**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide acceptable nursing services by failing to report the results of an immediate (STAT) x-ray for one resident (Resident #5) who had complaints of shortness of breath (SOB). Two days after the x-ray, the resident requested to go to the hospital, the hospital found a large pleural effusion (condition where excess fluid accumulates in the pleural space, the thin membrane that separates the lungs from the chest wall) and a chest tube (drains access fluid) had to be placed. Additionally, the facility failed to administer intravenous (IV, method of administering fluids, medications, or nutrients directly into the bloodstream through a needle or catheter inserted into a vein) medications as ordered for two residents (Resident #3 and Resident #12). The census was 127.Review of the facility's Change of Condition policy, last reviewed 2/6/25, showed: -Policy: The attending physician/physician extender (Physicians, Nurse Practitioners, & Physician's Assistants, or Clinical Nurse Specialist) and the Resident Representative (RR) will be notified of a change in a resident's condition, per standards of practice and federal and/or state regulations; -Procedure:-1. Guideline for notification of physician and RR (not all inclusive):-Significant change in medical or cognitive baseline;-Accident or incident;-Abnormal lab results in conjunction with a change in condition;-2. Document in the Interdisciplinary Team (IDT) Notes:-Resident change of condition;-Physician/Physician Extender Notification;-Notification of RR. Review of the facility's Physician Orders policy, last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines;-Procedure: -Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders;-Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders must be documented clearly in the medical record. The required components of a complete order: -Date and time of order;-Name of practitioner providing order;-Name and strength of medication or treatment;-Quantity and duration;-Dosage and frequency;-Route of administration;-Indication and diagnosis;-Stop Date, if indicated;-Physician orders that are missing required components, are illegible or unclear must be clarified prior to implementation;-Physician Order Sheet (POS) will be maintained with current physician orders as new orders are received. Discontinued (DC) orders will be marked as discontinued with the date, and all new orders will be written in the appropriate area on the POS with the date the order was received;-Physician orders will be transcribed to the appropriate administration record, Medication Administration Record (MAR) or Treatment Administration Record (TAR);-Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from pharmacy, if available. Review of the facility's Infusion Therapy Medication Administration policy, dated 12/17, showed: -Procedures:-M. Document in Nursing Progress Notes: -1. Date;-2. Time;-3. Flushing agent;-4. Medication, solution;-5. Infusion rate;-6. Site assessment, complications, if any;-7. Patient response to procedure;-8. Type of solution and medication;-9. Duration of medication infusion;-10. Any untoward reactions. 1. Review of Resident #5's face sheet, showed diagnoses included hypertensive heart failure, congestive heart failure, peripheral vascular disease and weakness. Review of the resident's care plan, in use during survey, showed:-Focus: Resident prefers independent leisure; -History/potential for behavior problem: Alcohol consumption to excess; -The resident is at risk for falls, deconditioning, gait/balance problems and episodes of incontinence; -Resident has the potential for impaired skin integrity related to a history of wounds. Review of the resident's progress notes, showed:-On 8/2/25 at 1:53 P.M., Nurse was called to patient (pt) room related to fall, nurse observed pt walker facing the door and pt on the floor behind the walker. Nurse observed wet pull up. Shoes noted on pt. When asked what happened, pt replied I was headed to the bathroom when I lost my balance. Range of motion completed, aides and nurse used the Hoyer (mechanical lift) to lift pt up to wheelchair. Physician and resident representative aware;-On 8/3/25 at 11:06 A.M., Complaints of pain noted, as needed (PRN) oxy (pain medication) given as ordered hour later, effective. Patient on incident follow up for fall. Patient alert x 4 (to person, place, time and situation), walks with walker;-On 8/4/25 at 12:20 P.M., late entry: Resident was discussed during the Interdisciplinary Team (IDT) meeting in relation to a recent fall while self-transferring to the bathroom. Fall occurred without apparent injury; however, risk for future falls remains a concern. Current interventions in place to reduce fallrisk include PT/OT, reeducation on using the call light to ask for assistance, and proper footwear. Staff re-educated resident on safety precautions with follow up fall protocol in place. Resident's care plan updated accordingly;-On 8/4/25 at 2:32 P.M., Late Entry: Resident on incident follow up (IFU) precautions. No complaints of pain or discomfort at this time. Resident is currently resting in recliner in room with call light in reach;-On 8/6/25 at 11:30 A.M., Late Entry: Upon assessment resident complaint of shortness of breath. Oxygen saturation (sats) read 85% (normal range, 95-100%). Resident denies any complaints of pain or chest pains, 2 liters (L) of oxygen was applied to resident and oxygen sats increased to 94%. Resident continues to complain of shortness of breath. Physician notified and STAT chest x-ray was ordered;-On 8/6/25 at 12:57 P.M., Late Entry: The change in condition reported on this CIC Evaluation are/were: Shortness of breath; At the time of evaluation resident/patient vital signs, weight and blood sugar were:-Blood Pressure: 129/65 (normal 120/80) on 8/6/2025 at 11:19 A.M. Position: Sitting right arm;-Pulse: 69 (normal range, 60-100) on 8/6/2025 at 12:33 P.M.;-Respirations: 16 (normal 12-20) on 8/6/2025 at 12:33 P.M.;-Pulse Oximetry: O2 97% on 8/6/2025 at 12:32 P.M. Method: Room Air;-Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Respiratory Status Evaluation: Shortness of breath;-Pain Status Evaluation: Does the resident/patient have pain? No-Nursing observations, evaluation, and recommendations are: Resident complaints of shortness of breath, physician notified. New order received and implemented. STAT chest x-ray;-Primary care provider feedback: X-ray;-New intervention Orders: Oxygen (if available);-On 8/6/25 at 5:30 P.M., Late Entry: The change in condition on this CIC evaluation are/were: shortness of breath. At the time of evaluation resident/patient vital signs, weight and blood sugar were: -Blood Pressure: BP 155/91 - 8/7/2025 10:18 A.M. Position: Lying right arm;-Pulse: 69 on 8/6/2025 at 12:33 P.M. Pulse Type: Regular-Respirations: 16.0 on 8/6/2025 at 12:33 P.M.-Weight: 290.0 pounds (lb) on 8/6/2025 5:05 P.M. Scale: Standing-Pulse Oximetry: Oxygen 97.0% on 8/8/2025 at 10:00 A.M. Method: Oxygen via Nasal Cannula;-Outcomes of physical assessment: respiratory status elevation: shortness of breath;-Primary care provider feedback: X-ray;-New intervention Orders: Oxygen (if available);-On 8/6/25 at 7:50 P.M., x-ray received, no fractures noted. Physician notified. Power of Attorney (POA) notified, no new orders received at this time. Review of the resident's x-ray results, dated 8/6/25, showed:-Procedure: Chest;-Clinical information: Shortness of breath;-Findings: AP (Anterior-Posterior) view of the chest submitted. No prior studies. Asymmetric density right base (abnormal finding) and possible effusion (abnormal collection of fluid in a body cavity) presented view. Left lung without focal opacity by one view (normal finding). No pneumothorax (air accumulates in the space between the lining and chest wall). The cardiac silhouette is enlarged by AP technique. Left chest pacer;-Impressions: Right basilar opacity (shadow or darkening seen on a chest x-ray) one view. Correlate clinically for atelectasis (collapse of whole lung or area of the lung), chronic scarring, and/or pneumonia. Review of the resident's progress notes, showed:-On 8/7/25 at 8:48 P.M., during rounds, resident did not report any pain or voice any concerns to this nurse. Resident was provided with ice water and his/her call light place within reach;-On 8/8/25 at 10:25 A.M., resident complaint of shortness of breath this morning. Vital signs taken within normal limits. Resident and family member requested transfer to the emergency room for further evaluation. Physician notified. During an interview on 8/12/25 at 12:10 P.M., the hospital employee reported the nurse at the facility told the son the chest x-ray was clear. When the hospital scanned the patient, they noted a large right pleural effusion, and a chest tube was placed. The family told the facility nurse the resident needed to go to the hospital due to new use of oxygen and sounding gurgly (making a low, bubbling sound). During an interview on 8/28/25 at 1:55 P.M., the Assistant Director of Nursing (ADON) said the resident was transported out in the evening. The nurse assigned to the resident no longer works at the facility. It was not reported to the ADON the resident had shortness of breath. The ADON was aware of the x-ray but believed it due to the fall the resident had. The ADON expected staff to notify the physician if the resident continued to have shortness of breath and had a continued need for oxygen. During an interview on 8/28/25 at 1:18 P.M., the Director of Nursing (DON) said the x-ray results are received by the charge nurse, and they are reported to the physician. She expected staff to notify the physician of reports based on what was reported. The results are expected to be reported within that shift and attempts to contact the physician are documented. Nursing staff are expected to document in real time. The DON reviewed the resident's x-ray results and said the resident might have some pneumonia based on what it said. She expected nursing to contact the physician if the resident continued to have shortness of breath, requiring the use of oxygen. She expected physician's orders to be followed and for staff to be knowledgeable of and follow facilities policies. 2. Review of Resident #3's face sheet, showed his/her diagnoses included severe sepsis (systemic (conditions that affect the entire body or multiple organ systems) infection) with septic shock (life-threatening condition that occurs when an infection triggers a widespread inflammatory response that leads to dangerously low blood pressure and organ failure), diabetes, acute (a sudden onset and has a short duration) kidney failure, weakness and cognitive communication deficit. Review of the resident's care plan, dated 8/15/25, showed:-Focus: Activities of daily living (ADL, daily self-care activities) deficit related to quadriplegia (complete or partial paralysis (partial or complete loss of muscle function and movement) of both arms and both legs);-Goal: Resident requires assistance with ADL care and mobility. Here on a skilled rehab stay to increase in strength, mobility, endurance and independence;-Interventions: -Bed mobility: Totally dependent on staff for repositioning and turning; -Dressing: Dependent on staff; -Eating: Dependent one assist; -Personal hygiene and oral care: Dependent on staff; -Transfer: Two assist with Hoyer; -Discuss any concerns related to loss of independence, decline in function; -Encourage discussion of feelings about self-care deficit as indicated. Review of the resident's MAR, dated 8/14/25 through 8/16/25, showed:-Ertapenem Sodium (antibiotic) Solution Reconstituted (the process of adding a liquid diluent to a dry ingredient to make a specific concentration of liquid) one gram (gm). Use one gm intravenously (IV) every 24 hours for infection for five days, order date 8/14/25 at 8:00 P.M.; -On 8/14/25 at 11:22 P.M., Not Administered See Nurses Note (NA); -On 8/15/25 at 7:44 P.M., NA. Review of the resident's progress notes, dated 8/14/25 through 8/16/25, showed no progress notes regarding the ertapenem not being administered. No notifications to the physician or RR the ertapenem was not administered as ordered. During an interview on 8/29/25 at 9:55 A.M., Pharmacy Representative (PR) said a one-day supply of ertapenem was sent to the facility on 8/14/25. The remaining four-day supply was sent on 8/15/25. Review of the resident's hospital Emergency Department (ED) record, dated 8/16/25, showed: -Resident presents to ED via Emergency Medical Services (EMS) from the facility with hypotension (low blood pressure) and dizziness on 8/16/25;-Resident was admitted on [DATE] with hypotension and unresponsive. Resident was transferred to the intensive care unit (ICU) for septic shock for urinary tract infection (UTI). Resident was treated with meropenem (antiobotic) for seven days for gram neagitive sepsis. A Peripherally Inserted Central Catheter (PICC, a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart) was placed in left upper extremity (UE) prior to discharge to facility on 8/14/25 so the resident could continue the antibiotic for three days. Resident reported he/she did not receive any infusions through his/her PICC line since his/her discharge from the hospital. Attempts were made to obtain medical records from the facility ended in the facility staff hanging up on the hospital;-Resident was started on vancomycin (antiobotic) and cefepime (antiobotic) in ED. Will continue overnight pending infectious disease (ID) consult. 3. Review of Resident #12's face sheet, showed his/her diagnoses included human herpes virus 6 encephalitis (HHV-6, brain inflammation caused by the human herpes virus), epilepsy (seizures), diabetic, heart failure, weakness and need for assistance with personal care. Review of the resident's care plan, dated 8/8/25, showed:-Focus: Resident requires IV therapy acyclovir (antiviral medication used to treat infections) three times a day through 8/13/25;-Goal: Will not have complications or adverse reactions when receiving IV therapy for 30 days;-Interventions: -Administer IV therapy as ordered, explain procedure to the resident; -Change dressing to insertion site as ordered/ indicated; -Observe for possible side effects- report abnormal symptoms to physician; -Observe the IV site for edema (swelling), redness, drainage, etc. Report abnormal findings to physician. Review of the resident's MAR and progress notes, dated 8/7/25 through 8/26/25, showed:-Acyclovir powder, use 730 milligrams (mg) IV three times a day for viral infection until 08/13/25, order date 8/7/25 at 5:37 P.M., DC 8/10/25 at 12:39 A.M.; -On 8/7/25 at 10:00 P.M., blank (no documentation); -On 8/8/25 at 6:00 A.M., blank; -On 8/8/25 at 2:00 P.M., blank; -On 8/8/25 at 10:00 P.M., blank; -On 8/9/25 at 6:00 A.M., blank; -On 8/9/25 at 2:00 P.M., blank; -On 8/9/25 at 10:00 P.M., blank;-Progress note dated 8/11/25 at 10:03 A.M., Pharmacy called and relayed problem with acyclovir IV medication. Due to dosage, storage and reconstitution needed, pharmacy would like the physician to be called and possibly change the dosage to ensure integrity of medication. Please follow up with pharmacy about new order;-Progress note dated 8/11/25 at 10:56 A.M., Nurse verified Acyclovir dose with physician per pharmacy inquiry, give 1000 mg IV three times a day. Call placed to pharmacy to provide updated order;-Acyclovir powder, use 1000 mg IV three times a day for viral infection, order date 8/11/25 at 10:48 A.M., DC on 8/12/25 at 1:59 P.M.: -On 8/12/25 at 6:00 A.M., NA;-Progress note, dated 8/13/25 at 3:03 P.M., IDT Risk Meeting held today regarding the resident is currently receiving Acyclovir prophylaxis (action taken to prevent disease) without a designated stop date related to a viral infection/outbreak. Resident is compliant with the medication regimen and tolerating it well with no reported side effects at this time;-Progress note, dated 8/13/25 at 10:43 P.M., Resident still remains on ABT for viral outbreak. No adverse reactions noted at this time;-Acyclovir powder, use 750 mg IV every eight hours for viral infection until 08/18/25, order date 8/14/25 at 10:53 A.M.; -On 8/15/25 at 6:00 A.M., NA; -On 8/15/25 at 2:00 P.M., NA; -On 8/15/25 at 10:00 P.M., NA; -On 8/16/25 at 6:00 A.M., NA;-Progress note, dated 8/16/25 at 10:32 P.M., Resident remains on ABT Acyclovir 750mg intravenously. No adverse reaction noted;-No progress notes regarding missed doses of IV ABT;-No progress notes with notification to physician and RR regarding missed doses of IV ABT. During an interview on 8/29/25 at 9:55 A.M., PR said the acyclovir was first sent out on 8/11/25 and the last time it was sent to the facility was on 8/15/25. The pharmacy sent out a seven-day supply total to the facility. 4. During an interview on 8/28/25 at 1:18 P.M., the DON and Administrator said they expected staff to follow physician orders. They expected staff to be knowledgeable of and to follow the facility policies. They expected if staff documented NA in the resident's MAR for a progress note to be entered on why the medication was not administered. On 8/29/25 at 1:23 P.M., the DON and Administrator said if an IV ABT was not administered as ordered, they expected notifications to the physician and RR to be documented in the resident's progress notes. 2593947

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was free from additional harm after experiencing an unwitnessed fall. Staff transferred the resident back to his/her bed while the resident showed signs of injuries (Resident #8). The resident sustained fractures following the fall. In addition, the facility failed to transfer a resident (Resident #1) appropriately utilizing a mechanical lift. The sample size was 24. The census was 121. Review of the facility's Fall Management Policy, dated 2/28/23, showed: -Policy: To provide an environment that remains as free of accidents and hazards as possible. The Facility will complete a fall evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries; -Definition: -A Fall is a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object; -An unwitnessed fall occurs when a Resident is found on the floor and the Resident/Employee is unaware of how he/she got there; -Prevention/Treatment: -Prior to moving the Resident, the Charge Nurse will evaluate for injury; -If injury is known or suspected; -Provide emergency first aid treatment as applicable. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Cognitively intact; -No behaviors; -Required substantial/maximal assistance for mobility and transfers; -Diagnoses included anemia. Review of the resident's progress notes, showed: -2/13/25 at 9:16 P.M., the resident was found on the floor by staff. Resident stated he/she was trying to reach something on his/her bedside table and slipped out of bed. Resident denies pain at this time. No visible injuries. Denies hitting head. Resident refused to turn to be placed on Hoyer (mechanical lift) pad. Educated resident on the safety of using a Hoyer. Resident insisted to be lifted by two male staff to be placed back into bed. One male staff held his/her legs and other male staff held under his/her arms. Placed resident back to bed. Multiple staff present at the time. Resident refuses to have vitals taken. Notified doctor; -2/14/25 at 2:04 A.M., Doctor and evening shift supervisor notified. Resident is now having complaints of left arm pain, refusing to be changed by the Certified Nursing Assistant (CNA). Call made to physician for an x-ray. Resident notified; -2/14/25 at 8:55 A.M., X-ray to left arm/shoulder completed. Awaiting the results; -2/14/25 at 12:04 P.M., Received the x-ray results. This nurse called the doctor and reported the results. Resident has a non-displaced fracture involving the supracondylar left humerus (a break to the lower part of this bone, close to the elbow) that suggests metastatic disease. The doctor recommends sending the patient to the hospital. This nurse talked to the patient and explained that the doctor recommended he/she go to the hospital. Resident is alert and oriented and able to understand he/she has a fracture and is own responsible party. Resident declined going to the hospital and states he/she could wait and if it gets worse, then would go to the hospital; -2/14/25 at 3:24 P.M., the resident refused vital signs during this shift. Dr here and made aware. Continues to be assisted with activities of daily living; -2/14/25 at 9:23 P.M., the resident resiting in bed with the rise and fall of the chest. Resident complained of pain to the left arm. This writer offered resident a pain medication to help with pain. The resident declined pain medication. This writer had conversation with the resident on how he/she fell, and why he/she did not want to go to the hospital. Resident responded saying, I am afraid of what else they will find. This writer encouraged resident to go. Resident continues to decline offer stating is he/she changes his/her mind, he/she will let this writer know. Vital signs refused. Swelling noted. Offered to elevate arm. Resident declined medical doctor. Review of the resident's care plan, in use during the time of the investigation, revised 2/14/25, showed: -Focus: The resident is at risk for falls. 2/13/25 fall; -Goal: The resident will be free of minor injury through the review date; -Interventions: Anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of the resident's progress note, showed: -2/15/25 at 2:38 A.M., resident requested to go to the hospital. Medical doctor made aware. Resident left facility via stretcher for complaints of pain to left hip radiating down his/her leg. Resident going to the hospital; -2/20/25 at 4:07 P.M., spoke with staff at the hospital. Diagnoses of left distal femur fracture (thigh bone just above the knee joint) and left humerus fracture. No anticipated discharge date available at this time. Review of the resident's hospital Discharge summary, dated [DATE] at 10:14 A.M., showed: -Left distal femur fracture-occurred after fall out of bed experiencing dizziness; -Left distal humerus fracture. During an interview on 5/30/25 at 2:33 P.M. and 6/2/25 at 7:27 A.M., the resident said on 2/13/25 around 10:00 P.M., he/she reached for something on the night stand and fell from the bed, onto the floor. He/She screamed in pain and for help because he/she could not get to the call light. Two female staff members came to the room to assist him/her back in bed. They did not offer a Hoyer to transfer the resident back into bed. The resident said, If they did offer it, I don't know how they would have gotten me on it because I was in so much pain and the way my body was positioned would not allow a Hoyer to lift me without causing further pain. I was in so much pain, I would have refused a Hoyer anyway. The resident was not sure who the two staff members were, only they were from an agency and not regular employees of the facility. The staff members did not complete range of motion on the resident. They did not take vitals. The two staff got in position to transfer the resident back to bed. The resident said, something did not feel right when the staff were about to lift the resident. He/She asked the two staff members to stop and requested two male staff members transfer him/her back to bed. The staff members texted the male CNAs to assist the resident back into bed. Approximately five minutes later, CNAs Q and T entered the resident's room to transfer him/her back into bed. CNA Q grabbed the resident's legs while CNA T grabbed the resident's arm. The resident said CNA T grabbed him/her by the arm, under his/her elbow. As they lifted the resident, the resident said he/she felt a crack in his/her arm and yelled out, ouch, my arm, my arm, my arm! They then transferred the resident into the bed. The female staff said, they did not do anything to your arm. Make sure to document that they did not do anything to his/her arm. The resident said he/she was in so much pain after being placed in bed. An aide entered his/her room shortly after and said he/she needed to take vitals. The resident refused and said he/she was in pain. The resident was also distrustful of the aide because he/she said the resident was not in pain and did not want to work with the aide. He/She did not have any vitals taken due to pain. The next day someone came in and took x-rays. Later, the resident found out he/she had a fracture. He/She was afraid to go to the hospital and initially declined. That evening, Licenced Practical Nurse (LPN) O arrived and the resident told him/her what happened as he/she trusts LPN O. LPN O convinced the resident to go to the hospital. During an interview on 6/2/25 at 4:52 A.M., LPN O said he/she arrived to work the following day after the resident fell. The resident told him/her what happened the night before. LPN tried providing care to the resident and the resident cried out in pain. He/She encouraged the resident to go to the hospital. LPN O was not sure who the staff were who worked with the resident. He/She believed they were agency staff. During an interview on 6/2/25 at 7:04 A.M., CNA R said he/she was present when the fall occurred. He/She heard the resident yelling and saw him/her on the floor. He/She immediately got the nurse and explained the resident needed a mechanical lift and was on the floor screaming out in pain. He/She could not recall the nurse and said the nurse worked for an agency and had not returned since the incident. The nurse did not get a chance to obtain vitals because the resident refused and kept saying I am hurt and insisting staff get him/her off the floor. CNA R and the unknown nurse educated the resident on the importance of using the mechanical lift. Again, the resident refused. As they were going to lift the resident, the resident asked for CNAs Q and T. The aides arrived and lifted the resident off the floor and placed him/her back in bed. The nurse said he/she would document in the progress note the resident refused a mechanical lift and vitals. Later that evening, CNA R returned to the resident's room to get vitals. The resident refused and said he/she was in pain. He/She did not return to follow up on vitals as this was close to 10:00 P.M. when it happened and the shift was almost over. During an interview on 6/2/25 at 9:02 A.M., CNA Q said he/she and CNA T received a text message from the nurse asking for assistance in getting a resident off the floor. When they arrived, the resident was on the floor screaming in pain saying, It hurts, it hurts, it hurts. The resident also said to get him/her off the floor. At first, CNA Q said he/she did not recall the nurse doing range of motion because the resident was in so much pain and insisted on being transferred back to bed. They did not use a pad to transfer the resident. He/She could not recall exactly how the resident was lifted. He/She grabbed the resident by the legs and CNA T, who has since been terminated, grabbed the resident by the arms. He/She could not recall how the resident's arms were grabbed and how his/her body was positioned prior to the transfer. After transferring the resident back to bed, CNA Q continued with his/her assignments. During an interview on 6/2/25 at 9:21 A.M., LPN S said if there was an unwitnessed fall, the resident should be assessed by the nurse prior to moving the resident. If the resident is alert and oriented, denies pain, range of motion performed, vitals taken and no visible signs of injury, the resident could be transferred back into bed using a lift or pad. This was after a full head to toe assessment. If the resident was in pain, or showed signs of pain, it would be unsafe to transfer the resident back into bed. Staff should call Emergency Medical Services (EMS) if a resident showed signs of injury following a fall. During an interview on 6/2/25 at 4: 15 P.M., the Director of Nursing (DON) said if the resident complained of pain after a fall, staff should not attempt to move the resident and should call EMS immediately. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse, Assistant Director of Nursing and Administrator said staff should have contacted EMS following the resident's fall if he/she showed signs of injury. They could not recall who the nurse was as he/she was through an agency and the facility has stopped utilizing agency staff. The Administrator was told the resident was not injured during the transfer. They staff should not have moved the resident following the fall. During an interview on 6/3/25 at 11:34 A.M., the facility's Medical Director said she was not familiar with the resident. However, staff should have contacted EMS prior to moving the resident if he/she showed signs of an injury. 2. Review of the facility's Total Lift Transfer policy, reviewed on 11/28/22, showed: -Policy: The facility will utilize a Total Lift Device on residents who are unable to assist with transfers; -Responsibility: Employees, nursing administration, Director of Nursing; -Procedure: -Measure resident for appropriate sling size according to Manufactures Guidelines; -Explain the procedure; -Ensure lifting device battery is charged; -Clear an unobstructed path for the lift device; -Ensure appropriate room to pivot the lift; -Position the lift near the receiving surface; -Place the lift at the correct height; -Lock the bed/chair wheels; -Inspect equipment; ensure in good condition (sling/straps); -Place sling under the resident; -Lower lift for easy attachment of the sling; -Position the sling under the resident with the base of the sling at the base of the resident's spine, top of the sling at the top of the head; cross straps prior to hooking the straps of the lift; -Match the corresponding colors on each slide of the sling and observe that all sling loops are securely connected; -Lift resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution; -Evaluate resident's level of comfort and observe for signs of pinching or pulling of the skin; -Standing next to the resident, press the up button on the lift controls to slowly raise the lift to the height necessary to clear the surface. maintain contact with the resident to guide/steady the resident during the lift transfer, as necessary; -Standing next to resident use the down button on the lift control to slowly lower the resident to the desired surface, guide/steady as necessary; -Detach the sling from the lift ensuring the bar of the lift does not touch resident; -Move the lift away from the resident; -Lifting from the chair: Lock the wheels of the chair; -Attach the sling to the lift using color coded straps; cross straps prior to securing to the lift; -Open the legs of the lift using the hand controls; -Raise resident using the hand controls; -Safely lower resident to the chair ensuring proper placement; -Unhook sling from lift ensuring the lift bar does not touch resident; -Lifting from the floor: Place the sling centered under resident; -Open the legs of the lift; -Attach the sling to the lift using color coded straps; cross sling straps prior to securing to the lift; -Raise resident from the floor to the desired surface. Review of Resident #1's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Wheelchair for mobility device; -Dependent to chair/bed-to-chair transfer; -Diagnoses included multiple sclerosis (MS, chronic disease of the central nervous system) and paraplegia (paralysis of the lower parts of the body). Review of the resident's care plan, in use at time survey, showed: -Focus: Limited physical mobility related to MS, paraplegia and needs assistance with meals; -Goals: Will demonstrate the appropriate use of adaptive devices to increase mobility; -Will remain free of complications related to immobility, including contractures, thrombus formation (blood clots), skin breakdown, fall related injury; -Interventions: Hoyer lift transfer with medium size sling, provide supportive care, assistance with mobility as needed, document assistance as needed; -Focus: Resident is at risk for falls related to deconditioning; -Goal: Resident will not sustain serious injury through the review date; -Interventions: Anticipate and meet the resident's needs, follow facility fall protocol. Observation on 6/2/25 at 5:05 A.M., showed CNA N and LPN O entered the resident's room to transfer the resident using a Hoyer lift. The Hoyer sling or pad was applied under the resident while in bed. The resident was not properly adjusted prior to lifting the resident. CNA N adjusted the resident's head and feet with one hand while controlling the lift and the resident was suspended in the air. The resident's wheelchair was placed away from the bed. The resident was dangling and spun around while the lift was wheeled closer to the wheelchair. LPN O did not spot and support the resident. The resident was lowered to the wheelchair without being adjusted and repositioned comfortably. During an interview 6/3/25 at 10:59 A.M., CMT (Certified Medication Technician) D said Hoyer lift transfers required two staff to provide residents' safety. The staff should make sure they were using the correct size of the sling or pad. One staff would operate the Hoyer while the other would make sure the resident would not slide out of the sling, and make sure to hold and support the resident's head and legs. The staff should make sure the resident was comfortable in the chair or bed after transfer. During an interview on 6/3/25 at 11:28 A.M., LPN C said two staff were required at all times to transfer residents using Hoyer lift. One staff can spot and keep the resident stable while the other operates the Hoyer. The resident's head, legs and body should be assisted and kept steady, and without flopping to the chair. The resident's wheelchair should be positioned parallel and close to the bed. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said Hoyer-transferred residents should have two staff at all times, providing residents' safety. The staff should make sure the Hoyer's legs were opened when used, and the resident's body should be adjusted and leveled. The resident should be supported, avoiding being dangled in the air and providing a minimum distance from the bed when lifted up. She expected staff to provide the residents with safe transfer at all times and to follow their mechanical transfer policy. MO00238874 MO00237238 MO00254710

See Event ID 0WE513. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24 and 10/31/24. Based on interview and record review, the facility failed to ensure staff followed their change in condition policy for two residents. The facility failed to report to the physician two residents' (Resident #50 and Resident #47) change of condition and failed to follow the speech therapy recommendations for a modified diet and 1:1 mealtime assistance for one resident (Resident #50) with dysphagia. Resident #50 was hospitalized . Resident #47 complained of nausea and vomiting and staff administered medication to stop the nausea and vomiting, but failed to notify the resident's physician and failed to provide on-going assessments and monitoring of the resident. The next day, the resident said he/she was still having nausea and vomiting and the medication did not help. He/She was transferred to the hospital and was admitted with diagnoses that included nausea and vomiting. Four residents were sampled for change in condition and problems were found with two. In addition, the Director of Nursing (DON) documented she completed wound/skin treatments for seven of seven residents sampled on the day shift of 12/15/24, when she was not present in the building (Residents #6, #56, #57, #58, #60, #62, and #64). The sample size was 25. The census was 116. Review of the facility's Notification Of A Change In Condition policy, revised on 4/26/23, showed: -Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations; -Responsibility: All Licensed Nursing Personnel, Nursing Administration, and Director of Nursing; -Procedure: -1. Guidelines for Notification of Physician/Resident Representative: -Significant Change or Unstable Vital Signs; -Emesis (vomit)/Diarrhea; -Change in Level of Consciousness; -Abnormal Complaints of Pain, Ineffective Relief of Pain from current Regimen; -Unusual Behavior; -2. Document in the Interdisciplinary Team (IDT) Notes: -Resident Change in Condition; -Physician Notification; -Notification of Resident Representative. Review of the facility's Medication Administration - General Guidelines policy, dated 12/17, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions; -When PRN (as necessary/as needed) medications are administered, the following documentation is provided: -a. Date and time of administration, dose, route of administration (if other than oral), and if applicable the injection site; -b. Complaints or symptoms for which the medication was given; -c. Results achieved from giving the dose and the time results were noted; -d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. 1. Review of Resident #50's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/24, showed: -admission date of 12/6/24; -Severe cognitive impairment; -Eating and oral hygiene: Partial/moderate assistance (Helper does less than half the effort); -Toileting, bathing, upper body dressing, lower body dressing, put on/take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, sit to stand, chair to bed transfer, and toilet transfer: substantial maximal assistance (helper does more than half the effort); -Mobility device: Wheelchair; -Swallowing disorder: Coughing or choking during meals or when swallowing medication, and complaints of difficulty or pain with swallowing; -Nutritional approaches: Mechanically altered diet and therapeutic diet; -Diagnoses included dementia, diabetes, cognitive communication deficit and dysphagia (difficulty swallowing). Review of the resident's care plan, showed: -Focus: Impaired cognitive function/dementia or impaired thought processes related to dementia, date initiated: 12/08/2024, created on: 12/08/2024; -Goal: Will be able to communicate basic needs on a daily basis through the review date; -Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness; -Ask yes/no questions in order to determine the resident's needs; -Communicate with the resident/family/caregivers regarding resident's capabilities and needs; -Cue, reorient and supervise as needed; -The care plan did not address the resident's dysphagia, and was not updated with changes in diet, per the ST recommendations. Review of the resident's order summary, showed: -Code status: Cardiopulmonary resuscitation (CPR), order date 12/6/24; -Pureed diet (diet of foods that are blended, mashed, or whipped into a smooth, lump-free consistency, similar to pudding), pureed texture, nectar consistency (thickened liquid consistency that's similar to heavy syrup and is easily pourable. These liquids are used for people with swallowing difficulties), alternate bites of food and sips of liquid for 1:1 feeding assistance, swallow precautions, oral care times (x) 3 (with each meal), order date 12/11/24; -Pureed diet, pureed texture, nectar consistency, alternate bites/sips, aspiration precautions for 1:1 feeding assistance, liquid via teaspoon (tsp), oral care x 3, order date 12/13/24. Review of the task activities of daily living (ADL) eating, dated 12/6/24 through 12/9/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: -12/6/24: -5:00 P.M., Independent (Resident completes the activity by them self with no assistance from a helper), 76% - 100%; -10:59 P.M., Independent, 76% - 100%; -12/7/24: No documentation; -12/8/24: No documentation; -12/9/24: No documentation. Review of the resident's Speech Therapy treatment encounter notes, dated 12/9/24 through 12/10/24, showed: -Evaluation dated 12/9/24: Completed St. Louis University Mental Status exam (SLUMS) with the following results: Resident presents with mild-moderate oral dysphagia characterized by prolonged mastication (chewing), decreased bolus formation (swallowing abnormality that occurs when the tongue has reduced coordination to form a bolus after chewing), and requiring occasional cues to swallow. Recommend downgrading to mechanical soft with thin liquids, 1:1 assistance for small bites/sips and alternating bites of food and sips of liquid; -12/10/24: Resident seen this A.M. for speech therapy to target cognitive skills and swallow function. Resident observed at breakfast time with mechanical soft foods and thin liquids. Resident required assistance to put correct condiments on desired foods (i.e., jam on biscuit), and consistent verbal cues to alternate bites of food and sips of liquid. Discussed with nursing; -Oral intake: Swallowing abilities: Moderate, Current diet: Mechanical soft textures, Current liquids: Thin liquids. Review of the task ADL eating, dated 12/10/24 through 12/11/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: -12/10/24: -10:17 A.M., Independent, 76% - 100%; -9:00 P.M., Setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity), 51% - 75%; -9:02 P.M., Setup or clean-up assistance, 76% - 100%; -12/11/24: -5:00 P.M., Setup or clean-up assistance, 25% - 50%; -10:59 P.M., Setup or clean-up assistance, 26% - 50%. Review of the resident's ST treatment encounter notes, dated 12/11/24, showed resident seen this A.M. for speech therapy to target swallow function. Resident lying flat in bed and breakfast tray covered and across the room upon arrival. Food heated up and mechanical soft consistency and thin liquids administered. The oral phase was characterized by significantly prolonged mastication, decreased bolus formation and significant residue post liquid wash. The pharyngeal phase is characterized by cough post thin liquids. Trialed nectar thick liquid- no overt (apparent) signs or symptoms (s/s) of aspiration noted however, cannot rule out silent aspiration. Trialed puree consistency, oral phase appeared more functional. Recommend puree and nectar thick liquids, medications crushed in puree, alternate bites of food and sips of liquid, 1:1 feeding assistance, and frequent oral care. Discussed with nursing and called and informed resident's family. -Oral intake: Swallowing abilities: Moderate, current diet: Puree consistencies, Current liquids: Nectar thick liquids; Review of the task ADL eating, dated 12/12/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: 12/12/24: No documentation. Review of the resident's ST treatment encounter notes, dated 12/12/24 through 12/13/24, showed: -12/12/24: Resident seen this afternoon for speech therapy to target cognitive skills and ensure diet tolerance. Resident administered nectar thick liquid and puree consistency. The oral phase was characterized by minimal oral residue and cleared with liquid wash. No overt signs/symptoms of aspiration noted. -12/13/24: Resident seen this afternoon for speech therapy to target swallow function. Resident increasingly confused. Oral care administered prior to PO trials. Resident with oral residue from previous meal. Attempted to administer a small amount of nectar thick liquid via tsp. Resident required max verbal cueing to accept and swallow small amounts. Trials stopped due to resident fatigue/alertness. -Called family to discuss a plan and options (nothing by mouth (NPO) verses (vs) percutaneous endoscopic gastrostomy (PEG, a flexible plastic tube that is inserted into the stomach through the abdominal wall to provide nutrition, fluids, and medication) vs. puree/nectar pleasure diet. Family reported understanding of risks and said to continue puree with nectar with swallowing precautions (1:1 feeding assistance, small sips/bites, sips via tsp, only feeding when alert). Speech Therapist (ST) X discussed with the nursing regarding the steady decline seen in resident the past few days. Nurse reported he/she would talk with the doctor; -Oral intake: Swallowing abilities: Marked resident attempts to initiate participate, current diet: Puree consistencies, Current liquids: Nectar thick liquids. Review of the task ADL eating, dated 12/13/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: -12/13/24: -9:30 A.M., Setup or clean-up assistance, 51% - 75%; -1:00 P.M., Independent, 76% - 100%. Review of the nurse's notes, dated 12/13/24 at 10:39 P.M., showed ST X and the resident's family had concerns. ST X stated the resident has difficulty swallowing and may be at risk for aspiration. Moist lung sounds auscultated (listened to) to both lobes. Call placed to exchange, unable to contact anyone, will report to next shift. Review of the task ADL eating, dated 12/14/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: 12/14/24: No documentation. Review of the nurses notes, dated 12/14/24, did not show staff attempted to contact the physician. Review of the task ADL eating, dated 12/15/24, showed: -Follow up question: Eating: The ability to use suitable utensils to bring food and or liquid to mouth and swallow for and or liquid once the meal is placed before the resident and what percentage of the meal was eaten: 12/15/24: 11:46 A.M., Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), 76% - 100%. Review of the nurses note, dated 12/15/24 at 2:30 P.M., showed Certified Nurse Aide (CNA) S and Certified Medication Technician (CMT) DD made nurse aware the resident appears to have a change in condition. Nurse called out to resident with no answer and eyes remaining closed. Resident noted slow shallow breaths. CMT DD begins to take vital signs noting no critical results. Sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert) given to further evaluate awareness and resident begins to blink eyes, no further movement assessed, breathes remain same. With CMT DD remaining at bedside, this nurse notes CPR noted in documentation. This nurse alerts Registered Nurse (RN) on sister unit of resident's change and possible emergent condition that required immediate evaluation. 911 notified. This nurse also alerts Administrator of resident's needed evaluation. Nurse back at bedside and remained on the line with 911 operator. Emergency Medical Technicians (EMT) arrive to facility to evaluate and transport resident to hospital for evaluation and treatment if indicated. Resident eyes remaining closed, slow breathes, leaving facility via ambulance transport. Review of the Emergency Medical Services (EMS) report, dated 12/15/24, showed: -2:59 P.M., blood pressure (BP) - unable to obtain, respiratory rate 16 (normal range, 1-18 breaths per minute); -3:13 P.M., blood pressure 71/42 (normal range, less than 120 systolic/less than 80 diastolic), pulse 62 (normal range, 60-100). Altered mental status, combative, uncooperative. Review of the resident's care plan, showed: -Focus: The resident has a swallowing problem related to complaints of difficulty or pain with swallowing, Coughing or choking during meals or swallowing med, difficulty with thin liquids; -12/13/24 Pureed diet with Nectar thick liquids, date Initiated: 12/15/2024, created on: 12/15/2024; -Goal: The resident will not have injury related to aspiration (accidental breathing in of food or fluid into the lungs) through the review date; -Interventions: -Alternate small bites and sips. Use a teaspoon for eating. Do not use straws, date initiated: 12/15/2024, created on: 12/15/2024; -Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris, date Initiated: 12/15/2024, created on: 12/15/2024; -Diet to be followed as prescribed: Pureed diet with Nectar thick liquids. Aspirations Precautions, date Initiated: 12/15/2024, created on: 12/15/2024; -Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly, date initiated: 12/15/2024, created on: 12/15/2024; -Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards, date initiated: 12/15/2024, created on: 12/15/2024; -Monitor for shortness of breath, choking, labored respirations, lung congestion, date initiated: 12/15/2024, created on: 12/15/2024. During an interview on 12/19/24 at 8:15 A.M., CNA P said he/she worked on the same side the resident resides on 12/13/24 from 7:00 A.M. until 11:00 P.M. He/She was not assigned to the resident. The resident was up in his/her wheelchair most of the shift, propelling himself/herself up/down the halls. During an interview on 12/19/24 at 9:59 A.M., RN T said CMT DD asked him/her to pass a pain medication to a resident between 2:00 P.M. and 3:00 P.M. and asked RN T to help reposition the resident. RN T said he/she assisted CMT DD reposition the resident and RN T said he/she also checked the resident's vital signs at that time and they were within normal limits (WNL). No concerns regarding the resident were reported to RN T. RN T did not chart the vital signs that he/she obtained because they were WNL. During an interview on 12/19/24 at 11:05 A.M., CMT DD said he/she worked on 12/13/24, 12/14/24 and 12/15/24, 16 hour shifts from 7:00 A.M. until 11:00 P.M. CMT DD said he/she did not know the resident has specific recommendations for feeding such as alternate bites/sips and 1:1 feeding assistance. CMT DD said he/she was aware the resident was on thickened liquids and needed assistance with eating. CMT DD did not know how to locate the specific recommendations other than looking at the 24 hour report sheet or asking the nurse. The facility used to have a book at the nurses station with information about the residents, but he/she had not seen that in a long time. Sunday afternoon, CMT DD said he/she checked the resident's vitals and then asked RN T to come in and look at the resident. CMT DD said when he/she spoke to the resident, he/she would wave his/her hand like he/she did not want to be bothered. RN T came in and checked the resident's vital signs and said nothing was wrong with the resident at 2:00 P.M. CMT DD said just by observing the resident, he/she wanted someone else's opinion because the resident was talking and now the resident was just waving CMT DD away. CMT DD asked CNA S to get Licensed Practical Nurse (LPN) CC to come and check out the resident. When the resident was breathing, it sounded like when you have a cold and need to cough. The resident was making a gurgling sound. CMT DD said LPN CC told CMT DD this was not normal for the resident and sent the resident to the hospital. There was not a nurse on the resident's hall for the day shift on Sunday. During an interview on 12/19/24 at 3:03 P.M., LPN CC said he/she took care of the resident on 12/12/24 and the resident was propelling himself/herself around in his/her wheelchair, touching everything. When LPN CC listened to the resident's lungs, he/she had coarse and wheezing lung sounds. The resident ate a mechanical soft diet on Thursday evening and fed himself/herself in the dining room. The resident was not sitting at a table with staff that assisted with feeding. LPN CC said it was not reported the resident needed assistance with eating. LPN CC was not aware the resident's diet was changed to a pureed diet or that the resident was on nectar thick liquids. The resident propelled himself/herself out of the dining room a couple of times during dinner and had to be brought back into the dining room to finish eating. On 12/15/24, LPN CC was not working upstairs on the resident's unit. CNA S told LPN CC he/she attempted to report concerns regarding the resident to RN T, but RN T told CNA S that he/she was working the other hall upstairs and a nurse was coming in for the hall CNA S was working on. CNA S reported the concerns to LPN CC and LPN CC went upstairs to assess the resident. LPN CC said initially when he/she looked at the resident, he/she was lethargic and slow to open his/her eyes. LPN CC said this was too great of a change from when he/she cared for the resident on Thursday, so LPN CC called 911. LPN CC said the resident had a coarse cough and he/she was admitted to the facility with a pneumonia diagnosis. LPN CC said he/she listened to the resident's lung sounds before he/she sent the resident out and the resident still had course and wheezing lung sounds. LPN CC reported to the Administrator that there was no nurse on the resident's hall and requested to have the person on call him/her. LPN CC reported to the Administrator again there was still no nurse on the hall at 1:30 P.M. and that it sounded like the hall needed a nurse. At 2:55 P.M. LPN CC notified the Administrator that he/she had to go upstairs to assess the resident and he/she was in the process of calling 911 to send the resident out and informed the Administrator there was still no nurse on the resident's hall. The resident went from wandering around by himself/herself in the wheelchair on Thursday to barely moving and not verbally responding on Sunday. During an interview on 12/20/24 at 8:05 A.M., CNA S said he/she worked worked a double shift on 12/14/24 from 7:00 A.M. until 11:00 P.M. This was the first day he/she had worked around the resident. The resident was not assigned to him/her. He/She transferred the resident into his/her wheelchair. The resident seemed kind of out of it, lethargic. He/She was not propelling himself/herself on 12/14/24 and did not want any breakfast. He/She told the nurse. At dinner, the resident was more alert. The resident fed himself/herself a bit. On 12/15/24, he/she found the resident lying on a mat next to his/her bed while passing lunch trays. They notified LPN CC who sent the resident to the hospital. During an interview on 12/20/24 9:20 A.M., LPN Y said he/she worked the evening shift on 12/13/24. He/She was informed by ST X the resident was having difficulty swallowing during shift change. ST X asked if he/she needed to be sent out to the hospital. LPN Y said he/she would follow up with the doctor see if the resident needed any labs or he/she had any other orders. LPN Y listened to the resident's lung sounds and could hear moist lung sounds. He/She sat him/her up and encouraged him/her to cough. He/She coughed a dry cough. LPN Y called the exchange line more than 3 times. He/She wasn't able to leave a message, so he/she put it on the 24 hour report sheet and notified the next shift. ST X said the resident was already on a mechanical soft diet. Other recommendations were to take small bites one at a time and they posted a sign in his/her room. The LPN was unable to contact the physician or leave a message, so LPN Y entered a nursing note and passed the information to the next nurse. During an interview on 12/20/24 at 10:18 A.M., LPN Z said he/she worked on the night shift of 12/13/24. LPN Z said and it was not passed in shift report that ST X reported the resident's difficulty swallowing and wanted the doctor notified to see if the doctor wanted him/her sent to the hospital or labs or x-rays done. LPN Z passed onto the next shift they were waiting on a phone call from the doctor to discontinue Seroquel (antipsychotic that helps regulate mood and behaviors) and that the doctor had not called back. During an interview on 12/20/24 at 11:39 A.M., CNA AA said he/she worked the day shift on 12/15/24. He/She said at breakfast, the resident was in his/her room in bed, CNA AA took the lids off and opened everything for the resident. CNA AA was not told the resident was a feeder and he/she did not feed the resident. CNA AA set up the meal for the resident in bed. CNA AA did not thicken the resident's drinks and the resident was given thin liquids. During an interview on 12/19/24 at 8:45 A.M., LPN U said on 12/13/24, the resident was propelling himself/herself in wheelchair around the unit and LPN U had to place the resident behind the nurses station with him/her to keep an eye on the resident. On 12/14/24, the resident didn't want breakfast but wanted ice cream. LPN U fed him/her ice cream. On 12/14/15 the resident stayed in his/her wheelchair and did not propel himself/herself around the unit like he/she had on Friday. During an interview on 12/20/24 at 12:08 P.M., ST X said ice cream would not be safe because it melts in the mouth. If on pureed and staff thinned ice cream, it would be ok, but not for nectar. During an interview on 12/20/24 at 10:48 A.M., LPN BB said he/she worked 12/14/24 from 3:00-7:00 P.M. LPN BB was not given report on the resident. He/She did not know ST X reported the resident had difficulty swallowing and wanted the doctor notified to see if the doctor wanted him/her sent to the hospital or and labs or x-rays done. During an interview on 12/20/24 at 12:08 P.M., ST X said the resident was evaluated on 12/9/24 and the resident was pretty confused. Originally when she saw him/her, she put him/her on mechanical soft diet, for mild oral dysphagia. On 12/10/24 at breakfast, the resident was still really confused. The ST X reported to nursing the resident needed assistance alternating bites of food with liquid but did not change his/her diet. ST X told the nurse. The nurse is was supposed to inform the CNAs. ST X did not speak with the CNAs. ST X put the diet communication order into the physician's mailbox when an order is changed. ST X does not call the physician. On 12/11/24, ST X noticed the resident's swallowing was decreasing again. ST X put him/her on pureed and nectar thin liquids. ST X spoke with nursing. On 12/13/24, ST X added instructions and modified instructions: Pureed texture, Nectar consistency, alternate bites/sips, 1:1 feeding assistance for aspiration precautions, provide liquid via a teaspoon, to receive oral care three times daily. ST X saw the resident later in the day and he/she was more confused, had something in his/her mouth and wasn't managing secretions and the swallow function was not safe. The first red flag was when she put a moist spoon to his/her mouth and he/she wasn't accepting liquid from the spoon. He/She was not safe for by mouth (PO) trials, and was at high risk for aspiration. The resident seemed like he/she was getting worse, and it was progressing quickly. ST X consulted his/her supervisor to report the resident's change of condition and asked what should he/she do in the situation. If the resident is not consuming food and liquids safely, see if the family wants to go PEG, or PEG and pleasure feedings, or to continue with PO diet - continue the oral feedings with the safe strategies with 1:1, small bites, small sips, sips via teaspoon only feeding when alert. ST X talked to the nurse during shift change and relayed the resident had rapidly declined over the past three days and questioned when the resident should be sent to the hospital. The nurse said he/she would call the doctor. ST X was concerned as the resident was at high risk for aspiration and concerned he/she had aspirated. On 12/13/24, late in the day, ST X woke the resident. He/She was kind of out of it. ST X cleaned his/her mouth, there were food in his/her mouth. ST X said PO intake doesn't appear safe and nobody told her the doctor didn't respond. ST X felt the physician should have been aware of her observations. ST X did not contact the physician. Under no circumstances should the resident have been left alone with a tray by himself/herself and regular liquid. ST X expected nursing to notify CNAs of recommendations. Review of the hospital record, dated 12/15/24, showed: -Arrival time 3:23 P.M. BP 100/69, heart rate 41 beats per minute, pulse 39, temperature 84.1 (rectal); -Radiology: chest-scattered bilateral ground glass opacities with pleural effusions which is favored to represent pneumonia; -3:58 P.M., ST called the family on Friday (12/12/24) that resident may be aspirating; -Diagnosed with shock, symptomatic bradycardia (slow heart rate), hypothermia (low body temperature) and unspecified anemia (low levels of healthy red blood cells to carry oxygen throughout your body). During an interview on 12/23/24 8:46 A.M., the Primary Care Physician (PCP) said she expected staff to follow the change of condition policy. She expected staff to follow physician orders, including special diets. If the resident is given food or liquids that do not follow a special diet, the resident would be at risk for aspiration. Staff should always follow ST recommendations. If the resident was given a meal to eat alone in his/her room with a drink that was not thickened, the risk is the resident could aspirate. Staff did not contact her regarding a change in condition reported to them by ST X on 12/13/24. The PCP expected to be contacted with any change of condition and if staff are unable to reach the PCP, staff should call the exchange and if unable to reach the exchange, staff should contact the Medical Director (MD). The outcome of the resident's health could have been managed better if the orders were followed and the resident was monitored more closely. During an interview on 12/23/24 at 10:08 A.M., the MD said staff did not contact her on 12/13/24 regarding the resident. She expected staff to follow orders. The outcome of the resident's health could have been managed if orders and recommendations orders were followed. During an interview on 12/23/24 at 2:24 P.M. the Administrator and Director of Operations said they expected staff to be knowledgeable of and to follow the facility's policies and procedures. The expected if a resident had a change of condition to notify the physician, nurse management, and the resident representative. They expected the change of condition and notifications to be documented in the resident's progress notes. They expected staff to follow physician orders including special diets and ST recommendations for feeding assistance. They said the health of the resident could have been better managed if the staff followed the physician orders and recommendations, however, the resident could have had the same outcome. They expect staff to follow all orders and recommendations for all residents. The Administrator said she was aware on 12/15/24 at 2:00 P.M., the second floor did not have a nurse on the resident's hall and was notified at 2:55 P.M. that LPN CC was doing a 911 call for the resident to send the resident to the hospital. They expected the on call nurse to follow up with nursing on the second floor to make sure everything was running smoothly on Sunday. 2. Review of Resident

See Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118.

See Event ID 0WE512. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24. Based on interview and record review, the facility failed to ensure staff were readily available to respond to residents' needs as evidenced by not answering call lights timely. One resident, with a history of bypass surgeries (Resident #24) was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. The resident was admitted to the hospital with atrial fibrillation (a-fib, abnormal heart rhythm characterized by a rapid and irregular heartbeat). Another resident (Resident #25) was returning from the hospital with EMS at the same time that Resident #24 was having chest pains and that EMS crew could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). The sample was 30. The census was 118.

See Event ID 0WE512. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time Resident #25 was having chest pains and that EMS crew also could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from neglect. Facility staff failed to provide prompt and adequate incontinence care. Four out of four sampled residents, who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), were observed with two incontinence briefs on, both of which were saturated and with strong odors of urine and feces. Three residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take several hours for staff to answer call lights. Additionally, facility staff neglected to respond to a call light for one resident, with a history of bypass surgeries (Resident #24) who was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time that Resident #24 was having chest pains and that EMS crew could not find staff readily available. Additionally, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. 1. Review of Resident #34's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/31/24, showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; and -At risk for pressure ulcers. -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -A strong odor of urine emitting from the room into the hall. -The resident lay in his/her bed on a low air loss mattress. -Registered Nurse (RN) D pulled the resident's bed covers down to show the resident wore two briefs. -The resident's outer brief was soaked with urine, with the padding in the brief in clumps. -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift. -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., Certified Nurse Aide (CNA) E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day. -He/She was the only CNA assigned to care for the resident on the hall. -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care. -He/She had just provided incontinence care to the resident. -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before he/she gave the resident incontinence care. 2. Review of Resident #33's admission MDS, a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night; -CNA E checked for incontinence by peeking in the resident's brief and by touching the resident's brief on the outside of his/clothes on his/her lower buttocks. If the CNA felt the brief was hard that meant the resident was incontinent and needed care. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it is inappropriate to feel the resident's brief through his/her clothing while they are walking down the hall to see if the resident is soiled. ADON M expected staff to provide privacy and to visually check the residents brief to see if the resident is soiled. It is inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition. -Wheelchair for locomotion. -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed. -Dependent on staff for chair/bed-to-chair transfers. -Always incontinent of bowel and bladder. -At risk for pressure ulcers. -Moisture Associated Skin Damage (MASD) present. -Pressure reducing device for bed. -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and bowel movement emitting from the room into the hall. -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned. -The resident lay in his/her bed on a low air loss mattress. -The resident wore two briefs which were soaked with urine. -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine. -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine-soaked areas. -The resident wore a hospital gown that was also urine soaked. -The resident had dried feces on his/her buttocks and inside of the inner brief. -The resident's mattress was visibly wet with urine. -The resident's bilateral buttocks were reddened. -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M. (eleven hours). -The staff did not usually provide incontinence care during the night shift. -Lying in a pool of urine on the wet sheet was annoying to the resident. -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD). -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M. -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care. -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time. -He/She only put two briefs on residents if they asked for them. -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet. -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff. -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine. -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting and personal hygiene: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day (almost 12 hours). The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. until 6:30 A.M. the following day. Night shift starts at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident. ADON M said he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported to ADON M that the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility' policies. ADON M expected staff to make rounds on the residents every two hours and know what residents they are responsible for each shift. 5. Review of Resident #31's quarterly MDS, dated [DATE], showed the resident: -Cognitively intact. -Rejection of care not exhibited. -Frequently incontinent of bowel and bladder. -At risk for pressure ulcers. -Diagnoses included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness and reduced mobility. Review of the resident's current care plan, showed: -Focus: ADL self-care performance deficit. -Goal: Resident requires assistance with ADL care and mobility. -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed. -Toilet use requires staff assistance of one. -Transfer requires staff assistance of one. -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff do not come in and offer to change him/her when he/she is soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The trash was just changed and was overflowing with soiled briefs and the staff member who came in and took the trash, threw a fit wanting to know why all the briefs were in the trash can. The resident then became tearful and said he/she is doing the best he/she can. The resident said it would be helpful if the staff would assist him/her in changing his/her brief when he/she is soiled but said staff will not assist him/her because there was not enough staff. The resident said it takes up to two hours for staff to answer his/her call light, if they come at all. The resident said staff do not pass or offer ice water. The resident said he/she has a small green cooler he/she keeps on his/her walker and the resident fills this small cooler up himself/herself. 6. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -11/9/21: Focus -ADL self-care performance deficit. Goal - Resident requires assistance with ADL care and mobility. Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24: Focus - Frequently incontinent bowel and bladder. Goal - Will remain free from skin breakdown. Interventions: Incontinent - Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she is incontinent of bowel and urine. Most nights, staff check him/her for incontinence one time, which is not enough. Staff tell him/her there is not enough help to check him/her more than once. If he/she turns on his/her call light, it can take hours for staff to answer it, or they will answer it, turn the call light off, then leave without taking care of him/her. It makes him/her feel bad when he/she is left wet for long periods. 7. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -8/22/23: Bladder incontinence related to impaired mobility. Goal: Will remain from skin breakdown due to incontinence and brief use. Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she is incontinent of bowel and bladder. Most night shifts, staff will check and change him/her twice at the most, sometimes only once, and in the past couple of weeks, there had been some nights no one came to check him/her at all. When he/she is checked once or not at all, he/she lays in a puddle of urine. Most nights, he/she is unable to turn on his/her call light because staff do not leave the call light where he/she can reach it. When the call light is in reach and he/she turns it on, it can take hours for someone to answer it. He/She feels ignored by staff. 8. Review of Resident #24's electronic medical record (EMR), showed: -Diagnoses of high blood pressure and a-fib. -A progress note, dated 9/27/24 at 3:47 A.M., and documented by Licensed Practical Nurse (LPN) N: This nurse was notified that resident called 911 stating he/she was having chest pain. His/Her chest felt like it was filling with water. EMS arrived asking resident why he/she did not turn on his/her call light for this nurse to evaluate him/her. Resident stated he/she just wanted to go to the hospital. Resident transferred to stretcher going to hospital for evaluation. No signs or symptoms noted. Review of the staffing schedule for the night shift of 9/26/24 (the shift started at 11:00 P.M. on 9/26/24 and ended at 7:00 A.M. on 9/27/24), showed one nurse working on the two units on the first floor where Resident #24 resided. Review of the resident's Des [NAME] Department of Public Safety report (EMS/ambulance report) dated 9/27/24, showed: -911 Caller: Resident #24. -Alarm: 3:15 A.M. Dispatched: 3:17 A.M. Arrived: 3:21 A.M. -3:34 A.M.: Had to wake up staff to locate the resident. -3:36 A.M.: Caller (resident) states he/she has been having chest pains for 45 minutes. -3:37 A.M.: Attempted to contact staff two times no answer to locate resident's room number. -3:38 A.M.: EMS has been on the scene for over 10 minutes at the front door. -3:40 A.M.: Staff was contacted a third time and finally picked up. Dispatch advised that DSFD (Des [NAME] Fire Department) was on scene and ambulance was there for over 10 minutes. Staff was asked to check a resident name for a room number. They advised they would have to go downstairs and look for it. -Narrative: Upon arrival, observed Resident #24 laying supine (on the back) in bed. The resident could speak without deficit and appeared to be stable. The resident advised he/she was having substernal (behind the breastbone) chest pain that did not radiate for approximately and hour and a half. Resident advised he/she tried to call staff for approximately one hour however, no one would answer his/her call light. It should be noted, staff was found sleeping in the hallway wrapped in blankets sleeping and other staff members coming in from their vehicles in the parking lot. An ECG was conducted at which time A-fib was observed. The resident was provided with 324 milligram aspirin orally. During transport (to the hospital) no changes in the resident's vitals were observed. -Call closed at 4:12 A.M. During an interview on 9/27/24 at 7:29 A.M., Emergency Medical Technician (EMT) AA said they had been at the facility for 10 minutes and could not find any staff. Dispatch called the facility and did not get an answer. Upon entrance to the facility, several call lights were flashing and there was no staff in sight. While walking around trying to find the resident's room, the paramedics saw a someone curled up on the couch, asleep. Resident #24 said he/she yelled for help for 10 minutes. When they didn't respond, he/she called 911. Two staff eventually appeared, and several staff were seen exiting their cars and returning to the building. The lights were off at the nurse's station and one of the staff had to restart the computer to get the resident's face sheet. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she worked on the night shift of 9/26/24. He/She worked on the same floor, but not the same unit where the resident resided. During that shift EMS was in the building and said they had been looking for staff because the resident had called them and said he/she was having chest pain. He/She also saw a policeman in the building at the same time EMS was in the building. He/She was not sleeping on duty and did not see other staff sleeping. 9. Review of Resident #25's EMR, showed: -admission date of 9/8/24. -Diagnoses of syncope (fainting), vertigo (light headed/dizziness), A-fib and cognitive communication deficit; -A progress noted dated 9/26/24 at 8:36 P.M.: Resident complained of feeling like he/she did when he/she had a brain bleed. He/She said he/she wants to go to the hospital for evaluation. Physician and DON notified. -A progress note dated 9/27/24 at 3:37 A.M.: Resident returned from hospital. Family arrived with resident. During an interview on 9/27/24 1:50 P.M., Family Member (FM) MM said he/she arrived at the facility from the hospital on 9/27/24 at 3:30 A.M. The Des [NAME] Police Department (PD) and ambulance were in the building. The paramedic said they had been walking around trying to find staff and the resident who called the police for 20 minutes. There were call lights going off. Another resident was having chest pain, had his/her call light on, and when no one answered it, he/she called 911. FM M walked around with the paramedics for an additional 20 minutes before staff came out of a dark room. During an interview on 10/31/24 at 8:17 A.M., the Director of Nursing (DON) said no one told her the paramedics and police could not locate staff when they responded to Resident #24's emergency call or when Resident #25 returned to the facility. No one told her a staff member was found sleeping by the EMS crew. If they would have called her, she would have come in at that time and began an investigation as to why the staff could not be found and why a staff member was sleeping on duty. 10. Review of Resident #20's EMR, showed: -admission date of 9/9/24. -Diagnoses included: Heart failure, below the knee amputation (BKA) of right leg and diabetes mellitus. Review of the resident's progress notes, showed: -On 9/11/24, at 7:15 P.M., Fire and Ambulance arrived, making nurse aware 911 had been called for the resident's room. This nurse approached room noting this resident in bathroom on toilet. Two EMTs entered the restroom to assess resident. Resident stated he/she would like to be transported to ED for eval for pain. Resident left facility at this time remaining alert and able to make needs known. During an interview on 9/27/24 at 12:09 P.M., EMT AA said EMS was dispatched to the facility on Labor Day weekend and staff were seen sleeping. The residents were complaining they had not received their medication. The agency staff said there was not a nurse in the building, and they didn't pass meds, because the residents were new admits and they had not received their meds from the pharmacy. Review of the resident's hospital ED records, showed: -Arrival Date/Time: 9/11/24 at 6:20 P.M -Chief Complaint: [TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118. Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing (DON). Review of the facility's Certified Nurse Aide (CNA) job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Review of Resident #33's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Always incontinent of bowel and bladder; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's care plan during the survey, showed: -Focus: ADL, self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; During an interview and observation on 10/28/24 at 4:23 A.M., the resident lay in bed on his/her right side. Registered Nurse (RN) D said residents do not get changed often on the night shift. RN D pulled the white quilt back and pulled the resident's sweatpants down. Observation showed the resident wore two briefs. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. Before exiting the room, RN D went to wash his/her hands in the resident's bathroom and there was a large amount of dried feces on the left side of the toilet seat. During an interview and observation on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident took himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it. He/She pulled the resident's sweatpants down which showed the resident wore two briefs. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident had the outer brief over the pull up, because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she walked down the hall because the resident took himself/herself to the bathroom. CNA E said he/she glanced, peeked at the resident when he/she walked down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees. The resident's shirt was wet up to his/her waist and below his/her elbows. CNA E walked and guided the resident to the bathroom. When CNA E entered the bathroom there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet. ADON M had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet as the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. The resident had no open areas or red areas. CNA E did not change the resident during the night shift. During an interview on 10/28/24, at 6:05 A.M., CNA E, said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident walked the halls last night; -CNA E checked for incontinence by peeking in the resident's brief. He/She also touched the resident's brief on the outside of his/clothes, on his/her lower buttocks. If the CNA felt the brief was hard it meant the resident was incontinent and needed care. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it was inappropriate to see if the resident was soiled by feeling the resident's brief through his/her clothing while the resident walked down the hall. ADON M expected staff to provide privacy and to visually check the resident's brief to see if the resident was soiled. It was inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 2. Review of Resident #34's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheel chair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast; -Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder; -Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the resident's room into the hall; -The resident lay on his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24, at 4:35 A.M., RN D said: -He/She did not think the resident was changed during the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and was lying in urine extending up to his/her shoulders. During an interview on 10/28/24, at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was assigned to care for the resident; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident was lying on a wet absorbent pad before CNA E gave the resident incontinence care. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder. Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility; -Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections; -Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility; -Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Review of the resident's progress notes, showed no documentation the PCP or RRP was alerted to a change in the resident's skin or that a new order for treatment was obtained. Review of the resident's weekly skin assessment, dated 10/21/24, showed no new skin issues noted. There was no documentation to show existing skin issues. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and feces emitting from the resident's room into the hall; -The odor of urine and feces was strong upon entry into the room; -The resident was lying in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident was lying on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident was wearing a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24, at 4:52 A.M. and at 5:06 A.M., the resident, said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24, at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected moisture associated skin damage (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24, at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed no documentation of skin issues at the resident's buttocks or groin. During an interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time earlier this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had on two briefs. The resident said it depended on what staff changed him/her if they put one or two briefs on. The resident said it seemed like they put two briefs on all the time. The resident said he/she was changed and repositioned one time each shift, but needed changed and repositioned more often. The resident said when he/she turned his/her call light on it took an hour to an hour and a half before staff responded to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid with approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed out each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had on two briefs and the briefs were soaked with urine. RN D said it was not appropriate for any resident to have on two briefs. If a resident wore two briefs, staff could think the resident was dry by only looking at the outer brief. If residents were left soiled for an extended periods of time it could cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., with the resident, showed: -He/She wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs as they were uncomfortable, too tight between his/her legs and cut into his/her groin. During an interview on 10/31/24 at 7:23 A.M., ADON M expected residents to be rounded on every two hours. ADON M expected residents to only have one brief on. The resident's skin integrity was at risk due to the moisture. It could cause skin break down because the briefs did not allow for oxygen to get to the skin. It was imperative to only use one brief on residents. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Eating and oral hygiene: Partial moderate assistance (helper does less than half the effort); -Frequently incontinent of bladder; -Always incontinent of bowel; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident wore two briefs. The inner brief was brown and saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she did not like to be soiled for extended periods of time. The resident also said his/her family got ice water for him/her on the days they were at the facility. On days the family was not at the facility, the resident was not offered ice water. During an interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., the resident, said: -There was a cup with approximately four inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -Staff last checked on the resident around 6:00 A.M. that morning. The resident was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup as it sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief, and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident was lying on an absorbent pad that was also saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings extending up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J who was sitting in the hallway and asked CNA J who had the resident. CNA J responded the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. He/She said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 A.M. the following day. He/She said night shift started at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident but he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility's policies. ADON M said he/she expected staff to make rounds on residents every two hours and know what residents they were responsible for each shift. 5. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -11/9/21, Focus: ADL self-care performance deficit; -Goal, Resident requires assistance with ADL care and mobility; -Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24, Focus: Frequently incontinent bowel and bladder; -Goal: Will remain free from skin breakdown; -Interventions: Incontinent. Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she was incontinent of bowel and bladder. It was not uncommon for staff to put two incontinent briefs on him/her on the night shift, which he/she did not mind. Most nights staff checked him/her for incontinence one time, which was not enough. Staff told the resident there was not enough help to check him/her more than once. If he/she turned on his/her call light it could take hours for staff to answer it. Or, they would answer it, turn the call light off and leave without taking care of him/her. It made him/her feel bad when he/she was left wet for long periods. 6. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the EMR, showed: -8/22/23, Focus: Bladder incontinence related to impaired mobility; -Goal: Will remain from skin breakdown due to incontinence and brief use; -Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she was incontinent of bowel and bladder. Most night shifts, staff would check and change him/her twice at the most; sometimes only once. In the past couple of weeks there had been some nights no one came to check him/her at all. Sometimes staff put two incontinent briefs on him/her but he/she would prefer only one. When he/she was checked once or not at all, he/she laid in a puddle of urine. Most nights he/she was unable to turn on his/her call light because staff did not leave the call light where he/she could reach it. When the call light was in reach and he/she turned it on, it could take hours for someone to answer it. He/She felt ignored by staff. 7. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care not exhibited; -Frequently incontinent of bowel and bladder; -Diagnosis included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Review of the resident's care plan during the survey, showed: -Focus: ADL self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed; -Toilet use requires staff assistance of one; -Transfer requires staff assistance of one; -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff did not come in and offer to change him/her when he/she was soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The resident said the trash was just changed and was overflowing with soiled briefs. The staff member who came in and took the trash threw a fit and wanted to know why all the briefs were in the trash can. The resident then became tearful and said he/she was doing the best he/she could. The resident said it would be helpful if the staff assisted him/her to change his/her brief when soiled, but said staff would not assist him/her. The resident said it took up to two hours for staff to answer his/her call light if they came at all. The resident said staff did not pass or offer ice water. The resident said he/she had a small green cooler he/she kept on his/her walker. The resident filled this small cooler up himself/herself. 8. During an observation on 10/31/24 at 6:44 A.M. a resident walked up to the ice chest next to the nurse's station and opened the lid and said there was no ice in the cooler. The cooler was half full of water at that time. The resident made the comment that he/she last received ice before he/she went to bed. 9. During an interview on 10/28/24, at 4:10 A.M., RN D, said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care; -He/She had not told the Administrator or DON, as he/she understood they were already aware; -He/She had to wake CNA F around 1:00 A.M. to answer call lights. CNA F was sleeping at the nurses' station in a chair with a blanket; -He/She found CNA E asleep in a bed in an un-occupied resident room at 3:30 A.M.; -The CNAs typically started to round on residents at 5:00 A.M. to clean up the residents before day shift came in. During an interview on 10/28/24 at 5:18 A.M., CNA F said rounds should be completed every two hours. While making rounds residents were checked to see if they need to be changed, repositioned, trash was checked to see if it needed to be taken out and see if the residents needed fresh ice and water. CNA F said he/she completed rounds on night shift between 11:30 P.M. and 12:00 P.M., 2:00 A.M. and 5:00 A.M. CNA F said if residents wore two briefs, it helped the urine not go all the way to the resident's back. CNA F said it was not normal to put two briefs on residents. He/She would only put two briefs on a resident if they requested it. CNA F said when a resident had two briefs on it was hard to determine if the resident was wet. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift was from 11:00 P.M. to 7:00 A.M. and rounds were completed two times before 5:00 A.M. When he/she came in at 11:00 P.M. he/she made rounds with the evening shift CNA. During rounds he/she checked to see if residents needed ice water, tv remote, call light, if the residents needed to be changed or taken to the bathroom and made sure the residents were breathing. If a resident had on two briefs it was not good because the outer brief could look dry and the inner brief could be wet. He/She would be reluctant to change them if the resident looked dry. If residents were not changed it could cause them to get red bottoms or bed sores. CNA F said when there was only one CNA on each side and one nurse it took a long time to answer call lights. CNA F said if four to five call lights were on he/she would quickly go to each person with a call light on to make sure there was not an emergency like slipping off the bed or a fall. CNA F said he/she would then start changing the first resident that had the call light on. It took up to 20 minutes to change one resident because he/she had to go to the room see what he/she needed, then go to the clean utility closet and get supplies, then go back to the resident's room to clean and change the resident. CNA F said it could take up to an hour and forty minutes to answer a call light at times. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes some residents wore two incontinent briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:16 A.M., the Administrator and DON said they expected call lights to be answered within 15 to 20 minutes. They said it was not appropriate for residents wait for a call light to be answered over the period of one to two hours. If a resident waited one to two hours for a call light to be answered there was a risk if the resident needed to use the restroom, they could attempt to take themselves and fall. They wanted call lights answered as promptly as possible because the staff did not know what the resident needed. Ice water should be passed every shift at a minimum and more if needed. It was not appropriate to feel a resident's brief through the resident's clothing in the hallway to check and see if the resident was soiled. MO00242946 MO00241933 MO00243961

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy by failing to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and perform wound treatments for three of three residents sampled (Residents #10, #8 and #1). The facility also failed to assess a resident at the time of admission for one of three sampled residents (Resident #18). The census is 129. Review of the facility Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: Wound Management: -Wound treatment will be provided in accordance with physician's orders: Cleansing method, type of dressing and frequency of dressing change; -Charge Nurse will notify physician in the absence of treatment orders; -Wound dressings will be applied in accordance with manufacturer's recommendations; -Wound Characteristics/Documentation: Location of the wound. Size (shape, depth, tunneling and/or undermining), volume and drainage characteristics. Pain evaluation. Condition of the wound bed. Condition of the peri-wound (skin surrounding the wound); -Guidelines for Dressing Selection: Obtain physician's order; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of the treatments will be monitored through ongoing evaluation of the wounds. Review of the facility Physician Orders policy, last reviewed on 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Responsibility: Licensed Nursing, Administration, and Director of Nursing (DON); -Procedure: Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders. Physician orders must be documented clearly in the medical record. Physician orders must be documented clearly in the medical recorded. Physician orders will be transcribed to the appropriate administration record electronic medication administration record (eMAR) or electronic treatment administration record (eTAR). Review of the facility's Admission/readmission Assessment policy revised 1/24/19, showed; -Policy: Residents are to be evaluated upon admission or readmission; -Procedure: Complete the section for skin. Review of the Licensed Practical Nurse (LPN) job description, revised 5/2022, showed: Essential Functions of LPN: Assesses and documents the resident's condition and nursing needs. Performs treatments for assigned residents. Documents treatments as required. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/24, showed: -admission date 7/5/24; -Diagnoses included high blood pressure, peripheral vascular disease (lack of blood flow to the legs), diabetes, high cholesterol and stroke; -Cognitively intact; -Wounds. Review of the resident's eTAR, dated September 2024, showed: -An order, dated 9/7/24, at 3:00 P.M., both lower extremities cleanse with wound cleanser, apply betamethasone valerate 0.1% ointment (a steroid that treats inflammation), cover with silicone dressing gauze and wrap with kerlix (gauze) every evening shift, every other day; -On 9/15/24 the treatment was documented as completed. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's treatment to both lower extremities. Observation on 9/16/24 at 6:52 A.M., showed the resident lay in bed. The resident said the dressings on his/her legs were not being done like the doctor said. The resident pulled the cover back and there were three dressings: left knee dated 9/14, dressing to right lower extremity dated 9/14 and left lower extremity dated 9/14. Certified Nursing Assistant (CNA) C read the dates on the dressing and confirmed the dates. Observation on 9/17/24 at 6:59 A.M., showed the resident lay in bed. The resident said the nurse came in and changed his/her dressings that morning around 5:30 A.M. The resident pulled the covers back and all three dressings were dated for 9/16. Observation on 9/17/24 at 3:49 P.M., showed the resident informed the wound doctor and wound nurse the dressing had not been changed on schedule. The wound nurse said the date showed 9/16, but the resident said the dressings were done that morning around 5:30 A.M. Observation on 9/18/24 at 8:08 A.M., showed the resident lay in bed. He/She reiterated the dressings were changed yesterday morning, and he/she remembered the nurse's name. During an interview on 9/18/24 at 8:15 A.M., LPN D said he/she changed the dressings on the resident the morning of 9/17/24, but could not recall the time. During an interview on 9/18/24 at 12:22 P.M., LPN E said dressings should be done as ordered by the physician and should be dated and initialed when the dressing was applied. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation was the nurses performed wound dressing changes as ordered to, initialed and dated the dressing when completed, and document the treatment had been completed. 2. Review of Resident #8's admission face sheet, showed: -admission date of 9/4/24; -Diagnoses of cellulitis (a bacterial skin infection) of left lower limb, malignant (cancerous) melanoma (skin cancer) of the left lower limb, high blood pressure and renal (kidney) disease. Review of the resident's skin observation tool, located in the electronic medical record (EMR), showed: -Date: 9/9/24 at 3:25 P.M., and Lock Date 9/16/24 at 3:30 P.M.: No documentation about a skin tear on the resident's left wrist/hand area. Review of the resident's progress note, located in the EMR, showed on 9/12/24 at 11:58 P.M., LPN G documented the resident slid to the floor onto his/her bottom while attempting to ambulate with walker to the restroom. Resident stated he/she became weak and slid to the floor. Zero complaints of pain or discomfort upon assessment. The documentation did not show the resident sustained any injuries as a result of the incident. Observation on 9/16/24 at 7:03 A.M., showed the resident lay in bed with a dressing on his/her left wrist/hand. The dressing was dated 9/12/24. The resident said the skin tear occurred when he/she fell a few days ago. No one had changed the dressing since 9/12/24. Review of the resident's Physician's Order Summary (POS) and TAR on 9/17/24, showed no order for a skin tear to the resident's left wrist/hand. During an interview on 9/17/24 at 10:35 A.M., LPN G said the resident fell on 9/12/24, and obtained a skin tear on his/her left wrist/hand. He/She cleaned the skin tear, applied a dressing and wrote the date 9/12 on the dressing. He/She should have contacted the physician and got an order and entered the order on the POS and TAR. LPN G got busy and forgot. The resident was admitted to the hospital yesterday and was not available for observation of the skin tear. During an interview on 9/18/24 at 12:47 P.M., the DON said LPN G should have assessed the resident's skin tear, called the physician, obtained an order and entered the order on the POS and TAR. All of that should have been documented. Normally a skin tear treatment would be ordered to be changed daily. If the order was not entered on the TAR, the EMR system would not alert the nurses to change the dressing. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Diagnoses of Alzheimer's Disease, anxiety disorder and depression. Review of the resident's POS, showed: -An order dated 8/24/24, to cleanse right lateral forearm, clean with wound cleanser. Apply A&D ointment (a skin protectant that helps treat and/or prevent diaper rash/chapped skin) and wrap with kerlix, change every other day; -An order dated 8/29/24, to right proximal (located close/nearby) posterior (located behind) leg, clean with wound cleanser. Apply A&D ointment and wrap with kerlix, change dressing every other day. Review of the resident's TAR, showed the treatments initialed as completed every other day. Observation on 9/16/24 at 7:05 A.M., showed the resident had an undated dressing to the right lower extremity and right upper extremity. During an interview on 9/18/24 at 12:22 P.M., LPN E said dressings should be done as ordered by the physician and should be dated and initiated when the dressing is applied. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation was for nurses to perform wound dressing changes as ordered and initial and date the dressing when completed, and document the treatment had been completed. 4. Review of Resident #18's admission MDS, dated [DATE], showed the following: -admission date of 9/4/24; -Cognitively intact. Review of the resident's medical record, showed diagnoses included hip fracture, high cholesterol, diabetes and anxiety disorder. Review of the resident's admission nursing assessment, dated 9/5/24, showed no assessment of a surgical wound to the right hip. Review of the resident's POS, showed no order for a dressing to the surgical incision to the right hip. Review of the resident's telephone hospital discharge summary to the nurse, not dated, showed: -Gauze dressing as needed; -Bruising to the right leg. Observation and interview on 9/16/24 at 6:52 A.M., showed the resident had an undated dry dressing to the right hip. The dressing appeared to be old and the tape was soiled. The resident said that he/she did ask the nurses about the dressing this morning because he/she had a follow up with the orthopedic surgeon today. The response from the nurse was to let the doctor remove the dressing. Observation and interview on 9/16/24 at 7:14 A.M., showed the resident had an undated dry dressing to his/her right hip. The dressing appeared to be old and the tape was soiled. The resident said the nurses had not changed the dressing since he/she arrived at the facility. During an interview on 9/18/24 at 12:22 P.M., LPN E said a resident should be assessed from head to toe during an admission assessment and any dressings or surgical wounds should be noted on the assessment. If a resident has a dressing in place during the assessment and there is no order, the nurse should call the doctor for clarification. Surgical wounds should be assessed daily for drainage and infection. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation is the nurses perform a complete skin assessment when a resident admits to the facility. The nurses should note any dressings and wounds and clarify with the physician for treatment orders. Surgical wounds should be looked at daily and documented. MO00240093 MO00241424 MO00241889

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time Resident #25 was having chest pains and that EMS crew also could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. Review of the Facility Assessment, dated 8/2/24, showed: -Purpose: The Facility Assessment is a complete review of the internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider. The Facility Assessment will be the basis for surveyors to ascertain whether your are prepared to competently take care of the population you have identified that you serve; -There are three components to the review: -1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethic/cultural/religious factors that impact care; -2. Services and care offered based on resident needs; -3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, and education and training; -The assessment is not intended to be a static tool but is intended to be a living document. It should include the business plan, staffing plan, the types of resident served, and the resources and physical plant required to competently care for the identified populations; -People Involved in Completing: Administrator, Director of Nursing (DON), Maintenance Director, Human Resources/Payroll Director, Activities Supervisor, Social Services Director and Medical Director; -Resident Profile: Average daily census - 120-130; -Special Treatments and Conditions (a daily average): Radiation - 0-2, Oxygen Therapy - 20-30, Suctioning - 0-5, Tracheostomy Care - 0-5, Behavioral Health Needs (including wandering, aggression, anxiety, depression, socially inappropriate) - 50-60, Active or Current Substance Use Disorders - 15-25, Intravenous (IV) Medications - 10-15, Injections - 20-30, Advanced Wound Care Needs - 10-20, Dialysis - 10-20, Ostomy Care - 0-5, Hospice Care - 0-10, and Isolation or Quarantine for Active Infectious Disease - 0-20; -Assistance with Activities of Daily Living (ADLs): Bed Mobility Sit to Lying - Supervision/Partial/Moderate Assist (86 residents) and Dependent/Maximum Assist (15), Mobility Sit to Stand - Supervision/Partial/Moderate Assist (92) and Dependent/Maximum Assist (19), Bathing - Supervision/Partial/Moderate Assist (96) and Dependent/Maximum Assist (34), Transfers - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (14), Eating - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (6), Toileting - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (12); -Current Staff on Payroll: Licensed Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)) 20-28, Nurse Aides (Certified Nursing Assistants (CNAs)) 30-40, Other nursing personnel (e.g., Administrative Duties) 7; -The assessment did identify how many nurses and/or CNAs were needed to provide prompt and adequate care by shift (day shift 7:00 A.M. - 3:00 P.M., evening shift 3:00 P.M. - 11:00 P.M. and night shift 11:00 P.M. - 7:00 A.M.). Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing. Review of the facility's CNA job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Observation during the initial tour of the facility on 10/28/24 at 4:00 A.M., showed two nurses on duty (one nurse was assigned to the two units downstairs, and one nurse was assigned to the two units upstairs) and five CNAs on duty (two CNAs assigned downstairs and three CNAs assigned upstairs). Review of the facility census report, dated 10/27/24, showed the following: -Joliet (downstairs unit): 22 residents; -[NAME] (downstairs unit): 38 residents; -[NAME] (upstairs unit): 31 residents; -Tranquility (upstairs unit): 27 residents. During an interview on 10/28/24 at 4:10 A.M., RN D said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were only two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them and the residents were neglected; -He/She did not feel the staffing ratio to residents was safe for the employees or the residents; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care. During an interview on 10/28/24 at 5:17 A.M., and 5:30 A.M., CNA F said he/she began work yesterday around 11:00 P.M. He/She worked on one of the two upstairs units. He/She was the only CNA working that unit, which is not unusual. It was difficult to give care to all his/her residents last night due to the lack of staff. If it's just him/her working, he/she cannot check the residents every two hours or answer the call lights timely. He/She can only check the residents two times at the most. When there are two CNAs on the unit, he/she is able to check the residents every two hours and is able to answer the call lights more promptly. During an interview on 10/28/24 at 6:13 A.M., Assistant Director of Nursing (ADON) M said there should be three to four CNAs working upstairs and downstairs on night shift and there should be one to two nurses upstairs and downstairs for night shift. ADON M said he/she was on call last night and did not receive any calls regarding staffing concerns. ADON M said he/she was not aware the facility only had one nurse upstairs and downstairs and two CNAs upstairs and downstairs. ADON M said if staff would have contacted him/her, he/she would have come into the facility to assist or would have given staff extra directions. ADON M said if the facility does not have the appropriate amount of staff, it could cause a deficit to resident care. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses because it would not do any good. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift is from 11:00 P.M. to 7:00 A.M. and rounds are completed two times before 5:00 A.M. When he/she comes in at 11:00 P.M., he/she makes rounds with the evening shift CNA. During rounds, CNA F checks to see if the resident needs ice water, remote, call light, see if the residents need changed or taken to the bathroom and to make sure the residents are breathing. If a resident has on two briefs, it is not good for the resident because the outer brief can look dry and the inner brief could be wet. CNA F would be reluctant to change them if the resident looked dry. If residents are not changed, it can cause them to get red bottoms or bed sores. CNA F said when there is only one CNA on each side and one nurse, it takes a long time to answer call lights. CNA F said if four to five call lights are on, he/she will quickly go to each person with a call light on to make sure there is not an emergency like they are slipping off the bed or have fallen. CNA F will then start changing the first resident who had the call light on. It takes up to 20 minutes to change one resident because he/she has to go to the room see what he/she needs, then go to the clean utility closet and get supplies, and then go back to the resident's room to clean and change the resident. CNA F said it can take up to an hour and forty minutes to answer a call light at times. CNA F said sometimes when you go back to the resident who had the call light on, they have called 911 and say nobody was answering their call light. CNA F said sometimes staff on night shift will fall asleep and when it happens the first time, they are given a warning. If it happens a second time, they would get fired. CNA F said sometimes when sitting in a chair if it is quiet at night, staff can doze off but it does not happen often. If a resident is a two person assist, then CNA F has to go and find another staff member to assist and the resident has to wait on care to be provided. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work, he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes, some residents wore two incontinence briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:30 A.M., the Administrator said based on current resident acuity levels identified in the Facility Assessment, the facility needs the following number of staff on the midnight shift: -One nurse on all four units for a total of 4 nurses; -Three CNAs for the two units downstairs (one on each unit and to one split between the two units); -Four CNAs on the two units upstairs (two on each unit) for a total of seven CNAs on night shift. Four nurses and seven CNAs total are needed to ensure residents receive appropriate care in a timely manner. There should always be at least one staff member on each unit at all times. Review of the facility nursing staffing reports (staff in/out time punches) for the midnight shifts from 10/14/24 through 10/29/24, showed the facility failed to provide the Administrator's expected staffing (four nurses) on the following dates: 10/16, 10/17, 10/18, 10/19, 10/21, 10/22, 10/23, 10/24, 10/25 and 10/27/24. Review of the facility nursing staffing reports for the midnight shift from 10/14/24 through 10/29/24, showed the facility failed the Administrator's expected staffing (seven CNAs) on the following dates: 10/14, 10/16, 10/18, 10/19, 10/23, 10/24, 10/25, 10/26, 10/27 and 10/28/24. During an interview on 10/31/24 at 6:09 A.M., LPN A said he/she worked the night shift last night. He/She was the only nurse working the two downstairs units. There is supposed to be one nurse for each unit. If he/she is covering just one unit, he/she can get everything done even if something unexpected happens. If he/she is covering both units, he/she can get everything done, but it may not be timely. If something unexpected happens while he/she is covering two units, he/she may not be able to get everything done. It is not too often that three CNAs are scheduled for the two downstairs units. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. 2. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and ADON M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. CNA E did not change the resident during the night shift. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. - this interview is listed under #1. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; -At risk for pressure ulcers; -No skin issues present; -Pressure reducing device for bed; -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the room into the hall; -The resident lay in his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was the only CNA assigned to care for the resident on the hall; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before CNA E gave the resident incontinence care. 4. Review of Resident #45's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -Moisture Associated Skin Damage (MASD) present; -Pressure reducing device for bed; -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -There was a strong odor of urine and bowel movement emitting from the room into the hall; -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned; -The resident lay in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident wore a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside of the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed there was no documentation found of skin issues at the resident's buttocks or groin. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time in the early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 5. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. Review of the resident's forms list on 10/31/24 at 12:44 P.M., showed no Braden assessment completed for the resident in 2024. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 [TRUNCATED]

Based on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107. Review of the facility's Resident Rights policy, dated 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. The Resident/Resident Representative will be informed on their rights upon admission; -Procedures: -Employees will receive education and training on resident rights upon hire and annually; -The Administrator/designee will process concerns with resident rights; -Resident Rights: -Exercise rights; -Planning/implementing care; -Respect and dignity; -Self-determination; -Safe environment. Review of Resident #89's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/23, showed: -Cognitively intact; -Exhibited no behaviors; -Dependent on staff for personal hygiene, showers, toileting hygiene and transfers. Helper does all of the effort; -Always incontinent of bowel and bladder; -Diagnoses included cancer, diabetes and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). Review of the resident's undated care plan, in use during the time of the investigation, showed: -Focus: The resident has bowel and bladder incontinence related to impaired mobility; -Goal: The resident will remain free from skin breakdown due to incontinence and brief use; -Interventions: Clean peri-area with each incontinent episode. Resident prefers/request to use two briefs at night due to increased incontinence; -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, bilateral hand contractures and requires assistance with mobility; -Goal: The resident will demonstrate appropriate use of adaptive devices to increase ability with ADLs through the review date; -Interventions: Personal hygiene routine. The resident prefers his/her family member to assist with shaving. The resident would like for staff to offer assist with shaving if family is not available. Bed mobility. Requires staff assistance to turn and reposition in bed. Observation on 3/5/24 at 9:35 A.M., showed a strong odor of BM present at the doorway of the resident's room. The resident's call light was pressed. The resident lay in bed on his/her back. He/She emitted a strong smell of urine and BM. A towel soiled with BM was on the floor near the resident's bed. The resident's trash can did not have a trash can liner, and contained wadded up paper. A brown substance was smeared on the inside of the trash can. The resident's bed was in the center of the room. To the left of the resident's bed was a nightstand, approximately one foot away from the head of the resident's bed. On top of the nightstand sat an unsealed bag. Observation of the bag, showed approximately three used briefs, filled with BM, in the open plastic bag. During an interview on 3/5/24 at 9:36 A.M., the resident said he/she pressed his/her call light earlier during the morning, and no one came to check on him/her. He/She had a bowel movement and needed to be changed. Observation and interview on 3/5/24 at 9:37 A.M., showed Certified Nursing Assistant (CNA) Q responded to the resident's call light. The resident said he/she needed to be changed. When shown the bag on the resident's nightstand, close to the resident's head, CNA Q said the bag contained used briefs filled with BM. He/She tied the bag and removed it from the resident's nightstand. When shown the trash can, CNA Q said BM was in the trash can and the trash can needed a liner. He/She was not sure who left the bag of soiled briefs on the nightstand and had not changed the resident's trash can from earlier that day. CNA Q said he/she would get the resident cleaned up. Observation and interview on 3/5/24 at 10:51 A.M., showed the resident lay in bed on his/her back. The bag of briefs soiled with BM had been removed from the resident's room. The soiled towel remained on the floor in the resident's room. The trash can still contained the smeared BM on the inside, with no liner. The resident said the aide cleaned him/her up and said he/she would return to get the resident up and in his/her wheelchair. On 3/4/24, he/she was changed around 2:00 P.M., after lunch. He/She pressed the call light during the evening shift, and no one responded. After a change in shift, around 11:45 P.M., he/she was changed again. The resident said he/she always smelled of urine and BM and was used to it. He/She had not been changed until 9:37 A.M. on 3/5/24, after the surveyor arrived in the resident's room. He/She had a spinal cord injury and could not turn his/her head to see the bag of dirty briefs on the nightstand. The resident said the aide must have left the briefs in the resident's room the night before and could not recall who the aide was. He/She smelled odors of BM and urine, but thought it was him/her because staff rarely cleaned him/her. The resident said he/she was afraid of the situation being addressed because of fear of retaliation. He/She said since the last survey, things had gotten worse and the resident felt it was retaliation because he/she spoke with the surveyors. He/She said staff already did not do anything prior to the first survey, but it had gotten worse. He/She said, I have to survive here. The resident pressed his/her call light for assistance to get out of bed and into his/her wheelchair. The resident had tears in his/her eyes during the interview. Observation on 3/5/24 at 11:01 A.M., showed CNA Q and CNA M arrived and said they would get the resident into his/her chair. The aides transferred the resident using a mechanical lift and sat the resident in the wheelchair. CNA M left as CNA Q placed a blanket over the resident. CNA Q obtained a trash can liner and placed it into the trash can. He/She did not clean the inside of the trash can and the smear of BM remained. CNA Q adjusted the resident's movable nightstand and placed the call light, a cup of water and television remote control within reach, then left the resident's room. Observation on 3/5/24 at 11:22 A.M., showed the Administrator walked past the resident's room. The surveyor showed the BM smeared trash can to the Administrator. She said it was absolutely unacceptable and removed the trash can from the resident's room. The odor remained in the resident's room. During an interview on 3/6/24 at 11:40 A.M., the Administrator said residents should be treated with dignity and respect. It was unacceptable for a bag of dirty briefs to be present in the resident's room. Staff should have removed the briefs after providing care to the resident. The resident's trash can should have been removed and cleaned after the aide discovered the smear of BM in the trash can. The resident should be able to express concerns without fear of retaliation. MO00231882 MO00231534

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID # MK6L13. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 11/16/22. Based on observation, interview and record review, the facility failed to ensure pain management by not following physician orders or assessing pain for two residents (Resident #20 and Resident # 29) who required such services. The sample was 3. The census was 98. Review of the facility's Physician Order policy, dated 9/28/22, showed the following: -Purpose: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, State and Federal guidelines; -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available. Review of the facility's Pain Management Policy, last review date 11/15/22, showed: -Policy: The facility will use a systematic approach to pain management; recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management. The facility will provide employees education on pain management & opioid overdose; -Responsibility: nursing personnel, nursing administration, and Director of Nursing (DON); -Procedure: Recognition: -1. Evaluate/Prevent: -Recognize when resident is experiencing pain and identify circumstances when pain can be anticipated; -Evaluate resident for pain on admission and routine evaluations; -Manage/Prevent pain, consistent with the comprehensive evaluation and plan of care; -Current professional standards of practice, and resident's goals/preferences; -2. Observe for nonverbal indicators: -Change in gait (e.g., limping), skin color/perspiration, vital signs (V/S) (e.g., increased pulse, respirations, blood pressure); -Loss of function or decline in activities of daily living (ADL) (e.g., rubbing a specific location of the body, or guarding a limb); -Fidgeting, increased restlessness; -Facial Expressions (e.g., grimacing, frowning, clenching of the jaw); -Behavioral Changes (e.g., pacing, irritability, depressed mood, decreased participation in activities); -Weight Loss, Loss of Appetite, Difficulty Eating; -Difficulty Sleeping or Decline in Activity Level; -Negative Vocalization (e.g., groaning, crying, whimpering, screaming); -Skin Conditions; -3. Verbal Descriptors: -Heaviness/Pressure; -Stabbing; -Throbbing; -Hurting/Aching; -Gnawing; -Cramping; -Burning; -Numbness, tingling, shooting, radiating; -Spasms; -Soreness, tenderness, discomfort, pins, needles; -Tearing/Ripping; -Pain evaluation: -1. Nursing will complete a Pain Evaluation Tool, appropriate for the Resident's Cognitive Status, to assist with Evaluation of a Resident's Pain; -2. Evaluation of Pain by the Licensed Nurse or Medical Provider; -History of pain and treatment; -Non-Pharmacological, Pharmacological, & Alternative Medicine (CAM) Treatment; Response/Effective to treatment; -Ask the resident to rate the intensity of his/her pain using a numerical scale, verbal or visual descriptor that is appropriate and preferred by the resident; -Reviewing the resident's current medical conditions (e.g., pressure injuries, diabetes with neuropathic pain (pain caused by damage to the nerves), immobility, infections, amputation, oral health conditions, cerebrovascular accident (CVA, stoke), venous and arterial ulcers ulcer (caused by decreased blood circulation), and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue)); -Identifying Key Characteristics of Pain: -Duration; -Frequency; -Location; -Timing; -Pattern (e.g., constant, or intermittent); -Radiation; -Obtaining Descriptors of Pain (e.g., stabbing, aching, pressure, spasms); -Identifying activities, Resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate Pain; -Impact of Pain on ADL (e.g., sleeping, social activities, physical activity and mobility, emotions, intimacy, appetite, and mood, etc.); -Current prescribed pain medications, dosage, frequency, treatments, and modalities; -Pain management and treatment: -1. Based on the evaluation, nursing in collaboration with the physician/prescriber, other health care professionals, the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent/manage a resident's pain beginning at admission; -2. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing medical conditions that may be associated with pain management goal; -3. The interdisciplinary team, the resident and/or the resident's representative will collaborate and discuss realistic, and measurable goals for treatment; -4. Factors influencing treatment: -Cause, location, and severity of pain; -Resident's medical condition; -Resident's current medications; -Resident's desired level of relief & tolerance (e.g., partial Pain reduction with fewer adverse consequences); -Potential risk/benefits and adverse consequences of medications; -Available treatment options; -Resident's elected hospice benefit; -5. Non-Pharmacological Interventions: -Environmental comfort measures (e.g., adjusting room temperature, comfortable seating/lines, assistive devices); -Loosening constrictive bandage, clothing, or device; -Applying Splinting (e.g., pillow or folded blanket); -Physical Modalities (e.g., cold compress, warm shower/bath, massage, turning/repositioning); -Exercises to assist with Stiffness, contractures, and restorative nursing programs to maintain Joint mobility. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the Resident coping techniques and education about Pain); -6. Pharmacological interventions will follow a systematic approach for selecting medications/doses to manage pain. The practitioner and interdisciplinary team (IDT) is responsible for developing a pain management regimen that is specific to each resident who has pain/potential for pain; -General principles for analgesics (a medication to relieve pain); -Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic for pain therapy; -Consider evidence-based practice tools to assist in the evaluation of the resident's pain; -Consider administering medication routinely instead of as needed (PRN) or combining longer acting medications with PRN medications for breakthrough pain; -Utilize the most effective and least invasive route for analgesic administration (e.g., oral, rectal, topical, injection, infusion pump and/or transdermal); -Use lower doses of medication initially and titrate slowly upward until comfort is achieved; -Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects; -Review medical conditions which may require several analgesics and/or adjuvant medications; -Documentation will clarify the rationale for a Treatment Regimen and acknowledge associated risks; -Opioids (medication for pain) will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences; -Nursing will notify practitioner if the resident's pain is not controlled by the current treatment regimen; -Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with advanced, complex, or poorly controlled pain; -7. Monitoring, Re-evaluation, and care plan revision; -Nursing will reassess resident's pain management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, pruritus, nausea, vomiting, addiction and falling or drowsiness) at established intervals; -If Re-Evaluation findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated; -If pain has resolved or there is no longer an indication for pain medication, the IDT will work to discontinue or taper analgesics (as needed to prevent withdrawal symptoms). 1. Review of Resident #20's medical record showed the following: -admitted on [DATE]; -A baseline care plan, dated 12/30/22 was started at 7:47 P.M. Pain was not listed as a focus. -Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/23, showed: -Cognitively intact; -Required extensive assistance of two staff for bed mobility and transfers; -On a scheduled pain regimen in the last 5 days, receives PRN medications for pain, and has occasional pain; -Diagnoses included coronary artery disease (CAD, damage or disease in the heart's major blood vessels), hip fracture, hypertension (high blood pressure), arthritis, anxiety and depression. Review of the resident's physician orders for December 2022, showed the following: -An order dated 12/30/22, for a wound consult for ulcer at genitals and pressure areas on the sacrum (large triangular bone at base of spine) buttocks and posterior (lower) genital area; -An order, dated 12/30/22, for oxycodone-acetaminophen (opioid used to treat severe pain) 10-325 milligrams (mg), give one tablet by mouth one time a day for pain; -An order, dated 12/30/22, for OxyContin (an opioid, used to treat severe pain) tablet extended release 20 mg, give one tablet twice a day for pain; -An order, dated 12/30/22, for pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain. Review of the resident's MAR, dated 12/1/22 through 12/31/22, showed the following: -Oxycodone-acetaminophen tablet 10-325 mg, give one tablet by mouth one time a day for pain was documented as not administered on 12/31/22 at 8:00 A.M.; -OxyContin tablet extended release 20 mg, give one tablet twice a day for pain was documented as not administered on 12/30/22 at 8:00 P.M. and not administered on 12/31/22 at 8:00 A.M. and 8:00 P.M.; -Pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain, showed: --Staff did not document a pain assessment on 12/30/22 during the night shift, --Staff did not document pain on 12/31/22 during the evening shift, --Documented a pain level of 6 on 12/31/22 during the night shift. Review of the resident's medical record, showed there was no documentation found regarding notifying the Primary Care Physician (PCP) and family of the resident's missed medication administrations. Review of the facility's on-site formulary (medication dispensary system) medication list, showed the following medication was stocked in the system: -Oxycodone-acetaminophen tablets were available in 10-325 mg tablets. Review of the resident's physician orders, showed an order, dated 1/3/23, for an x-ray to lumbar spine (lower back) diagnosis of severe back pain. Further review of the resident's medical record showed the staff reported the x-ray results to the PCP on 1/4/23. There were no new orders. During an interview on 1/11/23 at 8:35 A.M., the resident said he/she was often in pain and he/she did not always get his/her medications. He/she made the staff aware, but nothing happened. Observation on 1/11/23 at 8:43 A.M., showed Nurse F administering treatments to the resident's genital area, buttocks, and left femur. Nurse F turned the resident to his/her right side and the resident moaned loudly and said his/her back hurt because he/she had a bad back. The resident continued groaning and was sweating while the nurse administered treatments. The nurse did not offer any pain relief medications or offer to stop his/her task and come back at a later time. The nurse did not ask the resident to describe and rate his/her pain. During an interview on 1/12/23 at 10:23 A.M., Nurse C said if a resident is complaining of pain and is a new admission, Nurse C would check the resident's orders to see if the resident had an existing order for a pain medication. If the resident had an existing order, he/she would pull the medication form the on-site formulary and administer the pain medication. If the resident did not have an order for pain medication, Nurse C would contact the physician to get an order. This would be documented in the resident's progress notes. 2. Review of Resident #29's medical record, showed the following: -admission date of 1/3/23 at 5:58 P.M.; -discharge date [DATE] at 12:00 P.M.; -A baseline care plan, dated 1/3/23, showed, E. Pain: 1. Presence of pain, yes or no, blank, with yes not checked and no not checked; -Diagnoses listed osteoarthritis of left knee, osteoarthritis of right knee, and low back pain. Review of the resident's physician orders, dated 1/11/23, showed the following: -An order, dated 1/3/23 at 11:00 P.M., for pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain; -An order dated 1/3/23 at 6:30 P.M., for Meloxicam (reduces pain, swelling, and stiffness of the joints) tablet 15 milligrams (mg), give 1 tablet by mouth PRN for knee pain once daily if Tylenol has not improved pain; -An order dated 1/3/23, for Tylenol 500 mg, give 2 tablets three times per day for pain; -An order dated 1/3/23 at 6:15 P.M., for Hydrocodone-Acetaminophen (Norco, opioid used to relieve moderate to severe pain) tablet 5-325 mg, give one tablet by mouth every 12 hours PRN for pain. Review of the resident's electronic medication administration record (eMAR), dated 1/1/23 through 1/31/23, showed the following: -Pain assessment every shift, times not noted when pain was assessed on each shift, Day shift 7:00 A.M. through 3:00 P.M., Evening shift 3:00 P.M. through 11:00 P.M., Night shift 11:00 P.M. through 7:00 A.M.: -1/3/23 Night shift pain level 8, no PRN medication administered; -1/5/23 Night shift pain level at 5, no PRN pain medication administered; -1/6/23 Evening shift pain level at 5, no PRN pain medication administered; -1/7/23 Day shift pain level at 4, no PRN pain medication administered; -1/7/23 Night shift pain level at 5, no PRN pain medication administered; -1/8/23 Day shift pain level at 4, no PRN pain medication administered; -1/8/23 Evening shift pain level at 7, no PRN pain medication administered; -1/8/23 Night shift pain level not assessed (blank). -The routine Tylenol was given 1/3/23 at 10:00 P.M. through 1/8 at 10:00 PM. Review of the resident's progress notes, dated 1/3/23 through 1/9/23, showed; -1/3/23 no nurse progress note on night shift related to pain rated at 8 or PRN pain medication offered or other interventions provided; -1/5/23 no nurse progress note on night shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/6/23 no nurse progress note on evening shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/7/23 no nurse progress note on day shift related to pain rated at 4 or PRN pain medication offered or other interventions provided; -1/7/23 no nurse progress note on night shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on day shift related to pain rated at 4 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on evening shift related to pain rated at 7 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on night shift related to why pain was not assessed. -There was no documentation found notifying the PCP of pain. During an interview on 1/12/23 at 10:23 A.M., Nurse C said if a resident has scheduled Tylenol three times a day and was still rating pain from a 4 to an 8. Nurse C would assess the resident's pain and administer the PRN pain medication and come back and reassess the resident's pain. Nurse C would call the physician and inform the physician the resident is still complaining of pain and inform the physician what has already been done for the resident and ask if the physician wants to try something different because the current medication is not effective. Nurse C expected the certified nursing assistant (CNA) to report to the nurse of a resident complaining of pain. This would be documented in the resident's progress notes. During an interview on 1/12/23 at 12:50 P.M., the Regional Nurse Consultant (RNC) said if a resident had Tylenol scheduled three times a day and PRN pain medications and the resident had complaints of pain that ranged from 4 through 8, she expected staff to offer a PRN pain medication. She expected the nurse to enter a progress note if other interventions were completed for the resident if no PRN pain medication was administered. During an interview on 1/13/23 at 11:36 A.M., the resident's Primary Care Physician (PCP) #2 said if a resident has complaints of pain, the expectation is the PRN pain medication be administered. 3. During an interview on 1/12/23 at 7:20 A.M., Nurse E said the following: -Nursing staff works eight hour shifts; -Day shift works from 7:00 A.M. through 3:00 P.M.; -Evening shift works from 3:00 P.M. through 11:00 P.M.; -Night shift works from 11:00 P.M. through 7:00 A.M. During an interview on 1/12/23 at 11:18 A.M., CNA J said if a resident reported pain, he/she would ask the resident where the pain was and how it happened and then report the pain to the nurse. During an interview on 1/12/23 at 11:25 A.M., CNA D said if a resident reported pain, he/she would report it to the certified medication technician (CMT) and if there was not a CMT, he/she would report it to the nurse. During an interview on 1/12/23 at 11:34 A.M., CMT A said if a resident reported pain, he/she would ask the level of pain and where the pain was located. CMT A would then check the resident's eMAR to see if the resident had any PRN pain medication. If the resident was complaining of pain that is higher than normally reported, he/she would report it to the nurse. If CMT A was unsure if the pain was a new pain, he/she would report it to the nurse so the nurse could assess the resident's pain. If a PRN pain medication was administered and not effective, he/she would report it to the nurse. The nurse can assess the resident and call the physician to report the assessment. During an interview on 1/12/23 at 12:50 P.M., the RNC said if a resident was complaining of pain, she expected staff to inform the nurse. The nurse should look in Point Click Care (PCC, electronic charting system) to see what the resident has ordered for pain. If the resident has chronic pain, the nurse should administer the PRN pain medication. If there is a change from the resident's baseline, the nurse should contact the physician and get an order. This would be documented in the resident's progress notes. She expected the nurse to enter a progress note if other interventions were completed for the resident if no PRN pain medication was administered. During an interview on 1/19/23 at 12:25 P.M., the facility's Medical Director, said the following: -She expected staff to follow all physician orders as prescribed; -She expected staff to pull medications from the facility formulary if they were available; -She expected staff to notify her after one day of missed medications so she could determine if a change in plan of care was needed; -She expected staff to write a progress note in the residents' medical record showing they notified her of the missing medication, pharmacy estimated arrival of the medication and any new orders. MO00211979

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to Event ID MK6L12 Based on interview and record review, the facility failed to ensure a resident's complaints of pain and change in condition were assessed and interventions implemented. Resident #6 reported pain and staff noticed a change in condition, however no interventions were implemented until the resident was placed on hospice and pain medication ordered. An x-ray ordered by hospice revealed an acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). The sample was 14. The census was 96. Review of the Pain Management Guidelines policy, revision date 9/2017, showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: -Recognize when a resident is experiencing pain; -Identify circumstances when pain can be anticipated; -Evaluates existing pain and cause; -Practice Guidelines: -Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion, restlessness, etc. To distinguish between pain and other signs or symptoms of distress (delirium, depression, etc.) it is imperative to assess resident to confirm signs and symptoms are indeed related to pain; -If any resident reports inadequate pain control, resident will have an assessment performed; -Following the pain evaluation, notify the physician of the findings; - The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/22, showed: -Diagnoses included hypertension (HTN, high blood pressure), diabetes mellitus (DM), Alzheimer's disease and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); -Severe cognitive impairment; -Behavior Symptoms: verbal/vocal symptoms like screaming, behavior not exhibited; -Pain Management: -Been on a scheduled pain medication regimen, yes; -Received PRN pain medication, yes; -Received non-medical intervention for pain, yes; -Pain presence, no. Review of the resident's electronic medication administration record (eMAR,) dated 9/1/22 through 9/30/22, showed the following medications for pain: -An order date of 12/01/20 at 8:45 P.M., acetaminophen (Tylenol) tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of September 2022; -An order start date of 12/2/20 at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., administered twice daily in the month of September with 1 opportunity missed on 9/16/22 at 4:00 P.M.; -No other pain medications were prescribed in the month of September 2022. Review of the resident's record, showed no pain tool assessments completed in the month of September 2022. Review of the resident's nurse's notes, showed: -No progress note documentation related to pain from 9/23/22 through 10/13/22. Review of vital signs summary, showed pain documented at a 0 (0-10, 1 indicating mild pain and 10 is worst pain possible), daily from 9/20/22 to 10/14/22. During an interview on 11/10/22 at 7:27 A.M., Nurse E said that he/she is the regular nurse for the [NAME] unit and worked with the resident. Nurse E said the resident used to be very mobile and would be a frequent resident in the hallway and dining room between his/her room and the nurse's station throughout the night. Nurse E said after returning from vacation on 9/23/22, the resident was like a different person. The resident was not getting up at night. The resident was now yelling out help but unable to say what he/she needed help with. You could hear the resident yelling help at the nurse's station. Nurse E said during report, it was passed on the resident was yelling out for help but the resident was unable to say what he/she needed help with. Nurse E did not report the decline because he/she said everyone had noticed the resident was declining in health. Nurse E said the resident was diagnosed with degenerative brain disease and he/she thought the resident yelling out for help was related to the brain degeneration. Nurse E did not link the resident asking for help to pain because the resident used to tell him/her what he/she needed. Nurse E said he/she would not usually chart if a resident is calling out for help, it would just be passed on in report to the next nurse. During an interview on 11/10/22 at 8:55 A.M., Certified Nurse Aide (CNA) G said he/she noticed the resident not eating as much and not wanting to get out of bed. The resident would often complain of pain to his/her left leg by saying, my leg hurts, my leg hurts. CNA G said the resident started complaining of pain the beginning of October 2022. CNA G said it was reported to the charge nurse anytime the resident complained and the nurse would say we know he/she fell a while ago and that is why his/her leg hurts. CNA G said every time he/she worked with the resident, he/she complained of pain. CNA G said if he/she noticed the resident was not up, he/she would go and check on the resident and the resident would be complaining of pain to his/her left leg. CNA G said the resident didn't want to get up and didn't want to move and the nurses asked the CNAs to get the resident up every other day. The resident would yell for help and CNA G would go in and get the resident up. The resident used to do well with transfers and stand and after he/she started complaining of left leg pain, he/she didn't want to stand on it and it took two people to transfer the resident. During the transfers, the resident would groan. When the resident started not wanting to get out of bed, this was a change for the resident. During an interview on 11/10/22 at 1:57 P.M., Nurse I said the resident had a change in condition that started approximately two weeks before the resident expired on 10/24/22. The resident used to be a one person assist and propel him/herself in the wheelchair and feed him/herself without assistance. The changes the resident showed were being sleepy, needing assistance with meals, yelling out for help out of nowhere. Nurse I said he/she would go in to see if the resident needed changed. The resident had no medication changes to make the resident sleepy. He/she called the POA and explained how the resident was acting and asked if the POA wanted the resident to stay a full code or change the resident's code status to a DNR and the POA changed the resident's code status to a DNR. The POA and family came in and the social worker talked to the family about hospice. The POA and family kept saying the resident was hurting and that the resident was rubbing his/her left leg. When Nurse I went in to assess the resident, he/she did not observe pain. The POA and family kept saying the resident was having some type of pain. During an interview on 11/14/22 at 9:52 A.M., Family Member (FM) K said he/she received a phone call on 10/13/22 around 8:30 A.M., from CMT F stating the resident had a decline in the last day or two and Family Member K needed to come into the facility. After arriving at the facility, the resident wasn't able to move, was bed ridden and was coughing and choking on food. FM K said other family came with him/her to see the resident on 10/13/22 and the resident was grabbing the family, screaming my leg, my leg. Staff did not do an assessment. CMT F said he/she was giving the resident Tylenol as needed. The family was concerned because nobody reported the changes the resident had and this had been going on for several weeks. The facility did not notify the family or the doctor when this started happening. A nurse told the family that lots of residents yell and scream and then walked out of the room. Review of physical therapy notes, dated 10/14/22, showed: -Patient up in wheelchair upon arrival. Bilateral lower extremities active range of motion preformed to right lower extremity in seated position for improved strength to maximize independence with transfers. Patient complained of left thigh pain when attempting to extend left knee. Patient rubbing area stating it hurts. Nursing consulted and brought in to assess patient's complaint of pain. -Pain present, assessment indicated; -Behaviors exhibited: patient rubbing left thigh nursing notified; -Does pain limit patient's functional activities, yes; -Pain limits the following functional activities, left lower extremity range of motion; -What relieves pain, remaining still; -What exacerbates pain, range of motion; -Response to session intervention; -Patient progress: progress and response to treatment, patient did not meet goals due to discharge from therapy services and transition to hospice care. During an interview on 11/10/22 at 11:05 A.M., Physical Therapist R said he/she went to do an evaluation on 10/14/22 and the resident was sitting up in the wheelchair next to the bed. Physical Therapist R said when he/she tried to do leg exercises with the resident's left leg the resident began rubbing his/her left thigh area and Physical Therapist R asked the resident if he/she was in pain and the resident said it hurts. Physical Therapist R stopped the exercise and went and got the nurse, he/she does not recall who the nurse was. The nurse came in and looked at him/her and said ok I will keep an eye on him/her and left. Physical Therapist R stopped the session due to pain. Physical Therapist R is unsure if there was any other follow up completed after that. Review of the resident's nurse's notes, dated 10/14/22 at 10:09 P.M., showed resident has been admitted to hospice for diagnosis of Senile Degeneration of the Brain. New orders have been entered, follow up with medication MAR. Resident tolerated medications well on this shift without any difficulty in swallowing, resident only consumed about 50 percent of dinner, with assistance with ADLs, vitals are with in normal limit, resident denies being in any pain at this time, resident call light is within reach. Review of the resident's eMAR dated 10/1/22 through 10/24/22, showed the following medications for pain: -An order date of 12/01/20 at 8:45 P.M., acetaminophen tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of October 2022; -An order start date of 12/2/20 at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., -10/1/22 through 10/14/22 administered twice daily at 8:00 A.M. and 4:00 P.M.; During an interview on 11/15/22 at 2:00 P.M., the Interim Director of Nursing (DON) said if a staff member reports to a nurse that a resident is having pain, the expectation is the nurse will assess the resident and contact the family, physician, nurse on call and DON and document the assessment and notifications in a progress note. The Interim DON expected pain documentation to be accurate and equal to what the resident is reporting. Review of hospice records, showed: -Visit date 10/14/22 at 2:15 P.M.; -Visit type Hospice RN start of care: -Resident getting scheduled Tylenol twice daily that is not managing pain. New order for tramadol 50 mg every 6 hours PRN for pain. First does give as soon as possible. Licensed Practical Nurse (LPN) I states understanding to notify hospice if medication is ineffective; -Eligibility criteria- Resident has been a resident at the facility since 2017 in long term care where he/she has been able to make his/her needs known, fed self, and was interactive with fellow residents and staff. In the last month resident has taken a significant decline now calling out day and night with complaints of left hip and knee pain which is unmanaged. Resident has 3 pound weight loss since last month, unable to stand anymore, needs assistance x 2 with staff to assist with transfers. Family can see dramatic decline; -Pain assessment: -Location of pain: extremity's lower; -How does the patient describe the pain: aching; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicate effects of pain on quality of life: appetite, functional status, mobility, sleep/rest disturbance; -Comments regarding patient's cognitive function: Resident did not know birthdate, place, or time of year. Resident able to follow direction and able to indicate pain location and remembered that the hospice nurse was going to get him/her something for pain (half an hour later). Minimum interaction only responded to pain questions and need for relief; During an interview on 11/14/22 at 8:35 A.M., Hospice Nurse C said he/she saw the resident on 10/14/22. It was reported the resident had an acute decline in the last month or two. The last 2-3 weeks, the resident was unable to stand or bear weight, prior the resident was able to stand. A facility nurse told Hospice Nurse C the resident had no falls in the last 3 months. Hospice Nurse C said the resident was in tears because he/she was hurting so badly during the admission. It was reported to Hospice Nurse C the resident had been complaining of pain and yelling out and complaining of left leg and knee pain for the last 2-3 weeks. The resident told Hospice Nurse C, I hurt here, and pointed to left upper thigh and knee. The facility nurse told Hospice Nurse C Oh, the resident always does that. Family was unsure if the resident had a fall. Hospice Nurse C asked the family if the facility had done an x-ray and the family said they were unsure if an x-ray had been completed. In his/her Hospice template (a report that is passed to members on the hospice team for the resident), a note was placed for the team that Hospice Nurse C had concerns the facility staff was not taking the resident's pain seriously and to please monitor pain during visits and to let facility staff know if any uncontrolled pain is noticed, mostly left hip/knee pain. Hospice Nurse C obtained a new order for tramadol for pain. Review of hospice records, showed: -Visit date 10/15/22 at 11:29 A.M.; -Visit type Hospice RN rapid subsequent visit; -Pain assessment: -Describe behavior: Negative vocalization, repeated trouble calling out; -Location of pain: extremities lower; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicates what makes pain worse: activity, movement, exercise; -Narrative: admission follow up visit. Resident in common room visiting with family upon arrival. Tramadol was administered 20 minutes prior to arrival for left knee pain. Family stated that an order for an x-ray would be placed for left knee/hip x-rays, no order given to facility and unable to see chart. Resident falling asleep during visit, confused and minimally verbal, only yells help every few minutes. Resident did shake head yes after asking if pain medication was helping. Hospice nurse will send scripts to pharmacy and speak with physician about obtaining x-rays. Educated on nonverbal signs of pain and discomfort. During an interview on 11/10/22 at 9:35 A.M., Hospice Nurse L said the resident was admitted to hospice on 10/14/22 and he/she saw the resident on 10/15/22 for a follow up visit. The family was requesting an x-ray because the resident was reporting pain to the left leg and knee. Hospice Nurse L said that at the end of each visit the hospice staff send out a report to the case manager. Hospice Nurse L sent a report to the case manager requesting follow up regarding the request for x-ray since the resident was on hospice, asking the case manager to check with the attending physician. The family's main concern was pain. The family did voice when the resident was started on tramadol the resident wasn't calling out as often and said that before the tramadol was started the resident was calling out constantly. Hospice Nurse L said he/she did not hear anything for a little while but then saw a color report (reports that are sent out to staff that are on the residents caseload) about the resident from another hospice nurse that said the resident had to have been in severe pain for quite a while and has an acute fracture with no evidence of previous falls. Review of vital signs summary for pain, showed: -Pain documented at 2 on 10/15/22 at 12:15 P.M., with PRN tramadol 50 mg administered at 12:15 P.M.; -Pain documented at 1 on 10/15/22 at 12:43 P.M.; -Pain documented at 1 on 10/15/222 at 4:43 P.M., with PRN tramadol 50 mg administered at 4:43 P.M. Review of vital signs summary for pain, showed: -Pain documented as 0 on 10/16/22, 10/17/22 and 10/18/22. Review of pain assessments completed for the month of October 2022, showed: -10/18/22 at 1:22 P.M., pain assessment completed with score of 0; -10/18/22 at 6:29 P.M., pain assessment completed with score of 0. Review of hospice records, showed: -Visit date 10/18/22 at 2:20 P.M.; -Visit type RN hospice subsequent with supervisor visit; -Narrative: On arrival resident resting in bed with relaxed facial expression, scoring zero on pain. Careful exam of left leg from iliac crest (iliac crest is the curved area at the top of the ilium bone, the largest of three bones that make up the pelvis) to ankle preformed because family stated resident had been grasping at left leg and complaining loudly of severe pain over the weekend and yesterday. Hospice nurse did not find any deformity, point tenderness, heat resistance to passive range of motion. Patient was able to support his/her left legs weight and lower it to the bed on his/her own without grimacing. Situation discussed with physician and obtained orders for left hip and knee x-rays to reduce residents family's anxiety; Review of the resident's nurse's notes, dated 10/18/22 at 4:31 P.M., showed the resident has complaints of pain to left knee and hip, hospice in facility, new order for 2 view x-ray to left knee pelvis and hip, family and physician aware. Review of the x-ray results dated 10/18/22, showed: -Clinical Information: Increased pain to both areas, difficulty bearing weight; -Unknown etiology (unknown cause); -Findings: There is moderate arthritic changes of the hip with circumferential collar osteophytes (When hip cartilage thins, the hip bones may produce osteophytes (a smooth bony growth or deposit) to compensate.) and joint space narrowing. Acute fracture involving the femoral neck. Bony mineralization (the process of deposition of minerals on the bone for the development of bone) is within normal limits for age. No evidence of osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Remainder the pelvis is intact; -Impression: Acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). Review of the resident's nurse's notes, showed: -10/18/22 at 10:11 P.M., x-ray results reported to physician findings left knee no fracture but fracture to left hip noted; -10/18/22 at 10:39 P.M., resident has no bruising or bones protruding from skin, no pain noted upon touch doing assessment. During an interview on 11/14/22 at 11:44 A.M., Hospice Nurse Q said the first time he/she went to see the resident, he/she read the notes from the hospice admission which said the resident had a decline in the last several weeks and stopped eating. Resident scoring 5-6 on the pain score, complaining of left knee pain and reaching down towards the knee. The resident was clear the pain was from his/her knee. Resident's leg was not rotated, there was no heat or swelling at the knee. Hospice Nurse Q lifted and flexed the resident's left leg with no point tenderness. The family told Hospice Nurse Q the resident was miserable over the weekend so Hospice Nurse Q called the physician and obtained an order for an x-ray to the left knee, hip and pelvis. After the x-ray was completed, hospice received a call that the resident has a left femoral neck fracture. Hospice Nurse Q said the resident could have been experiencing referred pain from the left hip to the knee. The resident was admitted to hospice due to a decline but the decline could have been caused from the hip fracture. While speaking to the family, they were very frustrated because staff reported the resident had not fallen since September. The family felt like something had been missed with the resident because the pain had been there for several weeks. Family was also concerned nothing was done by the facility with the resident's complaints of pain. Review of vital signs summary for pain, showed: -Pain documented as 3 on 10/19/22 at 1:17 A.M., with PRN morphine sulfate concentrate solution 0.25 ml administered at 1:18 A.M.; -Pain documented as 1 on 10/19/22 at 5:24 A.M., with no PRN pain medication administered; -Pain documented as 7 on 10/19/22 at 9:23 P.M., with PRN morphine sulfate concentrate solution 0.25 mg administered at 9:23 P.M. Review of the resident's nurse's notes, showed: -10/19/22 at 6:01 A.M., Last evening nurse reported to this writer positive fracture results to left hip x-ray. This nurse had no prior reason to suspect a health concern related to fracture due the fact the writer had no knowledge of any incidence that could have caused a fracture. The Hospice nurse called and asked the condition of the resident. This writer assessed the patient's pain level at 11:10 P.M. and administered a dose of Morphine per PRN orders. The resident admitted presence of pain. Later the resident was noted hallucinating and a PRN dose of Lorazepam (medication used to relieve anxiety) was administered. Both medications showed positive results and the resident slept. The resident was observed alert after some time but there was no signs or symptoms of pain to necessitate further dose of morphine. Monitoring still continues; -10/19/22 at 9:03 P.M., resident remains in bed, ate 10% of dinner with no complaints. Supplement offered. Denied any pain. This nurse asked resident was he/she in pain. Resident declined. -10/19/22 at 9:21 P.M., resident yelling out help uncontrollable. This nurse asked resident was he/she in pain. Resident shook his/her head yes. This nurse administered PRN morphine 0.25 ml, resident currently in room sleeping peacefully. Review of hospice records, showed: -Visit date 10/21/22 at 11:13 A.M.; -Visit type Hospice PRN visit; -Narrative: Resident is alert and identifies that he/she is having left knee pain which is referred pain from the left femoral head fracture. Resident had received Morphine Sulfate extended release tablet 15 mg at 5:00 A.M. and was given an additional 5 mg of Morphine during visit to reduce discomfort during assessment. Reviewed plan of care with Nurse I that resident should receive routine Morphine Sulfate extended release every 12 hours and additional liquid morphine as needed every 3 hours for breakthrough pain. During an interview on 11/14/22 at 9:52 A.M., Family Member (FM) K said the family placed the resident on hospice and was started on hospice on 10/14/22. Family said the hospice nurse could see the resident was in pain. The resident was in pain and yelling out daily until the 12 hour liquid morphine was started by hospice. The hospice nurse started the resident on tramadol on 10/14/22 and when this did not relieve the pain, the hospice nurse started the resident on morphine tablets. When this did not relieve the pain, the hospice nurse changed the pain medication to 12 hour liquid morphine. During an interview on 11/14/22 at 11:44 A.M., Hospice Nurse Q said the tramadol that was prescribed was not touching the resident's pain so different orders were obtained for Morphine in tablet form and when that was not effective, the Morphine was changed to liquid Morphine which was effective for the resident's pain. MO00208740