Every finding on record at Armour Oaks Senior Living Community

Based on interview and record review, the facility failed to contact Emergency Medical Services (EMS), to initiate and provide continuous Cardiopulmonary Resuscitation (CPR) timely per facility policy for one sampled resident (Resident #1) out of three sampled residents, who was a full code status. The facility census was 31 residents. The Administrator and Director of Nursing (DON) were notified on [DATE] at 2:45 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator and DON became aware of the violation of the facility's CPR policy. The facility in-serviced the staff on the CPR policy and procedures, medical emergencies and ensured code status updates for all residents. The IJ was corrected on [DATE]. Review of the facility policy Residents' Rights Regarding Treatment and Advance Directives, dated 2022, showed:-It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.-Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated.-Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. -The facility will use the process as provided by state law for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes. Review of the facility policy medical Emergency Response, dated 2022, showed:-It is the policy of this facility to respond to medical emergencies for resident, staff and visitors.-The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid, and summon for assistance.-CPR will continue unless there is a do not resuscitate (DNR) order in place, there are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection or decomposition) or initiating CPR could cause injury or peril to the rescuer.-A nurse will assess the situation and determine the severity of the emergency, stay with the resident, and designate a staff member to announce a code blue if necessary, notify the physician and call 911 as needed. -If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of EMS and in accordance with the resident's advance directives, or in absence of advance directive or a DNR order, and if the resident does not show obvious signs of clinical death. -The facility will ensure CPR certified staff are available at all times. -This facility will not implement a No CPR policy. Review of the facility Policy and Procedure for CPR, dated 8/2020, showed:-Residents have the right to make decisions concerning their care, including the right to accept or refuse CPR. This decision will be indicated in the resident's advance directives.-While awaiting physician's order to withhold CPR, staff will document a resident's refusal of CPR, per the advance directives purple sheet. -This choice will be confirmed at least annually.-If a resident experiences a cardiac or respiratory arrest, the CPR-certified staff member will review the resident's chart to determine if they are a full code or DNR. Review of Resident #1's admission Record showed the resident:-admitted on [DATE].-The advanced directive was left blank, no indication of code status. Review of the resident's Hospice Record, dated [DATE], showed:-No DNR order.-Care plan showed DNR. Review of the resident's Progress Note, dated [DATE] at 7:42 P.M., showed the resident: -Was admitted for respite stay via non-emergency transport on a gurney.-The resident presented as nonverbal and responds only to painful stimuli during repositioning.-The resident remains at Full Code status. Review of the resident's Progress Note, dated [DATE] at 2:20 P.M., showed the resident:-Presented febrile with a temp of 102.0 Fahrenheit (F). (Normal temperature for adults is in the range of 97 F to 99 F.)-The nurse administered Tylenol 750 milligrams (mg) and notified Hospice (end of life care). -After being seen by Hospice, vitals taken again, all WNL (within normal limits) with temperature at 97.8 F. Review of the resident's Progress Note dated [DATE] at 9:24 A.M., showed: -Informed of resident declining condition - watery stool and draining feeding from his/her mouth.-At about 7:15 A.M., abnormal vital signs: blood pressure low, no #s; temperature 102 F; pulse 35; oxygen 99% with 3 Liters of oxygen. -Called Hospice immediately on [DATE] and was told one of their nurses would be at facility promptly.-The resident was found unresponsive at 8:31 A.M. -Tried to inform family, but unable to leave a message as mailbox was full. -Informed DON, then called 911, and staff started CPR on the floor until paramedics arrived and took over. -The resident was pronounced dead at 9:01 A.M. Review of the resident's Outside the Hospital Do-Not-Resuscitate Order, dated [DATE], showed it was signed by the physician on [DATE]. During an interview on [DATE] at 9:23 A.M., the DON said:-The situation happened a couple of weeks ago regarding Licensed Practical Nurse (LPN) A and the resident's code status.-The resident was admitted for respite care with Hospice services in place. -The resident was a Full Code upon admission with consideration of changing to DNR.-There was no durable power of attorney for the resident which delayed the change in code status for the resident.-The DON advised once the hard copy of the DNR was completed and in the facility, the code status could be changed in the electronic medical record for the resident.-The following morning, [DATE] at 8:34 A.M., LPN A sent a message to the DON stating the resident had passed. -At 8:45 A.M. the DON advised LPN A the resident remained a Full Code unless there was a DNR document from Hospice.-At 8:46 A.M. the DON advised if there was no DNR document then life saving measures were to be done until EMS were onsite.-At 8:46 A.M. the DON advised the Clinical Manager to assess the situation and initiate a code, call 911 and complete CPR until EMS arrived. -He/She expected all CPR certified staff to perform CPR on all residents without a DNR. -Only licensed staff are expected to be CPR certified. During an interview on [DATE] at 12:36 P.M., LPN A said:-The resident was admitted as a Hospice patient and a Full Code. -The resident passed away on [DATE] and on [DATE] the family and Hospice had changed the code to DNR.-The DON was aware of the code status change.-When the resident passed away on [DATE] at 8:31 A.M., he/she went by the new code status.-The DON told him/her no, he/she had to do CPR because the resident was a Full Code.-The resident's profile on the computer said the resident was a DNR. The DON made him/her start CPR on the resident.-When the fire department arrived, they took over CPR and requested a print out the resident's code status.-He/She delayed printing the resident's code status and was hiding in the medication room.-The Hospice nurse arrived at the facility with a hard copy of the DNR and advised the first responders to stop CPR.-The fire department stopped life saving measures and left the facility.-There was no official copy of the DNR in the facility until after the resident passed away.-He/She said it was not common practice to change a code status on the resident profile prior to receiving the hard copy of the DNR.-When there was no DNR in place CPR should be started immediately. During an interview on [DATE] at 10:43 A.M., LPN B said:-On [DATE], he/she was in the social worker's office in the basement of the facility when the DON texted a copy of the conversation with LPN A and asked him/her to go assess the situation.-He/She went to check on the resident and the resident did not have any signs of life.-He/She checked the chart to verify the code status and the resident was a Full Code.-He/She told LPN A he/she needed to start CPR.-LPN A said the resident was a DNR and no CPR was needed.-There was no DNR form located for the resident.-LPN A said the DNR was in the computer, but there was no hard copy signed by the physician.-LPN B told LPN A to go with him/her and to start compressions.-They moved the resident to the floor and LPN A started compressions.-LPN B took a call from the Hospice physician who advised there was a Hospice staff in route to the facility with a DNR document.-He/She understood there had to be a hard copy of the DNR document and that CPR must be done until one was presented.-EMS arrived, took over CPR and pronounced the resident deceased at 9:01 A.M. when the Hospice staff arrived with the signed DNR.-LPN A said there was a change in the code status for the resident and an order was added in the computer, but there was no physical DNR signed in the facility.-He/She felt the event lasted about 10 to 15 minutes.-LPN A was delaying action.-Although the DON had told LPN A to start CPR, he/she was still casually washing his/her hands and standing at the nurses station when LPN B arrived at the nurses station.-He/She felt like Hospice should have handled the change in status prior to the resident coming for respite care.-The way Hospice handled the change in status created confusion. Review of LPN A's Employee File showed:-LPN A was first aid CPR certified on [DATE]. -On [DATE] LPN A failed to initiate life-saving measures on a resident despite explicit direction from the supervisor to do so. -The employee stated the resident's electronic medical record listed the resident as DNR; however, there was no an actual written order signed by a physician or person responsible for the resident. -It is both the facility policy and standard professional protocol for all individuals to receive life saving measures unless a DNR order is physically present. -Despite the argument, that said order was in transit to the facility at the time, the employee violated the codes of conduct in the employee handbook. During an interview on [DATE] at 1:00 P.M., the Medical Director said:-The staff were required to do CPR unless the signed DNR document was present. -The situation with this resident was one of those in which CPR should have been started. 3012230

Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator had a thermometer and the temperature was checked daily, failed to ensure the freezer compartment of the medication refrigerator was not frozen solid, failed to ensure there were no loose pills in the medication cart, failed to ensure medications that were opened had the date they were opened written on them, failed to ensure there were no other items kept in the medication cart in with the resident's prescribed medications and failed to ensure there were not cleaning agents in the medication cart in with the resident's prescribed medications. The facility census was 36 residents.Review of the facility's policy, Storage of Medication Requiring Refrigeration, dated October 2022 showed:-The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls.-The facility would ensure that all medications and biologicals would have been stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity:-Refrigerated refers to temperature maintained between 36 to 46 degrees Fahrenheit (F).-Temperature to have been monitored daily to ensure proper temperature control and documented on the temperature log with the date, time, and signature of the person performing the check clearly written. Review of the facility's policy, Medication Administration, dated 2022 showed to keep the medication cart clean, organized, and stocked with adequate supplies. 1. Observation of the Certified Medication Technicians (CMT) medication cart on 8/20/2025 at 9:00 A.M. with CMT B showed:-There was a facility walkie talkie in with the resident's prescribed medications.-There were a container of bleach wipes in with the resident's prescribed medications.-A resident's prescribed container of Enulose (a medication used to treat constipation) 473 milliliter (ml) bottle was opened without the date it was opened written on it. -There were four white capsules in a medication cup without a name or room number on the medicine cup.-There was one round blue pill loose in the bottom of a drawer.-There was one orange capsule loose in the bottom of a drawer. During an interview on 8/20/25 at 9:20 A.M. CMT B said:-There should not have been any loose pills in the drawers of the medication cart.-There should not have been a container of bleach wipes in with the residents' medications.-Prescribed Medications that were opened should have the date it was opened written on it. -There should not have been a walkie talkie in with the resident's medications.-The staff member who used the cart was responsible for keeping it clean and ensuring the medication had a date written on it if it had been opened. 2. Observation on 8/20/25 at 9:30 A.M. of the Nurses' medication cart, medication room, and medication refrigerator with Licensed Practical Nurse (LPN) A showed:-There was no thermometer in the medication refrigerator. -The Nurse verified there was no thermometer in the medication refrigerator.-There was no temperature recorded on the temperature log for 8/19/25 or 8/20/25. -The freezer department in the medication refrigerator was one solid block of ice.-There were four boxes of Tuberculin (TB a skin test used to detect TB)1 ml vials in the refrigerator.-There was one Glargine Insulin (a long- acting insulin used to treat high blood sugar) pen in the medication refrigerator.-The medication cart showed one loose Ondansetron (a medication used for anti- nausea and vomiting) 4 milligram (mg) pill in a drawer.-A resident's prescribed Guaifenesin (medication used to relieve chest congestion) 473 ml bottle was open without an open date written on it. -There were a container of bleach wipes in with the resident's medications. Review of the Refrigerator Temperature Check for August 2025 showed:-It was recorded on August 5th there was no thermometer in the medication refrigerator. -There was no refrigerator temperature check done on August 18 or 19. During an interview on 8/20/25 at 9:50 A.M. LPN A said:-There should not have been any loose pills in the medication cart.-There should not have been any other objects in with the residents' medication.-There should not have been bleach wipes in with the residents' medications.-The nurse who used the medication cart should have been responsible for keeping it clean.-He/She did not know how staff would have checked the temperature of the medication refrigerator if there was no thermometer in it.-The night nurse was responsible for checking the temperature of the medication refrigerator and documenting it on the sheet.-He/She did not know who was responsible for ensuring the freezer in the medication refrigerator was defrosted. During an interview on 8/22/25 at 1:15 PM with the Director of Nursing (DON) said:-The night Nurse was responsible for checking the temperature of the medication refrigerator.-The temperature should have been checked every day.-The temperature should have been between 38 to 42 degrees F.-The temperature should have been recorded daily. -If something was off the nurse should have adjusted the temperature of the medication refrigerator then rechecked it. -The Nurse Manager or DON should have been informed if the temperature was off and that there was no thermometer.-The freezer compartment should not have been a block of ice, he/she did not know who was responsible for defrosting the freezer.-The Charge Nurse should have ensured the temperature was checked daily, the sink was clean, and there was soap so the staff could wash their hands before preparing medications. -There should not have been any personal items or loose pills in the medication cart.-The staff member who used the cart was responsible for ensuring it was kept clean and there were no loose pills.-The DON was ultimately responsible for the medication carts, medication refrigerator, and the medication room.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP - precautions taken by a facility for the prevention of transmission of multidrug-resistant organisms) for three sampled residents (Resident #24, Resident #7, and Resident #8); failed to ensure accurate documentation of a resident's tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin test for five sampled residents (Residents #3, #4, #6, #9, and #18) out of 12 sampled residents and failed to ensure hand hygiene was completed during medication pass. The facility census was 36 residents. Review of the facility's policy, Enhanced Barrier Precautions, dated 2022 showed: -The use of gown and gloves for use during high contact resident care activities. High contact activities include: Dressing, bathing, transferring, providing hygiene. changing linens, changing briefs or assisting with toileting, device care: urinary catheters, feeding tubes, any skin opening requiring a dressing. -All staff would have received training on enhanced barrier precautions upon hire and at least annually and were expected to comply with all designated precautions. -Clear signage would have been posted on the door or wall outside of the resident's room which indicated the type of precautions, required personal protective equipment (PPE – safety gear used to reduce exposure to substances, germs, and objects), and the high contact resident care activities that require the use of gown and gloves. -An order for EBP would have been for residents with any of the following: Pressure ulcers (injury to the skin and underlying tissue resulting from prolonged pressure on the skin), diabetic foot ulcers (a breakdown of the skin and deeper tissues of the foot), unhealed surgical wounds, and chronic venous stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins), and indwelling medical devices (central lines (a flexible tube inserted into a large vein), urinary catheters (a tube inserted into the bladder for urinary drainage), feeding tubes (a medical device that delivers liquid nutrition directly to the stomach through a flexible tube). -Implementation of EBP included: -Make gowns and gloves available immediately outside of the resident's room. -Ensure access to alcohol-based hand rub in every resident room. -Position a trash can inside the resident room near the exit for discarding PPE after removal. -The Infection Preventionist would have incorporated periodic monitoring and assessment of adherence to determine the need for additional training and education. Review of the facility's policy, Medication Administration, dated 10/2022 showed: -Staff was to wash hands prior to administering medication per facility protocol. 1. Review of Resident # 24's face sheet showed he/she was admitted on [DATE] with a Stage 2 pressure ulcer (a superficial wound affecting the top two layers of the skin) on his/her buttock. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/19/25 showed: -He/She had a pressure ulcer. -He/She was moderately cognitively impaired. Review of the resident's August 2025 Physician's Order Sheet (POS) showed the following orders: -EBP related to dressings to his/her buttock. Gown and gloves during cares for dressing, dated 8/18/25 at 7:00 P.M. -Cleanse his/her bilateral buttock with Wound Cleanser, pat dry, apply zinc ointment (medication used to heal skin), and cover with bordered dressing (a non-woven adhesive tape that hold the dressing in place and maintains a moist wound environment) daily and as needed, dated 8/19/25. -Wash lateral thigh with normal saline, apply Santyl (ointment used for wound debridement), cover with non-adherent dressing then cover with Abdominal pad (ABD highly absorbent used for wound care) every day shift, dated 8/19/25. Observation and interview on 8/18/25 at 9:26 A.M. showed: -Staff had went into the resident's room and did not don (apply) PPE. -Staff had provided care to the resident and had not used PPE. -There was no sign on the door stating the resident was on EBP. -There was no isolation cart at the resident's room or along the hallway. -The resident said he/she had a wound on his/her hip. -He/she said the staff did not wear PPE when caring for him/her. 2. Review of Resident #7's face sheet showed he/she was admitted with the following diagnoses: -Protein calorie malnutrition (a nutritional disorder resulting from insufficient intake of protein and calorie). -Adult failure to thrive (unexplained weight loss, malnutrition, and disability that affects older adults). -Dysphagia (difficulty swallowing foods or liquids). Review of the residents quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired. -He/She had a feeding tube. Review of the August 2025 POS showed the following orders: -Enteral feed every six hours: Jevity (a calorie dense therapeutic nutrition) 1.5 240 milliliters (ml) via Percutaneous Endoscopic Gastrostomy tube (PEG tube – a feeding tube that provides direct access to the stomach for nutrition, hydration, and medication), dated 5/8/25. -EBP related to Peg tube, gown and gloves during cares for peg tube, every shift, dated 8/18/25. Observation and interview on 8/18/25 at 9:40 A.M. showed: -Staff went into the resident's room and did not don (apply) PPE. -Staff provided care to the resident and had not used PPE. -There was no sign on the door stating the resident was on EBP. -There was no isolation cart at the resident's room or along the hallway. -The resident had a feeding tube. -He/she did not feel up to being interviewed. 3. Review of Resident #8's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Obstructive uropathy (a disorder that occurs when urine flow is obstructed). -Retention of urine (difficulty urinating and completely emptying the bladder). -History of urinary tract infections (an illness in any part of the urinary tract). -Artificial opening of urinary tract (a surgically created pathway for urine to exit the body). Review of the resident's quarterly MDS dated [DATE] showed: -He/She was severely cognitively impaired. -He/She had a catheter (a tube inserted into the bladder to drain urine). Review of the resident's August 2025 POS showed the following orders: -18 French (Fr – size of the catheter)10 cubic centimeters (cc – the amount of fluid to fill the balloon it takes to secure the catheter in place) supra pubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen just above the pubic bone to drain urine when a person cannot urinate), change monthly and as needed for occlusion, dated 8/7/25. -EBP related to supra pubic catheter, gown and gloves during cares every shift, dated 8/18/25. Observation and interview on 8/18/25 at 1:10 P.M. showed: -Staff had completed resident cares and had not used PPE. -There was no sign on the door stating the resident was on EBP. -There was no isolation cart at the resident's room or in the hallway. -The resident said staff had emptied his/her foley and had not worn a gown only gloves. 4. During an interview on 8/20/25 at 9:00 A.M. CMT B said: -They just started using EBP this week. -There should have been a sign on the door that showed you what to wear when doing cares with the resident. -The Director of Nursing (DON) came around and provided education on EBP by doing 1:1 education. -The facility had not been doing EBP before the survey started. During an interview on 8/20/25 at 9:40 A.M. Certified Nursing Assistant (CNA) A said: -He/She had worked at the facility for a few months. -He/She thought that EBP meant washing your hands. -He/She could not remember if the DON had provided education about EBP during orientation. -The just started using EBP this week after survey started. -He/She had not received EBP education from the DON this week. During an interview on 8/20/25 at 9:50 A.M. Licensed Practical Nurse (LPN) A said: -They have just started doing EBP since survey started. -If you had any opening in your body such as a foley catheter, feeding tube, or open wound you should have been on EBP. -There should have been a sign on the resident's door indicating what PPE to have been worn when performing cares with the resident. -There should have been an isolation cart outside the resident's room with PPE in it. -The DON just came around yesterday providing education 1:1 with the staff. -The DON was responsible for ensuring EBP were in place and providing education to the staff. 5. During an observation of the medication pass on 8/20/25 at 8:20 A.M. with CMT B showed: -He/She did not cleanse his/her hands before administering medication to the resident in room [ROOM NUMBER] A. -He/She did not cleanse his/her hands after administering medication to the resident in room [ROOM NUMBER] A. -He/She did not cleanse his/her hands after administering medication to the resident in room [ROOM NUMBER] B. -CMT A continued to pass medications to the rest of the residents. During an interview on 8/20/25 at 9:00 A.M. CMT B said: -You should wash your hands or use a hand sanitizer before starting the medication pass, before administering medications to each resident, and after you were done passing medications. -The facility had provided a lot of education about when you were to wash your hands. -The DON was responsible for ensuring staff washed their hands when they were supposed to have cleansed their hands. During an interview on 8/20/25 at 9:50 A.M. LPN A said: -During medication pass staff should cleanse their hands before starting the medication pass, after the medication pass and after passing medications to each resident. -The DON had provided education almost monthly about washing your hands. During an interview on 8/22/25 at 1:15 PM the DON said: -He/She had just initiated EBP after the first day of survey. -He/She had identified seven residents who should have been on EBP. -He/She had provided education to the staff on Monday night. -He/She should have started it previously. -The CMT or Nurse should have washed/cleansed their hands before and after the medication pass, as well as after each resident. 6. Review of the facility's undated Resident Screening for Tuberculosis policy showed: -Prior to or at the time of admission all residents will receive TB testing. -All initial and follow up TB tests shall be administered and interpreted (48-72 hours for skin test) by a trained health care professional on staff. 7. Review of Resident #6's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization report showed an annual TB skin test was administered on 9/23/24. The test was documented as 0 mm induration with no read date. 8. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization report showed an annual TB skin test was administered on 4/21/25. The test was documented as 0 mm induration with no read date. 9. Review of Resident 3's Face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization report showed an annual TB skin test was administered on 3/17/25. The test was documented as 0 mm induration with no read date. 10. Review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization report showed an annual TB skin test was administered on 3/24/25. The test was documented as 0 mm induration with no read date. 11. Review of Resident #4's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's immunization report showed an admission TB skin test was administered on 7/3/25. The test was documented as 0 mm induration with no read date. The resident did not have a second step TB skin test. During an interview on 8/22/25 at 1:15 PM, the Director of Nursing (DON) said: -TB skin test results should be read 48-72 hours after they are administered. The read date should be documented. -The facility's electronic medical records system did not have a spot to document the TB skin test read dates. -All new admissions should have a two-step skin test.

Based on observation, interview and record review, the facility failed to ensure appropriate measures were taken to provide safe conditions for food storage by not maintaining documentation of walk-in freezer temperatures. The facility census was 36 residents.Review of the facility's Monitoring of Cooler/Freezer Temperature, undated, showed:-The facility maintained temperatures of coolers and freezers at the appropriate temperature to promote food safety.-Logs for recording temperatures for each refrigerator or freezer was posted in a visible location outside the freezer or refrigerator unit.-Temperatures were checked and logged at least twice per day by designated personnel.-Logs were changed out and completed monthly.-All frozen storage was maintained at or below -4 Fahrenheit (F-a unit of measuring temperatures).-If temperatures were above 10 for freezers the supervisor was notified and took corrective action:--The unit was repaired as soon as possible.--If not corrected within two hours all food items were relocated to a different unit.--Internal temperatures readings were taken on all perishables, and potentially hazardous food was discarded if not in an acceptable range.1.Review of the facility's July 2025 Freezer Temperature Log, showed:-Freezer logs were missing temperatures the entire month of July 2025 with a squiggly line drawn down column. -NOTE: these logs were not the logs observed on the outside of the unit during initial kitchen tour.-No walk-in freezer temperature logs were provided for August 2025.Observation on 8/18/25 at 10:58 A.M. showed:-The walk-in freezer had a broken thermometer located outside of the unit.-The thermometer inside of the walk-in freezer read 22 F.-A large container of chocolate ice cream was noted to be melting.-The clip board hanging on the outside of the freezer door, used for documenting daily temperatures was dated July 2025, with multiple dates left blank.During an interview on 8/18/25 at 10:58 A.M., the Dining Services Manager said:-He/She had not been made aware of the freezer not being at the correct temperature.-He/She was going to put in a work order to have it looked at. During an interview on 08/20/2025 at 8:52 A.M., [NAME] A said:-Everybody in the kitchen checked food and equipment temperatures and wrote it on the log.-Reach-in coolers and freezers were temperature checked first thing in the morning.-After they were checked it was documented on the chart hanging on the wall next to the walk-in cooler and freezer.-Freezer should not be above 14 F. During an interview on 08/20/2025 at 9:36 A.M., [NAME] B said:-The temperature in the freezers should be below zero. -He/She noticed it wasn't working and told maintenance about it last month. -Temperature logs were hanging on the outside of the walk-in freezer doors. During an interview on 08/20/2025 at 10:03 A.M., [NAME] C said:-He/She checked freezer temperatures in the beginning and ending of his/her shift.-He/she recorded the temperatures on the log hanging outside of the door.During an interview on 08/20/2025 at 1:58 P.M., the Dietary Services Director said:-Everyone in the kitchen was responsible for checking and documenting equipment temperatures, however it was mainly the cook's responsibility because they are the first one in the kitchen in the morning. -He/She expected the morning and night cooks to do equipment temperature checks and report any issues to him/her.During an interview on 08/20/2025 at 2:33 P.M., the Administrator said:-He expected the Dietary Services Director to make sure temps were being logged for all equipment.-He/She should have been notified if the equipment was not working.

Based on observation, interview and record review the facility failed to ensure appropriate measures were taken to provide safe and sanitary conditions for food storage and preparation by not maintain cleanliness of the kitchen and kitchen equipment; not labeling and dating opened food; not wearing appropriate hair coverings; not cleaning utensils; not documenting food temperatures during preparation; not documenting refrigeration temperatures. The facility census was 36 residents.Review of the facility's Record of Food Temperatures policy, undated, showed:-The facility recorded food temperatures daily to ensure food was at the proper serving temperatures.-Food temps were checked while items were prepared in the dietary department.-Hot foods were to be held at 135 Fahrenheit (F-a unit of measure for temperatures) or greater.-Potentially hazardous cold food temperatures were kept at or below 41 F.-Staff were to measure and record temperatures for each food product at all meals and document on the food temp logs.-No food was served that did not meet the food code standard temperatures.Review of the facility's Monitoring of Cooler/Freezer Temperature, undated, showed:-The facility maintained temperatures of coolers and freezers at the appropriate temperature to promote food safety.-Logs for recording temperatures for each refrigerator or freezer was posted in a visible location outside the freezer or refrigerator unit.-Temperatures were checked and logged at least twice per day by designated personnel.-Logs were changed out and completed monthly.-All refrigerator storage must be maintained at or below 41 F.-All frozen storage must be maintained at or below -4 F.-If temperatures were above 41 for coolers and 10 for freezers, the supervisor was notified and took corrective action:--The unit was repaired as soon as possible.--If not corrected within two hours all food items were relocated to a different unit.--Internal temperatures readings were taken on all perishables and potentially hazardous food was discarded if not in an acceptable range.-Refrigerated food was labeled, dated and monitored for it to be used by the use by date.Review of the facility's Date Marking for Food Safety policy, undated, showed:-The facility adhered to a date marking system to ensure food safety. -Refrigerated food was held at 41 F or less for a maximum of seven days.-Food was clearly marked to indicate the date.-The individual opening the food was responsible for date marking the food.-The Head [NAME] or designee was responsible for checking the refrigerator daily for food items that were expiring and discarded accordingly.-The Dietary Manager or designee spot checked refrigerators weekly for compliance and documented accordingly.Review of the facility's Dietary Employee Personal Hygiene policy, undated, showed:-Hair restraints were worn by all kitchen staff.-Hair restraints included hairnet, hat and beard restraints were to be worn to prevent hair from contacting food.Review of the facility's Routine Cleaning and Disinfection policy, undated, showed:-It was the policy of the facility to ensure routine cleaning and disinfection to provide a safe, sanitary environment.-Cleaning was defined as: removal of visible soil from objects and surfaces using water and detergents or enzymatic (a chemical used for cleaning) products.-Routine cleaning of visibly soiled surfaces was performed as needed.Review of the facility's Food Safety Requirements, undated, showed:-Food was stored, prepared, distributed and served in accordance with professional standards for food service safety.-Equipment used in the handling of food, including dishes, utensils, mixers, grinders and other equipment that came in contact with food was to be clean after use.-Dry food storage must be clean and dry.-Safe refrigerated storage included:--Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals.--Labeling, dating and monitoring refrigerated food.--Keeping foods covered or in tight containers.-All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination.-Clean dishes shall be kept separate from dirty dishes.-Dietary staff must wear hair restraints (including beards) to prevent hair from contacting food.-Hairnets should be worn when cooking, preparing or assembling food.Review of the facility's July 2025 Cooler Temperature Log, showed:-Cooler logs were missing temperatures on July 23rd through July 27th.-NOTE: these logs were not the logs observed on the outside of the units during initial kitchen tour.-No equipment temperature logs were provided for August 2025.Review of the requested food temperature logs for July through August 2025 showed:-July 1st evening meal temperature check was not documented.-July 2, 3, 4 and 5 breakfast, noon and evening meals temperature checks were not documented.-July 7th noon meal temperature checks were not documented.-July 8th evening meal temperature check was not documented.-July 10, 11 and 12 no meals had temperature checks documented.-July 13th evening meal temperature check was not documented.-July 13, 14, 15 breakfast, noon and evening meals temperature checks were not documented.-July 16th evening meal temperature check was not documented.-July 17th and 18th evening meal temperature check was not documented.-July 21st no meals had temperature checks documented.-July 23rd evening meal temperature check was not documented.-July 24th breakfast and evening meals temperature check not documented.-July 25th noon meal temperature checks were not documented.-July 26th breakfast and noon meals temperature check not documented.-July 29th evening meal temperatures check not documented.-August 1st breakfast and noon meals temperature check not documented.-August 3rd noon and evening meals temperature checks were not documented. -August 4th and 5th evening meal temperature check was not documented. -August 5th evening meal temperature check was not documented.-NOTE: No additional August 2025 temperature logs were provided.Observation on 08/18/2025 at 10:58 A.M., showed:-Dry storage had opened and not labeled a bottle of pancake syrup.-There was one dented can of pineapple and one dented can of mandarin oranges on the ready-to-serve storage rack. -There were four Rubbermaid plastic storage containers on the prep table containing dry cereal, two of which were not labeled or dated. -The reach-in cooler had a July 2025 temperature log hanging on the outside of the door.--The temperature log was missing more than 50% of the entries for the month.-There was no temp log for August.-An opened, undated and expired jar of pickles (5/22/25 based on manufacture dating) was in the reach-in cooler.-Floors in the kitchen, storage area and walk-in coolers were noted to have debris and were sticky in some areas. -An undated open bottle of grape jelly was sitting on a shelf in the food prep area, not refrigerated (manufacturer label showed refrigerate after opening).-The stove hoods were covered in grease.-There were drops of grease dripping on to the stove surface. -There was an opened package of sliced cheese in the walk-in cooler with no date.-There were no temperature logs for walk-in cooler.-The thermometer located on the outside of the walk-in cooler was broken. The hanging thermometer was in the back of the cooler and could not be read without moving three large jars of salad dressing.-Jars of salad dressing were in the walk-in cooler and were caked with dried on and gloopy dressing.-Stand up freezer, used for stored bread, had no temp log with a digital thermometer on the top.-Coffee filters were in a box with soaked in dried out brown substance sitting on a cafeteria tray on a portable stainless steel food cart.-A plastic circular container under the wall mounted knife holder was full of utensils. The cook reported they were clean, but upon inspection three knives were found inside the container with dried on food particles stuck to them.During an interview on 08/18/2025 at 10:58 A.M., the Dining Services Director said:-Dented food cans were sent back for credit and should not be on the storage racks.During an observation on 08/182025 at 11:00 A.M., a dishwasher was doing dishes with a beard net tucked below his/her chin.Observation on 08/20/2025 at 8:38 A.M., showed the Dining Services Director was in the food prep and cooking areas with no hair net or beard net.Observation on 08/20/2025 at 8:42 A.M., the August 2025 temp log for the reach-in cooler was blank, hanging on the outside of the door.Observation on 08/20/2025 at 8:44 A.M., an opened container of sour cream in the reach-in cooler was opened with no label showing the date it was opened. Observation on 08/20/2025 at 8:46 A.M., there were no food temp logs present in the cooking and food prep areas. During an interview on 08/20/2025 at 8:52 A.M., [NAME] A said:-He/She temped the foods after they were done cooking.-The food was immediately put on the steam table where it was temped.-Everybody in the kitchen checks food and equipment temperatures and wrote it on the log.-The log was in the kitchen in food prep area.-Reach-in and walk-in coolers and freezers were temperature checked first thing in the morning.-After they were checked it was documented on the chart hanging on the wall next to the units.-The freezer should not be above 14 F and cooler around 30 F.-Hair nets were worn all day until it was time to leave.-A box of new hair nets was located under the serving table when you first walk in the kitchen doors.-When food was opened and not all used it was supposed to be labeled with a date when it was opened. -There should be a label on opened containers, and he/she threw it away if it did not have one. -Dented cans were put aside and were not used in the kitchen. -Jelly should be refrigerated after opening and should have a date label on it.-Cleaning was done everyday and there were schedules we followed.During an interview on 08/20/2025 at 9:36 A.M., [NAME] B said:-He/She checked the food temperatures when it came out of the oven and when the food left the kitchen. -He/She recorded the temperatures in the temp book.-This was done for every meal, every day.-We temp it and the Dining Services Director made sure it was done.-The walk-in and reach-in coolers temperatures should be in the 30s.-The temperature in the freezers should be below zero. -He/She noticed it wasn't working and told maintenance about last month. -If he/she did not see dates on opened food he/she removed it. -There should be dates on all the food, including leftovers. After the third day he/she threw it away.-When he/she opened foods he/she marked it with an open date. -Everyone in the kitchen wore hair nets, even when washing dishes. -Temperature logs were hanging on the outside of the reach-in, walk-in, and freezer doors. -There was a cleaning list.-He/She cleaned messes as he/she saw them. -All kitchen staff were responsible for cleaning the kitchen.-The kitchen and prep equipment were cleaned twice a day, after breakfast and after lunch.-He/she was unsure what the dinner crew did.During an interview on 08/20/2025 at 10:03 A.M., [NAME] C said:-He/She made sure there were no dented cans on the racks.-Dented cans went to a different area in the kitchen and were discarded.-They should never be on the rack to be served.-Kitchen staff put labels on boxes with the date it was opened. -He/She expected there to be dates on any opened containers.-He/She threw out items if they were not dated.-Food that said it should be refrigerated after opening should go in the walk-in or reach-in coolers. -He/She checked the food temps while preparing and put them in the logbook.-He/She checked cooler and freezer temperatures in the beginning and ending of his/her shift and recorded the temperatures on the log hanging outside of the door.-Hair nets were worn when we entered the kitchen.-Should not see anyone in the kitchen cooking area without a hairnet.-Dishwashers need hair nets and beard nets.-There was a clip board with cleaning schedules for the reach-ins and walk-ins.-Once it was cleaned the person who cleaned put their initials on the clipboard.-NOTE: no cleaning schedules of checklists were provided.During an interview on 08/20/2025 at 1:58 P.M., the Dietary Services Director said:-There was a cleaning schedule that staff completed, as well as closing lists for each position.-There is a weekly deep clean list that staff were responsible for doing.-Weekly list was signed-off by the Dietary Services Director. - The Dietary Services Director was responsible for ensuring the cleaning was being done. -He/She had noticed an issue with cleaning not getting done. -There have been some write ups and other disciplinary actions.-He/She provided reminders to staff every day.-He/She provided training and monthly in-services.-He/She expected the kitchen staff to complete the cleaning list.-Staff should have recorded food temperatures and documented them on the log.-Everyone in the kitchen was responsible for checking and documenting equipment temperatures, however it was mainly the cooks responsibility because they are the first one in the kitchen in the morning. -He/She expected the morning and night cooks to do equipment temperature checks.-Staff were expected staff to wear hairnets and beard nets, including the dishwashers.-Opened containers should be labeled and dated with open date and expiration date.-Expect kitchen staff to wipe off bottles and containers before putting them in the coolers.During an interview on 08/20/2025 at 2:33 P.M., the Administrator said:-He/She expected the Dietary Services Director to make sure temps were being logged for all food and equipment.-He/She expected dietary staff to be always wearing hair coverings, including beards and dishwashers.-He/She expected kitchen staff to be cleaning daily. -He/She expected the Dining Services Director to notify him/her of failing equipment. Observation on 08/21/2025 at 1:28 P.M. of the refrigerator in the kitchenette in the dining room on the unit showed:-Opened sliced cheese with no label or date.-Opened gallon of milk with no opened date. -Opened bottle of grape jelly on the counter with no label and no open date.

Based on observation, interview and record review, the facility failed to ensure resident rights were being honored by not treating one resident (Resident #9) out of 12 sampled residents, with dignity while standing up next to the resident and being assisted with eating during scheduled mealtimes. The facility census was 36 residents.A policy regarding feeding assistance was requested and not received.1. Review of the resident's face sheet, undated, showed:-The resident was admitted [DATE].-The resident was diagnosed with aphasia (a condition affecting speech caused by a stroke).Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used in nursing homes to evaluate resident health and functional needs), dated 6/19/25, showed:-The resident had moderate cognitive impairment.-The resident lacked ability to use suitable utensils to bring food and/or liquid to his/her mouth and swallow food and/or liquid once the meal was placed before the resident-The resident needed supervision and touching assistance while eating.Review of the resident's Care Plan (a personalized document outlining a resident's medical, emotional, and daily living needs and the specific strategies used to meet them, ensuring person-centered care), dated 7/12/25, showed:-The resident required assistance with eating.-The resident had a swallowing problem related to aphasia.Observation on 08/19/2025 at 11:31 A.M., showed:-Seven residents were sitting at a round table; one was Resident #9.-Staff were noted to walk around the table and offered feeding assistance to residents.-Residents were fitted with clothing protectors.-Resident #9 was fed by an aide who was standing up next to the resident and between the resident and another resident. -Another aide was standing next to another unidentified resident, also feeding him/her while standing.-Resident ate 25-50% of the lunch meal.During an interview on 08/20/2025 at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The resident needed feeding assistance.-He/She helped the resident with feeding.-He/She knows how to feed residents, he/she had been a CNA for ten years.-That is the only training he/she received.-He/She sat down to feed the residents.-He/She had seen other aides standing up to feed residents.During an interview on 08/20/2025 at 9:49 A.M., Certified Medication Technician (CMT) A said:-He/She did not usually assist with feeding.-He/She would sit down to feed the residents.-He/She noticed some aides standing over the residents while helping them eat.Observation on 08/21/2025 at 8:45 A.M., showed:-The resident was not at the breakfast table.-Another resident in a Broda chair received feeding assistance from an aide.-The aide stood over the resident while wiping his/her face during the meal.During an interview on 08/21/2025 at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-Aides were expected to sit down and feed the residents.-He/She expected them to have conversations during mealtimes and feeding assistance. During an interview on 08/22/2025 at 1:15 P.M., the Director of Nursing (DON) said:-Aides were expected to know the diet and how to feed residents when they required assistance.-Aides also checked resident preferences to make sure it is what the resident.-Aides were expected to communicate with residents as they were feeding the resident.-All staff were encouraged to sit next to the residents they were assisting and not tower over the top of them.-Clothing protectors should be offered before putting them on the residents.

Based on interview and record review, the facility failed to ensure the correct code status (a form or statement that indicated preferences to receive life sustaining measures such as cardio-pulmonary resuscitation (CPR)) was documented in the Electronic Health Record (EHR) for one resident (Resident #4) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's Residents' Rights Regarding Treatment and Advance Directives (a legal document that stated specific healthcare wishes), undated, showed:-The facility supported each resident's right to formulate an advance directive.-On admission the facility determined if the resident had an Advance Directive, and if not, determined whether the resident would like to formulate one.-Upon admission if the resident had an Advance Directive, copies were made and placed on the chart and communicated with staff.-During the development of the care plan (a detailed document summarizing a person's health conditions, goals, and the specific treatments or services needed to achieve those goals) the facility identified, clarified and reviewed with the resident or legal representative whether they desired to make any changes related to the Advance Directive.-Any decisions were documented in the resident's medical record and communicated to the staff. 1. Review of Resident #4's face sheet, undated, showed:-He/She was admitted into the facility on [DATE].-He/She was cognitively intact. Review of the resident's Physician Order Summary (POS), dated [DATE], showed:-The resident was listed as Do Not Resuscitate (DNR). -There was no DNR form located in the resident's file. Review of the resident's Care Plan, dated [DATE], showed:-The resident was listed as DNR. During an interview on [DATE] at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The code status was in the resident's chart.-If he/she needed to know the code status he/she looked in the chart. During an interview on [DATE] at 9:49 A.M., Certified Medication Technician (CMT) A said:-Charting in the EHR said what the resident's code status was.-The EHR said at the top of the face page what the code status was. During an interview on [DATE] at 11:17 A.M., the resident was interviewed but did not clearly understand the questions regarding his/her code status. During an interview on [DATE] at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-Advance Directives were in the resident's record.-Paper copies were kept at the nurse's station in a book.-The nurse was asked to provide the book, and it was not at the nurse's station.-The Director of Nursing (DON) must have had it. During an interview on [DATE] at 11:21 A.M., the DON said:-We had a DNR book located at the nurse's station, categorized by last name.-There was a paper copy in the resident's paper chart, and it was scanned into the EHR. -He/She would expect the code status to be in the EHR and the paper chart. -He/She would expect the care plan to say DNR or full code. During an interview on [DATE] at 11:54 A.M., the Minimum Data Set (MDS-a comprehensive assessment tool used in nursing facilities to evaluate resident health and identify needs) Coordinator provided a copy of the resident's progress EHR note and said:-The EHR was showing the resident was a full code (the resident wished to have CPR).-He/She accidentally put the wrong code status in the resident's file.-He/She put another resident's code status in the resident's file. During an interview on [DATE] at 1:15 P.M., the DON said:-He/She expected the resident's code status to be documented as an order in the EHR.-Residents were considered a full code unless there was a DNR signed and dated by the resident or representative and physician and care planned.-He/She would expect the correct code status be assigned to correct resident.

Based on interview and record review, the facility failed to follow physician orders when weights were not monitored, documented and reported for one resident (Resident #9) diagnosed with Congestive Heart Failure (CHF- condition where the heart muscle did not pump blood effectively enough to meet the body's needs) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's Medication Administration policy, dated 10/2022, showed to obtain and record vitals (heart rate, pulse, blood pressure and weights) per physician orders.1.Review of the Resident #9's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident had moderate cognitive impairment.Review of the resident's Physician Order Summary (POS), dated August 2025, showed:-The resident was diagnosed with CHF.-The resident was ordered Torsemide (water pill that helped rid excess fluid) oral table, 40 milligrams (mg), related to edema (swelling that resulted from an abnormal accumulation of fluid in the body's tissues) and CHF.- Weigh daily for 14 days one time a day related to edema and CHF for 14 days.--Notify doctor if there was a weight gain of more than three pounds in 24 hours.--Starting 8/17/25.Review of the resident's Medication Administration Record (MAR), dated August 2025, showed the resident received Torsemide as ordered.Review of the resident's Treatment Administration Record (TAR), dated August 2025, showed:-The resident was not weighed on August 17, 18, 19, 20.-The resident was weighed on August 21 at 136.8 pounds.-The resident was not weighed on August 22.During an interview on 08/20/2025 at 9:13 A.M., Certified Nursing Assistant (CNA) A said:-The aides and sometimes the nurses weighed the residents.-He/She had a list of residents who needed to be weighed and weighed them.-He/She wrote the information on paper and gave it the nurse, or he/she would enter into electronic charting.During an interview on 08/20/2025 at 9:49 A.M., Certified Medication Technician (CMT) A said:-The resident was supposed to be weighed twice a month.-The aides or the nurses did the weights.-The clinical manager printed off a list of residents who needed weighed and he/she wrote the weights down and gave them to the nurse.During an interview on 08/21/2025 at 9:13 A.M., Licensed Practical Nurse (LPN) A said:-The resident was on weight monitoring for nutrition and eating tracking.-The resident was on daily weights.-The aides did the weights for the residents that were assigned to them.-The aides wrote the weights down and gave it to the nurse who documented in the resident's Electronic Health Record (EHR).-He/She expected daily weights to be done for the residents who had orders for it.-If residents had a fluctuating weight it was reported to the physician.-Aides were able to weigh the residents but not able enter into the EHR.During an interview on 08/21/2025 at 11:21 A.M., the Director of Nursing (DON) said:-The resident received daily weights.-The CNAs completed the weights.-The CNAs documented the weights in the vitals tab in the EHR or gave it to the charge nurse or nurse manager.-The nurses input the weights into the EHR quickly. -If they were not documented in the EHR they could be in the nurse manager's office.-He/She would check and provide them if found. -The resident was on daily weights due to CHF. -NOTE: no additional weight documentation was provided.During a follow up interview on 08/22/2025 at 1:15 P.M., the DON said:-He/She expected physician orders to be followed.-If the orders were to obtain daily weights, he/she expected nursing staff to follow those orders.-Normally the CNA assigned to that resident weighed the resident.-Weights were documented in the TAR or the vitals tab in the resident's EHR. -Weights were reported to the charge nurse or nurse manager.-CNAs were able to enter weights into the EHR or they gave a written copy to the nurse to enter.-If there was a change in the weight the charge nurse notified the physician.A message was left with the physician's messenger services 08/26/2025 at 8:40 A.M. Return call has not been received.

Based on observation, interview, and record review the facility failed to ensure a resident's oxygen equipment was kept in a sanitary manner when not in used for two sampled residents, (Resident #36 and Resident #37) out of 12 sampled residents. The facility census was 36 residents.Review of the facility's policy, Oxygen Concentrator, dated 2022 showed:-Staff was responsible for the use and care of oxygen concentrators.-Keep delivery devices covered in a plastic bag when not in use.-Change oxygen tubing and mask weekly and as needed if it becomes soiled or contaminated.-Change nebulizer tubing devices every 72 hours. 1. Review of Resident #36's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 6/26/25 showed:-He/She was cognitively intact.-Continuous positive airway pressure (CPAP - a treatment for sleep apnea which uses a mask to deliver constant and steady air pressure to help you breath while asleep) was not checked.-Oxygen (a therapy treatment that provides extra oxygen to help people with breathing difficulties) was not checked. Review of the resident's Physician's Order Sheet (POS) and Treatment Administration Record (TAR) for August 2025 showed to check and change CPAP tubing weekly every Sunday night shift, dated 2/26/23. Observation on 8/18/25 at 9:43 A.M. showed the resident had a CPAP machine and the mask sitting in the resident's drawer not in a bag. During an interview on 8/18/25 at 9:45 A.M. the resident said he/she needs assistance to get in and out of bed, the staff put his/her CPAP in the drawer. Observation on 08/19/25 at 11:50 A.M. showed the resident's CPAP mask sitting on a visible solid pad. Observation on 08/20/25 at 10:00 A.M. showed the resident's CPAP mask sitting on the same dirty pad. Observation on 8/21/25 at 9:45 A.M. showed the resident's CPAP mask was inside his/her pillowcase. 2. Review of Resident #37's Face sheet showed he/she was admitted on [DATE] with a diagnosis of COPD and Chronic Respiratory Failure (a long- term condition where the lungs can't effectively exchange oxygen and carbon dioxide, leading to shortness of breath). Review of the resident's August 2025 POS showed an order for Ipratropium-Albuterol (a combination medication used to treat and prevent wheezing and shortness of breath) Solution 0.5 to 2.5 (3) milligrams (mg)/3 milliliters (ml) one vial orally every six hours for cough related to COPD, dated 8/5/25. Observation on 8/18/2025 at 9:47 A.M. and on 8/20/25 at 10:50 A.M. showed the nebulizer mask was sitting in the drawer of the resident's nightstand not in a bag. 3. During an interview on 8/20/25 at 11:00 A.M. Certified Medication Technician (CMT) B said:-Oxygen equipment when not in use should have been stored in a bag.-They had received education from the Director of Nursing (DON) many times concerning oxygen/oxygen equipment storage.-It was the nurses' responsibility to ensure the oxygen equipment was stored correctly. During an interview on 8/20/25 at 11:10 A.M. Licensed Practical Nurse (LPN) A said:-Oxygen equipment when not in use should have been stored in a bag.-If the CPAP mask was sitting on a soiled pad, it should have been changed out.-They had received education from the DON many times concerning oxygen/oxygen equipment storage.-It was the nurses' responsibility to ensure the oxygen equipment was stored correctly. During an interview on 8/22/25 at 1:15 PM. the DON said when not in use oxygen equipment should have been stored in a bag and dated when it had been changed out.

Based on observation and interview, the facility failed to maintain the door between the kitchenette and the dining room in good repair; failed to prevent the accumulation of debris inside the climate control units of resident rooms [ROOM NUMBERS]; failed to ensure the cover of the cleanout was secured firmly to the floor. This practice potentially affected at least 25 residents who used the dining room and 4 residents who resided in resident rooms [ROOM NUMBERS]. The facility census was 36 residents.1. Observation on 8/18/25 at 10:32 A.M., showed the half door, which separated the dining room from the serving kitchenette dragged on the floor when it was opened and closed.During an interview on 8/18/25 at 10:33 A.M., Maintenance Person A said the door dragged on the floor due to a loose hinge.During an interview on 8/20/25 at 12:44 P.M. the Assistant Plant Operations Director said facility staff lean on that door when it is open and that caused the door to drag.2. Observation on 8/18/25 at 10:51 A.M., showed the presence of debris including a decoration inside the climate control unit in resident room [ROOM NUMBER].3. Observation on 8/18/25 at 10:58 A.M., showed a buildup of debris inside the climate control unit in resident rom 21.During an interview on 8/18/25 at 11:01 A.M., Maintenance Person A said the slats of the grate which covered the inside of the climate control unit, were too wide so more items accumulated within the climate control units in certain rooms and he/she was unaware of items which accumulated into the climate control units.4. Observation on 8/18/25 at 12:43 P.M., showed the cover of the cleanout (a capped pipe that provides access to a sewer or drain line, allowing for inspection, cleaning, and maintenance of the system) outside of laundry in the basement smoke zone, moved, when the cover was stepped on. During an interview on 8/18/25 at 12:43 P.M., Maintenance Person A said he/she did not know the cleanout cover was loose and not tightened.

Based on interview and record review, the facility failed to prevent misappropriation of controlled substances for three sampled residents (Resident #1, #2, #3) when Registered Nurse (RN) A repeatedly signed out duplicate doses of narcotics out of five sampled residents. The facility census was 100 residents. On 5/7/25 the Administrator was notified of the situation and RN A was suspended immediately pending investigation. Upon completion of the investigation, RN A was terminated for violating facility policy on 5/1/25, 5/4/25 and 5/6/25. Training was completed immediately for 100% of all nurses and Certified Medication Technicians (CMT)s on abuse and neglect, medication administration and controlled substances prior to being allowed to work and/or pass medications. The deficiency was corrected on 5/7/25. Review of the facility Abuse, Neglect, and Exploitation policy dated 2022 showed: -It is the policy of the facility to provide protections for the health, welfare and the rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. -The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. -New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. -Existing staff will receive annual education through planned in-services and as needed. -Training topics will include: --Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Review of the facility Controlled Substance Administration and Accountability policy dated 2022 showed: -It is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. -All controlled substances are accounted for when obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. -Written documentation must be clearly legible with all applicable information provided. -The controlled drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. -The controlled drug record is a permanent medical record document and in conjunction with the medication administration record (MAR) is the source of documenting any patient-specific narcotic dispensed from the pharmacy. -The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. -Inventory verification for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. 1. Review of the undated facility Internal Investigation showed: -On 5/7/25 Licensed Practical Nurse (LPN) A reported to Director of Nursing (DON) there was a medication error. -There was a discrepancy between the amount of hydrocodone (narcotic medication) pills in the bubble pack versus how many were recorded on the narcotic sheet. -Upon review, it was confirmed that one pill had been removed from the bubble pack, but it was not properly recorded on the controlled substance verification sheet or with the MAR. -Both staff who were present at the most recent reconciliation were drug tested. -RN A had already left the facility but was suspended pending investigation and sent for a urine drug screen (UDS). -RN A reported giving medications outside of time parameters to multiple residents. -RN A would give medications at the beginning of his/her shift although it did not trigger on the MAR and again about an hour before the end of his/her shift. -RN A did not chart administration of the narcotics in the resident's MAR. -The nurses verified during medication count, one nurse would count the pills and the other confirmed the number on the reconciliation sheet. -That practice was not in compliance with the facility policy as both nurses need to visually count and reconcile because the person counting pills could easily say an inaccurate number to comply with the reconciliation sheet. -The facility determined RN A either negligently or willfully committed several repeat medication errors and/or inaccurate medication counts, and was terminated from employment and his/her license reported to the board. -The facility reimbursed medication inventory for all residents and no resident went without prescribed medication. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnosis including hypertensive heart disease with heart failure (a condition where the heart is damaged due to prolonged high blood pressure) and chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body). Review of the residents Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/11/25 showed the resident was moderately cognitively impaired. Review of the resident's Medication Review Report dated 5/28/25 showed Hydrocodone 5 - 325 milligram (mg), give one tablet three times a day for pain. Review of photocopy of the resident's bubble pack card containing Hydrocodone 5 - 325 mg dispensed 4/19/25 showed: -Card contained 45 tablets when dispensed on 4/19/25. -There were 28 pills in pack card when the copy was obtained on 5/7/25. Review of the resident's Controlled Drug Record dated 4/29/25 through 5/3/25 showed: -On 5/1/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -Three prior doses for 5/1/25 were signed out by other nurses. -No other discrepancies noted on controlled drug record. Review of the resident's Controlled Drug Record dated 5/3/25 through 5/7/25 showed: -On 5/4/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -Three prior doses for 5/4/25 were signed out by other nurses. -On 5/6/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -Three prior doses for 5/6/25 were signed out by other nurses. -On 5/7/25 at 7:00 A.M. RN A signed out a dose for Hydrocodone, count was 31 tablets at that time. -On 5/7/25 at 1:00 P.M. LPN A signed out a dose of Hydrocodone, count was 30 tablets at that time. Review of the resident's MAR dated 5/1/25 through 5/31/25 showed: -5/1/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose. -5/4/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose. -5/6/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose. -No documentation noted for 5/1/25, 5/4/25 and 5/6/25 by RN A. Review of the resident's progress notes dated 5/8/25 at 9:03 A.M. showed the family and physician were notified of the medication discrepancy. *NOTE: no progress notes by RN A for additional hydrocodone doses for 5/1/25, 5/4/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication. 2. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnosis including age-related cognitive deficit (declines in cognitive abilities like memory, reasoning, and judgment that are more significant than what's typically expected with normal aging) and pain in right hip. Review of the residents Quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired. Review of the resident's Medication Review Report dated 5/28/25 showed: -Hydrocodone 5 - 325 mg, give one tablet by mouth every six hours as needed for pain related to periprosthetic fracture around other internal prosthetic joint. -Hydrocodone 5 - 325 mg, give one tablet orally two times a day for pain related to periprosthetic fracture around other internal prosthetic joint. -Pregabalin 50 mg, give one capsule by mouth two times a day for nerve pain. Review of the resident's Controlled Drug Record for Hydrocodone dated 5/1/25 through 5/7/25 showed: -On 5/1/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -On 5/4/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -Two prior doses for 5/4/25 were signed out by other nurses. -On 5/6/25 RN A signed out an additional Hydrocodone at 8:00 P.M. -Two prior doses for 5/6/25 were signed out by other nurses. Review of the resident's Controlled Drug Record for Pregabalin dated 5/1/25 through 5/7/25 showed: -On 5/4/25 RN A signed out an additional Pregabalin at 8:00 P.M. -Two prior doses for 5/4/25 were signed out by other nurses. Review of the resident's MAR dated 5/1/25 through 5/31/25 showed: -5/1/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose. -5/4/25 at 7:00 P.M. Hydrocodone and Pregabalin was administered by the same nurse that signed the controlled drug record for that dose. -5/6/25 at 7:00 P.M. Hydrocodone was administered by the same nurse that signed the controlled drug record for that dose. - No documentation noted for 5/1/25, 5/4/25 and 5/6/25 by RN A. Review of the resident's progress notes dated 5/8/25 at 8:51 A.M. showed the family and physician were notified of the medication discrepancy. *NOTE: no progress notes by RN A for additional hydrocodone doses for 5/1/25, 5/4/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication. 3. Review of Resident #3's admission Record showed the resident was admitted on [DATE] with diagnosis including dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) and chronic pain. Review of the resident's Quarterly MDS dated [DATE] showed the resident was mildly cognitively impaired. Review of the resident's Medication Review Report dated 5/28/25 showed an order for Clonazepam 1 mg, give one tablet by mouth three times a day for anxiety. Review of the resident's Controlled Drug Record dated 4/25/25 through 5/5/25 showed: -On 5/1/25 RN A signed out an additional Clonazepam at 8:00 P.M. -Three prior doses for 5/1/25 were signed out by other nurses. Review of the resident's Controlled Drug Record dated 5/5/25 through 5/7/25 showed: -On 5/6/25 RN A signed out an additional Clonazepam at 8:00 P.M. -Three prior doses for 5/6/25 were signed out by other nurses. Review of the resident's MAR dated 5/1/25 through 5/31/25 showed: -5/1/25 at 7:00 P.M. Clonazepam was administered by the same nurse that signed the controlled drug record for that dose. -5/6/25 at 7:00 P.M. Clonazepam was administered by the same nurse that signed the controlled drug record for that dose. -No documentation noted for 5/1/25 and 5/6/25 by RN A. Review of the resident's progress notes dated 5/8/25 at 9:02 A.M. showed the family and physician were notified of the medication discrepancy. *NOTE: no progress notes by RN A for additional Clonazepam doses for 5/1/25 and 5/6/25 related to additional doses of narcotics and/or controlled medications administered and/or other form of accountability for the disposition of the medication. During an interview on 5/28/25 at 11:20 A.M. the DON said: -He/She was informed of a discrepancy with the count for controlled substances on 5/7/25 at 1:00 P.M. by LPN A. -Upon investigation he/she noted RN A was signing off controlled medications at about the same time as the previous nurse at 8:00 P.M. -RN A never confirmed or denied he/she was taking the medications, but did apologize alleging he/she goofed up. During an interview on 5/28/25 at 11:49 A.M. LPN A said: -He/She counted controlled medications with RN A one time and there were no concerns noted at that time. -He/She did not notice any unusual behaviors. -He/She was the Clinical Coordinator. -He/She did an audit of medications about once per month to ensure there were no expired medications or any other needs related to medications. -He/She audits controlled medications looking for pattens of administration, if anything is given outside of timeframes, if a medication not being used or anything suspicious. -The nurses are expected to review medications on the medication carts. -The DON assists with controlled substance audits. During an interview on 5/28/25 at 12:07 P.M. LPN B said: -He/She counted with RN A two to three times. -He/She counted with RN A on 5/7/25 and the count was correct. -He/She was counting the number of pills in the cards from the pharmacy. -RN A was confirming the numbers on the resident-specific controlled drug record for each medication. -There were no numbers that did not match on 5/7/25. -He/She left at approximately 10:30 A.M. on 5/7/25. -He/She did not have anyone to count with and left the keys with the DON. -Upon returning he/she counted the controlled substances with LPN A due to the discrepancy. -When the discrepancy was confirmed about both nurses, it was then reported to the DON. During an interview on 5/28/25 at 2:44 P.M. LPN A said: -He/She counted with LPN B when he/she returned from his/her lunch break. -The count was off and that was when they reported to the DON. -Resident #1 was the only resident with the count discrepancy. -Once the DON was notified there were additional discrepancies noted related to times when RN A had signed out medications. -He/She and LPN B both submitted to urine drug screens and were both negative as far as he/she was aware. During an interview on 5/28/25 at 3:06 P.M. RN A said: -He/She started working at the facility mid April. -He/She was no longer employed at the facility. -He/She denied knowing why he/she was no longer working at the facility. -The facility had questions about some medication errors, which was a simple mistake documentation wise. -There were medications due at 7:00 P.M. that were sometimes given. -When he/she came in, he/she would start medication pass. -There were a couple of medications that were given, but he/she administered the medications as well. -He/She was unable to recall what resident or medication was administered. -It looked like the second week of May was when the medication error occurred. -When counting controlled substances, the total amount of cards were counted, each medication was counted in each card. -There was a sign off sheet in the from of the narcotic book where the nurses signed to confirm count was done at shift change. -Scheduled controlled substances were to be signed in the controlled substance record and on the MAR on the computer. -When passing medications he/she would look at the time in the administration record, administer as assess the resident. -If an as needed (PRN) controlled substance, it should be documented when and why the medication was given in the controlled substance record and the MAR in the computer. -Most of the medications in question were scheduled. -He/She was not sure if the PRN medications were included in the progress notes. -He/She did not chart in the progress notes for any of the residents' (Resident #1, #2, #3, #4 and #5) progress notes. -He/She did not know how he/she would give controlled medications an hour apart. -The residents got the medication and it was a screw up on his/her part. -He/She was not aware of overdosing residents. -He/She did not confirm utilizing the five rights of medication administration. -He/she said he/she made some errors. During an interview on 5/28/25 at 3:50 P.M. the DON said: -He/She expects the nurse to count controlled substances at the beginning and at the end of each shift. -While counting the nurses should stand side by side so that both nurses can observed the medications in the card and the controlled substance record. -The DON, Clinic Coordinator or other delegated nurse are responsible for auditing controlled medications. -When passing medications, staff passing medications are expected to triple check the orders and sign the controlled substance record and MAR as they go. -The MAR should match the controlled substance record. -Staff are expected to follow the five rights of medication administration. During an interview on 6/3/25 at 11:06 A.M. law enforcement confirmed a report was filed and the investigation remained open at that time. During an interview on 6/4/25 at 10:17 A.M. the Administrator said: -He/She was informed of the controlled substance discrepancy on 5/7/25 once it was discovered by the DON. -The DON handled the investigation and he/she completed the summary of the investigation. -All new hire background checks are review by him/her. -He/She did note RN A had some prior incidents however it had been more than 20 years without additional reports or concerns. -During orientation all staff are educated on abuse and neglect, and all nurses and medication technicians are educated on medication administration, storage and controlled substances. -He/She expected RN A to follow the policies and procedures for controlled substances and medication administration. During an interview on 6/4/25 at 11:40 A.M. the physician said: -He/She was aware of the discrepancy with the controlled substances on 5/7/25. -Resident's #1, #2, and #3 would not be able to recall if they had gotten too much or not enough pain medication related to their diagnosis of dementia. -There have been no reports of residents receiving too much medication by the staff or by any residents. -He/She felt the medication was not administered a second time as there were no reports of any unusual behaviors or complications with any of the residents. MO00253947

Based on observation, interview and record review, the facility failed to ensure that hot water temperatures from faucets throughout the facility, were consistently between 105 ºF (degrees Fahrenheit) and 120 ºF. Resident rooms [ROOM NUMBER]) on the South east side of the facility, had water temperatures between 94 ºF and 99 ºF. Resident rooms 14, 21, 22, and 12 on the north side of the facility had temperatures that were 120.2- 121.4 ºF; and Resident rooms [ROOM NUMBERS] had water temperatures between 76.1 ºF and 92.3 ºF .The facility also failed to ensure that staff who are checking temperatures allowed to flow for at least 2 minutes before measuring the water temperatures. This practice potentially affected all residents. The facility census was 35 residents. Review of the facility's policy entitled Safe water Temperatures and dated 3/23, showed: It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Explanation and Compliance Guidelines: 1. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns, and will respond appropriately. 2. Staff will be educated on safe water temperatures upon employment and on a regular basis. 3. Thermometers will be available as needed for use by all staff. 4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. 5. Water temperatures will be set to a temperature of no more than 120° F and no less that 105, or the state's allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office. Review of the Section for Long Term Care Policy entitled Maximum/ Minimum Water temperatures revised 10/1/98, showed: -State Regulations require that all facilities maintain water temperatures between 105 ºF--- 120 ºF at plumbing fixtures accessible to residents. - DHSS staff shall use the dial or digital thermometers to measure water temperatures. - In some situations, water temperatures may fluctuate significantly even at the same plumbing fixtures. Measurements at any water fixture should be taken for at least two minutes in order to determine fluctuation patterns or until the temperature has been constant for at least 30 seconds. 1. Review of water temperatures in the following rooms on 4/17/25, after the faucets were allowed to flow for two minutes, showed the following: The water temperature in Resident room [ROOM NUMBER] was 76.1 ºF. The water temperature in Resident room [ROOM NUMBER] was 92.3 ºF. The water temperature in resident room [ROOM NUMBER], was 104.0 ºF. The water temperature in the shared faucet or rooms [ROOM NUMBERS] was 104.1 ºF. The water temperature in room [ROOM NUMBER] was 104.5 ºF. The water temperature in room [ROOM NUMBER] was 94.4 ºF. The water temperature in room [ROOM NUMBER] was 94.6 ºF. The water temperature in room [ROOM NUMBER], was 99.5 ºF. The water temperature in room [ROOM NUMBER], was 120.2 ºF. The water temperature in room [ROOM NUMBER], was 121.4 ºF. The water temperature in room [ROOM NUMBER] was 120.5 ºF. The water temperature in room [ROOM NUMBER], was 120.7 ºF. Observation on 4/17/24 at 1:12 P.M., showed the temperature gauge of the hot water heater was set at a temperature between 115 ºF and 116 ºF. During an interview on 4/17/25 at 1:24 P.M., the Maintenance Assistant said the water from the hot water heater delivers water to a holding tank for the facility, then the holding tank delivers hot water to a mixing valve (a component in modern plumbing systems which has the function of blending hot and cold water to achieve a warm outlet temperature) to mix with water that is colder, then delivers the water to the facility. During an interview on 4/17/25 at 5:50 P.M., the Administrator said the following about the cold water temperatures in resident rooms [ROOM NUMBERS]: - The water that goes to those rooms has to travel a longer distance. - Because the water in rooms [ROOM NUMBER] originates from the Assisted Living Facility (ALF) side and the ALF residents are not running water as often as the SNF residents. During a phone interview on 4/22/25 at 2:07 P.M., the Administrator said: - He/she was not aware of the water temperatures which varied so much prior to an incident where one resident was reported to had an issue while in the shower. - Prior to that incident he/she was unaware of any plumbers being called to the facility to look at the issue of inconsistent water temperatures at the facility. During a phone interview on 4/22/24 at 2:22 P.M., the Maintenance Person said: - He/she was not sure what occurred on 4/17/25 to cause the inconsistent water temperatures. - They did not have a correct method of how their water system would regulate hot water temperatures because of the adjustments that were made to the thermostats on the hot water heaters. - He/she was confused to why there was such a wide variance in hot water temperatures. - In the past they have not had any inconsistent with water temperatures. - Facility leadership was evaluating whether to contact a professional plumber to look at their water pipe system. - In the past, when he/she measured hot water temperatures, he/she let that water flow for one minute, before measuring the hot water temperature, because he/she was unaware of how the hot water should be measured.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to safeguard against mold possibly getting into food and/or beverages; failed to change the deep fryer oil in a timely manner; failed to consistently document hot food temperatures at the steam table to ensure they were suitably cooked to lessen the chance of bacterial contamination; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 34 residents with a licensed capacity for 38 residents at the time of the survey. 1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the initial kitchen inspection showed the following: -On a shelf above a four-slice toaster in the Dry Storage (DS) area was an open 20-ounce (oz.) squeeze bottle of grape jelly that was not dated as to when it was opened. -There was a slick moldy residue on the black partition inside the ice machine. -Dried residue was encrusted on the manual can opener on a food preparation table by the convection oven. -The grease in the deep fryer was dark enough to keep the bottom basket resting racks form being seen. -There were multiple splatters on the inside top and sides of the microwave with large droplets on its turntable plate. -An aluminum foil lined utensil drawer next to the steam table had an overabundance of food crumbs in its bottom. -An open 1-gallon (gal.) jug of soy sauce with a label which read refrigerate after opening for quality was on the bottom shelf of the wheeled cart next to the convection oven. -The wheeled cart next to the convection oven also had a foil lined utility drawer with large bits of food in the bottom. -The large green cutting boards and small green cutting board were heavily scored to the point of plastic flaking off. -There was a grape, plastic pieces, and a bread clip on the floor under racks in the walk-in refrigerator. -There was plastic, paper, and numerous pieces of various foods on the floor of the walk-in freezer. Observation on 1/10/24 at 9:23 A.M. during the follow-up kitchen inspection showed the following: -There was a slick moldy residue on the black partition inside the ice machine. -Dried residue was encrusted on the manual can opener on a food preparation table by the convection oven. -The grease in the deep fryer was dark enough to keep the bottom basket resting racks form being seen. -There were multiple splatters on the inside top and sides of the microwave with large droplets on its turntable plate. -An aluminum foil lined utensil drawer next to the steam table had an overabundance of food crumbs in its bottom. -An open 1-gallon (gal.) jug of soy sauce with a label which read refrigerate after opening for quality was on the bottom shelf of the wheeled cart next to the convection oven which also had a foil lined utility drawer with large bits of food in the bottom. -The large green cutting boards and small green cutting board were heavily scored to the point of plastic flaking off. -There was a grape, plastic pieces, and a bread clip on the floor under racks in the walk-in refrigerator. -There was plastic, paper, and numerous pieces of various foods on the floor of the walk-in freezer. -There was no thermometer in the reach-in refrigerator. Review of the food temperature logs on a clipboard lying on a food preparation table next to the steam table in the kitchenette showed the following: -The last date for recorded temperatures was in November of 2023. -Multiple meals were left unrecorded on the last seven days of that month. During an interview on 1/16/24 at 1:05 P.M. the Dietary Manager (DM) said the following: -The cooks were responsible for cleaning the walk-ins' floors every day. -He/She would expect foodstuffs to be stored at their correct temperatures. -Damaged food preparation items were either found on his/her walk-through inspections or reported to them by their dietary staff and they were discarded. -Food preparation items were cleaned by rinsing them and then running them through the dishwasher twice. -He/She would expect food to be free of foreign substances. -Refrigerators should have a thermometer inside even if there was one built in on the outside. -The deep fryer's oil was changed every two weeks because they used it a lot, but sometimes they were also waiting on their delivery for new oil.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 34 residents with a licensed capacity for 38 residents at the time of the survey. 1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a handwashing sink, and an ice machine. Observation on 1/11/23 between 12:47 P.M. and 1:48 P.M. during the facility LSC room-by-room inspections with the Assistant Operations Director (AOD) showed the following: -There was a facility-wide fire sprinkler system. -There was a boiler room, a beauty shop, and an employee break room in the basement. -There were at least 20 resident rooms with sinks and bathrooms, a kitchenette, a bathhouse, a janitor's closet with a mop hopper sink, and a public restroom on the first floor. Review of the facility's water-borne pathogen program entitled Water Management - Infection Control, last reviewed on 9/8/23, showed the following: -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -Under the section Water Management Plan it read under point #2 that the facility implements a water management program that considers the ASHRAE industrial standard and the CDC toolkit. During an interview on 1/16/24 at 1:45 P.M., the AOD said the following: -He/She periodically tested water temperatures and flushed pipes. -There were no tests for chloramine (A secondary disinfectant most commonly formed when ammonia was added to chlorine to treat drinking water to provide longer-lasting disinfection as the water moved through pipes to consumers) levels. -The paperwork in their water management binder was their complete program. -He/She was educated on the program with the Operations Director and he/she gradually took over the whole process. During an interview on 1/16/23 at 2:26 P.M., the Administrator said the following: -The Operations Director was responsible for the water management program there. -They had taken a course about it over the last summer and had received instructions from a previous chief executive officer (CEO).

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for three sampled residents (Residents #19, #31 and #3) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's MDS 3.0 completion policy dated 2022 showed the facility would conduct an accurate assessment of the resident. 1. Review of Resident #19's care plan dated 3/1/23 showed: -The resident had a regular diet with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods are finely chopped, blended, or ground to make them smaller, softer, and easier to chew) and regular, thin liquids. -The resident admitted to hospice services (end of life care) on 5/19/23. -An update on 8/5/23 showed the resident had weight loss over the last four months. -No interventions of receiving tube feeding (a medical device used to provide nutrition to individuals who cannot obtain nutrition by swallowing) or fluids intravenously (IV-a tube placed into a vein). Review of the resident's significant change MDS dated [DATE] showed the resident weighed 117 pounds. Review of the resident's quarterly MDS dated [DATE] showed the resident weighed 107 pounds. Review of the resident's quarterly MDS dated [DATE] showed the following assessment of the resident: -Weighed 99 pounds. -Did not have significant weight loss (Significant weight loss is defined as 5% or more in the last month or 10% or more in the last six months. 117 pounds down to 99 pounds is a weight loss of 18.18% in six months, which is significant). -Was not on hospice. -Was not on a mechanical soft diet. -The proportion of total calories the resident received through parenteral (feeding of nutritional products to a person through intravenous (an IV) or tube feeding was 51% or more. -The average fluid intake per day by IV or tube feeding was 501 cubic centimeter (cc)/day or more. Observation on 1/8/24 at 10:37 A.M., 10:57 A.M., and 11:14 A.M. showed the resident was not receiving tube feeding or fluids by IV. Observation on 1/10/24 at 9:34 A.M. and 10:28 A.M. showed the resident was not receiving tube feeding or fluids by IV. Observation on 1/10/24 at 10:30 A.M. showed the resident had multiple beverages that were thin consistency, was being fed food of soft consistency by hospice staff and was not receiving tube feeding or fluids by IV. Observation on 1/11/24 at 5:21 A.M. showed the resident was not receiving tube feeding or fluids by IV. During an interview on 1/11/24 at 7:59 A.M., 1/11/24 10:04 A.M. and 1/16/24 at 9:06 A.M., the MDS Coordinator said: -The resident went on hospice on 5/19/23. -He/She made an error on hospice on the MDS. -He/She should have marked yes for hospice. -He/She marked the wrong box for diet and artificial route. -The resident's diet should have been marked as mechanical soft. -The resident's mechanical soft diet started 5/4/23. -Weight loss should have been marked as yes. Review of the resident's Physician's Order Sheet (POS) dated 1/16/24 showed the resident: -Had a diet order dated 5/4/23 of a regular diet with mechanical soft texture and regular, thin fluid consistency. -Had an order for hospice dated 6/21/23. -Did not have an order for tube feeding or fluids by IV. 2. Review of Resident #31's admission MDS dated [DATE] showed: -The proportion of total calories the resident received through parenteral or tube feeding was 51% or more. -The average fluid intake per day by IV or tube feeding was 501 cc/day or more. Review of the resident's care plan dated 1/8/24 showed: -The resident had a regular diet with regular texture and regular/thin liquids. -No interventions of receiving tube feeding or fluids by IV. Observation on 1/8/24 at 10:36 A.M. showed the resident was not receiving tube feeding or fluids by IV. Observation on 1/10/24 at 8:49 A.M., showed the resident was eating a regular texture breakfast and was not receiving tube feeding or fluids by IV. Observation on 1/10/24 at 9:17 A.M., at 9:34 A.M., at 10:27 A.M., and at 11:19 A.M. showed the resident was not receiving tube feeding or fluids by IV. During an interview on 1/11/24 at 7:59 A.M. and 10:04 A.M., the MDS Coordinator said the two items were marked incorrectly on the resident's MDS. Review of the resident's POS dated 1/11/24 showed the resident: -Had a diet order dated 12/22/23 of regular texture and regular, thin fluid consistency. -Did not have an order for tube feeding or fluids by IV. 3. Review of Resident #3's care plan dated 9/15/23 showed: -The resident had a suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis). -The resident was able to feed himself/herself. -The resident had a diet order of mechanical soft texture and regular/thin fluid consistency. Review of the resident's admission MDS dated [DATE] showed the following staff assessment of the resident: -Had an indwelling catheter (a tube passed through the urethra into the bladder to drain urine). -Was always incontinent of bladder (The MDS directed users to mark urinary incontinence not rated when an indwelling catheter was in use). -Mechanically altered diet was left blank. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had an indwelling catheter. -Was always incontinent of bladder. -The resident was on a mechanically altered diet. -The proportion of total calories the resident received through parenteral or tube feeding was 51% or more. -The average fluid intake per day by IV or tube feeding was 501 cc/day or more. Observation on 1/8/24 at 11:22 A.M. showed the resident: -Was not receiving tube feeding or fluids by IV. -Had a urinary catheter. Observation on 1/10/24 at 9:45 A.M. and 11:04 A.M. through 11:27 A.M. showed the resident: -Was not receiving tube feeding or fluids by IV. -Had a urinary catheter. Review of the resident's POS dated 1/11/24 showed the resident: -Had a diet order dated 9/12/23 of regular diet with mechanical soft texture and regular, thin fluid consistency. -Did not have an order for tube feeding or fluids by IV. -Had an order for a suprapubic catheter dated 9/12/23. During an interview on 1/11/24 at 7:59 A.M. and 10:04 A.M., the MDS Coordinator said: -He/She always marked incontinent of bladder if the resident had an indwelling catheter. -He/She did not know it should be marked not rated on the MDS if the resident had an indwelling catheter. -The resident was on a mechanical soft diet. -He/She marked the wrong box for tube feeding and IV fluids. 4. During an interview on 1/16/23 at 1:15 P.M., the Director of Nursing said he/she expected the MDS's to be accurate.

Based on interview and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of transfer from the facility for two sampled residents (Residents #17, and #32) out of 12 sampled residents. The facility census was 34 residents. The facility did not have a policy for Ombudsman notification. 1. Review of Resident #17's Admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Acute (severe and sudden onset) respiratory failure (a condition where there is not enough oxygen in body tissues) with hypoxia (insufficient oxygen in the blood). -Pneumonia (an infection that affects one or both lungs). Review of the resident's hospital record showed he/she admitted to hospital on 8/13/23 and discharged back to the facility on [DATE] for Acute Respiratory failure with Hypoxia. Review of the facility Ombudsman notification dated August 2023 showed that the facility failed to send the Ombudsman notification of any discharges to hospital. During an interview on 1/11/24 at 12:47 P.M., the Director of Nursing (DON) said: -The Business Office Manager (BOM) left the position in March 2023. -The new BOM had not been sending anything to the Ombudsman. -A bed hold notification and policy was sent to the resident's family. -The resident left to the hospital on 8/13/23 and returned on 8/21/23 to his/her original room. -The current BOM did not know he/she was supposed to be sending discharge notices to the Ombudsman. -Note: The BOM was out of the building during the interview process. 46890 2. Review of Resident #32's discharge Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by the facility staff) dated 10/31/23 showed a discharge return not anticipated. Review of the resident's electronic record on 1/11/24 showed no documentation of the Ombudsman being notified of the resident's discharge to the Assisted Living Center on 10/31/23. During an interview on 1/16/24 at 12:00 P.M., the Administrator said: -His/Her expectation was for the BOM to notify the state Ombudsman of resident discharge or transfers monthly. -He/She was responsible of ensuring that the state Ombudsman was notified by the BOM of resident transfer and discharges at least monthly. --Note: BOM out of building during interview process.

Based on observation, interview and record review, the facility failed to ensure the facility reported an allegation of abuse immediately to the Administration when on 1/1/24 Certified Medication Technician (CMT) B attempted to get Resident #30's vital signs (temperature, pulse and respirations) which resulted in the resident becoming agitated, yelling and remaining upset after the alleged incident out of 12 sampled residents. The facility started their investigation on 1/8/24 seven days after the alleged incident. The facility census was 34 residents. Review of the facility's Abuse, Neglect and Exploitation policy dated 10/2022 showed: -It was the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations, include training for new and existing staff on activities that constitute abuse, neglect, and exploitation, and establish coordination with the Quality Assurance and Performance Improvement (QAPI) program. -The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. -new and existing staff will receive education through planned in-services and as needed -Training will include prohibiting and preventing all forms of abuse, neglect, misappropriation and exploitation; identifying what constitutes abuse, neglect, misappropriation, and exploitation; recognizing sighs of abuse, neglect, misappropriation, and exploitation; reporting process for abuse, neglect, misappropriation, and exploitation; and understanding behavioral symptoms of residents that may increase the risk of abuse such as: --Aggressive reactions of residents. --Wandering or elopement-type behaviors. --Resistance to care. --Outbursts or yelling out. --Difficulty in adjusting to new routines or staff. -The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury; not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Review of Resident #30's Move-in Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Congestive Heart Failure (CHF a chronic condition in which the heart doesn't pump blood as well as it should). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's Adjustment Issues care plan, dated 10/5/23 showed: -The resident was having issues related to his/her admission, affecting his/her daily living. -Staff were to encourage ongoing family involvement. -Staff were to encourage participation in activities of choice. --The resident refused to go to activities or have activities brought to his/her room. -Note: The care plan did not show behaviors or signs or symptoms of distress related to the adjustment issue and did not show what referrals or interventions the resident might need or what staff should do other than encourage family involvement. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 11/20/23 showed the resident: -Was severely cognitively impaired. -Had verbal behaviors directed towards others one to three days out of the past seven. -Behaviors did not disrupt the resident's cares or living environment. -Did not reject cares. -Required supervision to moderate assistance with most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting). Review of the resident's progress note, dated 1/9/24 at 5:40 P.M. showed: -It was reported that the resident said he/she was physically and emotionally abused by a worker. The resident described what the staff member looked like and the staff person gave him/her medication. The resident said the staff person had called him/her an asshole many times before and this time said he/she was not as mature as his/her [AGE] year old child. The resident said the staff person wanted to take his/her temperature and he/she said he/she didn't want the staff touching him/her. -The resident said he/she tried to push the thermometer away and the staff used his/her strength and pushed the resident's hand to the resident's head and took the resident's temperature while the thermometer was still in the resident's hand. -The resident said he/she didn't feel safe with that staff member in his/her room, but felt safe now. -The resident said it was physical and verbal abuse and he/she didn't want it happening to anyone else. -He/She told Licensed Practical Nurse (LPN) B. -He/She had never saw or heard anyone else being abused, but he/she stayed in his/her room. -The resident said he/she didn't think the staff person should talk that way or act that way. The staff person was belligerent and rude and he/she didn't want the staff person in his/her room anymore. Review of the resident's Noncompliance care plan, dated 1/10/24 showed: -The resident was noncompliant with medical treatments and cares and often refused cares, medications and help with ADL's. -Staff were to ensure continuity of care and involve the resident in decisions affecting the resident. -Note: The care plan did not show intervention options staff could try that might be beneficial to the resident. Review of the resident's Staff to Resident Verbal and Physical Abuse Investigation Incident Summary, for an alleged incident dated 1/1/24 showed: -LPN B reported on 1/8/24 at 4:46 P.M. to the MDS Coordinator that the resident reported he/she was physically and emotionally abused by a worker. The resident described the alleged perpetrator and said he/she gave his/her medications. The alleged perpetrator was identified as CMT B. The resident said CMT B had called him/her an asshole many times and told the resident he/she wasn't as mature as his/her [AGE] year old child. The resident said CMT B wanted to take his/her temperature and he/she didn't want CMT B touching him/her. He/She tried to push the thermometer away and CMT B used his/her strength and pushed the resident's hand to his/her forehead and took his/her temperature while the thermometer was still in the resident's hand. The resident said he/she felt safe at the time, but not when CMT B was in his/her room. The resident said it was physical and verbal abuse which he/she didn't want to happen to anyone else and he/she didn't want CMT B in his/her room anymore. The resident said he/she told LPN B. -CMT B was placed on suspension pending investigation findings. -CMT B said on 1/1/24 the resident verbally abused him/her, calling him/her several curse words and insisting he/she leave him/her alone when he/she attempted to take his/her vitals. He/She attempted to explain he/she had to take his/her vitals in order to give the resident's medicine and as a routine check. When he/she attempted to place the blood pressure cuff the resident said to get away from him/her and the resident pulled his/her own arm away. He/She left the room at the time. He/She denied saying anything negative to the resident at the time. CMT B said he/she would never tell the resident or say he/she was immature because it would demean the resident. -All residents in the facility were interviewed and all denied staff being rough, rude or abusive, except for incidents which had already been investigated. -Staff were interviewed to determine if anyone witnessed negative interactions with residents or if the resident was rude or mean to staff. Review of the resident's Investigation Interview with CMT B dated 1/8/24 showed: -He/She never said the resident was immature, never called the resident names, and would never be forceful with the resident. -On 1/1/24 he/she was attempting to take the resident's vitals as part of his/her monthly vital routine. The resident was particularly grumpy and mean. -When he/she began to wrap the cuff around the resident's arm the resident yelled at him/her, calling him/her a stupid bitch and stating he/she didn't want CMT B to take his/her blood pressure. -When he/she attempted to remove the cuff the resident yanked his/her arm away and called him/her a bitch and accused him/her of abuse. -He/She told the resident he/she wouldn't take his/her blood pressure and just needed his/her cuff back. The resident let him/her take the cuff and continued to yell abuse and he/she left. -He/She didn't report the incident to the Administrator or DON because he/she thought the nurse would. -He/She decided it was a behavior and would no longer go in the resident's room by himself/herself. -From the time of the 1/1/24 incident he/she had taken another staff member with him/her when giving the resident's medications to protect himself/herself from the resident being mean to him/her. Review of the resident's Investigation Interview with LPN B dated 1/8/24 showed: -On 1/8/24 the resident told him/her he/she didn't want CMT B in his/her room anymore and explained CMT B had verbally and physically abused him/her. -When CMT B tried to take his/her temperature he resisted by pushing CMT B's hand away, but CMT B held onto his/her hand and forced the thermometer to his/her forehead and said his/her [AGE] year old was more mature than him/her. -The resident reported the allegation after 3:00 P.M. and CMT B had already left so he/she thought it had just happened on 1/8/24 and reported it to the MDS Coordinator. Review of the resident's Investigation Interview with the resident dated 1/9/24 showed: -On 1/9/24 the resident was interviewed and said there were two incidents in which CMT B was abusive to him/her and on one of the occasions CMT B was physically abusive to him/her. -He/She reported the verbal and physical abuse incident to the nurse who came in his/her room when it happened, but didn't remember the nurse who came in. -The two verbal incidents were when CMT B called him/her an asshole and when CMT B said his/her [AGE] year old child was more mature than him/her. -He/She couldn't remember which time the physical abuse had happened. During the physical abuse he/she had a thermometer in his/her hand when CMT B forced his/her hand to his/her forehead to take his/her temperature and acknowledged it was odd that he/she should be holding the thermometer instead of CMT B. -He/She confirmed repeatedly there had been no other incidents since 1/1/24. Review of the resident's Investigation Interview with the MDS Coordinator dated 1/9/24 showed: -He/She hadn't witnessed any abuse himself/herself. -LPN B reported the allegation to him/her. -He/She interviewed the resident who gave the same report he/she gave to LPN B. Review of the resident's Investigation Interview with Registered Nurse (RN) A dated 1/9/24 showed: -He/She did not witness the alleged incident, but on 1/1/24 he/she heard yelling from the resident's room. When he/she entered the room the resident was yelling abuse. -He/She asked the resident what happened. -CMT B said he/she was just trying to take the resident's vital signs and the resident was being mean. CMT B then left. -The resident told him/her CMT B called him/her an asshole and was trying to force him/her to take his/her blood pressure. The resident didn't mention CMT B forced him/her to take his/her own temperature. -He/She was dealing with a resident's transfer to the hospital and Emergency Medical Services (EMS) was there so he/she made sure the resident was safe and left the room. -He/She was caught up in what he/she was doing and failed to report the alleged incident to the DON or Administrator and forgot about it until being interviewed for the investigation. -He/She was unaware of any other problems since 1/1/24. Review of the resident's Investigation Interview with Certified Nursing Assistant (CNA) B dated 1/9/24 showed: -He/She had never heard a staff member being rude to the resident. -Within the past week CMT B asked him/her to accompany him/her while giving the resident his/her medication. -He/She had witnessed the resident being rude to CMT B on a few occasions, calling him/her names and telling CMT B to get out of his/her room. -He/She hadn't witnessed CMT B being rude or mean. -There were a few residents who would get pretty rude and the resident was one of them. Staff just have to be kind to the resident and smile and not take it personally. Review of the resident's undated Investigation Interview with CNA C showed: -He/She had never heard the resident or any other resident complain of a rude staff member or one who had been abusive and had never witnessed that himself/herself. -He/She had never been in the room with the resident and CMT B. -The resident could be tough to deal with if he/she was in a bad mood. -He/She had never heard the resident cuss at staff. Review of the resident's undated Investigation Interview with the DON showed: -The resident could be grumpy, but was easy to keep calm and talk to if a person just listened. The resident would go on for a while though. -He/She had to provide coaching to CMT B before on his/her tone of voice with residents, but had never heard CMT B call residents names or seen him/her be physically forceful with them. Review of the Investigation Interview section of the resident's investigation showed: -Ten additional staff, whose names and dates of interviews were not identified, said they had not heard of issues of staff being rude or abusive to residents. They all reported the resident could be difficult to care for if he/she was in a bad mood which was often. -The MDS Coordinator interviewed all other residents who all denied being a victim of or witnessing abuse. Review of the Investigation Conclusion showed: -The facility couldn't substantiate that physical or verbal abuse took place. -There were not enough facts provided with witnesses on either account of the alleged incident to confirm who was telling the truth and there was no physical evidence of abuse. -There was no established pattern of behavior or witness statements to confirm either party was telling the truth. -Staff failed to notify management of the alleged incident when it first was presented, therefore the facility failed to report the abuse allegation in a timely manner. The allegation was reported and investigated immediately once management was made aware. Review of the Investigation Corrective Actions showed: -The resident was interviewed and confirmed he/she felt safe in the facility as long as he/she didn't have to interact with the CMT B. -The resident would receive cares in pairs to confirm he/she was safe from other possible allegations. -CMT B was immediately suspended pending investigation and had been terminated for other performance related issues unrelated to abuse. -Staff were educated on abuse and neglect, including reporting allegations immediately to the DON or Administrator. During an interview on 1/10/24 at 11:58 A.M. LPN B said: -The resident asked him/her to come into his/her room and said he/she didn't want that other nurse to come. He/She said CMT B was always mean to him/her and said his/her [AGE] year old child was more mature than him/her. CMT B didn't know how to talk to people. CMT B was rude and mean and shouldn't be taking care of residents. -He/She knew CMT B had a [AGE] year old child so it seemed possible CMT B might have said that. -He/She spoke to CMT B to ask what happened. CMT B said he/she tried to take the resident's temperature and the resident tried to grab his/her hand. The resident said don't touch me and didn't want him/her in his/her room. CMT B said he/she told the resident he/she had to take his/her vital signs and he/she never offered to get another staff person. CMT B just went ahead and got the resident's vitals. -The resident had a right to refuse getting his/her vital signs. The staff were all educated on that. -CMT B told me after the resident grabbed him/her, he/she told the resident he/she wasn't as mature as his/her [AGE] year old child because the resident was being rude to him/her. -He/She never heard from either CMT B or the resident that CMT B forced the resident's hand to his/her forehead in an attempt to take his/her temperature. -The resident said he/she didn't want that bitch in his/her room. -Verbally CMT B comes off as being rough in his/her tone. He/She would tell a resident he/she was busy and didn't have time to do something for them. He/She had spoken to CMT B about his/her tone of voice and to come to him/her if he/she had any problems with any residents. -He/She had never seen CMT B physically rough with any residents. CMT B's tone of voice was blunt and he/she would sometimes tell a resident he/she was passing medications and was busy instead of seeing if he/she could quickly help. His/Her natural tone of voice was loud and sounded abrasive. -He/She had talked with CMT B twice about his/her tone of voice and he/she would do better for a while. -CMT B's focus was on whatever he/she was doing and he/she acted like interruptions were an inconvenience. He/She made residents feel like that. He/She could be nice to residents as well, but was very task focused. During an interview on 1/10/24 at 1:00 P.M. the resident said: -CMT B called him/her an asshole and said he/she wasn't as mature as his/her [AGE] year old child. -There was a physical incident when CMT B wanted to take his/her temperature. He/She told CMT B he/she didn't want him/her taking his/her temperature because he/she had called him/her an asshole one other time. CMT B used force as he/she used counterforce to keep his/her hands and thermometer off his/her forehead. CMT B went ahead and was trying to take his/her temperature anyway, but not with his/her full strength. CMT B kept pushing forward and forced the thermometer onto his/her forehead. -He/She yelled out he/she was being abused. -Someone opened the door and he/she told them he/she was being abused, but CMT B said no, he/she wasn't being abused and his/she was just taking his/her temperature. -The other staff left. -Days later LPN B came and talked with him/her about it and said he/she had talked with CMT B. He/She hadn't seen CMT B since. -He/She was afraid CMT B wasn't capable of cleaning up his/her act. He/She didn't want CMT B going around acting like he/she did with him/her. -He/She hadn't done anything to provoke a comment like being called an asshole. He/She thought that could be classified as either verbal abuse or rudeness. In his/her mind it was verbal abuse. In CMT B's mind he/she didn't do anything wrong. In CMT B's mind the resident should do anything he/she told them to do, but the resident had the final rule on what was done in their care. -When he/she tried to push CMT B away from taking his/her temperature CMT B said his/her [AGE] year old child was more mature than him/her. When he/she forced the thermometer on his/her forehead he/she would call that abuse. He/She had the right to say no which CMT B completely disagreed with. During an interview on 1/10/24 at 1:30 P.M. the Administrator said: -The alleged incident happened 1/1/24. -He/She interviewed RN A who said he/she de-escalated the situation and was busy with another resident's transfer to the hospital and forgot to report to the DON and Administrator. During an interview on 1/10/24 at 1:57 P.M. RN A said: -He/She was busy with trying to get a resident sent out to the hospital emergency room (ER) when he/she heard the resident yelling out hey, hey, hey. -He/She told the Emergency Medical Technicians (EMT's) he/she needed to check on the resident. -When he/she got to the resident's room CMT B was in there. When he/she opened the door CMT B had a blood pressure cuff on the resident's wrist and said he/she was trying to get the resident's blood pressure and the resident didn't want that. -He/She would have told CMT B not to get the resident's blood pressure and that the resident had a right to refuse, but the cuff was already on and at that point the resident had stopped yelling and was allowing CMT B to get his/her blood pressure. -He/She told the resident he/she would come back and they would talk. -He/She left to make sure the other resident got sent out and EMS didn't need anything else from him/her. -He/She returned to the resident's room. The resident said he/she didn't want his/her blood pressure taken and that CMT B was forcing him/her and held his/her hand close to his/her (the resident's) chest. CMT B was forcing him/her to do something he/she didn't want to do which was abusive. When the resident talked with him/her he/she was adamant about getting it reported. He/She told the resident he/she would talk with CMT B. -He/She talked with CMT B and told him/her the resident alleged he/she called him/her an asshole. CMT B just rolled his/her eyes and gave a smile like the resident's accusations weren't true and never acknowledged he/she said that. -He She could never recall the resident ever saying any other staff person was abusive. -The resident could be a little agitated at times. He/She could tell something had set the resident off. -He/She told the resident CMT B would not come back into his/her room. -He/She thought the incident in which CMT B said his/her [AGE] year old child was more mature than the resident was a separate one that happened after 1/1/24. The resident didn't mention that on 1/1/24. -CMT B came across abrasively. It was the way he/she presented himself/herself to the residents. He/She was very short with the residents. For example CMT B rushed when he/she gave residents their medications. He/She wasn't warm with the residents and was focused on getting his/her job done. -He/She felt it was a dignity issue, like someone who wasn't concerned about the resident's needs, just in getting the job done. -He/She had never heard CMT B yell at a resident. -He/She had been educated after the 1/1/24 incident by the Administrator to report to the DON or Administrator with any issues that might be abuse or need addressing. He/She was educated to put any incidents involving a resident in a progress note, complete an incident note and get all staffs' statements. During an interview on 1/12/24 at 1:09 P.M. CMT B said: -On 1/1/24 he/she went around the facility getting vital signs on all the residents. -He/She told the resident he/she had to get his/her vital signs. The resident seemed OK with that until he/she put the blood pressure cuff on his/her wrist and it started tightening. The resident said Ouch, your hurting me. Take it off me. -He/She was reaching to get the blood pressure cuff and the resident jerked his/her hand away. He/She told the resident he/she had to take the cuff off in order to keep it from tightening on his/her wrist. The resident called him/her a bitch, said he/she was fucking stupid and told him/her to get the fuck out of his/her room. -He/She pushed a button and it released pressure on the cuff. He/She told the resident he/she had to take the cuff off and wasn't leaving without the cuff. -He/She denied calling the resident an asshole at that time or any other time and denied he/she told the resident his/her [AGE] year old child was more mature than him/her. -He/She denied getting or trying to take the resident's temperature. -CNA C came into the room and asked the resident what he/she needed. The resident told CNA C to get CMT B out of his/her room. -He/She was in the process of leaving anyway, so he/she just walked out of the resident's room. The nurse never walked into the resident's room (Note: This statement was inconsistent with statements made by CNA C and RN A.) -LPN B told him/her the resident didn't want him/her in his/her room at all. -A few months back LPN B told him/her he/she came across as mean and like he/she was mad at the residents. He/She told LPN B he/she tried to stay neutral. -The DON had talked with him/her about walking away if he/she became frustrated and getting the charge nurse. That was when one of the residents refused to take medication from him/her because of his/her race. He/She might have sighed when the resident said that. -He/She should have asked the resident if he/she was OK with him/her getting the resident's vital signs prior to just taking them. He/She just assumed it would be OK. -Since the incident on 1/1/24 the resident would tell him/her, he/she didn't want his/her medications from him/her and to get out of his/her room. He/She would tell a nurse. He/She assumed the resident's being angry with him/her was just temporary. -He/She might have come across as angry with him/her on 1/1/24 because he/she told the resident he/she had to get his/her blood pressure and hadn't asked the resident if he/she could do so. He/She could have asked another CNA to get the resident's vitals. On 1/1/24 he/she had to ask the nurse to give the resident his/her medications because he/she was so angry with him/her. -He/She probably could have approached the resident with a smile and greeted him/her before he/she got started. That would have made a difference. He/She was just focused on getting the resident's blood pressure because staff have to get it before giving the resident one of his/her medications. During an interview on 1/18/24 at 10:51 A.M. the Administrator said: -He/She expected nurses to talk with staff if there were dignity issues and to report them to the DON immediately who would review the issues with him/her. -He/She and the DON would decide if Human Resources needed to be involved and have documentation in the employee's record. -Staff should do a grievance on the resident's behalf so the issue could be addressed. During an interview on 1/18/24 at 11:37 A.M. the DON said: -All staff have been educated on dignity upon hire before they ever work on the floor and dignity education was presented throughout the year in monthly meetings. -He/She had to talk to CMT B a number of months ago about paying attention to his/her tone of voice. When the residents' anxiety levels increased it tended to cause CMT B's anxiety level to increase. -If there was a possible dignity issue Social Services should complete a resident grievance. If substantiated there would be documentation in the employee's Human Resources file. -CNA's should report dignity issues to him/her. When in doubt if there was a possible dignity or abuse issue they should report to both him/her and the Administrator. -Nurses should make sure the resident was OK if they had a complaint against a staff member and they should assign a different CNA to the resident. Nurses should talk to the resident about how they were feeling and let him/her (the DON) and the Administrator know immediately of all dignity and possible abuse issues. MO00230038

Based on observation, interview, and record review, the facility failed to ensure medications were administered safely and were not left at bedside for one sampled resident (Resident #25) and to prime a insulin pen prior to administration for one sampled (Resident #23) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Resident Self-Administration of Medication Policy dated November 2017 showed: -A Resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. -All Nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. 1. Review of Resident #25's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/10/23 showed: -The resident was moderately cognitively impaired. -He/she was independent or required supervision with his/her activities of daily living (ADL's eating, dressing, bathing, and toileting). Review of the resident's Care Plan dated 10/23/23 showed: -There was no assessment or plan for self-administration of medications. -There was no assessment or plan to have medications at bedside. Review of the resident's Medication Administration Record (MAR) dated December 2023 showed: -Calcium Carbonate Tablet (Tums an antacid used to treat heartburn) 500 milligram (mg), give 1 tablet by mouth two times a day for Heartburn. -Lactulose Encephalopathy Oral Solution (used to treat constipation) 10 grams (gm)/15 milliliter (mL), give 15 mL by mouth two times a day for constipation. -GlycoLax Powder (Polyethylene Glycol 3350 - Miralax used to treat constipation) give 17 gm by mouth two times a day for constipation. -No order for medications to be left at bedside. -No order for Milk of Magnesia (used as an antacid or laxative). -No order for a throat spray. Review of the resident's MAR dated January 2024 showed: -Tums 500 mg, give 1 tablet by mouth two times a day for Heartburn. -Lactulose 10 gm/15 mL by mouth two times a day for constipation. -Miralax give 17 gm by mouth two times a day for constipation. -No order for medications to be left at bedside. -No order for Milk of Magnesia. -No order for a throat spray. Review of the resident's Physician's Order Sheet (POS) dated January 2024 showed: -Tums 500 mg, give 1 tablet by mouth two times a day for Heartburn. -Lactulose 10 gm/15 mL by mouth two times a day for constipation. -Miralax give 17 gm by mouth two times a day for constipation. -No order for medications to be left at bedside. -No order for Milk of Magnesia. -No order for a throat spray. Observation on 1/8/24 at 10:24 A.M., of the resident's room showed: -A medicine dosage cup with a large chewable tablet on the overbed table. -A medicine dosage cup with pink liquid on the overbed table. -A bottle of throat spray on the nightstand. During an interview on 1/8/24 at 10:24 A.M., the resident said: -The pink liquid was Milk of Magnesia. -The large chewable tablet was Tums. -Staff would put the medications on the table, and he/she would take them when he/she wanted. Observation on 1/10/24 at 10:21 A.M., of the resident's room showed: -A medicine dosage cup with pink liquid was on the overbed table. -A bottle of throat spray was on the nightstand. Observation on 1/11/24 at 5:54 A.M., of the resident's room showed: -A medicine dosage cup with a Tums was on the overbed table. -A bottle of throat spray was on the nightstand. Observation on 1/11/24 at 7:07 A.M., of the resident's room showed a bottle of throat spray was on the nightstand. During an interview on 1/11/24 at 9:59 A.M., Licensed Practical Nurse (LPN) A said: -The only liquid medication the resident received was Lactulose (used to treat constipation). -The resident did not have any liquid medication ordered that was pink in color. Observation on 1/16/24 at 9:15 A.M., of the resident's room showed a bottle of throat spray on the nightstand. During an interview on 1/16/24 at 9:33 A.M., Certified Medication Technician (CMT) A said: -He/she followed the instructions on the MAR regarding route, time, and dosage. -The MAR should match the POS. -Any Over the Counter (OTC) medications should be on the MAR. -Staff cannot leave medications at bedside, even if the resident tells them to just leave that medication on the table. -Staff must watch the resident take all medications. -There should be an order for an oral throat spray. -There should be an order for Milk of Magnesia. -There should be an order for everything. -If he/she saw a medication in a resident's room that was not on the MAR, he/she would take it out of the room and give it to the nurse. -He/She had not seen any medications in the resident's room. -The resident should not have an oral throat spray at bedside. -No residents were able to self-administer medications. -There should be no medications at bedside. -The resident did not have an order for an oral throat spray. -The resident did not have an order for Milk of Magnesia. -The only medications that should be given were on the MAR. -He/She would go to the nurse who would follow up with the doctor if a resident wanted a medication not on the MAR. -The resident had an order for Tums and Miralax. -The resident did not like the Miralax. -The resident had asked for Milk of Magnesia instead of Miralax. -The Tums was scheduled to be given at 8:00 A.M. and 8:00 P.M., the order did not indicate it was to be left at bedside. During an interview on 1/16/24 at 10:59 A.M., LPN B said: -The only pink liquid in the medicine cart was Milk of Magnesia, cherry flavor. -The resident did not have an order for Milk of Magnesia. -All PRN medications should be on the MAR. -There had to be an order to leave medications at bedside. -No resident's had an order for medications to be left at bedside. -There should be an order for throat spray. -There should be an order for Milk of Magnesia. -There should be an order for anything the resident was taking. -The MAR should match the POS. -All OTC medications should be on the MAR. -CMT's should follow the MAR, and only give medications that were on the MAR. -When a Certified Nursing Assistant (CNA) or CMT saw any medication at bedside, they should remove it from the resident's room and give it to the charge nurse. -If he/she saw medications at bedside, he/she would remove it and throw it away. -He/She said the resident should not have medications at bedside. -The Tums should not have been left at the resident's bedside. -The resident did not have orders for Milk for Magnesia or a throat spray. -Self-administering medications was not appropriate without an order. -All medications should be on the MAR. These should be the only medications given. -If a resident asked for a medication, staff should tell the nurse, and the nurse should call the physician. During an interview on 1/16/24 at 11:39 A.M., the Director of Nursing (DON) said: -He/she expected the MAR to be followed when passing medications. -The MAR and POS should match. -He/She did not recall any resident having an order for medications at bedside. -The resident had an order for Milk of Magnesia last summer that was discontinued and not reordered. -The resident should not have any medications at bedside, including Tums, Milk of Magnesia, and a throat spray. 46890 2. Review of the facility's Insulin Pen Policy dated 2022 showed: -Prime the insulin pen. -Dial two units by turning the dose selector clockwise. -With needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on tip of the needle. If not, repeat until at least one drop appears. Review of Resident #23's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was diagnosed with Insulin Dependent Diabetes. -He/She received Insulin injections seven out seven days during the assessment look back period. Observation on 1/10/24 at 11:12 A.M., of Registered Nurse (RN) A showed he/she did not prime the insulin pen prior to administration of insulin. During an interview on 1/10/24 at 11:22 A.M., RN A said he/she had never been instructed to prime insulin pens prior to administering insulin even from the pharmacy. During an interview on 1/16/24 at 1:15 P.M., the DON said: -He/She would expect insulin pens be primed prior to administering. -He/She would be responsible to audit that insulin was being administered correctly. -He/She was not aware insulin pen's were not being primed.

Based on interview and record review, the facility failed to develop a comprehensive care plan that included one high risk medication for one sampled resident (Resident #31) out of five residents sampled for medication review. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's care plan dated 12/28/23 showed no care plan for the use of anticoagulant medication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed the resident was on an anticoagulant (medication used to slow down the blood clotting process) medication. Review of the resident's Physician's Order Sheet (POS) and Medication Administration Record (MAR)'s dated January 2024 showed a physician's order dated 12/22/23 for Eliquis (an anticoagulant) 5 milligrams (mg), one tablet by mouth two times a day related to heart disease. During an interview on 1/16/24 at 9:06 A.M., the MDS Coordinator said he/she did not usually care plan for anticoagulant medications. During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing (DON) said he/she would expect the use of anticoagulant medication to be in the care plan.

Based on interview and record review, the facility failed to submit a resident's discharge assessment for one supplemental resident (Resident #28) out of four residents who triggered for assessment concerns. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #28's discharge assessment dated [DATE] showed it was not submitted to Centers for Medicare & Medicaid Services (CMS) and was marked do not submit to CMS on 9/8/23. Review of the Resident Assessment Instrument (RAI) Manual dated October 2023 showed the following on page 1 of chapter 5: -Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS a federally mandated assess tool completed by facility staff for care planning) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. During an interview on 1/11/24 at 7:59 A.M., the MDS Coordinator said he/she did not submit private pay resident's assessments to CMS. During an interview on 1/16/24 at 1:15 P.M., the Director of Nursing said he/she expected the MDS to be completed and submitted accurately.

Based on observation, interview, and record review, facility staff failed to assess one sampled resident (Resident #3) out of nine sampled residents to assess and determine the proper and safe method of transferring him/her after an injury occurred to his/her lower left leg during a transfer, and continued to transfer the resident in an unsafe manner after his/her injury; failed to ensure transfer one sampled resident (Resident #9) out of nine sampled residents in a safe manner; and failed to have a policy for transfers and weight bearing status for residents. The facility census was 36 residents. Record review of the facility's undated Nurse Assistant in a Long Term Care Facility showed: -There was no information regarding weight bearing status during one or two staff member assisted transfers. -There was no information regarding assessing the residents for the proper transfer technique. 1. Record review of Resident #3's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Hypertension (HTN - high blood pressure), -Anemia (A decrease in hemoglobin in the blood to levels below the normal range), -Spinal stenosis (narrowing of the spinal canal), -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), -Chronic venous insufficiency (CVI - the veins cannot pump enough oxygen-poor blood back to the heart), -Glaucoma (a condition of increased pressure inside the eye which could lead to blindness), -Gastroesophageal reflux disease (GERD - back-up of stomach acid/heartburn). Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated tool required to be completed by the facility staff) dated 4/05/11, showed the resident: -Had minimal difficulty with hearing. -Was sometimes understood by others. -Could sometimes be understood by others. -Had severely impaired cognition. -Required the extensive assistance of one staff member for bed mobility, transfers, eating, toilet use, and personal hygiene. -Required total dependence of one staff member with bathing. -Had not walked in his/her room or in the corridor. -Was unsteady when moving from a seated to standing position and required staff assistance. -Used a wheelchair. -Had a catheter (a tube passed through the urethra into the bladder to drain urine). -Was incontinent of bowel. Record review of the resident's significant change MDS dated [DATE], showed the resident('s): -Had minimal difficulty with hearing. -Was sometimes understood by others. -Could sometimes be understood by others. -Had severely impaired cognition. -Required the extensive assistance of one staff member for bed mobility, transfers, eating, and toilet use. -Required total dependence of one staff member with bathing and personal hygiene. -Had not walked in his/her room or in the corridor. -Was unsteady when moving from a seated to a standing position and required staff assistance. -Used a wheelchair. -Had a catheter. -Was frequently incontinent of bowel. Record review of the resident's Care Plan dated 6/20/11, showed the resident needed assistance with all transfers and would bear partial weight during transfers. Record review of the resident's physician's orders [REDACTED]. -Aspirin tablet 325 milligrams (mg) by mouth, take one tablet daily for a prophylaxis (a medication designed to prevent the occurrence of disease or its dissemination). -Caltrate 600 tablet plus vitamin D, take one tablet daily for osteoporosis (a decrease in bone mass and density and enlargement of bone spaces producing fragility). -Famotidine tablet 20 mg by mouth, one tablet daily for GERD. -Levothyroxine tablet 100 micromilligrams (mcg), one tablet by mouth daily for [DIAGNOSES REDACTED] (below normal function of the thyroid gland which regulated metabolism). -Sertraline tablet 50 mg, take one tablet by mouth daily for depression. -Multivitamin tablet with minerals, take one tablet by mouth daily for a supplement. -Vitamin C tablet 500 mg, take one tablet by mouth daily for a supplement. -Namenda tablet 5 mg, take one tablet by mouth twice a day for dementia. -Donepezil tablet 10 mg, take one tablet by mouth in the evening for dementia. -Acetaminophen tablet 325 mg (pain reliever, fever reducer), take two tablets by mouth every four hours as needed. -Hydrocodone APAP 5-325 mg (pain reliever), take one tablet every four hours as needed for pain. Record review of the resident's Incident Report dated 8/29/11, showed: -The report had been completed by Licensed Practical Nurse (LPN) A. -The resident had bruising around his/her left ankle with edema (swelling) and was painful when touched. -The residents legs were elevated. -A phone call was made for an x-ray to be completed at the facility. -The resident was later sent to the emergency room . -The physician, family member, and MDS Coordinator had been notified. Record review of the resident's Nurse's Notes dated 8/29/11 at 9:30 A.M., showed: -The resident had bruising and edema (fluid swelling) to the left ankle. -The resident was moaning. -The staff member was unable to rate the resident's pain. -The resident's physician was called to obtain orders for an immediate x-ray. Record review of the resident's Nurse's Notes dated 8/29/11 at 11:30 A.M., showed: -As needed pain medication had been given to the resident. -The resident was resting in bed with his/her lower legs elevated. Record review of the resident's Nurse's Notes dated 8/29/11 at 12:10 P.M., showed: -As needed pain medication had been given to the resident. -The resident was resting in bed with his/her lower legs elevated. Record review of the resident's Nurse's Notes dated 8/29/11 at 3:00 P.M., showed: -An outside company came to the facility and completed an x-ray on the residents left lower leg. -At 6:39 P.M., the results of the x-ray showed the resident had a oblique fracture to the left distal fibula (a broken lower leg of the outer and narrower of two bones of the human lower leg, extending from the knee to the ankle), and then the nurse called the physician. -At 6:45 P.M., the physician called back and gave orders for the resident to be sent to the hospital emergency room . -The resident's spouse and responsible party were notified. -At 7:13 P.M., the resident was sent to the hospital by ambulance. Record review of the resident's Radiology Report dated 8/29/11 at 6:51 P.M., showed: -A very faint line involving the inferior fibula was consistent with a nondisplaced fracture. -A summary showing the resident had an oblique fracture to the left distal fibula. Record review of the resident's undated Investigation Summary related to his/her left leg injury showed: -On 8/29/11, a Certified Nursing Assistant (CNA) reported the resident's left ankle was swollen and bruised. -The day charge nurse notified the MDS Coordinator and he/she assessed the injury. -An x-ray was obtained from an outside company. -The x-ray report showed an oblique fracture to the left distal fibula. -The physician was notified and the resident was sent to the emergency room . -The resident returned from the hospital at 12:35 A.M., with his/her left lower leg immobilized with a soft cast. -The Director of Nursing (DON) reviewed staffing assignments for the past 72 hours. -The DON interviewed staff over the past 24 hours. -Some of the staff reported the resident frequently hung his/her feet off the wheelchair foot rests or to the side of the wheelchair foot rests. -The staff reported the resident had not been standing for transfers and the resident would bend his/her knees and bring his/her feet away from the floor during transfers. -The conclusion was the injury probably occurred from a transfer. -Note: The investigation did not state how the resident transferred or if the resident had been assessed for the proper method for transfers. Record review of the resident's Nurse's Notes dated 8/30/11 at 12:35 A.M., showed: -The resident returned from the hospital with a [DIAGNOSES REDACTED]. -The resident had a soft cast with an ace bandage over it placed on his/her lower leg. -The resident had a soft blue boot on his/her foot. Record review of the resident's Nurse's Notes dated 8/30/11 at 2:00 A.M., showed: -The resident had ice bags placed on his/her leg for the swelling. Record review of the resident's Nurse's Notes dated 8/30/11 at 6:00 A.M., showed: -The resident had ice bags placed on his/her leg for the swelling. -The resident received narcotic medication from the hospital to be taken as needed for pain. Record review of the resident's hospital x-ray report dated 9/1/11 showed: -A three view x-ray had been completed on the residents left lower leg. -There was no sign of a fracture of the lower leg. -There was mild soft tissue swelling. Record review of the resident's Care Plan updated on 9/1/11, showed the resident: -Had a dark bluish bruise to the left lower ankle area and lower leg. -Had edema (swelling) and pain when the leg was touched. -Had an x-ray from an outside source that showed a fracture. -Was sent the emergency room and x-rays showed no fracture of the lower leg. -Returned to the facility with a soft cast to the lower left leg to protect the tissue. -Required a two person transfer with a gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move and transfer). Record review of the resident's Nurse's Notes dated 9/5/11 at 12:30 A.M., showed: -The left lower leg was checked. -The left lower leg had a soft cast with an ace bandage due to an ankle contusion to the ankle and lower leg. -The resident could move his/her toes. -The toes were soft and flexible. Observation on 9/12/11 at 12:50 P.M., showed the resident ('s): -Was in the dining room in his/her wheelchair with foot pedals on it. -Feet resting on the foot pedals. -Had a soft cast (white padding wrapped with an ace bandage) on his/her left foot. -Had a thin dark blue bunny boot (a soft boot to prevent pressure/injury to the foot) from his/her ankle to his/her toes. Observation on 9/12/11 at 2:10 P.M., showed: -CNA B and CNA D were preparing to transfer the resident from the wheelchair to the bed. -A gait belt was put around the residents trunk area right above the waist. -CNA B and CNA D lifted the resident with one hand each holding onto the gait belt on each side of the resident's back. -The resident did not put any weight on his/her feet during the transfer. -The resident flexed his/her feet upward to pull his/her legs from touching the floor by bending at the hips and knees. Record review of the resident's Nurse's Notes dated 9/13/11 at 5:30 A.M., showed: -The resident complained of right leg pain. -The resident flinched when the right lower leg was touched. -The resident had been given a narcotic (pain medication) for pain. -The resident was going to get up shortly. -The pain medication helped to decrease pain for the resident when he/she was transferred from his/her bed to his/her wheelchair. During an interview on 9/13/11 at 10:20 A.M., LPN A said: -The resident had swelling of his/her lower left leg. -An x-ray had been completed at the facility by an outside company. -The x-ray showed the leg had a fracture. -The resident had been sent to the emergency room at the hospital. -The hospital x-ray's showed the resident did not have a fracture. -The resident was sent back to the facility with a soft cast on his/her leg. -He/she was not sure what happened to the resident's leg. -He/she had been told by the resident's physician to leave the soft cast on his/her foot. -He/she was not in the facility when the injury occurred. During an interview on 9/13/11 at 11:25 A.M., CNA B said: -He/she had heard from other staff the resident had bumped his/her leg on the wheelchair. -The resident had x-rays of his/her foot. -The resident had a soft cast on his/her foot now. During an interview on 9/13/11 at 11:28 A.M., CNA D said: -The resident had a soft cast on his/her foot but did not know what happened. Observation on 9/13/11 at 12:05 P.M., showed the resident: -Was in his/her bed lying on his/her back. -Had a soft cast on his/her left foot. -Had a white gauze bandage wrapped around his/her foot and ankle. -Did not have bunny boots on. -Had a pair of thick, light blue bunny boots that start at the mid-calf of the leg and go over the toes lying in his/her wheelchair. During an interview on 9/13/11 at 1:12 P.M., the DON said: -He/she could not determine what truly happened to the resident's foot. -He/she could not determine which staff members were involved. -He/she had talked to different staff members that worked during 72 hours prior to the injury. -He/she did not obtain statements from all staff members. -He/she only took his/her own personal notes. -He/she had determined the resident did not put weight on his/her feet during transfers. -The resident had been transferred with a gait belt with the assistance of one staff member. -After the injury to his/her foot he/she had the staff transfer the resident with a gait belt with the assistance of two staff members. -He/she had not ordered a therapy evaluation to determine the proper method of transferring the resident. -The evaluation was not necessary and could be Medicare fraud. -He/she relied on the staff to tell him/her how the resident transfers. -He/she had not assessed the resident to determine the proper method of transferring the resident. During an interview on 9/13/11 at 1:43 P.M., LPN A said: -Before the injury to the resident's left foot he/she transferred with a gait belt with the assistance of one staff member. -After the injury the resident was transferred with a gait belt and the assistance of two staff members. -During a two person transfer with a gait belt the resident should put weight on his/her feet. During an interview on 9/13/11 at 3:40 P.M., LPN B said: -LPN A had told him/her the resident's left lower leg had swelling and the resident was not holding his/her foot right and an x-ray had been ordered. -He/she had come onto his/her shift. -The x-ray report came back with a fracture of the lower leg. -He/she sent the resident to the emergency room . -He/she was not sure what happened to the resident's foot. -The resident had been transferred with the assistance of one person and a gait belt prior to the injury. -The resident would pivot on his/her left foot during the transfers. -After the injury the resident was transferred with a gait belt and the assistance of two staff members. -During a two person transfer with a gait belt the resident did not need to put weight on his/her feet. During an interview on 9/14/11 at 9:30 A.M., the Physical Therapy Director said: -He/she had not received an order for [REDACTED]. -The resident was on a handwritten list on 9/6/11 for a possible therapy evaluation. -He/she discussed this with the DON on 9/8/11. -The DON said not to do an evaluation of the resident until the physician saw the resident. -During a two person transfer with a gait belt, the resident should put weight on his/her feet. Observation and interview on 9/14/11 at 9:32 A.M., showed: -CNA B and CNA C were preparing to transfer the resident from his/her wheelchair to the bed. -A gait belt was put around the residents trunk area right above the waist. -CNA B and CNA C lifted the resident with one hand each holding onto the gait belt on each side of the resident's back and one hand each on the resident's sides. -The resident did not put any weight on his/her feet during the transfer. -The resident flexed his/her feet upward to pull his/her legs from touching the floor by bending at the hips and knees. -The resident was suspended in the air during the transfer. -The resident was grimacing and hollered out during the transfer, "owwww...that's hurting my side." -CNA C started assessing the resident and said, "I want to make sure you don't have an owwie." -CNA B and CNA C said the resident had not put any weight on his/her feet during the transfer. The resident needed to be transferred with a mechanical lift (a mechanical lift used to transfer residents that cannot bear weight on their feet). The transfer caused the resident pain, and the gait belt left marks on the resident's front torso. The resident had not been putting weight on his/her foot since the lower leg injury. Observation and interview on 9/14/11 at 9:35 A.M., showed: -The resident had light red coloration across the front of his/her chest, -CNAs B and C said the redness was in the area the gait belt had been placed during their transfer of the resident just prior the observation and that the redness was the width of the gait belt, -The gait belt was placed near the redness by a CNA and both CNAs said the redness was the width of the gait belt. During an interview on 9/14/11 at 10:00 A.M., LPN A said: -The resident did not have a weight bearing status change after the injury to his/her lower leg. -During a two person transfer with a gait belt the resident should put weight on his/her feet. -Nurse's do not determine if an evaluation was necessary to determine the best method for transferring the residents. -The resident used to stand and pivot on his/her left foot during the transfer. Observation on 9/14/11 at 11:30 A.M., showed: -The DON removed the soft cast off of the resident's left leg. -There was no bruising. -The resident had full range of motion of the foot. During an interview on 9/14/11 at 11:35 A.M., the DON said: -The physician said the soft cast could be removed and the leg assessed. -He/she had changed the method of transfer for the resident to a mechanical lift. -He/she did not have therapy evaluate for the proper method for transferring the resident. -He/she had not assessed the resident to determine the proper method for transferring the resident. -He/she went by what the staff had told him/her and switched him/her to the mechanical lift. -There was no system in place to assess and evaluate for the proper transfer methods for the residents. During an interview on 9/15/11 at 1:40 P.M., the DON said: -The facility used the Nurses Assistant Manual as a guide for transferring a resident. -The facility did not have a policy regarding transfers. During an interview on 9/19/11 at 1:15 P.M., the DON said: -He/she should have changed the way the resident was transferred after the injury occurred. During an interview on 9/20/11 at 2:10 P.M., the DON said: -If a resident was being transferred by one staff or two staff with a gait belt, the resident should be putting weight on his/her feet. During a telephone interview on 9/13/11 at 4:59 P.M., the resident's family member (also the resident's responsible party) said: -He/she had been notified when the resident's left leg injury had occurred. -He/she had been told by the DON an investigation was being done to determine what happened. -He/she had went to the hospital with the resident. -The resident had extensive bruising on his/her lower leg. -The bruising went from the ankle to midway up the calf of the leg. -The injury was very painful to the resident. On 9/21/11 at 10:41 A.M. and 9/27/11 at 8:33 A.M., a message was left for the resident's physician and the phone call was not returned. 2. Record review of Resident #9's face sheet showed the resident had [DIAGNOSES REDACTED]. -Cerebrovascular accident (CVA - stroke); -Hypertension (high blood pressure); -Hard of hearing; and -Weakness. Record review of the resident's physical therapy screening form dated 7/7/10, showed: -The resident had decreased ability with transfers; -The resident had decreased strength; -The resident had decreased balance; -The resident was ambulatory with a rolling walker for approximately 50 feet; -The resident required maximum assistance of one person with transfers; -The resident would have to go out of the facility for treatment due to insurance; -Treatment out of the facility would be hard on the resident; and -An evaluation was indicated. Record review of the resident's Resident Assessment Protocols (RAP - a problem-oriented framework for arranging MDS information and additional clinically relevant information about an individual's health problems or functional status) Summary dated 9/8/10, showed the resident could bear some weight for transfers. The RAP Summary did not indicate how this resident transferred or how many people were required to assist this resident during transfers. Record review of the resident's care plan dated 9/15/10 updated on 12/8/10, showed the resident could bear little weight for transfers. This care plan did not indicate how the staff were to transfer the resident and did not indicate how many people were to assist the resident with transfers. Record review of the resident's physical therapy screening form dated 11/8/10, showed no changes in the resident and an evaluation was not indicated. Record review of the resident's physician's history and physical dated 2/7/11, showed the resident needed assistance with transfers and had a [DIAGNOSES REDACTED]. Record review of the resident's care plan dated 9/15/10 and updated on 6/6/11, showed the resident could bear some weight on occasions with direction. This care plan did not indicate how the staff were to transfer the resident and did not indicate how many people were to assist the resident with transfers. Record review of the resident's annual MDS dated [DATE], showed the resident: -Had moderately impaired cognition. -Required the extensive assistance of one staff for transfers and bed mobility. -Required the total assistance of one for dressing, toilet use, and bathing. -Was frequently incontinent of bowel and bladder. Record review of the resident's physician's progress note dated 7/11/11, showed the resident was wheelchair bound, required assistance for transfers and had a [DIAGNOSES REDACTED]. Record review of the resident's September 2011 physician's orders [REDACTED]. -Received two acetaminophen (used for mild to moderate pain and to reduce fever) 500 mg tablets (a total of 1000 mg) twice daily at 6:00 A.M. and 6:00 P.M. for treatment of [REDACTED]. -Was to be up in a wheelchair as tolerated. Record review of the resident's physician's progress note dated 8/1/11, showed the resident was wheelchair bound, required assistance for transfers and had a [DIAGNOSES REDACTED]. Record review of the resident's nurse's note dated 8/13/11 at 10:00 A.M., showed the resident required total staff performance for activities of daily living (ADL's, how a resident grooms, eats, transfers, grooms, and toilets). Record review of the resident's nurse's note dated 8/14/11, day assessment, showed the resident required extensive assistance of one person with ADL's and transfers. Record review of the resident's nurse's note dated 8/16/11 on the 11:00 P.M. through 7:00 A.M. shift, showed the resident required the assistance of one staff member for ADL's and transfers and used a wheelchair for mobility with assistance. Record review of the resident's functional assessment dated [DATE], showed the resident: -Consistently required assistance with transfers or ambulation or required a wheelchair; had poor posture; and was unable to translate a thought into a purposeful movement; -Was dependent on staff for all personal care; and -Had overall weakness and poor endurance. Record review of the resident's nurse's note dated 8/20/11 on the 7:00 A.M. to 3:00 P.M. shift, showed the resident was up with the assistance of one person for transfers and ADL's. Record review of the resident's nurse's note dated 8/21/11 on the 3:00 P.M. to 11:00 P.M. shift, showed the resident required the assistance one one person with ADL'S and transfers. Record review of the resident's physician's progress note dated 9/12/11, showed the resident was wheelchair bound, required assistance for transfers and had a [DIAGNOSES REDACTED]. During an interview on 9/14/11 at 10:00 A.M., LPN A said: -During a two person transfer with a gait belt, the resident should put weight on his/her feet. -Nurses do not determine if an evaluation was necessary to determine the best method for transferring the residents. Observation on 9/14/11 at 10:17 A.M. showed: -The resident was alert, oriented and sitting in his/her wheelchair, -CNA E placed a gait around the resident's waist, -CNA E totally lifted the resident and transferred the resident from his/her wheelchair to his/her bed to a sitting position, -The resident's legs remained flexed (bent) at his/her hips and knees, -The resident did not bear weight during the transfer. -CNA E completed personal care for the resident during which the resident assisted in turning himself/herself from side-to-side, -CNA E then again placed a gait around the resident's waist, -CNA E totally lifted the resident and transferred the resident from his/her bed to his/her wheelchair, -The resident's legs remained flexed (bent) at his/her hips and knees, -The resident did not bear weight during the transfer. During an interview on 9/14/11 at 11:16 A.M., CNA E said: -The resident sometimes could bare weight during transfers and sometimes did not bear weight during transfers, -During transfers to and from bed on 9/14/11 at 10:17 A.M., the resident did not bear weight, -He/she totally lifted the resident while transferring the resident to and from his/her bed, -Sometimes the resident did bear weight, and the resident can bear weight. During an interview on 9/14/11 at 11:35 A.M., the DON said: -There was no system in place to assess and evaluate for the proper transfer methods for the residents. During an interview on 9/15/11 at 1:40 P.M., the DON said: -The facility used the Nurses Assistant Manual as a guide for transferring a resident. -The facility did not have a policy regarding transfers. Observation and interview on 9/16/11 at 9:08 A.M. showed: -The resident was preparing to be transferred from his/her wheelchair to his/her bed by CNA C and CNA F. -LPN A observed the transfer. -A gait belt was put around the resident's trunk area right above the waist. -CNA C and CNA F lifted the resident with one hand each holding onto the gait belt on each side of the resident's back, with one hand each on the resident's sides. -The resident did not put any weight on his/her feet during the transfer. -The resident flexed his/her feet upward to pull his/her legs from touching the floor by bending at the hips and knees. -The resident tips of his/her shoes rubbed along the floor during the transfer. -CNA C said only the top of the resident's toes touched the floor and the resident did not put weight on his/her feet. -CNA F said the resident hardly put weight on his/her feet at all. During an interview on 9/16/11 at 9:15 A.M., LPN A said: -The resident was always transferred with the assistance of two staff members and a gait belt. -He/she was unaware a one person transfer with a gait belt had been done and it should not have been done. -The resident did not put weight on his/her feet during the two person transfer. -The resident should put weight on his/her feet during the transfer but did not. -The transfer was not safe. During an interview on 9/20/11 at 2:10 P.M., the DON said: -The resident could sometimes put weight on his/her feet. -If a resident was being transferred by one staff or two staff with a gait belt, the resident should be putting weight on his/her feet. On 9/21/11 at 10:41 A.M. and 9/27/11 at 8:33 A.M., a message was left for the resident's physician and the phone call was not returned. 3. On 9/15/11 at 1:40 P.M., the facility policies regarding transfers, weight bearing status, care of a resident with a cast, and injuries of unknown origin was requested by surveyors, and the policies were not received.

Based on observation, interview, and record review, facility staff failed to provide weekly wound care assessments, failed to accurately stage and assess the pressure ulcer, and failed to put preventative measures in place to prevent the development of an unstageable, infected, avoidable pressure ulcer from developing for one sampled resident (Resident #3), failed to monitor and provide weekly wound care assessments for one sampled resident (Resident #1) with an unstabable pressure sore, failed to monitor and provide weekly wound assessment and ensure proper treatment for one resident (Resident #8) with an unstagable pressure sore out of nine sampled residents; and failed to have a policy in place for the prevention and treatment of pressure ulcers. The facility census was 36 residents. Record review of the Primaris website (Missouri's Quality Improvement Organization providing resources and services such as quality improvement projects for hospitals, nursing homes and physicians), recommendation for Risk Assessment Policy showed the following: -Each facility should have a policy that includes clear recommendations for: a structured approach to risk assessment; clinical areas to be targeted; the timing of risk assessment and reassessment; documentation of risk assessment; and communication of that information to the wider health care team. -Each facility should have a policy to educate health care professionals on how to achieve an accurate and reliable risk assessment. -Each facility should have a policy to document all risk assessments. Documentation of risk assessments ensures communication within the multidisciplinary team, provides evidence that care planning is appropriate, and serves as a benchmark for monitoring the individual's progress. -Each facility should use a structured approach to risk assessment to identify individuals at risk of developing pressure ulcers. A structured approach may be achieved through the use of a risk assessment scale in combination with a comprehensive skin assessment and clinical judgment. -Each facility should use a structured approach to risk assessment that includes assessment of activity and mobility. -Each facility should conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition. -Each facility should develop and implement a prevention plan when individuals have been identified as being at risk of developing pressure ulcers. Risk factors identified in a risk assessment should lead to an individualized plan of care to minimize the impact of those variables. -Staff should ensure that a complete skin assessment is part of the risk assessment screening policy in place. Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment relevant to the setting, as well as for clinical areas to be targeted and the timing of assessment/reassessment. It should make clear recommendations for documenting the skin assessment and communicating information to the wider health care team. -Educate professionals on how to undertake a comprehensive skin assessment. -Staff should inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Ongoing assessment of the skin is necessary to detect early signs of pressure damage. -Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin. Localized heat, [MEDICAL CONDITION], and induration have all been identified as warning signs for pressure ulcer development. As it is not always possible to see signs of redness on darkly pigmented skin, these additional signs should be considered in assessment. -Ask individuals to identify any areas of discomfort or pain that could be attributed to pressure damage. -Observe the skin for pressure damage caused by medical devices. -Document all skin assessments, noting details of any pain possibly related to pressure damage. -Accurate documentation is essential for monitoring the progress. Record review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) showed: -A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. -A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure ulcer prevention and healing include: identifying the individual resident at risk for developing pressure ulcers, identifying and evaluating the risk factors and changes in the resident's condition, identifying and evaluating factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. Risk Factors: -Many studies and professional documents identify risk factors that increase a resident's susceptibility to develop or to not heal pressure ulcers. Examples of these risk factors include, but not limited to: -Impaired/decreased mobility and decreased functional ability; -Co-morbid conditions, such as end stage [MEDICAL CONDITION] (kidney disease), [MEDICAL CONDITION] disease or diabetes mellitus (a condition in which the pancreas no longer produces enough insulin or when cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body); -Drugs such as steroids that my affect wound healing; -Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency; -Resident refusal of some aspects of care and treatment; -Cognitive impairment; -Exposure of skin to urinary and fecal incontinence; -Under nutrition, [MEDICAL CONDITION], and hydration deficits; and -A healed ulcer. The history of a healed pressure ulcer and its stage (if known) is important, since areas of healed Stage III or IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcers are more likely to have recurrent breakdown. -Some residents have many risk factors for developing pressure ulcers, such as diabetic [MEDICAL CONDITION] (loss of feeling in the extremities), frailty, cognitive impairment, and under nutrition. Pressure Points and Tissue Tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects): -Assessment of a resident's skin condition helps define prevention strategies. -Tissue closest to the bone may be the first tissue to undergo necrosis (localized death of living cells as from interruption of blood supply or infection). -An at-risk resident who sits too long on a non-cushioned surface may be more prone to get ischial (lower portion of the hip bone) ulceration. -Pressure ulcers may develop at other sites where pressure has impaired the circulation to the tissue. Repositioning: -Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one. Assessment of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. -Support Surfaces and Pressure Redistribution --Appropriate support surfaces or devices should be chosen by matching a device's potential therapeutic benefit with resident's specific situation. --Static pressure redistribution devices (e.g. solid foam, convoluted foam, gel mattress) may be indicated when a resident is at risk for pressure ulcer development or delayed healing. A specialized pressure redistribution cushion or surface, for example, might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning. Record review of the Pressure Ulcer Prevention guide developed by the National Pressure Ulcer Advisory Panel (NPUAP) dated 2009 showed: -International NPUAP Pressure Ulcer Definition A pressure ulcer is 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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. -Classification System --Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate " at risk " persons. --Category/Stage II: Partial thickness: 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 serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury: CategoryStage III: Full thickness skin loss Full thickness tissue loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. --Category/Stage IV: Full thickness tissue loss: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. --Unstageable/ Unclassified: Full thickness skin or tissue loss - depth unknown: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover " and should not be removed. --Suspected Deep Tissue Injury - depth unknown: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. -Risk Assessment --Risk Assessment Policy ---Each health care setting should have a policy in place that includes clear recommendations for: a structured approach to risk assessment relevant to that health care setting; clinical areas to be targeted; the timing of risk assessment and reassessment; documentation of risk assessment; and communication of that information to the wider health care team. ---Documentation of risk assessments ensures communication within the multidisciplinary team, provides evidence that care planning is appropriate, and serves as a benchmark for monitoring the individual's progress. ---A structured approach may be achieved through the use of a risk assessment scale in combination with a comprehensive skin assessment and clinical judgment. Evidence suggests that the introduction of those elements, inconjunction with the establishment of skin-care teams, education programs, and care protocols, can reduce the incidence of pressure ulcers. ---Alteration in skin condition may include dry skin, [DIAGNOSES REDACTED], and other alterations. The presence of non-blanching [DIAGNOSES REDACTED] also increases the risk of further pressure ulcer development. -Skin Assessment --Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment relevant to the setting, as well as for clinical areas to be targeted and the timing of assessment/reassessment. It should make clear recommendations for documenting skin assessment and communicating information to the wider health care team. -Nutrition for Pressure Ulcer Prevention --Since under nutrition is a reversible risk factor for pressure ulcer development, early identification and management of under nutrition is very important. Individuals at risk of pressure ulcer development may also be at risk of Under nutrition, and so should be screened for nutritional status. -Repositioning for the Prevention of Pressure Ulcers --High pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure she/he is exposed to. --An individual should be repositioned with greater frequency on a nonpressure- redistributing mattress than on a viscoelastic foam mattress. The repositioning frequency should depend on the pressure-redistributing qualities of the support surface. Support Surfaces -Selection of an appropriate support surface should take into consideration factors such as the individual's level of mobility within the bed, his/her comfort, the need for microclimate control, and the place and circumstances of care provision. Record review of the Pressure Ulcer Prevention guide developed by the NPUAP dated 2009 showed: -Complete an initial assessment of the individual with a pressure ulcer, to include: --The individual's and family's goals of care. If the individual is unable to participate, consult with family and/or significant others. --A complete health/medical and social history. --A focused physical examination that includes: --Factors that may affect healing. --Vascular assessment in the case of extremity ulcers. --Laboratory tests and x-rays as needed --Nutritional assessment (see Nutrition section of this guideline). --Pain related to pressure ulcers. --Risk for developing additional pressure ulcers Psychological health, behavior and cognition. --Social and financial support systems. --Functional capacity, particularly in regard to positioning, posture, and the need for assistive equipment and personnel. --The employment of pressure-relieving maneuvers. --Adherence to pressure-relieving maneuvers. --Integrity of seating and bed surfaces (wear and tear). --The individual's/family member's knowledge and belief about developing and healing pressure ulcers. -Reassess the individual if the ulcer does not show signs of healing as expected despite adequate local wound care, pressure redistribution, and nutrition. - Pressure Ulcer Assessment --Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings. ---A 2-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. -Role of Nutrition in Pressure Ulcer Healing --Screen and assess nutritional status for each individual with a pressure ulcer at admission and with each condition change - and/or when progress toward pressure ulcer closure is not observed. -Assess for Pain --Assess all individuals for pain related to a pressure ulcer or its treatment. -Support Surfaces --Provide a support surface that is properly matched to the individual's needs for pressure redistribution, shear reduction, and microclimate control. -Positioning --Do not position an individual directly on a pressure ulcer. -General Recommendations -Assess pressure ulcers at every dressing change and confirm the appropriateness of the current dressing regimen. -- Follow manufacturer recommendations, especially related to frequency of dressing change. --The plan of care should guide usual dressing wear times and contain provisionary plans for dressing changes as needed (for family, the individual, and staff) due to soilage, loosening, etc. --Choose a dressing to keep the wound bed moist. --Choose a dressing that remains in contact with the wound bed or skin barrier product to keep the periwound dry and prevent maceration. -Assessment of High-Risk Individuals and Pressure Ulcers --Have a high index of suspicion for the likelihood of infection in pressure ulcers that have necrotic tissue or a foreign body present; have been present for a long period of time; are large in size or deep; and/or are likely to be repetitively contaminated (e.g., near the anus). --Have a high index of suspicion for local wound infection in individuals with diabetes mellitus, protein-calorie under-nutrition, [MEDICAL CONDITION] or poor tissue perfusion, [DIAGNOSES REDACTED] disease, or immune-suppression. --Have a high index of suspicion for local infection in pressure ulcers when there are no signs of healing for 2 weeks, or when friable granulation tissue, foul odor, increased pain in the ulcer, increased heat in the tissue around the ulcer, increased drainage from the wound, an ominous change in the nature of the wound drainage (e.g., new onset of bloody drainage, purulent drainage), increased necrotic tissue in the wound bed, pocketing, or bridging is present. Record review of the CMS Resident Assessment Instrument (RAI) manaul version 3.0 dated 10/2011 showed: -Ulcer staging should be based on the ulcer's deepest visible anatomical level. If the pressure ulcer has ever been classified at a deeper stage than what is observed now, it should continue to be classified at the deeper stage. 1. Record review of Resident #3's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Hypertension (HTN - high blood pressure), - [MEDICAL CONDITION] (a decrease in hemoglobin in the blood to levels below the normal range), - Spinal stenosis (narrowing of the spinal canal), - Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), - Chronic [MEDICAL CONDITION] (CVI - the veins cannot pump enough oxygen-poor blood back to the heart), - [MEDICAL CONDITION] (a condition of increased pressure inside the eye which could lead to [MEDICAL CONDITION]), - [MEDICAL CONDITION] reflux disease (GERD - a back-up of stomach acid/heartburn). Record review of the resident's Care Plan dated 4/10/10 showed a problem of the resident having the potential for pressure ulcers and stasis ulcers (a breakdown of the skin (ulcer) caused by fluid build-up in the skin from poor vein function ([MEDICAL CONDITION]) related to incontinence, cognitive status, and limited mobility), and the resident having a [DIAGNOSES REDACTED]. The Care Plan approaches directed staff to: - Provide adequate food and fluid intake. - Apply heel and elbow guards as necessary. - Keep linens dry and wrinkle free. - Keep the resident's skin clean and dry. - Apply a protective barrier (cream) as needed. - Report any red or open areas to the charge nurse. - Observe the skin during bathing. - Assist and reposition the resident every two to three hours. - Provide skin assessments weekly per the charge nurse. - Perform the treatments as ordered. - Use Prevelon (heel protection devices) boots as ordered. - Updated on 6/28/10: The resident did not have any pressure ulcer or stasis ulcer formation. - Updated on 9/29/10: The resident did not have any pressure ulcer or stasis ulcer formation. Record review of the resident's Nurse's Notes dated 12/3/10 through 1/30/11, showed no notes regarding the development of the resident's pressure ulcer. Record review of the resident's physician's progress note dated 12/6/10 showed: - The resident had a [DIAGNOSES REDACTED]. - The resident did not have any swelling in his/her extremities. - There was no documentation of the resident having a wound. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated tool required to be completed by the facility staff) dated 12/8/10, showed the resident: - Had minimal difficulty with hearing. - Was usually understood by others. - Had severely impaired cognition. - Required the extensive assistance of one staff member for bed mobility, transfers, eating, toilet use, and personal hygiene. - Required total dependence of one staff member with bathing. - Was incontinent of bowel. - Was incontinent of bladder. - Was at risk for developing pressure ulcers. - Did not have any pressure ulcers. Record review of the resident's Braden Scale (a form used for predicting pressure ulcer risk) dated 12/8/10 showed the resident: - Had a total score of 15 which showed the resident was at mild risk for the development of pressure ulcers. Record review of the resident's Weekly Skin Assessment form dated 12/14/10 showed the following: - Skin color: Pink. - Skin turgor (the skin's ability to change shape and return to normal (elasticity)): Normal and tight. - Skin condition: Nothing documented. - Skin integrity: Intact (no breaks or opening in the skin). - Body diagram (Note: The form includes a diagram of the body, labeled front and back, left and right. Staff was instructed to use corresponding numbers and indicate on the diagram the location of the impaired skin integrity. Staff should write in the measurements and for any ulceration staff must also complete a wound assessment form per the instructions): Both heels were circled and "soft heel" was documented. - Treatment to the area (Note: Staff were instructed to list treatments and indicate the status of the area being treated; and staff may use the corresponding figures from the diagram to indicate the area being treated per the instructions): Heel protectors while in bed, started on 12/14/10. - Status: Continue treatment. Record review of the resident's Wound Assessment form dated 12/15/10 showed the following: - Anatomic location of the wound: Right lateral malleolus (bony, outer part of the ankle). - Age of the wound: Acute more than seven days. - Size: 2.0 centimeters (cm) long by 1.5 cm wide by "1 inch" deep (pressure ulcers are measured in cm only). - Shape: Round. - Stage: II. - For the section sinus tract (a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), and undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface; undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin): Nothing documented. - Exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury): Scant. -[MEDICAL CONDITION] (infection): No. - Surrounding skin: Intact. - Maceration (skin turns soft and white from consistent wetness): Nothing documented. - Edges: Attached (edges are connected to the sides of the wound). - Necrotic (localized death of living cells as from interruption of blood supply or infection) tissue: None. - Percentage of wound: Nothing documented. - Tissue bed: Dry. - Tenderness or pain: On touch. - Pain medication: Nothing documented. - Status: Unchanged and continue with current treatment orders. Initial assessment date: 12/15/10. Record review of the resident's Weekly Skin Assessment form dated 12/21/10 showed the following: - Skin color: Pink. - Skin turgor: Normal. - Skin condition: Warm and dry. - Skin integrity: Nothing documented. - Body diagram: Both heels were circled. - Treatment to the area: Nothing documented. - Status: Nothing documented. Record review of the resident's Weekly Skin Assessment form dated 12/28/10 showed the following: - Skin color: Pink. - Skin turgor: Normal and loose. - Skin condition: Warm and dry. - Skin integrity: #8 - Ulcer. There were no measurements documented. - Body diagram: Front right ankle area circled, labeled #8. There were no measurements documented. - Treatment to area #8: Medi Honey (a natural alternative for wound healing and protection; creates a moist, low pH (acid) environment that promotes new tissue formation and wound healing) started on 12/15/10. (Note: If the pressure ulcer was not improving the wound treatment should be changed every 14 days). - Status: No change. Record review of the resident's Weekly Skin Assessment form dated 12/29/10 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Normal and loose. - Skin condition: Warm and dry. - Skin integrity: #8 - Ulcer. There were no measurements documented. - Body diagram: Front right ankle and top of foot circled, labeled #8. There were no measurements documented. - Treatment to area #8: Medi Honey with a dressing, started 12/15/10. - Status: Continue treatment. Record review of the resident's January 2011 physician's orders [REDACTED]. - [MEDICATION NAME] cream, apply topically to both feet and apply heel protectors at bedtime, dated 10/03/09. - Ted hose (hose used to control [MEDICAL CONDITION]) on every morning; remove at bedtime, dated 6/21/04. Record review of the resident's Weekly Skin Assessment form dated 1/05/11 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Normal. - Skin condition: Warm and dry. - Skin integrity: Intact. - Body diagram: Front right ankle and top of foot circled, labeled #1. No measurements were documented. - Treatment to area #1: Medi Honey with foam dressing (an absorbent type of dressing). No start of treatment date documented. - Status: No change. Record review of the resident's physician's progress note dated 1/11/11 showed: - The resident had a [DIAGNOSES REDACTED]. - The resident did not have any swelling in his/her extremities. - There was no documentation of the resident having a wound. Record review of the resident's Weekly Skin Assessment form dated 1/12/11 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Normal and loose. - Skin condition: Warm and dry. - Skin integrity: #8 - Ulcer, #10 - Scar. - Body diagram: Front left outer side of foot circled, labeled #8. No measurements were documented. - Treatment to area #8: Medi Honey with dressing, with no start of treatment date documented. - Status: Nothing documented. Record review of the resident's Weekly Skin Assessment form dated 1/19/11 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Normal and loose. - Skin condition: Warm and dry. - Skin integrity: #8 - Ulcer, #10 - Scar. - Body diagram: Front left outer side of foot circled, labeled #8; Front right knee circled, labeled #10. No measurements were documented. - Treatment to area #8: Medi Honey with dressing daily, no start of treatment date documented. - Status: No change. Record review of the resident's Weekly Skin Assessment form dated 1/26/11 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Normal and shiny. - Skin condition: Warm and dry. - Skin integrity: Nothing documented. - Body diagram: Front right ankle and top of foot circled, labeled #8. No measurements were documented. - Treatment of area #8: Medi Honey, no start of treatment date documented. - Status: No change. Record review of the resident's Weekly Skin Assessment form dated 1/29/11 showed the following: - Skin color: Pink and race appropriate. - Skin turgor: Shiny. - Skin condition: Warm, "around ulcer" documented. - Skin integrity: #8 - Ulcer, #17 - [MEDICAL CONDITION] (swelling). - Body diagram: Front right ankle and outer side of foot marked with an "X" and labeled #8. Two centimeters in diameter, and one inch by three inch measurements were documented (the pressure ulcer was not measured according to the standards of practice of length, width and depth in cm.). The resident complained of pain was written next to the measurements. - Treatment to area #8: Medi Honey - outer ankle, two question marks were written in the area where the date treatment started should be documented. - Status: Contact physician for new treatment. Record review of the resident's Wound Assessment form dated 1/31/11 showed the following: - Anatomic location of the wound: Right lateral malleolus. - Age of the wound: Chronic more than one month. - Size: 2.0 cm long by 1.5 cm wide by 1.0 cm deep (the pressure ulcer was bigger and deeper). - Shape: Round. - Stage: III (the pressure ulcer went from no stage to a stage III in one week). - Sinus tract, tunneling, undermining: None. - Exudate: None. -[MEDICAL CONDITION]: None. - Surrounding skin: Intact, warm, dry, and [MEDICAL CONDITION] (swollen). - Maceration: Not present. - Edges: Attached. - Necrotic tissue: None. - Percentage of wound: 25%. - Tissue bed: Granulation tissue (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) present. - Tenderness or pain: No pain. - Pain medication: Nothing documented. - Status: Unchanged and continue current treatment orders, with nothing documented under initial assessment date. - Note: The pressure ulcer was bigger and deeper, the treatment orders were not changed, and there were no notes that showed the physician was contacted regarding the change. Record review of the resident's nurse's note dated 1/31/11 at 1:55 P.M., showed the wound on the resident's right ankle was re-evaluated. The area was round, approximately 2.0 cm by 1.5 cm by 1 cm in size. The wound bed was moist, and the resident denied pain. No redness or swelling was noted. Staff will continue treatment to the resident's right ankle. (This was written by the wound care nurse who completed the 1/31/11 wound care assessment