Every finding on record at Arbor Hills Care & Rehab Center

Based on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to ensure food items were dated and covered and failed to remove dented cans from the storage room. The facility also failed to maintain kitchen equipment in a clean condition during three of four days of observation and failed to ensure a sheet of ice was removed from the threshold of the walk-in freezer. In addition, the facility failed to utilize safe and sanitary food handling techniques when staff handled food from the steam table using gloved hands instead of utensils, used the steam table line as a cutting board, and mashed food for mechanical soft diets with gloved hands during one of two kitchen meal service observations. The facility also failed to ensure hall trays were transported in a manner to prevent contamination when not all food items were covered during three of three hall tray meal observations. The census was 89.1. Review of the facility's Refrigeration policy dated 3/31/21 and revised 8/21/21;-Subject Refrigeration:-Policy: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety;-Responsibility: Directory Aide, Dietary Cook, and Directory Manager;-Procedure: -Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with an expiration date of no more than three days unless otherwise indicated by the manufacturer; -Refrigerators shall be checked daily by the Dietary Manager and/or his/her designee to ensure leftovers or discarded before expiration date and all food is properly stored; -Storage of food should follow a FIFO (first in, first out). 2. Review of the facility's Dry Storage policy dated 3/31/21 and last reviewed 8/21/24, showed:-Subject: Dry Storage;-Policy: All food shall be stored according to regulatory guidelines governing food safety and sanitation and within established facilities guidelines;-Responsibility: Dietary Aide, Dietary Cook, and Dietary Manager;-Procedure: -All supplies must be 6 inches off floor and 18 inches from the ceiling; -All leftovers or opened packages shall be labeled, dated with open date then stored in a properly sealed container; -Food transferred from its original container, the container must be cleaned and sanitized refilled labeled and dated; -Dented cans shall be removed from storage. See Dented Can Policy; 3. Review of the facility's Dented Cans policy showed policy dated 8/20/22 and last reviewed, 8/24/24, showed:-Subject: Dented Cans-Policy: The Dietary Manager/ Designee will monitor cans in food storage for signs of rusting, dents or swollen seams; Damaged cans would not be used;-Responsibility: Dietary Aide, Dietary Cook, and Dietary Manager;-Procedure: -Dented or damaged cans upon observation will be removed from stock; -Directory Manager/ Designee will follow up with grocery vendor(s) to receive credit for returning the cans. 4. Observation of the kitchen on 2/17/25 at 9:50 A.M., 2/18/26 at 7:58 A.M, and 2/19/26 at 8:15 A.M., showed:-Walk in freezer: -Two (2) opened boxes of cookie dough exposed to air; -An opened box of puffed pastry sheets exposed to air; -An opened box of homestyle biscuits exposed to air; -An opened box of dinner rolls exposed to air; -A frozen meat item in a zip lock bag and without a date; -A frozen meat item wrapped in plastic wrap and without a date; -Hash browns in a plastic bag and without a date;-Dry storage room: -Five dented cans that sat on the floor. -An opened container of bay leaves, with plastic wrap over the opening. -A hole in the plastic and exposed to air; -An opened container of parsley, without a date; -An opened container of cinnamon without a date; -A box of salt opened on the side and exposed to air; -A package of cheerios, wrapped in plastic wrap and without a date -An opened bottle of honey without a date; -The sugar bin, both sides of the lids pushed to the opposite sides of the bin; sugar exposed to air; -The flour bin, lid not properly on bin; opened bag of flour inside bin, exposed to air;-The deep fryer: -Old grease in the fryer; -Old batter caked along the inside of the fryer; -Baked on grease on strainers and along the inside of the fryers;-Stove: -Caked-on stains along the front and on the sides of the stove; -Heavy caked-on stains along the front and on the side in between the grill;-Oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, and sides of oven;-Floor: -Noticeably dirty with food crumbs, dirt, debris and stains. 5. Observation of the kitchen walk in freezer on 2/17/25 at 9:50 A.M. and 2/18/26 at 7:58 A.M, showed a sheet of ice at the threshold of the freezer. 6. During an interview on 2/19/26 at 3:08 PM the Registered Dietitian (RD) said that she would expect for all food items to be properly labeled, dated and stored. It is everyone's responsibility to ensure that all food items are properly labeled, dated and stored. The kitchen should be cleaned daily. She wasn't sure how often deep cleaning was done but deep cleaning should be done more than what it was being done. She expected for ice to have not accumulated on the floor in the walk-in freezer. 7. During an interview on 2/20/26 at 2:31 P.M., the Director of Nursing (DON) said she would expect for all food items to be properly labeled, dated and stored. There is not a Dietary Manager. The Dietician was filling in at this time. It is her expectation that the kitchen floor should be clean, swept, and mopped. It was everyone's responsibility to ensure that the kitchen equipment is clean and that food items were properly labeled and stored. There should not have been ice at the threshold of the freezer. The Dietary Manager and Maintenance is responsible for ensuring that the ice was not on the floor. It was her expectation that the dented cans to have been removed from the storage room. 8. Observation of lunch hall tray meal service on the 300-hall on 2/17/26, showed at 1:02 P.M., hall trays were transported on an open-to-air wire rack from the main dining room to the 300-hall. The cart passed several residents in the dining room and staff walked past the cart. The cart contained 16 food trays. The plates were covered with a lid. A bowl of Fruit Crisps for desert sat on the trays, not covered. Nursing staff served the trays to the residents. 9. Review of the facility's breakfast menu for the date of 2/18/26, showed juice of choice, cereal of choice, egg, biscuit, sausage gravy, skim milk, and coffee or hot tea. 10. Observation of the kitchen breakfast meal service on 2/18/28 at 9:20 A.M., showed [NAME] I plated the trays, and a dietary staff passed the trays out one or two at a time to residents in the main dining room. The dietary staff served residents a cup of juice, a biscuit with gravy, and a sausage patty. At 9:37 A.M., the first tray was placed on the 300-hall cart. At 9:51 [NAME] I cut up sausage for the mechanical hall trays. He/She picked up the sausage from the steam table with gloved hands and placed them directly on the metal surface of the tray line. He/She cut the pieces with a knife, scooped them up with his/her hands and placed them on a plate. He/She picked up more sausage with his/her gloved hands from the steam table, placed them directly on the tray line and cut them up. He/She then scooped up some of the sausage and placed it on one plate and scooped up the rest and placed it on a different plate. [NAME] I then picked up a biscuit from the steam table with his/her gloved hands, placed them on one of the plates with the cut-up sausage and mashed it up with his/her hands. He/She did the same for all the mechanical plates made. After the last hall tray was plated, Dietary Aide E asked [NAME] I to plate a test tray. [NAME] I said he/she could not plate any extra trays because he/she was out of food. Observation of the steam table showed 1 biscuit and approximately 5 pieces of sausage remained. No gravy remained. 11. Observation of the breakfast hall tray meal service on the 300-hall on 2/18/26 at 10:01 A.M., showed the hall trays were delivered on an open-to-air wire cart from the kitchen, through the back corridor, down the main hall, and to the 300-hall. The lids over the plates were elevated and balanced on a bowl placed on the plate. The lids tilted off to one side and exposed a gap of approximately 2 inches, that left the food open to air. Staff began to pass the trays. 12. Observation of the lunch hall tray meal service on the 300-hall on 2/19/26 at 1:05 P.M., showed the hall trays were delivered on an open-to-air wire cart from the kitchen, through the main dining room past several residents, down the main hall, and to the 300-hall. It arrived at 1:06 P.M. and staff began to pass trays. No dessert bowls had lids and the deserts were opened to air. The cart rolled past residents in the hall and staff walked past the cart. 13. During an interview on 2/19/26 at 3:08 P.M., the RD said she is overseeing the dietary manager position until someone is hired. Food should be completely covered when transported through the halls. This includes desserts and drinks. Lids should be flush to the plate during transport. Staff should make enough food so residents who want seconds could have seconds or if a tray was dropped, it could be replaced with new food. Staff should use tongs to pick up food from the steam table. The food processor can be used to make mechanical soft diets. Staff should not mash up food with their hands. A cutting board should be used to cut food. It should not be cut up on the steam table.

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. The facility held funds for 44 residents. The census was 89.Review of the facility's Resident Trust policy, undated, showed:-Policy: The facility shall provide a RTF cash box and a separate bonded interest-bearing bank account for all residents who choose to have their personal money safeguarded and managed by the facility. The resident or their legal guardian are the only ones who can designate what the monies are spent on and have the right to request their RTF ledger at any time;-Procedures: --An internal audit of the RTF will be completed on a quarterly basis by the corporate office. --The RTF is to be reconciled monthly and balanced to the bank statement;-- Upon admission, each resident shall sign Resident Funds Management System's (RFMS) authorization to handle RTF. Should any resident desire to designate a person other than themselves to act as a Responsible Party Designee to receive their quarterly RTF account statements, and/or designated to someone to make expenditures for and on their behalf form their personal money, they will do so in writing. 1. Review of the facility's RTF reconciliation documentation from February 2025 through January 2026, showed no documentation of trial balances, bank statements, and reconciliations completed for nine of 12 months.2. Review of the facility's RTF records, showed no documentation of the facility providing quarterly statements to residents or their representatives for January through March 2025, April through June 2025, July through September 2025, and October through December 2025. 3. During an interview on 2/19/26 at 8:20 A.M., the Regional Business Office Manager (RBOM) said the facility provided quarterly statements to the residents and/or the residents financial Power of Attorney (POA). When the new ownership took over on 10/1/25, the prior ownership failed to provide January through September 2025 RTF reconciliation reports and quarterly statements for January through March 2025, April through June 2025, and July through September 2025,. The facility's current Business Office Manager (BOM) started three days ago, and the prior BOM failed to upload the facility's signed quarterly statements for October through December 2025. 4. During an interview on 2/20/26 at 11:45 A.M., the Administrator said 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 observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when staff spoke to one resident in an undignified manner (Resident #81), when the facility failed to provide adequate utensils at meals (Residents #24 and #79), and when staff stood over a resident while providing feeding assistance for one resident (Resident #9). The sample was 18. The census was 89. Review of the facility's Resident Rights policy, dated 1/28/26, showed the facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. Review of the facility's admission Agreement, undated, showed:-Resident Rights:--Residents Be Treated with Respect: Residents have the right to be treated with dignity and respect, as well as make their own schedule and participate in the activities their choose;-- Residents Free from Abuse and Neglect: Residents have the right to be free from verbal, sexual, physical, and mental abuse. 1. Review of Resident #81's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/18/25, showed:-Severe cognitive impairment;-Diagnoses included diabetes with diabetic chronic kidney disease;-No behaviors exhibited. Review of the resident's care plan, undated and in use at the time of the survey, showed:-Focus: Resident self-care performance deficit related to cognitive deficit requires total care with toiling he/she is incontinent of bowels and bladder and required one person assist with transfers as he/she is non ambulatory;--Goal: Will be free of body odor well-groomed and appropriately dressed through next review;--Interventions: Resident is totally dependent of one staff to provide bath/shower and as necessary. Observation on 2/17/26 at 2:06 P.M., showed the resident's door opened with full view of the room. From the hallway, Certified Nurse Aide (CNA) H was overheard telling the resident, Come on, you need to do this yourself. You are killing my back. During an interview on 2/17/26 at 12:04 P.M., the resident said the way the CNA H spoke to him/her made him/her feel like he/she was a child and he/she was humiliated. If he/she could do these things on their own, he/she would. During an interview on 2/19/26 at 3:10 P.M., CNA G said he/she just received an in-service on resident rights and resident abuse. He/She defined mental abuse as speaking to a resident in a demeaning and/or degrading manner. During an interview on 2/20/26 at 2:31 P.M., the Administrator said CNA H's comments were inappropriate. She expected the staff to treat all residents with dignity and respect. 2. Review of Resident #24's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Required supervision with eating;-Diagnoses included Alzheimer's disease, multiple sclerosis (causes breakdown of the protective covering of nerves), and anxiety. Observation on 2/17/26 at 12:46 P.M., showed lunch trays arrived in the dining room on Grace Hall. The residents were served baked chicken. The residents were provided either metal spoons or plastic forks. Residents were not provided knives. Observation on 2/17/26 at 12:57 P.M., showed the resident used his/her hands to tear off pieces of chicken to eat. During an interview, the resident said the food was good but he/she needed a knife. He/She preferred to cut chicken with a knife. Review of Resident #79's admission MDS, dated [DATE], showed:-No cognitive impairment;-Required supervision with eating;-Diagnoses included heart failure, hypertension (high blood pressure) and diabetes. Observation on 2/18/26 at 9:11 A.M., showed the resident seated at a table in the main dining room. The resident served breakfast, consisting of a bowl of oatmeal, sausage patties, biscuits and gravy, and orange slices. No knives were provided. The resident picked up a sausage patty and began tearing it apart with his/her hands and then put in the bowl of oatmeal. During an interview, the resident said he/she would have preferred to have a knife to cut up food. They were never given knives. Observation of breakfast on 2/18/26 at 9:16 A.M., showed CNA L used a fork to cut sausage patties into pieces to feed to a resident. During an interview, CNA L said it would be easier to assist residents if knives were provided to cut their food. Knives were never provided at breakfast, but sometimes they would be provided at lunch or dinner if something like pork was served. During an interview on 2/17/26 at 1:12 P.M., CNA K said sometimes residents were given forks and other times they were given spoons. A knife was needed to cut chicken. Knives were never provided. During an interview on 2/19/26 at 4:35 P.M., the Registered Dietician (RD) said residents should be given forks, spoons, and knives at meals. She was not aware of there being any issues with insufficient utensils prior to the start of the survey. More utensils were purchased this week. She believed the former Dietary Manager was made aware of the issue but never ordered anything. The issue could have been avoided if staff would have told the managers. During an interview on 2/20/26 at 2:20 P.M., the Administrator said it was more homelike for utensils to be provided at meals so residents could cut their food. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Required supervision with eating;-Diagnoses included coronary artery disease, hypertension, high cholesterol, stroke, epilepsy, and chronic obstructive pulmonary disease. Review of the resident's care plan, undated and in use at the time of the survey, showed:-Focus: Resident on a regular diet. Resident independent with supervision. Eats in dining room on locked unit with staff and peers;-Goal: Resident will maintain weight related to baseline and will continue to have adequate nutritional intake through next date;-Interventions: Provide and serve diet as ordered. RD to evaluate and make diet change recommendations as needed (PRN). Observation on 2/17/26 at 1:16 P.M., showed Assistant Director of Nurse (ADON) A stood next to the resident while feeding the resident his/her food. During an interview on 2/20/26 at 11:20 A.M. CNA S said when feeding residents, staff should sit next to the resident and feed them. It makes residents more comfortable when staff are seated next to them. When standing over a resident, it would generally make them feel uncomfortable or they may feel forced. Staff want to be considerate of the residents and make them feel comfortable. No one should be standing over residents while feeding them. It is also a dignity issue. During an interview on 2/20/26 at 11:37 A.M., ADON A said staff are supposed to be sitting when feeding residents. He/She thought about that after he/she was standing while feeding the resident. When feeding residents, there should be eye contact. Staff want the residents to feel comfortable and not rushed. There should be no hovering over the residents because it could take their attention away from eating or they could be distracted. It is also a dignity issue as well. During an interview on 2/20/26 at 2:31 P.M., the Director of Nursing (DON) said she would expect for Staff to be sitting down next to the residents when feeding the residents. This should be done for monitoring for swallowing issues and engaging with the resident and this could be a dignity factor.

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 for two residents (Resident #83 and #8). 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 89.Review of the facility's Resident Bed Hold policy, dated revised on 9/16/25, showed:-The Facility shall have a process in place to notify residents and/or their representatives in writing of the facility's bed-hold policy in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. In the event of an emergency transfer, the notice shall be provided within 24 hours.1. Review of Resident #83's medical record, showed:-discharged to the hospital on [DATE];-No documentation staff notified the Ombudsman of the discharge;-No documentation the bed hold notice was provided to the resident or his/her representative prior to the discharge. 2. Review of Resident #8's medical record, showed:-discharged to the hospital on1/27/26;-No documentation staff notified the Ombudsman of the discharge;-No documentation the bed hold notice was provided to the resident or his/her representative prior to the discharge. During an interview on 2/24/26 at 1:00 P.M. the Ombudsman Representative said he/she has not been receiving the discharge notices. The last one received was in January 2025. During an interview on 2/20/26 at 2:30 P.M., the Administrator said she did not have the bed holds or a copy of the discharge notices. She would expect for the nurse to provide the resident/resident representative the bed hold policy at the time of transfer or as soon as practicable and the Social Worker should follow up. The facility should maintain a copy for the medical record. The Ombudsman should receive a copy of the discharge notices monthly.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified three medication rooms and seven medication/treatment carts. Two medication rooms and four medication/treatment carts were sampled for medication storage. Issues were found with both medication rooms and three out of four medication/treatment carts when staff failed to remove/discard expired medication and failed to label medications with a resident's name on it. The census was 89. Review of the facility's Medication Storage in the Facility policy, dated 1/26, showed:-Medications labeled for individual residents are stored separately from floor stock medications;-Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. 1. Observation on [DATE] at 9:25 A.M., inside the drawers on the treatment cart, located on the 500 halls, showed:-One tube of jock itch cream, opened with an expiration date of 5/24;-One tube of hydrocortisone 1% cream (steroid medicine used to treat eczema, insect bites and other skin conditions) opened with an expiration date of 11/24;-One tube of triamcinolone 0.1 % cream (a prescription-strength topical corticosteroid) opened with an expiration date of 4/25;-One tube of Thera honey (medication used for wound care) opened with an expiration date of [DATE];-One bottle of Dakin's (topical antiseptic) opened with an expiration date of 5/25. Observation on [DATE] at 9:30 A.M., of the medication room located on the 200 halls, showed:-Inside the refrigerator, there was a bottle of latanoprost 0.005% eye drop (prescription eye medication used to treat pressure in the eye) with no name on it;-In the back of the refrigerator stuck between the shelf and the back of the refrigerator was a box with a vial of medication inside it. The label on the medication was faded and unreadable and the box was falling apart. The manufactures instruction was frozen onto the vial of medication. Registered Nurse (RN) Q said the frozen vial of medication was something insulin related. -Inside the cabinet located next to the sink, there were two boxes of DuoNeb nebulizer medication (prescription inhalation solution). One box was opened had an expiration date of [DATE]. The second box was open had an expiration date of 2/25;-One bottle of Geri Lanta (antiacid), opened with an expiration date of 10/24;-One Breo Ellipta (used to treat long term asthma), opened with an expiration date of 4/25;-On the shelf rack, was a large bottle of stool softener, docusate 100 milligrams (mg), opened with an expiration date of 12/25. During an interview on [DATE] at 9:25 A.M. RN Q said he/she did not know who was responsible for checking the expiration dates. The facility recently switched pharmacies and he/she would have expected the pharmacy to have checked the medications for expiration dates. 2. Observation on [DATE] at 6:55 A.M. of the treatment cart, located on the 200 hall, showed one tube of ice cold (pain relieving gel), opened with an expiration date of 6/25. Observation on [DATE] at 7:05 A.M., of the medication room located on the 200 halls, showed:-Inside the refrigerator was a box of Trulicity 0.75mg/0.5 milliliter (mL) (medication used to lower blood sugar) opened with an expiration date of [DATE];-A plastic bag with two insulin pens with no name on them. Licensed Practical Nurse (LPN) R said he/she did not know who the insulin belonged to; it looked like it was pulled from the stat kit. The nurse should check the expiration date before administering the medication. 3. Observation of the treatment cart located on the 100 hall on [DATE] at approximately 10:25 A.M., showed a box of Hydrofera Blue (used for wound care), opened with an expiration date of [DATE]; one tube of moisture barrier opened with an expiration date of [DATE]. During an interview on [DATE] at approximately 10:25 A.M., Certified Medication Technician (CMT) D said it had been a while since he/she checked for expirations dates. All CMT's and nurses should check for expiration dates as they go. 4. During an interview on [DATE] at 11:00 A.M., the Director of Nursing (DON) said the CMT's should check the medications on the carts, medication rooms and refrigerators for expiration dates daily. The refrigerator should be cleaned weekly by the night nurse. The DON said she would expect for the medications to be stored and labeled properly and the carts to be audited daily and as needed.

Based on observation, interview, and record review, the facility failed to follow proper infection control procedures when staff used non-medical-grade disinfectant wipes to clean the glucometer (device used to measure how much glucose (sugar) is present in the bloodstream) used on three residents (Residents #28, #46, and #48). In addition, the facility failed to store one resident's nebulizer tubing and mask per policy, creating a potential risk for cross-contamination and infection (Resident #52). The sample was 18. The census was 89. Review of the facility's Communicable Disease Management Policy, revised 10/2022, showed:-The Facility will establish Infection Prevention & Control Guidelines to prevent the transmission of infections, communicable diseases and healthcare associated infections (HAI) to ensure the safety of residents and employees;-Employees shall utilize barriers to avoid direct contact;-Employees shall implement Isolation barriers beyond standard precautions (precautions used to care of all residents regardless of their diagnosis or presumed infections status) as indicated in the following Centers for Disease Control and Prevention (CDC) Guidelines: (left blank). 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/10/26, showed:-Moderately impaired cognition;-Diagnoses included diabetes. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has diabetes;-Goal: Resident will have no complications related to diabetes through the review date;-Interventions included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of the resident's physician order summary (POS), dated 2/20/26, showed a physician order, dated 8/20/25 for Novolog (rapid-acting insulin) 100 unit/milliliter (ml) flex pen, inject per sliding scale: if 151 to 250 = 3 units; 251 to 350 = 6 units; 351 to 450 = 9 units; 451 to 500 = 12 units and call physician, subcutaneously (under the skin) four times a day related to diabetes. Observation on 2/18/26 at 7:50 A.M., showed Licensed Practical Nurse (LPN) J cleaned a glucometer with a lemon-scented disinfecting wipe and placed the glucometer on a barrier on top of the medication cart. The nurse performed a blood sugar test (a small drop of blood obtained from a finger prick with a lancing device, which is placed on a disposable test strip inserted into the meter) on the resident. He/She cleaned the glucometer with the lemon-scented disinfecting wipe and placed the glucometer on the barrier on top of the medication cart. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has diabetes;-Goal: Will be free from any signs and symptoms of hypoglycemia (low blood sugar) through the review date and will be free from any signs and symptoms of hyperglycemia (high blood sugar) through the review date;-Interventions included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of the resident's POS, dated 2/20/26, showed, an order, dated 8/5/25, for insulin lispro (rapid-acting insulin) 100 unit/ml (1 unit dial) pen, inject as per sliding scale: if 149 or less, no insulin; 150 to 199 = 1 unit; 200 to 249 = 2 units; 250 to 299 = 3 units; 300 to 350 = 4 units notify provider; 351+ = 5 units notify provider, subcutaneously (under the skin) with meals related to diabetes. Observation on 2/18/26 at 8:08 A.M., showed LPN J performed a blood sugar test on the resident using the same glucometer used on Resident #27. He/She cleaned the glucometer with a lemon-scented disinfecting wipe and placed the meter on the barrier on top of the medication cart. 3. Review of Resident #48's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes. Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident has diabetes;-Goal: Resident will have no complications related to diabetes through the review date;-Interventions included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of the resident's POS, dated 2/20/26, showed an order, dated 2/2/26, to please notify physician if blood sugar is less than 70 and more than 400 with meals for blood glucose monitoring. Observation on 2/18/26 at 8:20 A.M., showed LPN J performed a blood sugar test on the resident using the same glucometer used on Residents #27 and #46. He/She cleaned the glucometer with the lemon scented disinfecting wipe and placed the meter on the barrier on top of the medication cart. 4. During an interview on 2/20/26 at approximately 2:30 P.M., the Director of Nursing (DON), Administrator, and Corporate Nurse said staff should not use lemon-scented disinfecting wipes to clean multi-use equipment. The facility did not buy scented wipes for cleaning medical equipment. Staff should use the purple top Sani Wipes equipped with germicide content per infection control guidelines. 5. Review of Resident #52's annual MDS, dated [DATE], showed:-Diagnoses included dysphagia (swallowing disorder) following unspecified cerebrovascular disease (stroke), chronic systolic (congestive) heart failure, and muscle weakness;-Moderate depression.Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has emphysema/chronic obstructive pulmonary disease with (COPD, lung disease) exacerbation;-Goal: Resident will be free of signs and symptoms of respiratory infections through review date;-Interventions included: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Monitor for difficulty breathing on exertion and for signs and symptoms of acute respiratory insufficiency.Review of the POS, dated 2/18/26, showed:-An order, dated 12/14/25, for budesonide inhalation suspension 0.5 milligrams (mg)/2 ml, 0.5mg inhaled orally two times a day for COPD exacerbation;-An order, dated 5/7/24, for arformoterol tartrate inhalation nebulization solution, 15 micrograms (mcg)/2 ml, 15 mcg inhaled orally two times a day for COPD exacerbation. Observation on 2/17/26 at 9:46 A.M., showed the resident on his/her back in bed, with the head of bed elevated approximately 30 degrees. A nebulizer mask laid across his/her lap with nebulizer machine turned on. Observations on 2/18/26 at 7:27 A.M. through 12:35 P.M., showed soiled clothing on top of the nebulizer tubing, machine, and mask, which were balled up on a chair. During an interview on 2/19/26 at approximately 3:18 P.M., LPN F said the Certified Medication Technician (CMT) or Nurse should remove the nebulizer mask from a protective pad, place the medication in the cup, apply the mask to the resident, turn on the machine, and remain nearby to observe for nosebleeds or excessive coughing. No formal monitoring was required. During an interview on 2/20/26 at approximately 2:45 P.M., the DON said she expected the nebulizer to be stored on a clean surface and for the mask and tubing to be in a plastic bag with a date and changed every week. 6. During an interview on 2/20/25 at 9:22 A.M. the facility's Corporate Nurse said the facility did not have a policy that specified best practices for cleaning and storing nebulizer masks or glucometers. 2737724

Based on observation, interview and record review, the facility failed to transcribe a treatment order into the medical record timely and failed to follow physician orders when staff failed to administer the treatment as ordered for one resident sampled with wounds. The facility also failed to implement care plan interventions for pressure relief (Resident #3). The census was 89. Review of the facility's Physician Orders policy, dated 09/28/22, showed:-Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders;-Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders will be transcribed to the appropriate Administration Record Medication (MAR/eMAR) or Treatment Administration Record (TAR/eTAR);- Telephone/verbal orders: the licensed nurse is required to transcribe the order accurately in the medical record/ physician order sheet (POS) and on the appropriate MAR/TAR. Review of the facility's Wound Management policy, dated 11/15/22, showed: Wound treatment will be provided in accordance with physician's order. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/25, showed:-Severe cognitive impairment;-Functional limitations in range of motion in both upper and lower extremities;-Dependent on staff for Activities of Daily Living (ADL, grooming, dressing and bathing), rolling left to right and for transfers;-Diagnoses included non-Alzheimer's dementia, aphasia ( language disorder that impairs a person's ability to speak, understand, read, and write), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue);-Three stage 3 pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed. Slough (soft, moist, stringy, and yellow or white tissue that forms on the surface of a wound) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Review of the care plan, last revised on 02/06/26, and in use at the time of survey, showed:-Focus: Resident has unavoidable pressure ulcer (the resident developed a pressure ulcer eventhough the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; andrevised the approaches as appropriate) bilateral lower extremities;-Goal: Will have no complications related to (specify skin injury type) of the (specify location) through the review date;-Interventions: Perform treatment to wound per current treatment order. Assess wound for signs and symptoms of infection with each dressing change/treatment Report positive findings of redness warmth, swelling increased drainage, increased pain; pressure reducing mattress (specialized mattress designed to prevent pressure ulcers) while in bed. Review of the physician order summary dated 02/19/26, showed:-A physician order dated 02/07/26, for left foot site 6: Cleanse with normal saline/wound cleanser (NS/WC), apply skin prep (protective barrier) to peri-wound (wound edges), calcium alginate (highly absorbent dressing, used in managing heavy exudate (drainage) in non-infected, chronic wounds),triple antibiotic ointment (TAO), apply abdominal pad (ABD, soft absorbent dressing), wrap with gauze roll and secure with tape daily and as needed everyday shift for wound care;-A physician order dated 02/07/26, for left lateral (side) ankle site 9: Cleanse with NS/WC, pat dry, apply TAO, apply skin prep to peri-wound, apply calcium alginate silver (highly absorbent dressing, with broad-spectrum antimicrobial protection, used to manage infected or high-risk, heavily exuding wounds) and cover with gauze, wrap with gauze roll and secure with tape daily and as needed every day shift for wound care. Review of the wound physician notes dated 02/17/26, showed:-Site 6: Stage 3 pressure wound of the left, first metatarsal head(s) (MTH, rounded, bony end of the five long metatarsal bones in the foot that connect to the toes) foot full thickness; dressing treatment plan: alginate calcium with silver, once daily and as needed if saturated, soiled or dislodged; -Skin tear wound of the left, lateral ankle- exacerbated due to infection, hospital, wounds worse on return, full thickness: alginate calcium with silver once daily and as needed if saturated, soiled or dislodged. Review of the progress notes dated 02/17/26 through 02/19/26 showed no documentation the treatment was changed. Observation on 02/19/26 at 2:00 P.M., showed Licensed Practical Nurse (LPN) M and Assistant Director of Nursing (ADON) A entered the resident's room and performed hand hygiene, put on a gown and gloves. The resident was lying in bed on his/her back. The resident had a blue mattress on his/her bed. The mattress did not have a pump located on the end of the bed. LPN M held the resident's leg up while ADON A provided the wound care. ADON A removed the dressing on the left foot, cleaned the left first MTH and left ankle with wound cleanser, pated the areas dry, applied skin prep to the edges of the wounds, applied TAO to the calcium alginate. ADON A applied calcium alginate to both sites. She then applied an ABD pad to the first MTH and gauze pads to the left ankle, wrapped the areas with gauze and secured the dressing with tape. ADON A said she used plain calcium alginate. During an interview on 02/20/26 at approximately 8:30 A.M., ADON A said the facility's wound care physician visited the facility on Tuesday evenings. She was responsible for rounding with the physician and entered any new orders into the medical record. The wound physician usually completed about 90% of his notes while he was in the facility. Once ADON A received the wound physician notes, usually the next day, she was responsible for reviewing them for any new orders. Calcium alginate and calcium alginate with silver were not interchangeable. ADON A reviewed the wound note for 02/17/26 and said the treatment should have been calcium alginate with silver for both wounds and she should have used calcium alginate with silver. ADON A said she thought the resident had an air mattress on his/her bed. During an interview on 2/20/26 at 10:35 A.M. the Director of Nursing (DON) said the wound physician visited the facility weekly and the ADON rounded with him. He wrote the orders on a log, and the log was left with ADON A who was responsible for entering the orders into the medical record. Once the wound notes were obtained ADON A should review the orders to verify the orders matched the orders in the medical record. Calcium alginate and calcium alginate with silver were not interchangeable. The DON would have expected staff to follow physician orders and provide the treatment as ordered. If the resident had a wound, a specialized mattress would be an air loss mattress. During an interview on 2/20/26 at 2:30 P.M., the Administrator said she would have expected for staff to follow physician orders.

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for a dependent resident. The facility failed to ensure the resident received assistance in the dining room during meals and failed to ensure the resident's hands and nails were cleaned (Resident #3). The sample was 18. The census was 89. Review of the facility's policy titled ADL Care Shaving, reviewed on 07/21/22, showed: ADL care will include shaving to promote cleanliness and dignity; Review of the facility's policy titled Nail Care, reviewed on 07/21/22, showed: -The purpose of nail care is to clean the nail bed, trim nails and prevent infection;-Nails may be cleaned during bathing; -Nail care includes daily cleaning and regular trimming Review of the Resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/16/25, showed:-Severe cognitive impairment;-Dependent on staff for bathing and personal hygiene; -Functional impairment in range of motion to upper extremities on both sides;-Rejection of care exhibited: No;-Diagnoses included aphasia (a brain disorder that affects how you speak and understand language), dementia, paraplegia (paralysis to the lower half of the body), multiple sclerosis (MS, an autoimmune disease that affects the brain and spinal cord), and depression. Review of the resident's care plan, last revised on 02/06/26, showed:-Focus: Resident has paraplegia.-Goal: Resident will remain free of complications or discomfort related to paraplegia;-Interventions included: Assist with ADLs as required. Encourage resident to perform as much as possible of these activities;-Staff did not address the resident's preferences regarding personal hygiene such as shaving or nail care. Review of the resident's progress notes, showed no documentation the resident refused to be shaved or have his/her nails cleaned and trimmed. Observations of the resident on 02/18/26 at 8:10 A.M., 02/19/26 at 8:28 A.M. and at 12:35 P.M., showed the resident had significant gray stubble on and under his/her chin. The resident's nails were long with chipped red nail polish and a substantial amount of brown matter accumulated under his/her fingernails. During an interview on 02/19/26 at 9:50 A.M., Certified Nurse Aide (CNA) T said he/she was the resident's assigned aide. The resident did not resist care and preferred bed baths. When bathing residents, CNA T said he/she always offered to shave and provide nail care. The resident preferred long nails and liked to have them painted. The resident needed to be shaved. His/Her hair grew back fast. CNA T was going to give the resident a bath today and would shave him/her and provide nail care. Observation and interview on 02/20/26 at 9:00 A.M., showed the resident's chin was shaved, but whiskers under his/her chin remained. The resident's nails were long with chipped red nail polish and visible dark matter remained under his/her fingernails. The resident said he/she preferred to not have whiskers and preferred to have clean, long nails that were painted. During an interview on 02/20/26 at 9:03 A.M., CNA V said he/she was the shower aide. He/She did not offer resident's a shave when giving baths or showers. CNA V was not sure why he/she didn't offer. He/She did provide nail care during showers and baths. During an interview on 02/20/26 at 2:29 P.M., the Administrator said she would expect staff to offer to shave residents and clean their nails per the resident's preferences. If a resident refused staff should have documented it.

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for two residents (Resident #52 and #71). The failure placed both residents at risk for adverse effects and compromised therapeutic outcomes when Resident #52 was not monitored during a scheduled nebulizer treatment resulting in the treatment mask falling off the resident and Resident #71 had lidocaine patches applied for longer than recommended by the manufacturer. Sample size 18. The census was 89.1. Review of the state of Missouri Certified Medication Technician (CMT) Student Manual showed administering medications using a nebulizer: The CMT may administer inhaled medications using a nebulizer if permitted by facility policy. Due to variances in equipment, the facility must provide the CMT with training on the operation of the nebulizer system(s) being used in the facility. Documentation of the training and competency in use of the equipment must be placed in the employees' record. During an interview on 2/20/25 at 9:22 A.M., the Corporate Nurse said the facility does not have a policy to address the administration of nebulized medications. Review of Resident #52's care plan, in use at the time of survey, showed:-Focus: resident has chronic obstructive pulmonary disease (COPD, lung disease) with acute exacerbation;-Goal: resident will be free of signs and symptoms of respiratory infections through review date;-Interventions included: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Monitor for difficulty breathing (dyspnea) on exertion and for signs and symptoms of acute respiratory insufficiency.Review of the resident's physician order summary, showed an order dated 5/7/24, for Arformoterol Tartrate (medication used to treat COPD) inhalation nebulization solution 15 micrograms (mcg) inhale orally two times a day for COPD exacerbation. Review of the resident's medication administration record, showed CMT D documented the administration of the resident's Arformoterol Tartrate nebulizer treatment on 2/17/26 at 8:00 A.M.Observation on 2/17/26 at 9:46 A.M., showed the resident lay in bed on his/her back, with the head of bed elevated approximately 30 degrees. A nebulizer mask lay across his/her lap with the nebulizer machine running. The resident had noisy respiration with a rattling quality. During an interview on 2/20/26 at approximately 2:45 P.M., the Director of Nursing (DON) said she would expect the nursing staff to follow physician orders. The CMT should remain with the resident during the duration of the nebulizer treatment and report any changes to the nurse. 2. Review of the Lidoderm: Package Insert/Prescribing Information, dated 1/15/26, showed:-Generic name: lidocaine;-Dosage form: patch;-Lidoderm Dosage and Administration: Apply Lidoderm to intact skin to cover the most painful area. Apply the prescribed number of patches (maximum of 3), only once for up to 12 hours within a 24-hour period. Review of the Lidocaine Transdermal Patch: MedlinePlus Drug Information, showed:-How should this medicine be used: Prescription lidocaine transdermal comes as a 5% patch and as a 1.8% topical system to apply to the skin. Prescription lidocaine transdermal is applied only once a day as needed for pain. Never apply more than 3 of the lidocaine 5% patch or lidocaine 1.8% topical systems at one time and never wear them for more than 12 hours per day (12 hours on and 12 hours off). Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand;-In case of emergency/overdose: If you wear too many lidocaine transdermal patches or topical systems or wear them for too long, too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose. Review of Resident #71's medical record, showed:-Diagnoses included dementia and muscle weakness;-An order dated 1/29/26, for Lidoderm Patch 5 % (Lidocaine). Apply to painful area topically in the morning for pain;--No direction to remove the patch after 12 hours of use. Observation on 2/18/26 at 8:45 A.M., showed Certified Medication Technician (CMT) D obtained a Lidoderm 5% patch and entered the resident's room. CMT D pulled back the resident's blanket and exposed his/her right knee. The resident had 2 other Lidoderm patches in place. One dated 2/17/26 over the top of the resident's knee. The second patch dated 2/15/26 located to the inner aspect of the resident's knee. CMT D removed the old patches and applied the new patch to the top of the resident's right knee and said yesterday's patch was the patch over the front of the knee. The second patch he/she is not sure why it was still there. During an interview on 2/20/26 at 2:30 P.M., with the Administrator, DON and Corporate Nurse they said medications, such as a Lidoderm patch, should be given per manufacturer's recommendations. A Lidoderm patch can remain on for up to 12 hours. If the order is for one Lidoderm patch to be applied, a second patch should not be applied.

Based on observation, interview, and record review, the facility failed to provide sufficient dietary support personnel to effectively carry out the functions of the food and nutrition services. During one of two kitchen meal service observations, meals were served late and dietary staff failed to follow the menu and serve all menu items due to not having enough dietary staff. The census was 89.During an interview on 2/17/26 at 9:59 A.M., the Assistant Administrator, Director of Nursing (DON), and Corporate Nurse said mealtimes are scheduled for 8:00 A.M., 12:30 P.M., and 6:00 P.M. Review of the Schedule of Mealtimes, showed breakfast in the dining room scheduled at 8:00 A.M., lunch in the dining room scheduled for 12:30 P.M., and supper in the dining room scheduled for 6:00 P.M. Review of the facility's breakfast menu for the date of 2/18/26, showed juice of choice, cereal of choice, egg, biscuit, sausage gravy, skim milk, and coffee or hot tea. Observation of the breakfast meal service on 2/18/26 at 9:06 A.M. showed staff passed drinks in the main dining room. Meal service began at 9:20 A.M., when staff served the first food tray. Observation in the kitchen showed [NAME] I plated the trays, and a dietary staff passed the trays out one or two at a time to residents in the main dining room. The dietary staff served residents a cup of juice, a biscuit with gravy, and a sausage patty. No eggs were cooked or served, no cereal served, and no milk served. One cook and one dietary aide worked in the kitchen. During an interview on 2/18/26 at 7:58 A.M., [NAME] I said it was only him/her and another dietary aide working in the kitchen that day. He/she could not say when the hall cart would be sent to the floor. During an interview on 2/18/26 at 9:37 A.M., Dietary Aide E said the residents should also receive milk and cereal, but the kitchen is short staffed they could not serve everything on the menu. During an interview on 2/19/26 at 3:08 P.M., the Registered Dietician said she is overseeing the dietary manager position until someone is hired. The facility currently does not have a dietary manager. She would expect menus to be followed. Not having enough staff is not a sufficient reason to not follow the menu.

Based on interview and record review, the facility failed to follow physician orders when staff failed to obtain labs and an x-ray timely for one resident (Resident #3). The sample was 18. The census was 89.Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/25, showed:-Severe cognitive impairment;-Functional limitations in range of motion in both upper and lower extremities;-Dependent on staff for Activities of Daily Living (ADL, grooming, dressing and bathing);-Diagnoses included non-Alzheimer's dementia, aphasia (language disorder that impairs a person's ability to speak, understand, read, and write), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells);-One stage 2 pressure ulcer (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);-Three stage 3 pressure ulcers ((full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling);-Five unstageable, deep tissue injuries (a severe wound where the true depth of damage cannot be immediately determined). Review of the care plan, in use at the time of the survey, showed,-Focus: Resident has unavoidable pressure ulcer (the resident developed a pressure ulcer eventhough the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; andrevised the approaches as appropriate) bilateral lower extremities;-Goal: Will have no complications related to (specify skin injury type) of the (specify location) through the review date;-Interventions: Perform treatment to wound per current treatment order. Assess wound for signs and symptoms of infection with each dressing change/treatment. Report positive findings of redness, warmth, swelling, increased drainage, increased pain. Review of the progress notes dated 12/18/25 through 01/5/26, showed:-On 12/1/25 at 3:15 P.M., late entry, Wound Care provider gave an order for resident to have a wound culture (a laboratory test that identifies bacteria, fungi, or viruses causing infection in a wound, allowing for targeted antibiotic treatment) performed for right ankle for non-healing wound, this nurse notified the pharmacy that we currently do not have the wound swabs (a diagnostic procedure used to collect samples of fluid, pus, or tissue from a wound using a sterile swab) needed to perform culture;-On 12/22/2025 at 7:31 P.M., late entry, second nursing attempt to call the lab requesting wound swabs for culture order received from Wound Care provider. The nurse spoke with dispatch who stated that he/she would reach out to his/her manager to see if a phlebotomist could drop some off to facility;-On 01/1/26 at 4:54 P.M. provider gave new order for Doxycycline (antibiotic) 100 milligrams by mouth twice daily for 10 days;-Staff did not document when the facility received the swabs, when the wound culture was obtained, when the lab was notified the specimen was ready for pick up or the results. During an interview on 02/20/26 at approximately 8:30 A.M. and 12:50 P.M. Assistant Director of Nursing (ADON) A said the lab visited the facility on Mondays and Thursdays. When a new order for a lab was needed, the nurse should enter the order into the chart and complete a lab requisition. Wound cultures should be obtained the same day they are ordered, if the facility had the supplies. Once the culture was collected, the lab should be called for a pickup. The facility was out of swabs so the ADON called the lab two or three times to try to obtain the swabs. The ADON was told the lab would talk with dispatch to have someone drop some swabs off. The ADON did not recall when the swabs were dropped off. She obtained the culture on 12/29/25 or 12/30/25. She called the lab on 01/01/26 but the lab was closed. The lab did not pick up the swab until 01/05/26. The physician was aware, and he started the resident on an antibiotic because he suspected the resident had an infection. Review of the wound physician notes dated 02/17/26, showed:-Skin tear wound of the left, lateral ankle- exacerbated due to infection, hospital, wounds worse on return, full thickness:-Additional recommendations related to performed expanded evaluation: white blood count (WBC, blood test, measures the number of white blood cells), Erythrocyte Sedimentation Rate (ESR, blood test used to detect and monitor inflammation or infection), C-reactive protein (CRP, blood test used to detect infections, and monitor chronic diseases) , x-ray left ankle evaluate for osteomyelitis (infection in the bone);-Investigation: Recommended and/or reviewed:-Deep wound culture pending on skin tear wound of the ankle as of 02/08/26; -WBC (CBC) recommended on 02/17/26;-ESR recommended on 02/17/26;-CRP recommended on 02/17/26;-X-ray recommended (left ankle x-ray eval for osteomyelitis) on 02/17/26. Review of the progress notes dated 02/08/25 through 02/20/26, showed:-On 02/19/26 at 10:42 A.M. osteo panel (bone profile, blood and/or urine tests to evaluate bone health, assess the risk of osteoporosis, and monitor the effectiveness of treatments for bone diseases) ordered by wound care provider, lab tech in this morning to draw lab. Doctor has been updated;-Staff did not document when the deep wound culture or x-ray were completed. During an interview on 2/20/26 at 12:50 P.M., the ADON A said the deep culture pending from 02/08/26 was not obtained and would be obtained today. On 02/17/26, the wound physician ordered an osteo panel. ADON A wrote osteo panel on the lab requisition. The lab technician did not know what an osteo panel was and a thyroid panel (a group of blood tests used to evaluate how well your thyroid gland is functioning by measuring hormone levels), parathyroid hormone (blood test that measures the level of a hormone produced by the four, small, pea-sized parathyroid glands in the neck) and a vitamin D-25 hydroxy (measures how much vitamin d is in the body) was drawn. ADON A reviewed the lab results with the physician who said to draw the WBC, ESR and CRP on 02/23/26. ADON A said she was not aware the resident had an order for the x-ray before today because she did not scroll all the way down the wound note. The x-ray of the ankle will be completed today. During an interview on 02/20/26 at 10:35 A.M. the Director of Nursing (DON) said the lab provided swabs used for wound cultures. Wound cultures should be obtained within 24 hours, and the lab should be called for pick up. If the facility was out of swabs the nurse should call the lab and request some. If the swabs were not delivered within 24 hours, staff should notify the DON, and she would call the lab supervisor. The physician should also be notified if the culture was not obtained because the physician might extend the length of time to obtain the culture. If the physician was notified it should be documented in the progress notes. The DON was not aware there was an issue with the facility obtaining swabs from the lab. She would have expected documentation to show what follow up was done between 12/18/25 and 12/22/25. During an interview on 2/20/26 at 2:30 P.M., the Administrator said she would expect for staff to follow physician orders, and she would expect labs to be completed timely. If there was an issue with obtaining the lab timely, she would expect for it to be documented.

Based on interview and record review, the facility failed to ensure one of one resident sampled for a Level Two Pre-admission Screening/Resident Review (PASARR) had the services and supports recommended, and failed to ensure the services and supports were on the care plan (Resident #8). The census was 89.Review of the facility's PASARR policy, revised 2/24/26, showed residents should have required PASARRs. Information obtained from the PASARR should be documented on the care plan, including needed services. Review of Resident #8'squarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/25, showed:-Should the staff assessment for mental status be conducted? No;-Is there evidence of an acute change in mental status? No;-Diagnoses included: Schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). Review of the resident's PASARR level two summary of findings, dated 12/19/24, showed:-PASARR related disability: yes; specify, does have serious mental illness;-The PASARR level two evaluation indicated the following supports and services are to be provided by the facility: behavioral support plan; structured environment, crisis intervention services, medication therapy, Activities of Daily Living (ADL, grooming, dressing, bathing) and personal support network. Review of the care plan, in use at the time of survey, failed to show the resident had a level two PASARR and what the recommended supports and services were. During an interview on 2/19/26 at 4:30 P.M. Certified Nurse Aide (CNA) T said the resident sometimes called the staff names and last week he/she tried to hit him/her. When the resident had behaviors, he/she ignored them and reported it to the nurse. CNA T did not know what the resident's support plan was or what type of crisis interventions services the resident had in place. During an interview on 2/19/26 at 4:40 P.M. Licensed Practical Nurse (LPN) M said the resident never wanted to get up, and he/she was a hit or miss for allowing staff to provide his/her care. The resident's personal support network was his/her family. LPN M did not know what the resident's behavioral support plan or crisis intervention services was. During an interview on 2/19/26 at 4:45 P.M. the Social Services Designee (SSD) said she just started working at the facility on 2/16/26 and she did not know the resident. The MDS Coordinator was helping social services before she started, and she may know. During an interview on 2/19/26 at 4:50 P.M., the MDS Coordinator said level two PASARR supports and services should be on the resident's care plan. The facility had no residents who currently had a level two PASARR. The MDS Coordinator reviewed the resident's PASARR level two summary of findings and said the resident had a level two PASARR and she would update the care plan today. The MDS Coordinator did not know what the resident's behavioral plan or crisis intervention service was and said social services would know what services and supports the resident had. During an interview on 2/20/26 at 10:30 A.M. the Director of Nursing (DON) said if a resident had a level two PASARR, their recommended support and services should be included on the care plan. During an interview on 2/20/26 at 2:30 P.M. the Administrator said she would expect for the facility to provide the recommended services and support recommended on the level two PASARR, and it should be on the care plan.

Based on observation, interview, and record review, the facility failed to keep residents free of accidents when a Certified Nurse Aide (CNA) left a resident unattended in a filled whirlpool to gather supplies. (Resident #83). While the CNA exited the spa and another staff member entered, the resident slipped down into the water. The other staff member had to pull the resident up. The resident said water got in his/her mouth. The resident told another CNA that staff tried to kill him/her and said he/she was now too scared to go back into the whirlpool. The mechanical lift the CNA said he/she used was not assessed for safety concerns after the incident occurred. The facility also failed to ensure safe smoking practices when staff failed to ensure residents disposed of cigarettes in an appropriate receptacle during two of two smoke breaks observed (Residents #53, #69, #68, and #50), the facility identified 14 residents who smoked. The sample was 18. The census was 89. Review of the facility's policy tilted, ADL (activities of daily living) Care Bathing, revised 07/21/22, showed:-Stay with the resident throughout the bath: Do NOT leave the resident unattended;-Use emergency call signal to summon assistance if needed;-While assisting in/out of the tub, instruct the resident to hold onto the safety bars;-Place supplies within reach. 1. Review of Resident #83's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 01/02/26, showed:-Moderate cognitive impairment;-Rejection of care: behavior not exhibited;-Required substantial assistance for shower/bathing;-Required supervision for tub/shower transfer;-Diagnoses included diabetes mellitus, high blood pressure and dementia. Review of the resident's care plan, last reviewed on 01/15/26, showed:-Focus: Resident has history of resistance to care related to refuses to bathe;-Goal: Resident will cooperate with care;-Interventions included: Allow resident to make decisions about treatment regime, to provide sense of control;-Focus: Resident has a rash to his/her head and back with diagnosis of psoriasis vulgaris (chronic scaly, inflamed skin);-Goal: Resident will have no signs or symptoms of infection of the rash;-Interventions included: Give medication as ordered, monitor skin rashes for increased spread or signs of infection;-Focus: Resident requires max assistance with personal hygiene, toileting and showering. Can walk with rollator;-Goal: Resident will maintain proper hygiene without odor;-Interventions included: Encourage resident to participate to fullest extent possible with each interaction. Review of the resident's most recent Fall Risk Evaluation, dated 01/15/26, showed the resident was at moderate risk for potential falls. Review of the resident's February 2026 Order Summary, showed an order dated 05/31/24: Shower or Whirlpool Bath every evening shift every Monday, Wednesday and Friday for chronic psoriasis. Ensure ointment is applied after skin has been cleansed. Review of the resident's progress notes, showed:-On 02/05/26 at 6:27 P.M., late entry, Resident remains on monitoring for fearfulness for slipping in whirlpool. Resident has no complaint of pain or fearfulness at this time;-On 02/06/26 at 7:22 A.M., Resident remains on observation for slip/fall in whirlpool. Rested through the night, no complaints;-On 02/06/26 at 6:26 P.M., Resident remains on monitoring for fearfulness for slipping in whirlpool. Resident has no complaint of pain or fearfulness at this time;-No further documentation related to the resident's fearfulness after slipping in the whirlpool or any interventions to address the resident's fearfulness. Review of the facility's 11/01/25 to Current Incidents/Accidents log, showed the resident was listed. During an interview on 02/19/26 at 1:36 P.M., Certified Nurse Aide (CNA) H said the resident took baths in the whirlpool three times a week and was compliant with care. CNA H bathed the resident frequently. Staff were supposed to stay with residents the entire time the resident was in the whirlpool in case anything happened. CNA H had heard a few weeks ago that a CNA on the evening shift put the resident in the whirlpool and left the resident alone. CNA H saw the resident the next day. The resident said the CNA tried to kill the resident. The resident said, they won't get me in there no more. The resident was talking about the whirlpool. The resident had refused to get in the whirlpool since the incident. CNA H said he/she went and told the Director of Nursing (DON) after the resident told him/her about the incident. Staff were educated on leaving residents alone in the whirlpool. Review of the facility's Investigation, dated 02/04/26, showed:-On 02/04/26, the resident was receiving his/her scheduled bath with assistance from CNA V. During the bath process, CNA V asked the Environmental Services Director (ESD) to watch the resident for a moment while he/she grabbed some soap. Before CNA V stepped away from the area, the resident shifted his/her weight unexpectedly and started to slip. ESD immediately assisted and repositioned the resident. Charge nurse performed pain/skin evaluation with no new findings;-Upon completion of the investigation, the facility responded appropriately. The resident was safely secured and removed from the bathtub. The resident remains at baseline and staff will continue his/her plan of care. The following interventions have been put into place: -CNA provided 1:1 Coaching; -Inservice: ADL Care Bathing; -Inservices return demonstration bathing; -Monitor resident for fearfulness; -Updated care plan. Review of CNA V's witness statement, undated, showed: I stepped out the shower room to get the supply while the resident was in the whirlpool, but there was staff standing at the door. The resident started to slide in the whirlpool. Me and the staff member pulled him/her up immediately. Review of the ESD's witness statement, dated 02/04/26 at 5:00 P.M., showed: When I peeked in the shower room, I saw the resident slipping under and I pulled him/her up. Review of CNA V's Notice of Violation: Safety Requirements form, dated 02/04/26, showed:-Scheduled shift start: 3:00 P.M., scheduled shift end: 11:00 P.M.,-Incident description: Employee failed to gather all supplies before bath, stay with resident, requested assistance form another staff to oversee resident while gathering supplies.During an interview on 02/19/26 at 1:45 P.M., Licensed Practical Nurse (LPN) F said there was a recent incident involving the resident in the whirlpool. He/She believed the resident slipped. Staff came and got him/her and said the resident had slipped and needed to be looked at. When LPN F saw the resident, the tub had been drained. The resident was sitting in the tub facing out. The resident said he/she slipped. CNA V was the one who was bathing the resident when the incident occurred. Staff should be with a resident the entire time they were in the whirlpool. The DON was made aware and said to check on the resident every one to two hours. The resident was a little afraid. The resident had been getting showers ever since the incident occurred. During an interview on 02/19/26 at 2:04 P.M., the DON said they had recently completed education with staff about leaving residents alone in the whirlpool after a staff member stepped out to get towels. CNA V asked ESD to watch the resident while he/she stepped out. The DON was not sure if the ESD had CNA training or not. During an interview on 02/19/26 at 2:51 P.M., CNA V said when a bath was given, you should gather all needed supplies before taking the resident into the shower room. He/She used the bathtub Hoyer lift (mechanical lift used to transfer in/out of a bathtub) for the whirlpool. If a resident did not have good trunk control, they could slide down. A resident would not be able to slide completely out of the chair because the strap (belt) would be under their armpits. He/She thought there needed to be another strap that went over the lap too. CNA V's understanding was that a resident should not be left alone in the whirlpool. He/She had observed the resident seemed weaker in the days leading up to the incident. The resident used to be able to help but was now full contact for care. The day the incident happened, the resident looked weaker and told CNA V, I can't do it today, but CNA V was not aware the resident couldn't sit up properly. He/She gathered the resident's clothes, but did not have the special soap the resident used for his/her skin condition. CNA V took the resident into the spa around 3:30 P.M. or 4:00 P.M. CNA V strapped the resident into the Hoyer lift chair and lowered him/her into the whirlpool. CNA V needed the resident's special soap and had to get it from the nurse. The ESD came around the corner and CNA V asked her to watch the resident, who remained in the water filled whirlpool, while he/she went and got the soap. As the ESD walked into the spa and CNA V walked out, the ESD said the resident was sliding down. CNA V had his/her back to the resident when this happened. The strap of the Hoyer chair was under the resident's armpits. The ESD and CNA V pulled the resident up and repositioned him/her on the seat of the chair. The resident said he/she was scared and thought he/she was going down into the water. CNA V got the soap and finished the resident's bath. LPN F then came in and assessed the resident. Then the DON came in and assessed the resident. Afterwards, CNA V took the resident back to his/her room. He/She then went to the DON's office and the DON told him/her the correct way to provide a bath in the whirlpool. CNA V was then sent home and was off for a couple of days. When he/she came back, CNA V told the resident he/she was sorry for the fright. Observation on 02/19/26 at 3:20 P.M., showed the Faith Hall Spa had a bathtub Hoyer lift and a wall mounted call light pull station with string. The chair of the Hoyer lift had a belt bolted in the back at the top of the chair to go around the torso area. There was not a belt at the bottom to go over the lap area. During an interview on 02/19/26 at 3:20 P.M., the DON came into the spa room and looked at the bathtub Hoyer lift with the surveyor. The DON said the lift was used for residents who had poor trunk control. The DON said the belt at the top of the chair went around the waist area. Review of the bathtub Hoyer lifts Using the Invacare 1900 Lift For Non-Ambulatory Residents instructional video, showed the chair should have had a belt at the top to go around the torso and at the bottom to go over the lap. During an interview 02/20/26 at 8:30 A.M., the ESD said she was working late the day the incident took place. CNA V asked her to stand by in the whirlpool room so he/she could go get the resident's soap. She did not really feel comfortable being left with the resident, but said since she was a manager, she felt like she needed to do what was needed to help. The resident was sitting in the whirlpool. CNA V left and the ESD was alone with the resident. The resident then began to slide down into the water. She did not see a strap or belt around the resident. She grabbed the resident under his/her arms and pulled him/her up. The resident said he/she was ok, but his/her feelings were hurt. When CNA V returned, the ESD had already pulled the resident up. CNA V called for another staff member. The ESD backed out of the room to give space. The DON asked her to write a statement. She was present at the education, but did not participate. She would not put herself in that position again if asked to help. During an interview on 02/20/26 at 9:34 A.M., the resident said one of the CNAs left him/her alone in the whirlpool. The resident said he/she was going under the water, and water went in his/her mouth. It was for a short period of time. He/She was scared. The resident said he/she was not belted into a chair. One of the staff got him/her out of the water. The resident was scared to go back into the whirlpool now. There was nothing they could do to make him/her feel safe in the whirlpool. During an interview on 02/20/26 at 10:35 A.M., the DON said CNA V should have had all necessary supplies gathered prior to starting the bath. If CNA V needed help, he/she should have used the call light and asked another nursing staff to get the soap. LPN F made her aware of the incident. LPN F said the resident slipped but was not in distress. The resident was dressed and sitting in a chair when she saw and assessed the resident. Nursing staff told the DON the resident didn't want to go in the whirlpool anymore because he/she didn't want to deal with it. The DON was not aware CNA V said he/she used the bathtub Hoyer lift. The chair had not been assessed for safety concerns. The DON was not aware the chair should have had a lap belt. Any new interventions should have been included on the care plan. During an interview on 02/20/26 at 3:00 P.M., the Administrator said she expected staff to stay with residents the entire time when showering or bathing. If staff needed help, they should have used the call light and asked nursing staff for assistance. She was not aware the resident was afraid after the incident occurred. Any interventions should have been included on the care plan. The bathtub Hoyer lift had been removed and would not be used anymore. 2. Review of the facility's Smoking Protocol policy, dated 7/11/25, showed:-The facility shall maintain safety for residents who request to smoke/vape, as well as for those who do not;-Residents and resident representatives will be notified of the smoking protocol during the admission process and updated as needed;-Designated Smoking Area: Fireproof ashtray in which all smoking material will be disposed. No smoking material will be disposed of in waste cans, floors, or other inappropriate areas. Ashtrays will be emptied by maintenance/designee and will be placed in a fireproof metal container and emptied routinely. Smoking areas are to be maintained in such a manner that minimizes risk of fire hazards. Observation on 02/17/26 at 9:37 A.M., of the resident smoking area between the 200-hall and 300-hall, showed many cigarette butts on the ground, in the grass and on the concrete, too numerous to count. A large plastic flowerpot/planter filled with what appeared to be sand, contained a large number of cigarettes and a variety of trash items including a plastic cup, candy wrapper, and an empty pack of cigarettes. A red fireproof metal container contained a mix of medical gloves, a blunt wrapper and paper towels mixed with cigarettes butts. Two trash cans stood on either end of the smoking area filled with a variety of trash and cigarette butts. One cigarette butt rested against the facility siding. A walkway out to the garden was littered with cigarettes in the grass and on the walkway. Two smokeless ash trays were located near the back of the smoking area. Review of Resident #53's medical record, showed:-Diagnoses included hemiplegia and hemiparesis (weakness and/or paralysis on one side of the body) following a stroke affecting right dominate side and cognitive communication deficit;-A care plan showed focus initiated 01/22/26, the resident was a smoker:--Goal: Will not smoke without supervision and will not sustain any injuries from unsafe smoking practices;--Interventions included: Instruct on the facility policy on smoking: location, times, and safety concerns. Requires a smoking apron. Required supervision while smoking. Review of Resident #69's medical record, showed:-Diagnoses included lung disease and cognitive communication deficit;-A care plan showed focus initiated 10/14/24, the resident was a smoker;--Goal: Will not smoke without supervision and will not sustain any injuries from unsafe smoking practices;--Interventions included: Instruct on the facility policy on smoking: location, times, and safety concerns. Requires a smoking apron. Required supervision while smoking. Observation on 02/17/26 at 9:53 A.M., showed Housekeeper C entered the smoking area along with several residents. Housekeeper C passed cigarettes to the residents and assisted residents to light their cigarettes. He/She placed a smoking apron on Resident #53 and then lit his/her cigarette. At 10:08 A.M., Resident #53 placed his/her cigarette in the flowerpot/planter, and it continued to smoke. Housekeeper C did not intervene or educate the resident on the proper disposal of cigarettes. A second cigarette lay next to the flowerpot/planter on the ground and smoked. At 10:10 A.M., the cigarette on the ground stopped smoking but the one in the planter continued to smoke. At 10:11 A.M., Resident #69 threw his/her cigarette in the flowerpot/planter. Housekeeper C did not respond or educate the residents on the proper disposal of cigarettes. At 10:17 A.M., the cigarettes in the planter continued to smoke as the staff member assisted residents back into the facility. During an interview on 02/17/26 at 11:07 A.M., Housekeeper C said the Activity Director let staff know which residents had special needs, such as needing a smoking apron. Staff were to monitor residents who could not hold cigarettes safely or who accidentally dropped cigarettes. If a resident appeared to need more help than before, he/she would tell the Activity Director. There was not really any other reason why staff would intervene with residents smoking. Review of Resident #68's medical record, showed:-Diagnoses included lung disease and schizoaffective disorder (a disorder characterized by disorganized thinking);-A care plan showed focus initiated 11/17/23, the resident was a smoker:--Goal: Will not smoke without supervision and will not sustain any injuries from unsafe smoking practices;--Interventions included: Instruct on the facility policy on smoking: location, times, and safety concerns. Requires a smoking apron. Required supervision while smoking. Review of Resident #50's medical record, showed:-Diagnoses included muscle weakness and lung disease;-A care plan showed focus initiated 01/08/24, the resident was a smoker:--Goal: Will not smoke without supervision;--Interventions included: Must smoke with smoking apron. Instruct on the facility policy on smoking: location, times, and safety concerns. Required a smoking apron. Requires supervision while smoking. Observation of the resident smoke break on 02/18/26 At 7:47 A.M., showed residents headed to the smoking area and staff passed cigarettes. At 7:55 A.M., Resident #68 stood up and placed his/her cigarette in the flowerpot/planter. He/she then went inside. Staff monitoring the smoke break did not educate the resident on the proper way to dispose of a cigarette. At 7:57 A.M., Resident #50 sat in a Broda chair (medical reclining chair) and wore a smoking apron as he/she held his/her own cigarette. A staff person stood next to him/her and held a new, unlit cigarette out to the resident. Resident #50 flicked his/her cigarette at the flowerpot/planter. It hit the edge and bounced back at him/her and landed under his/her Broda chair. The staff person handed him/her another cigarette and assisted him/her to light it. The staff person did not pick up the cigarette or educate the resident on the proper way to dispose of cigarettes. During an interview on 02/19/26 at 11:45 P.M., the Administrator said the staff monitoring resident smoke breaks were responsible to supervise the residents while they were smoking, pass out cigarettes and ensure residents were safe while smoking. Cigarettes should have been disposed of in the self-closing ash can. The flowerpot/planter and trash cans were not appropriate areas to dispose of cigarette butts. No one should throw their cigarette butts onto the ground. There should not be any trash in the self-closing ash cans or the cigarette receptacles. Housekeeping and Maintenance were responsible for maintaining the smoking areas. It should be cleaned at least daily. If the cigarette butts were not disposed of appropriately, it could lead to a fire. She expected staff to educate residents about the proper way to dispose of cigarette butts and show them where to dispose of them correctly. 27439252737724

Based on observation, interview and record review, the facility failed to provide services to identify and treat pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) when staff failed to complete daily wound care as ordered for one resident (Resident #6). In addition, the facility also failed to ensure four residents, identified as at risk for development of pressure ulcers, received weekly skin assessments as ordered (Residents #6, #2, #3, and #7). The sample was 8. The census was 73.Review of the facility's Wound Care policy, dated October 2010, showed:-The purpose of this procedure is to provide guidelines for the care of wound to promote healing;-Verify that there is a physician's order for this procedure;-Review the resident's care plan to assess for any special needs of the resident. Review of the facility's Physician and Non-Physician Practitioner Orders policy, dated 1/1/22, showed with changing ways in communication it will be the practice of this facility to honor physician's/licensed independent practitioners orders in the following ways: Electronic Orders, including, but not limited to , direct entry into the clinical record electronic order system or entered in the clinical record by the nurse after acknowledged from written order. 1. Review of Resident #6's entry Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/25, showed-Two Stage 4 pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle);-Diagnoses included peripheral vascular disease (poor blood flow in the extremities), hemiplegia (paralysis on one side of the body) affecting left dominant side, pressure ulcer sacral (part of lower back that sits between the lower spin and buttocks) region, pressure ulcer to left leg, and cognitive communication deficit (difficulty with communication skills). Review of the resident's care plan, showed:-Focus initiated 8/28/25: The resident has a pressure ulcer Stage 4 to sacrum, Stage 4 to left leg;-Goal: Pressure ulcer will show signs of healing and remain free from infection;-Interventions included: Administer treatments as ordered and monitor for effectiveness. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 3/19/25, for weekly skin assessments on every Tuesday. Review of the resident's Wound Physician visits for evaluation and treatment, showed:-Visit, dated 6/16/25: --Sacrum pressure ulcer Stage 3 (full thickness tissue loss. Fat may be visible but bone, tendon or muscle is not exposed). Condition, stable. Measurements Length (L) 10.0 centimeters (cm), width (W) 8.0 cm, depth (D) 1.0 cm; --Left leg Stage 2 (partial thickness loss of dermis presenting as an intact blister or shallow open ulcer with a red-pink wound bed pressure ulcer). Condition, deteriorating. Measurements L 9.5 cm by W 5.0 cm by D 0.5 cm.-Visit dated 7/17/25:--Sacrum pressure ulcer Stage 3. Condition, improving. Measurements L 8.5 cm by W. 3.0 cm by D 0.5 cm; --Left leg Stage 2 pressure ulcer. Condition, improving. Measurements L 8.6 cm by W 7.0 cm by D 1.0 cm. Review of the resident's July 2025 Treatment Administration Record (TAR), showed:-Left lower extremity treatment orders:--An order dated 6/21/25 and discontinued on 7/3/25, for wound care. Cleanse left lower extremity with normal saline/wound cleanser. Apply Flagyl (antibiotic) to wound bed. Apply calcium alginate (wound dressing used to manage moderate to heavy drainage and promote a moist healing wound environment) to wound bed. Cover with dry dressing every day and as need for wound care:---Treatment not documented as administered as ordered 3 out of 3 days;--An order dated 7/4/25, for wound care. Cleanse left lower extremity with normal saline/wound cleanser. Apply non-adhesive dressing to wound bed. Cover with kerlix (gauze wrap) daily and as needed every dayshift for wound care:---Treatment not documented as administered as ordered 19 out of 28 days;-Sacral treatment orders:--An order dated 6/21/25 and discontinued 7/3/25, for wound care. Cleanse sacrum with normal saline/wound cleanser. Apply Flagyl to wound bed. Apply calcium alginate to wound bed Cover with dry dressing every day and as needed. Every dayshift for wound care: ---Treatment not documented as administered as ordered 3 out of 3 days;--An order dated 7/4/25, for wound care. Cleans sacrum with normal saline/wound cleanser. Lightly pack wound bed with 4x4 gauze. Cover with ABD dressing (absorbent dressing) every day and as needed. Every dayshift for wound care: ---Treatment not documented as administered as ordered 19 out of 28 days;-No documentation any as needed wound care treatments were provided. Review of resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/1/25, showed weekly skin assessments not completed on 8/6/25, 8/13/25 and 8/27/25. Review of resident's weekly wound assessment reviewed for the dates of 7/1/25 through 9/1/25, showed weekly wound assessments not completed on 7/31/25, 8/14/25 and 8/21/25. Review of the resident's August 2025 TAR, showed:-Left lower extremity treatment orders:--An order, dated 7/4/25 and discontinued 8/11/25, for wound care. Cleanse left lower extremity with normal saline/wound cleanser. Apply non-adhesive dressing to wound bed. Cover with Kerlix every day and as needed. Every dayshift for wound care:---Treatment not documented as administered as ordered 3 out of 11 days;--An order, dated 8/13/25 and discontinued 8/28/25, for wound care. Cleanse left lower extremity with normal saline/wound cleanser. Apply collagen to wound bed. Cover with foam dressing every day and as needed. Every dayshift for wound care:---Treatment not documented as administered as ordered 5 out of 16 days;--An order, dated 8/29/25 for wound care. Cleans left lower extremity with normal saline/wound cleanser, pat dry. Apply collagen to wound bed. Cover with non-adhesive dressing every day and as needed. Every dayshift for wound care:---Treatment not documented as administered as ordered 1 out of 3 days;-Sacral treatment orders:--An order, dated 7/4/25 and discontinued 8/8/25, for wound care. Cleanse sacrum with normal saline/wound cleanser. Lightly pack wound bed with 4x4 gauze. Cover with ABD dressing every day and as needed. Every dayshift for wound care:---Treatment not documented as administered as ordered 2 out of 8 days;--An order, dated 8/8/25 and discontinued 8/18/25, for wound care. Cleanse sacrum with normal saline/wound cleanser. Apply collagen to wound bed. Cover with foam dressing every day and as needed. Every dayshift for wound care:---Treatment not documented as administered as ordered 3 out of 10 days;--No sacral treatment for the dates of 8/19/25 through 8/20/25 documented as ordered or completed;--An order, dated 8/21/25 and discontinued 8/28/25, for wound care. Cleanse sacrum with normal saline/wound cleaner. Apply wound vac (a device that provides light suction to remove excess drainage from the wound bed) to sacral wound continuous suction. Every dayshift every Monday, Thursday for wound care:---Treatment not documented as administered as ordered 3 out of 3 days;--An order, dated 8/29/25 for wound care. Cleanse sacrum with normal saline/wound cleanser. Apply collagen and dry dressing daily every dayshift for wound care:---Treatment not documented as administered as ordered 1 out of 3 days; -No documentation any as needed wound care treatments were provided. Review of the resident's medical record, showed the resident discharged on 9/1/25. During an interview on 9/16/25 at 9:00 A.M., the Wound Care Physician said he expected staff to follow wound care orders as written and to mark the TAR when wound care has been completed. He was not aware the resident's TAR showed the resident did not receive wound care on several dates during the months of July 2025 and August 2025. He would have noticed the change in wound condition when he made weekly rounds and the resident did not have deterioration of the wound due to lack of care. The resident had overall decline related to poor prognosis and overall health decline. The resident was on hospice and his/her care focused on comfort. His/Her wounds never showed signs or symptoms of infection or not receiving wound treatments. He agreed if the treatment on the TAR is not documented, it means it was not completed but believes it was completed, the nurse just forgot to mark the TAR. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition;-At risk for pressure ulcers;-Diagnoses included dementia, generalized anxiety disorder and cognitive communication deficit. Review of the resident's ePOS, dated 9/15/25, showed an order dated 10/8/24, for weekly skin assessment, on every Wednesday dayshift. Review of resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/13/25, 8/27/25 and 9/3/25. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed:-Severe impaired cognition;-At risk for pressure ulcers;-Diagnoses included Alzheimer's, dementia and pressure ulcer to right ankle. Review of the resident's ePOS, dated 9/15/25, showed:-An order dated 8/20/25, wound care order to left hip, apply protective border gauze to left hip to protect bony prominence weekly on Monday and Thursday every dayshift to prevent area from opening;-An order last updated 8/28/25, wound care to right lateral (outer) foot, apply skin prep (protective barrier wipe) during day shift and as needed when soiled or dislodged for wound care;-No order for weekly skin assessments. Review of resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/14/25 and 8/21/25. 4. Review of Resident #7's entry MDS, dated [DATE], showed:-Moderately impaired cognition;-At risk for pressure ulcers;-Diagnoses included Alzheimer's disease, heart failure and moderate-protein calorie malnutrition. Review of the resident's ePOS showed an order dated 1/28/25, for weekly skin assessment perform weekly on every Tuesday dayshift for preventative. Review of the resident's weekly skin assessments reviewed for the dates of 7/1/25 through 9/11/25, showed weekly skin assessments not completed on 8/6/25, 8/13/25, 8/27/25 and 9/3/25. 5. During an interview on 9/15/25 at 2:20 P.M., the Administrator and Director of Nursing (DON) said, an X or blank space on the TAR indicates the order was not completed. They expected nursing staff to follow physician orders as they are written. They also expected nursing staff to mark a treatment as completed on the TAR once it has been completed. If not marked completed, it has not been done. They were not aware of Resident #6's missing documentation for wound treatments for the months of July and August 2025. If the treatments were not performed, this could be detrimental to the resident's wound healing process. Orders were most likely completed and nursing staff forgot to mark as completed. During an interview on 9/16/26 at 8:43 A.M., the DON said weekly skin assessments are to be completed every week on all residents in the facility regardless of whether the resident is on hospice. The weekly skin assessments usually occur on one of the resident's shower days during the week. The weekly skin assessments are usually done by the nurse and sometimes the wound nurse. Weekly wound assessments are different than the weekly skin assessments and should be documented separately. Weekly wound assessments are to be completed by the wound nurse during the wound physician rounds on Thursdays of every week, unless the wound nurse is not available and then the nursing staff should complete wound assessment. The difference between a skin assessment and wound assessment is that the skin assessment is a head-to-toe observation of the resident skin, and the wound assessment is only focused on the wound. She was not aware weekly skin, and wound assessments were not completed during July 2025, August 2025 and September 2025. The wound nurse was let go during this time and this could be the reason the assessments were missed. 26029142604488

Based on observation, interview and record review,, the facility failed to ensure one resident's (Resident #2) change in condition was appropriately documented and treated after the resident missed multiple doses of medication. The facility also failed to follow physician orders to order pain medication for one resident (Resident #6). The sample size was eight. The census was 73. Review of the facility's Change in Condition or Status policy, dated 12/2016, showed:-Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status;-Policy implementation: The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, refusal of treatment or medications two or more consecutive times, need to transfer the resident to a hospital/treatment center;-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's Administering Medications policy, dated 4/2019, showed:-Medications are administered in a safe and timely manner, and as prescribed;-Policy implementation: medications are administered in accordance with prescriber orders, including any required time frames.Review of the facility's Physician and Non-Practitioner Orders policy, dated 1/1/22, showed:-With changing ways in communication, it will be the practice of this facility to honor physician's/Licensed Independent Practitioner (LIP) orders in the following ways; -Verbal orders; -Electronic orders, including, but not limited to direct entry into the clinical recorder electronic order system or entered in the clinical record by nurse after acknowledged from written order. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 8/6/25, showed:-Moderately impaired cognition;-Diagnoses included dementia, generalized anxiety disorder, and cognitive communication deficit. Review of the resident's Physician's Orders Summary (POS), dated for 9/11/25, showed:-An order, dated 12/24/25, for Lorazepam (Ativan) Oral Tablet 1 milligram (mg). Give one tablet by mouth every 12 hours for anxiety. Review of the Resident's Medication Administration Record (MAR), dated 8/2025, showed:-On 8/24/25 the resident did not receive his/her second dose of Ativan;-On 8/25/25 the resident did not receive the first or second dose of Ativan;-On 8/26/25 the resident did not receive the first dose of Ativan. Review of the resident's individual resident's controlled substance record, dated 7/22/25, showed:-60 Ativan 1 mg tablets were ordered by the resident's psychiatrist and received by the facility on 7/22/25;-The first dose was administered to the resident on 7/23/25;-The last dose was administered to the resident on 8/24/25. Review of the resident's progress notes, dated 8/26/25, showed the resident was giving his/her lorazepam after 48 hours without. The resident went kind of unresponsive to questions. His/Her blood pressure was taken and was 98/53 (normal 90/60-120/80) . His/Her pulse was 54 beats per minute (normal 60-100). The Physician was called with no answer, so this writer (LPN B) sent the resident out to the hospital. During an interview on 9/11/25 at 1:25 P.M., Licensed Practical Nurse (LPN) B said on 8/26/25 the resident took his/her Ativan for the first time after missing four doses. The resident had a change in condition and became a bit unresponsive. LPN B reached out to the nurse manager who told him/her to call emergency services. Emergency services came and evaluated the resident, but his/her shift ended before the emergency services had left the facility. LPN B was under the impression that the resident was going to be transported to the hospital and documented that before his/her shift was over. LPN B was not aware the resident did not end up being transported to the hospital. LPN B expected resident medication to be reordered at least 10 days before the medication runs out. He/She was in a hurry and did not pass on the information about the resident's change of condition to the oncoming nurse. During an interview on 9/11/24 at 10:06 A.M., LPN A said new scripts should be obtained for resident medication at least 14 days before the medication is due to run out. He/She expected medication to be ordered in a timely manner, so residents do not have to go without medication. Changes in conditions should be reported to the Director of Nursing (DON) and the oncoming shift for continuity of care. During an interview on 9/11/25 at 11:31 A.M., the resident's Psychiatrist said he expected the facility to obtain orders for the resident's Ativan before the medication runs out to prevent the resident from going without his/her medication. He expected the facility to have an emergency supply of Ativan at the facility. He said the new script for Ativan was sent to the facility on 8/26/25 after the facility reached out to his office. During an interview on 9/11/25 at 1:51 P.M., the DON said when she became aware the resident missed multiple doses of medication, she immediately ensured that the medication was ordered. She would have expected for the medication to have been re-ordered at least 10 days before the last dosage was given. She was not made aware that the resident had a change of condition on 8/26/25 until the next day on 8/27/25. She said that LPN B never informed her or the oncoming nurse on 8/26/25 that the resident had a change in condition. She would expect for nurses to inform her and the oncoming shift of any changes in condition. She would have expected follow up assessments to be obtained on the resident's change in condition and said no assessments were completed due to lack of communication on LPN B's part. 2. Review of Resident #6's quarterly MDS, dated , 9/5/2025, showed:-admitted to facility 4/16/25;-discharged to hospital 9/1/25;-Intact Cognition;-Diagnoses included peripheral vascular disease (a circulatory disorder characterized by the narrowing, blockage, or spasm of blood vessels outside of the heart and brain, primarily in the limbs and organs), hemiplegia (paralysis) following unspecified cerebral vascular disease (blood vessels supplying blood to brain are damaged by blockage, bleeding or structural problems) affecting left dominant side, dysphagia (difficulty with speaking), pressure ulcer (wound with skin damage down to subcutaneous fat tissue) sacral (part of lower back that sits between the lower spin and buttocks) region stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), pressure ulcer to left leg stage II (wound with damage through top layer of skin), cognitive communication deficit (difficulty with communication skills). Review of the resident's POS, dated for 9/15/25, showed:-An order, dated 4/1/25, Acetaminophen (Tylenol) oral tablet 325 mg. Give two tables every six hours as needed for fever and/or pain. Max allowable dose of four grams (4000 mg) in a 24-hour period;-An order, dated 5/5/25, Hydrocodone-Acetaminophen (Norco, pain medication) oral Tablet 5 mg/325 mg. Give one tablet by mouth every four hours as needed (PRN) for moderate pain;-An order, dated 6/24/25, Norco oral Tablet 5 mg /325 mg. Give one tablet by mouth one time a day for moderate/severe pain;-An order, dated 4/1/25, assess for pain every shift for pain monitoring. Review of the resident's progress notes showed:-Order administration note dated 8/14/25 at 12:17 P.M., Hydrocodone-Acetaminophen oral tablet 5-325 mg, give one tablet by mouth one time a day for moderate/severed pain;- Nursing progress note dated 8/15/25 at 1:11 P.M., nurse spoke with Hospice nurse regarding the Hydrocodone medication order. Hospice nurse confirmed that the order has been entered and is awaiting pharmacy delivery. Resident will continue to be monitored for comfort and safety until medication is received and administered as ordered;-Nursing progress note dated 8/15/25 at 1:55 P.M, Primary Care Physician (PCP) currently in facility made aware that resident was out of hydrocodone medication and came off hospice a couple of days ago. PCP stated he would contact the pharmacy to send a three-day supply to facility and would have his office to take care of the script order on Monday (8/18/25). Also, placed call to responsible party and made him/her aware resident's condition and Hydrocodone 5/235 mg medication was out for a few days due to hospice nurse not recording medication. Resident has an order for Acetaminophen, which will be offered until medication arrives to facility. Review of the Resident's MAR, dated 8/2025 and 9/2025 showed:-On 8/16/25 Norco once a day dose, scheduled for 9:00 A.M., had been discontinued with no physician order;-On 8/16/25 Norco as needed every four hours dose, had been discontinued with no physician order;-On 8/17/25 through 9/1/25 the resident did not receive his/her Norco, once a day dose;-On 8/17/25 through 9/1/25 the resident did not receive his/her Norco, as needed every four hours dose. Review of the Resident's Treatment Administration Record (TAR), dated 8/2025 and 9/2025 showed:-On 8/11/25, evening shift, the resident was not assessed for pain;-On 8/20/25, night shift, the resident was not assessed for pain;-On 8/21/25, evening shift, the resident was not assessed for pain;-On 8/25/25, evening shift, the resident was not assessed for pain;-On 8/27/25, evening shift, the resident was not assessed for pain; During an interview on 9/16/25 at 10:06 A.M., the DON said she was not aware the resident's Norco was out and then was discontinued by a nurse without physician order. After reviewing nursing progress note dated 8/15/25, she said the physician's intention clearly states continue resident on Norco and follow up with script on Monday. She would have expected nursing staff to follow up on the resident's Norco script, and it is unacceptable for a nurse to change or discontinue medication without a physician's order. 260291426044882602553

Based on observation, interview, and record review, the facility failed to ensure that services were provided in accordance with the resident's care plan and accepted professional standards of clinical practices. The facility failed to ensure medications including torsemide (treats fluid retention), Amiodarone (heart medication), Lidocaine 4% patch, and Metoprolol (blood pressure medication) were ordered timely and administered for one resident (Resident #29) who had a diagnosis of congestive heart failure. In addition, the facility failed to ensure the resident was assessed for side rails and document a rationale for the use of side rails. The sample was 11. The census was 83. The administrator was notified on 4/28/25, of the past non-compliance. Staff were in-serviced on the side rail assessment policy and medication administration policy. The deficiency was corrected on 3/5/25. Review of the facility's Medication and Treatment Orders policy, revised July 2016, showed: -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis; -All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; -Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order; -Verbal orders must be signed by the prescriber at his or her next visit; -Orders for medications must include: Name and strength of the drug. Number of doses, start and stop date, and/or specific duration of therapy. Dosage and frequency of administration. Route of administration. Clinical condition or symptoms for which the medication is prescribed; and any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.); -Only authorized personnel shall call in orders for prescribed medications to the pharmacy; -Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Review of the facility's Side Rail policy, revised December 2016, showed: -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; -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: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and to stand and toilet; -Risk of entrapment from the use of side rails; -The use of side rails as an assistive device will be addressed in the resident care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -Less restrictive interventions that will be incorporated in care planning include: -Providing restorative care to enhance abilities to stand safely and to walk; -Providing a trapeze to increase bed mobility; -Placing the bed lower to the floor and surrounding the bed with a soft mat; -Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails; -The risks and benefits of side rails will be considered for each resident; -Consent for side rail use 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; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment; -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 #29's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/14/24, showed: -Diagnoses include anemia (low red blood cells), atrial fibrillation (irregular heart rate), heart failure, high blood pressure, peripheral vascular disease (PVD, circulation disorder), kidney failure, and cataracts; -Cognitively intact; -No behaviors; -No wandering; -Pain frequency: Almost constantly; -Pain interference with day to day activities: Almost constantly; -Pain score 9 out of 10; -Falls since admission: No. Review of the resident's care plan, revised on 11/20/24, showed: -Focus: Resident is at risk for fluid overload and/or dehydration potential fluid deficit related to diuretic use: -Goal: Resident will be free of symptoms of fluid overload and/or dehydration and maintain most mucous membranes, and good skin turgor; -Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor for fluid overload edema change in level of consciousness, and respiratory distress. Monitor vital signs as ordered/per protocol and record as needed. Notify physician of significant abnormalities; -Focus: Resident is at risk for falls related to history of syncope (fainting) with diagnosis with osteoporosis (thinning of bone density), peripheral artery disease (PAD, narrow or blocked arteries), history of lower extremity edema (swelling), and history of heart attack. On 11/17/24, noted on the floor with abrasion to left eye and skin tear to left eye: -Goal: Resident will not sustain serious injury; -Interventions included: Monitor for change in level of consciousness. Patient evaluate and treat as ordered or as needed. Sent to hospital for evaluation related to fall. Times 1 assist with transfers as needed; -Focus: Resident has history of complaints of acute/chronic pain. History of abdominal pain: -Goal: Resident will verbalize adequate relief with pain or ability to cope with incompletely relived pain; -Interventions included: Administer analgesia per orders/as needed. Receives lidocaine patch daily as ordered; -No documentation of the use of side rails. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated November 2024, showed: -An order, dated 11/4/24, torsemide oral tablet 20 mg. Give three tablets by mouth two times a day for swelling; -An order, dated 11/4/24, for Amiodarone HCl Oral Tablet 200 mg. Give 1 tablet by mouth one time a day for arrhythmia, showed: -An order, dated 11/4/24, Lidocaine External Patch 4%. Apply to skin topically one time a day for muscle ache; -An order, dated 11/4/24, Hospice, admitting diagnosis congestive heart failure. -An order, dated 11/4/24, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg. Give one tablet by mouth one time a day for HTN. Discontinued on 11/11/24; -An order, dated 11/11/24, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 mg. Give one tablet by mouth one time a day for HTN If systolic B/P less than 100 hold medication; -No order for the use of side rails. Review of the resident's medication administration record (MAR), dated November 2024, showed: -An order, dated 11/4/24, torsemide oral tablet 20 mg, give three tablets by mouth two times a day. Scheduled administration times 8:00 A.M. and 5:00 P.M.: -For the 8:00 A.M. scheduled administration: On 11/5 through 11/11 and 11/17/24, staff documented other/hold see notes. On 11/13, 11/15, and 11/16/24, staff documented refused; -For the 5:00 P.M. scheduled administration: On 11/4 through 11/8/24, staff documented hold or other/hold see notes. On 11/13 and 11/15/24 at 5:00 P.M., staff documented refused; -An order, dated 11/4/24, for Amiodarone HCl Oral Tablet 200 mg. Give 1 tablet by mouth one time a day. Scheduled administration time 9:00 A.M.: -On 11/6, 11/7, 11/8 through 11/11, and 11/17/24, staff documented hold or other/see progress notes. On 11/13, 11/15, and 11/16/24, staff documented refused; -A order, dated 11/4/24, for Lidocaine External Patch 4%. Apply to skin topically one time a day. Scheduled administration time 9:00 A.M.: -On 11/5 through 11/7, 11/9- 11/12, and 11/17/24, staff documented hold or other/see progress notes. On 11/13 through 11/16/25, staff documented refused; -An order, dated 11/4/24, for Metoprolol Succinate ER oral tablet extended release 100 mg. Give one tablet by mouth one time a day. Scheduled administration time 9:00 A.M.; -On 11/6 through 11/11/24, staff documented hold or other/see progress notes. Discontinued on 11/11/24; -An order dated, 11/11/24, for Metoprolol Succinate ER oral tablet extended release 50 mg. Give one tablet by mouth one time a day. Scheduled administration time 9:00 A.M.: -On 11/13, 11/15, and 11/16/24, staff documented refused. Review of the resident's progress notes, showed: -On 11/4/24 at 7:23 P.M., Torsemide oral tablet 20 mg, waiting on prescription; -On 11/5/24 at 9:54 A.M., staff documented on order on administration note. Medication name was not listed; -On 11/5/24 at 8:00 P.M., Torsemide oral tablet 20 mg, waiting on prescription; -On 11/6/24 at 10:42 A.M., staff documented on order on administration note. Medication name was not listed; -On 11/6/24 at 8:42 P.M., Torsemide oral tablet 20 mg, waiting on prescription; -On 11/7/24 at 11:42 A.M., staff documented on order on administration note. Medication name was not listed; -On 11/7/24 at 9:56 P.M., staff documented on order, waiting on pharmacy on administration note. Medication name was not listed; -On 11/8/24 at 2:45 P.M., staff documented, informed the nurse on administration note. Medication name was not listed; -On 11/8/24 at 5:57 P.M., Torsemide oral tablet 20 mg, medication on order; -On 11/9/24 at 10:18 A.M., staff documented informed the nurse on administration note. Medication name was not listed; -On 11/10/24 at 11:05 A.M., staff documented informed the nurse on administration note. Medication name was not listed; -On 11/11/24 at 10:44 A.M., staff documented, on order on administration note. Medication name was not listed; -On 11/11/24 at 6:31 P.M., Torsemide oral tablet 20 mg, not given, waiting on pharmacy. Documentation was crossed out. Strike out reason: Declined order. Strike out date: 11/11/24 at 7:19 P.M.; -On 11/12/24 at 10:09 A.M., Lidocaine external patch 4%. Staff documented on order; -On 11/17/24 at 9:58 A.M., Lidocaine external patch 4%. Staff documented informed the nurse. Review of the medical record, showed no documentation of pharmacy contact, physician contact, or hospice notification regarding medications not delivered, not administered, or refused by the resident. Review of the facility's E-Kit inventory, showed an active inventory for the following medications: -Amiodarone 200 mg; -Metoprolol ER Succ 25 mg; -Metoprolol ER Succ 50 mg; -Torsemide 10 mg; -No medications were pulled from the E-kit between 11/4 through 11/17/24. During an interview on 4/25/25 at 3:00 P.M., Pharmacist A said the resident's Amiodarone was never filled through the facility's pharmacy. Since the resident was hospice, they did not fill prescriptions for that hospice company. Metoprolol and Torsemide was also filled through the hospice company. The Lidocaine patch is a stock medication, so they facility would have it. During observation and interview on 4/25/25 at 3:48 P.M., the Director of Nursing (DON) said they do not have lidocaine patches in stock. They use a cream instead of the patch. At 4:07 P.M., the DON brought in a container of cream called, Triderma pain relief cream. The pharmacy stopped sending the patches at the end of last year. If someone has an order for the lidocaine patch, they would first see if they get the patch, otherwise they will use the pain cream instead. She would expect the order to change to reflect using the cream instead of the patch. During an interview on 4/25/25 at 4:20 P.M., Pharmacist B provided information on the medications ordered and filled by the hospice company. The Amiodarone was filled on 11/11/24 and delivered either the same day or the next day. The resident's Metoprolol 100 mg and 50 mg were filled on 11/11/24. The torsemide was filled on 11/11/24. They did not fill the Lidocaine patch order. Review of the resident's progress notes, dated 11/17/24, showed: -At 3:30 A.M., showed this writer was made aware by the Certified Nurse Aide (CNA) caring for the resident that upon rounds he/she found the resident on the floor next to the bedside commode and the bed. Resident was found laying on his/her left side, abrasion noted above the left eye, skin tear noted under the left eye. Staff times 2 assisted the resident back into the bed, bed placed at lowest position, side rails in placed, call light within reach. Resident encouraged to use call light and wait for assistance. Range of motion (ROM) level of consciousness within normal limits. Neurological checks initiated. Physician, DON, Responsible Party (RP) and Hospice made aware; -At 9:53 A.M., while making rounds, resident was found in another resident room. Resident climb over his/her side rails and walked across the hall and laid across that resident bed. Resident was escorted back to his/her room, placed in bed, side rails up and bed lowered. Wound care provided to resident left eye. Resident heart rate fluctuating. Torsemide and metoprolol held due to blood pressure being low. Hospice and physician contacted; -At 1:51 P.M., nursing reported today in the morning that patient had a fall and developed skin tear. No bleeding at this time. Advised nursing for close monitoring of the patient and neurological checks, to report for any changes. Later on, patient's adult child called and reported that patient is bleeding from the skin tear and complaining of severe pain. We decided to send patient to the emergency room for further evaluation; -At 7:39 P.M., hospice here at facility. Hospice nurse informed this writer that resident was admitted for anemia (low red blood cell count) and atrial fibrillation (irregular heart rate). Resident had a blood transfusion. Hospice informed this writer that resident has been discharged from hospice until he/she is discharged from the hospital. During an interview on 4/28/25 at 9:58 A.M., hospice dispatch read off the hospice notes. The initial assessment was completed on 11/4/24. There were 1-2 visits a week. It is a part of their protocol to speak to facility nursing staff. The resident's amiodarone was an ordered medication, as well as Metoprolol, with some parameters to hold it. The amiodarone was ordered to be taken once a day. The torsemide was never ordered by hospice. As long as the resident was able to swallow, they expect the medications to be administered. There was a triage note on 11/7/24, from the DON, who called about medication issues. It did not specifically define that the issues were or what medications. Hospice was notified the resident fell on [DATE]. They called at 5:16 A.M. and said he/she fell while transferring to the commode and had an abrasion to the left eye. There was no documentation of disorientation or being found in another room. They received another call at 12:13 P.M., to notify hospice that the resident was going to the hospital. During an interview on 4/28/25 at 1:20 P.M., the DON said she did not remember the resident. The Assistant Director of Nursing (ADON) said the resident was kind of confused. He/She had dementia. When the resident first arrived, he/she walked around, he/she was curious of things. If they did not have a resident's medication, the DON would be expected to be notified, so she can contact the pharmacy. They would also pull the medication from the E-kit. Not everyone is able to access the E-Kit, only the ADON and one other nurse. They would contact hospice to let the hospice nurse know if medications are not available. The ADON initially said the resident climbed over side rails of the other resident's bed. Then the ADON said it was never reported that the resident climb over the side rails. It was reported that the resident fell , and his/her family was update and asked for the resident to go out. The fall was called into hospice. The DON said she would expect there to be orders for side rails. There should be a side rail assessment. They do the assessment, but if the bed was delivered from hospice, the facility could have missed that assessment. MO00253193

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified three nurse medication carts and three medication rooms. Three of the three nurse medication carts were checked, and issues were found with all three carts. Staff failed to store Ativan (lorazepam, a controlled substance used to treat anxiety) liquid medication in the refrigerator, as it is labeled to be stored in the refrigerator, and had it stored in the nurse medication cart narcotic lock box. The sample was 9. The census was 83. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Policy Interpretation and Implementation: -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications; -Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly; -Only person authorized to prepare and administer medications shall have access to the medication room, any keys. During an interview on 4/1/25 at 5:14 P.M., Licensed Practical Nurse (LPN) B said the medication room behind the charting break room does not lock. Someone lost the key fob approximately 6 months ago. The Certified Nursing Assistant's (CNAs) think they can go in there and get the residents' nutritional supplements that are located in the refrigerator. LPN B said that is why the lorazepam is not in there. It is on the medication cart in the narcotic lockbox, so it is behind a double lock. During an interview on 4/2/25 at 10:28 A.M., Pharmacist C said the lorazepam is recommended to be in refrigerated if it is in a liquid form. The drug may just breakdown if not in a refrigerator. The pharmacist checked the bottle that he/she had at the pharmacy and said it does not say anything on the bottle but that it definitely should be stored in the refrigerator all the time. If the lorazepam is not stored in the refrigerator, the medication may not be as effective and it may breakdown. The medication is also supposed to be disposed of after 90 days of opening. Pharmacist C said the pharmacy just lost their entire stock of lorazepam and had to have it reordered because they lost power due to the recent tornado and their generator failed to turn on so all their medication that is stored in the refrigerator like the lorazepam had to be discarded. Observation and interview on 4/3/25 9:45 A.M., showed Registered Nurse (RN) A at the nurse medication cart. RN A said the lorazepam is kept in the narcotic lockbox in the medication cart. The medication should be in the fridge in the medication room but there is not a lock on the fridge in there and the medication needs to be under a double lock. RN A opened the narcotic box in the medication cart and an unopened box of Lorazepam sat in the narcotic box. During an interview on 4/3/25 at 1:00 P.M., the Director of Nursing (DON) said narcotics should be under a double lock and medications should also be refrigerated if it says to be refrigerated on the box. The DON said there are two types of liquid Ativan and the facility has the one that does not need to be refrigerated. It is called lorazepam Intensol. Observation and interview on 4/3/25 at 1:15 P.M., showed the DON entered the dining room where the nurse had the medication cart for Faith Hall. The DON opened the narcotic lockbox in the medication cart and verified a box of Ativan with a sticker to be refrigerated sat in the lockbox. The DON said, Yes that should have been refrigerated. The DON instructed the nurse to immediately dispose of the medication and to reorder the medication for the resident. The DON also said she will get a plastic lock today for the medication room so when the replacement medication arrives it can be under a double lock. The DON went to the Hope Meadows hall medication cart and opened the narcotic lockbox. A box of lorazepam Intensol sat in the box. The box had a sticker needs to be refrigerated. The DON said that should have been in the refrigerator then as well. The DON entered the medication room on the Hope hall and tried the nurses' key but was unable to open the locked box inside the refrigerator. There was no medication stored in the refrigerator. Finally, the DON entered the Grace Meadows hall and opened the medication cart. The narcotic lockbox contained a box of Ativan with a sticker needs to be refrigerated on the box. The DON told the nurse on the hall to get rid of it and to order new bottle for resident. During an interview on 4/3/25 at 1:30 P.M., the Administrator and DON said there is no reason for any CNA to be in the medication room. Badge swipe is the only way to get access to the medication room so they should not have access. Only Certified Medication Technicians (CMTs) and nurses should be in the medication rooms. The DON did not know about a key being lost for the medication room. The DON said she will get a clear lock for the medication room refrigerators so narcotic medications that need a double lock can be stored in the medication room.

Based on interview and record review, the facility failed to address an order of increased fluids from the Primary Care Physician (PCP) on 9/10/24 and again on 11/22/24 from the Registered Dietitian (RD) for a resident with diagnoses of severe malnutrition, renal (kidney) disease and abnormal lab values, for one out of three sampled residents (Resident #3). This resulted in the resident's hospitalization with the admitting diagnoses of renal failure, hypernatremia (high sodium levels in the blood) and altered mental status. The census was 84. Review of the facility's Nutrition and Hydration to Maintain Skin Integrity policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration; -When there is a decline in a resident's appetite, nutritional intake, weight, or overall condition, caregivers should first attempt to discover the factors compromising nutritional status and offer support with eating; -If intake continues to be inadequate, impractical or impossible, nutritional support must be implemented according to the plan of care; -Ensure that the resident's intake of fluid is sufficient. Sufficient fluid'' means the amount of fluid needed to prevent dehydration and maintain health; -The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition; -The specific amount of hydration needed is specific for each resident, and fluctuates as the resident's condition fluctuates; -Risk factors for dehydration include: fluid loss and increased fluid needs (e.g. uncontrolled diabetes), functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs, or dementia in which a resident forgets to drink or forgets how to drink; -Review supportive ancillary documentation that impacts the nutritional assessment, including, but not limited to, the food and fluid consumption record (Appetite Sheet), weight and height records, laboratory results, and nursing notes; -Implement nutritional support and interventions according to the plan or care. Review of Resident #3's Physician Order Sheet (POS), dated August 2024, showed: -An order, dated 6/14/24, for regular diet, mechanical soft texture, regular/thin consistency, a snack at night and Boost (a nutritional supplement for diabetics) three times a day. Use a divided plate; -An order, dated 8/21/24, for labs, including a complete metabolic panel (CMP, measures 14 substances in the blood to assess metabolism, kidney and liver function and electrolyte and fluid balance). Review of resident's lab report, dated 8/30/24, showed: -On 8/30/24 at 2:30 A.M., the blood sample was collected; -On 8/30/24 at 9:34 A.M., the blood sample was received by the lab; -On 8/30/24 at 11:35 A.M., the final report for the CMP was completed; -Sodium (measures the amount of sodium in the blood. Normal ranges are between 136 milliequivalents per liter (mEq/L) and 145 mEq/L) measured within normal range at 142 mEq/L; -Creatine (measures how well kidneys are functioning, normal levels are between 0.7 milligrams per deciliter (mg/dL) and 1.3 mg/dL. High levels of creatine can show kidney disease or dehydration) measured high at 1.4 mg/dL; -Blood urea nitrogen (BUN, measures the amount of urea nitrogen in blood, showing how well kidneys are functioning. Normal levels are between 10 mg/dL to 22 mg/dL. High BUN could indicate kidney problems) measured high at 30 mg/dL; -BUN to Creatine ratio (blood test that measures the levels of urea nitrogen and creatinine. Normal levels are between 8.6 to 16.7. A high BUN to creatinine ratio could indicate kidney problems or dehydration) measured high at 21.4286; -An order, dated 9/10/24, was handwritten by the PCP on the lab report to push fluids. Review of the resident's POS, dated September 2024, showed: -There was no order found to push fluids. Review of the PCP progress note, dated 11/11/24, showed: -The resident had generalized muscle weakness, was not well-looking, chronically ill and appeared poorly nourished; -The resident reported confusion, disorientation, memory lapse or loss, gait abnormality, difficulty with balance and poor coordination; -Plan of Care included to follow up with weight management; add Remeron (an appetite stimulant) 7.5 milligrams (mg) at night due to severe malnutrition. Review of the resident's Medication Administration Record (MAR), dated November 2024, showed: -An order, dated 11/11/24, discontinued on 11/19/24, for Remeron 7.5 mg, give once at bedtime for weight loss; -Documentation showed the facility administered the medication as ordered seven out of the eight opportunities. Review of the resident's progress notes, from 11/11/24 through 11/19/24, showed: -No documentation was found showing an order was given to discontinue the Remeron on 11/19/24. Review of the resident's Nutrition/Dietary Note, dated 11/22/24 at 12:23 P.M., showed: -The resident had a significant weight gain from 10/10/24 weight of 103.4 pounds (lbs) to 124.4 lbs on 11/8/24; -The resident height was 68 inches and current Body Mass Index (BMI, measured body fat based on height and weight) was 18.9, which was low for his/her age; -The RD believed the resident's October weight was inaccurate as there were no diagnoses or medications noted that could to contribute to weight fluctuation; -The resident was prescribed a mechanical soft diet with thin liquids, with special instructions to use a divided plate; -Supplements included Ensure (nutritional shake) three times a day (TID) and a snack at night; -Most recent labs from 8/30/24, showed creatine high at 1.4 mg/dL and BUN high at 30 mg/dL; -The PCP noted on the lab results to push fluids; -The RD recommended to update diet order to state push fluids 500 milliliters (ml)/2 cups at meals and 250 ml/1 cup in between; -The RD will continue to monitor weight, by mouth (PO) intake and labs as available; -The goal was to improve nutrition related labs and maintain weight plus four percent. Review of the resident's MAR, dated November 2024, showed there was no order to push fluids 500 ml at meals and 250 ml/1 cup between meals. Review of the resident's care plan, undated, showed: -Problem: The resident was at risk for unplanned/unexpected weight loss due to diagnosis of severe protein calorie malnutrition; -Interventions included: give supplements as ordered; give diet as ordered; push fluids 500 ml/2 cups at meals and 250 ml/1 cup in between meals, initiated on 11/22/24. Review of the resident's POS, dated December 2024, showed: -An order, dated 12/10/24, to push fluids 500 ml at meals and one cup in between meals, five times a day for hydration. Review of the resident's MAR, dated December 2024, showed: -An order, undated, to push fluids 500 ml at meals and 1 cup in between meals five times a day for hydration; -Documentation showed from 12/10/24 at 11:00 A.M. through 12/23/24 at 8:00 A.M., the facility documented they followed the order as written 15 times out of 65 opportunities; -Documentation showed the facility failed to follow the order three out of five opportunities on 12/19/24, 12/20/24 and on 12/21/24; -Documentation showed the facility failed to follow the order once out of five opportunities on 12/22/24. Review of the resident's progress note, showed: -A note, dated 12/16/24 at 2:34 P.M., an order was received from the PCP to obtain labs, including a CMP; -A note, dated 12/16/24 at 4:44 P.M., the nurse was informed by the RRP that while the resident was out having a computed tomography (CT scan, combines a series of x-ray images taken from different angles around the body), the office informed him/her that the resident's creatine level was high. The nurse reported the information to the PCP. Review of the resident's POS, dated December 2024, showed: -An order, dated 12/17/24, for labs, including CMP, one time only for creatinine level. Review of the resident's lab report, dated 12/18/24, showed: -On 12/18/24 at 4:26 A.M., the blood sample was collected; -On 12/18/24 at 11:11 A.M., the blood sample was received by the lab; -On 12/18/24 at 1:55 P.M., the final report for the CMP was completed; -Sodium measured high at 156 mEq/L; -Creatine measured high at 1.76 mg/dL; -BUN measured high at 43 mg/dL; -BUN to creatine ratio measured high at 24.4; -A handwritten note, unsigned and undated, showed a call was placed to the PCP to ensure orders were verified, to encourage fluids and repeat CBC and CMP labs in one month. Review of the resident's POS, dated December 2024, showed: -There was no documentation found to repeat CBC and CMP labs in one month; Review of the resident's progress notes, showed: -A note, dated 12/18/24 at 2:41 P.M., the resident's lab results were still pending and the nurse will pass the information on in report; -A note, dated 12/19/24 at 4:59 P.M., the resident's responsible part (RRP) called concerned the resident was getting fluids, stating he/she put a sports drink and water in the resident's personal fridge. The RRP stated the resident had a CT scan on Monday (12/16/24) and iodinate will need to get flushed out. The writer informed the RRP the resident was offered fluids. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/21/24, showed: -Severe cognitive impairment; -Required moderate assistance with eating; -Height of 68 inches; -Weight of 120 pounds; -Risk for pressure ulcers (a localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time); -No pressure ulcers present; -Diagnoses included non-traumatic brain dysfunction, hypertension (high blood pressure), kidney disease, Diabetes Mellitus, Alzheimer's disease, stroke, dementia and severe protein-calorie malnutrition. Review of the resident's progress notes, showed: -A note, dated 12/23/24 at 9:45 A.M., the resident was leaving the building with a family member for a doctor appointment; -A note, dated 12/23/24 at 11:47 P.M., a call was made to the RRP asked when the resident would return to the facility. The RRP stated the resident was sent to the hospital emergency department for evaluation on an order from the doctor during their appointment; -A note, dated 12/24/24 at 12:09 A.M., the nurse called the hospital emergency department and was informed the resident was admitted to the hospital. Admitting diagnoses were hyponatremia (low sodium in the blood), dehydration and altered mental status. During an interview on 1/28/25 at 12:20 P.M., the Director of Nursing (DON) said: -She expected nursing staff to have knowledge of and to follow facility policies; -She expected staff to be aware of and to follow resident's care plans; -It was the charge nurses' responsibility to take physician written orders off of lab results and put them into the resident's physician order sheet in the electronic medical record (EMR); -The DON read the RD's nutritional recommendations after his/her visit to residents and was responsible for putting the RD's orders into the residents' physician order sheet in the EMR; -If the DON was not present on the days the RD came in to assess residents, the RD would email his/her report and the DON was responsible for putting the RD's orders into the residents' physician order sheet in the EMR; -She expected all written, verbal or telephone orders entered into residents' physician order sheet in the EMR within 48 hours; -Residents' health could decline if orders were not put into the EMR in a timely manner; -She expected nurses to document in a progress note when an order was discontinued; -Both she and the Assistant Director of Nursing (ADON) were responsible monthly for reviewing EMRs to review if orders were put in correctly; -Both she and the ADON would review MARs occasionally, especially if a resident complained they were not getting medications; -She was not aware of any issues regarding orders not implemented or followed per the plan of care or PCP; -When there was a blank in the documentation on a MAR, it meant the order was not done; -She expected staff to follow orders and offer fluids to dependent residents; -She expected nurses to follow up with Certified Nursing Assistants (CNA) to ensure the residents were given fluids as ordered; -The residents were at risk of complications to their health related to possible dehydration and/or malnutrition if nursing staff did not administer fluids as ordered. During an interview on 1/30/25 at 2:58 P.M., the hospital charge nurse said: -He/She was the charge nurse on the floor where the resident was admitted to on 12/23/24; -The emergency room (ER) Physician notes, on 12/23/24, said the resident was significant for renal failure, altered mental status and hyponatremia; -The resident's labs taken on 12/23/24 while he/she was in the ER, showed estimated glomerular filtration rate (eGFR, measures how well kidneys filter waste. Normal range is 90 or higher) was 35, showing moderate to severe decreased kidney function, sodium was high at 154 mEq/L, BUN was high at 48 mg/dL and creatine level was high at 1.87 mg/dL; -The ER physicians often dictate their notes and do not review them after they were scribed into the medical record for accuracy; -Given the resident's lab result of sodium at 154, the resident had hypernatremia (high sodium levels in the blood), not hyponatremia. MO00247413

Based on observation, interview and record review, the facility failed to ensure two out of 17 sampled residents were free from abuse. Certified Nurse Aide (CNA) N yelled at Resident #6 in the dining room and pulled on the resident's arm- telling the resident he/she needed to leave and eat in their room, causing the resident to cry and be afraid. CNA G scolded Resident #7 when he/she yelled for assistance with continence care, due to not having a call light within reach. CNA G told the resident it was the last time he/she was going to care for the resident in bed, causing him/her to feel hurt and disrespected. During a later event, CNA G spoke disrespectfully towards the resident while walking past them. The census was 86. Review of the abuse prevention policy, dated 9/16/24, showed: -Prevention and reporting: Suspected resident/patient abuse, neglect and/or misappropriation of property; -The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc; -The Administrator has the primary responsibility in the facility for the implementation of the abuse/neglect program: -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property; -The facility encourages and supports all resident, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury. The facility takes all measures possible to ensure the resident, staff and families are free from fear of retribution if reports or incidents are filed with the facility; Allegations of abuse will be promptly reported and thoroughly investigated. The facility should immediately report all such allegations to the Administrator and to the Department of Health and Senior Services; -The administrator and Director of Nursing (DON) are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect: -Implementation and ongoing monitoring consist of the following: screening, training, prevention, identification, protection, investigation and reporting; -Definitions: -Abuse: -Willful infliction of an injury; -Unreasonable confinement; -Intimidation with resulting physical harm, pain or mental anguish; -Instances of abuse includes verbal, sexual abuse, physical and mental abuse; -Verbal abuse: oral, written or gestured language that includes disparaging and derogatory terms to the resident or their families with within their hearing distance; -Physical abuse: includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc; -Mental/emotional abuse: includes, but not limited to humiliation, harassment, and threats of punishment or deprivation; -Training: -Provide training for new employees and volunteers through new hire orientation and annually with ongoing training programs on abuse and neglect and the handling of abuse, and neglect. Training will include, but not limited to: -Definitions of abuse, neglect and mistreatment; -Identification and reporting of abuse, neglect and mistreatment; -Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions for resident; -How to provide protection for residents; -Investigation of abuse, neglect and mistreatment; -Document staff training and maintain with educational records in the facility; -Resident rights- how the residents are to be treated, including the right to be free from abuse and what to do if an employee/volunteer suspect that a resident has been violated; -Prevention: -Ensure that prevention techniques are implemented in the facility including, but not limited to an ongoing supervision of employees through visual observation or care delivery and recognition of signs of burnout, stress and frustration. It is the responsibility of the staff to promote a safe environment for the residents; -Identify, correct and intervene in situations where abuse, neglect and/or mistreatment are more likely to occur: sufficient staffing on each shift to meet needs of the residents, residents with needs and behaviors which might lead to conflict and supervision of staff to identify inappropriate behavior, such as rising derogatory language, rough handling and ignoring residents while giving care; -Instruct staff that they are required to report concerns and incidents; -Protection: -Provide for the immediate safety of the resident upon identification of the suspected abuse, including but not limited to: moving the resident to another room or unit, provide 1:1 monitoring as appropriate, immediate suspension of the suspected staff pending outcome of the investigation; -Initiate behavior crisis management interventions as applicable. -Reporting: -Any person witnessing or having knowledge of alleged violation involving abuse, neglect or misappropriation are to notify the Administrator and DON immediately. 1. Review of Resident #6's medical record, showed the following: -Moderately impaired cognitive skills for daily decision making. -Diagnoses include traumatic brain dysfunction, depression, and psychotic disorder. Review of the resident's care plan, in use during the survey, showed the resident has periods of crying and mood changes. Interventions included to provide active listening and support when needed, and to encourage the resident to express feelings. Observation of video footage, dated 3/8/25, showed the resident entered the dining room and walked towards a table. He/She pulled out the chair. Another resident approached the resident and spoke to him/her. Certified Nurse Aide (CNA) F approached the residents and motioned with his/her arms, then walked around both residents. CNA F pulled on the resident's left arm. Licensed Practical Nurse (LPN) G intervened and CNA F left the dining room. During an interview on 3/11/25 at 9:53 A.M., the resident said he/she was in his/her room and experienced an episode of urinary incontinence. A CNA entered the room, and helped him/her change clothes. The resident said his/her shoes were wet and the CNA said he/she could not go to lunch because his/her shoes were wet and he/she had to eat in his/her room. The resident walked to the dining room. While at his/her dining room table, the CNA began to yell at him/her and said you can not be in here without shoes, you have to eat in the room. The CNA pulled on his/her right arm. The resident said he/she cried and was very upset and felt terrible. It was just terrible, he/she is afraid of the CNA now, and didn't want the CNA working with him/her. During an interview on 3/12/25 at 1:13 P.M., Resident #20 said he/she sat at the table during lunch on 3/8/25. The resident saw a staff person push on Resident #6. It made Resident #20 scream, Stop that. Resident #6 was crying. Resident #20 was so scared because he/she couldn't do a damn thing. It scared Resident #20 because someone could also hurt him/her. During an interview on 3/12/25 at 1:40 P.M., Visitor H said he/she was in the dining room during lunch with Resident #20 on 3/8/25. Visitor H saw Resident #6 at the dining room doorway, and staff telling the resident he/she couldn't come into the dining room without shoes on, and pushed the resident out. Other residents go to the dining room wearing socks without shoes. Resident #6 was crying. Staff grabbed and pulled at the resident, who yelled, Get your hands off me. Visitor H told the staff not to put his/her hands on people. The staff person said do what you want and left. Other staff were present but did not intervene. Visitor H said it was physical abuse. It could have made the resident fall, it wasn't safe and could be frightening to other residents. Resident #6 was crying and this upset Resident #20. Visitor H told another staff person, in the office across from the chapel, that staff pushed Resident #6. This staff person said he/she would report it but could not nothing about nursing. Visitor H said he/she expected the staff person to report it and for someone to stick up for Resident #6. During an interview on 3/12/25 at 12:52 P.M., the Social Worker said she didn't see the CNA pull the resident's arm, but she went to the resident's table because she heard the resident crying. The Social Worker called the Administrator about 1:00 P.M. on 3/8/25, to report the resident and CNA were arguing and the resident was crying. The Administrator instructed her to tell the DON, which she did on 3/10/25 between 7:30 and 8:00 A.M. During an interview on 3/10/25 at 2:27 P.M., the DON said the incident occurred over the weekend. She found out about it on 3/10/24 before lunch, when the resident's grandparent reported to her that staff snatched his/her arm on Saturday 3/8/25, before lunch. During an interview on 3/10/25 at 3:38 P.M., the Administrator viewed the footage and suspended the CNA. Review of CNA F's timecard, showed he/she worked on 3/8/25 until 2:31 P.M. Observation on 3/10/25 during the day shift, showed CNA F worked directly with the residents. 2. Review of Resident #7's medical record, showed the following: -Intact cognitive response; -Diagnoses include muscle weakness, functional quadriplegia, acquired absence of left leg below the knee and end stage kidney disease. Review of the resident's care plan, updated on 10/24/24, showed: -The resident was at risk for psychosocial well-being; -Interventions included: Allow the resident time to answer questions and to verbalize feeling, perceptions and fears; Inform DON/Administrator of alleged abuse/neglect. During an interview on 3/12/25 at 9:52 A.M., the resident said: -CNA G worked the night shift on his/her hall; -He/She did not have a call light within reach and needed help with incontinence care; -He/She had to holler for help; -CNA G came into the room and told the resident he/she was too big for the CNA to move by him/herself; -CNA G scolded the resident, telling him/her not to holler because he/she would wake the other residents; -He/She tried to explain that he/she only hollered because the call light was not in reach; -CNA g left and came back with another CNA and provided care; -CNA G told the resident it was the last time he/she was going to care for the resident in bed before leaving the resident's room; -The resident was mad because he/she had to holler for the longest time and no one came to help him/her; -The resident's feelings were hurt and he/she felt disrespected; -He/She returned to the facility on Sunday around 7:40 P.M., after a birthday party; -He/She was waiting at the nurses station in his/her wheelchair to go back to his/her room; -CNA G came down the hall and passed the resident saying I'm not going to work with (him/her)! and called the resident a bad name, which he/she could not recall; -It made the resident feel mad and he/she did not want to tell anyone because he/she felt like all of the staff were up against him/her at that point and that they would not help the resident; -He/She did not want CNA G to provide care to him/her anymore. During an interview on 3/10/25 at 4:10 P.M., CNA G said: -Violation of resident rights was when a staff member used a threatening voice, refused to care for residents or refused to listen to residents' needs and/or wants; -He/She would notify the charge nurse or administrative staff of any violation of resident rights so they could investigate the incident; -He/She worked on 3/8/25 from approximately 2:45 P.M. until 8:59 P.M.; -He/She did not have any complaints from the resident regarding care; -He/She had a good relationship with the resident. During an interview on 3/12/25 at 7:50 A.M., the DON said: -The resident reported to her on 3/11/25 that a CNA was talking badly about him/her on Sunday, after the resident had returned from a birthday party; -The CNA said I am not going to put (his/her) fat ass into the bed while he/she was pushing another resident in a wheelchair past the resident at the nurses' station; -The DON looked at the video that was taken around the time described by the resident and determined the CNA in question was CNA G; -The video shows CNA G pushing another resident in a wheelchair past the resident and CNA F was seen speaking to resident. There was no audio to the video; -She had not begun her investigation yet but would try to find out determine what happened and then make the determination of what was best for the residents in regards to psycho-social care; -She expected staff to report any verbal abuse to residents; -She was going to terminate CNA G after the investigation due to other allegations of resident rights violations; -She was educating staff on resident rights; -The resident did not report any incidents of staff rudeness to her.

Based on observation, interview and record review, the facility failed to notify the Primary Care Physician and obtain orders for pressure ulcers (ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when they were first identified for two residents (Resident #2 and #5) out of three sampled residents. The facility also failed to administer treatments as ordered and failed to have consistent documentation of the wounds. The census was 84. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure. Review of the facility's Pressure Ulcer/Skin Breakdown Policy, revised April 2018, showed: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers: for example, immobility, recent weight loss, and a history of pressure ulcer(s); -The nurse shall describe and document/report full assessment of the pressure ulcer and current treatments; -The physician will assist the staff to identify the type of ulcer; -The physician will order pertinent wound treatments; -The physician will evaluate and document the progress of wound healing. During an interview on 2/3/25 at 4:05 P.M., the Director of Nursing (DON) said the facility did not have a policy to Follow Physician Orders. 1. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/22/24, showed: -Severe cognitive impairment; -Impairment on one side of upper body; -No mobility devices were used; -Total dependence on staff for all activities of daily living (ADLs) including bed mobility, transfers, and eating; -Received hospice care; -At risk for pressure ulcers; -No unhealed pressure ulcers present; -Pressure reducing device for chair and bed were present; -Diagnoses included heart failure, diabetes mellitus, dementia, chronic kidney disease, dysphagia (difficulty swallowing), cognitive communication deficit and contracture of left and right hands. Review of the resident's care plan, undated, showed: -Problem: The resident was incontinent of bowel and bladder related to confusion and was at risk of skin break down. The resident had a Stage II Pressure Ulcer noted to his/her coccyx (a small triangular bone at the base of the spinal column) on 12/28/24. Interventions included: Resident to wear bilateral heel protectors; Assess skin weekly and as needed and inform resident's responsible party (RRP) and Primary Care Physician (PCP) of changes in skin integrity; Treat right foot and ankle as ordered; Treat calluses (hard, thickened skin) as ordered; Treat coccyx as ordered. Review of the hospice handwritten care notes, dated 11/06/24 through 12/3/24, showed there was no documentation found showing the resident had wounds. Review of the facility weekly wound report, dated Week One of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 centimeters (cm) by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's (an antiseptic cleanser) moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Does the not specified statements above refer to the staff not documenting a stage for the wound? Who completes the weekly wound report? is it a designated wound nurse working at the facility? a nurse from a wound management co? I see the interview with the wound nurse below but couldn't tell if he/she was a facility employee. Review of resident's shower sheets, dated 12/3/24 through 12/15/24, showed there was no documentation found of any open areas or skin issues. Review of the hospice handwritten care notes, dated 12/3/24 through 12/15/24, showed there was no documentation found showing the resident had wounds. Review of the facility weekly wound report, dated Week Two of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 12/16/24 at 2:14 P.M., showed the resident's skin was intact with no open areas noted. Review of the facility weekly wound report, dated Week Three of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the hospice handwritten care notes, dated 12/16/24 through 12/24/24, showed there was no documentation found showing the resident had wounds. Review of the resident's shower sheet, dated 12/24/24 with no time notes, showed the coccyx area was circled with a note saying new open area. Review of the facility weekly wound report, dated Week Four of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 12/26/24 at 9:46 A.M., showed: -A pressure ulcer at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's progress notes, showed: -On 12/28/24 at 6:09 P.M., a family member reported the resident had an open area to his/her coccyx and an open area to his/her right ankle with multiple calloused areas on both heels and foot. A call was placed to the PCP for treatment orders for both pressure areas to cleanse the wounds with wound cleanser, apply Medihoney (antimicrobial to treat burns and wounds) and cover with bordered dressing (bandage) once a day and to apply skin prep (liquid film-forming dressing that forms a protective film over skin). There was no documentation found showing where to apply the skin prep; -On 12/28/24 at 6:49 P.M., showed the RRP was made aware of the new orders for the resident's wounds at his/her coccyx and right ankle; -There was no documentation found the facility notified the PCP or RRP of any wounds from 12/1/24 through 12/27/24. Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: -An order, dated 5/17/24, to apply skin prep to the medial (inner edge that runs from the heel to the big toe) right foot once a day. Documentation showed the facility completed the treatment as ordered 15 out of 31 opportunities; -An order, dated 12/29/24 for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of three opportunities; -An order, dated 12/29/24, for Stage II pressure injury at coccyx, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of three opportunities; Review of the resident's weekly skin assessment, dated 12/30/24 at 11:04 A.M., showed: -A pressure ulcer at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's physician order sheets, dated December 2024, showed there was no order for a treatment to the resident's left ankle. Review of the hospice handwritten care notes, dated 12/26/24 through 1/2/25, showed there was no documentation the resident had wounds. Review of the facility's weekly wound report, dated Week One of January 2025, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 1/2/25 at 2:16 P.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's weekly wound assessment, dated 1/2/25 at 4:32 P.M., showed: -A callous (hard thickened skin) located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 3 millimeters (mm) by 3 mm by .02 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 45 mm by 35 mm by .01 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 1 mm by 1 mm by 0 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements. Review of the hospice handwritten care notes, dated 1/3/25, no time noted, showed the resident had wounds to his/her coccyx and right lateral ankle. Review of the facility's weekly wound report, dated Week Two of January 2025, showed there was no documentation on the resident's wounds. Review of the resident's progress note, dated 1/10/25 at 11:24 A.M., showed the RRP was called to confirm and educated the family on the resident's declining status and wound care. Review of the resident's weekly skin assessment, dated 1/9/25 at 2:16 P.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 3.5 cm by 3.0 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's weekly wound assessment, dated 1/9/25 at 4:38 P.M., showed: -A callous located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 1 mm by 1 mm by 0 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 35 mm by 30 mm by .01 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 1 mm by 1 mm by 0 mm deep Apply skin prep daily, with off-loading boot. Waiting on hospice measurements. Review of the Hospice Nurse Wound assessment, dated 1/10/25 at 9:24 A.M., showed: -Hospice assessed and treated the resident's wounds; This is the first time hospice assessed the wound? -A Stage II pressure ulcer at the right buttock, first assessed on 1/10/25, wound bed 50% granulation, 25% slough and 25% eschar, with small amount of serosanguineous, foul-smelling exudate (drainage) measuring 3.5 centimeters (cm) by 2.5 cm; -A Stage III pressure ulcer at the right ankle, first assessed on 1/10/25, wound bed of 100% slough, with moderate amount of serosanguineous exudate, measuring 2 cm by 2 cm by 0.1 cm deep. Review of the facility's weekly wound report, dated Week Three of January 2025, showed there was no documentation on the resident's wounds. Review of the Hospice Nurse Wound Assessment, dated 1/15/25 at 12:17 A.M., showed: -Hospice assessed and treated the resident's wounds; -A Stage III pressure ulcer at the right buttock, first assessed on 1/10/25, wound bed described as fragile, moist, necrotic and pink, with a small amount of tan exudate with a musty odor, no measurements found, wound status described as deteriorating. -A Stage III pressure ulcer at the right ankle, first assessed on 1/10/25, wound bed described as necrotic and pink with a small amount of exudate, no odor, no measurements found, wound status described as evolving; -A Stage III pressure ulcer at the left ankle, first assessed left blank, wound bed described as dry pink, with no exudate or odor, no documentation found regarding wound status. Review of the resident's weekly skin assessment, dated 1/16/25 at 10:18 A.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 8.5 cm by 3.5 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 2.0 cm by 2.0 cm by 0.2 cm deep; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.5 cm by 1.5 cm with no depth noted Review of the resident's weekly wound assessment, dated 1/16/25 at 4:44 P.M., showed: -A callous located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 2 millimeters (MM) by 2 mm by .02 mm deep. Apply skin prep daily, with off-loading boot and border gauze (bandage) as needed. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 52 mm by 35 mm by .02 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 15 mm by 15 mm by .02 mm deep. Apply skin prep daily, with off-loading boot and border gauze (bandage) as needed. Waiting on hospice measurements. Review of the resident's progress note, dated 1/17/25 at 3:50 P.M., showed social services called the hospice four times to obtain their wound report and measurements for the wound nurse. The calls were not answered. Review of the resident's progress notes, showed there was no documentation found the RRP or PCP were notified of the Stage II pressure ulcer found on the resident's left ankle. Review of the resident's TAR, dated January 2025, showed: -An order, dated 5/17/24, to apply skin prep to the medial right foot once a day. Documentation showed the facility completed the treatment as ordered nine out of twenty one opportunities; -An order, dated 12/29/24, discontinue on 1/16/25, for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered seven out of sixteen opportunities; -An order, dated 1/17/25, for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of five opportunities; -An order, dated 12/29/24, for Stage II pressure injury at coccyx, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered ten out of twenty one opportunities; -There was no treatment order for the resident's left ankle. Review of the resident's electronic medical record (EMR), showed there was no documentation of the resident's Braden score (test that scores resident's risk of pressure ulcers). Observations on 1/22/25 at 12:47 P.M. and at 1:22 P.M., showed: -The resident asleep in his/her bed, laying on his/her right side, on a low air loss mattress, covered with a blanket; -The resident's bed was in a lowered position and the bed had bilateral side rails in the raised position; -The resident had a cup of liquid on his/her bedside table, out of reach of the resident; -The resident was not able to answer any questions, blinked and opened and closed his/her mouth when spoken to; -The resident's skin on his/her arms appeared dry with visible superficial cracks and the resident's lips appeared dry with flaky skin; -There was a stack of wound supplies at bedside. During an interview on 1/22/25, at 1:27 P.M. the Wound Nurse said: -She was responsible for all wound reports, all weekly skin assessments, all wound treatments (unless they were for non open areas or skin tears) and to round with the Wound Doctor once a week; -She was also responsible for completing treatments on any hospice residents unless the hospice nurse completed them; -She expected hospice nurses to document when they completed treatments on residents and to give report to the nurse so they could track the wound's healing status; -She expected nurses who got report from the hospice nurse to write a progress note documenting what was done, by whom, when and the status of the wound during treatment; -She expected nursing staff to alert her when there was a new skin issue by telling her verbally or by putting a note in the wound nurse binder at the nurses station; -She was responsible for assessing resident's skin when she was alerted to a new skin issue, to document her findings on a skin assessment in the resident's EMR, then write a progress note what skin issue was found, the notification of the PCP for treatment orders and notification of the RRP. -She was responsible for putting the physician orders into the resident's physician order sheets in the EMR; -She completed the resident's treatments to his/her right and left ankles and to his/her coccyx before the day shift nurse arrived; -Hospice nurses were responsible for completing weekly assessments on the hospice residents; -She expected hospice nurses to give their wound assessments on the day they were completed; -She was responsible for putting all wound assessments from both the Wound Physician and the hospice nurse into the residents' EMR and on the facility weekly wound report; Observation on 1/22/25 at 1:33 P.M., showed: -The Wound Nurse performed a skin assessment on the resident while the resident was in his/her bed; -The resident wore protective boots on both of his/her feet, had a pillow in between his/her knees and a pillow tucked under his/her right upper body as he/she lay on his/her right side; -The Wound Nurse exposed the resident's right ankle, showing a bandage which had exudate showing through to the surface of the bandage. The bandage was not dated or signed; -The Wound Nurse exposed the resident's left ankle, showing a bandage, which was not dated or signed; -The Wound Nurse exposed the resident's coccyx, showing a bandage was present, which was not dated or signed; -The Wound Nurse was not sure who changed the resident's bandages after she had completed the treatments earlier that morning and had dated and signed each bandage with the day's date and her initials. During an interview on 1/22/24 at 1:45 P.M., Registered Nurse (RN) C, said: -He/She did not administer any treatments to the resident that day; -He/She thought maybe a hospice nurse came and changed them after breakfast; -He/She expected the hospice nurse to document in the hospice binder when they visited, showing what they did during the visit; -He/She did not get a report from the hospice nurse today and would not document if he/she did get a report from hospice staff; -He/She was called to the resident's room a few weeks ago by the RRP; -The RRP was upset because the resident had a wound at his/her coccyx for at least a week and a half and still staff had not done anything about it; -RN C assessed the resident's coccyx and found a new wound was present. He/She called the PCP, got an order, put in the resident's EMR and applied the treatment to the resident; -It was the first time the nurse was alerted to any wound located on the resident's coccyx; -If a Certified Nursing Assistant (CNA) told the nurse of a new skin issue, or if the nurse found a new skin issue, he/she would assess the wound, notify the PCP and RRP, obtain new treatment orders, put the treatment order in the resident EMR and apply the treatment, documenting all in a progress note; -He/She would also alert the Wound Nurse either verbally or by writing a note in the Wound Nurse binder found at the nurses station. Review of the handwritten Hospice Care notes, showed: -A note, dated 1/21/25, no time noted, showed the hospice nurse completed wound treatments on the resident; -There was no documentation they visited the resident on 1/22/24. During an interview on 1/28/25 at 12:20 P.M., the Director of Nursing (DON) said: -If a resident received hospice care, hospice nurses were responsible for changing the wound treatments when they are there and if they are not there, the Wound Nurse was responsible; -Hospice was also responsible for weekly wound assessments and if they didn't do it, the Wound Nurse was responsible or charge nurse in her absence; -If hospice changed a wound treatment and/or completed weekly wound assessments, the charge nurse or Wound Nurse would document that it was complete in the resident's progress notes and in the TAR with a note, saying hospice completed. 2. Review of Resident #5's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, personal hygiene, bed mobility and transfers; -Wheelchair used for locomotion; -Always incontinent of bladder and bowel; -Diagnoses included kidney disease, diabetes mellitus, stroke, dementia and Parkinson's disease (disorder of central nervous system that affects movement). Review of the resident's current care plan, showed: -Problem: The resident was at risk for open areas related to decreased mobility and incontinence; -Interventions included: follow up with wound specialist as needed; Inform PCP and RRP of changes in skin integrity; Assess skin weekly and as needed and inform PCP and RRP of changes in skin integrity. Review of the resident's weekly skin assessment, dated 12/3/24 at 1:50 P.M., showed the resident had intact skin, no open areas, area to sacrum (was red), ointment applied. Review of the resident's shower sheet, dated 12/3/24, showed there were no areas circled or skin issues noted. Review of the resident's weekly wound assessment, dated 12/3/24, showed, Stage I pressure ulcer at the resident's coccyx, acquired on 12/3/24, wound bed had pink, moist tissue with no drainage, measuring at 5 mm by 5 mm with no depth, current treatment of collagen (used to absorb exudate) and border gauze daily. Review of the resident's weekly wound assessment, dated 12/5/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 0 mm by 0 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed. Review of the facility's wound report, dated Week One of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 1.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed. Review of the resident's weekly skin assessment, dated 12/9/24, showed: -A pressure ulcer (stage not applicable) at the resident's right heel, with no measurements noted; -A Stage I pressure ulcer at the resident's sacrum, measuring 1.5 cm by 0.5 cm by 0.1 depth. Review of the resident's shower sheet, dated 12/10/24, showed there were no areas circled or skin issues listed. Review of the resident's weekly wound report, dated 12/12/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation on the resident's coccyx. Review of the facility's wound report, dated Week Two of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 1.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed. Review of the resident's weekly skin assessment, dated 12/16/24, showed: -A suspected deep tissue injury at the resident's right heel, measuring 1.0 cm by 1.0 cm by 0.1 depth; -A Stage I pressure ulcer at the resident's sacrum, measuring 0.5 cm by 0.5 cm by 0.1 cm deep. Review of the resident's shower sheet, dated 12/17/24, showed the resident's left buttock was circled with a note showing there was an open area present with a treatment in place. There was also a circle around both the right and left heels with a note saying skin prep to heels. Review of the resident's weekly wound report, dated 12/19/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation on the resident's coccyx. Review of the facility's wound report, dated Week Three of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 0.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed; -The resident had an unspecified wound at his/her right heel, measuring 1.0 cm by 1.0 cm with no depth, with a treatment to apply skin prep daily and wear offloading boots. Review of the resident's weekly skin assessment, dated 12/23/24, showed: -A suspected deep tissue injury at the resident's right heel, measuring 1.0 cm by 1.0 cm by 0 depth; -A Stage I pressure ulcer at the resident's sacrum, measuring 0.5 cm by 0.5 cm by 0.1 cm deep. Review of the resident's shower sheet, dated 12/24/24, showed the resident's left buttock was circled with a note showing there was an open area present with a treatment in place. There was also a circle around both the right and left heels with a note saying skin prep to heels. Review of the resident's weekly wound report, dated 12/28/24, showed: -The resident had a callus at his/her right heel, acquired on 12/26/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation found on the resident's coccyx. Review of the facility's wound report, dated Week Four of December 2024, showed: -The re

Based on observation, interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who was found by staff without a pulse (Resident #1). The resident expired. The facility also failed to have a code status for one resident (Resident #2), failed to have adequate supplies on the crash cart to allow staff to respond appropriately to an emergency situation, and failed to have a CPR certified staff member on each shift. The census was 82. The Administrator was notified on [DATE] at 3:02 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Emergency Procedure Cardiopulmonary Resuscitation Policy, revised 2/2018, showed: -Policy Statement: Personnel have completed training on the initiation of CPR and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest (SCA); -General Guidelines: -1. SCA is a loss of heart function due to abnormal heart rhythms. Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults; -2. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest. Typically heart attacks are less sudden than SCA; -3. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA; -4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse; -5. Early delivery of a shock with a defibrillator (devices that apply an electric charge or current to the heart to restore a normal heartbeat) plus CPR within 3-5 minutes of collapse can further increase chances of survival; -6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: -a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or; -b. There are obvious signs of irreversible death (e.g., rigor mortis); -7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR; -8. If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives; -Preparation for CPR: -1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel; -2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care or facility BLS training material; -3. Provide periodic Mock Codes (simulations of an actual cardiac arrest) for training purposes; -4. Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort; -5. The CPR Team in this facility shall include at least one nurse, one Licensed Practical Nurse (LPN) and two Certified Nurses' Aides (CNA), all of whom have received training and certification in CPR/BLS; -6. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times; -7. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission; -Emergency Procedure, CPR: -1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: -a. Instruct a staff member to activate the emergency response system (code) and call 911; -b. Instruct a staff member to retrieve the automatic external defibrillator; -c. Verify or instruct a staff member to verify the DNR or code status of the individual; -d. Initiate the basic life support (BLS) sequence of events; -2. The BLS sequence of events is referred to as C-A-B(chest compressions, airway, breathing); -3. Chest compressions: -a. Following initial assessment, begin CPR with chest compressions; -b. Push hard to a depth of at least 2 inches at a rate of at least 100 compressions per minute; -c. Allow full chest recoil after each compression, and; -d. Minimize interruptions in chest compressions; -4. Airway: Tilt head back and lift chin to clear airway; -5. Breathing: After 30 chest compressions provide 2 breaths via ambu (manual self-inflating bag, a hand-held device used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) bag or manually (with CPR shield, (device used to safely deliver rescue breaths during CPR)); -6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2; -7. When the AED arrives, assess for need and follow AED protocol as indicated; -8. Continue with CPR/BLS until emergency medical personnel arrive. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included diabetes mellitus (DM, metabolic disease), Alzheimer's (dementia), epilepsy (seizure disorder), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side, and high blood pressure. Review of the resident's CPR Determinator, dated [DATE], showed: -Should an emergency occur, and I go into cardiac arrest I, the resident has chosen the following options for my care: -Yes, I do wish CPR efforts in the event of a cardiac arrest. I agree to the full 911 protocols and transportation to the nearest hospital; -Signed by power of attorney (POA). Review of Resident #1's care plan, dated [DATE], showed: -Focus: Full code status (in the event of no pulse, initiation of CPR and summoning 911); -Goal: Code status will be honored; -Interventions: Review and verify code status. Review of the resident's progress notes, dated [DATE] at 1:45 P.M., showed the interdisciplinary team met with the resident's POA. Remains full code. Review of the resident's June, 2024 physician orders, showed an order as a full code. Review of the resident's progress note, dated [DATE] at 2:26 A.M., showed LPN B was called to the resident's bedside at 1:55 A.M., for unresponsive and pulseless patient, confirmed Full code, no respirations, absent heart sounds and breath sounds, no pulse palpable in carotid (neck) and femoral (top of thigh near groin area) arteries, pupils fixed and dilated. Patient pronounced dead at 2:15 A.M. During an interview on [DATE] at 10:58 A.M., LPN A said he/she received nothing in report showing any change of condition on the resident on the night shift of [DATE]-[DATE]. At approximately 2:08 A.M., LPN A entered the room. LPN A turned on the light and the resident did not respond to him/her. The resident had no pulse, no blood pressure (B/P), no rise and fall of the chest, and the blood sugar (BS) was 87. LPN A did a sternal rub (assessing response to painful stimuli by applying the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli), to which there was no response. LPN A said he/she checked the resident's radial (wrist) pulse first with no pulse found, then checked the carotid (neck) pulse with no pulse found, the resident had no rise or fall of the chest. LPN A called LPN B to assess the resident. The resident was cool to the touch, but LPN A did not know if that was due to the air conditioning or because of the resident's condition. LPN A said he/she was not aware the resident was a full code and if he/she knew the resident was a full code, he/she would have initiated CPR. The code status is available in the EMR and would be checked by whomever assisted him/her. Some residents' code statuses are listed on the report log, but Resident #1's code status was not. Emergency Medical Services (EMS) was not called. On [DATE] at 2:59 P.M., LPN A said rounds are completed with residents every two hours. During rounds, staff ensure the residents are clean, offer hydration, are breathing and not in any distress. LPN A said when the resident was not responding, LPN A took the resident's blood pressure and could not get a reading on the resident. LPN A said he/she took the resident's blood sugar and the reading was 87. LPN A called the Primary Care Physician (PCP) and did not get an answer. LPN A said the crash cart was not brought to the resident's room. After LPN B assessed the resident at 2:08 A.M., LPN B called the PCP and the PCP answered and said to pronounce the resident at 2:15 A.M. LPN A said the resident's limbs moved easily and he/she had no rigor mortis. The resident had no discoloration to his/her skin. During an interview on [DATE] at 10:44 A.M., LPN B said he/she worked on the night shift [DATE]-[DATE]. About 2:00 A.M., LPN B said LPN A called him/her to ask for his/her assistance with the resident. LPN B went to the room, felt the resident who was cool to the touch and had no pulse. The resident was a full code. LPN B started chest compressions, and then stopped. LPN B was not sure if 911 was called and did not ask. EMS did not come. LPN B said he thought the resident was a DNR The protocol on a full code resident is start CPR and call 911. During an interview on [DATE] at 1:18 P.M., LPN B said when he/she went to assess the resident, he/she was under the impression the resident was a Do Not Resuscitate (DNR) because the resident had been on hospice services in the past. LPN B said when assessing the resident, he/she was cold to the touch, eyes were fixed and dilated, and the resident had no carotid pulse. LPN B said the resident did not have discoloration to his/her skin. LPN B called the PCP around 2:15 A.M. and told the PCP the resident had expired. LPN B asked LPN A if he/she needed assistance with anything else and LPN A asked LPN B to call the resident's family and write a progress note for him/her. LPN B returned to his/her assigned hall and made the phone call to the resident's family. LPN B said the resident's family came to the facility quickly after being notified. LPN B began writing the progress note and called LPN A and asked LPN A what the resident's code status was because LPN B said he/she always documents that in his/her notes when a resident expired. LPN A told LPN B the resident was a full code, LPN B responded, A full code, are you serious? LPN B said he/she had already notified the PCP and the family had already been to the facility to see the resident. LPN B did not call the PCP back to notify the PCP the resident was a full code status. LPN B said CPR was not ever initiated on the resident and 911 was not called. If he/she would have known the resident was a full code, he/she would have initiated CPR and called 911. He/She thought the resident's code status was DNR. LPN B did not speak to the DON about the resident because LPN A said he/she was going to update the DON. Review of LPN B's written statement, dated [DATE], included: I called over to make (LPN A) aware the (family) and doctor been notified, he/she gave me the case number from the Medical Examiner. And then I asked for his/her code status for my nurse note. That is when he/she said he/she was a full code. I stated, if I knew he/she was a full code, would of immediately called 911 and started CPR. During an interview on [DATE] at 11:41 A.M., CNA C said rounds are completed every two hours to see if the residents need changed or anything else. CNA C said CNA D asked him/her to assist him/her with the resident, CNA C was unsure of the time but said it was late. CNA C said he/she spoke to the resident when he/she went in to assist and the resident did not speak back to him/her. CNA C thought the resident was sleeping and asked CNA D if this was the resident who died, and CNA D responded yes. CNA C said the resident was not even cold and that is another reason he/she thought the resident was sleeping. CNA C said there was no discoloration to the resident's skin during care. CNA C did not know the resident was a full code and did not have access to see the resident's code status. During an interview on [DATE] at 11:54 A.M., CNA D said rounds are completed every two hours. During rounds, residents are checked to see if they need assistance to the bathroom or changed. CNA D said the last time he/she saw the resident was around 11:00 P.M. to 11:30 P.M. on [DATE]. CNA D said LPN A kept going into the resident's room to answer the call light for the resident's roommate. CNA D said he/she always sits at the end of the hall, and he/she noticed LPN A was walking rapidly out of the resident's room towards the nurse's station around 1:00 A.M., so CNA D went to the nurse's station to ask what was going on. LPN A told CNA D the resident was gone. LPN A was on the phone and talking fast and was saying he/she went into the resident's room to answer the call light for the resident's roommate and went to turn on the air conditioner and that was when he/she noticed the resident was not responding. CNA D went to the resident's room and pulled the privacy curtain, left the resident's room and asked CNA C for assistance with cleaning up the resident. CNA D said while providing postmortem care, the resident's limbs moved easily. CNA D said the resident's hands and shoulders were cold but that area that was not under the blankets and the air conditioner was on and blowing cold air onto the resident. CNA D said the area that was not exposed to the air conditioner was not cold to touch. CNA C said the resident had no discoloration to his/her skin and the resident looked like he/she was asleep. CNA D said he/she did not see another nurse come to the resident's room and no crash cart (holds emergency supplies for providing CPR) was brought to the resident's room. CNA D did not know the resident was a full code and did not have access to see the resident's code status. During an interview on [DATE] at 10:11 A.M., the Wound Nurse (WN) said the progress note written by LPN B showed the resident was a full code and there was no mention of CPR being administered or 911 being called. The progress note did not mention the last time the resident was seen alive and did not create a scenario of what happened. The WN said if a resident is found unresponsive, the code status needs to be checked. If the resident is a full code, CPR should be initiated, 911 should be called, and the crash cart needs to be brought to the resident. The backboard should be placed under the resident if the resident is in bed. If no backboard was available, the resident should be moved to the floor prior to starting CPR. CPR should always be done on a resident that is a full code even if you think the resident has expired. CNAs can be used to assist with calling 911, bringing the crash cart to the resident's room, paging overhead for additional assistance, and checking the code status for the resident. If the CNAs cannot see the resident's code status in the EMR, there is nowhere else the code status can be located. If staff is unsure of a resident's code status, the resident should be treated as a full code. During observation and interview on [DATE] at 6:09 A.M., LPN I said CNAs make rounds and check on residents every two hours. LPN I said if a resident is found unresponsive, he/she would check the resident's code status and if the resident was a full code, he/she would provide CPR and call 911. LPN I said the resident's code status can be located in the electronic medical record (EMR) system. LPN I said there is a code status book at the nurses station but it is not updated. Observation showed the code status book did not have Resident #1 in the book. All documentation related to the unresponsive resident should be put in a progress note in the EMR, how the resident was found, what was done after finding the resident. The physician, resident representative (RR), coroner, funeral home, DON, and Assistant Director of Nursing (ADON) would be notified. All notifications would be documented in the progress note. If a resident was on hospice services, the hospice company would be notified and would assist in making the notifications. During an interview on [DATE] at 6:37 A.M., CNA E said rounds are made on residents every two hours. If CNA E found a resident unresponsive, he/she would notify the charge nurse immediately. CNA E did not know where residents' code statuses could be located at in the facility. During an interview on [DATE] at 6:55 A.M., CNA F said rounds are completed every two hours and while making rounds, he/she is checking to see if the residents need changed, offer water or see if they need anything, and to make sure the resident is breathing. CNA F said if he/she found a patient unresponsive, he/she would alert the nurse. CNA F did not know where to locate resident code status in the facility. During an interview on [DATE] at 7:04 A.M., CNA G said rounds are done every two hours to see if residents need changed, to make sure the resident is breathing. If CNA G found a resident unresponsive, he/she would get the nurse immediately. CNA G did not know where to locate resident code status in the facility. During an interview on [DATE] at 7:08 A.M., CNA H said rounds are done every two hours. If CNA H found a resident unresponsive, he/she would get the nurse immediately. CNA H did not know where to locate resident code status in the facility. During an interview on [DATE] at 7:35 A.M., LPN J said CNAs round on residents every two hours, and he/she does walking rounds every hour between the CNA's rounds. CNAs are required to go into the residents' rooms while doing rounds to see if the residents need anything like assistance to the bathroom or help being changed. CNAs will also notify LPN J if a resident is in pain and is requesting pain medication. LPN J said if a resident is found unresponsive, he/she would check for breathing, pulse, rise and fall of the chest. After verifying the resident is unresponsive, LPN J would check the resident's code status and if the resident was a full code, he/she would initiate CPR and have someone call 911 while he/she was performing CPR. LPN J said residents' code status are located in the EMR and CNAs cannot see the residents' code status in the EMR. LPN J said if the resident did not have a code status in the EMR, the resident would be treated as a full code. LPN J said documentation of the event would be an informative progress note. The progress note would cover what happened from start to finish. Notifications would be made to the physician, RR, facility management and all notifications would be documented in the EMR. If a resident is a full code status, CPR would be initiated immediately when vitals are noted as absent. LPN J said there is no time he/she would not initiate CPR on a full code resident. He/She would always provide CPR to a full code resident. During an interview on [DATE] at 8:00 A.M., the DON said CNAs make rounds every two hours to check on residents to make sure they are clean and offer any assistance as needed. The DON said the nurse did not notify her of the resident's death. The DON said if a resident is found unresponsive, staff call for help, have someone check the code status. If the resident is a full code, they start CPR, have someone bring the crash cart, and call 911. Someone else can call the physician and notify them the resident was found unresponsive, CPR was started and the ambulance is in route. Response time is good, the fire department and police usually show up first while staff are providing CPR. Staff would report when the resident was found, and emergency staff will take over care for the resident. Someone would need to stay in the room and watch so they can put notes into the resident's record on what happened. The DON said there is never a time to not provide CPR to a full code resident. Regardless on how the resident is found, CPR should be started. The DON said the code status can be located in the EMR. The DON said the nurses and Certified Medication Technicians (CMT)s can see the code status in the EMR but she was unsure if the CNAs can see the residents' code status. During an interview on [DATE] at 9:25 A.M., the ADON said the CNAs cannot see the resident code status in the EMR. During an interview on [DATE] at 9:26 A.M., the DON said the CNAs did not have access to view a resident's code status in the EMR. The DON said if a resident does not have a code status documented in the EMR, that resident should be treated as a full code. The DON said all nurses are CPR certified. Some CNAs are CPR certified, but it is not mandatory for CNAs to be CPR certified. The DON said the Business Office Manager/Human Resources (BOM/HR) keeps the CPR certifications. The DON expected the CPR certifications to be up to date and available at the facility. At 2:24 P.M., the DON said she did not have CPR certifications for LPN A or LPN B, who worked the night shift on [DATE]. On the night shift of [DATE], there was not a CPR certified staff member working. The DON said the BOM/HR does not track the CPR certifications after receiving them. During an interview on [DATE] at 1:30 P.M., the Assistant Director of Nurses said the facility did no CPR training and/or expectations in 18 months. Neither LPN A nor LPN B were provided with CPR orientation, classes or inservices. During an interview on [DATE] at 2:55 P.M., the Administrator and the DON said they expected a CPR certified staff member to be present on each shift. The purpose of CPR is to save a life in crisis. They expected CPR to be performed on a resident who is a full code and found without vital signs. If a resident is listed as a full code, CPR should always be initiated. There is no reason not to do CPR on a full code resident. CPR should be initiated after recognizing a resident is without vital signs as soon as the code status is verified, if code status is unknown, then CPR should be initiated. They expected if CPR is started, it is not stopped until EMS arrives to take over care. They said CPR should have been initiated on the resident, EMS should have been called. EMS response time to the facility is three to five minutes. LPN A and LPN B were both in the resident's room so there was no reason they should have not initiated CPR and called 911 and continued CPR until EMS arrived. They said an LPN is not qualified to determine when to stop CPR and call time of death on a full code resident. They expected staff to be knowledgeable of and follow the facility policies. During an interview on [DATE] at 1:07 P.M., the resident's PCP said CPR should be performed on a resident who is a full code with absent vital signs and EMS should have been called. Facility staff should not stop CPR once started unless they continue for more than half an hour and no results They should they have continued CPR until EMS got there. The purpose of CPR is to try and revive the patient. The resident wishes should be followed for code status. 2. Review of Resident #2's EMR, showed: -admission date [DATE]; -Cognitively intact; -Diagnoses included DM, high blood pressure and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's physician orders on [DATE] at 8:44 A.M., showed no order for code status. Review of the resident's physician orders on [DATE] at 11:43 A.M., showed an order for full code entered on [DATE] at 10:25 A.M. by the MDS Coordinator (MDSC). During an interview on [DATE] at 12:01 P.M., the MDSC said she entered the resident's code status order at 10:25 A.M. because after running a report that was requested, she noticed the resident did not have a code status order in PCC. The resident was admitted to the facility on [DATE]. Code statuses are supposed to be entered on the day of admission when the resident comes into the facility. The resident was asked today what code status he/she preferred, and he/she decided on a full code. The MDSC said when a resident admits to the facility, the Social Service Director (SSD) normally obtains the code status and then gives the MDSC the signed code status and the MDSC enters the order into the EMR and uploads the signed code status into the resident's EMR. If a resident comes in after hours, the floor nurse does not normally obtain the code status. The MDSC will obtain the code status and place the order if SSD does not get it. If a resident does not have a code status in the EMR, the resident would be considered a full code. During an interview on [DATE] at 5:34 A.M., LPN L said the SSD completes the code status for admissions when she does the admission packet with the resident. During an interview on [DATE] at 7:55 A.M., the SSD said she usually obtains residents' code status when she completes the admission packet. The admission packet is completed the day the resident admits to the facility. All residents are considered a full code until the code status is signed. After the code status is completed, she gives the code status to the MDSC and the MDSC places the order and uploads the code status sheet into the resident's EMR. During an interview on [DATE] at 2:55 P.M., the Administrator and the DON said they expected all residents to have a code status obtained on admission and for the residents' code status wishes to be followed. They expected staff to be knowable of and to follow the facility policies. 3. During an observation and interview on [DATE] at 2:32 P.M., the DON said she expected the night nurses to check the crash cart nightly to ensure adequate supplies were on the cart. She expected to nurse to fill out the crash cart check list and include documentation if anything needed replaced. The crash cart check lists are turned into the DON nightly. Observation of the crash cart on Faith Hall showed the crash cart was missing the ambu bag, and the portable oxygen tank sitting next to the crash cart showed the portable oxygen tank measured empty with the needle sitting in the red area. The DON confirmed the portable tank was empty and said an empty oxygen tank would not be helpful in the event of an emergency. The DON said without an ambu bag and oxygen, the staff would have not been able to effectively administer CPR to a resident during an emergency. The crash cart was additionally missing oxygen tubing, suction extensions, suction tubing, suction tubing with connectors, isolation gowns, masks, intravenous line (IV, a soft, flexible tube placed inside a vein) catheter start kits, and hand sanitizer. The DON expected the crash cart to have all items listed on the checklist available on the crash cart. Review of the crash cart checklists from [DATE] through [DATE] showed: -Faith Hall, missing 31 out of 31 days; -Grace Hall, missing 31 out of 31 days; -Hope Hall, missing 14 out of 31 days; -Several items were marked as missing on all crash cart checklists that were turned in for Hope Hall. During an interview on [DATE] at 5:27 A.M., Registered Nurse (RN) K said the crash cart is checked nightly. The crash cart checklist is filled out nightly and turned into the DON. If not all the items can be located on the crash cart, it is noted on the crash cart checklist and the DON will restock what is not on the crash cart. During an interview on [DATE] at 5:34 A.M., LPN L said the night shift checks the crash carts every night and fills out the crash cart checklist. The crash cart checklist is turned into the DON nightly to let her know if anything is missing. The DON will restock the crash cart if items are missing. During an interview on [DATE] at 6:33 A.M., the DON said if there is no crash cart checklist, the nightly check was not completed. The DON expected the nightly check to be completed to ensure adequate supplies are on the crash cart so staff can respond to an emergency situation with everything needed to care for the resident. During an interview on [DATE] at 9:26 A.M., the DON said the crash carts are checked every day on night shift and this is documented on the crash cart checklist. The DON said sometimes the nurses turn them in to her and some keep them on the crash cart clipboard. During an interview on [DATE] at 2:55 P.M., the Administrator and the DON nurses should check the crash cart nightly to ensure adequate supplies are on the cart to respond to emergency situations. All supplies listed on the crash cart checklist should be on the crash cart. They expected staff to be knowledgeable of and follow the facility policies. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied w[TRUNCATED]

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure two of three residents (Resident (R)54 and R45) reviewed for abuse out of a total sample of 24 did not engage in verbal threats that escalated to physical abuse of kicking and slapping each other. R45 suffered psychosocial harm following the incidents as evidenced by her fearful comments to her psychiatric Nurse Practitioner and to other staff members. Findings include: Review of the facility's policy titled Abuse Prevention Program revised December 2016, revealed .Our residents have the right to be free from abuse, neglect, misappropriation and exploitation. This includes freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .As part of the abuse prevention the administration will: 1. Protect our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, vendors, visitors, family members, or any other individual . Review of the facility's reportable incidents with a look back period of January 2023 to May 2024 revealed both verbal and physical altercations occurred between R54 and R45. Once on 11/21/23 and again on 03/24/24, with both residents cursing, kicking and hitting each other. 1. R54 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and history of a traumatic brain injury sustained during an arrest several years ago. Review of R54's Minimum Data Set (MDS) assessments with an Assessment Reference Dates (ARD) of 10/13/23, 01/13/24, and 04/14/24 revealed Brief Interview for Mental Status (BIMS) scores of 10, nine, and 10, respectively which indicated moderate cognitive impairment. During the survey, R54 did not participate meaningfully in interviews when attempted, but he was observed each day of the survey exhibiting disruptive and verbally abusive behavior directed at staff and other residents. R54 was ambulatory via wheelchair and was rarely found in his room. Throughout the five-day survey, R54 was observed yelling and shouting vulgarities towards other residents and staff. Most of his behaviors were focused on his desire to go outside to smoke. Interviews with direct care staff (Certified Nurse Aide (CNA) 1 and Certified Medication Technician (CMT) 1 on 04/30/24 at 11:30 A.M. revealed they were unable to predict and/or prevent R54's behaviors. One intervention on his care plan was to have R54 on 15 minute checks but that intervention usually lasted 48-72 hours, situationally, and in response to his abusive behaviors, not as a deterrent. CNA1 stated .I try to keep him in sight all the time - but I can't watch him if I'm helping another resident that needs to go to the bathroom or whatever they need . Review of a facility investigation revealed on 11/21/23, R54 propelled himself to R45's room and stated, Suck my dick. R45 hit R54 on the head with her reacher/grabber tool and then R54 kicked R45. Next R45 kicked R54 back and threw water on R54. The kicking went back and forth until the two were separated by staff. After the separation, R54 continued to yell and threaten R45 and stated he will shoot everybody in this building. Cross Reference: F609 Reporting and F610 Investigation of allegations of abuse. Immediately after this incident, the facility transferred R54 to the hospital for a Geri-psychiatric evaluation. He returned the same night with no new orders to manage his behaviors. R54 was moved to a different room and placed on 15-minute checks for 72 hours. The next incident occurred on 03/24/24, when R54 propelled himself to the end of the hall near R45's room. Staff did not hear if any words were exchanged but saw R54 standing over R45 and hitting her on her head. R45 returned blows by hitting R54 with her reacher/grabber tool. Staff separated the residents. When asked by staff why he (R54) was near R45's room, R54 stated that he was looking for his room and then stated, I saw that bitch who threw water on me. She thinks I forgot. I don't forget shit and I hit her . Both residents were assessed and neither had any physical injuries from the incident. 2. R45 was admitted to the facility on [DATE] with diagnosis of vascular dementia and osteoarthritis and a BIMS score of 15 which indicated R45 was cognitively intact. She was ambulatory via specialty wheelchair. R45 was interviewed on 04/30/24 at 12:45 PM and confirmed the incident with R54 as described. She stated .nobody [sic] going to talk to me that way - if he does it again, I'll take care of it again - I take up for myself. R45 stated that her room is on the other side of the building now, but she occasionally sees R54 in the dining room and she stays away from him. When asked directly about the incident she remembered it and stated that she doesn't sleep well now .due to keeping watch on her door -so that man doesn't come in and do something to her . She stated she does feel more secure since her move off the hall where R54 resides, but she still sleeps with an eye on the door . Medical record review revealed that R45 was seen by psychiatry once monthly. Review of a Psychiatric Nurse Practitioner's progress note dated 04/09/24 and found in the Progress Note tab of the EMR revealed .Psych Impression: [R45 name] is an [AGE] year old resident at [facility name]. She complains of not sleeping at night because she has to watch for strange men coming in her room. Staff report she curses at them from time to time. This seems to be her personality and not necessarily a behavior issue addressed with medication . In the prior psychiatric visits, R45 mentioned that she slept well except for one time she complained of pain in her knees when trying to sleep. An interview with the Director of Nursing (DON) on 04/30/24 at 3:15 PM revealed the facility had sought alternate placement for R54 due to his aggressive behaviors, . and no-one will take him [R54] because of his behaviors. He has a sister that can't care for him in her home so he is here, and we have to play it by ear and try to stay between him and trouble .but it's not fair for the other residents to see him get his way every time he wants something by being loud, vulgar, and stubborn - he won't stop until he gets his way . In an interview with the Medical Director (MD) on 05/03/24 at 12:15 PM by phone, the MD stated he has intermittently provided situational or one-time orders to manage R54's behaviors when he was out of control until he could be re-evaluated by psych. He did not have specific information about the two incidents identified above.

Based upon record review, interview, and observations, the facility failed to implement pressure ulcer interventions after surgery for left hip repair and failed to follow physician's treatment orders for one of four residents (Resident (R) 63) reviewed for pressure ulcers out of a total sample of 24 residents. This failure caused actual harm when R63 acquired unstageable pressure ulcers on the left foot. Findings include: Review of the Census tab located in the electronic medical record (EMR) revealed R63 was initially admitted on [DATE] and readmitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R63 was readmitted with diagnoses including surgical repair of the left hip. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/23 revealed R63 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive decline. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 12/15/23 revealed a score of 16/18 indicating R63 was at risk for pressure ulcers. Review of a Skin Observation Tool assessment form located in the EMR and dated 12/23/23 revealed R63 had a left thigh surgical incision with a note stating the, resident has some swelling and a vertical surgical incision to left leg. There was no indication of any other wounds on R63. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 12/23/23 revealed a score of 17/18 indicating R63 was at risk for pressure ulcers. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 01/01/24 revealed a score of 10/18 indicating R63 was now at high risk for pressure ulcers. Review of the Care Plan located in the EMR revealed a concern/intervention related to left heel pressure sores initiated on 01/06/24 including bilateral heel protectors, promoting good nutrition and hydration, and monitoring skin and reporting to the physician. There were no previous interventions initiated after returning from the hospital post-surgery on 12/15/23. No off-loading of extremities or other pressure ulcer preventions/treatments noted before 01/06/24 after the two unstageable pressure ulcers developed. Review of a Skin Observation Tool assessment form located in the EMR and dated 01/06/24 revealed the first documentation of a left heel and left anterior foot scab area with a note stating the, resident has new area to left heel and anterior right side of foot, both areas are closed and have scabbed over. Areas are unstageable at this time. Treatment in place. Review of a Skin Observation Tool assessment form located in the EMR and dated 01/08/24 revealed R63 had a left heel pressure ulcer measuring 2.0 X 3.0 X 0.2 cm (centimeters) with a note stating the, resident w/o [without] skin issues to remaining body surface. Heel protectors placed bilaterally, tolerated assessment well. Review of an Encounter note located in the EMR dated 01/17/24 revealed a Stage 2, left foot wound with a 4.0 X 4.5 X 0.2 cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, and elevating extremities. Review of an Encounter note located in the EMR dated 01/31/24 revealed an unstageable, left foot wound with a 4.0 X 3.0 X unable to determine (UTD) cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the January 2024 electronic medication administration record (eMAR) revealed an order to apply skin prep to the scabbed area on the left foot twice a day that was not documented as completed on 01/07, 01/17, and 01/31/24. Review of an Encounter note located in the EMR dated 02/16/24 revealed an unstageable, left foot wound with a 3.0 X 3.0 X 0.2 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 02/21/24 revealed an unstageable, left foot wound with a 3.0 X 3.0 X 0.2 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the February 2024 eMAR revealed an order to apply skin prep to the scabbed area on left foot twice a day was not documented as followed on 02/02, 02/02, 02/11, 02/13, 02/22, 02/25, and 02/26/24. Another order to cleanse the left heel opening and apply Medi-honey and a foam dressing once daily was not documented as completed on 02/01, 02/03, 02/10, 02/11, 02/13, 02/17, 02/18/, 02/21, 02/23, 02/25, 02/27, 02/28, and 02/29/24. Review of an Encounter note located in the EMR dated 03/01/24 revealed an unstageable, left foot wound with a 2.5 X 2.0 X 0.2 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/06/24 revealed an unstageable, left foot wound with a 3.0 X 2.5 X 0.4 cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/13/24 revealed a Stage 4, left foot wound with a 2.0 X 2.5 X 0.5 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/21/24 revealed a Stage 4, left foot wound with a 2.2 X 2.3 X 0.4 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the March 2024 eMAR revealed an order to apply skin prep to the scabbed area on left foot twice a day was not documented as completed on 03/08, 03/12, 03/17, 03/22, 03/25, 03/26, and 03/27/24. Another order (discontinued on 03/26/24) to cleanse the left heel opening and apply Medi-honey and a foam dressing was not documented as completed on 03/01, 03/02, 03/12, 03/14, 03/15, 03/16, 03/17, 03/18, 03/19, 03/22, and 03/23/23. Another order (initiated on 03/28) to cleanse the area with normal saline, apply collagen, and cover with a dry dressing once daily was not documented as completed on 03/29/24. Review of an Encounter note located in the EMR dated 04/03/24 revealed a Stage 4, left foot wound with a 1.6 X 1.0 X 0.2 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 04/10/24 revealed a Stage 4, left foot wound with a 2.0 X 1.5 X 0.1 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of a Wound - Weekly Observation Tool located in the EMR and dated 04/24/24 revealed the left heel wound with a size of 1.0 X 3.0 X 0.1 cm, with defined edges and stable progress. Review of the April 2024 eMAR revealed an order to cleanse the area with normal saline, apply collagen, and cover with a dry dressing once daily was not documented as completed on 04/03, 04/04, 04/05, 04/12, 04/13, 04/14, 04/20, 04/21, 04/23, 04/26, and 04/28/24. Review of a Skin Observation Tool assessment form located in the EMR and dated 04/29/24 revealed R63 had a left heel pressure sore measuring 1.0 X 0.3 X 0.1 cm with a note stating, no other skin openings noted. An observation on 04/30/24 at 5:26 PM revealed R63 to be in Geri-chair in common area. R63 had bilateral heel boots on. Observation of R63's room revealed a regular mattress on bed. Observation on 05/03/24 at 12:10 PM revealed the bed of R63 did not have a low-air-loss mattress. In an interview on 05/01/24 at 2:45 PM, the Director of Nursing (DON) stated the low air loss mattress was not ordered for R63 because the administration did not want to pay for it. The DON stated the physician orders should always be followed. In an interview on 05/03/24 at 11:45 AM the Director of Nursing (DON) stated the CP should have been updated after hip surgery and interventions should have been implemented. MO00233924 MO00234710

Based on observation, interview and record review, the facility failed to prevent abuse between two residents. Resident #24 had previous verbally aggressive behaviors. Resident #24 threw hot coffee on Resident #14 when he/she refused to share his/her cigarettes. This caused burning and pain for the resident. The census was 40. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised dated April 2021, showed the following: -Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; -Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect resident from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors and/or any other individual. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/4/22, showed the following: -No cognitive impairment; -No moods or behaviors; -Required limited assistance with transfers; -Independent with bed mobility, locomotion on and off the unit, eating, toilet use and personal hygiene; -Diagnoses included end stage renal disease (ESRD), diabetes and seizure disorder. Review of Resident #24's care plan, dated 7/6/22, showed the following: -Focus: Diagnosis of bipolar anxiety, history of drug abuse, diagnosed with major depressive disorder with severe psychotic symptoms. History of erratic behaviors verbal physical aggression, argumentative; -7/26/22, Verbally aggressive towards staff and other residents and used expletives because he/she did not have any cigarettes -8/29/22, Yelling at certified medication technician to give pain meds early, used profanity. Awakened other residents; -9/1/22, Yelling at staff about facility isolation policy; -Interventions: Discuss resident's behavior and identify more appropriate coping strategies. Inform resident of how his/her behavior affects others and the importance of all residents feeling safe and secure, educate on the inappropriateness of using expletives with staff and other residents. Discuss the importance of everyone feeling safe and secure. Educate resident on smoking cessation strategies, such as nicotine patches. Educate resident on the appropriate way to speak with staff. Educate the resident on the reason for the isolation policy and discuss appropriate behavior. Medication adjustment as needed. -Goal: Will verbalize understanding of need to control verbally abusive behavior. Review of Resident #24's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Verbal behaviors; -Required supervision with personal hygiene, toilet use and dressing; -Independent with locomotion on and off the unit and eating; -Diagnoses included congestive heart failure, diabetes and depression. Review of Resident #24's nurse's note, dated 9/3/22 at 7:58 P.M., showed the resident displayed aggressive behaviors, threw phone because he/she wanted to smoke during the outside time of smoking. Resident yells, screams and behavior observed and deemed aggressive. Resident did not receive cigarette at this time due to behavior. Review of Resident #24's behavior note, dated 9/20/22 at 7:22 P.M., showed the resident showed erratic behavior via being verbal abusive to staff and resident, due to not having any cigarettes. The resident continued yelling at the top of his/her voice sending panic throughout the designated area where residents relax and enjoy the patio. The resident grew very upset that Resident #14 would not give him/her a cigarette and became volatile and aggressive thus striking Resident #14 with a hot cup of coffee and leading to a physical altercation. The resident was unable to be redirected after multiple attempts. A medication was unable to be administered due to aggressive and physical behavior. The resident was placed on 15 minute face checks until further orders are obtained. The Director of Nursing (DON) and administrator were made aware. The nursing staff attempted to assess behavior of the resident but he/she remained aggressive. The authorities and ambulance emergency medical technicians were called to further assist. Review of Resident #14's nurse's note, dated 9/20/22 at 7:02 A.M., showed the resident was assaulted by another resident with an incident that lead to being struck by a hot cup of coffee. The resident attempted to defend him/herself from being hit by anything else after being attacked verbally and physically for not sharing his/her own personal cigarettes. The resident is currently having visual difficulties and skin is burning at this time, noted via resident. The resident was separated from further dispute verbal and physical. First aid intervention to support further burning sensations cold compresses. The DON and administrator were made aware. The resident reassured he/she would be safe. A further assessment was completed to establish a baseline. The resident will continue to be monitored. The resident's physician was made aware. Five days later the resident complained of eyes burning and was sent to the hospital. He/she was sent back with no new orders. Observation showed no visable injuries/burns during an interview with the resident. During an interview on 10/17/22 at 11:30 A.M., Resident #14 said on 9/20/22 after dinner, Resident #24 started getting mad when he/she would not give him/her a cigarette. The resident tried to ignore Resident #24 even though he/she was calling him/her all kinds of bad names. The resident said Resident #24 left and came back and before he/she knew it, Resident #24 threw coffee in his/her face. The coffee was hot and blinded and burned him/her. The staff removed Resident #24 and other staff gave him/her care. The resident said he/she feels uncomfortable around Resident #24 for fear of more coffee being thrown at him/her. The resident said he/she tries to stay away to avoid conflict. Review of Resident #24's nurse practitioner progress notes, dated 9/21/22, showed the following: -Staff report no current behavioral concerns; -Talks about a peer that he/she gets into it with and how he/she tries to avoid him/her. Per report he/she threw hot coffee on his/her peer. States he/she did throw something on peer but it was Diet Pepsi; -Judgement: limited; -Insight: limited; -Monitor mood, side effects and medications. During an interview on 10/17/22 at 11:13 A.M., Resident #24 said he/she did not have any cigarettes and did not have an altercation. The resident said he/she did not want to talk. Review of Resident #24's nurse's notes, showed the following: -10/3/22 at 7:44 P.M., caught stealing another resident's money ($20.00) and when asked about the money, this resident proceeded to yell and use profanity towards the other resident. Nurse asked resident to not use such language several times to no avail. This resident states that he/she was upset because he/she didn't have any cigarettes and that his/her cell phone was broken; -10/4/22 at 7:39 P.M., resident is yelling and being verbally aggressive towards staff. Resident states is upset related to not having cigarettes. Resident asked this nurse to call sister. Called three times. Resident again started to be aggressive. Police called related to aggressiveness. Resident being aggressive towards emergency medical technicians (EMTs). Police stated to resident that if he/she didn't calm down they would have to take him/her with them. Escorted to hospital; -10/30/22 at 3:46 P.M., resident noted upset because he/she did not have any cigarettes and was heard yelling at staff and peer. Resident eventually calmed down. Observation on 10/17/22 at 11:13 A.M., showed Resident #24 and Resident #14 on the outside patio with other residents, without staff supervision. During an interview on 10/26/22 at 8:39 A.M., Certified Nurse Aide (CNA) O said when Resident #24 does not get his/her way, he/she will start to yell and scream. They continue to monitor Resident #24 and ensure Resident #24 and Resident #14 are not on the patio at the same time. During an interview on 10/27/22 at 9:20 A.M., the DON said they put Resident #24 on 15 minutes checks for 72 hours after the altercation between the two residents. The resident said he/she likes to be outside because it helps with his/her anger issues. The residents should have been monitored if they were both outside.

Based on observation, interview and record review, the facility failed to provide protective oversight which prevented or minimized the risk of elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) for one of ten sampled residents (Resident #5) with a history of elopement. The cognitively impaired resident eloped from the facility twice, unbeknownst to staff. The facility did not implement interventions to address the resident's wandering and elopements. The census was 43. The administrator was notified on 7/21/22 at 1:15 P.M. of an immediate jeopardy (IJ) which began on 5/14/22. The IJ was removed on 7/21/22. Review of the facility policy titled, Wandering and Elopements, revised March 2019 showed the facility was to identify residents at risk for unsafe wandering and to strive to prevent harm, while maintaining the least restrictive environment for residents. If a resident was identified as at risk for wandering, elopement or safety issues, the resident's care plan was to include strategies and interventions to maintain the resident's safety. If a resident was missing, staff was to initiate the elopement/missing resident emergency procedure by first determining if the resident was out on authorized leave or pass. If the resident was not authorized to leave, then staff was to initiate a search of the building(s) and premises. If staff did not locate the resident, then staff was to notify the administrator and director of nursing services, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies (i.e. emergency management, rescue squads, etc.). Review of Resident #5's hospital history and physical, dated 2/4/22 (and faxed to the facility on [DATE]), showed the resident presented to the hospital after a suspected fall and elopement from his/her previous nursing facility. The resident was found lying in the middle of the road. Review of the resident's undated face sheet, showed an admitted [DATE]. Review of the resident's elopement risk evaluation, dated 3/31/22, showed the following: -Score 0 (no elopement risk); -No history of elopement or an attempted elopement at home; -No history of attempting to leave the facility without informing staff; -The resident has not verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; -The resident does not wander. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/13/22, showed the following: -Severe cognitive impairment; -Diagnoses including non-Alzheimer's dementia, dementia without behavioral disturbance, high blood pressure, [CONDITION(S)], [CONDITION(S)] and alcohol dependence in remission; -Wandering not exhibited; -Required set up and supervision of bed mobility, transfers, ambulation in room, dressing, toilet use and personal hygiene; -Required supervision of locomotion; -No mobility devices. Review of the resident's progress notes, dated 5/14/22 at 9:41 A.M., showed the charge nurse was summoned outside by laundry staff, due to the resident being found on the parking lot. The resident was under the pavilion. The resident said that he/she was being discharged home today, as he/she had been at the facility for a year, but could not seem to find his/her car. The resident was up ad lib (as desired), skin warm and dry, in no apparent distress. History of dementia. The resident was easily redirected back to his/her room and immediately placed on 15 minute checks due to elopement. Staff notified the resident's responsible party, physician and the Director of Nursing (DON). During an interview on 6/16/22 at 4:00 P.M., Nurse F said the resident had a history of dementia and tended to say he/she wanted to go home. On 5/14/22, he/she last saw the resident prior to lunch in the dining room. Nurse F had just gotten up from the nurse's station to pass medications, when the housekeeper said he/she thought the resident was on the parking lot. Nurse F checked the security camera monitor and saw the resident out in front of the facility. The resident had walked straight out of the front door, on the way back from the dining room. Nurse F went outside. The resident stood in the middle of the driveway, where ambulances pull up to the facility. He/she had been going towards the parking lot. The resident, who experienced periodic confusion, said he/she would have left if his/her car had been on the parking lot. On a daily basis, the aides conducted rounds every two hours on all residents, except for those on incident follow up due to an incident or issue. Those residents were rounded on more frequently. After the resident eloped, he/she was on 15 minute checks and then as needed (PRN) supervision. Observation on 6/7/22 at 9:00 A.M., showed the front doors of the facility opened onto a driveway which to the left extended to an entrance/exit across from the intersection of two-way streets. On the right side of one of the streets was a sidewalk. That street intersected a four lane, heavily traveled two-way road. Further review of the resident's undated care plan, showed no documentation of the resident's elopement on 5/14/22, via the facility front door and did not include detailed monitoring interventions. During an interview on 6/21/22 at 1:15 P.M., the DON said the nurse on duty at the time of a resident's admission performed his/her admission and elopement assessments. The admission paperwork was factored into those assessments. They were aware the resident eloped from his/her previous facility. The nurse who filled out the resident's elopement assessment likely did not realize he/she mistakenly documented the resident did not have a history of elopement. Nursing and the MDS coordinator do the care plans. The resident's care plan should have been updated as soon as possible with documentation of his/her elopement on 5/14/22 and elopement interventions. Further review of the resident's progress notes, dated 5/26/22 at 1:34 P.M., showed at approximately 7:00 A.M., the charge nurse heard an alarm going off, checked the panel behind the nursing station and saw that it indicated patio and South alarms were triggered. The nurse checked the floor panel on the wall, but nothing was noted on the panel showing where South was located. The nurse went to the Faith Unit looking for another resident who had the potential to wander. That resident was on the couch in line-of-sight of staff, so the nurse assumed the alarm had sounded in error. At 7:09 A.M., the DON called and notified the charge nurse Resident #5 had eloped. The resident was previously last seen at approximately 5:00 A.M., during the morning medication pass, moving about in his/her room. Once the resident returned, he/she said he/she had gone outside via the exit closest to his/her room and then through the unlocked back gate. At 1:05 P.M., staff documented that another staff person had observed the resident walking down the street towards Chambers Road at 7:05 A.M., redirected the resident back to the facility, to the charge nurse and notified the assistant director of nursing. Review of Nurse E's written statement, dated 5/26/22, showed on the day in question, he/she had pulled onto the facility street at 7:00 A.M. on the way to work and saw the resident walking on the left sidewalk, heading towards the intersecting road. Nurse E stopped the resident and asked him/her where he/she was going. The resident replied, home. Nurse E told the resident that he/she had to return to the facility. The resident asked why. Nurse E said it was necessary to have his/her family come and take him/her out to make sure he/she was safe. The resident turned around and started walking back towards the facility. Nurse E trailed the resident in Nurse E's car. They entered the facility together. During an interview on 6/21/22 at 12:15 P.M., Nurse G said on 5/26/22, the resident eloped early in the morning. When the alarm sounded, staff did not do a head count. Everyone looked around and Nurse G thought all of the residents were still on the unit and learned via a call from the DON the resident eloped. Upon the resident's return, Nurse G made sure to see the resident periodically. During shift report, they were instructed to increase monitoring (frequency not specified). During an interview on 6/21/22 at 11:15 A.M., Nurse E said on 5/26/22, he/she was on the way in to work at 7:00 A.M., Nurse E saw the resident walking down the section of the sidewalk leading to the intersection and asked, where are you going? The resident said, I'm going home. Nurse E asked if the resident's family said he/she could leave. The resident said no, but they knew he/she was leaving. Nurse E asked the resident to come inside the facility and get things straightened out. The resident complied. During an interview on 6/7/22 at 11:30 A.M., the resident said he/she did not recall how he/she got out of the facility or anything about either elopement. The resident said he/she wanted to go live with his/her family. Further review of the resident's undated care plan, showed the following: -The resident is an elopement risk/wanderer related to impaired safety awareness. He/she independently ambulated a long hall, opened the door and exited the facility, setting off the alarm. He/she entered the fenced courtyard, removed the lock and exited the courtyard. Staff responded to the alarm, observed the resident in front of the building and accompanied him/her inside the building. No injury noted; -Identify a pattern of wandering: Is wandering purposeful, aimless or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate; -Replace the lock on the fence with a small chain lock. Keys to be kept in accessible locations for staff. Review of the resident's undated 15 minute checks, showed observations documented on 5/26/22 from 8:30 A.M. to 7:00 P.M. During an interview on 6/21/22 at 1:46 P.M., the MDS Coordinator said the resident's elopement on 5/26/22, was mentioned during the staff morning meeting. However, she was not informed of the resident's elopement on 5/14/22 or the resident's elopement from the previous facility. Otherwise, both would have been documented on the care plan with interventions. Observations on 6/7/22 at 9:00 A.M. and 3:00 P.M., as well as on 6/14/22 at 9:15 A.M. and 3:05 P.M., showed the front door was unlocked. It opened automatically when approached from inside or outside. During interviews on 6/21/22 at 2:45 P.M. and 7/21/22 at 4:25 P.M., the administrator said he was not aware of the resident's elopement from a prior facility or his/her elopement on 5/14/22. There was a coded lock on the gate through which the resident eloped on 5/26/22. However, the resident was able to break through it, because the metal posts to which the gate was welded on one side and secured via a lock on the other gave way. Consequently, the facility fixed it the same day by reinforcing the posts with a steel bar. The administrator expected the resident's care plan to reflect his/her risk for elopement and provide interventions to address it. In June, the resident was moved onto a memory care unit with its own alarm system. During an interview on 7/28/22 at 9:09 A.M., the physician's Long Term Care Navigator said the facility should have, but did not, notify the resident's physician of the resident's wandering or elopements. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 793

Based on observation, interview and record review, the facility failed to identify a Stage IV pressure ulcer (PU, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling) by not completing skin or wound assessments for one resident (Resident #1) and failed to treat and follow infection control measures per professional standards of care for one resident's wound (Resident #2) out of three sampled residents. The census was 43. The administrator was notified on 7/7/22 at 12:48 P.M., of an immediate jeopardy (IJ) which began on 6/18/22. The IJ was removed on 7/7/22. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's wound evaluation policy, revised September 2018, showed the following: -Purpose: to provide guidelines for the evaluation of current new wounds; -Policy: Evaluation of wounds will be performed on admission, weekly and on discovery; -Procedure: Evaluation is the formal process in which wound characteristics are assessed and documented; -Components of wound documentation included location, size, staged if a pressure ulcer, onset date for pressure ulcers, wound bed, drainage, odor, tunneling/undermining (when present), infection, healing (when present), surrounding skin and pain; -Wounds are observed during dressing changes. The nurse will note in the progress notes if the wound has worsened or deteriorated and the physician will be notified; -Wound assessments may be completed by the facility nursing staff or the designated wound care company; -Evaluation results are communicated to the members of the care team through documentation, care plan meetings and care planning; -The care plan will be created and updated accordingly. Review of the facility's wound care policy, revised September , showed the following: -In no way does glove use modify hand hygiene indications or replace hand hygiene action by rubbing with an alcohol-based product or by handwashing with soap and water; -Glove removal and hand hygiene will be used after touching a contaminated body site or non-intact skin; -Perform hand hygiene between glove use after handling potentially contaminated items or body fluids; -Glove use and hand hygiene will occur after contact with a mucous membrane and with non-intact skin ends; after removal of any form of material offering protection; -Use a disposable cloth to establish a clean field on resident's over-bed table. Place all items to be used during procedure on the clean field and arrange supplies so they are easily reached; -After treatment is completed, remove supplies from the over-bed table, clean the table with cleansing wipes, wipe reusable supplies with alcohol as indicated and return reusable supplies to the resident's drawer in the treatment cart; -If the wound has deteriorated or worsened, document findings in the clinical record; -Notify the physician with the new findings and document the physician's response; -Report other information in accordance with the facility policy and professional standards of practice. 1. Review of Resident #1's medical record, showed the following: -admitted on [DATE] and discharged on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 3/20/22, apply [MEDICATION(S)] (an antiseptic used to disinfect the skin, and to treat minor wounds such as cuts, scrapes and [CONDITION(S)]) to bilateral (both) heels daily; -A physician's note, dated 5/11/22, showing chief complaint was bilateral heel sores with swelling. The resident reports sores on both heels that are almost healed; no pain or fever but does have swelling. The plan of care did not include treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Skin assessments, dated 5/12/22 and 5/26/22, showed no documentation of any abnormal skin findings and no new skin issues noted; -There were no other skin assessments found after 5/26/22. Review of the resident's treatment administration record (TAR), dated 5/1/22 through 5/31/22, showed the facility did not administer the [MEDICATION(S)] to bilateral heels on 5/20/22 or 5/30/22. Further review of the resident's medical record, showed the following: -Review of the resident's care plan, dated 6/3/22, showed the resident had peripheral arterial disease (a circulatory condition in which narrowed blood vessels reduces blood flow to the limbs) with interventions that included monitor extremities (arms and legs) for signs and symptoms of injury, infection or ulcers; -A shower sheet, dated 6/9/22, signed by Nurse A, showed no abnormal findings on the resident's body; -A progress note dated 6/18/22 at 8:47 A.M., showed the resident was coming up the hall way in his/her wheelchair and the nurse noted there was a wet spot on the bottom of his/her left sock. The nurse removed the sock and saw an open area was on the resident's left lateral heel. The nurse observed maggots to the wound bed. The nurse cleansed the area and applied dressing, but was not sure if all maggots were removed. The resident did not complain of pain. A call was made to the Director of Nursing (DON) and the physician. The resident was sent to the hospital; -Review of the resident's progress notes, dated 5/1/22 through 6/18/22, showed no documentation of the resident's left heel; -There were no weekly wound assessments found in the medical record. Review of the resident's TAR, dated 6/1/22 through 6/30/22, showed the facility did not administer the [MEDICATION(S)] to bilateral heels on 6/12/22 or 6/17/22. During an interview on 6/22/22 at 1:39 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident was propelling him/herself down the hall in a wheelchair on 6/18/22, sometime in the morning, with his/her left foot elevated on a foot pedal; -She noticed the sock on the resident's left foot was soaked and dripping; -She asked the resident why the sock was wet and the resident could not answer; -She removed the sock off the resident's left foot and two maggots fell on to the floor; -The wound was approximately a quarter in size and located on the right side of the resident's heel; -She cleaned the wound out with Dakin's (antiseptic solution used to clean infected wounds, ulcers and [CONDITION(S)]) and saw there were more maggots inside of the wound bed, then covered the wound and notified the physician; -The resident said he/she couldn't feel the maggots in his/her wound, did not feel any itchiness or pain in that area and wasn't sure if he/she had hit the side of his/her heel against something; -The ADON had administered a treatment to the resident's left heel approximately two weeks ago and at that time the resident's left heel was soft without any open areas; -The resident was not seen by a wound physician or nurse practitioner (NP); -She expected nurses to write a note and alert her and the physician if there was any changes to a wound. Review of the resident's hospital records, dated 6/19/22 at 2:10 P.M., showed the following: -The resident was admitted to Emergency Department on 6/18/22 with an infected left heel decubitus ulcer infested with maggots; -The resident was cognitively intact, pleasant and cooperative; -The resident had an Infected Pressure Ulcer Stage IV located on his/her left heel. The PU's wound bed had necrotic/infected tissue, which had odor, measuring 2.6 centimeters (cm) by 1.4 cm with 1.0 cm depth; -The resident reported two or three months ago someone ran over his/her left foot with a wheelchair which then developed a blister and then an ulcer; -The resident had diabetes with peripheral [CONDITION(S)] evidenced with forefoot abnormal exam findings; -Plan of care included debridement (surgical removal of dead tissue) of the left heel PU Stage IV, [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (antibiotic) intravenously (IV, medication administered through the vein) for infection. During an interview on 6/22/22, at 12:10 P.M., Certified Nurses Assistant (CNA) D said the following: -He/she never gave the resident showers; -He/she would often help the resident put his/her shoes on his/her feet; -The resident wore socks and the CNA remembered the resident had a bandage on one of his/her heels because the CNA could see it peeking out of the resident's sock; -The resident would complain of pain to his/her foot and CNA D reported it to the nurse. He/she could not remember when the resident complained of pain or which nurse he/she reported to. During an interview on 6/22/22 at 12:14 P.M., Nurse B said he/she did not remember treating the resident. During an interview on 6/23/22 at 12:18 P.M., Nurse A said the following; -He/she administered treatments to the resident's left heel a few days before he/she was sent to the hospital; -When he/she was treating the resident's left heel with [MEDICATION(S)] per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she does not remember completing a skin assessment on the resident. During an interview on 6/22/22 at 3:20 P.M., the DON said the following; -She did not believe staff were administering the treatment to the resident's left heel because if they were, they would have known the wound opened; -She was aware staff were not completing weekly skin assessments for the resident before he/she was sent to the hospital; -She did not do anything to correct the action before the ADON discovered the maggots in the resident's left heel; -She was responsible for making sure staff completed weekly skin assessments. -She did not put interventions in place due to lack of permanent staffing. She had a plan to inservice staff on weekly skin assessments, but did not put it in place. 2. Review of Resident #2's medical record, showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A physician's progress note dated 6/9/22, showed chief complaint of a sacral wound. The resident still has a sacral wound but pain is decreasing. Plan of care for sacral wound was to continue Dakin's solution and Santyl; -A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No tunneling present. Wound bed had a small amount of slough and a large amount of granulated red tissue with a moderate amount of red, brown drainage. The wound had a foul odor. There was no treatment recommendation found; -A care plan, dated 6/15/22, showed the resident had a wound infection located at his/her sacrum and was receiving oral antibiotics. Interventions included maintain universal precautions when providing resident care. Observation on 6/22/22 at 7:54 A.M., showed the resident lying flat on his/her back on a low air loss mattress (LAL, used to circulate air to help alleviate pressure), that was not plugged in, on top of a chuck pad (an absorbent cloth pad) and a blanket folded in quarters underneath his/her buttocks. CNA C repositioned the resident to his/her left side and pulled down his/her brief to expose the resident's Stage IV PU located on his/her sacrum. The Stage IV PU was not covered with a bandage, appeared wet with a moderate amount of pink exudate (drainage) on the brief and had streaks of brown matter surrounding the wound. During an interview on 6/22/22 at 8:00 A.M., CNA C said the following: -He/she expected the resident to have a bandage covering his/her Stage IV PU to keep it clean; -He/she would notify the nurse so he/she could apply a treatment to the area. During an interview on 6/22/22 at 8:16 A.M., CNA D said the following: -In order to prevent and treat PUs, he/she would reposition residents every two hours, make sure they were clean and dry and try to get them up in a wheelchair during the day; -He/she would immediately tell the nurse if a wound was dirty or uncovered with a treatment. He/she expected the nurse to immediately come and treat the wound to prevent it from getting worse; -Nurses were responsible for making sure a LAL mattress was turned on and functioning. During an interview an 6/22/22 at 8:31 A.M., CNA C said the following: -LAL mattresses were used to help alleviate pressure from the resident's body to the mattress; -There should only be one layer between the LAL mattress and the resident to alleviate pressure and to cause less friction to the resident's skin; -LAL mattresses were used to help heal PUs. Observation on 6/22/22 at 9:19 A.M., showed the ADON and Nurse B perform wound care on the resident's sacrum; -Nurse B placed a bottle of Dakin's, an ABD pad, a package of 4 by 4 gauze pads and tape on top of the treatment cart; -Nurse B removed Santyl from a drawer in the treatment cart, which was labeled with the name of another resident, squirted what was left in the tube into a small plastic cup and set it on top of the treatment cart; -Nurse B did not sanitize or place a barrier down on the treatment cart; -Nurse B entered the resident's room, set the supplies down on a sanitized bedside table, washed his/her hands and donned (applied) gloves; -The ADON washed her hands and donned gloves; -Nurse B and the ADON turned the resident to his/her right side and the ADON removed the resident's bowel movement filled brief; -Nurse B used a wet wash cloth and wiped the resident's buttocks and wound free of bowel movement; -There was no bandage on the resident's sacral Stage IV PU and a small, soaked with yellow/brown exudate gauze fell out of the wound base; -Nurse B described the wound as having an odor with 25% slough visible in the center of the wound, with tunneling at four o' clock position, the edges were pale white and 75% beefy red tissue in the wound base; -Nurse B changed his/her gloves, without sanitizing his/her hands, poured Dakin's solution on a piece of gauze, pushed it into the center of the wound out and then used the same piece of gauze to clean out the rest of the wound; -Nurse B placed the Dakin's bottle on top of the resident's used chuck pad, on top of the bed; -Nurse B used a paper ruler to measure the wound; it measured 15 cm long by 9.7 cm wide; -Nurse B threw the paper ruler into the rolled up bowel movement filled brief located on the resident's bed; - Nurse B changed his/her gloves, without sanitizing his/her hands, opened a sterile packet with a stick inside and held it his/her right hand; -Nurse B used his/her left hand and removed the used paper ruler from the bowel movement filled brief and placed on the resident's bed; -Without changing his/her gloves or sanitizing his/her hands, Nurse B used the stick to measure the depth of the tunnel in the three o'clock position, then placed the stick close to the used paper ruler and showed it measured 0.5 cm deep; -Nurse B repeated the process using the same stick and used paper ruler to measure the depth and the four o'clock position (3.5 cm deep) and the center of the wound (5 cm deep); - Nurse B changed his/her gloves, without sanitizing his/her hands, placed Santyl onto a piece of gauze and placed it into the center of the wound bed, then placed an ABD pad over the wound and taped it on all four sides to secure it to the resident; -Nurse B gathered the dirty supplies and threw them into a trash bag from the bathroom; -Nurses B doffed (removed) his/her gloves, did not sanitize his/her hands and searched the resident's wardrobe for a clean brief; -Nurse B donned his/her gloves, without sanitizing his/her hands, and assisted the ADON with placement of the new brief onto the resident and repositioning him/her on the bed; -Nurse B doffed his/her gloves, did not sanitize his/her hands, picked up the dirty trash bags with one hand and picked up the opened glove box from the bedside table and the dirty Dakin's bottle from off the resident's used chuck pad; -Nurse B placed the dirty Dakin's on top of the treatment cart and then threw it in the trash. During an interview on 6/22/22 at 11:57 A.M., Nurse B said the following: -The resident was seen and treated by the wound NP yesterday; -Staff did not notify him/her the resident did not have a treatment on his/her sacrum; -He/she was expected to wash/sanitize his/her hands before and after wearing gloves, to change gloves between dirty to clean tasks for infection control; -Nurses were expected to use a new piece of gauze when cleaning a wound to prevent infection and cross contamination of the wound bed; -He/she should have used a new paper ruler instead of pulling it out of the dirty brief to prevent infection and cross contamination; -He/she should have used a barrier underneath wound supplies on the bed in order prevent cross contamination and for infection control; -He/she expected CNAs to alert him/her when a resident's wound was dirty or missing a treatment. Review of the resident's hospital records, showed the following: -admitted on [DATE]; -A physician's progress note, dated 6/29/22 at 1:46 P.M., showed the resident was seen and referred to the emergency room for a complicated sacral pressure ulcer Stage 3-4 with no history to indicate that the PU had been managed in the past. The resident was admitted mainly for being progressively lethargic. The resident's sacrum PU showed a large cavitary (an empty space) ulcer deep down into the fascial layer (layer of fibrous tissue that surrounds muscles, vessels and nerves), likely hood of constant contamination from the stool. He/she would require surgical debridement of the ulcer and the use of a wound vacuum-assisted closure (VAC, a method of decreasing air pressure around a wound to assist the healing). A diverting [CONDITION(S)] (a surgical procedure to divert the bowel to a stoma (an opening made in the abdomen) to allow waste to exit the body) was a must to prevent further [CONDITION(S)] (a life threatening infection) and progression of the sacral condition. He/she was currently receiving IV [MEDICATION(S)]. 3. During an interview on 6/22/22 at 7:26 A.M., Nurse A said the following: -Nurses were responsible for completing weekly skin assessments on residents if the treatment order popped up on their shift; -Nurses documented skin assessments in resident's electronic medical records (EMR); -Nurses were responsible for completing wound treatments if they fell on their shift; -Nurses were expected to document in the TAR when a wound was treated and describe what was done and describe the wound; -Nurses were expected to call the physician if a wound deteriorated to get new orders, document in progress notes, and inform the family; -There was no protocol to assess wounds weekly describing the wound and getting measurements; -Description of the wound and wound measurements were only expected when a wound was first discovered; -Nurses would know if a wound deteriorated or had a change of condition because they treated them every day; -Some residents were seen by a wound physician. He/she was not sure what the parameters were for a resident to see a wound physician; -If a wound deteriorated, nurses would notify the physician who usually sent them out to get new treatment orders from the hospital. During an interview on 6/22/22 at 8:09 A.M., Nurse B said the following; -He/she was not sure how to refer a resident to the wound physician. He/she would tell the ADON, who would then make the referral; -Most of the wound treatments were completed on the day shift; -Nurses were expected to get measurements on new wounds, describe the wound and put on a treatment until the physician gave new orders. He/she would notify the ADON and the family and document all in a progress note; -He/she would get new measurements if the wound deteriorated and notify the physician and the ADON. During an interview on 6/22/22 at 8:47 A.M., the DON said the following: -Nurses were responsible for completing wound treatments if they fell on their shift; -A wound NP came in on Tuesdays to see residents and he/she performed wound assessments with wound measurements; -The wound NP would send in residents' individual wound reports to the facility and she printed them out and kept them in a binder in her office; -She was using the wound NP individual wound reports as the facility wound report; -She expected nurses to complete weekly wound assessments on residents who did not see the wound NP and document the assessment in the EMR; -She expected nurses to put in wound measurements on the weekly skin observation tool only if it was a new wound. During an interview on 6/22/22 at 3:07 P.M., the Administrator, the DON and the ADON said the following: -They expected staff to follow facility policies and procedures; -They expected CNAs to write down any skin abnormalities on the shower sheet and nurses to sign off they received and reviewed the shower sheets; -They expected staff to change gloves and sanitize hands when going from a dirty to clean task for infection control; -They expected staff to use a new gauze when cleaning out different areas of a wound to prevent cross contamination and for infection control; -Removing a used paper ruler from a bowel movement filled brief and then using it when performing a treatment was unacceptable as it was against infection control. Fecal spores could be present on the paper ruler and contaminate a resident's wound; -They expected staff to use only medication prescribed to a resident for infection control; -They expected staff to keep supplies on barriers for infection control; -They expected staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -They expected staff to alert them and the physician if a wound has a change of condition; -They expected staff to assess wounds each time they perform a treatment change and to write a progress note if there was a change; -Staff could not assess correctly if a wound had a change of condition and only the DON had access to the wound reports from the wound NP; -Wounds can change overnight; -Staff was expected to completed wound measurements and assessments when newly found, upon admission and re-admissions; -The DON and ADON were responsible for monitoring wound reports; -Wound reports were not uploaded into residents' medical records due to lack of staffing; -Residents on LAL should only have one layer beneath them to facilitate wound healing; -All staff should be aware if a LAL mattress was plugged in and working appropriately. If there was an issue, they expected the staff to alert maintenance so it could get fixed. During an interview on 7/14/22 at 11:44 A.M., the Administrator said the following: -The administrative team met almost daily to discuss resident care; -He expected the DON to inform him there were issues with nursing staff not completing skin/wound assessments and wound treatments as ordered; -He was not informed by his clinical team that staff were not meeting expectations; -If his clinical team and/or the DON informed him of the issues surrounding skin assessments and wound care, he would have put corrective measures into place; -He expected his DON to ensure expectations for care were met by staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 735