometer in the freezer. During an interview on 5/1/25 at 11:00 A.M. Dietary Aide B said the following: -The containers of potato salad and [NAME] slaw did not come from the kitchen; -Only food from the dietary department should be in the refrigerator in the dining room; -He/She did not know when the last time the refrigerator was cleaned or who was responsible for the cleaning; -Food should be labeled with the date prepared and use by date three days after preparation. During an interview on 5/1/25 at 11:30 A.M. the Dietary Manager said the following: -The dietary department was responsible for the refrigerator in the main dining room and the prep/storage area and should be cleaning when dirty or food has been spilled; -Food that was made by the kitchen should be used within three days or discarded and should be dated when made. During an interview on 5/1/25 at 11:40 A.M. the Administrator said the following: -Food should be dated and discarded per the policy; -The refrigerators should be clean and equipped with a thermometer. MO253574

Based on observation, interview and record review, the facility failed to ensure facility staff provided four residents (Resident #2, #6, #10 and #11), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor, in a review of 11 sampled residents. The facility census was 61. Review of the facility's undated policy, Activities of Daily Living, showed the following: -The facility provides each resident with care, treatment and services according to the resident's individualized care plan; -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including bathing and grooming. Upon request, the facility responded they did not have a policy for showers, shaving, nail care or haircuts. 1. Review of the Resident #2's undated face sheet showed that he/she was his/her own responsible party. Review of the resident's care plan, revised 02/07/25, showed the following: -He/She required staff assist of one with bathing; -He/She required staff assist of one with personal hygiene. Review of the shower schedule, updated 03/10/25, showed the resident's scheduled shower days were Tuesdays and Fridays each week. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, required to be completed by facility staff, dated 03/16/25, showed the following: -Cognitively intact; -No rejection of cares; -The resident was dependent on staff for showering/bathing; -The resident required substantial/maximal assistance from staff for personal hygiene; -The resident was frequently incontinent of urine; -The resident was always incontinent of bowel. Review of the resident's April 2025 shower sheets showed the following: -Staff documented giving the resident a shower as scheduled on 04/01/25; -No documentation the resident refused, was offered, or received a shower as scheduled on 04/04/25; -The resident only received one of two scheduled showers for the first week of April; -On 04/08/25, staff documented the resident refused his/her scheduled shower. There was no documentation to show staff followed up or offered to shower the resident at a later time; there was no resident signature on the form; -No documentation the resident refused, was offered or received a shower as scheduled on 04/11/25; -The resident did not receive either of his/her scheduled showers for the second week of April; -On 04/15/25, staff documented the resident refused his/her scheduled shower. There was no documentation to show staff followed up, or offered to shower the resident at a later time; there was no resident signature on the form; -On 04/18/25, staff documented giving the resident a shower as scheduled and noted the resident had reddened areas on his/her buttocks and legs (17 days since staff gave the last documented shower on 04/01/25); -The resident only received one of two scheduled showers for the third week of April; -On 04/22/25, staff documented giving the resident a shower as scheduled; -On 04/25/25, staff documented the resident refused his/her scheduled shower. There was no documentation to show staff followed up or offered to shower the resident at a later time; there was no resident signature on the form; -The resident only received one of two scheduled showers for the fourth week of April; -On 04/29/25, staff documented staff gave the resident his/her scheduled shower and the resident had skin rashes, dryness, blisters and hardened skin. Review of the resident's census showed he/she discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident's May 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 05/13/25; -On 05/14/25, staff documented the resident's shower was due. There was no documentation to show the resident refused, staff followed up or offered to shower the resident at this time or at a later time. There was no resident signature on the form; -On 05/16/25, staff documented the resident refused his/her scheduled shower. There was no documentation to show staff followed up or offered to shower the resident at a later time. There was no resident signature on the form; CNA A signed the form; -The resident did not receive either of his/her scheduled showers for the third week of May; -On 05/20/25, staff documented the resident refused his/her scheduled shower. There was no documentation to show staff followed up or offered to shower the resident at a later time. There was no resident signature on the form; -On 05/23/25, staff documented giving the resident his/her shower as scheduled (24 days since last documented shower on 04/29/25); -The resident received one of two scheduled showers for the fourth week of May; -On 05/27/25, staff documented giving the resident his/her shower as scheduled (four days since last documented shower); -There was no documentation the resident refused, was offered or received a shower as scheduled on 05/30/25; -The resident received one of two scheduled showers for the fifth week of May. Review of the resident's June 2025 shower sheets (06/01/25 through 06/10/25) showed the following: -One 06/03/25, staff documented giving the resident his/her shower as scheduled; -There was no documentation the resident refused, was offered or received a shower as scheduled on 06/06/25; -The resident received one of two scheduled showers for the first week of June. Observation of the resident on 06/09/25 at 2:30 P.M., showed the following: -His/Her hair was long, stringy, greasy and matted in the back; -He/She had facial hair; -His/Her room smelled of body odor. During an interview on 06/09/25 at 2:30 P.M., the resident said the following: -He/She had recently been in the hospital for ten days and had not been shaved or showered since he/she has been back; -Prior to going to the hospital, he/she had only had one shower in the past two months; -He wanted to be bathed at least twice a week; -He/She preferred a shorter hair cut; -He/She would like to be shaved; -He/She told staff that he/she would like his/her hair cut and said they could not cut hair due to regulations; -He/She did not refuse showers. During an interview on 06/10/25 at 11:48 A.M., Certified Nurse Assistant (CNA) A said the following: -Sometimes showers did not get done; -The aides split up the shower assignments for the day and are responsible for showering/bathing their assigned residents; -He/She tried to get them done the next day if they were not completed on the resident's scheduled day; -Resident #2 refused showers a lot and then will ring the call light at the end of his/her shift and ask for his/her shower; he/she has had to tell the resident he/she could not do the shower; -He/She will have the resident sign the shower sheet if they refuse their shower. 2. Review of Resident #6's undated face sheet showed his/her family member was his/her responsible party. Review of the resident's care plan, revised 07/08/24, showed the following: -He/She had diabetes mellitus; -Staff to encourage him/her to practice good hygiene; -Refer to a podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails; -Wash feet daily with mild soap and water, dry thoroughly. May use a light dusting of powder or lotion. Do not apply lotion or powder between the toes; -He/She prefers a bed bath on Tuesdays only; -Staff to check nail length and trim and clean on bath day and as necessary, report any changes to the nurse; -The resident was totally dependent on staff to provide a bath twice a week and as necessary; -Staff to provide the resident with a sponge bath when a full bath or shower cannot be tolerated; -He/She required assistance bathing/showering; -He/She required two staff assistance with bathing; -He/She was able to request staff to assist with his/her baths; -Staff will bathe his/her lower body, back, and perform incontinent care as needed. Review of the shower schedule, updated 03/10/25, showed the resident's scheduled shower days were Wednesdays and Saturdays each week, and the resident preferred a bed bath on Tuesdays only. Review of the resident's April 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received a bed bath per his/her preference on 04/01/25; -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 04/02/25; -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 04/05/25; -The resident did not receive any of his/her scheduled showers or preferred bed bath for the first week of April; -No documentation the resident refused, staff offered or the resident received a bed bath on 04/08/25; -On 04/09/25, staff documented giving the resident his/her shower as scheduled; -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 04/12/25; -The resident received one of three scheduled/preferred showers or bed baths for the second week of April; -No documentation the resident refused, staff offered or the resident received a bed bath on 04/15/25; -On 04/16/25, staff documented giving the resident his/her shower as scheduled (seven days since last documented shower); -On 04/19/25, staff documented giving the resident his/her shower as scheduled; -The resident received two of three scheduled showers or bed baths for the third week of April; -No documentation the resident refused, staff offered or received a bed bath on 04/22/25; -On 04/23/25, staff documented giving the resident his/her shower as scheduled; -On 04/26/25, staff documented giving the resident his/her shower as scheduled; -The resident received two of three scheduled showers or bed baths for the fourth week of April; -No documentation the resident refused, staff offered or the resident received a bed bath on 04/29/25; -On 04/30/25, staff documented giving the resident his/her shower as scheduled; -The resident received one of three scheduled showers or bed baths for the fifth week of April; -There was no documentation that the resident's feet had been washed daily with mild soap and water and that powder or lotion had been applied as the care plan instructed. Review of the resident's May 2025 shower sheets showed the following: -No documentation that the resident refused or was offered or received a shower as scheduled on 05/03/25; -The resident only received one of three scheduled/preferred showers or bed baths for the first week of May; -No documentation that the resident refused or was offered or received a bed bath per his/her preference on 05/06/25; -On 05/07/25, staff documented giving the resident his/her shower as scheduled; -On 05/10/25, staff documented giving the resident his/her shower as scheduled; -The resident only received two of three scheduled/preferred showers or bed baths for the second week of May; -No documentation that the resident refused or was offered or received a bed bath per his/her preference on 05/13/25; -On 05/14/25, staff documented giving the resident his/her shower as scheduled; -On 05/17/25, staff documented giving the resident his/her shower as scheduled; -The resident only received two of three scheduled/preferred showers or bed baths for the third week of May; -No documentation that the resident refused or was offered or received a bed bath per his/her preference on 05/20/25; -On 05/21/25, staff documented giving the resident his/her shower as scheduled and documented the resident needed his/her nails cut; the charge nurse signed the form; no documentation to support a follow up or that the resident's nails had been cut; -No documentation that the resident refused or was offered or received a shower as scheduled on 05/24/25; -The resident only received one of three scheduled/preferred showers or bed baths for the fourth week of May; -No documentation that the resident refused or was offered or received a bed bath per his/her preference on 05/27/25; -On 05/28/25, staff documented giving the resident his/her shower as scheduled; -No documentation that the resident refused or was offered or received a shower as scheduled on 05/31/25; -The resident only received one of three scheduled/preferred showers for the fifth week of May; -No documentation the resident's feet had been washed daily with mild soap and water and that staff had applied powder or lotion as the care plan directed. Review of the resident's June 2025 shower sheets (06/01/25 through 06/10/25) showed the following: -No documentation the resident refused, staff offered or the resident received a bed bath on 06/03/25; -On 06/04/25, staff documented giving the resident his/her shower as scheduled; -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 06/07/25; -The resident received one of three scheduled showers or bed baths for the first week of June; -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 06/10/25; -No documentation the resident's feet had been washed daily with mild soap and water and that staff had applied powder or lotion as the care plan directed. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of cares; -The resident was dependent on staff for showering/bathing; -The resident required substantial/maximal assistance from staff for personal hygiene; -The resident was always incontinent of bowel. Observation of the resident on 06/10/25 at 8:55 A.M. showed the following: -The resident lay in bed; -He/She had dry, scaly, flaky skin all over his/her face and neck; -His/Her hair was long, greasy and disheveled; -He/She had a full facial hair; -His/Her nails were long (some approximately 0.5 inches), uneven, and dirty. During an interview on 06/10/25 at 8:55 A.M., the resident said the following: -It has been a while since he/she has been shaved or had a hair cut and he/she would like to be trimmed up because he/she was looking kind of wild; -Staff say they will do it, but they never get to it (cutting his/her hair, shaving, trimming nails); -The podiatrist comes to do his/her toe nails but he/she would like staff to trim or file his/her fingernails because they are way too long. 3. Review of Resident #10's undated face sheet showed his/her family member was his/her responsible party. Review of the shower schedule, updated 03/10/25, showed the resident's scheduled shower days were Mondays and Thursdays each week. Review of the resident's April 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 04/03/25; -The resident did not receive assistance with bathing as scheduled for the first week of April; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on on 04/07/25; -The resident did not receive assistance with bathing as scheduled, for the second week of April. Review of the resident's care plan, revised 04/10/25, showed the following: -The resident preferred to bathe in his/her room with a wash basin and sink at least two times per week at any time of the day and can complete this task independently; -He/She required one staff assistance to bathe; -Staff to check nail length and trim and clean on bath day and as necessary and report any changes to the nurse; -The resident has diabetes mellitus; -His/Her nails should always be cut straight across, never cut corners, file rough edges with emery board. Review of the resident's April 2025 shower sheets showed the following: -On 04/14/25, staff documented that the resident refused assistance with bathing on this scheduled day. There was no documentation to show staff followed up or offered to assistance the resident with bathing as the resident preferred at a later time. There was no resident signature on the form; -No documentation the resident refused, staff offered or the resident received assistance with bathing, as scheduled on 04/17/25; -The resident did not receive assistance with bathing the third week in April; -On 04/21/25, staff documented the resident received assistance with bathing as scheduled (this was the first documented assistance with bathing for April - 20 days in April with no documented assistance with bathing); -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 04/24/25; -The resident received assistance for one of two scheduled bathing days for the fourth week in April; -On 04/28/25, staff documented the resident received assistance with bathing as scheduled (seven days since last documented assistance with bathing); -The resident received assistance for one of two scheduled bathing days for the fifth week in April. Review of the resident's significant change MDS, dated [DATE], showed the following: -No rejection of cares; -The resident was dependent on staff for showering/bathing; -The resident required substantial/maximal assistance from staff for personal hygiene; -The resident was frequently incontinent of bowel. Review of the resident's medical record showed the resident began hospice services on 05/01/25. His/Her medical record and care plan did not include, and was not updated, to show if bathing services were to be provided by hospice. Review of the resident's May 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/01/25; -On 05/03/25, staff documented the resident received assistance with bathing as scheduled (five days since last documented assistance with bathing) and the resident needed his/her nails cut; the charge nurse signature was on the form; there was no documentation to support a follow up or that staff cut the resident's nails; -The resident received assistance with bathing for one of two bathing days for the first week in May; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/05/25; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/08/25; -The resident did not receive assistance with bathing for either of his/her scheduled days for the second week of May; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/12/25; -On 05/15/25, staff documented that the resident received assistance with bathing as scheduled (12 days since last documented assistance with bathing); -The resident received assistance with bathing for one of two bathing days for the third week in May; -On 05/16/25, documentation showed the resident received assistance with bathing from the Hospice Aide; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/19/25; -On 05/22/25 documentation showed the resident received assistance with bathing from the Hospice Aide (seven days since last documented assistance with bathing); -The resident received assistance with bathing for one of the two bathing days for the fourth week in May; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/26/25; -On 05/29/25, staff documented that the resident refused assistance with bathing. There was no documentation to show if staff followed up with or offered assistance with bathing; -The resident did not receive assistance with bathing for either of his/her scheduled bathing days for the fifth week in May. Review of the resident's June 2025 shower sheets (06/01/25 through 06/10/25) showed the following: -On 06/02/25, staff documented that the resident received assistance with bathing as scheduled (11 days since last documented assistance with bathing); -On 06/09/25, staff documented that the resident received assistance with bathing as scheduled and that he/she needed his/her nails cut. There was no documentation to support a follow up or that the resident's nails had been cut. Observation of the resident on 06/10/25 at 10:10 A.M. showed the following: -The resident lay in bed, -His/Her hair was disheveled; -He/She had facial hair; -His/Her fingernails were long (some approximately 0.5 inches) and visibly dirty with black debris under the nails. During an interview on 06/10/25 at 10:10 A.M., the resident said the following: -He/She does not get his/her showers; -He/She would like to be clean shaven and would like to get a shower. During an interview on 06/18/25 at 3:58 P.M., the resident's responsible party/guardian said the following: -The resident complained to him/her about lack of ADL care many times; -The resident's family member had occasionally come to shave the resident or cut his/her hair; -He/She had brought concerns to aides, nurses, the Assistant Director of Nursing (ADON), Director of Nursing (DON), and even the Administrator regarding lack of showers, not shaving the resident, nail care not being completed, the resident having odors, etc.; -The staff would tell him/her that the resident had refused his/her shower and the resident would tell him/her that he/she did not refuse; -Sometimes the resident would ask for a shower on a Wednesday and staff would tell him/her it's not your shower day, so you'll have to wait until tomorrow; -The resident needs assistance with ADL's and hasn't been independent with washing himself/herself up for over a year and a half. During an interview on 06/10/25 at 11:48 A.M., CNA A said Resident #10 has been good about receiving his/her showers and not refusing. 4. Review of Resident #11's undated face sheet showed the resident's family member was his/her responsible party. Review of the resident's care plan, revised 09/17/24, showed the following: -He/She was totally dependent on staff for bathing; -He/She required staff assistance of one for bathing. Review of the shower schedule, updated 03/10/25, showed the resident's scheduled shower days were Tuesdays and Fridays each week. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of cares; -The resident was dependent on staff for showering/bathing; -The resident required partial/moderate assistance from staff for personal hygiene; -The resident was always incontinent of urine; -The resident was always incontinent of bowel. *** Review of the resident's April 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received a shower as scheduled on 04/01/25; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled as scheduled on 04/04/25; -The resident did not receive either of his/her scheduled showers for the first week of April; -On 04/08/25, staff documented that the resident received his/her shower as scheduled (this was the first documented shower for the first eight days of April); -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 04/15/25; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 04/18/25; -The resident did not receive either of his/her scheduled showers for the third week of April; -On 04/22/25, staff documented that the resident received his/her shower as scheduled (11 days since last documented shower). Review of the resident's May 2025 shower sheets showed the following: -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/20/25; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/23/25; -The resident did not received either of his/her scheduled showers for the fourth week in May; -On 05/27/25, staff documented the resident received his/her shower as scheduled (11 days since last documented shower); -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 05/30/25; -The resident only received one of two of his/her scheduled showers for the fifth week in May. Review of the resident's June 2025 shower sheets (06/01/25 through 06/10/25) showed the following: -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 06/03/25; -On 06/06/25, staff documented that the resident received his/her shower as scheduled (10 days since last documented shower); -The resident received one of two scheduled showers for the first week of June; -No documentation the resident refused, staff offered or the resident received assistance with bathing as scheduled on 06/10/25. Observation of the resident on 06/10/25 at 10:20 A.M. showed the following: -The resident lay in bed; -His/Her hair was long, greasy and disheveled; -He/She had facial hair. During an interview on 06/10/25 at 10:20 A.M., the resident said the following: -Staff finally gave him/her a shower last week, but it had been three to four weeks prior to that since he/she had received a shower; -Staff shaved him/her last week, but he/she already need ed to be shaved again because his/her hair grows really fast; -He/She preferred to be shaved on shower days; -He/She also needed a hair cut. During an interview on 06/10/25 at 1:00 P.M., CNA B said there were usually around 12 showers on the schedule each day and they were assigned and split up among the four aides. During an interview on 06/10/25 at 3:15 P.M., CNA C said the following: -CNA's don't do nail care or shave residents during showers; -Nurses are responsible for nail care and shaving for all residents. During an interview on 06/17/25 at 11:52 A.M., Licensed Practical Nurse (LPN D) said the following: -He/She worked as the charge nurse; -CNAs are responsible for cleaning/clipping/filing fingernails for the residents unless the resident was diabetic; -For diabetic residents, he/she or the Charge Nurse would be responsible for providing nail care; -He/She was not aware of any residents that were diabetic that needed their nails clipped/filed/trimmed; -CNAs are responsible for washing/grooming/shaving/combing/brushing the hair of the resident, but they are not responsible for cutting the resident's hair; -Usually family members will cut the resident's hair; -He/She would expect CNAs to clean/clip/file the resident's nails and shave the resident on scheduled shower days and as needed (PRN); -There was usually a specific shower aide assigned to do showers and there have been no issues with getting showers completed. During an interview on 06/10/25 at 8:20 P.M., the Assistant Director of Nursing (ADON) said the following: -CNAs are responsible for completing showers, nail care, shaving and grooming residents; -For diabetic residents, the charge nurse would be responsible for completing nail care; -She would expect all residents to receive their two scheduled showers each week and as needed or requested to resident preference. During an interview on 06/10/25 at 8:20 P.M., the Director of Nursing (DON) said the following: -CNAs are responsible for showers, nail care, shaving, and grooming; -The charge nurse was responsible for completing nail care for diabetic residents, -She would expect all residents to receive their two scheduled showers each week and as needed or requested to resident preference. During an interview on 06/10/25 at 8:20 P.M., the Administrator said the following: -He would expect all residents to receive their two scheduled showers each week and as needed or requested to resident preference; -He would expect staff to follow the facility policy regarding activities of daily living. MO254858

Based on observation, interview and record review, the facility failed to maintain the water supply to the dishwasher in good working condition. The water pipe to the dishwasher leaked, causing water to pool under the dishwasher and run onto the floor in the dishwashing area. The facility census was 62. 1. Review of an inspection report dated 2/12/25 from the local county public health department showed: -Leaking plumbing or plumbing in disrepair; -Out of compliance with plumbing. Observation on 5/1/25 between 9:50 A.M. to 2:30 P.M. and again on 5/2/25 between 6:30 A.M. to 12:30 P.M. showed the following: -Water dripped out of pipes located under the dishwashing machine in the kitchen; -Pooled water under the dishwasher and the shelving attached to the dishwasher that flowed out from under the dishwasher and onto the floor. During an interview on 5/2/25 at 11:15 A.M. [NAME] C said the following: -The dishwasher had been leaking for over a year; -The kitchen staff mop up the water several times a day. During an interview on 5/1/25 at 10:20 A.M. the Dietary Manager said the following: -The local health department was at the facility several months again and cited them for a leaking pipe under the sink; this was repaired; -The leak under the dishwasher was new and a plumber has been scheduled to come out to repair the leak; -The facility was on the list for the plumber; -Kitchen staff mop the water up several times a day. During an interview on 5/2/25 at 1:00 P.M. the Administrator said: -He was not aware that the dishwasher has been leaking until recently; -He had contacted a plumber to come and repair the leak. During an interview on 5/5/25 at 1:00 P.M. a representative from the local county health department said the following: -An initial inspection was done on 2/12/25 of the kitchen; -There were some plumbing issues identified; -A revisit was done on 2/26/25, 3/12/25 and 3/26/25 with the leak in the dishwashing area identified and not corrected; -He was told that the area would be fixed. MO253574

Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when staff failed to ensure ordered medications were available for administration for two residents (Resident #1 and Resident #2), in a review of four sampled residents. The facility census was 61. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of infection of a joint prosthesis and low back pain. Review of the resident's physician orders dated 2/18/25 showed an order for Tramadol (medication used to relieve moderate to moderately severe pain, including pain after surgery) 50 milligrams (mg) every six hours as needed (PRN) for pain. Review of the resident's nurses note dated 2/19/25 at 6:03 P.M., showed staff notified the physician about the resident complaints of lower back pain, that Tramadol had not been delivered at this time and the physician needed to sign a script for the medication. The physician gave an order for Tylenol 500 mg every four hours PRN for pain; this nurse administered the medication. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/20/25 showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Occasional pain rated a four (0 being no pain and 10 being excruciating pain). Review of Medication Administration Record (MAR) dated 2/25 showed an order for Tramadol 50 mg every six hours for pain with an order date of 2/18/25 with no medication documented as given. Review of the resident's Medication Administration Record (MAR) dated 2/25 showed Tylenol ES (extra strength) 500 mg every four hours PRN for pain with an order date of 2/19/25 and administered as at 6:28 P.M. for a pain level of six with no documentation if the medication was effective. Review of the resident's nurses notes dated 2/23/25 at 1:11 P.M. showed Tramadol 50 mg every six hours PRN, new script required, notified physician. Review of the resident's MAR dated 2/23/25 at 1:11 P.M. showed Tramadol 50 mg. not available. During an interview on 3/3/25 at 2:30 P.M. Family Member (FM) A said the resident had an infection in his/her right hip prosthesis and had to have it removed several years ago, this has caused him/her pain since. When the resident admitted to the facility on [DATE], the hospital gave the facility an order for Tramadol for pain. The resident would call him/her crying in pain and the facility did not have the medication. He/she called the facility numerous times asking about the medication and was told a physician had to write a script. On 2/23/25, an agency nurse told him/her that the physician had been out of town and a different physician had to be called to get a script for the Tramadol. He/She did not know if the medication was delivered or not, he/she took the resident to another facility on 2/25/25. During an interview on 3/4/25 at 1:00 P.M. Licensed Practical Nurse (LPN) A said on 2/20/25 he/she notified the physician on call for the resident's primary physician asking for a script for the resident's Tramadol. He/She received a text message from the physician saying the script had been sent to the pharmacy. He/She called the pharmacy and the pharmacy relayed they did not receive the script. The pharmacy said they attempted to call the physician, but had no return call back. No one from pharmacy contacted the facility regarding the script. He/She was not told that the medication was not delivered to the facility. During an interview on 3/5/25 at 9:10 A.M. Registered Nurse (RN) B said he/she received a phone call from FM A on 2/23/25 very upset that the resident's Tramadol had not been available and that the resident had called him/her in extreme pain. He/She called the resident's physician and found out the physician was out of town, so he/she called the back up physician who then sent a script to the pharmacy for the medication. This was the first time he/she had worked with the resident and the resident had not expressed any pain for necessitating staff give the medication. During an interview on 3/4/25 at 2:00 P.M. the Director of Nursing said the following: -Medications should be available when ordered; -Narcotics require a script to be sent to the pharmacy, these scripts should be available upon admission; -Staff should follow up and ensure that medications are delivered from the pharmacy. 2. Review of Resident #2's face sheet showed admitted to the facility on [DATE] with diagnoses of cellulitis (a common bacterial infection of the skin and underlying tissues) of the right lower leg, diabetes with a foot wound, osteomyelitis (an infection of the bone) of the right foot and ankle. Review of the admission MDS dated [DATE] showed the following: -Able to make self understood and able to understand; -Alert and oriented and able to make decisions; -Received intravenous (IV) medications. Review of the nurses notes dated 2/25/25 at 5:12 P.M. showed the resident arrived per private vehicle. Resident is alert and oriented, able to make needs known. Resident has a single PICC ( peripherally inserted central catheter (PICC) is a thin, flexible tube that's inserted into a vein in the arm, leg, or neck. It's used to deliver fluids, blood, and drugs intravenously, and to draw blood) lumen to right upper arm. Resident will be receiving IV antibiotics every 8 hours for 34 days. Review of the nurses notes dated 2/25/25 at 9:37 P.M. showed the following: -Cefazolin ( used to treat bacterial infections in many different parts of the body) in sodium chloride intravenous solution 2-0.9 GM/100 ml, use 2 gram intravenously every 8 hours for wound for 34 Days; -New Admission. Spoke with pharmacy and medication is set for delivery on 2/26/25. Medication not in cubex (emergency medication box). Review of the MAR dated 2/25 showed the following: -Cefazolin 0.9 grams per 100 liters for 2 grams every 8 hours IV for wound infection for 34 days; -Documented on 2/25/25 at 10:00 P.M. as not available, 2/26/25 at 6:00 A.M. as not available and 2:00 P.M. as not available. During an interview on 3/4/25 at 11:00 A.M. Resident #2 said the following: -He/She has a severe infection in the right foot; -He/She was supposed to get an IV antibiotic three times a day; -He/She did not receive several doses when he/she was first admitted . During an interview on 3/4/25 at 11:15 A.M. Licensed Practical Nurse (LPN) A said the following: -The resident admitted around 3:00 P.M. on 2/25/25; -The hospital did not send the medication orders prior to the resident's arrival; -They were not aware that the resident had IV medications until the resident arrived at the facility with the orders; -Staff contacted the pharmacy and received the medication the next day. The resident missed several doses. During an interview on 3/4/25 at 12:20 P.M. the Admissions Coordinator said the following: -He/She received information regarding new admissions from the hospital; -He/She will send the information to their admission clinical liaison staff who was not at the facility. They reviewed the paperwork and made a decision if the facility was capable of meeting the prospective resident's needs; -Resident #2 was approved by the clinical liaison for admission and he/she sent the admission paperwork to the Director of Nursing via email on 2/25/25 at 11:40 A.M. with the resident's medication orders for the IV medication. Observation on 3/4/25 at 1:45 P.M. P.M. of the facility cubex showed cefazolin 2 gm available for IV administration. During an interview on 3/11/25 at 5:14 P.M. the facility's pharmacy consultants manager said the following: -Resident #1's Tramadol order did not come with a prescription for the narcotic when the resident was admitted ; -The pharmacy will communicate with the physician the need for the prescription; -The pharmacy received the prescription for the Tramadol on 2/24/25 and the medication was delivered to the facility on [DATE] at 9:43 P.M.; -Resident #2's cefazolin medication order was received by the pharmacy after the cut off time in the afternoon, the medication was delivered to the facility on [DATE] early in the evening; -Cefazolin medication was in the facility cubex and could have been pulled from there and administered from the emergency kit supply. During an interview on 3/4/25 at 2:00 P.M. the Director of Nursing said the following: -New admissions are screened by a clinical liaison who is not on site. The facility was not always aware of the resident's medications or needs prior to a resident being admitted to the facility; -If he/she was sent an email regarding the resident's admission, he/she did not read it; -Residents with IV medication orders should not miss doses, the medication should be communicated to the pharmacy as soon as possible and the medication and the equipment needed for the administration should be at the facility upon the resident's arrival; -She would expect the nurses to notify the physician if medications are not available and get orders for what they would want to have administered until the medication arrived; -She would expect the nurses to call the pharmacy to see when the facility could expect IV medication. During an interview on 3/4/25 at 2:10 P.M., the Administrator said he would expect medications to be given as ordered by the physician and if the medication was not available, the physician should be notified. During an interview on 3/17/25 at 12:15 P.M. the Medical Director said the following: -She would expect the facility to notify the physician when a medication was not available; -She would expect the facility to call the pharmacy to see why the medication was not not sent when ordered by the physician; -She would expect the facility to check the cubex to see if the medication was available and administer the medication from the cubex. MO250247 and MO250170

Based on observation, interview, and record review, the facility failed to ensure the safety of one resident (Resident #2), a resident dependent on staff for bed mobility, when staff rolled the resident to his/her side in the bed to provide care, the resident reached out to the side opposite of staff, and fell from the bed to the floor. The resident was to have a fall mat in place on the floor per his/her care plan. No fall mat was in place at the time of the fall. Staff reported the resident often reached out during care, but the resident had not been reassessed for safety with bed mobility. The resident required hospitalization as a result of the fall and sustained injuries including intracranial hemorrhage (bleeding inside the head), epidural hematoma (collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull), subdural hematoma (occurs when a blood vessel in the space between the skull and the brain (the subdural space) is damaged) , concussion, and right rib fracture. Staff also failed to safely transfer Resident #1, a resident who required staff assistance for transfers. The resident had a rotator cuff tear, and after being transferred unsafely by two staff and a gait belt when the resident did not bear weight, told staff that they had caused pain in his/her injured shoulder during the transfer. The facility census was 62. Review of the facility policy for Falls dated 9/17/19 showed the following: -The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents; -Policy: the facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety; -A fall is the unintentional coming to rest on the ground, floor or other lower level. If a resident loses balance and would have otherwise fallen if not for someone intervening is considered a fall. Includes witnessed and unwitnessed falls. Includes with or without injury; -Serious injury includes but not limited to: fracture, laceration requiring sutures, any falls related injury requiring an evaluation to the emergency room or admission to the hospital; -The Fall Risk Data Collection should be completed at Admission/readmission, with the Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), schedule, and post fall incidents. The Fall Risk Data collection can be completed at any other time the facility deems appropriate; -Residents found to be at high risk for falls are placed on the Fall Program, and Interventions are implemented to meet individual needs; -Resident room or bed, or assistive devices are identified with a symbol that indicates risk; -If a resident has a fall, they should be enrolled in the program, regardless of prior assessment status; -Following any falls, the facility staff completes an occurrence report. Details of the fall will be recorded and potential casual factors identified and investigated. Interventions will be implemented and the care plan updated; -Falls patterns and trends should be discussed and recorded in the Quality Assurance minutes to enhance the success of the program. Review of the facility policy for Safe Lifting and Movement of Residents dated 1/2017 showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices; -Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques; -Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged; -Enough slings, in the sizes required by residents in need, will be available at all times; -Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Review of the undated Skills Checklist (a form used to assess the knowledge and ability of the care giver in using a gait/transfer belt) Transfer-Two Person Transfer showed in part: -Position chair/wheelchair/commode to the resident's strong side; -Apply the gait belt; -One Certified Nurse Aide (CNA) stands in front of the resident with one foot parallel to the wheelchair and one foot at right angle to the wheelchair; -The other CNA stands behind with foot between the bed and the wheelchair; -CNA in front of the resident grasps gait belt at the resident's sides; -CNA behind the wheelchair grasps gait belt at the residents back with hand furthest from the bed and grasps gait belt at the resident's side with the other hand; -On a count of 3 both aides help the resident to stand by lifting up on the gait belt while encouraging the resident to push up with arms on the arm rests; -Do not pull on the residents shoulders or let the resident put arms around your neck. 1. Review of Resident #1 face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of pneumonia, alcohol induced dementia (is a type of alcohol-related brain damage), vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain. Cognition and brain function can be significantly affected by the size, location, and number of vascular changes.), muscle weakness, chronic obstructive pulmonary disease (COPD - an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs), and stroke. Review of the resident's care plan for fall risk dated 4/28/22 showed the following: -The resident is at risk for falls related to increased confusion, gait/balance problems and incontinence; -The resident will be free of injury; -Assistive devices will be within reach of the resident, call light within reach and encourage the resident use, educate resident/family/caregivers about calling for assistance prior to cares, and what to do if a fall occurs. Ensure personal items are within reach and a fall mat is beside the bed when the resident is in bed with initiation dates of 4/28/22. Review of the resident's care plan for Activities of Daily Living (ADL's) dated 8/29/23 showed the following: -The resident has an ADL self care performance deficit; -The resident will maintain current level of function; -The resident is able to reposition independently but requires verbal prompting to do so. The resident requires one staff participation to reposition and turn in bed. The resident is not toileted at his/her request, he/she does not feel safe sitting on the toilet. Resident uses incontinent briefs to maintain dignity and requires one staff assist for changing the brief. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be used by facility staff, dated 8/28/24 showed the following: -Alert and oriented and usually able to answer questions appropriately; -Able to understand others and make self understood; -Dependent upon staff for rolling side to side in bed; coming to a sitting position from a lying position and transfers; -No behaviors or rejection of cares; -Incontinent of bowel and bladder; -No history of falls; -No therapy services; -Height of five feet 10 inches, and weight of 140 pounds. Review of the resident's nurses notes dated 9/5/24 at 5:29 A.M., signed by Licensed Practical Nurse (LPN) A showed Certified Nurse Aide (CNA) B alerted this nurse that Resident #1 slid out of bed while he/she was providing care. The resident was on the floor on the left side of the bed with his/her left arm across his/her chest and legs fully extended. Resident was assessed with a small skin tear to the right forearm above the elbow. Called placed to the emergency contact and the physician with new orders for X-ray to thoracic, lumbar and right hip/pelvis. Review of the resident's nurses notes dated 9/5/24 at 12:31 P.M., showed at 10:00 A.M. contracted x-ray tech here to do resident x-ray. X-ray tech said the resident was uncooperative and he/she was unable to complete x-rays and was unable to do resident spinal x-ray due to the resident stiffening up and fighting against him/her. Review of the resident's nurses progress notes dated 9/5/24 at 2:45 P.M. showed family member here and requesting the resident go to emergency department for evaluation and treatment due to complaints of stomach and back pain. Physician here at this time and gave orders to send the resident to ER for evaluation and treatment. The Director of Nursing (DON) here and made aware. 911 called and advised of the resident requesting to be sent to ER for evaluation and treatment related to complaints of stomach and back pain. Review of the resident's progress note signed by the physician and dated 9/5/24 showed the following: Presenting Problem: Had a fall last night and acquired a skin tear, fell out of the bed. Had no complaints of pain until this morning and complained of pain to his/her mid back and low back pain on the right side. Has PRN (as needed) Tramadol ( pain relief medication, specifically indicated for moderate-to-severe pain). Order given for 2-view thoracic, lumbar, and right hip/pelvis X-rays; -The resident is seen today for a follow up problem. X-ray reviewed and was unremarkable for the right hip, thoracic and lumbosacral spine though osteopenia (a decrease in bone mineral density (BMD) below normal reference values) was revealed. Family member insists that the resident be sent to the hospital for severe pain. Perhaps there is something we missed on the X-ray. Gave orders to send the resident to the hospital. Review of the resident's nurses noted dated 9/5/24 at 6:22 P.M., showed at 5:00 P.M. the Director of Nurses (DON) made aware of the resident being admitted to a local hospital. At 5:45 P.M. the physician was called to report status of the resident. The resident was admitted with diagnosis of a brain bleed and collapsed lung. Review of the resident's hospital records dated 9/5/24, showed the resident presented to the emergency department with a fall. Diagnoses included fracture, intracranial hemorrhage (bleeding inside the head), epidural hematoma (collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull), subdural hematoma (occurs when a blood vessel in the space between the skull and the brain (the subdural space) is damaged) , concussion, and right rib fracture. During an interview on 9/18/24 at 10:00 A.M. the DON said the following: -Resident #1 had a fall out of his/her bed on 9/4/24 on the evening shift; -CNA B was changing the resident and the resident reached out for the privacy curtain and rolled out of the bed; -LPN A assessed the resident and found no injuries other than a skin tear to the right forearm; -The physician was notified and orders were received to obtain X-rays of the right hip pelvis region; -On 9/5/24 he/she assessed the resident and found no injuries and the resident's neuro checks were within normal limits. The contracted X-ray staff was at the facility, but was unable to complete the X-ray as the resident was combative; -The resident's family member was in the facility and requested the resident be sent to the hospital; -The resident was admitted to the hospital for a subdural bleed, subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane (subarachnoid space), fractures of multiple ribs on the right side. During an interview on 9/18/24 at 6:55 P.M. LPN A said the following: -CNA B informed him/her that the resident had rolled out of the bed as he/she was providing care; -He/She went to the resident's room and found the resident between the beds. The resident was alert and talking. The resident said the CNA had rolled him/her to give him/her care and he/she was reaching for something and fell out of the bed. The resident did not complain of pain. There was a skin tear of the right upper elbow. The resident's vital signs and neuro checks were within normal limits; -CNA B said the resident became stiff and resistive to care, the aide should have asked for help when the resident began to resist care. During an interview on 9/20/24 at 3:18 P.M. CNA B said the following: -The resident takes one person to change and two people to transfer in and out of the bed; -The resident usually does not get out of bed; -On 9/4/24 he/she was changing the resident by him/herself. He/She rolled the resident to the left side, the resident stiffened his/her body and reached for the privacy curtain; -The resident usually reached for the privacy curtain, he/she assumed this was something for him/her to hold on to; -Everything happened quickly, as the resident reached for the curtain, the resident rolled off the bed; -He/She did not see the resident land on the floor as he/she was on the opposite side of the bed; -There was no floor mat on the floor; -The resident laid on his/her side and there was a skin tear to his/her right elbow. The resident talked to him/her and then he/she left the room and got the nurse; -The resident said that he/she didn't think he/she hit his/her head, and said that his/her back hurt. During an interview on 9/18/24 at 1:30 P.M. the DON said the following: -Nurses can assess a resident for assistance needed for positioning and transfer; -If the resident was being uncooperative with cares, this needed to communicated to the nurses so the resident could have been assessed; -The resident was to have a fall mat placed at the side of the bed and this was not done, she would expect staff to follow the care plan and any safety measures that had been put into place; -She would have expected staff to communicate that the resident was resistive at times so he/she could have been assessed for bed safety. During an interview on 9/18/24 at 1;30 P.M. the Administrator said the following: -Staff was following the care plan and did not communicate that the resident was resistive to care at times; -He would expect staff to follow the care plan and to communicate to the nurses when a resident was resistive or combative so more help could be provided. 2. Review of Resident #2's face sheet showed: -admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (a chronic inflammatory disorder that can affects the joints), peripheral vascular disease (is a slow and progressive disorder of the blood vessels), diabetes, kidney disease, and amputation of above the right knee. Review of the resident's quarterly MDS dated [DATE] showed the following: -The resident was able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Requires substantial assistance of staff for toileting, showering, lower body dressing, putting on and taking off showed; -Partial assistance from staff with upper body dressing; -Partial to moderate assist with chair to bed and bed to chair transfer; -Sit to stand mobility not attempted due to medical condition or safety concern; -Used a manual wheelchair. Review of the resident's care plan for Activity of Daily Living (ADL) dated 7/22/24 showed the following: -The resident has an ADL self care deficit; -Interventions included a restorative program with passive range of motion to both upper extremities; and the resident required two staff participation with transfers. Review of the physician's progress notes dated 9/5/24, showed the resident was seen today for a routine rounds. Complains of shoulder pain. Plan: Arthropathy (arthritis) of shoulder region continue Norco (narcotic pain medication) scheduled and Tramadol (narcotic pain medication) as needed (PRN). Consider orthopaedic consultation. Review of the resident's progress notes dated 9/12/24 at 3:07 P.M., showed physician here at the facility today and wrote new orders. Refer resident to orthopaedic surgeon for possible injection of the shoulder joints, and/or further management. X-ray of bilateral shoulder 4 view related to bilateral shoulder arthropathy. Review of the resident's X-ray report dated 9/12/24 showed the following: -X-ray left shoulder - arthritic changes, sclerosis of the humeral (bone in your upper arm ) head; -X-ray of the right shoulder - diffuse osteopenia, (a condition where bone mineral density (BMD) is lower than normal) superiorly displaced humeral head and visualized proximal humerus. (the top part of the humerus, or upper arm bone, that connects to the shoulder joint) Review of the resident's nurses notes dated 9/13/24 at 12:09 P.M. showed physician aware of the X-ray results, the physician's nurse requested the resident be sent out to hospital based on results from right shoulder X-ray. Resident assessed and complained of pain 4/10 (pain scale is 0 being no pain and 10 being extreme pain). Review of the resident's nurses notes dated 9/13/24 at 12:09 P.M. showed received verbal order to have physical therapy (PT) evaluate the resident for transfer status. Review of the resident's nurses notes dated 9/13/24 at 1:31 P.M., showed report called from local hospital regarding resident status. Nurse said X-Rays were completed at ER and resident had a chronic rotator cuff tear. The resident soul be given PRN Tylenol for pain relief and would return to the facility. Resident returned to the facility. Review of the resident's hospital ER report dated 9/13/24 showed chronic rotator cuff tear with superior subluxation ( an incomplete or partial dislocation of a joint ) of the humeral head (A chronic rotator cuff tear with superior subluxation of the humeral head is a shoulder condition that occurs when a rotator cuff tear causes the humeral head to move out of the center of the shoulder socket and upward). Review of the resident's medical record from 9/13/24 through 9/17/24 showed no evaluation for transfer status by PT. During an interview on 9/17/24 at 10:45 A.M. Resident #2 said the following: -His/Her right shoulder has bothered him/her for some time; -Staff to transfer him/her using a Sit to Stand lift, would not always use the belt that helped lift him/her up in the lift and would not always use two staff during the transfer; -When the staff would not use the belt, this would pull on his/her arms and cause him/her pain; -After the injury to his/her arm, staff used a gait belt and two people to transfer him/her. Observation on 9/17/24 at 10:30 A.M. showed the following: -The resident sat in a wheelchair and informed CNA C and CNA D he/she needed to use the bathroom; -CNA C and CNA D moved the wheelchair into the bathroom and positioned the resident to the side of the toilet; -CNA C placed a gait belt around the resident's waist; -CNA C was on the right side of the resident and placed his/her left arm under the resident's arm pit and the left hand on the gait belt; -CNA D was on the left side of the resident and placed one hand on the gait belt and the other hand at the resident's back; -Both CNAs lifted the resident out of the wheelchair. As CNA C lifted the resident with the staff member's left arm under the resident the resident cried out in pain. They then instructed the resident to pivot his/her left foot, the resident was unable to pivot the foot, the CNA's drug the resident and placed him/her down onto the toilet; -The resident did not bear weight during the transfer, the resident's arms were wrapped around the arms of CNA C and CNA D; -Both staff members had difficulty holding the resident up; -The resident said his/her right shoulder was hurting after being pulled on by CNA C; -CNA D transferred the resident back to the wheelchair by placing the gait belt around the resident's waist and lifting the resident up with both hands on the gait belt and pivoting the resident back in the wheelchair. During an interview on 9/17/24 at 12:45 P.M. CNA C said the following: -Staff should put one hand on the gait belt and the other hand under the resident's arm when transferring with a gait belt; -He/She did not know why staff should not put a hand under a resident's arm when lifting. During an interview on 9/17/24 at 1:00 P.M. CNA D said the following: -You should never put your arm under the resident's arm when lifting, this could cause an injury; -The resident does not bear weight and should not be a two person gait belt transfer. During an interview on 9/17/24 at 2:00 P.M. Certified Occupational Therapy Assistant (COTA) E said the following: -The physical therapist was aware that there was an order for the resident to be evaluated for transfer; -The PT was not at the facility full time; -She did not know why the resident had yet to be evaluated. During an interview on 9/18/24 at 10:00 A.M. the DON said the following: -Resident #2 had complained of pain in the right shoulder to the physician. The resident has a rotator cuff tear and now has an appointment with an orthopedic surgeon; -Prior to the X-rays the resident was a two person Sit to Stand transfer, now he/she was transferred with two staff and a gait belt; -The physician ordered for the resident to be evaluated by physical therapy for transfer; -She did not know if the resident has been evaluated yet. During an interview on 9/18/24 at 12:20 P.M. the Director of Rehab said she found out about the order for physical therapy to evaluate the resident on 9/14/24, the resident had not been evaluated yet. During an interview on 9/18/24 at 2:30 P.M. the DON said: -When the physician writes an order for therapy, that order should be communicated immediately to the Director of Rehab, she does not know why this was not done; -Nursing can assess a resident for transfer and communicate any concerns regarding the transfer to therapy for consultation; -Staff should be using two staff members for the Sit to Stand and use the belt for the transfer; -She would expect staff to place both hands on the gait belt when transferring and communicate to their nurse and therapy if a resident was unable to bear weight; -If a resident was combative with cares, then two staff members should be assisting the resident; -The resident behaviors should be communicated to the nurse for assessment and follow up; -She would expect two staff members to provide care to residents who are combative or resistive to cares to prevent any injuries. MO242240 MO241655

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of five sampled residents, who was dependent upon staff for transfers and at risk for falls. Staff left the resident in bed positioned on mechanical lift mat with the bed in the high position and then left the room, leaving the resident unattended. The resident slid off the bed and fell to the floor sustaining a fracture of the left leg. The facility census was 60. The administrator was notified on 7/30/24 at 10:00 A.M., of the Past Non-Compliance which occurred on 7/16/24. On 7/16/24, the administrator became aware of the injury to Resident #1 which resulted from a fall from the bed. The facility began an investigation and determined that the resident was left unattended and had a fall from the bed which resulted in a fractured left leg. The facility began in-servicing all staff on safety, transferring the resident and not to leave a resident unattended while in bed. Residents were assessed for bed safety and care plans interventions were added for Resident #1 and any resident who had concerns with positioning in bed or safety when left unattended. The G grid deficiency was removed and corrected on 7/18/24. Review of the facility policy for Falls dated 9/17/19 showed the following: -The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents; -Residents found to be at high risk for falls are placed on the Fall Program, and interventions are implemented to meet individual needs. 1. Review of Resident #1's face sheet showed the following: -The resident admitted to the facility on [DATE]; -Diagnoses of heart failure and and stage 5 chronic kidney disease (kidney failure requiring dialysis), below the knee amputation of the right leg, and muscle weakness. Review of the resident's care plan for falls dated 5/9/24 showed the following: -The resident is at risk for falls due to deconditioning (the decline in physical function of the body as a result of physical inactivity and/or bed rest or an extremely sedentary lifestyle); - Ensure call light is within reach, personal items within reach, low bed with wheels locked, place wheelchair next to bed, and mechanical lift for transfers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/10/24 showed: -The resident is able to make him/herself understood and able to understand others; -Alert and oriented and makes appropriate decisions; -No behaviors; -Impairment on one side of the body; -Dependent upon staff for bed mobility, transfers and wheelchair mobility. Review of the resident's nurses note dated 7/15/24 at 9:27 P.M., signed by Registered Nurse (RN) A, showed at 8:45 A.M. he/she heard the resident asking for help. Upon entering room, observed the resident on his/her left side on the floor between his/her bed and the roommate's bed. The resident said, The bed is just slippery, and I rolled out of bed onto the floor. The resident was alert and oriented and able to make needs known. The resident complained of left knee pain. The left knee noted to be swollen. Resident assisted off the floor with a mechanical lift and three staff. Nurse Practitioner in the facility and informed of the fall. Orders received to send the resident to the emergency room for evaluation. Review of the resident's nurses notes dated 7/15/24 at 4:49 P.M. showed the resident returned from emergency room with diagnosis of fractured left tibia (large bone in the lower leg). During an interview on 7/30/24 at 11:40 A.M. the resident said the following: -A staff member was helping him get ready to go to dialysis and had rolled him/her to one side of the bed. He/She was close to the edge of the bed. The aide told him/her to stay and not move and left the room. He/She felt him/herself begin to slide off the bed and then rolled off the bed onto the floor. He/She began to yell for help. His/her left lower leg hurt. A nurse and two other staff members came into the room and helped him/her off the floor; -He/She went to the hospital to get an x-ray and returned to the facility. His/Her left lower leg was broken. During an interview on 7/30/24 at 11:55 A.M. Resident #2, Resident #1's roommate, said the following: -He/She heard a thud and saw Resident #1's arm was sticking up over the edge of his/her bed; -The curtain was partially pulled between his/her bed and Resident #1's bed; -He/She knew that Resident #1 had rolled off the bed; -Staff had just left the room; -He/She pushed the call light to get Resident #1 help; -Only a few minutes had passed and three staff members came in the room and helped get Resident #1 off the floor. During an interview on 7/30/24 at 12:46 P.M. Certified Nurse Aide (CNA) B said the following: -He/She was getting Resident #1 ready to go to dialysis; -When he/she rolled the resident onto his/her side he/she noticed the resident had scratched his/her back with something and it was bleeding; -He/She told the resident not to move, he/she would be right back and left the room to get the nurse; -Only a few minutes went by until RN A came and got him/her and another staff member to get the resident off the floor. During an interview on 7/31/24 at 8:28 A.M. RN A said the following: -He/She had checked on the resident earlier in the shift to make sure he/she was ready to go to dialysis; -A short while later, he/she was walking down the hall and heard the resident call for help; -When he/she entered the room, the resident was on the floor on the right side of the bed between his/her and the Resident #2's bed; -Resident #1 complained of pain in the left leg and there was swelling in the left knee; -The resident said that he/she slid off the bed, that the mattress was slippery; -He/She and two other staff members got the resident off the floor and he/she called the physician and got an order to send the resident to the hospital for an x-ray; -The resident returned from the hospital with a fractured left tibia. During an interview on 7/30/24 at 1:30 P.M. the Director of Nursing said the following: -After the incident all staff were in-serviced not to leave a resident unattended on the side of a bed; -While giving care and a staff member has to leave the room, staff should position the resident in the middle of the bed before leaving the room. During an interview on 7/30/24 at 10:45 A.M. and 2:00 P.M. the Administrator said the following: -It was reported to him/her on 7/15/24 that a staff member was assisting the resident with getting ready to go to dialysis. The resident said his/her back was itching and the resident was attempting to scratch his/her back using a back scratcher. The staff member had the resident dressed and the mechanical lift pad under him/her and told the resident not to move, that he/she was going to get the nurse. When the staff member came back, the resident was on the floor. A nurse assessed him/her and noted that the left leg was swollen. The resident was sent to the emergency room and returned. The resident sustained a fractured left leg. All staff have been in-serviced not to leave a resident on the edge of the bed but to use the call light if needing help. The resident's care plan has been updated to reflect that he/she was not safe to be left unattended while at the side of the bed; -All direct care staff had been in-serviced to position the resident in the center of the bed if they need to leave the resident room for any reason; -Staff should never leave a resident on the side of the bed and leave the room. MO239102

Refer to K2AZ12. Based on observation, interview and record review, the facility failed to obtain and administer pain medication timely after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, failed to ensure the medication was available for administration, and failed to plan care with interventions to address the resident's pain for two residents (Resident #1 and #3) out of three sampled residents. Resident #1 had an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain. The facility failed to obtain a refill for the resident's oxycodone resulting in the resident not having the pain medication for five days. The resident's pain level was high and the resident reported he/she became very angry and upset and aggressive due to the pain being out of control. The census was 62. The facility did not provide a policy for pain or for ordering or re-ordering narcotic medications. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of chronic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), disorder of the brain, emphysema (damage to the lung tissue that affects the ability to breath), seizure disorder, osteoarthritis ( a degenerative joint disease, in which the tissues in the joint break down over time). Review of the resident's care plan for pain with a revision date of 4/24/23 showed the following: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Monitor and report to the nurse resident complaints of pain or requests for pain treatment; monitor/record/report to the nurse any signs or symptoms of non-verbal pain, changes in breathing, monitor behavior (changes, irritable, restless, aggressive, squirmy), eyes, face, body; evaluate the effectiveness of pain interventions every shift; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/3/23 showed the following: -Able to make self understood, and able to understand others; -Some difficulty in new situations to make decisions; -No mood or behavior problems; -Independent with Activities of Daily Living (ADLs); -Has pain, but no scheduled pain management program, takes as needed (PRN) pain medication, no non-medical interventions marked. Pain intensity is a nine, with 0 being no pain and 10 being the worst pain imaginable; -Opioid medication usage left blank. Review of the resident's Physicians Order Sheet (POS) dated November 2023 showed an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain with a start date of 10/27/23. Review of the resident's Medication Administration Record (MAR) dated November 2023 showed oxycodone 5 mg by mouth BID for pain, documented as not given on 11/12/23 with the resident's pain level marked as not applicable in the AM and 0 in the PM. On 11/13/23 pain level marked as 0 in the AM and not applicable in the PM. Review of the resident's nurses notes dated 11/13/23 at 12:45 P.M. showed a call placed to physician's office, requesting new prescription for oxycodone 5 mg. Per the office nurse, the physician is waiting for an electronic prescription for the pharmacy. Pharmacy made aware. On 11/13/23 at 6:31 P.M. the nurses notes showed oxycodone 5 mg, script (prescription) needed. Review of the resident's MAR dated November 2023 showed on 11/14/23 no documentation of pain in the AM, and marked not applicable in the PM. Review of the resident's nurses notes dated 11/14/23 showed the following: -At 9:58 A.M. notation acetaminophen (over the counter pain reliever - Tylenol) 325 mg, give 2 tablets for pain, ineffective; -At 10:00 A.M. oxycodone 5 mg, pharmacy waiting on script form physician; -At 12:54 P.M. cyclobenzaprine HCL (a muscle relaxant to relieve pain) 5 mg for muscle spasms given, medication was ineffective. Review of the resident's MAR dated November 2023 showed on 11/15/23 no pain marked in the AM or the PM, and on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/15/23 at 10:58 P.M. showed oxycodone 5 mg for pain, awaiting script. Review of the resident's MAR dated November 2023 showed on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/16/23 at 9:33 P.M. showed oxycodone 5 mg for pain, awaiting pharmacy. Review of the resident's MAR dated November 2023 showed oxycodone 5 mg documented as given on 11/17/23 in the morning with a pain level of 8. During an interview on 11/17/23 at 11:00 A.M. the resident said the following: -He/She was in a lot of pain and has not been receiving his/her pain medication; -When asked to describe his/her pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain, the resident said his/her pain was a 30. He/she described the pain as very intense and affecting his/her entire body; -It had been almost a week since he/she had any pain medication, the nursing staff tell him/her they are waiting on the physician for a script; -He/She has been very angry and upset and aggressive due to the pain being out of control; -He/She wished the staff would do something, he/she doesn't know if he/she can take much more; -The resident was visibly upset, pacing about the room and spoke in an increasingly loud voice. During an interview on 11/17/23 at 11:10 A.M., Resident #2, Resident #1's roommate said the following: -The other day, Resident #1 was very angry and loud and was yelling and cursing at him/her; -Resident #1 had not had any pain medication and was very upset; -He/She wished the resident would stop yelling; -He/She did not understand why staff could not just give Resident #1 his/her pain medication. During an interview on 11/17/23 at 11:20 A.M. and 12:45 P.M. Licensed Practical Nurse (LPN) A said the following: -A couple of days ago, Resident #1 was yelling and screaming at his/her roommate; -He/She attempted to calm the resident, but he/she became louder and more upset; -The resident has not had any oxycodone in several days; -He/She has called the pharmacy who said they needed a script from the physician in order to fill the medication; -He/She called the physician who said that the script was sent to the pharmacy earlier in the day; -He/She did not know if oxycodone was in the facility emergency kit, he/she could not access the emergency kit. During an interview on 11/17/23 at 12:51 P.M. a representative of the facility pharmacy said: -Oxycodone was in the facility emergency kit; -The pharmacy received a refill sticker for Resident #1's oxycodone from the facility on 11/3/23. The pharmacy faxed back to the facility a script was needed. The pharmacy faxed the physician's office (also the facility's medical director), on 11/3/23, 11/6/23 and 11/14/23 that a script was needed to refill the medication. The pharmacy received the script from the physician on 11/17/23 at 9:45 A.M. During an interview on 11/17/23 at 1:10 P.M. the Director of Nurses (DON) said the following: -The facility switched pharmacies on 11/1/23. The old pharmacy removed their emergency kit and the new pharmacy just delivered their emergency kit last week; -Oxycodone was in the emergency kit. Observation on 11/17/23 at 1:10 P.M. with the DON of the medication room showed a small locked box marked as emergency kit, with the contents of the box on a paper out side of the box dated 11/1/23 with oxycodone 5 mg noted as available in the box. Observation and interview on 11/17/23 at 1:55 P.M. showed LPN B said the following: -The facility has been communicating the physician's office that a script was needed to refill the resident's medication; -The Administrator was made aware of the physician not providing a script for the medication and she has been talking with the physician's office; -He/She entered the resident's name in the emergency kit computer to obtain the code to open the emergency drug box to get the oxycodone. The prescription for the oxycodone did not show up for the resident. He/She called the pharmacy who said that the resident did not have an order for the oxycodone due to the physician not sending the script. The pharmacy had received the script just a few minutes ago and the pharmacy then entered the medication, and supplied LPN B with the code to open the emergency kit; -LPN B opened the emergency kit and obtained oxycodone 5 mg tablet and administered the medication to the resident. During an interview on 11/17/23 at 2:30 P.M. the resident said the following: -He/She has received oxycodone about an half hour ago (2:00 P.M.), he/she could not tell if his/her pain was less at this point; -He/She did not understand why he/she had to go without the pain medication. During an interview on 11/20/23 at 10:25 A.M. the Administrator said the following: -She became aware of the problem with Resident #1 not having the oxycodone on 11/14/23; -She called the physician's group and was told the resident was not a patient of the physician due to them not accepting the resident's insurance and this was why the physician had not sent a script for the oxycodone; -She informed the physician's group of the resident's secondary payment status and asked for the script to be filled; -She was unaware the script had not been filled until 11/17/23. 2. Review of Resident #3's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of gastric ulcer, anxiety, schizophrenia (mental illness), obsessive compulsive disorder, and hypertension. Review of the resident's comprehensive MDS dated [DATE] showed: -The resident is able to make self understood and understands others; -Cognitively able to make decisions appropriately; -Dependent upon staff for activities of daily living; -No scheduled pain medication, no non-medication interventions for pain, no pain present; -Does not receive opioid medication. Review of the resident's care plan for pain dated 11/17/23 showed: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Administer analgesia as per orders. Give one half hour before treatments or care; anticipate the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions 30 minutes to one hour after administration. Monitor/document side effects of pain mediation; provide the resident and family with information about pain and options available for pain management, discuss and record preferences; the resident is able to answer yes/no questions regarding pain and pain level. Review of the resident's POS dated November 2023 showed an order for Norco 5-325 mg ( is a relatively potent drug for moderate-to-severe pain control), one tablet every morning and bedtime for pain with an order date of 9/24/23. Review of the resident's MAR dated November 2023 showed Norco 5-325 mg one tablet every morning and bedtime for pain documented as not given on 11/10/23, 11/11/23, 11/12/23, 11/13/23 and 11/14/23. Review of the resident's nurse's notes dated 11/10/23 at 7:51 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Pharmacy and physician notified. Review of the resident's nurse's notes dated 11/11/23 at 6:22 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, script needed. Physician notified. Review of the resident's nurse's notes dated 11/12/23 at 9:10 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Review of the the resident's nurse's notes dated 11/13/23 at 12:38 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, new script needed. Review of the nurse's notes dated 11/13/23 at 12:41 P.M. showed: -Call placed to physician's office, requesting new script for Norco 5-325 mg. Per nurse at the physician's office, waiting an electronic script from pharmacy. Pharmacy made aware. Responsible party notified. Review of the nurses notes dated 11/14/23 at 9:08 P.M. showed Norco 5-325 mg, waiting on pharmacy to deliver. During an interview on 11/20/23 at 11:44 P.M. Resident #3 said he/she could not recall if he/she had received any pain medication. During an interview on 11/20/23 at 1:00 P.M. the Administrator and DON said they were not aware Resident #3 had gone without his/her pain medication. During an interview on 11/20/23 at 1:34 P.M. a representative of the facility pharmacy said the following: -The pharmacy faxed the physician on 11/1/23, 11/13/23 and 11/14/23 for a script for Resident #3's Norco 5-325 mg; -The pharmacy received a script from the physician on 11/14/23 at 7:39 P.M. and processed the order at 7:59 P.M.; -The medication was delivered to the facility on [DATE] at 3:33 A.M. During an interview on 11/20/23 at 2:00 P.M. the Administrator said she would expect narcotic medication be filled and refilled in a timely manner. She would expect the physician to be responsive and sign a script for the resident not to have a lapse in receiving the medication. MO 227481

Based on observation, interview and record review, the facility failed to obtain and administer pain medication timely after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, failed to ensure the medication was available for administration, and failed to plan care with interventions to address the resident's pain for two residents (Resident #1 and #3) out of three sampled residents. Resident #1 had an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain. The facility failed to obtain a refill for the resident's oxycodone resulting in the resident not having the pain medication for five days. The resident's pain level was high and the resident reported he/she became very angry and upset and aggressive due to the pain being out of control. The census was 62. The facility did not provide a policy for pain or for ordering or re-ordering narcotic medications. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of chronic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), disorder of the brain, emphysema (damage to the lung tissue that affects the ability to breath), seizure disorder, osteoarthritis ( a degenerative joint disease, in which the tissues in the joint break down over time). Review of the resident's care plan for pain with a revision date of 4/24/23 showed the following: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Monitor and report to the nurse resident complaints of pain or requests for pain treatment; monitor/record/report to the nurse any signs or symptoms of non-verbal pain, changes in breathing, monitor behavior (changes, irritable, restless, aggressive, squirmy), eyes, face, body; evaluate the effectiveness of pain interventions every shift; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/3/23 showed the following: -Able to make self understood, and able to understand others; -Some difficulty in new situations to make decisions; -No mood or behavior problems; -Independent with Activities of Daily Living (ADLs); -Has pain, but no scheduled pain management program, takes as needed (PRN) pain medication, no non-medical interventions marked. Pain intensity is a nine, with 0 being no pain and 10 being the worst pain imaginable; -Opioid medication usage left blank. Review of the resident's Physicians Order Sheet (POS) dated November 2023 showed an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain with a start date of 10/27/23. Review of the resident's Medication Administration Record (MAR) dated November 2023 showed oxycodone 5 mg by mouth BID for pain, documented as not given on 11/12/23 with the resident's pain level marked as not applicable in the AM and 0 in the PM. On 11/13/23 pain level marked as 0 in the AM and not applicable in the PM. Review of the resident's nurses notes dated 11/13/23 at 12:45 P.M. showed a call placed to physician's office, requesting new prescription for oxycodone 5 mg. Per the office nurse, the physician is waiting for an electronic prescription for the pharmacy. Pharmacy made aware. On 11/13/23 at 6:31 P.M. the nurses notes showed oxycodone 5 mg, script (prescription) needed. Review of the resident's MAR dated November 2023 showed on 11/14/23 no documentation of pain in the AM, and marked not applicable in the PM. Review of the resident's nurses notes dated 11/14/23 showed the following: -At 9:58 A.M. notation acetaminophen (over the counter pain reliever - Tylenol) 325 mg, give 2 tablets for pain, ineffective; -At 10:00 A.M. oxycodone 5 mg, pharmacy waiting on script form physician; -At 12:54 P.M. cyclobenzaprine HCL (a muscle relaxant to relieve pain) 5 mg for muscle spasms given, medication was ineffective. Review of the resident's MAR dated November 2023 showed on 11/15/23 no pain marked in the AM or the PM, and on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/15/23 at 10:58 P.M. showed oxycodone 5 mg for pain, awaiting script. Review of the resident's MAR dated November 2023 showed on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/16/23 at 9:33 P.M. showed oxycodone 5 mg for pain, awaiting pharmacy. Review of the resident's MAR dated November 2023 showed oxycodone 5 mg documented as given on 11/17/23 in the morning with a pain level of 8. During an interview on 11/17/23 at 11:00 A.M. the resident said the following: -He/She was in a lot of pain and has not been receiving his/her pain medication; -When asked to describe his/her pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain, the resident said his/her pain was a 30. He/she described the pain as very intense and affecting his/her entire body; -It had been almost a week since he/she had any pain medication, the nursing staff tell him/her they are waiting on the physician for a script; -He/She has been very angry and upset and aggressive due to the pain being out of control; -He/She wished the staff would do something, he/she doesn't know if he/she can take much more; -The resident was visibly upset, pacing about the room and spoke in an increasingly loud voice. During an interview on 11/17/23 at 11:10 A.M., Resident #2, Resident #1's roommate said the following: -The other day, Resident #1 was very angry and loud and was yelling and cursing at him/her; -Resident #1 had not had any pain medication and was very upset; -He/She wished the resident would stop yelling; -He/She did not understand why staff could not just give Resident #1 his/her pain medication. During an interview on 11/17/23 at 11:20 A.M. and 12:45 P.M. Licensed Practical Nurse (LPN) A said the following: -A couple of days ago, Resident #1 was yelling and screaming at his/her roommate; -He/She attempted to calm the resident, but he/she became louder and more upset; -The resident has not had any oxycodone in several days; -He/She has called the pharmacy who said they needed a script from the physician in order to fill the medication; -He/She called the physician who said that the script was sent to the pharmacy earlier in the day; -He/She did not know if oxycodone was in the facility emergency kit, he/she could not access the emergency kit. During an interview on 11/17/23 at 12:51 P.M. a representative of the facility pharmacy said: -Oxycodone was in the facility emergency kit; -The pharmacy received a refill sticker for Resident #1's oxycodone from the facility on 11/3/23. The pharmacy faxed back to the facility a script was needed. The pharmacy faxed the physician's office (also the facility's medical director), on 11/3/23, 11/6/23 and 11/14/23 that a script was needed to refill the medication. The pharmacy received the script from the physician on 11/17/23 at 9:45 A.M. During an interview on 11/17/23 at 1:10 P.M. the Director of Nurses (DON) said the following: -The facility switched pharmacies on 11/1/23. The old pharmacy removed their emergency kit and the new pharmacy just delivered their emergency kit last week; -Oxycodone was in the emergency kit. Observation on 11/17/23 at 1:10 P.M. with the DON of the medication room showed a small locked box marked as emergency kit, with the contents of the box on a paper out side of the box dated 11/1/23 with oxycodone 5 mg noted as available in the box. Observation and interview on 11/17/23 at 1:55 P.M. showed LPN B said the following: -The facility has been communicating the physician's office that a script was needed to refill the resident's medication; -The Administrator was made aware of the physician not providing a script for the medication and she has been talking with the physician's office; -He/She entered the resident's name in the emergency kit computer to obtain the code to open the emergency drug box to get the oxycodone. The prescription for the oxycodone did not show up for the resident. He/She called the pharmacy who said that the resident did not have an order for the oxycodone due to the physician not sending the script. The pharmacy had received the script just a few minutes ago and the pharmacy then entered the medication, and supplied LPN B with the code to open the emergency kit; -LPN B opened the emergency kit and obtained oxycodone 5 mg tablet and administered the medication to the resident. During an interview on 11/17/23 at 2:30 P.M. the resident said the following: -He/She has received oxycodone about an half hour ago (2:00 P.M.), he/she could not tell if his/her pain was less at this point; -He/She did not understand why he/she had to go without the pain medication. During an interview on 11/20/23 at 10:25 A.M. the Administrator said the following: -She became aware of the problem with Resident #1 not having the oxycodone on 11/14/23; -She called the physician's group and was told the resident was not a patient of the physician due to them not accepting the resident's insurance and this was why the physician had not sent a script for the oxycodone; -She informed the physician's group of the resident's secondary payment status and asked for the script to be filled; -She was unaware the script had not been filled until 11/17/23. 2. Review of Resident #3's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of gastric ulcer, anxiety, schizophrenia (mental illness), obsessive compulsive disorder, and hypertension. Review of the resident's comprehensive MDS dated [DATE] showed: -The resident is able to make self understood and understands others; -Cognitively able to make decisions appropriately; -Dependent upon staff for activities of daily living; -No scheduled pain medication, no non-medication interventions for pain, no pain present; -Does not receive opioid medication. Review of the resident's care plan for pain dated 11/17/23 showed: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Administer analgesia as per orders. Give one half hour before treatments or care; anticipate the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions 30 minutes to one hour after administration. Monitor/document side effects of pain mediation; provide the resident and family with information about pain and options available for pain management, discuss and record preferences; the resident is able to answer yes/no questions regarding pain and pain level. Review of the resident's POS dated November 2023 showed an order for Norco 5-325 mg ( is a relatively potent drug for moderate-to-severe pain control), one tablet every morning and bedtime for pain with an order date of 9/24/23. Review of the resident's MAR dated November 2023 showed Norco 5-325 mg one tablet every morning and bedtime for pain documented as not given on 11/10/23, 11/11/23, 11/12/23, 11/13/23 and 11/14/23. Review of the resident's nurse's notes dated 11/10/23 at 7:51 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Pharmacy and physician notified. Review of the resident's nurse's notes dated 11/11/23 at 6:22 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, script needed. Physician notified. Review of the resident's nurse's notes dated 11/12/23 at 9:10 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Review of the the resident's nurse's notes dated 11/13/23 at 12:38 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, new script needed. Review of the nurse's notes dated 11/13/23 at 12:41 P.M. showed: -Call placed to physician's office, requesting new script for Norco 5-325 mg. Per nurse at the physician's office, waiting an electronic script from pharmacy. Pharmacy made aware. Responsible party notified. Review of the nurses notes dated 11/14/23 at 9:08 P.M. showed Norco 5-325 mg, waiting on pharmacy to deliver. During an interview on 11/20/23 at 11:44 P.M. Resident #3 said he/she could not recall if he/she had received any pain medication. During an interview on 11/20/23 at 1:00 P.M. the Administrator and DON said they were not aware Resident #3 had gone without his/her pain medication. During an interview on 11/20/23 at 1:34 P.M. a representative of the facility pharmacy said the following: -The pharmacy faxed the physician on 11/1/23, 11/13/23 and 11/14/23 for a script for Resident #3's Norco 5-325 mg; -The pharmacy received a script from the physician on 11/14/23 at 7:39 P.M. and processed the order at 7:59 P.M.; -The medication was delivered to the facility on [DATE] at 3:33 A.M. During an interview on 11/20/23 at 2:00 P.M. the Administrator said she would expect narcotic medication be filled and refilled in a timely manner. She would expect the physician to be responsive and sign a script for the resident not to have a lapse in receiving the medication. MO 227481

Based on observation, interview and record review, the facility failed to obtain and administer pain medication timely after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, failed to ensure the medication was available for administration, and failed to plan care with interventions to address the resident's pain for two residents (Resident #1 and #3) out of three sampled residents. Resident #1 had an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain. The facility failed to obtain a refill for the resident's oxycodone resulting in the resident not having the pain medication for five days. The resident's pain level was high and the resident reported he/she became very angry and upset and aggressive due to the pain being out of control. The census was 62. The facility did not provide a policy for pain or for ordering or re-ordering narcotic medications. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of chronic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), disorder of the brain, emphysema (damage to the lung tissue that affects the ability to breath), seizure disorder, osteoarthritis ( a degenerative joint disease, in which the tissues in the joint break down over time). Review of the resident's care plan for pain with a revision date of 4/24/23 showed the following: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Monitor and report to the nurse resident complaints of pain or requests for pain treatment; monitor/record/report to the nurse any signs or symptoms of non-verbal pain, changes in breathing, monitor behavior (changes, irritable, restless, aggressive, squirmy), eyes, face, body; evaluate the effectiveness of pain interventions every shift; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/3/23 showed the following: -Able to make self understood, and able to understand others; -Some difficulty in new situations to make decisions; -No mood or behavior problems; -Independent with Activities of Daily Living (ADLs); -Has pain, but no scheduled pain management program, takes as needed (PRN) pain medication, no non-medical interventions marked. Pain intensity is a nine, with 0 being no pain and 10 being the worst pain imaginable; -Opioid medication usage left blank. Review of the resident's Physicians Order Sheet (POS) dated November 2023 showed an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain with a start date of 10/27/23. Review of the resident's Medication Administration Record (MAR) dated November 2023 showed oxycodone 5 mg by mouth BID for pain, documented as not given on 11/12/23 with the resident's pain level marked as not applicable in the AM and 0 in the PM. On 11/13/23 pain level marked as 0 in the AM and not applicable in the PM. Review of the resident's nurses notes dated 11/13/23 at 12:45 P.M. showed a call placed to physician's office, requesting new prescription for oxycodone 5 mg. Per the office nurse, the physician is waiting for an electronic prescription for the pharmacy. Pharmacy made aware. On 11/13/23 at 6:31 P.M. the nurses notes showed oxycodone 5 mg, script (prescription) needed. Review of the resident's MAR dated November 2023 showed on 11/14/23 no documentation of pain in the AM, and marked not applicable in the PM. Review of the resident's nurses notes dated 11/14/23 showed the following: -At 9:58 A.M. notation acetaminophen (over the counter pain reliever - Tylenol) 325 mg, give 2 tablets for pain, ineffective; -At 10:00 A.M. oxycodone 5 mg, pharmacy waiting on script form physician; -At 12:54 P.M. cyclobenzaprine HCL (a muscle relaxant to relieve pain) 5 mg for muscle spasms given, medication was ineffective. Review of the resident's MAR dated November 2023 showed on 11/15/23 no pain marked in the AM or the PM, and on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/15/23 at 10:58 P.M. showed oxycodone 5 mg for pain, awaiting script. Review of the resident's MAR dated November 2023 showed on 11/16/23 no pain marked in the AM or the PM. Review of the resident's nurses notes dated 11/16/23 at 9:33 P.M. showed oxycodone 5 mg for pain, awaiting pharmacy. Review of the resident's MAR dated November 2023 showed oxycodone 5 mg documented as given on 11/17/23 in the morning with a pain level of 8. During an interview on 11/17/23 at 11:00 A.M. the resident said the following: -He/She was in a lot of pain and has not been receiving his/her pain medication; -When asked to describe his/her pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain, the resident said his/her pain was a 30. He/she described the pain as very intense and affecting his/her entire body; -It had been almost a week since he/she had any pain medication, the nursing staff tell him/her they are waiting on the physician for a script; -He/She has been very angry and upset and aggressive due to the pain being out of control; -He/She wished the staff would do something, he/she doesn't know if he/she can take much more; -The resident was visibly upset, pacing about the room and spoke in an increasingly loud voice. During an interview on 11/17/23 at 11:10 A.M., Resident #2, Resident #1's roommate said the following: -The other day, Resident #1 was very angry and loud and was yelling and cursing at him/her; -Resident #1 had not had any pain medication and was very upset; -He/She wished the resident would stop yelling; -He/She did not understand why staff could not just give Resident #1 his/her pain medication. During an interview on 11/17/23 at 11:20 A.M. and 12:45 P.M. Licensed Practical Nurse (LPN) A said the following: -A couple of days ago, Resident #1 was yelling and screaming at his/her roommate; -He/She attempted to calm the resident, but he/she became louder and more upset; -The resident has not had any oxycodone in several days; -He/She has called the pharmacy who said they needed a script from the physician in order to fill the medication; -He/She called the physician who said that the script was sent to the pharmacy earlier in the day; -He/She did not know if oxycodone was in the facility emergency kit, he/she could not access the emergency kit. During an interview on 11/17/23 at 12:51 P.M. a representative of the facility pharmacy said: -Oxycodone was in the facility emergency kit; -The pharmacy received a refill sticker for Resident #1's oxycodone from the facility on 11/3/23. The pharmacy faxed back to the facility a script was needed. The pharmacy faxed the physician's office (also the facility's medical director), on 11/3/23, 11/6/23 and 11/14/23 that a script was needed to refill the medication. The pharmacy received the script from the physician on 11/17/23 at 9:45 A.M. During an interview on 11/17/23 at 1:10 P.M. the Director of Nurses (DON) said the following: -The facility switched pharmacies on 11/1/23. The old pharmacy removed their emergency kit and the new pharmacy just delivered their emergency kit last week; -Oxycodone was in the emergency kit. Observation on 11/17/23 at 1:10 P.M. with the DON of the medication room showed a small locked box marked as emergency kit, with the contents of the box on a paper out side of the box dated 11/1/23 with oxycodone 5 mg noted as available in the box. Observation and interview on 11/17/23 at 1:55 P.M. showed LPN B said the following: -The facility has been communicating the physician's office that a script was needed to refill the resident's medication; -The Administrator was made aware of the physician not providing a script for the medication and she has been talking with the physician's office; -He/She entered the resident's name in the emergency kit computer to obtain the code to open the emergency drug box to get the oxycodone. The prescription for the oxycodone did not show up for the resident. He/She called the pharmacy who said that the resident did not have an order for the oxycodone due to the physician not sending the script. The pharmacy had received the script just a few minutes ago and the pharmacy then entered the medication, and supplied LPN B with the code to open the emergency kit; -LPN B opened the emergency kit and obtained oxycodone 5 mg tablet and administered the medication to the resident. During an interview on 11/17/23 at 2:30 P.M. the resident said the following: -He/She has received oxycodone about an half hour ago (2:00 P.M.), he/she could not tell if his/her pain was less at this point; -He/She did not understand why he/she had to go without the pain medication. During an interview on 11/20/23 at 10:25 A.M. the Administrator said the following: -She became aware of the problem with Resident #1 not having the oxycodone on 11/14/23; -She called the physician's group and was told the resident was not a patient of the physician due to them not accepting the resident's insurance and this was why the physician had not sent a script for the oxycodone; -She informed the physician's group of the resident's secondary payment status and asked for the script to be filled; -She was unaware the script had not been filled until 11/17/23. 2. Review of Resident #3's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of gastric ulcer, anxiety, schizophrenia (mental illness), obsessive compulsive disorder, and hypertension. Review of the resident's comprehensive MDS dated [DATE] showed: -The resident is able to make self understood and understands others; -Cognitively able to make decisions appropriately; -Dependent upon staff for activities of daily living; -No scheduled pain medication, no non-medication interventions for pain, no pain present; -Does not receive opioid medication. Review of the resident's care plan for pain dated 11/17/23 showed: -The resident has pain; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Administer analgesia as per orders. Give one half hour before treatments or care; anticipate the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions 30 minutes to one hour after administration. Monitor/document side effects of pain mediation; provide the resident and family with information about pain and options available for pain management, discuss and record preferences; the resident is able to answer yes/no questions regarding pain and pain level. Review of the resident's POS dated November 2023 showed an order for Norco 5-325 mg ( is a relatively potent drug for moderate-to-severe pain control), one tablet every morning and bedtime for pain with an order date of 9/24/23. Review of the resident's MAR dated November 2023 showed Norco 5-325 mg one tablet every morning and bedtime for pain documented as not given on 11/10/23, 11/11/23, 11/12/23, 11/13/23 and 11/14/23. Review of the resident's nurse's notes dated 11/10/23 at 7:51 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Pharmacy and physician notified. Review of the resident's nurse's notes dated 11/11/23 at 6:22 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, script needed. Physician notified. Review of the resident's nurse's notes dated 11/12/23 at 9:10 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, need a script. Review of the the resident's nurse's notes dated 11/13/23 at 12:38 P.M. showed Norco 5-325 mg every morning and at bedtime for pain, new script needed. Review of the nurse's notes dated 11/13/23 at 12:41 P.M. showed: -Call placed to physician's office, requesting new script for Norco 5-325 mg. Per nurse at the physician's office, waiting an electronic script from pharmacy. Pharmacy made aware. Responsible party notified. Review of the nurses notes dated 11/14/23 at 9:08 P.M. showed Norco 5-325 mg, waiting on pharmacy to deliver. During an interview on 11/20/23 at 11:44 P.M. Resident #3 said he/she could not recall if he/she had received any pain medication. During an interview on 11/20/23 at 1:00 P.M. the Administrator and DON said they were not aware Resident #3 had gone without his/her pain medication. During an interview on 11/20/23 at 1:34 P.M. a representative of the facility pharmacy said the following: -The pharmacy faxed the physician on 11/1/23, 11/13/23 and 11/14/23 for a script for Resident #3's Norco 5-325 mg; -The pharmacy received a script from the physician on 11/14/23 at 7:39 P.M. and processed the order at 7:59 P.M.; -The medication was delivered to the facility on [DATE] at 3:33 A.M. During an interview on 11/20/23 at 2:00 P.M. the Administrator said she would expect narcotic medication be filled and refilled in a timely manner. She would expect the physician to be responsive and sign a script for the resident not to have a lapse in receiving the medication. MO 227481

Based on observation and interview, the facility failed to safely transfer one resident (Resident #1), in a review of two sampled residents, when staff failed to utilize a sit to stand lift to transfer the resident per the resident's plan of care and was at risk for falls. Staff transferred the resident using a transfer belt, the resident's knees buckled, causing staff to lower the resident to the floor and the resident suffered a fractured femur (large bone in the upper leg). The facility census was 58. Review of the facility policy for Safe Lifting and Movement of Residents, dated 1/17, showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belt, slide boards) and mechanical lifting devices; -Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged; -Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 1. Review of Resident #1's care plan for at risk for falls, revised on 4/11/23, showed: -The resident was at risk for falls; -The resident will be free from injury; -There were no approaches to indication to staff the method of transfer for the resident. Review of the resident's care plan for Activities of Daily Living (ADL) deficit, dated 4/11/23, showed : -The resident had a ADL self care deficit related to impaired mobility; -The resident will maintain current level of functioning; -The resident was able to transfer to toilet with extensive physical assistance. Certified Nurse Aide (CNA) assistance of two people and a lift. -Transfer: The resident used a sit to stand lift; -Transfers: The resident need extensive physical assistance of two people and a sit to stand mechanical lift. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 8/24/23, showed: -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Extensive assistance of two staff members for transfers, uses a wheelchair for locomotion; -Diagnoses of heart failure, hypertension, diabetes and Alzheimer's; -No history of falls. Review of the resident's nurse progress note, dated 9/24/23 at 6:30 P.M. signed by Licensed Practical Nurse (LPN) A, showed upon entering the bathroom the resident was noted on floor on his/her back in front of toilet after being lowered to the floor. His/her feet were near bottom right of the toilet. Resident complained of pain to right knee. Able to perform range of motion. Increased pain and decreased movement to right knee. Neurochecks within normal limits. No visible injury. Resident assisted via mechanical lift from floor to bed. During an interview on 10/3/23 at 12:00 P.M., Certified Nurse Aide (CNA) A said the following: -He/She worked on 9/24/23 when another CNA asked for help to transfer Resident #1; -Resident #1 used a sit to stand lift to transfer; -The sit to stand lift had not worked at all that day, and was not working the day before. Staff had to transfer the resident without the lift the day prior; -Three CNA's went to the resident to take the resident to the bathroom; -The resident asked them to take him/her to the shower room to use the toilet as there was more room; -He/She put a gait belt (a belt used around a person's waist to help the person stand up), there was one CNA on each side of the resident and he/she was standing behind the resident and assisted with pulling the resident's pants down; -As the other two CNA's helped the resident pivot to sit on the toilet, the resident's knee gave out and they lowered the resident to the floor; -The resident's right leg was bent under him/her and as they were trying to straighten his/her leg out, the resident said his/her knee hurt; -The nurse came in to assess the resident and they transferred the resident off the floor using a mechanical lift. They put the resident to bed and he/she complained of pain in the right leg; -CNA A said he/she did not know if there another lift that could have been used. During an interview on 10/3/23 at 12:12 P.M., CNA B said the following: -He/She had not taken care of Resident #1 prior to 9/24/23; -He/She knew the resident used a sit to stand lift and assistance of two to transfer, but the battery was dead in the sit to stand and there was no other one available to use; -He/She and two other CNA's took the resident into the shower room to transfer to the toilet; -The resident had a gait belt around his/her waist and when they stood the resident up and was turning him/her to sit on the toilet, the resident's knee gave out and they lowered the resident to the floor; -They got a mechanical lift and got the resident off the floor, he/she complained of pain in the right leg; -He/She did not know if there was another lift that could have been used. Review of the resident's nurse progress note, dated 9/24/23 at 6:50 P.M. signed by LPN A, showed the Nurse Practitioner (NP) on call gave orders for two views x-ray for right knee and left ankle due to pain and recent fall. Review of the resident's physician order sheet (POS), dated 9/24/23 at 7:54 P.M., showed an order for ibuprofen (medication for pain) oral tablet 600 milligrams (mg). Give 600 mg by mouth every eight hours as needed for pain related to fall. Review of the resident's nurses notes, dated 9/24/23 at 7:55 P.M., showed the NP added right ankle to existing x-ray orders per resident complaint of pain. Review of the resident's nurses notes, dated 9/24/23 at 10:35 P.M., noted as a late entry, showed talked with family member and informed resident would be sent to the emergency room , family member in agreement, he/she had been here during the evening shift and had previously been made aware of fall by previous shift. Was also aware of orders for x-rays and had left before X-ray technician arrived. He/She was kept informed of all information as it occurred and was made aware of resident going to hospital. Review of the resident's x-ray report, dated 9/24/23, showed the resident had a comminuted distal femoral (upper leg) fracture (when a bone breaks in many pieces) of the right leg. Review of the resident's nurses notes, dated 9/25/23 at 3:30 P.M., showed spoke with resident's family member who was present in resident's hospital room. The resident's family member said the resident had a fracture to the femur which was supposed to be repaired and the resident will have surgery on Wednesday. Review of the resident's nurses notes, dated 9/27/23 at 3:15 P.M., showed the resident's family member called from the hospital with a update. The resident just had surgery on his/her femur and was expected to be back at the facility in three to four days for rehabilitation. During an interview on 10/3/23 at 1:40 P.M. Licensed Practical Nurse (LPN) B said the following: -He/She worked on 9/24/23, but did not care for the resident; -He/She does recall a problem with the sit to stand lift and the battery not holding a charge, but was unaware that staff could not use it at all. During an interview on 10/3/23 at 5:05 P.M. LPN A said: -He/She was the nurse assigned to Resident #1 on 9/24/23; -He/She was aware that the sit to stand lift was not working. The staff had mentioned that the lift was not holding a charge, but was not aware that no other sit to stand lifts were available; -Staff were trying to assist the resident to the bathroom using a gait belt, when the resident's knee gave out and they had to lower the resident to the floor; -The resident complained on pain in the right leg, she notified the physician and the family and got orders to x-ray the leg and the hip; -The resident was eventually sent to the hospital. During an interview on 10/3/23 at 2:30 P.M. the Administrator said the following: -She would expect staff to use the mechanical lift per the facility policy; -She would expect staff to alert the nurse when a lift was not functioning properly. MO224958

Based on interview and record review, the facility failed to provide the necessary treatment and services consistent with standards of practice, when the facility failed to ensure weekly skin assessments were completed to include measurements, appearance, and any other wound characteristics for one resident, (Resident #2) of two sampled residents. The resident presented with a new open area on the sacrum (triangular bone at the base of the spine) on 9/16/23. The facility failed to consistently assess the wound to identify any changes in the wound necessitating a change in treatment. On 9/30/23, a wound care consultant assessed the resident's wound was now a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead skin) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). The census was 59. Review of the facility policy for Wound Care System Requirements revised 3/21 showed: -The following are the minimum wound care system requirements that are to be maintained in each facility: -This facility has a designated Wound Care Nurse, who completes weekly assessments and documentation; -Standardized Pressure ulcer/pressure injury (PU/PI) Risk Assessment Tool in use - Braden Scale (tool used to assess a resident for the risk of developing PU), completed upon admission, weekly for four weeks, and then quarterly or with any significant change; -Individualized turning and repositioning, toileting, incontinent care, and hydration per individual resident needs; -Certified Nurse Aides (CNA's) will observe skin during care daily. Any changes will be reported to the licensed nurse for follow up; -Skin checks by licensed staff weekly for all residents; -Monthly 100% Skin Audits of all residents by the Director of Nursing and administrative nurse team completed by the the 10 th of each month; -Support surfaces according to resident's risk level and specialty beds appropriate for existing wounds; -Weekly wound assessment is being completed, with individual documentation; -A PU/PI worksheet will be completed each time an in house acquired PU/PI is identified; -Physician will be notified of findings from PU/PI worksheet as needed, for further Physician review; -Other ulcers and skin conditions are assessed and documented weekly; -Weekly PU/PI and other skin condition reports are generated and distributed to the appropriate team members; -Weekly Care Management System meetings are being held with appropriate attendance and input; -The Registered Dietician (RD) is reviewing all residents with wounds on a monthly basis, and as needed (PRN); -The physician and family are notified timely when wounds are identified and with any significant change in status; -Treatments are being completed as ordered, and are changed if no progress is noted in two weeks; -Treatments orders are consistent with the Protocols, unless contraindicated; -Products are being used per the Protocol and formulary; -Care plans and Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff) reflect the current wound status, risk factors and individualized approaches/interventions; 1. Review of Resident #2's face sheet showed the resident was admitted to the facility on [DATE] with diagnoses of cerebral infarct (stroke), cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain.), encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and causes changes in mental function), Crohn's disease ( an inflammatory bowel disease that causes chronic inflammation of the GI tract, which extends from your stomach all the way down to your anus), diabetes. Review of the resident's Braden Scale for predicting PU/PI dated 9/8/23, showed the resident was at very high risk for developing a PU/PI. Review of the resident's nursing admission note dated 9/8/23, showed the resident's skin was intact with no open areas. Review of the resident's medical record dated 9/8/23 through 9/14/23 showed no care plan to address the resident's high risk for development of PU/PI or interventions for the prevention of PU/PI. Review of the resident's admission MDS dated [DATE] showed: -Unable to make self understood and unable to understand others; unable to make decisions; -Dependent upon two staff for Activities of Daily Living (ADL's); -Incontinent of bowel and bladder; -At risk for PU, no PU. Review of the nurses notes from 9/9/23 through 9/15/23 showed the skin was intact with no open areas. Review of the resident's nurses note dated 9/16/23 showed this nurse was informed by the Certified Nurse Aide (CNA) the resident has an open area on the right buttock. Cleansed with wound cleanser, applied xeroform (a treatment used on wounds that are not draining) and a border dressing ( a dressing used to cover the wound). During an interview on 10/3/23 at 12:00 P.M. Certified Nurse Aide (CNA) C said: -He/She usually took care of the resident; -When he/she was giving the resident a bath a few days after he/she was admitted , the top layer of skin on his/her bottom peeled off exposing a pink layer of skin, he/she had notified a nurse. Review of the resident's Physician Order Sheet (POS) dated 9/17/23 showed and order to cleanse open area on the right buttock with wound cleanser, apply xeroform and border dressing daily and as needed. Review of the resident's weekly skin assessment dated [DATE] showed: -Right buttock new open area; -No documentation of measurements including size and depth, color, odor, if drainage present, or other assessment of the wound. Review of the resident's medical record showed no documentation staff staff notified the RD of the resident's wound. per facility policy or completed a Braden Scale per policy. Review of the resident's care plan for actual impairment to the skin related to immobility, dated 9/18/23, showed: -On 9/17/23 - open area to the right buttock; -Goal: The resident will be free from injury to skin through the next review; -Administer treatments as ordered and monitor for effectiveness, avoid shearing while repositioning in bed, float heels while in bed as tolerated, frequent repositioning, PU redistributing mattress on the bed (low air loss), and wound measurements. Review of the resident's progress notes dated 9/18/23 signed by the physician showed: -Nursing staff reports a wound to the right buttock; -No documentation of size, staging, or appearance of the wound. Review of the resident's weekly skin assessment dated [DATE] showed the following: -Right buttock open area 2 x 3.5 x 0.1 cm (centimeters); -Left buttock darkened area, no measurements of the area to the left buttock; -No other assessment of the resident's wound. Review of the resident's daily skilled nurses notes dated 9/19/23 through 9/20/23 showed wounds to buttocks, treatment completed. Review of the resident's medical record dated 9/21/23 showed no documentation of a wound assessment related to the resident's PU. Review of the resident's daily skilled notes dated 9/22/23 and 9/23/23 showed open area to buttock with dressing intact. Review of the resident's weekly skin assessment dated [DATE] showed the following: -Open area to right and left buttock; -No documentation of wound assessments including the size or the appearance of the wound on the right buttock or dark area on the left buttock. Review of the resident's medical record for 9/25/23 and 9/26/23 showed no documentation of a wound assessment related to the PU. Review of the resident's weekly skin assessment dated [DATE] showed: -Right buttock - open area -Left buttock - open area. -There's was no assessment of either wound including measurements, or other characteristics of the wounds. Review of the medical record for 9/28/23 and 9/29/23 showed no documentation of a wound assessment related to the PU. Review of the resident's weekly wound assessment dated [DATE] showed the document was blank, with no assessment note. Review of the resident's outside wound care provider notes dated 9/30/23 showed: -Wound #1 - sacral is an acute Stage III pressure ulcer and has received a status of Not Healed. Initial wound encounter measurements are 8.5 cm length x 6 cm width x 0.2 cm depth. Adipose (fat tissue) is exposed. No tunneling has been noted. No undermining has been noted. There is a moderate amount of serosanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells.) noted which has no odor. The resident reports a wound pain of level 4/10. Wound bed has 26-50%,granulation (good tissue), 1-25% slough (dead tissue), 1-25% eschar (dead tissue), 1-25% epithelialization (new tissue); -Wound #1 (Pressure Ulcer) is located on the sacrum A skin/subcutaneous tissue level excisional/surgical debridement completed (removal of dead tissue) with the total measurement after the debridement of 8.5 cm length x 6 cm width x 0.2 cm depth; -Additional Orders: Calcium alginate sheet (primary dressing): Apply calcium alginate to wound base: -Apply Santyl (wound preparation) nickel-thick and Bactroban (antibiotic) to entire wound bed daily. Cut to fit size of wound; -Ancillary Services: Laboratory: Prealbumin ( test to show the amount of protein in the blood); -Laboratory: Hemoglobin A1c/Hemoglobin ( blood test to show the amount of red blood cells in the blood; -Radiology:X-ray, coccyx - and sacrum to rule out osteomyelitis (infection in the bone). Review of the resident's medical record dated 10/1/23 and 10/2/23 showed no documentation of the resident's pressure ulcers. During an interview on 10/2/23 at 10:55 A.M. Licensed Practical Nurse (LPN) B said: -The resident has an area to his/her coccyx (tailbone), it is not really a pressure ulcer, the skin just peeled off; -This area just developed and the resident was seen by the wound care provider. (the area was to the resident's sacrum, not coccyx) Observation of the resident on 10/2/23 at 10:55 A.M. showed: -The resident had a dressing located on his/her sacrum. LPN B removed the dressing; -There was a large pressure ulcer to the sacrum, encompassing the the right and left buttock with some drainage; LPN B did not measure the pressure ulcer at the time of the observation. During an interview on 10/2/23 at 4:00 P.M. the Assistance Director of Nursing (ADON) said: -He/She was made aware of the area to the resident's sacrum on 9/19/23 and he/she assessed the area and notified the wound care consultant of the new area; -He/She went with the wound care consultant on 9/30/23 for the initial assessment of the wound; During an interview on 10/3/23 at 12:40 P.M. the Wound care consultant said: -He/She had seen the resident on 9/30/23 and was concerned about the appearance of the wound on the resident's sacrum/coccyx; -The wound has a mushy feeling with a presence of bacteria and treated with Bactroban During an interview on 10/3/23 at 1:45 P.M. the Director of Nursing (DON) said: -She would expect nurses to assess a resident's skin upon admission, then weekly; -She would expect the nurses to follow the facility policy for completing skin assessments, documentation of the skin appearance and physician notification; -She would expect the nurses to notify the physician of any new or worsening skin conditions, if a pressure ulcer developed. -She would expect the nurses to document the skin condition on the skin assessments; -She would expect the nurses to implement interventions and follow any physician order and work with the contracted wound company. During an interview on 10/19/23 at 1:00 P.M. the DON said the following: -He/She was also the wound nurse; -A skin assessment should be completed on every resident one time a week; -The nurses should document on the skin assessment the appearance of the resident's skin and if there is an open area, the documentation should include the appearance of the wound, any drainage, any odor, and the size of the wound. There should also be documentation that the physician was notified and a treatment order obtained; -The wound nurse should be notified of any wounds or any changes in a wound as soon as this occurs; -If the resident would have had skin assessments completed per the facility policy, this would have identified the wound sooner, the deterioration of the wound and expedited the treatment process; -She did not know why the weekly skin assessments were not completed. During an interview on 10/3/23 at 2:00 P.M. the Administrator said: -She would expect the staff to assess the resident's skin upon admission and per the facility policy; -She would expect the staff to notify the physician of any areas of concern; -She would expect the staff to monitor, document and treat any skin issues; -She would expect the staff to follow physician orders and to notify the physician of any recommendations or orders from outside consultants. MO224953 and MO224619

Based on interview and record review, the facility failed to secure Resident #1 with a seatbelt while in the facility bus for transport to an appointment. While driving, staff had to apply the brakes hard causing the resident to come out of the wheelchair and slide approximately 12 feet to the front of the bus sustaining injuries including facial fractures and fractured ribs. The facility census was 60. The administrator was notified on 6/28/23 at 1:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 6/16/23. On 6/16/23, the administrator became aware of the violation. The facility suspended the staff member driving the bus and in-serviced the staff on the proper way to transport a resident in the facility bus including the application of a seat belt. The IJ was corrected on 6/18/23. Review of the facility policy for the use of Q'Straint (wheelchair securement system installed in the facility bus) showed: -Secure the wheelchair: Place the wheelchair facing forward in secure area, apply wheel locks, attach tie-downs into the floor anchorages and ensure they are locked in, attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees. Ensure all tie-downs are locked and properly tensioned; -Attach lap belts - use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. On the aisle side, attach belt with female buckle to rear tie-down pin connector ensuring buckle rests on passenger's hip. On the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle. Attach shoulder belt - extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/24/23, showed: -Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition of a person) of 13, which indicated the resident was alert and oriented and able to answer questions, able to make self understood and understand others; -Independent with bed mobility, locomotion on and off the unit; supervision with transfers, walking in room and personal hygiene; limited assistance with dressing and toilet use; -Not stable with movement or transfer without staff assistance; -Utilizes a wheelchair and walker for locomotion; -Diagnoses of heart failure, end stage renal disease (ESRD- occurs when the kidneys are no longer able to work at a level needed for day-to-day life), and cancer. Review of the resident's local ambulance report, dated 6/16/23 at 11:30 A.M., showed the following: -Upon arrival the resident was found lying on his/her right side in the aisle on the bus, head against the front of the bus. The bus driver said he/she had to step on the brakes hard and the resident fell out of his/her wheelchair and slid from the back of the bus to the front of the bus down the aisle, only stopping when he/she hit his/her head on the front of the bus. The resident complained of right sided rib pain, that was worse when taking a breath, and also complained of head pain where a laceration was located. The resident had pain on the nose with palpation. Review of the resident's nurses notes, dated 6/16/23 at 12:47 P.M., showed the facility transporter reported to the nurse the resident was at a local hospital as the resident fell out of the wheelchair on the bus on the way to dialysis. The nurse at the hospital said the resident was having x-rays. Review of the resident's hospital records, dated 6/16/23, showed the following: -The resident had a history of ESRD and was on dialysis. The resident was on his/her way to dialysis with no seat belt to his/her wheelchair. When the bus he/she was transported in braked, he/she fell out of the wheelchair. The resident hit his/her head. The resident complained of a headache, right shoulder pain, right upper and lower arm pain, and right sided rib pain; -The resident sustained fractures including a right orbital fracture (when one or more of the bones around the eyeball break, often caused by a hard blow to the face), fracture of the right maxillary sinus (facial bone), and fracture of the right fourth, fifth, sixth and seventh ribs. Review of the nurses notes, dated 6/17/23 at 12:45 P.M., showed the resident arrived at the facility at 12:45 P.M. from a local hospital. The resident had multiple rib fractures on the right side, a fractured orbit, and multiple closed fractures of the facial bone. Review of the resident's neuro check assessment, dated 6/18/23 at 7:40 A.M. showed the resident had a lot of bruising to the upper and lower extremities and remained in a lot of pain. During an interview on 6/27/23 at 2:55 P.M., Certified Nurse Aide (CNA)/bus driver A said: -He/She drove the bus on 6/16/23 and was taking Resident #1 to dialysis; -He/She loaded the resident onto the facility bus and secured the wheelchair in the back of the bus with the four straps used to secure the wheelchair to the floor of the bus. -He/She did not put the seat belt on the resident, because he/she was thinking about a phone call he/she had received prior to loading the resident onto the bus; -He/She drove several miles away from the facility and had to stop suddenly. He/She saw the resident leave the wheelchair and slide along the floor of the bus in the rearview mirror. The resident hit his/her head on the compartment located next to the driver's seat in the front of the bus; -The resident went several feet in the air until he/she landed on the floor of the bus; -The resident had blood coming from the top of his/her head; -He/She called 911 and an ambulance came and took the resident to a local hospital, he/she went back to the facility and told them what had happened; -He/She should have secured the resident with a seat belt. During an interview on 6/27/23 at 1:00 P.M. and 6/28/23 at 4:00 P.M., the Administrator said: -On 6/16/23, the resident was being transported via the facility bus when the bus driver reported he/she had to apply the brakes on the van hard. The resident came out of the wheelchair that had been secured in the back of the bus and slid to the front of the bus, hitting his/her head on a hard plastic compartment by the driver. The driver called 911 to transport the resident to the hospital; -The resident was hospitalized over night with fractures of the right orbital, nose and facial bones, ribs on the right side and a laceration to the top of the head; -She would expect all staff to place the seat belt on residents before driving the bus. MO220242

Based on observation, interview and record review, the facility failed to provide a safe environment for one resident(Resident #205) of 20 sampled residents and one additional resident (Resident #40). Maintenance staff failed to fix a grab bar in Resident #205 and #40's bathroom that both residents used. The grab bar came out of the wall during Resident #205's use, he/she fell , hitting his/her head. The resident was evaluated at the hospital and sustained a closed head injury as a result. The facility census was 54. The facility provided no policy regarding work order completion expectations. 1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/28/22, showed the following: -Cognitively intact; -Required total dependence of two staff for transfers; -Required extensive, physical assistance of one staff for toilet use; -Functional limitation in range of motion (ROM); lower extremity impairment on both sides; -Always continent of bowel and bladder; -Diagnoses included hip and other fractures. Observation and interview on 7/5/22 at 1:55 P.M. in resident room 212 showed the following: -Two large areas and two smaller areas of dry wall compound were visible on the wall in the restroom where the grab bars used to be attached to the wall; -A sign on the wall said do not touch wet paint; -The resident near the window (Resident #40) said the facility needed to replace the grab bar in the restroom. The bar was loose and his/her roommate grabbed it and fell to the floor on 7/1/22. His/Her roommate had to go to the emergency room , but is now back at the facility. He/She doesn't feel that the facility is going to replace the grab bar. Someone must have put dry wall compound on the wall recently, but didn't put the grab bar back up. He/She used the grab bars too and wants the grab bars to be re-installed. Observation of the resident on 7/5/22 at 2:20 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident's right leg has been amputated. During an interview on 7/5/22 at 2:20 P.M., the resident said the following: -He/She had been was at the facility for therapy; -He/She sustained injuries to both of his/her legs and his/her right leg had to be amputated; -He/She used the grab bar in the bathroom to assist with his/her transfers onto the toilet; -The grab bar in the bathroom had been loose and both he/she and his/her roommate had reported the concern as far back as three weeks ago; -His/Her roommate fell in the bathroom when the grab bar pulled out of the wall and the grab bar had not been replaced; -Without the grab bar he/she had to try and use the sink to stabilize him/herself during a transfer and he/she did not feel safe; -He/She could call for staff assistance, but it took them too long to answer his/her call light; -He/She was continent of bowel and bladder and sure hoped he/she did not have to have an accident (be incontinent) because of transfer issues and the lack of the grab bar. 2. Review of Resident #205's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with transfers and toileting; -Balance during transitions, moving from seated to standing position and moving on and off of the toilet, the resident was not steady, but able to stabilize without staff assistance; -Functional limitation in range of motion (ROM); lower extremity impairment on both sides; -Always continent of bowel and bladder; -Diagnoses included stroke, [CONDITION(S)] (paralysis of one side of the body) or [CONDITION(S)] (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and [CONDITION(S)] bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). During an interview on 7/6/22 at 9:28 A.M., the resident said the following: -He/She had had a stroke that affected his/her left, non-dominant side; -He/She had had several knee surgeries and his/her knees were weak; -He/She had had a recent fall in the bathroom, during a transfer off of the toilet, when the grab bar pulled out of the wall; -He/She had reported the grab bar being loose two or three times and it never got fixed. His/Her first report about the grab bar was a couple weeks before the fall; -After his/her fall he/she was sent to the hospital because he/she hit his/her head and he/she took blood thinners; -Since hitting his/her head on the sink, he/she had had really bad headaches; -He/She did not like having to take medications for pain but had had to increase use since the fall. Review of the resident's undated care plan showed the following: -Has limited physical mobility; -Has pain; prefers to have pain controlled by non-medication interventions; -At risk for falls; -On anticoagulant (blood thinner) therapy. Review of the resident's facility nursing notes showed staff documented the following: -On 7/1/22 at 6:03 P.M., the resident had a fall on 7/1/22 at 3:00 P.M. while transferring in the bathroom to the toilet. The resident obtained a raised reddened area on right side of his/her head as a result of hitting his/her head on the sink. Ambulance arrived at this facility at 3:15 P.M. and departed from this facility at 3:23 P.M.; -On 7/1/22 at 9:50 P.M., resident returned via ambulance. Review of the resident's hospital discharge papers showed the following: -Date of arrival, 7/1/22 at 5:37 P.M.; -Chief complaint: trauma: brought to the emergency room (ER) from Long Term Care Facility (LTCF) due to fall. Resident, who normally gets around by self, went to the restroom; grabbed hold of support bar and the bar broke. Resident dropped forward onto bilateral (both) knees and then hit right side of head on sink. Resident takes [MEDICATION(S)] (blood thinner); small abrasion to the right side of head, both knees and right elbow; found sitting in bathroom with back against the wall complaining of pain; -History: resident with history of stroke and presents to ER via emergency medical services (EMS) from LTCF secondary to fall; was using the restroom and when he/she grabbed on to a hand rail, the hand rail broke causing the resident to fall to the ground. Resident did strike his/her head. Currently complaining of headache, right hip pain, right and left knee pain and right ankle pain; -Diagnoses: closed head injury after fall encounter; acute pain; discharged back to the long-term care facility. During an interview on 7/6/22 at 3:10 P.M., the maintenance supervisor said the following: -He was aware that the grab bar of the bathroom of occupied resident room 212 had pulled out of the wall; -The grab bar had been reported to him as being loose a couple of times before he could actually get around to getting it fixed; -It wasn't until a resident fell and the grab bar was pulled out of the wall that he had gone to fix it; -He was the only one making repairs and addressing maintenance issues and he had just not gotten to it when it was first reported or when it was reported the second time; -He could not recall specifically when the loose grab bar had been reported but he thought it was maybe the middle of June; -He had received a work order on the loose grab bar; (a copy of the work order was requested but never provided by the facility); -A receptionist kept a spreadsheet that tracked the work orders (request and completion); (a copy of this spreadsheet was requested but never provided by the facility). Surveyor: [NAME], [NAME] During an interview on 7/13/22 at 2:43 P.M., the DON said he expected maintenance work orders for things such as resident grab bars, that are in use, to be repaired by the end of the day or within a 24 hour timeframe; During an interview on 7/13/22 at 3:22 P.M., the administrator said: -She expected maintenance staff to get repairs done as soon as possible; if critical, address it right away; floor staff should assess and flag any hazardous/dangerous areas/equipment; staff should then submit a work order and the following day/morning maintenance staff should be monitoring for the repair. MO 185 MO 608

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #20) identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive and without a pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired at the facility. The facility also failed to implement the facility policy addressing CPR requirements for staff and to monitor to ensure CPR certified staff were scheduled and present in the facility 24 hours a day, seven days a week. This failure affected 27 residents who were identified as full code status. Further review showed the facility failed to ensure the facility transporters, who transported two sampled residents (Resident #11 and #15) in the facility van, both of which had elected a full code status, were trained and certified to provide CPR. The facility census was 43. The Director of Nurses, administrative designee, was notified on [DATE] at 4:48 P.M. of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation, reviewed ,d+[DATE], showed the following: -Personnel have completed training on the initiation of CPR/Basic Life Support (BLS) in victims of sudden cardiac arrest; -If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record; -If the resident is a full code, per the medical record, a staff member that is certified in CPR will initiate CPR; -Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for clinical staff members who will direct resuscitative efforts, including non-licensed personnel; -Facility staff certified for CPR are available for each shift in the case of an actual cardiac arrest; -Staff will call 911 when CPR is initiated; -The certified staff in this facility have received training and received certification in CPR/BLS; -The facility's procedure for administering CPR shall incorporate the steps covered in the current American Heart Association guidelines for CPR and emergency cardiovascular care for facility BLS training material. 1. Record review of Resident #19's closed record showed the following: -Physician order sheets dated ,d+[DATE] showed the resident had elected to be a full code; -A care plan, revised [DATE] (the care plan shows a date of [DATE], even though the resident expired [DATE]), showed the resident's code status was a full code; -Nursing notes indicated on [DATE] at 4:22 P.M. the resident was without respirations or heart beat; -No documentation facility staff performed CPR or called 911. During an interview on [DATE] at 8:59 A.M., Licensed Practical Nurse (LPN) S said the following: -He/She was the charge nurse on [DATE]; -He/She assessed the resident and noted him/her to be without respirations or pulse; -The resident was on hospice so he/she assumed the resident was a Do Not Resuscitate (DNR); -He/She did not check the medical record for the resident's code status; -If a resident was a full code and goes into cardiac or respiratory arrest CPR should be started immediately; -He/She did not do CPR on the resident. During an interview on [DATE] at 4:38 P.M., the Assistant Director of Nurses (ADON) said the following: -She was notified by LPN S that the resident had no pulse or respirations; -She was told by LPN S the resident's code status was DNR; -She assessed the resident and noted no pulse, respirations or blood pressure; -She did not check the resident's code status. During an interview on [DATE] at 4:00 P.M., the Director of Social Services said the following: -She reviewed the resident's file and no DNR order was written for the resident; -The resident was a full code. During an interview on [DATE] at 2:56 P.M., the Medical Director said the following: -The resident had returned to the facility in failing health and the family placed the resident on hospice; -The resident had been a full code and the change in code status got over looked; -He would expect CPR to be started on a full code resident if the resident had respiratory or cardiac arrest. 2. Review of the nursing schedule dated [DATE] through [DATE] showed no 24 hour CPR certified staff coverage on the following days: [DATE], 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2021. Review of staff CPR cards provided by the facility showed 48 out of 72 cards from the following associations that offered an online only training with no skills component: -American Academy of CPR and First Aid, Inc.; -National CPR Foundation; -American Red Cross (online only component); -American CPR Care Association; -American Health Care Academy; -National Health and Safety Association. Review of Licensed Practical Nurse (LPN) O's American Academy of CPR and First Aid, Inc.'s card showed the following: -He/She has successfully completed the mentioned course, and has demonstrated proficiency in the subject by passing the examination, in accordance with the terms and conditions of American Academy of CPR and First Aid, Inc.; -Issue date [DATE] with renewal date of [DATE]. During an interview on [DATE] at 1:08 P.M., LPN O said the following: -He/She worked for an agency; -The agency requires CPR certification to be up-to-date; -He/She was currently CPR certified; -He/She received certification by taking an online class with no hands on skills component. During an interview on [DATE] at 10:15 a.m. Assistant Director of Nurses (ADON) said his/her CPR certification was current, but she could not print her card. Her CPR certification was online only certification with no skills component. Review of the Director of Nurses (DON) American Safety & Health Institute's certification card showed the following: -She has successfully completed and competently performed the required knowledge and skill objectives for Adult CPR; -Issue date was [DATE]; -Expiration date was [DATE]. During an interview on [DATE] at 10:15 A.M., the DON said her CPR certification had expired. During an interview on [DATE] at 1:05 P.M., the staffing coordinator said the following: -He/She completes the schedules for nursing staff; -After the schedule was completed the DON reviews the schedule; -He/She was not aware which staff members were CPR certified; -The ADON and DON were responsible for ensuring there was someone CPR certified in the building 24 hours a day, seven days a week; -It would be beneficial for him/her to know which staff members were CPR certified. During an interview on [DATE] at 4:15 P.M., the Corporate QA Nurse said the following: -She was aware of the regulation of CPR certified staff needing to be in the building 24 hours a day, seven days a week; -She was aware the certification required Basic Life Support (BLS) with a skills component; -She was aware that online certification does not meet the regulation for a health care setting; -She was unaware the facility had not been meeting the requirement for CPR certified staff in the building 24 hours a day, seven days a week. 3. Review of scheduled transportation appointments dated [DATE] - [DATE] showed the following: -Routine transportation of full code residents; -Resident #11 (full code status) was transported to and from dialysis 14 times; -Resident #15 (full code status) was transported to and from dialysis 14 times. Review of the CPR cards provided by the facility showed no CPR cards for Medical Records/Transportation staff member N or transportation staff M. During an interview on [DATE] at 2:16 P.M., Medical Records/Transportation staff member N said the following: -He/She transported residents to and from appointments when needed; -He/She does not know the code status of the residents being transported; -He/She was CPR certified, but never received a copy of his/her certification card; -He/She took the training at the facility in February or March of 2020. During an interview on [DATE] and [DATE], at 5:15 P.M. and 10:15 A.M. and 6:00 P.M., the DON said the following: -She expected all licensed staff to be CPR certified; -All agency staff members have to be CPR certified to work at the facility; -She was not sure if the staffing coordinator knows who was CPR certified; -There was no working list of CPR certified staff members; -Copies of CPR cards should be in the personnel file that human resources compiles; -The facility transports full code residents to appointments; -She was told the facility transportation staff members were CPR certified, but the facility was unable to find copies of certification cards; -She did not have copies of CPR cards for staff members prior to [DATE]; -She was unaware the majority of agency staff only had the online component for CPR certification; -She was not aware the online only component did not meet requirements; -She would expect staff to start CPR on any full code resident found without pulse or respirations. During an interview on [DATE] at 3:52 P.M., the administrator said the following: -She was not the administrator of the facility while Resident #20 was at the facility; -She would expect staff to perform CPR and call 911 if a full code resident was noted to be without a pulse or respirations; -Prior to receipt of the immediate jeopardy she was not aware of CPR certified staff requirements 24 hours a day 7 days a week; -Prior to receipt of the immediate jeopardy she was not aware the online certification did not meet the BLS requirement; -She expected there to be a BLS CPR certified nursing staff member on every shift; -She expected the transporters to be BLS CPR certified; -She was not aware the agency staff did not have the proper certification. NOTE: At the time of survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the level of the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to protect two residents (Resident #1 and #2) from physical abuse by Certified Nurse Aide (CNA) A. A camera in Resident #1's room recorded CNA A provide care and transfer the resident in an aggressive and abusive manner. The resident can be heard verbally expressing pain on the video by saying Ow several times during the incident. The resident sustained bruising to both arms and a skin tear to the left elbow. Resident #2 reported CNA A was rough while providing him/her with perineal care. Resident #2 told CNA A that it hurt, to which CNA A responded that is what the resident got for not helping with care. A sample of 12 residents was selected for review. The facility census was 56. On 9/30/21 at 12.59 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 8/17/21. On 8/29/21, the administrator identified the physical abuse of Resident #1 by CNA A in the video provided by Resident #1's family member. Upon discovery, the Assistant Director of Nursing (ADON) conducted an investigation, and notified appropriate parties. Facility staff were in-serviced on abuse and neglect and the ADON interviewed residents and conducted skin assessments on all residents to identify any further allegations or unexplained bruising or injury with no additional findings. The IJ was removed and corrected on 8/29/21. Review of the facility's policy on Abuse and Neglect, revised November of 2018, showed the following: -Abuse is defines as the willful (acted deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion; -The facility prohibits the mistreatment, neglect, or abuse of residents. This presumes that all instances of abuse can cause physical harm, pain, or mental anguish; -The facility's abuse prohibition program includes screening, training, prevention, identification, investigation, protection, and reporting/response; -The facility administrator will be designated as the facility abuse coordinator and will be responsible for overseeing the abuse prevention and prohibition program and directing any abuse investigation. 1. Review of Resident #1's care plan, revised 7/8/21, showed the following: -Diagnoses included overactive bladder, pain in the right shoulder, history of falling, pain in right knee, abnormal gait, lack of coordination, dementia without behavioral disturbance, age related osteoporosis, pain in unspecified ankle and joints and unspecified foot. -The resident has a terminal prognosis; -Hospice services; -The resident has pain; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -The resident has impaired visual function; -The resident requires assistance of one staff for transfers; -The resident has limited physical mobility and requires an assistive device for ambulation. Review of the resident's Admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff, dated 7/21/21, showed the following: -Diagnoses included osteoporosis and dementia; -Long and short term memory problems; -Required limited assistance of one staff for bed mobility, transfers, and walking; -Required extensive assistance of one staff for dressing. Review of the resident's skin assessment, dated 8/12/21, showed the following: -No new changes this week; -Skin impairment to bilateral knees with small purple discoloration; -Dry skin to bilateral feet. Review of the resident's nurse's note, dated 8/17/21 at 5:53 A.M., showed a skin tear was observed to the resident's left elbow. The area was cleansed, antibiotic ointment and a dry dressing were applied. Staff reported the resident bumped his/her elbow during a transfer. Review of the resident's skin assessment, dated 8/25/21, showed the following: -No new changes this week; -Skin impairment was redness to the abdomen on the right side. Review of the facility's self-report sent to the region on 8/29/21 showed the following: -The resident was admitted on [DATE] with a diagnosis of dementia; -The assistant director of nursing (ADON) received a phone call from the charge nurse on 8/29/21 at 11:31 A.M. who said the hospice agency was in the facility investigating the abuse of resident which was captured on video; -The ADON called the abuse emergency hotline and reported the incident. Review of the facility's investigation, dated 8/29/21, showed the following: -At 11:29 A.M. the charge nurse informed the ADON that the hospice nurse was in the facility to perform an investigation of a video showing abuse that a power of attorney (POA) had provided; -The ADON called the facility social worker who said the resident's POA was in the facility that morning and asked if the social worker had received his/her email. The social worker responded he/she had not and the POA said the email was a video that he/she also sent to other department heads and it needed to be reviewed; -At 12:15 P.M. the ADON reviewed the video and it showed a CNA abusing Resident #1; -At 12:30 P.M. the police were notified and asked for an officer to come to the facility to file a report; -At 12:45 P.M. an officer arrived at the facility, reviewed the video, and obtained a copy for evidence; -At 1:15 P.M. the administrator spoke to the POA who said he/she was unaware of the exact date or time of the video recording, but it was approximately two weeks ago; -At 3:45 P.M. the ADON discussed the video with the POA who said his/her sibling was in the facility early that morning and was going to record the resident when staff entered the room and asked him/her to step out of the room while staff got the resident up. The POA's sibling left his/her cellular phone on the dresser which was recording. The sibling sent the video to the POA the day before (8/28/21). The POA said the video was probably taken two weeks ago. Review of the resident's nurse's note, dated 8/29/21 at 3:27 P.M., showed the following: -The nurse assessed the resident's arms and noted a red, purple, fading, discoloration 4 centimeters (cm) by 2 cm to the right inner elbow; -There was a 2 cm by 1 cm red, purple, discoloration on the back of the right arm; -The resident had a circular area on the right hand in the webbing between the pinky and ring finger; -There were old fading discolorations to the left forearm that was 5 cm by 4 cm and a red/purple area to the top of the left hand that was 1 cm by 1 cm in diameter. Review of the undated video recording, provided to the facility by the resident's family, showed the following: -Resident #1 lay sideways across the bed on his/her back. The resident's feet and legs hung off the side of the bed. The resident had a shirt on around his/her neck, an incontinent brief, and pants up to his/her knees; -CNA A stood at the side of the resident's bed, in front of the resident, and pulled the resident's pants up a few inches; -CNA A pulled a chair over next to the resident's bed and told the resident pull them up referring to his/her pants; -The resident attempted to pull up his/her pants unsuccessfully and said I can't; -CNA A placed his/her right hand behind the resident's neck and forcefully and abruptly sat the resident up on the side of the bed without any warning or explanation to the resident of what he/she was doing; -The resident said Oh my God; -CNA A grabbed the resident's left arm with his/her right hand and forcefully put it through the sleeve of his/her shirt; -The resident loudly said Ow; -CNA A then grabbed the resident's right arm and forcefully puts it through the sleeve of his/her shirt; -CNA A pulled the resident's shirt down; -Without acknowledging or giving any instructions to the resident or applying a gait belt, CNA A lifted the resident under his/her arms and abruptly and aggressively threw the resident into the chair next to the bed; -The force of the transfer caused the resident to lean his/her upper body over the right arm of the chair; -The resident loudly shouted Ow, ow!; -The resident said Ow! a third time and began to cry; -The video ended. Review of the resident's skin assessment, dated 8/29/21, showed the following: -Skin impairment to the right inner elbow with red/purple discolorations that measured 4 cm by 2 cm and 2 cm by 1 cm; -A red area to the webbing of the right hand; -A 1 cm by 1 cm red/purple areas to the back of the left hand. Review of the police report, dated 8/29/21, showed the following: -The officer was dispatched to the facility at 12:49 P.M. on 8/29/21 in reference to elder abuser; -The officer arrived to the facility and made contact with the ADON; -The ADON said he/she was contacted by the resident's family member about the resident being abused by a staff member; -The ADON said the resident's family member sent the ADON a video of the resident being abuse by a staff member later identified as CNA A; -The officer reviewed the video which showed CNA A attempting to help dress the resident on his/her bed; -The resident lay on his/her back on the bed while CNA A tried to put on the resident's pants; -CNA A got the resident's pants pulled halfway up, then grabbed a chair and moved it next to the resident's bed; -CNA A is heard telling the resident to sit up and the resident responded I can't; -When the resident would not sit up, CNA A jerked the resident by the back of the neck to a seated position; -CNA A told the resident to put his/her arms in his/her shirt; -When the resident did not put his/her arms in the shirt, CNA A forcefully grabbed the resident's arms and put them in the shirt; -The resident can be heard saying Ow; -CNA A picked the resident up under the arms and threw the resident into a chair; -The resident tried to grab onto CNA A and CNA A slapped the resident's hand away twice; -The resident can be heard saying Ow several times out of pain; -The video ended with the resident crying due to the incident; -The ADON said the resident's family member said the incident occurred on 8/17/21 in the morning hours; -The family member, who is the POA for the resident said his/her sibling was in the facility on 8/17/21 to visit and was told he/she could not be in the room while CNA A dressed the resident; -The family member put his/her phone on record and left it on the room while he/she waited down the hall for the resident to be dressed; -The family member sent the video to the POA and told him/her something needed to be done about it; -The POA emailed the video to the staff at the facility; -The officer tried to reach CNA A by phone several times but was unable to reach him/her; -CNA A was entered as wanted in relation to the incident. During an interview on 9/2/21 at 10:54 A.M. the resident's POA said the following: -The incident on the video took place on 8/17/21; -The video was recorded on the POA's sibling's phone; -The POA's sibling captured the recording by accident; -The sibling was recording the resident when a CNA came in the room; -The sibling set the phone down and left the room and was not aware the phone was still recording; -The sibling did not find the recording until a week and a half after it was taken; -The resident had bruising to both his/her arms and a skin tear to the left elbow after the incident; -The resident had been much more jumpy and timid since the incident. The POA was in the facility daily to visit and he/she had to be much gentler with the resident since the recording. Observation of the resident with the ADON on 9/2/21 at 2:48 P.M. showed the following: -Three nickel sized, purple, bruises to the resident's right upper arm; -A large , grapefruit sized bruise, that was fading around the outside with a darker, purple area in the center, to the resident's right forearm; -Multiple dime sized, fading, purple, bruises to the resident's left arm; -A large, purple, bruise to the top of the resident's right hand and a smaller, fading, purple bruise at the base of the resident's right thumb. 2. Review of Resident #2's care plan, dated 8/19/21, showed the following: -admitted [DATE]; -Diagnoses included stroke and muscle weakness; -The resident had pain; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -The resident required total assistance from staff for personal hygiene care; -The resident was dependent on staff for toilet use. Review of the self-report sent by the facility on 8/20/21, showed the following: -The resident was admitted on the evening of 8/19/21; -The administrator spoke to the resident on 8/20/21 and the resident reported some concerns regarding his/her care over night; -The resident said he/she was spoken to in an aggressive and non-polite manner and the staff wiped the resident hard during perineal care; -The aide was suspended pending the investigation. Review of a signed statement by the administrator, dated 8/25/21, showed the following: -Resident #2 reported concerns regarding the care he/she received on 8/19/21 around 10:00 P.M.; -CNA A allegedly told the resident he/she wasn't helping enough when trying to roll the resident during incontinent care; -CNA A apparently wiped the resident hard. The resident hollered out and CNA A said That's what you get for being uncooperative; -A short time later, Resident #2 rang for the bed pan and a Licensed Practical Nurse (LPN) came in and got the resident situated on the bedpan; -When CNA A came in to provide perineal care the resident said he/she was mean as hell (no specifics given); -The administrator spoke to CNA A on 8/20/21 and told CNA A he/she was suspended pending investigation; -The administrator told CNA A there were some care concerns and asked him/her if he/she could think of anything that may have occurred. CNA A said Some family member said he/she didn't like my attitude; -The administrator asked CNA A to write a statement regarding anything out of the ordinary that could have prompted a complaint. CNA A never provided a statement; -CNA A was suspended on 8/20/21 and terminated on 8/25/21 due to resident care concerns. During a telephone interview on 9/18/21 at 1:00 P.M., Resident #2 said he/she was admitted to the facility on [DATE]. That first night, CNA A was rough and grabbed him/her by the arm and it was painful. The resident said he/she had been incontinent and CNA A came in the room. It was obvious CNA A did not want to be there and did not want to help the resident. CNA A was very rough when he/she provided the resident with perineal care. Resident #2 told CNA A it was hurting but CNA A did not stop and kept right on being rough. It was uncomfortable and painful. CNA A told Resident #2 that is what he/she got for wetting himself/herself. Resident #2 said he/she was fearful of CNA A due to his/her large size and his/her attitude. Resident #2 said no one should be treated that way and felt like he/she was physically abused by CNA A. During an interview on 9/2/21 at 3:00 P.M., the administrator said on 8/20/21/she spoke to Resident #2 who had some concerns regarding his/her care overnight. Resident #2 said CNA A told him/her to help more and was rough. The resident said CNA A wiped him/her hard and the resident told CNA A it hurt to which CNA A responded, you should have helped more. CNA A was suspended on 8/20/21 and did not provide a statement. CNA A was terminated on 8/25/21 due to the incident with Resident #2 for being rough and rude. The administrator said he/she would not consider CNA A's actions towards Resident #2 as abuse but rude and disrespectful. During an interview on 9/2/21 at 3:00 P.M., the administrator said CNA A was suspended on 8/20/21 due to a complaint made from another resident (Resident #2) about him/her being rude and rough during care. CNA A was terminated on 8/25/21 for the way he/she spoke to Resident #2 and because he/she was rough during care. On 8/29/21 the administrator got a call from the social worker at the facility who had been made aware of the incident with CNA A and Resident #1. The administrator watched the video provided by the resident's family member who said he/she thought the video was a couple of weeks old. CNA A had already been terminated from the facility at that time due to care concerns involving Resident #2. The administrator would consider the care observed in the video from CNA A to Resident #1 to be physical abuse. MO190199 MO190029 MO190157 MO190158 MO190389

Based on observation, interview, and record review the facility failed to provide protective oversight for one resident (Resident #1) who was at risk for elopement, in a review of three sampled residents. The facility assessed the resident as cognitively impaired and at risk for elopement. On 5/13/19 the resident left the facility without staff knowledge and fell down a stairwell in his/her wheelchair sustaining a cervical neck fracture. The facility census was 57. 1. Record review of the facility's Elopement Policy, dated as updated 5/18/18, showed the following: -Purpose: To provide 24 hour protective oversight and maintain an optimal quality of life for every resident. Residents are routinely assessed for cognitive impairment, behavior symptoms or other conditions that may place the person at risk for elopement. Care plans are developed accordingly with an emphasis on prevention of problematic or difficult behavior; -At Risk Protocol: -The pre-admissions screening process should thoroughly evaluate the resident's potential for wandering. Information should be gathered from all available resources. This will be reviewed by the DON or the nurse designee prior to admission utilizing the preadmission screening tool; -Elopement/Wander assessments should be completed upon admission, readmission, quarterly, annually, and with change of condition; -If after assessment the resident is determined to be at risk, and/or verbalizes/attempts to leave the facility, the resident should be placed on 15 minute checks until further evaluation and determination can be completed; -The Charge Nurse will assess the resident for pacing, anxiety, verbalization of discontent, or desire to leave. Findings should be documented on the observation worksheet; -Assign one Certified Nurse Assistant (CNA) to oversee the resident. The assigned CNA must make visual contact with that resident every 15 minutes, and must respond to all door alarms that sound. Residents showing active exit seeking behavior will be placed on 1:1 monitoring. Assign a second CNA to monitor during the primary aides breaks and lunch. The assigned CNA is responsible for notifying both the Charge Nurse and relieving aide when leaving the assigned area. The assignment sheet must reflect the CNA responsible for monitoring. When a resident is placed 1:1 monitoring, an additional staff member will be called in to relieve regular staff back to their normal duty; -Monitoring will continue to be documented on the observation sheet until further evaluation and determination is completed, at which time the Director of Nursing or designee, will review documentation to determine if the resident has been deemed no longer at risk, or if the resident will need to be transferred to a community who can manage the residents exit seeking behaviors by means of a locked unit. The assessment determination must be accompanied by 15 minute monitoring documentation worksheet without verbalization or attempt by the resident to leave the facilty; -The resident's care plan should reflect the potential to wander, with interventions to assist with possibility of future episodes; -After Elopement Occurrence: -After occurrence the resident will be placed on 1:1 monitoring; -Monitoring will continue to be documented on the observation sheet for at least 24 hours, at which time the Director of Nursing or designee, will review documentation to determine if the resident has been deemed no longer at risk or if the resident will need to be transferred to another community with a secured memory care unit. The assessment determination must be accompanied by 24 hours of monitoring without verbalization or attempt by the resident to leave the facility; -The care plan must immediately be updated, reflecting further intervention to prevent reoccurrence. 2. Record review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/24/19 showed the following: -Severe cognitive impairment; -Had no behaviors; -Had not wandered (move around from place to place usually without a plan or purpose) in the last seven days; -Required extensive assist of one staff for transfers; -Dependent on one staff for locomotion on and off the unit; -Had limitation in range of motion to lower extremity on both sides; -Mobility device included walker and/or wheelchair. Record review of the resident's wandering/elopement risk assessment, dated 1/25/19 showed the following: -Physically able to leave the building; -History of wandering in current/previous setting; -Cognitively impaired; -Change in functional status; -Visual/auditory/communication deficit; -Mobile with device; -The resident was at risk for wandering/elopement. Record review of the resident's nurse's notes dated as a late entry 3/29/19 at 1:38 P.M., showed the following: -The resident was found outside of the skilled unit of the facility, unwitnessed at the time; -The resident was alert and oriented to self with periods of confusion noted; -The resident was placed on every fifteen minute checks and will be frequently monitored per staff; -Management made aware. Record review showed no documentation the resident's care plan had been updated to show the resident was at risk for or had eloped from the facility. There was no documentation in the care plan showing the facility planned interventions to prevent an elopement following the 3/29/19 elopement. Record review of the resident's quarterly MDS dated [DATE] showed the following: -Severe cognitive impairment; -Had no behaviors; -Had not wandered in the last seven days; -Required limited assist of one staff for transfers and locomotion on and off the unit; -Had limitation in range of motion to lower extremity on both sides; -Mobility device included walker and/or wheelchair; -Had fallen since the last assessment (2/19/19); -Had two or more non-injury (no evidence of any injury noted on physical assessment by nurse or primary care physician, no complaints of pain or injury by the resident, and no change in the resident's behavior is noted after the fall) falls; -Had one injury (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain) fall. Record review of the resident's wandering/elopement risk assessment dated [DATE] showed the following: -Physically able to leave the building; -History of wandering in current/previous setting; -Cognitively impaired; -Change in functional status; -Visual/auditory/communication deficit; -Does not understand what is being said; -Mobile with device; -Early dementia; -The resident was at risk for wandering/elopement. Record review showed no documentation the resident's care plan had been updated to show the resident was at risk for elopement and no documentation interventions had been put in place to prevent elopement. Record review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Up ad lib (up at one's pleasure). Record review of the resident's nurse's notes dated 5/13/19 at 3:43 P.M. showed the following: -Nurse made aware of the resident being found on the floor related to an unwitnessed fall; -The resident was found on the first landing of the stairwell (off the skilled facility premises); -The resident was lying on his/her right side with two open areas noted to his/her right forehead; pressure applied to stop bleeding; -The resident's right elbow had a skin tear approximately 4.0 centimeters (cm) by 0.3 cm with pressure applied to the bleeding; -The resident was attempting to use the stairs without assistance and fell to the floor; -Called the ambulance to transport to the hospital. Record review of the resident's hospital transfer orders, showed the following: -admitted : 5/13/19; -Expected discharge date : 5/16/19; -Discharge Diagnosis: [REDACTED]. During an interview on 5/28/19 at 10:49 [NAME]M., maintenance personnel A said the following: -He/She was the one that found the resident; -He/She was in the lower level of a building heading towards another building when he/she heard a slight moan; -He/She looked over and saw a wheelchair and the resident laying on his/her side in the assisted living facility; -He/She yelled for help and a nurse arrived; -The nurse called the ambulance. During an interview on 6/11/19 at 8:28 [NAME]M., Certified Nurse Assistant (CNA) B, said the following: -He/She was not aware the resident's whereabouts was being monitored prior to the fall down the stairs; -The resident would self-propel in his/her wheelchair; -He/She denied any knowledge of the resident wandering or eloping. During an interview on 6/11/19 at 8:20 [NAME]M., Licensed Practical Nurse (LPN) A, said the following: -The resident did usually sit out in the television area near the nurse's station in his/her wheelchair and would be in line sight and if not staff would go look for him/her; -The resident did wander and self propelled his/her wheelchair; -He/She knew of no prior elopement attempts by the resident. Observation on 5/28/19 at 10:58 [NAME]M., showed the resident in his/her bed with a neck brace on. Observation on 5/28/19 at 2:00 P.M., showed the following: -The stairwell where staff found the resident was located through two sets of double doors, down two long hallways, and then through another door (off of the assisted living side of the facility), approximately 120 feet away from the skilled unit of the facility. During an interview on 5/28/19 at 3:02 P.M., the Director of Nursing (DON) said the following: -An elopement/wandering risk should be on the resident's care plan; -The resident's whereabouts should be known at all times. During an interview on 5/28/19 at 10:28 [NAME]M. and 3:02 P.M. showed the administrator said the following: -Maintenance personnel found the resident on the first landing of stairwell located off of the assisted living facility; -Through investigation she determined the resident had been let out of the skilled side of the facility into the assisted living by an independent living resident; -No alarms were on the door the resident went through to get to the assisted living side of the building (door coded); -Staff did not know the resident left the skilled facility; -The resident was seen ten minutes prior to being found in the stairwell; -He would have expected the elopement/wandering risk to be on the resident's care plan; -He was new to the facility and did not know the resident was an elopement risk; -All residents' whereabouts should be known at all times. MO 2, MO 2, and MO 7

Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for one resident (Resident #1), of five sampled residents resulting in the resident sustaining a head injury on three occasions. The last fall resulted in a subdural hematoma (brain bleed), requiring hospitalization . The resident returned to the facility on hospice. The facility failed to ensure facility staff used proper technique to transfer one resident (Resident #3), who required staff assistance to transfer safely from surface to surface, by pulling on his/her arms, and without the use of a gait belt (special belt, used to provide assistance during transfer, ambulation, or positioning in a chair). The facility census was 51. 1. Review of the facility's Accidents and Incidents-Investigating and Reporting policy statement, dated April 2013, showed the following: -It was the policy of the facility to provide a safe environment that strives to eliminate hazards and provide adequate care, supervision and assistive devices to prevent accidents; -Upon identification of an occurrence, an incident report will be completed; -The accident and reports will be forwarded to the Director of Nursing for review within 24 hours of the accident/incident; -After review, any additional investigation will be conducted to determine a possible root cause to assist with determining interventions to prevent reoccurrence; -The care plan will be updated with interventions when applicable. 2. Review of the Nurse Assistant in Long Term Care Facility, Student Manual Revised Edition 2001, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; -Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder; -The gait belt increases the comfort and safety of the resident during the transfer procedure; -The gait belt prevents injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist; -The gait belt is to be applied snugly around the resident's waist, over clothing below the ribs so the nurse assistant may grasp the belt securely. The belt must be applied securely to prevent it from sliding above the resident's waist; -If a resident is non-weight bearing the Certified Nurse Assistant (CNA) should transfer him/her using a mechanical lift; -Procedure for one person transfer from bed to chair and chair to bed showed instructions to place your hands underneath the gait belt. 3. Review of the facility's policy and procedure for Safe Lifting and Movement of Residents, undated, showed the following: -Policy statement: In order to protect the safety of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Policy interpretation and implementation: Residents safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -The use of gait belts are required to aid the direct care staff in a one or two- person assisted transfer. 4. Review of Resident #1's Admission Evaluation and Interim Care Plan dated 1/9/16, showed the following: -[DIAGNOSES REDACTED]. -The resident was alert, pleasant and cooperative; -No behaviors; -Assist with transfers, walking, toileting and locomotion; -Side rails; -Not able to balance while standing, sitting or during transition without physical help; -Ambulated with problems and with devices; -High risk for falls. Review of the Social Service note, dated 1/11/16 at 10:30 A.M., showed the facility received lots of calls from the resident's apartment (previous living arrangements), to pick the resident up after he/she fell . The resident was moved to the skilled nursing portion of the facility and the staff was surprised at his/her decline. He/she had lost the ability to transfer and ambulate independently over the last six months. Review of the resident's nurse's note, dated 1/13/16 at 5:45 A.M., showed the resident yelled for help, the CNA (Certified Nurse Assistant), found the resident in his/her room sitting in an upright position on the floor by the head of the bed. One side rail was up and it appeared the resident climbed over the side rail. The resident denied having a fall. Review of the resident's Fall Scene Investigation Report provided by the Director of Nursing(DON), dated 1/13/16 at 5:45 A.M., showed the following: -The resident was found on the floor (unwitnessed) in his/her room; -The resident was attempting a self-transfer prior to the fall; -The resident was alone and unattended; -The resident said he/she was trying to get out of bed just before the fall; -The resident was confused and anxious prior to the fall, which was normal behavior; -The resident had socks on and had no gait assist devices at the time of the fall; -Vision contributed to the fall, the resident was blind; -There was no alarm being used at the time of the fall; -The fall occurred next to transfer surface (assess postural hypotension- a drop in blood pressure when moving to one position from another); -Root cause of the fall was footwear, mood or mental status and vision or hearing; -The resident was blind, the bed was in a high position, the resident was confused and anxious; -Initial interventions to prevent future falls was to place the bed in low position, more frequent checks and call light in reach. Review showed no updates to the resident's interim care plan following the fall on 1/13/16. Review of the resident's nurse's note, dated 1/15/16 at 6:00 A.M., showed the nurse observed the resident sliding out of his/her recliner. Review of the resident's Fall Risk Evaluation, dated 1/15/16, showed the resident had one fall on 1/15/16 and a total score of 9 (10 or higher is at risk for falls). Review showed no updates to the resident's care plan following the fall on 1/15/16. Review of the resident's admission Minimal Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/20/16, showed the following: -[DIAGNOSES REDACTED]. -Long and short term memory problems; -Sometimes made self-understood; -Sometimes understands; -He was independent with activities of daily living; -Two falls since admission; -Severely impaired cognitive skills for daily decision making. Review of the resident's care plan, undated, showed the following: -The resident had a previous fall; -Fall risk factors present as determined by Fall Risk Screen; -Fall Risk Scores: 1/15/16 score 9 (10 or higher was at risk for falls), 1/27/16 score 20 (10 or higher indicated risk for falls); and 3/23/16 (10 or higher indicated at risk for falls); -Functional problem: Weak eye sight; -Normal progression of disease process with unavoidable or predicable decline; -The resident will not sustain a fall related injury by utilizing fall precautions through next review date 4/6/16; -Use fall risk screen to identify risk factors; -Provide/monitor use of adaptive devises: wheelchair; -Remind resident and reinforce safety awareness: Educate/remind resident to request assistance prior to ambulation; -Resident had impaired cognitive skills, short and long term memory problems and problem understanding others; -Resident was at risk of developing complications related to the needing of total assistance with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing; -Nursing staff to provide all activity of daily living care to ensure daily needs are met. Review of the resident's nurse's note dated 1/27/16 at 4:10 P.M., showed the resident was found on the floor by a certified nurse aide (CNA) who said the resident was leaning forward in his/her wheelchair and fell to the floor. He/she had a laceration above his/her right eye with a bump and increased swelling. His/her left lower leg was reddened. He/she was sent to the emergency room for an evaluation. Review of the resident's physician history and physical, dated 1/27/16, showed the resident fell from the wheelchair onto the floor face down hitting forehead to ground, hematoma (pooling of blood outside a blood vessel), to right forehead and small superficial laceration above eyebrow. Send to emergency room for a CT (a picture of the inside of a part of your body that is made by a computerized machine), of the head secondary to head injury. Review of the resident's Fall Risk Evaluation, dated 1/27/16, showed the resident had two falls and the total score was 20 (a score of 10 or higher is at high risk). Review of the resident's Fall Scene Investigation Report provided by the Director of Nursing, dated 1/27/16 at 4:10 P.M., showed the following: -fell to the floor and was witnessed in the center circle; -Transferred by staff and slid out/fell from wheelchair; -Assisted per the care plan; -Shoes were on and no gait assist devices at the time of the fall; -Legally blind and an alarm was not being used at the time of the fall; -Last toileted at 4:00 P.M. and was dry; -Given a laxative eight hours prior to the fall; -The resident was being pushed in wheelchair from room to sitting area, when propelling wheelchair the resident put his/her feet out causing him/her to fall forward out of the wheelchair; -Root cause of the fall was placing feet on floor while wheelchair being propelled; -Provided a drop seat wheelchair with foot pedals. The resident's care plan was not updated with interventions, only the fall risk score. Review of the resident's nurse note dated 1/27/16 at 9:15 P.M., showed the resident returned to the facility via ambulance, he/she was alert and confused. He/she had a laceration to his/her right eyebrow. Review of the resident's nurse note dated 2/3/16 at 11:30 A.M., showed a late entry for 1/27/16 showed a CNA was pushing the resident in a wheelchair toward the center circle in view of the nurses station and the resident pushed his/her feet to the floor causing him/her to fall from the chair hitting his/her head on the concrete circle, the resident was sent to the hospital. Review of the resident's nurses' notes showed the following: -On 1/28/16 at 3:00 A.M., staff found the resident on the floor on the mat sound asleep, it appeared he/she rolled out of bed; -On 1/28/16 at 3:00 P.M., staff assisted the resident for transfers; his/her right eye was swollen and reddened related to incident on 1/27/16; -On 1/31/16 at 5:20 A.M., the nurse documented the resident refused to stay in bed throughout the night. At 9:50 P.M. the housekeeper found the resident in his/her room on the floor on top of the mat, he was in a sitting position. At 5:30 A.M., the resident was found down on the floor on top of his/her mat again. Review showed the resident's care plan was not updated following the fall on 1/28/16 and 1/31/16. Review of the resident's nurses' note, dated 2/21/16 at 1:45 P.M., showed the resident was heard by the charge nurse yelling out, Help, help! and the charge nurse found the resident on the floor in front of the recliner. The resident tried to maneuver the chair forward and the chair was all the way in the air. The resident hit the side of his/her head and had a hematoma with redness. Review of the resident's Fall Scene Investigation Report provided by the Director of Nursing, dated 2/21/16 at 1:45 P.M., showed the following: -The factors observed at time of the fall was the equipment malfunction, the chair went up because the resident was unable to work it properly without assistance; -The recliner was up in the air; -The resident was found on the floor in his/her room; -The resident was reaching for something and slid out/fell from the recliner; -Alone and unattended; -The resident said he/she was trying to take a nap; -Shoes were on and didn't have any gait assist devices at time of fall; -Fall occurred next to transfer surface; -Placed in recliner after lunch and attempted to maneuver the recliner and ended up placing the recliner forward, the resident had to have the chair unplugged; -The root cause was the chair needed to be unplugged. Review showed the resident's care plan was not updated regarding the fall on 2/21/16. Review of the resident's nurse note, dated 3/23/16 showed the following: -At 11:30 A.M., showed the resident was in the common area in front of the nurse's station leaning forward and fell to the floor. Pressure was applied to the anterior head to stop the bleeding; -At 1:30 P.M., speech therapy said the resident vomited lunch, the resident was sent to the emergency room . Review showed the resident's care plan was not updated following the fall on 3/23/16. Review of the resident's Fall Scene Investigation Report provided by the Director of Nursing, dated 3/23/16 at 11:30 A.M. showed the following: -At the time of the fall the resident the resident lost their balance; -He/she had a witnessed fall to the floor in the common area; -Reaching for something and slid out/fell from wheelchair; -Didn't know what the resident said he/she was trying just before the fall; -The resident had a gait assist device at time of fall but was not in use; -Vision or hearing contributed to fall and unable to see what he/she was reaching for; -The fall occurred next to a transfer surface; -Balance was the root cause of the fall; -Initial interventions to prevent future falls was to keep the resident in view of the staff. The resident's care plan was not updated with interventions only included the fall risk score, which showed the resident was at risk for falling. Review of the resident's Fall Risk Evaluation, dated 3/23/16, showed a score of 20 (10 or higher is at risk for falls). Review of the resident's physician progress notes [REDACTED]. Bleeding was controlled. He/she had one episode of vomiting one hour later. If the resident throws up one more time, send to the emergency room for CT of the brain. Addendum-resident will be sent to emergency room for CT of brain secondary to fall/nausea/vomiting. Review of the resident's physician progress notes [REDACTED]. The resident vomited one hour later after fall, not sure if the vomiting was related to fall. The resident was sent to the ER for CT of the brain. The care plan was not updated. Review of the resident's hospital's consultation report, dated 3/23/16 at 10:45 A.M., showed the following: -Resident had an intracranial hemorrhage (a type of bleeding that occurs inside the skull) following a fall; -He/she was in a wheelchair today and would reach forward for something and fell striking his head on the concrete floor; -He/she had a laceration of his/her scalp; -Vomited soon, thereafter, and was sent to the emergency room ; -A CT scan showed a small interhemispheric (between two hemispheres), subdural hematoma (usually occurs after head trauma, constitute a rare type of subdural hematoma (a collection of blood outside the brain and usually caused by severe head injuries); -The resident complained of a headache in the region of the scalp laceration. Review of the resident's nurse note, dated 3/28/16 at 2:30 P.M., showed the resident was readmitted to the facility from the hospital with hospice care and a [DIAGNOSES REDACTED]. No verbal response but responded to painful stimuli. Received hospice evaluation. Review of the resident's interim care plan; dated 3/29/16, showed the following: -Hospice for end of life care; -Sensory alteration: Visual Function Loss related to cranial hemorrhage; -Communication impaired related to cognitive impairment and cranial hemorrhage; -Anticipate/provide needs; -Explain all procedures prior to start; -Assess the source/extent of impairment; -Will be free of injury (no approaches); -Will remain safe in environment; -Self-care deficit, dependent related to cognitive impairment and mobility deficit. During interview on 4/11/16 at 11:20 A.M., Licensed Practical Nurse (LPN) B said the resident kept saying I want to die and would flip forward out of his/her chair. If staff placed him/her in a recliner he/she would try to go over the side. The resident would say I want to die, why am I still here? When the resident tried to get out of his/her chair staff would remind him/her to sit back and he/she would say I want to die. The facility did everything they could he/she was just determined to hurt him/herself. One time he/she fell into the brick wall and LPN B helped him/her back into the recliner and he/she would continue to lean forward. During interview on 4/13/16 at 11:52 A.M., Registered Nurse (RN) C said they would catch the resident trying to pick things up off the floor and would place him/her back in the recliner. The fall packet was to be filled out after every fall. The care plan may not be updated if there was no new intervention. The fall assessment was in the chart with the date and any assessment or change in condition. During interview on 4/11/16 at 12:18 P.M., the Director of Nursing said he/she expected staff to complete a fall scene investigation report after each resident's fall, which was not part of the resident's medical record, to provide a root cause analysis and interventions to prevent reoccurrence. The interventions should be on the care plan. He/she never seen the Resident #1 walking, he/she had multiple falls when he/she resided in his/her apartment prior to admission to the skilled nursing facility. During interview on 4/14/16 at 2:30 P.M., the Director of Nursing said when a resident falls the nurse was to do an assessment and document a narrative nurses note in the resident's medical record regarding the fall. They were to complete a fall scene investigation report, which was not part of the resident's medical record, and place the interventions for the fall on the care plan. The falls were reviewed in stand up meetings and administration would let the nursing staff know of new fall interventions. 5. Record review of the Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/11/15 showed: -Severely impaired cognition; -Required limited staff assistance of one for transfers; -Not steady, only able to stabilize with staff assistance while moving from seated to standing position; -Not steady, only able to stabilize with staff assistance during surface to surface transfer; -Two or more falls. Review of the resident's care plan, dated 11/30/15, showed the resident had an activities of daily living deficit and he/she was to be transferred with one staff assist and the use of a gait belt. Observation on 4/11/16 at 5:35 A.M. showed the following: -Resident #3 lay in bed on his/her back; -CNA A sat the resident up on the side of the bed; -CNA A transferred the resident from his/her bed to the wheelchair by hooking his/her right arm under the resident's left arm and pulled the resident up pulling under his/her arms and with his/her left hand pulling on the back of the resident's pants. CNA A then placed the resident in his/her wheelchair; -The CNA did not use a gait belt; -The CNA rolled the resident in his/her wheelchair to the bathroom and had the resident hold on to the grab bar while he/she lifted him/her up by the back of the pants turning the resident toward the toilet; -The CNA did not use a gait belt. During interview on 4/11/16 at 12:18 P.M., the Director of Nursing said he/she expected all staff to use gait belts when transferring a resident. During interview on 4/14/16 at 2:25 P.M., the administrator said he/she expected staff to follow the facility's fall and transfer guide policy and procedure. MO# 0

Based on observation, interview, and record review, the facility failed to provide safety and adequate monitoring to prevent elopement and falls, one resulting in a hip fracture, and failed to evaluate and modify one resident's (Resident #1) care plan with appropriate interventions as necessary to reduce the risk of future falls and elopement, in accordance with current standards of practice, in a review of three sampled residents. The facility census was 60. 1. Record review of the facility's elopement policy provided by the Director of Nursing (DON) revised November 2010, showed the following: -Staff shall investigate and report all cases of missing residents; -Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or Director of nursing (DON); -If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving, get help if needed, instruct other staff member to inform the charge nurse or director of nursing; -When a departing individual returns to the facility , the director of nursing or charge nurse staff shall examine the resident for injuries, notify the attending physician, notify the resident's legal representative, complete and file an incident/ accident report, and document the incident in the resident's chart; -If an employee discovers that a resident is missing he/she shall determine if resident is on leave or pass; -If the resident is not on leave or pass but is missing the staff member should initiate a search of the building and premises; -When the resident returns to the facility, the Director of Nurses (DON) or charge nurse shall examine the resident for injuries, contact the attending physician, notify the resident's legal representative, notify the search teams, and document relevant information in the resident's medical record. 2. Record review of the facility's undated Elopement Risk Assessment policy provided by the DON showed the following: -All skilled nursing facilities are required to conduct comprehensive resident assessments at specific intervals during the resident's stay; -The goal of each assessment is to illicit specific information from the resident to ensure an effective, individualized plan or care that can be initiated and evaluated; -It was suggested that the assessments be completed at preadmission, upon admission, quarterly, and with any new behavior related to exit seeking activity. NOTE: The first few weeks of admission, change in diagnosis/condition, or a special event seem to be the higher risk time frames for elopement. 3. Record review of the facility's falls and fall risk, managing policy revised December 2007, provided by the DON, showed the following: -The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff, with the input of the attending physician will identify appropriate interventions to reduce the risk of falls; -If falling recurs despite initial interventions staff will implement additional or different interventions or indicate why the current approach remains relevant; -Staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable; - In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 4. Review of Resident #1's Admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/26/15 showed the following: -Brief Interview for Mental Status (BIMS) score of four (0-7 indicated severely impaired cognition); -No delusions, hallucinations, rejection or care, behaviors, or wandering; -Total dependence on two or more staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Total dependence on one staff for locomotion on the unit; -Always incontinent of bowel and bladder; -History of falls in the last month; -History of falls in the last six months without fracture. Review of the resident's undated falls care plan showed the following: -He/she had a [DIAGNOSES REDACTED].>-He/she was at risk for falls; -He/she had previous falls; -He/she had impaired mobility and used a wheel chair; -He/she would be free from fall injuries by utilizing fall precautions (not described) until the care plan review date of 4/27/15; -Fall interventions: low/platform bed, call light within reach (resident assessed with [REDACTED]. Review of the resident's nurse's notes dated 3/13/15 at 3:26 P.M. showed the following; -The resident was readmitted to facility; -[DIAGNOSES REDACTED]. -He/she was a fall risk; -Was to have staff supervision while up in chair, low bed with mats; - Required assist of one staff with transfers and ADLs (activities of daily living); -Propelled self in wheel chair. Review of the resident's nurse's notes dated 3/13/15 at 4:27 P.M. showed the following; -The resident propelled self throughout the facility; -Staff placed a wanderguard on the resident because he/she was identified to be an elopement risk. Review of the resident's nurse's notes dated 3/13/15 at 7:26 P.M. showed the following; -At 5:00 P.M., staff observed the resident on the floor in his/her room complaining of severe right hip pain upon movement and touch; -The staff assessed the resident's right leg and it appeared shorter than the other with no other apparent injuries; -The staff notified the physician; -The staff received orders to send the resident to the emergency room for evaluation and treatment with an x-ray of his/her right hip; -The resident was transferred by ambulance to the emergency room ; -The resident's representative was notified of incident and transfer. Review of the undated fall log, provided by the Director of Nurses (DON) showed the resident fell from his/her wheelchair, he/she self propelled him/herself to his/her room during an emergency and fell . Staff sent the resident to the emergency room . During an interview on 4/15/15 at 5:25 P.M., the DON said the resident wheeled him/herself back to his/her room and fell while facility staff were attending to another resident who coded elsewhere in the facility. Review of the resident's MDS discharge assessment with return not anticipated dated 3/13/15 indicated an unplanned discharge as a result of a fall with a major injury. Review of the fall log document, provided by the DON, showed the resident was readmitted to the facility on [DATE] with fall interventions of low bed, floor mats, and tilt in space wheelchair. Review of the resident's undated fall care plan showed no evidence the facility staff re-evaluated the care plan or added interventions to reduce the risk of future falls after the resident's fall on 3/13/15. Review of the resident's medical record showed no documentation of the resident's readmission or of an admission assessment of the resident, on 3/18/15. During an interview on 4/17/15 at 10:03 A.M., the DON said the nurses should document the admission assessment in the nurse's notes. Review of the undated document labeled fall log provided by the DON showed the resident fell out of bed on 3/20/15. The fall intervention was to put the resident in a chair while he/she was awake. Review of the resident's nurse's notes dated 3/20/15 at 1:50 A.M. showed the following: -Staff found the resident on the floor sitting on the mat with his/her back leaning against the bed; -The staff noted the bed was in low position; -No apparent injuries; -The staff assisted the resident back to bed. Review of the resident's fall care plan (not dated) showed no evidence the facility staff re-evaluated the care plan or added interventions to reduce the risk of future falls after the resident's fall on 3/20/15. Review of the document labeled fall log, undated, provided by the DON on 4/14/15 showed the resident fell out of bed on 3/24/15. The fall intervention for the resident was to put a bordered mattress on the bed. Review of the resident's nurses's notes dated 3/24/15 showed no documentation of the resident's fall and no intervention of bordered mattress. Review of the resident's fall care plan (not dated) showed no evidence the facility re-evaluated the care plan or added interventions to prevent the risk of future falls after the resident's fall on 3/24/15. Review of the document labeled fall log, not dated , provided by the DON on 4/15/15 showed the resident fell on [DATE]. The fall intervention was for the staff to check on the resident every 15 minutes. Review of the resident's nurse's dated 3/30/15 at 1:19 A.M., showed the following: -At 9:20 P.M., staff found the resident on the floor sitting on his/her buttocks; -The resident had increased pain in his/her right hip and knee; -Staff called the ambulance; -The resident remained on the floor due to increased pain with movement until the ambulance arrived; -Staff notified the resident's spouse; -At 9:35 P.M. the resident was transferred by ambulance to the emergency room . Review of the resident's nurse's notes dated 3/31/15 at 4:20 A.M. showed the following; -Late entry 3/30/15 at 6:30 P.M., the resident was back from the E.R.; -The staff was to check the resident every 15 minutes, the resident's bed was to be in low position and against the wall; -The resident required assist of two staff for all transfers and activities of daily living. Review of the resident's care plan dated 3/31/15 showed the following: -He/she had a [DIAGNOSES REDACTED].>-He/she had difficulty making decisions, understanding others, and with safety awareness; -The staff was to provide consistent routine and safety checks for the resident; -He/she was at risk for elopement related to poor impulse control. Staff failed to document interventions or approaches for the is risk.; -The resident required the staff to cue him/her for bed mobility, walking, and locomotion; -The resident required stand by assist of staff for transfers, dressing, and toilet use; -The resident used a wheel chair; -He/she was at risk for falls; -Fall interventions were low/platform bed, call light within reach, area free of clutter, Rise slowing from lying position to sitting, appropriate footwear, referral to physical and occupation therapy (these are all interventions from the undated Fall Care plan- not new interventions). Staff failed to add every 15 minute checks. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -3/30/15 Wanderguard check every shift for placement and function; -4/4/15 Xanax (antipshycotic) 0.5 mg (milligrams) one tablet every six hours as needed agitation. Review of the document labeled fall log, not dated , provided by the DON on 4/15/15 showed the resident fell on [DATE] and staff brought him/her to commons area until he/she went back to sleep. Review of the resident's nurse's notes dated 4/3/15 at 2:13 A.M., showed the following: -The resident was up in a wheelchair, propelling self; -The resident tried to get out of the chair; -The resident refused care and was non-compliant; -The resident was confused. Review of the resident's nurse's notes dated 4/3/15 at 11:17 A.M., showed the following: -The resident up in the wheelchair; -The resident was alert and oriented times one; -The resident was cooperative; -The resident was on fall precautions; -Pin alarm in place on the resident while in the wheelchair; -Low bed while the resident was in bed. Review of the resident's nurse's notes dated 4/4/15 at 12:50 A.M., showed the following: -Late entry, at 9:50 P.M. on 4/3/15 the staff found the resident sitting on the floor leaning against the bed; -No apparent injuries; -The staff assisted the resident to bed and performed peri-care then assisted the resident to his/her wheelchair; -The resident was currently sitting in his/her wheel chair in the commons area; -The staff contacted the physician at 12:45 A.M. and received a order for Xanax 0.5 mg 1 tab orally every six hours as needed for agitation; -The staff pulled the Xanax and gave the resident a Xanax; -Staff failed to document the description of the resident's behaviors which indicated the use of the Xanax and the effect of the medication for the resident. Review of the resident's nurse's notes dated 4/4/15 at 12:49 A.M., showed staff gave the resident Xanax 0.5 mg, one tablet by mouth. Review of the resident's care plan dated 3/31/15 and the resident's fall care plan (not dated) showed no evidence the facility re-evaluated the care plan or added interventions to prevent the risk of future falls after the resident's fall on 4/3/15. Review of the document labeled fall log, not dated , provided by the DON on 4/14/15 showed the resident fell on [DATE] after eloping from the facility. No fall intervention documented for this fall. Wanderguard changed for elopement. Review of the resident's nurse's notes dated 4/6/15 at 5:17 A.M., showed the following: -Late entry for 12:20 A.M. staff found the resident outside the building out the front doors and gate; -The resident was found out of his/her wheelchair on his/her hands and knees on the ground; -The staff was to keep monitoring; -Staff gave the resident Xanax; -At 5:00 A.M. the resident was asleep in his/her room. Review of the resident's nurse's notes dated 4/6/15 at 7:25 A.M. showed staff reported the incident to the resident's spouse and physician. Review of the typed investigation form dated 5/10/15 (wrong date should of been 4/10/15) provided by the DON, showed the following; -The resident was found outside the facility's front door on 4/5/15 at approximately 12:20 A.M.; -The resident did not sustain any injury; -The physician was notified; -The risk for the incident was identified on care care plan; -There were elopement interventions in place on the care plan; -The new intervention put in place was to apply a different type of wander guard device; -Contributing factors for the resident's elopement were that the resident could remove his/her wander guard; -The resident was considered an elopement risk prior to the incident; -He/she utilized a wander guard bracelet, was on every 15 minute checks, and was encouraged to stay in commons area except during care and sleeping; -Staff checked on the resident at 12:00 A.M. at approximately 12:13 A.M. the charge nurse returning from down the hall noted the resident was not located at the desk where she had left him; -The staff started a search for the resident; -A unidentified Certified Nurse Assistant (CNA) proceeded out the front doors and noted the resident with his/her wheel chair stopped on the drive less than 20 feet from front door; -Staff assisted the resident back in to the facility; -Staff applied a new wander guard to the resident (the new wander guard required a tool to remove it ) and continued with every 15 minutes checks for the resident. Review of the document labeled every 15 minute checks for the resident provided by the DON showed staff failed to provide the every 15 minute check forms for 4/5/15 to 4/8/15 (during the time the resident eloped from the facility). Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2015 showed that staff failed to document application, checks, and function of the resident's wanderguard ordered on [DATE]. Review of the resident's care plan dated 3/31/15 and the resident's fall care plan (not dated) showed: -Staff added intervention 4/5/15 the resident eloped related to stroke, dementia, and [DIAGNOSES REDACTED]; -Monitor resident for following, visitors in the building, use verbal and if necessary physical cues for redirection, seek referral for mental health evaluation as needed, reassure the resident when distressed, use discrete resident identifiers so staff are aware of the resident's elopement risk; -Reassess elopement risk quarterly; -Facilitate resident to call close family/friend for reassurance when exit seeking behaviors occur; -4/5/16 wanderguard changed; -The care plan showed no new evidence that staff assessed or determined new interventions for falls. Review of the resident's nurse's notes dated 4/8/15 at 1:18 A.M., showed the following: -Late entry at 11:00 P.M. on 4/7/15 staff found the resident on the floor (out of wheelchair) in the commons area by the nurse's station; -No apparent injuries; -Physician notified. Review of the resident's care plan dated 3/31/15 and the resident's fall care plan (not dated) showed no evidence staff re-evaluated the care plan or added new interventions to decrease the risk of future falls after the resident's fall on 4/7/15. Review of the document labeled fall log, not dated, provided by the DON on 4/15/15 showed the resident fell from his/her wheel chair on 4/8/15. The new fall intervention put in place was for staff to leave brakes unlocked so the resident could propel self. Review of the document labeled fall log, dated 4/15/15 , provided by the DON showed the resident fell on [DATE] while up ambulating. The fall intervention put in place was for therapy consult. Review of the resident's nurse's notes dated 4/14/15 showed no documentation of the resident's fall on 4/14/15. Review of the resident's nurse's notes dated 4/15/15 at 8:18 A.M., showed the resident remained on observation for the fall he/she had on 4/14/15 at 5:00 P.M. Review of the resident's care plan dated 3/31/15 and the resident's fall care plan (not dated) showed no evidence staff re-evaluated the care plan or added new interventions to decrease the risk of future falls after the resident's fall on 4/14/15. Observation on 4/15/15 showed the following: -The front entrance was a paved drive that sloped down a hill to a grassed area and parking; -At 10:20 A.M., the surveyor entered the facility through the front gate and two double doors; -Upon entrance the door alarm sounded; -The surveyor passed physical therapy and the MDS/Care plan coordinators office; -The surveyor stopped at the nurses station on right of the hall; -Registered Nurse (RN) A was at the nurse's station looking at a computer and a chart (He/she did not look up or acknowledge the alarm. No staff from therapy or the MDS/Care plan coordinator office acknowledged/checked on the alarm); -At 10:23 A.M., the surveyor introduced him/herself; -At 10:24 A.M., RN A went to the front doors walked outside and walked back in and turned off the alarm; -At 10:25 A.M., an unidentified male went out the front doors and the alarm sounded; -RN A was on phone trying to get hold of the DON or administrator; -At 10:28 A.M., RN A went to front doors and then went outside and talked to the unidentified male and then came inside and turned off the alarm (no other staff checked on the alarm between 10:25 and 10:28); -At 10:36 A.M., the DON was located and the surveyor started the entrance process. Observation on 4/15/15 at 12:20 P.M. showed the following: -The resident propelled him/her self in his/her wheelchair and an unidentified staff walked next to him/her; -The resident propelled self and ran into the wall multiple times and got stuck; -The unidentified staff redirected and assisted the resident to get away from the wall and the resident continued to propelled him/herself down the hall. During an interview on 4/15/15 at 10:55 A.M., Certified Nurse Assistant (CNA) L said: -A day or two prior to the resident's elopement on 4/5/15, the resident almost eloped out the front doors; -He/she found the resident in between the two front doors; -The door alarms did not go off and the resident did not have a wanderguard on at that time; -He/she was not the resident's assigned CNA, but he/she reported to the resident's assigned CNA; -He/she did not know if the incident was reported to the charge nurse or DON. During an interview on 4/15/15 at 3:00 P.M., CNA D said: -The resident had tried getting out of the facility a day or two prior to the elopement and he/she remembered CNA L saying something about it, but he/she did not report the incident to the charge nurse; -He/she was the assigned CNA for the resident on 4/5/15; -The resident did not have a wanderguard on at that time and had not had a wanderguard on since he/she was readmitted ; -The resident did not have a chair alarm on; -The resident had to sleep in reclined chair in the commons area because he/she was always trying to get up and falling; -The resident was sleeping in his/her recliner in commons area next to the nurse's station; -At 11:50 P.M. he/she told the other staff that he/she was taking a break and left the floor; -At 12:15 A.M. the charge nurse came over to the locked unit (where he/she was taking a break) and asked where the resident was; -The charge nurse and he/she started looking down the halls but couldn't find the resident; -He/she looked outside and found the resident down the hill on his/her stomach, looking up and yelling for help; -The resident's wheelchair was on the edge of the black top and stopped at the edge of the grass; -He/she and the other staff assisted the resident back in his/her wheelchair and took him/her to his/her room to be assessed; -The resident did not have a wanderguard on at the time of assessment and there was no wanderguard on the resident's wheelchair; -The door alarms did not go off when the resident eloped or when staff brought the resident back in; -He/she left the resident in care of the other staff who had been sitting at the nurse's stations (CNA B, CNA H and RN E); -The resident was on every 15 minute checks for falls but that it was impossible to check the resident every 15 minutes when taking care of the other residents. During an interview on 4/15/15 at 11:05 P.M., CNA B said: -He/she was not the assigned CNA for the resident the night the resident eloped; -The resident had been sitting in his/her wheelchair at the nurse's station; -CNA D was the assigned CNA for the resident; -CNA D left the floor at approximately 11:43 P.M. to go to the memory care unit for a break; -He/she started rounds for his/her residents around 11:45 P.M. and the charge nurse went on lunch break; -The charge nurse came back from his/her half hour lunch break and asked him/her where the resident was; -He/she told the charge nurse that the CNA assigned to the resident was in the memory care unit and he/she would need to check with him/her; -CNA D was off the floor for around 35 minutes; -He/she finished rounds and the resident was still missing; -The staff started searching all the halls and rooms for the resident; -CNA D went out the front doors and started yelling, he/she found the resident; -The resident was down the hill from the front doors; -The resident appeared to have rolled down the hill and fell out of the wheelchair; -Staff found the resident face down in the grass and he/she was yelling for help; -CNA D, CNA B and RN E went to help the resident back in his/her wheelchair; -The door alarms did not sound when the resident eloped or when staff brought him/her back in the facility; -The resident did not have a wanderguard on prior to the incident; -He/she had been assigned the resident prior to the elopement and never saw a wanderguard on the resident during cares. During an interview on 4/16/15 at 10:28 A.M., CNA H said: -He/she worked the night the resident eloped; -He/she was not the assigned CNA for the resident or the resident's hall; -Some time after midnight on the night the resident eloped RN E contacted all the staff because the resident was missing; -The staff started looking for the resident in all the rooms; -CNA D found the resident outside; -He/she, CNA D, and the charge nurse went out the front doors; -The resident was on his/her hands and knees in the grass trying to get back in his/her wheel chair; -The staff put the resident back in his/her wheel chair and took the resident back to his/her room; -The alarms did not sound when the resident eloped or when staff brought the resident back into his/her room; -The resident did not have a wanderguard on the night of the elopement and the wheelchair did not have a wanderguard on it; -The resident was a serious fall risk; -The resident fell all the time; -The resident tried to get up all the time and tried to get into anything and everything he/she could find; -The resident had difficulty communicating; -The resident needed one on one care; -The resident required more help than staff could provide and take care of the other residents. During interview on 4/16/15 at 12:45 A.M., CNA I said: -He/she was not assigned to the resident the night he/she got out the front doors; -The resident sat in the commons area in his/her wheel chair around 11:45 P.M. the night the resident went missing; -The resident was combative with cares and had been propelling self up and the halls that night; -He/she started round around 12:00 A.M.; -Around 12:45 A.M., CNA D contacted all staff because the resident was missing and the staff started a search; -CNA D found the resident outside in the front on the grass; -He/she did not hear any alarms go off that night. During interview on 4/16/15 at 11:20 A.M., Licensed Practical Nurse (LPN) G said: -He/she was at lunch when the resident went missing; -He/she never worked with the resident; -RN E came in to the lunch room to report the resident was missing; -He/she did not hear any alarms go off that night. During interview on 4/19/15 at 11:20 P.M., RN E said: -He/she was the charge nurse for the resident the night of 4/5/15 when the resident eloped; -The resident was sitting in a wheel chair in the commons area around 11:50 P.M. on 4/5/15; -He/she went to lunch around 12:00 A.M. on 4/6/14; -She left the resident with a CNA when he/she went to lunch at 12 :00 A.M. on 4/6/15,but he/she could not remember which CNA; -When he/she returned from lunch which was approximately 15 minutes long, the resident was missing; -He/she found CNA D back on the unit; -He/she and CNA D began a search for the resident; -CNA D found the resident outside on grass face down; -The resident had to go through two double doors and a closed gait to get to the grassed area in front of the facility; -The staff assisted the resident back in his/her wheelchair and brought the resident back into the facility; -The resident had no injuries; -The door alarms did not go off when the resident went out the front doors or when staff brought him/her back through the doors; -The resident did not have a wanderguard on him/her; -The wheelchair did not have a wanderguard on it; -The resident was on 15 minute checks because he tried to get up and fell ; -He/she did not check the resident for a wanderguard prior to the incident; -The resident had never tried to get out of the building prior to him/her going missing; -The resident kept trying to get out of the chair and was agitated after the elopement; -He/she administered Xanax to the resident to help calm him/her down; -He/she did not apply a wanderguard to the resident after the elopement; -He/she notified the DON, the physician and the resident's spouse of the elopement around 6:00 A.M. on 4/6/15. During an interview on 4/15/15 at 12:31 P.M., RN N said: -The resident was confused and tried to get out of the facility; -The staff checked on the resident periodically; -The resident had a wanderguard on; -The alarms go off when the residents with wanderguards get to close to the door; -The alarms is loud and it also pages the staff through the beepers to tell the staff what door and which resident is trying to elope; -The wander guards are checked every shift by taking the resident with a wanderguard close to the door and listen for the alarm; -He/she had never put a wanderguard on a resident; -He/she did not normally document the wanderguards; -Some residents get put on every 15 minute checks by staff and kept in the commons area for falls; -The charge nurse and the aide were both responsible for the every 15 minute checks and documentation; -The paper work for the every 15 minute checks was normally on the clip board and his/her clip board did not have the paper work on it; -He/she had been off for a few days and was not aware of any residents on every 15 minute checks at this time. During an interview on 4/15/15 at 4:20 P.M., the staffing coordinator (CNA C) said; -He/she was responsible for applying wanderguards on the residents; -He/she did not document when he/she applied wanderguard to the resident; -He/she did apply a wander on the resident but it was removed prior to his/her being transferred to the hospital on [DATE]; -He/she did not apply a wander guard on the resident when the resident returned from the hospital and was not sure who did; -He/she was responsible for changing the wanderguard's batteries for all residents; -The computer system would alert him/her when the wanderguards needed new batteries; -The resident had a watch wanderguard prior to leaving for the hospital and after his/her eloped but he/she was not sure what kind if any wanderguard was applied after the resident return from hospital prior to the elopement; -There were two types of wanderguards. The black elastic which was usually put on the wheelchairs and the watch wanderguard which was put on a resident's wrist with an allyn wrench; -The wanderguards have to be activated on the computer system; -The system did not keep track of the resident's wanderguard application or activation; -There was no documentation in the computer system to show when the resident had a wanderguard activated or applied; -He/she would keep track of the wanderguards on the residents in his/her head. During an interview on 4/15/15 at 1:00 P.M., RN N said: -He/she was not aware the resident was on every 15 minute checks; -He/she was not given the information in report; -The DON just informed him/her about the every 15 minute checks; -The resident had been on every 15 minute checks but then he/she thought the checks were stopped; -The resident was on every 15 minute checks because of the recent elopement and falls; -The resident should also have a mat on the floor beside his/her bed. During an interview on 4/15/15 at 3:15 P.M., RN N said: -Any nurse can put on the wanderguard; -He/she did not apply the resident's wanderguard or any other resident's wanderguard's; -CNA C normally applied the wanderguards on the day shift; -He/she was not aware of any other instances when the resident actually got out of the facility; -The wanderguard checks were not always put on the MAR or TAR; -He/she was not sure who was responsible for putting wanderguard checks on the MAR or TAR; -Staff just know what residents have wanderguards.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) who required the assistance of two persons to transfer of five residents sampled was transferred in a safe manner. The facility assessed the resident required extensive assistance of two staff for transfers. The facility did not update the resident's care plan to show the resident required the assistance of two persons for transfer. On 9/27/14, the resident sustained [REDACTED]. Following the incident, the physician directed two staff transfer the resident and the facility updated the resident's care plan regarding the transfer. On 10/8/14, one staff transferred the resident without assistance. The resident complained of leg pain following the improper transfer. The facility census was 58. 1. Review of the facility's policy for safe lifting and movement of residents dated February 2014 showed: -Policy statement; to protect the safety and well being of staff and residents, and to promote quality care; this facility uses appropriate techniques and devices to lift and move residents; -Policy interpretation and implementation; resident safety, dignity, comfort and medical condition will be incorporated into the goals and decisions regarding the safe lifting and moving of residents; manual flitting residents will be eliminated when feasible; nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis and staff will document resident transferring and lifting needs in the care plan; such assessments include resident's preference for assistance, resident's mobility (degree of dependency), resident's size, weight bearing status, cognitive status, whether the resident is usually cooperative with staff, and the resident's goals for rehabilitation. 2. Review of Resident #1's admission minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 5/12/14 showed: -He/she had a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). -He/she required extensive assistance of one staff with transfers. Review of the resident's care plan dated 5/13/14 showed: -Problem; falls/history of falls; -He/she needed assistance with bathing, dressing, and activities of daily living (ADL); -Goals; safe environment and manage likelihood of a fall; -Interventions did not include a transfer method. Review of the resident's significant change MDS dated [DATE] showed: -The resident had a brief interview for mental status (BIMS) score of 9 (moderate cognitive impairment). -He/she required extensive assistance of two staff with transfers. Review of the resident's care plan dated 5/13/14 showed the facility did not update the care plan to show the resident required extensive assistance of two staff with transfers. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes dated 9/28/14 at 4:25 A.M. showed he/she had a 14 centimeter (cm) laceration to the left lower extremity repaired with 30 sutures and dermabond (skin adhesive) at an outside facility. Interview on 10/8/14 at 7:20 P.M. showed the resident said he/she injured her/his leg on the bed when staff was assisting her/him to bed. Interview on 10/8/14 at 6:30 P.M. showed CNA (Certified Nurse Aide) A said: -The resident was a one person assist because he/she could walk; -He/she applied a gait belt and began the transfer, but stopped when the resident screamed out, "Ow, ow, ow!"; -He/she noticed bleeding from the resident's left leg; -He/she did not recall the resident hitting the bed, but noted blood residue on the bed frame portion of the bed; -The resident's transfer status was changed to a two person assist after the accident. Interview on 10/8/14 at 6:15 P.M. showed the director of nursing (DON) said: -The CNA was assisting the resident from the Broda (specialized chair to tilt/recline) chair to the bed when the resident began to call out in pain; -The CNA noted a gash on the resident's leg with profuse bleeding; -The resident was transported to the hospital for treatment; -An investigation was conducted which showed no apparent cause of the injury. Review of the registered nurse (RN) investigation dated 9/27/14 showed the resident suffered a skin injury which involved a large laceration with bleeding to the left lower extremity during a staff transfer on 9/27/14 at 7:15 P.M. Review of CNA A's written statement (from the 9/27/14 RN investigation) dated 9/27/14 at 6:45 P.M. showed: -CNA A started to transfer the resident from the gerichair to the bed; -He/she immediately stopped the transfer when the resident yelled out in pain; -CNA A noticed the resident had a large open area on the left leg with bleeding to the floor. Review of the Registered Nurse (RN) F's written statement (from the RN investigation) dated 9/27/14 showed: -On 9/27/14 at 7:15 P.M., the CNA came out of the resident's room and yelled for help; -The RN entered the resident's room and found the resident sitting on the side of the bed with a large laceration to the left outer calf (lower leg) and a large amount of blood on the floor; -The RN observed the resident's leg had yellow adipose (fat tissue) tissue and muscle exposed; -Emergency medical response was called to transport the resident to an outside facility for evaluation and treatment of [REDACTED]. -At 7:30 P.M., the resident was transported to an outside facility for medical treatment. Review of the resident's emergency room discharge instructions from an area hospital dated 9/27/14 showed: -His/her [DIAGNOSES REDACTED]. -Tests/procedures while in the emergency room included irrigation of the wound, suture tray, and application of a sterile dressing; -Change dressing (wet to dry) three times daily for the next ten days; -Norco 5/325 milligrams (mg) (narcotic pain medication); one tablet every six hours as needed for pain. Review of the resident's POS showed a physician's orders [REDACTED]. Review of the RN investigation report (regarding the resident's injury during a transfer on 9/27/14) showed the facility initiated interventions on 10/5/14 to prevent future skin injury occurrences to the resident including increasing assistance from one person to two person assistance with transfers. Review of the resident's care plan dated 5/13/14 showed the care plan was not updated to reflect the changes to the resident's transfer status until 10/5/14. Observation on 10/8/14 at 7:20 P.M., showed: - The resident seated in a Broda chair awaiting assistance to bed; -The call light was placed on the bed out of the resident's reach; -The resident's left lower leg with a dressing; the leg was edematous and red; -The right leg had a dressing due to stasis ulcers (a change in the skin when blood collects or pools in the veins of the lower extremities). Observation on 10/8/14 at 7:30 P.M., showed: -The resident sitting on the edge of the bed with a gait belt around him/her; -CNA B standing beside the resident; -The resident complained of his/her legs hurting, which he/she described as worse than having a baby. Interview on 10/8/14 at 7:30 P.M. showed CNA B said he/she lifted the resident from the chair to the bed (by him/herself) because the resident wanted in bed. Interview on 10/22/14 at 2:20 P.M., showed CNA B said: -He/she was called to the resident's room to assist the nurse, but was told to wait because the surveyor wanted to observe the transfer; -The resident wanted to go to bed; -The resident was a one person transfer the last time he/she cared for the resident (date unknown); -He/she performed a one person transfer; -He/she did not normally take care of the resident and was unaware the resident was a two person transfer until after he/she had transferred the resident. Interview on 10/8/14 at 5:15 P.M. showed CNA C said: -The resident was a one person assist because he/she could stand; -The resident had an injury approximately one or two weeks ago; -He/she did not know what happened. Interview on 10/8/14 at 7:30 P.M. showed RN A said the resident was a two person assist with transfers. Interview on 10/14/14 at 3:30 P.M. showed the MDS coordinator said: -The facility's MDS program will trigger care areas to be care planned; -The MDS coordinator reviews the areas and determines whether they need to be addressed on the care plan; -If the MDS indicated a resident required extensive assistance of two staff with transfers, he/she would address the transfer on the care plan; -Resident #1's care plan falls dated 5/14/14 did not indicate a transfer technique to be used; -Resident #1's care plan dated 5/13/14 for activities of daily living function and rehabilitation potential addressed he/she was a two person assist with gait belt for transfers. Interview on 10/22/14 at 9:30 A.M. showed the Director of Nurses said he/she would expect all nursing staff to be familiar with the resident's care plan and perform care as directed on the resident's individualized plan, including the method of transfer a resident required. During an interview on 10/14/14 at 3:48 P.M., the administrator said he/she would expect nursing staff to transfer a resident as specified on the care plan and by the physician. MO 629

Based on observation, interview, and record review the facility failed to assure the safety of one resident (Resident #1), a resident dependent on staff for transfers with a mechanical lift, in a review of three residents. The facility transferred the resident with a Hoyer (mechanical) lift which had not been appropriately maintained. During the transfer a loose and separated plastic cover on a lift leg became lodged under the resident's chair. When staff attempted to dislodge the lift leg by pulling back hard on the lift, the lift tipped and the resident fell to the floor. The resident sustained [REDACTED]. The facility's census was 61. 1. Review of the facility's undated policy on Accident/Incident Report showed the following: - An incident is defined as any happening, not consistent with the routine operation of the long-term facility that does not result in bodily injury or property damage; -An accident is defined as any happening, not consistent with the routine operation of the long-term care facility, that results in bodily injury other than abuse; -All accidents/incidents are reported to physician and family as soon as possible; -When witnessing a resident fall or when a resident is found on the floor and presumed to have fallen, an initial assessment that includes the following will be done: range of motion, full body search, vital signs taken; -The resident should not be moved until the initial assessment is completed; -Notify physician and family as appropriate; -Documentation in clinical notes includes an accurate description of the accident/incident, results of range of motion, body search and vital signs check, notification of physician and family, and remedial measures and/or treatments. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 10/17/12, showed the resident's cognition was intact for daily decision making. The resident required total assist of two or more staff with bed mobility and transfers. [DIAGNOSES REDACTED]. Record review of the resident's care plan, reviewed 11/16/12, showed the following: -Problems: I am unable to care for myself, a fall risk and have potential for pain related to C3-4 spinal injury with paralysis; -Listen to my requests as I can make all my needs known; -Provide with a safe environment and manage the likelihood of falls; -Requires mechanical lift for all transfers and assist. Review of the resident's nurse progress note showed the following: -On 11/27/12 at 8:06 P.M., while being lifted into bed via Hoyer lift, the strap from the wheelchair became tangled in the Hoyer pad. The Hoyer tipped causing the resident to be lowered to the floor. No apparent injuries at that time. The resident was Hoyer lifted into bed safely. Now complains of pain to his/her right hip. No abnormalities noted to right hip at this time. Call placed to the physician, waiting for return call; -On 11/28/12 at 3:34 A.M., the resident complained of severe pain to right hip and leg. Call placed to the resident's physician and orders received to send to the emergency department for evaluation. Review of the resident's physician order [REDACTED]. Fall Precautions. No weight bearing to right lower extremity. Bed to chair transfers as tolerated with Hoyer lift. Record review of the resident ' s history and physical from the hospital, dated 11/28/12, showed the resident was a quadriplegic who was confined to bed and chair. He/she had very little power in his/her legs and minimal power in his/her arms. He/she was usually transferred to and from bed to chair and vice versa using a Hoyer lift. The resident was lifted from his/her chair to bed on the night of admission using a Hoyer lift , but for some reason the lift tipped and he/she was lowered to the floor. The staff prevented the Hoyer lift from hitting. He/she was eventually transferred back to bed. He/she experienced some pain over the right hip but was able to sleep, but when he/she woke early in the morning he/she had severe pain. It was decided to transfer him/her to the emergency room for further evaluation. There was a painful limitation of movements of the right hip which was kept in slight external rotation. In the ER he/she was diagnosed to have an intertrochanteric fracture of the right hip with minimal impaction and displacement. He/she was admitted for further management. Interview on 12/5/12 at 12:00 P.M., showed Certified Nurse Aide (CNA) C said he/she and CNA D were getting the resident up out of his/her wheelchair with the Hoyer lift. They had the Hoyer lift legs under the resident ' s wheelchair and the black strip on the Hoyer lift leg had come up and caused the Hoyer lift to get stuck under the resident's chair. The CNA C had pulled back hard on the Hoyer lift to get the Hoyer lift unstuck, the Hoyer lift shifted over due to the resident's weight, and the resident was swinging in the sling and fell to the floor. CNA D went to get the charge nurse. The charge nurse looked at the resident while he/she was on the floor and asked him/her if he/she was okay. The resident landed on the floor and bounced and he/she kept the Hoyer lift from landing on the resident's knees. CNA D went to get the charge nurse. The charge nurse looked at the resident while he/she was on the floor and asked him/her if he/she was okay. The nurse assistants put the resident back to bed. The resident complained of pain to his/her right groin after he/she was turned to his/her left side. CNA said the resident requested Tylenol and he/she reported this to the charge nurse. CNA C said he/she had told multiple nurses the black strip on the Hoyer lift legs would come up and get caught on the residents' wheelchairs. The problem had never been fixed. This problem occurred with each of the facility's Hoyer lifts. Interview on 12/5/12 at 2:18 P.M., CNA D said he/she was assisting CNA C lifting the resident from his/her wheelchair using the Hoyer lift. CNA C went to the pull the lift out and it was stuck, he/she pulled it again and somehow it went over. The Hoyer lift was tilted over and the resident was falling and CNA D braced the resident and he/she fell to the floor. CNA D went to get the charge nurse. The charge nurse told the nurse assistants to get the resident to bed. When the resident was back in bed he/she complained of hurting to his/her right groin and thigh. Interview on 12/7/12 at 3:45 P.M., showed Licensed Practical Nurse (LPN) A said the nurse assistants told him/her they were lifting the resident out of his/her wheelchair and the strap from the wheelchair got in the way causing the Hoyer lift to tip over. When LPN A was called to the resident's room the resident lay on the floor with the Hoyer pad underneath him/her. LPN A asked the resident if he/she was hurt and he/she said no just my pride. LPN A did range of motion to the resident the best he/she could because the resident was always in pain. The staff used the Hoyer lift to place the resident back in bed. He/she said after the resident was in bed the resident said his/her right hip was a little sore, no pain medication was given at that time. LPN A called the physician. He/she said the physician was always called to let them know what happened. The physician did not call back. LPN A went back to the resident's room at approximately 1:00 A.M. and the resident was sleeping, he/she did not do an assessment at that time. The resident complained of pain at 3:00 A.M. to his/her right leg and hip area. LPN A called the resident's physician and the physician said the facility could have x-rays done or the resident could be sent to the emergency department. LPN A said the resident was in so much pain that he/she was sent to the emergency department. LPN A said the certified nurse assistants should check and make sure the Hoyer lifts are functioning and clear of obstruction prior to lifting the resident. Interview on 12/5/12 at 2:00 P.M., showed the resident said the he/she was sitting in his/her wheelchair and was very tired when the CNA's came in his/her room to help. The Hoyer lift was faulty because he/she remembered the black plastic strip on top of the Hoyer legs being loose. One CNA had him/her in the Hoyer lift and the Hoyer lift was stuck. The CNA jerked it three times and on the fourth jerk the resident was swung to the floor. He/she bounced two times on the floor on his/her right buttocks. One CNA grabbed for the resident and the other CNA grabbed for the Hoyer lift. The resident was way up in the air when he/she swung out in the sling and landed on the floor. The resident was put into bed at 8:15 P.M. or 8:30 P.M. and no one had checked on him/her until 3:00 A.M. Where the Hoyer lift legs open the plastic pieces come off and get caught on his/her wheelchair. This has happened three to four times before, enough times the CNA's should have known better than to jerk him/her loose. After the fall he/she received a note from maintenance saying the strip had been glued down. Interview on 12/5/12 at 12:15 P.M., showed the Director of Nursing (DON) said he/she brought the nurse assistants back in the resident's room to re-enact what happened on 11/27/12 and it was determined it was the rubber tracking strip along the leg of the Hoyer lift. As the CNA's were pulling back on the Hoyer lift the rubber tracking came loose and got stuck on the wheelchair and they lost their balance. He/she hadn't received any reports of the rubber tracking coming loose from the Hoyer lift legs. After the incident maintenance had special tacky glue and applied it to the rubber stripping along the legs of the Hoyer lift and the Hoyer lift was not in use until it was fixed. If the CNA's noticed any problem with the equipment or anything loose they are to let the charge nurse or medical supply know immediately. The Hoyer lifts are checked every shift to make sure they are working properly. Interview on 12/10/12 at 11:15 A.M., showed the Assistant Director of Environmental services said one rubber strip (front leg cover) on top of the Hoyer lift legs had come completely off and the other had come up at the end (from the 11/27/12 incident). He/she had used contact cement glue to place the strip back on to the Hoyer lift legs. He/she did not call the manufacturer to see if glue was recommended to hold the strips in place on the Hoyer lift. He/she checked the next day and the strips were still glued to the legs of the Hoyer lift. Observation on 12/5/12 at 12:15 P.M. showed the surveyor asked the DON to see if the rubber tracking was attached to the two Hoyer lifts the facility currently used. The DON pulled on the rubber tracking on both of the Hoyer's lift legs and the rubber stripping came up on each leg of each lift approximately fourteen inches. The Hoyer lift had been used prior to this observation. Observation on 12/5/12 at 12:45 P.M., showed the Maintenance Supervisor using glue to attach the strips to the Hoyer lift legs and clamps to hold the strip to the Hoyer lift while it dried. Interview on 12/5/12 at 3:20 P.M., showed the DON and Maintenance supervisor said there was no schedule for checking the Hoyer lifts. Staff let them know when something was wrong and they fix it then. Adhesive silicone was used to glue the rubber strip to the Hoyer lift. Interview on 12/10/12 at 8:50 A.M., with a representative of Invacare (Hoyer lift manufacturer),showed he/she said the black strips on top of the Hoyer lift legs are called the front leg covers and they were replaceable. To attach front leg covers to the Hoyer lift a thermal bond double sided tape was to be used. Glue had not been tested therefore was not recommended. The front leg covers could come up and off if there wasn ' t enough clearance for the Hoyer lifts' legs. Complaint #MO