La Belle Manor Care Center

Based on observation, interview, and record review, the facility failed to maintain two of two ice machines free of a buildup of debris; failed to ensure refrigerated food items were covered, labeled and dated; and failed to ensure trash cans were covered when not in use. The facility census was 35.
1. Review of the facility policy, Ice Handling and Cleaning, dated 2020, showed the following:
-Guideline: Ice will be stored and served to residents in a sanitary manner;
-Ice will be handled, transported and stored to protect against contamination;
-Ice machine will be wiped down daily with sanitizer;
-Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral buildup in the ice discharge area and the floor of the machine.
Observation on 5/27/25 at 9:49 A.M. of the kitchen ice machine showed black debris and reddish rusty-colored debris visible inside the unit along the door hinge over the ice stored below. The exhaust vent on the exterior of the unit had a heavy buildup of dark fuzzy debris on the rear vent cover.
Observation on 5/27/25 at 2:09 P.M. of the staff breakroom ice machine showed reddish rusty-colored debris visible inside the unit around several screw heads and along the door hinge over the ice stored below. An area of crusty white and green debris was visible on the metal hinge strip inside the unit in one corner.
During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said the following:
-Staff used the ice machine in the staff breakroom to obtain ice for residents;
-Dietary and/or housekeeping staff wiped the exterior of the ice machines down monthly;
-The vendor performed maintenance on the unit but she was unsure how often this was completed;
-Dietary staff cleaned and sanitized the inside of the ice machine when the volume of ice was low. Staff last performed this process the second week of April;
-The black debris inside the kitchen ice machine was always visible. The black debris and the red areas came off a little when staff cleaned the unit. Dietary staff cleaned the exhaust vent on the back of the unit monthly. She was aware there was a buildup of fuzzy debris on the vent;
-She was unaware the breakroom ice machine had a buildup of red rusty debris inside the unit. Staff cleaned this unit monthly.
During an interview on 5/28/25 at 2:22 P.M., the Maintenance Supervisor said the following:
-The vendor maintained the ice machines;
-He was unsure who was responsible for cleaning the ice machines;
-Maintenance was not responsible for cleaning either unit.
2. Review of the facility policy, Labeling and Dating Foods (Date Marking), dated 2020, showed the following:
-All foods stored with properly labeled according the following guidelines;
-Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date;
-Prepared food or opened food items should be discarded when:
-The food item does not have a specific manufacturer expiration date and has been refrigerated for seven days;
-The food item was leftover for more than 72 hours;
-The food item was older than the expiration date.
Observation on 5/27/25 at 10:18 A.M. of the Special Care Unit (SCU) refrigerator showed the following:
-A 12-ounce blueberry-flavored sports drink was mostly empty and was not dated or labeled to show a resident or staff name;
-A small bowl of an unknown white creamy substance was uncovered and was not labeled or dated;
-A small disposable plastic cup held small pieces of cut-up fruit. The fruit was starting to turn brown and dry up. The cup was not covered, labeled or dated.
Observation on 5/28/25 at 8:32 A.M. of the SCU refrigerator showed the following:
-A 12-ounce blueberry-flavored sports drink was mostly empty and was not dated or labeled to show a resident or staff name;
-A small bowl of an unknown white creamy substance was uncovered and was not labeled or dated;
-A small disposable plastic cup held small pieces of cut-up fruit. The fruit was starting to turn brown and dry up. The cup was not covered, labeled or dated;
-One cupcake with blue icing sat inside on the shelf and was not covered or dated;
-One plastic beverage cup with brown liquid was not covered, labeled or dated.
During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said the following:
-Staff in the SCU and housekeeping staff check the SCU refrigerator for outdated items. She checked the refrigerator two to three times a week for proper labeling, dating, food covers and any items that needed to be discarded;
-The SCU needed some plastic wrap and labels so food items were properly stored;
-The brown liquid in a cup was probably a resident's supplement shake, and the cupcakes were leftover from the recent holiday weekend.
3. Observation on 5/27/25 at 10:23 A.M. showed a trash can sat near the dish machine in the kitchen. The can was partially full of food debris and paper trash and was uncovered. There were no staff actively working in the dish machine area of the kitchen. A second trash can sat near the convection oven. The lid was removed and the can was partially full of food waste and paper trash. There were no staff utilizing the trash can for food preparation.
During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said trash cans should be covered with a lid when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop and consistently implement a regular maintenance program, including routine inspections of bed frames, mattresses and bed rails, to identify areas of possible entrapment for seven residents (Resident #10, #3, #20, #189, #9,#36, and #35), in a review of 13 sampled residents. The facility census was 35.
The facility did not have a policy related to risk of entrapment with resident beds.
Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following:
-Between 1985 and 1/1/09, 803 incidents of patients getting caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA;
-Of those reported, 480 died and 138 had non-fatal injuries;
-Most patients were frail, elderly or confused;
-Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattresses, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
1. Review of resident #10's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/23/25, showed the following:
-Cognitively intact;
-Diagnoses include paraplegia (paralysis that affects the lower half of the body) and vision deficits;
-Range of motion limitations lower extremity one side;
-He/She was dependent for bed mobility and transfers.
Review of the resident's care plan, revised on 05/05/25, showed the following:
-He/She has an activities of daily living (ADLs) self-care performance deficit related to right below the knee (BKA) amputation and impaired balance;
-The resident required assistance of two staff to turn and reposition in bed every two hours and as necessary;
-The resident uses mobility bars to maximize independence with turning and repositioning in bed;
-The resident requires mechanical lift with two staff for transfers.
Observation on 05/28/25, at 12:00 P.M., showed the resident lay on his/her back in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
2. Review of Resident #3's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Range of motion limitations to upper and lower extremity on both sides;
-He/She was dependent for bed mobility and transfers.
Review of the resident's care plan, revised on 05/27/25, showed the following:
-He/She has an activities of daily living (ADLs) self-care performance deficit related limited mobility;
-The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary;
-The resident requires one or two staff to move between surfaces;
(The care plan did not address bed rails.)
Observation on 05/28/25, at 9:53 A.M., showed staff transferred the resident with the mechanical lift to bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Staff provided incontinence care to the resident. The resident did not use the bed rails to assist in turning during cares.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
3. Review of resident #20's quarterly MDS, dated [DATE], showed the following:
-Range of motion limitations lower extremity one side;
-He/She rolled left and right independently;
-Staff provide partial/moderate assistance for sit to lying, lying to sitting on side of the bed;
-Staff provide substantial/maximum assist for sit to stand, chair/bed-to-chair and toilet transfers;
Review of the resident's care plan, revised on 05/27/25, showed the resident ADL self-care performance deficit related to dementia and impaired balance. (The care plan did not address bed rails.)
Observation on 05/28/25 at 10:11 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
4. Review of Resident #189's admission MDS, dated [DATE], showed the resident was independent to roll left to right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer and sit to standing position.
Review of the resident's care plan, revised on 05/28/25, showed the following:
-The resident required assistance from one or two staff to turn and reposition in bed every two hours and as necessary;
-He/She required assistance from one or two staff to move between surfaces;
-The resident had limited physical mobility related to weakness, recent hospitalization, dementia and anxiety.
(The resident's care plan did not address bed rails.)
Observation on 05/28/25, at 11:23 A.M., showed the resident lay awake in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-He/She was independent with bed mobility;
-He/She required supervision with transfers.
Review of the resident's care plan, revised 03/19/25, showed the resident needed one staff to assist with ADLs. (The care plan did not address bed rails.)
Observation on 05/27/28 at 10:32 A.M. showed the resident lay in bed on his/her right side. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
6. Review of Resident #36's admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-He/She required moderate assistance with bed mobility;
-He/She required maximum assistance with transfers.
Review of the resident's care plan, revised 03/12/25, showed the following:
-High risk for falls related to gait/balance problems;
-He/She was dependent of one to two staff for transfers;
-He/She required assistance of one staff to turn, reposition in bed;
(The care plan did not address bed rails.)
Observation on 05/27/25 at 10:38 showed the resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
7. Review of Resident #35's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-He/She was independent with bed mobility;
-He/She required supervision with transfers.
Review of the resident's care plan revised 03/06/25, showed the following:
-The resident has an ADL self-care performance deficit related to Alzheimer's disease;
-The resident was able to transfer himself/herself.
(The care plan did not address bed rails.)
Observation on 05/27/25 at 10:32 A.M. and 05/29/25 at 3:00 P.M. showed the resident had a one-half bed rail in the raised position on the right side of his/her bed.
Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment.
8. During an interview on 05/28/25, at 2:30 P.M., the Maintenance Director said the following:
-He and the Housekeeping/Laundry Supervisor measured all the resident beds (with bed rails) once and wrote them on a piece of paper;
-They only measured the beds one time but not recently, maybe within the last year;
-He was not aware routine inspection of the bed rails was something that needed to be done.
Review of an untitled and undated document, provided by the Housekeeping/Laundry Supervisor on 05/28/25, showed a list of numbers (identified by the Housekeeping/Laundry Supervisor as room numbers) and three areas (rail, headboard, foot) with measurements next to each.
During an interview on 05/28/25, at 2:45 P.M., the Housekeeping/Laundry Supervisor said the following:
-She and the Maintenance Supervisor measured all the resident beds with bed rails one time within the last 12 months;
-The number on the provided document was the room number and the three areas with entries was the length in inches between the bed rails and head/foot board to the mattress;
-She unaware the measurements needed to be done routinely.
During an interview on 05/28/25, at 2:30 P.M., the Administrator said the following:
-The Maintenance Supervisor and the Housekeeping/Laundry Supervisor measured all of the beds with bed rails for risk of entrapment;
-The measurements were done only once;
-Maintenance and housekeeping/laundry staff were responsible to obtain the measurements on a routine basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards and failed to implement a water management team and parameters for findings related to water monitoring. The facility failed to ensure nursing staff performed appropriate hand hygiene during care for two residents (Residents #2 and #189), in a review of 13 sampled residents, and for two additional residents (Resident #23 and #31), failed to utilize Enhanced Barrier Precautions (EBP) (infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes and other long-term care facilities) per facility policy during wound care for one sampled resident (Resident #1). The facility census was 35.
1. Review of the facility's undated policy, Legionella Policy and Water Management, showed the following:
-As part of the infection prevention and control program, our facility has a water management program,
overseen by the maintenance department and the water management team;
-The water management team included the administrator, maintenance, Director of Nursing (DON) and medical director;
-The team is to identify areas in the water system where Legionella can grow and spread in order to reduce the risk of Legionnaire's disease;
-The Centers for Disease Control and Prevention (CDC) water prevention toolkit and ASHRAE recommendations have been used in developing a water management program;
-Measures used to control the spread of Legionella: diagram of where control measures are applied, monitor control limits, documentation of the program;
-The Water Management Program will be reviewed at least annually/or as needed if: the control limits are consistently not met, a major maintenance project, water service change, any diagnosis of disease associated with the water system.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:
-The bacterium Legionella can cause a serious type of pneumonia called LD (Legionnaire's disease) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;
-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the undated, Centers for Disease Control and Prevention Legionella Environmental Assessment Form showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F and Legionella become dormant below 68 degrees F.
The state agency requested, but the facility provided no documentation to show the facility's water management program was reviewed at least annually per facility policy.
The state agency requested, but the facility provided no documentation to show that the water management team, with the specific required staff members, actively held meetings.
Review of water temperatures, obtained by the state agency on 05/28/25, showed the following water temperatures fell between 77 and 113 degrees, where Legionella generally grows well:
-At 12:45 P.M., the Special Care Unit (SCU) room [ROOM NUMBER], hot water faucet temperature was 108.1 F (too cool);
-At 12:48 P.M., the SCU room [ROOM NUMBER], hot water faucet temperature was 102.4 F (too cool);
-At 12:51 P.M., the SCU dining room, cold water faucet temperature was 80.6 F (too warm) and hot water faucet temperature was 109.6 F (too cool);
-At 1:00 P.M., the central hall, room [ROOM NUMBER], hot water faucet temperature was 105.5 F (too cool);
-At 1:03 P.M., the central hall, room [ROOM NUMBER], cold water faucet temperature was 80.6 F( too warm) and hot water faucet temperature was 106.5 F (too cool);
-At 1:15 P.M., the southeast hall, shower sink, hot water faucet temperature was 104.4 F (too cool).
During an interview on 05/29/25 at 11:45 A.M., the infection preventionist (IP) said the following:
-The water management team consisted of the administrator, DON, IP, maintenance director, housekeeping supervisor and the medical director;
-Water management meetings were conducted with Quality Assurance (QA) meetings;
-The Maintenance Director checked the water temperatures;
-Maintenance and housekeeping flush the lines of sinks, showers, and tubs in rooms not in use.
During an interview on 05/29/25 at 2:20 P.M., the Maintenance Director said the following:
-The water management team met monthly with safety walks throughout the facility; he did not have documentation of these meetings;
-His role was to check the water temperatures and flush the unused water supplies, check the boiler room and showers for standing water; he did not have documentation of those checks;
-Hot water should not be over 122 degrees and had to be at least 109 degrees;
-He started checking the cold water temperatures in November;
-He did not know what ASHRAE was;
-The facility had developed the water management team and obtained the CDC packet.
During an interview on 05/29/25 at 2:45 P.M. and 06/09/25 at 1:51 P.M., the Administrator said the following:
-The facility used the CDC tool kit, but not the ASHRAE guidelines that the policy referred to due to the expense of the ASHRAE guidelines;
-The Maintenance and Housekeeping Supervisors do safety rounds and flush lines and report anything abnormal verbally to her; there was no written documentation of this being completed;
-They have discussed water management in the QA meetings.
2. Review of the facility's undated policy, Infection Control, showed the following:
-Purpose: to ensure precautions are taken when caring for residents regardless of their diagnosis or presumed infection status;
-Procedure: Hand washing; staff will wash hands:
-After touching blood, body fluids, secretions, excretions and contaminated items whether or not gloves are worn;
-Immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to another resident or environments;
-Between tasks and procedures on the same resident to prevent cross contamination of different body sites;
-Plain soap should be used for routine hand washing;
-An antimicrobial agent or waterless antiseptic agent can be used for specific circumstances (e.g. control of outbreaks or hyper-endemic infection);
-Gloves: Staff will wear clean, non-sterile gloves when touching blood, body fluids, secretions, excretions and contaminated items;
-Before touching mucous membranes and broken skin;
-Gloves will be changed between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms;
-Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident;
-Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments.
3. Review of Resident #23's quarterly Minimum Data Set (MDS) , a federally mandated assessment instrument completed by facility staff, dated 05/12/25, showed the following:
-Always incontinent of bowel and bladder;
-Moderate assistance with toileting and personal hygiene.
Review of the resident's care plan, revised 05/27/25, showed the following:
-The resident had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's disease;
-Totally dependent on one or two staff for personal hygiene;
-The resident required assistance of one staff for toileting.
Observation on 05/27/25 at 11:00 A.M. showed the following:
-Certified Nurse Assistant (CNA) J was in the shower room with the resident;
-CNA J wore gloves and removed a urine soaked incontinence brief from the resident;
-While wearing the same soiled gloves, CNA J assisted the resident to put on compression hose and house shoes;
-With the same soiled gloves, CNA J assisted the resident to stand and provided peri-care with wash cloths then pulled up the resident's new incontinence brief and clean pants;
-CNA J removed his/her gloves, and without washing his/her hands, assisted the resident to walk to the dining room, touching the resident's gait belt and walker.
4. Review of Resident #31's quarterly MDS, dated [DATE], showed the following:
-Continent of bowel and bladder;
-Supervision with toileting;
-Moderate assistance with personal hygiene.
Review of the resident's care plan, revised 05/27/25, showed the following:
-The resident had bladder incontinence related to Alzheimer's disease;
-Staff to clean peri area with each incontinence episode.
Observation on 05/27/25 at 11:20 A.M. showed the following:
-CNA J entered the resident's room and without washing his/her hands with soap and water or using hand sanitizer, put on gloves;
-The resident lay in bed and was incontinent of urine;
-CNA J unfastened the resident's urine soiled incontinence brief and cleaned the resident's perineum with wash cloths, then rinsed the perineum;
-While wearing the same gloves he/she wore to provide peri-care, CNA J rolled the resident to his/her right side and touched the resident's left hip with his/her gloved hands;
-With his/her left-hand, CNA J washed and rinsed the resident's buttocks. With the same gloved hand, he/she touched a tube of barrier cream, removed cream from the tube and applied it to his/her soiled gloved hand and then applied the barrier cream to the resident's buttocks;
-CNA J removed his/her gloves and removed the urine soiled linens from the resident's bed with his/her bare hands;
-Without washing his/her hands or using hand sanitizer, CNA J put on clean gloves, and put a clean incontinence brief and pants on the resident as he/she rolled the resident back and forth in bed.
During an interview on 05/27/25 at 2:25 P.M., CNA J said the following:
-Staff should wash hands before and after providing cares, when soiled and when changing gloves;
-Staff should change gloves before and after cares and when soiled;
-He/She should have changed his/her gloves, and washed his/her hands after peri-care and before touching clean items.
Observation on 05/29/25 at 9:15 A.M. showed the following:
-CNA A wore gloves and rolled the resident to his/her right side, rolled a urine soaked bed pad up under the resident, rolled a clean bed pad under the wet bed pad, and cleaned urine from the resident's left buttock with wet wash cloths;
-While wearing the same gloves, CNA A rolled the resident partially to his/her left side, touched the resident's right thigh with his/her gloves, and provided front pericare;
-CNA A continued to roll the resident onto his/her left side by touching the resident's right hip with the same gloves he/she wore when providing peri-care and removed the urine soaked bed pad. CNA A did not remove his/her gloves and covered the resident with the top sheet and cover;
-While wearing the same soiled gloves, CNA A got clean clothes from the resident's closet, put a new incontinence brief and pants on the resident and covered the resident;
-CNA A removed his/her gloves, did not perform hand hygiene, and went out to the hall;
-CNA A returned to the resident's room, did not perform hand hygiene and put on new gloves;
-CNA A assisted the resident to sit up, removed the resident's gown and put on a clean shirt. CNA A applied deodorant to the resident, put house shoes and a gait belt on the resident, and assisted the resident to stand with a walker and walk to the door.
During an interview on 05/29/25 at 9:38 A.M., CNA A said the following:
-He/She was to perform hand hygiene before providing care, when hands were soiled during care, when changing gloves, and after providing care;
-He/She should change his/her gloves if his/her gloves were soiled;
-He/She was not aware he/she should change his/her gloves when only cleaning urine during incontinence care.
5. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:
-Dependent on staff for toileting hygiene, chair/bed-to-chair transfers, rolling left and right, changing positions from sitting to lying and lying to sitting on the side of the bed;
-Needed partial to moderate assistance from staff for upper body dressing;
-Always incontinent of bowel and bladder.
Review of the resident's care plan, revised 05/05/25, showed the following:
-He/She had limited physical mobility and was totally dependent on two staff for toilet use;
-He/She had functional bladder incontinence;
-Clean peri-area with each incontinence episode.
Observation on 05/28/25 at 8:15 P.M., showed the following:
-Nurse Assistant (NA) E and NA F entered the resident's room;
-NA E did not wash his/her hands before donning gloves;
-NA E removed the resident's incontinence brief that was soiled with urine and feces;
-NA E performed peri-care to the resident's buttocks;
-NA E did not change gloves and performed front peri-care;
-NA E removed his/her gloves, did not perform hand hygiene, and put on a new pair of gloves. NA E put a clean incontinence brief on the resident, removed the resident's shirt, obtained mineral cream from a container with his/her gloved fingers, put mineral cream on the resident's back, arms, and chest, and put a new gown on the resident.
-NA E removed his/her gloves and used hand sanitizer (NA E did not wash his/her hands with soap and water as directed in facility policy after providing incontinence care.)
During an interview on 05/30/25 at 12:05 A.M., NA E said the following:
-He/She should wash his/her hands after performing any resident care;
-He/She should change gloves anytime they became visually soiled or when moving from a dirty area to a clean area during peri-care;
-He/She should change gloves after providing incontinence care, and should not touch clean items with soiled gloves.
6. Review of Resident #189's admission MDS, dated [DATE], showed the following:
-Partial/moderate assistance from staff for toileting hygiene and lower body dressing;
-Frequently incontinent of bowel and bladder.
Review of the resident's care plan, revised on 05/28/25, showed the following:
-The resident had an ADL self-care performance deficit related to confusion, dementia and impaired balance;
-He/She required assistance from one or two staff to dress and for toileting.
Observation on 05/28/25 at 11:38 A.M. showed the following:
-The resident lay in bed;
-The resident's incontinence brief, fitted sheet, cloth pad and mattress were soiled with urine;
-NA B and CNA D, did not perform hand hygiene before donning gloves;
-NA B performed front peri-care for the resident;
-NA B removed his/her gloves, did not wash his/her hands, and put on a new pair of gloves;
-CNA D performed peri-care to the resident's buttocks;
-Neither CNA D nor NA B wiped any other areas of the resident's skin that were soiled with urine, including the resident's legs or back;
-CNA D removed the resident's incontinence brief and placed it in a bag, removed the wet fitted sheet and cloth pad and placed them on the bare mattress at the end of the bed;
-NA C put the urine soiled bedding in a bag;
-The mattress had a visible wet spot from where the urine saturated bedding had been in contact with the mattress;
-While wearing the same gloves used to provide peri-care and to handle the soiled linens, NA B and CNA D rolled the resident to his/her back against the urine soiled mattress and dressed the resident;
-NA B and CNA D removed their gloves, did not perform hand hygiene, and put on new gloves;
-NA B and CNA D made the resident's bed without disinfecting or cleaning the urine from the mattress;
-NA B removed his/her gloves, did not perform hand hygiene, and left the resident's room;
-CNA D removed his/her gloves and used hand sanitizer. (CNA D did not wash his/her hands with soap and water as directed in facility policy.)
During an interview on 05/28/25, at 5:18 P.M., CNA D said the following:
-He/She should wash his/her hands before and after providing any care;
-He/She should wash his/her hands or use hand sanitizer before putting on gloves, when changing gloves, and after removing gloves;
-Staff should not place a resident on a urine soiled mattress without placing a barrier between the soiled mattress and the resident's skin;
-He/She did not perform hand hygiene before applying gloves or in between glove changes when providing care for the resident.
7. During interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following:
-Staff should wash their hands before and after resident contact, before and after providing care, before applying gloves, in between glove changes, and after removing gloves;
-Staff should wear gloves when providing any care to a resident;
-Staff should change their gloves after providing care, when gloves becoming dirty or are visibly soiled, and in-between front and back pericare;
-Staff should remove soiled gloves and wash their hands with soap and water prior to touching clean items;
-Staff could use hand sanitizer for hand hygiene, but should wash their hands with soap and water after using hand sanitizer two or three times during care.
During an interview on 05/30/25 at 1:39 P.M., the Administrator said the following:
-Staff should wash their hands before any procedure, in between cares, during care if hands become soiled, and when changing gloves;
-Staff should wear gloves when providing direct resident care.
8. Review of the facility's undated policy, Enhanced Barrier Precautions (EBP), showed the following:
-EBP is an infection control strategy to reduce the transmission of multidrug-resistant organisms (MDROs) and other infections in nursing homes. EBP expands on Standard Precautions by requiring gowns and gloves during specific high-contact resident care activities for residents at increased risk of MDRO acquisition or those known to be colonized or infected with an MDRO;
-EBP focuses on targeted use of personal protective equipment (PPE) (gowns and gloves) during specific high-contact activities, rather than requiring them for all residents;
-Activities like dressing, bathing/showering, transferring, and device care are examples of high-contact activities where EBP is used;
-EBP is generally intended to be in place for the duration of a resident's stay or until the risk factors (e.g., wound or device) are resolved;
-Residents may require EBP if they have an MDRO infection or colonization, have wounds or indwelling medical devices, or are deemed at higher risk by the facility;
-Gowns, staff will wear a clean, non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
9. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Dependent on staff for bed mobility and transfers;
-Has one Stage II pressure ulcer (partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer).
Review of the resident's care plan, last reviewed 5/5/25, showed the following:
-The resident had a pressure ulcer or potential for pressure ulcer development related to mobility;
-Administer treatments as ordered and monitor for effectiveness;
-The resident's care plan did not identify the need for or the use of EBP when providing care for the resident.
Review of the resident's Physician Order Sheet (POS), dated May 2025, showed an order to cleanse daily with normal saline or wound cleanser and pat dry, apply Urgoclean (wound dressing that aids in the continuous removal of slough and wound debris) dressing to wound base, cover with optifoam (a foam dressing) dressing every day shift for wound care;
Observation on 5/30/25 at 9:32 A.M., showed the following:
-EBP supplies hung on the outside of the resident's room door;
-Licensed Practical Nurse (LPN) P pushed the treatment cart into the resident's room, applied hand sanitizer to his/her hands and put on gloves. LPN P did not put on a gown;
-LPN P gathered dressing supplies from the treatment cart and placed them directly on the resident's bed without a barrier;
-LPN P removed the heel protector, sock and dressing from the resident's right outer ankle;
-Wearing the same gloves, LPN P placed clean gauze under the resident's right foot, picked up a bottle of wound cleanser, sprayed the dime-sized wound and removed the packing from the wound;
-LPN P removed his/her gloves, applied hand sanitizer and put on new gloves;
-LPN P cut a small piece of Urgoclean dressing and applied it to the wound;
-LPN P applied an optifoam dressing to cover the wound;
-LPN P removed his/her gloves, did not wash or sanitize his/her hands, then dated the dressing with a pen, and put socks and the heel protector on the resident's foot.
During interview on 5/30/25 at 9:42 A.M., LPN P said residents with catheters or wounds usually have enhanced barrier precautions. He/She forgot to put on a gown prior to performing the resident's dressing change. He/She should have placed the dressing supplies on a barrier but the resident had his/her breakfast on the bedside table. He/She should wash his/her hands and change gloves when going from a dirty task to a clean task, before he/she started a procedure and when the procedure was complete.
During interview on 05/30/25 at 1:13 P.M., the DON said staff should use EBP on any resident with a wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, for two residents (Resident #8 and #20) in a review of 13 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (a decline or improvement in two or more assessed areas of resident status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revisions of the care plan. The facility census was 35.
Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, Chapter 2, revised October 2023, showed the following:
-The SCSA is a comprehensive MDS assessment for a resident that must be completed when the Interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change;
-A significant change is a major decline or improvement in a resident's status that:
1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting;
2. Impacts more than one area of the resident's health status; and
3. Requires interdisciplinary review and/or revision of the care plan;
- When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met;
-After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record;
-An SCSA is appropriate when:
1. There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline within two weeks.
Review of the facility's policy, Electronic Transmission of the MDS, revised 08/27/23, showed the following:
-All staff members responsible for completion of the MDS receive training on the assessment process, computer entry, and transmission process, in accordance with the MDS 3.0 RAI instruction manual, before being permitted to use the MDS computer system. A copy of the MDS 3.0 RAI instruction manual is maintained by the resident assessment coordinator;
-Staff members are trained on updates/revisions to the MDS 3.0 form and software upgrades as they are released. Such training is provided by the corporate staff and/or computer software vendor;
-The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.
1. Review of Resident #8's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Mobility devices use include a walker;
-Independent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, all transfers, and walking 10 feet, 50 feet and 150 feet.
Review of the resident's electronic health record showed the resident was away from the facility and hospitalized from [DATE] - 01/27/25.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Mobility devices used include a wheelchair and walker (change, requiring more assistance from the previous assessment);
-Set-up assistance from staff needed for eating and to roll left and right (change, decline in these areas from the previous assessment);
-Supervision from staff to complete upper body dressing, put on/take off footwear and sitting to lying transfers (decline in these areas from the previous assessment);
-Partial/moderate staff assistance for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, lying to sitting on the side of the bed, sit to stand transfer, chair/bed-to-chair transfers, toilet transfer, tub/shower transfer, walking 10 feet, wheeling 50 feet and wheeling 150 feet (decline in these areas from the previous assessment);
-This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as an admission assessment.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Mobility devices use include a walker (change, improvement, requiring less assistance from the previous assessment);
-Independent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, all transfers, and walking 10 feet, 50 feet and 150 feet (change, improvement in these areas from the previous assessment);
-This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as a quarterly assessment.
2. Review of Resident #20's quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Mobility devices include a walker and wheelchair;
-No range of motion impairment;
-Set-up assistance from staff needed for eating and oral hygiene;
-Supervision from staff to complete toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, toilet transfers, tub/shower transfers and walking 150 feet;
-Independent with rolling left and right, sit to lying transfer, lying to sitting on the side of the bed, sit to stand transfer, chair/bed-to-chair transfers, walking 10 and 50 feet, wheeling 50 and 150 feet;
-Occasionally incontinent of bowel and bladder.
Review of the resident's electronic health record showed the resident was away from the facility and hospitalized [DATE] - 01/16/25 with a hip fracture and 01/20/25 - 01/24/25 with a small bowel obstruction.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Severely impaired cognition (change, decline from previous assessment);
-Diagnosis of hip fracture;
-Mobility devices of wheelchair only (change, requiring more assistance from the previous assessment);
-Functional impairment one side lower extremity (change, decline from previous assessment, resident's ability decreased);
-Set-up assistance from staff for eating;
-Supervision from staff for rolling left and right (change, decline from previous assessment, resident requiring more assistance);
-Partial/moderate assistance from staff for oral hygiene, sit to lying transfer and lying to sitting on the side of the bed (change, decline from previous assessment, resident requiring more assistance);
-Substantial/maximum assistance from staff for upper body dressing, sit to stand transfer, chair/bed-to-chair transfer and toilet transfer (change, decline from previous assessment, resident requiring more assistance);
-Dependent on staff for toileting, shower/bathe self, lower body dressing, put on/take off footwear, personal hygiene, tub/shower transfer and wheeling 50 and 150 feet;
-Walking did not occur (change, decline from previous assessment, resident requiring more assistance);
-Always incontinent of bowel and bladder (change, decline from previous assessment, resident with decreased ability);
-This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as an admission assessment.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Independently rolls left and right (change, improvement from previous assessment, resident requiring less assistance);
-Dependent on staff for sit to stand transfer, chair/bed-to-chair transfer, toilet transfer and upper body dressing (change, decline from previous assessment, resident requiring more assistance);
-This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as a quarterly assessment.
During an interview on 05/30/25 at 12:42 P.M., the MDS coordinator said the following:
-She was responsible for completing the MDS assessments;
-She had received training on the completion of an MDS;
-She followed the RAI manual to determine the assessment type needed to be completed;
-When a resident returns from the hospital, an admission assessment was completed regardless if the resident was a resident before hospitalization;
-A significant change MDS was completed when there was a change, good or bad, in two or more areas of the MDS;
-Resident #8 and #20 went to the hospital and came back so they needed an admission assessment completed.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the MDS assessments should follow the RAI manual.
During an interview on 05/30/25 at 1:39 P.M., the administrator said the MDS should be the correct assessments by the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for three sampled residents (Resident #4, #8 and #20), in a review of 13 sampled residents. The facility census was 35.
Review of the Resident Assessment Instrument (RAI) Manual, version 1.18.11, dated October 2023, showed the following:
-Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status;
-The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts;
-admission refers to the date a person enters the facility and is admitted as a resident. Completion of an OBRA admission assessment must occur in any of the following admission situations: when the resident has never been admitted to this facility before; OR when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge;
-It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team (IDT) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment;
-Cognitive patterns: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions;
-Preferences for customary and routine activities: The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident's preferences and is not meant to be all-inclusive.
Review of the facility's policy, Electronic Transmission of the MDS, revised 08/27/23 showed the following:
-All staff members responsible for completion of the MDS receive training on the assessment process, computer entry, and transmission process, in accordance with the MDS 3.0 RAI instruction manual, before being permitted to use the MDS computer system. A copy of the MDS 3.0 RAI instruction manual is maintained by the resident assessment coordinator;
-Staff members are trained on updates/revisions to the MDS 3.0 form and software upgrades as they are released. Such training is provided by the corporate staff and/or computer software vendor;
-The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.
1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/28/25, showed the following:
-Cognitively intact;
-Diagnosis of heart failure, pneumonia, arthritis and depression;
-Section D, mood, social isolation was coded as never (choices are never, rarely, sometimes, often, always, resident declines to respond, resident unable to respond);
-Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response);
-The resident was the primary respondent for Section F;
-Section GG, Functional Abilities and Goals, showed the resident was dependent on staff for upper body dressing and required partial to moderate assistance for rolling left and right;
-Section I, Diagnosis, the resident had a diagnosis of pneumonia;
-Section J, Pain Management, received scheduled pain medication regimen was marked no;
-Section N, Medications, high-risk drug classes: use and indication, is taking hypoglycemic (medication to treat diabetes and/or lower blood sugar (the amount of sugar in the blood)) and indicated was check marked;
-Section O, Special Treatments, Procedures, and Programs: Restorative Nursing Program was indicated as completed three out of seven days for active range of motion.
Review of the resident's electronic health record showed no documentation of pneumonia for the observation period of the assessment. The resident was on scheduled pain medication including metadone hydrochloride (a narcotic pain reliever used to treat chronic pain) 10 milligrams three times a day with an order start date of 02/06/24, did not take a hypoglycemic medication and was not on a formal restorative program.
During an interview on 05/27/25 at 10:32 A.M., the resident said the following:
-He/She stayed in his/her room by choice due to a condition related to the resident's knee and very seldom left the room;
-He/She chose to eat all meals in his/her room;
-He/She used the bed rail to turn independently from left to right and can dress the upper portion of his/her body;
-The only activity he/she participated in was independently watching television in his/her room and will go outside and go home during the summer.
Observation on 05/27/25 at 10:32 A.M., showed the resident sitting up awake in his/her room watching television and playing a game on his/her phone.
Observation on 05/28/29 at 10:17 A.M., showed the resident sitting up awake in his/her room watching television and used the side rail to reposition himself/herself in bed.
Observation on 05/28/25 at 6:00 P.M., showed the resident sitting up in his/her bed eating supper and watching television.
Observation on 05/29/25 at 9:33 A.M., showed the resident sitting up in his/her bed watching television.
2. Review of Resident #8's electronic health record showed the resident admitted to the facility on [DATE].
Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status.
Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (three days after discharge with return anticipated MDS submission).
Review of the resident's electronic health record (EHR) showed the following:
-The resident was hospitalized from [DATE] to 01/27/25 and transferred from the facility;
-The resident became physically aggressive with staff on 01/27/25;
-The resident refused a shower/bath on 01/31/25;
-The resident refused to go to dialysis on 01/28/25 and 02/01/25.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Re-entry to the facility on [DATE] after a short-term general hospital stay;
-admission date 09/30/22;
-Diagnosis of end stage renal disease (where the kidneys lose the ability to remove waste and balance fluids) with dialysis (treatment that cleans the blood when the kidneys are not functioning properly);
-Section D, Mood, social isolation is coded as never (choices are never, rarely, sometimes, often, always, resident declines to respond, resident unable to respond);
-Section E, Behavior, no behavior symptoms or rejection of cares (inaccurate based on documentation in the resident's EHR);
-Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response);
-The resident was the primary respondent for Section F.
During an interview on 05/27/25, at 12:08 P.M., the resident said the following:
-He/She stayed in his/her room by choice due the noise and activity up on the other unit;
-He/She liked being in a section and room all by himself/herself as no one bothered him/her or wandered in and out of his/her room;
-He/She did not care for activities or groups of people and liked to stay in his/her room and watch television.
Observation on 05/27/25 at 12:08 P.M., showed the resident sitting at the back dining room table (where he/she eats on a daily basis by choice), eating lunch.
Observation on 05/28/25 at 11:20 A.M., showed the resident sat in his/her recliner in his/her room sleeping.
Observation on 05/28/25, at 6:50 P.M. showed the resident sat in his/her recliner in his/her room watching television.
Observation on 05/29/25 at 9:28 A.M., showed the resident was out of the facility at dialysis.
3. Review of Resident #20's electronic health record showed the following:
-admitted to the facility on [DATE];
-Had a Durable Power of Attorney as responsible party;
-Transferred from the facility to the hospital on [DATE] and was hospitalized .
Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status.
Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (three days after discharge with return anticipated MDS submission).
Review of the resident's EHR, showed the following:
-The resident was hospitalized until 01/16/25 and then transferred back to the facility;
-The resident was transferred from the facility to the hospital on [DATE] and was hospitalized .
Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status.
Review of the resident's EHR, showed the resident was hospitalized until 01/24/25 and then transferred back to the facility.
Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (four days after discharge with return anticipated MDS submission).
Review of the resident's admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Re-entry to the facility on [DATE] after a short-term general hospital stay;
-admission date 09/09/22;
-Diagnoses included dementia and hip fracture;
-Section F, Preferences for Daily Routine, for all preference: choosing what clothing to wear, take care of personal belongings or things, choose type of bathing, snacks between meals, choose own bedtime, have family involved in discussions about your care, using the phone in private and having a place to lock your things and keep them safe; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response);
-Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response);
-The resident was the primary respondent for Section F.
During an interview on 05/27/25, at P.M., the resident said the following:
-He/She does not care to use the phone in privacy, who would he/she talk to, no one ever called;
-He/She could care less if any of his/her belongings were locked up, what does he/she have that anyone would want;
-He/She did not care if he/she went to activities with people, he/she liked to watch TV in his her room;
-He/She did not read anything because he/she preferred watching TV
Observation on 05/27/25 at 11:22 A.M., showed the resident sat up awake in his/her wheelchair in his/her room with the television on and at the sink washing his/her face.
Observation 05/28/25 at 10:23 A.M., showed the resident lay awake in bed watching television.
Observation on 05/28/25 at 6:38 P.M., showed the resident sat up awake in his/her wheelchair in his/her room waiting to be put to bed for the evening.
Observation on 05/29/25 at 9:24 A.M., showed the resident sitting up in his/her wheelchair in the dining room.
During an interview on 05/30/25 at 1:08 P.M., the activities director said the following:
-She completed section F and sometimes the MDS coordinator completed the section if she was unable to get it done and the MDS needs to be completed;
-She asked all of the questions in section F when doing a resident interview;
-People with altered cognition can sometimes answer the questions in section F and should be given the opportunity to answer the questions;
-The MDS should be coded correctly;
-She felt like she coded the MDS correctly;
-She had been trained on how to complete the MDS.
During an interview on 05/30/25, at 12:42 P.M., the MDS coordinator said the following:
-She used the RAI manual for MDS completion;
-To complete the MDS, she does record review and interviews with staff and the resident;
-When a resident goes to the hospital, their next assessment should be an admission assessment, regardless if they transferred from the facility or not;
-The activities director completes section F of the MDS if available, if not available, she will complete section F after interviewing the resident.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the MDS should be coded correctly following the RAI manual.
During an interview on 05/30/25 at 1:39 P.M., the administrator said the MDS should be coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for four residents (Resident #3, #10, #14 and #26), in a review of 13 residents. The facility census was 35.
Review of the undated facility policy, Comprehensive Care Plan Policy, showed the following:
-A comprehensive care plan is a detailed document outlining a resident's agreed-upon goals of care and the planned activities for their medical, nursing and allied health care. It reflects shared decisions made with the resident, their caregivers and family, about tests, interventions, treatments and other activities needed to achieve these goals. This plan is a dynamic, living document that's updated as the resident's condition changes, ensuring all healthcare team members are informed of the latest critical information;
-Key aspects of a comprehensive care plan:
a. Resident-centered: the plan prioritizes the resident's goals and preferences, reflecting their individual needs and wishes;
b. Multidisciplinary: it involves collaboration among various healthcare professionals, including doctors, nurses, therapists, and other specialists;
c. Dynamic and evolving: the plan is regularly updated as the resident's condition changes, ensuring it remains relevant and accurate;
d. Accessible: it should be readily available to all members of the healthcare team, facilitating seamless communication and continuity of care;
e. Focus on outcomes: the plan outlines measurable goals and activities aimed at improving the resident's health and well-being.
1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 03/13/25, showed the following:
-Dependent on staff for bed mobility and hygiene;
-Always incontinent of bowel and bladder;
-Diagnoses included Alzheimer's disease and dementia.
Review of the resident's care plan, last reviewed 05/27/25, showed the following:
-The resident had an activities of daily living (ADL) self-care performance deficit related to limited mobility;
-The resident required assistance of one to two staff with personal hygiene and toileting.
(The care plan did not include documentation to show the resident was always incontinent of bowel and bladder.)
Observation on 5/28/25 at 9:53 A.M., showed Nurse Assistant (NA) B and NA C transferred the resident to bed. The resident was incontinent of bowel and bladder. NA B and NA C provided incontinence care for the resident.
2. Review of Resident #10's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Diagnoses included paraplegia (paralysis of lower limbs and body) and respiratory failure (not enough oxygen in the body);
-No documentation to show the resident used oxygen.
Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following:
-Diagnoses included hypertension (high blood pressure), paraplegia and acute respiratory failure with hypoxia (low levels of oxygen);
-Oxygen via nasal cannula (NC) (prongs placed in the nose to deliver oxygen) on 2 to 4 liters, for oxygen saturation (the percentage of oxygen-carrying blood in the body) less than 92 percent (%) every night shift (ordered 5/15/25).
Review of the resident's Medication Administration Record (MAR), dated May 2025, showed staff monitored and documented the resident's oxygen saturation every night and administered oxygen per NC as ordered.
Review of the resident's care plan, last reviewed 05/05/25, showed the care plan did not include documentation to show the resident required oxygen at night to keep oxygen saturation above 92%.
During interview on 05/28/25 at 10:16 A.M., the resident said he/she only used his/her oxygen at night.
Observation on 05/29/25 at 9:33 A.M., showed the resident lay in bed with his/her oxygen on per NC.
3. Review of Resident #14's readmission MDS, dated [DATE], showed the following:
-Cognition is intact;
-Diagnoses included paraplegia, peripheral vascular disease (a condition where the blood flow is restricted due to narrowed or blocked blood vessels)and non-pressure, chronic ulcer of skin (open sore or wound caused by poor blood flow);
-Not at risk for pressure ulcer;
-No unhealed pressure ulcer;
-Care area assessment showed no documentation of a wound vac (a medical device that uses suction to help difficult-to-heal wounds close faster).
Review of the resident's May POS showed an order for left midline gluteus and posterior left thigh wound: Cleanse with wound cleanser, apply strips of duoderm extra thin (adhesive occlusive wound covering) to wound border. Wound vac 125 mmHg negative pressure continuous. Black granufoam (type of wound dressing used with a wound vac) to wound bed. Cover with drape. Track pad away from wound, do not place track pad directly over the wound, and do not place any foam directly on good skin, every day shift every Mon, Wed, Sat for wound care.
Review of the resident's care plan, last revised 05/27/25, showed the following:
-No documentation to show resident required a wound vac;
-At risk for pressure ulcers related to paraplegia;
-Administer treatments as ordered;
-Skin breakdown 07/23/24 of right foot inner 4th toe.
Observation in the resident's room on 05/27/25 at 10:20 A.M., showed a wound vac sat on the resident's bedside table.
During an interview on 05/27/25 at 10:20 A.M. the resident said the wound vac had been taken off since Saturday (05/24/25) due to odor and staff were completing wet to dry dressings (a type of dressing/wound care) until his/her wound clinic appointment on 05/28/25.
During an interview on 05/28/25 at 10:00 A.M., the resident said he/she just returned from the wound clinic and the wound vac was re-applied.
Observation on 05/28/25 at 10:00 A.M. showed the wound vac was in place, powered on and attached to the resident.
Observation on 05/29/25 at 9:50 A.M. showed the resident in bed sleeping; a wound vac was in place, attached to the resident.
4. Review of Resident #26's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Diagnoses include coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning);
-No indication of oxygen use.
Review of the resident's May 2025 POS showed an order for oxygen for oxygen saturation of less than 90 % or complaints of dyspnea (shortness of breath) with an order start date of 05/21/25.
Review of the resident's care plan, revised on 05/27/25, showed no documentation to address oxygen usage.
During an interview on 05/27/25 at 11:08 A.M., the resident said he/she had been in the hospital recently and needed the oxygen after being hospitalized . He/She uses the oxygen quite a bit, but mainly at night and puts it on himself.
Observation on 05/27/25 at 11:08 A.M., showed the resident sat in his/her room on the side of the bed with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail.
Observation on 05/28/25 at 10:22 A.M., showed the resident sat in his/her room on the side of the bed with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail.
Observation on 05/28/25 at 5:40 P.M. showed the resident sat in the dining room waiting for supper, his/her oxygen concentrator in the resident's room was running with the oxygen tubing draped over the urinal hanging on the resident's raised side rail.
Observation on 05/29/25 at 9:34 A.M., showed the resident lay in bed sleeping with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail.
During an interview on 06/03/24 at 4:29 P.M., Licensed Practical Nurse (LPN) P said the MDS/Care plan coordinator was responsible for the comprehensive care plans and should address all areas needed to care for the resident.
During an interview on 05/30/25 at 12:42 P.M., the MDS/Care plan coordinator said the following:
-She develops the comprehensive care plan after the admission MDS;
-The care plan should reflect the most current level of care to be provided for the resident;
-The comprehensive care plan should include things like Enhanced Barrier Precaution (EBP) use, oxygen therapy and wound vac use for wounds.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following:
-The MDS/Care plan coordinator usually does the comprehensive care plan;
-The care plan should reflect the most current level of care for the resident and include items like oxygen use, EBP use, bowel and bladder status, wound treatment to include wound vac and anything that would impact the care provided.
During an interview on 05/30/25 at 1:39 P.M., the administrator said she would expect the care plan to reflect the current level of care needed to be provided for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update and revise problems and interventions on resident care plans to reflect current care needs for three residents (Resident #10, #4 and #1) in a sample of 13 residents and failed to include Resident #20's responsible party and Durable Power of Attorney (DPOA) in his/her care planning decision making. The facility census was 35.
Review of the undated facility policy, Resident Plan of Care, showed the following:
-It is the policy of the facility to initiate a resident's plan of care on admission, by charge nurse, that is located in the electronic health record;
-The MDS Coordinator follows electronic health record for date of plan of care to be completed.
The facility did not provide a care plan revisions policy.
1. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/23/25, showed the following:
-Cognitively intact;
-Diagnoses included paraplegia (paralysis of lower limbs and body) and pressure ulcer (localized skin and soft tissue injury) of unspecified buttock, unspecified stage (the severity and depth of tissue damage caused by the ulcer);
-Had one stage two pressure ulcer (partial thickness skin loss appearing as a shallow open sore) and one stage three (deep wound where the skin in completely damaged exposing fatty tissue beneath) pressure ulcer;
Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following:
-On 05/14/25, apply thin layer of Calmoseptine (barrier cream to protect the skin from moisture) to protect skin surrounding wound. Do not get ointment in the wound bed. Apply 0.125 percent (%) Dakins (antiseptic solution to treat and prevent infections in wounds) moistened gauze, dry gauze, abd (absorbent dressing) pads, tape. Be sure to pack area of depth and undermining on left ischium (lower back portion of the hip bone), every morning and at bedtime for wound care;
-No documentation of an order for Enhanced Barrier Precautions (EBP) (an infection control intervention in nursing homes designed to reduce the transmission of multidrug-resistant organisms (MDROs).
Review of the resident's care plan, last reviewed 05/05/25, showed the following:
-The resident has three Stage IV ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling) on coccyx (tailbone), left and right gluteal cleft (the crease between the buttocks) or potential for pressure ulcer development related to history of ulcers, immobility;
-Left ischial (paired bone in the pelvis that forms part of the hip bone) wound, cleanse area with soap and water, pat dry, apply Calmoseptine to wound edges and calcium alginate silver (type of absorbent dressing that contains silver) to wound bed, cover with ABD pad and tape or silicone border, change daily and as needed (PRN); right ischial wound - apply Calmoseptine twice a day and PRN. Keep weight off affected area at all times. Limit time in wheelchair, up for meals only (dated 02/27/25);
-Staff failed to update the resident's care plan with current wound care orders and listed no documentation regarding EBP.
2. Review of Resident #4's annual MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Cognitively intact;
-No behaviors or rejection of cares;
-Participates in the restorative nursing program three out of seven days for active range of motion (ROM);
-No antibiotic use.
Review of the resident's care plan, revised on 05/05/25, showed the following:
-The resident has a psychosocial well-being problem potential related to social isolation related to pandemic coronavirus (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) and nursing home lock down;
-The resident has unplanned/unexpected weight loss related to acute illness being COVID-19;
-The resident has a behavior problem; will slide himself/herself out of his/her wheelchair when he/she wants to lay down and if staff do not come immediately to call light;
-The resident has limited physical mobility related to weakness and knee joint replacement with restorative to work with the resident two to three times weekly for gentle ROM upper and lower.
During an interview with the resident, on 05/27/25 at 10:32 A.M., the resident said the following:
-He/She stays in bed most of the time due to issues with his/her right knee;
-He/She is losing weight on purpose by watching what he/she eats; he/she used to be 500 pounds and now is 300 something by choice, not due to any illness;
-He/She stays in his/her room most of the time by choice and will go out to his/her house during the summer;
-He/She does not have a restorative program;
-He/She has had urinary tract infections in the past few months but has not had COVID for quiet some time;
-He/She was not confined to his/her room by the facility and can come and go as he/she pleases.
Review of the resident's electronic health record for the past twelve months showed no diagnoses of COVID, no behaviors of sliding himself/herself purposefully from the wheelchair, no orders for isolation to his/her room, no restorative program and no unplanned weight loss related to acute illness/COVID. The resident's care plan did not accurately reflect the resident.
3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Dependent on staff for bed mobility and transfers;
-Has one Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister).
Review of the resident's care plan, last reviewed 05/05/25, showed the following:
-The resident has a pressure ulcer or potential for pressure ulcer development related to mobility;
-Administer treatments as ordered and monitor for effectiveness;
-The resident's care plan did not identify the need for or the use of EBP when providing care for the resident.
Review of the resident's POS, dated May 2025, showed the following:
- Cleanse the right ankle daily with normal saline or wound cleanser and pat dry, apply Urgoclean (wound dressing that aids in the continuous removal of slough and wound debris) dressing to wound base, cover with optifoam (a foam dressing) dressing everyday shift for wound care (dated 05/13/25);
-No diagnoses of a pressure ulcer or documentation of an order for EBP.
4. Review of Resident #20's face sheet showed the resident had a family member as the responsible party and Durable Power of Attorney (DPOA). The resident was admitted on [DATE].
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident has severe cognitive impairment;
-Diagnoses of dementia.
Review of the resident's care plan showed the last revision date was 05/27/25.
During an interview on 05/27/25, at 2:50 P.M., the resident's DPOA said the following:
-He/She lived quite a distance from the facility and did not visit the resident much;
-He/She was unaware if the resident has ever had a care plan meeting as he/she had never been notified of the meetings or invited to attend a care plan meeting;
-He/She would like to be notified of the resident's care plan meeting, and if possible, could be on a conference call to discuss the resident.
Review of the resident's electronic health record, for the prior 12 months, showed no documentation regarding an explanation that the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan.
During an interview on 06/03/24 at 4:29 P.M., LPN P said the MDS/Care plan coordinator updated the care plans to reflect the current level of care.
During an interview on 05/30/25 at 12:42 P.M., the MDS/Care plan coordinator said the following:
-She was usually the one that updated the care plans, the nurses can, but they do not usually update them;
-If an issue was no longer a problem, it should be resolved on the care plan;
-The care plan should be up to date and reflect the most current level of care to be provided for the resident.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nurses said the following:
-All nursing was responsible for updating the care plans;
-The MDS/Care plan coordinator also updated the care plans;
-If an issue was no longer a problem it should be resolved on the care plan;
-The care plan should reflect the most current level of care for the resident.
During an interview on 05/30/25 at 1:39 P.M., the administrator said she would expect the care plan to be updated as needed to reflect the current level of care to be provided to the resident.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #438), in a review of fifteen sampled residents, received his/her divalproex sodium delayed release (DR) (a medication to treat epilepsy and mood disorders) medication in the proper form, when staff crushed and administered the medication. Further review showed Certified Medication Technician (CMT) A entered an order to crush the resident's medications without consulting the charge nurse, Director of Nursing, or the physician. The facility census was 36.Review of the facility's undated policy, titled Policy for Medication Administration, showed it did not address crushing medications.Review of the facility's policy, Policy for following Physician Orders, revised 08/29/24, showed the policy did not address who could obtain and enter physician orders. 1. Review of drugs.com for divalproex sodium DR showed the following:-Swallow the capsule or tablet whole and do not crush, chew, break, or open it;-Not all medications are suitable for crushing. Drugs that should not be crushed are DR. These are controlled release and are designed to release medicine over an extended period to allow less frequent administration. Crushing may mean a fatal dose is released. Review of Resident #438's face sheet showed he/she had a diagnosis of restlessness and agitation. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/21/25, showed the following:-Cognitively intact;-No difficulty swallowing. Review of the resident's July 2025 Physician Order Summary (POS) showed the following:-Divalproex sodium oral tablet DR 250 milligrams (mg), give one tablet by mouth three times daily, start date 05/14/25;-Crush medications per resident's request, created and started 07/22/25 at 3:00 P.M., to end indefinite; order confirmed by CMT (certified medication technician) A. Review of the resident's nurses' progress notes, dated 07/22/25, showed no documentation staff contacted the physician regarding a request for an order to crush the resident's medications, including his/her divalproex sodium DR or that an order had been received.During an interview on 07/23/25 at 4:06 P.M., the resident said the following:-He/She always had a hard time swallowing his/her pills;-He/She had not asked staff to crush his/her medications. Observation on 07/23/25 at 12:03 P.M., showed the following:-CMT A removed the resident's medication card of divalproex sodium delayed release 250 mg from the medication cart;-CMT A popped out one divalproex sodium DR 250 mg from the medication card and placed it into a medication cup;-CMT A then poured the tablet into a plastic sleeve, crushed the medication, and placed the crushed medication in a medication cup with applesauce;-CMT A administered the crushed medication in applesauce to the resident;-CMT A crushed and administered medication that was not supposed to be crushed. During an interview on 07/23/25 at 1:38 P.M., CMT A, said the following:-The former DON allowed him/her to put medication orders and crush orders into the computer;-The resident said he/she was having trouble swallowing, so CMT A put an order in the computer for medications to be crushed;-He/She had taken it upon him/herself to put the order in to crush the resident's medications;-He/She did not consult the charge nurse, the Director of Nursing, or the physician prior to adding the order;-The physician was unaware staff crushed any of the resident's medications;-He/She attended an in-service on crushing medications;-Only a few medications were discussed as not being able to be crushed during the in-service. He/She did not read the list of medications during the in-service and he/she did not get a copy of the list of medications which should not be crushed;-He/She did not check the resident's medication list before entering the crush order;-He/She did not realize that DR stood for delayed release. During an interview on 07/23/25 at 1:19 P.M., the facility's pharmacist said the following:-Divalproex sodium DR should not be crushed because it was a delayed released medication;-There could be complications administering divalproex sodium DR crushed. The medication was intended to be released evenly over a period of time. If the medication was administered in a crushed form, the medication would be absorbed too quickly and would not be absorbed as intended;-There were substitutions for this medication if the resident had issues with swallowing;-The other forms would be liquid or crystals. During an interview on 07/24/25 at 10:28 A.M., the DON said the following:-All medication orders should be entered by a Licensed Practical Nurse (LPN) or Registered Nurse (RN);-The order for crushing the resident's medications should have come from the physician;-She did not believe the facility had a policy regarding crushing medications;-She had conducted an in-service for medications which could not be crushed;-Divalproex sodium DR should not have been crushed. It was on a list of non-crushable medications shared with staff during the in-service training;-Crushing divalproex sodium DR would have affected the way the medication was released;-It was inappropriate for the CMT to enter orders to crush medications. During an interview on 07/24/25 at 10:42 A.M., the Administrator said the following:-Any orders for medications or crushing medications should be entered by an LPN or RN;-She would have expected the physician to be contacted for an order to crush a resident's medication;-If staff had any question regarding medications being crushed, the RN should call the physician;-It was not appropriate to crush divalproex sodium DR. The medication was on the do not crush list that was given in an in-service conducted by the DON on 07/10/25;-She would expect nursing to contact the physician if a resident was having trouble swallowing medication and get a new order for a liquid or granules;-There was a potential for harm if a resident was given a medication that should not have been crushed;-It was not appropriate for a CMT to put in a physician order to crush a resident's medications. During an interview on 07/24/25 at 9:51 A.M., the resident's primary care physician said the following:-Divalproex sodium DR oral tablets were not crushable;-Medication orders should be entered by an LPN or RN;-No staff contacted her before entering the order;-A CMT should not be entering medication orders for any resident;-Administering a crushed divalproex sodium DR would interfere with the medications absorption rate. The medication would be absorbed at a quicker rate than intended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services as recommended to assist one resident (Resident #3), in a review of 13 residents, and two additional residents (Resident #18 and #24), with mobility and/or limited range of motion (ROM) to attain or maintain their highest level of functioning. The facility census was 35.
Review of the undated facility policy, Restorative Nursing Program Policy, showed the following:
-Non-skilled rehabilitation: Restorative nursing provides non-skilled rehabilitative care with focus on maintaining or improving daily living skills;
-Restorative aides and nurses must be trained. Registered nurses (RNs) or licensed practical nurses (LPNs) will provide supervision;
-Daily documentation of restorative activities is required. Specific interventions and time spent must be documented;
-The program needs to be reviewed and adjusted as needed. The RN/LPN typically review monthly and the resident care team review quarterly.
1. Review of Resident #18's Physician's Orders, dated April 2025, showed the resident was discharged from skilled physical therapy on 04/01/25.
Review of the resident's Functional Maintenance Program (FMP; also known as the restorative nursing program) referral, dated 04/02/25, showed to perform bilateral upper and lower extremity exercises with weights and ambulate distance as tolerated with front wheeled walker two times a week.
During an interview on 05/30/25 at 10:35 A.M., the Physical Therapist said if a resident needed restorative services after discharge from skilled therapy, therapy completed the FMP with directions for the the restorative program.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/16/25, showed the following:
-Severe cognitive impairment;
-Diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors);
-Limited ROM bilateral lower extremities;
-Partial/moderate staff assistance for lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit-to-lying/lying-to-sit on the side of the bed, sit to stand transfer, chair/bed-to-chair transfer and toileting transfer;
-Did not walk;
-Mobility per wheelchair;
-Participated in the restorative nursing program three out of seven days for active ROM.
Review of the resident's Care Plan, revised on 04/23/25, showed the following:
-The resident had an ADL self-care performance deficit related to disease process Parkinson's disease;
-The resident required assistance from one or two staff to dress, with personal hygiene, for toileting and to move between surfaces;
-Encourage the resident to participate to the fullest extent possible with each interaction;
-The resident was high risk for falls related to gait/balance problems;
-The resident had a fall with no injury related to poor balance.
-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility.
Review of the facility's Restorative Nursing Program binder (where the FMP participation was documented) showed no evidence the resident received restorative nursing treatments or participated in the FMP since discharge from skilled physical therapy on 04/01/25.
Observation on 5/27/25 at 11:25 A.M. showed the resident self-propelled in his/her wheelchair to the dining room for lunch.
Observation on 05/28/25 at 5:15 P.M. showed the resident self-propelled his/her wheelchair to the dining room for supper.
Observation on 05/29/25 at 11:20 A.M. showed the resident self-propelled his/her wheelchair to the dining room for lunch.
During an interview on 05/30/25 at 9:33 A.M., the resident said no one from the nursing staff did any therapy or walked with him/her.
2. Review of Resident #24's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-No ROM limitations;
-Used a walker for independent ambulation;
-Independent with upper and lower body dressing, sit to lying, lying to siting on side of bed, sit to stand, chair/bed-to-chair transfers and toilet transfers;
-Supervision for shower/bathing and tub/shower transfers;
-Participated in the restorative nursing program three of seven days for active ROM.
Review of the resident's Physician's Orders, dated May 2025, showed an order to discharge from skilled occupational therapy and skilled physical therapy services as of 05/16/25 and start a FMP for ambulation and strengthening activities.
Review of the resident's FMP referral, dated 05/16/25, showed orders for the resident to walk with a rollator (a four wheeled walker with a seat) in the hallway, distance to tolerate, and resident to complete 15 repetitions of heel raises, marching, mini-squats and hip abduction with walker with supervision daily.
Review of the resident's Care Plan, revised on 05/27/25, showed the following:
-Diagnosis of Parkinsonism (various conditions that cause symptoms similar to Parkinson's Disease that can include symptoms such as tremors, stiffness of the arms and legs, difficulty walking and loss or weakness of movement);
-The resident was at moderate risk for falls related to deconditioning;
-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility;
-The resident had a fall with no injury related to unsteady gait.
Review of the facility's Restorative Nursing Program binder showed no documentation the resident received restorative nursing treatments or participated in the FMP as ordered since discharge from skilled physical therapy on 05/16/25.
Observation on 5/27/25 at 11:15 A.M. showed the resident walked unassisted with a rollator to the dining room for lunch.
Observation on 05/28/25 at 5:10 P.M. showed the resident walked unassisted with a rollator to the dining room for supper.
Observation on 05/29/25 at 11:20 A.M. showed the resident self-propelled in his/her wheelchair to the dining room for lunch.
During an interview on 05/30/25 at 9:30 A.M., the resident said he/she did not have therapy, it stopped a few weeks ago. He/She used to go to the room for therapy, but since that stopped, all he/she did was walk himself/herself to places in the building. Nursing staff did not do any exercises with him/her and did not typically walk with him/her.
3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following:
-Diagnosis of Alzheimer's disease;
-Severely impaired cognition;
-Dependent with bed mobility, bathing, personal hygiene, dressing, eating and transfers;
-Restorative nursing program provided three of the last seven days.
Review of the resident's Functional Maintenance Program referral, dated 5/9/25, showed the following:
-Physical therapy completed the referral for the functional maintenance program;
-Perform generalized range of motion (ROM) to hips and knees for flexion/extension, abduction/adduction for ten reps each motion to tolerance to reduce right lower extremity (RLE) pain and prevent further contracture formation;
-Five times a week.
Review of the resident's Physician Orders, dated May 2025, showed no orders for the Functional Maintenance Program.
Review of the facility's Restorative Nursing Program binder showed no documentation the resident received restorative nursing services after his/her FMP referral on 5/9/25.
Review of the resident's Care Plan, updated 5/17/25, showed the following:
-The resident had an activity of daily living (ADL) self-care performance deficit related to limited mobility;
-The resident will improve current level of function in ADLs through the review date;
-The resident required assistance from one to two staff to eat, toilet, bed mobility and transfers;
-Encourage the resident to participate to the fullest extent possible with each interaction.
4. During an interview on 05/30/25 at 11:29 A.M. and 06/09/25 at 2:19 P.M., the Restorative Aide (RA) said the following:
-She was the only RA;
-She did not work 05/27/25 or 05/28/25 and had worked in the special care unit as a staff member on 05/29/25 and was off today (05/30/25);
-She was pulled to work on the floor almost daily for the last few months and had not been able to do the restorative program;
-When she was able to perform restorative services, she documented the minutes in the restorative binder;
-No staff performed restorative services for the residents if she was not able.
During an interview on 05/30/25 at 9:00 A.M., the Director of Nursing (DON) said the following:
-The facility had a restorative program;
-She tried not to pull the RA to the floor as a CNA but sometimes it was necessary;
-According to the staff assignments for the month of May, the RA only performed restorative services on two days;
-If the RA was pulled to work the floor as a CNA, there was not a back up assigned to perform restorative services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess seven residents (Residents #10, #3, #20, #189, #9, #36, and #35), in a review of 13 sampled residents, for risk of entrapment from bed rails prior to installation, and failed to review the risk and benefits of the bed rails with the resident or resident representative and obtain consent prior to installation. The facility census was 35.
Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following:
-Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling;
-Assessment by the patient's health care team will help to determine how best to keep the patient safe;
-Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet;
-When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients;
-A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety;
-Reassess the need for using bed rails on a frequent, regular basis.
1. Review of Resident #10's face sheet showed the resident was his/her own responsible party.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/23/25, showed the following:
-Cognitively intact;
-Diagnoses include paraplegia (inability to voluntarily move the lower extremities), vision deficits and kidney disease;
-Range of motion limitations to the lower extremity on one side of the body;
-He/She was dependent for bed mobility and transfers.
Review of the resident's Care Plan, revised on 05/05/25, showed the following:
-He/She had an activities of daily living (ADLs) self-care performance deficit related to right below the knee (BKA) amputation, impaired balance and stage IV wounds (deep wound reaching muscles, ligaments or bone);
-The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary;
-The resident used mobility bars to maximize independence with turning and repositioning in bed;
-The resident required a mechanical lift with two staff for transfers.
Observation on 05/27/25 at 2:53 P.M., showed the resident lay on his/her back in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/28/25 at 10:16 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/28/25, at 12:00 P.M., showed the following:
-The resident lay on his/her back in bed watching television;
-Licensed Practical Nurse (LPN) O and the Assistant Director of Nursing (ADON) completed the resident's dressing change and incontinence care;
-The resident used the bed rails to assist in turning and positioning during the dressing change and incontinence care.
Observation on 05/29/25, at 9:15 A.M., showed the resident lay in bed with his/her eyes closed. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident and obtained consent prior to installation.
2. Review of Resident #3's face sheet showed the resident's family member was his/her responsible party.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Diagnoses include Alzheimer's disease, dementia, and anxiety;
-Range of motion limitations to upper and lower extremity on both sides;
-He/She was dependent for bed mobility and transfers.
Review of the resident's Care Plan, revised on 05/27/25, showed the following:
-He/She had an activities of daily living (ADLs) self-care performance deficit related limited mobility;
-The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary;
-The resident required one or two staff to move between surfaces;
(The resident's care plan did not identify the resident had bed rails on his/her bed.)
Observation on 05/27/25, at 2:53 P.M., showed the resident lay on his/her back in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/28/25, at 9:53 A.M., showed staff transferred the resident with the mechanical lift to bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Staff provided incontinence care to the resident. The resident did not use the bed rails to assist in turning as staff provided his/her care.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
3. Review of Resident #20's face sheet showed the resident's family member was the resident's responsible party.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident has severe cognitive impairment;
-Diagnoses include hip fracture and dementia;
-Range of motion limitations lower extremity one side;
-He/She rolled left and right independently;
-Staff provided partial/moderate assistance for sit to lying, lying to sitting on side of the bed;
-Staff provide substantial/maximum assist for sit to stand, chair/bed-to-chair and toilet transfers.
Review of the resident's Care Plan, revised on 05/27/25, showed the following:
-He/She had an activities of daily living (ADLs) self-care performance deficit related to dementia and impaired balance;
-The resident had a fall with no injury related to poor balance;
(The care plan did not address the resident's transfer status or bed mobility. The resident's care plan did not identify the resident had bed rails on his/her bed.)
Observation on 05/28/25 at 10:11 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/28/25 at 6:38 P.M., showed the following:
-Certified Nursing Assistant (CNA) N and Nurse Assistant (NA) E transferred the resident to bed with the sit-to-stand mechanical lift;
-Staff raised the one-half bed rails on both sides of the bed;
-The resident used the bed rails to assist in turning and positioning while staff provided incontinence care.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
During an interview on 06/03/25, at 11:14 A.M., the resident's responsible party said the facility never contacted him/her related to bed rail use or asked him/her to give consent for bed rails to be used on the resident's bed.
4. Review of Resident #189's face sheet showed his/her family member was designated as the resident's emergency contact. The resident's responsible party was not identified.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Diagnosis include heart failure (a chronic condition in which the heart does not pump blood as well as it should);
-Independently rolls left to right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer and sit to standing position.
Review of the resident's Care Plan, revised on 05/28/25, showed the following:
-The resident had an ADL self-care performance deficit related to confusion, dementia and impaired balance;
-The resident required assistance from one or two staff to turn and reposition in bed every two hours and as necessary;
-He/She required assistance from one or two staff to move between surfaces;
-The resident had limited physical mobility related to weakness, recent hospitalization, dementia and anxiety;
-Provide supportive care and assistance with mobility as needed;
(The resident's care plan did not identify the resident had bed rails on his/her bed.)
Observation on 05/28/25, at 10:27 A.M. and 11:23 A.M., showed the resident lay awake in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/28/25, at 11:38 A.M., showed the following:
-The resident lay awake in bed;
-The resident had one-half bed rails in the raised position on both sides of his/her bed;
-NA B, NA C and CNA D performed incontinence care for the resident. The resident held onto the bed rails as staff turned him/her side to side when providing care.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
5. Review of Resident #9's face sheet showed he/she had a guardian.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnoses included progressive neurological condition, Alzheimer's disease, dementia, and seizure disorder;
-Severe cognitive impairment;
-He/She was independent with bed mobility;
-He/She required supervision with transfers.
Review of the resident's Care Plan, revised 03/19/25, showed the following:
-Unsteady gait;
-He/She needed assistance from one staff with ADLs.
(The resident's care plan did not address bed mobility and did not identify the resident had bed rails on his/her bed.)
Observation on 05/27/28 at 10:32 A.M. showed the resident lay in bed on his/her right side. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
6. Review of resident #36's face sheet showed he/she had a legal guardian.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Diagnoses included dementia, left hip fracture, and hypertension;
-Severe cognitive impairment;
-He/She required moderate assistance with bed mobility;
-He/She required maximum assistance with transfers.
Review of the resident's Care Plan, revised 03/12/25, showed the following:
-The resident had an ADL self-care performance deficit related to dementia and limited mobility due to left hip fracture;
-Alteration in musculoskeletal status related to left hip fracture;
-High risk for falls related to gait/balance problems;
-He/She was dependent of one to two staff for transfers;
-He/She required assistance of one staff to turn, reposition in bed;
(The resident's care plan did not identify the resident had bed rails on his/her bed.)
Observation on 05/27/25 at 10:38 showed the resident sat in his/her recliner. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Observation on 05/29/25 at 3:00 P.M. showed the resident in his/her wheelchair in his/her room. The resident had one-half bed rails in the raised position on both sides of his/her bed.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
7. Review of Resident #35's face sheet showed he/she had a legal guardian.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnoses included progressive neurological condition ( a condition in which the brain and nervous system function gradually declines) and dementia;
-Severe cognitive impairment;
-He/She was independent with bed mobility;
-He/She required supervision with transfers.
Review of the resident's Care Plan, revised 03/06/25, showed the following:
-The resident had an ADL self-care performance deficit related to Alzheimer's disease;
-The resident was able to transfer himself/herself;
(The resident's care plan did not address bed mobility and did not identify the resident had bed rails on his/her bed.)
Observation on 05/27/25 at 10:32 A.M. and 05/29/25 at 3:00 P.M. showed the resident walked in the hallway. The resident had a one-half bed rail raised on the right side of his/her bed.
Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation.
8. During an interview on 05/29/25, at 4:03 P.M., the DON said she had not done any bed rail assessments, obtained informed consent, provided education to families or completed quarterly evaluations related to bed rail use. She was not aware that was her responsibility.
During an interview on 05/29/25, at 2:00 P.M., the Administrator said the DON was responsible for obtaining consent for bed rails and for any ongoing education, assessments and evaluations.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the resident census and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 35.
Review of the facility's undated policy, Posting Daily Staffing, showed the following:
-The direct care staff for the facility shall be posted daily across from the nursing desk between the Southeast and Southwest hall;
-The charge nurse shall complete this at the beginning of each shift;
-The number of each category shall be posted along with the actual hours worked and the census for each shift;
-The completed forms shall be given to Director of Nursing to keep for at least 18 months.
1. Review of the facility daily staffing sheets for nursing staff for May 2025 showed the following:
-On 05/01/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for registered nurse (RN), licensed practical nurse (LPN), certified medication technician (CMT), certified nurse assistant (CNA), nurse assistant (NA) or the census for the day or evening shift;
-No completed daily staffing sheet for nursing staff for 05/02/25 and 05/03/25;
-On 05/04/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shift.
-No completed daily staffing sheet for nursing staff for 05/05/25 through 05/09/25;
-On 5/10/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shift.
-No completed daily staffing sheet for nursing staff for 05/11/25 through 05/26/25.
Observation on 05/27/25 at 10:30 A.M. and 4:00 P.M., showed the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shifts.
Observation on 05/28/25 at 10:00 A.M., 2:18 P.M. and 8:30 P.M. showed the incomplete daily staffing sheet for 5/27/25 remained posted. There was no staffing posted for 05/28/25.
During an interview on 05/29/25 at 12:00 A.M., the Assistant Director of Nursing (DON) said the charge nurse was responsible for updating the daily staffing sheet for nursing staff each shift.
During an interview on 06/03/25 at 4:29 P.M., LPN P said the Director of Nursing (DON) was responsible for updating the daily staffing sheet.
During an interview on 05/30/25 at 1:13 P.M., the DON said the following:
-The posted nurse staffing should be up to date;
-She was not sure who was responsible for filling out the posted staffing sheets;
-The completion of the posted nurse staffing had fallen through the cracks;
-She received the completed staffing sheets and knew the posted staffing was not getting done.
During interviews on 05/28/25 at 2:50 P.M. and 05/30/25, the Administrator said the following:
-The posted staffing sheets should be up to date;
-Usually the charge nurse completed the daily staffing sheet and gave the sheets to the DON to save.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 27 opportunities observed, 10 errors occurred, resulting in a 37.0% error rate, which affected one resident (Resident #10) in a review of of 13 sampled residents and three additional residents (Resident #15, #32 and #28). The facility census was 35.
Review of the facility's undated policy, titled Policy for Medication Administration, showed it did not address crushing medications.
Review of the facility's undated policy, Insulin Pen Usage, showed before each use, prime the pen to remove air bubbles and ensure a clear needle.
Review of the Humalog Kwik pen package insert showed if you do not prime the insulin pen before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle.
Review of the Fiasp FlexTouch pen package insert showed if you do not prime before each injection, you may get too much or too little insulin. Turn the dose selector to select two units, hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, hold the pen with the needle pointing up and press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat the above steps.
1. Review of Resident #10's May 2025 Physician Order Sheets (POS) showed the following:
-Diagnoses of type 2 diabetes mellitus with other circulatory complications (condition in which the body has trouble controlling blood sugar and damage the blood vessels leading to circulatory complications);
-Accucheck (blood glucose test) three times daily and at bedtime;
-Humalog KwikPen Insulin (insulin Lispro) (fast acting injectable medication to control blood sugar (the amount of sugar in the blood)) insulin pen, 100 units/ml; amount per sliding scale (a dose amount to be determined based on the Accucheck); if blood sugar is 210-219 give one unit, if blood sugar is 220-229 give two units, if blood sugar is 230-239 give three units, if blood sugar is 240-249 give four units, if blood sugar is 250 to 259 give five units, if blood sugar is 260-269 give six units, if blood sugar is 270-279 give seven units, if blood sugar is 280-289 give eight units, if blood sugar is 290-299 give nine units, if blood sugar is 300-310 give 10 units, if blood sugar is 311-320 give 11 units, if blood sugar is 321-330 give 12 units, if blood sugar is 331-340 give 13 units, if blood sugar is 341-350 give 14 units, if blood sugar is 351-360 give 15 units, if blood sugar is 361-370 give 16 units, if blood sugar is 371-380 give 17 units and if blood sugar is 381-390 give 18 units subcutaneous.
Review of the resident's May 2025 medication administration record (MAR) showed the following:
-Accucheck three times daily and at bedtime; scheduled for 7:30 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M.;
-Humalog KwikPen Insulin (insulin Lispro) insulin pen, 100 units/ml; amount per sliding scale; scheduled for 7:30 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M.
Observation on 05/28/25 at 4:27 P.M. showed the following:
-Licensed Practical Nurse (LPN) K obtained the resident's Accucheck with results of 259 milligrams per deciliter (mg/dL) and determined Humalog sliding scale insulin dose was to be five units;
-LPN K removed the resident's Humalog flex pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle;
-LPN K did not prime the insulin pen;
-LPN K dialed five units of Humalog insulin for sliding scale and administered the medication in the resident's subcutaneous tissue of the abdomen.
2. Review of Resident # 15's May 2025 POS showed the following:
-Diagnoses of type 2 diabetes mellitus;
-Accucheck three times daily (TID);
-Fiasp (fast acting insulin used to manage blood sugar levels) five units sub-q twice daily at 8:00 A.M. and 5:00 P.M.
Review of the resident's May 2025 MAR showed the following:
-Accucheck three times daily (TID) at 8:00 A.M., 5:00 P.M. and 8:00 P.M.;
-Fiasp five units sub-q twice daily; scheduled for at 8:00 A.M. and 5:00 P.M
Observation on 05/28/25 at 4:45 P.M. showed the following;
-LPN K obtained the resident's Accucheck with a blood glucose reading of 197 mg/dL;
-LPN K removed the resident's Fiasp FlexTouch pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle;
-LPN K did not prime the insulin pen;
-LPN K dialed up five units of Fiasp insulin and administered the medication in the resident's subcutaneous tissue of the abdomen.
During an interview on 05/28/25 at 4:55 P.M. LPN K said she was not aware that insulin pens needed to be primed with two units prior to giving the desired amount of insulin.
3. Review of drugs.com for Donepezil (medication used to treat Alzheimer's disease) showed the following:
-Donepezil tablets should be swallowed whole; do not crush, break or chew;
-Crushing the tablet can lead to increased rate of absorption, leading to a higher concentration in the body than intended, increased risk of side effects or even overdose.
4. Review of drugs.com for K-Dur (potassium supplement) showed the following:
-K-Dur should not be crushed;
-Crushing the tablet can cause the drug to release all at once, leading to a sudden increase in potassium levels, can cause digestive tract injuries and can increases the risk of side effects.
5. Review of Resident #32's May 2025 POS showed the following:
-Diagnoses included infection of the mouth, malignant neoplasm of the left breast (breast cancer), unspecified dementia, hypokalemia (low level of potassium in the blood);
-Amoxicillin (antibiotic) 875 mg orally (PO) twice daily (BID);
-Calcium (supplement) 600 mg with vitamin D (supplement) PO BID;
-Donepezil 10 mg, two tablets PO in the evening;
-K-Dur 20 milliequivalents (meq) PO three times daily (TID).
Review of the resident's May 2025 MAR showed the following:
-Amoxicillin 875 mg PO to be given at 8:00 A.M. and 5:00 P.M.;
-Calcium 600 mg with vitamin D to be given at 8:00 A.M. and 5:00 P.M.;
-Donepezil 10 mg, two tablets PO to be given at 5:00 P.M.;
-K-Dur 20 meq PO to be given at 8:00 A.M., 12:00 noon, and 5:00 P.M.
Observation on 05/28/25 at 7:45 P.M. showed the following:
-Certified Medication Technician (CMT) L removed from the medication cart, medication cards of Amoxicillin 875 mg, Donepezil 10 mg and K-Dur 20 meq, labeled for the resident;
-CMT L removed a stock bottle of calcium 600 mg plus vitamin D from the medication cart;
-CMT L poured one calcium 600 mg with vitamin D into a medication cup;
-CMT L popped out one amoxicillin 875 mg, two Donepezil 10 mg tablets and one K-Dur 20 meq into the medication cup. CMT L then poured all the medications into a plastic sleeve, crushed the medications and placed the crushed medications in a medication cup with applesauce;
-CMT L administered all of the crushed medications in applesauce to the resident at one time and not separately;
-CMT L also crushed and administered medications that were not supposed to be crushed.
6. Review of drugs.com for Tylenol Arthritis (pain medication, also called Tylenol 8 Hour) showed the following:
-Tylenol Arthritis should be swallowed whole; do not crush, chew, split or dissolve;
-Tylenol Arthritis is an extended release medication, designed to be released into the body gradually over an extended period;
-If Tylenol Arthritis is crushed, you will disrupt the extended-release mechanism; this can lead to a shorter duration of activity, increased risk of side effects and overdose.
7. Review of Resident #28's May 2025 POS showed the following:
-Diagnoses included unspecified dementia with anxiety disorder, GERD and pain unspecified;
-Alprazolam (medication to treat anxiety disorders, panic disorders and anxiety caused by depression) 0.25 mg PO BID;
-Famotidine (medication used to treat and prevent ulcers in the stomach and intestines) 20 mg PO BID;
-Tylenol arthritis (pain medication) 650 mg PO BID.
Review of the resident's May 2025 MAR showed the following:
-Alprazolam 0.25 mg PO to be given BID at 12:00 noon and at 5:00 P.M.;
-Famotidine 20 mg PO to be given BID at 8:00 A.M. and 5:00 P.M.;
-Tylenol 8 hour arthritis pain oral tablet, extended release 650 mg to be given two times a day for pain, scheduled at 8:00 A.M. and 5:00 P.M.
Observation on 05/28/25 at 8:10 P.M. showed the following:
-CMT L removed from the medication cart narcotic lock box, a medication card of alprazolam 0.25 mg, labeled for the resident;
-CMT L removed from the medication cart, a medication card of famotidine 20 mg, labeled for the resident;
-CMT L removed from the medication cart, a stock bottle of Tylenol 8 Hour, 650 mg;
-CMT L popped out one alprazolam 0.25 mg and one famotidine 20 mg from the medication cards and placed them in a medication cup. CMT L removed one Tylenol 8 Hour 650 mg from the stock bottle and placed it into the medication cup; CMT L then poured all of the medications into a plastic sleeve, crushed all of the medications and then placed the crushed medications in a medication cup with applesauce;
-CMT L administered all of the crushed medications in applesauce to the resident at one time and not separately;
-CMT L also crushed and administered medications that were not supposed to be crushed.
During an interview on 05/30/25 at 1:13 P.M. the Director of Nursing (DON) said she would expect the insulin pens to be primed prior to dialing up the resident's dose.
During an interview on 05/30/25 at 1:39 P.M. and 06/09/25 at 1:51 P.M. the administrator said the following:
-She was not sure about the procedure for priming insulin pens;
-She would not expect extended release or enteric coated medications to be crushed.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #10), in a review of 13 sampled residents, and one additional resident (Resident # 15) who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air from the needle and cartridge) the Humalog Kwik pen (prefilled pen of fast acting insulin (medication injected under the skin used to treat diabetes)) and Fiasp FlexTouch pen (prefilled pen of fast acting insulin) needle as instructed by the manufacturer prior to administration of the medication, potentially affecting the amount of insulin dispensed with each dose. The facility census was 35.
Review of the facility's undated policy, Insulin Pen Usage, showed before each use, prime the pen to remove air bubbles and ensure a clear needle.
Review of the Humalog Kwik pen package insert showed if you do not prime the insulin pen before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle.
Review of the Fiasp FlexTouch pen package insert showed if you do not prime before each injection, you may get too much or too little insulin. Turn the dose selector to select two units, hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, hold the pen with the needle pointing up and press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat the above steps.
1. Review of Resident #10's May 2025 Physician Order Sheets (POS) showed the following:
-Diagnosis of type 2 diabetes mellitus;
-Humalog KwikPen insulin pen, 100 units/milliliter (ml); amount per sliding scale (a dose amount to be determined based on the accucheck). If blood sugar is 210-219, give 1 unit; if blood sugar is 220-229, give 2 units; if blood sugar is 230-239, give 3 units; if blood sugar is 240-249, give 4 units; if blood sugar is 250 to 259, give 5 units; if blood sugar is 260-269, give 6 units; if blood sugar is 270-279, give 7 units; if blood sugar is 280-289, give 8 units; if blood sugar is 290-299, give 9 units; if blood sugar is 300-310, give 10 units; if blood sugar is 311-320, give 11 units; if blood sugar is 321-330, give 12 units; if blood sugar is 331-340, give 13 units; if blood sugar is 341-350, give 14 units; if blood sugar is 351-360, give 15 units; if blood sugar is 361-370, give 16 units; if blood sugar is 371-380, give 17 units; and if blood sugar is 381-390, give 18 units subcutaneous.
Observation on 5/28/25 at 4:27 P.M. showed the following:
-Licensed Practical Nurse (LPN) K obtained the resident's blood sugar level with results of 259 milligrams per deciliter (mg/dL) and determined Humalog sliding scale insulin dose was to be 5 units;
-LPN K obtained the resident's Humalog flex pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new needle;
-LPN K did not prime the insulin pen;
-LPN K dialed 5 units of Humalog insulin for sliding scale and administered the medication in the resident's abdomen.
2. Review of Resident #15's May 2025 POS showed the following:
-Diagnosis of type 2 diabetes mellitus
-Fiasp (fast acting insulin) 5 units twice a day at 8:00 A.M. and 5:00 P.M.
Observation on 5/28/25 at 4:45 P.M. showed the following;
-LPN K obtained the resident's Fiasp FlexTouch pen from the medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new needle;
-LPN K did not prime the insulin pen;
-LPN K dialed up 5 units of Fiasp insulin and administered the medication in the resident's subcutaneous tissue of the abdomen.
3. During an interview on 5/28/25 at 4:55 P.M., LPN K said he/she was unaware the insulin pens needed to be primed.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing said the following:
-Staff was to prime insulin pens;
-Staff was to administer insulin in accordance with facility policy, physician orders, and manufacturer guidelines.
During an interview on 5/30/25 at 1:39 P.M., the Administrator said nursing staff was to prime and administer insulin pens as recommended by the manufacturer's recommendations.

Based on observation and interview, the facility failed to timely destroy expired medications. The facility census was 35.
1. Observation of the licensed nurses medication cart on 05/28/25 at 2:30 P.M. showed the following:
-One bottle of ketoconazole 2% shampoo labeled for Resident #3, had an expiration date of 12/2022;
-One tube of Aspercreme (topical pain relief cream), labeled for Resident #6, had an expiration date of 03/2025;
-One bottle of Murine ear drops (wax removal drops), labeled for Resident #2, had an expiration date of 08/2024;
-One stock (facility's supply) tube of hydrocortisone 1% cream had an expiration date of 03/25;
-One stock bottle of nystatin powder (an antifungal medication) had an expiration date of 09/30/23;
-One stock bottle of stoma adhesive had an expiration date of 02/01/25;
-One stock tube of Aspercreme had an expiration date of 12/2024.
During an interview on 05/28/25 at 3:00 P.M., Licensed Practical Nurse (LPN) K said the charge nurses check the licensed nurses cart for outdated medications randomly.
During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following:
-Expired medications should not be in the medication carts;
-Certified Medication Technicians (CMTs) and the licensed nurses should check the medication carts weekly;
-The pharmacist should check all medication carts and the medication room monthly.
During an interview on 05/30/25 at 1:39 P.M., the Administrator said the following:
-Expired medications should not be in the medication carts;
-The pharmacist was to check the carts monthly;
-She was not aware if or when nursing staff was to check the carts for outdated medications.

Based on interview and record review, the facility failed to ensure one resident (Resident #7) with a developmental delay and learning disability, in a review of nine sampled residents, received person centered interventions to address behaviors affecting others that did not make the resident feel like staff were treating him/her like a child. Staff told the resident to go to his/her room when the resident displayed disruptive behaviors. The staff physically took the resident to his/her room even when the resident refused instead of attempting other interventions to address the resident's behaviors. The facility census was 41.
The facility did not provide a policy on providing care and services for residents with behavioral issues upon request.
1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/23/24, showed the following:
-The resident was cognitively intact;
-No behaviors present;
-He/She was independent with ambulation;
-Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood.
Review of the resident's Care Plan, dated 2/23/24, showed the following:
-The resident was resistive to the nurse at times related to anxiety, with example of showering without his/her family member present;
-Allow the resident to make decisions about treatment regimen, to provide sense of control;
-Encourage as much participation/interaction by the resident as possible during care activities;
-Give clear explanation of all care activities prior to and as they occur during each contact;
-Monitor the resident and his/her family member's behaviors towards each other;
-Praise the resident when behavior is appropriate;
-The resident liked coloring in adult coloring books, listening to music on his/her phone with headphones, walking to the country store, playing Bingo weekly, and going on outings.
Review of the resident's Behavior Note, dated 5/18/24 at 2:19 P.M., showed the following:
-The resident asked staff to take a photo of him/her to send to a friend online;
-The staff explained, they were unable to take the photo;
-The resident said it was the person he/she was dating and the person wanted naked photos;
-The resident denied sending any photos.
Review of the resident's Social Services Note, dated 5/20/24 at 4:02 P.M., showed the following:
-The resident carved on the back of his/her room door because he/she was mad;
-The social services director called the guardian regarding the resident's behaviors of carving in the door and asking staff to take pictures for a person online;
-The guardian said maybe he/she should take the resident's the phone and tablet.
Review of the resident's Care Plan showed no updates following the residents behaviors on 5/18/24 and 5/20/24.
Review of the resident's Nurse Note, dated 7/11/24 at 3:35 P.M., showed the following:
-The resident was upset with social services regarding a trip to visit a family member in the hospital;
-The resident cursed at staff and was upset with a family member.
Review of the resident's Social Service note, dated 7/11/24 at 4:00 P.M., showed the following:
-The resident went into the social services director's office screaming and demanding the staff member to call his/her guardian about going with a sibling to see a parent at the hospital;
-The social services director explained the guardian approved for the resident to leave with another family member;
-The resident yelled, the family member needed to stay out of his/her business and the resident was done with the guardian.
Review of the resident's Care Plan showed no updates following the resident's behaviors on 7/11/24.
Review of the resident's Social Services Note, dated 7/31/24 at 1:47 P.M., showed the following:
-The resident went to the Social Service Director's office and said a resident of the opposite sex asked him/her to go to bed with him/her;
-He/She was all over the other resident the day before;
-The staff instructed the resident to stay away from the other resident.
Review of the resident's Social Services Note, dated 8/5/24 at 1:47 P.M., showed the following:
-The resident kept approaching a staff member from the kitchen and wanted the staff member to come help the resident in his/her room;
-The resident wore only a bra and underwear, asking the staff member why he/she recently started working at the facility;
-The administration told the kitchen staff to give the resident's snacks to the nurse to give to the resident.
Review of the resident's Care Plan, dated 8/5/24, showed the following:
-The resident has potential to be physically and verbally aggressive (hitting walls, slamming doors, using profanity), related to anger/temper;
-Analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document;
-Give the resident as many choices as possible about care and activities;
-The resident liked everything to be his/her way and becomes angry when asked to do something, i.e., to come out of his/her room during the day, triggers for physical aggression;
-Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others;
-Psychiatric consult as indicated;
-Redirect resident to his/her room to calm down so it does not interrupt other residents;
-The resident had a behavior problem talking inappropriately about sex;
-Explain to the resident that it is inappropriate for him/her to be in a state of undress in the building other than in his/her room or shower and that anytime anyone enters his/her room, the resident should be completely dressed;
-The resident sometimes speaks of sex and wanting the young staff from kitchen to come into his/her room. He/She was in a state of undress;
-The resident wanted to run around the building with inappropriate clothing that was not covering him/her. The staff redirected the resident to his/her room to dress appropriately.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/23/24, showed the following:
-The resident was cognitively intact;
-No behaviors present;
-He/She was independent with ambulation;
-Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood.
Review of the resident's Nurse Note, dated 9/11/24 at 1:16 P.M., showed the resident wore a night gown all day with a tear on the underarm allowing the side of his/her chest to be exposed. The resident was defiant even when the Administrator and Director of Nursing (DON) attempted to instruct the resident on rationale to change. The resident did not change out of the gown.
Review of the resident's Nurse Note, dated 9/12/24 at 11:46 A.M., showed the following:
-The resident pushed a resident in a wheelchair forcefully and allowed the other resident to go freely in the wheelchair;
-The staff attempted to redirect the resident about the dangers in this, but the resident remarked back he/she did this all the time and became defiant;
-The staff instructed the resident to get dressed as he/she was in night clothes, the resident said this was his/her home and he/she could dress as he/she pleased;
-The staff attempted to explain as that was true, they were in a group setting and the resident needed to respect others as well.
Review of the resident's social services note, dated 9/13/24 at 2:30 P.M., showed the following:
-The Social Services Director spoke with the resident's guardian, regarding the resident's behavior that week and asked about who was coming to see the resident for an independent living facility (ISL);
-The guardian said they were waiting on a court date for the resident's family member to take guardianship.
Review of the resident's nurse note, dated 9/22/24 at 12:46 A.M., showed the following:
-The resident came up to the nurses' station asking for Tylenol;
-The nurse asked the resident why he/she was not in bed and the resident said he/she and another resident were watching a movie;
-The nurse told the resident that it was midnight and the resident proceeded to argue with the nurse and said, it was not midnight but a little after 11:00 P.M.;
-The nurse showed the resident the time on his/her personal cell phone and the resident said he/she only followed the time on his/her own phone;
-The nurse told the resident he/she needed to go to bed because it was late and the television was supposed to be turned off at 10:00 P.M., per the DON;
-The resident said the DON was not his/her parent;
-The nurse said he/she would talk with the Administrator about the resident being told to go to bed every night;
-The resident continued to argue with the nurse then stormed off to another resident's room.
Review of the resident's Care Plan showed no additional interventions were added regarding the resident's behaviors on 9//11/24, 9/12/24 and 9/22/24.
Review of the resident's medical record showed no documentation the physician was notified of the resident's behaviors on 9/11/24, 9/12/24 and 9/22/24.
Review of the resident's Social Services Note, dated 11/13/24 at 9:16 A.M., showed the following:
-The resident was out of control cursing and yelling;
-He/She was scheduled to go to a physician's appointment, but the resident's family member was unable to take the resident and the facility transporter was off;
-The resident was so angry and couldn't control himself/herself and went off at everybody;
-The resident thought someone should be called in on their day off to take him/her, when the staff told the resident no, the resident became angrier;
-The resident went all over the facility cursing and did not stop;
-Older residents were doing activities in the north dining room when the resident started cussing, the staff asked the resident to stay in his/her room until the resident cooled off;
-These behaviors happened most every day, the resident always said he/she would tell his/her family;
-The Social Services Director called the resident's guardian, but the guardian had to do something else and had to go.
Review of the resident's nurse note, dated 11/13/24 at 9:45 A.M., showed the nurse heard the resident cussing from the hallway, so the nurse told the resident that the language was not appropriate at the facility, however, the resident did not acknowledge the nurse was talking and continued down the hallway.
Review of the resident's Nurse Note, dated 11/13/24 at 10:07 A.M., showed the following:
-The resident said his/her family member could not take the resident to an appointment and asked the staff to call the Restorative Aide (RA) as the resident tried to get hold of the RA to see if he/she could take the resident to the appointment;
-The staff explained social services would be in the facility and could help the resident;
-The resident waited at every room the staff member entered and upon coming out of the rooms, asked for phone numbers of other staff and he/she wanted to go to the appointment;
-The staff attempted to rationalize with the resident that they were doing all they could do on short notice;
-The resident woke up another resident after the staff asked him/her not to do this. Staff attempted to reinforce this resident could not help Resident #7.
Review of the resident's Nurse Note, dated 11/13/24 at 11:15 A.M., showed the following:
-The nurse asked the resident to go to his/her room several times;
-The resident said he/she was waiting for Tylenol; the nurse explained the resident could not have Tylenol at that time because the resident received it with morning medications and it was too soon;
-The nurse asked the resident again to go to his/her room as the resident was being disruptive and had been asked by multiple staff;
-The resident refused to go to his/her room on his/her own;
-The nurse attempted to assist the resident into a standing position by hooking the nurse's right arm under the resident's left arm and was unable to get the resident to move, so the nurse asked for assistance from Certified Medication Tech (CMT) G;
-The nurse and CMT G were able to assist the resident into a standing position using the same technique, one staff member one each side of the resident with their arms looped with the resident;
-The resident continued to be resistive as the staff attempted to walk the resident to his/her room. At that time the nurse went behind the resident and held onto his/her hips while the CMT G walked backwards in front of the resident holding his/her hands, while the staff continued to ask the resident to go to his/her room on his/her own so they didn't have to continue to disrupt the other residents this way and it was disrespectful to the other residents;
-The staff and resident got in front of the nurses' station, then the resident refused to move his/her feet any further and began pushing her body against the nurse. CMT G hugged the resident around the waist to keep the resident in a standing position and asked another staff member to get a wheelchair;
-The resident said the staff didn't know the other half of why he/she was upset and the nurse said the resident could tell them when he/she was in his/her room;
-The nurse instructed the resident to sit in the wheelchair so they could continue down to his/her room, but the resident resisted, the staff applied pressure to resident's shoulders and upper thighs and lowered him/her into the chair;
-The staff took the resident down to his/her room with resistance, as the resident kept grabbing the wheels and causing the chair to stop;
-Once in the resident's room, the nurse asked him/her what was the other half of why he/she was upset, the resident refused to say;
-The staff locked the brakes on the wheelchair and left the room;
-The nurse returned five minutes later and took the wheelchair out of the room. The resident was in bed.
Review of the resident's Activity Note, dated 11/14/24 at 9:23 A.M., showed the following:
-On 11/13/24 the resident asked administration why the housekeepers could not transport him/her to the appointment;
-The staff told the resident, the housekeepers had never transported anyone before and they were not able to do so;
-The resident became irate with everyone in the building, cussing out the administrator and DON;
-The Activity Director was in the morning activity and could hear the resident screaming at the Administrator and DON through the double doors over the music playing;
-The resident went through the double doors and turned around to scream at the DON;
-The Activity Director asked the resident to not cuss in front of the other residents because it was visibly upsetting them and making them agitated and a little frightened of the resident due to the outburst. The resident said he/she didn't care;
-The resident was beyond the point of reason;
-The staff redirected the resident several times but the resident did not care;
-The outburst lasted from 9:00 A.M. until 12 P.M.
Review of the resident's care plan showed no updates or interventions added regarding the resident's behaviors on 11/13/24.
During an interview on 11/14/24 at 12:00 P.M., Licensed Practical Nurse (LPN) E said the following:
-The staff canceled the resident's appointment because his/her transportation was not available;
-The resident was upset because he/she was looking forward to the trip;
-The resident wanted other staff members contacted to provide transportation because the facility's transportation driver had a day off;
-None of the other staff were available to transport the resident to the appointment;
-The resident started cussing, yelling, stomping in the hallways, and slammed doors;
-Another resident tried to go to the restroom but Resident #7 followed him/her into the restroom, so staff told the resident to stay out and give the other resident some privacy;
-The nurse told the resident he/she was being rude and disrespectful to the other residents and asked the resident to go to his/her room until they could help the resident through the frustration, however, the resident said, no;
-The Social Services Director asked the resident to go back to his/her room so they could talk and the resident said no;
-LPN E placed one hand on the resident's upper arm and another at the waist and guided the resident towards his/her room;
-The resident suddenly stopped and refused to go any further;
-He/She went to get a CMT for assistance;
-The resident sat in a high back chair in back dining room and refused to move;
-Both staff members wrapped an arm around both of the resident's arms and assisted him/her to stand up from the chair;
-Both staff members guided the resident across the dining room and at the nurses' station the resident stopped;
-CMT G took both of the resident's hands and LPN E put both hands on the resident's waist to guide the resident towards his/her room, but the resident wouldn't move and instead attempted to fall backwards;
-LPN E told the resident to stop and another employee obtained a wheelchair;
-LPN E placed the wheelchair behind the resident and told him/her to sit down, but the resident refused;
-LPN E placed his/her hand on the resident's shoulder and pushed down, so the resident sat down;
-LPN E and the CMT G took the resident down to his/her room via wheelchair;
-The staff left the resident in his/her room with another resident present;
-Around 2:30 P.M., the resident was up walking in the dining room, calm and quiet;
-The staff did not attempt any other interventions because the resident was not redirectable;
-The resident was dependent on on another resident for emotional support and guidance;
-The other resident had a stroke in July 2024, which affected his/her speech and mobility;
-The other resident was moved from next door to Resident #7 to the front hall, so the other resident would have more privacy and could focus on rehab;
-Resident #7 was able to walk to the front hall to see the other resident but it was an adjustment;
-When the resident was not redirectable, then the staff were supposed to tell the resident to go to his/her room.
During an interview on 11/14/24 at 12:50 P.M., the resident said the following:
-The resident was mad because an appointment was canceled again;
-He/She was waiting at the nurses' station for Tylenol (pain medication), but the staff told him/her to go back to his/her room;
-The resident told the staff he/she did not want to and was waiting on Tylenol but LPN E made him/her go anyway by force, leading him/her down the hall and pushing him/her in a wheelchair to the room;
-LPN E told the resident to stay in his/her room until the resident could calm down;
-The resident was not scared of staff, he/she was mad because he/she had to go back to his/her room;
-He/She felt the staff treated him/her like a child but he/she was an adult.
During an interview on 11/14/24 at 1:32 P.M., the Social Services Director said the following:
-He/She scheduled the appointment and the resident's family member said he/she would take the resident to the appointment;
-The transportation driver was off because no residents were scheduled for transportation;
-The resident's family member called the morning of the appointment to report he/she was not available to transport the resident;
-When the resident did not get his/her way, the resident exploded and became loud, cussing and other behaviors;
-On 11/13/24, the resident went into the Administrator's office and started cussing and yelling at the Administrator;
-The Administrator told the resident his/her behavior was inappropriate and go to his/her room;
-The resident refused so the staff had to work with him/her to get the resident in his/her room.
During an interview on 11/14/24 at 3:45 P.M., the Director of Nursing said the following:
-The resident was cussing and yelling around other residents who were participating in activities;
-The staff asked the resident to go to his/her room and calm down multiple times;
-The staff got the resident up and the resident stood still;
-The staff got a wheelchair for him/her to sit down;
-LPN E and CMT G acted the way he/she expected;
-The staff did not attempt any other interventions because the resident was not redirectable.
During an interview on 11/14/24 at 4:15 P.M., and 11/27/24 at 11:00 A.M. the Administrator said the following:
-The resident did have behaviors;
-He/She previously had behaviors of yelling and cussing at the Administrator;
-When the resident was in these moods, the resident did not redirect easily;
-The behaviors were almost like a tantrum;
-In the past, the resident became so mad that he/she punched the wall and door in his/her room;
-The staff have told the resident the behavior was inappropriate and not tolerated;
-The administrator expected staff to attempt other interventions listed on the resident's care plan before physically taking the resident to his/her room.
During an interview on 11/15/24 at 2:18 P.M., the resident's Nurse Practitioner said the following:
-He/She witnessed the resident's behavior on 11/13/24;
-Several staff members spoke with the resident about going to his/her room because he/she was upsetting the other residents but the resident refused;
-Two staff attempted to get the resident to walk but he/she refused;
-The two staff members got the resident to sit in the wheelchair and started toward his/her room;
-The resident put his/her feet down on the floor to prevent the staff from going any further so the staff put footrests on the wheelchair to prevent the resident from putting his/her feet down;
-The staff started again but the resident grabbed hold of the wheels to prevent it from going any further;
-The staff took the resident's hands off the wheels and continued to his/her room;
-Staff never asked the Nurse Practitioner to evaluate or assess the resident for behaviors;
-He/She never saw the resident have this type of behavior previously.
During an interview on 11/15/24 at 2:51 P.M., the resident's physician said the following:
-The DON and other nurses kept him/her informed about the resident's behaviors;
-When the resident did not sleep well his/her behaviors became worse;
-He/She did not make any changes in the resident's medication orders or recommend therapy yet, but would when he/she thinks it was necessary and would benefit the resident.
MO245107

Based on interview and record review, the facility failed to ensure one resident (Resident #7), of nine sampled residents,was free from physical restraints after the resident presented with verbal behaviors. Staff forced the resident to sit in a wheelchair by physically pushing the resident down into a wheelchair when the resident refused to walk to his/her room. The resident was normally able to ambulate independently. Once in the wheelchair, staff physically removed the resident's hands when the resident held onto the wheels of the chair to prevent staff from moving him/her. Staff placed footrests on the wheelchair when the resident used his/her feet to prevent the chair from moving so that staff could transport the resident to his/her room. The facility census was 41.
The facility did not provide a policy on physical restraints upon request.
1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/23/24, showed the following:
-The resident was cognitively intact;
-No behaviors present;
-He/She was independent with ambulation;
-Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood.
Review of the resident's Care Plan, dated 2/23/24, showed the following:
-The resident was resistive to the nurse at times related to anxiety, with example of showering without his/her family member present;
-Allow the resident to make decisions about treatment regimen to provide sense of control;
-Encourage as much participation/interaction by the resident as possible during care activities;
-Give clear explanation of all care activities prior to and as they occur during each contact;
-Monitor the resident and his/her family member's behaviors towards each other;
-Praise the resident when behavior is appropriate;
-The resident liked coloring in adult coloring books, listening to music on his/her phone with headphones, walking to the country store, playing Bingo weekly, and going on outings.
Review of the resident's Social Services Note, dated 11/13/24 at 9:16 A.M., showed the following:
-The resident was out of control cursing and yelling;
-He/She was scheduled to go to a physician's appointment but the resident's family member was unable to take the resident and the facility transporter was off;
-The resident was so angry and couldn't control himself/herself and went off on everybody;
-The resident thought someone should be called in on their day off to take him/her, when the staff told the resident no, the resident became angrier;
-The resident went all over the facility cursing and did not stop;
-Other residents were doing activities in the north dining room when the resident started cussing. The staff asked the resident to stay in his/her room until the resident cooled off;
-The Social Services Director called the resident's guardian, but the guardian had to do something else and had to go.
Review of the resident's Nurse Note, dated 11/13/24 at 11:15 A.M., showed the following:
-The nurse asked the resident to go to his/her room several times;
-The resident said he/she was waiting for Tylenol, which the nurse explained the resident could not have Tylenol at that time because the resident received it with morning medications and it was too soon;
-The nurse asked the resident again to go to his/her room as the resident was being disruptive and had been asked by multiple staff;
-The resident refused to go to his/her room on his/her own;
-The nurse attempted to assist the resident into a standing position by hooking the nurse's right arm under the resident's left arm and was unable to get the resident to move, so the nurse asked for assistance from Certified Medication Tech (CMT) G;
-The nurse and CMT G were able to assist the resident into a standing position using the same technique, one staff member one each side of the resident with their arms looped with the resident;
-The resident continued to be resistive as the staff attempted to walk the resident to his/her room. At that time the nurse went behind the resident and held onto his/her hips while CMT G walked backwards in front of the resident holding his/her hands, while the staff continued to ask the resident to go to his/her room on his/her own so they didn't have to continue to disrupt the other residents this way and it was disrespectful to the other residents;
-The staff and resident got in front of the nurses' station, then the resident refused to move his/her feet any further and began pushing her body against the nurse. CMT G hugged the resident around the waist to keep the resident in a standing position and asked another staff member to get a wheelchair;
-The resident said the staff didn't know the other half of why he/she was upset and the nurse said the resident could tell them when he/she was in his/her room;
-The nurse instructed the resident to sit in the wheelchair so they could continue down to his/her room, but the resident resisted, the staff applied pressure to resident's shoulders and upper thighs and lowered him/her into the chair;
-The staff took the resident down to his/her room with resistance, as the resident kept grabbing the wheels and causing the chair to stop;
-Once in the resident's room;
-The staff locked the brakes on the wheelchair and left the room.
During an interview on 11/14/24 at 12:00 P.M., Licensed Practical Nurse (LPN) E said the following:
-The staff canceled the resident's appointment because his/her transportation was not available;
-The resident was upset because he/she was looking forward to the trip;
-The resident started cussing, yelling, stomping in the hallways, and slammed doors;
-Another resident tried to go to the restroom but Resident #7 followed him/her into the restroom, so staff told the resident to stay out and give the other resident some privacy;
-The nurse told the resident he/she was being rude and disrespectful to the other residents and asked the resident to go to his/her room until they could help the resident through the frustration, however, the resident said, no;
-The Social Services Director asked the resident to go back to his/her room so they could talk and the resident said no;
-Licensed Practical Nurse (LPN) E placed one hand on the resident's upper arm and another at the waist and guided the resident towards his/her room;
-The resident suddenly stopped and refused to go any further;
-LPN E went to get a CMT for assistance;
-The resident sat in a high back chair in the back dining room and refused to move;
-Both staff members wrapped an arm around both of the resident's arms and assisted him/her to stand up from the chair;
-Both staff members guided the resident across the dining room and at the nurses' station the resident stopped;
-The CMT G took both resident's hands and LPN E put both hands on the resident's waist to guide the resident towards his/her room, but the resident wouldn't move and instead attempted to fall backwards;
-LPN E told the resident to stop and another employee obtained a wheelchair;
-LPN E placed the wheelchair behind the resident and told him/her to sit down, but the resident refused;
-LPN E placed his/her hand on the resident's shoulder and pushed down, so the resident sat down;
-LPN E and the CMT G took the resident down to his/her room via wheelchair;
-The staff left the resident in his/her room with another resident present.
During an interview on 11/14/24 at 12:50 P.M., the resident said the following:
-The resident was mad because an appointment was canceled again;
-He/She was waiting at the nurses' station for Tylenol but the staff told him/her to go back to his/her room;
-The resident told the staff he/she did not want to and was waiting on Tylenol but LPN E made him/her go anyway by force, leading him/her down the hall and pushing him/her in a wheelchair to the room. The resident did not want to go to his/her room;
-LPN E told the resident to stay in his/her room until the resident could calm down;
-The resident was not scared of staff, he/she was mad because he/she had to go back to his/her room;
-He/She felt the staff treated him/her like a child but he/she was an adult.
During an interview on 11/14/24 at 3:45 P.M., the Director of Nursing said the following:
-The resident was cussing and yelling around other residents who were participating in activities;
-The staff asked the resident to go to his/her room and calm down multiple times;
-The staff got the resident up and the resident stood still;
-The staff got a wheelchair for him/her to sit down;
-LPN E and CMT G acted the way he/she expected;
-The staff did not attempt any other interventions because the resident was not redirectable.
During an interview on 11/14/24 at 4:15 P.M., and 11/27/24 at 11:00 A.M. the Administrator said the following:
-The resident did have behaviors;
-He/She previously had behaviors of yelling and cussing at the Administrator;
-When the resident was in these moods, the resident did not redirect easily;
-The behaviors were almost like a tantrum;
-In the past, the resident became so mad that he/she punched the wall and door in his/her room;
-The staff have told the resident the behavior was inappropriate and not tolerated;
-The administrator expected staff to attempt other interventions on the resident's care plan before physically taking the resident to his/her room.
During an interview on 11/15/24 at 2:18 P.M., the resident's Nurse Practitioner said the following:
-He/She witnessed the resident's behavior on 11/13/24;
-Several staff members spoke with the resident about going to his/her room because he/she was upsetting the other residents but the resident refused;
-Two staff attempted to get the resident to walk but he/she refused;
-The two staff members got the resident to sit in the wheelchair and started toward his/her room;
-The resident put his/her feet down on the floor to prevent the staff from going any further so the staff put footrests on the wheelchair to prevent the resident from putting his/her feet down;
-The staff started again but the resident grabbed hold of the wheels to prevent it from going any further;
-The staff took the resident's hands off the wheels and continued to his/her room.
MO245107

Based on record reviews, document review, and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments for 3 (Residents #21, #34, and #36) of 5 sampled residents reviewed for resident assessments.
Findings included:
A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.
A review of Resident #21's medical record indicated the facility readmitted the resident on 03/30/2023.
A review of Resident #21's medical record revealed the last completed Minimum Data Set (MDS) was an admission MDS with an Assessment Reference Date (ARD) of 04/06/2023.
A review of Resident #34's admission Record indicated the facility readmitted the resident on 04/21/2023.
A review of Resident #34's medical record revealed the last completed MDS was an admission MDS with an ARD of 04/28/2023.
A review of Resident #36's admission Record revealed the facility admitted Resident #36 on 03/28/2023.
A review of Resident #36's medical record revealed the last completed MDS was an admission MDS with an ARD of 04/10/2023.
In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she knew she was behind on completing MDS assessments. The MDS/CP Coordinator stated she did not like being behind, but knew it was totally 100% her fault the MDS assessments were not being completed. She stated she was unsure of why the MDS assessment was not completed, but stated it should have been.
During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated she expected MDS assessments to be timely, and acknowledged the facility had a problem with that. According to the DON, the MDS assessments were not completed timely, and she was unsure why.
In an interview on 08/30/2023 at 2:11 PM, the Administrator stated MDS assessments should be completed on time.

3. A review of an admission Record indicated the facility admitted Resident #21 on 01/31/2022 with diagnoses that included stage 4 pressure ulcer of sacral region, displaced intertrochanteric fracture of left femur, and reduced mobility.
A review of Resident #21's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2023, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an indwelling catheter and was always incontinent of bowel.
A review of Resident #21's comprehensive care plan revealed the resident did not have a care plan to address the use of their indwelling urinary catheter.
During an observation on 08/28/2023 at 10:23 AM, Resident #21 was observed to have an indwelling urinary catheter.
In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she did not know why Resident #21's indwelling catheter was not care planned other than she just missed it.
During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated the MDS/CP Coordinator was responsible for ensuring all things related to a resident's care was included on the care plan immediately. The DON indicated she was not aware Resident #21's catheter was not care planned but it should have been. Per the DON, Resident #21 has had the urinary catheter since they were admitted . According to the DON, not care planning Resident #21's catheter could lead to the resident getting a urinary tract infection if the staff were unaware of how to care for the catheter.
In an interview on 08/30/2023 at 2:12 PM, the Administrator stated her expectation was for care plans to be updated for the care areas and treatments specific for that resident. The Administrator indicated she was unaware Resident #21's catheter was not care planned but it should have been. Per the Administrator, the negative outcome of the resident's catheter not being care planned was that the resident could develop sepsis (a life-threatening medical emergency caused by the body's overwhelming response to an infection) if not cared for properly.
Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure staff developed a care plan to address the needs of 3 (Residents #21, #36, and #140) of 12 sampled residents.
Findings included:
A review of the facility's policy titled, Resident Plan of Care Policy & Procedures, revised 05/18/2023, revealed, It is the Policy of [facility name] 1) To initiate Residents plan of care on admission by Charge Nurse, and placed in careplan binder located at each nursing desk for Charge Nurse and C.N.A. [certified nursing assistant] access to insure resident getting needs met.
1. A review of Resident #36's admission Record revealed the facility admitted Resident #36 on 03/28/2023, with diagnoses including dementia with psychotic disturbance and anxiety disorder.
A review of Resident #36's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2023, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #36 received antipsychotic medication for seven days during the assessment period.
A review of Resident #36's comprehensive care plan revealed the resident did not have a care plan to address the use of an antipsychotic medication.
In an interview on 08/29/2023 at 1:56 PM, MDS/Care Plan (CP) Coordinator stated she was not sure how she missed care planning Resident #36 for antipsychotic medication use, since it was identified on the April 2023 MDS assessment. She stated she just missed it. The MDS/CP Coordinator stated it was important to care plan antipsychotic use to ensure staff knew to monitor for signs and symptoms related to the medication.
During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing stated she would expect the resident's care plan to be reflective of the care received.
In an interview on 08/30/2023 at 2:11 PM, the Administrator stated she was not aware the resident was not care planned for their antipsychotic use. Per the Administrator, she would expect the resident's use of an antipsychotic medication to be care planned.
2. A review of Resident #140's admission Record, revealed the facility readmitted the resident on 08/16/2023, with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, emphysema, essential hypertension, and shortness of breath.
A review of Resident #140's Progress Notes, dated 08/16/2023 at 2:35 PM, revealed Resident #140 would readmit to the facility on palliative care.
A review of Resident #140's comprehensive care plan revealed the resident did not have a care plan to address the resident received palliative care.
In an interview on 08/29/2023 at 1:56 PM, the Minimum Data Set (MDS)/Care Plan (CP) Coordinator stated she missed care planning Resident #140 for palliative care. The MDS/CP Coordinator stated the resident's palliative care should have been care planned but she missed it. She stated it was important to ensure it was on the care plan, so staff knew how to care for Resident #140 properly and honored the resident's wishes for palliative care.
During an interview on 08/30/2023 at 1:52 PM, the Director of Nursing stated she would have expected the resident's need for palliative care should have been care planned.
In an interview on 08/30/2023 at 2:11 PM, the Administrator stated she would expect the resident's needs for palliative care to be care planned.

Based on record reviews, document review, and interviews, the facility failed to timely complete the admission Minimum Data Set (MDS) for 3 (Residents #21, #34, and #36) of 5 sampled residents reviewed for resident assessments.
Findings included:
A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day if: - this is the resident's first time in this facility, OR, - the resident has been admitted to this facility and was discharged return not anticipated, OR - the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.
A review of Resident #21's medical record indicated the facility readmitted the resident on 03/30/2023.
A review of Resident #21's admission MDS with an Assessment Reference Date (ARD) of 04/06/2023 revealed the assessment was signed as completed on 05/19/2023.
A review of Resident #34's admission Record indicated the facility readmitted the resident on 04/21/2023.
A review of Resident #34's admission MDS with an ARD of 04/28/2023 revealed the assessment was signed as completed on 07/11/2023.
A review of Resident #36's admission Record revealed the facility admitted Resident #36 on 03/28/2023.
A review of Resident #36's admission MDS with an ARD of 04/10/2023 revealed the assessment was signed as completed on 06/06/2023.
In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she knew she was behind on completing MDS assessments. The MDS/CP Coordinator stated she did not like being behind, but knew it was totally 100% her fault the MDS assessments were not being completed. She stated she was unsure of why the MDS assessment was not completed, but stated it should have been.
During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated she expected MDS assessments to be timely, and acknowledged the facility had a problem with that. According to the DON, the MDS assessments were not completed timely, and she was unsure why.
In an interview on 08/30/2023 at 2:11 PM, the Administrator stated MDS assessments should be completed on time.

Based on interview and record review, the facility failed follow their policy by not notifying the state agency of an injury of unknown origin for one resident (Resident #200), in a review of 13 sampled residents. The facility census was 52.
1. Review of the facility's undated policy Abuse Prevention Policy, showed the facility must ensure all alleged violations of mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are immediately reported to the facility administrator and to other officials in accordance with state law through established procedures (including the state survey and certification agency). If serious bodily injury to a resident resulted, a report must be made immediately and not later than two hours after forming the suspicion. The facility must report the suspicion and not wait until confirmed with an investigative process. The facility must have evidence all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of the all investigations must be reported to the administrator or his/her designated representative and to other officials in accordance with state law (including to the state survey and certification agency) within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
2. Review of Resident #200's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, dated 5/10/19, showed the following:
-Severely impaired cognition;
-Required extensive assistance from one staff for bed mobility, toileting, and transfers;
-Diagnoses included Alzheimer's disease (progressive disease which destroys memory and other important mental functions), osteoarthritis (arthritis where protective tissue at the end of bones wears down), convulsions (uncontrolled actions of the body where muscles contract and relax rapidly and repeatedly), fracture (break in bone) left femur and left artificial hip.
Review of an incident report, dated 7/21/19 at 6:00 P.M. showed the following:
-Nursing description: Certified Medication Technician (CMT) called Licensed Practical Nurse (LPN) G to the special care unit (SCU). Upon entering the SCU, LPN G noted certified nurse assistants (CNAs) were in the shower room and the resident lay on the floor in front of the toilet. The CNAs reported they transferred the resident onto the toilet and the resident became lethargic, color drained from his/her face and his/her eyes rolled upwards. The CNAs transferred the resident to the floor. The resident was able to somewhat respond to staff, stating, I don't feel good. On interview with nursing staff, the resident was not dropped or sat down on floor hard;
-Immediate action taken: Head to toe assessment without injuries noted. Resident assisted from floor into wheelchair, taken to room, and transferred into bed.
Review of an incident report, dated 7/23/19 at 8:00 P.M. and revised on 7/24/19 at 1:39 A.M., showed the following:
-Nursing description: CNA called LPN B to the resident's room at 8:00 P.M. The resident was in bed. LPN B observed a very large bruise and raised area on the resident's right thigh and leg. The resident had pain with assessment but was unable to give a description;
-Immediate action taken: LPN B called the director of nursing (DON) and an investigation was started. The physician was notified and orders to keep the resident on bed rest until x-ray obtained in the morning. The resident to have pelvic and right hip x-ray;
-Notification of DON: 7/23/19 at 9:30 P.M.
During an interview on 1/10/20 at 12:05 P.M., LPN B said the following:
-On the evening of 7/23/19, CNA D called him/her to assess the resident after staff discovered the bruising;
-Upon assessment, he/she observed what looked like a terrible, new purple bruise on the resident's thigh. The resident complained of pain when the area was touched and experienced pain with assessment;
-He/She called the physician to report and informed him/her the bruise was not present the day before. The physician said not to move the resident and gave an order for x-rays in the morning;
-No staff saw or knew of the resident having a fall.
During an interview on 1/9/20 at 2:33 P.M., LPN E said on 7/24/19, staff called him/her to the resident's room. He/She entered the room to find the resident in the bed on his/her back. The resident had bruising to his/her hip area and the leg looked asymmetrical. The hip area was almost black and dark purple on the thigh area.
Review of the facility Investigation Report, dated 7/24/19 at 8:30 A.M., showed on 7/23/19, bruising was noted to inner and outer right thigh. After interviews, noted the resident had syncope episode on toilet on 7/21/19 and was two manned to floor. X-ray showed right hip fracture. Determination made that when resident was transferred onto the floor was when fracture occurred which is consistent with bruising showing up 24 to 48 hours after incident.
Review of health status notes, dated 7/24/19, showed the following:
-At 9:00 A.M., mobile x-ray here to x-ray hip and pelvis;
-At 9:15 A.M., x-ray technician reports the resident's hip is clearly broken. Call to physician, awaiting call back for further orders;
-At 10:00 A.M., the resident departed with ambulance service to hospital for evaluation and treatment of right hip fracture.
Review of the resident's radiology report, dated 7/24/19, showed the following:
-Osteopenia (bone condition characterized by decreased bone density, which leads to bone weakening and an increased risk of bone fracture);
-Right hip view impression: comminuted (reduced to minute particles or fragments) displaced right femoral intrachanteric (hip) fracture.
During interviews on 1/9/20 at 4:16 P.M. and 1/23/20 at 2:35 P.M., the DON said the following:
-Staff notified her on the evening of 7/23/19 of the resident's hip and leg bruising;
-She began the investigation into the cause of the injury the next morning (7/24/19) after he/she arrived to work around 8:00 A.M. or 9:00 A.M.;
-She did not know the cause of the bruising until after she began the investigation the morning of 7/24/19 and learned the resident had an unresponsive spell on 7/21/19;
-Given the new guidelines with the two hour reporting timeline, the facility should have reported the injury of unknown origin.
Complaint MO164342

Based on observation, interview, and record review, the facility failed to ensure the range hood was free of grease and debris; failed to ensure the can opener was clean and free of an accumulation of food debris; and failed to ensure trash cans in the kitchen were covered when not in use. The facility census was 52.
1. Observation on 1/7/19 at 12:29 P.M. showed the range hood had three baffle filters with a heavy buildup of dark fuzzy debris and a moderate buildup of clear and yellow grease. Further observation showed a heavy accumulation of dark fuzzy debris on the fire suppression piping and nozzles under the range hood. Strands of dark fuzzy debris hung off the fire suppression system piping and blew in the breeze of the range hood exhaust system.
Review of the range hood sticker on the exterior of the hood on 1/7/19 at 2:59 P.M. showed the hood had previously been professionally cleaned 4/10/19.
During an interview on 1/7/19 at 3:20 P.M., Dietary Staff A said maintenance staff was supposed to clean the baffle filters. Maintenance staff took them outside, hosed them off and put them back in the hood. He/She wasn't sure how often this was supposed to be done and said the filters looked like they were overdue to be cleaned.
During an interview on 1/8/19 at 10:00 A.M., the dietary manager said maintenance staff cleaned the range hood baffle filters monthly. Dietary staff wiped down the exterior of the hood monthly.
During an interview on 1/8/19 at 10:48 A.M., the maintenance supervisor said his assistant cleaned the baffle filters monthly. Maintenance staff should check the baffles weekly and clean them monthly. Maintenance staff cleaned the baffles sometime last month and were needing to clean them again. The kitchen staff were supposed to clean the piping and fire suppression system inside the hood. The hood was professionally cleaned and inspected every six months, but the vendor had not cleaned the rangehood for over six months.
2. Observation on 1/7/19 at 12:37 P.M. and at 2:06 P.M. showed white crusty and flaky debris on the can opener blade. [NAME] flaky debris fell off onto counter when the blade was picked up for inspection and then replaced into the holder. [NAME] flaky debris still remained on the blade.
Observation on 1/7/19 at 3:04 P.M. showed Dietary Staff A used the can opener to open a large can of spaghetti sauce. He/She did not clean the blade prior to utilizing the can opener.
Observation on 1/7/19 at 3:10 P.M. showed Dietary Staff A used the can opener to open a second can of spaghetti sauce. Red sauce was visible on the can opener blade. He/She did not clean the blade prior to utilizing the can opener, nor did he/she clean the blade after opening either can of spaghetti sauce.
During an interview on 1/8/19 at 10:00 A.M., the dietary manager said staff should clean the can opener blade daily and should wipe it down with sanitizer solution cloths when soiled.
3. Observation on 1/7/19 at 12:23 P.M. showed an open trash can next to the two-well sink outside of the dry storage room. The trash can was 3/4 full of food waste, foil, and paper trash, etc. No staff were preparing food or utilizing the trash can.
Observation on 1/7/19 at 2:06 P.M. showed no staff were present in the kitchen. The trash can under the dish machine counter was 1/4 full of food waste and was not covered. The lid was under the counter and against the back wall.
Observation on 1/7/19 at 2:21 P.M. showed no staff were present in the kitchen and no cooking was in progress. The trash can under the dish machine counter remained uncovered.
Observation on 1/7/19 at 3:37 P.M. showed no staff in the kitchen. The trash can next to the dry storage room had a lid that was only partially on the trash can. Contents of the trash can were visible. Further observation showed the trash can under the dish machine counter was open and the lid sat against the back wall.
During an interview on 1/8/19 at 10:00 A.M., the dietary manager said trash cans lids should be covered when not in use.