Bethesda Southgate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents were free from derogatory and disrespectful remarks from staff members (Resident #1 and Resident #2). The sample was three. The census was 106 with 79 in certified beds.
Review of the facility's Resident Rights and Responsibility Policy, dated 6/2022, showed the following:
-Purpose: To provide an awareness to all staff of the rights and responsibilities of each resident;
-Responsibility: It is the responsibility of all employees to know and to comply with this policy;
-Policy:
-The 1987 Nursing Home Reform Law requires that each nursing home provide care for its residents in a manner that promotes and enhances the quality of life for each resident, ensuring dignity, choice and self-determination;
-During orientation and minimally, at annual in-services, all employees shall be fully informed of resident rights and responsibilities. Bethesda will not tolerate infringement of resident rights by any employee. Allegations of violations of resident rights shall be reported and investigated promptly. Bethesda shall take appropriate measures to ensure that the rights of the residents are protected.
-Resident Rights:
-Each Resident has a right to:
-Right to Dignity, Respect and Freedom:
-a. To be treated with consideration, respect and dignity;
-b. To be free from mental and physical abuse;
-c. To self-determination.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/25, showed the following:
-Severe cognitive impairment;
-No moods or behaviors;
-Mobility by a wheelchair;
-Substantial assistance with transfers;
-Diagnoses of high blood pressure, diabetes, Alzheimer's Disease and dementia.
Review of the resident's Incident Reporting and Grievance Form, dated 4/11/25, showed the following:
-Brief Description: Receptionist (REC) B informed the Administrator on 4/11/24 at 8:22 P.M. that he/she observed Certified Nurse Aide (CNA) A roughly transfer the resident on 4/10/25. REC B said CNA A was rude to the resident during the interaction;
-Nature of the Event: Customer Service;
-Please explain customer service event: Rough transfer and attitude;
-Please describe resolution: Investigation started on 4/11/25. The resident was assessed by the Nurse Manager on 4/11/25. No injuries noted and no distress.
Review of the resident's care plan, showed no documentation regarding resident rights.
During an interview on 4/23/25 at 11:16 A.M., CNA A said he/she is going to be honest. He/She tries to meet the residents where they are, meaning he/she tries to be completely honest while dealing with residents. CNA A said when the resident said are you trying to kill me?, CNA A said we all have to go someday. CNA A said he/she did not mean the statement in any type of disrespectful way. CNA A said this happened when he/she was trying to transfer the resident to his/her wheelchair and take the resident to bed.
Review of CNA A's employee file, showed documentation of termination on 4/15/25.
During an interview on 4/23/25 at 1:41 P.M., the resident said he/she was doing fine. The resident said he/she did not remember anything about the incident.
During an interview on 4/24/25 at 11:16 A.M., REC B said one day last week, he/she did not remember the day, he/she was at the front desk and CNA A was transferring the resident. REC B said you could hear the resident yell out, What are you doing trying to kill me?. REC B said he/she looked up and saw CNA A look in the resident's face and say Well, we all have to die. REC B said he/she felt uncomfortable and could see the resident rubbing his/her arm after the transfer. REC B said he/she reported this to the Administrator.
2. Review of Resident #2's admissions MDS, dated [DATE], showed the following:
-No cognitive impairment;
-No behaviors;
-Wheelchair and walker used for mobility;
-Dependent for transfers;
-Diagnoses of fractured hip, anemia, high blood pressure and end stage renal disease (ESRD, a condition where the kidneys have permanently lost the ability to function, requiring dialysis or a kidney transplant to survive).
Review of the resident's Incident Reporting and Grievance Form, dated 4/17/25, showed the following:
-Date of the Event: 4/16/25;
-Brief Description of the Incident: The resident reported CNA C was rough during care. The resident said he/she was rude during the interaction. The resident reported the staff pushed him/her towards the bed during the transfer;
-Nature of the Event: Customer Service;
-Type of Customer Service Event: Staff Attitude;
-Date Grievance Resolved: 4/17/25;
-Please describe the resolution: The resident was informed CNA C would no longer provide care. The resident vocalized that he/she was happy with the resolution and did not desire any further follow up;
-Comments: The resident spoke with Administrator and said the CNA was rough during care. The resident reported the CNA was rougher than needed while cleaning the resident after soling him/herself by spilling the urinal. The resident reported the staff was discourteous and rude. The resident reported during the transfer to bed, the CNA pushed him/her towards the bed. The Resident was asked to describe the pushing event. He/She said the CNA placed one hand on his/her shoulder while standing him/her to transfer, and pushed him/her towards the bed. The resident said he/she sat back onto the bed. When asked if the staff member was guiding him/her towards the bed for transfer, the resident said maybe. The resident said he/she was in a very frustrated mood during the interaction due to his/her medical condition.
During an interview on 4/23/25 at 11:45 A.M., the resident said he/she had spilled some urine on his/her bed. The resident said a friend was visiting, who said the resident was sleeping. The CNA said he/she is going to get his/her f**king ass up. The CNA was rough when getting him/her up. The resident said he/she felt disrespected being talked to that way. The resident said he/she made the Administrator aware.
Review of the resident's care plan, showed no documentation regarding resident rights.
During an interview on 4/24/25 at 12:10 P.M., CNA C said he/she arrived on shift and did his/her rounds and went into the resident's room. He/She was visiting with family. He/She saw the bed was wet. CNA C transferred the resident from the bed to the wheelchair. He/She cleaned the bed and took the resident to the bathroom. CNA C cleaned the resident, changed his/her pants and transferred him/her back to the wheelchair. During the time, the resident's family member said he/she was leaving. CNA C wheeled the resident out of the bathroom and later that evening put the resident to bed. The resident had no concerns. CNA A said he/she did not curse at or around the resident at any time. CNA C said he/she was inserviced on the facility resident rights and customer service policy on 4/19/25.
3. During an interview on 4/23/25 at 9:15 A.M., the Administrator said he/she expected all staff to follow the facility's resident's rights policy. The Administrator said he only inserviced the one staff member and did not inservice other staff members. The Administrator said staff are inserviced annually on resident rights.
MO00252640
MO00252894
MO00253195

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for one of one resident (Resident (R) 134) reviewed for self-administration of medications out of a sample of 23 residents. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents.
Findings include:
During medication pass observation with Licensed Practical Nurse (LPN) 1 on 07/07/24 at 11:56 AM, she placed one tablet of ferrous sulfate 325 milligrams (mg) into a clear medication cup. LPN1 stated that was all R134 received at this time. LPN1 then entered R134's bedroom, where R134 was sitting up in her wheelchair with the overbed table in front of her. LPN1 placed the medication cup on the table and told R134 that the medication was her iron pill. Then LPN1 walked out of the room. The observing surveyor stayed in R134's bedroom until R134 took the medication, which was two to three minutes later.
Review of R134's ''Face Sheet'' (facility provided) revealed R134 was admitted to the facility on [DATE] with a diagnosis including anemia.
Review of admission ''Minimum Data Set (MDS)'' with Assessment Reference Date (ARD) of 06/30/24 revealed a ''Brief Interview for Mental Status (BIMS)'' 15 out of 15, indicating R134 was cognitively intact.
Review of R134's electronic medical record (EMR), located under tab ''Evaluations/Forms'' revealed no evidence of a self-medication administration form.
Review of R134's ''Orders'' (facility provided) revealed ''Ferrous sulfate 325 mg, oral, three times a day [TID], starting 06/24/24.'' There was no indication R134 was to self-administrator the medication.
Review of R134's ''Resident Profile Report'' (facility provided) revealed no evidence of a care plan for self-administration of medication.
During an interview on 07/09/24 at 11:00 AM, the Director of Nursing (DON) confirmed R134 has not been assessed for self-administering medications and stated that nurses were not to leave medication with residents without watching them take the medication.
During an interview on 7/10/24 at 10:00 AM, LPN1 confirmed that medication should not be left with residents. LPN1 stated she usually did not leave medication with a resident. LPN1 confirmed she should not have left the room until R134 took the medication.
Review of facility policy titled ''2.1 Self Administering Medications,'' revised 08/2018, revealed ''To provide general guidelines to nursing staff regarding resident self-administration of medications . Policy: Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications and with administrator/Executive Director approval. An evaluation will be completed and documented prior to allowing self-administration of medications, quarterly, with any change of condition or for any route not previously evaluated to be given (example: evaluated to self-administer oral medications only and later has inhaler ordered) . If the evaluation indicates the resident may self-administer medications, the resident's/community member's physician must also give an order allowing the self-administration . Practice: . 3. All medication will be kept in a locked container at the bedside/apartment. The resident/community member, the charge nurse/Certified Medication Tech (CMT) and the Director of Nursing (DON) will each have a key. 4. Self-administration will be addressed in the resident's/community member's care plan/individual service plan.''

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure one of three residents and their representatives (Resident (R) 1) reviewed for facility initiated emergent hospital transfers were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and/or the Resident Representatives (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.
Findings include:
Review of R1's untitled and undated face sheet provided by the facility revealed the resident was most recently readmitted to the facility on [DATE] with diagnoses which included intracranial hemorrhage, persistent vegetative state, and spastic hemiplegia.
Review of R1's SNF-SBAR [Skilled Nursing Facility - Situation, Background, assessment, and Recommendation] document, dated 06/17/24 and provided by the facility, revealed . NP [nurse practitioner] came in and this nurse had reported to NP that resident O2 sats [oxygen saturations] lower 90s, upper 80s. Course lung sounds all lobes with audible whz [wheezing]. N.O. [new order] received to send pt [patient] to ER [Emergency Room].
During an interview on 07/10/24 at 3:55 PM, the Administrator confirmed no written notification was sent to the resident's court appointed guardian for the transfer on 06/17/24. The Administrator stated it was her expectation the facility would follow their policy related to resident transfers and written information being provided.
Review of the facility's policy titled, Discharge/Transfer of a Resident, Including Against Medical Advice, revised 12/2022 revealed Purpose: To provide guidelines when discharging or transferring a resident to another health care residence . Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: . An immediate transfer or discharge is required by the resident's urgent medical need . Contents of the transfer/discharge notice must include: The reason for the transfer, The effective date of the transfer or discharge, An explanation of the right to appeal the transfer or discharge to the State .Provide transfer/discharge notice to the resident/representative . as indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents' pressure ulcers were assessed and received the necessary treatment and services to promote healing and to prevent worsening of pressure ulcers for one of three residents (Resident (R) 1) reviewed for pressure out of 23 sampled residents. R1 had a history of a pressure ulcer on her left pinky finger healing and reopening. The facility failed to ensure measures were taken to prevent the pressure ulcer from reopening and worsening from a stage 2 pressure ulcer to a stage 3 pressure ulcer. Additionally, the facility started treatment on the pressure ulcer without notifying and obtaining a physician's order. These failures placed R1 at risk for further worsening of the pressure ulcer.
Findings include:
Review of R1's untitled and undated face sheet provided by the facility revealed the resident was most recently readmitted to the facility on [DATE] with diagnoses which included intracranial hemorrhage (bleeding in the skull), persistent vegetative state, and spastic hemiplegia (type of paralysis where muscles contract uncontrollably).
Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24, located in Aspen MDS Viewer, revealed the resident was originally admitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed the resident to be severely impaired for cognitive skills for daily decision making. The MDS indicated the facility assessed the resident had limitations in her range of motion (ROM) as she had upper and lower extremity impairment to both sides. The facility assessed R1 to be at risk for developing pressure, had no unhealed pressure ulcers, and had moisture associated skin damage (MASD).
Review of R1's care plan titled, Resident Profile Report, reviewed on 11/13/20 and provided by the facility, revealed for the area of Skin . I currently have a stage 2 [pressure] to my left pinky finger. OT [occupational therapy] is going to see me to see if there is a hand splint that would work for me. My goal is for this area to heal and remain free from skin breakdown .
Review of R1's care plan titled, Resident Profile Report, reviewed on 11/20/20 and provided by the facility, revealed for the area of Skin.I currently have an open area to my left pinky finger. My nurse is applying a tx [treatment] to this area. OT has seen me and ordered a soft hand splint that would work for me. My goal is for this area to heal and remain free from skin breakdown .
Review of R1's Visit Report for [R1's Name], dated 11/17/20, completed by the facility's contracted wound care physician and provided by the facility revealed . Chief Complaint . Left small finger pressure ulcer . LSP [left small pinky] pressure ulcer where finger is pressed against the adjacent ring finger noted 11/08 [11/08/20]. Duoderm gel [pressure treatment medication] started with dry dressing-has resolved on exam today to fragile epithelium. Noted as a stage 2 pu [pressure ulcer]. Has attempted to use towel rolls to limit contractures of the hand/fingers but she will not hold on to these. OT consulted .
Review of R1's Visit Report for [R1's Name], dated 02/11/21, completed by the facility's contracted wound care physician and provided by the facility revealed . Chief Complaint . Recurrent Left small finger[LSF] pressure ulcer . LSF pressure ulcer where finger is pressed against the adjacent ring finger noted 11/08/ [11/08/20]. Had resolved after 2nd reccurence [sic] but reopened and worse this time. Appears maybe the thumb is reaching across and irritating this part of the finger. Has attempted splinting, dressings before and most have not stayed on well. This recurrence first noted 02/04 [02/04/21] .
Review of R1's Visit Report for [R1's Name], dated 03/16/21, completed by the facility's contracted wound care physician and provided by the facility revealed . Chief Complaint . Recurrent Left small finger pressure ulcer, wound L [left] thumb . Currently dressing order is foam. CMC [carpometacarpal] thumb brace caused a wound at the edge on the thumb, maybe from patient attempting to get the splint off-has been padded with moleskin. This wound is smaller, but now open, partial thickness-dressed with gauze today .
Review of R1's care plan titled, Resident Profile Report, reviewed on 07/02/24 and provided by the facility, revealed for the area of Restorative Therapy . I will not wear hand rolls, so they have been discontinued-please do ROM to my hands as I allow . The care plan also revealed for the area of Skin, I am at risk for impaired skin integrity due to immobility, incontinence, involuntary movements, and comorbidities that put my skin at risk for breakdown. Please check my skin daily with care and inform the nurse of any skin issues . There was not documented evidence of when the hand rolls were started, worn, or refused.
Review of R1's Wound Assessment Report, dated 07/10/24, provided by the facility and completed by the facility's contracted wound care revealed .Wound 1: Key Facts .Pressure Injury-Stage III [stage 3] .Onset date 07/10/24. Location .Hand, Left 5th digit [left pinky finger] .Status .Healed .Facility acquired-Yes. Wound 1: Assessment. Wound edge: attached. Peri-wound: Erythema, Fragile .Drainage: Minimum: Clear, thins, watery (serous) .Stage III [stage 3] .Wound 1: Images & Measurements. L x W x D [length by width by dept] 0.6 x 0.4 x 0.1 cm [centimeters] .Area 0.2 cm. Volume 0.0 cm. Color R [red]: 88%, Y [yellow] 11%, B [black]: 1% .
Review of R1's physician Order Sheet, dated 07/10/24 and provided by the facility revealed Wound Care TAR [treatment administration record] . Pressure ulcer, Little finger, Left, Other, BID [twice daily], Cleanse left little finger (5th digit) with wound cleanser. Apply zinc to 5th finger twice daily and PRN [as needed]. The order did not indicate if any dressing was to be applied.
Review of R1's skin assessment documentation titled, Flowsheet Print Request, dated 05/29/24 through 06/21/24 and provided by the facility revealed on 06/21/24 (date the resident was readmitted to the facility from the hospital) revealed . Skin Abnormalities General . none .
Review of R1's skin assessment documentation titled, Flowsheet Print Request, dated 06/28/24 through 07/10/24 and provided by the facility revealed on 06/28/24 . Skin Integrity General-intact . On 07/05/24, it was documented . Skin Integrity General- Localized abnormality . Skin Abnormalities General Comment-chafing palm of L [left] hand, erythema to buttock . There was no documented evidence of any skin abnormalities to the resident's left pinky finger.
Review of R1's would treatment documentation titled, Flowsheet Print Request, dated 06/21/24 through 07/10/24 revealed no documented evidence of any treatments order and/or completed to R1's left pinky finger.
Review of R1's active physician Orders, provided by the facility revealed a wound care order dated 06/21/24 of Wound Care TAR . erythema, Abdomen, Dry, BID Cleanse area around gtube with wound cleanser and pat dry. Apply calvida [used for wound treatment] and use t-drain sponge underneath g-tube. There was no documented evidence of any ordered treatments to R1's left pinky finger.
Observation and interview on 07/09/24 at 9:33 AM of R1 revealed she was lying in her bed, eyes open and just finished receiving a bolus tube feeding from Licensed Practical Nurse (LPN) 2. The resident had a dressing to her left hand. When asked about the dressing to R1's left hand, LPN2 stated the dressing was due to the resident's left hand being contracted and her nail digging into her skin causing a wound. There was no preventive device in place to the resident's left hand.
Observation on 07/09/24 at 11:25 AM revealed R1 lying in bed, eyes closed, with a dressing to her left hand, with no device in place in her left hand.
During an interview on 07/10/24 at 11:55 AM, when asked about the dressing that was applied to R1's left hand, the Director of Nursing (DON) stated the dressing to her left hand was typically applied for the resident's pressure injury. The DON stated the resident reopened it when she rubbed her finger against her thumb. When the DON was asked if she could provide any documented evidence where the facility had attempted interventions to prevent the pressure for reoccurring and/or worsening, the DON stated she would look for nursing documentation to show the resident was not compliant with the interventions attempted. The DON stated the facility had attempted everything they could think of to prevent the reopening of the pressure to the left pinky finger. When asked what interventions had been attempted, the DON stated they have tried hand rolls such as wash clothes, clear plastic device that sits in the palm (palm protector), and event tried covering the area with dressings; however, the resident would dig until she removed the covering.
During an interview on 07/10/24 at 1:35 PM, the DON stated she was unsure whether the pressure sore was on R1's left hand or her right hand. The DON stated they (facility) were still looking for documentation over the last few years of attempted and failed interventions to prevent the reopening and worsening of the pressure.
During a subsequent interview on 07/10/24 at 2:07 PM, the DON provided some documentation related to R1's noncompliance with preventative devices. The DON was again asked what the facility has done to prevent the worsening of R1's pressure ulcer on her left pinky finger from reopening and worsening. The DON stated the facility had attempted the use of a palm protector at one time (could not recall the timeframe); however, she did not know how long this was used or attempted to be used. The DON stated, whatever is in the [physician] orders, When asked if she could provide documented evidence where devices such as the palm protector were ordered and then discontinued, the DON stated, I don't know. I'll have to check the chart. The DON stated R1 was ordered the palm protector on 11/27/20 to her left hand at all times; however, there was no documented evidence the palm protector was being applied, no documented evidence of the resident's noncompliance, no TAR, and no documented evidence when the order was discontinued. When asked if there was any type of documented evidence such as at TAR or Certified Nursing Assistant (CNA) documentation of the attempted devices and of R1's noncompliance, the DON stated not every order for devices goes on a TAR.
During an observation with LPN2 on 07/10/24 at 2:30 PM, R1 was lying on her back with her head turned to the left, facing the wall behind her bed. R1's left hand was first observed under the flat sheet on her bed. The nurse lifted her hand from under the sheet, observed what appeared to be a blister that had popped on the palm side of her 5th finger (left pinky finger) and observed her thumb hitting this area. There was slight redness noted on her finger and around the popped blister area, which was an irregular circle shaped with no drainage, and clean edges. There was no dressing on the finger. LPN2 stated R1 has had the open area since she returned to the facility from her most recent hospital stay. When asked by the surveyor how the staff prevent the resident from digging her thumb into her skin, the nurse stated that they would roll her finger with gauzes and then rolled her hand with gauze to prevent the pressure from forming.
During an interview on 07/10/24 at 3:35 PM, LPN2 confirmed R1 had a dressing applied to her left hand on 07/09/24. LPN2 stated she did not remove R1's dressing to her left hand to look at (examine/assess) why the dressing was applied. LPN2 stated the dressing did not have a date it was applied and did not have any initials of who applied the dressing. LPN2 confirmed prior to this date (07/10/24) there was no physician order for a dressing to be applied to R1's left pinky.
During an interview on 07/10/24 at 3:37 PM, the Nurse Manager (NM) stated she was first notified this morning (07/10/24) R1's left pinky had reopened. The NM stated if the nursing staff was aware R1's left pinky finger had reopened yesterday (07/09/24), then she should have been notified of it yesterday. The NM verified there was no physician's order for any type of treatment or dressing yesterday. The NM verified the resident's physician was not notified yesterday and there should not have been any type of treatment or dressing applied to R1's pinky finger yesterday without an order from the physician.
During an interview on 07/10/24 at 3:55 PM, when asked about R1 having a treatment initiated and completed for a pressure injury to her left pinky finger without a physician's order, the Administrator stated it was her expectation the nursing staff would have followed the facility's policy. The Administrator stated it was her expectation the nursing staff would have followed the facility's policy related to notifying the physician when R1's pressure reopened.
During an interview on 07/10/24 at 4:02 PM, the DON stated it was her expectation the nursing staff would have followed the facility's polices related to R1's physician being notified and the treatment being started without a physician's order. (Cross reference F688)
Review of the facility's policy titled, Wounds: Treatment of Pressure and Non-Pressure Injuries, including Staging and Documentation, revised 10/2023 revealed Purpose: To provide guidelines for use in wound assessment, treatment, and documentation . It is the responsibility of the Director of Nursing to oversee this policy procedure. Policy: . A physician's order is required for ALL wound treatment . B. Assessment/Documentation: 1. Any wound is to be assessed by a licensed nurse or licensed practitioner. The location, stage, size, odor, undermining, tunneling, exudates, necrotic tissue, and presence of absence of granulation tissue, peri-wound and wound edge description should be noted and documented in the resident's medical record at least weekly. Wound assessment documentation should be completed for pressure injuries and recommended for any other skin issues of concern. a. Location: Describe the precise location of the wound in anatomical terms. b. Staging: (Pressure Injuries) . 3. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, red, moist, and may present as an intact or ruptured serum-filled blister . 4. Stage 3 Pressure Injury: Full thickness tissue loss. Full-thickness loss of skin in which adipose (fat) is visible in the ulcer granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . c. Size: Measure the wound in centimeters including the length, width, and depth. Measure wound from 'healed margins to healed margins' vs. 'edge to edge.' . d. Odor: Describe the odor of the wound as none, mild, or foul (after cleaning). e. Color: Describe the color of the involved area. Note options for documentation here include describing the wound bed (including granulation tissue, slough, or eschar) in terms of color such as pink, red, yellow, white, black, or brown and estimate percentage of colors. f. Surrounding Tissue (Periwound): Assess the surrounding tissue and document the involved areas i.e., inflammation, maceration, or wet wound edges, tenderness, warm or cool to touch, skin turgor, hypertrophic/callused/thickened, or any other finding. g. Drainage: Describe the type, amount, and color of the drainage (exudates). Examples: yellowish green, gray, serosanguinous, etc. - amount: zero, small, moderate, and large. h. Pain: Describe pain related to the wound and incorporate interventions to reduce pain in the care plan. Document interventions and outcomes in the medical record . C. Monitoring of Wounds: . When a wound is present monitoring should include the following: an evaluation of the injury if no dressing is present, an evaluation of the status of the dressing, if present (whether it is intact, if there is drainage, is it or is it not leaking) . All dressings will be dated and initialed by the nurse apply the dressing . F. Documentation. It is critical that all caregivers document their observations and activities. For example, CNAs are critical to the process by reporting abnormal skin observations, . Nurses also have a variety of documentation responsibilities as indicated throughout and are critical to the process of documenting interventions that have been taken to AVOID pressure injuries . 'Avoidable' means that the resident developed a pressure injury, and that the facility did not do one or more of the following: . Define and implement interventions consistent with recognized standard of practice. Monitor and evaluate the impact of the interventions. Revise the interventions as appropriate . Documentation is key to show that everything is being done to prevent those avoidable pressure injuries and heal pressure injuries .
Review of the facility's policy titled, Skin Integrity, Assessment and Prevention of Wounds/Other Skin Conditions, revised 09/2022 revealed, Purpose: To prevent avoidable skin breakdown and pressure injuries, provide guidelines for the treatment of impaired skin and guidelines for documentation . Responsibility: It is the responsibility of the Nurse Manager to oversee this policy . Policy: All resident's will be assessed for the risk of skin breakdown. Risk factors identified will be evaluated. Interventions will be developed and implemented to minimize or stabilize the risk. Interventions will be care planned. Practice: . II. Prevention. The following guidelines, which should be implemented based on medical history and physical assessment using an interdisciplinary team approach . Abnormal findings will be assessed by a licensed nurse and appropriate interventions and documentation completed by the nurse . 4. Pressure Reduction. Appropriate pressure reducing positioning devices should be used . Contact Rehabilitation Services for evaluation of seating and positioning devices and orthotic devices . E. All assessments, interventions, and outcomes must be documented in the medical record .
Review of the facility's policy titled, Condition Changes, Incidents, Injuries-Reporting of, revised 01/2023 revealed Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents . Responsibility: It will be the responsibility of the licensed nurses to know and follow this policy . When reporting changes in condition or incidents, the following procedure should be followed: 1. Evaluate symptoms and/or injury. Complete overall head to toe assessment . Document assessment and findings on SBAR [Situation, Background, Assessment, and Recommendation] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure safe water temperatures in residents' bathrooms/personal sinks were maintained for two of 23 sampled residents (Resident (R) 51 and R17). The residents' bathroom sink hot water temperatures were greater than 120 degrees Fahrenheit (F). This failure placed both residents at risk for skin irritation, redness, pain, and burns.
Findings include:
1. Review of R51's untitled and undated face sheet, provided by the facility, revealed the resident was most admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia.
Review of R51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/24, provided by the facility, revealed the facility assessed a Brief Interview of Mental Status (BIMS) score could not be obtained on the resident. The facility assessed R51 had short and long term memory problems, and was severely cognitively impaired when making decisions regarding tasks of daily life. The facility assessed the resident to need partial to moderate assistance for hygiene and could independently use her wheelchair.
During an interview on 07/07/24 at 12:33 PM, when asked if her water gets hot, R51 stated, Hot? It blows it out hot. R51 stated she independently used the sink to wash her hands. When asked what she did when the water temperature got hot, the resident stated she hurried up.
During an observation and interview on 07/07/24 at 1:12 PM, the Administrator in Training (AIT) took the water temperature and stated it was 130 degrees F.
During an interview on 07/07/24 at 5:48 PM, Licensed Practical Nurse (LPN) 3 stated R51 was able to get to the bathroom sink in her wheelchair independently. LPN3 stated R51 had the ability to turn the hot water on; however, she did not think she would have the cognitive ability to adjust the water temperature to a warm temperature.
During an interview on 07/07/24 at 6:00 PM, Certified Medication Tech (CMT) 2 stated R51 could make it to the bathroom sink independently and turn on the water. CMT1 stated the resident would not know how to turn on the water to adjust it to a warm temperature.
2. Review of R17 untitled and undated face sheet, provided by the facility, revealed the resident was most recently admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia.
Review of R17's quarterly MDS with an ARD of 06/19/24, provided by the facility, revealed the facility assessed the resident to have a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The facility assessed R17 needed partial to moderate assistance with hygiene, and independently used the wheelchair.
During an observation and interview on 07/07/24 at 1:11 PM, the AIT took the water temperature in R17's bathroom and confirmed the temperature was 128.1 degrees F.
During an interview on 07/07/24 at 5:48 PM, LPN3 stated R17 could get to the bathroom sink without assistance using her wheelchair. LPN3 stated the resident could turn the water on, and if it was too hot, she would pull her hand back; however, she would need someone to adjust the water temperature for her.
During an interview on 07/07/24 at 6:00 PM, CMT2 stated R17 had the ability to get to the sink independently in her wheelchair but she would not have the cognitive ability to adjust the water if it was too hot.
During an interview on 07/07/24 at 2:45 PM, the Administrator stated any water temperature above 120 degrees F was out of the regulatory range. When asked about the sink water temperatures that were above 120 degrees F, the Administrator stated it was important to get the temperatures down below the regulatory range for the safety of the residents. When asked what safety concerns there were for residents using sinks with water temperatures above 120 degrees F, the Administrator stated residents could receive skin injuries such as burns.
During an interview on 07/07/24 at 2:49 PM, the Maintenance Director stated he came in today and adjusted the water temperature coming from the hot water tank to the long term care (LTC) mixing valve from 130 degrees F to 117 degrees F. The Maintenance Director stated the hot water temperature of the residents' sinks should have been below 120 degrees F for the safety of the residents.
During an interview on 07/07/24 at 3:44 PM, when asked how the hot water temperature setting got to 130 degrees F, the Maintenance Director stated I don't know.
Review of the facility's water temperature logs for the past six months revealed no documented water temperatures of 120 degrees F.
Review of the facility's policy titled, Water Temperature Management, revised 07/2024 revealed . Purpose: To achieve the lowest potential for adverse impact of the safety and health of staff, residents, and visitors coming into the organization's facilities. Policy: The facility will insure [sic] that plumbing fixates that supply hot water and are accessible to the residents shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120 F) .

Based on interview and record review, the facility failed to follow their infection control policy when staff failed to complete the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for three employees. The census was 110 with 31 in state license beds.
Review of the facility's Tuberculosis Screening and Testing of Employees and Volunteers, dated May 2024, showed the following:
-Purpose: To establish guidelines for consistency in tuberculosis screening and testing for new employees and volunteers and annual testing and assessment for existing employees and volunteers.
-Scope: Level I policy affecting all employees and all volunteers who work ten or more hours weekly in long term care communities which includes skilled nursing.
-Responsibility: It is the responsibility of the Infection Preventionist/Employee Health Nurse or designee to perform annual health screenings.
-There was no documentation regarding an annual one step tuberculin skin tests (TST).
1. Review of Staff Member A's employee file, showed the following:
-Hire date: 1/22/2001;
-No documentation of an annual one step.
2. Review of Staff Member B's employee file, showed the following:
-Hire Date 3/21/2011;
-No documentation of an annual one step.
3. Review of Staff Member C's employee file, showed the following:
-Hire Date: 2/13/2023;
-No documentation of an annual one step.
4. During an interview on 7/15/24 at 12:51 P.M., the Director of Nursing (DON) said an annual health screening is completed for employees employed more than a year. The DON said this started in October, 2023. The corporate office changed the policy in line with the federal guideline. The DON said she did not know a one step was still required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the oxygen nasal canula was contained when not in use for 1 (Resident #41) of 2 sampled residents receiving oxygen therapy.
Findings included:
A review of a facility policy titled, Oxygen Administration, revised 02/2019, revealed, Purpose: To provide guidelines for oxygen administration. Policy: A physician order is required to administer oxygen. The order should include the administrative device, liter flow and the parameters for use. Practice: 1. Oxygen should be ordered by the physician. The order should indicate the administrative device, the liters per minute, frequency and indications for use.
A review of Resident #41's Resident Information document revealed the resident had diagnoses that included acute posthemorrhagic anemia (loss of a large amount of blood in a short period of time), dementia, and cerebral infarction (stroke).
A review of Resident #41's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment as evidenced by a Staff Assessment for Mental Status (SAMS).
On 10/31/2022 at 11:08 AM, Resident #41 was observed lying in bed on their right side with their eyes closed, receiving oxygen (O2) at 1.5 liters per minute (LPM) by nasal canula. The oxygen tubing was not dated.
On 10/31/2022 at 2:50 PM, Resident #41 was observed lying in bed on their left side with their eyes closed, receiving O2 at 1.5 LPM by nasal canula. The oxygen tubing was not dated.
On 11/01/2022 at 9:29 AM, Resident #41 was out of their room. The oxygen concentrator was against the wall next to the head of the bed, with the oxygen tubing draped over the top and back of the concentrator.
During an observation and an interview on 11/01/2022 at 1:22 PM, the DON accompanied the surveyor to Resident #41's room. The oxygen concentrator was against the wall, next to Resident #41's head of bed. The oxygen tubing was draped over the top and back of the concentrator and was not bagged or dated. The DON stated it was not the facility's policy to date the oxygen tubing. She indicated all of the oxygen tubing was changed monthly. She indicated the resident's oxygen tubing should be bagged when it was not in use and certainly should not be draped over the concentrator. She stated the resident's oxygen tubing needed to be changed at that time since it was contaminated and could cause a spread of infection if it was reused. She removed the tubing from the concentrator at that time.
During an interview on 11/01/2022 at 2:46 PM, LPN #3 stated Resident #41 started declining the previous week around Wednesday, and that was when they started applying oxygen for the resident's comfort. LPN #3 stated Resident #41 started bouncing back yesterday (10/31/2022) and had not needed oxygen since then. Last night one of the certified nursing assistants (CNAs) came to LPN #3 and asked if the resident needed their oxygen on. LPN #3 checked the resident's pulse oximetry, and it was 95% so she told the CNA that the resident did not need it. LPN #3 indicated that when her residents were not using their oxygen, she usually threw away the tubing, but stated it should at least be bagged when not in use and should never be tossed over the concentrator because it could cause a spread of an infection if reused.
During an interview on 11/02/2022 at 11:45 AM, the Administrator stated that she expected that any time a resident was not using their oxygen, the tubing should either be removed or bagged to eliminate the possibility of the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of a Resident Information document revealed no admission date was listed for Resident #36. The diagnoses included on the information sheet included stage four chronic kidney disease.
A review of a physician's order dated 07/29/2021 revealed Resident #36 was to be on a 1200 milliliter (mL) fluid restriction daily.
A review of an admission Minimum Data Set (MDS), dated [DATE], revealed the facility admitted Resident #36 to long-term care in the facility from the assisted living area within the facility on 08/31/2022 with a diagnosis of stage four chronic kidney disease with dialysis and congestive heart failure. The admission MDS noted Resident #36 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS revealed Resident #36 received renal dialysis.
A review of the care plan for Resident #36, with a reviewed date of 09/09/2022, revealed the resident was to receive a renal diet with a 1200 mL fluid restriction per each 24-hour period.
A review of a Dietary Progress Note, documented by the Registered Dietitian (RD) and dated 10/31/2022, revealed Resident #36 had no edema reported in the last 30 days and noted Resident #36 was on 1200 mL fluid restrictions per each 24-hour period. The note revealed Resident #36 had been educated on diet restrictions related to end stage renal disease but often ordered items not recommended for the diet prescribed.
A review of a flowsheet for Resident #36 for October 2022 revealed documentation that Resident #36 consumed over the 1200 mL fluid restriction for 11 of 31 days for the month.
During an observation and interview with Resident #36 on 10/31/2022 at 9:50 AM, Resident #36 had a full water pitcher with approximately 500 mL of water on an overbed table in their room. Resident #36 stated the dialysis center would tell the resident if the resident was drinking too much fluid.
During an interview with Certified Nursing Assistant (CNA) #2 on 11/03/2022 at 8:34 AM, the CNA stated she thought Resident #36 was on a fluid restriction due to the resident's dialysis but was not sure. CNA #2 stated Resident #36 had a water pitcher in the room but did not drink it. CNA #2 stated the fluid intake for Resident #36 was monitored by the CNAs according to how much fluid was on the meal tray. CNA #2 stated Resident #36 occasionally asked for a soda, and she would get it for Resident #36 and let the nurse know. CNA #2 stated Resident #36 was cognitively intact and did not drink a lot of fluids. CNA #2 then checked the CNA care guide and stated Resident #36 was not on a fluid restriction.
An interview on 11/03/2022 at 8:36 AM with Licensed Practical Nurse (LPN) #6 revealed that Resident #36 was not on a fluid restriction. LPN #6 stated if a resident had an order for fluid restrictions, dietary staff would notify a nurse and would not put a water pitcher in the resident's room. LPN #6 stated the CNAs documented a resident's fluid intake in the computer. LPN #6 looked in the chart for Resident #36 and stated there was no information regarding fluid restrictions for Resident #36.
In an interview on 11/03/2022 at 8:50 AM, the Dietary Manager (DM) stated Resident #36 was on fluid restrictions and received eight ounces of fluids each meal on the meal tray.
In an interview on 11/03/2022 at 8:55 AM, the RD stated Resident #36 was supposed to be on a 1200 mL fluid restriction, but Resident #36 usually asked for additional fluids. The RD provided a document titled Fluid Restriction Guidelines with the name of Resident #36 that identified a 1200 mL fluid restriction. The RD stated the sheet gave a breakdown of the amount of fluids the dietary department was supposed to put on the meal tray and the amount of fluid nursing was to provide for Resident #36. The document noted that dietary staff provided 240 mL of fluids on the meal tray for breakfast, lunch, and dinner. The document noted nursing staff provided 200 mL of fluids on day shift, 160 mL on evening shift, and 120 mL on night shift.
On 11/03/2022 at 9:20 AM, an interview with the Corporate Director of Clinical Informatics (CDCI) revealed when the CNAs pulled up a resident in the kiosk, the care plan for the resident was there for review.
On 11/03/2022 at 10:02 AM, the CDCI requested that CNA #2 look at Resident #36 in the kiosk. CNA #2 pulled up Resident #36 and replied there was no information regarding fluid restrictions for Resident #36. The CNA was viewing a section titled Activities of Daily Living. The CDCI asked CNA #2 to look under the section of Fluids and Snacks, and the care plan noted Resident #36 was on a 1200 mL fluid restriction.
In an interview on 11/03/2022 at 10:28 AM, LPN #6 stated if a resident had an order for fluid restrictions, dietary would give them a breakdown of fluids the nursing staff provided for the resident each shift and dietary staff would put the sheet at the nurses' station. LPN #6 stated the information would be on the shift report sheet. LPN #6 stated there was not a fluid breakdown sheet posted at the nurses' station and there was no information on the shift report regarding fluid restrictions for Resident #36.
In an interview on 11/03/2022 at 11:15 AM, LPN #6 stated she did not document the amount of fluids provided for Resident #36 with medications because she did not know Resident #36 was on fluid restrictions and indicated she did not know where the fluid intake should be documented. LPN #6 stated she did not know who monitored the 24-hour intake for Resident #36. LPN #6 stated she had removed the water pitcher from the room of Resident #36.
In an interview on 11/03/2022 at 11:25 AM, the Unit Manager stated the nurses could document on a fluid intake sheet in the software system, but the nurses did not document the amount of fluids consumed by a resident during the administration of medications. The Unit Manager stated the total 24-hour intake for Resident #36 was not totaled or monitored by any of the staff. The Unit Manager stated if a resident was on fluid restrictions, this would be documented on the shift report sheet for the resident, and the fluid restrictions of 1200 mL was on the shift report sheet for Resident #36.
In an interview on 11/03/2022 at 11:37 AM, the Director of Nursing (DON) stated if a resident was on fluid restrictions, dietary staff provided a document that listed the amount of fluids provided with meals, and the nurses would give 120 mL with each medication pass. Per the DON, the CNAs documented the resident's fluid intake in the software system. The DON stated Resident #36 was on fluid restrictions, so the staff knew to not give Resident #36 extra fluids. The DON stated if the physician wanted a resident on strict fluid restrictions, they would document the fluid intake on an intake and output sheet and ask the physician to write an order for strict fluid restrictions. The DON stated Resident #36 should not have a water pitcher in the room, but Resident #36 was non-compliant with their fluid restriction and would go to the kitchen and ask for a soda or get water from the sink in the bathroom.
In an interview on 11/03/2022 at 12:32 PM, the Administrator stated dietary would put a specified amount of fluids on the meal tray for Resident #36 and the nurses would give a specified amount of fluids to Resident #36 during medication pass. The Administrator stated the fluid restrictions for Resident #36 were on the care plan and on the shift report sheet, and LPN #6 and CNA #2 should have known. The Administrator stated Resident #36 had been educated on the importance of diet and fluid restrictions, but Resident #36 was still non-compliant.
Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to the transcription and following of physician's orders for 1 (Resident #11) of 6 residents reviewed for medication regimen review and related to following physician's orders regarding fluid restrictions for 1 (Resident #36) of 1 resident reviewed for dialysis.
Findings included:
A review of a facility policy titled, Bethesda Long Term Care Nursing Practices Policy and Procedure, updated 09/2022, specified It is the responsibility of the licensed nurse and the CMT [Certified Medication Technician] to understand and comply with this procedure, it is the responsibility of the Nurse Manager to maintain, enforce and monitor the procedure. The policy further indicated, Telephone and verbal orders should be documented in the resident's electronic medical record then read back to the ordering physician/independent practitioner for verification. There must be evidence of a diagnosis, condition or indication for use on the medical record for each medication ordered by the resident's licensed practitioner. The policy further instructed staff to check all orders for clarity and completeness.
1. A review of Resident #11's Resident Information revealed the facility admitted Resident #11 with diagnoses which included altered mental status, hyponatremia, and moderate protein and calorie malnutrition.
A review of an admission Minimum Data Set (MDS) assessment, dated 10/12/2022, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident required supportive to extensive assistance with activities of daily living (ADLs), had one pressure ulcer, one venous ulcer, and required no other skin treatments.
A review of Resident #11's Care Plan, updated 10/14/2022, revealed interventions related to the resident's skin condition that directed staff to check the resident's skin daily with care, to notify the nurse of any new areas of redness and/or impairment, and to provide treatments as ordered by the physician.
A review of a physician's order, dated 10/26/2022, revealed an order for triamcinolone 0.1% topical cream (a steroid cream used for skin rashes) for dermatitis twice a day.
A review of a pharmacy Shipment Summary dated 10/26/2022, revealed one tube of triamcinolone cream 1% was delivered on 10/27/2022.
On 10/31/2022 at 10:11 AM, observations of Resident #11 revealed the resident was in a wheelchair in their room. During an interview at that time the resident stated they had a rash on their right arm that had been there for four days and voiced concern that nothing had been done about the rash. A red spotted area was observed on the resident's right forearm.
During an interview on 11/02/2022 at 8:14 AM, Certified Nursing Assistant (CNA) #1 stated Resident #11 had noticed a rash, which was noticed the prior Wednesday (10/26/2022). CNA #1 was unsure if the resident was being treated for the rash.
During an interview on 11/02/2022 at 9:38 AM, Resident #11 reported the nurses had not treated the resident's arm with medication.
During an interview on 11/02/2022 at 9:59 AM, the Nurse Practitioner (NP) stated Resident #11 was seen twice a week by the NP and additionally twice a week by the physician. The NP stated Resident #11 had not had a rash until 10/25/2022, after returning to the facility with family, and a prescription was written on 10/26/2022 for triamcinolone cream. The NP stated the resident had voiced concerns about not getting medication for the rash.
During an interview on 11/02/2022 at 1:38 PM, Licensed Practical Nurse (LPN) #3 reviewed the Treatment Administration Record (TAR) and reported that, according to the TAR, the resident had been receiving the treatments with triamcinolone. LPN #3 retrieved an unopened box from the medication cart with a label containing Resident #11's name and instructions to apply the triamcinolone cream 1% twice a day. Upon opening the box, it was observed the tube of the medication was sealed and unopened.
During an interview on 11/02/2022 at 2:10 PM, the NP reported a nurse called on the night of 11/01/2022 and reported the rash was worse so an order to hold the triamcinolone was given to the nurse.
A review of the medical record revealed no evidence of an order to hold or discontinue the triamcinolone cream.
During a follow-up interview with the NP on 11/02/2022 at 3:07 PM, the NP was able to show notes from the communication system on a cellular phone, and it revealed a telephone order was given to Registered Nurse (RN) #1 to discontinue the triamcinolone cream on 11/01/2022 at 10:48 PM. The NP stated the triamcinolone cream would be prescribed again after an examination of Resident #11.
During an interview on 11/02/2022 at 3:16 PM, the Director of Nursing (DON) demonstrated that if an order was discontinued, it would show a grey area on the resident's medication records. There were no orders entered to discontinue the triamcinolone cream for Resident #11. The DON provided the MAR for Resident #11, and the MAR revealed on 11/02/2022 at 8:39 AM there was documentation the triamcinolone cream had been applied by LPN #5.
During an interview on 11/02/2022 at 4:49 PM, RN #1 reported they called the NP regarding the fact that Resident #11's rash had become worse, but had not received any orders to discontinue any medications. RN #1 stated there was a tube of triamcinolone cream in Resident #11's room and that she applied the medication to the resident.
During an interview on 11/03/2022 at 9:34 AM, the DON identified an expectation for nurses to follow provider orders.
During an interview on 11/03/2022 at 10:48 AM, the Administrator identified an expectation for nursing staff to follow orders and policy and procedures.

Based on observation, interview and record review, the facility failed to ensure services provided or arranged by the facility, meet professional standards of quality by failing to clarify medication orders, for one of 18 sampled residents (Resident #191). The census was 137 with 99 in certified beds.
Review of Resident #191's care plan, dated 9/20/19, showed:
-Resident admitted for rehabilitation services following a hospitalization. Diagnoses included stroke, left sided weakness. Resident takes significant medication to help prevent blood clots which may cause bruising, or to bleed more easily. Please tell the nurse if you see any bruising or active bleeding. If resident complains of light headedness, or dizziness or appears to be light headed, or dizzy please tell the nurse.
Review of the resident's physician orders sheet, showed an order dated 9/19/19 for Hydralazine (used to treat high blood pressure), 25 milligrams (mg), every 6 hours. Next to the order a note, *At home, patient was taking the medication with the following details: Special instructions, hold if systolic blood pressure (the top number; refers to the amount of pressure in the arteries during the contraction of the heart muscles) is less than 140. No clarification if the medication is to continue to be held if less than 140 during the stay at the facility.
Review of the resident's medication administration record, showed Hydralazine 25 mg every 6 hours, administered on the following dates and times:
-On 9/20/19 at 6:00 A.M, 11:52 A.M., and 6:55 P.M.;
-On 9/21/19 at 12:00 A.M., 5:45 A.M., 11:51 A.M, and 6:00 P.M.;
-On 9/22/19 at 12:00 A.M., 5:08 A.M., 11:30 P.M, and 6:59 P.M.;
-On 9/23/19 at 12:30 A.M., 6:44 A.M, 12:08 P.M., 5:53 P.M., and 11:46 P.M.
Review of the resident's vital sign record, showed:
-On 9/20/19 at 9:51 A.M., blood pressure documented as 137/67;
-On 9/21/19 at 10:54 P.M., blood pressure documented as 128/61;
-On 9/22/19 at 2:48 P.M, blood pressure documented as 117/66;
-On 9/23/19 at 10:00 A.M., blood pressure documented as 94/53;
-On 9/24/19 at 9:56 A.M., blood pressure documented as 114/52.
During an interview on 9/24/19 at 12:00 P.M., Licensed Practical Nurse (LPN) R said the parameters were the ones the resident used at home. The orders should have been clarified upon admission. Upon reviewing the admission orders in the hard chart, the order showed to hold if systolic BP is less than 140. This should not have been added as a note, it should have been included in the order. During the interview the physician called and the nurse said the surveyor is asking about the resident's Hydralazine parameters. The physician then provided an order to hold if systolic blood pressure is less than 100.
During an interview on 9/25/19 at 9:37 A.M., the Director of Nursing said the staff should follow physician orders and the facility policy regarding medication administration.

Based on interview and record review, the facility staff failed to complete a comprehensive discharge summary for one of three closed record sampled residents (Resident #86). The census was 137 with 99 in certified beds.
Review of Resident #86's closed medical record, showed the resident discharged to the community on 6/22/19. Staff did not complete a discharge summary, which would include a final summary of the resident's status, a reconciliation of all pre and post discharge medications and a post-discharge plan of care.
During interviews on 9/24/19 at 6:37 P.M. and 9/25/19 at 9:37 A.M., the Director of Nursing (DON) said there is not a nursing discharge summary in the resident's file. It is the nurse's responsibility to ensure that the discharge packet is completed. After the nurse gives the information to the resident and places it in the chart, medical records then reviews it to ensure that it is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to follow the perineal care (cleansing from the front of the hips, between the legs and buttocks) policy and ensure appropriate perineal care was provided for two of three observations (Residents #6 and #42). The census was 137 with 99 in certified beds.
Review of the facility's perineal care policy, revised 11/2017, showed:
-Purpose: To provide guidelines for performing perineal care;
-Responsibility: it is the responsibility of all nursing staff to follow this policy;
-Policy: Perineal care is to be done at least daily and as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum (groin) to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene;
-Perineal care: always work from the dirtiest to the cleanest area or front to back. To prevent the spread of fecal matter into the genital area. A new area of the washcloth should be used for each wipe. Always pat the area dry, do not scrub the skin.
-Female perineal care: Gently cleanse the inner legs and outer groin area, spread the groin tissue and clean the internal groin fold cleansing in a front to back motion. Dry the skin with a clean towel;
-Male perineal care: Perineal care should be performed from the genitals and cleanse toward the anal area. A separate washcloth should be used each time. Cleanse other skin between the legs working from a clean to dirty area. Pat the area dry.
1. Review of Resident #6's Significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/19, showed:
-Cognitively intact;
-Total staff dependence for toileting and hygiene;
-Always incontinent of bowel and bladder;
-Diagnoses included: arthritis, seizure disorder and urine retention.
Review of the resident's care plan, updated 9/18/19, showed:
-He/she is incontinent of bowel and bladder and uses incontinence products. Keep him/her clean, dry and odor free.
During an observation and interview on 9/20/19 at 9:24 AM, Certified Nurse Aide (CNA) L entered the resident's room, explained care, washed his/her hands and applied gloves. He/she removed the covers and unfastened the urine saturated brief. He/she lowered the brief and exposed the front of the groin. CNA L applied perineal care body wash on a moistened washcloth. He/she cleaned all areas of the genitals using the same section of the wash cloth. He/she disposed of the wash cloth, sanitized hands and reapplied gloves. CNA L obtained a moistened wash cloth, applied perineal care body wash, assisted the resident onto his/her side, and exposed the buttocks. CNA L used the wash cloth and cleaned the anal area in a back and forth motion. He/she did not clean the buttocks. CNA L removed his/her gloves, sanitized hands, reapplied gloves and applied barrier cream to buttocks and posterior thighs. CNA L said he/she did not realize he/she did not change areas of the washcloth or get a clean washcloth for the cleansing of the different areas of the genitals. He/she had forgotten to cleanse the buttocks of urine.
2. Review of Resident #42's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Total staff dependence for all care needs;
-Always incontinent of bowel and bladder;
-Diagnosis included: quadriplegia (paralysis in all four limbs) and seizure disorder.
Review of the resident's care plan, dated 7/17/19, showed:
-Incontinent of bowel and bladder. He/she wears briefs, change him/her routinely and he/she is unable to verbalize his/her needs.
During an observation on 9/20/19 at 9:08 A.M., CNA M entered the room, washed hands, applied gloves and explained care to the resident. CNA M unfastened a urine saturated brief and tucked the brief under the resident's hip, then turned the resident over onto his/her side. He/she exposed the buttocks and then assisted the resident onto his/her back. CNA M obtained a soapy washcloth and wiped the front groin in a downward motion. He/she did not separate the groin skin folds and clean the inner skin folds. CNA M removed his/her gloves, washed hands and applied gloves. He/she assisted the resident on to his/her side and exposed the buttocks. A scant amount of stool noted on the pull sheet under the resident. CNA M obtained a wash cloth from the soapy basin and wiped in between the buttocks in back and forth motion and did not change areas of the wash cloth. He/she used the same wash cloth and wiped up toward the groin in a back and forth motion. He/she disposed of the washcloth and obtained another wash cloth and wiped the anal area in a back and forth motion.
3. During an interview 9/24/19 at 1:01 P.M., the Director of Nursing said that buttocks and hips should be cleaned during perineal care. Staff should follow the facility's perineal care policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident received treatment and care in accordance with professional standards of practice when the facility failed to ensure the resident's physician's order for a hospice consult was followed timely (Resident #85). In addition, incorrect information regarding the resident being a ward of the state provided to the hospice company resulted in the resident's hospice consult being declined. The facility failed to clarify the error with the hospice company. This resulted in the resident not receiving hospice services, which are services provided above and beyond the services provided by the facility, to include additional care aides and nurses, chaplain services and bereavement services for the family for a year after the resident passes. The facility census was 137 with 99 residents in certified beds.
Review of the facility's Resident Handbook, revised [DATE], showed the following:
-Surrogate: A person identified from the Missouri statutes to make decisions regarding medical treatment for a resident who lacks decisional capacity, who has a qualifying condition and who does not have an Advance Directive in effect. The facility recognizes the following order of authority: legal representative, spouse, adult children, parents, adult brothers/sisters, grandparents, adult grandchildren and guardian of the estate.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:
-Moderate cognitive impairment;
-No behaviors;
-Total dependence on two staff for transfers and moving on/off the toilet;
-Assistance of one staff for bed mobility, dressing and personal hygiene;
-Diagnoses included high blood pressure, diabetes, dementia, seizure disorder and depression.
Review of the resident's face sheet, showed:
-An admission date of [DATE];
-Emergency contact, Family Member B;
-Financially responsible, Family Member B.
Review of the resident's social service notes, showed:
-On [DATE], Family Member B contacted social services and reported Family Member A, passed away last week. Family Member A was the financial power of attorney (FPOA) and responsible party for the resident. Family Member B was requesting to become power of attorney (POA). Social services reviewed resident FPOA in chart and there was no second agent listed. Social services discussed with social services supervisor. Social services contacted Family Member B and notified him/her due to the resident's capacity and was unable to make decisions. He/she would need to pursue guardianship. Social services noted he/she had resources available regarding guardianship. Family Member B stated he/she believes the resident can make that decision. After discussing with the charge nurse and nurse manager, social services informed Family Member B that psych can complete an evaluation with the resident for capacity/ability to complete a POA. Family Member B aware and agreeable to psych consult. Family Member requested to be present for psych visit. Social services to follow.
Review of the resident's psychiatric care and wellness assessment, dated [DATE], showed the resident seen at staff request. Family needs to appoint a new POA and wonders if the resident has the capacity to do so. On exam, the resident is pleasantly confused. No agitation or depression. Only oriented to self. Clearly does not understand the meaning of a POA or guardian, does not have the capacity to appoint a POA.
Further review of the resident's social services notes, showed:
-On [DATE], Social services follow up after Psych saw resident. Social services provided resources to Family Member about guardianship. Family Member plans to review documents and follow up with social services;
-On [DATE], annual MDS completed, resident was laying down due to not feeling well. Resident seemed to have some confusion during assessment. Resident reported he/she just feels like she doesn't know what to do with him/herself. Family Member is involved in resident's care;
-On [DATE], Family Member B notified social services he/she no longer plans to pursue guardianship due to costs. Social services to follow.
Review of the resident's physician's orders, dated [DATE], showed an order for a hospice consult.
Review of the resident's nurse's notes, showed:
-On [DATE] at 2:24 P.M., the resident is having some episodes of lethargy. No appetite for breakfast and lunch. Resident is up in wheelchair at the dining room table for meals. This nurse attempted to assist resident with eating and resident did not respond. Resident had head in his/her hands. When questioning resident if he/she was having any pain, he/she would look up at this nurse and did not respond and placed his/her head back in his/her hands. Staff placed resident in his/her bed. Took morning medication. Refused to drink. Skin color pale, warm to touch. Not responding to verbal commands. Call placed to physician, waiting on call back. Spoke with Family Member B and informed him/her about the resident's change in condition, said he/she was on his/her way;
-On [DATE] at 9:49 P.M., the physician returned the call around 4:00 P.M., gave an order for a Hospice Evaluation. Family Member B was here at the time, informed him/her of the doctor order;
-On [DATE] at 9:59 P.M., resident in bed this shift, lethargic at times. Family here visiting;
-On [DATE] at 11:15 A.M., resident continues to be lethargic at times, refused to open eyes or acknowledge staff at breakfast, refused to take all medications. Family aware of condition, per supervisor, family discussing hospice;
-On [DATE], resident in bed, requesting fluids, alert and talking, Family Member visiting;
-On [DATE], resident moaning out in pain this morning. Resident was seen pulling oxygen nasal cannula off. Resident moaned in excess pain while he/she was getting out of bed. Tylenol, as needed (PRN) given with some effectiveness. Noticed hospice consult was ordered on [DATE], but he/she has not been admitted . Called Hospice to see if he/she was evaluated and what the status was. Registered nurse (RN) not aware of consult order. RN came in to see resident at 1:15 P.M. During this time, resident's breathing pattern changed to cheyn stoke (abnormal breathing pattern). Hospice RN called the physician for comfort mediations. This nurse called Family Member B to make sure hospice was the route he/she wanted to go and he/she said yes. While RN was speaking with the physician, he/she was informed the resident is a ward of the state, so his/her Family Member cannot sign hospice papers;
-On [DATE], resident unresponsive, not breathing and no pulse. Called Family Member B and made aware of resident's death. Call placed again to Family Member B to see what time he/she will be coming in to see resident and the funeral home the resident will be sent to. Family Member B said the preferred funeral home. Family Member B here.
Review of the resident's medical record, showed no documentation the resident was a ward of the state.
During an interview on [DATE], the Social Services supervisor said Family Member B was on the consent and disclosure form and he/she did attend care plan meetings. On [DATE], the resident did not have a state appointed guardian and no attempt had been made through the facility attorney for guardianship. With a consult order, the first step is to call the family and make them aware of the order. Next to call hospice, then fax the order and face sheet to hospice. The facility did not fax the information.
During an interview on [DATE], the hospice administrative secretary said they never received any documentation regarding the resident and the next of kin (NOK) would have been able to sign the hospice agreement.
Review of the resident's medical examiner death certificate, showed pronounced dead on [DATE] at 8:25 A.M. Is patient enrolled in a Hospice program: No.
During an interview on [DATE] at 5:54 P.M., when the surveyor inquired about the resident's hospice consult order, the administrator said the resident was a ward of the state and the hospice agreement could not be signed. She said the resident's Family Member was incompetent. When asked who deemed the Family Member incompetent, the administrator said he/she wasn't incompetent, he/she was nervous and did not want to make those decisions.
During an interview on [DATE] at 10:30 A.M., Family Member B said following his call to Social Services inquiring about taking over POA, nothing happened. He/she did not have a lot of money and after visiting with an attorney, he/she decided he/she could not afford to go through the court system to become POA. The facility took over POA once Family Member A died. The facility took complete control over the resident and he/she had no control over any decisions. He/she was the resident's last remaining relative. He/she was not aware the resident was not on hospice. He/she wanted hospice services provided for him/her. During the resident's final days, he/she was in and out of consciousness and in a lot of pain. All he/she could do was pray the Lord would take the resident.
During an interview on [DATE] at 3:48 P.M., the administrator said she did not say the resident was a ward of the state. If the resident was a ward of the state, there would be documentation in the hard chart and business office. Regarding the hospice consult order, social services said the facility did not have a guardian who could fill out the paperwork. She would have expected the physician's order to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure safety in the outdoor courtyard for one resident (Resident #235) with a history of falls when the ground next to the pathway to the courtyard had washed away, leaving an approximate 5 inch drop to the ground from the pathway. The resident self-propelled in a wheelchair to the courtyard and the wheelchair tipped off the side of the pathway. This failure resulted a serious injury of three fractured ribs and required the resident to be sent to the hospital. In addition, the facility failed to follow their transfer policy for one resident that was transferred in a Hoyer lift (mechanical lift) without the required two person assistance (Resident #26). The census was 137 with 99 residents in certified beds.
1. Review of the facility's fall management and reduction program policy, revised 3/2019, showed:
-Purpose: To provide guidelines to manage and attempt to reduce the incidence of resident falls;
-Responsibility: It is the responsibility of all staff to know and follow this policy;
-Policy: All residents admitted will be assessed upon admission, quarterly and as needed for fall risk using the MORSE fall risk scale (method of assessing a resident's risk of falling). Appropriate safety interventions, including potentially being placed in a fall reduction program, will be implemented. A fall interdisciplinary team (IDT) will consist of nursing, therapy and other disciplines as appropriate. This team will meet at least weekly to review and make appropriate recommendations for residents who have fallen;
-Practice: Upon admission to the facility, all residents will be assessed using the MORSE fall risk scale;
-At a score above 45, the resident is identified at a high risk of falls. A fall reduction program will be initiated;
-If at any time the MORSE fall risk assessment receives a total score above 45 and the resident is not already in the fall prevention/reduction program, the nurse will place the resident in the program and update the care plan;
-The fall management/reduction program (a score above 45) requires the following:
-To alert staff to the increased fall risk by communicating in shift reports and in the care plan. It is also identified in the resident's electronic record denoting high fall risk status. Other safety interventions specific to the individual resident will be implemented as deemed appropriate by the nurse or supervisor and added to the care plan.
Review of Resident #235's medical record, showed:
-admitted on [DATE];
-Diagnoses included: End stage kidney disease, history of syncope (fainting) and collapse.
Review of the resident's admission nursing flowsheet, showed:
-On 9/21/19 at 4:48 P.M.: The resident is a new admission and medications were verified;
-Transfer assistance: Partial/moderate assistance;
-Used a manual wheelchair;
-Ability to wheel 50 to 150 feet with two turns: substantial/maximal assistance;
-Barriers to learning: cognitive deficits, memory problems;
-General symptoms: confusion, disorientation, edema (swelling), faintness and weakness;
-Neurological symptoms: faintness, memory problems;
-Makes self-understood and understands others;
-Tremors (shaking): yes;
-General safety measures: frequent checks on rounds;
-Fall in the last three months: yes, presence of a secondary diagnosis;
-Gait weak or impaired fall risk: impaired;
-Mental status MORSE: forgets limitations;
-MORSE fall risk score: 75;
-Participative in fall prevention: yes;
-Behaviors exhibited: calm and impulsive;
-Orientation assessment: Orientated times four;
-Assistive device: wheelchair;
-Locomotion on unit and support provided: total dependence of one person physical assist;
-Elopement or wandering: no;
-Short term memory: impaired;
-Precautions observed: bleeding, fall risk, transfer and mobility.
Review of the resident's admission physician order sheet, showed:
-An order dated 9/21/19 at 5:37 P.M., for fall risk precautions, constant order. The resident is a high fall risk, keep the bed in the lowest position when in bed and the bed against the wall per resident's spouse.
Review of the resident's completed nursing Morse Fall Scale assessments, showed:
-On 9/21/19 at 6:54 P.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations.
Further review of the resident's nursing flow sheet assessments, dated 9/21/19 at 9:00 P.M. into 9/22/19, showed:
-Behaviors exhibited: agitated, impulsive, irritable, refused care and uncooperative;
-Verbally aggressive description: cursing;
-Interventions used after behavior: comfort and compassion, constant monitoring, toileting;
-Impact on behavior on the resident: significantly interferes with the resident's care;
-Resident used wheelchair: yes;
-Wheel 50-150 feet: independent;
-Gait weak or impaired fall risk MORSE: impaired;
-Mental status fall risk MORSE: forget limitations;
-MORSE fall risk score: 75;
-Date, time of fall: 9/22/19 at 3:15 P.M;
-Fall witness: unwitnessed;
-Interventions in place to prevent falls: adequate lighting, attendance while in bathroom, frequent observations;
-Injury: bruise and no treatment needed;
-Location of fall: resident's bathroom;
-Description of fall: unknown, found on the floor. Physician notified and no new orders. Family notified;
-Neurological symptoms: memory problems;
-Gait: unsteady.
Review of the resident's completed nursing Morse Fall scale assessments, showed:
-On 9/22/19 at 3:15 P.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations.
Review of the admission baseline care plan, updated on 9/22/19, showed:
-Activities of Daily Living (ADL, are routine daily care tasks or activities): The resident is on fall precautions. He/she is at the facility for physical and occupational therapy. He/she requires assistance with ADLs. Staff to encourage the resident to do as much as possible for himself/herself and encourage him/her to call for assistance as needed;
-Goal: To return to pre-hospital level of independence of ADL capacity. The resident can self-propel in his/her wheel chair throughout the facility;
-General information: The resident has diagnoses of end stage renal disease and syncope. He/she is alert and oriented times four and able to make needs known. He/she is on fall precautions. He/she has behaviors of impulsiveness and noncompliance, staff to remind him/her to ask for assistance for transfers as needed.
Further review of the resident's completed nursing Morse Fall scale assessments, showed:
-On 9/23/19 at 2:00 A.M., the resident scored a 75 (high fall risk), had a history of falls in the last three months, had a secondary diagnosis, no use of ambulatory aid and used bed rest, had an impaired weak gait or impaired fall risk and mental status or forgetting limitations.
Further review of the resident's nursing admission flow sheet, dated 9/23/19 at 2:00 A.M., through 4:52 P.M., showed:
-Neurological symptoms: memory problems;
-General safety measures: frequent checks on rounds;
-History of fall in the last three months: yes;
-Use of ambulatory aid MORSE: none, bed rest, wheelchair or nurse;
-Gait weak or impaired: impaired;
-Mental status fall risk MORSE: impaired and forgets limitations;
-MORSE fall risk score: 75;
-Locomotion on the unit: independent.
Further review of the resident's nursing admission flow sheet, dated 9/24/19 at 1:56 A.M., through 12:28 P.M., showed:
-Neurological symptoms: none;
-Orientation assessment: orientated x four;
-Gait: unsteady.
Observation on 9/24/19 at 10:50 A.M., showed the resident lay on the ground in the landscaping outside the rehab unit leading into the courtyard. Multiple staff present and provided assessment of the resident. The resident told staff he/she had propelled himself/herself out of the rehabilitation unit doorway into the courtyard. The front wheels of his/her wheelchair caught the edge of the concrete pad and he/she tipped forward out of the wheelchair, fell and hit the pipe that protruded out of the ground. He/she did not hit his/her head. He/she heard a loud pop when he/she fell onto the pipe and his/her left lower rib area hurt. Staff called emergency services. During an observation and interview at 10:52 A.M., the facility onsite physician responded to assess the resident. The physician stated the resident had marks, bruising and pain from hitting the pipe. The resident did not hit his/her head and the facility had called emergency services.
During an interview on 9/24/19 at 10:55 A.M., Certified Occupational Therapy Assistant (COTA) C said he/she had been sitting at a table outside in the courtyard working with another resident and heard someone yell out. He/she looked up and saw the resident lying down on his/her side on the ground and the wheelchair lying on top of the resident. He/she ran over to the resident and pulled the wheelchair off of him/her. The physical therapist walked outside and COTA C told him/her to go get help, while he/she remained with the resident until nurses arrived.
During an observation and interview on 9/24/19 at 11:00 A.M., emergency services arrived on scene and provided care to the resident. The resident noted to voice pain to the area of his/her left lower ribs. Maintenance supervisor D said the depth of the concrete pad from the top of the pad to the ground was five inches, the area where the resident fell had a sprinkler head and the dirt had been washed out. During an interview at 11:45 A.M., the maintenance supervisor said he had called the groundskeeper and dirt would be added to the area to back fill in the low spot. He did not know how long the low spot had been like that, the area could have been like that for six months or a year. The sprinkler maybe causing the dirt to wash out. At 12:02 P.M., the maintenance supervisor added the vent pipe the resident fell onto measured 7 3/4 inches from the top of the pipe to the ground.
During an interview on 9/24/19 at 1:40 P.M., the Director of Nursing (DON) said the emergency room had called and notified the facility the resident had fractured some of his/her ribs. The facility would be starting an investigation.
During an interview on 9/24/19 at 1:49 P.M., the hospital emergency room (ER) registered nurse (RN) called and informed the surveyor the resident had fractured his/her left 6th, 7th and 8th ribs. The resident had experienced a lot of pain and the ER. RN had administered morphine (narcotic pain medication) to control the resident's pain. The hospital will be conducting further scans.
Observation of the courtyard on 9/24/19 at 2:50 P.M., showed the area where the fall had occurred, showed no changes or improvements. No safety precautions noted in place.
Review of the resident's emergency room visit and assessment notes, dated 9/24/19 at 11:36 A.M., showed:
-Subjective: The patient presents to the emergency room from a fall at 11:00 earlier today. The patient was in his/her wheelchair when a wheel fell off the sidewalk and the wheelchair fell over and he/she impaled himself/herself onto a PVC pipe. The patient complains of rib pain. He/she is in a wheelchair due to weakness in his/her legs after last hospital admission;
-Review of skin: Abrasions to the left flank (side) and left medial (middle) ecchymosis (bruising);
-Radiology impression: Fractures of the left sixth, seventh and eighth ribs with minimal displacement;
-Summary statement: Discharge with oral Dilaudid (narcotic pain medication) and Lidocaine (pain medication) patches.
Review of the resident's readmission nurse note, dated 9/24/19 at 10:29 P.M., showed the resident readmitted into the facility. Diagnosis of rib fracture related to fall in the yard out of his/her wheelchair. Instructed to splint his/her chest with a pillow in order to take deep breaths with the least amount of pain. Educated the resident and spouse regarding risk of pneumonia if unable to deep breathe. Physician onsite with the resident and discussed future care with the resident and spouse. New orders for Dilaudid and pain patch. The resident rates pain a 10 out of 10 (0 indicated no pain and 10 indicated the worse pain imaginable). Pain medications given. The resident unable to sit up and must keep the head of the bed low. He/she had to eat dinner with the head of the bed low and cannot tolerate the head of the bed being elevated.
Review of the resident's readmission physician progress note, dated 9/24/19, showed:
-History and physical: admitted for fall, near syncope and passing out. Recent fall and broke three ribs;
-Past medical history: stroke, irregular heartbeat, diabetic neuropathy (loss of sensation in fingers and feet) and kidney failure;
-Neuro: Alert and orientated times one;
-Plan: Rib fractures pain management.
Review of the resident's readmission nursing assessment pain flow sheet, showed:
-On 9/24/19 at 8:28 P.M., a pain rated 10, or the worst pain possible in the chest. Pain medication given. At 3:00 A.M., no pain noted;
-On 9/25/19 at 5:10 A.M., and 6:02 A.M., a pain rated 10. Medication administered and effective.
Review of the resident's physician order sheet (POS), reviewed on 9/25/19 at 7:57 A.M., showed:
-An order for Lidocaine 4 percent (%) patch- apply daily for chest pain;
-Hydromorphone (Dilaudid) 2 milligram (mg) every four hours as needed for severe pain, administered on 9/24/19 at 8:28 P.M., with a pain 10/10, administered 9/25/19 at 5:10 A.M. with a 10/10 pain scale.
Observations on 9/25/19, showed:
-At 8:25 A.M., the resident sat in his/her wheelchair in the dining room for breakfast. He/she talked to other residents and noted to brace his/her left arm against his/her left side. He/she appeared pale and slow to move in his/her wheelchair;
-At 8:28 A.M. and 9:32 A.M., no dirt, rock or material had been placed in the area of the courtyard where the resident fell.
During an interview on 9/25/19 at 9:37 A.M., the therapy program director said the resident had been admitted to the facility the weekend before. He/she received the initial therapy evaluation on Sunday and had been noted to have impaired cognition by the occupational therapist. The physical therapy assistant saw the resident on 9/25/19 in the morning, however the resident did not perform much of the session related to his/her pain and the therapy session stopped.
During an interview on 9/25/19 at 10:15 A.M., Certified Nurse Aide (CNA) F said he/she had taken care of the resident on the day of his/her fall, on 9/24/19 and had also cared for him/her the morning of 9/25/19. On the morning of 9/24/19 the resident did not want to get up and had slept in, and ate a late breakfast while in bed. CNA F felt the resident had been confused and after the resident ate, he/she assisted the resident out of the bed and into the bathroom. When the resident had finished in the bathroom, he/she assisted him/her to get dressed and into the wheelchair. The resident seemed slightly confused at times and unsteady during the transfers from the bed and in the bathroom. The resident appeared comfortable and wanted to remain in his/her room. A facility housekeeper began to clean the resident's room and was talking to the resident. CNA F reported to the resident's nurse he/she was going to lunch break and the resident was in his/her room. While he/she was on break, staff reported that a resident had fallen in the courtyard.
Observation of the courtyard on 9/25/19 at 11:04 A.M., showed no dirt, rock or safety markers in place.
During an interview on 9/25/19 at 12:40 P.M., Licensed Practical Nurse (LPN) G said the courtyard is used by the facility rehabilitation residents. The area is usually used by residents who are alert and orientated. Nursing staff usually use the courtyard as a walk through as it connects different areas of the rehab hallways. At times, physical therapy staff will work with a resident out in the courtyard. Nursing staff do not monitor which residents use the courtyard. Staff know if a resident is out in the courtyard by seeing them through the windows or hearing the doors close. There are no alarms on the doors to the courtyard. The courtyard is in disrepair.
During an interview on 9/25/19 at 1:32 P.M., RN H said that he/she had not been told or in-serviced on additional safety precautions regarding the courtyard since the resident had fallen on 9/24/19.
During an interview on 9/25/19 at 1:42 P.M., Housekeeper I said he/she entered the resident's room on 9/24/19 and started to clean the room. The resident had told him/her that he/she wanted to go outside and he/she liked to be outside. Housekeeper I told the resident he/she needed to let someone know he/she wanted to go outside. The resident told housekeeper I that he/she did not need to tell anyone, and the resident propelled himself/herself out of the room. Housekeeper I did not tell nursing staff of the resident's desire to go outside. Housekeeper I continued to clean the resident's room, and looked out the resident's window that faced the courtyard and noted the resident coming out of the facility door into the courtyard. He/she assumed a staff member had let the resident out of the door. A few minutes later, he/she looked out the window again and observed the resident on the ground next to the concrete sidewalk and several staff around the resident.
During an observation and interview on 9/25/19 at 2:05 P.M., the courtyard was noted to not have any new safety precautions in place, no dirt to back fill in the area of the fall. The administrator said that the company grounds management is aware and a plan is in place to address the issue. There was no immediate plans to repair the area. He/she did have bags of dirt at the facility but the sprinkler needed to be repaired first or the dirt would wash away. He/she could not place a hand rail at that location and he/she was waiting to speak to the vice president.
During an interview on 9/25/19 at 2:18 P.M., the maintenance director said he had contacted the company grounds director and he came and observed the area of the courtyard where the resident had fallen. There had been no decision made if rock or dirt would be added to the site. It had been discussed the sprinkler head needed to be repaired first or it would wash away any dirt.
During an interview on 9/25/19 at 3:48 P.M., the administrator said she had placed a large planter in the courtyard in the area of the fall incident. She will be working with corporate to repair the area of the courtyard.
2. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/19, showed:
-A Brief Interview of Mental Status (BIMS) score of 10 out of 15, showed the resident cognitively moderately impaired;
-Diagnoses included high blood pressure, diabetes, hyperlipidemia (high level of lipids), stroke, hemiplegia (paralysis on one side of the body) and depression;
-Total dependence and required two person assist for transfers;
-Impairment on one side of the upper and lower extremities;
-Uses a wheelchair.
Review of the resident's care plan, dated 7/12/19, showed resident needed extensive assist of two with bed mobility, dressing and toileting. He/she used a Hoyer (mechanical) lift for transfers.
Observation on 9/23/19 at 1:56 P.M., showed the surveyor knocked on the resident's door. There was no answer; surveyor opened the door to the resident's door and said hello. The resident was observed in a sling that was hooked to a Hoyer lift. He/she was suspended approximately two feet above his/her wheelchair. CNA F was observed with the electronic remote in his/her hand. There was no other staff in the room except the resident and CNA F. CNA F continued to transfer the resident while he/she was suspended in the air. CNA F managed the hand control to transfer the resident from his/her wheelchair to the bed. The resident's body received no guidance during the transfer. The resident was transferred and lowered onto the bed. CNA F unhooked the sling and moved the Hoyer lift to the middle of the resident's room. CNA F said another staff will come in and assist him/her with turning the resident. CNA F exited the room.
During an interview on 9/23/19 at 2:00 P.M., the resident said he/she is often transferred by one staff using the Hoyer lift. It depended on which staff was operating the Hoyer lift that determined if he/she felt safe during the transfer.
Review of the facility's Use of Mechanical Lift policy and procedure, revised November 2017, showed facility policy requires two persons when using any mechanical lift. Resident's transfer needs should be assessed upon admission, quarterly, and as needed. This is to be documented in the resident's care plan.
During an interview on 9/23/19 at 2:10 P.M., the administrator and DON said they would expect staff to follow the facility's policy in regards to Hoyer transfers. They would expect the residents to be transferred by two staff. There should be one staff to operate the lift and the other staff to guide the resident's body. The administrator confirmed that the CNA F had received training and education on transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow an immediate family member to act on behalf of a resident in order to support the resident in decision-making for medical and financial matters. In addition, the facility failed to pursue a legal representative or court-appointed guardian after the immediate family member's rights were revoked by the facility and after it was determined that the resident was not capable of making their own medical and financial decisions (Resident #85). The facility census was 137 with 99 residents in certified beds.
Review of the facility's Resident Handbook, revised [DATE], showed the following:
-Resident's representative: The person designed in writing by the resident or resident's legal representative to receive communication on behalf of resident and to make health care or financial decisions, or both, on behalf of the resident. The resident's representative may be the resident's legal representative and/or the resident's immediate family member;
-Surrogate: A person identified from the Missouri statutes to make decisions regarding medical treatment for a resident who lacks decisional capacity, who has a qualifying condition and who does not have an Advance Directive in effect. The facility recognizes the following order of authority: legal representative, spouse, adult children, parents, adult brothers/sisters, grandparents, adult grandchildren and guardian of the estate.
Review of the Resident #85's medical record, showed on a Durable Power of Attorney (DPOA) for Financial Management was signed on [DATE]. deceased Family Member A was named as the DPOA for Financial Management.
Review of the resident's progress notes, showed:
-On [DATE], Family Member B contacted social services on [DATE] and reported Family Member A passed away last week. The Family Member A was Financial Power of Attorney (FPOA) and responsible party for the resident. Family Member B was requesting to become POA. Social services reviewed resident's FPOA in the chart and there was no second agent listed. Social services discussed with social worker supervisor. Social services contacted Family Member B and notified him/her due to resident's capacity and unable to make decisions, he/she would need to pursue guardianship. Social services noted he/she had resources available regarding guardianship. Family Member B stated he/she believes the resident can make that decision. After discussing with the charge nurse and nurse manager, social services informed son that psych can complete an evaluation with resident for capacity/ability to complete POA. Family Member B was aware and agreeable to psych consult. Family Member B requested to be present for psych visit. Social services will follow;
-On [DATE], Social services followed up with Family Member B on [DATE] after psych saw resident. Psych noted in resident's chart he/she does not have the capacity to appoint a POA. Social services notified Family Member B. Social services provided resources to Family Member B about guardianship. Family Member B plans to review documents and follow up with social services. Social services will follow;
-On [DATE], Family Member B notified social services on [DATE] that he/she no longer plans to pursue guardianship due to costs. Social services discussed with social services supervisor. Social services will follow;
-On [DATE], Social Worker N and Social Services Supervisor O contacted Missouri Adult and Abuse hotline on [DATE] and reported suspected financial exploitation from deceased Family Member A regarding resident's Long Term Care (LTC) insurance. In addition, social services contacted state for guidance regarding the resident's LTC insurance checks and how to proceed due to resident no longer having financial POA due to Family Member A passing away. Staff explained resident's current financial situation. Social Services Coordinator O, Social Worker N, and assistant administrator contacted Family Member B on [DATE]. On [DATE], Family Member B notified social services that he/she planned for a bank representative to come to the facility in order to open a bank account in the community. On [DATE], social services supervisor discussed with Family Member B that resident no longer having a financial POA due to Family Member A's passing and the inability to create a new one because of the resident's cognitive status. Family Member B said he/she planned to deposit the resident's un-cashed checks from the resident's LTC insurance into the account. Social services supervisor explained facility's role with protective oversight for resident re-explained psych determined the resident does not have the mental capacity to appoint a POA or open a bank account in the community. Family Member B questioned what his/her role as a family is. Social services followed up and explained his/her role of being a family member and providing support to the resident, but legally he/she is unable to handle financial or health affairs regarding the resident due to no second agent listed on the previous POA. Social services supervisor notified Family Member B that the facility had contacted the state of Missouri to receive guidance on how to proceed with the checks. Supervisor advised Family Member B to cancel the bank appointment until we receive feedback and direction regarding the checks.
Review of the resident's medical record, showed:
-A progress note on [DATE], showed the resident moaning out in pain this morning. Resident was seen pulling oxygen nasal cannula off. Resident moaned in excess pain while he/she was getting out of bed. Tylenol, as needed (PRN) given with some effectiveness. Noticed hospice consult was ordered on [DATE], but he/she has not been admitted . Called hospice to see if he/she was evaluated and what the status was. Registered nurse (RN) not aware of consult order. RN came in to see resident at 1:15 P.M. During this time, resident's breathing pattern changed to cheyn stoke (abnormal breathing pattern). Hospice RN called the physician for comfort mediations. This nurse called Family Member B to make sure hospice was the route he/she wanted to go and he/she said yes. While RN was speaking with the physician, he/she was informed the resident is a ward of the state, so his/her Family Member cannot sign hospice papers;
-No documentation the resident was a ward of the state;
-No documentation to warrant the facility revoking Family Member's right to make medical decisions for the resident, such as the right to sign for hospice services.
During an interview on [DATE] at 8:36 A.M., Social Worker N and Social Services Coordinator O said they were actively involved in the resident's case. On [DATE], the resident's surviving family member contacted Social Worker N to notify him/her that Family Member A passed away and he/she wanted to be the resident's POA. They reviewed the documentation and it showed that there was no second party. The resident needed an evaluation to determine if he/she could make decisions. Family Member B believed the resident could make decisions. They did not believe Family Member B was present during the evaluation, but they would have to confirm that. They discussed the process of guardianship with Family Member B. He/she was given information on resources and was told he/she would need a lawyer. Family Member B later said it was too costly. In February 2019, he/she appeared with LTC paperwork and checks that were sent to Family Member A since his/her death. Social Worker N and Social Services Coordinator O met with corporate compliance and education nurse to discuss the financial issue. The resident's surviving family member wanted to take the resident to the bank, the facility called the hotline for assistance regarding misappropriation and medical. They spoke to the investigator. He/she came out to the facility, but they did not remember when. The investigator said he/she would follow up. They played phone tag in March and April. They attempted to contact the investigator again on [DATE] and the administrator called [DATE]. The facility never received any documentation or a letter regarding the investigation. The facility did not contact the facility's attorney on how to settle the matter of guardianship for the resident. There was no attempt to get an emergency guardian. There was a concern as to who would sign the hospice documents. They knew the resident was sick and declined quickly, but they were not aware if the resident was on hospice. They confirmed that there are morning meetings Monday through Friday. It was obvious that the resident was declining. The resident continued to receive care and the facility met his/her needs. They have care plan meetings quarterly and if there was a significant change. The resident's surviving family member (Family Member B) was on the consent and disclosure form. He/she attended a couple of care plan meetings; however, they did not know the dates of attendance. They confirmed that the resident was not a ward of the state or had a guardian. Social Worker N did not contact the physician about the resident's guardianship status once it was established that the resident could no longer make his/her own decisions. If there was an order for a hospice consultation, they would call the resident's family to make them aware and they would call hospice. Either nursing or the social worker would fax the information to hospice. Social Worker N confirmed he/she did not fax the order to hospice.
During an interview on [DATE] at 10:09 A.M., the hotline investigator said he/she received a hotline call from the facility in February 2019. There was one allegation that was financial. There were no allegations or information about the facility requesting assistance with guardianship in the initial report. The resident received a large check and they believed that the surviving family member would spend the money without the resident knowing about it. There were checks from LTC insurance in the amount of $4900. The investigator contacted the surviving family member who said the facility called the bank and told the bank employee that he/she would spend the money. He/she also tried to take the resident to the bank, but he/she was stopped by the facility. On [DATE], the investigator spoke to him/her regarding guardianship. The family members said he/she would like to do it because the LTC checks would cover it; however, he/she was no longer able to after the facility contacted the bank. The bank would not allow him/her to cash the checks. The investigator visited the facility and interviewed the resident. The resident was asked who was handling the money and who he/she wanted to handle the money. The resident continued to say, I don't know, I don't know. The investigator confirmed that he/she tried to contact Social Worker N, but they continued to miss each other. The investigator had a conversation with Social Worker N about how the surviving family member could use the money to hire an attorney to assist with guardianship. There was no discussion on how the investigator could assist the facility with guardianship for the resident and this was not within the scope of his/her job. The investigator confirmed that the LTC check had in care of and the family member's name on it. Family Member B's name was not on the bank account, but his/her name was on the check. The investigator also confirmed that the allegation was unsubstantiated.
During an interview on [DATE] at 1:47 P.M., Social Worker N said the resident's surviving family member reported that the resident's checks were going to the deceased family member's house and LTC insurance company asked why the checks were not cashed. Family Member B did not know what to do with the checks and he/she asked the facility what to do with them. The facility contacted the LTC company and it was reported the checks had not been cashed, but they were going to be re-issued in the resident's name. Social Worker N said the resident's family wanted to spend the money on the resident, and they were told they would have to provide receipts. The resident's son planned to go to the bank, but Social Worker N called the bank to make them aware that the resident did not have a POA. They called the hotline for misappropriation, but they also wanted to see what the surviving family member's motives were and if he/she was appropriate to be the resident's POA. They asked the investigator if he/she was the appropriate person to be a guardian. The family member was advised of the option of using the checks for an attorney, but he/she declined to be a guardian. Social Worker N did not know why he/she no longer wanted to do it. He/she did have difficulty understanding the POA process. He/she believed the resident could appoint a POA. There was no indication of misappropriation prior to the son receiving the LTC checks.
During an interview on [DATE] at 2:25 P.M., Business Office Manager P said the resident's deceased family member was the POA for finances. The resident's surviving family member came to the facility with three checks from LTC insurance and asked what to do with them. He/she was told to call the deceased family member's spouse for more information and the social worker said he/she could use those checks to establish guardianship because it would be expensive. According to the LTC insurance company, the checks were not cashed. Business Office Manager P was not involved with the checks, but he/she recalled when Family Member B wanted to take the resident to the bank, but he/she did not witness it. The LTC insurance checks were sent to the family, and the family would pay the facility. The facility does not receive the checks from LTC insurance. The resident's surviving family member could have used the money to provide for the resident. Business Office Manager P was very familiar with the resident. He/she was always well taken of. Business Office Manager P said he/she did not think there was any misappropriation. The facility can provide assistance for a POA for medical decisions, but an attorney would have to assist for financial decisions.
During an interview on [DATE] at 3:48 P.M., the administrator said she was not the administrator at the time, so she did not have any knowledge of the event regarding the checks. She was not aware of any restrictions regarding Family Member B leaving the facility with the resident. She was not aware of any indications that the surviving family member misappropriated the resident's money. She did not believe she said the resident was a ward of the state. The facility was seeking guidance from the state. She did not know why the physician believed the resident was a ward of the state. If the resident was a ward of the state, there would be documentation in the medical record. They did not have a family member that could fill out the hospice paperwork. They contacted the investigator to attempt to have a guardian in place in February 2019, and it was still on-going at the time of the resident's passing. The administrator did not know if the facility reached out to an attorney, but they did reach out to corporate compliance. In determining who made the resident's medical and financial decisions after the hotline call and the psych evaluation, the administrator said she did not know if there were any decisions to be made regarding medical or financial matters, but the facility would have updated the next of kin. The administrator confirmed that proceedings were not made to provide guardianship to the resident once the surviving family member stated he/she was no longer interested. There is no policy regarding guardianship.
During an interview on [DATE] at 4:38 P.M., Social Worker N and Social Services Coordinator O said there were no issues or concerns with misappropriations prior to the surviving family member attempting to cash the checks. He/she told the facility he/she was going to take the resident to a restaurant, but he/she also planned to take him/her to the bank. They confirmed that they needed guidance to help the resident with the money and they did not know what the surviving family member's intentions were. The surviving family member was told not to take the resident out of the facility due to uncertainty. The resident's family member did continue to visit the resident and there were no other concerns. The corporate office advised Social Worker N and Social Service Coordinator O to contact the hotline and to ask about guardianship.

Based on interview and record review, the facility failed to check the Nurse Aide Registry to ensure new employees did not have a Federal Indicator for abuse or neglect (which means the individual cannot work in a certified long-term care facility without a good cause waiver) prior to hire for two out of eight sampled employees. The census was 137 with 99 in certified beds.
1. Review of Floor Finisher A's employee record, showed the following:
-Date of hire: 9/10/18;
-No record of a Federal Indicator check.
2. Review of Activity Assistant B's employee record, showed the following:
-Date of hire: 1/14/19;
-No record of a Federal Indicator check.
3. During an interview on 9/24/19 at 4:00 P.M., Human Resources confirmed that the two employees did not have a federal indicator check completed. It was not included in their employee file. All new employees are required to have a federal indicator check completed.
4. During an interview on 9/24/19 at 5:15 P.M., the administrator said she would expect new employees to have a federal indicator check completed.