Every finding on record at Alpine Breeze Health and Wellness

Based on observation, interview and record review, the facility failed to ensure adequate supervision and implement effective measures to prevent resident elopement for one sampled resident (Resident #1) of 8 sampled residents who resided on the facility's secured memory care unit. On 4/29/26, the main door out of the memory care unit did not fully latch after use. As a result, the resident was able to exit the secured unit unsupervised, access the facility elevator and make his/her way out of the facility through a door where the alarm had been temporarily disabled, without staff awareness, and was later located by law enforcement at a local barbershop without injury. The facility census was 146 residents.The Administrator was notified on 5/7/26 of the past noncompliance which began on 4/29/26. The facility immediately completed education for wandering and elopement risk, alarm response and missing persons. An elopement drill with staff was completed on 4/30/26. All resident elopement assessments were updated on 4/30/26. A Quality Assurance Performance Improvement (QAPI) was put in place on 4/30/26 to review and interpret all audit findings. The deficiency was corrected on 5/1/26. Review of the facility's Elopements and Wandering Residents policy Dated 8/1/25 and reviewed 4/20/26 showed:-This facility ensured that residents who exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.- Elopement occurred when a resident left the premises or a safe area without authorization, such as an order for discharge or leave of absence, and/or any necessary supervision to do so.-The facility was equipped with door locks/alarms to help avoid elopements.-Alarms were not a replacement for necessary supervision. 1. Review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of mild cognitive impairment of unknown origin. Review of the resident's admission assessment dated [DATE] showed:-He/She was at high risk for elopement.-He/She could ambulate and propel him/herself and/or wandered.-He/She had intentionally or unintentionally attempted to leave the community. Review of the resident's Care Plan Report dated 4/22/26 and revised on 4/29/26 showed:-He/She was admitted to the Garden Unit (memory care) due to his/her elopement risk.-Interventions include documenting behavior patterns and triggers; offering companionship, reassurance and redirection when exit-seeking began; monitoring for possible contributing factors that might lead to potential elopement risk, including restlessness in late afternoon, increase in anxiety or packing belongings, providing structured, meaningful activities during high-risk times such as late afternoon Review of the Facility Incident Report dated 4/29/26 showed:-On 4/29/26 at approximately 8:20 P.M., staff reported that law enforcement officers came to the facility to confirm that the resident lived at the facility.-The facility did a head count of the memory care unit and verified the resident was not in the facility.-The Director of Nursing (DON) was notified that law enforcement was returning the resident to the facility.-Police reported the resident had been located at a barbershop nearby the facility.-The barbershop owner contacted law enforcement after observing the resident state, I'm not sure where to go.-Law enforcement transported the resident back to the facility.-The resident returned at approximately 8:27 P.M. and was assessed for injuries or visible marks.-No notable injuries were observed.-The resident was wearing weather appropriate clothing and weather conditions were clear with no precipitation or visibility concerns during the time of the incident.-The resident was interviewed and reported that he/she exited the building via the memory care unit entry door, accessed the elevator, traveled to another floor and exited the building via the 400 hall exit door, which the stop sign alarm did not activate due to routine maintenance from the alarm company. He/She did not recall hearing an alarm at the time.-Review of the door identified that the memory care unit entry door was not fully latched at the time, allowing the resident to open the door and leave the unit.-It was then identified that the resident exited the elevator, and the 500 and 600 halls had a stop sign barrier across the door, which acted as a visual deterrent and the 400 hall did not have the banner.-The door alarm did not alarm due to routine maintenance activity completed on this hall by an outside vendor.-The outside vendor left at approximately 5:15 P.M.-The staff reported the last known visual of the resident prior to returning at approximately 7:45 P.M. Review of the resident's Progress Notes dated 4/29/26 at 8:25 P.M. showed:-Law enforcement arrived at the facility at 8:20 P.M. stating that a resident was at the barber shop down the street.-The resident was unable to tell the officers where he/she lived.-A head count was done at 8:20 P.M. and noted that the resident was not in the facility.-Law enforcement stated they were bringing the resident back.-At approximately 8:35 P.M. the resident arrived at the facility.-The resident was taken to his/her room. -Vital signs were completed and noted, water offered, and vital signs repeated again.-The resident denied pain or discomfort.-Skin assessment was done and no injury noted.-The resident was resting in bed.-The resident was placed on 15-minute checks. Review of the resident's Skin Check dated 4/29/26 showed he/she did not have any new wounds. Observation and interview on 5/7/26 at 11:30 A.M. showed the resident used a walker when ambulating. He/she said: -He/She did not remember going off of the unit.-He/She did not think he/she had been outside.-He/She did not remember leaving the facility.-He/She would not know how to get out.-He/She was hoping his/her son would come take him/her home, but they did not want him/her there.-He/She guessed the staff were taking good care of him/her at the facility.-He/She did not like being in a place when he/she did not know why he/she was there. Observation of memory care unit doors on 5/7/26 at 11:50 A.M. showed:-The doors had codes to open and would not open without a code. -The door closest to the resident's room led outside to an area that is fenced. -The door where the resident went out had a working alarm. -The doors to the outside had alarms, but not the interior doors. During an interview on 5/7/26 at 3:30 P.M., the Administrator said:-The resident was able to get off the memory care unit because another resident's family member left the unit door unlatched. -The resident took his/her walker with him/her. -The unit door was flush so it could not be determined by looking if it was latched or not. -The doors to the outside had alarms, but the interior doors did not. -There were staff were present, but they were busy with other residents since it was after dinner time.-Nobody missed the resident because he/she was not gone very long. -The resident showed them how he/she pushed the button at the elevator door to go up. - When the resident got off the elevator, he/she turned right and walked down the hall.-The resident showed them how he/she exited the facility. -The staff would not necessarily have noticed if he/she was gone right away.-The upstairs staff would not have necessarily known who he/she was.-The door alarm was not on that day because there was a company at the facility working on the alarm system. Incident 3000358

Based on interview and record review, the facility failed to ensure one of ten sampled residents, Resident #1 was free from abuse, when on 1/27/26 at approximately 2:23 A.M. Resident #2 struck Resident #1 on the face while Resident #1 was sleeping in bed, due to an auditory hallucination. As a result of the altercation, Resident #1 sustained a laceration to the inner lip and minor swelling to his/her left eye. The facility census was 142 residents.The Administrator was notified on 2/16/26 of the past noncompliance which began on 1/27/26. The residents were separated, and Resident #2 was placed on 1:1 observation. Resident #1 was transferred to the hospital for evaluation and treatment and returned to the facility with no new orders. Resident #2 was transferred to the hospital for psychiatric evaluation and admitted . The facility immediately completed education for staff on the Abuse, Neglect and Exploitation policy. The deficiency was corrected on 1/27/26. Review of the facility's Abuse, Neglect and Exploitation policy, dated 8/22/22, showed:-It was the policy of this facility to provide for the protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.-Physical Abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. 1. Review of Resident #1's admission Record face sheet, dated 1/22/26, showed he/she was admitted with the following diagnoses:-Cerebral palsy, (a disorder caused by abnormal brain development or damage, affecting motor function, posture and balance).-Sequelae of cerebral infarction, (chronic, often permanent physical, cognitive and emotional deficits from a stroke). Review of Resident #1's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/24/26, showed the resident was cognitively impaired. Review of the resident's Care Plan Report, dated 1/22/26, showed the resident had impaired cognitive function/dementia (progressive decline in memory, thinking, behavior and language severe enough to disrupt daily life), and impaired thought processes, neurological (disorders of the brain, spinal cord and peripheral nerves) symptoms. Review of Resident #2's admission Record face sheet, dated 12/2/25, showed he/she was admitted with the following diagnoses:-Personality disorder, unspecified, (long-term mental health condition caused by inflexible and unhealthy patterns of thinking, feeling and behaving).-Cognitive communication deficit, (impairment of communication resulting from underlying communication issues). Review of Resident #2's Preadmission Screening and Resident Review (PASSR/MI) Level II Evaluation, dated 5/10/23, showed:-He/She had a legal guardian.-He/She had a long-standing history of psychiatric diagnoses including schizophrenia, paranoid type, (a chronic mental health condition characterized by intense, irrational suspicion along with prominent auditory hallucinations (a perceptions of sounds without any external sources) and delusions of persecution), chronic; schizoaffective disorder, (a mental health condition combining schizophrenia symptoms with mood disorder episodes), bi-polar type; antisocial personality disorder (a chronic mental health condition characterized by manipulating, exploiting for violating the rights of others), personality disorder, insomnia (persistent difficulty falling and staying asleep).-His/Her behaviors indicate positive symptoms of schizophrenia including auditory and visual hallucinations, delusional thinking and psychosis.-Progress notes, dated 7/22, indicated complaint of spiritual battles using metaphysical spear and a foreign presence that was attempting to steal his money.-Per progress note, dated 7/22, he/she had increased delusions and hallucination when Risperdal (risperidone-medication for treating schizophrenia and bipolar mental health issues), or Clozaril (clozapine-atypical antipsychotic used for treatment-resistant schizophrenia or schizoaffective disorders) dosages decrease . briefly taken off Clozaril due to low white blood cell count and started on Zyprexa (antipsychotic medication used to treat schizophrenia and bipolar disorder) but did not have good response.-He/She denied he/she was the aggressor in any physical altercation he/she had gotten into, but had defended him/herself if necessary, in the past.-He/She reported a history of mood dysregulation and impulsive behaviors because of it.-He/She had a longstanding history of paranoid ideation, delusional thinking and process and reality testing problems His/Her conversations tended to lean on government involvement in reading his/her thoughts. He/she presented as mostly suspicious of others.-He/She reported he/she didn't trust other residents at his/her nursing facility. He/She reported to be appropriate and largely quiet.-He/She reported that he/she used to hear what everyone thought.-He/She reported he/she was spiritual, so he/she knew the spirits of those who came before us were real. Review of Resident #2's MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #2's Care Plan Report, dated 1/27/26, showed:-The resident had a guardian for financial, medical and/or personal decision-making due to impaired capacity to make complex decisions independently.-The resident used psychotropic medications related to personality disorder disease process and symptoms of depression. Interventions included: consulting with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly; discuss with physician and family ongoing need for use of medication; review behaviors/interventions and alternative therapies attempted.-The resident had a behavior problem of potential aggression related to his/her spiritual beliefs that others may be the devil or working with the devil. Interventions included: administering medications as orders; monitor for side effects and effectiveness.-Most recent Gradual Dosage Reduction (GDR) attempted 1/21/26 failed. Review of Resident #1's Progress Notes dated 1/27/26 showed: -At approximately 2:23 A.M., the resident approached the south nurses' station with visible bleeding from his/her nose. -He/She appeared alert and oriented but upset. -Charge nurse assisted the resident with cleaning his/her face, applied ice to the nose and administered PRN (as needed) Tylenol (non-steroidal pain medication) per order. The bleeding was controlled. The resident was immediately placed at the nurses' station for close observation.-He/She reported his/her roommate woke him/her up, and proclaimed he/she was the devil, and struck him/her in the face.-He/She denied provoking the incident and denied loss of consciousness.-No other injuries were noted at the time of assessment.-The provider was notified at 3:05 A.M. and gave orders to send him/her out for evaluation and treatment. Review of Resident #2's Progress Notes, dated 1/27/26 showed: -Following an altercation involving his/her roommate, he/she was placed on 1:1 supervision for safety.-He/She was alert but exhibited delusional and religiously occupied speech.-He/She stated, It had nothing to do with the TV, it was about him/her being the devil. I've been up for a couple of days. I'm trying to trap the devil's power; trying to do the right thing. He/She was provoking me. I wasn't trying to hurt him/her. I was trying to let him/her know he/she's using his/her power - the devil's power.-He/She continued to verbalize paranoid and delusional content.-He/She ambulated to the bathroom, returned to his/her table and then to bed without difficulty. Due to his/her statements and behaviors the provider was notified.-Medication history was reviewed. He/she had recently had Gradual Dose Reduction (GDR) of medication and was being closely monitored by psychiatry.-Provider was notified at 3:05 A.M. and the resident was ordered transfer for psychiatric evaluation and treatment. Public Administrator (PA). for the resident was contacted and voicemail left, Emergency Medical Services (EMS) contacted at 3:41 A.M. Report called to receiving hospital. Review of Resident #2's Social Services - Trauma Informed Care, dated 1/27/26 at 3:23 A.M., showed:-Physical assault - did not apply.-Serious injury, harm or death you cause to someone else - did not apply.-Any other stressful event or experience - did not apply.-Did any of the events affect your overall health and well-being - No. Review of Resident #1's Trauma Informed Care, dated 1/27/26 at 2:58 A.M., showed:-He/She was interviewed by the Social Worker.-He/She had been physically assaulted. Review of Resident #1's skin check, dated 1/27/26 at 3:25 A.M., showed the resident had a laceration (tear or break in the skin) to the inner lip and minor swelling to left eye. Review of Resident #1's Emergency Provider Report, dated 1/27/26, showed:-He/She was seen for assault, head and facial contusions (bruises) and intraoral laceration (cuts to the lips, cheeks, tongue or gums).-He/She was transferred from his/her care facility for the evaluation of head/facial injuries following an assault.-He/She was reportedly struck multiple times in the face by his/her roommate while sleeping.-He/She believed he/she lost consciousness.-He/She complained of generalized headache and facial pain.-He/She denied trouble speaking or swallowing, focal weakness or neuro deficits.-All systems were reviewed and negative except skin laceration, headache and facial pain.-He/She was awake and alert, no acute distress.-Mild left infraorbital swelling, no proptosis (abnormal bulging of the eye).-Left mid-face tenderness with associated bruising, dried blood in nares with no evidence of hematoma (clotted or partially clotted blood trapped in tissue or body spaces), intraoral laceration to bottom lip.-Oriented to person, place and time; speech within normal limits.-Maxillofacial Computer Tomography (CT) scan (a non-invasive, painless imagine procedure to create cross-sectional views of the facial bones, jaw, teeth and sinuses) without contrast on 1/27/26 at 5:14 A.M. showed: no acute intracranial hemorrhage (bleeding), fracture or territorial infarct (large vessel blood flow blockage); left facial and periorbital (surrounding the eye socket) soft tissue swelling, no acute maxillofacial fracture.-Laceration Management #1 - procedure performed by Emergency Department physician.-Location of wound: Inner lower lip, wound length 2.5 centimeters (cm).-Repair skin: Chromic, suture size 4-0, 2 sutures.-Closure layers: 1.-Suture technique: simple.-Post-procedure complications: No complications, condition improved, tolerated procedure well, condition stable.-His/Her oral laceration was repaired without complications, pain improved, remained at neuro baseline. Review of the Facility Investigation Summary Resident to Resident Incident, dated 1/27/26, showed:-Residents involved were Resident #1 and Resident #2.-On 1/27/26 at approximately 2:23 A.M., Resident #1 was observed exiting a room with small bleeding noted.-Staff immediately responded and provided care.-The incident was identified as a resident-to-resident behavioral event involving Resident #2.-Resident #1 sustained a nosebleed and a laceration to the inner lip; bleeding resolved with first aid.-The event appeared acute and isolated in nature.-The event was determined to be an acute resident-to-resident behavioral incident.Review of the Police Department Report, dated 1/27/26, showed:-The victim was Resident #1.-The suspect was Resident #2.-Officer A reported being dispatched to the facility regarding a reported assault on 1/27/26 at 10:51 A.M.-Upon arrival, he/she made contact with the administrator who stated that around 3:30 A.M. on 1/27/26, Resident #1 was assaulted by Resident #2. Resident #2 was at the hospital at the time for a psychiatric evaluation.-He/She contacted Resident #1 who stated earlier that morning, his/her roommate, Resident #2 approached him/her while he/she was in bed and stated, I want to suck your dick.-Resident #1 told Resident #2, No.-Resident #1 stated that Resident #2 began to punch him/her in the face multiple times with a closed fist.-He/She asked Resident #1 how many times Resident #2 struck him/her and he/she stated he/she did not know.-Resident #1 further stated while Resident #2 was striking him/her, he/she repeatedly shouted, I'm the devil.-Resident #1 stated he/she was able to push Resident #2 away from him/her and at that point was able to escape and make his/her way to the nurses' station.-Resident #1 had visible swelling and bruising on his/her right cheek and right eye, and additionally his/her bottom lip was severely swollen and visibly split on the left side.-Resident #1's eyes were very bloodshot; however he/she was unable to determine whether the bloodshot appearance was caused by the assault.-Resident #1 was transported to the hospital by the facility staff prior to the arrival by the police and was medically cleared by staff at the hospital, per the Administrator.-He/She then spoke with the Administrator regarding the incident and asked if anyone had witnessed the assault, to which he/she responded no.-The Administrator stated there were no security cameras that captured the assault.-The Administrator also advised that both residents suffered from major cognitive impairments.-It was noted that Resident #2 was not his/her own guardian. During a telephone interview on 2/16/26 at 1:20 P.M., Resident #1's family member said:-The resident had stitches in his/her mouth-The stitches were put in at the hospital-The resident was asleep and his/her roommate jumped on him/her.-Resident #2 said Resident #1 was the devil.-The resident did not show anyone at the facility the stitches, except the Administrator and the police.-The resident got the kind of stitches that would melt, so three weeks later, a person would not be able to see them. During an interview on 2/16/26 at 1:30 P.M., Resident #2 said:-He/She remembered hitting Resident #1. -Resident #1 was yelling and making weird noises. -He/She thought Resident #1 was the devil. -He/She was trying to protect him/herself. -Resident #1 was trying to put his/her spirits in him/her. -He/She was afraid of Resident #1, so he/she hit him/her with his/her fist in the face. -He/She was trying to block Resident #1's eye. -Resident #1 woke up. - He/She wasn't trying to harm Resident #1, just block his/her eye because he/she was visualizing attacking him/her with his/her spirit. -The devil took flesh from dead people from the grave, and he/she put two and two together and thought that was Resident #1. -Resident #1 did not fight him/her; he/she said, I didn't do anything! -He/She said the medicine did not have anything to do with it - it was reality.-He/She felt safe at the facility now. There was nobody else at the facility with the devil in them. During an interview on 2/19/26 at 1:30 P.M., Psychiatric Nurse Practitioner A said:-Resident #2 had been doing well.-The attack was not intentional. It was his/her response to fight off the devils.-Nothing had been reported by staff as far as behaviors.-The resident had roommates before with no issues.-The resident's mind was responding to stimuli he/she perceived.During an interview on 2/19/26 at 3:45 P.M., the Director of Nursing (DON) said:-Resident #1 would have been Resident #2's second roommate. -He/She did not have any anticipation this could happen between the two residents. -He/She got a call at 2:00 AM when the incident happened. When he/she got to the facility, at approximately 2:30 AM., the altercation had already happened, and the residents were separated. -He/She interviewed Resident #1 first. -Resident #1 was obviously surprised and trying to figure out what was going on. He/She had swelling on his/her lip. The bloodshot eyes were baseline and not from the incident. -At the time Resident #1 did not have soft tissue swelling on his face. -He/She interviewed Resident #2 also. He/She felt like he/she was doing an act of service. He/She kept saying they didn't understand that the devil was in Resident #1. -This was new to him/her because Resident #2 had never talked about anything demonic in the past. -The police came to the facility after Resident #1 had returned. -Resident #2 went out for psychiatric evaluation at the hospital on 1/27/26 and came back on 2/11/26. -He/She did not feel like this could have been predicted. -He/She did not feel like this was abuse. -He/She did not feel that Resident #2 had any ill will when he/she hit Resident #1.-He/She was aware of all of his/her residents and their behaviors, and he/she would not have guessed this would happen. During an interview on 2/19/26 at 4:22 P.M., the Administrator said:-It was totally out of the norm to receive a call like that about Resident #2. -He/She had never had behaviors before that.-Resident #1 never showed him/her his/her lip. -He/She would not have known what the stitches might look like.-He/She spoke to Resident #2 since he/she came back. -When Resident #2 spoke to him/her, he/she greeted him/her normally. -Residents had the right to sleep without being struck.-Resident #2 did not understand what he/she was doing when he did it - not even a little bit. -Since Resident #2 believed Resident #1 was trying to give him/her visions of the devil, this was outside of his/her baseline. -He/She did not believe Resident #2 was acting with intent. -Acting with intent would mean he/she had the ability to make that decision, and he/she did not think he/she had that ability. -He/She did not feel like this was abuse and he/she did not think that even a little.-Resident #2 did not have the capability to make that decision to act with intent. 2745832

Based on observation and interview, the facility failed to maintain that all foods were up to date and not expired in the walk in refrigerator; keeping the walk in refrigerator floor dry, ice buildup in the walk in freezer; black hose that connects to the cooling unit was falling apart and had insulation sticking out of it; ice and food on the floor of the walk in freezer. This practice potentially affected 140 residents who ate food from the kitchen. The facility census was 140 residents.Sanitation Inspection policy date implemented 9/1/21 showed:It was the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service area were clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:-All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.-Sanitation inspections would be conducted in the following manner:--Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.--Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas were clean and comply with sanitation and food service regulations.Inspections would be conducted but not limited to the following areas:--Dry storage.--Freezer.--Refrigerator. 1. Observations during the breakfast meal preparation on 8/15/25 from 5:26 A.M. through 8:00A.M., showed:-Expired salad mix with the date expiration date of 7/15/25.-Water on the floor of the walk-in refrigerator.-Ice buildup in the walk-in freezer on the ceiling and floor. -Corn and other food on the rubber rug on the floor of the walk-in freezer. -Black hose that connects to the cooling unit was falling apart and had insulation coming out of it. During interview on 8/15/25 at 5:26 A.M the Dietary Manager (DM) said:-They receive one truck a week and the truck driver would clean out the expired food and restock it with new food.-The kitchen was cleaned every day by staff.

Based on observation and interview, the facility failed to ensure there was negative airflow in required areas such as restrooms and soiled utility rooms in the following rooms: resident room [ROOM NUMBER], 311, 309, 306/307, 306/304, 305, 303, 302/300, 301, 210, 208, 102, 607, 603, 512, 511, 510, 508, 507, 506, 503, 502, 406, 407, 404, This practice potentially affected 44 residents. The facility census was 140 residents. **Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. 1. Observations on 8/13/25 with Maintenance Person A, showed the following:-At 3:35 P.M. there was the absence of negative air flow in the shared restroom of resident rooms 310/308.-At 3:40 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 3:42 P.M. there was the absence of negative airflow in in the restroom of resident room [ROOM NUMBER].-At 3:46 P.M. there was the absence of negative airflow in the shared restroom of 306/304.-At 3:49 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 3:52 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 3:55 P.M. there was the absence of negative airflow in the shared restroom of resident rooms 302/300.-At 3:56 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER]. 2. Observations on 8/14/25 with Maintenance Person B, showed the following:-At 9:26 A.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 9:29 A.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 11:30 A.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 1:33 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 1:37 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 1:49 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 1:57 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 2:02 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].- At 2:05 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 2:08 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 2:12 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 2:39 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER].-At 2:50 P.M. there was the absence of negative airflow in the restroom of resident room [ROOM NUMBER]. During an interview on 8/14/25 at 3:10 P.M., Regional Maintenance Supervisor said he/she was not sure why the ventilation worked in some resident rooms and did not work in other rooms. During a phone interview on 8/26/25 at 12:21 P.M., the Facility Maintenance Director said he/she has not checked for negative airflow in the ceiling vents in the resident rooms and the last time he/she remembered negative airflow being checked for, was in 2024 by an assistant maintenance person who was no longer employed at the facility.

Based on observation, interview and record review the facility failed to provide individualized and customized activities based on the resident's previous lifestyle (occupation, family, hobbies), preferences and comforts, failed to ensure to individualized activities for resident who are bed-bound or unable to participate in group activities for one sampled resident (Resident #118) and failed to provide cognitively appropriate activities for residents residing in the memory care unit, out of 29 sampled residents and potential affect all 27 residents residing on the memory care unit. The facility census of 140 residents. Review of the facility's Activities Policy revised on 8/1/25 showed:-The facility will provide an ongoing activity program to support resident choices of activities based on their comprehensive assessment, care plan and preference for each resident. -Activates will be designed with the intent to enhance the resident sense of well-being, belonging and usefulness by: --Promote or enhance, physical activity, cognition, emotional health, self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.--Reflect on the residents, choices, interest and age. -Activities may be conducted in different ways, one-one programs and person appropriate.-Activities can occur at any time and are not limited to formal activities, provided by activities staff. 1. Review of Resident #118's admission Record showed, the resident had diagnosis to include: -Vascular Dementia (is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage.-Schizoaffective disorder, bipolar type, (is a condition characterized by psychotic symptoms (like hallucinations and delusions, as seen in schizophrenia) alongside mood episodes (mania and sometimes depression, as seen in bipolar disorder). -Cognitive Communication deficit (is an impairment in the ability to use and/or comprehend verbal or nonverbal language).Review of the resident's Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff for care planning) dated 7/30/25 showed: -He/She was moderately cognitive impaired. -Sometimes understand others, rarely able to make his/her needs known. Review of the resident's Activity Log dated July 2025 showed: -The resident resided on long term care units. -For Active participation for social and parties, he/she attended 10 out 18 opportunities. No documentation of the resident's preferred activities or of 1:1 activities offered for the resident.-Refused to attend movies, music, religious services, board games, arts & crafts, and beauty/barber. Observation on 8/13/25 at 12:05 P.M., the resident showed: -He/She was in bedroom lying in bed. -CNA B provided the resident with a lunch meal tray. Observation on 8/18/25 at 7:47 A.M., of the resident showed: -He/She in laid down in his/her bed covered up with blanket. -Would not verbally respond when asked question. Observation on 8/19/25 at 9:40 A.M., of the memory care unit showed:-Resident #118 was in room in bed with blanket covering head. -A few residents in chairs or recliner watching TV in a common area. -There were three resident's walking hallways and wandering around the memory care area. -The activities office was located on memory care unit. -The activities staff were in the room with door shut. -DON and Administrator in the area, along with a CNA and one CMT on unit, interacting with residents or redirecting residents as needed. They were not assisting with resident activities.Review resident's posted activities calendar dated 8/19/25 showed:-Had schedule for arts and craft at 10:30 A.M. for all residents. -Had popcorn social schedule at 1:30 P.M. and puzzles & pondering at 2:30 P.M.Observation the memory care unit on 8/19/25 at 10:00 A.M., showed:-Care staff offering water to all the residents. -The DON and Administrator on the unit at that time, walking around the unit, checking on residents and staff.-The Administrator entered the activity room to obtain activities for the residents while the two activity staff were in the activity office away from residents. Observation the memory care unit on 8/19/25 at 10:05 A.M., showed: -The Administrator obtained large playing cards, sat in living area with memory care unit residents to offer activity. -He/She had turned on music and started to dance, as memory care residents got up started to dance also. -Activity Aides were in activity room with the door open and did not participate or interact with the memory care residents while the activity was going on. Observation of Resident #118 on 8/19/25 at 10:26 A.M., showed:-He/She laid in bed had the blanket over his/her head. -The resident did not leave his/her bedroom and activities staff did not attempt to interact or encouraged to participate in activities with the resident at that time. 2. During an interview on 8/18/25 at 2:21 P.M., Certified Nursing Assistant (CNA) B said: -The resident will get up go to bathroom then lay back down. He/She was not aware of any activities provided for Resident #118. -Not aware any activity provided expect for food/snack offered like popcorn.-During memory care unit activities only seen the activity staff member hand out snacks or drinks, normally on their phone in the activity office.-Had not seen ongoing interaction with the residents during schedule activities times.-No planned physical activity/movement or seen interacting with the resident like with remembering when young or daily events.-Had not seen activities utilizing the secure courtyard as did in past. During an interview on 8/19/25 at 9:52 A.M., Activities Aide (AA) A said:-He/She recently hired as Activities Aide, he/she had not attended any special activity training for his/her position as Activities Aide. -He/She had just started working on changing and offering more group activities, individual activities for those residents on memory care and all residents at the facility. -He/She was working on printing off coloring pages for the residents to color if they wish to. -The activities staff were spread thin (short staffed) and only had one person to provide activities at that time. -He/She would document in the facility's activities binder on each resident log sheet if the resident attended or refused to attend activities that day and time. -He/She not aware of any activities plan for those residents that were bed bound residents.-Not aware any special activities for those residents on memory care unit. -The facility had same activities calendar for all resident in the facility. During an interview 8/20/25 at 12:23 P.M., Anonymous staff member said:-He/She said mainly seen activities such as offering popcorn, drinks and other snacks as activities.-He/She has not seen activities staff interacting with the any resident on memory care unit during the snack activity times.-Whenever he/she is assigned to the memory care unit, he/she would ensure they had TV on, has music, game shows or movies. -He/She had not seen activities staff provided one-one activities for those residents who were bed bound or refuse to attend group activities. -He/She would try to plan some daily activities around remember old events or songs that happen in residents time frame and review current daily news.-He/She would expect staff to interact with residents about different topic such as summertime, would ask if they every plant garden, what type of plants etc . During an interview on 8/20/25 at 12:38 P.M., Activities Director said: -Activity staff provide one on one activities for those residents who were bed bound, to include activities such as nail spa day, talking with the resident. -Resident #118 have tried offer and setup activities does not like to attend group offer painting does not like.-Resident #118 was offered nail spa day for the resident today did not want to attend. -Document in the activity log sheet for each resident. During an interview on,08/20/25 2:45 P.M. Director of Nursing (DON) said: -He/She would expect have one-one activities for those residents that were bed bound and unable to attend groups activities.-Would expect to provide more cognitive appropriated activities for those residents on memory care unit such as reading, body movement activity and singing, -He/She would not consider offering snack and popcorn as a positive activity for the resident. -Drinks and snacks should be part of appropriate activity not the sole activity itself. -He/She would expect activity planning be focus on resident preference, likes, hobbies and person center.

Based on observation and interview the facility failed to maintain a faucet in resident room [ROOM NUMBER] in good repair and failed to maintain the cleanout (a capped pipe that provides access to a sewer or drain line, allowing for inspection, cleaning, and maintenance of the system) cover on the 300 Hall secured tightly to the cleanout valve. This practice potentially affected 23 residents and any facility staff who worked on the 300 Hall. The facility census was 140 residents. Observation on 8/13/25 at 10:35 A.M. and 3:39 P.M., showed the cleanout cover moved when it was stepped on.During an interview on 8/13/25 at 3:39 P.M., the Facility Maintenance Director said he/he did not know the cleanout cover needed to be tightened.During a phone interview on 8/26/25 at 12:19 P.M., the Facility Maintenance Director said typically, the facility does not have issues with the cleanout covers so they do not really check them, however if a cleanout cover is reported as loose or slack, they would address it.2. Observation on 8/13/25 at 3:32 P.M. and on 8/15/25 at 9:31 A.M. showed the faucet in resident room [ROOM NUMBER] had a broken handle and a leak in the faucet drainpipe. During an interview on 8/13/25 at 3:33 P.M. the Facility Maintenance Person said he/she did not know about the broken handle or the leak in the pipe from the faucet in resident room [ROOM NUMBER].

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for a gradual dose reduction of two psychotropic medications for one sampled resident (Resident #6) out of 29 sampled residents. The facility census was 140 residents.Review of the facility's Medication Regimen Review and Reporting policy and procedure revised 9/2018, showed the Medication Regimen Review is a thorough evaluation of the medication regimen of the resident with the goal of promoting the positive outcomes and minimizing adverse consequences and potential risks associated with medication. The medication review includes review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The Medication review also involves collaborating with other members of the Interdisciplinary Care Team, including the resident, family/responsible party. The policy showed:-The consultant pharmacist has access to residents and the resident's medical record and reviews the medication regimen and medical record at least monthly to appropriately monitor the medication regimen and ensure that the medications the resident receives are clinically indicated.-In performing the medication review the consulting pharmacist incorporates federally mandated standards of care in addition to other professional applicable standards.-Resident specific medication review recommendations and findings are documented and acted upon by the nursing facility and /or physician.-The nursing facility follows up on the recommendations to verify that appropriate action has been taken.-For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his/her rationale of why the recommendation is rejected in the resident's medical record. 1. Review of Resident #6's Face Sheet showed the resident was admitted on [DATE], with diagnoses including anxiety disorder, personality disorder (a class of mental health conditions characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the culture, schizophrenia (a chronic mental illness characterized by a combination of symptoms that significantly impair a person's daily functioning and social relationships), and depression. Review of the resident's Medication Regimen Review on 6/30/25, showed the consultant pharmacist completed the resident's medication review and showed the following: -6/30/25 The resident has been taking Remeron (an antidepressant) 30 milligrams (mg) at bedtime, Cymbalta (Duloxetine-a medication used to treat anxiety and depression) 60 mg daily and Abilify (Aripiprazole-an antipsychotic) 15 mg daily for quite some time now. Please evaluate the current dose and consider a dose reduction. Record review of the resident's Medical Record showed there were no notes or other documentation showing the physician had tried a gradual dose reduction of Cymbalta or Abilify or documented why it was not clinically indicated or in the best interest of the resident to try a gradual dose reduction of these medications. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/8/25, showed the resident:-Was alert, oriented and cognitively intact with minimal confusion.-Received antipsychotic and antidepressant medications during the lookback period.-Antipsychotics were used on a routine basis.-A gradual dose reduction had not been attempted.-A gradual dose reduction had not been documented by a physician as clinically contraindicated. Review of the Pharmacy Drug Regimen Review Response dated 7/9/25, showed:-The physician's response, showed agreed and the physician changed the physician's order to Remeron 15 milligrams (mg).-The physician did not respond to the pharmacist's recommendation for a gradual dose reduction for Cymbalta or Abilify. Review of the resident's POS showed a physician's order dated 7/9/25 for Remeron 15 mg at bedtime Review of the resident's Physician's Order Sheet dated August 2025, showed physician's orders for:-Abilify 15 mg daily for anxiety (ordered 4/12/25) was still an active order.-Cymbalta 60 mg daily for depression (ordered 5/15/25; revision date 7/31/25) was still an active order. During an interview on 8/19/25 at 4:17 P.M., Registered Nurse (RN) A said:-The Director of Nursing (DON) or Assistant Director of Nursing (ADON) ensured the recommendations were put in the resident's medical record because the pharmacist's recommendations do not come directly to the Charge Nurses.-If the nurse is made aware of the recommendation, the nurse will notify the physician and if a gradual dose reduction is recommended, they will document the new order.-If the physician does not agree with the gradual dose reduction, the physician will tell them why and they will document that in the resident's medical record.-He/She did not know what the expectation was for the physician to respond to the pharmacist's recommendation. During an interview on 8/20/25 at 1:39 P.M., Licensed Practical Nurse (LPN) A said:-If the nurse gets the recommendation from the pharmacist recommending a gradual dose reduction, they will contact the physician to inform him/her of it.-He/She will follow whatever order the physician gives, whether it's to increase or decrease the medication.-If the physician does not want to follow the pharmacist's recommendation, they usually will tell them they don't want to change the medication, and the nurse will document that in the resident's medical record. During an interview on 8/20/25 at 2:45 P.M., the Director of Nursing (DON) said:-He/She expected the physician to review the pharmacist's recommendations for a gradual dose reduction for each medication documented.-The physician should respond as soon as the recommendation was received, within 7 days of notification or during the month of the review (depending on the recommendation) and document the response in the resident's medical record.-If the physician does not agree with the pharmacist's recommendation, the physician should document the clinical rationale for why he/she does not agree with the recommendation. -After 5 days he/she should contact the physician if there was no response.

Based on observation, interview and record review, the facility failed to ensure the fall investigation was completely documented and the post fall documentation was correct to show the resident's change in condition after a fall with injury for one sampled resident (Resident #6) and failed to maintain a safe transfer for one sampled resident (Resident #143), out of 29 sampled residents. The facility census was 140 residents. Review of the facility Fall policy and procedure dated 9/1/21, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy showed: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. -When a resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury. -The document went into no further detail regarding how the staff should documentation on the investigation or post fall assessment or what should be documented. Review of the facility's Safe Resident Handling/Transfers policy dated 9/1/21 showed: -It was the policy of this facility to ensure that residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts were a safer alternative and should be used. -The interdisciplinary team or designee would evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. -Mechanical lifting equipment or other approved transferring aids would be used based on the residents needs to prevent manual lifting except in medical emergencies. -Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts. -Handling aids may include gait belts, transfer boards, and other devices. -The staff would inspect the equipment prior to use to ensure functionality and would alert maintenance or other designee if the equipment were not functioning properly. -Damage, broken, or improperly functioning lift equipment would not be used and tagged out according to facility policy. -The facility would ensure that there were appropriate amounts of varying sizes of slings to accommodate residents and that residents would be measured correctly as per the manufacturer's instructions on proper sling sizing. -Two staff members must be utilized when transferring residents with a mechanical lift. -Staff would be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. -Staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency places in their education file. -Staff members were expected to maintain compliance with safe handing/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. -Resident lifting and transferring would be performed according to the resident's individual plan of care. -Staff would perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. -Slings would be laundered according to manufacturer's instructions and any damaged, broken or unsafe slings would be removed from service and replaced. -The lift(s) would be cleaned and disinfected according to manufacturer's instructions and after each resident use. 1.Review of Resident #6's Face Sheet showed the resident was admitted on [DATE], with diagnoses including stroke with paralysis on the right dominant side, diabetes, high blood pressure, Chronic Obstructive Pulmonary Disorder (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) anxiety disorder, unsteadiness on feet, difficulty walking, high blood pressure, lack of coordination, blindness in one eye, contracture of the right hand and shoulder and abnormal posture. Review of the resident's Care Plan updated 3/14/25 showed the resident was at risk for falls due to unsteady gait/balance, psychotropic medications, and history of falls. It showed the resident had a non-injury unwitnessed fall, had poor balance, poor communication and comprehension, unsteady gait, poor impulse control, and poor decision-making abilities. It showed the resident had a non-injury fall on 3/14/25 while trying to self-transfer. Interventions showed nursing staff would: -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Ensure bolsters are in place. -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. -Encourage/remind the resident to use mobility aides (cane and wheelchair) when ambulating/transferring to aide with fall prevention. -Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in his/her wheelchair. Resident is weight bearing as tolerated when wearing orthopedic boot. -Encourage resident to use his/her call for assistance with transfers. -Post a sign in the resident's room to remind the resident to use his/her call light and/or request assistance with transferring (6/16/20). -Place anti roll-back on wheelchair to prevent the wheelchair from moving with transfers. -Check the resident's range of motion (specify number) times daily. -Continue interventions on the at-risk plan. -Continue current interventions for fall risk intervention include re-education on using call light for all transfers. -For no apparent acute injury, determine and address causative factors of the fall. -Monitor/document/report as needed for 72 hours to the physician for signs and symptoms of pain, bruises, change in mental status, ne onset of confusion, sleepiness, inability to maintain posture, and agitation. -Place the resident in a room with higher visibility for increased supervision. -Encouraged the resident to use his/her call light to ask for assistance (3/14/25). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/6/25, showed the resident: -Was alert, oriented and cognitively intact with minimal confusion. -Needed substantial to maximum assistance with bathing, dressing, toileting, and mobility. -Had upper and lower impairment on one side and used a wheelchair for mobility. -Needed substantial to maximal assistance to transfer. -Had a non-injury fall since admission. Review of the resident's Incident Report/Fall investigation dated 6/14/25, showed: -The resident had an unwitnessed fall on 6/14/25. -The nurse documented nursing staff observed the resident in his/her room, lying on the floor on his/her right side next to his/her bed. -The resident's mobility status showed the resident was wheelchair bound. -The resident said he/she was trying to transfer to his/her wheelchair and missed it. -The resident was alert, and denied hitting his/her head, and there were no injuries noted at this time. -The resident's range of motion was within normal limits. The resident was able to bear weight on his/her left side. -Nursing staff assisted the resident up and back to bed per his/her request. -Nursing staff encouraged the resident to call for help with transfers and the resident verbalized understanding. -The resident's call light was within reach. -The nurse documented that neurological checks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs-temperature, blood pressure, pulse, respirations and oxygen level) were initiated, however the resident's vital signs were not documented on this document. -The nurse documented the notifications to the resident's physician and Director of Nursing (DON) and documented the resident's plan of care was ongoing. -There was a section of the report to document any predisposing factors that could have contributed to the resident's fall (environmental, physiological, situational factors) and there was also space to document any additional information that was related to the fall or notes. These sections were left blank. -The investigation/incident report was incomplete in showing a comprehensive account of the resident's fall. Review of the resident's undated Post Fall Huddle showed: -The resident had an unwitnessed fall on 6/14/25 at 11:55 P.M. -The resident was observed on the floor in his/her room. -He/she was alert and had good judgement. -The lighting in the room was okay, but the resident's vision contributed to his/her fall. -The resident was attempting to transfer prior to his/her fall. -The resident used a wheelchair and needed assistance per his/her care plan. -The document showed areas to be completed that were left blank such as behaviors exhibited, any factors observed at the time of the fall, what footwear the resident was wearing, the last time staff had checked on the resident and what the resident was doing at the time, if the resident was having pain at the time or had received any pain medication prior to the fall and factors observed at the time of the fall. Review of the resident's Care Plan showed updated fall interventions dated 6/14/25 that showed: -Therapy evaluation and treatment (6/14/25). -Educate on locking brakes on wheelchair (6/14/25). -Eye exam (6/14/25). Review of the resident's Fall Risk Score dated 6/15/25, showed a score of 30 (a score of 30 was determined to be at high risk for falling). Review of the resident's Nurse's Note showed on 6/15/25-the nurse documented the resident complained of pain to his/her right knee after his/her fall. The resident had no bruising; some swelling was noted. The physician was notified and new orders for an x-ray (were obtained). Review of the resident's Care Plan showed updated interventions dated 6/15/25, that showed the resident complained of knee pain and the nursing staff obtained an x-ray. Review of the resident's Post Fall Observation dated 6/15/25, showed: -The nurse documented the resident's vital signs. -The resident complained of pain to his/her right knee with movement. -The resident's current pain level was zero and he/she did not complain of new or worsened pain. -An x-ray was ordered, obtained and the conclusion showed the resident had osteoarthritis to his/her right knee. -There had been no reports of swelling, bruising or injury since the event; the resident had no change in mental status, activity of daily living (bathing, dressing, toileting, hygiene) ability or mobility. -There had been no change in physician's orders related to this event and the resident had no change in the resident's sleep pattern. -The nurse included no additional notes or comments. Review of the resident's Post Fall Huddle dated 6/16/25 showed: -This was the follow up to the undated Post Fall Huddle (second page). -The resident was assessed and the assessment showed the resident's vital signs were documented, the resident had no injury, his/her range of motion of upper and lower extremities were within normal limits, and the resident had no pain. -The resident said he/she had a few drinks prior to his/her fall. -The root cause showed the resident would receive further evaluation, was educated on locking his/her wheelchair brakes and obtain an eye exam for the resident. -Immediate interventions was to educate the resident on the dry (substance-alcohol/drug) policy. Review of the resident's Nursing Notes showed: -On 6/16/25 the nurse documented the interdisciplinary team meeting regarding the resident's unwitnessed, non-injury fall was held and they discussed self-transferring. A new intervention to develop a sign posted in the resident's room to remind the resident to use his/her call light and/or request assistance with transferring. The physician and Assistant Director of Nursing (ADON) were notified. -6/17/25 the nurse notified the resident's physician of the results of an x-ray to the resident's right ankle. A new order was obtained for the resident to be on non-weight bearing status and a referral to the orthopedic clinic for follow up evaluation and treatment. An additional note showed the resident's family was notified (at the resident's request) and an appointment was set with the orthopedic clinic. Review of the resident's Care Plan updated showed on 6/17/2025 resident complained of ankle pain-an x-ray was ordered and obtained, and the resident was referred to the orthopedic clinic for follow up. The result of the x-ray noted the resident had a fracture. The resident said he/she attempted to walk to the bathroom and did not request assistance. Review of the resident's Social Service Notes showed on 6/18/25 the Social Services Designee visited with the resident regarding his/her fall with fracture on 6/14/25. The Social Service Designee asked the resident how the fall happened, and the resident said, it just happened. The Social Service Designee asked the resident if he/she was under the influence of alcohol or drugs when he/she fell and the resident denied this. The Social Service Designee educated the resident on the facility policy on illicit substance that alcohol/drugs were not allowed on facility premises. Review of the resident's Post Fall Observation dated 6/18/25, showed: -The nurse documented the resident's vital signs. -The resident's current pain level was zero and he/she did not complain of new or worsened pain, but the resident had physician's orders for Tylenol and Hydrocodone (narcotic) for pain as needed. -There had been no reports of swelling, bruising or injury since the event; the resident had no change in mental status, activity of daily living (bathing, dressing, toileting, hygiene) ability or mobility. -There had been no change in physician's orders related to this event and the resident had no change in the resident's sleep pattern. -The nurse included no additional notes or comments. -Documentation on the report did not show the resident had an x-ray of his/her ankle and results showed the resident sustained a right foot/ankle fracture since the incident, did not show the treatments provided (orthopedic treatment and rehabilitation), change in mobility status or current physician's orders. Review of the resident's Physician's Notes dated 6/19/25, showed the Nurse Practitioner completed a physical examination of the resident and reviewed his/her medical record, labs, medications and current health status. The Nurse Practitioner documented: -The resident's chief complaint at this visit was regarding activity of daily living deficits, mobility, debility, poor endurance, fall risk and right sided paralysis due to stroke. -The resident's plan and progress was discussed with nursing staff and therapy. The resident said: I had a fall a few days ago where I hurt my foot. It has been a 10/10 pain ever since it happened. There was an x-ray and I guess maybe it's broken and I am supposed to go out to an appointment to see a doctor about my foot. I know I am not supposed to put any weight on it, but I do sometimes anyway. The pain is the same no matter if I have taken pain medicine or not. -The resident's current functional status as of 6/18/25 showed the resident had a new onset of a right tibula-fibula fracture ( a serious break in the lower leg's two bones. Symptoms include severe pain, swelling, bruising, and the inability to bear weight) with non-weightbearing for right lower extremity. -Due to the resident's inability to maintain non-weightbearing status of right lower extremity, therapy boot was recommended and provided. -The resident's right lower extremity continued to have increased swelling and 10/10 (on a scale from zero to 10, 10 is severe pain) pain. manual resistance. The resident was awake, alert and in no apparent distress. He/she was well-developed, well-groomed and dressed for the day, sitting in his/her wheelchair in the physical therapy gym, receiving therapy. Awaiting transfer to orthopedic appointment this morning. -There was some mild tenderness to palpation of right hand, tenderness to right lower extremity, ankle and foot. -Range of Motion: Functional range of motion in left upper and lower extremities. Limited range of motion in right-sided extremities. The resident used a manual wheelchair to self-propel throughout the facility. -The assessment and plan showed the resident had an unwitnessed fall on 6/14/25, with subsequent right lower extremity pain. The resident got an x-ray to the right ankle on 06/17/25 and a referral to orthopedics was completed. The resident is now non-weightbearing to that right lower extremity. The Nurse Practitioner will continue to provide education about the importance of non-weightbearing status and use of the therapy boot until he/she has been assessed by the orthopedic surgeon. -The resident will continue with skilled therapy services as necessary. Currently, the resident is receiving physical therapy twice a week and has also been receiving some occupational therapy as well. Review of the resident's undated Fracture Checklist and Timeframe showed: -The resident's fracture was discovered on 6/17/25 at 4:15 P.M. -Swelling was noted to the resident's right ankle and foot. The physician, Administrator, DON and corporate staff were notified and the physician ordered pain medication as needed, to elevate the resident's foot with ice as needed and make an appointment for follow up evaluation with the orthopedic clinic. -The resident had an unwitnessed fall on 6/14/25 while transferring himself/herself in his/her room. This could have contributed to the fracture. After determining the root cause of the fall, risk of alcohol consumption should be reviewed. -The resident received rehabilitation (physical and occupational therapy) three times weekly and had no complaints of pain. Pain is currently being addressed. -There was no device that could have contributed to the fracture. -The resident was interviewed on 6/17/25 and said he/she fell because he/she was drinking and his/her ankle did not hurt. -The summary of the investigation of fracture showed the resident sustained a fracture to his/her right ankle due to an unwitnessed fall on 6/14/25. The resident was going to visit the orthopedic clinic on 6/19/25. Observation on 8/14/25 at 8:10 A.M., showed the resident was sitting in his/her wheelchair in the dining area. On the resident's right foot was a brace from his/her foot to just under his/her knee that was wrapped with a brown bandage. The resident denied pain but did not talk about his/her fall. During an interview on 8/20/25 at 1:25 P.M., Licensed Practical Nurse (LPN) B said: -When a resident has a fall, the nurse will assess the resident for injury and notify the physician and family. -If the fall was witnessed, they will ask the witness for a statement and document what occurred, take the resident's vital signs and assess for injury and follow up as the physician ordered. -If the fall was unwitnessed they will try to get the resident's statement and start neurological checks then assess and follow up with the physician and follow any orders given. -The nurse documents the initial nursing note about the fall and it should be as detailed as possible. -The nurse also completes the incident report and fall risk assessment. -The DON/ADON completed the actual fall investigation. -The nurses complete the post fall assessments. -The post fall assessment required them to document the update of the resident after the resident's fall like positioning in bed, mobility status, pain, change in the resident's condition/health status and any current information related to the resident's fall. -Documentation on the incident report and post fall observation should all be detailed, completed in full and show the status/condition of the resident. It should be comprehensive. During an interview on,08/20/25 2:45 P.M. DON said: -The resident had been drinking alcohol and tried to transfer himself/herself and fell. -They initially did not know that the resident had a fracture, initially the resident complained of knee pain and then later complained of foot/ankle pain and when they obtained the x-ray they discovered a fracture. -The initial Incident Report should be comprehensive and should be completed in full and include any and all information related to the fall. -The investigation should include the root cause of the resident's fall. The interdisciplinary team discussed the resident's fall in the post fall huddle and the root cause was discussed and determined the root cause of his/her fall, but this information was not included on the resident's incident report/fall investigation. -The Post Fall Observation should reflect the updated health status of the resident at the time and should show any changes that have occurred with the resident's care and mobility. 2. Review of Resident #143 admission Sheet dated 3/22/24 showed the following diagnoses: -Morbid (severe) obesity due to excess calories. -Muscle weakness. -Difficulty in walking. -Need for assistance with personal care. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -Substantial/maximal assistance for toileting hygiene. -Substantial/maximal assistance for shower/bathe self. -Substantial/maximal assistance for lower body dressing. -Partial/moderate assistance for upper body dressing. -Wheelchair mobility. Observation and interview of Certified Nursing Assistant (CNA) D on 8/14/25 at 10:51 A.M. showed: -CNA D was in the process of moving resident in a Hoyer lift by his/herself. -CNA D was moving resident from the bed to a motorized wheelchair. -Resident was in the air over the floor between the bed and the wheelchair when observed. -CNA D continued to attempt to aim the resident over the motorized wheelchair. -CNA D said there were supposed to be two people but did not know when the other staff member was coming. -While in the air the resident asked to be put back into the bed. -CNA D said he/she put the call light on and additional staff would be coming (to assist). -CNA D kept trying to put the resident in the motorized wheelchair. -CNA D had the resident recline the motorized wheelchair by having the resident reach back for the control knob while the resident was still in the air in the Hoyer lift. -The resident leg got caught on the lift and he/she cried out ow. -CNA D fixed the resident's leg and tried to re-adjust the resident. -The resident kept saying ow. -Surveyor asked staff to put the resident back into the bed. -The resident also asked to be put back into bed. -CNA D put resident back into bed. During an interview and observation on 8/14/25 at 11:02 A.M., CNA D said: -This was his/her first day working at this facility. -This was the first resident he/she had to transfer this morning. -He/She said everyone knows you were supposed to have two people when transferring a resident by a Hoyer, but the staff take too long and the resident wanted to get up. During an observation on 8/14/25 at 11:08 A.M. showed: -The resident's call light was still on. -No other staff member showed up to help. During an interview on 8/14/25 at 11:15 A.M., the resident said: -That was the first time a staff member had moved him/her by themselves using a Hoyer lift. -Usually there are two staff members. -He/She had never saw CNA D before. -He/She did not know why CNA D thought he/she could move him/her by themselves. During an interview on 8/20/25 at 10:03 A.M., CNA E said: -It takes two people to transfer a resident with a Hoyer lift. -He/She would first check on the resident then if they wanted to be moved, he/she would get a second person. During an interview on 8/20/25 at 10:50 A.M., Registered Nurse (RN) C said: -It takes two people to transfer a resident with a Hoyer lift. -One person should never transfer a resident with a Hoyer by themselves. -Staff would go into a room to do minor preparations but if the resident wants up then they would go get help. During an interview on 8/20/25 at 2:37 P.M., the DON said: -It takes two people to transfer a resident with a Hoyer lift. -One person should never transfer a resident with a Hoyer by themselves. -They are trained on the facility policy related to transfers. -

Based on observation, interview and record review, the facility failed to ensure the catheter bag and tubing (a catheter is a flexible tube inserted through a narrow opening into the bladder for removing fluid. The fluid goes into a collection bag) was kept below the bladder to prevent cross contamination and infection for one sampled resident (Resident #149) out of 29 sampled residents. The facility census was 140 residents. Review of the facility Catheter Care policy and procedure revised 8/1/25, showed it was the facility's policy to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy showed staff was to ensure the drainage bag was located below the level of the bladder to discourage backflow of urine. 1.Review of Resident #149's Face Sheet showed the resident was admitted on [DATE], with diagnoses including kidney disease, uropathy (any condition that impairs the normal flow of urine through the urinary tract, which includes the kidneys, ureters, bladder, and urethra), and need for personal assistance. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning dated 4/28/25, showed the resident:-Was alert, oriented and cognitively intact with minimal confusion.-Used an indwelling catheter for urination. Review of the resident's Care Plan dated 7/31/25, showed the resident had an indwelling catheter. Interventions showed nursing staff should:-Provide catheter care each shift.-Monitor for signs and symptoms of discomfort of urination and frequency, pain, signs and symptoms of urinary infection (and report to physician).-Position the resident's catheter and tubing below the level of the bladder and away from the entrance room door. Review of the resident's Physician's Order Sheet dated August 2025, showed physician's orders for catheter change as needed for leakage, obstruction, accidental removal or when ordered. (8/12/25) Observation on 8/15/25 at 5:43 A.M., showed the resident was laying in his/her bed on his/her back with his/her eyes closed resting comfortably. His/her catheter bag and tubing were laying in the resident's bed at the same level of his/her bladder, between the resident's legs, and was not below the bladder. Observation on 8/15/25 at 8:00 A.M., showed the resident was laying in his/her bed on his back with the cover over his/her head. The resident's catheter bag and tubing were still laying on the bed between the resident's legs at the same level of his/her bladder and not below the bladder. There was yellow fluid in the tubing. During an interview on 8/18/25 at 11:20 A.M. Certified Nursing Assistant (CNA) A said:-When he/she came in to work and went to check on the resident, the resident's catheter bag was always in a different place.-He/She has come into the resident's room and found the resident's catheter bag on the bed and today it was on the floor.-He/She hung the catheter bag on the side of the resident's bed.-Normally the resident's catheter bag was supposed to be hung on the side of the resident's bed, below the resident's bladder at all times.-He/She did not know whether the resident or other staff was placing the catheter bag in different places. -When they go in to check on the resident, they are supposed to check to see if the resident's catheter bag was placed correctly at the side of the resident's bed and below the resident's bladder. During an interview on 8/20/25 at 1:32 P.M., Licensed Practical Nurse (LPN) A said:-The resident's catheter bag should always be below the bladder.-The only reason the catheter bag would be on the bed was the nurse was in process of changing the catheter bag out and there should be a sterile field that the catheter bag is laying on in that scenario, otherwise it should never be on the bed.-The CNA rounds should be every two hours and they should be making sure it is in the right position, is not leaking and is below the bladder.-If the catheter bag is on the floor they should notify the nurse so the bag can be changed. She said it should never be found on the floor. During an interview on 8/20/25 at 2:45 P.M., the Director of Nursing (DON) said:-The resident's catheter bag placement should be below the waist and bladder at all times.-The catheter bag should never be laid on the bed or on the floor.

Based on observation, interview and record review, the facility failed to ensure infection control practice with the enteral tube feeding (A medical devices use to provide nutrition to residents who require to resident who cannot obtain nutrition by mouth requiring supplemental nutrition) process of changing the pump tubing every 24 hours for one sample resident (Resident #45), failed to ensure infection control practice wearing Personal Protective Equipment (PPE - is equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, face masks or face shields, respirators, foot and eye protection, and gowns) for residents on Enhanced Barrier Precaution (EBP, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.) maintained during direct contract of a resident's with a Percutaneous endoscopic gastrostomy tube (Peg-tube/Feeding Tube (TF), is a flexible tube inserted through the abdominal wall into the stomach) during administration of medications through PEG tube for one sampled resident ( Resident #91) and failed to ensure EBP maintained during dressing change and cleaning of Peg tube insertion site for the resident out of 29 sampled residents. The facility Census of 140 residents. Review of the facility's Enhanced Barrier Precaution (EBP) dated 4/23/25 showed: Refer to infection control intervention designed to reduce transmission of Multidrug-resistant organisms (MDROs is a germ that is resistant to many antibiotics) that employs targeted gown, and gloves use during high contact resident care activities that provided opportunities for transfer of germs to staff hands and clothing. -EBP will be obtained for resident with any of the following to include indwelling medical devices, wounds, catheters-High contact resident care activities include not limited to device care or use of feeding tubes wear gown, gloves and face mask as needed for potential of splatter1. Review of Resident #45 admission Record showed the resident admitted with the following diagnoses:-Adult failure to thrive (has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). -Protein-calorie malnutrition (is the state of inadequate intake of food).Review of the resident's Tube Feeding Care Plan dated revised 5/3/25 showed:-The resident dependent on tubing feeding and water flushes. -Provide site Peg-tube site care as ordered and monitor for infections. See physician orders for current feeding orders. Review of the resident's Physician Order Sheet (POS) dated 7/1/25, showed physician order for: -Enteral Feedings formula of Jevity 1.2 calories, via pump run at 55 milliliter (ml) per hour. Turn feeding off at 8:00 A.M. and back on at 12:00 P.M., total of 20 hour of running eternal feedings. -Every shift nursing staff to check PEG tube placement before initiation of formula, medication administration, and flushing of the feeding tube.-EBP for peg tube included gown and gloves required for high contact resident care activities. Review of the residents Registered Dietitian (RD) Dietary Note dated 7/21/25, showed the resident continuing to use tube feeding for all his/her nutritional/hydrational needs. Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/30/25 showed: -He/she was severely cognitive impaired. -Required tube feeding for main source of nutrition.Observation on 8/13/25 at 11:34 A.M., of the resident's tube feeding (TF) showed:-TF pump was not running and not connected to the resident.-The formula bottle of Jevity 1.2 calorie was dated 8/12/25 at 3:50 P.M.-The tubing was dated 8/11/25 at 8:30 P.M.-The TF tubing had not been changed on 8/12/25 when nursing staff would have hung new bottle of formula. Observation on 8/14/25 at 9:51 A.M., of the resident's TF showed: -The resident TF pole and pump was in room with no eternal formula connected or running at that time. -The old formula bottle was dated 8/13/25 and tubing had been thrown away. Observation on 8/14/2025 at 11:58 A.M., of the resident tube feeding setup showed:-On the resident door had signage for EBP, required gown and gloves for whomever was providing direct contact care. -Registered Nurse (RN) D enter the resident's room washed his/her hands and then applied gloves to his/her hands. -He/She apply a gown.-RN D had already setup TF supplies needed for reconnection of TF formula and had primed the tubing prior surveyor arrival. -He/She had new tubing connected and dated the tubing for 8/14/25 with the nurse initials. Observation on 8/18/25 at 2:06 P.M., of the resident's TF showed: -Was connected and running at 60 ml an hour. -Formula bottle dated 8/17/25 at 5:00 P.M. -Feeding tube tubing was dated 8/16/25.-The TF tubing had not been changed on 8/17/25 when staff would have hung a new bottle of formula. 2. Review of Resident #91's admission Record showed the resident admitted with the following diagnoses:-Huntington Disease (loss of nerve and brain cells, results in progressive movement, thinking, cognitive, and psychiatric symptoms).-Adult Failure to Thrive.Review of the resident's Tube Feeding Care Plan dated revised 4/22/25, showed:-The resident dependent on tubing feeding and water flushes. -Provide site Peg-tube site care as ordered and monitor for infections. See physician orders for current feeding orders. Review of the resident's Quarterly MDS dated [DATE], showed:-He/She was severely cognitive impaired. -Had diagnosis of Huntington Disease.-Required tube feeding for main source of nutrition. Review of the resident's POS dated August 2025, showed: -Clean tube feeding insertion site every day with normal saline and apply a split gauze pad. - Enteral Feedings formula of Jevity 1.5 calories, via pump run at 55 ml per hour. Turn feeding off at 6:00 A.M. and back on at 10:00 A.M., total of 20 hour of running eternal feedings. -Every shift nursing staff to check PEG tube placement before initiation of formula, medication administration, and flushing of the feeding tube.-Enhanced Barrier Precautions (EBP) for peg tube gown and gloves required for high contact resident care activities. Observation on 8/15/25 at 5:30 A.M. to 7:00 A.M., of the resident's medication administered via feeding tube showed:-On the resident door had signage for EBP, required who ever will be providing direct contact care for the resident, would be required to wear PPE of gown and gloves during cares. -RN A washed hand and checked vital signs prior to medication administration via PEG tube. -RN A had prep the resident's medications crushed four of the five pills to be given and dissolved capsula potassium in medication cup of water. He/she had difficulty get it to dissolve. -Entered the resident's room to started medication pass via PEG tube at 5:55 A.M. -He/She placed TF supplies on barrier on table in the room and then went washed his/her hands with soap and water. Placed clean gloves on hands. -He/She checked PEG tube placement and check for residual prior to medication administered. -Disconnected feeding tubing and flushed PEG tube with water prior to medication administered. -RN A completed medication pass one medication at a time. -He/She did not wear additional PPE of a gown during the TF medication administration process. -RN A proceeded change PEG tube dressing, with same gloves hands. -He/She removed the old split dressing from PEG tube site, slight amount reddish drainage noted on the old dressing.-RN A then cleanse the area with wet gauze pad and dried. -He/She removed soiled gloves and sanitize his/her hand, then placed a new pair of gloves on his/her hands.-He/She applied a clean split gauze pad around PEG tub insertion site and secured with tape. -Removed gloves and washed hands soap and water prior to exiting the resident room. -He/She did not wear additional PPE of a gown during the process of changing the resident's PEG tube site dressing. During an interview on 8/15/25 at 7:00 A.M., RN A said:-Residents on EBP care staff should wear a gown, gloves and mask if needed, when preform direct resident care during like wound care or peri care. -He/She was not required to wear gown during the care of the resident PEG tube feeding process and PEG tube site care. 3. During an interview on 8/20/25 at 11:30 A.M., Certified Nursing Assistant (CNA) A said PPE should be worn during peri care, catheter care, direct contact with residents that placed on EBP. During an interview on 8/20/25 at 11:38 A.M., Certified Medication Technician (CMT) A said: -PPE of gown and gloves should be worn during any direct contact care provided for a resident who had been placed on EBP. -Licensed nursing staff would be responsible for the resident care with PEG tubes related to feeding, medication, cleaning of PEG tube site and tube feedings process. During an interview on 8/20/25 at 11:55 A.M., CMT B said:-Resident with tube feeding would be placed on EBP, gown and gloves worn during direct contract resident care. -Licensed nursing staff would be responsible for the resident care with PEG tubes. During an interview on 8/20/25 at 12:04 P.M., RN C said: -Resident on EBP due to PEG tube, the licensed nursing would be responsible for providing setup and monitoring of PEG tube and site, administration of TF formula. -He/She would expect staff to wear PPE of gown and gloves to during the TF process.-TF tubing should be changed every 24 hours and to ensure to label and date the tubing when replaced. -The facility provides monthly trainings, and he/she had completed annual skill check off. During an interview 8/20/25 at 12:23 P.M., RN B said: -He/She would wear PPE of a gown and gloves during the resident's TF process.-Licensed nursing staff would be responsible for changing tube feeding tubing at least every 24 hours.-TF formula and tubing should be dated when first opened and should be checked the dated before administration of tube feeding formula. During an interview on 8/20/25 at 1:42 P.M., Assistant Director of Nursing (ADON) said:-He/She would expect residents with tube feeding would be placed on EBP. -During resident TF care licensed nursing staff should wear PPE of gown and gloves. -He/She would expect TF tubing to be changed every 24 hours. During an interview on,08/20/25 2:45 P.M. Director of Nursing (DON) said: -Resident would be placed on EBP if indwelling medical devices such as PEG tube.-For resident requiring EBP, he/she would expect all care staff to wear gown and gloves during direct resident care. -He/She would have expected licensed nursing staff should have worn gown and gloves during care PEG tube site, Tube feedings process and during medication administration via PEG tube. -He/She would expect licensed nursing staff be responsible for ensuring the resident tube feeding tubing be changed every 24 hours and as needed.

Based on observation, interview and record review, showed the facility failed to complete the correct procedure during tracheostomy care to include cleaning the inner canula, failed to use Enhanced Barrier Precautions (EBP-a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes. They focus on using personal protective equipment (PPE) like gowns and gloves during specific high-contact resident care activities for residents at increased risk of acquiring or known to be colonized or infected with an MDRO) upon entering the resident's room and failed to use infection control practices to prevent cross contamination during tracheostomy care for one sampled resident (Resident #15) out of 29 sampled residents. The facility census was 140 residents.Review of the resident's Tracheostomy Care policy and procedure dated 9/1/21, showed the facility will ensure that residents who need respiratory care, including tracheostomy (a surgical airway management procedure which consists of making an incision on the front of the neck to open a direct airway to the trachea) care, is provided such care consisting with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.-Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan. General considerations include providing tracheostomy care twice daily, and correctly sized cannulas (a hollow tube). -The facility will ensure staff responsible for providing tracheostomy care, are trained and competent according to professional standards.-Procedure with the use of a reusable cannula: perform hand hygiene; put exam gloves on both hands, remove the old dressing discard both and perform hand hygiene.-Open and set up sterile tracheostomy kit and apply sterile gloves. Pour saline of sterile water into basin of the kit with the non-dominant gloved hand. Remove the inner cannula using sterile technique and place in the cleaning container. Clean the inner cannula with the sterile brush or sterile pipe cleaner. Reinsert the inner cannula, Clean the stoma (the surgical opening created in the neck that leads to the trachea) with normal saline, moistened gauze or cotton tipped applicator. Dry the area with additional gauze, dispose of equipment and perform hand hygiene-Procedure with use of disposable cannula: Explain the procedure and screen for privacy; perform hand hygiene; put on clean gloves. Slowly remove the present inner cannula from the tracheostomy tube by squeezing the tabs on the connecter until both snaps clear the lock on the outer cannula. Dispose of the inner cannula. Pick up the new inner cannula, touching only the outer portion. Insert and lock the inner cannula into position. Discard gloves and perform hand hygiene. 1.Review of Resident #15's Face Sheet showed the resident was admitted on [DATE], with diagnoses including tracheostomy, dysphagia (difficulty swallowing), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/6/25, showed the resident:-Was alert, oriented and cognitively intact with minimal confusion.-Had a tracheostomy. Review of the resident's Physician's Order Sheet dated August 2025, showed physician's orders for:-EBP with gown and gloves required for high contact resident care activities every shift for precautions (5/5/25).-Change disposable inner cannula size 6 daily, every day shift for tracheostomy care and as needed (8/14/25).-Cleanse stoma area with normal saline, pat dry daily and as needed, every day shift for stoma care (5/12/25).-Tracheostomy care daily and as needed. Change inner cannula, gauze dressing and tracheostomy collar daily and as needed, every day shift (4/17/25).-Gown and gloves were required during high contact resident care activities.-EBP will be utilized during high-contact resident care activities including, but not limited to dressing, bathing, transfers, linen changes, incontinent care, wound and/or indwelling device care. -Nursing staff may assist with trach care daily and as needed. Observation and interview on 8/14/25 at 10:20 A.M., showed there was an EBP sign on the resident's door and there was PPE outside of his/her room in the hallway in a box. The resident was sitting in his/her wheelchair watching television while wearing oxygen. The resident's tracheostomy looked clean and there was a split gauze around the tracheostomy (on the stoma) which was also clean. The resident was alert and oriented and said:-He/She had his/her tracheostomy replaced on Friday last week and it was a little tight, but he/she was not having much distress or discomfort currently.-The nursing staff was keeping it clean and maintaining it well.-He/She was to see the physician tomorrow and would inform him/her of what he/she was experiencing. Observation and interview on 8/14/25 at 2:24 P.M., showed there was an EBP sign on the resident's door and there was PPE outside of his/her room in the hallway. The resident was sitting in her wheelchair watching tv. The Assistant Director of Nursing (ADON) said he/she would be completing the resident's tracheostomy care. The resident's tracheostomy care supplies were in a closed sterile container on the resident's tray table. The following occurred:-The ADON re-entered the room at 2:32 P.M., holding a gown (packaged) and an unopened tracheostomy care container.-Without donning the gown, he/she placed the packaged gown on the small dresser the television was on.-He/She washed his/her hands and opened the tracheostomy care container, put on the sterile gloves, placed the sterile barrier cloth on the tray table and put the sterile supplies (that were inside of the container) on top of the sterile barrier cloth.-The ADON opened and poured the saline (salt water) solution into the tracheostomy care container then placed the sterile cloths inside the solution.-He/she took the sterile cotton swabs, with one hand, dipped them in the solution, and cleaned around and under the resident's tracheostomy. He/she discarded them then took the wet cloths from the solution and cleaned the resident's skin around and under the resident's tracheostomy. When he/she was done, he/she discarded them.-Without removing the sterile gloves, washing or sanitizing his/her hands, he/she placed a clean split gauze under the resident's tracheostomy.-The ADON degloved, sanitized his/her hands then discarded the gloves and tracheostomy care tray. He/she said he/she was going to check the orders for the right sized inner cannula and exited the resident's room.-The ADON re-entered the resident's room at 2:48 P.M. and put on the gown, pulled the residents privacy curtain (there were other people in the room), sanitized his/her hands, opened another tracheostomy care container, removed the sterile gloves from that container and donned the sterile gloves.-The ADON then opened the container with the inner cannula in it.-He/She removed the inner cannula from the resident's tracheostomy (that had a yellowish phlegm) with one hand and discarded it.-The ADON then took the new inner cannula and placed it into the resident's tracheostomy with the opposite hand. *NOTE: He/She did not cleanse the resident's stoma insertion site after removing the old inner cannula before placing the new inner cannula. During an interview on 8/14/25 at 2:56 P.M., the ADON said:-He/She thought he/she messed up when he/she opened the tracheostomy care supplies container and used his/her bare hands to put the sterile cloth down prior to donning the sterile gloves.-He/She did not remember if he/she had not donned a gown when he/she re-entered the resident's room and began to perform the resident's tracheostomy care.-He/She had checked the resident's tracheostomy orders prior to completing the resident's tracheostomy care, but he/she second guessed himself/herself which was why he/she left the room the second time.-He/She checked the cannula size and realized he/she had the correct inner cannula size.-He/She did not realize she had not washed or sanitize hands after she discarded the soiled cotton cloths and swabs.-He/She should have removed his/her gloves after cleaning around the resident's tracheostomy and washed or sanitized his/her hands.-He/She forgot to clean the outside and inside the resident's tracheostomy after removing the inner cannula, before inserting the new one. -He/She was frazzled and frustrated.-He/She should ensure he/she has all of the supplies he/she needed prior to starting tracheostomy care.-He/She should of don a gown upon entering the resident's room every time he/she is completing tracheostomy care and wash his/her hands and don gloves before beginning tracheostomy care.-He/She should ensure that he/she removes his/her gloves and washes his/her hands or sanitizes after every dirty to clean task during care.-He should remove his/her gown, gloves and wash his/her hands before leaving the resident's room.

Based on interview and record review the facility failed to ensure communication was established and completed between the facility and the hospice nursing staff for one sampled resident (Resident #130) out of 29 sampled residents. The facility census was 140 residents. Review of the Hospice Service Facility Agreement policy and procedure, dated 9/1/2021 showed a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the residents were addressed and met 24 hours per day.Review of the Nursing Facility Services Agreement signed dated 5/24/24 showed the manner in which the facility and hospice were to communicate with each other and document such communications to ensure that the needs of the patients were addressed and met 24 hours a day. 1.Review of Resident #130's admission Sheet dated 5/8/25 showed the following diagnoses:-Anoxic brain damage (type of brain damage resulting from a complete lack of oxygen to the brain, leading to brain cell death).-Dysphagia (inability or difficulty swallowing). Review of the resident's Physician's Orders showed an order for the resident to begin hospice services on 7/25/25. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 8/7/25 showed:-He/She was severely cognitively impaired-never/rarely made decisions.-Was on hospice services. Review of the facility's hospice communication book on 8/18/25 showed no documentation of any communication notes between hospice and the facility. During an interview on 8/18/25 at 10:58 A.M., the Certified Nursing Assistant (CNA) F said:-The CNAs do nothing with hospice. -He/She had seen the nurse communicate with hospice by the phone. During an interview on 8/18/25 at 11:20 A.M., the Registered Nurse (RN) C said:-He/She would communicate by phone.-If he/she needs more medication than he/she would call hospice, and they would give the orders then the RN would put the orders in the system.-Hospice was supposed to be filling out information in the book that they were there and what they had observed. During an interview on 8/20/25 at 2:37 P.M., the Director of Nursing (DON) said:-Hospice would communicate through the book.-Nurses would check in with the DON or the Assistant Director of Nursing (ADON).-If there were any changes the hospice staff would put the changes in the book.-Then if there was a change in condition hospice staff would talk to the DON.-The DON was responsible to make sure the information was put in the communication book.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from physical abuse out of 8 sampled residents when on 4/17/25 Resident #1 struck Resident #2 on the head with rock resulting in an approximately 3 centimeter (cm) laceration and a hospital visit. The facility census was 138 residents. The Administrator was notified on 4/23/25 of the past noncompliance which began on 4/17/25. The facility immediately completed education for staff on the facility's Abuse and Neglect policy, the facility's Behavior Management police and de-escalation techniques. Resident #1 was placed on 1:1 supervision until his/her transport to the hospital on 4/18/25. Resident #2 was treated. The deficiency was corrected on 4/18/25. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 8/22/22, showed: -It was the policy of the facility to provide protections for the health, welfare and rights of each resident by implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident to resident altercations. -Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. -Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior by corporal punishment 1. Review of Resident #1's facility admission Record Face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Homelessness. -Anxiety disorder (a mental condition characterized by excessive fear, worry or nervousness), uncomplicated. -Mood disorder due to known physiological condition. -Major depressive disorder (persistent sadness, loss of interest or pleasure in activities) recurrent. -Hemiplegia (a condition characterized by paralysis on one side of the body) and hemiparesis (a condition involving weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side. Review of Resident #1's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 4/18/25, showed he/she was cognitively intact. Review of of Resident #1's Level One Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition, dated 9/27/24, showed: -The person completing the document was the hospital case manager. -The resident did not show any signs of a major mental disorder. -He/She did have a current, suspected or history of a major mental illness. -The resident did not have any area of impairment due to serious mental illness. -The resident did not have a diagnoses of a major neurocognitive disorder. -The resident did not show behavioral symptoms. -The resident had a stable mental condition monitored by a physician or licensed mental health professional at least monthly or behavior symptoms exhibited in the past, but not currently present or psychiatric conditions exhibited in the past but not recently present. -The resident had impaired situational memory. -The resident displayed difficulty making decisions in new situations or occasionally required supervision with decision making and had issues with memory, mental function or ability to be understood/understand others. Review of Resident #1's Trauma Informed Care assessment, dated 4/13/25, showed: -He/She had an altercation with another resident on that date. -He/She was glad to be separated from the other resident, because he/she had a temper. -He/She stated he/she would stay to him/herself to prevent further incidents. Review of Resident #1's Care Plan Report, updated 4/17/25, showed: -He/She had a history of a traumatic event; no known triggers. Interventions included: medications as ordered to relieve anxiety or known stressors. -He/She had an altercation with a resident on 11/6/24 and was found to be the instigator in a dispute regarding a wheelchair. Interventions included: administering medications as ordered; color coding wheelchairs for easy identification. -He/She had an altercation with another resident on 4/13/25. Interventions included placing the resident on 15-minute checks for 72 hours; scheduled for team health; smoking times alternated for 48 hours; trauma informed assessment completed; determining what might lead to altercations; monitoring the resident's behavior and progress to assess effectiveness of care plan -He/She had an altercation with another resident on 4/17/25. Interventions included maintaining a calm, respectful tone of voice; listening attentively to the resident's thoughts and feelings, validating his/her emotions; use clear and simple language so the resident could understand; he/she was placed on 1:1 oversight. Review of Resident #2's facility admission Record Face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Difficulty in walking. -Muscle weakness. -Long term drug therapy. Review of Resident #2's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #3's facility admission Record Face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Displaced fracture of left femur; closed fracture with routine healing. -Encounter for orthopedic aftercare. Review of Resident #3's quarterly MDS, dated [DATE], showed he/she was cognitively intact Review of Resident #3's Care Plan, report updated 4/13/25, showed: -He/She had an altercation with another resident. Interventions included: monitoring for behavioral changed such as mood swings, irritability, changes in sleep patterns or decreased productivity and report changes to physician; encouraging positive coping skills; increasing social interaction with peers. Review of Resident #1's progress note, dated 4/17/25 at 5:01 P.M., showed: -It was reported the resident was outside and threw a rock. -The nurse immediately went outside. -The resident was yelling and cursing stating, I didn't do shit! I didn't even mean to hit that man! -The Administrator attempted to deescalate the situation; resident struck the Administrator's phone out of his/her hand. -Police were called to assist. -The resident (Resident #2) who was hit with the rock pressed charges. -Police stated they were unable to take the resident. -The resident was immediately placed on 1:1 observation. -The physician and the resident's family member were made aware. -He/She was calm, resting in bed at that time with 1:1 observation at bedside; he/she apologized to the Administrator. Review of Resident #2's Progress Note, dated 4/17/25 at 2:55 P.M., showed: -It was reported the resident was injured with a rock by another resident. -Resident had a laceration of approximately 3 cm long to the back of his/her head and complained of pain. -Physician notified and ordered to send resident to the hospital as he/she was on blood thinners. Review of Resident #2's Care Plan Report, updated 4/18/25, showed: -He/She had a risk of trauma related to injury with a rock by another resident. Interventions included: assessment for trauma on 4/17/25; no new triggers identified with trauma assessment; referral to in-house psychological services. Review of Resident #2's Progress Note, dated 4/18/25 at 1:50 P.M., showed: -He/She had been self-propelling manual wheelchair outside by the front entrance. -Another resident threw a rock, not intending to hit this resident. -The rock did hit him/her on the back of the head. -He/She had no loss of consciousness; remained alert and oriented to baseline. -A 3 cm x 0.1 cm x < 0.1 cm laceration was noted to the back of the head; the area was cleansed, ice was applied. -He/She remained with the nurse until the ambulance arrived for transport. -Emergency Department (ED) evaluation was required per the resident's physician due to his/her use of blood thinner. -The Director of Nursing (DON), facility Administrator, physician and the resident's sister were notified. -His/her care plan was updated. Review of Resident #2's hospital Patient Visit Information, dated 4/17/25, showed: -He/She was seen for a scalp laceration. -He/She received the head injury on 4/17/25. -It did not appear serious at the time. -He/She received a head computed tomography (CT - a detailed imaging procedure that uses x-ray and computer technology to create cross-sectional pictures) which was negative. Review of the facility's Resident to Resident Investigation Summary, dated 4/18/25, showed: -On 4/17/25 Resident #1 had a resident-to-resident altercation with Resident #2. -Resident #1 was on the patio having a supervised smoke break. -Resident #1 became agitated at Resident #3 who Resident #1 felt was looking at him/her funny. -The Administrator attempted to intervene and deescalate. -Resident #1 struck the Administrator's hand, smacking his/her phone out of his/her hand. -Resident #1 got angry and threw a rock at Resident #3 and missed striking Resident #2. During an interview on 4/21/25 at 12:40 P.M., Resident #3 said: -On the day of the incident, he/she went outside and Resident #1 was already out there. -Resident #1 told him/her that he/she could not come out there and said, Get on out of here! -He/She was nowhere near Resident #1 who was sitting in the smoking area. -Resident #1 wheeled his/her chair over toward him/her, stopped at the fountain and picked up a rock. -He/She began backing away from Resident #1, who kept coming toward him/her. -He/She did not say anything to Resident #1. He/She did not think he/she could hit him/her with the rock, because he/she only had one good arm. -Resident #1 threw the rock and it hit the other resident, Resident #2, whose back was toward him/her. -He/She did not see anything else because the Administrator told him/her to go inside. -Resident #1 could get verbally aggressive with people. Resident #1 had his/her own room because he/she could not get along with anyone. During and observation and interview on 4/21/25 at 1:00 P.M., Resident #2 said: -Resident #1 threw the rock at someone and it hit him/her. -He/She was minding his/her business and Resident #1 was behind him/her and threw the rock at Resident #3. -He/She went to the hospital. -Resident #1 had a fight before with Resident #3 earlier in the week. -The place where the rock hit him/her was painful, but he/she had not asked for any pain medication. -He/She had an approximately inch long closed laceration on the back of his head. There was no discoloration or visible swelling. -He/she was angry and wanted to press charges. During an interview on 4/22/25 at 11:00 A.M., Resident #1 said: -He/She threw a rock at Resident #3, because Resident #3 had previously punched him/her in the face. -He/She was outside on a smoke break and Resident #3 was making fists at him/her. -He/She did not want to keep seeing the other resident when he/she was outside, so he/she picked up a rock and threw it, but it hit the other resident (Resident #2). -He/She and Resident #3 got along sometimes, but he/she did not like him/her. During an interview on 4/23/25 at 1:30 P.M., Resident #1's physician said: -He/She was aware of the rock throwing incident. -Medication adjustments were reviewed and the resident was put on 1:1 observation. -The staff were concerned about the safety of the other residents. -Resident #1 had dementia that was progressing. -Resident #1 had to be sent out for evaluation, because the facility was not able to manage his/her signs and symptoms. -It was never justified for a resident to throw a rock at another resident. During an interview on 4/23/25 at 2:00 P.M., the DON said: -He/She was at the facility on 4/17/25. Someone said help was needed outside, so he/she went running. -He/She took Resident #2 into his/her office. His/her laceration was very superficial and they were not originally going to send him/her to the hospital. It was cleansed and ice was applied. He/She was sent to the hospital due to being on a blood thinning medication. -Resident #1 should not have thrown a rock at Resident #3. During an interview on 4/23/25 at 2:00 P.M., the Administrator said: -It was never appropriate for a resident to throw a rock at another resident. -He/She did not feel the incident was predictable because prior to 4/13/25 the resident did not have behaviors. -When Resident #1 threw the rock, he/she had just gone outside. MO00252926

Based on observation, interview, and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to Vendor A who provided necessary services to the residents. On [DATE] at 9:02 A.M., the running water to the facility was shut off for non-payment. The facility had received a 10-day notice of shut off for non-payment which expired on [DATE]. This affected all residents in the building. The facility census was 113 residents. The Administrator was notified on [DATE] at 3:56 P.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of a facility e-mail, dated [DATE] at 11:38 A.M. showed: -An attached 10-day notice from Vendor A was sent to the facility management Account Manager for payment. -Copied on the e-mail was the facility Administrator and Chief Financial Officer. Review of the facility 10-Day Notice dated [DATE] showed: -Attention resident the water service is scheduled to be disconnected [DATE] at 7:00 A.M., for default on account. -The city will be notified that water had been shut-off and property may be considered unfit for occupancy. -This information was provided so you may make necessary arrangements. -Please note the water company cannot discuss any account information with tenants. During an interview on [DATE] at 8:38 A.M. Vendor A said: -Two late notices were mailed on [DATE], which notified of a late fee and shut off. -The facility received a second shut off notice on [DATE]. -The water was scheduled to be shut off at 9:00 A.M. on [DATE]. -The facility's outstanding balance was $14,000.81 and the overdue balance $6,686.00. -Someone called him/her on [DATE] and wanted to make a payment, they were told only credit/debit cards would be accepted. -They said OK and hung up. No name was provided and no payment was received. -Leniency was provided because a call was made on the facility behalf on [DATE]. -Due to no payment being made, the facility was placed on the shut off list for 9:00 A.M. on [DATE]. Observation on [DATE] at 9:02 A.M., showed no running water in the facility: -The running water in the bathroom and water fountain by the nurse's station was off. -The Administrator just noticed the water was shut off to the building during the observation. During an interview on [DATE] at 9:07 A.M., the Director of Nursing (DON) and Regional Nurse Consultant said: -The water was turned off in the past 15 minutes. -The water was on at 8:00 A.M. -Vendor A said the water would be turned back on in an hour. -Vendor A was just paid $6,738.69 and will be switching to an auto pay system. -The facility was activating their emergency water supply. -They will use water supply for toilets. -The facility was given a 10-day shut off notice on [DATE]. -The notice was sent to corporate to be paid on [DATE]. Observation on [DATE] at 9:20 A.M., showed the facility's running water had been re-connected and the facility once again had running water. During an interview on [DATE] at 8:38 A.M., Vendor A said: -The water was shut off at 9:00 A.M. -Payment was made for the overdue balance of $6,736.10. -The remaining balance was $7,723.71 was due on [DATE]. -The water was turned back on in the facility at 9:15 A.M. During an interview on [DATE] at 2:50 P.M., Certified Nurse Aides (CNA) A said: -He/she had no notice the water was going to be turned off. During an interview on [DATE] at 2:50 P.M., CNA B said: -He/she had just finished incontinent care on a resident and went to wash his/her hands and there was no water. -He/she had to use hand sanitizer on his/her hands until the water came back on then he/she washed his/her hands. -It would have been nice to know the water was going to be shut off. During an interview on [DATE] at 11:42 A.M., the Administrator said: -He/she received the 10-day shut off notice on [DATE] from Vendor A. -The 10-day shut off notice was e-mailed to the Chief Financial Officer and the facility management Account Manager on [DATE] for payment. -He/she expected the water bill to be paid and the water should have never been shut off. -He/she had not received training on the new bill paying system at this time but planned on the training to happen at any time on [DATE]. During an interview on [DATE] at 11:58 A.M., the facility management Account Manager said: -This was the facility's third party billing company. -They were in a transition period and started receiving the facility accounts from another billing company in [DATE]. -The original water bill was sent to the previous billing company and not received by this billing company until the facility sent the shut off notice. -The shut off notice was sent to him/her on [DATE] via e-mail. -A check was cut on [DATE] in the amount of $6,686.10 and sent through the mail from the east coast office. -The check was not cut earlier, because it was still in the window for being shut off and figured the check would be received by Vender A before the water was shut off. -The facility executives were just trained on this system last week and the facility staff were next on the list. -Once all the accounts are set up an Administrator will be able to see all accounts to see if they had been paid or approve for them to be paid. -All the facility's accounts have been set up on auto pay to the vendors. -Vendor A was just overlooked and had not been set up at the time of the water being shut off. -He/she has pulled all the facility vendors to make sure the were set up for auto pay and to make sure none were past due. -The check sent to Vendor A will be applied to the remaining balance due on [DATE]. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview, and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is I substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00248678

Based on interview and record review, the facility failed to prevent the misappropriation of one sampled resident (Resident #1). Certified Nurses Aide (CNA) A used CashAPP (a mobile payment service that allows users to send, receive and store money digitally) for multiple withdrawals totaling $617.89 from the resident's bank account out of nine sampled residents. The facility census was 112 residents. On 1/24/25, the facility administration was notified of the past noncompliance which occurred on 1/11/25. Facility staff had subsequently been educated on abuse, neglect and exploitation protocols, resident belongings, and transactions involving resident funds. The money missing from the resident's account was replaced. The deficiency was corrected on 1/13/25. Review of the facility's Abuse, Neglect and Exploitation policy dated 8/22/22 showed: -It was the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Misappropriation of Resident Property meant the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Review of the facility's Resident Personal Belongings policy dated 9/1/22 showed: -It was the policy of the facility to protect the resident's right to possess personal belongings while in the facility and assure the personal belongings and/or possessions were rightfully returned to the resident or the resident's representative in the event of the resident's discharge from the facility or death. -The facility would exercise reasonable care for the protection of the resident's personal property from loss or theft. Review of the facility's Transactions Involving Resident Funds or Property policy dated 3/12/24 showed: -It was the practice of the facility that any time there was a transaction involving resident funds, the resident must be provided a receipt for such transaction. Copies of each transaction were filed in the business office. -The facility would not utilize the resident's credit or debit card or non-cash forms of payment on personal devices. -No facility employee should knowingly exploit resident property. 1. Review of Resident #1's admission Record face sheet dated 1/21/25 showed he/she was admitted to the facility on [DATE] and he/she was his/her own responsible party and he/she did not have a guardian or power-of-attorney. Review of the resident's Brief Interview for Mental Status Evaluation (BIMS) dated 12/2/24 showed he/she was cognitively intact. Review of the resident's facility Care Plan dated 1/11/24 showed: -He/She was recently financially exploited. -He/She felt distrustful and angry over the event. -The goal was that re-traumatization would be avoided. -Interventions included: educating the resident on risks of giving others access to financial information; psychiatric evaluation as needed and referral to social services department as indicated. Review of the resident's Trauma Informed Care document dated 1/11/25 showed: -He/She was the involved resident. -He/She was financially exploited recently which left him/her feeling distrusting of other and angry. -This affected his/her overall health and well-being. Review of the resident's Progress Notes dated 1/11/25 showed: -An Interdisciplinary Team (IDT) meeting was held for alleged misappropriation of funds, primarily a debit card belonging to the resident. -An investigation was initiated immediately. -The Administrator, Director of Nursing (DON), family member, physician, local police department and Centers for Medicare and Medicaid Services (CMS) were notified. -His/Her care plan was updated, resident was interviewed and educated on the risk of giving any monetary access to anyone. -He/She was allowed to express feelings of sadness and disappointment. -He/She denied feeling afraid or unsafe in his/her current setting. Review of the resident's undated Abuse Investigation Report showed: -The alleged incident was reported on 1/11/25 at 10:23 A.M. -The most recent bank transaction was 1/10/25. -The alleged incident occurred in the resident's room. -He/She was the person reporting the alleged incident. -The allegation was misappropriation via a bank debit card. -He/She was not physically injured and did not require medical attention. -There were no witnesses. -The staff person allegedly involved was CNA A. -No other residents reported having money or funds missing or taken. -No staff had observed abuse or misappropriation. -Family Member A was called to review the charges on the resident's debit card. $244.00 was accounted for as spent by the resident; $617.89 was unaccounted for. -Police report #25-0070 by Officer A who spoke with the resident in his/her room accompanied by the Administrator. -Additional information included was that CNA A had been terminated from employment at the facility on 1/7/25 for poor performance and customer service. Review of the resident's Abuse Investigation Resident Questionnaire dated 1/11/25 at 10:23 A.M. showed: -The resident stated he/she asked CNA A to order him/her food because he/she did not know how to do Door Dash (an on-demand food delivery service that connects customers with local restaurants). -This happened sometime in December, but he/she did not remember an exact day. -The name on the bank statement had CNA A's name to the Cash App withdrawal. Review of the resident's Abuse Investigation Staff Questionnaire dated 1/11/25 at 3:52 P.M. showed: -CNA A was asked of he/she had used a resident's money source to purchase food for the resident; he/she answered he/she had not, but helped the resident order food from Door Dash on his/her phone. -When asked if he/she was aware of the restrictions on using a resident's money source, he/she replied he/she was. -When asked if he/she had any knowledge of the resident's debit card, he/she replied he/she had never seen his/her debit card. Review of the facility Investigation Timeline document dated 1/11/25 showed: -The resident identified as his/her own responsible party. -At 10:23 A.M., the resident reported an allegation that a former staff member used his/her debit card. He/She was offered assistance to order a new debit card, but he/she reported her family member had called and canceled the old card the night before. -The Administrator was notified and risk management was updated. -The resident stated CNA A got access to his/her bank card because he/she asked him/her to order food, because he/she did not know how to use Door Dash. -He/She said it had to have happened in December, but he/she did not remember the exact date. -He/She said the name on the bank statement showed the staff person's name next to the Cash App. -He/She said he/she felt safe at the facility. -At 12:09 P.M., Family Member A was contacted. He/She reviewed the charges of $244.00 from the ATM and confirmed this amount was accounted for by the resident. $617.89 remained unaccounted for, potentially spent by the alleged staff person. Family Member A sent the facility the December bank statement. -At 3:52 P.M., former staff person CNA A was contacted and interviewed. When asked if he/she used the resident's money source to purchase food, he/she stated, No, I helped the resident order food from Door Dash on his/her phone for him/her. -On 1/13/25 at 12:55 P.M., local Police Department was contacted for a follow-up on the resident's report. Police Officer B was assigned to the case. -On 1/15/25 at 10:09 A.M., Police Officer B contacted the Administrator by telephone. -He/She reported he/she had another investigation of a similar nature on CNA A from a previous employer and he/she would be coming out to the facility to follow up on this case with the resident. -The Administrator asked why this had not shown up on CNA A's background check. Police Officer B explained no charges had been filed yet, so nothing appeared on the criminal record. Review of the local Police Department report #25-0070 dated 1/11/25 showed: -The victim was the resident. -The complainant was the Administrator. -The suspect was CNA A. -The detailed description stated $861.89 worth of purchases were made on the resident's card. -The narrative stated a previous employee used patient's Cash App card. Employee was terminated. -Police Officer A was dispatched to the facility on 1/11/25 at 11:00 A.M. in regard to a larceny. -He/She spoke to the resident who allowed his/her nurse, CNA A access to his/her debit card to make purchase requested by the resident. -The resident specifically stated he/she did not allow CNA A to make any purchases outside his/her specified requests. He/She observed several unknown charges to his/her card between the dates of 1/1/25 and 1/10/25. -These transactions included transfers between the account and a Cash App account associated with CNA A, transactions through Door Dash, a general purchase an a cash withdrawal from the resident's bank ATM. -He/She spoke with the building Administrator who stated CNA A had been terminated from his/her employment at the facility on 1/10/25 and he/she learned of the theft prior to contacting law enforcement on 1/11/25. -The resident was able to provide a transaction statement which was scanned into the file. During an interview on 1/24/25 at 11:00 A.M., the resident said: -He/She allowed CNA A to use his/her bank card so he/she could order Door Dash, since he/she did not know how. -He/She did not authorize CNA A to use her card for any other purpose. -He/She was upset and distrustful due to this happening. -He/She was not going to let anyone else use her card. -The Administrator replaced his/her missing money. During an interview on 1/24/25 at 2:30 P.M., the Administrator said: -He/She became aware of the missing money when the resident came and told him/her. -CNA A denied knowledge of the resident's debit card. -All staff were trained regarding misappropriation of funds at orientation and CNA A had received this training. -CNA A's background check was clear when the facility hired him/her. -It was his/her expectation that staff followed the facility policies regarding handling and misappropriation of residents' money. -What another person was going to do was not always predictable. During an interview on 2/4/25, Family Member A said: -The resident was his/her grandparent. -He/She had access to the resident's bank account because sometimes the resident asks him/her to review his/her account. -The resident had tried to order food and the card did not work, so he/she called Family Member A to find out how much money he/she had in the account. -The resident's account only had about $30 in it and he/she felt there should have been more. -When he/she reviewed the bank statement with the resident they found there were some Cash App transactions and Door Dash transactions that had not been authorized by the resident. -He/She saw to it that the resident's card was closed so it could not be used again. Review of CNA A's employment file showed he/she had received competency training regarding compliance with the facility's abuse/neglect policy which included identification of misappropriation on 11/6/24 and completed a quiz regarding prevention of abuse on 11/6/24. He/she had signed off on the policy on that date. MO00247972

Based on interview and record review, the facility failed to permit one sampled resident (Resident # 1) to return to the facility after hospitalization out of five sampled residents. The facility census was 108 residents. Review of the facility policy Transfer and Discharge (including Against Medical Advice - AMA), dated 9/1/21 showed: -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. -Transfer and discharge included movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. -Facility-initiated transfer or discharge was a transfer or discharge which the resident objected to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. -The facility would evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. -The facility permitted each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. -The physician shall document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than non payment of the stay or the facility ceasing to operate. -The facility was to have obtained a physician's order for the emergency transfer or discharge, stating the reason the transfer or discharge was necessary on an emergency basis. -The facility was to correctly complete the discharge documents and send them with the resident. 1. Record review of Resident #1's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Paraplegia (loss of movement of both legs and generally the lower trunk). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Post-Traumatic Stress Disorder (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world). -Bipolar Disorder ((formerly called manic-depressive illness or manic depression) is a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). -Need for assistance with personal care. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool completed by staff and used for care planning) dated 7/10/24 showed he/she: -Was cognitively intact. -Had no verbal behaviors directed toward others such as threatening, screaming, and cursing. -Had no physical behaviors such as hitting, kicking, pushing, scratching, and grabbing others. -Required limited assistance of one staff member for bed mobility, -Was dependent of staff assistance of two or more staff members for transferring, bathing, toileting, and personal hygiene. -Required supervision/set-up of one staff member for eating, and locomotion on and off the unit. Review of the resident's nursing care plan dated 7/10/24 showed he/she: -He/She had the right to have received a 30-day notice of discharge/transfer which included the reason, effective date, location to which the resident would be transferred/discharged , and the name, address, and telephone number of the Ombudsman (advocate). -He/She had the right to a safe transfer and or discharge through sufficient preparation by the facility. -Was verbally abusive to staff. -Was uncooperative with his/her cares. -The facility staff was to have the resident participate in his/her care and make decisions as possible. -The facility staff was to negotiate with the resident allowing him/her to make decisions. Review of the resident's Level Two Nursing Facility Preadmission Screening and Resident Review (PASRR - is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 8/22/24 showed: -Resident had a current, suspected, or history of a Major Mental Illness showed: --Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). --Bipolar Disorder. --Post-Traumatic Stress Disorder. --Mood Disorder (a variety of conditions characterized by a disturbance in mood as the main feature). -The Level II Evaluation indicated the following supports and services were to be provided by the Facility: --Behavioral Support Plan. --Structured Environment. --Crisis Intervention Services. --Discharge Planning. --Medication Therapy. --Activities of Daily Living program. --Personal Support Network. Review of the facility Notice of Immediate Involuntary discharge date d 10/4/24 showed: -The resident was discharge on 10/4/24 to Family Member A's home. -The notice did not indicate the right to make an appeal and who and how to contact to make the appeal. -Transfer or discharge for the resident's welfare and the resident's needs could not be met in the facility. -The resident was actively seeking to become pregnant in a long term facility and refused to adhere to facility policies in relation to his/her safety and the safety of other residents. -The notification was given to the resident. Review of the resident's Progress Notes dated 10/4/24 at 2:30 P.M., showed: -The Director of Nursing (DON) visited with the resident regarding the smoking policy, illicit drug consumption and possession inside the facility and use on the facility property, and the resident acknowledged the policy. -Informed the resident that due to resident's resistance to follow policies the physician had revoked his/her leave of absence. -He/She had severe edema to both legs that had a shiny appearance. -The resident reported that pain was rated at an 8 out of 10 (pain scale). -Resident was offered to be transported to the hospital for evaluation and treatment, and the resident agreed. -Resident was sent to the hospital. Review of the Order Summary report dated 10/4/24 showed an order to transfer the resident to the hospital related to swelling to both his/her legs. Review of the resident's Progress Notes dated 10/4/24 at 5:36 P.M., showed: -A call was placed to the resident's family member. -The resident's family member expressed that he/she knew how the resident was, and that the resident could not under any circumstances be discharged to and live with him/her due to the resident's ongoing behavior. Review of the resident's Progress Notes dated 10/4/24 at 6:06 P.M., showed the resident was given an Immediate Discharge Notice, a copy was emailed to Ombudsman, the Ombudsman was called and a message was left on the Ombudsman voicemail. Review of the facility Transfer/Discharge Report dated 10/4/24 showed: -The resident was transferred/discharged on [DATE] at 6:10 P.M., to an acute care hospital. -No behaviors were listed on the report. During an interview on 10/8/24 at 11:00 A.M., Social Services Designee (SSD) said: -The resident was to be discharged to his/her family member's house. -The family member said the resident could not be discharged there. -The resident was then discharged to the hospital. -The facility could not treat the resident while wanting to become pregnant in the facility. During an interview on 10/8/24 at 1:15 P.M., the resident said: -He/She was discharged to the hospital. -The facility was not allowing him/her back to the facility. -He/She was discharged on [DATE]. -He/she wanted to return to the facility. During an interview on 10/8/24 at 4:00 P. M, hospital social worker said: -He/She was notified on 10/7/24 that the facility was not taking the resident back. -The facility had done an Immediate Discharge Notice with the family member's address on it. -He/She was currently trying to find placement for the resident. Review of the Missouri Department of Health & Senior Services (DHSS) Appeals Unit letter dated 10/9/24 showed: -The resident as Petitioner. -The facility as Respondent. -The respondent discharge notice dated 10/4/24 failed to contain the required information specifically it failed to contain the address, fax, phone and email address that a request for a hearing needed to be sent to. -The burden of showing that the facility has complied with all requirements for appropriate discharge of the resident shall be upon the facility, Respondent discharge did not meet the requirements for appropriate notice to discharge Petitioner; therefore, Respondent's discharge is DISMISSED. -ORDER --Respondent's discharge of Petitioner is dismissed due to inadequate notice. Petitioner may remain at Respondent's facility. If Petitioner has been discharged , based upon the defective notice, Respondent is directed to proceed in accordance with the regulation for Petitioner's return to Respondent's facility. During an interview on 10/9/24 at 9:20 A.M., the Hospital Nurse said: -The facility had sent the resident to the hospital with a Emergency Discharge Notice. -The resident was reported to have violent behaviors but none were observed since admission. -The resident was admitted to the hospital because the facility refused to accept the resident back when stable and ready to readmit. During an interview on 10/9/24 at 2:24 P.M., the Hospital Unit Manager said: -The resident was stable, ready for discharge and the facility would not accept the resident back. -The resident was admitted because the facility refused to accept the resident back when stable and ready to readmit. During an interview on 10/9/24 at 9:53 A.M., the Family Member A said: -He/She lived at the address listed on the Emergency Discharge Notice. -He/She could not care for the resident and the resident could not live with him/her. -The facility had not called him/her to see if the resident could be discharged . -The facility had only informed him/her of the most recent problems after he/she was discharged . During an interview on 10/9/24 at 10:15 A.M., the Director of Nursing (DON) said: -The facility felt that in order to protect the residents in the facility an emergency discharge was needed. -The resident was discharged to the hospital. During an interview on 10/9/24 at 10:40 A.M., the facility Administrator said: -It was determined due to the resident brining in unknown males to the facility, and the possibility of the resident bringing in illicit substances, this posed a serious safety issue so the facility would do an emergency discharge and discharge the resident to the hospital due to her current medical issue. During an interview on 10/9/24 at 10:03 A.M., Registered Nurse (RN) A said: -The resident as having male visitors in his/her room. -The resident was trying to get pregnant. -The facility nor staff were prepared to handle a pregnant resident or a resident trying to get pregnant. -The resident was on several medications that would be harmful to a baby if the resident became pregnant. -The resident would cuss and yell at staff and other residents. -Staff were unsure who all the male visitors were that came to visit the resident. -The resident had said he/she met them on the street. During an interview on 10/9/24 at 10:15 A.M., the DON said: -The resident was receiving illicit substances from people from outside the facility. -The resident kept bringing in strange men to the facility. -The resident informed him/her that he/she was wanting to get pregnant. -The resident would leave the facility property with his/her male visitors. -It was deemed a resident safety issue when the resident kept bringing men into the facility to try and get pregnant. -The facility was concerned because the resident had said that the men that were brought into the facility were homeless. -The facility felt that to protect the other residents in the facility that an emergency discharge needed to be done. -The resident was discharged to the hospital. During an interview on 10/9/24 at 10:40 A.M., the facility Administrator said: -He/she would have never accepted the resident into the facility knowing that the resident was wanting to get pregnant. -The information was not known until after the resident was at the facility. -He/she would have expected that if the resident had a history of violent behaviors, the resident would have not been admitted to the facility. -The facility was not the place for a resident that wanted to get pregnant. -It was determined that due to the resident bringing in unknown males to the facility, and the possibility of the resident bringing in illicit substances, and that this posed a serious safety issue that the facility would do an emergency discharge and discharge the resident to the hospital due to her current medical issues. During an interview on 10/9/24 at 12:30 P.M., the Physician said: -That once it was known that the resident wanted to get pregnant the resident was not appropriate for the facility. -He/She had no experience in treating a resident that wanted to get pregnant in the long term care setting. -The resident was on several medications that were harmful to the baby if the resident were to get pregnant. -The best course of action was for the facility to discharge the resident to seek placement in a facility that could manage a resident that wanted to become pregnant. -He/She ordered the resident transferred to the hospital to be evaluated for the swelling in his/her legs. During an interview on 10/16/24 at 12:46 P.M., the Administrator said: -The resident had filed an appeal. -An attorney had contacted the facility and said the resident should return. -The facility said they couldn't meet the needs of the resident and does not plan to allow the resident to readmit. Review of the facility Amended Notice of Discharge for Emergency Situation- Unsafe Environment and Unable to Meet need of Resident dated 10/17/24 showed: -The letter was addressed to the resident in care of an attorney. -The letter was sent to Family Member A and the Ombudsman. -The effective date of the discharge was 10/4/24. -The discharge was deemed an emergency and the resident was discharged to the hospital. During an interview on 10/17/24 at 3:30 P.M., Attorney said: -The resident was given an emergency discharge 10/4/24 and sent to the hospital. -The resident had appealed. -The hearing officer dismissed the appeal as the resident was given an inadequate notice. -The facility had refused to allow the resident to return. -The facility issued an amended discharge letter 10/17/24. -The facility may face further legal action. During an interview on 10/17/24 at 3:49 P.M., Ombudsman A and Ombudsman B said: -Family member A was not an option for discharge, the facility social worker had said it was not an option. -The facility social worker was spoken to before the discharge letter was issued on 10/4/24. -The resident had filed an appeal and had representation from an attorney. -The discharge letter from 10/4/24 was dismissed as it was not proper notice. -The resident had filed a second appeal related to the 10/17/24 discharge notice. MO00242997

Based on interview and record review, the facility failed to provide an discharge notice for one sampled resident (Resident #1) which included the request for an appeal and the location to which the resident was transferred that would meet the resident's level of care out of five sampled residents. The facility census was 108 residents. Review of the facility policy entitled Transfer and Discharge (including Against Medical Advice) dated 9/1/21 showed: -It was the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility was not expected. -The facility was to evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. -The facility was to correctly complete the discharge documents and send them with the resident. 1. Review of Resident #1's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Paraplegia (loss of movement of both legs and generally the lower trunk). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Post-Traumatic Stress Disorder (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world). -Bipolar Disorder ((formerly called manic-depressive illness or manic depression) is a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). -Need for assistance with personal care. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool completed by staff and used for care planning) dated 7/10/24 showed he/she was cognitively intact. Review of the resident's nursing care plan dated 7/10/24 showed: -He/She had the right to have received a 30-day notice of discharge/transfer which included the reason, effective date, location to which the resident would be transferred/discharged , and the name, address, and telephone number of the Ombudsman (advocate). -He/She had the right to a safe transfer and or discharge through sufficient preparation by the facility. Review of the resident's Progress Notes dated 10/4/24 at 5:36 P.M., showed: -A call was placed to the resident's family member. -The resident's family member expressed that he/she knew how the resident was, and that the resident could not under any circumstances be discharged to and live with him/her due to the resident's behavior. Review of the resident's Progress Notes dated 10/4/24 at 6:06 P.M., showed the resident was given an immediate discharge notice, a copy was emailed to Ombudsman and the Ombudsman was called and a message was left on the Ombudsman's voicemail. Review of the facility Notice of Immediate Involuntary discharge date d 10/4/24 showed: -The resident was discharge on 10/4/24 to Family Member A's home. -The notice did not indicate the right to make an appeal and the who and how to contact to make the appeal. During an interview on 10/8/24 at 11:00 A.M., the Social Services Designee (SSD) said: -The resident was to be discharged to Family Member A's home. -Family Member A said the resident could not be discharged there. -The resident was then discharged to the hospital. During an interview on 10/8/24 at 1:15 P.M., the resident said: -He/She was discharged to the hospital. -The facility was not allowing him/her back to the facility. -He/She was discharged on [DATE]. During an interview on 10/8/24 at 4:00 P.M., Hospital Social Worker said: -He/She was notified on 10/7/24 that the facility was not taking the resident back. -The facility had done an immediate discharge with the family member's address on it. Review of the Missouri Department of Health & Senior Services (DHSS) Appeals Unit letter dated 10/9/24 showed: -The resident as Petitioner. -The facility as Respondent. -The respondent discharge notice dated 10/4/24 failed to contain required information specifically it failed to contain the following: A request for hearing should be sent to DHSS Appeal Unit, with the mailing address, fax and phone number and email address. -The burden of showing that the facility has complied with all requirements for appropriate discharge of the resident shall be upon the facility, Respondent discharge did not meet the requirements for appropriate notice to discharge Petitioner; therefore, Respondent's discharge is DISMISSED. -ORDER: --Respondent's discharge of Petitioner is dismissed due to inadequate notice. Petitioner may remain at Respondent's facility. If Petitioner has been discharged , based upon the defective notice, Respondent is directed to proceed in accordance with the regulation for Petitioner's return to Respondent's facility. During an interview on 10/9/24 at 9:20 A.M., the Hospital Nurse said the facility had sent the resident to the hospital with a Emergency Discharge Notice. During an interview on 10/9/24 at 2:24 P.M., the Hospital Unit Manager said the resident was stable, ready for discharge and the facility would not accept the resident back. During an interview on 10/9/24 at 9:53 A.M., the Family Member A said: -He/She lived at the address listed on the Emergency Discharge Notice. -He/She could not care for the resident and he/she could not live with him/her. -The facility had not called him/her to see if the resident could be discharged to his/her home. During an interview on 10/9/24 at 10:15 A.M., the DON said: -The facility felt that to protect the other residents in the facility an emergency discharge was needed. -The resident was discharged to the hospital. During an interview on 10/9/24 at 10:40 A.M., the facility Administrator said: -It was determined due to the resident bringing in unknown males to the facility, and the possibility of the resident bringing in illicit substances; this posed a serious safety issue so the facility would do an emergency discharge and discharge the resident to the hospital due to his/her current medical issues. -The resident was given the discharge notice. Review of the facility Amended Notice of Discharge for Emergency Situation- Unsafe Environment and Unable to Meet need of Resident dated 10/17/24 showed: -The letter was addressed to the resident in care of an attorney. -The letter was sent to Family Member A and the Ombudsman. -The effective date of the discharge was 10/4/24. -The discharge was deemed an emergency and the resident was discharged to the hospital. During an interview on 10/17/24 at 3:49 P.M., Ombudsman A and Ombudsman B said: -Family member A was not an option for discharge, the facility social worker had said it was not an option. -The facility social worker was spoken to before the discharge letter was issued on 10/4/24. -The resident had filed an appeal and had representation from an attorney. -The discharge letter from 10/4/24 was dismissed as it was not proper notice. -The resident had filed a second appeal related to the 10/17/24 discharge notice. MO00242997

Based on interview and record review, the facility failed to develop a quality assurance program regarding interventions of ensuring the interventions from the Registered Dietitian (RD) were included within the resident's medical record and the documentation of the volume of supplements consumed by residents, for continued issues of weight loss. This practice potentially affected at least three residents (Residents #15, #85 and #7) of 19 sampled residents. The facility census was 91 residents. 1. Review of the Nutrition and Weight Section of facility's undated Quality Area Report and Analysis, showed the departments (Dietary and the Assistant Director of Nursing (ADON) which were responsible to address weight loss with the percentages of weight loss, which indicated significant weight loss and a blank space in the column under the Action Performance Improvement Program (PIP) dated 7/13/23. 2. Review of the facility's policy, dated 9/1/21, titled Weight Monitoring showed: -Staff were to identify and assess each resident's nutritional status and risk factors. -Staff were to develop and consistently implement interventions. -Staff were to monitor the effectiveness of the interventions and revise them as needed. -Staff were to complete a comprehensive nutritional assessment upon admission and once unplanned weight loss was noted. -The comprehensive nutritional assessment was to include food and fluid intake. -Staff were to monitor resident weights weekly or daily if weight loss was noted. -The physician was to document the diagnosis or clinical condition that may be contributing to weight loss. -The Registered Dietitian (RD) was to be consulted with to assist with interventions and document the interventions in the nutrition progress note. 3. Review of Resident #15's Medical record showed the following recorded weights for that resident: -On 5/3/2023 -- 119.0 pounds (did not identify how he/she was weighed). -On 6/13/2023 -- 114.0 pounds (weighed sitting). -On 7/17/2023 -- 110.0 pounds (weighed sitting) showing there was an 8.8 percent weight loss from 5/3/23 to 7/17/23, which was significant weight loss. -On 8/8/2023 -- 110.0 pounds (weighed in a wheelchair). -On 9/12/2023 --105.0 pounds (weighed in a wheelchair). -On 10/10/2023 --104.0 pounds (weighed in a wheelchair) This weight indicated a weight loss of 12.61 percent in 6 months (5/3/23 to 10/10/23) which was significant weight loss. Review of the resident's monthly Medication Administration Record (MAR) dated 10/2023, showed physician's orders for House supplement 120 ml four times daily (start date 6/2/23), Prostat 30 ml twice daily (start date 7/2/23), and a multivitamin daily for supplement for wound healing (start date 7/11/23). The MAR's showed: -10/2023 MAR showed orders were followed daily except on 10/1/23 and 10/2/23 when there was no documentation showing the supplements were administered. 4. Review of Resident #85's medical record showed the following recorded weights for that resident: -On 8/30/23 - 131 pounds. -On 9/12/23 - 131.0 pounds (weighed in wheelchair). -On 10/16/23 - 110.0 pounds (weighed using a full body lift). 5. During an interview on 10/23/23 at 12:36 P.M. the Director of Nursing (DON) said: -All physician's orders should be followed. -Nursing staff uses the dietary communication form to communicate any changes in dietary orders to the dietary department. -The communication form should be filled out based on recommendations and orders from the physician, Speech Therapy, Registered Dietician and any new admission dietary orders. -The Dietary Manager created up the resident dietary cards based on this information. -House supplements include magic scups, prostat liquid protein and health shakes depending on the resident's dietary order. -All of these supplements are kept in the dietary department (kitchen). -Previously the house supplements were only documented on the MAR/Treatment Administration Record (TAR) and not on the diet cards. -The Certified Medication Technician (CMT) would let dietary staff know how many house supplements they needed and then dietary staff would bring the number and type of supplements needed to the floor. -There was a discrepancy and they realized residents were not getting their supplements as ordered. -In addition, the CMT's were documenting the supplement consumption incorrectly and they should be documenting how much the resident drank. 6. Review of Resident #7's medical record showed the following recorded weights for that resident: -On 7/17/23 --134 pounds. -On 8/8/23 --134 pounds. -On 9/12/23 -- 118 pounds. -On 10/10/23 -- 102 pounds. -On 10/18/23 -- 112 pounds. (this was a reweigh with new scales). -From 7/17/23 to 10/18/23, showed a significant (16.4%) weight loss over 4 months. Review of the resident's MAR dated 10/1/23 to 10/31/23, showed the resident: -Had House Supplement three times a day for weight loss give 120 ml by mouth Supplement order dated 9/18/23. -Had no documentation of amount consumed for 51 out 51 opportunities. -No documentation on 10/1/23 and 10/2/23 supplemental was given. During an interview on 10/19/23 at 11:27 A.M., CNA F said: -He/She also works a CMT. -The resident's mighty shake and med pass were to be document on the MAR with yes or no. -The resident's MAR did not have a place to document amount supplement taken. -He/She do not record if the resident amount of supplement consumed. During an interview on 10/23/23 12:33 P.M., DON said: -Previously document the supplement drinks on resident's MAR. -The CMT would be responsible for documenting amount of supplemental the resident had consumed. -CNA were able to assist the resident in ensuring the supplement shakes were drank and then report the intake to the CMT or Nurse. -Resident #7 was able to eat and drink with setup assistance by facility staff. The resident has had a decline in intake of meals and drinking his/her supplemental shakes/drinks. -The IDT have been reviewing the resident for reason of his/her weight loss and have implement intervention for resident's due to his/her decline in intake of meals. -The resident's new interview were to increase supplement drinks to four times a day and the facility were talking with family about referring the resident for Hospice services. -Supplemental drinks were to document on the resident's TAR in ml consumed and not just check mark as given. 7. During the Quality Assurance (QA) interview on 10/23/23 at 9:59 A.M. the DON said: -The most recent QA meeting was in August 2023. -Weight loss was always discussed in QAPI (Quality Assurance and Performance Improvement) meetings. -They discussed which residents triggered for weight loss, according to the reports. -The issue of the facility staff not documenting the amount of supplement that residents who were being watched for weight loss, had not come up as in issue. - The Registered Dietitian (RD) sent written recommendations through email. - The facility staff used the e-mailed recommendations for the interventions. - The facility prints the monthly weight reports. The weight reports are sent to the RD and the interventions were based on the assessment. - The interventions were entered into the computer system but the progress notes are not being entered. - The verification of supplement intake was through the MAR and the Certified Medication Technicians (CMTs) were supposed to document the intake on the MARs. - The QA committee addressed potential inaccuracies of the scale, by obtaining a new scale. - The QA committed did not address the inclusion of the RD recommendations into the medical record. - The QA committee did not address how facility staff should document the amount of a supplement that residents consumed. During an interview on 10/23/23 at 10:41 A.M., the Administrator said the residents were getting supplements but the amount consumed did not have a parameter.

Based on interview and record review, the facility failed to ensure that invoices were paid in a timely manner, so they would not be overdue, for the following entities: a pest control company, the local water company, a construction company, a Laboratory testing company, the local water company, and a laundry repair company. This practice potentially affected all residents. The facility census was 91 residents. 1. During a telephone interview on 10/23/23 at 12:44 P.M., the Customer Service Representative for the pest control company said: - The facility was not current with payments. - The last time a notice was sent to the facility was on 10/5/23. - As of the last notice, the facility owed $2,701.53. 2. During a phone interview on 10/23/23 at 12:58 P.M., the Account Person at the local water company said: - At that time the facility owed a past due amount of $4,835.63. - The most previous notice was sent to the facility on [DATE]. - The water company delivered a notice by hand on 10/17/23. - At that time no one from the facility had called to make arrangements for payment. 3. During a phone interview on 10/23/23 at 1:08 P.M., the Construction Company owner said: - The facility owed his/her company for handrail work which his/her company completed back on July 6, 2023. - He/She provided a copy of the invoice dated 7/6/23 which showed an amount of $6,840.00 for installing new handrails and materials and labor. 4. During a phone interview on 10/23/23 at 2:02 P.M., The Account Manager Consultant for the laboratory testing company said: - The facility has outstanding bills which the facility has not paid for June 2023 through September 2023. - The facility's outstanding bill is $1,299.35. - Their company has not received a payment since the facility changed names. 5. During a phone interview on 10/23/23 at 2:10 P.M., the representative from the Medical Waste Disposal company said: -The facility had two unpaid open invoices for $1,728.13. -The first invoice is for September 2023 and the 2nd invoice is for October 2023. 6. During a phone interview on 10/23/23 at 2:53 P.M., the representative from the laundry equipment repair company, said: - The facility owed $775.62, and had not received any payments since the facility changed names no payments under the current name. - He/she has communicated with Interim Business Office Manager (BOM) several times and the Interim BOM said he/she didn't take care of accounting and they were working on getting the invoices paid but he/she could not tell him/her when that bill would be paid. 7. During a phone interview on 11/2/23 at 11:58 A.M., the BOM said the following in explaining the process of how an invoice was processed: - He/She received the invoice. - He/She communicates with the various departments (dietary, central supply maintenance, nursing etc.) to verify if a product was received or a service happened. - The Administrator signs off on the invoice. - The invoice was then sent to the corporate office. During a phone interview on 11/2/23 at 1:04 P.M., the Administrator said: - When the invoices come to the facility, he/she gave them to the BOM. - The BOM sent the invoices to the corporate office.

Based on observation and interview, the facility failed to do the following: maintain the floor of the walk-in refrigerator free of food debris; maintain the ceiling vents over the steam table and the area between the dishwasher and the food preparation table free of a grease buildup; maintain the pipes and floor under the dishwashing area free of grime; maintain the deep fat fryer free of a buildup of grease; wash the food processor between uses with a three-step process instead of a two-step process; maintain the cutting boards free of numerous grooves and areas that were not easily cleanable; and failed to maintain the milk at the south nurse's station. This practice potentially affected 89 residents who ate food from the kitchen. The facility census was 91 residents. 1. Observations on 10/16/23 from 9:15 A.M. through 1:28 P.M., showed: - One onion was on the floor of the walk-in refrigerator. - Three dessert items were uncovered in the walk-in refrigerator. - The presence of debris in two of the utensil drawers. - A heavy buildup of grease and dirt on the ceiling vents and the light fixtures over the food preparation area. - At 11:59 A.M., the Dietary Manager (DM) washed the food processor container in a two step process instead of a three-step process. - A heavy buildup of grease inside the deep fat fryer. - The DM used a cutting board with numerous indentations and grooves on that cutting board, to dice onions. - A 10 in. crack on a dietary cart that was not easily cleanable. - At 10:04 A.M., Dietary Aide (DA) A's hair was not fully restrained. - At 10:36 A.M., DA A made chocolate cupcakes with his/her hair not properly restrained. During an interview on 10//16/23 at 1:53 P.M., DA A said he/she did not know part of his/her hair was uncovered. During interviews on 10/16/23, the DM said the following: - At 1:57 P.M., the DM said it was in June or July 2023, and that was the last time he/she notified the maintenance dept. to clean the vent over the food preparation area. - At 1:59 P.M. the DM said he/she assigned dietary staff to check for food, debris and grime under the walk-in fridge shelves once per week. - At 2:02 P.M., the DM said at that current time, he/she did not have a full time dishwasher and if the was a full time dishwasher that person would be assigned to clean the area under the dishwasher once per month. - At 2:06 P.M., he/she was behind in the food preparation and he/she was moving too fast, and he/she did not do a three step process. - At 2:17 P.M., said he/she would expect the hair of all dietary staff to be fully restrained. - At 2:24 P.M., He/she requested new cutting boards a week ago; those cutting boards were in the kitchen when he/she got there in January 2023. -At 2:39 P.M., the DM said he/she had no idea of the last time the whole deep fat fryer was cleaned. He/she changed the oil last week. - At 2:40 P.M. DM said the last time the drawers were ran through the dishwasher was last week. 2. Observation on 10/18/23 at 1:13 P. M, showed a container of milk that was sitting in ice at the South Nurse's station. The ice only came to about 1/3 of the weight of the milk container. Observation showed the temperature of the milk that was poured into a cup was 50.1 F (degrees Fahrenheit). During an interview on 10/18/23 at 1:18 P.M., Certified Nurse's Assistant (CNA) L said the milk was placed in a tub of ice at the south nurse's station prior to lunch, daily.

Based on observation, interview, and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to Vendor A and Vendor B who provided necessary services to the residents. On [DATE] at 9:22 A.M., the running water to the facility was shut off for non-payment. The facility had received a 10 day notice of shut off for non-payment which expired on [DATE]. As of [DATE] the facility also had an outstanding balance for Vendor D of $2,558 and the fire service was not being completed. The facility census was 111 residents. The Administrator was notified on [DATE] at 2:40 P.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. During the entrance interview on [DATE] at 9:40 A.M., the Director of Nursing (DON) said: -The facility running water had been shut off at around 9:34 A.M., apparently for non-payment, and they were currently working on getting it turned back on. -The facility had gotten one notice of non-payment that he/she knew of, which was sent to Accounts Payable towards the end of March. -When the running water was shut off in the facility earlier, the facility notified the Corporate office and they were to have been working on payment. -The bill should have been paid and they were hoping to get the running water turned back on within one to two hours. Observation on [DATE] at 9:48 A.M., showed no running water in the facility: -The running water for the Administrator's office sink was tested and it did not come on. -The running water was also tested for room [ROOM NUMBER]'s sink and the water did not come on. Record review of a payment receipt, dated [DATE] at 10:07 A.M., showed the facility paid $8,697.47 to Vendor A with confirmation on [DATE]. During an interview on [DATE] at 10:25 A.M., the Director of Maintenance said: -The facility had been on fire watch since the water got shut off. -He/she had staff at all doors, following the fire watch protocol. -He/she personally had been continually rounding in the building to ensure that all was being appropriately completed. -The kitchen had plenty of water to last a few days. -He/she was upset the facility had not paid the bill, resulting in getting the running water shut off. During an interview on [DATE] at 11:02 A.M., Licensed Practical (LPN) A said: -This situation had happened in the facility in the past where the running water had been shut off for non-payment of the water bill. -He/she felt as though the Corporation that owned the facility did not care about the consequences on the residents for not paying the bills. During an interview on [DATE] at 11:08 A.M., LPN B said: -He/she was getting fed up with these types of occurrences where the bills did not get paid and the residents and staff suffered because of it. -He/she felt as though the Corporation did not care about what happened in the facility. During an interview on [DATE] at 11:15 A.M., Resident #5 said: -This was the third time that the running water had been shut off in the facility since the new company had bought it. -He/she was told the shut off was due to the facility not paying their bills. -These types of issues had gotten worse over the past couple of years. -Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff and used for care planning), dated [DATE], showed he/she was cognitively intact. During an interview on [DATE] at 11:25 A.M., Resident #7 said he/she was getting his/her things together to go to his/her family's house to take a bubble bath, because he/she was not going to wait and see if the facility water came back on. Record review of the resident's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Observation on [DATE] at 11:45 A.M., showed the facility's running water remained shut off. During an interview on [DATE] at 12:20 P.M., Resident #8's family member said: -His/her family member had been a resident at the facility for 18 months. -The resident usually got baths completed by Hospice (end of life care) on Tuesdays and Thursdays. -The Hospice staff had come by and the running water was shut off, so they left. -He/she hoped they would come back after the running water was restored. -He/she was very frustrated as this had happened in the past where the facility neglected to pay the water bill and the running water was disconnected. During an interview on [DATE] at 12:30 P.M., Resident #6 said: -He/she had not been able to get a shower. -The bath aide had all of his/her belongings in the shower room, ready to come get him/her and the water got shut off. -He/she was very angry as this had happened before. -The facility doesn't pay their bills and the services get stopped. -He/she was afraid to go and flush the toilet. -He/she was using hand sanitizer for his/her hands after toileting and using disposable wipes to wipe him/herself after using the toilet. -The residents should not have to go through this. -The residents paid to stay in the facility and if they pay their bills, the facility should pay theirs. -He/she and other residents had voiced their concerns, but nothing changed. -These issues had gotten much worse since the new company took over. -Record review of the resident's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Observation on [DATE] at 1:30 P.M., showed the facility's running water had been re-connected and the facility once again had running water. During an interview on [DATE] at 3:50 P.M., Vendor A (water company) said: -The facility's running water was officially shut off at 9:25 A.M., on [DATE]. -The facility's running water was officially turned back on at 1:15 P.M., on [DATE]. -The water bill was outstanding on [DATE] and a notice went to the facility on [DATE] notifying the facility of the outstanding amount owed which was $5,251.60. -An additional $ 52.04 was added on to the total due on [DATE]. -The notice on [DATE] threatened shut off for [DATE], with a latest shut off being [DATE], however, that did not happen as the company was giving the facility a chance to call or make payment arrangements. -A new 10 day shut off notice was sent on [DATE]. -We should have shut the facility's water off on [DATE], but gave them the day to make contact with them. -When contact still had not been made by the facility, the facility's running water was shut off on [DATE]. -After the payment was made on [DATE] to restore the running water, the facility still owed the company $4,331.29 which would come due on [DATE]. 2. During an interview on [DATE] at 4:45 P.M., Vendor B, for sewer services, said: -The facility had an over due amount and the facility owed them $18,376.78 which included April's bill. -The facility would be getting a late notice the first week of [DATE] if not paid by then. -If the full amount due was not paid by [DATE], the facility would get a 10 day shut off notice. -If the sewer was disconnected, the water would be shut off again at the same time. During interview on [DATE] at 2:20 P.M., the Director of Maintenance said: -He/she does not have a lot to do with the billing. -He/she does know what is outstanding and he/she shares that with his/her Corporate Director who is over 14 buildings, however he/she does not know what happens after he/she shares the information about the outstanding balance. 3. During an interview on [DATE] at 12:23 P.M., Vendor D (the alarm system servicing company) said: -They were no longer servicing the facility due to lack of payment. -The facility had a current outstanding balance of $2,558. -If the current fire alarm system quit working, they would not come out and service the facility as they had in the past. -They would have to pay their outstanding balance or obtain a new company to service their fire alarm system. During an interview on [DATE] at 9:30 A.M., Vendor D said: -The company took over monitoring the facility's fire alarm in mid-January. -The monitoring service was paid for in advance for a year. -The agreement was for the company to provide the facility with service as needed, monitoring, and scheduled inspections. -The facility currently has three open invoices totaling $5,116. -The facility has not paid for any service calls or the inspections his/her company has provided. -He/she is monitoring the account and if the monitoring bill for the following year is not paid the monitoring portion will be disconnected immediately. -The facility is in need of repairs to the their system, he/she was called about issues with the fire alarm panel. The work that was needed could not be done by his/her company, because it was proprietary in nature. He/she was initially going to facilitate locating a contractor to make the needed system updates and repairs, but due to the non-payment made the decision to not move forward with that due to fear of being stuck with the bill to the outside contractor. He/she is unsure if the facility's Maintenance Director has found someone to complete the repairs needed. 4. During an interview on [DATE] at 11:15 A.M., the Corporate Nurse Consultant said: -He/she was aware that the issue appeared to be with the third party company hired by the corporation to pay the bills. -There had to have been a breakdown in communication when it came to the bills and communicating what was owed to the third party company. -He/she had been in touch with the new Corporate Executive Officer (CEO) who was in the process of reaching out to the supervisor for the third party company who paid the bills. During an interview on [DATE] at 12:10 P.M., the Corporate Director of Accounting said: -The old process made it very easy for the invoices to fall through the cracks and not get paid as the facility received the bills, sent them to the third party billing company for processing, the third party billing company had to send them back to the facility Director and Administrator for approval, and the facility had to send them back to the third party billing company for payment. -With all the back and forth, the bills often did not go through to the correct place and in turn, did not get paid. During an interview on [DATE] at 2:45 P.M., the Accounts Payable Manager for the third party billing company said: -He/she was in charge of the two accounts payable representatives who paid all the bills for the corporation. -The three individuals were only responsible for the corporation's bills only. -The practice which had been in process was that the facility received the invoice. -The facility scanned those invoices to the third party accounting company. -The third party billing company would send them back to the facility Director and Administrator for approval. -Once the facility staff did their approval, they would scan it back to the third party billing company. -This process allowed for a lot of invoices to fall through the cracks and not get paid. -The third party billing company had just adopted a new process which should help to keep the invoices from falling through the cracks. -The third party billing company's goal was to get all the back outstanding bills paid to avoid any further disconnections or loss of services. -The bills were coming to the facility in a timely manner and as far as he/she was aware, there was money available for bill payment. During an interview on [DATE] at 11:00 A.M., the DON said: -He/she would have expected that all facility bills would be paid in a timely manner. -He/she would have expected that no services were disconnected. During an interview on [DATE] at 11:06 A.M., the Administrator said: -He/she would have expected the third party billing company would have paid the bills in a timely manner. -He/she would have expected there would have been no services shut off due to non-payment. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00217150

Based on observation, interview, and record review, the facility failed to ensure the resident was offered three meals a day, to ensure the resident went to the dining room for meals, to offer a room tray if the resident refused to go to the dining room for meals, and to prevent a significant weight loss of 37.6 pounds, 28.6% for one sampled resident (Resident #81). The facility also failed to ensure adequate monitoring of nutritional interventions by not documenting the amount of supplements consumed by one sampled resident with significant weight loss, who had no additional nutritional interventions (Resident #57) out of 24 sampled residents. The facility census was 111 residents. Record review of the facility policy titled Nutrition (impaired)/unplanned weight loss dated revised (MONTH) (YEAR) showed: -Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. -The staff and physician will define the individual's current nutritional status and identify residents at significant risk for impaired nutrition. -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. -The physician will review for medical causes of weight gain, anorexia, and weight loss before ordering interventions. -The physician will help identify medical conditions and medications that may be causing weight gain or loss or increasing the risk for either gaining or losing weight. -The physician will review carefully, and rule out medical causes of, oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. -The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. -The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). 1. Record review of Resident #81's face sheet showed he/she admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].). -Diabetes. -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Major [MEDICAL CONDITION] (a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working). Record review of the resident's nutritional evaluation/data collection form dated 7/1/16 showed he/she: -Was receiving a mechanical soft diet. -Weighed 146 pounds. -Had an average daily intake of 75% to 100% for breakfast, lunch, and dinner meals. -Had no documentation of snacks or supplement intakes. -Food/beverage preferences, dislikes, and ethnic/cultural/religious practices affecting meals were not listed. -Was alert, had impaired hearing (no description documented), used glasses, was able to make self understood, and understand others. -Had upper and lower dentures. -Did not have any chewing problems. -Did not have any swallowing problems. -Did not have any behaviors. -Required assistance with eating. -Required 1848 calories a day, 66 grams (gms) of protein a day, and 1080 milliliters (ml)'s of fluids a day. -Was eating well. Seemed to be meeting nutritional needs. -Recommend continue plan of care. Record review of the resident's food/beverage preference list showed: -It was completed on 8/3/16. --This was five months after his/her admission to the facility. Record review of the resident's nutritional evaluation/data collection form dated 3/7/17 showed he/she: -Was receiving a regular diet with 90 ml's of med pass supplement three times a day. -Weighed 170 pounds. -Had no documentation of average daily meal intake. -Had no documentation of snacks or supplement intakes. -Food/beverage preferences were referred to the preference sheet. -Was alert, had adequate hearing, used glasses, was able to make self understood, and understand others. -Had upper and lower dentures. -Did not have any chewing problems. -Did not have any swallowing problems. -Did not have any behavior problems. -Required supervision/cueing with eating. -Required 1904 calories a day, 68 gms of protein a day, and 2040 ml's of fluids a day. Record review of the resident's nutritional evaluation/data collection form dated 5/3/18 showed he/she: -Was receiving a regular diet with 90 ml's of med pass supplement three times a day. -Had no documentation of average daily meal intake. -Had no documentation of snacks or supplement intake. -Food/beverage preferences were referred to the preference sheet. -Was alert, had impaired hearing (was hard of hearing), used glasses, was able to make self understood, and understand others. -Had upper and lower dentures. -Did not have any chewing problems. -Did not have any swallowing problems. -Did not have any behavior problems. -Ability to feed self was left blank. -Required 1925 calories a day, 77 gms of protein a day, and 2310 ml's of fluids a day. -Recommend discontinue med pass. Record review of the resident's psychiatric progress notes dated 6/24/18 showed the resident isolated himself/herself, was internally preoccupied and guarded. Record review of the resident's food and beverage preference list showed: -It was dated 8/3/16. -There were no updates to the resident's preference list since that date. Record review of the resident's psychiatric progress notes dated 10/4/18 showed the resident continued to have the same behaviors of isolating himself/herself, was internally preoccupied and guarded. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/2/19 showed he/she: -Was cognitively intact. -Required supervision and set up with eating. -Had [DIAGNOSES REDACTED]. -Had no difficulties of loss of food/fluids from mouth while eating. -Had no difficulties of holding food/fluids in mouth while eating. -Had no difficulties coughing or choking during meals. -Had no complaints of pain with swallowing. -Weighed 169 pounds. -Did not have any weight loss or weight gain in the last one or six months. Record review of the resident's psychiatric progress notes dated 1/4/19 showed the resident continued to isolate himself/herself in his/her room, was internally preoccupied and guarded. Record review of the resident's nutritional progress notes dated 2/5/19 showed he/she: -Had a 10 pound weight loss in (MONTH) 2019. -Had a significant weight loss of 5.9% in one month and 7.5% in three months. -Was receiving 60 ml's of med pass supplement twice a day and was taking [MEDICATION NAME] (an antidepressant medication used for its appetite stimulant effects). -Recommend continue med pass supplement. Record review of the resident's nutritional progress notes dated 3/4/19 showed he/she: -Had a three pound weight loss in one month, 13 pound loss in three months, and 16 pound loss in six months. -Had a significant weight loss of 7.6% in three months. -Was receiving 60 ml's of med pass supplement twice a day. -Recommend if (MONTH) weight is still showing weight loss, may need to increase med pass supplement. Record review of the resident's annual MDS dated [DATE] showed he/she: -Was cognitively intact. -Required supervision and set up with eating. -Had [DIAGNOSES REDACTED]. -Had no difficulties of loss of food/fluids from mouth while eating. -Had no difficulties of holding food/fluids in mouth while eating. -Had no difficulties coughing or choking during meals. -Had no complaints of pain with swallowing. -Weighed 156 pounds (which is a 13 pound 8.3% loss in three months). -Did not have any weight loss or weight gain in the last one or six months. Record review of the resident's psychiatric progress notes dated 4/5/19 showed the resident continued to isolate himself/herself in his/her room, was internally preoccupied and guarded. Record review of the resident's psychiatric progress notes dated 6/27/19 showed the resident continued to isolate himself/herself to his/her room, was internally preoccupied and guarded. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Required supervision and assistance from one staff member with eating. -Had [DIAGNOSES REDACTED]. -Had no difficulties of loss of food/fluids from mouth while eating. -Had no difficulties of holding food/fluids in mouth while eating. -Had no difficulties coughing or choking during meals. -Had no complaints of pain with swallowing. -Weighed 156 pounds. -Did not have any weight loss or weight gain in the last one or six months. Record review of the resident's documented weights showed the resident weighed 155.4 pounds on 7/3/19. Record review of the resident's physician's progress note dated 7/31/19 showed the resident had the following assessment: -He/she had no new issues. -Had no nausea or vomiting. -Abdomen was soft, non-tender with normal bowel sounds. -Extremities revealed no [MEDICAL CONDITION]. -Weight loss was better. -Continue current care plan, medications and supplements. Record review of the resident's documented weights showed the resident weighed: -151.4 pounds on 8/6/19. Record review of the resident's physician's progress note dated 8/30/19 showed the resident had the following assessment: -Had noted weight loss. -Weighed 151 pounds (was 168 pounds in (MONTH) (YEAR), an 11% loss in eight months). -Had no nausea or vomiting. -Abdomen was soft, non-tender with normal bowel sounds. -Extremities revealed no [MEDICAL CONDITION]. -Increase supplement to three times a day. Record review of the resident's Physician Order Sheet (POS) dated (MONTH) 2019 showed: -an order for [REDACTED]. -an order for [REDACTED]. Record review of the resident's Medication Administration Record [REDACTED] -an order for [REDACTED]. --Was documented as refused on 9/11/19, 9/12/19, 9/13/19, 9/15/19, 9/16/19, 9/18/19, and 9/19/19. -an order for [REDACTED]. --No documentation of the amount of ml's the resident consumed. --Documented the resident refused the supplement 26 times out of 69 opportunities. -an order for [REDACTED]. --No documentation of the amount of ml's the resident consumed. --Documented the resident refused the supplement two times out of 21 opportunities. Record review of the resident's documented weights showed he/she weighed: -144.2 pounds on 9/4/2019. -143.6 pounds on 9/10/2019. Record review of the resident's nurse's notes dated 9/10/19 showed the resident: -Weighed 143 pounds. --Loss of 5.2% in 30 days. --Loss of 7.6% in 90 days. -Was provided a regular diet. -Was offered Med Pass (a supplement) as ordered. -Would be weighed weekly until stable and be referred to the dietitian as needed. Record review of the resident's nurse's notes dated 9/13/19 showed the resident: -Refused all medications and evening meal. -Said he/she was not taking any medications or eating anything because they were trying to poison him/her. Record review of the resident's nurse's notes dated 9/14/19 showed the resident: -Continued to refuse all medications and meals. -Said he/she was not going to take any medications or eat anything because someone was trying to poison him/her. -Was not sleeping at night, was pacing back in forth would not sit or lay down. Record review of the resident's nurse's notes dated 9/15/19 showed the resident: -Had been non-compliant with staff and caregivers. -Refused all medications and treatments. -Had increased anxiety and agitation. Record review of the resident's nurse's notes dated 9/16/19 showed he/she: -Refused all medications. -Refused to go to the dining room to eat. -Was sitting on the side of his/her bed since early morning. -Would not speak to or look up at anyone. -Continued to exhibit paranoia. -Continued to pace in his/her room and look out the door down the hallway. Record review of the resident's RD progress note dated 9/18/19 showed the resident: -Weighed 144 pounds. --Loss of seven pounds in 30 days. --Loss of 12 pounds in 90 and 120 days. --A significant weight loss of 7.6% in 90 days. -Had been refusing medications and meals. -Had order for med pass supplement 60 ml's three times a day. -Had an order for [REDACTED].>-Had a recommendation to increase the med pass to 90 ml three times a day. --The last documented RD visit was on 3/4/19. That visit recommendation was to increase the med pass supplement if the resident's weight in (MONTH) still showed a loss. --There was no RD visit documentation between 3/4/19 and 9/18/19. -Refer to the RD as needed. Record review of the resident's care plan dated 9/19/19 showed he/she had been refusing medications, insulin, and meals. He/she believed his/her spouse was divorcing him/her and the behaviors were related to that delusion. The goal for the resident was to cooperate with cares through the next review date. Staff were instructed to use the following interventions: -Give clear explanation of all care activities prior to and as they occur during each contact. Attempt to explain consequences of refusing medications, insulin, and meals. -If possible, negotiate a time for Activities of Daily Living (ADL) so the resident participates in the decision making process. Return at the agreed upon time. -If the resident resists with ADL's, reassure him/her, leave and return later and try again. -Keep the resident's physician notified of refusals and possible impact on his/her status. -Praise the resident when behavior is appropriate. -Provide consistency in care to promote comfort with ADL's. Maintain consistency in timing of ADL's, caregivers, and routines, as much as possible. -Provide the resident with opportunities for choice during care provision. Record review of the resident's psychological assessment dated [DATE] showed the resident: -Reported his/her sleep had been excessive. -Reported he/she had trouble swallowing and this was the reason he/she was not eating. -Reported his/her spouse was talking about divorce and that was very upsetting to him/her. -Was observed to be paranoid during the assessment by the Psychologist. -Was difficult to assess as he/she said very little and nodded his/her head when asked yes/no questions. -Reported he/she was not hopeful about the future, was bothered by thoughts he/she couldn't get out of his/her head, was not in good spirits, felt helpless, was sad, was withdrawn, felt downhearted, felt worthless, worried a lot about the past, had a lack of motivation, had a lack of energy, frequently got upset over little things, preferred to avoid social gatherings, and believed his/her mind was not as clear as it used to be. -Was seen by the psychiatrist on 6/27/19 when medications were decreased and he/she remained isolative, internally preoccupied and guarded. Record review of the resident's psychiatric progress note dated 9/20/19 showed the resident: -Was not taking his/her medications and was not eating. -Told staff he/she was refusing to take medications and eat because his/her spouse was divorcing him/her. --The reasoning behind the spouse divorcing the resident was coming from the spouse not visiting for a while. -Also told staff he/she was not taking medications and eating because he/she couldn't swallow. --A video swallow was ordered. -Was withdrawn and guarded, had soft and sparse speech, had a paranoid affect, had poor concentration, memory, and insight. Record review of the resident's psychological progress note dated 9/23/19 showed the resident: -Was lying down awake in his/her bed. -Was emotionally withdrawn with appetite disturbance, depression, fatigue, and feelings of helplessness. -Exhibited symptoms of suspiciousness including interpersonal problems, and loss of pleasure/interests. -Exhibited uncooperativeness with anxiety, grief/loss issues, paranoia, sleep disturbance, and withdrawal. -Had a short term therapy goal of staff were to encourage the resident to ventilate negative feelings that may be interfering with the ability to cope with anger, guilt, anxiety, and helplessness. -Had a long term therapy goal of stabilization/reduction of affective and/or cognitive symptoms, increase compliance with treatment plan and reduction of behavioral problems. Record review of the resident's documented weights showed the resident weighed 138.0 pounds on 9/24/2019. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Required supervision and assistance from one staff member with eating. -Had [DIAGNOSES REDACTED]. -Had no difficulties of loss of food/fluids from mouth while eating. -Had no difficulties of holding food/fluids in mouth while eating. -Had no difficulties coughing or choking during meals. -Had no complaints of pain with swallowing. -Weighed 138 pounds (which is an 18 pound, 13% weight loss in three and six months). -Had a 10% weight loss in six months. -Was not on a prescribed weight loss regimen. Record review of the resident's physician's progress note dated 9/27/19 showed: -The resident was seen for his/her annual history and physical. -The resident had significant psychiatric issues during the past year. -There was no mention of the resident refusing medications or meals. -There was no mention of the resident's significant weight loss. Record review of the resident's psychological progress notes dated 9/30/19 showed the resident: -Was emotionally withdrawn with appetite disturbance, depression, fatigue, and feelings of helplessness. -Exhibited symptoms of suspiciousness including interpersonal problems, and loss of pleasure/interests. -Exhibited uncooperativeness with anxiety, grief/loss issues, paranoia, sleep disturbance, and withdrawal. -Had a short term therapy goal of staff were to encourage the resident to ventilate negative feelings that may be interfering with the ability to cope with anger, guilt, anxiety, and helplessness. -Had a long term therapy goal of stabilization/reduction of affective and/or cognitive symptoms, increase compliance with treatment plan and reduction of behavioral problems. Record review of the resident POS dated (MONTH) 2019 showed the resident had an order for [REDACTED]. Record review of the resident's MAR indicated [REDACTED] -Had an order for [REDACTED].>-Had an order to monitor behaviors including refusing care, refusing to eat, refusing to get out of bed dated 10/22/19. -Documentation showed the resident did not refuse care, refuse to eat, or refuse to get out of bed on 10/22/19 on the evening or night shift. --The day shift did not have a yes or no indication of refusal. -an order for [REDACTED]. --No documentation of the amount of ml's the resident consumed. Record review of the resident's physician's progress notes dated 10/8/19 showed the resident: -Presented with dysphagia (difficulty swallowing). -Had difficulty with all liquids and solids. -Was experiencing silent aspiration (a condition when food or fluids that should go into the stomach go into the lungs instead. Usually when this happens the person will cough in order to clear the food or fluid out of their lungs. However, sometimes the person does not cough at all) daily with poor intake often refusing to eat or drink. Record review of the RD report dated 10/11/19 showed the resident was not included on the list of resident's seen. Observation on 10/21/19 from 11:30 [NAME]M. to 12:15 P.M. showed: -The noon meal was being served in the main dining room. -The resident was not in the dining room. -The resident's tray card and thickened water and thickened tea were on the dining room table. Observation and interview on 10/21/19 at 12:20 P.M. showed the resident: -Was in his/her dark room laying on his/her side with his/her eyes closed. -Did not have the window curtains open. -Did not have any light of any source on in his/her side of the room. -Did not go to the dining room for the noon meal. -Did not have a room tray brought to him/her for the noon meal. -Said no one offered to bring him/her anything to eat. -Said he/she did not want to lose weight. Record review of the resident's meal intake record dated (MONTH) 2019 showed: -Staff documented on 10/21/19 the resident consumed 26% - 50% of the noon meal. -Staff documented on 10/21/19 the resident drank 240 cubic centimeters (cc) of fluid at the noon meal. -Staff documented on 10/22/19 the resident consumed 76% - 100% of the noon meal. -Staff documented on 10/22/19 the resident drank 120 cc's of fluid at the noon meal. -Staff documented on 10/23/19 the resident consumed 26% - 50% of the noon meal. -Staff documented on 10/23/19 the resident drank 240 cc's fluid at the noon meal. -Staff documented on 10/24/19 the resident consumed 76% - 100% of the noon meal. -Staff documented on 10/24/19 the resident drank 120 cc's at the noon meal. -Staff documented on 10/25/19 the resident consumed 26% - 50% of the noon meal. -Staff documented on 10/25/19 the resident drank 120 cc's at the noon meal. Record review of the resident's documented weights showed he/she: -Weighed 131.4 pounds on 10/22/19. --Which is a seven pound, 5% weight loss in one month. --Which is a 24.6 pound, 18.7% weight loss in six months. --Which is a 37.6 pound, 28.6% weight loss in nine months. -Continuous observation on 10/22/19 from 11:20 [NAME]M. to 12:00 P.M. during the noon meal showed: -The resident was not in the dining room. -Staff were bringing residents to the dining room. -Staff were serving meals to the resident's who were in the dining room. -The resident was in his/her room with the door closed, the lights turned off, the window curtains closed laying on his/her right side with his/her eyes closed. -The resident did not have a room tray for the noon meal. -No staff were seen writing down meal intakes. Record review of the resident's nurse's notes dated 10/22/19 at 11:36 [NAME]M. showed the resident refused to go to lunch, became loud and cursing that he/she wasn't hungry and was not going to the dining room. During an interview on 10/22/19 at 12:10 P.M. the resident: -Answered questions calmly and in a soft tone of voice. -Said he/she did not and was not going to go to the dining room. -Said staff had not offered to bring him/her a room tray. Record review of the resident's nurse's notes dated 10/23/19 showed the resident: -Weighed 131.4 pounds. --A loss of 7.8 pounds, 5.6% in 30 days. --A loss of 20 pounds, 13.2% in 90 days. --A loss of 23.6 pounds, 15.2% in 120 days. -Was to be encouraged to go to the dining room for meals. -Refuses to go to the dining room saying he/she was not hungry. -Had orders for a puree diet, med pass supplement 90 ml three times a day, and [MEDICATION NAME] as an appetite stimulant. -Was to remain on weekly weights until weight stabilized. Continuous observation and interview on 10/23/19 from 11:30 [NAME]M. to 12:15 P.M. showed: -At 11:30 [NAME]M. the resident's tray ticket and unopened nectar thick liquids were on the dining room table. -At 11:45 [NAME]M. the resident was in his/her room in his/her bed with his/her eyes closed. --The resident said he/she was going to go to the dining room for the noon meal a little bit later. -At 11:47 [NAME]M. Certified Nursing Assistant (CNA) B said he/she had checked on the resident a couple minutes ago and the resident said he/she would go to the dining room in a little while. --CNA B said he/she would check on the resident in a couple minutes to encourage him/her to go to the dining room for the noon meal. --CNA B said the resident was wasting away. -At 12:05 P.M. the resident remained in his/her room in bed with his/her eyes closed. --The dietary staff delivered four room trays to the unit. --The resident did not have a room tray delivered to him/her. -At 12:20 P.M. The resident was still in his/her room in bed with his/her eyes closed. --No room tray was delivered to the resident. --The resident did not go to the dining room. --The resident's tray card and unopened thickened liquids were still on the dining room table. -No staff were seen writing down meal intakes. Continuous observation on 10/24/19 from 11:30 [NAME]M. to 12:15 P.M. showed: -At 11:30 [NAME]M. the resident was in his/her dark room laying on his/her back with his/her eyes closed. -At 11:55 [NAME]M. room trays were delivered to the unit. --CNA B delivered the room trays. --The resident did not have a room tray on the cart. --No food was taken to the resident. --The resident did not go to the dining room. -At 12:15 P.M. the resident was in his/her dark room on his/her back he/she did not have a meal tray in his/her room. --The resident said he/she did not have anything to eat for the noon meal. --The resident said the staff did not offer to bring him/her anything to eat for the noon meal. -No staff were seen writing down meal intakes. During an interview on 10/25/19 at 8:50 [NAME]M. the resident said: -The reason he/she did not eat was because he/she did not have an appetite. -He/she would not eat the majority of lunch meals. -He/she would not eat some dinner meals. -He/she did not have a room tray brought to him/her if he/she refused to go to the dining room for a meal. -He/she did not eat any lunch meals between 10/21/19 and 10/24/19. -Staff did not offer to bring him/her anything to eat for the lunches that he/she refused to go to the dining room. -He/she did not like the med pass supplement. -He/she had not been told he/she was losing weight. -He/she did not want to lose any weight. During an interview on 10/25/19 at 10:00 [NAME]M. Certified Nurses Aide (CNA) C said: -He/she would try to convince resident to participate by talking with them and trying to find out why they didn't want to participate so he/she could try to find something they would like to do. -He/she would ask the resident multiple times about going to the dining room. -He/she would notify the charge nurse if the resident was adamant about not going to the dining room. -He/she would offer the resident a snack or a room tray if the resident would not go to the dining room. -The kitchen staff passed the snacks. -Snacks including snack cakes, cookies, crackers, and sometimes fruit would be offered after meals. -He/she did not know what was available for resident's who required a puree diet. -Room trays were delivered to the unit when the nursing staff notified the kitchen staff the resident's were ready for the meal. -The charge nurse would notify the CNA's of any resident's who were losing weight. -If he/she was aware of a resident who was losing weight and that same resident was not going to the dining room for meals, he/she would make sure the resident had something to eat for all three meals at least offered. If the resident would refuse, he/she would notify the charge nurse. -It was the CNA's responsibility to chart meal intakes into the computer after the meal was done. -He/she would walk around the dining room and look at the plates and glasses for the resident's on his/her assigned unit and would keep track of everyone's meal intake in his/her head until he/she entered the amounts into the computer for each resident. During an interview on 10/25/19 at 10:15 [NAME]M. Registered Nurse (RN) A said: -He/she would encourage resident's to participate in different activities in the facility that they were interested in. -He/she would encourage the resident to go to the dining room for meals, he/she would try to determine why the resident was not wanting to go to the dining room so the appropriate treatment can be done if needed. -Dietary staff passed the snacks after meals. -Cottage cheese, pudding, applesauce and bananas were the snacks that were offered to residents who had a puree diet. -He/she knew all resident's received a tray at each meal because he/she was in the dining room and would make sure everyone in the dining room had a tray. -The CNA's were responsible for documenting meal intakes after the meal into the computer. He/she did not know how the CNA's gathered the intake amounts that were entered into the computer. -He/she would expect to be notified of a resident refusing a meal so documentation could be done and further assessments could be done as needed. -The meal intake record should reflect what the resident ate at each meal. -The RD would be notified by the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) if a resident had a significant weight loss. -The ADON, DON or RD would order supplements, weekly weights if a resident needed further interventions. -He/she did not know how often the RD was at the facility, he/she had not seen him/her. -He/she was aware of Resident #81's weight loss. During an interview on 10/25/19 at 10:45 [NAME]M. Certified Medication Technician (CMT) C said: -He/she would make sure a resident would get food offered at each meal, in the dining room or a room tray. -He/she would feed the resident if needed to make sure the resident ate at every meal. -It was the CNA's and CMT's responsibility to pass snacks to the resident's. -It was the CMT's responsibility to pass the Med pass supplement to the resident's. -Med pass was given as scheduled/ordered which could be during or between meals. -He/she would ask the charge nurse if he/she did not know who had weight loss. -It was the CNA's responsibility to document the meal intakes after meals into the computer. He/she did not know the process the CNA's used to gather the meal intake amounts that were entered into the computer. -If a resident did not eat the documentation on the meal intake record should reflect the actual amount the resident ate. Continuous observation on 10/25/19 from 11:30 [NAME]M. to 12:00 P.M. showed: -At 11:30 [NAME]M. the resident was not in the dining room. --The resident's tray card and unopened thickened liquids were on the dining room table. -At 11:36 [NAME]M. staff brought the resident to the dining room. -At 11:42 [NAME]M. the resident was served his/her meal of pureed nectar thick minestrone soup, pureed ham and Swiss cheese sandwich, pureed mandarin oranges, nectar thick water and nectar thick tea. --The resident fed himself/herself the pureed thickened soup, the pureed sandwich, and took a few

Based on observation, interview, and record review, the facility staff failed to put individualized interventions in place to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); failed to accurately complete weekly skin assessments by a licensed nurse; and failed to notify the resident's physician of skin changes for two residents (Resident #2 and Resident #22); and failed to employ trained and competent staff to provide wound care to a resident with a negative pressure wound treatment (wound vac - a mechanical device that utilized negative pressure vacuum to a wound site to remove infectious material from the wound bed, promote granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) of the wound bed, and assist to draw the edges of the wound together for wound healing) for one resident (Resident #24) out of 26 sampled residents. The facility further failed to follow the facility policy related to assessing, monitoring, and documenting pressure ulcers. The facility census was 106 residents. Record review of the Facility's Pressure Ulcer Prevention: Licensed Nurse Skin Checks Policy revised on 3/2012 showed: -The facility policy statement said: All residents will have a thorough weekly skin evaluation performed by a Licensed Nurse. -The Licensed Nurse performs a weekly head to toe check of the resident skin, paying particular attention to the surfaces of the skin that comes in contact with the bed and chair, or with any orthotic devices, tubes, braces or positioning devices and the residents skin folds and bony prominence areas such as heels and tail bones. -The Licensed Nurse observes for any redness, rashes, bruising, open area and any scars over bony prominences. -Any significant abnormal findings are to be reported to the resident's physician and the resident's contact person. -The Licensed Nurse should document that the skin check had been performed on Weekly Skin Documentation Form. -Abnormal findings are to be documented in the Nurse's Notes or to be documented on the back of the resident's Treatment Administration Record (TAR). Record review of the facility's Weekly Skin Documentation showed: -Staff were instructed to document the following: --Was the resident's skin intact or not intact. --List any abnormalities such as rashes, scratches, skin tears or pressure ulcers. --Use the body graph to show the location of any abnormalities. --The resident's skin color such as pale or flushed. --Was the resident's skin warm, dry, cool, or clammy. --Was the resident's skin turgor (resiliency of the skin) good, fair, or poor. --What special equipment was in use for the resident. --Did the resident have [MEDICAL CONDITION] (swelling) and where. --Does the resident have any scars over bony prominences. Record review of the facility's Certified Nurse Aide (CNA) Daily Skin Inspection policy revised on 3/2012 showed: -The CNA Daily Skin Inspection form is to be initiated by the licensed nurse. It is to be completed for all residents scoring an 18 or less using the Braden Risk Assessment or any residents who had a wound. -The CNA Daily Skin Inspection form is to be completed by a CNA on a daily basis, documenting a skin check had been performed along with the findings from the skin check. -During the course of the resident's daily care and bathing, the CNA performs a daily head to toe check of the resident skin, paying particular attention to the surfaces of the skin that comes in contact with the bed and chair, or with any orthotic devices, tubes, braces or positioning devices and the residents skin folds and bony prominence areas such as heels and tail bones. -The CNA observes for any redness, rashes, bruising, open area and any scars over bony prominences. -Any abnormal findings are to be reported to the licensed nurse. -The CNA should document the skin check on the CNA Daily Skin Inspection Form. -It is strongly recommendation that the Director of Nursing (DON) requires this form to be initiated on all residents in the facility (this may be helpful for early identification and treatment of [REDACTED]. Record review of the facility's CNA Skin Inspection Record showed: -Staff were instructed to complete the CNA Skin Inspection Record daily. -Record the letter of the site on the chart that identifies the location of the skin problem and mark the area on the body figure with an "'x". -The CNAs were instructed to report any change in the resident's skin condition to the nurse immediately. -A body figure was diagrammed on the form with ten identifiable areas (sites A, B, C, D, E, F, G, H, I, J) for the front of the resident and ten identifiable areas (sites, K, L, M, N, O, P, Q, R, S, T) for the back of the resident to document any skin issues. -Staff were instructed to document the following each day: --Check the box if the resident's skin was clear. --Document the location according to the skin man diagram if the resident had: ---Redness. ---Rash. ---Bruise. ---Open areas. ---Dressings. Record review of the Facility's Wound Care Policy and Procedures: Wound Evaluations revised on 12/2011 showed: -Evaluation of wounds will be performed on admission, weekly and on discovery. -Evaluation components include; location, measurements, appearance, drainage, odor, presence of undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin); or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), healing process, stage and date of onset for pressure ulcers, pain and [MEDICAL CONDITION]. -Evaluation results are to be communicated to the members of the care team through documentation, care plan meetings and care planning. -Treatments should also be re-evaluated every two to three weeks. If there is no wound progression or no change in treatment, documentation should occur as to why the wound is not progressing and any recommended treatment change or why the current treatment plan should be maintained. Record review of the facility's Wound Care Policies and Procedures: Wound Documentation policy revised on 12/2011 showed: -Documentation of wounds will be performed consistently using approved forms. -Wounds should be documented on admission and/or discovery of the wound. -Wounds should be numbered for consistency in documentation. The reoccurrence of a wound over an old site will retain the original number of that wound. -Wound evaluations and treatments are documented on the Wound Treatment and Progress Record. -Each wound is documented on a separate Wound Treatment and Progress Record. Dressing changes and evaluations are documented on side one. Initial and weekly evaluations of the wound size and description are documented on side two. Record review of the facility's Wound Treatment and Progress Record Form showed: -Side one documentation included: --Mark the location of the identified wound. --Wound treatment administered. --Description of the wound drainage; the general appearance of the wound; the appearance of the surrounding skin. --Documentation of wound dressing changes. -Side two documentation included: --Weekly documentation of the wound type (pressure or non-pressure) --Documentation of the wound size length (l), width (w) and depth (d) in centimeters (cm)and description. --Documentation of the stage of a pressure ulcer. --Documentation of the wound thickness for a non-pressure ulcer (such as partial thickness and full thickness. Record review of the facility's Wound Care Policies and Procedures: Turning and Repositioning revised on 12/2011 showed: -All residents identified at risk for skin breakdown, or with the presence of wounds, will be placed on a turning/repositioning program. -The turning/repositioning program should be organized, planned, documented, monitored, and evaluated based on an assessment of the resident's needs. -The expected repositioning times and positions should be defined by the facility team as to ensure that the care providers have a clear understanding of the resident's individualized turning/repositioning program. Record review of the KCI (Kinetic Concept Incorporated) Wound V.A.C. Therapy Guidelines dated July 2007 showed: - Always count the total number of pieces of foam used in the wound and document that number in the patient's chart. - V.A.C. (Vacuum Assisted Closure) Foam Dressings are not bioabsorbable. -Always count the total number of pieces of foam removed from the wound and ensure the same number of foam pieces was removed as placed. - Foam left in the wound for greater than the recommended time period may foster in growth of tissue into the foam, create difficulty in removing foam from the wound, or lead to infection or other adverse events. Record review of the facility's Wound Care Policies and Procedures dated 12/2011 showed, the policy did not address the use of a Wound VAC for residents with pressure ulcers or non-pressure wounds and the facility did not have a policy and procedures to instruct the facility nursing staff on how to use the wound vac. 1. Record review of Resident #2's Resident Admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident was receiving hospice (care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less) services. -The resident had the following medical Diagnoses: [REDACTED]. --Dysphasia (inability or difficulty swallowing). --Hypertension (HTN - high blood pressure). --[MEDICAL CONDITION] (paralysis caused by illness or injury that results in the partial or total loss of use of all four extremities). --[MEDICAL CONDITION] (loss of ability to produce or comprehend language due to [MEDICAL CONDITION]). Record review of the resident's Nursing Data Collection Tool/Braden Scale (a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) for Predicting Pressure Sore Risk dated 2/19/14 showed: -A total score of 18 or below are considered at risk for skin breakdown. -The resident's Braden Score was ten, which showed the resident was at risk for developing pressure ulcers. Record review of the resident's undated Skin Risk Analysis and Interventions showed: -The Skin Risk Analysis and Interventions form should be completed by the facility staff if the resident scored 18 or less on the Braden Skin Risk Assessment and/or the resident had a wound. -The resident scored ten on the Braden Skin Risk Assessment completed on 2/21/14. -The following interventions were to be initiated by the facility staff: --Inspect the resident's skin daily. --Treat dry skin with moisturizers. --Reposition the resident every two hours while in bed. --Use pillows to keep bony prominences from direct contact. --Use pillows or devices that totally relieve pressure on the heels if the resident is completely immobile. --Gatch the resident's knee (slight elevation of the knee) when the head of the bed is elevated. --Reposition the resident every hour while in a chair. --If the resident's Braden Score is 11 or less staff should increase the frequency of turning and supplement turning with small shifts in position. Record review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 3/4/14 showed the resident: -Was usually able to understand others and was usually able to be understood by others. -Was severely cognitively impaired. -Required total staff assistance for bed mobility, transfers, dressing, eating, personal hygiene, and bathing. -Received tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing) nutrition. -Was at risk to develop pressure ulcers. -Had no unhealed pressure ulcers. -Had no ulcers, wounds, or skin impairments. -Received hospice services. Record review of the resident's Pressure Ulcer Care Plan dated 3/4/14 showed: -The resident was at risk for skin breakdown. -Staff were to assess the resident's skin daily. -Licensed nurse was to perform weekly skin assessments. -Staff were to change the resident's position throughout their shift to avoid pressure points. -The care plan was updated on 3/26/14 to show the resident had dry heels and staff were directed to apply A & D ointment (used to prevent, treat, and relieve rashes caused by incontinence) to both lower extremities. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was sometimes able to understand others and was sometimes able to be understood by others. -Was severely cognitively impaired. -Required total staff assistance for bed mobility, transfers, dressing, eating, personal hygiene, and bathing. -Received tube feeding nutrition. -Was at risk to develop pressure ulcers. -Had no unhealed pressure ulcers. -Had no ulcers, wounds, or skin impairments. -Received hospice services. Record review of the resident's Weekly Skin Documentation dated 6/5/14 showed: -The resident's skin was intact, warm, dry, and with fair turgor. -No documentation by the facility staff of the resident's skin color, special equipment in use, [MEDICAL CONDITION], and presence of scars over bony prominences. Record review of the resident's CNA Skin Inspection Record dated June 2014 showed: -The staff documented the resident's crustaceous endoscopies [DEVICE] (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) as an open area in sites "B" and "I" daily from 6/1 - 6/30/14. Site B was the right front torso. Site I was the left front torso. -The staff documented the resident's Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) as an open area in sites "C" and "H" daily from 6/1 - 6/30/14. Site C was the right front groin. Site H was the left front groin. -The staff documented the resident's skin was clear by marking an "x" in the "Clear" column 22 out of 30 days. Record review of the resident's Weekly Skin Documentation dated 6/12/14 showed: -The resident's skin was intact, warm, dry, and with good turgor. -No documentation by the facility staff of the resident's skin color, special equipment in use, [MEDICAL CONDITION], and presence of scars over bony prominences. Record review of the resident's Care Plan Conference Summary dated 6/14/14, showed the resident had no skin issues at that time. Record review of the resident's Weekly Skin Documentation dated 6/19/14 showed: -The resident's skin was warm, dry, and with good turgor. -No documentation by the facility staff that the resident's skin was intact. -No documentation by the facility staff of the resident's skin color, special equipment in use, [MEDICAL CONDITION], and presence of scars over bony prominences. Record review of the resident's Hospice Aide Visit Note dated 6/24/14 showed: -The resident had a large, soft, fluid-filled blister on his/her right heel. Record review of the resident's CNA Skin Inspection Record dated 6/24/14 showed: -The resident's skin was clear. -The resident had pressure and swelling to his/her heel in the column for " Redness " . -The staff did not document on the body diagram. Record review of the resident's Nurse's Notes dated 6/24/14 showed: -The facility staff was notified of a closed blister to the resident's right heel area by the resident's hospice aide. -The resident had boots on his/her feet with his/her feet elevated on an air mattress. -an order for [REDACTED]. Record review of the resident's Physician's Telephone Order Sheet (TOS) dated 6/24/14 showed: -Skin prep to the resident's right heel and to the resident's left heel every shift for a closed right heel blister. Record review of the resident's CNA Skin Inspection Record dated 6/25/14 showed: -The staff documented the resident had an open area on sites B, I, C, and H, which are the resident's PEG tube site and the resident's Foley catheter site. -No documentation by the facility staff of a skin issue with the resident's heels. Record review of the resident's hospice Nursing Comprehensive Update/Visit Note dated 6/26/14 showed: -The resident had a large blister on his/her right heel. -The facility staff were instructed to float the resident's heels (place a positioning device under the resident's calves with the resident's heels positioned over the edge not resting on a surface). Record review of the resident's CNA Skin Inspection Record dated 6/26/14 showed: -The staff documented the resident had pressure and swelling to his/her heel in the column for redness. The staff did not document which heel. -No documentation of the corresponding site on the skin man diagram. Record review of the resident's Weekly Skin Documentation dated 6/26/14 showed: -The resident's skin was intact with a large blister to the right heel reported by the day shift nurse. -The resident's skin was warm and dry and the skin turgor was good. -No documentation by the facility staff of the resident's skin color, special equipment in use, [MEDICAL CONDITION], and presence of scars over bony prominences. --No documentation the licensed staff assessed the resident's skin after the CNA Daily Skin Inspection Record documented pressure and swelling to the resident's heel on 6/24/14. Record review of the resident's CNA Skin Inspection Record dated 6/27/14 showed: -The resident's skin was clear. -The resident had an open area on sites B, I, C, and H, which are the resident's PEG tube sites and the resident's Foley catheter sites. -No documentation by the facility staff of a skin issue with the resident's heels. Record review of the resident's CNA Skin Inspection Record dated 6/28/14 showed: -The resident had pressure and swelling to his/her heel in the column for redness. -No documentation by the facility staff of the corresponding site on the skin man diagram. Record review of the resident's Nurse's Notes dated 6/28/14 showed: -The resident had a large blister to his/her right heel/foot. -The blister was warm to the touch and the resident had facial grimacing when staff touched the blistered area. -Skin prep was applied to the blistered area. -The resident had PRAFO boots (Pressure Relief Ankle Foot Orthosis - a device that is worn on the calf and foot similar to a boot and is often used for patients that spend the majority of their time in bed to prevent bedsores or ulcers from developing on the back of the heel) applied. -The resident's feet were elevated and his/her heels were floated off surfaces. -The licensed nurse did not document any measurements of the resident's right heel blister. Record review of the resident's hospice Nursing Focused Visit Note dated 6/29/14 showed: -The resident had a large raised blister on his/her right heel. -The blister was closed and fluid-filled. -The blister measured 10 centimeters (cm) in length and 13 cm in width. -Facility staff were instructed to keep the resident's feet/heels elevated off of the bed. Record review of the resident's CNA Skin Inspection Record dated 6/29/14 showed: -The resident had pressure and swelling to his/her heel in the column for redness. -No documentation by the facility staff of the corresponding site on the skin man diagram. Record review of the resident's hospice Nursing Comprehensive Update/Visit Note dated 6/30/14 showed: -The resident had a large blister on his/her right heel. -The blister was fluid-filled and intact. -The resident's heels were elevated off of a wedge pillow.. -Skin prep has been applied to the resident's blister. -The resident was on a low air loss mattress (a pressure relieving device). Record review of the resident's CNA Skin Inspection Record dated 6/30/14 showed: -The resident's skin was clear. -The resident had pressure and swelling to his/her heel in the column for redness. The staff did not identify which heel had pressure and swelling. -No documentation by the facility staff of the corresponding site on the skin man diagram. Record review of the resident's Nurse's Notes dated 6/30/14 showed: -The blister to the resident's right heel/foot was intact. -Skin prep was applied to the resident's blistered area. -Hospice informed the facility staff when the resident's blister opens, the facility staff should follow the physician and facility wound protocol per the facility wound nurse and to notify hospice of any changes. Record review of the resident's CNA Daily Skin Inspection Record dated 7/1/14, 7/2/14, and 7/3/14 showed: -The resident had a dressing on his/her right foot. Record review of the resident's Nurse's Notes from 7/1/14 - 7/4/14 showed no documentation from the licensed nurse regarding the resident's right heel blister. Record review of the resident's CNA Daily Skin Inspection Record dated 7/4/14 showed: -The resident had an open area on his/her right heel. -The resident had a dressing on his/her right foot. Record review of the facility Wound Nurse's Nurse's Notes dated 7/4/14 provided by the facility wound nurse showed: -The Nurse's Note was titled "Weekly Wound Measurements". -The resident had a left heel blister -The blister measured 16 (l) x 12.6 (w) x 0 (d). -The wound nurse did not document the unit of measurement (centimeters or inches). -There was no documentation that the wound nurse assessed the resident's skin after the resident had an identified skin alteration on the CNA Daily Skin Inspection Record dated 6/24/14. -There was no documentation that the wound nurse assessed the resident's skin after the resident had an identified large blister on the right heel on the Weekly Skin Assessment on 6/26/14. --The resident's blister was on the right heel, not the left heel. Record review of the resident's Weekly Wound Tracking Worksheet dated 7/4/14 showed: -The resident had a facility acquired pressure ulcer. -The resident's pressure ulcer was staged as unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) the previous week. -The resident's pressure ulcer was staged as unstageable the current week. -The resident's pressure ulcer was on the left heel. -The onset date of the pressure ulcer was 6/26/14. -The pressure ulcer had 100% granulation. -The wound was being treated with skin prep until the blister opens. --The resident's pressure ulcer was on the resident's right heel not his/her left heel. Record review of the resident's Nurse's Notes dated 7/4/14 showed: -The staff noticed drainage from the resident's right heel blister. -The resident's heel was placed on a towel and the blister was allowed to drain. -Skin prep was applied to the wound. -The staff did not document that they notified the resident's physician of the wound change. Record review of the resident's CNA Daily Skin Inspection Record dated 7/5/14 showed: -The resident had an open area on his/her right heel. -The resident had a dressing on his/her right foot. Record review of the resident's TOS dated 7/5/14 showed a new physician's orders [REDACTED]. -Cleanse the resident's right heel with a wound cleanser and pat dry. -Apply Triple Antibiotic Ointment (TAO - an antibiotic ointment indicated in the treatment of [REDACTED]. used to wrap wounds and burns) and secure with tape daily and as needed. Record review of the resident's Nurse's Notes dated 7/5/14 showed: -The resident had an open blister to his/her right heel with minimal amount of clear drainage. -The area was cleansed with wound cleanser and TAO was applied to the wound. -The resident's heels were off loaded off surfaces and the staff was educated regarding the importance of floating the resident's heels at all times. Record review of the facility Wound Nurse's Nurse's Notes dated 7/5/14 - 7/11/14 provided by the facility wound nurse showed: -The Nurse's Note was titled "Weekly Wound Measurements". -The resident had a right heel blister -The blister measured 13 long x 9.5 wide x 0 deep. -The wound nurse did not document the unit of measurement (centimeters). Record review of the resident's CNA Daily Skin Inspection Record dated 7/6/14 showed: -The resident had an open area on his/her right heel. -The resident had a dressing on his/her right foot. Record review of the resident's CNA Daily Skin Inspection Record dated 7/7/14 showed: -The staff did not document any skin issues on the resident. Record review of the resident's CNA Daily Skin Inspection Record dated 7/8/14 showed: -The resident's skin was clear. -The resident had an open area on sites E, F, O, and P. (Site E is the front of the resident's right foot. Site F is the front of the resident's left foot. Site O is the back of the resident's foot/heel. Site P is the back of the resident's right foot/heel) -The resident had a dressing on sites E, F, O, and P. Observation of the resident on 7/8/14 at 2:20 P.M. showed: -The resident was sitting in a reclining position in his/her Broda chair (a chair that provides seating and positioning options that enable even the most challenging individuals to find a comfortable way to sit) in the resident common area. -A wedge (a positioning device used to assist with side-lying support in bed) was placed on the Broda chair's leg rest under the resident's legs. -The resident was wearing Bunny Boots (soft, quilted cotton boots designed to minimize friction and reduce pressure to heels) on his/her right foot and on his/her left foot. -His/her heels were resting on the metal bar at the bottom of the Broda chair leg rest. Observation of the resident on 7/9/14 at 6:05 A.M. showed: -The resident was resting in his/her bed on his/her back on a low air loss mattress (a pressure relieving mattress). -The head of the resident's bed was elevated at approximately 30 degrees. -The resident had bunny boots on both his/her feet. -The resident's left leg was positioned on top of a wedge with his/her left foot resting on the wedge. -His/her left leg was elevated higher than his/her head. -The resident's right leg was on the mattress with his/her right foot/heel resting on the mattress. Observation of the resident on 7/9/14 at 6:56 A.M. showed: -The resident was resting in his/her bed on his/her back on a low air loss mattress. -The head of the resident's bed was elevated at approximately 30 degrees. -The resident had bunny boots on both his/her feet. -The resident's left leg was positioned on top of a wedge with his/her foot resting on the wedge. -His/her left let was elevated higher than his/her head. -The resident's right leg was on the mattress with his/her right foot/heel resting on the mattress. Observation of the resident on 7/9/14 at 8:12 A.M. showed: -The resident was resting on his/her back on a low air loss mattress (a pressure relieving mattress). -The head of the bed was elevated at approximately 30 degrees. -The resident had bunny boots on his/her right foot and his/her left foot. -The resident's left leg and right leg were positioned on top of a wedge with his/her left foot/heel and right foot/heel resting on the wedge. -The resident's feet were elevated higher than the resident's head. Observation of the resident on 7/9/14 at 11:47 A.M., 12:12 P.M., and 12:47 P.M. showed: -The resident was sitting in his/her Broda chair in the main common area. -The resident was wearing bunny boots on his/her right foot and on his/her left foot. -A wedge was placed under the resident's legs on the leg rest of the Broda chair. -The resident's heels were resting on the metal bar at the bottom of the Broda chair. -The facility staff did not reposition the resident. Record review of the resident's CNA Daily Skin Inspection Record dated 7/9/14 showed: -The resident had an open area on the on sites E, F, O, and P. -The resident had a dressing on sites E, F, O, and P which are the resident's feet. Observation on 7/10/14 at 9:09 A.M. showed the following: -The resident was resting in his/her bed on his/her back on a low air loss mattress. -The resident's head of the bed was elevated at approximately 45 degrees. -The resident had bunny boots on his/her left foot and on his/her right foot. -The resident's legs were elevated and his/her heels were resting on a wedge. -The resident's legs were elevated higher than his/her head height and the resident was in a "v" position in the bed. -The wound nurse removed the dressing applied to the resident's right foot/heel. -The resident had a large, deflated blister covering dark purplish colored skin with no drainage over the right heel and inner ankle area. -The wound nurse cleansed the wound with wound cleanser then applied a thick layer of TAO to the wound site. -The wound nurse covered the wound with [MEDICATION NAME] and wrapped the right foot/heel with Kerlix. -The wound nurse described the wound as an unstageable pressure ulcer but possibly a Suspected Deep Tissue Injury (SDTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue). Observation and interview on 7/10/14 at 10:02 A.M. showed: -CNA B and CNA C transferred the resident to his/her Broda chair utilizing a Hoyer lift (a mechanical device with a sling attached, to lift and transfer a non ambulatory resident). -CNA B and CNA C adjusted the resident multiple times to fit into the Broda chair while lowering the resident into the Broad chair. -The resident's outer thighs and buttocks areas fit snug against the sides of the Broda chair. -CNA B and CNA C said the Broda chair fit very snug against the resident's outer thighs and buttocks areas. -CNA B and CNA C were not able to demonstrate a gap between the sides of the Broda chair and the resident's lower body. -CNA B and CNA C placed a wedge under the resident's legs on the leg rest of the Broda chair. -CNA B and CNA C applied bunny boots to the resident's right foot and to the resident's left foot. -CNA B and CNA C rested the resident's feet on the wedge with the resident's heels resting on the wedge. During an interview on 7/10/14 at 10:41 A.M., CNA B said: -The Broda chair was very snug against the resident's lower body. -He/she was not sure why the wedge was used, but thought the wedge was used as a positioning device for the resident's legs while the resident was in the Broda chair. -He/she was not sure why the wedge was used to elevate the resident's legs while the resident was in bed, but thought the wedge was used as a positioning device to keep the resident's feet/heels off of the bed. -He/she thought the resident's bunny boots were a pressure relieving device to protect the resident's heels from touching anything. -The resident's heels should be floated and not touch or rest on a surface such as the bed, a wedge, or the bottom rail of the Broda chair. -The resident should be repositioned at least every two hours. During an interview on 7/10/14 at 10:45 A.M., CNA C said: -The Broda chair was very snug against the resident's lower body. -He/she was not sure why the wedge was used, but thought the wedge was used as a positioning device for the resident's legs while the resident was in the Broda chair. -He/she was not sure why the wedge was used to elevate the resident's legs while the resident was in bed, but thought the wedge was used as a positioning device to keep the resident's feet/heels off of t

Based on observation, interview and record review, the facility staff failed to accurately assess a Wound Vac (Negative-pressure wound therapy (NPWT), that is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds for resident's with pressure ulcers or non- pressure wounds) to assure all of the black foam was removed correctly from a surgical wound which resulted in a surgical debridement, for one resident (Resident #23) of 26 sampled residents. The census was 106 residents. Record review of the Facility's Pressure Ulcer Prevention Policy and Procedures revision dated 3/2012 showed: -All residents will have thorough weekly skin evaluation performed by a Licensed Nurse. -The licensed nurse performs a Braden Scale for Predicting Pressures Sores Risk on admission to the facility, weekly for the next 3 weeks after admission, then quarterly and as needed as the resident's functional or cognitive status changes. -The Licensed Nurse performs a weekly head to toe check of the resident skin, paying particular attention to the surfaces of the skin that comes in contact with the bed and chair, or with any orthotic devices, tubes, braces or positioning devices and the residents skin folds and bony prominence areas such as heels and tail bones etc.. -The Licensed Nurse observes for any redness, rashes, bruising, open area and any scars over bony prominences. -Any significant abnormal findings are to be reported to the resident's physician and resident contact person. -The Licensed Nurse should documented the skin check had been performed on Weekly Skin Documentation Form. -Abnormal findings are to be documented in the Nurse's Notes or to be documented on the back of the TAR. Record review of the Facility's Wound Care Policy and Procedures revised 12/2011 showed: -Evaluation of wounds will be performed on admission, weekly and on discovery. -Wound evaluation is the formal process in which wound characteristics, underlying condition and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. -Evaluation components include; location, measurements, appearance, drainage, odor, presence of undermining or tunneling, healing process, stage and date of onset for pressure ulcers, pain and [MEDICAL CONDITION]. -Evaluation results are to be communicated to the members of the care team through documentation, care plan meetings and care planning. -Treatments should also be re-evaluated every two to three weeks. If there is no wound progression or no change in treatment, documentation should occur as to why the wound is not progressing and any recommend treatment change or why should maintain current treatment. -The facility should have a system in place for daily observation of pressure ulcers or wounds which may include: -An evaluation of the status of the dressing and present of pain status. -The status of the skin surrounding the ulcer that can be observed without removing the dressing. -The evaluation of potential complications (increase in size, redness, swelling or drainage). -Recommended the resident's nursing progress notes, reflects the nurse's observation and management of wounds, from shift to shift perspective and with each wound dressing change. At a minimum, weekly documentation is recommended to provide a review of the wound. -As part of the process of managing in-house acquired pressure ulcers it is recommended the facility to have a quality-assurance/performance improvement process that is designed to identify potential problem at their source, where there is a greater potential of correcting the system breakdown. -Weekly Documentation of the wound should include the date observed and the following: -Location with staging and depth description for non- pressure wounds (such as partial thickness, full thickness). -Measurement (length, width, depth and the presence, and location of any extent of undermining, tunneling or sinus tract, measured per facility protocol. -Presence, type, color, odor, appearance and approximate amount of any exudate. -Presence of any pain and the frequency. -Wound bed characteristics (color, type of tissue) -Description of wound edges and surrounding skin as appropriate. Education should be provided to the staff upon hire and ongoing in order to expand their awareness of factors that influence pressure ulcers and intervention available. This includes education of the resident's, family and staff as to their role in pressure ulcers prevention. Record review of KCI (Kinetic Concept Incorporated) Wound V.A.C. Therapy Guidelines dated July 2007 showed: - Always count the total number of pieces of foam used in the wound and document that number in the patient ' s chart. - V.A.C. (Vacuum Assisted Closure) Foam Dressings are not bioabsorbable. -Always count the total number of pieces of foam removed from the wound and ensure the same number of foam pieces was removed as placed. - Foam left in the wound for greater than the recommended time period may foster in growth of tissue into the foam, create difficulty in removing foam from the wound, or lead to infection or other adverse events. Record review of the Facility Wound Care Policies and Procedures dated 12/2011 showed, the policy did not address the use of Wound VAC's (a Negative-pressure wound therapy (NPWT), this is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds) for resident's with pressure ulcers or non- pressures wounds and the facility did not have policy and procedures to instruct the facility nursing staff on how to use the wound vac. 1. Record review of Resident #23's face sheet showed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. -Open Abdominal Wound -MRSA ([MEDICAL CONDITION] - a type of bacteria that is resistant to many antibiotics) -[MEDICAL CONDITION] -[MEDICAL CONDITION] (a medical condition in which excess body fat has accumulated to the extent that it can result in many serious, potentially life-threatening health problems) -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) Record review of the admission Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/1/14 showed the resident: -Was able to make his/herself understood. -Was able to understand others. -Cognition was intact. -Required extensive assistance of two staff member with bed mobility, dressing and hygiene. -Required total assist of two staff member with transfers and -Had a surgical wound. Record review of the resident's Braden Scale dated 4/24/14 showed a score of 12. A total score of 18 or below was considered at risk for pressure sores. Record review of the resident's Physician Telephone Order (PTO) sheet dated 4/24/14 showed orders for the resident to receive the following supplements: - Protein Powder 1 packet by mouth with meals. -Zinc Sulfate 220 milligrams (mg) by mouth daily. -Multivitamins with minerals one tablet by mouth daily. -[MEDICATION NAME] Acid 500 mg by mouth every 12 hours. Record review of the resident's Care Plan dated 5/9/14 showed: -The facility identified the resident had a large abdominal surgical wound from [MEDICATION NAME] Necrosis (an irregular breakdown of cells, typically caused by infection, cancer, or injury), on admission. - Staff was to notify the charge nurse if the dressing was loose, off or the wound vac was beeping. -The charge nurse was to identify the problem and correct it. -If the charge nurse was unable to do so, they were to take down the dressing and apply wet to dry dressings every day until a new wound vac could be obtained. -Staff was to provide vitamins and supplements as ordered for wound healing. -The wound team was to evaluate wounds, treatments and heeling weekly. -Staff was to maintain the Wound Vac with settings as ordered. Record review of the resident's Physician order [REDACTED]. -Cleanse the abdominal wound with normal saline and or wound cleanser. - Apply negative pressure wound therapy with black foam at 175 mm/hg (millimeters of mercury) continuous. -Change the dressing on Monday, Wednesday and Fridays. Record review of the resident's facility wound Nurses Notes dated 4/25/14 showed: -The abdominal wound measured 27 cm (centimeter) x 17 cm x 25 cm. -Black foam was applied to the wound bed with cover applied. -Suction was obtained at 175 mm/hg. -The resident was in contact isolation [MEDICAL CONDITION] in his/her wound per hospital record. -The resident was on a low air loss mattress for pressure relief. -The Wound Vac was to be changed on Mondays, Wednesdays and Fridays. Record review of the resident's facility Wound Nurse's Notes dated 5/1/14 showed: -Wound Care Company A Wound Nurse Practitioner, was at the facility for wound rounds. -The abdominal wound measured 6 cm x 69 cm x 6.0 cm. -The wound did not have any undermining (the separation of tissue from the surface under the edge of the wound) or sinus tract (a narrow opening or passageway underneath the soft tissue and results in dead space with potential for abscess formation, a collection of pus that has built up within the tissue of the body) was noted on the exam. - No odor. -The wound had less than 25% yellow slough (A layer or mass of dead tissue separated from surrounding living tissue) and 75% pink granulation (is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). Record Review of the resident's Wound Treatment and Progress Record dated 5/1/14 showed: -The wound dressing was saturated with drainage, had a red appearance, and the surrounding skin was pink. Record review of the resident's physician telephone order dated 5/1/14 showed: -Staff was to change the Wound Vac two times a week on Mondays and Thursdays. Record review of the resident's facility Wound Nurse's Notes dated 5/6/14 showed: -The Wound Vac dressing was changed because the Wound Vac was not functioning well and was alarming. -The KCI representative was notified for a new Wound Vac. -The abdominal wound measured 4.5 cm x 67 cm x 5.0 cm. Record review of the resident's PTO dated 5/8/14 showed: -Staff was to continue the Wound Vac at 125 mm/hg continuous suction. -Staff was to change the Wound Vac dressing on Tuesday and Thursdays and on Saturdays, if needed. -Staff was to use gauze and abdominal dressings on 5/8/14 for the wound dressings, because the licensed staff would be in serviced on the wound vac on 5/9/14. Record Review of the resident's Wound Treatment and Progress Record dated 5/8/14 showed: -The wound dressing was saturated with drainage, had a red appearance, and surrounding the skin was pink. Record review of the resident's facility Wound Nurse's Notes dated 5/15/14 showed: -The abdominal wound measured 4.5 cm x 54 cm x 4.5 cm. -The wound did not have drainage. -The wound had less than 15% yellow slough in the wound bed with 85% granulation noted. -The abdominal wound was packed with black foam and draped as per the policy. -The Wound Vac was replaced at 175 mm/hg with suction continuous. Record Review of the resident's Wound Treatment and Progress Record dated 5/22/14 showed: -The wound dressing was saturated with drainage, had a red appearance, and the surrounding skin was pink. Record review of the resident's facility Wound Nurse's Notes dated 5/22/14 showed: -The abdominal wound measured 4.0 cm x 45 cm x 4.0 cm. -The wound had less than 25% yellow slough in the wound bed with 75% granulation noted in the wound bed. -Serous sanguineous (a thin, watery, and pale red to pink in color fluid) drainage was noted in the wound vac container. -The wound was prepped with skin prep to the outside perimeter of the wound. -The wound bed was filled with black foam and secured with drapes. -The Wound Vac was started at 125 mm/hg as ordered. Record review of the resident's facility Wound Nurse's Notes dated 5/29/14 showed: - The Wound Vac was removed. - The wound was cleansed with wound cleanser. -Pinpoint opening at 12 o'clock on the right lateral upper part of the wound noted to have yellow drainage. -Area with pressure applied expresses a small amount of yellow/creamy drainage. -All areas of the wound were cleansed. -The abdominal wound measured 4.0 cm x 24.5 cm x 4.0 cm. -The Wound Vac was re applied with suction at 125 mm/hg continuous suction as ordered. -The Director of Nursing (DON), Public Administrator and the physician were notified of the resident's wound status. -The Wound Vac application was completed. -Continue with the current treatment order. Record Review of the resident's Wound Treatment and Progress Record dated 5/29/14 showed: -The wound dressing was saturated with drainage, had a red appearance, and surrounding skin was pink. -Sinus Tract was noted on the left side of the wound at 12 o'clock with yellow drainage noted. Record review of the resident's Daily Skilled Nurse's Note dated 5/29/14 showed: -The Wound Vac had been changed on 5/29/14 and was running continuously at 175 mm/hg of pressure. Record review of the resident PTO dated 5/29/14 showed and order for: -Staff to swab the left lateral upper abdominal wound drainage for culture and sensitivity (A culture is done to find out what kind of organism (usually bacteria) is causing an illness or infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection. Record review of the resident's facility Wound Nurse's Notes dated 5/30/14 showed: -A swab of the right lateral upper wound edge was obtained for culture and sensitivity (A culture is done to find out what kind of organism (usually bacteria) is causing an illness or infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection). - Closer inspection of the right lateral aspect of the abdominal wound showed a small piece of black foam was found imbedded in the wound. -A possible sinus tract at 12 o'clock on the right lateral part of the wound continued to drain copious amounts of yellow drainage with pressure applied above the wound. -The DON was notified as well as the resident's Public Administrator. -The Assistant Director of Nursing (ADON) contacted the local wound care hospital for an evaluation of the wound. Record review of the resident's Daily Skilled Nurse's Note dated 5/30/14 showed: -The wound care hospital representative was at the facility to evaluate the resident for admission. No bed was available for the resident on 5/30/14. A bed was to be available 5/31/14. Record review of the resident's Nurses Notes on 5/31/14 at 11:45 A.M., showed the resident was transferred to the local wound care hospital. Observation of the resident's wound care on 7/16/14 at 3:00 P.M., showed the resident had returned to the facility from the hospital without a Wound Vac. During an interview on 7/15/14 at 1:50 P.M., Licensed Practical Nurse (LPN) G said: -Staff nurses did the Wound Vac dressings. -The facility had Wound Care Company A wound nurse, making wound rounds at the facility until the company changed and signed a contract with Wound Care Company B about the end of May 2014. -The wound nurse had the staff remove the dressings, the wound nurse would measure and assess the wound, and staff would redress the wound. -All nurses had Wound Vac training. -On 5/29/14, LPN G found what he/she thought was a sinus tract and notified the physician who ordered a culture of the wound drainage. -The Wound Care Company A Nurse Practitioner was on vacation. -On 5/30/14 LPN G saw a small dark speck. The nurse thought there was also a sinus tract at 12 o'clock. The nurse wasn't sure but thought it was a piece of foam. - LPN G had the nurse from Wound Care Company B, who was at the facility, assess the wound. -The Wound Care Company B nurse said he/she thought the speck was a piece of foam. -LPN's cannot remove foam imbedded in the wound. During an interview on 7/16/14 at 10:10 A.M., LPN A said: -He/she had not had Wound Vac training. -He/she heard that on 7/16/14 Wound Care Company B was going to do a Wound Vac in-service for the facility licensed staff. During an interview on 7/18/14 at 9:30 A.M., the ADON said: -Staff was expected to remove all of the black pieces of foam when removing the Wound Vac. -The wound nurse was expected to monitor the wound care for the resident receiving Wound Vac therapy. -If areas of the wound were imbedded with back foam the staff would be expected to notify the physician and the wound company. -Staff was not to put the Wound Vac back on the resident in the event black Wound Vac foam is found imbedded in the tissue. During an interview on 7/18/14 at 11:00 A.M., the Chief Operating Office/Registered Nurse (RN) Wound Nurse Consultant said: -He/She had met with the DON who said the facility had a resident with a Wound Vac. -He/she took the Wound Vac off and saw the resident had foam in the wound bed, an abscess and a sinus tract. -The resident looked ill and was sent to the hospital. -The resident had to have a surgical debridement. -He/she had spoken with staff on 7/17/14 and staff told the nurse they were not comfortable with Wound Vac's.