Every finding on record at Amberwood Estates Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to complete monthly resident trust fund (RTF) reconciliations, resulting in the inability to accurately account for money held in the RTF account. In addition, the facility failed to provide quarterly statements to residents and their representatives. This affected 41 residents whose funds were handled by the facility. The census was 83.Review of the facility's Resident Trust policy, dated 2/2022, showed:-Policy: To maintain a complete and accurate accounting for resident monies. The Administrator is responsible for the establishment and accurate maintenance of the RTF and the related resident trust petty cash account including the handling of the funds according to corporate policies as well as state and federal regulations;-Procedures: The resident may retain his/her right to receive, retain and manage his/her own personal funds;-Segregation of Duties: --Fund Custodian - Disburses RTF money after obtaining appropriate signatures; --Record-Keeper - Completes the monthly reconciliation of the RTF per resident trust petty cash account;--Authorization/Verification - Reviews for accuracy, approves and signs the monthly RTF reconciliation. Reviews the quarterly RTF statements before being mailed;--Witnesses to RTF Transactions - A person who witnesses signatures on Resident Trust Fund transactions is not a person directly responsible for receiving, disbursing, posting, reconciling or verifying the RTF;-Maintaining Documentation: RTF documentation is retained in a file labeled by the month. The monthly file needs to contain supporting documentation for any activity to the resident trust fund and the resident trust petty cash account including depositions, withdrawals, receipts, and interest allocations. Also retained in the monthly file are the signed monthly resident petty cash reconciliations, bank statements, and a copy of the quarterly statements-Deposits and Withdrawals: For those residents with direct deposit, the private portion is listed on the Deposit Transaction & Distribution Report. All cash disbursements from the resident trust petty cash require the resident's and/or his/her legal representative's signature on the Resident Trust Petty Cash Tracking Log or Withdrawal Slip. If a resident is unable to sign, two witness signatures are required on the withdrawal;-Monthly Reconciliation of RTF: --On a monthly basis, two reconciliations are completed: -- RTF Reconciliation is reviewed by the Accounting Office to confirm the trial balance, bank statement and reconciliation report agree;--Resident trust petty cash reconciliation is prepared to identify any outstanding balance remaining in the account at month end;--The resident trust reconciliations are completed by the 20th of the month;-Quarterly statement of account: The facility mails the quarterly statements no later than the 25th of the month following the end of the quarter. The Administrator reviews the statements prior to mailing. 1. Review of the facility's RTF reconciliation from January through December 2025, showed:-Account A held resident funds from January through May 2025. Reconciliations completed during that time;-May 2025:--RTF account balance: $73,118.12;--Trial balance: $73,117.50;--Reconciliation completed with $0.00 difference;-Account B held resident trust petty cash and Account C held resident funds from June through December 2025;-June 2025:--Trial balance for 41 accounts: $73,117.50;--No documentation of reconciliation completed;-July 2025:--Account B balance of $0.01;--Account C balance of $0.01;--No documentation of reconciliation completed;-August 2025:--Account B balance of $0.01;--Account C balance of $0.01;--No documentation of reconciliation completed;-September 2025:--Account B balance of $0.01;--Account C balance of $1,851.02;--Trial balance for 33 accounts: $1,851.00;--No documentation of reconciliation completed;-October 2025:--Account B balance of $1,945.15;--Account C balance of $46,595.24;--Trial balance of 37 accounts: $46,594.26;--Reconciliation completed with $0.00 difference;-No documented explanation of the $26,523.24 difference in the RTF between May and October 2025. 2. Review of Resident #10's medical record, showed:-Had a financial Power of Attorney (POA); -Diagnoses included end stage renal disease and diabetes;-Cognitively intact;-Funds held in RTF account.Review of resident's RTF statements and facility Trial Balance reports, showed:-Trial balance for resident as of 5/31/25: $6,613.08;-Trial balance for resident as of 10/31/25: $3,038.69;--A difference of $3,574.39 from May to October 2025;-Resident RTF statement for 10/7/25 through 11/28/25, showed a beginning balance of $1,558.00 and ending balance of $2,832.83;-Resident RTF statement 1/2/26 through 2/3/26, showed with a beginning balance of $869.05 and ending balance of $569.07. During an interview on 2/3/26 at 2:36 P.M., the resident's financial Power of Attorney (POA) said the facility previously notified him/her that the resident was required to spend down funds in the resident's trust account. He/She had not yet completed shopping and had spent approximately $200.00. He/She was unaware that the resident's trust account balance was $569.07, as of 2/2/26. The facility did not explain how the resident's trust account balance decreased from $6,613.08 in May 2025 to $3,038.69 in October 2025. The facility did not provide quarterly RTF statements and did not inform him/her that quarterly statements were available. 3. Review of Resident #33's medical record, showed:-Responsible for his/her own finances;-Diagnoses included Parkinson's disease and Alzheimer's disease;-Severe cognitive impairment;-Funds held in RTF account. Review of resident's RTF statements and facility Trial Balance reports, showed:-Trial balance for resident as of 5/31/25: $11,712.65;-Trial balance for resident as of 10/31/25: $8,342.03;--A difference of $3,370.62 from May to October 2025;-Resident RTF statement for 10/7/25 through 11/28/25, showed a beginning balance of $971.00 and ending balance of $8,367.22;-Resident RTF statement for 1/2/26 through 2/3/26, showed a beginning balance of $9,315.44 and ending balance of $8,715.87. During an interview on 2/3/26 at 1:15 P.M., the resident said he/she was unaware of the balance of his/her patient trust account and did not know why balance decreased from $11,712.65 in May 2025 to $8,342.03 in October 2025. A staff member previously discussed funeral arrangements with him/her; however, he/she did not understand the information provided. His/Her family member may have additional information regarding his/her resident trust account. During an interview on 2/3/26 at 1:15 P.M., the resident's family member said several months earlier, a nurse notified him/her that the resident had excess funds in his/her resident trust account. The family member requested the facility to speak directly to the resident to identify his/her needs so family member could assist with spending down the funds. The facility did not make further contact with the family member after that discussion and he/she was unaware how the resident's trust account balance decreased from $11,712.65 in May 2025 to $8,342.03 in October 2025. 4. Review of Resident #63's medical record, showed:-admission date 7/4/23;-Funds held in RTF account. Review of Resident #64's medical record, showed:-admission date 8/1/24;-Funds held in RTF account. During interviews on 2/2/26 at 11:58 A.M. and 1:28 P.M., 2/3/26 at 12:30 P.M., and 2/4/26 at 9:25 A.M., the Business Office Manager (BOM) was asked to provide documentation of the quarterly statements given to Residents #10, #33, #63, and #64, for the year 2025. 5. During an interview on 2/4/26 at 9:25 A.M., the BOM said she could not find documentation of the quarterly statements provided to all the residents who had funds held in the resident trust account. She began employment at the facility a few days ago and she did not have knowledge about the trust account details for Residents #10 and #33. She expected the facility to reconcile resident trust account monthly and to provide quarterly statements to residents and or their responsible parties. 6. During an interview on 2/4/26 at 10:12 A.M., the Administrator said she was aware the facility was required to maintain seven years of financial records and to ensure records were accessible within 24 hours of a request from the state survey agency. She had two e-mail addresses for corporate staff to whom she could direct questions about the RTF accounts, but she did not know their phone numbers or job titles. She had been employed at the facility for three months and did not have the reports detailing the variance between the May 2025 trial balance of $73,117.50 and the October 2025 trial balance of $46,594.26, a difference of $26,523.24. She expected the facility to reconcile resident trust accounts monthly and to provide quarterly statements to residents or their responsible parties each quarter.

Based on interview and record review, the facility failed to use the personal funds of a resident only when authorized in writing for two of four sampled residents (Residents #64 and #63). The census was 83.1. Review of Resident #64's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/25, showed:-Diagnoses included quadriplegia (paralysis of all four limbs), contracture of right hand and both shoulders;-Moderately impaired;-Minimum depression. Review of resident's care plan, in use during the survey, showed:-Focus: Activity care plans for individuals should be personalized to their needs and interests; -Goal: Will have his/her personal preferences honored as safely allowed;-Intervention: Tailor activities to the person's interests, abilities, and needs. Review of the resident's facility Withdraw Receipt form, dated 11/20/25, showed:-Receipt #W000003, record # 111925C, total amount of $325.54;-The resident's signature section and witness sections blank;-Transactions included:-On 10/8/25, amount: $4.03. From: Dollar General. Description: NTH 100;-On 10/9/25, amount: $18.42. From: Tucker's Place. Description: Salad. During an interview on 2/2/26 at 10:30 A.M., the resident said he/she was unaware of anyone in his/her family making the purchases on the receipt, dated 11/20/25. 2. Review of Resident #63's quarterly MDS, dated [DATE], showed:-Diagnoses included dysphagia following cerebral infarction (difficulty swallowing caused by a stroke);-Severe cognitive impairment;-Moderate depression.Review of resident's care plan, in use during the survey, showed:-Focus: Wishes to stay here long-term;-Goal: Continue to express satisfaction with living arrangements through the review period;-Intervention: Encourage social interactions and participation in activities with others that have similar interests. Review of the resident's facility Withdraw Receipt form, dated 11/24/25, showed:-Receipt #W000001, record #110925C, total amount of $146.43;-The resident's signature section and witness sections blank;-Transaction, amount: $146.43. From: Wal-Mart. Description: Clothing. During an interview on 2/3/26 at 1:58 P.M., the resident said he/she did not remember authorizing the purchase on 11/24/25 or receiving the items from Wal-Mart. During an interview on 2/3/26 at 2:20 P.M., the resident's financial Power of Attorney (POA) said he/she made the purchase but thought he/she signed something when the facility reimbursed him/her for the items but was not sure. During an interview on 2/4/26 at10:12 A.M., the Administrator said she expected the resident or the resident's responsible party to sign the facility's Withdraw Receipt prior to deducting money from the resident's patient trust account.

Based on observation, interview and record review, the facility failed to ensure the residents had a homelike environment by failing to maintain a comfortable sound level throughout the facility, failed to maintain adequate hot water temperatures for three residents (Resident #67, #5 and #6) and failed to thoroughly clean one resident's room (Resident #42). The sample was 22. The census was 83. Review of the facility's Environment of Care policy, dated 4/1/22, showed: -The facility staff will provide a safe, clean, comfortable and homelike environment; -The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; -The facility will provide for the maintenance of comfortable sound levels. 1. Observation and interviews during the meal service on 1/29/26 at 11:45 A.M., showed approximately 30 residents ate in the dining room. A fire exit door was located in the dining room. At 11:51 A.M., the alarm sounded. The sound was extremely loud. No staff responded to the alarm. The alarm sounded for approximately two minutes before a staff responded to the alarm. At 11:52 A.M., the alarm sounded again. The alarm continued to go on and off until 11:58 A.M., when the Activity Director (AD) entered the code into the alarm to turn it off. The AD said the plates to the door were not connecting, causing the alarm to constantly sound. The plates were not connecting due to the cold weather. During interviews with residents in the dining room, residents said the alarms were constantly sounding. One resident said This is so annoying and it's constant. Can't you all do something about this? Observations during the survey from 1/29/26 through 1/30/26 and 2/2/26 through 2/4/26, showed alarms throughout the facility continued to sound throughout the days. During an interview on 2/3/26 at 1:41 P.M., the Administrator said the alarms have been sounding continuously since she started working at the facility in October 2025. The alarms sounding off constantly was not homelike. The Maintenance Director ordered parts to repair the alarm. 2. Review of Resident #67's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/19/25, showed: -Cognitively intact; -Dependent on staff for bathing and personal hygiene; -Diagnoses included heart failure and high blood pressure. Review of the care plan, in use at the time of survey, showed: -Focus, resident had an Activities of Daily Living (ADL, grooming, dressing, bathing) self-care deficit; -Goal, the resident will improve current level of function through the review date; -Interventions, assist times one staff for a bed bath, twice a week and as needed as requested. During an interview on 1/29/26 at 9:51 A.M., the resident said he/she had not been taking his/her shower lately because the water was cold. The water had been cold since it got cold outside. Observation on 1/29/26 at 9:51 A.M., showed when the resident's sink faucet was turned on to cold, no cold water came out of the faucet. When the hot water ran continuously for two minutes, the temperature (T) of the hot water measured 58.9 degrees Fahrenheit (F) with a calibrated digital thermometer. 3. Review of Resident #5's admission MDS, dated [DATE], showed: -Cognitively intact; -Dependent on staff for bathing and personal hygiene; -Diagnoses included anxiety, depression and post-traumatic stress disorder (PTSD). Review of the care plan, in use at the time of survey, showed: -Focus, resident had an ADL self-care performance deceit; -Goal, the resident will maintain/improve level of functioning through the review date; -Intervention, the resident is totally dependent on two staff to provide bath/shower and as necessary. During an interview on 1/29/26 at 9:30 A.M., the resident said the facility only had hot water sometimes. Observation on 1/29/26 at 9:30 A.M., showed when the resident's sink faucet was turned on to cold, no cold water came out of the faucet. When the hot water ran continuously for two minutes, the T of the hot water measured 52.0 degrees F with a calibrated digital thermometer During an interview on 2/2/26 at 6:30 A.M., Certified Nurse Aide (CNA) B said some of the rooms did not have hot water since it got cold outside. He/She got hot water from the eye wash station for the residents to use for care. 4. Review of Resident #6's comprehensive MDS dated [DATE], showed: -Cognitively intact; -No rejection of care; -Very important in choosing between a shower, tub bath, bed bath and sponge bath; -Required substantial/maximal assistant with shower/bathing; -Diagnoses included renal failure, neurogenic bladder (loss of bladder control caused by a nerve damage from a medical condition or injury that affects the brain, spinal cord or nerves) and paraplegia. Observation on 1/29/26 at 9:26 A.M., showed the resident's water in his/her room sink ran for approximately three minutes. The water never got warm and was cool to the touch. During an interview on 1/29/26 at 9:27 A.M., the resident said the water in his/her room had not worked in several months. The shower rooms on the unit he/she resides on do not have hot water. During an interview on 2/3/26 at 11:09 A.M., CNA G said the resident had not been showered on a regular basis due to the water on the unit being cold. When CNA G worked, he/she offered to take residents to a different unit for a shower. Due to the cold water on the unit, the residents on the unit were not receiving at least two showers or bed baths per week. During an interview on 1/29/26 at 10:37 A.M., the facility Maintenance Director said there had been an issue with water temperature levels in some of the rooms and he had been investigating the issue for about a week. Initially circulation pumps in the facility were down and replaced by the Maintenance Director, establishing hot water circulation, but some resident rooms were still not receiving hot water. A number of the rooms were able to be adjusted appropriately via the mixing valves at the sinks, but many resident rooms continued having issues with water temperature levels. The Maintenance Director was now going room by room to investigate the sink-side piping in each resident room to determine the issue. The hot water temperatures should be between 108 degrees Fahrenheit but no higher than 115 degrees Fahrenheit, as indicated by the set temperature gauge at the main water heater distribution valve. 5. Review of Resident #42's quarterly MDS, dated [DATE], showed: - Diagnoses included Parkinson's disease without dyskinesia (neurodegenerative disorder without erratic movements), with fluctuations and other lack of coordination and mild depression; - No behaviors. Review of the resident's care plan, in use during the survey, showed: -Focus: ADL self-care performance deficit related to stroke with residual effects; -Goal: Will have needs met daily through the review period; Interventions: Staff assistance to the extent needed to accomplish task. Observations on 1/30/26 at 8:41 A.M., 2/2/26 at 10:25 A.M. and 2/3/26 at 9:50 A.M., of the resident's room and bathroom, showed: - The perimeter of the room's walls had multiple small, dark pellet-like substances scattered along the floor surface and within crevices adjacent to the wall and furniture base; - Accumulated dirt and debris along the perimeter of the room; - The bathroom toilet had visible brown staining and streaking on the exterior porcelain surface of the toilet base, extending vertically down the front of the fixture. Accumulated dirt and discoloration was around the base of the toilet where it met the flooring, with darkened residue and debris noted along the perimeter of the toilet base. The flooring immediately surrounding the toilet base was soiled and discolored. During an interview on 1/30/26 at 8:43 A.M., the resident said housekeeping staff entered the room and mopped briefly, but did not do a thorough cleaning. 6. During an interview on 2/4/26 at 2:55 P.M., the Administrator said she expected the facility to provide a safe, clean, comfortable and homelike environment. 1594432 1594427 2679753 2566067

Based on observation, interview and record review, the facility failed to identify a grievance official responsible for overseeing the grievance process. In addition, the facility failed to post signage informing residents of the location of grievance forms or the process for filing grievances orally, in writing or anonymously. This deficient practice had the potential to affect all residents in the facility. The census was 83.Review of the facility's grievance policy, dated 4/1/2022, showed:-Policy: Of this facility to provide residents, resident representatives, family and visitors with methods of sharing grievances and/or concerns with the facility;-Procedure: -The facility will have Grievance Forms available 24 hours per day , 7 days per week in an unsecured common area. The facility will notify the resident individually and/or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing and the right to file grievances anonymously. -Grievance Official: Is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances (for example, the identity of the resident for those grievances submitted anonymously); issuing written grievance decisions to the resident and coordinating with state and federal agencies as necessary in light of specific allegations; -Grievance Official: Shall be considered the Social Services Director unless otherwise indicated or directed by the Executive Director/Nursing Home Administrator/Risk Manager. The Grievance Official will have their name, business address (mailing and email) and a business phone number posted in prominent locations throughout the facility. The facility Grievance Official can be contacted by calling the facility during week day, day time business hours or contacting the NHA,/Executive Director for evenings, weekends, holidays or other times when the designated Grievance Official may not be present in the facility; -The Individual filing the grievance has the right to a reasonable expected time frame for completing the review of the grievance, being kept apprised of progress toward a resolution and a right to obtain a written decision regarding his or her grievance. - Staff will assist residents/resident representatives/visitors who cannot write or who choose not to write if they request to file a formal grievance. Grievances that are verbally noted by a staff member will be recorded utilizing the facility Grievance Form (on paper or entered in the electronic grievance tracking system form).During a group interview on 1/30/26 at 10:30 A.M., eight residents, who the facility identified as alert and oriented, attended the group meeting. All eight residents did not know where the grievance form was located. Six residents did not know how to file a grievance if one was located. All in attendance did not know who the Grievance Official was. The previous Grievance Official was the Social Worker, but the facility did not have a Social Worker. Six residents said they did not know who else to go to for grievances or concerns. Observations on 1/29/26 through 2/4/26, showed: - -Grievance forms not readily accessible to residents;- -No visible information posted identifying who the Grievance Officer was, where the forms were located or how residents could file grievances orally, writing or anonymously; - -Grievance forms were observed in the receptionist's office, behind a desk in an unmarked folder and were provided only upon request;- -The receptionist's office was kept locked at night.During an interview on 1/30/26 at12:22 P.M., the front desk staff H, said residents requesting to file a grievance were directed to the receptionist desk to obtain a grievance form. Front desk staff H said if a resident required assistance completing the form, the resident was referred to the social worker. Front desk staff H said the facility did not have a social worker at the time of the interview and residents requiring assistance were referred to the Human Resource (HR) office. Front desk staff H said his/her involvement ended at that point and he/she was not aware of what occurred with the grievance after the resident was referred.Observations during the investigation on 1/29/26 through 2/4/26, showed Grievance forms were not readily accessible to residents. No visible information was posted identifying who the Grievance Officer was, where the forms were located or how residents could file grievances orally, in writing or anonymously. Grievance forms were observed in the receptionist's office, behind a desk in an unmarked folder and were provided only upon request. The receptionist's office was kept locked at night.During an interview on 1/30/26 at12:30 P.M., the Human Resource (HR) Manager said grievance forms were turned in to her because the facility did not have a social worker at the time of the interview. The HR Manager said if additional assistance was needed, she requested support from the Activity Director. The HR Manager said if a grievance could not be resolved, the grievance was forwarded to the Administrator or the Director of Nursing. The HR Manager said her involvement ended once the grievance was forwarded. The HR Manager said she did not know who was designated as the grievance officer and assumed the social worker would serve in that role. During an interview on 2/4/26 at 2:10 P.M., the administrator said she expected the facility to have signage posted identifying the Grievance Officer and to have grievance forms freely accessible to resident, family members, and visitors without requiring staff assistance. The administrator said the grievance process should allow grievances to be filed anonymously.

Based on interview and record review, the facility failed to provide residents and/or resident representatives a bed hold policy at the time of transfer or as soon as practicable when residents were transferred to the hospital. In addition, the facility failed to send a copy of discharge notices to the representative of the Office of State Long Term Care (LTC) Ombudsman. The census was 83.Review of the facility's Transfer and Discharge policy, dated 4/1/22, showed:-30-day facility-initiated discharge (notice requirements before transfer/discharge):--The facility must send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman;-Planned discharges and transfer to the hospital: If the facility initiates the discharge, a copy of the notice of intent to transfer or discharge should be sent to the Office of the State LTC Ombudsman;--Unplanned discharges/emergency transfer to hospital: In situations where the facility has decided to discharge the resident while the resident was still hospitalized , the facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Review of the facility's Ombudsman notifications showed the last notification was provided in July 2025. Review of the facility's discharge report, dated 4/18/24 through 2/2/26, showed from 9/1/25 through 2/2/26, 31 residents were transferred to acute care hospitals, 15 residents discharged home, and three residents discharged to another facility. During an interview on 1/23/26 at 1:27 P.M., the Ombudsman representative said the last transfer log he/she received was from August 2025. During an interview on 2/3/26 at 9:15 A.M., the Administrator said the nurse on the floor was responsible for giving the resident and/or resident representative the facility's bed hold policy when a resident was transferred to the hospital. The facility did not have the bed holds documentation for resident's who were transferred to the hospital, and they did not have a copy of the notices of discharges after July 2025. During an interview on 2/4/26 at 2:50 P.M., the Administrator said she would expect for the bed hold policy to be given at the time of transfer, and she would expect the Ombudsman be provided the notice of discharge monthly.

Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL) care received at least two showers weekly for three of 22 sampled residents (Residents #80, #6, and #67). The census was 83.Review of the facility's Showering/Bathing policy, dated 4/1/22, showed:-Policy: It will be the policy of this facility to assure that showers/bathing are offered to residents at least two times weekly or per resident/resident representative preference unless specifically ordered otherwise by the physician or care planned otherwise;-A schedule will be developed for each resident with showers (or bed bath or alternate means of bathing) according to room placement or resident preferences;-Certified Nursing Assistants (CNAs)/Nursing staff should complete the assignment sheet/shower sheet or POC electronic documentation on each day shower/bathing is provided-Refusals for showers/bathing should be reported to the licensed nursing staff;-If a resident desires an alternative shower/bathing schedule it is their right to have an alternative shower/bathing schedule that fits their individualized needs and efforts should be made to accommodate these wishes once the staff are notified of the desired changes During an interview on 2/4/26 at 8:55 A.M., the shower schedule was requested. As of 2/4/26 at 4:00 P.M., no shower schedule was provided. 1. Review of Resident #80's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/25, showed:-Moderate cognitive impairment;-No behaviors;-Mobility device: walker;-Independent with toileting and personal hygiene, shower or bath, upper and lower body dressing;-Required assistance in eating and oral hygiene;-Diagnoses included high blood pressure, stroke, non-Alzheimer's dementia, depression, and generalized muscle weakness. Review of the resident's care plan, in use at time of survey, showed:Focus: The resident requires assistance with mobility/transfers and requires equipment;Goal: The resident will have their transfer and mobility needs met with the necessary equipment and assistance;-Interventions: [NAME] type - rollator;-Focus: The resident has an ADL (activities of daily living) self-care performance deficit related to impaired mobility, he/she bilateral lower extremities edema (swelling);-Goal: The resident will maintain or improve level of functioning;-Interventions: Bathing/showering - avoid scrubbing and pat dry sensitive skin, check nail length, trim, and clean on bath days and as necessary. Requires limited assistance of one staff with showering twice weekly and as necessary;-Focus: The resident has potential for impairment to skin integrity;-Goal: The resident will maintain or develop clean and intact skin;-Intervention: Monitor and report to physician for any sign and symptoms of skin breakdown. Review of the resident's Shower Sheet/Skin Condition forms, showed:-October 2025: Shower or bed bath completed 10/21/25;-November 2025: Shower or bed bath completed on 11/11/25 and 11/14/25;-December 2025: Shower or bed bath completed on 12/16/25;-January 2026: Refused shower or bed bath on 1/16/25. Observation and interview on 1/29/26 at 9:26 A.M., showed the resident with long, messy and greasy hair with a strong body odor. He/She said he/she got showers every two weeks or once a month. He/She tried to have showers once a week but there were not enough shower rooms for everybody. They all used the same shower room. He/She needed assistance to go to the shower room but was able wash self independently. Observation and interview on 1/30/26 at 9:15 A.M., showed the resident wore a baseball cap, uncombed and greasy hair. He/She said he/she had not had a shower for a while now. Observation on 2/3/26 at 12:21 P.M., showed the resident continued to wear a baseball cap and wore the same clothes from the day prior. During an interview on 2/3/26 at 5:32 P.M., the Assistant Director of Nursing (ADON) said the residents should have showers at least twice a week. The staff fill out the shower sheets when providing residents' showers. It should be documented when resident refused. Resident #80 refused showers at times. 2. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-No rejection of care;-Very important in choosing between a shower, tub bath, bed bath and sponge bath;-Required substantial/maximal assistant with shower/bathing;-Diagnoses included renal failure, neurogenic bladder (loss of bladder control caused by a nerve damage from a medical condition or injury that affects the brain, spinal cord or nerves) and paraplegia. Review of the resident's care plan, revised 1/7/25, in use during the time of the investigation, showed:-Focus: The resident prefers to have a bed bath daily;-Goal: The resident prefers to have a bed bath through review date;-Interventions: The resident prefers to have a bed bath but no preference on the time of day. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, showed:-November 2025: Shower or bed bath completed 11/1/25, 11/12/25, 11/22/25 and 11/28/25;-December 2025: Shower or bed bath completed 12/6/25, 12/13/25, 12/24/25 and 12/31/25. Review of the resident's Shower Sheet/Skin Condition Reports for January 2026, showed shower or bed bath completed on 1/17/26 and 1/23/26. During an interview on 1/29/26 at 9:27 A.M., the resident said the water in his/her room had not worked in several months. The shower rooms on the unit he/she resided on did not have hot water. As a result, he/she was not offered bed baths or showers. He/She could not recall the last time he/she had a shower and preferred a shower or bed bath daily. During an interview on 2/2/26 at 10:12 A.M., the resident said this past Saturday, 1/31/26, his/her aide offered a shower. The resident informed the aide the hot water was not working on his/her unit, and asked if the aide could take him/her to another unit. The aide said he/she did not have time to go to another unit and offered a bed bath instead. The resident agreed to the bed bath and asked the aide to obtain hot water from a different unit. The aide said it was too much and documented the resident refused a shower. When asked if the resident reported this to the nurse, he/she said No. Nothing would be done about it. The resident said he/she was upset that he/she did not receive a shower or bed bath. During an interview on 2/3/26 at 11:09 A.M., CNA G said the resident had not been showered on a regular basis due to the water on the unit being cold. When CNA G worked, he/she offered to take residents to a different unit for a shower. The resident preferred a shower or bed bath daily, but his/her preferences had not been met. Other residents were to receive showers or bed baths twice per week. Due to the cold water on the unit, the residents on the unit were not receiving at least two showers or bed baths per week. 3. Review of Resident #67's admission MDS, dated [DATE], showed:-Cognitively intact;-No rejection of care;-Dependent on staff for bathing and personal care;-Diagnoses included high blood pressure, heart failure and chronic obstructive pulmonary disease (COPD). Review of the resident's care plan, in use at the time of survey, showed,-Focus: Resident has an ADL self-care performance deficit;-Goal: Will improve current level of function through the review date;-Interventions: Bathing/showering: check nail length and trim and clean on bath day and as necessary. Report changes to the nurse. During an interview on 1/29/26 at 9:51 A.M., the resident said he/she [NAME] been taking his/her shower lately because the water was cold. During an interview on 1/30/26 at 11:05 A.M., the resident he/she has been taking a whore bath (washing only the arm pits, breast and genital area in the bathroom sink) because there was no hot water. Review of the shower sheets provided by the facility dated 11/1/25 through 1/26/26, showed 19 forms were provided. One out of 19 showed the resident received a shower, nine out of 19 opportunities a bed bath was completed, and nine out of 19 opportunities were refused. 4. During an interview on 2/3/26 at 5:20 P.M., the Director of Nursing (DON) and ADON said showers or bed baths were to be offered at least twice per week. If a resident preferred to have a shower or bed bath daily, the resident's preferences should have been honored. Some residents may not have received a shower or bed bath twice weekly due to water temperatures not being adequate. If a resident wanted a shower, staff could take a resident to a different unit. If the resident preferred a bed bath, staff could have obtained hot water from another unit. There was no excuse for the resident to have not received a shower. 5. During an interview on 2/4/26 at 2:50 P.M., the Administrator, DON, and MDS Coordinator said resident choices should be honored. If a resident preferred a shower or bath daily, his/her preferences should have been honored. 159442725629812699478

Based on interview and record review, the facility failed to ensure the physician or designee responded to the pharmacy recommendations timely for three out of five residents sampled for medication review (Resident #11, #5, and #9). The sample was 22. The census was 83. During an interview on 2/4/26 at 8:55 A.M., the pharmacy review policy was requested. As of 4:00 P.M. on 2/4/26 no policy was received. 1. Review of Resident #11's medical record showed, a diagnosis of schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations, delusions, disorganized speech) with a mood disorder (major depression or bipolar mania/depression). Review of the care plan, in use at the time of survey, showed:-Focus: Resident used psychotropic medications;-Goal: Will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date;-Interventions included: Consult with pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate at least quarterly. Review of the order summary sheet, in use at the time of survey, showed:-A physician order for Quetiapine 25 milligrams (mg), give one tablet at bedtime (hs) for schizoaffective disorder, start date was 6/25/25;-A physician order for Ramelteon 8 mg at hs for insomnia, start date was 6/25/25. Review of the note to attending physician/prescriber review dated 12/10/25 and 1/15/26, showed:-Resident was currently prescribed sedative/hypnotic. Ramelteon 8 mg every bedtime (hs) for the treatment of insomnia since 6/5/25; -According to Center for Medicare and Medicaid Services (CMS) guidance under F605 (chemical restraints), for any resident who is receiving a psychotropic medication, the facility must show evidence that a gradual dose reduction (GDR) has been attempted unless clinically contraindicated;-Please consider a trial dose reduction: Ramelteon 4 mg every hs;-If a GDR attempt is not indicated at this time, please indicate reasoning below:- Dose reduction attempt at this time would risk decompensation of patient;-Resident is taking lowest effective dose. Previous GDR attempt on (blank), resulted in adverse effects and/or exacerbation of resident's condition;-Other: See Physician's progress notes for rationale.-The forms were blank and unsigned by the physician/prescriber;- Resident is currently prescribed antipsychotic, Quetiapine 25 mg every hs for the treatment of schizoaffective disorder since 6/5/25;-According to CMS guidance under F605 (chemical restraints), for any resident who is receiving a psychotropic medication, the facility must show evidence that a gradual dose reduction has been attempted unless clinically contraindicated;-Please consider a trial dose reduction: Quetiapine 12.5 mg every hs;-If a GDR attempt is not indicated at this time, please indicate reasoning below:- Dose reduction attempt at this time would risk decompensation of patient;-Resident is taking lowest effective dose. Previous GDR attempt on (blank), resulted in adverse effects and/or exacerbation of resident's condition;-Other: See Physician's progress notes for rationale.-The form was blank and unsigned by the physician/prescriber. Review of the progress notes dated 12/10/25 through 2/4/26, showed there was no documentation showing the physician was made aware of the pharmacy review and recommendations. 2. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/5/25, showed:-Cognitively intact;-Diagnoses included anxiety, depression and post-traumatic stress disorder (PTSD). Review of the care plan in use at the time of survey, showed:-Focus: Resident used psychotropic medications related to bipolar disorder;-Interventions included: consult with pharmacy, medical doctor, to consider dosage reduction when clinically appropriate at least quarterly. Review of the note to attending physician/prescriber review dated 12/11/25, showed:-Resident was currently on as needed (prn) Lorazepam 2 mg twice a day with the following diagnosis: Anxiety;-Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need.-PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration for the prn order;-New order for prn: (blank) (include duration and rationale) handwritten was decrease to one mg by mouth everyday as needed. The form was signed by the physician and dated 12/17/25. There was no duration noted, or a rationale documented if the medication was to exceed the 14 days. Review of the physician order sheet, in use at the time of survey showed, a physician order for Lorazepam 1 mg every day prn anxiety. Start date was 12/31/25, end date was indefinite. Review of the note to attending physician/prescriber review dated 1/16/26, showed, this resident is currently on prn Lorazepam 1 mg every 24-hour prn with the following diagnosis: Anxiety;-Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need.-PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration for the prn order. Please consider discontinue prn Lorazepam; new order for prn: (blank) (Include duration and rationale); adjust routine order to (blank);-The form was blank and unsigned by the physician/prescriber. Review of the progress notes dated 12/31/25 through 2/4/26 showed, there was no documentation showing the physician documented the duration and/or rationale for the medication. 3. Review of Resident #9's annual MDS, dated [DATE], showed:-Diagnoses included Spastic quadriplegic cerebral palsy (brain injury), and dysphagia, oropharyngeal phase (difficulty swallowing);-Moderate severe depression;-No behaviors. Review of the resident's care plan in use at time of survey, showed:-Focus: Has admitted to hospice with admitting diagnosis sepsis (immune system triggers widespread inflammation that damages its own organs and tissues);-Goal: The resident's comfort will be maintained through the review date;-Interventions: Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review of the resident's active order summary, showed:-A physician order for Morphine Sulfate Oral Solution 20 mg/5 milliliters (ML), Give 0.25 ml by mouth every two hours as needed for shortness of breath and/or severe pain;-A physician order for Erythromycin Ophthalmic Ointment 5 mg/gram (GM), instill 1 drop in both eyes two times a day related to unspecified superficial keratitis (inflammation of the cornea, the clear, front surface of the eye), unspecified eye. Review of the resident's Note to Attending Physician/Prescriber dated 11/18/25, showed:-Current order: Morphine 20 mg/5ML, give 0.25 ML every two hours prn;- Recommendation: Please clarify the strength for the above order. The typical strength for the dose listed above is Morphine 100 mg/5 ML. Please review stock on hand and be sure the order strength matches the strength on hand;-There was a line to mark agree, disagree or comment: The form was blank;-Current order: Erythromycin Ophthalmic (Ophth.) ointment and TobraDex ophth (prevents inflammation and infection of the eye). -Recommendation: Duplicate therapy. This resident is receiving the above medications which have similar effects and may be considered duplicate therapy. -Please evaluate the need for both ophth. antibiotics. If continued, please clarify the Erythromycin to include a stop date and be sure to separate applications;-There was a line to mark agree, disagree or comment: The form was blank.-The form was unsigned by the physician/prescriber. Review of the resident's Note to Attending Physician/Prescriber showed, dated 12/11/25, showed:-Current order: Morphine 20 mg/5ML give 0.25 ML every two hours prn;-Recommendation: Please clarify the strength for the above order. The typical strength for the dose listed above is Morphine 100 MG/5 ML. Please review stock on hand and be sure the order strength matches the strength on hand; -There was a circle around 20 mg/5ml and handwritten was error 20mg/ml;-Current order: Erythromycin Ophthalmic (Ophth.) ointment and TobraDex ophth.-Recommendation: Duplicate therapy. This resident is receiving the above medications which have similar effects and may be considered duplicate therapy. Please evaluate the need for both ophth antibiotics. If continued, please clarify the Erythromycin to include a stop date and be sure to separate applications; -Handwritten was discontinue both ointments;-The form was signed and dated 12/17/25. Review of the resident's Note to Attending Physician/Prescriber showed, dated 1/16/25, showed:-Current order: Morphine 20 mg/5ML give 0.25 ML every two hours prn;- Recommendation: please clarify the strength for the above order. The typical strength for the dose listed above is Morphine 100 mg/5 ML. Please review stock on hand and be sure the order strength matches the strength on hand;-There was line to mark agree, disagree or comment: The form was blank;-Current order: Erythromycin Ophthalmic (ophth.) ointment and TobraDex ophth; -Recommendation: Duplicate therapy. This resident is receiving the above medications which have similar effects and may be considered duplicate therapy. Please evaluate the need for both ophth. antibiotics. If continued, please clarify the Erythromycin to include a stop date and be sure to separate applications;-There was line to mark agree, disagree or comment: The form was blank.-The form was unsigned by the physician/prescriber. Review of the Medication Administration Record (MAR), dated 1/1/26 through 1/31/26 showed:-A physician order for Morphine Sulfate Oral Solution 20 mg/5ml, give 0.25 ml by mouth every two hours as needed for shortness of breath and/or severe pain, start date was 10/10/2025;-A physician order for Erythromycin Ophth. Ointment 5 mg/gm, instill 1 drop in both eyes two times a day related to unspecified superficial keratitis, unspecified eye, start date was 10/30/25;-Documentation showed the medication was administered. Review of the resident's progress notes from 12/16/25 through 1/28/26 showed no documentation related to Morphine Sulfate Oral Solution 20 mg/5ml or Erythromycin Ophth. 4. During an interview on 2/4/26 at 9:50 A.M. the Director of Nursing (DON) said when she got to the facility the Assistant Director of Nursing (ADON) was in charge of the pharmacy reviews. That ADON was no longer at the facility. The DON did not know if the pharmacy reviews were addressed by the physician or not. Going forward, the pharmacy will email the reviews to both the ADON and the DON. 5. During an interview on 2/4/26 at 2:50 P.M., the Administrator said she would expect for the pharmacy reviews to be completed monthly and the physician/provider to review the recommendations.

Based on observation, interview and record review, the facility failed to ensure food was served at a palatable, safe and appetizing temperature during tray service by failing to maintain the temperature of hot foods to at least 120 degrees Fahrenheit (F). This deficient practice affected all residents who ate at the facility, including (Residents #19, #67, #6 and #74). The sample size was 22. The census was 83.Review of the facility's Final Cooking Temperatures policy, revised 10/1/23, showed:-Policy: Food is to be cooked to specified temperatures and times to mitigate the presence of dangerous microorganisms. The danger zone for food temperatures is above 41 degrees Fahrenheit (F) and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 1.Review of Resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/23/25, showed:-Cognitively intact;-Diagnoses included anemia (low red blood cell count), ulcerative colitis (inflammation and sores in the colon and rectum), Crohn's disease (chronic inflammatory bowel disease) and inflammatory bowel disease. Review of the care plan in use at the time of survey showed:-Focus: Resident was on a regular diet;-Goal: Will comply with recommended diet through review date;-Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. During an interview on 2/3/26 at 12:15 P.M., the resident said he/she barely ate the food here. The food was terrible and he/she ate his/her own snacks and food. 2. Review of Resident #67's quarterly MDS, dated [DATE], showed:-Cognitively intact;- Diagnoses included heart failure and high blood pressure. Review of the care plan in use at the time of survey, showed:-Focus: Has nutritional problem or potential nutritional problem related to obesity. He/She was on a regular diet;-Goal: Will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date;-Interventions: Provide and serve diet as ordered. During an interview on 1/29/26 at 9:57 A.M. the resident said the food tasted bad. 3. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Exhibited no behaviors;-Diagnoses included malnutrition. During an interview on 1/29/26 at 9:27 A.M., the resident said the food was not good and was often cold when it arrived. 4. Review of Resident #74's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Exhibited no behaviors;-Diagnoses included renal disease and diabetes. During an interview on 1/29/26 at approximately 9:45 A.M., the resident said the food was okay when he/she was able to eat at the facility. Sometimes it was served cold. 5. Observation on 2/3/26 at 12:37 P.M., showed lunch served on the 200 unit. A tray was removed from the cart. Lunch consisted of lasagna, coleslaw and orange sherbet. The food temperature was taken with a digital thermometer. The lasagna was lukewarm and initially showed a temperature of 125 degrees (F). After 15 seconds, the temperature dropped to 112 degrees (F). The coleslaw was cool to the taste and wilted. The temperature was at 66 degrees (F). The sherbet was melted. 6. Observation on 2/3/26 at 12:41 P.M., showed the food cart arrived on the 100 unit hall. At 12:48 P.M., two staff members began passing the hall trays. At 12:56 P.M. the last tray was passed. A test tray was removed from the cart. Food temperatures were taken using a digital thermometer. The salad had a white creamy dressing on it. The salad was warm to taste and the temperature was 76.0 degrees F. The lasagna was warm to the taste and the temperature was 102.6 degrees F. The rainbow sherbet was mostly melted. The sherbet was cool to taste and the temperature was 28.2 degrees F. 7. Observation on 2/3/26 at 5:40 P.M., showed the hall trays arrived on the 100 hall unit. One staff member began delivering trays to the residents' rooms. At 5:48 P.M. the last tray was delivered. A test tray was taken to the nurse's station. Food temperatures were taken using a digital thermometer. Licensed Practical Nurse (LPN) E said the temperature of the chicken bites was 95.4 degrees F. The temperature of the corn was 109.9 degrees F and the temperature of the fruit cup (oranges) was 70.5 degrees F. 8. During an interview on 2/4/26 at 9:14 A.M., the Dietary Manager said she would expect food to be served at an appetizing and safe level. Food should be served at 135 degrees (F) when it reached the resident. Cold foods should be at freezing level and sherbet should be served frozen. If food was not served at appropriate levels, residents ran the risk off food-borne illnesses. 9. During an interview on 2/4/26 at 2:50 P.M., the Administrator said she would expect food to be served at a safe and appetizing level. 1594427 [NAME], [NAME] (74) [NAME], [NAME] (37681) - Food No NotesBRADFORD, [NAME] (6) [NAME], [NAME] (37681) - Food No NotesPROWELL, [NAME] (74) [NAME], [NAME] (37681) - RESIDENT NOTE No NotesBRADFORD, [NAME] (6) [NAME], [NAME] (37681) - RESIDENT NOTE No Notes

Based on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings were documented as attended and consisted of the required committee members when the Administrator, Infection Preventionist Nurse (IP) and the Medical Director failed to attend the facility's QAPI meetings. The census was 83.Review of the facility's Quality Assessment and Assurance (QAA) policy and procedure, revised 10/1/123, showed:-Policy: It will be the policy of the facility to hold a QAA committee meeting at least quarterly;-Procedure: A facility will maintain a quality assessment and assurance committee consisting at a minimum of:--The director of nursing services (DON);--The Medical Director or his/her designee;--At least three other members of the facility's staff, at least one of whom must be the administrator, owner, a board member or other individual in a leadership role;--The infection preventionist. Review of the facility's QAPI sign in sheets, showed:-QAPI meeting held on 5/6/25. No IP staff in attendance;-QAPI meeting held on 6/10/25. No IP or Administrator in attendance;-QAPI meeting held on 8/27/25. No Administrator, IP or Medical Director in attendance;-QAPI meeting held 1/21/26. No IP staff in attendance. During an interview on 2/3/26 at 1:41 P.M., the Administrator said she was unable to locate the meeting minutes for February 2025 and October 2025, but knew the meetings were held. As of now, they did not have an IP nurse. She would have expected all required members to attend QAPI meetings and proof of attendance should have been documented.

Based on observation, interview, and record review, the facility failed to follow acceptable infection control standards and failed to follow Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact care activities as recommended by Center for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Service (CMS)), when staff failed to wear a gown while providing high contact care for four out of five residents observed for care (Resident #79, #81, #72, and #9). The facility also failed to use correct infection control techniques while providing peri-care to one of the five residents observed (Resident #79), and when staff placed linens on the floor and on another resident's bed for two of the five residents observed for care (Residents #79 and #81). The sample size was 22. The census was 83. Review of the facility's EBP policy, dated 8/25/25, showed:-An order for EBP will be obtained for residents with any of the following chronic wounds, indwelling medical devices (feeding tube) and/or infection or colonization with a novel or targeted MDRO when contact precautions do not apply;-Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gown and gloves;-For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities dressing, transferring, providing hygiene, changing linens and changing briefs or assisting with toileting. Review of the facility's Standard Precautions for Infection Control policy, revised 4/1/22, showed it will be the policy of the facility to assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. Contaminated laundry shall be minimally handled with the appropriate use of personal protective equipment and placed in bags that prevent leakage, at the location of use. 1. Review of Resident #79's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 12/22/25, showed:-Severe cognitive impairment;-Dependent on staff for toilet and personal hygiene;-Always incontinent of bladder and bowel;-Diagnoses included stroke, multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue) and altered mental status. Review of the care plan, in use at the time of survey, showed:-Focus: Resident was always incontinent of bladder;-Goal: Will decrease frequency of urinary incontinence through the next review date;Interventions included clean peri-area (the cleansing of the genital and anal areas) with each incontinence episode. Observation on 2/2/26 at 6:48 A.M., showed an EBP sign and PPE on the door to the resident's room. The resident was in bed. Certified Nurse Aide (CNA) C put gloves on, rolled the resident onto his/her side, and cleaned the resident's back side. CNA C changed his/her gloves and rolled the resident onto his/her back and cleaned the resident from the genital to the abdomen (back to front). He/She changed his/her gloves and rolled the resident toward the window, and removed the soiled pad and placed it on the floor, without a barrier between the soiled linens and floor. CNA C removed the blankets off the resident's bed and placed them on his/her roommate's bed, tucked a pad and brief halfway underneath the resident and rolled the resident to straighten the pad and fasten the brief. CNA C assisted the resident in getting dressed and transferred the resident into the wheelchair. CNA C took the blankets he/she placed on the roommate's bed and used them to make the residents bed. CNA C did not wear a gown while providing care to the resident or while making his/her bed. During an interview on 2/4/26 at 10:20 A.M., the Assistant Director of Nursing (ADON) said when staff provide peri-care to a female resident, they should wipe the resident from the front to the back. Linens should not be taken from one resident's bed, placed on another resident's bed, and then placed back on the resident's bed because of cross contamination. Staff knew which residents required EBP by the signage on their door. Staff should wear a gown, gloves and mask as needed when providing high contact care. 2. Review of Resident #81's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for toilet and personal hygiene;-Always incontinent of bladder and frequent incontinent of bowel;-Diagnoses included stroke. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident had an activities of daily living (ADL, grooming, dressing, bathing) deficit;-Goal: Will maintain improve level of functioning;-Inventions included staff assistance to the extent needed to accomplish task;-Focus: EBP for wounds, gown and gloves required for high contact resident care activities;-Goal: Will maintain or develop clean and intact skin by the review date;-Interventions included keep the skin clean and dry, use lotion to dry skin. Review of the resident's physician order sheet, in use at the time of survey, showed a physician order, start date 6/3/25, for EBP for chronic wound. Gown and gloves required for high contact resident care activities. Observation on 2/2/26 at 5:25 A.M., showed an EBP sign and PPE on the resident's door. CNA C entered the resident's room, performed hand hygiene and put on two pair of gloves. No gown was worn. CNA C unfastened the resident's brief and cleaned his/her groin and between the resident's legs and assisted the resident to roll onto his/her side. CNA C removed the soiled blanket from the bed and placed it on the floor, with no barrier between the soiled linens and the floor. CNA C cleaned the resident's back side, removed one glove from his/her right hand, and with one glove still on the right hand, tucked the soiled pad halfway under the resident. CNA C changed his/her gloves, then folded a blanket into one forth and placed a brief on top of it and tucked it halfway under the resident. CNA C rolled the resident onto the other side and straightened the blanket and brief out and fastened the brief. He/She said the facility ran out of pads. CNA C changed his/her gloves and picked up the linens off the floor and placed in a trashed bag and removed them from the room. During an interview on 2/4/26 at 10:20 A.M., the ADON said staff should not double glove. They should remove their gloves and perform hand hygiene. Soiled linens should not be placed on the floor. 3. Review of Resident #72's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Dependent on staff for toilet and personal hygiene;-Always incontinent of bladder and frequent incontinent of bowel;-Diagnoses included stroke and hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Has an ADL self-care performance deficit related to bed immobility status post stroke and amputation. Resident preferred to stay in bed at all times;-Goal: Will maintain current level of function through review date;-Interventions included, resident was totally dependent of one staff for toilet use. He/She used incontinent products. Review of the resident's physician order sheet, in use at the time of survey, showed a physician order, start date 6/3/25, for EBP for chronic wound. Gown and gloves required for high contact resident care activities. Observation on 2/2/26 at 5:05 A.M., showed the resident in bed. CNA B put gloves on and rolled the resident side to side and provided peri-care. No gown was worn by CNA B while he/she provided care. 4. Review of Resident #9's significant change MDS, dated [DATE], showed:-Rarely/never understood;-Dependent on staff for toilet and personal hygiene;-Always incontinent of bladder and bowel;-Diagnoses cerebral palsy (a disorder of movement, muscle tone or posture), and gastrostomy (g-tube, feeding tube) status. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Has an ADL self-care performance deficit related to cerebral palsy and being dependent on staff for his needs;-Goal: Resident will be met daily through the review date;-Interventions: Resident was totally dependent on one staff for personal hygiene and oral care;-Focus: EBP for g-tube, gown and gloves required for high contact resident care activities;-Goal: Will remain free of side effects or complications related to tube feeding through review date;-Interventions, check resident for tube placement and gastric contents/residual volume per facility protocol and record. Review of the resident's physician order sheet, in use at the time of survey, showed no physician order for EBP. Observation on 2/2/26 at 6:13 A.M., showed an EBP sign and PPE on the door to the resident's room. The resident was in bed. CNA C had gloves on and rolled the resident side to side while providing peri-care. No gown was worn by CNA C while he/she provided peri-care. 5. During an interview on 2/3/26 at 4:50 P.M., CNA G said he/she knew which residents required EBP because there was a sign on the door and PPE on or by the door. Staff should wear a gown, mask, face shield and gloves every time they enter the room and remove it before they exited the room. Staff should not double glove. Soiled linens should be placed in a trash bag and not on the floor or on other resident's beds. When providing peri-care, staff should wipe residents from front to back. 6. During an interview on 2/3/26 at 4:55 P.M., CNA J said when peri-care was provided to the residents, staff should wipe the residents from front to back. Staff should not double glove. Soiled linens should be placed in a linen cart or in a trash bag. He/She knew which residents required EBP because they would have a sign and PPE on the door. Staff should wear gown, gloves, and mask when providing close contact care to the residents. 7. During an interview on 2/4/26 at 2:50 P.M., the Administrator said she expected staff to follow the facility's infection control policies and procedures. 2717294

Based on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist (IP) for the facility's infection control and prevention program (IPCP). The census was 83.Review of the facility's Infection Prevention and Control Program policy, revised 11/28/22, showed, the facility will designate one or more individual(s) as the infection preventionist(s) who is responsible for the facility's IPCP. The IP will have completed specialized training in infection prevention and control. During an interview on 1/29/26 at 8:57 A.M., the Administrator said the IP worked part time, and the Assistant Director of Nursing (ADON) was currently in the process of obtaining her specialized training. During an interview on 2/4/26 at 10:55 A.M., the Administrator said the facility currently did not have an IP. The IP they had was no longer responding to the Administrator's calls. The Administrator would expect for the facility to have an IP.

Based on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year. The facility failed to document the length of time the in-services were provided for each individual CNA's training hours. The census was 83.A policy related to CNA 12-hour training was not provided by the facility.Review of the facility's In-Service Training Report sheets, dated from 3/19/25 through 1/5/26 and provided as training records for CNA B, CNA J, CNA K. CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R, showed the heading consisted of facility name, date, subject, time start and end, type of in-service, and instructor. Time start and end lines were all blank. Four columns were labeled for summary of meeting, employee name, position, and employee signature. They were signed by employees with different positions. There were no individual records for each CNA that showed they completed 12 hours of in-services in a year.During an interview on 2/3/26 at 4:10 P.M., the Director of Nurses (DON) said the education did not include the duration of the education, and there should be material showing what was discussed. She expected CNAs to receive 12 hours of required education each year. The duration of the in-service should be documented along with the education material with the sign in sheet.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting of residents who expired, for one of one sampled resident who expired and had money left in their resident trust account (Resident #9). The census was 83.Review of Resident Trust policy dated 2/2022, showed no funds are released until a final audit of the account is completed. Such funds are to be provided within 30 days of the death of the resident. Reference state regulations for further guidelines.Review of Resident #9's resident trust fund account, showed:-Resident expired on [DATE];-A balance of $5,175.22;-A TPL had not be completed and money remained in the resident trust fund account. During an interview on [DATE] at 11:13 A.M., the Business Office Manager (BOM) said she had started her position four days earlier and she was aware that TPL letters were required to be sent to the State of Missouri's Department of Social Services (DSS) within 30 days of a resident's death. The BOM said she was awaiting a check from the corporate office reflecting closure of the resident's patient trust account, which would accompany the TPL letter. During an interview on [DATE] at 10:25 A.M., the Administrator said she expected TPL forms to be sent within 30 days of a resident's death.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction or termination of Medicare Part A services and Notice of Medicare Non-Coverage (NOMNC-form CMS-10123, a notice that indicates when care is set to end from a skilled nursing facility) for three sampled residents upon discharge from Medicare Part A services. Two residents (Residents #3 and #82) remained in the facility. One resident (Resident #95) discharged to the community. The census was 83. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following:-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters;-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; and-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Review of the facility's Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) policy, issued 4/1/22, showed:-Policy: Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Fee (FFS) Medicare and the Medicare Advantage Programs. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers;-Procedure: -If the facility believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitation services based upon not reasonable and necessary, the facility will notify the resident or his/her authorized representative in writing. The notice requirement will be fulfilled using the SNFABN; -The facility will issue the NOMNC when there is a termination of all Medicare Part A services for coverage reasons; -The NOMNC is issued when all covered services end for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay; -The NOMNC and the SNFABN will be issued to the resident no later than two days before the termination of skilled services. 1. Review of Resident #3's medical record, showed:-Medicare Part A skilled services start date of 5/29/25 and end date of 9/5/25;-Remained in the facility;-No NOMNC form issued;-No SNFABN form issued. 2. Review of Resident #82's medical record, showed:-Medicare Part A skilled services start date of 6/6/25 and end date of 9/12/25;-Remained in the facility;-No NOMNC form issued;-No SNFABN form issued. 3. Review of Resident #95's medical record, showed:-Medicare Part A skilled services start date of 6/27/25 and end date of 8/5/25;-discharged to the community;-No NOMNC form issued. During an interview on 2/3/26 at 1:41 P.M., the Administrator said the facility had not issued any SNFABN or NOMNC forms upon discharge from Medicare Part A. She would have expected the notices to be provided upon discharge from Medicare Part A services.

Based on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice for one resident with an enteral tube feeding (TF, delivers liquid nutrition directly into the stomach or small intestine via a tube for patients unable to meet their nutritional needs by mouth). The facility identified one resident as having a tube feeding (Resident #9), and issues were identified. Staff failed to follow the TF flush infusion rate and duration as ordered by the physician. In addition, staff failed to stop or hold the infusion while providing personal care while the resident's head of bed was lowered, increasing the risk of aspiration of the tube feeding formula. The census was 83. Review of the facility's Enteral Tube Feeding policy, dated 1/1/22, showed:-Verify/obtain physician order for enteral feeding;-Be certain that the order for the enteral feeding tube specifies rate, amount, times of administration and any specific orders related to stopping/holding tube feeding;-Verify/obtain orders related to water flushes per shift for additional hydration, auto-flush for additional hydration, flushes prior to and after medication administration;-Standard orders for flushes prior to and after medication administration should be 30-50 milliliters (ml) or as ordered by physician;-Flushes between medications administered are 5 -10 ml or as ordered by physician;-Enteral tube feeding may be accomplished via use of a feeding pump, gravity bag or utilization of syringe/bolus methods as ordered by physician depending on the tolerance to tube feeding and nutritional needs of the resident;-Elevate the head of bed (HOB) 30-45 degrees or per physician orders while tube feeding is infusing, with the exceptions of brief personal/incontinence care, positioning or as indicated by physician orders;-Orders may be received to hold enteral tube feeding for periods during the course of the day for medication administration, therapy involvement or to allow for care and services. Review of Resident #9's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/21/25, showed:-Impairment of both upper and lower extremities;-Diagnoses included non-traumatic spinal cord dysfunction, cerebral palsy (CP, is a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), and malnutrition;-Nutritional approach: Feeding tube. Review of the resident's care plan in use at time of survey showed:-Focus: The resident requires tube feeding related to dysphagia (difficulty swallowing), weight loss;-Goals: The resident will remain free of side effects or complications related to tube feeding. The resident's insertion site will be free of signs and symptoms of infection. The resident will be free of aspiration;-Interventions: Flush gastrostomy tube (g-tube) with water per order. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. Review of the resident's electronic Physician's Order Sheet (ePOS) showed:-An order for enteral feed every day and night shift for nutrition, Glucerna 1.5 (high calorie liquid nutrition) at 60 milliliters per hour (ml/hr) to run 22 hours a day;-An order for enteral feed, every shift, flush tube with 200 ml of water every six hours. Observation on 2/2/26 at 5:27 A.M., showed the resident's TF pump screen showed feeds infusing at 60 ml per hour, with the flush at 160 ml every 0 hours. The Glucerna bottle dated 2/2/26 at 12:45 A.M., while the water flush bag was marked, 2/ . The liquid in the water flush bag was full to 1000 ml level. During an interview and observation on 2/2/26 at 5:35 A.M., Licensed Practical Nurse (LPN) A said the flush should not be on zero. He/She flushed the tube when the TF and water were hung at 12:45 A.M. He/She did not complete the date on the water flush bag because it was wet when he/she tried to mark the date. If the pump screen showed every 0 hours, it means the pump was not flushing. He/She then adjusted the pump for the flush duration time to every 4 hours. Observation on 2/2/26 at 6:13 A.M., showed the resident lay flat in bed with his/her TF infusing at 60 ml/hr. Certified Nurse Aide (CNA) C provided personal care. The staff turned the resident from side to side. After CNA C finished care, he/she raised the head of the bed up. The TF infusion was not held or stopped while care was provided. Observation on 2/2/26 at 1:21 P.M., showed the resident's TF pump screen read feeds continued infusing at 60 ml/hr with flush set to 160 ml every 4 hours. Observation on 2/3/26 at 12:16 P.M., showed the resident's TF pump read feeds infusing at 60 ml/hr, with flush at 160 ml/hr, every 0 hours. Observation and interview on 2/3/26 at 4:37 P.M., showed the resident's TF pump still showed feeds infusing at 60 ml/hr, with flush at 160 ml/hr, every 0 hours. The Glucerna bottle dated 2/3/26 at 12:00 A.M. The flush documented as started at 12:00 A.M with 900 ml. Observation showed the water was at approximately at 700 ml. LPN F said he/she was not sure why the flush was set to every 0 hours. He/She was not assigned to the resident. He/She then left the room to ask the nurse assigned to the resident. Upon return, LPN F said LPN E told him/her the flush order was at 200 ml/hr every 6 hours. LPN F then adjusted the pump per order. During an interview on 2/3/26 at 4:43 P.M., LPN E said he/she had just checked the resident's order. He/She unclogged the tube earlier that day. He/She did not see the TF infusion rate and duration in the pump because it was beeping with clogged error on the screen. He/She unclogged the tube and restarted the infusion without paying attention to the infusion rate on the screen. During an interview on 2/3/26 at 5:32 P.M., the Director of Nursing (DON) said she expected staff to follow the physician's orders, including TF infusion rates and duration. The nurse assigned to the residents was responsible for checking orders and the TF pump. The management personnel: DON, Assistant DON (ADON), Minimum Data Set (MDS) Coordinator, wound nurse, and therapy, conduct daily morning meetings, and they review the 24-hour nursing report, including new orders. On 2/4/26 at 9:49 A.M., the DON said she expected the staff to hold or stop the TF infusion when lying flat and providing care or repositioning. The CNAs should not touch the TF pump and should notify the nurses prior to providing residents' care who receive TF.

Based on observation, interview and record review, the facility failed to ensure double portions and a divided plate and sack lunch were provided for one resident (Resident #74) per the physician's and Registered Dietician's (RD) orders. The facility failed to ensure the RD assessed residents upon admission, quarterly, annually, and as needed for three sampled residents (Resident #74, #19, and #5). In addition, the facility failed to notify the physician or RD of fluctuations in resident's weights for two residents (Residents #19 and #5). The sample size was 22. The census was 83.Review of the facility's undated Nutritional Assessment and Diet History Policy, showed:-A nutritional assessment and diet history will be completed for each resident according to State and Federal requirements. The assessment/history form should be initiated within 72 hours; however, it is desirable to visit each new resident within the first 24 hours of admission and diet history should be completed by the Dietary Manager within seven days of admission;-The nutritional assessment will include appropriate clinical data as required. Pertinent lab data, diagnoses, food-drug interactions, hydration status and ideal body weight range, weight loss or gain percentages, if applicable. Review of the facility's undated Nutritional Reassessments policy, showed:-Policy: Reassessments shall be performed when there is a significant change in the nutritional status of a resident. All residents will be reassessed on a yearly basis using the admission date as a guide;-Procedure: The RD will reassess the high-risk residents and those identified with special needs by the Dietary Manager on the Dietician's progress notes form. Review of the facility's Weights and Weight Loss policy, dated 4/1/22, showed:-Policy: It will be the practice of this facility to implement the following systems regarding weight documentation;-New admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician;-The RD is to review all admission weights for possible interventions;-Significant weight loss shall be addressed by the physician and/or RD through discussions with the resident and/or resident representative for known preferences and desires and development and implementation of interventions to attempt to address the weight loss;-Monthly weights will be completed by the nursing department, unless otherwise indicated or ordered;-Weekly and daily weights may be obtained per RD or physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention. 1. Review of Resident #74's Nutrition Assessment, dated 4/11/24, showed:-Regular diet, no oranges, bananas, beans, potatoes or tomatoes. Double eggs at breakfast and double meat with lunch and dinner;-Divided dish;-Weight on 4/10/24 measured 207 pounds. Review of the resident's medical record showed no additional Nutrition Assessments after 4/11/24. Review of the resident's care plan, revised 12/26/24, in use during the time of the investigation, showed:-Focus: The resident has nutritional problems or potential nutritional problems. He/She is on a regular diet;--The resident will maintain adequate nutritional status as evidence by maintaining weight, no signs and symptoms of malnutrition through review date;--Interventions: Monitor/record/report to medical doctor as needed for signs of malnutrition, muscle wasting and significant weight loss. Provide and serve diet as ordered;-Focus: The resident needs dialysis (process of filtering the blood for individuals with kidney failure) related to renal (kidney) failure;-Goal: The resident will have minimized risk of complications related to dialysis through the review date;-Interventions: Provide sack lunch and/or snacks for the resident to take to dialysis on dialysis days. Review of the resident's undated current active orders showed an order dated 7/23/25: Provide sack lunch and/or snack for patient to take to dialysis on dialysis days. Review of the resident's monthly weights for August, September, October and November 2025, showed a weight of 187.2 pounds. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/25, showed:-Cognitively intact;-Exhibited no behaviors;-Required set up or assistance with eating;-Diagnoses included renal disease and diabetes;-Weight of 185 pounds;-No weight loss or gain in six months. Review of the resident's weight report, showed:-On 12/9/25, a weight of 187 pounds;-On 1/7/26, a weight of 187 pounds. During an interview on 1/29/26 at approximately 9:45 A.M., the resident said he/she had been at the facility for about four years. He/She attended dialysis and was supposed to be provided with a sack lunch to take. He/She never received a sack lunch. The resident was also supposed to get double portions and never did. He/She weighed over 200 pounds when he/she was first admitted to the facility. There were times when he/she returned from dialysis, and there was no food available for him/her. Observation on 1/29/26 at 11:49 A.M., showed the resident ate lunch in the dining room. His/Her meal consisted of one serving of turkey, one serving of stuffing and a scoop of mixed vegetables. The meal was on a regular plate. The resident used a spoon and attempted to cut the turkey. Observation and interview on 1/30/26 at 9:31 A.M., showed the resident at the front lobby waiting on transportation to dialysis. The resident had no sack lunch. The resident said he/she was not offered a sack lunch or snack to take to dialysis. During an interview on 2/2/26 at 9:04 A.M., the resident said he/she ate breakfast and did not receive double portions. He/She never received double portions and wanted them. He/She was weighed at dialysis and was 187 pounds. The only time he/she was weighed was when he/she went to dialysis. The facility had not provided snacks or a sack lunch. His/Her family members brought bread, lunch meat, milk and cereal so the resident would have food upon his/her return from dialysis. The resident also said he/she had not seen a dietician in about two years. Observation on 2/2/26 at 10:10 A.M., showed the resident at the front lobby about to attend dialysis. The resident did not have a sack lunch, or snacks provided by the facility. Observation on 2/3/26 at 12:17 P.M., showed the resident received a lunch tray. The meal consisted of one serving of lasagna, one serving of coleslaw, one piece of bread and juice. The food served on a regular plate. No double portions or divided plate was provided. The resident said he/she wanted double portions. Observation on 2/3/26 at 3:41 P.M., showed the resident weighed by Certified Nursing Assistants (CNAs) I and CNA J. The resident weighed 185.4 pounds. CNA I said the resident was regularly weighed at the dialysis center. During an interview on 2/4/26 at 9:14 A.M., the Dietary Manager said she observed meal services and double portions had not been served to residents. Residents receiving dialysis were not provided with sack lunches. Residents were expected to receive double portions and sack lunches, as ordered. The Dietary Manager said she now had a list of residents who were to receive double portions and sack lunches and would ensure they received them going forward. 2. Review of Resident #19's admission MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included anemia (low red blood cell count), ulcerative colitis (inflammation and sores in the colon and rectum)/ Crohn's disease (chronic inflammatory bowel disease). Review of the care plan in use at the time of survey showed:-Focus: Resident on a regular diet;-Goal: Will comply with recommended diet through review date;-Interventions included RD to evaluate and make diet changes recommendations as needed. During an interview on 2/3/26 at 12:15 P.M., the resident said the food was terrible. He/She barely ate the food provided by the facility. He/She mostly ate his/her own food and snacks. Review of the resident's weight log showed:-On 11/18/25 weight measured 378 pounds;-On 12/9/25 weight measured 362 pounds;.-On 1/7/26 weight measured 356 pounds. Observation on 2/3/26 at 3:56 P.M., showed staff weighed the resident using the mechanical lift. The resident's weight measured 341pounds. Review of the resident's medical record showed there was no dietary evaluation completed and there was no progress note showing the DM/RD was made aware of the weight fluctuations. 3. Review of Resident #5's admission MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included anxiety, depression and post-traumatic stress disorder (PTSD). Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident has diabetes;-Goal: Will have no complications related to diabetes through review date;-Interventions included dietary consultation for nutritional regimen and ongoing monitoring. Review of the resident's medical record, showed:-An admission dietary profile dated 11/10/25 showed on 10/30/25 weight measured 331.5 pounds;-A weight log, showed on 1/7/26 the resident measured 340 pounds. No other weights documented on the weight log; -No RD note or documentation showing the DM/RD was aware of the resident's weight fluctuations. Observation on 2/3/26 at 3:56 P.M., showed staff weighed the resident using the mechanical lift scale. The resident was moving while being weighed. The resident's weight measured 325 pounds. 4. During an interview on 2/3/26 at 4:10 P.M., the Director of Nursing (DON) said residents should have a dietary assessment on admission, quarterly and when there is a significant change. The facility did not have dietary notes for the residents. 5. During an interview on 2/3/26 at 5:10 P.M., the Administrator said there were no dietary notes/assessments in the medical records since 2024. The RD started in December 2025. There was a dietary technician who visited with the residents and documented on behalf of the RD. If there were any dietary or nutritional concerns, staff were to notify the RD or Dietary Technician. Dietary notes should be documented regularly. Dietary assessments were to be completed upon admission, quarterly, annually and if there was a significant change. If a resident had an order to receive double portions and a sack lunch, the resident should have received it.

Based on interview and record review, the facility failed to follow physician orders for one resident when staff documented a resident's weight loss medication as unavailable when the medication was available and did not administer the medication as ordered (Resident #19). The census was 83.Review of the facility's Charting and Documentation policy, dated 4/1/22, showed:-It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed;-Observations, medications administered, services performed, etc., should be documented in the resident's clinical records;-Entries into the clinical record should be made by the appropriate staff members;-If it is necessary to change or add information in the resident's medical record, it shall be completed by means of an addendum, appropriate striking technique and signed and dated by the person making such change or addition. Review of Resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/23/25, showed:-Cognitively intact;-Diagnoses included anemia (low red blood cell count), anxiety and depression. Review of the care plan in use at the time of survey showed:-Focus: Regular diet;-Goal: Will comply with recommended diet through review date;-Interventions included administer medications as ordered. Monitor/document for side effects and effectivities; assist the resident with developing a support system to aid in weight loss efforts, including friends, family, other residents, volunteers, etc. During an interview on 1/29/26 at 10:52 A.M., the resident said he/she has not been receiving his/her Zepbound injections (medication used for weight loss). He/She has only received two injections. Review of the physician order sheet, in use at the time of survey, showed a physician order for Zepbound subcutaneous solution 2.5 milligram (mg)/0.5 milliliters (mL), inject 2.5 mg subcutaneously (under the skin) one time a week on Thursday for weight management. Start date 12/04/25. Review of the resident's Medication Administration Record (MAR) for the month of December 2025, showed a physician order for Zepbound inject 2.5 mg subcutaneously one time a week on Thursday for weight management. Two out of four opportunities staff documented other, see nurse's notes, and one out of four opportunities was blank. Review of the resident's progress notes, dated 12/1/25 through 12/31/25, showed on 12/4/25 at 10:21 A.M., medication unavailable, reordered 12/3/25 and on 12/18/25 at 11:00 A.M. medication unavailable, reordered 12/18/25. There was no other documentation. Review of the resident's MAR dated 1/1/26 through 1/31/25, showed a physician order for Zepbound inject 2.5 mg subcutaneously one time a week on Thursday for weight management; Documentation showed two out of five opportunities staff documented other, see nurse's notes. Review of the resident's progress notes dated 1/1/26 through 1/31/26, showed on 1/1/26 at 4:55 P.M., medication unavailable and on 1/22/26 at 7:06 P.M. medication unavailable. During an interview on 2/3/26 at 12:03 P.M., the pharmacist said the resident's Zepbound was filled on 12/4/25 and 12/28/25. Each box had four pens. During an interview on 2/3/26 at 5:50 P.M., Nurse S checked the refrigerator in the medication room and said the resident had six Zepbound 2.5 mg pens in the refrigerator. During an interview on 2/4/26 at 2:50 P.M., the Director of Nursing (DON) said she expected staff to accurately document medications and treatments in the residents' clinical record, as ordered.

Based on interview and record review, the facility failed to develop and implement comprehensive policies and procedures to prevent potential sexual abuse for two residents who were identified by staff as being in a sexual relationship (Residents #86 and #80). The census was 83.Review of the facility's Abuse, Neglect and Exploitation policy, revised on 3/3/22, showed:-Policy: It is 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;-Definition of sexual abuse: non-consensual sexual contact of any type with a resident;-Policy Explanation and Compliance Guidelines;-The facility will develop and implement written policies and procedures that:--Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;--Establish policies and procedures to investigate any such allegations; --Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; --Establish coordination with the QAPI (Quality Assurance and Performance Improvement) program; --The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law;--The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written;-The policy did not include establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as to identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. Review of Resident #86's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/7/25, showed:-Cognitively intact;-No behaviors exhibited;-Diagnoses included high blood pressure, diabetes, unspecified injury of head, and generalized muscle weakness. Review of the resident's Social Services Sexuality Assessment, dated 7/11/24, showed:-Cognitively able to complete the assessment;-No history of sexually inappropriate behavior;-No cultural, spiritual or religious beliefs that influence his/her views, beliefs or attitudes of sexuality;-Never been hurt in a sexual way or forced to have sex when he/she didn't want to;-Never been tested for STIs (sexually transmitted infections) or human immunodeficiency virus (HIV, a virus that attacks the body's immune system);-Does not want to be tested for STIs. Review of Resident #80's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No behaviors exhibited;-Diagnoses included high blood pressure, stroke, non-Alzheimer's dementia, depression, and generalized muscle weakness. Review of the resident's Social Services Sexuality Assessment, dated 8/7/24, showed:-Cognitively able to complete the assessment;-Did not wish to participate in the assessment. During an interview on 2/3/26 at 5:32 P.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said Residents #86 and #80 were a couple and were sexually active. They allowed the residents to have privacy in a room when they became intimate. During an interview on 2/4/26 at approximately 11:00 A.M., the DON said she was notified by staff that a Certified Nurse Assistant (CNA) stood by the closed door when the residents had sexual activity to make sure no other residents or staff entered the room. She was not sure if the facility had policies, residents' consents, or any type of documents regarding the residents' consensual sexual activities. During an interview on 2/4/26 at 1:40 P.M. and 2:50 P.M., the Administrator said the facility did not have policies or protocols in place for sexually active residents. This was needed to ensure all residents had the capacity to consent. The facility should have policies and procedures in place that include protocol for sexually active residents to determine capacity to consent to sexual contact with other residents.

Based on observation, interview and record review, the facility failed to make accessible for examination, the results of the most recent survey, certifications and complaint investigations of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility available to residents, visitors and resident representatives. The sample size was 22. The census was 83.Review of the facility's Resident Rights policy, showed the policy did not address residents' rights to examine the results of the most recent federal or state survey and any plan of correction in effect for the facility.Observation on 1/29/26 through 2/4/26, showed the facility did not post the results of the most recent survey, certifications and complaint investigations made respecting the facility in a place readily accessible to residents, and family members and legal representatives of residents. During a group interview on 1/30/26 at 10:30 A.M., eight residents, who the facility identified as alert and oriented, attended the group meeting. All residents said they were not sure where they would look to review the survey results from the prior annual survey and complaints investigated. During an interview on 2/4/26 at 2:07 P.M., front desk staff H said the survey binder was typically kept on a shelf behind the receptionist desk and provided upon request, but currently was being kept in the administrator's office. He/She and was unaware of the reason.During an interview on 2/4/26 at 2:10 P.M., the Administrator said she would expect the statement of deficiencies and plans of correction from the prior survey, to include any complaints investigated, to be available to the residents and the public.

Based on observation, interview and record review, the facility failed to promote and facilitate self-determination for one resident (Resident #6) who was dependent on staff for bathing/showering by failing to ensure the resident received showers or bed baths, in accordance with the resident's preferences. The sample size was 22. The census was 83. Review of the facility's Resident Rights, Dignity and Visitation Rights policy, issued 4/1/22, showed:-Policy: It will be the policy of this facility that employees shall treat residents with kindness, respect and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers in the exercise of these rights. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability;-Procedure: -Residents are entitled to exercise their rights and privileges to the fullest extent possible; --The facility will make effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity; providing care that is comfortable and consistent with his/her normal life habits, observing resident's choices whenever able. Review of the Resident #6's care plan, revised 1/7/25, in use during the time of the investigation, showed:-Focus: The resident prefers to have a bed bath daily;-Goal: The resident prefers to have a bed bath through review date;-Interventions: The resident prefers to have a bed bath but no preference on the time of day. Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review, showed:-November 2025: Shower or bed bath completed 11/1/25, 11/12/25, 11/22/25 and 11/28/25;-December 2025: Shower or bed bath completed 12/6/25, 12/13/25, 12/24/25 and 12/31/25. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/25, showed:-Cognitively intact;-No rejection of care;-Very important in choosing between a shower, tub bath, bed bath and sponge bath;-Required substantial/maximal assistant with shower/bathing;-Diagnoses included renal failure, neurogenic bladder (loss of bladder control caused by a nerve damage from a medical condition or injury that affects the brain, spinal cord or nerves) and paraplegia. Review of the resident's Shower Sheet/Skin Condition Report for January 2026, showed shower or bed bath completed on 1/17/26 and 1/23/26. Observation on 1/29/26 at 9:26 A.M., showed the resident's water in his/her room ran for approximately three minutes. The water never got warm and was cool to the touch. During an interview on 1/29/26 at 9:27 A.M., the resident lay in bed in his/her room. He/She said the water in his/her room had not worked in several months. The shower rooms on the unit he/she resides on does not have hot water. As a result, he/she was not offered bed baths or showers. He/she could not recall the last time he/she had a shower and preferred a shower or bed bath daily. During an interview on 2/2/26 at 10:12 A.M., the resident said this past Saturday, his/her aide offered him/her a shower. The resident informed the aide the hot water was not working on his/her unit, and asked if the aide could take him/her to another unit. The aide said he/she did not have time to go to another unit and offered a bed bath instead. The resident agreed to the bed bath and asked the aide to obtain hot water from a different unit. The aide said it was too much and documented the resident refused a shower. When asked if the resident reported this to the nurse, he/she said No. Nothing would be done about it. The resident said he/she was upset that he/she did not receive a shower or bed bath. During an interview on 2/3/26 at 11:09 A.M., CNA G said the resident has not been showered on a regular basis due to the water on the unit being cold. When CNA G worked, he/she offered to take residents to a different unit for a shower. The resident preferred a shower or bed bath daily, but his/her preferences had not been met. Other residents were to receive showers or bed baths twice per week. Due to the cold water on the unit, the residents on the unit were not receiving at least two showers or bed baths per week. During an interview on 2/3/26 at 5:20 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said showers or bed baths were to be offered at least twice per week. If a resident preferred to have a shower or bed bath daily, the resident's preferences should have been honored. Some residents may not have received a shower or bed bath twice weekly due to water temperatures not being adequate. If a resident wanted a shower, staff could take the resident to a different unit. If the resident preferred a bed bath, staff could have obtained hot water from another unit. There was no excuse for the resident to have not received a shower. During an interview on 2/4/26 at 2:50 P.M., the Administrator, DON and MDS coordinator said resident choices should be honored. If a resident preferred a shower or bath daily, his/her preferences should have been honored.

See the deficiency cited at Event ID F7TJ13. Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 2/16/23. The facility conducted an investigation and immediately in-serviced staff on 2/17/23 regarding elopements and residents at risk for wandering. The facility instituted corrective measures on 2/17/23 including moving the resident Leave of Absence (LOA) book to the nurse's station, requiring residents and resident families to confirm an upcoming LOA with the floor charge nurse, and initiating mandatory communication between floor charge nurses and facility reception to coordinate resident LOAs. The IJ was corrected on 2/17/23. Review of the facility's Elopements and Wandering Residents policy, revised on 6/2/22, showed: -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team; -Adequate supervision will be provided to help prevent accidents or elopements; -Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code); -The designated facility staff will look for the resident. 1. Review of the Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/23, showed: -Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, indicating severely impaired cognitive function and decision-making capacity; -Medical Diagnoses included anoxic (lack of oxygen to the organs causing permanent damage) brain damage, mixed receptive-expressive language disorder, encephalopathy (disease of the brain that alters brain function or structure), and cardiac arrest; -Use of wheelchair; -Limited one-person assistance with transfers. Review of the resident's Face Sheet showed the resident was listed at the facility as his/her own responsible party. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident has a communication problem related to unclear speech and impaired cognition. History of tracheostomy. He/She is able to make some basic needs and wants known and is able to understand most basic communication; -Goal: Resident will be able to make basic needs known on a daily basis through the review date; -Interventions: Ensure/provide a safe environment for the resident, monitor and report any changes in ability to communicate, potential factors for communicating problems, and potential for improvement; -Problem: Resident has impaired cognitive function related to anoxic brain damage. Confusion and forgetfulness noted; -Goal: Resident will maintain current level of cognitive function through review date; -Interventions: Cue, reorient and supervise as needed, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the resident's most recent Elopement Risk Evaluation, conducted on 6/28/21, showed the resident scored a seven, indicating he/she was at low risk for elopement. Review of the resident's progress notes showed: -A note from 2/17/23 at 7:00 A.M., stating the resident was found not to be in the facility at that time; -A note from 2/17/23 at 1:38 P.M., stating the resident had been found at home and his/her family member would be discharging him/her from the facility. Review of the National Weather Service (NWS) climate data records for the St. Louis metropolitan area on 2/16/23 showed a high of 41 degrees Fahrenheit (F) and a low of 31 degrees F, with trace amounts of snowfall between 9:00 P.M. and midnight. During an interview on 2/17/23 at 5:20 P.M., Hospital Staff B said the resident arrived to the hospital on 2/17/23 at 2:29 P.M. The resident was alert to self and had a body temperature of 85 degrees F upon arrival (normal 97.7-99.5 F). Review of Emergency Department Medical Records from SSM Health St. Louis University Hospital showed: -Medical diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hypertension, and hypothermia; -The resident was admitted to the Emergency Department on 2/17/23 at 2:26 P.M. after being found by police outside his/her old address in the cold. The resident reported to EMS (emergency medical services) that he/she had walked to this address from Oakwood Estates Health and Rehabilitation; -Resident's core body temperature upon arrival was 84 degrees Fahrenheit, obtained by rectal thermometer, as an oral thermometer showed a temperature too low to read accurately; -Physical range of motion assessments could not be conducted as the resident was slow to respond and placed in the fetal position to promote increasing core body temperature; -The resident presented with a heart rate of 59 beats per minute, indicating hypothermia-induced bradycardia (a decrease in baseline heartrate caused by low core body temperature). During an interview on 3/30/23 at 12:51 P.M., Family Member A said the resident had been at the facility for almost two years prior to the incident, and each time he/she signed out the resident, he/she notified the facility 24 hours or greater in advance of the upcoming LOA. On 2/17/23 around 9:00 A.M., he/she was contacted by facility staff who asked how the resident was doing, unaware the resident was not LOA with family. When Family Member A said the resident was not with family, facility staff said the resident had left in the afternoon on 2/16/23 with family in a black pickup truck. Family Member A again told staff the resident was not with family, and the facility staff hung up. Family Member A arrived at the facility between 9:30 A.M. and 10:00 A.M. on 2/17/23 and staff said the resident had left the facility with another resident's family on 2/16/23 around 3:30 P.M. and was last seen crossing the street. Family Member A gave a family member's address to the police, assuming the resident would remember his/her childhood address and go there. Law enforcement found the resident at this address, sitting in his/her wheelchair, approximately six miles away from the facility. The weather was cold that night, possibly below 30 degrees, and the resident was found in a sweatshirt and pants with no jacket on. The resident's family arrived to pick the resident up and found him/her soiled, breathing heavily, and hypothermic. The resident was taken to the hospital immediately, treated for hypothermia, and released later that evening. During an interview on 3/23/23 at 12:11 P.M., Receptionist C said on 2/16/23, he/she saw the resident in the facility front lobby area between 3:30 P.M. and 4:00 P.M., dressed as if he/she was leaving the facility. The resident was wearing a blue sweater, khakis, and penny loafers. At that time, a family visiting another resident at the facility was exiting the facility, and Resident #15 exited with them towards a black pickup truck in the parking lot. He/she thought it was the resident's family at that time. Receptionist C informed the unit manager the resident had left on LOA with family, to which the unit manager responded the resident was his/her own responsible party and did not sign out for LOA. Receptionist C's shift ended, and he/she was unsure if the facility began looking for the resident that evening. The following morning, 2/17/23, Receptionist C arrived at work and was told the resident was missing and facility administration had begun searching for the resident. During an interview on 3/23/23 at 11:58 A.M., Certified Nursing Assistant (CNA) D said he/she saw the resident at the facility on 2/16/23 at breakfast in the dining room, where the resident frequently ate his/her meals. CNA D did not see the resident that afternoon, and was told the resident was LOA with family for the evening. The following morning, CNA D arrived to the facility and was told by the unit manager the resident had eloped from the facility. CNA D was familiar with the resident. The resident's cognition was fair, but most days the resident needed cueing or prompting for orientation. During an interview on 3/23/23 at 12:41 P.M. Nurse A said he/she was told by offgoing nurse during handoff that on 2/16/23 between 3:00 and 4:00 P.M. the resident exited the building with a family visiting another resident, and facility staff were under the impression the resident had left LOA with his/her family. The resident's family member was known to sign him/her out, but the resident's family member had not been seen at the facility or notified staff of the resident's LOA on that day. The following day, 2/17/23, Nurse A arrived at the facility and was told by staff the resident had not returned to the facility the previous evening. Nurse A checked the resident's room, but was unable to find him/her. Nurse A then began to ask nursing staff if they had seen the resident, and staff responded they were under the impression the resident was LOA with family. Nurse A reviewed the resident's medical record and noted no notes in the resident's record that would indicate he/she had gone LOA with family on the evening of 2/16/23. Nurse A called the resident's family member to inform him/her the resident was missing and then checked the resident sign-out book kept at the facility's front lobby area. The resident's signature was not in the sign-out book, and administration contacted law enforcement to begin searching for the missing resident. During an interview on 3/23/23 at 2:07 P.M., Certified Medication Technician (CMT) B said the evening shift staff on 2/16/23 were informed by the offgoing day shift staff the resident was LOA with family for the evening, and would not be at the facility. CMT B did not pass medications to the resident that evening as the resident was not in the facility. During an interview on 3/23/23 at 12:39 P.M., the Director of Nurses (DON), who started in this role on 2/27/23, said prior to the new process being implemented the system seemed essentially honor-based, meaning residents were expected to sign out at the log book near the front desk, but staff were not checking the log book each time a resident left the facility for a LOA. The DON said she would expect staff to document LOAs in a resident's record, and if staff are unsure if a resident was currently LOA from the facility, they should check the sign-out book at the nurse's station and the medical record to confirm. During an interview on 3/23/23 at 12:21 P.M., the Administrator said on 2/16/23, the resident left from the facility with another resident's family, reportedly in a black pickup truck. Facility staff thought it was the resident's family at that time. Facility staff were under the impression the resident was LOA with their family and not returning for the evening. The following morning it was discovered the resident had not signed out with family and had eloped from the facility. The Administrator contacted law enforcement and the resident's family to notify them of the incident. Prior to the implementation of the new LOA process residents were simply expected to sign out at the LOA book near the front desk with no communication expectations in regards to staff notification of leave. The Administrator would expect staff who were questioning the validity of a resident's LOA status to first check the sign-out book and the resident's medical record to verify. MO00214224 MO00214218

Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 2/16/23. The facility conducted an investigation and immediately in-serviced staff on 2/17/23 regarding elopements and residents at risk for wandering. The facility instituted corrective measures on 2/17/23 including moving the resident Leave of Absence (LOA) book to the nurse's station, requiring residents and resident families to confirm an upcoming LOA with the floor charge nurse, and initiating mandatory communication between floor charge nurses and facility reception to coordinate resident LOAs. The IJ was corrected on 2/17/23. Review of the facility's Elopements and Wandering Residents policy, revised on 6/2/22, showed: -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team; -Adequate supervision will be provided to help prevent accidents or elopements; -Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code); -The designated facility staff will look for the resident. 1. Review of the Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/23, showed: -Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, indicating severely impaired cognitive function and decision-making capacity; -Medical Diagnoses included anoxic (lack of oxygen to the organs causing permanent damage) brain damage, mixed receptive-expressive language disorder, encephalopathy (disease of the brain that alters brain function or structure), and cardiac arrest; -Use of wheelchair; -Limited one-person assistance with transfers. Review of the resident's Face Sheet showed the resident was listed at the facility as his/her own responsible party. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident has a communication problem related to unclear speech and impaired cognition. History of tracheostomy. He/She is able to make some basic needs and wants known and is able to understand most basic communication; -Goal: Resident will be able to make basic needs known on a daily basis through the review date; -Interventions: Ensure/provide a safe environment for the resident, monitor and report any changes in ability to communicate, potential factors for communicating problems, and potential for improvement; -Problem: Resident has impaired cognitive function related to anoxic brain damage. Confusion and forgetfulness noted; -Goal: Resident will maintain current level of cognitive function through review date; -Interventions: Cue, reorient and supervise as needed, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the resident's most recent Elopement Risk Evaluation, conducted on 6/28/21, showed the resident scored a seven, indicating he/she was at low risk for elopement. Review of the resident's progress notes showed: -A note from 2/17/23 at 7:00 A.M., stating the resident was found not to be in the facility at that time; -A note from 2/17/23 at 1:38 P.M., stating the resident had been found at home and his/her family member would be discharging him/her from the facility. Review of the National Weather Service (NWS) climate data records for the St. Louis metropolitan area on 2/16/23 showed a high of 41 degrees Fahrenheit (F) and a low of 31 degrees F, with trace amounts of snowfall between 9:00 P.M. and midnight. During an interview on 2/17/23 at 5:20 P.M., Hospital Staff B said the resident arrived to the hospital on 2/17/23 at 2:29 P.M. The resident was alert to self and had a body temperature of 85 degrees F upon arrival (normal 97.7-99.5 F). Review of Emergency Department Medical Records from SSM Health St. Louis University Hospital showed: -Medical diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hypertension, and hypothermia; -The resident was admitted to the Emergency Department on 2/17/23 at 2:26 P.M. after being found by police outside his/her old address in the cold. The resident reported to EMS (emergency medical services) that he/she had walked to this address from Oakwood Estates Health and Rehabilitation; -Resident's core body temperature upon arrival was 84 degrees Fahrenheit, obtained by rectal thermometer, as an oral thermometer showed a temperature too low to read accurately; -Physical range of motion assessments could not be conducted as the resident was slow to respond and placed in the fetal position to promote increasing core body temperature; -The resident presented with a heart rate of 59 beats per minute, indicating hypothermia-induced bradycardia (a decrease in baseline heartrate caused by low core body temperature). During an interview on 3/30/23 at 12:51 P.M., Family Member A said the resident had been at the facility for almost two years prior to the incident, and each time he/she signed out the resident, he/she notified the facility 24 hours or greater in advance of the upcoming LOA. On 2/17/23 around 9:00 A.M., he/she was contacted by facility staff who asked how the resident was doing, unaware the resident was not LOA with family. When Family Member A said the resident was not with family, facility staff said the resident had left in the afternoon on 2/16/23 with family in a black pickup truck. Family Member A again told staff the resident was not with family, and the facility staff hung up. Family Member A arrived at the facility between 9:30 A.M. and 10:00 A.M. on 2/17/23 and staff said the resident had left the facility with another resident's family on 2/16/23 around 3:30 P.M. and was last seen crossing the street. Family Member A gave a family member's address to the police, assuming the resident would remember his/her childhood address and go there. Law enforcement found the resident at this address, sitting in his/her wheelchair, approximately six miles away from the facility. The weather was cold that night, possibly below 30 degrees, and the resident was found in a sweatshirt and pants with no jacket on. The resident's family arrived to pick the resident up and found him/her soiled, breathing heavily, and hypothermic. The resident was taken to the hospital immediately, treated for hypothermia, and released later that evening. During an interview on 3/23/23 at 12:11 P.M., Receptionist C said on 2/16/23, he/she saw the resident in the facility front lobby area between 3:30 P.M. and 4:00 P.M., dressed as if he/she was leaving the facility. The resident was wearing a blue sweater, khakis, and penny loafers. At that time, a family visiting another resident at the facility was exiting the facility, and Resident #15 exited with them towards a black pickup truck in the parking lot. He/she thought it was the resident's family at that time. Receptionist C informed the unit manager the resident had left on LOA with family, to which the unit manager responded the resident was his/her own responsible party and did not sign out for LOA. Receptionist C's shift ended, and he/she was unsure if the facility began looking for the resident that evening. The following morning, 2/17/23, Receptionist C arrived at work and was told the resident was missing and facility administration had begun searching for the resident. During an interview on 3/23/23 at 11:58 A.M., Certified Nursing Assistant (CNA) D said he/she saw the resident at the facility on 2/16/23 at breakfast in the dining room, where the resident frequently ate his/her meals. CNA D did not see the resident that afternoon, and was told the resident was LOA with family for the evening. The following morning, CNA D arrived to the facility and was told by the unit manager the resident had eloped from the facility. CNA D was familiar with the resident. The resident's cognition was fair, but most days the resident needed cueing or prompting for orientation. During an interview on 3/23/23 at 12:41 P.M. Nurse A said he/she was told by offgoing nurse during handoff that on 2/16/23 between 3:00 and 4:00 P.M. the resident exited the building with a family visiting another resident, and facility staff were under the impression the resident had left LOA with his/her family. The resident's family member was known to sign him/her out, but the resident's family member had not been seen at the facility or notified staff of the resident's LOA on that day. The following day, 2/17/23, Nurse A arrived at the facility and was told by staff the resident had not returned to the facility the previous evening. Nurse A checked the resident's room, but was unable to find him/her. Nurse A then began to ask nursing staff if they had seen the resident, and staff responded they were under the impression the resident was LOA with family. Nurse A reviewed the resident's medical record and noted no notes in the resident's record that would indicate he/she had gone LOA with family on the evening of 2/16/23. Nurse A called the resident's family member to inform him/her the resident was missing and then checked the resident sign-out book kept at the facility's front lobby area. The resident's signature was not in the sign-out book, and administration contacted law enforcement to begin searching for the missing resident. During an interview on 3/23/23 at 2:07 P.M., Certified Medication Technician (CMT) B said the evening shift staff on 2/16/23 were informed by the offgoing day shift staff the resident was LOA with family for the evening, and would not be at the facility. CMT B did not pass medications to the resident that evening as the resident was not in the facility. During an interview on 3/23/23 at 12:39 P.M., the Director of Nurses (DON), who started in this role on 2/27/23, said prior to the new process being implemented the system seemed essentially honor-based, meaning residents were expected to sign out at the log book near the front desk, but staff were not checking the log book each time a resident left the facility for a LOA. The DON said she would expect staff to document LOAs in a resident's record, and if staff are unsure if a resident was currently LOA from the facility, they should check the sign-out book at the nurse's station and the medical record to confirm. During an interview on 3/23/23 at 12:21 P.M., the Administrator said on 2/16/23, the resident left from the facility with another resident's family, reportedly in a black pickup truck. Facility staff thought it was the resident's family at that time. Facility staff were under the impression the resident was LOA with their family and not returning for the evening. The following morning it was discovered the resident had not signed out with family and had eloped from the facility. The Administrator contacted law enforcement and the resident's family to notify them of the incident. Prior to the implementation of the new LOA process residents were simply expected to sign out at the LOA book near the front desk with no communication expectations in regards to staff notification of leave. The Administrator would expect staff who were questioning the validity of a resident's LOA status to first check the sign-out book and the resident's medical record to verify. MO00214224 MO00214218

Based on interview and record review, the facility failed to ensure each resident received adequate oversight to prevent an elopement or unaccompanied exit from the facility when one of 15 sampled residents left the building unaccompanied during a winter evening. The facility failed to provide necessary protective oversight when no member of the facility staff verified if the resident had been signed out for a leave of absence. The resident was missing for over 21 hours and was found outside approximately six miles away from the facility. The resident was evaluated at the hospital and diagnosed with hypothermia (Resident #15). The facility census was 92. The administrator was notified on 3/23/23 at 11:37 A.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 2/16/23. The facility conducted an investigation and immediately in-serviced staff on 2/17/23 regarding elopements and residents at risk for wandering. The facility instituted corrective measures on 2/17/23 including moving the resident Leave of Absence (LOA) book to the nurse's station, requiring residents and resident families to confirm an upcoming LOA with the floor charge nurse, and initiating mandatory communication between floor charge nurses and facility reception to coordinate resident LOAs. The IJ was corrected on 2/17/23. Review of the facility's Elopements and Wandering Residents policy, revised on 6/2/22, showed: -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team; -Adequate supervision will be provided to help prevent accidents or elopements; -Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code); -The designated facility staff will look for the resident. 1. Review of the Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/23, showed: -Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, indicating severely impaired cognitive function and decision-making capacity; -Medical Diagnoses included anoxic (lack of oxygen to the organs causing permanent damage) brain damage, mixed receptive-expressive language disorder, encephalopathy (disease of the brain that alters brain function or structure), and cardiac arrest; -Use of wheelchair; -Limited one-person assistance with transfers. Review of the resident's Face Sheet showed the resident was listed at the facility as his/her own responsible party. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident has a communication problem related to unclear speech and impaired cognition. History of tracheostomy. He/She is able to make some basic needs and wants known and is able to understand most basic communication; -Goal: Resident will be able to make basic needs known on a daily basis through the review date; -Interventions: Ensure/provide a safe environment for the resident, monitor and report any changes in ability to communicate, potential factors for communicating problems, and potential for improvement; -Problem: Resident has impaired cognitive function related to anoxic brain damage. Confusion and forgetfulness noted; -Goal: Resident will maintain current level of cognitive function through review date; -Interventions: Cue, reorient and supervise as needed, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the resident's most recent Elopement Risk Evaluation, conducted on 6/28/21, showed the resident scored a seven, indicating he/she was at low risk for elopement. Review of the resident's progress notes showed: -A note from 2/17/23 at 7:00 A.M., stating the resident was found not to be in the facility at that time; -A note from 2/17/23 at 1:38 P.M., stating the resident had been found at home and his/her family member would be discharging him/her from the facility. Review of the National Weather Service (NWS) climate data records for the St. Louis metropolitan area on 2/16/23 showed a high of 41 degrees Fahrenheit (F) and a low of 31 degrees F, with trace amounts of snowfall between 9:00 P.M. and midnight. During an interview on 2/17/23 at 5:20 P.M., Hospital Staff B said the resident arrived to the hospital on 2/17/23 at 2:29 P.M. The resident was alert to self and had a body temperature of 85 degrees F upon arrival (normal 97.7-99.5 F). Review of Emergency Department Medical Records from SSM Health St. Louis University Hospital showed: -Medical diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hypertension, and hypothermia; -The resident was admitted to the Emergency Department on 2/17/23 at 2:26 P.M. after being found by police outside his/her old address in the cold. The resident reported to EMS (emergency medical services) that he/she had walked to this address from Oakwood Estates Health and Rehabilitation; -Resident's core body temperature upon arrival was 84 degrees Fahrenheit, obtained by rectal thermometer, as an oral thermometer showed a temperature too low to read accurately; -Physical range of motion assessments could not be conducted as the resident was slow to respond and placed in the fetal position to promote increasing core body temperature; -The resident presented with a heart rate of 59 beats per minute, indicating hypothermia-induced bradycardia (a decrease in baseline heartrate caused by low core body temperature). During an interview on 3/30/23 at 12:51 P.M., Family Member A said the resident had been at the facility for almost two years prior to the incident, and each time he/she signed out the resident, he/she notified the facility 24 hours or greater in advance of the upcoming LOA. On 2/17/23 around 9:00 A.M., he/she was contacted by facility staff who asked how the resident was doing, unaware the resident was not LOA with family. When Family Member A said the resident was not with family, facility staff said the resident had left in the afternoon on 2/16/23 with family in a black pickup truck. Family Member A again told staff the resident was not with family, and the facility staff hung up. Family Member A arrived at the facility between 9:30 A.M. and 10:00 A.M. on 2/17/23 and staff said the resident had left the facility with another resident's family on 2/16/23 around 3:30 P.M. and was last seen crossing the street. Family Member A gave a family member's address to the police, assuming the resident would remember his/her childhood address and go there. Law enforcement found the resident at this address, sitting in his/her wheelchair, approximately six miles away from the facility. The weather was cold that night, possibly below 30 degrees, and the resident was found in a sweatshirt and pants with no jacket on. The resident's family arrived to pick the resident up and found him/her soiled, breathing heavily, and hypothermic. The resident was taken to the hospital immediately, treated for hypothermia, and released later that evening. During an interview on 3/23/23 at 12:11 P.M., Receptionist C said on 2/16/23, he/she saw the resident in the facility front lobby area between 3:30 P.M. and 4:00 P.M., dressed as if he/she was leaving the facility. The resident was wearing a blue sweater, khakis, and penny loafers. At that time, a family visiting another resident at the facility was exiting the facility, and Resident #15 exited with them towards a black pickup truck in the parking lot. He/she thought it was the resident's family at that time. Receptionist C informed the unit manager the resident had left on LOA with family, to which the unit manager responded the resident was his/her own responsible party and did not sign out for LOA. Receptionist C's shift ended, and he/she was unsure if the facility began looking for the resident that evening. The following morning, 2/17/23, Receptionist C arrived at work and was told the resident was missing and facility administration had begun searching for the resident. During an interview on 3/23/23 at 11:58 A.M., Certified Nursing Assistant (CNA) D said he/she saw the resident at the facility on 2/16/23 at breakfast in the dining room, where the resident frequently ate his/her meals. CNA D did not see the resident that afternoon, and was told the resident was LOA with family for the evening. The following morning, CNA D arrived to the facility and was told by the unit manager the resident had eloped from the facility. CNA D was familiar with the resident. The resident's cognition was fair, but most days the resident needed cueing or prompting for orientation. During an interview on 3/23/23 at 12:41 P.M. Nurse A said he/she was told by offgoing nurse during handoff that on 2/16/23 between 3:00 and 4:00 P.M. the resident exited the building with a family visiting another resident, and facility staff were under the impression the resident had left LOA with his/her family. The resident's family member was known to sign him/her out, but the resident's family member had not been seen at the facility or notified staff of the resident's LOA on that day. The following day, 2/17/23, Nurse A arrived at the facility and was told by staff the resident had not returned to the facility the previous evening. Nurse A checked the resident's room, but was unable to find him/her. Nurse A then began to ask nursing staff if they had seen the resident, and staff responded they were under the impression the resident was LOA with family. Nurse A reviewed the resident's medical record and noted no notes in the resident's record that would indicate he/she had gone LOA with family on the evening of 2/16/23. Nurse A called the resident's family member to inform him/her the resident was missing and then checked the resident sign-out book kept at the facility's front lobby area. The resident's signature was not in the sign-out book, and administration contacted law enforcement to begin searching for the missing resident. During an interview on 3/23/23 at 2:07 P.M., Certified Medication Technician (CMT) B said the evening shift staff on 2/16/23 were informed by the offgoing day shift staff the resident was LOA with family for the evening, and would not be at the facility. CMT B did not pass medications to the resident that evening as the resident was not in the facility. During an interview on 3/23/23 at 12:39 P.M., the Director of Nurses (DON), who started in this role on 2/27/23, said prior to the new process being implemented the system seemed essentially honor-based, meaning residents were expected to sign out at the log book near the front desk, but staff were not checking the log book each time a resident left the facility for a LOA. The DON said she would expect staff to document LOAs in a resident's record, and if staff are unsure if a resident was currently LOA from the facility, they should check the sign-out book at the nurse's station and the medical record to confirm. During an interview on 3/23/23 at 12:21 P.M., the Administrator said on 2/16/23, the resident left from the facility with another resident's family, reportedly in a black pickup truck. Facility staff thought it was the resident's family at that time. Facility staff were under the impression the resident was LOA with their family and not returning for the evening. The following morning it was discovered the resident had not signed out with family and had eloped from the facility. The Administrator contacted law enforcement and the resident's family to notify them of the incident. Prior to the implementation of the new LOA process residents were simply expected to sign out at the LOA book near the front desk with no communication expectations in regards to staff notification of leave. The Administrator would expect staff who were questioning the validity of a resident's LOA status to first check the sign-out book and the resident's medical record to verify. MO00214224 MO00214218

Based on observation, interview and record review, the facility failed to ensure a resident was free from neglect by failing to ensure a staff member provided the services necessary to avoid physical harm. Certified Nursing Assistant (CNA) A failed to follow the resident's plan of care, the facility abuse and neglect policy and acceptable standards of practice for one resident (Resident #2) when he/she transferred the resident without the required mechanical lift. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 71. The Administrator was notified on 11/4/21 at 4:00 P.M., of the past non-compliance which occurred on 10/21/21. On 10/25/21 the administrator became aware of the violation of the resident's right to be free from neglect. The staff member was suspended and later terminated. The facility in-serviced staff on the abuse/neglect policy and procedures. An investigation was completed. The deficiency was corrected on 11/3/21. Review of the facility's Abuse, Neglect and Exploitation policy, dated 9/1/21, showed: -Policy: It is 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; -Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional crisis. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument used by facility staff, dated 9/3/21, showed: -Brief Interview of Mental Status (BIMS) score of 13 out of 15; -A BIMS score of 13 showed the resident as cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Total dependence with required two person assist with transfers; -Total dependence with required one person assist with personal hygiene, eating, toileting, and bed mobility; -Mobility device: wheelchair; -Range of Motion (ROM) impairment on both sides of the upper and lower extremity. Review of the resident's care plan, dated 9/28/20 and revised 9/13/21, showed: -Focus: The resident has Activity of Daily Living (ADL) self-care performance deficit related to immobility to his/her upper and lower extremities: -Goal: The resident will maintain current level of function though the review date; -Interventions: Transfer: The resident required mechanical lift with 2(x) staff assistance for transfers; -Focus: The resident had a [CONDITION(S)]: -Goal: The resident will be able to communicate needs daily; -Interventions: ROM exercises several times a day. If resident is able, teach how to do correct action ROM; -Focus: Contractures (a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints): Resident has bilateral (both sides) upper and lower extremity contracture/risk for contracture status post [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: Minimize worsening of his/her contractures; -Interventions: Therapy working with splinting, stretching, support, custom power wheelchair; -Focus: Resident has [CONDITION(S)]/[CONDITION(S)] (paralysis or severe weakness on one side or one part of the body) with contractures with limited ROM for bilateral upper and lower extremities and weakness. He/she is able to utilize the touch pad call light when positioned on his/her right shoulder; -Goal: The resident will maintain optimal status and quality of life within limitations imposed by [CONDITION(S)]/[CONDITION(S)]; -Interventions: Monitor and document/report: -New or worsening contractures; -Pain; -Skin breakdown; -Pain management as needed; -Physical therapy, occupational therapy, and speech therapy and treat as ordered; -ROM (active/passive) with A.M. (morning)/P.M. (evening) care daily. Review of the resident's electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's abuse investigation report, showed: -Date/time alleged incident occurred: 10/21/21 at 3:00 P.M. to 11:00 P.M. shift; -Type of abuse: Neglect; -Resident physically injured: yes, left humerus (the arm between the shoulder and elbow) fracture; -Did injuries require medical attention: yes, sent to emergency room , and sling applied; -Name of person allegedly involved: Certified Nurse Aide (CNA) A; -Summary of interview with person reporting alleged incident: On 10/25/21 at 10:00 A.M., administrator and Nurse Manager B interviewed Resident #2 regarding left humerus fracture. He/she said on the evening of 10/21/21, the CNA lifted him/her under his/her arms from his/her chair to put him/her to bed. He/she heard a pop in his/her left arm, but had no pain. On 10/22/21, he/she noticed a dull ache in his/her left arm, but really did not think anything about it. He/she again had a little worse pain on 10/23/21 and requested an x-ray. The x-ray revealed a left humerus fracture. He/she was sent to the hospital for an evaluation and returned the next day. The resident conveyed he/she did not want to get anyone in trouble. The resident knew the CNA did not mean to hurt him/her. CNA A will be re-educated and counseled on proper transfer technique. Review of the resident's progress notes, showed: -No documentation of the left shoulder prior to 10/23/21; -On 10/23/21 at 8:03 A.M., resident requested x-ray to left shoulder, left arm due to increased pain. Physician made aware with new order to x-ray left arm and shoulder; -On 10/23/21 at 8:45 A.M., X-ray here to do test, results pending; -On 10/23/21 at 12:56 P.M., X-ray results in: acute (of abrupt onsite or short duration) proximal (location situated at the point of attachment) humeral fracture. Physician immediately called, new order, send to emergency room . Director of Nursing (DON) in building and made aware; -On 10/23/21 at 1:02 P.M., notified resident that he/she had a fracture to left humerus and doctor wants him/her to go to hospital, writer asked resident did he/she fall, he/she denies falling; -On 10/23/21 at 1:30 P.M., ambulance here to transport resident to hospital. Resident left per stretcher with two emergency medical technicians (EMTs), all paper work given along with x-ray results. Writer noted no swelling to left arm and no warmth felt; -On 10/24/21 at 4:45 A.M., resident returned via stretcher with two EMTs transferred safely to bed. Resident is alert and oriented x 4 (person, place, time and situation), able to make needs known to staff. Has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Sling in place to left arm, in a flexed position. Left arm hot to touch. Right arm remains in extended position. Resident stated that he/she only experiences pain when being touched, refused pain medication at this time. Review of the resident's radiology results report, dated 10/23/21, showed: -Procedure: Left humerus; -Increased pain; -Findings: Acute fracture of the left humeral head neck (the area just below the humeral head) junction is noted with apex (top end) medial (center) deformity. There is generalized osteopenia (a condition where the body does not make new bone as quickly as it reabsorbs old bone); -Impression: Acute proximal humeral fracture. Orthopedic evaluation is recommended; -Procedure: Left shoulder; -Increased pain; -Impression: Acute proximal left humeral fracture. Orthopedic evaluation is recommended. Review of the facility's investigation, of CNA A's summary interview taken by the administrator showed, CNA A transferred the resident on the evening of 10/21/21 into bed without the Hoyer lift (mechanical lift) because the resident did not have a pad (Hoyer pad, used to transfer the resident with the use of the Hoyer lift) under him/her. CNA A said once he/she laid the resident down, the resident complained of some discomfort in his/her arm, but nothing out of the ordinary. He/she said he/she did not hear a pop or anything out of the ordinary. He/she lifted the resident under his/her arms like a bear hug and transferred him/her into bed. The resident had no complaints the rest of the night. During an interview on 11/4/21 at 12:21 P.M., CNA A said he/she assisted the resident to bed either on 10/20/21 or 10/21/21. The resident's wheelchair was next to the bed. He/she placed a gait belt around the resident, underneath the breast area. The belt was secured. He/she stood in front of the resident and lifted the resident up and he/she stepped over into the bed. The resident was able to stand on his/her feet, but could not balance him/herself without assistance. His/her feet stayed on the ground when he/she assisted him/her from the wheelchair to the bed. After the resident was in bed, CNA A provided incontinence care and provided a massage of the back, legs, and the derriere (behind). The resident lay on his/her right side, facing the window during the massage. The resident never complained of pain. He/she never said ouch or anything similar. CNA A was aware the resident should had been transferred with a Hoyer lift; however, the resident did not have a pad underneath him/her. CNA A asked laundry for a Hoyer lift pad and he/she reported to a nurse that the resident did not have a Hoyer pad, but the nurse said he/she would make note of it. CNA A said he/she asked staff in the building to assist with transferring the resident, but he/she received responses such as, I'll be there in a minute, I'll be there, or I have other people. CNA A waited, but one minute turned into 30 minutes and then it turned into an hour. CNA A told a Certified Medication Technician (CMT) that he/she would transfer the resident alone. The CMT told CNA A that if he/she still needed help after their lunch break, he/she would assist. The resident was aggravated and wanted to go to bed. CNA A confirmed the facility's interview summary; however, he/she said the resident never said he/she was in pain and he/she did not give the resident a bear hug. CNA A said he/she was not responsible for the resident's fracture. He believed it happened before or after he/she transferred him/her. The resident would had yelled if the fracture happened during the transfer. The CNA A said he/she wished he/she waited until someone came to assist him/her. CNA A admitted that it was not the first time he/she transferred the resident without the Hoyer lift. There was always a second person with him/her and they used the gait belt. Observation and interview on 11/4/21 at 1:30 P.M., showed the resident sat in a tilted wheelchair. His/her left arm in a sling. He/she had complaints of pain, but said the medication was helpful. The resident was asked about his/her arm. The resident said a staff person (he/she identified the gender of CNA A) picked him/her up out of the chair. He/she could not remember if there was a Hoyer pad underneath or not, but it is usually not an issue. The resident confirmed it was CNA A that picked him/her up. The resident said CNA A believed he/she was smaller than he/she was. He/she said, you're small and picked him/her up. CNA A lifted him/her underneath the armpits. He/she did not use a gait belt. He/she was not exactly lifted off his/her feet, but it was close. CNA A was close in front of him/her and hugged him/her a little when he/she was lifted up. When the resident was lifted, he/she heard and felt a pop. He/she believed CNA A heard the pop because he/she told the resident you're stiff. The resident thought the same thing, but he/she did have pain. He/she told CNA A and he/she said it was because he/she was stiff. The resident confirmed CNA A massaged his/arm after the transfer. The resident confirmed that CNA A only massaged his/her arm and never received a massage from CNA A in the past. The resident said he/she had stiffness in his/her arm before he/she was transferred by CNA A, but he/she could move his/her arm. After the transfer by CNA A, the resident felt pain. The pain did not go away and it became worse. He/she told staff the next day and an x-ray was ordered. The resident said earlier that day on 10/21/21, he/she was transferred with the Hoyer lift from the bed to the wheelchair and there were no problems. He/she remembered he/she had to wait before he/she was transferred to his/her bed by CNA A, but he/she did not know why. The resident believed his/her roommate also heard what happened, including the pop. During an interview on 11/4/21 at 12:00 P.M., the resident's roommate said he/she remembered when CNA A transferred Resident #2 to the bed. He/she heard something like a pop. He/she did not see anything because the privacy curtain was pulled. He/she said there definitely was not a Hoyer lift in the room. During an interview on 11/4/21 at 3:00 P.M., the administrator said CNA A was initially suspended and later terminated. The administrator confirmed the interview statement made by CNA A. She was told by CNA A that he/she rubbed cream on the resident's arm after the transfer. Facility staff were re-educated on the facility's Abuse and Neglect policy and transfer policy. She would expect staff to transfer residents according to their care plan. MO 635

Based on observation, interview and record review, the facility failed to develop and implement interventions to stabilize or improve nutritional status to acceptable parameters, for one sampled resident identified with severe weight loss (unplanned loss greater than 5% of body weight in one month, greater than 7.5% in three months, or greater than 10% in six months) (Resident #88). The census was 97. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/20, showed: -Severe cognitive impairment; -Delusions exhibited; -Rejection of care not exhibited; -Antipsychotic medication used seven of seven days; -No gradual dose reduction (GDR) attempted. GDR not documented by a physician as clinically contraindicated; -No weight loss of 5% or more in the last month or 10% or more in the last six months; -[DIAGNOSES REDACTED]. Review of the resident's facility medical record, showed: -A physician's orders [REDACTED]. -May 2019 weight: 226.2 pounds (lbs); -A pharmacist monthly medication regimen review (MRR), dated 6/12/19, in which irregularities were noted. No documentation specifying which irregularities were noted, the pharmacist's recommendation, or the physician's response; -June 2019 weight: 209.6 lbs; -The resident experienced severe weight loss (unplanned loss of greater than 5% in one month) of 7.34% between May and June 2019. Review of the resident's registered dietician (RD) note, dated 6/26/19, showed the resident noted with weight loss of 16.6 lbs in one month. Staff reported the resident was trying to lose weight, which was positive. No new recommendations. Review of the resident's medical record, showed: -July 2019 weight: 205.6 lbs; -No documentation of RD notes completed in July 2019; -August 2019 weight: 186.4 lbs; -The resident experienced severe weight loss of 9.07% between July and August 2019. Review of the resident's annual nutrition assessment, dated 8/2/19, showed the RD documented an unplanned significant weight loss of 11.3% in the past five months. Resident trying to lose weight, which was positive. Regular LCS diet continues to meet needs. No new recommendations. Review of the resident's RD note, dated 8/26/19, showed the resident triggered for significant weight loss of 12.8% in three months. Resident weighed 197.2 lbs, and still obese. He/she desired weight loss. Fair appetite noted. Staff reported resident refused meals at times, but ate junk food/fast food and soda all day long. The resident used to eat all his/her meals, as well as junk food and soda, so weight loss is likely related to decreased caloric intake from meals. Encouraged resident to eat meals and not junk/fast food and soda. No new recommendations. Review of the resident's progress notes, dated 8/27/19, showed a pharmacist MRR completed with irregularities noted. No documentation specifying which irregularities were noted, the pharmacist's recommendation, or the physician's response. Review of the resident's medical record, showed: -September 2019 weight: not documented; -A dietary order, dated 9/6/19, for health shakes with all meals for weight loss; -A nurse's note, dated 9/11/19, in which staff documented the resident refused the health shake at breakfast and stated he/she was trying to lose weight not gain weight; -A nurse's note, dated 9/15/19, showed the resident consumed 50% of his/her meal at breakfast and 0% at lunch. He/she refused health shakes and bought snacks from the vending machine; -October 2019 weight: 170.4 lbs; -The resident experienced a severe weight loss (unplanned loss of greater than 7.5% in three months) of 8.58% between August and October 2019. Review of the resident's RD note, dated 10/21/19, showed the resident noted with significant weight loss. Resident desired weight loss and refused health shakes. Staff reported the resident eats junk food from the vending machine. Staff encouraged him/her to eat meals, not from the vending machine, but he/she still does it. Recommended to discontinue health shakes. No new supplements or interventions recommended. Review of the resident's progress notes, dated 10/30/19, showed: -A pharmacist MRR completed with irregularities noted. No documentation specifying which irregularities were noted, the pharmacist's recommendation, or the physician's response. -At 10:42 A.M., staff documented a care plan meeting was held. The resident noted to have weight loss and to refuse supplements. Fair appetite noted. Resident liked snacking, rather than eating the ordered diet; -At 2:09 P.M., staff documented the resident refused breakfast and lunch. He/she ate other food (hog head cheese) brought in by his/her family. Review of the resident's care plan, undated and in use at the time of survey, showed: -Problem: Impaired nutritional status. Unplanned/unexpected weight loss related to poor food intake. Has [DIAGNOSES REDACTED]. Has had a medication adjustment and noted to have appetite fluctuations. He/she likes to order out and eat fast food or junk food; -Interventions included: -Encourage eating nutritionally sound meals; -Hospice consult as indicated; -Occupational therapy, speech therapy to screen, evaluate, and treat as indicated; -Labs as ordered, and report to physician and RD; -Monitor and record food intake at each meal; -Monitor/document/report signs/symptoms of dysphagia (difficulty swallowing); -Notify dietician if meal intake is poor for more than 48 hours -Offer substitutes as requested or indicted. He/she likes fast food; -Supplements as ordered, and notify physician and RD if refused consistently; -The care plan failed to reflect the resident's desired outcome of weight loss; -The care plan failed to describe the resident's ongoing refusal of meals, and action taken by staff to educate the resident regarding alternatives and consequences; -The care plan failed to identify individualized measurable objectives, interventions, and timeframes for how staff will address his/her nutritional status. Review of the resident's medical record, showed: -A nurse's note, dated 11/4/19, in which staff documented the resident observed banging his/her head on the dining room table. Resident sent to hospital for assessment; -A nurse's note, dated 11/6/19, in which staff documented the resident returned to facility from hospital with [DIAGNOSES REDACTED]. -November 2019 weight: 165.2 lbs. Review of the resident's nutritional assessment, completed by the RD, dated 11/20/19, showed: -Resident readmitted to facility with orders for regular texture, NAS LCS diet; -Fair appetite noted; -No current nutritional supplement; -No documentation of resident's likes/dislikes; -No new recommendations. Review of the resident's medical record, showed: -No documentation of a pharmacist MRR completed in November 2019; -No documentation of a pharmacist MRR completed in December 2019; -No documentation of RD notes completed in December 2019; -December 2019 weight: 164.0 lbs; -The resident experienced a severe weight loss (unplanned loss of greater than 10% in six months) of 21.76% between June and December 2019. Review of the resident's nurse's notes, dated 1/7/20 and 1/22/20, showed staff documented the resident continued to skip meals and to eat junk food. Review of the RD note, dated 1/22/20, showed the resident noted with significant weight loss of 34.8 lbs in over five months. The resident only lost 2.8 lbs in the past two months, so weight probably stabilizing. Resident continues to consume little of his/her meals and refuse all supplements. Continues to drink soda and eat junk food. Staff to continue encouraging resident to eat meals and not junk food, but poor compliance expected. No new recommendations. Review of the resident's monthly weights, showed: -January 2020 weight: 162.4 lbs; -February 2020 weight: 141.6 lbs; -The resident experienced a severe one month weight loss of 12.81% between January and February 2020. Review of the resident's medical record, showed: -On 1/27/20, the resident's primary physician, Physician L, documented a visit with the resident related to a fall. Resident noted with new or worsening medical problems over the last month. Plan: Continue physical/occupational therapy for gait disorder with falls due to poor judgment, deconditioning, and stroke. No documentation regarding nutritional status; -On 2/13/20, the Nurse Practitioner (NP) from Physician L's office, documented the resident's poor appetite and weight loss. Plan: Labs ordered and referred to neurologist; -On 2/26/20, a different physician from Physician L's office, documented a visit with the resident for malignancy follow-up. Resident asked for donuts, but had decreased appetite. Resident refused lab work ordered by NP on 2/13/20. Malignancy follow-up not feasible. Hospice recommended. Observation of the resident, showed: -On 3/3/20 at 1:30 P.M., he/she was escorted by staff to the vending machine, where he/she bought two bags of chips, a candy bar, and a soda; -On 3/4/20 at 7:48 A.M., he/she was served breakfast. He/she ate without difficulty and consumed approximately 50% of his/her meal; -On 3/5/20 at 8:05 A.M., he/she was served pancakes and a sausage patty for breakfast. He/she ate without difficulty and consumed approximately 50% of his/her meal; -On 3/5/20 at 1:10 P.M., he/she wandered around the dining room with a soda and bowl of vanilla ice cream. The resident said he/she likes vanilla ice cream. The resident approached the nurse's station and attempted to hit a staff member. Staff intervened and redirected the resident to a dining room table. The resident calmed down and ate his/her ice cream. During an interview on 3/5/20 at 5:45 A.M., Certified Medication Technician (CMT) I said the resident has mental health [DIAGNOSES REDACTED]. The resident has lost a lot of weight. He/she does not eat much during meals, but likes other foods, such as burgers and fries. The resident snacks on food several times during a shift, instead of eating one meal. He/she is on a diabetic diet, but eats food from the vending machine. The CMT did not know if a different diet had been attempted. During an interview on 3/5/20 at 8:10 A.M., Certified Nurse Aide (CNA) K and Nurse J said the resident has declined over the past year. He/she buys food from the vending machine, but doesn't eat what he/she purchases. His/her appetite is poor, and it is difficult to determine what he/she will eat. CNA K and Nurse J did not know if the resident's physician or RD had ever recommended an appetite stimulant. During an interview on 3/5/20 at 3:10 P.M., the RD said when the resident first started losing weight, the RD thought it was acceptable. The resident was obese and expressed a desire to lose weight. He/she seemed to become obsessed with weight loss, because staff started reporting the resident refused to eat. The RD ordered the resident to receive health shakes for approximately one month, but the resident refused them. The RD could not recall other interventions attempted. She thought staff might have tried giving the resident supplemental frozen treats. Any intervention attempted by staff should be documented in the resident's record. The RD relies on staff to tell her what the resident likes/dislikes, and will/won't do. The resident's eating habits seem to be a behavioral issue due to his/her mental health. He/she is on a diabetic diet, but does not eat meals served. A change in the type of diet ordered would unlikely result in the resident eating, because he/she prefers to eat junk food. If a resident has significant weight loss, the RD conducts a nutritional assessment and makes recommendations. Facility staff is responsible for notifying the resident's physician of the RD's recommendations, and the physician either accepts or rejects them. During an interview on 3/5/20 at 12:30 P.M., the Director of Nurses (DON) said she could not locate the resident's physician's progress notes from June through December 2019. She could not locate the resident's missing monthly pharmacy MRR, either. Without the pharmacy consults, she was unable to say whether the physician received the recommendations, or agreed with them. The pharmacy consults and physician documentation should be in the resident's medical record. During an interview on 3/5/20 at 2:01 P.M., the DON said when a resident experiences significant weight loss, multiple interventions should be attempted to improve nutritional status. The resident received health shakes for approximately one month, but he/she did not like them. He/she has orders for a diabetic diet, but he/she does not like the food served and eats junk food from the vending machine. The DON did not know if interventions of a non-diabetic diet, double portions, or appetite stimulants had been attempted. If an intervention was attempted but unsuccessful, it should be documented on the resident's care plan. Recently, the DON spoke to the resident's psychiatrist and some of the resident's [MEDICAL CONDITION] medications were reduced. However, the resident continues to have behavioral symptoms and will require continued use of [MEDICAL CONDITION] medication. During an interview on 3/5/20 at 3:38 P.M., the administrator said the resident was just placed on hospice in hopes of the extra attention bringing about a bounce-back from his/her decline. The resident's psychiatrist thought one of the resident's medications contributed to his/her weight loss, so that medication was recently discontinued. All nutritional interventions should be documented in the resident's medical record, and his/her care plan should be updated. Care plans should be individualized for each resident. During an interview on 3/10/20 at 11:19 A.M., Social Worker M, employed with Physician L's office, said the physician was not in the office at that time. She spoke to the resident's physician and completed a review of the resident's chart regarding nutritional status. The resident became Physician L's patient in September 2019. Facility staff did contact the physician's office regarding the resident's weight loss and refusal to eat meals; however, they did not report the resident's preference to snack throughout the day and to eat food from the vending machine. The physician's office has not received recommendations from the RD, or from the pharmacist's monthly medication regimen reviews. It is expected for recommendations from the RD and the pharmacist to be communicated to the physician. The physician's office contacted the facility and requested they provide all RD and pharmacy recommendations to the physician's office on a monthly basis. The resident was referred to hospice due to his/her weight loss. MO 315

Based on observation, interview and record review, the facility failed to assist one resident observed with his/her left shoulder and arm wedged in the side rail on his/her bed for approximately 10 minutes. The resident was visible from the hallway as multiple staff passed his/her room. In addition the facility failed to assess the side rail usage for the resident's safety and ensure the use of the side rail was the appropriate and least restrictive device. The facility identified seven residents with side rails, five were sampled and problems were found with one (Resident #14). The census was 97. Review of the facility's Restraints-Side Rails policy, revised 6/2019, showed: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -Definition: Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.); -General Guidelines: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed.) (Note: The side rails may have the effect of restraining one individual and not the other, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident's care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 6. Less restrictive interventions that will be incorporated in care planning include: a. Providing restorative care to enhance abilities to stand safely and to walk; b. Providing a trapeze to increase bed mobility; c. Equipping the resident with a device that monitors attempts to arise; e. Providing staff monitoring at night with periodic assisted toileting for residents who can comprehend this information. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rails will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including proper assessment and care planing. While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request.) 10. Manufacturer instructions for the operation of side rails will be adhered to. 11. The resident will be checked periodically for safety relative to side rail use. 12. If the side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. 13. When side rail usage is appropriate, the facility will access the space between the mattress and side rail to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 14. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders, but are still restraints if they meet the definition of a restraint. 15. Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/19, showed: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -Required extensive staff assistance for bed mobility; -Required total staff assistance for transfers, dressing, eating, personal hygiene and bathing; -Incontinent of bowel and bladder; -Side rails: none used. Review of the resident's care plan, updated 11/24/19, showed: -Problem: Risk for falls related to (r/t) daily use of [MEDICAL CONDITION] drug use, increased anxiety and restlessness. Resident has had a fall from bed, no injury r/t frequent movement; -Approach: Check range of motion (Specify #) times daily. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document /report as needed (PRN) x 72 hours to physician for signs and symptoms of pain, bruises and changes in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation. -Place side rails up X 2 for safety. Review of the resident's physician's orders [REDACTED]. Review of the resident's medical record, showed no side rail assessment was completed. Observation on 3/1/20, showed: -7:16 A.M., during the initial tour of the facility, the resident was calling out loudly mom, mom from the centralized nurse's station. The resident's room was the first room on the right, visible from the nurse's desk. The resident called out repeatedly mom, mom. His/her voice was high pitched, loud and urgent. The resident was partially behind the privacy curtain but visible from the hallway. The resident lay in his/her bed, on a bare mattress, with the head of the bed slightly raised, moving his/her legs back and forth. Both half side rails were up. His/her head was raised at an awkward angle, with his/her left shoulder and arm wedged between the mattress and half side rail on the left side. The resident moved his/her legs and feet in a sliding motion on the mattress. The lower half of the bed was raised slightly at the knees. He/she repeatedly called out mom, mom in a urgent loud voice. Three unidentified nurses were at the nurse's desk. No one from the nurse's desk checked on the resident; -7:20 A.M., three nursing staff, including Nurse E, stood or sat at the 100/200/300 nurse's station. A loud voice saying something repetitively could be heard coming from the 300 hall. When asked who was making that noise. Nurse A said it was Resident #14. He/she is saying mom. He/she does that all the time; -7:21 A.M.: two unidentified certified nurse aides (CNAs) passed the resident's room. Neither staff member looked in the room. The resident continued to call out repeatedly mom, mom in a loud high pitched voice. The resident remained with his/her left arm/shoulder wedged between the mattress and left side rail; -7:23 A.M.: one unidentified CNA passed the room, looked in the room, twice, but did not go in. The resident continued to yell out mom, mom in a loud high pitched voice; -7:26 A.M.: a nurse passed the resident's room on his/her way to the nurse's station, walked back, looked in the room, went in and straightened the resident onto the center of the mattress. He/she lay on a bare mattress, without a sheet, moving his/her legs up and down. The side rails were raised on both sides. He/she continued to call out mom, mom but it was no longer high pitched; -8:30 A.M.: the resident was slumped over to the left of the bed, leaning against the side rail. During an interview on 3/5/20 at 6:00 A.M., CNA H, said he/she has taken care of the resident on the day shift. He/she has often found the resident against and or wedged between the mattress and the side rail. The resident moves in his/her bed and has to be positioned frequently when in bed. He/she had not reported it to anyone and said everyone is aware the resident does this. During an interview on 3/15/20 at 4:34 P.M., CNA P said he/she has assisted other staff to take care of the resident on the day shift. He/she has helped position the resident in bed and helped with transfers. He/she has had to hold the resident's hands while staff provided care. He/she hasn't seen the resident in the side rail. During an interview on 3/15/20 at 4:45 P.M., CNA Q said he/she has taken care of the resident on the night shift. The resident usually sleeps during the night. The resident does slide down in the bed because of the type of mattress he/she has. It takes two staff to position him/her in the bed. The resident is active and moves his/her legs in bed when awake. During an interview on 3/4/20 at 7:08 A.M., Nurse B said he/she works the night shift. When the resident is awake he/she hollers out. He/she heard the resident holler the morning of 3/1/20. The resident's holler sounded different, more urgent. As he/she entered the room, he/she could see the resident's left shoulder and arm was wedged in the side rail. He/she repositioned the resident at that time. He/she was unaware staff had passed the room. He/she would expect the staff to go in and check on the resident. He/she did not report the resident was wedged in the side rail to anyone. During an interview on 3/4/20 at 10:28 A.M., the Maintenance Director said no one reported the resident was sliding down between the mattress and side rail. He checked the half side rail at this time and was able to lock it in place so it stopped it from moving. He was unaware how long the side rail had been loose. He would have expected the staff to report anytime they find problems with side rails. In addition he was aware he should measure the gap between the mattress and side rail to make sure a resident wasn't able to slide between them. He has not begun measuring any of the side rails. During an interview on 3/13/20 at 10:43 A.M., the Director of Nurses (DON) said she has worked at the facility since July of 2019 and the resident has used the side rails since then. Staff did not report any problems with the resident's side rails. She would have expected the staff to report any problems to the charge nurse or DON. They were doing side rail assessments but when the facility changed the electronic charting from one company to another in September of 2019, and the side rail assessments weren't being completed due to a problem with the system. She was unaware they still weren't being completed until now. She is aware the facility should assess side rails for safety which includes measuring the gaps between the mattress and the side rail and ensure the side rails are in good repair. The prior Maintenance Director was assessing the side rails for safety. He took the documentation regarding the assessments with him. During an interview on 3/5/20 at 7:44 A.M., the administrator said the Maintenance Director reported the resident's loose side rail. The side rail was removed and his/her mattress was replaced with a Bolster mattress (mattress with built in raised sides). This was the first time she was made aware of the problem with the side rail. She was unaware the resident was wedged in the side rail. In addition she was not aware staff failed to assist the resident while he/she was wedged in the side rail even though he/she was visible as they passed the room. She would expect staff to immediately go in reposition the resident, assess him/her for pain and injury and report it to the charge nurse and DON. Staff should not pass the room without assessing the resident. During an interview on 3/16/20 at 2:26 P.M., the DON said she expects the staff to follow the policy. During an interview on 3/5/20 at 9:55 A.M., the resident's physician and facility Medical Director said he spoke with the facility regarding the resident. The resident has a behavior of yelling out but he would expect staff to assist the resident if he/she needed positioning. He also would expect the facility to follow the policies for Bed Safety and Proper Use of Side Rails. He was unaware the facility was not completing side rail assessments and doesn't recall the facility discussing it in the Quality Assurance meeting. He would also expect the facility to inspect side rails per the facility's policy.

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This resulted in one resident with a history of pressure ulcers developing new stage III pressure ulcers and worsening of two stage II pressure ulcers into an unstageable pressure ulcer when the facility failed to monitor the resident's skin, accurately assess and document wound observations, and obtain treatment orders timely after staff reported to the nurse the resident had new open areas (Resident #267). In addition, issues were identified with three additional residents who developed new and/or worsening pressure ulcers when the facility failed to follow physician orders, accurately assess and document wound observations, report new and deteriorating pressure ulcers to the physician and use proper technique when treating wounds to prevent infection (Residents #59, #33 and #116). The facility identified seven residents with pressure ulcers and all seven were included in the sample of 20. The census was 96. Review of the facility's undated Measurement, Assessment of Pressure Ulcers, Wounds and Other Skin Problems policy, showed: -At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and describe skin condition in the clinical record; -All measurements will be recorded in centimeters. All ulcers will be measured weekly and results recorded; -Identify the type of ulcer. The medical record should clearly support the clinical basis for the determination of etiology (cause) of the ulcer; -Identify the stage or extend of tissue destruction involved; -Ulcer assessment: -Obtain length, width and depth; -Assess wound/skin condition for drainage and record type and amount; -Assess for presence of necrotic (dead) tissue; -Assess for presence of granulation tissue (new tissue growth); -Assess the periwound (skin surrounding the wound) and wound edges; -Assess odor and pain; -Describe any problems with adherence to treatment of [REDACTED]. Example: Refuses treatment or to relieve pressure. 1. Review of Resident #267's medical record, showed: -[DIAGNOSES REDACTED]. -A Braden assessment (used for predicting pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) risk), dated 3/4/19, showed a score of 17, which indicated the resident at risk for pressure ulcers; -A Braden assessment dated [DATE], showed a score of 14, which indicated the resident at moderate risk for pressure ulcers. Review of the resident's care plan, dated 12/1/18 and reviewed on 1/8/19, showed: -Problem dated 3/8/19: readmitted with left gluteal (buttocks) proximal (situated closer to the center of the body) and distal (situated further from the center of the body) wound at a stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister). Updated 3/18/19, left gluteal fold wounds merged to unable to stage (unstageable pressure ulcer, obscured full-thickness skin and tissue loss), coccyx (tail bone area) proximal and distal stage II, right gluteal stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed), and scrotum stage II: -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions: Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Updated 3/18/19, low air loss mattress, consult wound management, heel protectors when in bed; -Problem: The resident has limited physical mobility related to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints): -Goal: The resident will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury. Review of the resident's care card, located in the resident's room and updated on 3/11/19, showed: -Toileting: Incontinent, needs help with changing; -Mobility: Assist to bed/chair with one person assist; -Skin integrity: Preventative care; -Pressure ulcers: Blank. Review of the resident's progress notes, showed: -On 3/4/19 at 7:46 P.M., Skin/Wound Note: Resident readmitted to the facility on [DATE]. Resident has two open areas to the left gluteal fold (also referred to the ischium, the back lower portion of the hip, on which the body rests when sitting): -Area one measures 2.2 centimeters (cm) by 3.4 cm (length by width), 100% pink, minimum drainage noted, periwound (the tissue surrounding the wound) intact; -Area two measures 1 cm by 1 cm, 100% pink, scant (small amount) drainage noted, periwound intact; -New order for Duoderm (a sterile occlusive dressing) every three days until healed; -On 3/8/19 at 4:46 P.M., Skin/Wound Note: -Left gluteal proximal: 2.2 cm by 3.4 cm, 100% pink, minimal drainage noted, periwound intact, Duoderm every three days; -Left gluteal distal: 1 cm by 1 cm, 100% pink, scant amount of drainage noted, periwound intact Duoderm every three days until healed; -On 3/14/19 at 5:05 P.M., Skin/Wound Note: -Left gluteal proximal: 2.8 cm by 3.6 cm, 100% pink, minimal drainage noted, periwound intact, Duoderm every three days; -Left gluteal distal: 1.2 cm by 1 cm, 100% pink, scant amount of drainage noted, periwound intact Duoderm every three days until healed; -On 3/15/19 11:02 P.M., Skin/Wound Note: This writer was notified of and open area located on the right gluteal area near the fold. Resident denies pain at this present time. Resident is incontinent of bowel and bladder, and alert with a disorganized thought process. On coming charge nurse will be notified of area and treatment nurse will be made aware of this occurrence for a treatment order to be in place to heal area. Resident is currently resting in bed positioned on his side for pressure relief; -On 3/16/19 at 7:41 A.M., responsible party made aware of the resident's three areas to both buttocks; -On 3/17/19 at 3:55 A.M., resident continues on monitoring related to multiple areas to left buttocks. Dressings remain intact. Pain management medications administered as scheduled with effectiveness; -On 3/18/19 at 3:59 P.M., Skin/Wound Note: -Resident has an unstageable area to the left gluteal fold. Area had two areas that have now merged to make one area. Left gluteal fold measures 4 cm by 5.5 cm by 0.3 cm (length by width by depth), wound bed with dark colored slough (moist dead tissue), periwound pink, moderate serous (clear) drainage noted. treatment of [REDACTED]. No odor present; -Coccyx has a small stage II, measures 1 cm by 0.5 cm, 100% pink tissue with scant serous drainage; -Coccyx distal measures 4 cm by 2 cm, scant drainage, 100% pink tissue. treatment of [REDACTED]. -Right gluteal stage III, measures 2 cm by 4.5 cm by 0.2 cm, 50% pink, 50% [MEDICATION NAME] (a tough protein substance that is found in blood plasma. When tissue damage results in bleeding, [MEDICATION NAME] is converted at the wound into [MEDICATION NAME]), moderate serous drainage, periwound intact, no odor present. treatment of [REDACTED]. -Scrotum has a stage II present, measures 1.5 cm by 1 cm, 100% pink, scant drainage noted. Treatment: apply Santyl and leave open to air; -New orders noted for all open areas, low air loss mattress (LAL) ordered today, heel protectors to heels when in bed. Orders for Wound Management; -On 3/19/19 at 1:20 P.M., Health Status Note: Physician here visiting and saw resident. New order, may have indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) till wounds heal; -On 3/22/19 2:25 P.M, Skin/Wound Note: -Right Ischial (gluteal): 3.5 cm by 1.5 cm by 0.2 cm, 100% [MEDICATION NAME], moderate serous drainage, periwound intact, Silver alginate (dressing, works by stopping the growth of bacteria that may infect an open wound), Santyl, 4x4 gauze, tape, daily; -Left Ischial (gluteal): 5 cm by 3 cm by 0.3 cm, 100% [MEDICATION NAME], moderate serous drainage, periwound intact, silver alginate, Santyl, 4x4, tape, daily. -Coccyx: 5.5 cm by 1 cm by 0.1 cm, moderate serous drainage, periwound intact, silver alginate, Santyl, 4x4, tape, daily; -(No documentation of the coccyx proximal wound or scrotal wound). Review of the facility's wound reports, showed the following for the resident: -March 3/2/19 through 3/8/19: -Left gluteal proximal stage II measured 2.2 cm by 3.4 cm, 100% pink, no drainage, facility acquired on 3/4/19, Duoderm every three days; -Left gluteal distal stage II measured 1 cm by 1 cm, 100% pink, no drainage, periwound intact, facility acquired on 3/4/19, Duoderm every three days; -March 3/9/19 through 3/15/19: -Left gluteal proximal stage II measured 2.8 cm by 3.6 cm, 100% pink, no drainage, periwound intact, facility acquired on 3/4/19; -Left gluteal distal state II measured 1.2 cm by 1 cm, 100% pink, no drainage, periwound intact, facility acquired on 3/4/19, Duoderm every three days; -March 3/16/19 through 3/22/19: -Right ischial (gluteal) stage III measured 3.5 cm by 1.5 cm by 0.2 cm, 100% [MEDICATION NAME], moderate serous drainage, periwound intact, facility acquired on 3/19/19, silver alginate, Santyl, 4x4, tape daily; -Left ischial stage III measured 5 cm by 3 cm by 0.3 cm, 100% [MEDICATION NAME], moderate serous drainage, periwound intact, facility acquired on 3/19/19, silver alginate, Santy, 4x4, tape daily; -Coccyx stage III measured 5.5 cm by 1 cm by 0.1 cm, 100% [MEDICATION NAME], moderate serous drainage, periwound intact, facility acquired on 3/19/19, silver alginate, Santyl, 4x4, tape daily; -(No documentation of the coccyx distal wound or scrotal wound). Review of the resident's handwritten and undated physician order [REDACTED]. -An order dated 3/16/19, to apply Duoderm to right gluteal fold every three days and as needed; -An order dated 3/18/19: -Left gluteal fold Santyl, normal saline, calcium alginate, dry dressing and tape daily; -Right gluteal fold Santyl, normal saline, calcium alginate, dry dressing, and tape daily; -Coccyx proximal and distal Santyl, normal saline, dry dressing daily; -Low air loss mattress; -Consult for wound management; -An order dated 3/19/19, may insert 14 French (size) 10 milliliters (ml) indwelling urinary catheter till wound heals. During an interview on 3/27/19 at 10:21 A.M., Nurse K said nurses do skin assessments based on the schedule and the treatment nurse completes his/her own assessments on residents with major wounds. Review of the facility's 400/500 hall skin assessment schedule, showed: -The resident's room scheduled to have skin assessments completed on Tuesdays, day shift; -All skin assessments are to be completed by the end of the shift; -All skin must be seen by a licensed nurse and documented. Review of the facility's undated skin assessment policy, located at the nurse's station on 400/500, showed: -Licensed nurse weekly skin assessment: All residents should have their skin assessed weekly by a licensed nurse. The skin assessment schedule encourages continuity in the required documentation; -Certified Nursing Assistant (CNA) shower assessments: This assessment recognizes the important role CNAs play in pressure ulcer prevention and empowers them to do a regular skin check. It provides a formal method of communication to the licensed nurse of their review of resident's skin which then would be followed up by the licensed staff. Review of the resident's Licensed Nurses Weekly Skin Assessment forms, from 1/1/19 through 3/26/19, showed only three assessments completed: -Dated 2/21/19: Any open ulcers: Not indicated yes or no; -Dated 3/14/19: Any open ulcers: Yes, Duoderm every three days until healed. Documentation on the picture of the human body, showed the wound located to the left outer hip/buttocks area; -Dated 3/21/19: Any open ulcers: Yes. Documentation on the picture of the human body, showed a small circle to the left side of the coccyx area, mid left and mid right buttocks. No documentation on the left gluteal, right gluteal and/or scrotum. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet, from 1/1/19 through 3/26/19, showed only two forms completed: -Dated 1/16/19, showed no open areas; -Dated 2/27/19, showed the resident at the hospital. Observation on 3/26/19 at 11:50 A.M., showed the Assistant Director of Nursing (ADON) obtained the treatment cart and entered the resident's room. She obtained supplies to change the resident's dressing with the treatment administration record (TAR) located on the treatment cart and open for the ADON to review as she completed the treatments. As the ADON gathered supplies, CNA P assisted the resident to turn to the left side. The resident had a wound located to the left ischium (gluteal) with no dressing. The wound appeared to have depth. The center most, deep part of the wound bed with a white color. A serous drainage ring visible on the bed pad under the resident. Yellow moist tissue visible in the wound bed. A dressing located to the coccyx intact. A small open area on the posterior side of the scrotum with several smaller areas in the surrounding tissue. The CNA assisted the resident to the far left side and exposed the left ischial (gluteal) wound with no dressing. The wound bed black and the black tissue pulled away from the wound edge on one side as CNA P pulled on the resident's right hip and exposed depth to the wound and yellow/tan tissue. There were no loose dressings located in the bed or on the pad from the left and right ischial (gluteal) wounds. The ADON removed the dressing to the coccyx and exposed two open areas, one distal and one proximal, both the approximate size of a dime with pink wound beds. The ADON applied the ordered treatment to each wound. During an interview on 3/26/19 at 12:22 P.M., the ADON said the wound nurse stages the wounds, but he/she believed the left ischium is unstageable. This wound appeared to be deteriorating and it looked like it was separating from the wound edge. All of the other wounds appeared to be improving. The coccyx wounds, she believed to be stage II and the right ischium a stage III. The small areas to the scrotum were healing well. The last time she observed the wound was approximately a week earlier. She was not sure why the dressing was off the left and right ischium (gluteal) when she went in the room to do the treatment. She was told by the CNA about an hour prior to the treatment that the resident had to be cleaned, but he/she did not say the treatment came off. If it did, she would expect the CNA to tell the nurse. During an interview on 3/26/19 at 12:30 P.M., CNA P said he/she is the CNA assigned to care for the resident. He/she changed the resident at approximately 10:45 A.M. and he/she thought the treatments were on at that time. He/she did not remove them and they did not fall off during care. During an interview on 3/26/19 at 12:39 P.M., Nurse K said he/she is the nurse assigned to care for the resident. He/she did not remove the dressings. He/she believed that sometimes the resident removes them and throws them beside the bed. Observation at this time, with CNA P and Nurse K, showed no dressings on the floor. CNA P and Nurse K verified the dressings were not on the floor. During an interview on 3/27/19 at 10:42 A.M., with the Director of Nursing (DON) and administrator, the DON said skin assessments are completed weekly and during showers by CNAs. Nurses complete the licensed nurse weekly skin assessment and CNAs complete the shower sheets. If new areas are identified; the nurse should call the physician to obtain orders, asses the wound and document. They then communicate the new area to the wound nurse so she can follow up. Any nurse can and should get orders for a treatment. It is not appropriate to wait three days to obtain treatment orders and assess the wound. She was not sure what preventative measure were in place prior to the development of the new wounds. The LAL was not ordered until after the new wounds were identified. At 1:47 P.M., the DON said it was the responsibility of the wound nurse to review and track the completion of weekly skin assessments and the shower sheets. These were not being done for the resident. The licensed nurse weekly skin assessments and shower sheets that were provided were the only ones available for the resident from 1/1/19 through current (3/27/19). 2. Review of Resident #59's Annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/19/18, showed: -Short and long term memory issues; -Locomotion on and off the unit did not occur; -Total dependence with two person assist required for bed mobility, transfers, eating and personal hygiene; -Incontinent of bladder and bowel; -Impairment on one side for upper body and lower body; -Medical [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 2/21/19 and updated on 3/15/19, showed: -Problem: Remains at risk for pressure areas and skin breakdown related to Stage II to coccyx and healed pressure areas. On 3/15/19, Right elbow healed, open blister to right inner thigh and left lower leg left open to air; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions: Administer treatments as ordered and monitor for effectiveness; Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the resident's electronic medical record skin and wound progress notes, reviewed on 3/26/19 at 3:46 P.M., showed: -On 3/14/19 at 4:49 P.M.: -Right inner thigh: measured 2.5 cm by 4 cm, dark colored area, slightly raised, no drainage, skin intact, left open to air; -On 3/21/19 at 4:42 P.M.: -Right hip proximal: measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, no drainage, periwound intact, border gauze daily; -Right hip distal measured 1.2 cm by 0.8 cm by 0.1 cm, 100% pink, no drainage, periwound intact, border gauze daily; -Left medial leg measured 3.0 cm by 2.4 cm by 0.1 cm, 100% pink, no drainage, periwound intact, border gauze daily; -Right medial thigh: 3.0 cm x 2.0 cm x 0.1 cm, 100% pink, no drainage, periwound intact, border gauze daily. Review of the resident's POS, dated (MONTH) 2019 and reviewed on 3/22/19 and 3/25/19, showed: -Treatment order dated 11/28/18, Off load area every shift; -(No treatment orders for the resident's right hip distal and proximal stage II pressure ulcers, left medial leg Stage II or right medial thigh Stage II). Review of the facility's wound reports, dated (MONTH) 3/16/19 through 3/22/19, showed the following for the resident: -Right hip proximal stage II measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, minimal drainage, periwound intact, facility acquired on 3/19/19, border gauze daily; -Right hip distal stage II measured 1.2 cm by 0.5 cm by 0.1 cm, 100% pink, minimal drainage, periwound intact, facility acquired on 3/19/19, border gauze daily; -No documentation of the resident's left medical leg stage II and right medical thigh stage II. Review the resident's wound clinic wound assessment sheet, dated 3/19/19 at 1:15 P.M., showed: -Right hip wound proximal measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, moderate serous drainage noted, periwound intact; -Right hip wound distal measured 1.2 cm by 0.8 cm by 0.1 cm, 100% pink, moderate serous drainage, periwound intact; -Left medial leg measured 3.0 cm by 2.4 cm by 0.1 cm, 100% pink, small/moderate serous drainage, periwound intact; -Right medial thigh measured 3.0 cm by 2.0 cm by 0.1 cm, 100% pink, small/moderate serous drainage, periwound intact; -Treatment ordered (All wounds unless specified): Apply Kerramax border gauze dressing (super absorbent wound dressing with a soft flexible heat-sealed border) to hip area, change daily and to inner thigh/medical leg wounds; -Pillow between legs; -Off loading, turn schedule. Observation on 3/22/19 at 7:55 A.M., showed the wound nurse performed wound care for the resident: -The TAR on the treatment cart, opened and the wound nurse verified the following orders listed for the resident: -Right hip proximal and distal, border gauze every day; -Right medial thigh, border gauze daily; -Left medial leg, border gauze daily; -All three orders dated 3/21/19; -He/she obtained supplies from the cart, took them into the resident's room, placed them on the window sill and went to the sink to wash hands and don gloves; -He/she removed the pillow from between the resident's legs, set up a barrier cloth on the resident's bed, removed his/her gloves, washed hands at the sink and donned new gloves; -He/she moved the supplies from the window sill, placed them on the barrier, proceeded to tear open three gauze sponges and three border gauze dressings; -He/she removed the resident's brief, exposing the right hip, took off the dirty undated dressing and touched the wound bases with his/her right gloved hand. He/she said the wound consisted of two small areas that are Stage II, 100% pink, scant drainage, periwound intact; -Without changing gloves, he/she removed the left medial leg and right medial thigh bandages, touched both wound bases with the same right gloved hand and described them as: -Left medial leg, Stage II with 10% slough and 60% necrotic tissue in the center of the wound, moderate drainage, periwound intact; -Right medial thigh, Stage II with pink tissue, 10% light yellow slough in the center of the wound, scant drainage, periwound intact; -He/she washed his/her hands and donned new gloves; -He/she measured the residents wounds with the same paper wound measurement tape by placing the tape inside each wound bed. He/she used the same pair of gloves for all four of the following wound measurements: -Right distal hip, Stage II measured 1.0 cm by 0.7 cm; -Right proximal, stage II measured 0.3 cm by 0.2 cm; -Left medial leg, Stage II measured 2.8 cm by 2.4 cm; -Right medial thigh, Stage II measured 2.0 cm by 2.5 cm; -The wound nurse left the resident on the dirty bed sheets, with his/her right and left legs rubbing against each other with no dressing to cover the wounds, walked to the bedroom sink, washed his/her hands and donned new gloves; -Without cleansing the wound, he/she took a border gauze dressing and placed it directly on the resident's right hip Stage II pressure ulcers; -Without changing gloves or cleansing the wound, he/she placed a border gauze dressing on the right medial thigh Stage II pressure ulcer; - Without changing gloves or cleansing the wound, he/she placed a border gauze dressing on the left medial leg Stage II pressure ulcer. Observation on 3/25/19 at 11:30 A.M., showed the resident lay in bed on his/her back with the right medial thigh without a dressing applied. At 11:35 A.M., the wound nurse performed wound care for the resident: -She entered the resident's room with treatment supplies from the treatment cart, including a communal bottle of wound cleanser. She placed the supplies on the window sill, without a barrier; -She cleansed her hands and donned gloves; -She examined the resident's right medial thigh Stage II, touched the wound base with her right gloved hand and described it as rough, scabbed, dry, 95% yellow, greenish circle in the middle of the wound, surrounded by pink tissue and has two new small Stage II areas located above the existing wound, approximately 1 cm wide; -Without changing gloves, she removed the dirty bandage from the resident's left medial leg Stage II, touched the wound base with the same gloved hand and described it as 75% necrotic tissue, some yellow tissue in the center of the wound surrounded by pink tissue with bloody scant drainage; -Without changing gloves, she exposed the resident's right hip by pulling down the resident's brief. There was not a dressing on the right hip or in the brief. The wound nurse used the same gloved finger and rubbed it over the two wounds on the right hip and stated the Stage II wounds were healed, with no drainage. (Both the right hip distal and proximal Stage II wounds presented with bright pink, shiny tissue); -The wound nurse proceeded to cleanse the wounds by using the communal bottle of wound cleanser off of the window sill, spraying 4 by 4 gauze sponges with the solution and then placing the wound cleanser back on the window sill; -After the wound nurse completed the wound treatments for the residents, she took the communal wound cleanser bottle off of the window sill and placed it back on the treatment cart. Observation on 3/27/19 at 8:15 A.M., showed the resident lay in bed on his/her right side with a pillow placed between the knees and a dirty, used silicone border dressing wadded up on the bed near the resident's legs. The left medial leg Stage II covered with a border gauze dressing dated 3/26/19, saturated with red, brown drainage. The dressing half off of the wound. Unable to see right medial thigh wound due to the position of the resident. During an interview on 3/26/19 at 2:19 P.M., the DON said: -The wound nurse is expected to recognize slough and necrotic tissue in a wound bed and to cleanse a wound before applying a new dressing due to infection control; -The wound nurse is expected to change gloves before the treatment begins, from a dirty to clean task, to perform hand hygiene every time gloves are removed and should treat each wound separately; -It is not acceptable to touch the wound base of several different wounds with the same dirty gloved hand or to use the same wound measurement tape to measure several different wounds; -It is important to maintain sterile technique to avoid cross contamination between wounds, to prevent further compromising the resident; -It is not appropriate to use communal items such as wound cleanser, normal saline, or a box of gloves without putting the items on a clean barrier in the resident's room due to infection control. 3. Review of Resident #33's POS, dated 3/1/19 through 3/31/19, showed: -[DIAGNOSES REDACTED]. -An order dated 10/10/18, to cleanse the wound on the top left foot and apply [MEDICATION NAME] (antiseptic used for skin disinfection), 4x4 gauze and Kling (gauze wrap) once a day; -An order dated 1/28/19, to apply Santyl to the left outer foot wound (no frequency noted); -No further pressure ulcer treatment orders found as late as 3/25/19 at 12:20 P.M. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has high risk for pressure ulcer development; -On 10/17/18 - readmitted with a Stage I (an observable, pressure-related alteration of intact skin) pressure ulcer on top of left foot; -On 2/22/19 - Left dorsal (upper side) foot - Stage II. Left lateral (outer side) foot and left plantar (bottom/heel area) foot - unstageable pressure ulcers; -On 3/8/19 - All wounds remain; -On 3/15/19 - Resident is non-compliant with wound care, refuses treatments; -Goal: Will have intact skin, free of redness, blisters or discoloration; -Interventions included: Administer treatments as ordered. If resident refuses treatment, have another nurse attempt treatments. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation on 3/25/19 at 10:15 A.M., showed the resident lay in bed awake. The wound nurse took equipment into the resident's room, washed hands, put on gloves, removed the dressing dated 3/24/19, from the resident's wound on the left lateral foot, the left dorsal foot and left planter area of the left foot. The wound nurse changed gloves, cleaned each area individually with wound cleanser, applied wet with normal saline 4 by 4 gauze, dry 4 by 4 gauze to each area individually, wrapped the entire foot with [MEDICATION NAME] gauze, secured with tape, removed gloves, washed hands and left the resident's room. Review of the resident's TARs, dated 3/1/19 through 3/31/19, showed an order dated 3/5/19, to cleanse all the areas with wound cleanser, apply a wet to dry dressing and wrap with [MEDICATION NAME] daily. During an interview on 3/25/19 at 12:20 P.M., the DON verified there was no order for staff to clean the areas with wound cleanser, apply a wet to dry dressing and wrap with [MEDICATION NAME] once a day, on the POS. She would expect staff to obtain an order to discontinue the previous order and write the current order on the POS and TARs. She thought the resident had been seen by the specialized wound management company earlier in the month, they may have changed the treatment orders, but she would expect staff to write the new orders on the POS and discontinue the old orders, no longer in use. She could not find any documentation of the resident being seen in March, 2019 by the wound management company, in the resident's medical record. 4. Review of Resident #116's quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer of the sacrum (tailbone area); -Severe cognitive impairment with short and long term memory problems; -One Stage III pressure ulcer and two unstageable pressure ulcers; -Incontinent of bowel and bladder; -Required total assistance from the staff for transfers, dressing, hygiene and bathing. Review of the resident's care plan, dated 8/9/18, updated on 11/16/18 and in use during the survey, showed: -Problem: Pressure ulcer to the coccyx or potential for pressure ulcer development related to immobility; -On 2/22/19 - Coccyx Stage III healing well; -On 3/8/19 - Coccyx Stage III remains; -Goal: Pressure ulcer will show signs of healing and remain free from infection. Resident will have intact skin, free of redness, blisters or discoloration; -Interventions included: Administer treatments as ordered and monitor for effectiveness. Monitor dressing during care to ensure it is intact and adhering. Report lose dressing to treatment nurse. Review of the resident's TAR, dated 3/1/19 through 3/31/19, showed an order dated 12/26/18 to apply Santyl, 4 by 4 gauze, ABD (fluffy, surgical dressing) and secure with tape every day. Observation and interview on 3/25/19 at 6:10 A.M., showed the resident lay in bed, awake. CNA Z unfastened the resident's adult incontinence brief, turned him/her onto his/her side and revealed a large pressure ulcer on the coccyx. No dressing covered the pressure ulcer, or was found in the brief, bed or floor. CNA Z said he/ (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice by not following physician orders for oxygen therapy, failing to provide ongoing assessment and documentation of the resident's respiratory status and response to oxygen therapy and failing to care plan interventions for oxygen therapy. As a result, the resident experienced acute on chronic [MEDICAL CONDITION] (inability to breathe) which required re-hospitalization , for one resident (Resident #320). In addition, the facility failed to obtain orders for oxygen usage for one resident (Resident #63). The sample was 20. The census was 96. 1. Review of the Resident #320's hospital records, dated 3/5/19, showed: -Hospital admitted [DATE]; -Resident was wheelchair bound and oxygen dependent and was found by nursing home staff unresponsive, lying on the floor without supplemental oxygen. The resident's blood oxygen saturation rate was 77% on room air. Emergency personnel were called for transport to emergency room ; -On arrival at emergency room , the resident was intubated (insertion of a tube through the mouth into the airway) and placed on mechanical ventilation (a machine that helps a person breathe when they cannot breathe on their own). Review of the resident's hospital discharge orders, dated 3/5/19, showed: -Discharge [DIAGNOSES REDACTED].>-Oxygen Saturation (percentage of oxygen in the blood), check as needed for respiratory distress (difficulty breathing) or change in condition per nurse assessment; -Oxygen instructions: Oxygen at 3 Liters (L) per minute by nasal cannula (a devise for delivering oxygen by way of two small tubes that are inserted into the nares) continuously. Review of the resident's facility medical record, showed: -Readmission date of [DATE]; -Medical [DIAGNOSES REDACTED]. -Social service progress note, dated 3/6/19 at 12:35 P.M., showed the resident: -Alert and oriented times two (able to recall person and place), with some confusion and forgetfulness; -Required limited assistance of one to two staff for transfers and assistance of one person for activities of daily living (ADLs; bathing, toileting, dressing, etc.); -Propelled self by wheelchair; -A Health status progress note, dated 3/5/19 at 5:03 P.M., showed: -Resident admitted to the facility from the hospital; -Oxygen at 2-3L per minute per nasal cannula; -A physician order sheet (POS), dated (MONTH) 2019, showed no order for oxygen therapy and/or to check the resident's oxygen saturation as needed for respiratory distress or change in condition per nurse assessment. Review of the resident's physician visit note, dated 3/12/19, showed: -Exam: Not awake, lethargic (lack of energy, sluggish), disorientation, labored breathing and a decrease of breath sounds heard; -Order: Acute on chronic hypoxic [MEDICAL CONDITION] with [MEDICAL CONDITION] ([MEDICAL CONDITION] brain disease), probably hypercarbic carbon [MEDICATION NAME] narcosis (elevated levels of carbon [MEDICATION NAME] in the blood, causing organ damage). Send back to hospital for continuous positive airway pressure ([MEDICAL CONDITION])/bi-level positive airway pressure ([MEDICAL CONDITION]) ([MEDICAL CONDITION] and [MEDICAL CONDITION] are devices that deliver pressurized air to expand the lungs and assist with breathing) with oxygen. Further review of the resident's POS, showed an order dated 3/12/19, to send the resident back to the hospital emergency room for acute on chronic hypoxic [MEDICAL CONDITION]. Review of the resident's progress notes, showed no documentation a nurse assessed the resident, obtained an oxygen saturation level, or documentation of the resident's condition upon transfer to the hospital. Review of ambulance transport report, dated 3/12/19, showed: -Resident returning from the hospital to the facility; -Resident on 3L of oxygen via nasal cannula. Review of the resident's progress notes, showed no documentation a nurse assessed the resident, obtained an oxygen saturation level, or documentation of the resident's condition upon return from the hospital. Further review of the resident's POS, reviewed on 3/22/19 at 2:05 P.M. and on 3/25/19 at 2:45 P.M., showed no orders for oxygen therapy and/or to check the resident's oxygen saturation level. Review of the resident's (MONTH) 2019 medication administration record (MAR) and treatment administration record (TAR), reviewed on 3/22/19 at 2:10 P.M. and on 3/25/19 at 2:50 P.M., showed no documentation of the administration of oxygen therapy or oxygen saturation tests for the resident. Review of the resident's care plan, dated 3/7/19 and reviewed on 3/25/19 at 3:34 P.M., showed no documented [DIAGNOSES REDACTED]. Observations on 3/21/19, showed: -At 10:45 A.M., the resident sat in a wheelchair in his/her room. The resident's chin to his/her chest and his/her body slumped over the right side of the wheelchair. His/her right arm dangled down to the wheelbase. He/she rammed the wheelchair into the wall. An oxygen concentrator unit located alongside the resident's bed and an empty oxygen tank attached to the back of the resident's wheelchair. The resident wore the nasal cannula connected to the empty oxygen tank; -At 11:01 A.M., the resident used his/her left arm to propel him/herself around his/her bedroom. The resident's chin rested on his/her chest and his/her body slumped over the right side of the wheelchair. The resident's right arm dangled down to the wheelbase. An empty oxygen tank attached to the back of his/her wheelchair and the resident wore a nasal cannula connected to the empty oxygen tank; -At 11:53 A.M., the resident in his/her room, slumped all the way over onto the right side of his/her wheelchair. His/her right arm drug on the floor. The resident's chin rested on his/her chest and the resident grunted with his/her eyes closed. An empty oxygen tank attached to the back of his/her wheelchair and the resident wore a nasal cannula connected to the empty tank. Certified Nurse Aide (CNA) M entered the room and then immediately exited the room stating he/she needed clean supplies. CNA M did not offer to assist the resident; -At 12:43 P.M., the resident propelled him/herself down the hall. He/she used his/her right arm to pull on the handrails attached to the wall. An empty oxygen tank attached to the back of his/her wheelchair and the resident wore a nasal cannula connected to the empty tank. He/she slumped to the right side, head to chest and shouted Help me, please help me! Clinical Support Staff N in the hall, passed water and ice to residents and responded, Yep and walked away. A nurse in the hall passed medication from a medication cart did not respond to the resident. The resident continued to propel him/herself down the hall towards the nurse's station, by pulling on the handrails, grunted, cursed and called for help; -At 12:47 P.M., the Assistant Director of Nursing (ADON) saw the resident at the nurse's station and asked him/her what he/she needed. Without waiting for a response, the ADON turned the resident around in his/her wheelchair and propelled the resident back down the 100 hall towards his/her room. The resident remained slumped all the way to the right side of the wheelchair, hung over the arm rest with his/her arm down to the floor. The resident wore a nasal cannula attached to an empty oxygen tank on the back of his/her wheelchair. The ADON did not check the oxygen tank's flow meter or gauge, assess the resident and/or obtain oxygen saturation levels on the resident; -At 12:48 P.M., the ADON left the resident in his/her room and said she will get someone to help. The resident said Damn it! to him/herself. The ADON returned moments later with the Director of Nursing (DON). The DON removed the resident's nasal cannula and helped the ADON transfer the resident to the toilet; -At 12:58 P.M., CNA M entered the room. The ADON left the room and said she would return with a new oxygen tank. CNA M finished dressing the resident and propelled the resident out of the bedroom to the dining room. No staff assessed the resident or obtained an oxygen saturation on the resident. The resident did not have an oxygen tank on his/her wheelchair and wore no oxygen. The nasal cannula slung over the resident's wheelchair, in between the resident and the back of the wheelchair. The resident slumped to the right side of the wheelchair and hung over the right arm rest, with his/her head to his/her chest; -At 1:19 P.M., the resident sat in the dining room, the DON approached him/her and talked to him/her at the table. The DON adjusted the resident's collar and walked away. The resident still had no oxygen tank and wore no oxygen; -At 1:26 P.M., CNA O came into the dining room with a full oxygen tank. CNA O locked the resident's wheelchair and said to the resident he/she had to stay at the table. The resident yelled no, take it off and struggled to unlock the wheels of the wheelchair. The resident could not unlock his/her wheelchair. After placing the oxygen tank on the back of the resident's wheelchair, the CNA attached the nasal cannula. CNA O tried to put the nasal cannula on the resident, without first explaining to the resident what he/she prepared to do, and said You have to wear this. The resident screamed back No, I don't. The CNA put the nasal cannula back down over the handle of the wheelchair, unlocked the resident's wheelchair and walked away. Observations on 3/22/19, showed: -At 6:50 A.M., the resident lay in bed in his/her room, a nasal cannula wrapped around the handle bar on the back of the resident's wheelchair. No oxygen tubing connected to the concentrator located at the bedside. The oxygen tank on the wheelchair empty. The resident wore no oxygen; -At 7:10 A.M., the resident sat on the edge of his/her bed, slumped over to the right side and tried to stand up with very shallow breathing. His/her head bowed down, chin to chest. The resident opened and shut his/her eyes intermittently. The resident did not have oxygen on; -At 7:14 A.M., CNA B walked into the resident's room and saw the resident on the side of the bed. CNA B said he/she was going to get someone to help the resident and left the room without doing anything to assist the resident. A few minutes later, CNA B returned again, walked in the room, repeated he/she will get help and left again. The resident continued to try to stand by clutching his/her roommate's wheeled walker for support. The resident lost his/her balance and fell back onto the bed, with the right side of his/her body draped over the footboard; -At 7:27 A.M., CNA B returned with Nurse C. Nurse C and CNA B washed their hands and put on gloves. The resident sat on the side of the bed, slumped to right side with shallow breathing. The resident's eyes closed and his/her head bowed down with his/her chin on his/her chest. Nurse C did not assess the resident, check the resident's oxygen saturation level and/or apply oxygen on the resident; -At 7:28 A.M., CNA B left the room. Nurse C stood 3 feet away from the resident, with a curtain partially blocking his/he view of the resident. The resident sat on the edge of the bed, fidgeted by clasping and unclasping his/her hands, wiped his/her nose and mouth and crossed his/her legs back and forth on top of each other. The resident struggled to sit up straight, but kept falling back to the right side. The resident closed his/her eyes intermittently, with shallow breaths as he/she drooled. The resident grunted and asked for help. Nurse C responded by telling the resident the CNA will return and to not stand up. Nurse BB did not assess the resident or place oxygen on the resident; -At 7:32 A.M., CNA B returned to the room with clean clothes and briefs. CNA B dressed the resident and transferred the resident to his/her wheelchair with assistance from Nurse BB. Nurse BB then left the room without assessing the resident, checking the resident's oxygen saturation and/or placing oxygen on the resident. CNA B propelled the resident out of the room to eat breakfast in the dining room. The resident did not wear the nasal cannula and the oxygen tank on the wheelchair was empty; -At 7:50 A.M., the resident sat in the dining room, slumped to one side, chin to chest, eyes closed and drooled, with shallow breathing. No oxygen on the resident; -At 8:32 A.M., the resident sat in his/her wheelchair in front of the nurse's station. Nurse A saw the resident and propelled him/her down the hall to the dining room. Nurse A bent down and examined the oxygen tank gauge and walked away; -At 8:38 A.M., Nurse A returned to the resident with a full oxygen tank. Nurse A put a pulse oximeter (test to show blood oxygen saturation) on the resident's left hand, index finger. The oxygen saturation level measured 66% (normal 95% to 100%). The nurse did not put oxygen on the resident or further assess the resident; -At 8:41 A.M., Nurse A propelled the resident down the hall to his/her room. The resident wore the pulse oximeter that measured 68% oxygen saturation. The resident slumped all the way to the right side, eyes closed, and did not respond to questions. His/her chin rested on his/her chest and the resident had shallow breathing; -At 8:45 A.M., Nurse BB joined Nurse A in the resident's room. His/her oxygen saturation measured 63%. The resident wore no oxygen; -At 8:46 A.M., The resident breathed shallow breaths, did not respond to questions, slumped all the way to the right side, chin to chest and drooled with his/her eyes shut. Nurse BB placed an oxygen face mask (a disposable plastic mask worn over the nose and mouth, used to administer oxygen) on the resident and turned on the oxygen tank. Nurse A knelt down next to the resident's wheelchair and held the face mask to the resident's face. The resident's oxygen saturation measured 67% and raised to 69%; -At 8:49 A.M., the resident's oxygen saturation measured 82% as he/she continued to receive oxygen. Nurse BB left the room stating he/she needed to send the resident back to the hospital. The resident began to open his/her eyes and started to talk. His/her oxygen saturation raised to 97%; -At 8:54 A.M., the resident's oxygen saturation measured steady at 95% as he/she continued to receive oxygen. Nurse BB returned to the room to get the resident's blood pressure with a wrist blood pressure cuff. The nurse's did not perform a head to toe assessment of the resident, including counting respirations and/or listening to the resident's lung sounds; -At 9:00 A.M., the paramedics arrived to the room with a stretcher. The paramedics asked Nurse BB for the resident's medical [DIAGNOSES REDACTED]. Nurse BB told the paramedics the resident had a physician order for [REDACTED]. -At 9:10 A.M., the paramedics left the building with the resident on a stretcher to take him/her to the hospital emergency room . During an interview on 3/22/19 at 9:20 A.M., Nurse BB stated: -He/she did not know if the resident had oxygen orders; -Nurse BB looked at the (MONTH) 2019, POS and said there were not any oxygen orders or respiratory assessment orders listed; -The resident had a recent [DIAGNOSES REDACTED].>-He/she did not know the last time the resident had oxygen; -The resident did not exhibit any behaviors this morning; -The resident was admitted on [DATE] from the hospital with oxygen. The resident had not worn oxygen since he/she arrived; -The resident's physician sent him/her out to the emergency room last week due to [MEDICAL CONDITION]. At the time, the physician made the determination. The resident was not on oxygen. During an interview on 3/22/19 at 12:40 P.M., the DON said: -The nurse who admits a resident to the facility is responsible for ensuring all physician orders from the hospital are reconciled; -The ADON is responsible to check physician orders to ensure they are correct; -Nurses are expected to know the [DIAGNOSES REDACTED]. -Resident's with [MEDICAL CONDITION] and pneumonia [DIAGNOSES REDACTED]. -The DON assumed the resident had a physician order for [REDACTED]. -Signs and symptoms of respiratory distress include lethargy, weakness, confusion, shortness of breath, anxiety and aggressive behaviors; -Nurses are expected to recognize signs of respiratory distress; -Nurses are expected to know how to assess a resident in an emergent situation by completing a head to assessment including vital signs, respiration count and listening to lung sounds. During an interview on 3/26/19 at 9:45 A.M., the facility's Medical Director said: -If a resident was admitted to the facility following intubation at the hospital, it is expected they have oxygen therapy orders as needed and respiratory assessment orders as needed; -If a resident with a [DIAGNOSES REDACTED]. Review of the resident's hospital discharge orders, dated 3/26/19, showed: -Discharge [DIAGNOSES REDACTED]. -Oxygen Saturation - Check as needed for respiratory distress or change in condition per nurse assessment; -Oxygen instructions- Oxygen at 3L per nasal cannula continuously. Review of the resident's POS, dated (MONTH) 2019 and reviewed on 3/27/19 at 6:20 A.M., showed: -an order for [REDACTED]. -Pulse oximeter (oxygen saturation test) every shift, notify physician if oxygen saturation less than 90%. Review of the resident's (MONTH) 2019 MAR and TAR, reviewed on 3/27/19 at 6:36 A.M. and at 12:10 P.M., showed no orders for oxygen therapy or oxygen saturation tests for the resident. During an interview on 3/27/19 at 7:00 A.M., Nurses G and H stated oxygen and pulse oximeter orders are kept in the nurse's MAR and TAR binder. Observation on 3/27/19 at 6:23 A.M., showed the resident in the hall in his/her wheelchair. He/she called out for help. Nurse H walked down the hall, approached the resident and asked how he/she could help. Nurse H then propelled the resident to the nurse's station. The resident had an oxygen tank on the back of his/her wheelchair, the gauge read near empty, with the oxygen flowmeter set at 2L per minute and not the 3L as ordered. The nasal cannula located behind the resident, wrapped around the handle of the wheelchair. The nasal cannula out of reach of the resident. The resident wore no oxygen. Observation at 3/27/19 at 8:11 A.M., showed the resident propelled him/herself in his/her wheelchair on the 200 hall and grunted. The DON approached the resident and said she needed to get the resident a new oxygen tank because this one is empty. The DON propelled the resident down the hall, towards the nursing station. The resident was sat upright in the wheelchair. Observation on 3/27/19 at 8:22 A.M., showed the resident in his/her room with the nasal cannula inserted in his/her nostrils. A full oxygen tank hung off of the back of the resident's wheelchair with the oxygen tubing attached. The oxygen flow meter was set at 0L per minute. Observation on 3/27/19 at 9:45 A.M., showed the resident sat upright in his/her wheelchair and propelled him/herself down the 200 hall, with a nasal cannula inserted in his/her nostrils. The oxygen tank full and flow meter set at 2L per minute. Further review of medical record, reviewed on 3/22/19 at 3:40 P.M., showed: -Documentation of vital signs obtained on 3/19, 3/20 and 3/22/19, the resident on oxygen via nasal cannula. The amount of O2 was not listed; -No respiratory assessments documented in the progress notes. During an interview on 3/22/19 at 12:40 P.M., the DON said she expects the nursing staff to accurately document all vital signs including the amount of oxygen administered. Nurses are expected to document respiratory assessments in the progress notes, especially when administering oxygen to residents. On 3/26/16 at 10:15 A.M., the DON said care plans are created collaboratively with the ADON and should include all of the resident's pertinent medical diagnoses, including [MEDICAL CONDITION] and pneumonia, information found on the hospital transfer forms and assessments from the admitting nurse. The ADON is responsible for checking care plans for accuracy. 2. Review of Resident #63's face sheet, showed: -Re-admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's POS, dated 2/1/19 through 2/28/19, showed an order, dated 1/30/19, for oxygen at 2L per nasal cannula as needed (PRN). Review of the resident's POS, dated 3/1/19 through 3/31/19, showed: -An order, dated 2/28/19, to check and record PRN oxygen saturation; -An order, dated 3/2/19, for [MEDICATION NAME] (medication used to treat asthma) treatment PRN 2.5-0.5 milligram (mg)/3 milliliter (ml) every six hours, inhale 1 vial per nebulizer (machine used for breathing treatments); -No order for how many liters of oxygen to administer. Review of the resident's care plan, dated 12/26/18, showed: -Focus: Resident has a [DIAGNOSES REDACTED]. On 1/30/19, resident was readmitted with the [DIAGNOSES REDACTED]. -Interventions: Advise resident to minimize contact with known offending allergens; -Focus: Resident has a [DIAGNOSES REDACTED]. -Interventions: Check breath sounds and monitor/document for labored breathing; -Monitor/document for the use of accessory muscles while breathing; -Monitor vital signs as ordered/needed. Notify the physician of significant abnormalities; -Oxygen settings: Oxygen as ordered/needed; -Check oxygen saturation as ordered/needed. Observation of the resident, showed: -On 3/22/19 at 12:04 P.M., the resident's oxygen tank located on the back the wheelchair. The oxygen tubing hung around the oxygen tank and the nasal cannula was uncovered hanging against the tank. The oxygen tubing not dated; -On 3/22/19 at 1:45 P.M., the resident not in the room. The nebulizer mask uncovered on the bedside table. The mask not dated; -On 3/25/19 at 11:06 A.M., the resident not in the room. The nebulizer mask uncovered on the bedside table. The mask not dated; -On 3/25/19 at 1:58 P.M., the resident's oxygen tank on the back the wheelchair. The oxygen tubing hung around the oxygen tank and the nasal cannula uncovered and hung against the tank. The oxygen tubing not dated. During an interview on 3/27/19 at 10:30 A.M., the DON said she would expect the resident's oxygen orders to be complete. It should include the amount of liters of oxygen to administer. She would expect the nasal cannula and the mask to be covered and dated. 3. Review of the facility's oxygen administration policy, dated 2012, showed: -Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Procedure: -Check the physician's order for liter flow and method of administration; -At regular intervals, check liter flow contents of the oxygen cylinder, fluid level in humidifier and assess resident's respirations to determine further need for oxygen therapy; -Monitor resident's response to therapy with pulse oximetry as necessary; -Documentation guidelines: -Date, time, method of administration and liter flow as ordered; -Condition of the resident before procedure and effectiveness of oxygen therapy; -Vital signs before oxygen was started and periodically after initiation of therapy; -Care Plan Guideline: -Problem: Identify the appropriate problem under which to list oxygen administration as an approach; -Goal: List measurable goals to be accomplished with a target date; -Approaches included: List necessary monitoring and observation of the resident's respiratory function.

Based on observation, interview and record review, the facility failed to notify the physician for three of three residents with severe weight loss, failed to administer nutritional boluses as ordered for three of four residents, failed to complete meal consumption reports for three residents and failed to notify the physician with recommendations made by the Registered Dietician for seven residents. This affected three of 13 sampled residents and four from an expanded sample (Residents #4, #14, #6, #20, #21, #22, and #11). The census was 67. 1. Review of Resident #4's initial Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/26/13, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Severe impairment with daily decision making; -Inattention and disorganized thinking present; -Limited assistance required with transfers, ambulation and dressing; -Extensive assistance required with hygiene; -Total dependence required with eating; -No weight gain or loss of 5% or more in the last month, or 10% or more in the last six months; -Height of 64 inches; -Weight of 111 pounds (lbs); -Feeding tube ([DEVICE], a tube inserted through the abdomen for the delivery of food, fluid and/or medications directly into the stomach). Review of the resident's nutritional progress notes dated 12/18/13 and completed by the Registered Dietician (RD), showed: -Dietary information: Staff were to monitor intake and both poor and fair were circled. Weight 102 pounds and underweight circled. The plan was increase his/her weight; -Assessment: Staff reported little intake at meals. Would add bolus feeding (use of a [DEVICE] to provide nutrition to individuals who will not or cannot eat by normal means) to support needs and increase weight; -Recommendation: Bolus of 1 can of [MEDICATION NAME] 1.2 (nutritional supplement) after meals if meal intake is under 50%. Review of the weight log, dated 12/23/13, showed the resident weighed 110.6 pounds. Review of the resident's physician's orders [REDACTED]. Review of the medication administration record (MAR) and meal intake record, dated 1/1/14 through 1/31/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if the resident ate less than 50% of meal; -No consumption amount recorded for 47 meals; -Consumption amounts documented of less than 50% with no bolus feedings given during the following times: -Breakfast on 1/16, 1/17, 1/19, 1/22, 1/23; 1/24, 1/26, 1/27, 1/29 and 1/31/14; -Lunch on 1/19, 1/20, 1/21 1/22, 1/24, 1/26, 1/27 and 1/31/14. Review of the resident's nutritional progress note, dated 1/31/14, showed a recommendation for a basic metabolic panel (BMP, a blood test that checks for kidney function and electrolytes) after three days and for a bolus feeding of 1 can of Diabetisource (diabetic nutritional supplement) three times daily if the resident ate less than 50%. Review of the resident's POS, dated 2/1/14 through 2/28/14, showed: -an order for [REDACTED]. -No order for the BMP. Review of the resident's MAR and meal intake record, dated 2/1/14 through 2/3/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if the resident ate less than 50% of meal; -No consumption amounts recorded for six meals; -Consumption of less than 50% with no bolus feedings given on 2/3/14 for breakfast and lunch. Review of the resident's laboratory tests, showed no BMP results for 2/3/14. Review of the resident's MAR and meal intake record, dated 2/4/14 through 2/5/14, showed no consumption amounts recorded for two meals. Review of the resident's nurse's notes showed: -On 2/5/14, obtained an order to change the bolus feeding to [MEDICATION NAME] 2.0, 1 can if the resident ate less than 50% of meal for increased caloric intake due to significant weight loss; -No notes regarding additional bolus feedings that the MAR did not reflect. Review of the resident's MAR and meal intake record, dated 2/6/14 through 2/7/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if he/she ate less than 50% of a meal; -No consumption amounts recorded for three meals and consumptions of less than 50% with no bolus feedings given on 2/6/14 for breakfast and 2/7/14 for lunch. Review of the weight log, dated 2/7/14, showed the resident weighed 99.6 pounds, which was an 11 lb or 9.95% decrease in 1 1/2 months, resulting in a severe weight loss (The guidance to surveyors defines severe weight loss as greater than 5% in one month, greater than 7.5% in three months or greater than 10% in six months). Review of the resident's MAR and meal intake record, dated 2/8/14 to 2/28/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if he/she ate less than 50% of a meal; -No consumption amount recorded for 22 meals and consumptions of less than 50% with no bolus feedings given during: -Breakfast on 2/8, 2/13, 2/14, 2/17, 2/18, 2/20, 2/23 and 2/26/14 for breakfast; -Lunch on 2/20 through 2/23, 2/25 and 2/26/14; -Dinner on 2/23/14. Review of the resident's nutritional progress note, dated 2/28/14, showed a recommendation for a bolus feeding of [MEDICATION NAME] 2.0, 1 can if the resident ate less than 50%. Review of the resident's MAR and meal intake record, dated 3/1/14 through 3/10/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if he/she ate less than 50% of meal; -No consumption amounts recorded for eight meals and consumptions of less than 50% with no bolus feedings given during: -Breakfast on 3/3, 3/7 and 3/10/14; -Lunch on 3/3, 3/7 and 3/10/14. Review of the weight log, dated 3/10/14, showed the resident weighed 99.6 pounds with no change from the last recorded weight. Review of the resident's MAR and meal intake record, dated 3/11/14 through 3/19/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if he/she ate less than 50% of meal; -No consumption amounts recorded for 19 meals and consumptions of less than 50% with no bolus feedings given during: -Breakfast and lunch on 3/11, 3/12, 3/15 and 3/16/14. Review of the resident's care plan, updated on 3/18/14, showed the following: -Problem: The resident is very small with a poor appetite. He/She consumes 25-50% of meals. At risk for weight loss and fluid insufficiency. -Goal: Weight will be stable and/or show a gradual increase by next review. -Approaches included administering supplements as ordered; providing diet as ordered; offering substitutions for uneaten food; offering snacks between meals; dietary consults as needed; weighing as ordered per doctor and/or facility protocol; notifying doctor and dietician of significant weight loss. Observations on 3/19/14 of the resident showed: -At 7:39 A.M., the resident in his/her room during breakfast service. At 7:42 A.M., nurse O tried to wake the resident up. He/she proceeded to get up and went directly to the smoking area; -At 12:18 P.M., the resident in his/her room during lunch service. No staff encouraged the resident to come into the dining room. At 12:34 P.M., he/she entered the dining room, requested a meal tray and left. Staff continued to serve trays in the dining room. Review of the meal intake record printed on 3/21/14, showed no amount of consumption documented for either meal. Observations of the resident, on 3/20/14 showed: -At 7:48 A.M., entered the dining room; -At 7:56 A.M., received a banana chocolate chip muffin, scrambled eggs, 2 sausage links, a carton of whole milk, a cup of orange juice and a cup of milk. He/She began to feed himself/herself; -At 7:58 A.M., got up from dining table, after having eaten one bite of scrambled eggs, half a sausage link and approximately two bites of the muffin. He/She did not drink any of the liquids. No staff member attempted to encourage the resident to eat anymore or offer something different, prior to him/her going back to his/her room. Review of the resident's MAR and meal intake record, dated 3/20/14 to 3/21/14, showed: -[MEDICATION NAME] 2.0, 1 can three times daily if he/she ate less than 50% of a meal; -No consumption amounts recorded for four meals and no bolus feeding given on 3/20/14 for breakfast. Observation on 3/21/14 at 10:12 A.M., showed Certified Nurse Aide (CNA) E weighed the resident. He/She weighed 98.4 pounds. During an interview on 3/21/14 at 10:36 A.M., the administrator said the CNAs are responsible for documenting meal consumption amounts. She expects every resident's meal consumption to be documented. If residents have an order for [REDACTED]. During an interview on 3/21/14 at 1:11 P.M., the Director of Nurses (DON) said she did not know why the BMP ordered for 2/3/14 had not been obtained. During an interview on 3/21/14 at 1:45 P.M., CNA B said the resident typically did not eat and often refused breakfast and lunch. He/She would not drink juice but would drink water and milk. CNA B reports to the nurse if the resident does not eat over 25%. He/She did not know that if the resident consumed less than 50% of his/her meal that this must be reported to the nurse so that a bolus feeding could be administered. The CNAs are responsible for logging consumption amounts. During an interview on 3/21/14 at 2:15 P.M., Nurse C said the resident had poor eating habits and received a bolus feeding when he/she consumed under 50% of a meal. During an interview on 3/21/14 at 2:25 P.M., Nurse D said he/she looks at the resident's consumption amounts and decides if the resident was to receive a bolus feeding. He/She does not document meal consumption and does not know how to obtain the CNA's consumption records from the computer system. During an interview on 3/21/14 at 2:33 P.M., the DON said the CNAs are responsible for documenting meal consumption amounts. It is important for meal consumptions to be recorded. She expects the nurse to look at the meal consumption amounts and to record any bolus feedings administered. The bolus feeding should be administered if meal consumption amount is under 50%. The nurse did not administer the bolus feeding if the MAR was blank. During an interview on 3/21/14 at 4:15 P.M., Nurse A said the resident received a bolus feeding if he/she ate less than 50%. He/She typically worked with the resident three to four times a week. The resident typically ate 25-35% of the evening meals, but he/she ate over 50% the night before. The nurse typically is able to see what the resident consumes, but does ask a CNA if he/she is not able to. He/She does not check the electronic medical record system for meal consumption amounts, because he/she does not know how. During an interview on 3/26/14 at 12:02 P.M., the facility's medical director and the resident's physician said the bolus feeding was ordered to prevent weight loss because the resident did not eat very much. He would have expected the resident to receive the bolus feeding if the resident ate less than 50% as ordered. The facility staff did not inform him of the resident's severe weight loss. He would have expected the facility to inform him of the weight loss. During an interview on 3/27/14 at 12:08 P.M., the RD said she changed the nutritional supplement to [MEDICATION NAME] 2.0 in order to increase caloric intake. She was unable to assess the resident's hydration status since the BMP was not completed. She was unaware of the facility's process after her dietary recommendations are made. During an interview on 3/27/14 at 1:51 P.M., the administrator said the RD came to the facility monthly and as needed. She expects staff to notify the DON immediately when a significant weight loss is discovered so that a telephone dietary recommendation could be obtained. During an interview on 3/21/14 at 2:33 P.M., the DON said the charge nurse was responsible for notifying the doctor of significant weight loss. There are two restorative aides responsible for obtaining weights. The restorative aide fills out a flowsheet and is able to see if there is weight loss. The weights are given to the MDS coordinator, who decides on the plan of action to be taken. The MDS coordinator may decide to get a reweight, weights three days in a row and/or weekly weights. Weight loss is discussed in a weekly interdisplinary team meeting that consists of dietary, social services, the MDS coordinator, DON, Assistant Director of Nurses (ADON) and the activities department. The DON and MDS coordinator give the team's meeting notes to the charge nurse on each hall, which provide instructions on what resident orders are needed. The DON, ADON and MDS coordinator are all responsible for making sure these tasks are completed. 2. Review of Resident #14's significant change MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory problems; -Severe cognitive impairment; -Required total assistance of staff for all activities of daily living; -Weight: 98 lbs; -No weight change; -Not on a planned weight increase program. Review of the resident's electronic POS, dated 1/1/14 through 1/31/14, and printed on 3/21/14, showed the following: -House supplement (a high calorie supplement used to increase weight) three times a day with meals; -Med pass supplement (A supplement given with a medication pass, to provide additional calories and protein) give 60 milliliters (mls) three times per day. Review of the resident's electronic MAR, dated 1/1/14 through 1/31/13, and printed on 3/21/14, showed the following: -House supplement three times per day with meals; -Staff initialed as given on one of 31 days; -Med pass supplement: 60 ml three times per day; -Staff initialed as given on one of 31 days. Review of the resident's weight flow sheet, showed the following: -1/8/14: Weight: 91 lbs; -30 days: 0% weight loss; -90 days: 2.02% weight loss; -180 days: 8.73% weight loss. Review of the resident's nutritional progress notes, dated 1/9/14, showed the following: -Current body weight of 91 lbs, stable for one month; -Recommended weight range: 126 - 154 lbs, weight increase desired; -Diet order: Pureed with double entree, house supplement three times per day with meals; -Med pass supplement 60 mls three times per day. Would increase med pass supplement to 90 mls three times per day to further promote weight increase. Review of the resident's electronic POS, dated 2/1/14 through 2/28/14, and printed on 3/21/14, showed the following: -House supplement three times a day with meals; -Med pass supplement 60 mls three times per day. Review of the resident's electronic MAR, dated 2/1/14 through 2/28/14, and printed on 3/21/14, showed the following: -House supplement 60 mls three times per day with meals; -Staff initialed eight of 28 days; -Med pass supplement: 60 mls three times per day; -Staff initialed: eight of 28 days. Review of the resident's weight flow sheet, showed the following: -2/6/14: Weight: 90.2 lbs; -30 days: 0.88% weight loss; -90 days: blank; -180 days: 10.16% weight loss. Review of the resident's nurse's notes, dated 2/6/14 at 12:48 P.M., showed the following: -Maintained current weight of 91 lbs; -If weight declines, notify the physician. Review of the resident's weight flow sheet, showed the following: -3/7/14: Weight: 78.6 lbs; -30 days: 12.86% weight loss; -90 days: blank; -180 days: blank. Review of the resident's nurse's notes, showed the following: -3/7/14: No documentation regarding weight loss; -3/10/14 at 8:42 A.M.: Call placed to responsible party regarding coughing and gagging episode. Request the family make decision about placing a feeding tube or changing the resident's code status. (No documentation whether staff informed family of weight loss or whether staff notified the physician regarding the weight loss). Review of the resident's nutritional progress notes, dated 3/10/14, showed the following: -Current body weight: 78.6 lbs, significant weight loss for one month (The guidance to surveyors defines significant weight loss as 5% in one month, 7.5% in three months or 10% in six months). This reflects a 12.4 lb or 13.63% severe weight loss; -Recommended weight range: 126 - 154 lbs; -Diet order: Pureed with double entree, pudding thick liquids, house supplement three times per day with meals; -Med pass supplement three times per day; -Would increase med pass supplement to 90 mls three times per day; -Oral intake improvements needed to slow weight loss or start tube feeding if desired. Review of the resident's care plan, updated 3/18/14, showed the following: -Problem: Received a pureed diet with thickened liquids due to inability to swallow without choking related to disease process. His/Her appetite has decreased, does not like the consistency of the food; -Intervention: Administer diet as ordered, weigh as ordered, offer substitutions consistent with diet, consult dietitian as needed, offer small bites and allow ample time to swallow. Review of the resident's electronic MAR, dated 3/1/14 through 3/19/14, and printed on 3/21/14, showed the following: -House supplement three times per day with meals; -Staff initialed five of 19 days; -Med pass supplement: 60 mls three times per day; -Staff initialed five of 19 days. Observations showed the following: -3/19/14 at 12:55 P.M., CNA F fed the resident a pureed meal with a double entree, pudding thickened tea, water and no health shake. The resident consumed approximately 50% of meal -3/20/14 at 12:37 P.M., CNA F fed the resident a pureed meal with a double entree, pudding thickened juice and water, and no health shake; He/She consumed 25% of meal; -Review of the resident's dietary card, showed healthshake with each meal; -3/20/14 at 2:00 P.M.: Weight: 79.2 lbs. Review of the resident's electronic POS, dated 3/1/14 through 3/31/14, and printed on 3/21/14, showed the following: -House supplement three times per day with meals; -Med pass supplement: 60 mls three times per day, discontinued 3/21/14; -New order: Med pass supplement 90 mls, pudding thick consistency, three times per day. During an interview on 3/21/14 at 7:35 A.M., CNA F said the resident should receive thickened liquids and a house supplement with meals. Dietary staff are responsible for putting the resident's liquids on the tray including the house supplement. The house supplement has rarely been on the tray, especially in the evening time. The house supplement wasn't on the resident's tray on 3/19 and 3/20/14, but the CNA failed to ask for it. He/She should have asked dietary for the house supplement. During an interview on 3/21/14 at 8:00 A.M., Nurse G said the resident has an order for [REDACTED]. The certified medication technicians (CMTs) are responsible for administering the med pass supplement and the house supplement is given with the meals. He/She wasn't aware of the resident not receiving the house supplement at meal times. He/She recently started working on the unit and didn't know whether the prior nurse notified the resident's physician regarding the significant weight loss. He/She didn't know the dietitian recommended to increase the med pass supplement from 60 mls to 90 mls. In addition he/she wasn't aware of staff failing to document the administration of the house supplement or the med pass supplement. During an interview on 3/21/14 at 8:00 A.M., the DON said when the dietitian writes recommendations, he/she will give a copy to her and the MDS coordinator. She will make a copy and forward them to the charge nurse so they can contact the physician for orders. She didn't know why the nurses hadn't completed the recommendations. She expected the nurses to call the physician and notify him/her of weight loss and any dietary recommendations. She was not aware of the staff not providing the house supplement as ordered. The dietary staff are responsible for placing the house supplement on the resident's tray. Nursing staff should make sure the resident receives the house supplement. She said the CMTs are responsible for passing the med pass supplement. She doesn't know why staff failed to document whether the resident received the house supplement or the med pass supplement. During an interview on 3/21/14 at 2:32 P.M., the DON said the restorative aid documents the resident's weight from month to month and would be able to see any weight changes. Once weights are completed they are given to the charge nurse. The charge nurses are responsible for notifying the physicians of any weight loss. During an interview on 3/25/14 at 8:21 A.M., a family member said he/she had spoken to staff members recently about the resident's weight loss and had watched the staff fed him/her. Staff said the resident ate what he/she wanted and enjoyed sweets. He/She had tried to feed him/her and he/she seemed to like the house supplements. They recently decided to take the resident off of hospice and have a feeding tube inserted to help supplement his/her intake. During an interview on 3/26/14 at 12:06 P.M., the resident's physician said staff did not notify him of the resident's weight loss or of the dietitian's recommendations. He expected them to notify him whenever a resident had a weight loss and about any recommendations the dietitian had given. During a telephone interview on 3/27/14 at 12:00 P.M., the RD said she makes recommendations according to subjective information gathered from staff. Once the recommendations are completed she gives copies of the recommendations to various administrative staff. 3. Review of Resident #6's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Limited assistance with activities of daily living; -Supervision oversight with eating; -[DIAGNOSES REDACTED]. -Current weight in pounds: 235 lbs; -No known weight loss. Review of the resident's care plan, dated 2/18/14, showed the following: -Problem: May be at risk for episodes of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) related to insulin dependent diabetes. Regular textured low concentrated sweets diet. Will consume 75% - 100% of all meals and weight will be stable; -Goal: Weight will remain stable through next review; -Intervention: The facility will provide diet as ordered. Review of the resident's March electronic POS, showed the following: -3/14/14, Diabetic tube feeding (bolus) give 240 cubic centimeters (cc) per [DEVICE] four times a day. Review of the resident's electronic MAR , dated 3/14/14 through 3/20/14, showed to have zeros and blank spaces seven times regarding bolus administration. Review of the resident's electronic nurse's notes, dated 3/14/14 through 3/20/14, did not address zeros or blank spaces in the MAR. Observation on 3/17/14, showed the following: -11:20 A.M., the resident lay in bed calm and quiet; -12:20 P.M., the resident lay in bed calm and quiet with eyes closed; -12:30 P.M., staff assisted the resident to eat as he/she lay in bed. The resident ate 90%. Observation of the resident on 3/18/14, showed the following: -6:40 A.M., the resident lay in bed with eyes closed; -8:00 A.M., staff fed the resident a puree breakfast meal. The resident ate 90% -8:20 A.M., the resident lay in bed with eyes open; -12:10 P.M., staff assisted the resident to eat as he/she lay in bed. The resident ate 60%. Review of the resident's electronic medical record, showed the following weights; -January 2014: 235 lbs; -February 2014: 253 lbs; -March 2014: 226 lbs. Observation on 3/21/14 at 12:00 P.M., showed staff weighed the resident and he/she weighed 222 lbs. This reflects a severe weight loss of 12.25% in one month and a severe weight loss of 5.53% in two months. During an interview on 3/21/14 at 12:00 P.M., CNA N said all weights were recorded correctly and any loss should be reported to the charge nurse During an interview on 3/21/14 at 1:25 P.M., the DON said the following: -The blank spaces and zeros mean the bolus was not administered; -The resident should have received the bolus feedings as ordered and did not know why they were not; -The charge nurse should have notified the physician about the weight loss. During an interview on 3/26/14 at 12:00 P.M., the medical director said the following: -The resident's diet order was changed from regular liquid to diabetic liquid because the resident has diabetes. This supplement would help increase the resident's weight; -The bolus should have be administered as ordered. He should have been notified of the bolus not being administered and of any weight loss. He was not aware of the resident's severe weight loss. 4. Review of Resident #20's significant change in status MDS, dated [DATE], showed the following: -Usually understood/understands; -Extensive assistance of one person required for bed mobility, transfers, locomotion on/off the unit, toilet use and personal hygiene; -Total dependence for eating; -[DIAGNOSES REDACTED]. -Height of 68 inches; -Weight of 210 lbs.; -Feeding tube. Review of the resident's weight records, showed the following: -1/21/14: 214 lbs; -1/27/14: 214.40 lbs. Review of the RD's progress notes, dated 1/31/14, showed the following: -Current weight of 214 lbs, an increase of 4 lbs; -Fibersource HN (nutritional supplement/meal replacement) 250 ml (one can) bolus if the resident's meal consumption was below 50%; -Fibersource HN 250 ml bolus twice a day routinely; -Recommend to discontinue the routine twice a day Fibersource HN bolus. Review of the resident's weight records, showed the resident weighed 213.20 lbs. on 2/6/14. Review of the resident's meal consumption record completed by the CNAs, and progress notes completed by the nurses, showed no documentation of the following meals from 2/1/14 through 2/28/14: -Breakfast: 2/3, 2/4, 2/6, 2/11, 2/12, 2/14, 2/17, 2/18, 2/20, 2/21 and 2/24/14; -Lunch: 2/3, 2/4, 2/6, 2/8, 2/11, 2/12, 2/14, 2/17, 2/18, 2/20, 2/21, 2/23, 2/24 and 2/28/14; -Dinner: 2/4, 2/5, 2/6, 2/9, 2/12, 2/17, 2/18, 2/18, 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, 2/26 and 2/28/14. Review of the resident's MAR, dated 2/1/14 through 2/28/14, showed the following orders: -Fibersource HN 250 mls routinely at 9:00 P.M. and 1:00 A.M.; -Staff documented the administration of the Fibersource HN at 9:00 P.M. and 1:00 A.M.; -Fibersource HN 250 mls, bolus at breakfast, lunch and supper, if the resident ate less than 50%; -Staff documented the administration of the Fibersource HN 250 mls bolus when the resident ate 50% or more according to the consumption record completed by the CNAs: -Breakfast: 2/2, 2/7, 2/10 and 2/12/14; -Lunch: 2/1, 2/5 and 2/7/14; -Dinner: 2/2, 2/3, 2/11 and 2/13/14; -Staff failed to document the administration of the Fibersource HN 250 mls bolus, on 2/10/14, at lunch when the CNA meal consumption record showed the resident ate 0% of his/her lunch. Review of the RD's progress notes, dated 2/28/14, showed the the following: -Current weight of 213.2 lbs, an increase of 4 lbs; -Fibersource HN 250 mls (one can) bolus if the resident's meal consumption was below 50%; -Fibersource HN 250 ml bolus twice a day routinely; -Recommend to discontinue the routine twice a day Fibersource HN bolus. Review of the resident's meal consumption record completed by the CNA's, and progress notes completed by the nurses, showed no documentation of the following meals from 3/1/14 through 3/22/14: -Breakfast: 3/3, 3/4, 3/5, 3/6, 3/13 and 3/17/14; -Lunch: 3/3, 3/4, 3/5, 3/6, 3/9, 3/13 and 3/17/14; -Dinner: 3/3, 3/4, 3/6, 3/7, 3/10, 3/11, 3/13, 3/14, 3/15, 3/16 and 3/17/14. Review of the resident's MAR, dated 3/1/14 through 3/31/14, showed the following orders: -Fibersource HN 250 mls routinely at 9:00 P.M. and 1:00 A.M.; -Staff documented the administration of the Fibersource HN at 9:00 P.M. and 1:00 A.M.; -Fibersource HN 250 mls, bolus at breakfast, lunch and supper, if the resident consumed less than 50%. During an interview on 3/21/14 at 8:00 A.M., the DON said the CNAs are responsible for completing the meal consumption records in the computer system before their shift was completed. She had never pulled the resident's individual meal consumption records from the computer system because she did not know how. She did not know why the nurses documented administering a bolus after a meal when the consumption sheet showed the resident ate 50% or more of the meal. During an interview of 3/21/14 at 2:25 P.M., Nurse D said he/she decides whether to administer the bolus after meals after he/she sees what the resident ate. He/She does not always record the resident's meal intake in the progress notes. He/She does not know how to access the CNA's meal consumption records from the computer system. During an interview on 3/21/14 at 4:15 P.M., Nurse A said he/she does not know how to access the CNA's consumption reports from the computer system. He/She tries to see what the resident ate so he/she can determine if a bolus should be administered after the meal. He/She does not always document the consumption. During a telephone interview on 3/27/14 at 10:35 A.M., the administrator said she reviewed the resident's RD recommendations and medical record. Staff failed to contact the resident's physician about the RD recommendations on 1/31/14 and again on 2/28/14, to discontinue the routine Fibersource HN bolus feedings. During a telephone interview on 3/27/14 at 12:20 P.M., the RD said she repeated the 1/31/14 recommendation on 2/28/14, because it had not been addressed. 5. Review of the Resident #21's admission face sheet, showed an admission date of [DATE]. Review of the resident's POS, dated 1/1/14 through 1/31/14, showed a [DIAGNOSES REDACTED]. Review of the resident's weight record, showed the following: -1/8/14: 167.40 lbs.; -2/7/14: 165.80 lbs. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Sometimes understood/understands; -Limited assistance of one person required for bed mobility, transfers, walking in room/corridor, toilet use and personal hygiene; -Independent for eating; -Height of 63 inches; -Weight of 165 lbs; -Feeding tube. Review of the resident's meal consumption record completed by the CNAs, and progress notes completed by the nurses, showed no documentation of the following meals from 2/1/14 through 2/28/14: -Breakfast: 2/1, 2/15, 2/16, 2/18, 2/19, 2/25, 2/26, 2/27 and 2/28/14; -Lunch: 2/1, 2/15, 2/16, 2/18, 2/19, 2/25, 2/26, 2/27 and 2/28/14; -Supper: 2/1, 2/2, 2/10, 2/11, 2/16, 2/25, 2/26 and 2/27/14. Review of the resident's MAR, dated 2/1/14 through 2/28/14, showed the following: -Diabetisource (nutritional supplement) 250 mls per bolus if the resident consumed less than 50% of the meal; -Staff documented the administration of the Diabetisource HN 250 mls bolus when the resident ate 50% or more according to the consumption record completed by the CNAs: -Breakfast: 2/2, 2/3, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10, 2/11, 2/12, 2/14, 2/17, 2/20, 2/22, 2/23 and 2/24/14; -Lunch: 2/3, 2/5, 2/8, 2/10, 2/12, 2/14, 2/17, 2/20, 2/22, 2/23 and 2/24/14; -Dinner: 2/3, 2/4, 2/5, 2/7, 2/8, 2/19, 2/22 and 2/24/14; -Staff failed to document the administration of the Diabetisource HN 250 mls bolus, on 2/21/14, at lunch when the CNA meal consumption record showed the resident ate 0% of his/her lunch. Review of the resident's weight record, showed the following: -3/10/14: 161.40 lbs. Review of the resident's meal consumption record completed by the CNAs, and progress notes completed by the nurses, showed no documentation of the following meals from 3/1/14 through 3/19/14: -Breakfast: 3/13 and 3/16/14; -Lunch: 3/13 and 3/16/14; -Supper: 3/1, 3/2, 3/10, 3/11, 3/15, 3/16, 3/17 and 3/18/14. Review of

Based on observation, interview and record review, the facility failed to promote the highest practicable physical well-being by not scheduling oral surgery in a timely manner for one of 13 sampled residents. As a result, the resident suffered from pain and had a severe weight loss. (Resident #2) The census was 76. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/12, showed the following: -Usually understood; -Sometimes understands; -Short/Long term memory problem; -Disorganized thinking: Behavior continuously present, does not fluctuate; -Poor appetite not indicated; -Independent for eating with set-up assistance; -[DIAGNOSES REDACTED]. -No pain; -Weight of 187 pounds (lbs.); -No oral/dental problems. Review of the facility monthly weight review form, dated 9/13/12, showed the resident weighed 180.2 lbs. Review of the resident's most recent available MDS assessment, an annual, dated 10/5/12, showed the following: -Pain section: No pain. Not on a scheduled pain medication regimen. No PRN (as needed) pain medications. -Oral/Dental section: Mouth or facial pain, discomfort, or difficulty chewing. No natural teeth or tooth fragments; -Independent for eating with set-up assistance; -No nutritional approach; -Weight of 184 lbs. Review of the resident's nurse's notes, dated 10/11/12 at 10:42 P.M., showed the resident received antibiotics for facial swelling. Review of the resident's nutrition progress notes, showed the following: -11/30/12 (no time documented), weight of 178 lbs., weight loss of 11 lbs. in three months; -12/28/12 (no time documented), weight loss due to decreased intake. Received health shakes twice a day, refused snacks. Review of the facility monthly weight review form, dated 12/12, showed the resident weighed 168.8 lbs. Review of the resident's nurse's notes, showed the following: -On 1/3/13 at 6:00 P.M., staff documented the resident had a poor appetite at dinner. He/She consumed 10% of the meal and became agitated when staff encouraged him/her to eat more. Review of the residents physician's orders [REDACTED]. -Regular consistency diet; -An order dated 1/28/09, for [MEDICATION NAME] (pain reliever and fever reducer) 325 milligrams (mg) two tablets every four hours as needed; -An order dated 1/28/09, for an [MEDICATION NAME] coated 81 mg aspirin daily. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility was unable to provide a copy of the resident's PRN MAR for 1/7/13 through 2/6/13. Review of the resident's nurse's notes, showed the following: -On 1/7/13 at 10:55 P.M., he/she had a swollen mouth and complained of tenderness. The resident could eat soft foods but had a poor appetite at dinner; -On 1/9/13 at 7:00 P.M., the resident had a poor appetite during dinner. He/She consumed 10% of the meal. Review of the resident's nutrition progress notes, showed the following: -1/14/13 (no time documented), weight decreased 11 lbs. in 180 days. Did not eat well but liked desserts. Received two desserts during meals. Review of the resident's care plan, dated 1/18/13, showed the following: -Assist and encourage the resident (via cues and coaching) during meals; -Several broken or carious teeth; -Unable to have teeth pulled due to the need for anesthesia; -Monitor resident for pain and swelling; -Administer medications as ordered; -Continue to search for a dentist; -Provide appropriate diet per order; -Monitor for chewing or swallowing difficulties; -Monitor intake of food and fluids; -Monitor chewing for any signs or symptoms of pain; -The resident's care plan did not provide instruction to staff regarding daily dental care; The care plan did not address the resident's weight loss. Review of the resident's social service progress notes, dated 1/18/13 (no time documented), showed: -The administrator spoke to staff at the resident's dental office; -The dental office manager said the resident needed to see an oral surgeon for tooth or gum problems, because the dental staff had done everything they could do; -Dental office staff said the closest place for the procedure would be Hannibal, Missouri; -Social service director to call provider services in Jefferson City Missouri on 1/21/13 for a listing of all available oral surgeons, in order to schedule the resident's appointment. Review of the resident's nutrition progress notes dated 2/12/13 (no time documented), showed the resident's weight decreased to 165.1 lbs. Review of the dietitian consult report for all residents, dated 2/12/13, showed the dietician noted following concerns: -The resident did not have a dietary assessment form in his/her chart; -The resident should receive two desserts with every meal; -Monthly weights were only partially documented in the resident's charts; -Monthly weights were not entered into the database in order to generate a weight variance report; -Weights needed to be entered in the database, in order to run variance reports and make interventions PRN; -Health shakes were not labeled with residents' names or being distributed on the unit. Review of the resident's POS, dated 2/7/13 through 3/6/13, showed the following: -Regular diet; -An order dated 2/18/13, [MEDICATION NAME] ([MEDICATION NAME] antibiotic) 500 mg three times (TID) daily for seven days. During a telephone interview on 3/4/13 at 11:00 A.M., the resident's physician said the antibiotic had been ordered to treat the resident's gum infection. Review of the resident's pain assessment MAR, dated 2/7/13 through 3/6/13, showed staff documented the resident had no pain through 2/28/13. However the PRN medication MAR indicated [REDACTED].M. and 2/11/13 at 5:10 P.M., for left and right cheekbone pain Review of the resident's nurse's notes, showed the following: -On 2/22/13 at 7:09 P.M., poor appetite and fluid intake at dinner. Ate less than 10% of the meal with a certified nurse aide (CNA) attempting to provide extensive assistance. Drank a 4 ounce health shake with strong encouragement. Alert and confused as usual; -On 2/23/13 at 8:00 P.M., received antibiotic for a urinary tract infection and had a poor appetite at dinner. He/She consumed 25% of dinner; -On 2/27/13 at 7:00 P.M., resident's physician made aware of his/her decline in appetite. Review of a physician's telephone order, dated 2/27/13 at 6:50 P.M., showed the following orders: -Obtain a complete metabolic panel (CMP), complete blood count (CBC), blood urea nitrogen (BUN) and creatinine level lab work; (Results of the CMP, CBC, BUN and creatinine levels showed all were within normal limits) -Health shake TID with meals. Observations of the resident during the survey process showed: -On 2/25/13 at 10:18 A.M., the resident sat in his/her wheelchair and had broken and blackened carious bottom teeth visible. The resident ate peppermints from a large bag in his/her lap; -On 2/25/13 at 12:35 P.M., staff served the resident a regular diet of shoepeg corn salad, a barbecued riblet, pork and beans, Texas toast and one serving of peach cobbler with iced tea. At 1:10 P.M., the resident had consumed 5% of the beans and 100% of the tea. The meat, toast and salad were untouched. Nurse Q asked the resident if he/she wanted any more and the resident declined. After prompting, the resident ate a spoonful of beans and Nurse Q moved away. The resident stopped eating at that time. At 1:13 P.M., CNA O cleared the resident's plate away after the resident said he/she had finished. The resident consumed one spoonful of peach cobbler. At 1:24 P.M., the resident left the dining area having consumed 5% of the cobbler. Staff provided no further cueing and did not offer a health shake to the resident; -On 2/27/13 at 8:15 A.M., staff served the resident a regular diet of hot cereal, scrambled eggs, bacon and coffee. At 8:20 A.M., the resident left the breakfast table. He/She consumed 95% of the lightly toasted bread, 50% of the eggs, 100% of the bacon and coffee and none of the hot cereal. Staff provided no cueing, encouragement or health shake during the meal; -On 2/28/13 at 12:42 P.M., staff served the resident spaghetti, a slice of toast, one piece of cake, a cup of water and a cup of iced tea. He/she had a bag of peppermint candy in his/her lap. The resident sat staring into space and did not eat. At 12:48 P.M., the Director of Nurses (DON) began feeding the resident. At 12:56 P.M., the resident began rejecting spoonfuls of food raised to his/her lips. He/She continued drinking the tea. The resident told the DON he/she did not want any more of his/her lunch. The resident consumed none of the toast or water, 10% of the spaghetti and cake, 5% of the salad, and 100% of the tea. Staff failed to provide a health shake. During an interview on 2/28/13 at 6:51 A.M., Certified Medication Technician (CMT) N said: -Staff assessed pain in the resident via facial grimacing; -The resident received a pain pill with his/her morning medications; (The CMT was referring to the aspirin 81 mg as the resident's pain pill) -Sometimes, when he/she was not eating he/she indicated tooth pain by pointing to his/her mouth. During an interview on 2/28/13 at 9:13 A.M., the Registered Dietitian (RD) said: -She saw the resident on 2/12/13; -At that time, she recommended the resident receive two desserts with meals; -She was unaware the resident experienced tooth pain and had dental problems; -Two desserts with each meal probably did not help with his/her dental issues; -There was quite a bit of staff turnover, which is quite frequent, in the special care unit; -Problems with communication and documentation made it difficult for her to know what was going on with the residents in that unit; -She did her own calculations in order to determine whether or not a resident had significant weight loss; -At times, his/her recommendations were not carried out by staff; -She gives her recommendations to the administrator and DON after she finishes; -The facility would not allow her to give her recommendations directly to the facility dietary manager. Review of the resident's medical record, from 1/19/13 through 2/28/13, showed no documentation of efforts by the Social Service Director or any facility staff regarding the resident's oral surgery. During an interview on 2/28/13 at 12:05 P.M., the social service director said: -Administrator H and DON U (the former DON) informed her of the resident's dental needs in mid January 2013; -They did not say how long the resident had experienced tooth pain; -She contacted another facility with Medicaid residents and they told her the closest place dental services could be secured for residents with medicaid was in Hannibal Missouri; -She set up an oral surgery appointment for the resident in Hannibal Missouri on 2/21/13; -Staff told her the resident missed the appointment because he/she refused to go; -Staff believed the resident had oral pain and the pain affected how the resident ate; -She never thought of asking the resident's physician or facility medical director if a referral to a local hospital for the surgery could be made. During an interview on 2/28/13 at 12:30 P.M., CNA O said: -He/She worked on the day shift regularly; -Sometimes, the resident's mouth was swollen due to a tooth infection; -The swelling of his/her mouth was an ongoing occurrence; -The resident took antibiotics to treat it; -Sometimes the resident did not eat due to pain; -He/She did not eat the chicken served at lunch the previous day due to difficulty chewing it; -The resident should be on a mechanical soft diet not a regular diet because of his/her teeth. During an interview on 2/28/13 at 2:13 P.M., Nurse Q said: -Last week, the resident had an appointment for oral surgery; -Due to a misunderstanding among staff regarding transportation, the resident missed his/her appointment; -Transportation arrangements are the responsibility of the Social Service Director; -For some reason, the responsibility for the resident's transportation got passed to someone else who then passed it back off to the Social Service Director; -Every morning, the resident received four pain pills (The nurse was referring to two Tylenol, one 81 mg aspirin and the antibiotic) -The resident's mouth tended to swell once a month to every couple of months; -The resident had been treated with antibiotics; -The resident's bottom teeth were broken and rotten; -Nurse Q had not looked in the resident's mouth for a while and did not know the condition of his/her top teeth but recalled seeing very few top teeth; -The resident's family members regularly brought him/her candy; -The nurse on the night shift got the resident up daily and brushed his/her teeth. During an interview on 3/1/13 at 5:47 A.M., CNA P said: -He/She noticed that the resident's mouth would regularly swell due to tooth infections. During an interview on 3/1/13 at 5:26 A.M., CMT N said: -The resident thought he/she could still brush his/her own teeth and consequently sometimes would not allow CMT N to clean his/her teeth; -He/She had never seen the resident brush his/her own teeth and did not know if the resident could do it; -On a daily basis, he/she took a warm, wet towel and wiped the resident's teeth; -He/She did not brush the resident's teeth with a tooth brush because it made his/her gums bleed. During an interview on 3/1/13 at 8:23 A.M., the social service director said: -Facility staff should have taken the resident to his/her oral surgery appointment on 2/21/13; -When a resident needs transportation for an appointment, she was responsible to print out logs listing the transport schedule and post them at the appropriate nurse's station; -She had to be away from the facility for part of the day on the day of the resident's oral surgery appointment; -When she returned to the facility that day, the resident was still at the facility; -Staff said they did not know the resident had an appointment; -She needed to speak with staff regarding how transportation for special care unit residents would be handled in the future; -Last week, she made transportation binders for staff to begin using; -She had not yet attempted to reschedule the resident's oral surgery; -First, she planned to see if the surgery could be arranged through a local hospital; -If she could not schedule the surgery through a local hospital, she planned to make another appointment in Hannibal Missouri. During an interview on 3/1/13 at 9:00 A.M., administrator H said: -She knew about the resident's dental needs prior to February 2013, but did not know exactly when the issue first came to her attention; -When staff made an appointment for a resident needing transportation, a transfer form should be filled out and submitted to social services; -The social service director was responsible to make the arrangements, copy the details and placed the a copy in the transportation book as well as enter the information onto a spreadsheet; -She knew for a fact the transportation book had been used for at least a year prior to the resident missing his/her appointment because she had been using it. During an interview on 3/1/13 at 9:00 A.M., the DON said: -Staff were not using the transportation book at the time the resident's oral surgery appointment on 2/21/13 got overlooked; -Staff began using the transportation book again because of the resident's missed appointment; -The frequency with which staff should clean the resident's teeth depended upon the resident's level of comfort and tolerance; -The DON did not know what the resident's level of comfort and tolerance had been during daily dental care; -Staff reported the resident grimaced due to tooth pain; -A tooth brush or toothette oral swab should be used to clean the resident's teeth. Further review of the medical record, showed staff did not attempt to alter the consistency of the resident's diet. There was no documentation of any order or assessment for change in diet consistency or evaluate the resident's difficulty chewing. During an interview on 3/1/13 at 9:00 A.M., the corporate nurse said: -The resident's dental problems were brought to her attention in early February; -The resident's dentist said he/she needed to be anesthetized and no one but the people in Hannibal Missouri would be able to do that; -After a missed oral surgery appointment for a resident with carious and broken teeth, a new appointment should be rescheduled immediately. During an interview on 3/1/13 at 11:00 A.M., the corporate nurse said the facility's medical director made rounds at the facility that day. She asked him if he could assist in getting the resident a consultation with a local oral surgeon. He made a telephone call and made a referral for the resident to consult with an oral surgeon at a local hospital. During an interview on 3/1/13 at 12:00 P.M., the DON said she had been the DON for just a few weeks. To date, she has not received any RD recommendations. During an interview on 3/1/13 at 12:30 P.M., administrator H said she left the facility about a month ago. The facility hired an interim administrator until they hired administrator I (the current administrator) about a week ago. The RD e-mails her recommendations to the administrator after she leaves. She looked on the administrator's e-mail and said the RD had sent an e-mail with her 2/12/13 recommendations. The e-mail had not been opened. During an interview on 3/1/13 at 12:49 P.M., restorative aide R said: -On 3/1/13, the resident weighed 145 lbs. (This represents a severe weight loss of 20 lbs. or 12.12% for one month, 23.8 lbs. or 14.09% for three months, and a 34.4 lb. or 19.08% for six months. The CMS guidance to surveyors identifies a weight loss of 5% in one month, 7.5% in three months and 10% in six months as significant. A weight loss greater than that is severe); -He/She had been going downhill since January 2013; -The resident's level of cognition fluctuated. During a telephone interview on 3/4/13 at 11:00 A.M., the resident's physician said: -The resident had gum infections four to five times last year; -The resident currently took antibiotics for gum infections; -He/She had a lot of broken and carious teeth; -The resident needed to have all of his/her teeth extracted; -He kept asking facility staff when the resident would be returning to the dentist; -Facility staff had an ongoing problem making arrangements for the resident to receive oral surgery; -Staff told him the resident missed his/her oral surgery appointment due to bad weather; -The resident's ongoing issue with weight loss was due to his/her dental problems; -The resident's jaw frequently swelled due to gum infections; -When the resident's gums got infected, he/she had trouble chewing; -Gum infections caused tooth pain which prevented the resident from chewing well; -Failure to chew his/her food well resulted in the resident experiencing difficulty swallowing. During a telephone interview on 3/1/13 at 2:50 P.M., the DON said staff should have informed her if the resident had difficulty eating or pain. Any Nurse at the facility can downgrade a diet per nursing judgement. If the resident had pain that did not get relief from the [MEDICATION NAME], staff should have asked the resident's physician for something stronger. During a telephone interview on 3/6/13 at 2:50 P.M., the dietary manager said health shakes ordered with meals are served by the dietary staff. At the time of the survey process, she did not have any orders for the resident to receive health shakes.

Based on interview and record review, the facility failed to appropriately assess, monitor and notify the physician for one extended sampled resident who had a fall and a change of condition which resulted in hospitalization with [DIAGNOSES REDACTED].#2 and #3). The census was 83. 1. Review of Resident #21's admission record, showed an original admission date of [DATE]. His/her [DIAGNOSES REDACTED]. Review of the resident's Outside the Hospital Do Not Resuscitate Order, dated 3/5/11, showed the following: -Authorize emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation in the event of a cardiac or respiratory arrest, [MEDICAL CONDITION] means (heart stops beating) and respiratory arrest means (breathing stops); -This decision will not prevent the resident from obtaining other emergency medical care and medical interventions such as intravenous fluids, oxygen or other therapies deemed necessary to provide comfort care or to alleviate pain; -The resident may revoke this order at any time; -Signed by the resident's family member and physician. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/11 showed: -Short/Long term memory problem; -Cognitive impairment; -Mood: trouble concentrating on things such as reading the newspaper or watching television; -Limited assistance of staff for eating; -Required total assistance of staff for bed mobility, transfers, toilet use, personal hygiene and bathing; -Range of Motion: lower leg impairment; -Incontinent of bowel and bladder. Review of the resident's skilled daily nurses note, dated 12/21/11, showed the following: -2:00 P.M.: Alert, assisted to wheelchair per staff, meals eaten in main dining room, appetite good, incontinent of urine; -9:35 P.M.: In bed for supper, appetite good, no signs or symptoms of discomfort. Review of the resident's skilled daily nurses note, dated 12/24/11 at 7:00 A.M.,(first nurse's note since 12/21/11 at 9:35 P.M.), showed the following: -Staff found the resident on the floor laying on his/her left side has history of left [MEDICAL CONDITION]; -The physician ordered an X-ray of the left arm and left hip; -Nothing in the notes where staff completed neurochecks or any further assessment on the resident. There was nothing to show how staff determined the possible cause of the fall. Review of the resident's skilled daily nurses note, dated 12/25/11 at 11:00 A.M., (first nurse's note since 12/24/11 at 7:00 A.M.), showed the following: -Sluggish, lethargic and unable to make needs known; -Responds to touch stimuli, moans with touch, unable to verbalize pain, received routine pain medicine; -Does not open eyes on command; -Very little fluid intake during the breakfast meal, less than 120 cubic centimeters (cc); -Spit out medication after several attempts given; -Unable to swallow small sips of water; -Observed pocketing food. Review of the resident's nurses note, dated 12/25/11 at 8:45 P.M., (next note after the 11:00 A.M. entry), showed the resident observed lying in bed with his/her right arm hanging from bed. Resident unable to follow simple commands, grip test incomplete. His/Her extremities were flaccid (limp). Unresponsive to name calling but responsive to painful stimuli. Respirations rapid at 32 breaths per minute, (normal respirations 15 to 20 breaths per minute). Nail beds to right hand cyanotic (bluish color caused by a lack of oxygen). Resident lies with his/her mouth wide open. Physician called and order received to send to the emergency room . Resident is Do Not Resusitate (DNR) family phoned, family said yes to emergency room (ER) evaluation. Review of the patient transfer form filled out by facility staff and transported with the resident to the ER dated 12/25/11, showed the resident appeared comatose, flaccid extremities, cyanotic nail beds to right hand, only responsive to painful stimuli. This was outside the residents normal behavior. Resident's mouth wide open unable to follow simple commands. It noted the resident was DNR but family wished to transport to ER for evaluation. Review of the resident's medical record, showed no additional information regarding the fall, neuro checks, vital signs or the resident's change in mental status. Review of the resident's emergency room progress note, showed the following: -12/25/11 at 9:38 P.M.: the resident arrived per ambulance, unresponsive; 10:33 P.M.: Family at bedside; -12/26/11 at 5:50 A.M.: received from Emergency Department at 3:00 A.M., systolic (top number) blood pressure 80's (normal: 100 to 120), 4th liter of normal saline [MEDICATION NAME] infusing at this time. Patient is cool to touch, unable to get a temperature reading, a warming blanket placed on the resident, 10:33 A.M.: Impression: Septic shock (Septic Shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure), due to urinary tract infection and left hip infection, acute [MEDICAL CONDITION]. Plan: Family wants comfort measures. Review of the resident's hospital history and physical dated 12/26/11 at 3:14 P.M., showed the following: -History obtained from emergency department, resident is currently unresponsive; -Sent by nursing home because of altered mental status and hypotention (low blood pressure); -Baseline he/she is more alert, noted per staff to be lethargic; -EMS arrived at the scene (facility), oxygen saturation rate (amount of oxygen in the blood) is 86% on room air, (normal 95 to 100%), he/she had uneaten food and dried pills in his/her mouth, responding to painful stimuli; -Urinalysis showed infection; -Left hip decubitus ulcer with oozing pus; -Vital signs: Blood pressure (BP) 93/57 (normal BP 120/80), heart rate 96 (normal 60-80), Respiration of 18, Temperature of 97.4 (normal 98.6), Oxygen saturation 100% on 3 liters of oxygen, poor skin turgor (skin inability to return to normal shape when pulled, sign of dehydration); -Impression: Multiorgan dysfunction including [MEDICAL CONDITION], acute [MEDICAL CONDITION]; -Currently remains critically ill; -admitted to hospital. Review of the resident's discharge summary, dated 1/6/12, showed [DIAGNOSES REDACTED]. -Condition at discharge: stable, placed on hospice. During an interview on 4/16/12 at 10:47 A.M., Nurse K said he/she took care of the resident on the morning of 12/25/11. The night shift said in report the resident had fallen the day before. He/she first observed the resident while he/she sat at the dining room table for breakfast. He/she observed the resident sliding out of his/her wheelchair and not acting his/her normal self. He/she had a poor appetite and pushed the food out of his/her mouth with his/her tongue. Staff tried to give the resident fluids but he/she refused. The resident would not open his/her eyes, so he/she checked his/her pupils by holding the resident's eyes open, he/she appeared to be uncomfortable and leaning in the wheelchair. Staff placed the resident in the bed and he/she checked on the resident but failed to document the resident's condition or vital signs in the nurses notes. The resident refused to get up for lunch and moaned when staff called his/her name. He/she called the physician on his/her shift to notify him of the resident's change in condition but failed to document it in the nurses notes. During an interview on 4/16/12 at 3:15 P.M., CNA W said he/she took care of the resident on 12/25/11 on the 3:00 P.M. to 11:00 P.M. shift. After getting report he/she checked on the resident. He/she said hello to the resident but he/she didn't respond. He/she noticed the resident's skin being very red and got the nurse, at that time. Nurse K said the resident would be going to the hospital. CNA W said he/she didn't go back to check on the resident the remainder of his/her shift because the nurse would be sending the resident to the hospital. During an interview on 4/13/12 at 9:00 A.M., the Director of Nurses said she would have expected the staff to monitor, document and notify the physician of any change in the resident's condition. She said she was not employed at the facility at the time of the resident's change in condition. During an interview on 4/13/12 at 9:30 A.M., the resident's physician said he would expect the staff to document and notify him of any changes in the resident's condition. He said the staff should have done neurological checks after the fall on 12/24/11 and should have notified him of the resident's condition change when it occurred, on the morning of 12/25/11. He said staff had not informed him of the resident's change of condition. Review of the "Neurological Checklist" form showed staff should do the following for all unwitnessed falls or falls in which the head is struck: -Initial assessment followed by every 15 minute assessment x 4; -Every 30 minutes x 2; -Every hour x 2; -Once per shift for 72 hours. Review of the facility's policy on Resident Condition Change (Observing, Recording and Reporting), dated April 2006, showed the following: -Basic Responsibility: Nurse; -Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented; -Guidelines: 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: Observe and inquire if resident has headache or pain. Observe for personality changes. Observe for alterations in consciousness. Observe for incontinence. Observe for proper reflexes (response to painful stimuli). Take vital signs and include temperature.. Observe for unequal pupils. Observe for shortness of breath and variations in respiration (irregular). Observe for cyanosis or flushing. 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If staff unable to reach the attending physician or the on call physician, call the facility medical director for emergency situations. 3. Complete a incident, accident or risk management report per facility guidelines. 4. Notify the resident's responsible party. 5. Monitor resident's condition frequently until stable. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Sometimes understands and sometimes understood; -Short term and long term memory problems; -Limited assistance for transfers, walking in room and corridor, dressing and eating; -Continent of bowl and bladder; -Resident had recent fall with no injury; -[DIAGNOSES REDACTED]. Review of resident's nurse's notes, showed the following: -1/30/12 at 1:05 A.M., the resident complained of a small headache. Resident was observed to have bruise above and below the left eye and left side of face. Neuro checks completed. Resident had a strong hand grip, respirations even, oxygen saturation level 95%, and lung's clear. -At. 5:30 A.M., resident's physician called and orders to send the resident out for evaluation; -11:00 A.M., resident returned from the hospital with [DIAGNOSES REDACTED]. Further review of the resident's medical record, showed no further documentation to indicate staff conducted any additional neurochecks. Review of resident's nurse's notes, showed the resident fell on [DATE] at 11:45 A.M., and neuro checks were completed. Further review of the resident's medical record, showed no further documentation to indicate staff conducted any additional neurochecks. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Sometimes understand and sometimes understood; -Short and long term memory problems; -Limited assistance needed for locomotion, transfers and feeding; -Maxum assistance to the toilet and bathing; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's nurses notes, showed the following: -On 2/9/12 at 7:35 P.M., resident was noted in the dining room with head and knees on the floor. Resident was assisted to his/her wheelchair; -Neuro checks were completed; -Range of motion to upper and lower without any concern. Further review of the resident's medical record, showed no further documentation to indicate staff conducted any additional neurochecks. During an interview on 4/13/12 at 7:30 A.M., the DON said she could not find neuro check assessments for Residents #2 and #3. She expects nurses to monitor residents and do neuro checks for the required time frames. During an interview on 4/13/12 at 8:30 A.M., the corporate nurse said staff should be using the a neurological assessment form for head injuries. The facility does not have a written policy for falls and neuro checks. Review of the "Neurological Checklist" form showed staff should do the following for all unwitnessed falls or falls in which the head is struck: -Initial assessment followed by every 15 minute assessment x 4; -Every 30 minutes x 2; -Every hour x 2; -Once per shift for 72 hours. During an interview on 4/13/12 at 9.00 A.M., the facility's medical director said he expects the facility to call him when a resident has a head injury. The facility should have a neurological assessment protocol to follow.