Every finding on record at Woodland Manor Nursing Center

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #134) out of five sampled residents exposed during wound care. The census was 126. Review of the facility's policy titled, Resident Privacy/Dignity/Customer Service, not dated, showed:- Staff will knock on doors before entering a resident's room or ask permission before entering behind curtains and wait for a reply before opening the curtains;- Staff will close curtains completely, window and doors fully during care;- Residents will not be exposed in an embarrassing manner. 1. Review of Resident #134's medical record showed:- An admission date of 11/17/25;- Diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar ), chronic kidney disease (gradual loss of kidney function over time), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), constipation, and obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep due to throat muscles relaxing and blocking the airway). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/04/26, showed:- Cognition intact;- Dependent on staff for dressing, bed mobility, transfers, and toileting;- Always incontinent of bladder and bowel;- Moisture associated skin damage (MASD - skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, or wound drainage). Observation of the resident on 03/25/26 at 11:16 A.M. through 11:39 A.M., showed:- Registered Nurse (RN) J and Certified Nurse Aide (CNA) K entered the room to perform wound care;- RN J closed the door, no curtain available to close for the resident's privacy, and started performing wound care; - At 11:19 A.M., RN J opened the door to retrieve more supplies from a treatment cart and left the door open for several minutes with the resident's buttocks exposed and visible from the hallway; - RN J returned to the room, closed the door, and continued with the resident's wound care;- At 11:26 A.M., RN J opened the door to retrieve more supplies from a treatment cart, left the door open for several minutes with the resident's buttocks exposed and visible from the hallway, and two CNAs walked by the room and looked in; - RN J returned to the room, closed the door, and continued with the resident's wound care;- At 11:28 A.M., RN J opened the door to retrieve more supplies from a treatment cart and left the door open for several minutes with the resident's abdomen exposed and visible from the hallway; - RN J and CNA K failed to provide privacy during wound care for the resident. During an interview on 03/26/25 at 10:15 A.M., RN J said the resident's door should remain closed during wound care for a resident's privacy. During an interview on 03/27/26 at 11:14 A.M., the Director of Nursing (DON) said she would expect staff to always protect a resident's privacy during wound care by pulling the curtain or closing the door. During an interview on 03/30/26 at 9:55 A.M., the Administrator said he would expect a resident's privacy to be protected during wound care.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, before beginning psychotropic (medications that affect the mind, emotions, and behavior) medications for nine residents (Residents #2, #6, #7, #10, #24, #37, #67, #104, and #123) out of nine sampled residents. The facility census was 126. Review of the facility policy titled, Medication Policy and Procedure, dated 02/15/18, showed: - Psychotropic medications include antianxiety, hypnotic (induces sleep), and antipsychotic (medications used to treat psychosis symptoms such as delusions, hallucinations, and paranoia, by regulating brain chemicals) medications; - The physician or psychiatrist will document the discussion with the resident and/or responsible party regarding the risk versus the benefit of the use of medication, including off label use of the medication. 1. Review of Resident #2's medical record showed: - An admission date of 07/14/24; - Diagnoses of major depressive disorder (MDD - a serious mental health condition characterized by at least two weeks of persistent, pervasive low mood, loss of interest, and low self-esteem), anxiety disorder (excessive, persistent fear or worry that interferes with daily life), and bipolar disorder (mood disorder that can cause intense mood swings); - An order for olanzapine (an antipsychotic medication) 5 milligrams (mg) by mouth two times a day, dated 11/26/25; - An order for buspirone (an antianxiety medication) 15 mg by mouth three times a day, dated 11/26/25; - An order for sertraline (an antidepressant medication) 125 mg by mouth one time per day, dated 12/03/25; - No documentation of consent or education of risks and benefits for the olanzapine, buspirone, and sertraline use was provided to the resident and/or their representative. 2. Review of Resident #6's medical record showed: - An admission date of 07/31/25; - Diagnoses of cerebral infarction (stroke) and moderate protein-calorie malnutrition (nutrition problem leading to health issues or weight loss); - An order for mirtazapine (an antidepressant medication also used to stimulate appetite) 7.5 mg by mouth once a day at night, dated 12/05/25; - No documentation of consent or education of risks and benefits for the mirtazapine use was provided to the resident and/or their representative. 3. Review of Resident #7's medical record showed: - An admission date of 02/14/25; - Diagnoses of generalized anxiety disorder and MDD; - An order for bupropion (an antidepressant medication) 200 mg by mouth every 12 hours for MDD, dated 12/01/25; - An order for clonazepam (an antianxiety medication) 0.5 mg by mouth every 12 hours for generalized anxiety disorder, dated 09/09/25; - An order for escitalopram (an antidepressant medication) 10 mg by mouth upon rising for MDD, dated 01/10/26; - No documentation of consent or education of risks and benefits for the buproprion, clonazepam, and escitalopram use was provided to the resident and/or their representative. 4. Review of Resident #10's medical record showed: - An admission date of 08/04/25; - Diagnoses of MDD, anxiety disorder, suicidal ideations (thinking about, considering, or planning suicide, ranging from fleeting thoughts to detailed, active plans), and post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events); - An order for duloxetine (an antidepressant medication) 60 mg by mouth upon rising, dated 01/08/26; - No documentation of consent or education of risks and benefits for the duloxetine use was provided to the resident and/or their representative. 5. Review of Resident #24's medical record showed: - An admission date of 10/30/25; - Diagnosis of MDD; - An order for sertraline 50 mg by mouth once a day, dated 01/16/26; - An order for buproprion extended release (XL) 300 mg by mouth once a day, dated 01/16/26; - No documentation of consent or education of risks and benefits for the sertraline and buproprion use was provided to the resident and/or their representative. 6. Review of Resident #37's medical record showed: - An admission date of 03/06/26; - Diagnoses of anxiety and restless leg syndrome; - An order for hydroxyzine (used to treat anxiety) 50 mg 0.5 tablet by mouth every six hours as needed for anxiety, dated 03/06/26, with no stop date; - An order for clonazepam 0.25 mg by mouth in morning, dated 03/07/26; - An order for buspirone 5 mg by mouth three times a day, dated 03/06/26; - No documentation of consent or education of risks and benefits for the hydroxyzine, clonazepam, and buspirone use was provided to the resident and/or their representative. 7. Review of Resident #67's medical record showed: - An admission date of 03/07/26; - Diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychophysical visual disturbances (visual impairments), and depression; - An order for venlafaxine (an antidepressant medication) 37.5 mg by mouth once a day in the morning, dated 03/08/26; - No documentation of consent or education of risks and benefits for the venlafaxine use was provided to the resident and/or their representative. 8. Review of the Resident #104's medical record showed: - An admission date 03/04/26; - Diagnoses of dementia, bipolar disorder, and unspecified psychosis (a mental disorder with a severe loss of contact with reality); - An order for fluoxetine (an antidepressant) 40 mg by mouth upon rising, dated 03/04/26; - An order for lamotrigine (an antiseizure medication also used to treat bipolar disorder) 200 mg by mouth at bedtime, dated 03/04/26; - No documentation of consent or education of risks and benefits for the fluoxetine and lamotrigine use was provided to the resident and/or their representative. 9. Review of Resident #123's medical record showed: - An admission date of 01/08/22; - Diagnosis of MDD; - An order for duloxetine 30 mg by mouth one time per day, dated 02/19/26; - No documentation of consent or education of risks and benefits for the duloxetine use was provided to the resident and/or their representative. During an interview on 03/27/26 at 1:42 P.M., the Director of Nursing (DON) said she would expect residents to have informed consent for psychotropic medications. During an interview on 03/30/26 at 9:59 A.M., the Administrator said he would expect residents to be informed of risks and benefits of psychotropic medications

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected one resident (Resident #13) out of three sampled residents. The facility census was 126. Review of the facility's policy titled, Medicare Coverage Notification, revised 01/17/18, showed:- When resident's Medicare coverage is coming to an end, the social services designee (SSD) is required to give at least a 72-hour notice of non-coverage to the resident and/or responsible party;- A SNF ABN is provided at least three days prior to discharge and signed by the resident and/or responsible party upon notice of non-coverage if the resident is discharging from Medicare services and remain in facility. 1. Review of Resident #13's medical record showed:- The resident discharged from skilled Medicare services on 11/05/25, and remained in the facility;- The resident's representative received a SNF ABN on 11/04/25;- The facility failed to provide the SNF ABN form to the resident and/or the representative at least two calendar days before the skilled Medicare services ended. During an interview on 03/26/26 at 9:07 A.M., the Director of Social Services said the SNF ABN should have been provided at least two days prior to the last day covered by Medicare. During a phone interview on 03/30/26 at 9:55 A.M., the Administrator said the SNF ABN form should have been provided to the resident and/or the representative at least two days prior to the end of the Medicare coverage.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment. The deficient practice had the potential to affect all residents. The facility's census was 126.Review of the facility's policy titled, Homelike Environment, revised 02/13/21, showed:- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible;- The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting to include a clean, sanitary and orderly environment. Observation on 03/24/26 at 12:30 P.M., of the shower room located at the end of the 100 Hall showed:- The door propped open;- A 4 inch (in.) by 12 in. piece of tile trim missing at the base of the door entry;- A white, plastic shower curtain with a 2 in. by 2 in. brown stain near the top, torn in half, and the bottom half lay in the shower room floor and three hooks missing at the top which caused it to droop;- A 24 in. by 2 in. area of peeling ceiling paint located in the shower room on the left;- A 6 in. by 3 in. area of peeling ceiling paint and a 1 in. by 1 in. hole in the ceiling located in the shower room on the right;- A wheelchair seat cushion lay on the shower floor;- A toilet full of a dark brown liquid with a foul odor;- A toilet seat with stained areas and cracked, peeling areas;- A walker folded up to the right side of the toilet;- Three wheelchair leg rest/foot pedals located on a wire shelf above the left side of the toilet. Observation on 03/25/26 at 8:30 A.M., of the shower room located at the end of the 100 Hall showed:- The door propped open;- A 4 in. by 12 in. piece of tile trim missing at the base of the door entry;- A white, plastic shower curtain with a 2 in. by 2 in. brown stain near the top, torn in half, and the bottom half lay in the shower room floor and three hooks missing at the top which caused it to droop;- A 24 in. by 2 in. area of peeling ceiling paint located in the shower room on the left;- A 6 in. by 3 in. area of peeling ceiling paint and a 1 in. by 1 in. hole in the ceiling located in the shower room on the right;- A pair of soiled pants lay on the floor; - Three wheelchair leg rest/foot pedals located on a wire shelf above the left side of the toilet. Observation on 03/26/26 at 2:20 P.M., of the shower room located at the end of the 100 Hall showed:- The door propped open;- A 4 in. by 12 in. piece of tile trim missing at the base of the door entry;- A white, plastic shower curtain with a 2 in. by 2 in. brown stain near the top, torn in half, and the bottom half lay in the shower room floor and three hooks missing at the top which caused it to droop;- A 24 in. by 2 in. area of peeling ceiling paint located in the shower room on the left;- A 6 in. by 3 in. area of peeling ceiling paint and a 1 in. by 1 in. hole in the ceiling located in the shower room on the right;- A pillow and two wheelchair seat cushions lay on the floor beside the left side of the toilet;- A 2 in. by 3 in. area of brown splatter on the wall to the right side of the toilet;- Three wheelchair leg rest/foot pedals located on a wire shelf above the left side of the toilet;- A plugged-in hairdryer lay in the sink;- An opened bottle of aftershave liquid without a lid sat on the sink. During an interview on 03/27/26 at 10:50 A.M., Certified Nurse Aide (CNA) E said there were two shower rooms on the 100 Hall and staff used both. The shower curtain had been torn for a month or two. If something needed to be fixed or replaced, staff filled out a work order and placed it in the plastic box on the wall. During an interview on 03/27/26 at 10:55 A.M. the Maintenance Director said staff notified him if things need fixed or replaced by filling out work orders and putting them in the box hung on the walls of each hall. He checked the boxes three times a day. During an interview on 03/27/26 at 1:45 P.M., the Director of Nursing (DON) said she would expect shower rooms to be in good repair and to have shower curtains not torn.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer and/or discharge to a hospital, including the reason for the transfer for seven residents (Residents #2, #4, #6, #8, #27, #68, and #73) out of 12 sampled residents. The facility's census was 126. Review of the facility policy titled, Discharge Procedures, undated, showed: - Before transfer or discharge, the facility shall send written notification to the resident in a language and manner reasonable calculated to be understood by the resident; - The notice must also be sent to any legally authorized representative of the resident and to at least one family member; - A copy of the notice will be forwarded to the Department of Health and Senior Services regional office and the regional coordinator of the Missouri State Ombudsman's (advocate for the resident in nursing facilities) office; - The written notice should include the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged . 1. Review of Resident #2's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. 2. Review of Resident #4's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfer and included the reason for the transfer. 3. Review of Resident #6's medical record showed: - Transferred to hospital on [DATE], and returned to the facility on [DATE]; - Transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. 4. Review of Resident #8's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; -The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. 5. Review of Resident #27's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. 6. Review of Resident #68's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. 7. Review of Resident #73's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE]; - No documentation the resident or resident's representative was informed in writing of the transfers and included the reason for the transfers. During an interview on 03/27/26 at 10:18 A.M., Licensed Practical Nurse (LPN) G said he/she was unaware of any official transfer form. During an interview on 03/27/26 at 10:57 A.M., the Social Services Designee (SSD) said he/she filled out the Bed Hold notice and mailed it to the resident's responsible party, but he/she did not fill out the transfer notices. It was the responsibility of the nurse transferring the resident to the hospital. During an interview on 03/27/26 at 2:00 P.M., the Director of Nursing (DON) said nurses were responsible to complete the transfer sheets at time of the transfer and she would expect them to be completed.

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) for four residents (Residents #10, #24, #67, and #104) out of 25 sampled residents. The facility's census was 126. Review of the facility policy titled, MDS Policy and Procedure, dated 02/22/22, showed: - The resident interview must be completed by the MDS coordinator or other specialized disciplines; - A comprehensive review of the resident's medical record will be completed; - Once the resident and staff interviews are completed and the medical record is reviewed, the MDS assessment section may be completed as detailed in the Resident Assessment Instrument (RAI) Manual (the official, comprehensive guide for nursing homes on how to use the RAI system to assess resident care needs). Review of the RAI Manual, Version 3.0, dated October 2024, showed: - Section A1500: Preadmission Screening and Resident Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) should be marked Yes (or coded one) if PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual developmental disability or related condition; - Section I: Active diagnoses are defined as physician documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nurse monitoring, or risk of death during the seven-day look-back period; - Section N0415: High-Risk Drug Classes Used and Indication should be marked yes if the resident is taking any medications by pharmacological classification during the last seven days and checked if there is an indication noted for all medications in the drug class; - Section O0110: Special Treatments, Procedures, and Programs should be checked for any treatment, procedure, and program performed within the last 14 days. 1. Review of Resident #10's medical record showed: - An admission date of 08/04/25; - Diagnoses of major depressive disorder (MDD - a serious mental health condition characterized by at least two weeks of persistent, pervasive low mood, loss of interest, and low self-esteem), anxiety disorder (characterized by excessive, persistent fear or worry that interferes with daily life), and post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events). Review of the resident's PASRR, dated 08/13/25, showed: - Resident with a serious mental illness. Review of the resident's admission MDS, dated [DATE], showed: - The resident was not considered by the state level II process to have a serious mental illness and/or intellectual disability or a related condition. 2. Review of Resident #24's medical record showed: - An admission date of 10/30/25; - Diagnosis of myelofibrosis (type of bone cancer); - Had a port (medical device to deliver medications) with weekly chemotherapy (treatments for cancer). Review of the resident's quarterly MDS, dated [DATE], showed: - No diagnosis of cancer; - Did not receive chemotherapy. 3. Review of Resident #67's medical record showed: - An admission date of 03/07/26; - Diagnoses of thrombophilia (a condition causing blood to clot easily), atrial fibrillation (abnormal heart beat), heart disease (heart does not pump as it should), chronic kidney disease, depression, chronic obstructive pulmonary disease (COPD - lung disease), obstructive sleep apnea (breathing issues because compromised airway that causes breathing issues during sleep), and cardiac pacemaker (a medical device to help the heart to function); - An order for warfarin (an anticoagulant medication) 3 milligram (mg) 0.5 by mouth with the evening meal on 03/27/26; - An order for furosemide (a diuretic medication) by mouth every morning, dated 03/08/26; - An order for venlafaxine (an antidepressant medication) 37.5 mg by mouth every day in the morning with breakfast, dated 03/08/26; - An order for oxygen at 2 liters per minute by nasal cannula (device used to deliver oxygen with two small tubes that fit into the nostrils) continuously, dated 03/07/26; - An order for bilevel positive airway pressure (BiPAP – a machine to assist with breathing) every shift with settings 14 over 8 with 2 liters of oxygen bleed in while sleeping, dated 03/07/26. Review of the resident's admission MDS, dated [DATE], showed: - No diagnoses for renal failure and depression; - Did not receive anticoagulant; - No for BiPAP and non-invasive mechanical ventilation used. 4. Review of Resident #104's medical record showed: - An admission date of 03/04/26; - Diagnoses of cellulitis (skin infection) right lower limb and left foot osteomyelitis (bone infection); - An order for ceftriaxone (an antibiotic medication) 2 grams intravenous (IV - administered into the vein) with lunch for 20 days, dated 03/29/26; - An order for peripherally inserted central catheter (PICC – tube/catheter inserted into a vein for medication administration) line dressing change every 7 days every morning shift. Catheter length was 51 centimeters (cm) with single lumen (opening in the catheter), dated 03/11/26. Review of the resident's admission MDS, dated [DATE], showed: - Did not receive IV medications. During an interview on 03/27/26 at 3:15 P.M., the MDS Coordinator said he/she gathered the information from the residents' medical records such as the care plan, progress notes, and orders, and talked to the staff. If it was not mentioned during those reviews, then it would not be coded on the MDS. During an interview on 03/30/26 at 9:55 A.M., the Administrator said he would expect the MDS to accurately reflect the resident's condition at the time of the assessment.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions to meet the highest practicable physical, mental, and psychosocial well-being for four residents (Residents #6, #37, #67, and #104) out of 25 sampled residents. The facility's census was 126.Review of the facility policy titled, Care Plan Section Responsibility, undated, showed:- Objective was to ensure individualized completion of the care plan, and family /resident participation in the resident's plan of care with admission, quarterly, annual update, and if there is a significant change of condition;- The care plan must be based upon the resident assessment, choices and advancedirectives, if any. As the resident's status changes, the facility, attending practitionerand the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. 1. Review of Resident #6's medical record showed:- An admission date of 07/31/25;- Diagnosis of benign prostatic hyperplasia (BPH - an enlargement of the prostate causing difficulty in urination) without lower urinary tract symptoms;- An order for suprapubic (a thin, flexible tube inserted into the bladder through a small incision in the lower abdomen) catheter care every shift to clean with normal saline and pat dry, apply a drain sponge and tape in place, dated 03/26/26;- An order to monitor the urinary catheter output each shift, dated 11/11/25. Review of the resident's care plan, last reviewed 02/13/26, showed:- Did not address the suprapubic catheter, the care, and the monitored output with goals and interventions. 2. Review of Resident #37's medical record showed:- An admission date of 03/06/26;- Diagnoses of Ogilvie syndrome (condition of colon dilation without mechanical blockage) and ileostomy (a surgical procedure where the intestine goes through an opening in the abdominal area to allow waste to come out). Review of the resident's care plan, last reviewed 03/13/26, showed:- Did not address the ileostomy with goals and interventions. 3. Review of Resident #67's medical record showed:- An admission date of 03/07/26;- Diagnoses of thrombophilia (a condition causing blood to clot easily), atrial fibrillation (an abnormal heart beat), heart disease (the heart does not pump as it should), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), and a cardiac pacemaker (medical device to help the heart function);- An order for prothrombin time (PT - evaluates the ability of the blood to clot properly, used to help diagnose bleeding)/international normalized ratio (INR - used to monitor the effectiveness of blood thinning drugs) on 03/27/26;- An order for warfarin (a blood thinner) 3 milligrams (mg) 0.5 tablet by mouth with the evening meal on 03/27/26. Review of the resident's care plan, last reviewed 03/14/26, showed:- Did not address the anticoagulant medication and the lab orders for the titration of the dose with goals and interventions;- Did not address the cardiac pacemaker with goals and interventions;- Did not address dementia and care with goals and interventions. 4. Review of the Resident #104's medical record showed:- An admission date 03/04/26;- Diagnoses of cellulitis (skin infection) right lower limb, atrial fibrillation, diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), dementia, bipolar (a mental disorder that causes unusual shifts in mood), obstructive sleep apnea (an airway issue causing breathing to stop for periods of time during sleep), chronic obstructive pulmonary disease (COPD - a lung disease), heart failure (the heart does not function as it should), and asthma (a lung condition making it more difficult to breathe);- An order for ceftriaxone (an antibiotic medication) 2 grams intravenously (IV - administered into a vein) with lunch for 20 days, dated 03/29/26;- An order for metronidazole (an antibiotic medication) 500 mg by mouth every 12 hours for 20 days, dated 03/29/26;- An order for doxycycline (an antibiotic medication)100 mg by mouth every 12 hours for 20 days, dated 03/29/26;- An order for bilevel positive airway pressure (BiPAP - a machine to assist with breathing) machine to use every shift at times of rest and at night. BiPAP instructions were nasal mask with settings of peak inspiratory pressure (highest level of pressure applied to the lungs) of 22 and expiratory positive airway pressure (low pressure applied to the lungs) of 18 with a set breathing back up rate of 10 breaths per minute. Keep oxygen saturation (percent of oxygen in the blood) of 92 percent or greater, dated 03/04/26;- An order for BiPAP every Sunday morning shift to wash the mask/tubing and headgear with mild soap and water, allow to air dry, dated 03/04/26;- An order for albuterol sulfate (a bronchodilator medication used to open the airways) hydrofluoroalkane (HFA - a propellant in an inhaler) 90 microgram (mcg)/actuation 2 HFA aerosol inhaler inhalations every 6 hours as needed for shortness of breath, dated 03/04/26;- An order for peripherally inserted central catheter (PICC - tube/catheter inserted into a vein for medication administration) line dressing change every 7 days every morning shift. Catheter length was 51 centimeters (cm) with single lumen (opening in the catheter), dated 03/11/26;- An order for insulin lispro (a medication to treat DM) subcutaneous (beneath the skin) pen per sliding scale with meals for a blood sugar of 0 - 140 = 0 units, 141 - 180 = 2 units, 181 - 220 = 4 units, 221 -260 = 6 units, 261 - 300 = 8 units, 301 - 350 = 10 units, and for greater than 351 give 12 units and call physician, dated 03/04/26;- An order for Toujeo Max (a medication for DM) subcutaneous insulin pen 40 units subcutaneous in the morning, dated 03/04/26- An order for Eliquis (a blood thinning medication) 5 mg by mouth every 12 hours, dated 03/04/26. Review of the resident's care plan, last reviewed 03/11/26, showed:- Did not address the PICC line and care with goals and interventions;- Did not address antibiotics related to wounds and infection and care with goals and interventions;- Did not address the respiratory needs of the medications, oxygen, BiPAP, and care with goals and interventions;- Did not address DM, medications, and care with goals and interventions;- Did not address the blood thinning medication and care with goals and interventions;- Did not address dementia and care with goals and interventions. During an interview on 03/27/26 at 1:50 P.M, the Director of Nursing (DON) said he/she would expect the care plan to accurately reflect the resident's current condition. The care plan should be revised as needed with resident changes. During an interview on 03/27/26 at 3:40 P.M., the Pavillion Nurse Manager said he/she worked on the care plans. Residents with indwelling devices, oxygen, BiPAP, and antibiotics should be on the care plan. Care plans should be revised as needed with changes to accurately reflect the resident's condition. During an interview on 03/30/26 at 9:55 A.M., the Administrator said he would expect the care plan to accurately reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen use and oxygen tubing care was obtained for two residents (Residents #27 and #40) and the facility also failed to follow physician's orders for oxygen use for three residents (Residents #8, #81, and #123) out of 12 sampled residents. The facility census was 126.Review of the facility policy titled, Physician's Orders, undated, showed: - Orders received by the physician are to be followed as prescribed. Review of the facility policy titled, Oxygen Storage/Use, undated, showed: - Oxygen tubing is to be bagged when not in use; - Did not address when to change the oxygen tubing. 1. Review of Resident #8's medical record showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD – a lung disease) and malignant neoplasm (cancerous tumor) of the upper right and left lung and of the lower right and left lung. Review of the resident's March 2026 physician order sheet (POS), showed: - An order for oxygen at 2 liters per minute (LPM) via nasal canula (NC – a device used to deliver oxygen with two small tubes that fit into the nostrils) every shift, dated 07/13/24. Review of the resident's care plan, review date of 03/04/26, showed: - Resident receives oxygen therapy related to medical diagnosis, as evidenced by use of oxygen with interventions of: Observe for signs/symptoms of respiratory distress, oxygen to be provided via nasal cannula or mask at the LPM prescribed by physician; Staff to provide the oxygen concentrator, tubing, tank, etc; Tubing/mask to be changed weekly and as needed (PRN). Observation of the resident on 03/24/26 at 12:00 P.M., showed: - The resident sat in his/her wheelchair in his/her room with oxygen on at 3 LPM via an undated NC per the oxygen concentrator; - An oxygen canister attached to the wheelchair, not in use, and an undated NC not stored in a storage bag. Observation of the resident on 03/25/26 at 2:35 P.M., showed: - The resident lay in bed with oxygen at 3 LPM via an undated NC per the oxygen concentrator; - An oxygen canister attached to the wheelchair, not in use, and an undated NC not stored in a storage bag. During an interview on 03/24/26 at 12:00 P.M., the resident said his/her oxygen should be set at 2 LPM and not 3 LPM, and staff changed his/her NC, but he/she was not sure of how often. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of COPD, chronic atrial fibrillation (an irregular heart rhythm), and pneumonia (infection and inflammation of the lung). Review of the resident's March 2026 POS showed: - No order for oxygen administration. Review of the resident's care plan, review date of 03/04/26, showed: - Resident receives oxygen therapy related to medical diagnosis with interventions of: Monitor oxygen saturations (percent of oxygen in the blood) as needed, observe for signs and symptoms of respiratory distress, oxygen to be provided via nasal cannula or mask at rate prescribed by physician; Staff to provide oxygen concentrator, tubing, tank, etc.; Tubing/mask to be changed weekly and PRN; Maintain oxygen saturation at 90% or greater with oxygen use as ordered by the physician. Observation of the resident on 03/24/26 at 12:15 P.M., showed: - The resident lay in bed with oxygen on at 3 LPM via an undated NC per the oxygen concentrator. 3. Review of Resident #40's medical record showed: - An admission date of 01/08/22; - Diagnoses of COPD and dependence on supplemental oxygen. Review of the resident's March 2026 POS showed: - No order for oxygen administration. Review of the resident's care plan, review date of 03/04/26, showed: - Resident receives oxygen therapy related to medical diagnosis with interventions of: Monitor oxygen saturations as needed, observe for signs and symptoms of respiratory distress, oxygen to be provided via nasal cannula or mask at rate prescribed by physician; Staff to provide oxygen concentrator, tubing, tank, etc.; Tubing/mask to be changed weekly and PRN; Maintain oxygen saturation at 90% or greater with oxygen use as ordered by the physician. Observation of the resident on 03/24/26 at 11:51 A.M., showed: - The resident sat in his/her wheelchair in his/her room with oxygen on at 3 LPM via an undated NC per the oxygen concentrator. Observation of the resident on 03/26/26 at 2:38 P.M., showed: - The resident sat in his/her wheelchair in his/her room with oxygen on at 4.5 LPM via an undated NC per the oxygen concentrator. Observation of the resident on 03/27/26 at 6:36 A.M., showed: - The resident sat in his/her wheelchair with no oxygen via NC; - The undated NC lay on the floor and not in a storage bag. 4. Review of Resident #81's medical record showed: - An admission date of 12/01/12; - Diagnoses of chronic pulmonary edema (fluid builds up in the lungs), heart failure, shortness of breath, and asthma (a lung disease). Review of the resident's March 2026 POS showed: - An order for oxygen 2 LPM via NC PRN for shortness of breath, may titrate to maintain saturations above 90%, notify physician if saturations are less than 90%, dated 01/29/25. Review of the resident's care plan, review date of 03/04/26, showed: - Continuous oxygen related to asthma with interventions of: Administer medication, respiratory treatments, and oxygen as ordered; Monitor for worsening cough, decreased lung sounds or temperature; Monitor lung sounds, pallor (unnatural skin color), cough, and character of sputum; Monitor respiratory rate and effort. Observation of the resident on 03/24/26 at 11:34 A.M., and 03/27/26 at 10:01 A.M., showed: - The resident sat in his/her wheelchair in his/her room with oxygen on at 3 LPM via an undated NC per the oxygen concentrator; - An oxygen canister attached to the wheelchair, not in use, with an undated NC wrapped around the left wheelchair arm rest and not stored in a storage bag. Observation of the resident on 03/26/26 at 2:36 P.M., showed: - The resident sat in his/her wheelchair in the hallway with oxygen on at 3 LPM via undated NC per an oxygen canister. During an interview on 03/24/26 at 11:34 A.M., the resident said he/she always required oxygen. The staff did not change the NC, but he/she had extra NCs and could change it. 5. Review of Resident #123's medical record showed: - An admission date of 01/08/22; - Diagnoses of COPD and acute onset chronic respiratory failure with hypoxia (a sudden, dangerous worsening of chronic low oxygen levels with a pre-existing lung disease); - An order for oxygen 2 LPM continuously, dated 05/06/25; - An order to change the oxygen canister and tubing every Sunday, dated 05/06/25. Observation of the resident on 03/24/26 at 12:06 P.M., showed: - The resident lay in bed with oxygen on at 3.5 LPM via an undated NC in his/her left nostril only per the oxygen concentrator. Observation on 03/27/26 at 9:30 P.M., and 12:00 P.M., showed: - The resident lay in bed with oxygen on at 3 LPM via an undated NC per the oxygen concentrator. During an interview on 03/24/26 at 12:06 P.M., the resident said the staff changed the oxygen tubing when they realize it had not been changed in a while. During an interview on 03/27/26 at 10:18 A.M., Licensed Practical Nurse (LPN) G said oxygen tubing should be changed weekly, dated when changed, placed in a bag when not in use, and the resident should have an order for oxygen that matched the setting. During an interview on 03/27/26 at 1:42 P.M., the Director of Nursing (DON) said the oxygen setting should match the physician's order and tubing should be labeled with the date it was changed.

Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation of the controlled medications and to ensure nursing staff counted and signed the narcotic count sheet at the beginning and at the end of each shift for four out of four sampled medication carts. The facility census was 126.The facility did not provide a policy regarding the receipt and disposition of controlled medications or reconciliation of controlled medications. 1. Review of the 100 Hall Certified Medication Technician (CMT) Cart Change of Shift Narcotic Count sheet, dated 03/01/26 - 03/26/26, showed:- No signature and/or initials by the nurse or CMT for 63 out of 151 opportunities. During an interview on 03/26/26 at 12:02 P.M., CMT F said all narcotics should be counted at the beginning and end of each shift and the count sheet should be signed verifying the count was completed and accurate. 2. Review of the 100 Hall Nurse Cart Change of Shift Narcotic Count Sheet, dated 03/01/26 - 03/27/26, showed:- No signature/and or initials by the nurse for 86 out of 157 opportunities. During an interview on 03/27/26 at 11:50 A.M., Licensed Practical Nurse (LPN) G said narcotics should be counted by the oncoming and off going nurse and the narcotic sheet should be signed when counted. 3. Review of the 400 Hall CMT Cart Narcotic Package Count Shift Reconciliation sheet, dated 03/12/26 - 03/26/26, showed:- No designated signature space for oncoming staff to sign;- No signature and/or initials by the nurse or CMT for the oncoming shift for 43 out of 43 opportunities;- No signature and/or initials by the nurse or CMT for the off going shift for four out of 43 opportunities. During an interview on 03/26/26 at 2:00 P.M., CMT B said the count sheet should be signed when coming on shift and going off shift after counting the narcotics. 4. Review of the 400 Hall Nurse Cart Narcotic Package Count Shift Reconciliation sheet, dated 03/12/26 - 03/26/26, showed:- No designated signature space for oncoming staff to sign;- No signatures/and or initials by the nurse for the oncoming shift for 44 out of 44 opportunities;- No signature/and or initials by the nurse for the off going shift for 14 out of 44 opportunities. During an interview on 03/26/26 at 2:05 P.M., LPN H said he/she knew there were some dates not signed on the sheet, but staff should sign and count the narcotics at the start of their shift and again at the end of their shift. During an interview on 03/27/26 at 1:45 P.M., the Director of Nursing (DON) said she would expect staff to count narcotics at the beginning and end of every shift and sign the count sheet.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored in accordance with currently accepted practices when refrigerator temperatures were not completed for the Certified Medication Technician (CMT) and Nurse refrigerators, located on the 100 Hall. The facility also failed to ensure one resident (Resident #24) out of 25 sampled residents had a physician's order to keep an inhaler (hand-held portable device that delivers medication to the lungs) at the bedside. This had the potential to affect all residents. The facility census was 126. Review of the facility's policy titled, Storage of Medications, revised 07/22/24, showed: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly; - Did not address checking and the appropriate refrigerator temperatures; - Did not address a resident keeping a medication at the bedside. Review of the package insert for Tubersol (a solution used in a skin test to help diagnose tuberculosis (TB - a serious illness that mainly affects the lungs), on fda.gov, undated, showed: - Store at 35 - 46 degrees Fahrenheit ( F); - Do not freeze, discard product if exposed to freezing; - A vial which has been entered and in use for 30 days should be discarded. Review of the package insert for Lantus (long acting insulin) insulin pens, on lantus.com, dated v2.0-08/2022, showed: - Before opening, store Lantus in the refrigerator (36 - 46 F); - Lantus can be refrigerated until the expiration date, once the expiration date has passed, Lantus should be thrown away; - Do not allow Lantus to freeze. Review of the package insert for Novolog (a rapid acting insulin) insulin pens, on novolog.com, dated September 2025, showed: - Store unused Novolog pens and vials in refrigerator at 36 - 46 F until expiration; - Storage after use, keep at room temperature (below 86 degrees F) or refrigerate for up to 28 days; - Keep away from direct heat and light; - Dispose of after 28 days. Review of the package insert for Trulicity (an injectable medication used to decrease insulin secretion, on trulicity.lilly.com, dated 12/2025, showed: - Store the pen in the refrigerator, but do not freeze the pen. Review of the package insert for influenza vaccine, on cdc.gov, last reviewed 09/16/16, showed: - Vaccines should be stored at recommended temperatures; - In general, influenza vaccines should be refrigerated between 36 - 46 F and should not be frozen, vaccines that have been frozen should be discarded; - Vaccines should not be used after the expiration date on the label. Review of the package insert for cyanocobalamin (vitamin B 12) vials, undated, on dailymed.nlm.nih.gov, showed: - Store at 68 - 77 F. Review of the package insert for acetaminophen suppositories (a pain/fever reliever in a small solid that is inserted into the body via the rectum that melts or dissolves at body temperature), on medlineplus.gov, revised 10/15/25, showed: - Keep this medication in the container it came in, tightly closed; - Store it at room temperature and away from excess heat and moisture. Review of the package insert for Bisacodyl suppositories (fast acting, stimulant laxative that is inserted rectally to relieve constipation), on medlineplus.gov, revised 11/15/16, showed: - Keep this medication in the container it came in, tightly closed; - Store at room temperature and away from excess heat and moisture. 1. Review of the 100 Hall med room/Nurse Refrigerator Temperature Log for 03/1/26 - 03/26/26 showed: - No temperatures recorded for 03/01, 03/04, 03/07, 03/13 - 03/15, 03/18, 03/19, and 03/21 - 03/25, with 13 missed out of 31 opportunities; - A temperature of 34 F on 03/02, 03/03, 03/05, 03/08 - 03/10, 03/12, 03/16, 03/17, 03/20, and 03/26; - A temperature of 32 F on 03/06/26. Observation on 03/26/26 at 11:50 A.M., of the 100 Hall med room/Nurse refrigerator showed: - A thermometer reading of 34 F; - Four unopened vials of Tubersol; - One opened vial of Tubersol, dated 03/24/26; - 33 unopened Lantus and Novolog insulin pens; - One unopened Trulicity pen; - 11 unopened, single use influenza vaccines; - Two unopened vials of cyanocobalamin; - 63 unopened acetaminophen suppositories; - 26 unopened Bisacodyl suppositories. 2. Review of the 100-hall med room/CMT refrigerator temperature log for 03/01/26 - 03/26/26 showed: - No temperatures recorded for 03/01, 03/04, 03/11, 03/13-03/15, 03/18, 03/21, and 03/22, with nine missed out of 31 opportunities; - A temperature of 34 F on 03/02, 03/03, 03/05, 03/07 - 03/10, 03/12, 03/16, 03/17, 03/19, and 03/20. Observation on 03/26/26 at 11:58 A.M., of the 100 Hall med room/CMT refrigerator showed: - A thermometer reading of 34 F. During an interview on 03/26/26 at 12:00 P.M., CMT F said the day shift CMT was responsible for checking the refrigerator temperatures and the logs should be updated daily. During an interview on 03/27/26 at 1:45 P.M., the Director of Nursing (DON) said she would expect refrigerator temperatures to be recorded daily and within the appropriate range. 2. Review of Resident #24's medical record showed: - An admission date of 10/30/25; - An order for albuterol sulfate (a bronchodilator medication used to open the airways) hydrofluoroalkane (HFA – a propellant in an inhaler) 90 microgram (mcg)/actuation 2 HFA aerosol inhaler inhalations four times a day as needed for shortness of breath nebulization, dated 03/10/26; - No order for medications to be kept at bedside; - No documentation of an assessment for the medication to be self-administered safely; - Did not address the self-administration of the medication on the care plan. Observations of the resident's room showed: - On 03/25/26 at 10:33 A.M., 03/06/26 at 11:47 A.M., and 03/27/26 at 9:00 A.M., the albuterol sulfate HFA 90 mcg aerosol inhaler on the resident's bedside table. During an interview on 03/27/26 at 9:00 A.M., the resident said he/she used the albuterol inhaler about once a day if needed. He/She used it when having difficulty breathing. During an interview on 03/27/26 at 11:05 A.M., CMT B said if residents had medications at bedside, the residents were supposed to tell staff when the medications were used so that staff could chart it in the resident's medical record. He/She said Resident #24 had not told him/her about using the inhaler at bedside and did not know if he/she really ever used the inhaler. There should be an order by the physician to say the resident could use medication at the bedside. During an interview on 03/27/26 at 12:00 P.M., Licensed Practical Nurse (LPN) C said he/she did not think there was a documented formal assessment to be completed for residents with medications at the bedside. He/She would expect the resident to tell staff when taking medications stored at the bedside. There should be an order in the resident's medical record by the physician to the say resident could use medication at the bedside. During an interview on 03/27/26 at 1:50 P.M., the DON said she would expect there to be a physician's order to use a medication at the bedside. She did not think there was a formal assessment documented anywhere but the resident should be assessed for safety and should tell staff when a medication was self-administered at the bedside.

Based on observation, interview, and record review, the facility failed to follow infection control precautions by not changing gloves or washing hands during resident care for four residents (Residents #7, #11, #103, and #134) out of six sampled residents, by not following enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for five residents (Residents #7, #41, #103, #104, and #134) out of five sampled residents, and during medication administration for three residents (Residents #38, #104 and #141) out of seven sampled residents. The facility census was 126.Review of the facility's policy titled, Policy and Procedure - Enhanced Barrier Precautions, dated 04/01/24, showed: - Whenever a resident has an infection regardless of their MDRO status, the community will utilize EBP for any time that physical contact is needed in caring for the resident. The EBP will be utilized by the staff for any residents with chronic wounds or indwelling medical devices during any high contact with that resident; - The gowns and gloves will be outside the resident room for the staff to don before entering the room and two containers will be in the room, 1) for soiled linens and clothing and 2) for the soiled gloves and gowns to be disposed of after use by the staff; - The staff will always adhere to universal precautions and perform handwashing before exiting the room; - In-services for EBP for the staff will be conducted every six months; - Did not address high contact resident care activities. The facility did not provide a hand hygiene policy. 1. Observation of Resident #7's wound care on 03/25/26 at 10:50 A.M., showed: - No EBP signage outside of the resident's room; - Registered Nurse (RN) J and Certified Nurse Assistant (CNA) K performed hand hygiene, put on gloves, and did not put on a gown; - RN J removed the soiled dressing from the resident's left shin and ankle and placed it in the trash can beside the bed; - RN J removed the soiled packing strip from the shin wound, did not perform hand hygiene, did not change gloves, sprayed the shin wound with wound cleaner, wiped with gauze, did not perform hand hygiene, and did not change gloves; - RN J sprayed the ankle wound with wound cleaner, wiped with gauze, did not change gloves, and did not perform hand hygiene; - RN J packed the left shin wound with plain packing strip, covered with silver alginate, covered with an ABD pad, wrapped with Kerlix, and secured with clear tape; - RN J did not perform hand hygiene, changed gloves, covered the left ankle wound with silver alginate, applied barrier cream around the wound, wrapped with Kerlix, and secured with clear tape; - RN J and CNA K removed gloves, performed hand hygiene, and exited the room. 2. Observation on 03/25/26 at 11:16 A.M., of Resident #134's wound care showed: - No EBP signage outside of the resident's room; - RN J and CNA K performed hand hygiene, put on gloves, and did not put on a gown; - RN J removed the soiled dressings; - RN J did not perform hand hygiene and changed gloves; - RN J sprayed wound cleaner on the right and left buttock wounds, wiped the left buttock with gauze, did not perform hand hygiene, did not change gloves, wiped the right buttock with gauze, did not perform hand hygiene, and changed gloves; - RN J covered the left and right buttock wounds with silicone border gauzes; - RN J removed gloves, did not perform hand hygiene, and covered resident with a blanket; - CNA K and RN J performed hand hygiene before leaving the room. During an interview on 03/26/26 at 10:15 A.M., RN J said he/she had never heard of EBP. Gowns, gloves, and masks should be worn during wound care, and that hand hygiene should be performed before, after, and when going from dirty to clean tasks during wound care. 3. Observation on 03/26/26 at 8:25 A.M., of Resident #141's medication administration showed: - Certified Medication Technologist (CMT) F did not perform hand hygiene; - CMT F obtained an acetaminophen (a medication that reduces pain and fever) 650 milligram (mg) tablet from the medication cart and poured it directly from the stock medication container into his/her bare hand and placed the medication into a pill cup; - CMT F placed 10 additional medications into the same pill cup; - CMT F administered the medications to the resident. 4. Observation on 03/26/26 at 8:35 A.M., of Resident #38's medication administration showed: - CMT F did not perform hand hygiene, - CMT F obtained a loratadine (a medication that treats allergies) 10 mg tablet from the medication cart and poured it directly from the stock medication container into his/her bare hand and placed the medication into a pill cup; - CMT F placed five additional medications into the same pill cup; - CMT F administered the medications to the resident; - CMT F obtained a bottle of cyclosporine (medication that treats chronic dry eyes) 0.05% eye drops from the medication cart; - CMT F did not perform hand hygiene, put on gloves, administered the eye drops to the resident's right and left eyes; - CMT F obtained a facial tissue and blotted the left and the right eye with the same tissue. During an interview on 03/26/26 at 10:15 A.M., CMT F said he/she should not touch medications with his/her bare hands and should sanitize or wash his/her hands prior to and after administering medications. He/She should not use the same tissue to blot both eyes. 5. Observation on 03/26/26 at 12:30 P.M., of Resident #104's intravenous (IV – administered into a vein) antibiotic medication administration showed: - No EBP signage outside of the resident's door; - Licensed Practical Nurse (LPN) H performed hand hygiene, put on a mask and gloves, and did not put on a gown; - LPN H entered the resident's room, performed hand hygiene and put on a mask and gloves; - LPN H administered the ceftriaxone (an antibiotic medication) IV medication to the resident. During an interview on 03/26/26 at 12:40 P.M., LPN H said EBP should include a gown and gloves, and EBP should be worn during hands on care, such as for dressing, urinary catheter care, and IVs. 6. Observation on 03/27/26 at 9:37 A.M., of Resident #103's catheter care showed: - No EPB signage; - CNA I entered room, performed hand hygiene, put on gloves, and did not put on a gown; - CNA I cleaned the resident's front peri area, didn't perform hand hygiene, and changed gloves; - CNA I cleaned the urinary catheter from the insertion site and away, didn't perform hand hygiene, and changed gloves; - CNA I cleaned the resident's buttocks, removed the soiled brief, did not perform hand hygiene, did not change gloves, placed a clean brief on the resident, adjusted the incontinent pad under the resident, pulled the resident up in the bed with the incontinent pad, placed the blanket over the resident, removed gloves, performed hand hygiene, and exited the room. During an interview on 03/27/26 at 11:56 A.M., CNA I said he/she did not know anything about EBP. He/She wore gloves and a gown when a resident was on contact or airborne isolation. Hand hygiene should be performed before and after perineal care, before helping a resident eat, and sometimes when changing gloves. Gloves should be changed when they were soiled or going from a dirty to clean task. 7. Observation on 03/27/26 at 9:45 A.M., of Resident #11's incontinent care showed: - CNA A cleaned the resident's right front peri area with a wet wash cloth, didn't perform hand hygiene, changed gloves, cleaned the left front peri area, did not perform hand hygiene, changed gloves, cleaned the back peri area and the buttocks with a wet wash cloth, did not perform hand hygiene, changed gloves, and dried the resident with a dry wash cloth. 8. Observation on 03/27/26 at 10:58 A.M., of Resident #41's incontinent care showed: - No EBP signage outside the resident's room; - CNA A and CNA E entered the room, performed hand hygiene, put on gloves, and did not put on a gown; - CNA A and CNA E performed the resident's incontinent care and the resident had a urinary catheter (a tube inserted into the bladder to drain urine) and a wound. During an interview at 03/27/26 at 10:50 A.M., CNA A said he/she did not know what residents were supposed to be on EBP or what it really was for. He/She got report from other staff about what residents had precautions. He/She changed gloves and washed hands when going from clean to dirty and dirty to clean tasks. 9. Observation on 03/27/26 at 11:24 A.M., of Resident #41's wound care showed: - No EBP signage outside the resident's room; - LPN G entered the room, performed hand hygiene, put on gloves, and did not put on a gown; - LPN G performed the resident's wound care. 10. Observation on 03/27/26 at 11:37 A.M., of Resident #41's transfer showed: - No EBP signage outside of the resident's room - CNA A and CNA E entered the room, performed hand hygiene, put on gloves, and did not put on a gown; - CNA A and CNA E transferred the resident. During an interview on 03/27/26 at 11:45 A.M., LPN G said gloves and gowns should be worn for high contact care of residents with urinary catheters and/or chronic wounds. During an interview on 03/27/26 at 12:00 P.M., LPN C said he/she did not know what EBP was or who qualified for being on it. He/She got information about who was on precautions from other staff. During an interview on 03/27/26 at 11:10 A.M., the Director of Nursing (DON)/Infection Preventionist (IP) said she would expect staff to perform hand hygiene before, after, and when going from dirty to clean tasks during wound care or resident care tasks. Only residents who had a weird wound, who were infectious, or had an organism listed on the list provided by the Centers of Disease Control and Prevention (CDC) should be on EBP. Residents should only be on EBP for the chronic phase of the infection, so they would be on EBP for the rest of their lives. Residents who were on EBP should have a sign on their door and an isolation cart outside of the room. When performing high contact care for a resident with a chronic wound or indwelling device who are on EBP, she would expect staff to wear a gown and gloves. During an interview on 03/27/26 at 1:45 P.M., the DON/IP said staff should not touch medications with their bare hands and should sanitize or wash their hands prior to and after administering medications. EBP should be worn when caring for and administering medications through an IV. During an interview on 03/30/26 at 10:00 A.M., the Administrator said he would expect staff to follow EBP precautions for residents who qualify and would expect staff to change gloves and wash hands before, after, and when going from dirty to clean tasks during resident care. Staff should not touch medication with their bare hands and should perform hand hygiene prior to and after administering medications.

Based on observation, interview, and record review, the facility failed to provide showers for three residents (Resident #1, #2, and #5) out of six sampled residents. The facility's census was 124.Review of the facility's policy, Showers, dated January 5, 2017, showed:- It is the policy of the facility to provide showers on a bi-weekly basis;- Requests for more frequent showers will be granted and addressed via the plan of care;- Shower sheets will be reviewed by the charge nurse;- The charge nurse will forward all completed shower sheets to the clinical nurse managers;- Clinical nurse managers will ensure a shower sheet is received for each shower and ensure interventions are in place for any areas identified during showers and track the area weekly on the weekly skin or pressure report;- Shower sheets will be kept in the clinical managers' office for a period of two weeks.Review of the Certified Nursing Assistant (CNA) Meeting notes, dated November 25, 2025, showed:- Showers need to be completed in a timely manner, not at the end of a shift. Day shift - after breakfast and Evening shift - before dinner unless time doesn't permit or resident requests after;- Residents are to be showered twice weekly on their scheduled days and if missed, made up on Sundays;- If a resident refused a shower, notify the charge nurse. We cannot force care, but we can and should encourage residents;- Make sure to fill out shower sheets and document in activities of daily living (ADL) charting. If it is not documented, it did not happen. Fill out sheets for refusals as well and have resident sign if capable.1. Review of Resident #1's medical record showed:- admission date of 06/17/24;- Diagnoses of multiple sclerosis (a chronic autoimmune disease affecting the brain and spinal cord, where the immune system attacks the protective covering of nerve fibers, disrupting nerve signals), chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), and weakness.Review of the resident's quarterly Minimum Data Set (MDS - a mandatory assessment completed by the facility) assessment, dated 11/22/25, showed:- No cognitive impairment;- Dependent on staff for dressing;- Supervision or touching assistance from staff for personal hygiene;- Dependent on staff for showering/bathing.Review of the facility shower schedule showed:- From 10/02/25 to 10/20/25, the resident's shower days were Monday and Thursday;- From 10/20/25 to 11/05/25, the resident's shower days were Wednesday and Saturday;- From 11/05/25 to 12/20/25, the resident's shower days were Monday and Thursday.Review of the resident's shower sheets from October 1 to December 30, 2025 showed:- October had eight opportunities for receiving a shower. The resident received a shower on 10/20. Seven showers were missed out of eight opportunities.-November had eight opportunities for receiving a shower. The resident received a shower on 11/10, 11/13, 11/17, 11/20, and 11/24. Three showers were missed out of eight opportunities;- December, had nine opportunities for receiving a shower. The resident received a shower on 12/8, 12/18, and 12/22. Six showers were missed out of nine opportunities.2. Review of Resident #2's medical record showed:- admission date of 02/27/19;- Diagnoses of COPD, heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and rheumatoid arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints, causing inflammation, pain, swelling, and stiffness, usually in the hands, wrists, and feet). Review of the resident's quarterly MDS assessment, dated 11/08/25, showed:- No cognitive impairment;- Substantial/maximal assist from staff for upper body dressing;- Dependent on staff for lower body dressing;- Partial or moderate assistance from staff for personal hygiene;- Dependent on staff for showering/bathing. Review of the facility's shower schedule showed the resident's shower days were Monday and Thursday. Review of the resident's shower sheets from October 1 to December 31, 2025 showed:- In October, the resident received no showers, for a total of eight missed showers out of eight opportunities;- In November, the resident received no showers, for a total of eight missed showers out of eight opportunities;- In December, the resident received a shower on 12/15, for a total of eight missed showers out of nine opportunities.During an interview on 12/31/25 at 12:29 P.M., Resident #2 said he/she did not get his/her showers twice a week. He/she received a shower every two or three weeks but wanted one at least once a week. He/she did not get a bed bath in between showers. Staff only wiped his/her butt when they cleaned him/her up. He/she couldn't remember the last time he/she had a shower. Observation of the resident's room during the interview showed a musty urine/body odor. 3. Review of Resident #5's medical record showed:- admission date of 03/16/23;- Diagnoses of muscle weakness, need for assistance with personal care, and Parkinson's disease (a progressive movement disorder of the nervous system).Review of the resident's quarterly MDS assessment, dated 12/21/25, showed:- Moderate cognitive impairment;- Partial or moderate assistance from staff for upper body dressing;- Substantial/maximal assistance from staff for lower body dressing;- Partial or moderate assistance from staff for personal hygiene;- Substantial/maximal assistance from staff for showering/bathing.Review of the facility's shower schedule showed the resident's shower days were Monday and Thursday.Review of the resident's shower sheets, dated October 1 to December 31, 2025, showed:- In October, the resident received no showers, for a total of eight missed showers out of eight opportunities;- In November, the resident received a shower on 11/05, 11/13, 11/17, 11/20, 11/24 offered but refused, and 11/27, for a total of two showers missed out of eight opportunities;- In December, the resident received a shower on 12/04, 12/08, 12/11 offered but refused, 12/15, 12/18, and 12/25 offered but refused, for a total of three showers missed out of nine opportunities.During an interview on 12/31/25 at 1:06 P.M., the resident said he/she only received showers once a week but would like them twice a week.During an interview on 12/31/25 at 1:14 P.M., the Social Services Director said he/she had done grievances for residents not getting their showers. They had been talking about it, and the Director of Nursing (DON) was aware. He/she didn't notice a resident odor, but he/she noticed the hair. He/she would go on the floor and see the greasy hair, he/she mentioned it to staff, and the resident would get put on the shower schedule. During an interview on 12/31/25 at 1:26 P.M., the Assistant Director of Nursing (ADON) said there was an issue with residents receiving showers. She didn't think staff encouraged the residents to take showers. She thought that was a big problem. During an interview on 12/31/25 at 4:37 P.M., the ADON said staff were to fill out shower refusals, but they may not be scanned in yet because of Medical Records being behind. She did not know if the forms were not being filled out, scanned in, or if the staff were not doing what they were supposed to be doing. During an interview on 12/31/25 at 6:00 P.M., the Administrator, ADON, and Nurse Manager B said they would expect staff to offer the residents a shower at least twice a week.

Based on interview and record review, the facility failed to notify the physician and resident representative of a fall for one resident (Resident #1) out of five sampled residents. The facility census was 122. 1. Review of the facility policy titled, Following a Resident Fall, dated 04/29/25, showed: - The licensed nurse assess the resident for injuries (including neuro checks if indicated) and provides necessary treatment and initiates the Situation, Background, Assessment, Recommendation (SBAR - a structured communication tool used to improve the clarity and efficiency of information exchange between healthcare professionals, especially when reporting a change in a resident's condition); - The physician and resident's representatives are notified; 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 03/05/2025, showed: - admitted to facility on 02/21/23; - Cognition impaired; - Diagnoses of dementia (a general term for a decline in mental ability severe enough to interfere with daily life), diabetes (a condition that happens when your blood sugar is too high. It develops when your pancreas doesn't make enough insulin or any at all), chronic kidney disease stage 2 (medical condition where the kidneys stop functioning normally and can no longer filter waste from the blood), and hypertension (high blood pressure); - Delusions (fixed, false beliefs that a person firmly holds despite evidence to the contrary, and they are a symptom of various mental health conditions); - Verbal behaviors directed towards others 4-6 days a week; - Rejection of care 1-3 days a week; Review of Resident #1's Care Plan with interventions, updated on 04/24/24, showed he/she is at risk for falls with interventions to notify physician and responsible party of fall. Review of Resident #1's progress notes showed a late entry on 05/09/25 at 4:36 P.M., which said the following: - Nurse was notfied by staff that Resident #1 was seen stuck between his/her bed and the wall; - The bed was moved from the wall and the resdent assessed; - At the time of the assessment the resident's main complaint was being on the floor; - No visible signs of acute injuries at that time; - Resident placed into the bed through the night shift staff; - Resident continued with normal behaviors of calling out, never mentioned any injury from the fall; - No documentation regarding calling the resident's responsible party or doctor. During an interview on 06/03/25 at 3:05 P.M., Certified Nurse Aide (CNA) A said he/she was in Resident #1's room providing incontinent care on 05/08/25. CNA A turned to wet a washcloth, and heard the resident scream. CNA A turned back to see Resident #1 on his/her knees on the floor between the bed and the wall. CNA A went immediately and informed Registered Nurse (RN) B of the incident. CNA A said he/she did not know if RN B contacted the resident's representative or doctor. CNA A said it is part of the facility's policy for charge staff to notify a resident's family and doctor. During an interview on 06/03/25 at 3:05 P.M., CNA C said he/she assisted CNA A and RN B with transferring Resident #1 from the floor to the bed after he/she was found on the floor. CNA C said he/she did not know if RN B notified the resident's representative or doctor of the fall. During an interview on 06/03/25 at 12:40 P.M., the Director of Nursing (DON) said it is facility policy to contact a resident's family and doctor of an incident such as a fall. The DON said it would be the charge nurse's responsibility to make those notifications, assess the resident for injury and document all of that information in the record. The DON said, RN B failed to do any of those. The DON said she began an investigation when she heard about the situation. The Administrator held RN B's paycheck until RN B could come to the facility and place a late entry into the progress notes for Resident #1's medical record. Complaint # MO254482, MO254511

Based on interview and record review, the facility failed to provide their final investigation in a timely manner after a report of sexual abuse for one resident (Resident #1) of three sampled residents. On 4/5/2025, Resident #1 reported Registered Nurse (RN) A had sexually assaulted him/her on 04/3/25. As of 04/15/25, the facility had not completed the investigation. The census was 130. Review of the facility's Abuse Policy and Procedures/Investigation Protocols dated 12/14/18 showed: - Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor, the Administrator (ADM) or the Director of Nurses (DON); - Once the ADM/DON determine that there is possible mistreatment, the ADM or DON will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident; - The person in charge of the investigation will report the conclusions of the investigation to the ADM or DON designee within five working days of the reported incident. The final report shall contain the following; - Name, age. diagnosis and mental status of the resident allegedly abused or neglected; - The original allegation (note day, time, location, the specific allegation, by whom, witness to the occurrence, circumstances surrounding the occurrence and any noted injuries); - Facts determined during the process of the investigation, review of medical record and interview of all witnesses; - Conclusion of the investigation based on known facts; - If the allegation is determined to be valid and perpetrator is an employee, include on a separate sheet the employee's name, address, phone number title, date of hire, date of birth , social security number, copies of previous disciplinary actions and current status (still working, suspended or terminated); - Attach a summary of all interviews conducted; - The final written report will be sent to the Department of Health and Senior Services. 1. Review of the facility's self-report sent to the Central Registry Unit (CRU) on 04/05/25 showed: - On 04/05/25, Resident #1 reported to Emergency Medical Services (EMS) that staff RN A had sexually assaulted him/her on 04/03/25; - The resident was being sent out for a psychiatric evaluation; - RN A had been suspended pending the investigation. No completed investigation of the allegations had been received in the regional office as of 04/15/25 (7 business days after initial report). During an interview on 04/15/25 at 11:00 A.M., the ADM said he had not completed the investigation. He had not obtained a written statement from RN A or from the resident. He said he did not realize he needed to provide the final report since the facility had determined there was no abuse. Complaint #252300

Based on interview and record review, the facility failed to ensure a code status was consistently documented throughout the medical record for two residents (Residents #17 and #92) out of 21 sampled residents and for two residents (Residents #33 and #53) outside the sample. The facility census was 127. Review of the facility's policy titled, Advance Directives, not dated, showed: - Upon admission, every resident or resident representative is asked to determine code status; - Full Code - cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) performed when the resident experiences a catastrophic event such as cardiac/respiratory arrest or Do Not Resuscitate (DNR - does not want CPR); - The resident's code status will be reviewed with the resident and/or the resident representative annually; - The resident has the right to change their code status at any time. Review of facility's Code Status book (a book that gives each resident's code status) showed: - For Resident #17, a DNR code status; - For Resident #33, a DNR code status; - For Resident #53, a DNR code status; - For Resident #92, a Full Code status. 1. Review of Resident #17's medical record showed: - An admitted [DATE]; - A DNR code status on the facesheet; - An order for a DNR code status, dated [DATE]; - A Full Code status signed by the resident, facility representative, and the physician on [DATE]. Review of the resident's care plan, last revised [DATE], showed: - A DNR code status on [DATE]; - Social Services Designee (SSD) discussed advanced directives and code status with the resident and/or the resident representative on [DATE]; - Assure advanced directives were discussed and appropriate paperwork was obtained on [DATE]; - Advanced directives, when available, will be used according to policy for Full Code status on [DATE]. During an interview on [DATE] at 9:10 A.M., Resident #17 said staff went over the code status a couple months ago and he/she signed something. The resident said he/she wanted to be a Full Code. 2. Review of Resident #33's medical record showed: - An admitted [DATE]; - A DNR code status on the facesheet; - A DNR code status signed by the resident's representative, facility representative, and the physician on [DATE]; - A Full Code status signed by the resident's representative, facility representative, and the physician on [DATE]; - An order for DNR code status, dated [DATE]. Review of the resident's care plan, reviewed [DATE], showed: - A Full Code status, dated [DATE]; - Staff will follow the advance directive as written, dated [DATE]. 3. Review of Resident #53's medical record showed: - An admitted [DATE]; - A Full Code status on the facesheet; - A DNR code status signed by the resident, facility representative, and the physician on [DATE]; - An order for Full Code status, dated [DATE]. Review of the resident's care plan, reviewed [DATE], showed: - A Full Code status, dated [DATE]; - My advanced directive order for Full Code status will be honored, dated [DATE]; - Staff to initiate CPR and call 911, dated [DATE]. 4. Review of Resident #92's medical record showed: - An admitted [DATE]; - A DNR code status on the facesheet; - A Full Code status signed by the resident, facility representative, and the physician on [DATE]; - An order for DNR code status, dated [DATE]. Review of the resident's care plan, reviewed [DATE], showed: - My advance directive decision for Full Code status will be honored, dated [DATE]; - I have a copy of my advanced directives scanned into my electronic medical record or placed in a code status binder located at the nurses station, dated [DATE]. During an interview on [DATE] at 9:18 A.M., the Administrator said staff were instructed to open the scanned signed advance directive in the resident's electronic chart to confirm the code status. There was a book with copies of the advanced directives kept in the SSD's office. During an interview on [DATE] at 2:00 P.M., the SSD said he/she was in charge of the residents' code status but another staff member had taken over the task. The SSD had a binder in his/her office with the residents' code status. 49152 49999

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when 13 residents (Residents #7, #17, #30, #34, #37, #39, #48, #50, #92, #101, #105, #121, and #126) out of 13 sampled residents transferred to the hospital. The facility's census was 127. Review of the facility policy titled, Hospital Transfer and Bed Hold Policy, undated, showed: - If the attending physician orders his/her patient to be transferred to the hospital, the family or responsible party will be notified and arrangements will be made; - Before there is a transfer of a resident to a hospital or a resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. The first will be during the admission process by the reading of the Bed Hold Policy. The second notice will be provided to the resident and family or DPOA at the time of the transfer to the hospital. A copy of this policy will be sent with other papers accompanying the resident to the hospital. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital for medical evaluation on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 10/05/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 2. Review of Resident #17's medical record showed: - The resident transferred to the hospital for medical evaluation on 07/31/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 3. Review of Resident #30's medical record showed: - The resident transferred to the hospital for medical evaluation on 08/08/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 4. Review of Resident #34's medical record showed: - The resident transferred to the hospital for medical evaluation on 05/06/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 5. Review of Resident #37's medical record showed: - The resident transferred to the hospital for medical evaluation on 05/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 07/10/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 10/06/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 6. Review of Resident #39's medical record showed: - The resident transferred to the hospital for medical evaluation on 11/24/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 7. Review of Resident #48's medical record showed: - The resident transferred to the hospital for medical evaluation on 02/18/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/05/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 08/16/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 8. Review of Resident #50's medical record showed: - The resident transferred to the hospital for medical evaluation on 02/20/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/08/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/25/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 9. Review of Resident #92's medical record showed: - The resident transferred to the hospital for medical evaluation on 11/25/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 10. Review of Resident #101's medical record showed: - The resident transferred to the hospital for medical evaluation on 04/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/10/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/30/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 06/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 06/27/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 11. Review of Resident #105's medical record showed: - The resident transferred to the hospital for medical evaluation on 05/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 08/16/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 09/11/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 12. Review of Resident #121's medical record showed: - The resident transferred to the hospital for medical evaluation on 12/05/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. 13. Review of Resident #126's medical record showed: - The resident transferred to the hospital for medical evaluation on 06/04/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative of the resident's transfers to the hospital. During an interview on 12/06/24 at 1:30 P.M., the Social Services Designee (SSD) said the nurses were responsible for notifying the resident's representative of the resident's transfer to the hospital. During an interview on 12/06/24 at 2:30 P.M., the Administrator said the resident's representative should be notified by phone of the resident's transfer to the hospital but the facility did not notify them in writing. The Resident Transfer form was filled out by the nurse transferring the resident to the hospital and that form was given to emergency medical services to pass along to the hospital staff. The hospital staff should give it to the resident's representative. The notification was not mailed to the resident representatives because they would not receive it until after the resident had returned to the facility in most cases. 49150 49152 49999

Based on interview and record review, the facility failed to inform the resident and/or legal representative in writing of their bed hold policy at the time of transfer to the hospital for 12 residents (Resident #7, #17, #30, #34, #37, #48, #50, #92, #101, #105, #121, and #126) out of 13 sampled residents. The facility's census was 127. Review of the facility policy titled, Hospital Transfer and Bed Hold Policy, undated, showed: - In the event that you are transferred to a hospital, a copy of the bed hold policy will be sent with you. If you are a Medicaid recipient, you have access to Therapeutic Leave. You have 12 days leave between January and June and 12 days between July and December of each year; - Before there is a transfer of a resident to a hospital or a resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. The first will be during the admission process by the reading of the Bed Hold Policy. The second notice will be provided to the resident and family or DPOA at the time of the transfer to the hospital. A copy of this policy will be sent with other papers accompanying the resident to the hospital. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital for medical evaluation on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 10/05/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 2. Review of Resident #17's medical record showed: - The resident transferred to the hospital for medical evaluation on 07/31/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 3. Review of Resident #30's medical record showed: - The resident transferred to the hospital for medical evaluation on 08/08/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 4. Review of Resident #34's medical record showed: - The resident transferred to the hospital for medical evaluation on 05/06/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 5. Review of Resident #37's medical record showed: - The resident transferred to the hospital for medical evaluation on 05/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 07/10/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 10/06/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 6. Review of Resident #48's medical record showed: - The resident transferred to the hospital for medical evaluation on 02/18/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/05/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/13/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 08/16/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 7. Review of Resident #50's medical record showed: - The resident transferred to the hospital for medical evaluation on 02/20/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/08/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/25/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 8. Review of Resident #92's medical record showed: - The resident transferred to the hospital for medical evaluation on 11/25/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 9. Review of Resident #101's medical record showed: - The resident transferred to the hospital for medical evaluation on 04/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/10/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/30/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 06/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 06/27/24, and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfers. 10. Review of Resident #105's medical record showed: -The resident transferred to the hospital for medical evaluation on 08/16/24, and readmitted to the facility on [DATE]; -The resident transferred to the hospital for medical evaluation on 09/11/24, and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 11. Review of Resident #121's medical record showed: - The resident transferred to the hospital for medical evaluation on 12/05/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 12. Review of Resident #126's medical record showed: - The resident transferred to the hospital for medical evaluation on 06/04/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. During an interview on 12/06/24 at 2:35 P.M., the Administrator said that the bed hold policy was sent with the resident to the hospital at the time of transfer and that the hospital staff were responsible for giving it to the resident's representative. 49150 49152 49999

Based on interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents (Residents #3 and #17) out of 21 sampled residents. The facility census was 127. Review of the facility's policy titled, Care Plan Section Responsibility, March 2024, showed: - A care plan will be developed upon admission per Centers for Medicare and Medicaid Services (CMS) guidelines. It will be updated quarterly, and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individual's needs. Care plan will also be updated with a significant change of condition; - The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident's status changes, the facility, attending practitioner, and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. 1. Review of Resident #3's medical record showed: - An admitted [DATE]; - Diagnoses of urinary tract infections, falls, polyneuropathy (sensation issues involving peripheral nerves), long term use of antibiotics, hypothyroidism, major depressive disorder (MDD - long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about every day situations), hypertension (high blood pressure), atrial fibrillation (abnormal heart rate and rhythm), heart failure (inability for heart to pump blood as it should), and pain. Review of the resident's Physician Order Sheet (POS), dated December 2024, showed: - An order for apixaban (anticoagulant) 5 milligrams (mg) oral every 12 hours, dated 09/27/24; - An order for famciclovir (antiviral medication) 250 mg oral once a day in morning, dated 09/27/24; - An order for gabapentin (nerve pain medication) 300 mg oral every 12 hours, dated 09/27/24; - An order for duloxetine (depression medication) 60 mg oral once a day in morning, dated 10/03/24; - An order for alprazolam (anxiety medication) 0.5 mg oral once a day at bedtime, dated 11/17/24. Review of the resident's care plan, last reviewed on 10/04/24, showed: - The anticoagulant not addressed; - The antiviral medication not addressed; - The nerve pain medication not addressed; - Depression and anxiety medications, depression, and anxiety not addressed; - Heart failure not addressed. 2. Review of Resident #17's medical record showed: - An admitted [DATE]; - Diagnoses of chronic kidney disease, cerebrovascular disease (damage to the brain from interrupted blood supply), asthma (lung condition making breathing difficult), blindness in one eye, diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), hypertension, atrial fibrillation, and unspecified psychosis (a mental disorder with a severe loss of contact with reality). Review of the resident's POS, dated December 2024, showed: - No order for Xanax (anxiety medication); - No order for Remeron (depression medication); - An order for quetiapine (antipsychotic medication) 100 mg oral once a day at bedtime, dated 08/07/24. Review of the resident's care plan, last reviewed on 10/20/24, showed: - Received Xanax for anxiety, initiated 03/23/22; - Received quetiapine 75 mg at bedtime, updated 10/27/22; - Vision impairment with intervention to provide large print reading material, initiated 01/10/22; - Weight loss related to significant weight loss evidenced by Remeron 7.5 mg for seven days then increase to 15 mg, initiated 09/14/22. During an interview on 12/03/24 at 2:43 P.M., Resident #17 said he/she was completely blind and could only see light differences and shadows. He/She couldn't read at all because of being blind. Resident #17 said he/she can tell if someone was around him/her by the shadow but could not tell who was there and relied on his/her other senses like hearing to distinguish the people he/she interacted with. During an interview on 12/06/24 at 12:25 P.M., Licensed Practical Nurse (LPN) Q said Resident #17 was completely blind and could only see light differences and shadows. During an interview on 12/10/24 at 10:38 A.M., the Minimum Data Set (MDS - a mandatory assessment completed by the facility staff) Coordinator would expect the care plan to accurately reflect the resident's current condition. During an interview on 12/06/24 at 5:45 P.M., the Director of Nursing (DON) and Administrator said they would expect the care plan to accurately reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents and failed to update the care plan with new interventions to prevent additional falls for two residents (Residents #3 and #39) out of two sampled residents. The facility also failed to prevent resident access to liquor in an unlocked office. This had the potential to affect all residents who were able to move freely around the facility. The facility census was 127. Review of the facility policy titled, Falls, dated 09/22/21, showed: - The Minimum Data Set (MDS - a federally mandatory assessment completed by facility staff) defines a fall as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force; - Procedure following a fall includes ascertaining if there were injuries, providing treatment if necessary, fill out a fall event report for any falls sustained by a resident, determine possible cause of fall, neuro checks will be initiated with unwitnessed falls or if a head injury is apparent at time of fall, notify physician, family, and supervisor. - Review with physician if there is a necessity for physical or occupational evaluation and complete documentation in resident's chart; - The nursing office will follow up with the review and assessment and the care plan office will follow up with the interventions; - The care plan team will address the risk factors for the fall and revise the resident's care plan and/or facility practices, as needed, to reduce the likelihood of another fall; - All staff in-serviced on falls yearly and as needed and is part of the New Hire Orientation Program; - All residents are to be assessed by licensed nurses for falls on admission and the care plan team will be reviewed quarterly. 1. Review of Resident #3's admission MDS, dated [DATE], showed: - Cognition intact; - Dependent on staff for toileting and to go from lying to sitting positions; - Dependent on staff for lying to sitting and sitting to lying positions; - Sit to stand and toilet transfer not attempted due to medical condition or safety concerns; - Resident used a wheelchair and/or walker. Review of the resident's medical record showed: - No documentation of a fall on 12/03/24; - No documentation of an assessment of the fall on 12/03/24; - No documentation of notification to appropriate persons per the facility policy for the fall on 12/03/24. Review of the resident's care plan, last revised 10/04/24, showed: - At risk for falls evidenced by total dependence with transfers and fall within last month, dated 09/27/24; - Impaired physical mobility evidenced by total dependence to transfer and ambulate, dated 09/27/24; - Provide appropriate level of assistance to promote safety of the resident, dated 09/27/24; - Interventions included assist resident with activities of daily living (ADLs) and keep call light and most frequently used personal items within reach, dated 09/27/24; - The fall with interventions on 12/03/24, was not addressed. During an interview on 12/04/24 at 12:32 P.M., Resident #3 said he/she fell on [DATE] at 7:30 P.M. After waiting for someone to the answer the call light he/she pressed a little after 4 P.M., the resident had soiled him/herself from not being able to wait any longer to go to the bathroom. CNA N and an unknown nurse assistant (NA) came in the room to assist the resident from the wheelchair back to the bed. CNA N and the unknown NA lifted the resident up with the gait belt and on the way to the bed, one of the resident's legs buckled and the resident fell on his/her knees to the ground. CNA N and the unknown NA got another staff member to help put a Hoyer lift (a mechanical lift) sling pad under the resident and was transferred by the Hoyer lift to the bed. He/She usually could get to the bed from the wheelchair with assist of one to two staff members but was weak from waiting so long in the wheelchair. He/She did not have enough strength to help as much with transferring to the bed. During an interview on 12/04/24 at 5:30 P.M., CNA N said on 12/03/24 at around 9:30 P.M., the resident transferred to the bed with his/her help and another staff with a gait belt. The resident's leg buckled before making it to the bed and he/she and the other staff member lowered the resident to the ground. He/She put a Hoyer lift sling pad under the resident and transferred the resident back to the bed with the Hoyer lift. It was not reported to any other staff since he/she helped lower the resident to the ground and the resident did not fall. During an interview on 12/06/24 at 4:40 P.M., CNA P said if someone was lowered to the ground during a transfer, then it was not considered a fall and he/she would not alert the nurse. If someone did fall, then he/she would get the nurse. The nurse was in charge of charting everything in the computer and notifying everyone who needed to be notified. 2. Review of Resident 39's Admission MDS, dated [DATE], showed: - Cognition intact; - Partial/moderate assistance with mobility and ambulation; - Wheelchair or walker for assistive devices. Review of the resident's medical record showed: - Resident fell on [DATE], at the nurses station and hit the back of his/her head resulting in bleeding from a head wound and sent to the hospital for evaluation; - No documentation of a fall or an assessment for 12/05/24. Review of the resident's care plan, last revised 10/17/24, showed: - At risk for falls as evidenced by problem with balance and fall within last two to six months, dated 10/10/24; - Interventions included to maintain record of falls and evaluate for patterns, assist with ADL's as needed, and assess contributing factors related to fall history, dated 10/10/24; - The falls with interventions on 11/24/24, and 12/05/24, were not addressed. Observation on 12/05/24 at 9:27 A.M., showed Resident #39 in his/her room standing up and supporting him/herself on the roommate's bed with both hands. The resident lost his/her balance and fell on his/her buttocks landing on the floor on right side of the bed. Staff saw the resident on the floor and told Licensed Practical Nurse (LPN) O. LPN O said the resident was care planned for falls and liked to be on the floor to scoot around. LPN O asked a another staff to get the resident from his/her room and bring them to the nurse's station for one-on-one closer observation. During an interview on 12/03/24 at 11:29 A.M., CNA L said Resident #39 liked to be on the ground and scoot around. He/She usually did not fall, but lay himself/herself on the ground. The resident should be care planned for it. During an interview on 12/06/24 at 5:45 P.M., the Director of Nursing (DON) said if a fall was witnessed and hit his/her head, or unwitnessed and couldn't verify if the resident hit his/her head, then the Medical Director wanted all residents sent to the emergency room . If a fall was witnessed and hit his/her head, she would expect the licensed nurse to do an incident report. If a resident did not hit his/her head, then do an incident report, follow for 72 hours with neuro checks. It was considered a fall if a resident was assisted to the floor, but if a resident placed themselves on the floor, it would not be considered a fall. She did not know about Resident #3's or Resident #39's falls. 3. Observations of the unlocked Activity Director's office on 12/04/24 at 7:54 A.M., and 4:31 P.M., and 12/05/24 at 7:54 A.M., and 11:36 A.M., showed a 12 pack of alcoholic beer, an unopened bottle of rum, two 1/2 bottles of tequila, a bottle of coffee liqueur, an opened 1/4 bottle of blue agave tequila, an opened bottle of white rum, an unopened bottle of white rum, a 1/2 bottle of peach schnapps, a 1/2 bottle of brandy, and a 1/2 bottle of amaretto on a shelf visible from the hallway through the opened door. No staff were present. Two residents walked in the hallway outside of the Activities Director's office. During an interview on 12/05/24 at 11:45 A.M., the Activity Director said residents didn't usually enter his/her office if no one was in it, but there had been confused residents enter the office and use the trash can as a bathroom. The door was closed and locked when he/she left for lunch and for the day. The door was not closed when he/she stepped out of the office for a short period. During an interview on 12/06/24 at 6:00 P.M., the Administrator said he expected liquor to be stored in a location that was not accessible to the residents. 49152

Based on observation, interview, and record review, the facility failed to assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or if applicable, the resident representative, and the facility also failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for eight residents (Residents #3, #7, #48, #50, #105, #111, #127, and #389) out of eight sampled residents. The facility's census was 127. The facility did not provide a policy for side rails. 1. Review of Resident #3's admission Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 10/04/24, showed: - Intact cognition; - Dependent with bed mobility; - Diagnoses of falls, difficulty walking, morbid obesity (overweight), pain, heart failure (the heart does not pump blood as well as it should), and atrial fibrillation (abnormal heart beat). Review of the resident's care plan, revised 10/04/24, showed: - Risk of falls related to history of falls; - Bed mobility with supervision and transfers with total assist. Review of the resident's medical record showed: - Side rail evaluation completed on 09/27/24; - No documentation of informed consent for the use of the side rails. - On 12/03/24 at 11:10 A.M., the resident rolled side to side holding on to the bilateral quarter side rails in the upright position while staff performed incontinence care; - On 12/06/24 at 10:30 A.M., the resident lay in bed with the bilateral quarter side rails in the upright position. During an interview on 12/03/24 at 11:00 A.M., Resident #3 said he/she used the side rails to turn and reposition himself/herself in bed and did it independently. 2. Review of Resident #7's quarterly MDS, dated [DATE], showed: - Intact cognition; - Dependent with bed mobility; - Diagnoses of anemia (low blood levels of iron), heart failure, hypertension (high blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), wound infection, diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), hyperlipidemia (high blood level of cholesterol), seizure disorder (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), anxiety disorder(persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's care plan, revised 11/05/24, showed: - Risk for falls; - Impaired physical mobility. Review of the residents' medical record showed: - Side rail evaluation completed on 10/06/23; - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails. Observations of the resident showed: - On 12/03/24 at 11:30 A.M., and 12/05/24 at 9:30 A.M., the resident lay in bed with the bilateral quarter side rails in the upright position. During an interview on 12/04/24 at 9:00 A.M., Resident #7 said he/she used the side rails to turn himself/herself in bed. 3. Review of Resident #48's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Moderate assistance with bed mobility; - Diagnoses of coronary artery disease (a condition that occurs when the arteries in the heart narrow or become blocked restricting blood flow to the heart), heart failure, hypertension, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), DM, hyperlipidemia, fracture, stroke, dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), and psychotic disorder (a severe mental illness that causes a person to lose touch with reality and have abnormal perceptions and thoughts). Review of the resident's care plan, revised 08/21/24, showed: - Risk of falls related to a fall; - Resident will assist with turning and repositioning in bed and transfers. Review of the resident's medical record showed: - Side rail evaluation completed on 02/13/24; - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails. Observations of the resident showed: - On 12/03/24 at 11:12 A.M., the resident lay on the right side while holding onto the U-shaped side rail in the upright position on the right side of the bed; - On 12/06/24 at 11:50 A.M., the resident rolled side to side holding onto the U-shaped side rail in the upright position on the right side of bed while staff performed wound care and incontinence care. 4. Review of Resident #50's quarterly MDS, dated [DATE], showed: - Moderately impaired cognition; - Moderate assistance with bed mobility; - Diagnoses of cancer, anemia, coronary artery disease, hypertension, renal failure, DM, hyperlipidemia, anxiety disorder, and depression. Review of the resident's care plan, revised 09/16/24, showed: - Risk for falls; - Impaired physical mobility; - Requires extensive assistance with bed mobility and transfers. Review of the resident's medical record showed: - Side rail evaluation completed on 04/11/24; - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails. Observations of the resident showed: - On 12/03/24 at 11:24 A.M., and 12/04/24 at 1:00 P.M., the resident lay in bed with the bilateral quarter side rails in the upright position. During an interview on 12/03/24 at 11:20 A.M., Resident #50 said he/she used the side rails to turn himself/herself in the bed. 5. Review of Resident #105's quarterly MDS, dated [DATE], showed: - Cognition mildly impaired; - Partial to moderate assistance for bed mobility; - Diagnoses of anxiety, major depressive disorder, stroke, DM, and osteoarthritis. Review of the resident's care plan, revised 11/04/24, showed: - Risk for falls; - Limited bed mobility; - Impaired physical mobility and range of motion due to contracture of the left hand and cognitive status mildly impaired. Review of the resident's medical record showed: - No documentation of side rail assessments; - No documentation of informed consent for the use of the side rails. Observation on 12/05/24 at 8:15 A.M., showed the resident lay in bed with the bilateral one-quarter, inverted U-shaped side rails in the upright position. 6. Review of Resident 111's admission MDS, dated [DATE], showed: - Cognition intact; - Bed mobility rolling, sit to lying, and lying to sitting in bed require supervision or touching assistance; - Sit to stand or bed to chair transfer require partial to moderate assistance; - Diagnoses of cancer, DM, right humerus (upper arm bone) fracture, stroke, dementia, and traumatic brain injury (TBI), COPD, and falls. Review of the resident's care plan, revised 10/19/24 showed: - Impaired physical mobility; - A recent fracture related to a fall; - Vertigo (dizzy feeling) and syncope (sudden temporary loss of consciousness); - Elopement attempts. Review of the resident's medical record showed: - No documentation of side rail assessments; - No documentation of informed consent for the use of the side rails. Observation on 12/06/24 at 8:20 A.M., showed: - The resident lay sideways in bed with the bilateral U-shaped quarter side rails in the upright position. 7. Review of Resident #127's admission MDS, dated [DATE], showed: - Moderate cognitive impairment; - Moderate assistance with bed mobility; - Diagnoses of atrial fibrillation (a heart condition that causes an irregular heartbeat, often resulting in a faster than normal rate), hypertension, urinary tract infection (a bacterial infection that occurs in the urinary tract), dementia, malnutrition (lack of sufficient nutrients in the body), anxiety disorder, depression, and COPD. Review of the resident's care plan, revised 10/09/24, showed: - Risk of falls related to a fall; - The resident will assist with turning and repositioning in bed and transfers. Review of the resident's medical record showed: - Side rail evaluation completed on 02/13/24; - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails. Observation of the resident showed: - On 12/05/24 at 9:42 A.M., the resident lay in bed with the bilateral U-shaped side rails in the upright position. During an interview on 12/06/24 at 3:19 P.M., Resident #127's family member said the resident used the side rails to turn side to side and get out of bed. 8. Review of Resident #389's admission MDS, dated [DATE], showed: - Cognition intact; - Standby assistance with bed mobility; - Diagnoses of anemia, atrial fibrillation, heart failure, hypertension, renal failure, wound infection, hyperlipidemia, thyroid disorder (a condition that occurs when the thyroid gland doesn't produce the right amount of hormones), arthritis, and depression. Review of the resident's care plan, revised 11/23/24, showed: - High risk of falls. Review of the resident's medical record showed: -Side rail evaluation completed on 11/17/24; - No documentation of informed consent for the use of the side rails. Observations of the resident showed: - On 12/06/24 at 8:00 A.M., the resident lay in bed with the bilateral U-shaped side rails in the upright position; - On 12/06/24 at 8:22 A.M., the resident sat on the left edge of the bed with the bilateral U-shaped side rails in the upright position. During an interview on 12/06/24 at 3:15 P.M., Resident #389 said he/she used the side rails to reposition in bed. During an interview on 12/06/24 at 2:45 P.M., the Director of Nursing (DON) said she would expect side rail assessments to be done quarterly and with changes. During an interview on 12/19/24 at 8:50 A.M., the DON said the nurse managers on the hall were responsible for the completion of the informed consent of the side rails and the MDS Coordinator was responsible for the quarterly assessments of the side rails. 49152 49999

Based on observation, interview and record review, the facility failed to ensure CPR was initiated when a resident with physician's orders for full code status was found unresponsive on [DATE] and expired (Resident #24). The facility identified 70 of 179 residents as having a full code status at the time of the incident. The facility also failed to notify the physician regarding the frequency of a resident's use of an as needed pain medication and provide the medication to the resident in a timely manner and re-evaluate the transfer status for a resident who could no longer bear weight to ensure safety and prevent potential injury during transfers. This affected two of 21 sampled residents (Residents #19 and #21). The census was 160. 1. The administrator was notified of the Immediate Jeopardy (IJ) Past Non-Compliance on [DATE]. The IJ started on [DATE] and was removed on [DATE], when the last nurse who provided direct resident care was inserviced on the facility's updated code status policy, which specifically delineated the facility's expectation on which staff member would be in charge of finding out the resident's code status and delegate responsibilities in the event a resident was found unresponsive. The IJ was removed and corrected on [DATE]. Review of Resident #24's hospital's documentation, faxed to the facility on [DATE], prior to the resident's admission, showed the following: -Code status: Full code; -Discussed at length home health nurse arrangements for outpatient palliative care (focuses on providing patients with relief from the symptoms and stress of a serious illness) versus hospice care (supportive care provided to people in the final stage of a terminal illness); -The resident's child expressed wanting to speaking to his/her sibling regarding further course: having biopsy procedure versus palliative care; -The resident was not interested in further biopsy or invasive procedures for his/her liver masses. He/She leaned towards conservative methods including palliative and comfort measures. Review of the resident's undated referral/admission report sheet, (information the facility received from the hospital to determine if the facility would accept the resident for admission), showed the following: -Multiple liver and lung [MEDICAL CONDITION] consistent with metastatic disease, no interest in having liver biopsy; -Ambulates with wheelchair; -Rehabilitation to home: plan to go home with spouse; -Question about hospice and if family was ready for this; -Height: 5'2 Weight 147 pounds; -Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer on the sacrum (triangular bone situated between hip bones) which measured 5.2 centimeters (cm) by 6.5 cm. There was a presence of slough (stringy tissue that may or may not be firmly attached to surrounding tissue) on the pressure ulcer. Review of the resident's admission face sheet, showed the following: -admitted , of [DATE], from a local hospital; -[DIAGNOSES REDACTED]. Review of the resident's admission evaluation and interim care plan, dated [DATE], showed the following: -Arrival time: 5:15 P.M.; -Heart/Circulation: [MEDICAL CONDITION] (new onset) and high blood pressure; -Temperature: 97.9 degrees (normal 98.6), pulse 56: (normal 60 to 100 beats a minute), blood pressure: ,[DATE] (normal ,[DATE]), weight: 115 pounds, 98% oxygen saturation (O2 sat, a measure of oxygen in the blood) (normal 95% to 100%); -Cognitive/Emotional factors: Alert and oriented times three (person, place and time), follows commands; -Skin: Reddened and scaly shins, cold bilateral lower extremities, purple discoloration to both hands and wrists, Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcers to right shin and coccyx (tailbone). Review of the resident's medical record, showed a document that had not been completed called the code status policy (present in all residents' medical records). Residents could choose to be full code or no code with details regarding code status protocol as follows: -Full code: -Begin CPR. Every measure would be taken to resuscitate individual; -911 will be called; -Patient transported to hospital; -Note: CPR may cause fractured ribs, lung puncture and may not necessarily resuscitate; -No code-Do not resuscitate (DNR); -No CPR; -May use oxygen to keep individual comfortable; -May provide medication for comfort if needed. Review of the resident's physician's order sheet, dated [DATE], showed: -admitted : [DATE]; -Code status: Full code; -Physical therapy/occupational therapy evaluation and treatment; -Inform Physician C of the resident's admission on [DATE] (When the physician returned to work); -Telephone orders verified by Nurse F (Licensed Practical Nurse (LPN)/evening shift charge nurse) on [DATE] at 6:30 P.M.; -A telephone order to change the resident's primary care physician to Physician D, effective [DATE] at 8:30 P.M. Review of the resident's nurse's notes, showed the following: -[DATE] at 5:15 P.M., the resident was admitted into the facility. The resident displayed no coughing, shortness of breath or dyspnea (difficulty or labored breathing). Extremities cool to touch, pink in color. Purple discoloration noted to both hands. Open area to coccyx. Will have the nurse evaluate for any treatment orders in the morning; -[DATE] at 6:30 P.M., Physician DD, the on-call physician for Physician C verified orders; -[DATE] at 8:30 P.M., Physician DD, discussed transferring the resident to Physician D's care due to Physician C being out of town for an extended period of time; -[DATE] at 12:30 A.M., the resident's temperature: 96.8 degrees, respirations: 20 (normal 12 to 20 breaths per minute), blood pressure ,[DATE], 92% O2 sat on room air. Continued complaints of nausea, relieved with sips of water and crackers. Denies pain. Bilateral lower extremities reddened with hard skin on surfaces; -[DATE] at 5:25 A.M., wound nurse unable to arouse. No heart tones audible. No pulses present. Noted blood pooling under skin on prone (stomach) side. Cool to touch. Bed laid in flat position; -[DATE] at 2:45 A.M. (late entry), answered call light with Certified Nurse Aide (CNA) E, the resident complained of not feeling right. Alert and oriented times three, grips/pushes/pulls weak but equal and unchanged from assessment at midnight; -[DATE] at 3:30 A.M. (late entry), visual room check. Bed and resident dry. In bed resting quietly. Respirations even and unlabored with no signs and/or symptoms of distress noted; -[DATE] at 8:15 A.M., Physician D returned call and gave [DIAGNOSES REDACTED]. Review of the facility's medical examiner death reporting form, dated [DATE], completed by Nurse A (Registered Nurse (RN)/night shift charge nurse), showed the following: -Events of Death: found and pronounced dead on [DATE] at 5:25 A.M. by Nurse I (RN/wound nurse); -No mottling (an indication of death, characterized by marks with spots or smears of color) present; -Body not stiff; -Skin cold; -One coccyx wound, acquired from the hospital. Review of the facility's investigation report, dated [DATE], showed the following: -CNA E was the last staff member to see the resident alive on [DATE] during 4:00 A.M. rounds; -CNA E's statement, dated [DATE]: During 4:00 A.M. rounds, the resident was sleeping and dry. After 5:00 A.M., nurse A said the resident was no longer with us. Nurse I and Nurse S (LPN/wound nurse) were standing at the nurse's station. Nurse I and Nurse S had gone into the resident's room to do the wound treatment but the resident was unresponsive. An addendum to statement, also dated [DATE], showed Nurse J (RN/day supervisor/skill MDS coordinator) told Nurse A he/she had to contact people (not specified), including the facility's medical director. No CPR was initiated; -Nurse I's statement (undated): The resident was unresponsive upon entering his/her room. His/Her arm was cold. Nurse I turned on the bed light and noted discoloration of the resident's lips and fingernails. The resident did not respond to verbal or tactile (touch) stimulation. No pulse noted. Nurse I sent Nurse S out of the room to get Nurse A. Nurse A and Nurse S came back into the room and Nurse A checked the resident for vital signs. Nurse I asked Nurse A what the resident's code status was and the last time the resident was checked. Nurse A did not know the resident's code status and said the last time the resident had been checked was around 4:00 A.M. Nurse A left the room and went towards the nurse's station. Nurse I and Nurse S remained in the resident's room because Nurse I thought Nurse A was checking on the resident's code status. After 30 seconds passed and Nurse A did not come back to the room or call the code, Nurse I and Nurse S went to the nurse's station. Nurse J and Nurse A had the chart and were discussing which physician to contact. Since Nurse J and Nurse A had the chart and had not called a code, Nurse I assumed the resident had a DNR code status. Nurse J had taken over the situation, so Nurse I resumed doing wound treatments for other residents. Later that day, the Director of Nurses (DON) asked why he/she did not initiate CPR and he/she said because the resident was deceased . The DON told him/her the resident's code status was full code, to which he/she said he/she had been unaware the resident was full code. On [DATE] at 10:20 A.M., the Assistant Director of Nurses told him/her because he/she found the resident, it was his/her responsibility to start CPR. He/She had no reason to think the resident was a full code because Nurse A never returned to the room or announced a code. Nurse J and Nurse A were at the nurse's station with the chart and discussed which physician to contact between themselves because there had been a mix-up during admission. He/She never looked at the chart and there was no reason for him/her to think the resident was anything but DNR code. The administrator asked him/her to write a statement during this conversation and he/she wrote, If there was a need for an investigation it should have included everyone involved and if there was a question about who was telling the truth all the people involved should have been suspended until the investigation was complete. It definitely should have included N J; -Nurse S's statement (undated): Upon entering the resident's room with Nurse I for wound treatment, the resident appeared very pale and white. The resident was unresponsive, not breathing, did not have a pulse and his/her skin was very cold. As Nurse I did the sternum rub, Nurse S went to get Nurse A and directed Nurse A to bring his/her stethoscope. Nurse S reentered the room at the same time Nurse A entered the room. Nurse I said it seemed as if the resident had been expired for a while. Nurse A said he/she saw the resident around 3:00 A.M. and left the room. Nurse I and Nurse S waited in the room a few minutes after Nurse A left. Nurse I and Nurse S left the resident's room since Nurse A did not return and saw Nurse J and Nurse A discussing which physician and which family member to contact. Nurse S did not look at the chart because Nurse J and Nurse A had it and were taking care of the situation. Nurse I and Nurse S proceeded with wound treatments for other residents. No CPR was initiated on the resident; -Nurse A's statement (undated): On [DATE] at 3:30 A.M., a visual room check was done on the resident. He/She lay in bed breathing and resting with his/her brief dry. At 5:15 A.M., Nurse S called Nurse A to the resident's room for Nurse I. The resident was unresponsive with no heart tones heard or radial (wrist)/jugular (neck) pulses felt. Nurse S and Nurse I turned the resident on his/her side to look for blood pooling on his/her back/coccyx which was present. No CPR was initiated. At 5:20 A.M., he/she returned to the nurse's station where he/she and Nurse J discussed which physician to contact to pronounce death and provide a death diagnosis. Nurse J said he/she should call the resident's family first. At 5:35 A.M., he/she informed Physician DD the resident passed away. He/She contacted Physician DD because Physician D had not been made aware the resident was to be assigned to him/her. Physician DD told Nurse A he/she could not give a death [DIAGNOSES REDACTED]. Nurse J directed him/her to contact the medical director, who told him/her to contact the hospital the resident came from to see if the attending physician there could give a diagnosis. At 8:15 A.M., Nurse A spoke with Physician D, who gave a death [DIAGNOSES REDACTED]. -Nurse J's statement (undated): At 5:30 A.M., he/she approached the nurse's station and was informed by Nurse I, Nurse S and Nurse A the resident expired at 5:25 A.M. Nurse A had the resident's chart in front of him/her with the phone in his/her hand. Nurse A informed Nurse J the resident was full code but asked which physician he/she should call. Nurse J asked which physician was listed on the resident's chart and Nurse A said the on call physician for Physician D discussed the resident transferring to Physician C's care during the day shift. After Nurse A contacted the on call physician for Physician D, Nurse J directed Nurse A to contact the resident's family. Nurse J then directed Nurse A to contact the facility's medical director. Nurse J did not ask or advise Nurse A about CPR initiation, to call the code or to call 911. No CPR was initiated; -DON's statement, dated [DATE]: On [DATE] when she arrived at the facility, Nurse J notified him/her the resident expired at 5:25 A.M. Nurse J said the resident had been found deceased and body cold to touch. Nurse I said he/she and Nurse S entered the room to assess the resident's wound. The resident appeared to be very pale in color and his/her skin was cold to touch. The resident was unresponsive, had no pulse or respirations. Nurse I and Nurse S called Nurse A to the resident's room, who verified the resident had no pulse or respirations. The resident's chart did not have a code status policy form, but the physician's order sheet did indicate full code. Nurse A did not initiate CPR and said they all were aware of the resident's full code status. Nurse I did not check the chart or take initiative to confirm the resident's code status and he/she did not initiate CPR due to the resident being cold and obviously deceased . Nurse A said he/she did not initiate CPR for the same reasons. Nurse I and Nurse A acknowledged awareness of treating a resident as a full code in the absence of a code status sheet. Nurse S said he/she and Nurse I entered the room and saw the resident was laying on his/her back and his/her skin was pale and cold. They attempted to awaken the resident without success. He/She said CPR should have been initiated but he/she felt with Nurse I being present the situation was being handled. He/She was aware CPR should be initiated in the absence of a code status sheet. Nurse J arrived at the nurse's station approximately five to ten minutes after the resident was found deceased . Nurse I and Nurses A and S were at the nurse's station, informed him/her the resident had expired and Nurse A asked for guidance on which physician to contact. He/She said there was discussion at the nurse's station regarding the resident being a full code but because Nurse I was present and CPR had not been initiated the family must have said they did not want it. He/She learned the resident's family had not been notified after he/she asked Nurse A and instructed Nurse A to call the family and physician. It was too late to do any interventions, which was why Nurse J notified the DON of the incident immediately upon her entering the building. The hospital's records showed the resident was a full code prior to his/her admission to the facility. During an interview on [DATE] at 12:49 P.M., Nurse F said he/she was the evening charge nurse, on [DATE], that completed the resident's nursing assessment and verified the physician's orders. The resident's extremities were cool to touch upon admission. He/She redressed an area to the resident's buttocks and did not recall any discoloration on the resident's buttocks. During an interview on [DATE] at 8:32 A.M., CNA E said he/she saw the resident and had a conversation, on [DATE] at around 11:00 P.M., when he/she passed out ice and linens. He/She did not recall the color of the resident's skin at this time. He/She saw the resident again while the charge nurse did an assessment on the resident around 2:45 A.M. The resident's skin appeared ashen at this time. He/She did 4:00 A.M. rounds and the resident appeared to be resting quietly and he/she checked the resident's brief which was dry. The wound nurses came on the hall anywhere from 4:25 A.M. to 5:25 A.M. Nurse A said the resident passed away. Nurses I, J, A and S were at the nurse's station. Nurse A asked Nurse J what to do. Nurse J told Nurse A to call the physician. CNA E and CNA R left the nurse's station and went to the resident's room. The resident's skin was very pale and his/her skin appeared more ashen than earlier at 2:45 A.M. when Nurse A did the assessment on him/her. No one performed CPR on the resident. During an interview on [DATE] at 4:23 P.M., Nurse I said he/she and Nurse S entered the resident's room on [DATE] at approximately 5:30 A.M. to provide wound care to the resident's buttocks. The resident did not respond when they knocked on his/her door. He/She was unresponsive and did not appear to be breathing. Nurse I turned on the bed lights and saw the resident's body which appeared to be ashen, his/her lips were blue, his/her skin was cold to touch, with no pulse and/or respirations. He/She sent Nurse S out of the room to get Nurse A. He/She checked the resident's fingernails, respirations and did a sternum rub on the resident with no response. When Nurses A and S came to the room, Nurse I asked Nurse A for the resident's code status. Nurse A said he/she was unfamiliar with the resident because he/she was a new admission then left the room. Nurse A did not say he/she was going to check the resident's code status at this time. Nurse I and Nurse S waited for Nurse A to come back to the room, but left approximately 30 to 45 seconds later when Nurse A did not call the code or come back to the resident's room with the crash cart. During this time, Nurse I checked the resident's legs, feet and backside. The temperature in the room felt cool and the resident's skin felt cold. The resident had an open area on his/her buttocks and the buttocks were darkish gray, darker than the rest of the resident's body. The resident's back did not appear noticeably different from the rest of the resident's body and was not the darkish gray color the resident's buttocks were. When Nurse I and Nurse S approached the nurse's station, Nurse J and Nurse A were discussing the resident. Nurse I did not ask for the resident's code status at that time because there were two experienced nurses handling the situation. Nurse I said CPR should not have been done on the resident because he/she was waiting on Nurse A to convey the code information to him/her. He/She did not perform CPR for the resident because he/she was unaware the resident was a full code at the time of the incident. If he/she knew the resident's full code status, he/she would have performed CPR. The reason he/she did not initiate CPR is because CPR would not be performed on a resident that was a DNR. The resident's code status dictates what staff's actions are when a resident is found unresponsive. Nurse I had the authority to take over with this situation, but he/she did not know the resident's code status. He/She was waiting on Nurse A to call the code because it was his/her responsibility to make the decision. The facility's code status policy was if a resident was a full code or there was no code status sheet filled, staff were expected to call the code, call 911, bring the crash cart and start CPR. He/She was not asked for a statement at the time of the incident but submitted his/her statement of the incident after the incident occurred. During an interview on [DATE] at 3:48 P.M., Nurse S said on [DATE] around 5:15 to 5:30 A.M., he/she and Nurse I entered the resident's room after knocking on the door and not getting a response. The resident appeared pale (whitish), his/her chest did not rise and skin felt cold when his/her wrist, forehead and feet were touched. The resident did not have a pulse. Nurse I did a sternum rub and sent Nurse S to get Nurse A, who was the charge nurse at this time. When Nurse A and he/she got back to the resident's room, Nurse I showed Nurse A the resident's buttocks, which was a pale, bluish color. He/She could not recall what the resident's back looked like. Nurse A left the resident's room and said the resident died . He/She did not recall Nurse A saying he/she would go get the resident's code status or Nurse I advising him/her to obtain the code status while they were in the resident's room. He/She did not inquire on the resident's code status. Nurse I and he/she stayed in the room waiting on Nurse A to tell them whether or not to begin CPR and when he/she did not return, they walked up to the nurse's station. Nurse I and Nurse A had a discussion, but he/she did not know what was said because he/she was not a part of this conversation. He/She did not see any staff perform CPR for the resident and he/she did not do CPR. He/She should have done CPR for the resident because the resident was a full code. The code status policy was if the resident had no code status sheet filled out or had chosen to be full code, a code should be called from the intercom, 911 is to be called, a crash cart is to come down and CPR to be initiated immediately. He/she did not learn of the resident's code until following the incident. During an interview on [DATE] at 10:44 A.M., Nurse A said he/she was the night shift charge nurse assigned to the resident on [DATE] during the night shift. The evening shift charge nurse he/she received report from said the resident's skin was always cold. On [DATE] at approximately 2:45 A.M., he/she did an assessment on the resident which showed no concerns. At approximately 5:00 A.M., the wound nurses, Nurse I and Nurse S came on the hall to provide wound treatment for [REDACTED].M., Nurse S approached Nurse A and said the resident was gone. Nurse A did not recall Nurse S asking about the resident's code status. When Nurse A entered the resident's room, Nurse I said the resident was gone. Nurse A could not find a pulse from the resident's left jugular and wrist. He/She found no pedal (area on top of foot) pulse. The resident's skin felt cooler than during prior assessments that night and appeared dusky and pale, with his/her toes barely blue. The resident was overall pale, with his/her coccyx area discolored with a pale blue color. He/She did not check the resident's pupils. Nurse A left to get the resident's chart in order to call the physician and the resident's family. He/She did not think to check the resident's chart for the code status or initiate CPR because he/she relied on Nurse I's nursing judgment that the resident had passed. He/She should have checked the resident's chart to find the resident's code status. Around 6:00 A.M. or 6:30 A.M., while Nurse A was going through the resident's chart, he/she saw the resident was a full code. He/She would have done CPR if he/she knew the resident's code status, but it was too late by the time he/she found out. During an interview on [DATE] at 8:10 A.M., Nurse J said he/she started his/her shift on [DATE] at 5:00 A.M. He/She came to the nurse's station around 5:30 A.M. Nurse I and Nurse A were at the nurse's station. Nurse J asked Nurse A for the resident's chart. Nurse A said he/she would not need it because the resident passed away. Nurse A then proceeded to ask what physician and which family member to notify. Nurse J did not ask Nurse A for the resident's code status. During the conversation, Nurse A informed him/her the resident was a full code. Nurse J did not think to ask about CPR and did not go down to see the resident. He/She should have gone to check on the resident and initiated CPR. If a resident was a full code, staff were expected to announce a code, call 911, bring the crash cart to the room and CPR initiated immediately. The crash cart was located in the utility room that all staff have access to. Any staff member can bring the crash cart to the room. During an interview on [DATE] at 7:58 A.M., Nurse Z said if staff find a resident unresponsive, they are supposed to check the resident's code status. If the resident is a full code or if no code status is specified, the code should be announced to the room, 911 is to be called and the crash cart to be brought down to the room. This should all happen immediately. If the resident is a full code, CPR should always be done. During an interview on [DATE] at 9:30 A.M., Nurse U said the residents' code status sheets were located in the front of the chart. If the resident did not have a code sheet filled out or if the code sheet showed the resident was a full code, staff would call the code, call 911, grab the crash cart and initiate CPR. Review of the facility policy regarding Code Status and CPR, showed the only policy provided was one dated [DATE]. During an interview on [DATE] at 11:35 A.M., the DON said she got to the facility between 7:00 A.M. and 8:00 A.M. on [DATE]. She expected the nurses involved in this incident to perform CPR for the resident. It was unacceptable for the nurses not to perform CPR for the resident. The facility's policy states if a resident was a full code, staff were supposed to call the code, bring the crash cart down, call 911 and perform CPR. It was not in the nurses' scope of practice to determine if a resident was still alive. She referred Nurse Supervisors I and J and Nurses A and S to the Missouri Board of Nursing as a result of this incident. During an interview on [DATE] at 12:00 P.M., Physician D said he/she expected staff to follow the facility's code status policy and to call 911 and initiate CPR if a resident was a full code. During an interview on [DATE] at 11:45 A.M., the facility's medical director said he expected staff to follow the facility's code status policy. If the resident was a full code or a code status sheet was not completed, staff should do CPR. If a resident was a DNR, nurses would need to contact the physician to report the death because they would not be the final determinant of death. 2. Review of Resident #19's care plan, updated [DATE], showed the following: -Problem: Pain: [DIAGNOSES REDACTED]. -Approach: Administer as needed (PRN) [MEDICATION NAME] (generic for Tylenol) as ordered for pain relief. Assess pain characteristics: duration, location and quality. Assure that pain medication is available if needed. Notify doctor if pain medication is ineffective or the pain intensity increases. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -Pain monitoring: Monitor every shift; -Order dated [DATE]: [MEDICATION NAME] 325 milligrams (mg) two tablets by mouth every four hours PRN for pain or elevated temperature. Review of the resident's Medication Administration Record [REDACTED] -Front of MAR: Tylenol 325 mg two tablets by mouth every four hours PRN for pain or elevated temperature. Staff initialed as given 28 times; -Back of MAR: Staff documented the administration of Tylenol for complaints of back and leg pain 27 times. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed no documentation staff notified the physician regarding the resident's leg or back pain. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Front of MAR: [MEDICATION NAME] 325 mg two tablets by mouth every four hours PRN for pain or elevated temperature. Staff initialed as given 45 times; -Back of MAR: Staff documented the administration of Tylenol for complaints of back and leg pain 45 times. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed no documentation staff notified the physician regarding the resident's leg or back pain. (Next note [DATE]). Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Front of MAR: [MEDICATION NAME] 325 mg two tablets by mouth every four hours PRN for pain or elevated temperature. Staff initialed as given 54 times; -Back of MAR: Staff documented the administration of Tylenol for complaints of back and leg pain 56 times. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment, completed by facility staff), dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory loss; -Required extensive assistance of staff for bed mobility, dressing, toilet use, personal hygiene and bathing; -Total assistance of staff for transfers; -Range of Motion: Upper and lower extremity impairment on one side; -Incontinent of bowel and bladder; -Pain: Scheduled pain medication regimen: no. Pain presence: yes. Pain frequency: Occasional. Pain intensity: moderate. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed no documentation staff notified the physician regarding the resident's leg or back pain. (Next note [DATE]). Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Front of MAR: [MEDICATION NAME] 325 mg two tablets by mouth every four hours PRN for pain or elevated temperature. Staff initialed as given 54 times; -Back of MAR: Staff documented the administration of Tylenol for complaints of back and leg pain 56 times. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed no documentation staff notified the physician regarding the resident's leg or back pain. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Front of MAR: [MEDICATION NAME] 325 mg two tablets by mouth every four hours PRN for pain or elevated temperature. Staff initialed as given 19 times; -Back of MAR: Staff documented the administration of Tylenol for complaints of back and leg pain 20 times. Observation and interview, during the initial tour of the facility on [DATE], showed the following: -9:00 A.M.: the resident stopped this surveyor and said he/she asked staff for two Tylenol before breakfast because his/her legs were really hurting. He/She went to breakfast at 7:30 A.M. After breakfast he/she told an unknown CNA he/she needed Tylenol for leg pain, and the CNA said he/she would tell the Certified Medication Technician (CMT); -9:10 A.M.: An unknown CNA asked the resident if he/she was ready to go to lay down. The resident said, No because he/she was waiting for pain medicine. CMT administered two Tylenol at that time. Observation and interview, on [DATE], showed the following: -9:50 A.M.: The resident lay in bed and said he/she asked for a pain pill twice that morning and had yet to receive it; -10:10 A.M.: CNA L provided perineal care and the resident asked for pain medication. CNA L said he/she would tell the CMT. The resident said it had been 20 minutes since the last time he/she asked for pain medicatio

Based on observation, interview and record review, the facility failed to ensure resident's safety alarms, put in place by the facility to prevent or reduce the risk of falling, were in place and/or functioned properly. Of the 21 residents sampled, 15 had orders for bed/chair alarms. Of those 15, problems were found with four residents and one expanded sampled resident. (Residents #18, #17, #25, #2 and #15). The census was 160. 1. Review of Resident #18's admission face sheet, showed an admission date of [DATE]. Review of the resident's Fall Risk Screening, completed by the facility staff, dated 6/4/15, showed the following: -Total score of 32; -A resident who scores a 10 or higher is at risk. Consider environmental risk factors in resident interventions. Review of the resident's nurse's notes, showed the following: -6/4/15 at 9:15 P.M.: Staff found the resident on the floor after hearing bed alarm sounding; -6/5/15 through 6/10/15, showed no documentation regarding resident removing or taking apart his/her bed or chair alarm. Review of the resident's admission Minimum Data Set (MDS), dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -No mood/behavior problems; -Required extensive assistance of staff for bed mobility, transfers, dressing and toilet use; -Required total assistance of staff for personal hygiene and bathing; -Incontinent of bowel and bladder; -Fall prior to admission: yes; -Fracture related to a fall: yes; -Number of falls since admission resulting in injury: one. Review of the resident's nurse's notes, dated 6/11/15 through 6/17/15, showed no documentation regarding the resident removing or taking apart his/her bed or chair alarm. Review of the resident's care plan, dated 6/17/15, showed the following: -Problem: Risk for falls related to multiple falls, recent fall with cervical fracture, poor balance; -Goal: Will not sustain a fall related injury through his/her discharge date ; -Interventions: Keep call light within reach. Transfer with gait belt and assist of two. Encourage to use call light and wait for assistance. Make sure gripper socks and or shoes on when out of bed. Ensure wheelchair alarms are in place and turned on at all times (updated on 8/7/15). Review of the resident's nurse's notes, dated 6/18/15 through 7/17/15, showed no documentation regarding the resident removing or taking apart his/her bed or chair alarm. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Order dated 6/4/15, for bed and chair alarms at all times. Observation on 8/7/15 at 5:35 A.M., showed the resident lay on the floor at the foot of his/her bed calling for help. His/her neck brace intact and blood noted on the floor. He/she complained of his/her head and hip hurting. The bed alarm was not sounding. This surveyor called for the charge nurse and director of nurses and staff responded. Review of the resident's nurses notes, showed the following: -8/7/15 at 5:45 A.M.: Resident found on floor, on his/her back, blood on floor under head. Neurological checks (done by the nurse to access changes in consciousness). Hand grips equal, range of motion with in normal limits, tongue midline. Laceration to left side of scalp. Bed alarm found taken apart, battery out sitting on wheelchair next to the bed. Alarm checked at bedtime during medication pass, intact and functioning. At 5:50 A.M., 911 called. During an interview on 8/7/15 at 7:50 A.M., Certified Nurse Assistant (CNA) V and Nurse CC said the resident was non complaint, takes off his/her alarms and disconnects them. CNA V said he/she last saw the resident asleep with his/her alarms intact. Review of the resident's nurses notes, showed the following: -8/8/15 at 12:00 P.M.: Resident returned from hospital via ambulance. status [REDACTED]. Laceration noted to left scalp, sutures clean, dry and intact. Moderate amount of purple bruising noted to left shoulder and left buttock. During an interview on 8/11/15 at 10:30 A.M., Nurse X said staff had reported quite a few times of the resident disconnecting alarms and taking him/her self to the bathroom. During an interview on 8/10/15 at 1:00 P.M., the Director of Nurses (DON) said she was unaware the resident removed his/her alarms until after the recent fall. The resident's care plan should have been updated to reflect this sooner. During an interview on 8/11/15 at 10:50 A.M., the DON said if she had known the resident removed and/or dismantled the alarms she would have instructed staff to place the alarm box out of the resident's reach. 2. Review of Resident #17's history and physical from a local hospital, dated 6/24/15, showed the following: -[DIAGNOSES REDACTED]. -Resident presents to the emergency room with complaints of falling again today. He/she had been discharged two days ago after falling. Last night he/she fell and hit his/her head. He/she has a large bruise on his/her forehead and right eye. He/she is confused and unable to recall how he/she fell ; -Non-weight bearing on the right leg and wears an immobilizer (splinting device that helps prevent unwanted movements); -Assessment: Frequent falls and had a right patellar (knee) fracture, from two days ago. Review of the resident's admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -Understood and understands; -Limited assistance of one person required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Continent of bladder and bowel; -[DIAGNOSES REDACTED]. -Disorganized thinking: Behavior present, fluctuates (comes and goes, changes in severity); -Falls prior to admission; -One fall without injury since admission. Review of the resident's care plan, dated 7/8/15, showed the following: -Inability to perform activities of daily living and transfers independently; -Assist with transfers; -Ensure wheelchair and bed alarms are in place and turned on at all times; -Weight bearing as tolerated with immobilizer in place to the lower right leg; -Risk for injury due to history of seizures; -Impaired vision; -Provide frequent reminders to use call light and wait for assistance. Review of the resident's physician's progress notes, dated 7/20/15, showed the resident had ambulatory dysfunction with fall due to decreased safety awareness caused by mild dementia. Observation on 8/7/15 at 6:40 A.M., showed the surveyor entered the resident's room. The resident who was standing in the bathroom, poked his/her head around the corner of the bathroom door and said he/she did not have clothes on, was ok and did not need assistance. The resident's wheelchair sat outside the bathroom with a pressure safety alarm (a flat pad that is laid on a bed in the seat of a chair, when the resident stands, the alarm sounds) on it. The alarm was not sounding. The surveyor exited the resident's room, and asked CNA W (working the unit on the night shift) if the resident should be walking in the bathroom unassisted. The CNA said it was alright for the resident to be up by him/herself, then went into another residents room. The surveyor went to the nurse's station and asked Nurse G if the resident should be up walking independently. The nurse said the resident should not be up unassisted, then went to the resident's room. During an interview on 8/7/15 at 7:05 A.M., CNA W said he/she did not know the resident had safety alarms. Had he/she known, he/she would have assisted the resident at the time the surveyor asked. Review of the residents CNA kardex (care plan) located on the back of the resident's closet door, showed the resident should have an alarm on the bed and chair. During an interview on 8/7/15 at 6:45 A.M., the Assistant Director of Nurses said if a resident uses an alarm, they need assistance to transfer and/or ambulate. She did not know why the resident's bed or wheelchair alarm had not sounded alerting staff. The resident fell at home and alarms had been placed as a safety precaution. At 7:15 A.M., the ADON said she spoke to CNA W. She did not know why CNA W did not know the resident used safety alarms. The CNA should have been aware of it, since it is on the CNA kardex in the room. During an interview on 8/7/15 at 7:30 A.M., Certified Occupational Therapist Assistant Y said the resident was discontinued from skilled therapy about a week ago. They had been working with the resident on transfers, safety, toileting and upper body strength. The resident had a [DIAGNOSES REDACTED]. The resident had poor safety awareness. He/she did not always remember safety issues and wanted to get up independently because he/she cannot remember not to be up without assistance. The resident needs to wear the immobilizer when standing. During an interview on 8/7/15 at 9:00 A.M., Nurse G said when he/she assisted the resident this morning, the resident did not have the immobilizer on. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed the following: -Highly impaired hearing; -Impaired vision; -Usually understood and usually understood; -Limited assistance of one person required for bed mobility, locomotion on/off the unit, dressing and personal hygiene; -Extensive assistance of two (+) persons required for transfers; -[DIAGNOSES REDACTED]. -Two falls since the prior assessment on 2/13/15, one resulted in injury and one resulted in major injury. Review of the resident's Risk for Falls assessment, dated 6/20/15, showed a score of 21. A score of 10 or greater indicates the resident is at risk to fall. Review of the resident's POS, dated 7/25/15 through 8/24/15, showed an order for [REDACTED]. Observation on 8/7/15 at 6:40 A.M., showed the resident lay in bed sleeping. He/she had no alarm on the bed. Review of the CNA's kardex, located on the back of the resident's closet door, showed the resident should have a bed and chair alarm. Observation on 8/7/15 at 9:30 A.M., showed the resident lay in bed sleeping. He/she had no alarm on the bed. During an interview at that time, Nurse G said the resident should have an alarm on the bed for safety. CNA T, present at that time, said he/she laid the resident down after breakfast. He/she did not notice the resident did not have an alarm on the bed. 4. Review of Resident #2's admission MDS, dated [DATE], showed the following: -Understood and understands; -Moderately impaired hearing; -Vision adequate; -Extensive assistance of one person required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Moving from a seated to standing position: Not steady, only able to stabilize with assistance; -Surface to surface transfer: Not steady, only able to stabilize with assistance; -Occasionally incontinent of bladder and bowel; -[DIAGNOSES REDACTED]. -No falls in the last 2-6 months prior to admission; -No falls since admission. Review of the resident's POS, dated 7/25/15 through 8/24/15, showed an order for [REDACTED]. Review of the resident's care plan, dated 7/31/15, showed the following: -admitted to facility after stroke with left sided weakness; -Risk for falls related to left sided weakness; -Assist with transfers; -Keep call light within reach; -Encourage to use call light and wait for assistance; -Ensure that wheelchair and bed alarms are in place and turned on at all times. Observation on 8/5/15 at 2:00 P.M., showed the resident lay in bed. His/her wheelchair sat next to the bed with an alarm on it, but he/she had no bed alarm. Observation on 8/7/15 at 6:40 A.M., showed the resident was out of the room. His/her bed had no safety alarm. At 9:30 A.M., the resident lay in bed sleeping. Nurse G checked the resident's bed and said the resident did not have a safety alarm on the bed. Review of the CNA's kardex, located on the back of the resident's closet door, showed the resident should have a bed alarm. The nurse said he/she did not know why the resident did not have the safety alarm on the bed. 5. Review of Resident #15's annual MDS, dated [DATE], showed the following: -Sometimes understood and sometimes understands; -Total dependence of two (+) persons required for bed mobility, transfers and toilet use; -Total dependence of one person required for dressing, eating and personal hygiene; -[DIAGNOSES REDACTED]. -No falls. Review of the resident's POS, dated 6/25/15 through 7/24/15, showed a handwritten order dated 6/21/15 for a bed and chair alarm. Review of the resident's Risk for Falls assessment, completed on 6/30/15, showed a score of 14. Review of the resident's care plan, dated 7/27/15, showed the following: -Resident is confused; -Hospice program; -Prior history of falls and uses a gerichair (reclining chair); -Bed and chair alarms, make sure they are intact and functioning properly. Observation on 8/5/15 at 1:00 P.M., showed CNA P and CNA Q transferred the resident from the tilt in space wheelchair (tilting, contoured wheelchair) to the bed to provide incontinence care. Observation of the bed at that time, showed the resident had an alarm cord (one end attaches to a pressure alarm pad underneath the sheet and one end attaches to an alarm box) hanging from underneath the sheet, but there was no alarm box for it to plug into. The CNAs left the room without noticing the safety alarm cord dangling from underneath the sheet. Observation on 8/6/15 at 9:20 A.M., showed the resident lay in bed sleeping. The resident's alarm cord remained dangling from underneath the sheet without being attached to an alarm box. Review of the CNA's kardex located on the back of the resident's closet door, showed the resident should have alarms on the bed and chair. Observation on 8/7/15 at 5:35 A.M., showed the resident sat up in the wheelchair in his/her room. The alarm cord was attached to an alarm box and attached to the bed frame. 6. During an interview on 8/10/15 at 1:00 P.M., the Director of Nurses said they place alarms on residents at risk to fall. The purpose of the alarm is to alert staff when a resident at risk to fall, is up without assistance. The alarms are placed on the care plan and the CNA kardex. The kardex is placed on the back of the resident's closet door as a reference for the CNAs. CNAs should check residents every time they make rounds to ensure they have the alarms in place. The alarms are on the medication administration record and the nurse's are suppose to check the alarms as well.

Based on interview and record review, the facility failed to verify hospital discharge MEDICATION ORDERS FOR [REDACTED]. The resident expired on [DATE] from an acute [MEDICAL CONDITION] embolism (a blood clot which traveled to a main artery of the lungs). The census was 152. Review of Resident #25's admission face sheet, showed the following: -Originally admitted to the facility on [DATE] and readmitted to the facility [DATE]; -[DIAGNOSES REDACTED]. Review of the hospital admission progress note dated [DATE], showed the following: -admitted to the hospital on [DATE] from the facility; -admitting [DIAGNOSES REDACTED]. -Right proximal humerus (upper arm bone) fracture sustained from a fall at the facility on [DATE]. Review of the hospital laboratory report dated [DATE], showed the following: -[MEDICATION NAME] (plasma protein that is converted to [MEDICATION NAME] during blood clotting) 13.8, normal range (11XXX,[DATE].7); -INR (measures blood coagulation) 1.0, normal range (2XXX,[DATE].0); -PTT (blood test used to monitor how long it takes for blood to clot) 30.1, normal range (23XXX,[DATE].3). Review of the hospital operative report dated [DATE], showed the resident had an open reduction and internal fixation (type of surgery used to repair a fractured bone) with a compression screw to the right hip. Review of the hospital discharge medication orders dated [DATE], showed the following: -An order dated [DATE], for [MEDICATION NAME] (anticoagulation medication to prevent blood clot formation) 30 milligrams (mg)/0.3 milliliters (ml) solution injection subcutaneous (under the skin) daily; -An order dated [DATE], to discontinue [MEDICATION NAME] (anticoagulation medication) 5,000 units injection daily; -[MEDICATION NAME] started on [DATE] and last administered on [DATE] at 8:47 A.M. Review of the admission physician order [REDACTED]. -No order for [MEDICATION NAME] 30 mgs injections written on the physician order [REDACTED]. -[MEDICATION NAME] injections not administered until [DATE] at 6:00 A.M. Review of the nurse's note dated [DATE] at 2:00 P.M., showed the resident returned to the facility from the hospital. Licensed Practical Nurse (LPN) J completed the skin assessment and removed the resident's indwelling urinary catheter (tube inserted into the bladder to drain urine). Review of the nurse's noted dated [DATE] at 2:00 P.M., showed LPN I contacted the resident's attending physician and verified admission orders [REDACTED]. Review of the nurse's notes dated [DATE] through [DATE], showed no documentation the facility contacted the surgeon regarding the [MEDICATION NAME] injections. Review of the nurse's note dated [DATE] at 8:45 A.M., showed LPN I contacted the surgeon's office and spoke with the office nurse. LPN I informed the office nurse there was a discrepancy with the [MEDICATION NAME] order for the resident and it needed clarification with the surgeon if the resident needed to receive the [MEDICATION NAME] or did the surgeon want the resident to receive a different anticoagulation medication. Review of the nurse's note dated [DATE] at 1:30 P.M., showed the surgeon's office called the facility and spoke with LPN I and gave an order to administer [MEDICATION NAME] 30 mgs injections daily for two weeks then start Aspirin (medication used to prevent blood clots) 81 mgs daily. Review of the MAR indicated [REDACTED].M. Review of the nurse's noted dated [DATE] at 8:10 A.M., showed the resident had labored breathing and purple facial color, could respond, was weak, with oxygen saturation (level of oxygen in the blood, normal 95 or higher) 88% at 2/liters per oxygen cannula. Vital signs blood pressure ,[DATE] (normal blood pressure ,[DATE]), pulse 101 (normal ,[DATE]), respirations 20 (normal ,[DATE]) and temperature 97.4 degrees Farenheit (normal 98.6 degrees). Nebulizer treatment administered, oxygen saturation increased to 99%, 911 notified and emergency medical services (EMS) made aware of the resident's change in condition. EMS arrived and transported the resident to the emergency room . Review of the hospital admission history/physical examination form dated [DATE], showed the following: -readmitted to the hospital on [DATE]; -admitting [DIAGNOSES REDACTED]. -Computerized Tomography Scan (CT scan, multiple x-ray images of the structures of the body) of the chest using [MEDICAL CONDITION] protocol, showed a small left lower lobe (lung) [MEDICAL CONDITION] (blood clot in the lung) with tiny filling defect also evident in the right lower lobe of the lung; -Ultrasound (specialized sound waves used by a computer for images) of the lower extremities showed nonocclusive (not causing or characterized by occlusive) thrombus (clot) in the right common femoral vein (largest vein in the groin) and extreme superficial femoral veins. Review of the hospital laboratory result dated [DATE] and [DATE], showed the following: -On [DATE] at 9:47 A.M., PT 14.2 (normal range 11XXX,[DATE].7) and INR 1.1 (normal range 2XXX,[DATE].0); -On [DATE] at 2:16 P.M., PTT greater than 150.0 (normal range 23XXX,[DATE].3); -On [DATE] at 8:16 P.M., PT 15.1, INR 1.2 and PTT 36.7; -On [DATE] at 5:35 A.M., PT 16.1, INR 1.3 and PTT at 2:00 A.M., 20.5. Review of the hospital discharge/expiration summary dated [DATE], showed the following: -admitting [DIAGNOSES REDACTED]. -Returned to the emergency roiagnom on [DATE], with shortness of breath with acute [MEDICAL CONDITION] and small [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) of the lower extremity; -Fully anticoagulated with [MEDICATION NAME] and [MEDICATION NAME] (anticoagulation used to prevent blood clot formation); -The patient expired at the hospital on [DATE]; -The final cause of death acute [MEDICAL CONDITION]. Review of the facility's investigation statement dated [DATE], showed the resident became dyspneic (short of breath) during breakfast in the dining room on [DATE]. Oxygen saturation level decreased and staff administered a nebulizer treatment. The resident's oxygen saturation level increased and staff sent the resident to the hospital on [DATE], with an admitting [DIAGNOSES REDACTED]. The DON questioned the nursing staff on [DATE], if the resident received any anticoagulation such as [MEDICATION NAME] and was told by LPN J the resident was on [MEDICATION NAME]. The DON reviewed the resident's chart and noted the resident received [MEDICATION NAME] in the hospital which was discontinued upon discharge from the hospital on [DATE]. The [MEDICATION NAME] 30 mgs injections daily was on the hospital discharge orders, but the [MEDICATION NAME] injections did not get transcribed onto the admission POS. The DON spoke with LPN I, responsible for transcribing the medications onto the admission POS. LPN I said in the investigation statement, he/she contacted the resident's attending physician regarding the [MEDICATION NAME] order and was informed by the attending physician to contact the surgeon regarding verification of the [MEDICATION NAME] order. The DON wrote in the investigation statement, a notation was written on the calendar for nursing staff to contact the surgeon on Monday [DATE], regarding the resident's [MEDICATION NAME]. The DON questioned the resident's attending physician and informed the physician that LPN I said he/she contacted the resident's attending physician regarding the verification on the [MEDICATION NAME] order dated [DATE] and was informed by the attending physician to contact the resident's surgeon and declined to give the [MEDICATION NAME] order to LPN I. The DON said the attending physician informed her that was normally what he did regarding the [MEDICATION NAME] orders. The resident's attending physician examined the resident on [DATE], [DATE] and [DATE] and did not order the [MEDICATION NAME] on any of these dates. The order for the [MEDICATION NAME] was obtained on [DATE], from the surgeon and administered to the resident on [DATE] at 6:00 A.M. During an interview on [DATE] at 10:30 A.M., LPN J said the resident returned to the facility on [DATE], at approximately 2:30 P.M. and he/she completed the skin assessment on the resident. LPN J said the other charge nurse, LPN I did the actual admission of the resident which included contacting the resident's attending physician to verify admission orders [REDACTED]. He/she administered the resident medications during his/her shift, but the [MEDICATION NAME] was not written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN J said he/she returned to work on [DATE], contacted the surgeon's office to schedule a return appointment for [DATE]. LPN J said he/she was unaware the [MEDICATION NAME] was not verified when he/she called the surgeon on [DATE]. LPN J said he/she returned to work on [DATE] and administered medications to the resident, except the [MEDICATION NAME] injections. LPN J said he/she returned to work on [DATE] and received report from the night charge nurse regarding the resident not receiving any anticoagulation medication. LPN J said LPN I called the surgeon on [DATE], regarding the [MEDICATION NAME] 30 mgs injection daily. LPN J said on [DATE], the surgeon ordered [MEDICATION NAME] 30 mgs injection daily for two weeks, then start Aspirin 81 mgs daily. The surgeon did not order any PT/INR laboratory tests. LPN J said he/she did not notify the DON at any time regarding the issue with the [MEDICATION NAME] order. During an interview on [DATE] at 1:00 P.M., LPN I said he/she readmitted the resident to the facility on [DATE]. LPN I said he/she contacted the resident's attending physician to verify all hospital discharge orders including the [MEDICATION NAME] 30 mg injection daily. The attending physician told him/her to contact the resident's surgeon regarding the order for [MEDICATION NAME]. He/she asked the other charge nurse LPN J to contact the surgeon to verify the [MEDICATION NAME]. LPN I said LPN J said the resident was not to be on the [MEDICATION NAME], but LPN I said he/she asked LPN J to please call the surgeon to verify the [MEDICATION NAME]. LPN I said he/she received another resident into the facility and started the admission on another resident. He/she assumed LPN J followed up with a phone call to the surgeon regarding the [MEDICATION NAME]. LPN I said he/she worked on [DATE] and during report given by the night charge nurse, the [MEDICATION NAME] was discussed again. LPN I said LPN J said during report on [DATE], the resident is not to be on the [MEDICATION NAME]. LPN I said he/she assumed LPN J called the surgeon on [DATE] to verify the [MEDICATION NAME] order. LPN I returned to work on [DATE] and during report the night charge nurse mentioned again regarding the need to call the surgeon for verification regarding the [MEDICATION NAME]. LPN I said he/she pulled the resident's chart and called the surgeon on [DATE] and received the order for [MEDICATION NAME] 30 mg injection daily for two weeks then start Aspirin 81 mgs daily. LPN I said he/she did not notify the DON regarding the issue with the [MEDICATION NAME]. During an interview on [DATE] at 9:00 A.M., the attending physician said the resident was readmitted to the facility on [DATE]. The attending physician said he came into the facility on [DATE], examined the resident and the resident's condition was stable. He said the resident had a history of [REDACTED]. The charge nurse had notified him on [DATE], regarding the hospital discharge orders and he said all the orders were verified except the [MEDICATION NAME]. The physician said he did not verify the [MEDICATION NAME] order and informed the charge nurse to contact the resident's surgeon regarding the [MEDICATION NAME] order. During an interview on [DATE] at 2:50 P.M., the hospital attending physician said the resident was readmitted to the hospital on [DATE], due to acute [MEDICAL CONDITION] and a small [MEDICAL CONDITION] to the lower extremity. The physician said the resident was treated appropriately with anticoagulant of [MEDICATION NAME] and [MEDICATION NAME] when the [DIAGNOSES REDACTED]. The physician said the [MEDICATION NAME] not administered from [DATE] until [DATE], could possibly contribute to the acute [MEDICAL CONDITION], [MEDICAL CONDITION] and cause of death. During an interview on [DATE] at 10:15 A.M., the surgeon said he wrote an order for [REDACTED]. The resident was discharged from the hospital with the [MEDICATION NAME] order on [DATE]. He said no nursing staff from the facility contacted him to verify the [MEDICATION NAME] order when the resident was readmitted to the facility on [DATE]. The resident returned to his office for a follow-up postoperative examination on [DATE] and his/her assistant ordered [MEDICATION NAME] 30 mgs subcutaneous injections daily for two weeks, then start Aspirin 81 mgs daily. He expected the nursing staff to call and verify the [MEDICATION NAME] injection as ordered on [DATE]. The surgeon said the [MEDICATION NAME] was an anticoagulant that prevents the formation of blood clots and [MEDICATION NAME] would prevent the resident from developing a blood clot. During an interview on [DATE] at 8:15 A.M., the DON said the [MEDICATION NAME] was ordered on [DATE], by the surgeon. She said the [MEDICATION NAME] was usually administered at 6:00 A.M., but the nursing staff should have administered the [MEDICATION NAME] on [DATE], when the order was obtained. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a new policy and procedure for verifying and transcribing medication orders on new/readmitted residents. The facility in-serviced all licensed nursing staff regarding the new policy and procedure. All new or readmission orders [REDACTED]. The admission order sheets were revised with a signature and dateline for an internal admissions audit. The facility will continue to monitor the new admission/readmission orders [REDACTED]. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with the State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation (s). MO 624