Every finding on record at Aspen Point Health and Rehabilitation

Based on interview and record review, the facility failed to ensure an accurate reconciliation and documentation of destruction of Schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence), Schedule IV and schedule V narcotic controlled substance medications (substances in these schedules have a lower potential for abuse), for one sampled resident (Resident #51) and three additional residents (Resident #46, #27 and #50). Review showed staff documented the number of narcotic medications destroyed as two different amounts on two different forms for Resident #46 and Resident #27. Further review showed staff documented the removal of narcotic medication from the controlled drug record, after the medication had been destroyed, for Resident #46, #27, #51 and #50, but there was no documentation on the medication administration record to show staff had administered the medication. The facility census was 53. Review of the facility policy, Controlled Substance Administration and Accountability, dated 12/09/25, showed the following:-It is the policy of this facility to promote safe, high quality resident care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in to prevent loss, diversion or accidental exposure;-General Protocols:-All controlled substances are accounted for in one of the following ways: -All controlled substances 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;-In all cases, the dose noted on the usage form must match the dose recorded on the medication administration record, controlled drug record or other facility specified form and placed in the resident's medical record;-The controlled drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and resident administration;-Obtaining/Removing/Destroying Medications: The entire amount of controlled substances obtained or dispensed is accounted for. Review of the facility policy, Medication Administration, dated 02/07/24, showed the following:-Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards;-Policy Explanation and Compliance Guidelines: -Sign medication administration record (MAR) after administration; -If medication is a controlled substance, sign narcotic book. 1. Review of Resident #46's January 2026 Physician Order Sheets (POS) showed an order for hydrocodone/APAP (Schedule II narcotic controlled substance) 5/325 milligram (mg), take one tablet by mouth every six hours as needed for pain; start date of 05/21/25 and discontinued 01/29/26. Review of the resident's January 2026 Medication Administration Record (MAR) showed no documentation staff had administered the medication to the resident in the month of January. Review of the resident's Controlled Drug Receipt/Record/Disposition form (form used to reconcile the narcotic medication and document the date, time of administration, amount of narcotic administered and the remaining count and signature of the staff removing, administering or destroying the narcotic), for the resident's hydrocodone/APAP 50 mg tablets that was dispensed on 06/08/25, showed the following:-On 01/20/25 (incorrect year) (no time), the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) documented destroying three tablets;-Entries on the form after 01/20/26 included:-On 01/21/ (no year documented) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 15 tablets; this administration was not documented on the MAR;-On 01/23/ (no year) at 10:50 P.M., staff documented removing one tablet from the medication card, leaving a balance of 14 tablets; this administration was not documented on the MAR;-If the form and narcotic had been pulled and destroyed on 01/20/26, there would have been no way for the staff to be able to document the removal of this medication on the form after the identified destruction date. Review of a typed destruction log, provided by the facility, showed on 01/29/26 (later date than on the Controlled Drug Receipt/Record/Disposition form), 14 tablets of the resident's hydrocodone/APAP 5/325 mg medication, that was dispensed on 06/08/25, was destroyed via drug buster (a disposable system that uses activated charcoal to neutralize pills, liquids and patches in 15 minutes). The documented destruction amount on the Controlled Drug Receipt/Record/Disposition form did not match the documented destruction amount on the typed form. During an interview on 02/09/26 at 4:40 P.M. and 02/18/26 at 10:45 A.M., the DON said the following:-The documented destruction date on the disposition form was 01/29/26; she just had bad handwriting;-Staff should be documenting the administration of the narcotic on the MAR if they remove the narcotic from the count sheet log and should not be administering medication if the order has been discontinued;-The disposition form showed 30 tabs were destroyed in the destruction box, but the final count and typed destruction log showed 14 tabs were destroyed, so that was what she destroyed. Her handwriting was terrible, and she was in a hurry. 2. Review of Resident #27's December 2025 POS showed orders for the following:-Tramadol (schedule IV narcotic controlled substance) 50 mg, take one tablet by mouth four times a day for moderate to severe pain; start date of 12/02/25 at 5:00 P.M. and discontinue date of 12/13/25 at 7:02 A.M.;-Tramadol 50 mg, take one tablet by mouth three times a day for moderate to severe pain; start date of 12/13/25 at 9:00 A.M. and discontinue date of 12/19/25 at 10:53 A.M.;-Tramadol 50 mg, take one tablet by mouth two times a day for moderate to severe pain; start date of 12/19/25 at 5:00 P.M. and discontinue date of 12/23/25 at 09:10 A.M. Review of the resident's December 2025 MAR showed no documentation staff had administered the resident's tramadol medication after 12/23/25. Review of the resident's January 2026 POS showed no order for tramadol. Review of the resident's January 2026 MAR showed no documentation staff administered the resident's tramadol medication in the month of January. Review of the resident's Controlled Drug Receipt/Record/Disposition form for tramadol hcl 50 mg tablets, dispensed 12/02/25, showed the following:-On 12/23/25 (no time), the ADON and the DON documented destroying three tablets;-The last entry for 12/23 (no year), at 5:00 P.M., showed ten tablets remained;-On 12/24 (no year) at 8:00 A.M., staff documented removing one tablet from the medication card, leaving a balance of nine tablets; this administration was not documented on the MAR;-On 12/24 (no year) at 5:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of eight tablets; this administration was not documented on the MAR;-On 12/25 (no year) at 8:00 A.M., staff documented removing one tablet from the medication card, leaving a balance of seven tablets; this administration was not documented on the MAR;-On 12/25 (no year) at 5:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of six tablets; this administration was not documented on the MAR;-On 12/30 (no year) at 5:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of five tablets; this administration was not documented on the MAR;-On 01/12/26 at 6:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of four tablets; this administration was not documented on the MAR;-On 01/13/26 at 6:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of three tablets; this administration was not documented on the MAR;-If the form and narcotic had been pulled and destroyed on 12/23/25, there would have been no way for the staff to be able to document the removal of this medication on the form after the identified destruction date. Review of a typed destruction log, provided by the facility, showed on 12/23/25, 26 tablet of the resident's tramadol hcl 50 mg, that was dispensed on 12/02/25, was destroyed via drug buster. The documented destruction amount on the Controlled Drug Receipt/Record/Disposition form did not match the documented destruction amount on the typed form. During an interview on 02/09/26 at 4:40 P.M. and 02/18/26 at 10:45 A.M., the DON said the following:-When an order is discontinued or changed, the medication is pulled from the medication cart by the nurse and brought to her or the ADON for destruction;-She must have documented an incorrect destruction date of 12/23/25 on the disposition form and the typed destruction log; it should have been 01/13/26;-The documentation of 26 tabs being destroyed on the typed destruction log was just an error as the disposition page showed 26 tabs had been delivered and she must have just looked at the wrong number. 3. Review of Resident #51's November 2025 POS showed orders for the following:-Pregabalin (schedule V narcotic controlled substance) 50 mg, take one capsule by mouth at bedtime for neuropathy; start date of 07/24/25, hold from 11/01/25 to 11/02/25 and discontinued 11/20/25;-Pregabalin 75 mg take one capsule by mouth at bedtime for chronic pain; start date 11/20/25. Review of the resident's November 2025 MAR showed no documentation staff administered pregabalin 50 mg after 11/19/25 to the resident. Review of the resident's December 2025 POS showed no order for pregabalin 50 mg. Review of the resident's December 2025 MAR showed no documentation staff administered the pregabalin 50 mg to the resident. Review of the resident's January 2026 POS showed no order for pregabalin 50 mg. Review of the resident's January 2026 MAR showed no documentation staff administered pregabalin 50 mg after 11/19/25 to the resident. Review of the resident's Controlled Drug Receipt/Record/Disposition form, for the resident's pregabalin 50 mg tablets, that was dispensed on 11/13/25, showed the following:-On 11/21/25, the ADON and the DON documented destroying 19 tablets;-Entries on the form after 11/21/25 included:-On 11/22 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 28 tablets; this administration was not documented on the MAR;-On 11/25 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 27 tablets; this administration was not documented on the MAR;-One 12/03 (no year) at HS, staff documented removing one tablet from the medication card, leaving a balance of 26 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/06 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 25 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/08 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 24 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/09 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 23 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/10 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 22 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/18 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 21 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 12/21 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 20 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-One 01/14 (no year) at 9:00 P.M., staff documented removing one tablet from the medication card, leaving a balance of 19 tablets; this administration was not documented on the MAR; there was no active order for this medication listed on the MAR;-If the form and narcotic had been pulled and destroyed on 11/21/25, there would have been no way for the staff to be able to document the removal of this medication on the form after the identified destruction date. Review of a typed destruction log, provided by the facility, showed on 11/21/25, 19 tablets of the resident's pregabalin 50 mg medication, dispensed on 11/13/25, was destroyed via drug buster. During an interview on 02/09/26 at 4:40 P.M., the DON said she must have documented an incorrect destruction date of 11/21/25 on the disposition form and the typed destruction log. It should have been 01/14/26. 4. Review of Resident #50's September 2025 POS showed an order for oxycodone hcl (schedule II narcotic controlled substance) 5 mg, take one capsule by mouth every 12 hours as needed for moderate to severe pain; start date of 08/04/25 and discontinued 09/25/25. Review of the resident's October 2025 POS showed the following:-No order for oxycodone hcl 5 mg;-An order for oxycodone/acetaminophen 10/325 mg, give one tablet by mouth two times a day for chronic pain; start date of 10/25/25 and discontinue 01/24/26. Review of the resident's Controlled Drug Receipt/Record/Disposition form, for the resident's oxycodone hcl 5 mg tablets, dispensed on 08/02/25, showed the following:-On 09/26/25 (no time), the ADON and the DON documented destroying five tablets;-On 09/26 (no year) at 8:00 A.M., staff documented removing one tablet from the medication card, leaving a balance of seven tablets; this administration was not documented on the MAR-On 10/26 (no year) at 6:00 P.M., staff documented removing two tablets from the medication card, leaving a balance of five tablets; this administration was not documented on the MAR; there was no active order for this dose of medication listed on the MAR;-If the form and narcotic had been pulled and destroyed on 09/26/25, there would have been no way for the staff to document the removal of this medication on the form after the identified destruction date.Review of a typed destruction log, provided by the facility, showed on 09/26/25, five tablets of the resident's oxycodone hcl 5 mg medication, that was dispensed on 08/02/25, was destroyed via drug buster. Interview on 02/09/26 at 4:40 P.M. and 02/18/26 at 10:45 A.M., showed the DON said the following:-She must have documented an incorrect destruction date of 09/26/25 on the disposition form and the typed destruction log; it should have been 10/26/25;-The documentation of the removal of two tablets on 10/26/25 she believed was due to staff taking two tablets to administer which would have been a correct amount for the current order at that time. Interview on 02/09/26 at 12:02 P.M., showed Registered Nurse (RN) A said the following:-When narcotic orders are changed or discontinued, the count sheet and card are pulled and given to the DON. There was no documentation of the handover that he/she was aware of or has ever done;-The floor staff does not destroy any narcotics; the medication and the form are pulled and given to the DON;-The DON destroys the narcotics. Interview on 02/18/26 at 10:33 A.M., showed the ADON said the following:-When a narcotic medication order was changed or discontinued, the nurse pulls the medication and the log off the cart and brings it to him/her and the DON for destruction;-Her initials in the destruction box of the disposition form shows she acknowledged the medication had been destroyed;-She checks the final count with the documented amount destroyed and the numbers should match;She may have been in a hurry with the destruction process and errors were made in the documentation. During an interview on 02/09/26 at 5:55 P.M. and 02/18/26 at 10:55 A.M. the Administrator said the following:-She would expect the documentation on the disposition form to be clear and accurate, including the documentation of the destruction;-The documented destruction on the disposition form should match the documented destroyed amount on the typed destruction log;-If staff remove a narcotic from a medication card and document the removal of that medication on the disposition form, staff should also be documenting the administration on the MAR.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 opportunities observed, six errors occurred, resulting in a 24.0% error rate, affecting one resident (Resident #45), in a medication administration review of four sampled residents. The facility census was 53. Review of the facility, Medication Administration Policy, dated 02/07/24, showed the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician;-Review the Medication Administration Record (MAR) to identify medication to be administered;-Compare the medication source (bubble pack, etc.) with the MAR to verify resident name, medication name, form, dose, route and time;-Administer medication as ordered in accordance with manufacturer specifications;-Do not crush medications with do not crush instructions;-Do not crush medications include slow release and enteric coated medications. 1. Review of drugs.com for pantoprazole sodium delayed release (medication used to reduce stomach acid) showed the following:-Do not crush, chew or break the tablet; swallow it whole;;-Crushing the tablet can lead to the medication being released too soon in the stomach rather than the small intestine and the medication will not be absorbed properly, resulting in suboptimal treatment for conditions like acid reflux. 2. Review of drugs.com for venlafaxine hcl extended release 24 hour (medication used to treat depression) showed the following:-Swallow the extended-release tablet whole and do not crush, chew or break;-Crushing the tablet destroys the mechanism that slows the release of the medication and causes dose dumping, where the entire, daily, long-acting dose is released at once, rather than over 24 hours. Releasing the full dose at once significantly increases the risk of side effects, including dizziness, vomiting, racing heart, seizures and increased blood pressure. A sudden high dose can lead to serotonin syndrome, a potentially life-threatening condition marked by extreme agitation, hallucinations, high body temperatures, tremors and coma. The medication will not last the full 24 hours, leading to premature wearing off, which may cause withdrawal-like symptoms. 3. Review of drugs.com for enteric coated baby (used to treat pain, fever and heart conditions) showed the following:-This is a delayed-release form of medication designed to bypass the stomach and dissolve in the intestines to minimize stomach irritation;-Swallow whole. Do not chew, break or crush;-Crushing makes the tablet dissolve in the stomach instead of the intestine, increasing the risk of side effects such as heartburn, stomach pain, stomach ulcers and bleeding. The drug will be released immediately rather than delayed and will be destroyed by stomach acid before it is absorbed, meaning the intended dose will not be given. 4. Review of drugs.com for potassium chloride extended release (mineral supplement used to treat low potassium levels in the blood) showed the following:-Swallow whole. Do not chew, break or crush;-This extended-release medication is specifically designed to release the potassium slowly over several hours;-If you crush or chew this medication, you release the entire dose at once, causing a dose dump, which can cause serious health conditions, including severe stomach irritation/damage, cardiac risks, throat/esophageal irritation and loss of effectiveness. 5. Review of Resident #45's February 2026 Physician Order Sheets (POS) showed the following:-Diagnoses included gastroesophageal reflux disease (GERD) (digestive disorder where stomach acid flows back into the esophagus), major depressive disorder, vitamin B12 deficiency anemia, high blood pressure, heart failure and dysphagia (difficulty swallowing);-Pantoprazole sodium delayed release 20 milligrams (mg), give one tablet daily;-Venlafaxine hcl extended release 24 hour 75 mg tablet, give one tablet daily for depression;-Aspirin tablet chewable 81 mg, give one tablet by mouth one time a day for pain;-Potassium chloride extended release 20 milliequivalents (meq), give one tablet by mouth one time a day related to hypertension;-Cyanocobalamin (vitamin B12) 1000 mcg, give one tablet by mouth one time daily related to vitamin B12 deficiency anemia;-No order to crush medications. Review of Resident #45's February 2026 Medication Administration Record (MAR) showed the resident's morning medications included the following:-Pantoprazole sodium delayed release 20 mg, give one tablet daily, scheduled for 8:00 A.M.;-Venlafaxine hcl extended release 24 hour 75 mg tablet, give one tablet daily for depression, scheduled for 8:00 A.M.;-Aspirin tablet chewable 81 mg, give one tablet by mouth one time a day for pain, scheduled for 9:00 A.M.;-Potassium chloride extended release 20 meq. give one tablet by mouth one time a day related to high blood pressure, scheduled for 10:00 A.M.;-Cyanocobalamin 1000 mcg, give one tablet by mouth one time daily related to vitamin B12 deficiency anemia, scheduled for 9:00 A.M. Observation on 02/10/26 at 9:05 A.M. showed the following:-Certified Medication Technician (CMT) D prepared one tablet of the resident's pantoprazole sodium delayed release 20 mg from the resident's pharmacy medication card and placed the tablet in a medication cup;-He/She prepared one tablet of the resident's venlafaxine hcl extended release 24 hour 75 mg from the resident's pharmacy medication card and placed the tablet in a medication cup;-He/She prepared one tablet of enteric coated baby aspirin 81 mg from a facility stock bottle (not chewable as ordered) and placed the tablet in a medication cup;-He/She prepared one tablet of potassium chloride extended release 20 meq from the resident's pharmacy medication card and placed the tablet in a medication cup;-He/She prepared one tablet of cyanocobalamin 100 mcg from a facility stock bottle (not 1000 mcg as the order read) and placed the tablet in a medication cup;-Observation of the medication cart drawer showed there was a stock bottle of cyanocobalamin 1000 mcg available for use;-CMT D then poured all the medications into a plastic sleeve, crushed the medications and placed the crushed medications in a pudding cup;-CMT D administered the medications to the resident. During an interview on 02/10/26 at 9:20 A.M., CMT D said the following:-He/She was aware of what medications could be crushed and what medications should not be crushed;-He/She had placed all the medications in the plastic sleeve, but made sure the aspirin was in the middle, so it did not get crushed;-He/She thought the 1000 mcg dose must have been a mistake because that was too large a dose and all he/she had to use was the 100 mcg bottle of cyanocobalamin. During an interview on 02/11/26 at 11:10 A.M. the Director of Nursing (DON) and Administrator said the following:-They would expect staff to follow physician orders;-They would expect staff to verify doses of ordered medications with the MAR and the bottles of medication;-They would expect staff to only crush medications that could be crushed;-Staff should not crush enteric coated medications, extended-release medications or delayed release medications

Based on observation, interview and record review, the facility failed to ensure staff maintained infection control practices for one additional resident (Resident #45), in a medication administration review of four residents. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) (a Centers for Disease Control and Prevention recommended infection control intervention for nursing homes designed to reduce multidrug-resistant organism transmission) for one resident (Resident #3), in a review of 18 sampled residents. Resident #3 had a gastrostomy tube (a device inserted through the nose, mouth, or directly into the stomach/intestine to deliver essential nutrients, fluids, and medication directly to the gastrointestinal tract) and documented methicillin resistant staphylococcus aureus (MRSA - a bacteria that spreads through skin to skin contact or contaminated surfaces) in a wound. Staff failed to use appropriate infection control practices during incontinence care. The facility census was 53. Review of the facility, Medication Administration Policy, dated 02/07/24, showed the following:-Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards, in a manner to prevent contamination or infection;-Remove medication from source, taking care not to touch medication with bare hand. 1. Review of Resident #45's February 2026 Physician Order Sheets (POS) showed the following:-Aspirin (medication used to treat pain, fever and heart conditions) tablet chewable 81 milligrams (mg), give one tablet by mouth one time a day for pain;-Metoprolol tartrate (medication used to treat high blood pressure) 12.5 mg, give by mouth two times daily for high blood pressure;-Potassium chloride extended release (mineral supplement used to treat low potassium levels in the blood) 20 milliequivalents (meq), give one tablet by mouth one time a day related to high blood pressure. Review of the resident's February 2026 Medication Administration Record (MAR) showed the following:-Aspirin tablet chewable 81 mg scheduled for 9:00 A.M.;-Metoprolol tartrate 12.5 mg scheduled for 10:00 A.M.;-Potassium chloride extended release 20 meq scheduled for 10:00 A.M. Observation on 02/10/26 at 9:05 A.M. showed the following:-Certified Medication Technician (CMT) D prepared one tablet of enteric coated baby aspirin 81 mg from a facility stock bottle, placed the tablet in his/her bare hand, and then put it into a medication cup;-He/She prepared one tablet of metoprolol tartrate 12.5 mg from the resident's pharmacy medication card and placed the tablet in his/her bare hand and then into a medication cup;-He/She prepared one tablet of potassium chloride extended release 20 meq from the resident's pharmacy medication card and placed the tablet in his/her bare hand and then into a medication cup;-CMT D poured all the medications into a plastic sleeve, crushed the medications and placed the crushed medications in a pudding cup;-CMT D administered medications to the resident. During an interview on 02/10/26 at 9:20 A.M., CMT D said the following:-He/She should not touch medications with bare hands;-He/She did not realize he/she used his/her bare hands to touch the resident's medications. During an interview on 02/11/26 at 11:10 A.M., the Director of Nursing (DON) and Administrator said staff should not put medications from a pharmacy medication card or stock bottle into their hand when preparing medications for administration. 2. Review of the facility policy, EBP, revised 04/23/25, showed the following: -It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDROs);-EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;-Additional epidemiologically important MDROs may include, but are not limited to methicillin-resistant staphylococcus aureus (MRSA);-Implementation of EBP: -a. Make gowns and gloves available near or outside of the resident's room; -b. PPE for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room;-High-contact resident care activities include: -d. Providing hygiene; -f. Changing briefs or assisting with toileting; -g. Device care or use: central lines, urinary catheters, feeding tubes; -h. Wound care: any skin opening requiring a dressing. 3. Review of the facility policy, Perineal Care, revised 05/01/25, showed the following: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;-Policy explanation and compliance guidelines:-Change gloves if soiled and continue with perineal care;-Apply skin protectants as need and according to facility policy regarding skin care. 4. Review of Resident #3's undated face sheet showed the following: -Diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow, coughing or choking), stroke and unspecified dementia (a progressive decline in cognitive function - memory, thinking, and reasoning - severe enough to interfere with daily life). Review of the resident's electronic health record, lab results, showed the following: -Wound culture of the left heel collected on 12/24/25;-Results of the wound culture showed moderate growth of MRSA. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 01/06/26, showed the following:-Severe cognitive impairment;-Dependent on staff for toileting hygiene;-Always incontinent of bowel and bladder;-Coughing or choking during meals or when swallowing medications;-Feeding tube;-At risk for pressure ulcers;-Has one or more unhealed pressure ulcers;-Infection of the foot;-Applications of dressings, ointments/medications, and dressings to feet. Review of the resident's care plan, revised on 01/09/26, showed the following:-The resident required EBP for an indwelling medical device and chronic wounds;-EBP included the use of gown and gloves during high-contact resident care activities, including, but not limited to dressing, bathing, transfers, linen changes, incontinent care, wound and/or indwelling device care;-The resident required tube feeding related to swallowing problems;-He/She has a self-care performance deficit related to cognitive impairment, decreased strength and history of cerebral vascular accident (stroke);-Dependent on staff for toileting hygiene and personal hygiene. Review of the resident's February 2026 POS showed EBP for g-tube (a tube inserted through the abdomen into the stomach for the purpose of administration of nutrition) and chronic wound. Gown and gloves required for high-contact resident care activities every shift for isolation precautions. Observation on 02/10/26 at 9:33 A.M. showed the following:-A sign on the resident's door that read STOP: Enhanced Barrier Precautions;-Everyone must: Clean their hands, including before entering and when leaving the room;-Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing;-Do Not wear the same gown and gloves for the care of more than one person;-EBP supplies, including gowns, were available directly outside the resident's room;-The surveyor entered the resident's room after Certified Nursing Assistant (CNA) B and Licensed Practical Nurse (LPN) C had already begun providing incontinence care; both staff wore gloves but no gowns; -The resident was incontinent of bowel and bladder;-CNA B performed incontinence care while LPN C provided help with positioning and turning the resident from side to side;-During incontinence care, CNA B needed additional supplies and removed his/her soiled gloves, completed hand hygiene, put on a new pair of gloves, collected needed supplies and completed additional incontinence care until all feces were removed from the resident's skin;-Without changing gloves, CNA B picked up a tube of barrier cream from the resident's bedside table, touched the resident's right hip and applied the barrier cream to the resident's bilateral buttocks;-CNA B and LPN C positioned the resident and removed their gloves, completed hand hygiene and left the room; -The resident had a feeding tube in his/her abdomen; -There was an intact wound dressing on the resident's left heel;-During cares, CNA B and LPN C did not wear a gown when providing high contact resident care. During an interview on 02/10/26 at 9:45 A.M. and 02/11/25 at 11:20 A.M., CNA B said the following: -He/She wore gloves but did not wear a gown;-There was a sign on the resident's door for EBP and he/she was aware the resident needed EBP related to his/her tube feeding and wounds;-EBP should be used to prevent the spread of infection;-Gloves should be changed when going from a clean area to a dirty area;-Gloves should be changed when they become dirty, and before touching barrier cream or applying barrier cream after peri-care has been completed;-He/She did not realize that he/she touched the tube of barrier cream with dirty gloves. During an interview on 02/18/26 at 4:05 P.M., LPN C said the following: -Staff is made aware of what resident's need EBP by the sign on the door, the order in the computer and the PPE bin outside the resident's door;-EBP was required during care for residents with a urinary catheter (a tube inserted in a bladder to drain urine), a feeding tube or with wounds;-Staff should be using a gown and gloves when providing care to Resident #3;-On 2/10/26, he/she assisted CNA B in providing incontinence care for the resident;-He/She wore gloves only and should have also worn a gown because the resident had a feeding tube and wounds;-He/She did not realize a gown was needed until they had already started providing care;-He/She and CNA B should have stopped providing care and put on a gown. During an interview on 2/10/25 at 12:35 P.M., the Infection Preventionist (IP) said the following: -Staff should utilize EBP for all direct care provided for Resident #3;-She noticed staff did not have EBP on when she was in the room;-She would expect staff to wear gloves and a gown when providing care for the resident as the resident had a gastrostomy tube and wounds on his/her left heal with MRSA. During an interview on 02/11/26 at 4:59 P.M., the Director of Nursing (DON) said the following: -EBP should be worn for any resident that required it when they are performing high contact prolonged care;-EBP would be required for indwelling medical devices, catheters, MDRO wounds and residents with a feeding tube;-EBP, including gowns and gloves, are to be worn during high contact care;-She would expect staff to change their gloves when going from clean to dirty or when they become soiled;-Staff should not touch a barrier cream tube with soiled gloves;-Staff should not apply barrier cream with soiled gloves.

Based on observation, interview, and record review, the facility failed to change gloves in between dirty and clean tasks, complete appropriate hand hygiene and properly handle dirty linens and trash for four residents (Resident #9, #18, #27 and #51) in a review of 24 sampled residents. The facility census was 55. Review of the facility policy, Infection Prevention and Control Program, revised 04/23/25, showed the following: -Thes facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines;-All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services;-Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures;-All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE;-Environmental cleaning and disinfections shall be performed according to facility policy;-All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. Review of the facility policy, Hand Hygiene, revised 04/06/25, showed the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility;- Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-ABHR with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom;-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves and immediately after removing gloves. Review of the facility policy, Handling Soiled Linen, revised 09/01/21, showed the following: -It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infections. This policy pertains to soiled linen;- Linen includes sheets, blankets, pillows, towels, washcloths and similar items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services;- Contaminated linen is linen that has been soiled with blood or other potentially infectious materials;-Linen can become contaminated with pathogens from contact with intact skin, body substances or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen;-All used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated. Other protective equipment may be required. Examples of linen that may require special handling include, but are not limited to visibly soiled with blood or large amounts of body fluids;-Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons;-Used or soiled linen shall be collected at the bedside (or point of use, such as the dining room) and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom;-Wash hands after contact with soiled linen. 1. Review of Resident #51's undated face sheet showed diagnosis include methicillin resistant staphylococcus aureus (MRSA - a type of bacteria that is resistant to many common antibiotics, making it harder to treat). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/08/25, showed the resident had a surgical wound and required wound. Review of the resident's August 2025 Physician Order Sheet (POS) showed the following: -Clean left hip with wound cleaner, pat dry. Apply calcium alginate (a type of wound care dressing for moderately to heavily exuding wounds) to wound bed, cover with 4x4 gauze then boarder gauze daily and as needed;-Enhanced barrier precautions (EBP) for chronic wound. Gown and gloves required for high-contact resident care activities. Review of the resident's care plan, revised on 08/11/25, showed the following: -The resident requires EBP related to wounds;-EBP includes the use of gowns and gloves during high-contact resident care;-The resident has actual impairment of skin integrity and follow facility protocols for treatment of injury. Observation on 8/14/25 at 12:42 P.M., showed the following: -The Assistant Director of Nursing (ADON)/wound care nurse performed a treatment to the resident's left hip surgical site;-The ADON performed hand hygiene, applied gloves and a gown and placed wound care supplies on a clean surface; -She removed the resident's old dressing which had a small amount of dried brown draining on the dressing; -The wound was approximately the size of a nickel with a pink center and a small amount of clear drainage; -The ADON removed her gloves, wrapped the old dressing up in the soiled gloves and placed them in the resident's trash can; -Without performing hand hygiene, the ADON applied a pair of new gloves; -She completed the resident's wound care and removed his/her gloves;-The ADON performed hand hygiene with ABHR at the end of the treatment after final glove removal. During an interview on 08/14/25 at 12:45 P.M., the ADON said she should have performed hand hygiene in between glove changes and did not due to not having her hand sanitizer readily available. She could have washed her hands with soap and water and did not. 2. Review of Resident #9's quarterly MDS, dated [DATE], showed the following:-Substantial/maximum assistance with toileting hygiene;-Requires substantial/maximum staff assistance for rolling left and right, sit to lying and lying to sitting on side of bed;-Range of motion limitations one side upper and lower body;-Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 08/11/25, showed the following:-He/She had an activities of daily living (ADL) self-care performance deficit;-He/She required maximum assistance of one staff for toileting hygiene;-He/She had an actual skin impairment;-Keep his /her skin clean and dry;-Clean his/her peri-area with each incontinence episode. Observation on 08/13/25 at 4:15 A.M., showed the following:-Certified Nurse Assistant (CNA) E was in the resident's room and applied gloves to check the resident for incontinence;-The resident was incontinent of urine;-CNA E obtained warm soapy washcloths from the sink, unfastened the resident's incontinence brief and placed the urine soaked incontinence brief on the floor; -CNA E washed the resident's front peri-area, then used another wet washcloth to rinse the resident's front peri-area and placed the soiled washcloths on the floor; -With the same soiled gloves, CNA E rolled the resident to his/her right side, touching his/her left hip, and removed the incontinence brief;-CNA E then cleaned the resident's buttocks with a soapy washcloth and rinsed the resident's buttocks with a wet washcloth;-With the same soiled gloves, CNA E placed a clean incontinence brief under the resident;-CNA E picked up the used washcloths and urine soaked incontinence brief off the floor and placed them in separate trash bags;-CNA E removed his/her gloves, used hand sanitizer then took the trash bags to the dirty utility room.-CNA E did not clean the floor where he/she placed the soiled washcloths and brief. During an interview on 08/13/25 at 5:31 A.M., CNA E said the following:-He/She puts on gloves, enters the room, and makes sure everything was set up to provide care;-If the resident had a bowel movement, he/she would change gloves before touching clean items;-Since the resident did not have a bowel movement, he/she did not think to change his/her gloves;-He/She forgot to wash hands or use hand sanitizer after removing his/her gloves. 3. Review of Resident # 18's quarterly MDS, dated [DATE], showed the following:-Dependent on staff for toileting hygiene;-Dependent on staff for showering/bathing;-Always incontinent of bladder. Review of the resident's care plan, revised on 08/12/25, showed the following:-He/She had an ADL self-care performance deficit;-He/She was dependent of staff for showering/bathing and toilet hygiene;-He/She had potential for impairment to his/her skin; -Keep his/her skin clean and dry;-He/She had bladder/bowel incontinence; -Clean his/her peri area with each incontinence episode. Observation on 08/13/25 at 4:40 A.M. showed the following:-CNA C and CNA D enter the resident's room, turned the light on, sanitized hands, donned gloves, and told the resident they were going to check him/her to make sure he/she was dry;-The resident was incontinent of urine;-CNA C pulled the resident's urine soiled brief down (touching the wet brief);-CNA D went to the resident's sink, got a warm washcloth, and handed it to CNA C;-CNA C washed the resident's face, pulled up the resident's gown, washed under the resident's arms and put deodorant under the resident's arms;-CNA C handed the soiled washcloth to CNA D to rinse at the sink;-CNA C added body wash to the washcloth before turning the resident on his/her left side and cleaning his/her back then bottom;-CNA C removed the wet brief and dirty gown from under the resident and laid it directly in the resident's wheelchair seat sitting next to the bed (not in a bag);-CNA C placed a dirty towel directly on the wheelchair seat next to the bed (not in a clear bag);-Using the same gloves, CNA C put a clean brief, socks, pants, and shirt on the resident and pulled the blankets back up over the resident;-CNA D picked the dirty linens and trash up from the resident's wheelchair and placed them in clear bags, doffed his/her gloves, and took the dirty linens and trash to the cart in the hallway;-CNA C doffed gloves and washed hands with soap and water;-Staff did not clean the resident's wheelchair seat. During an interview on 08/14/25 at 10:10 A.M., CNA C said the following:-He/She should put the dirty linens directly into a clear bag rather than placing them in the resident's wheelchair;-He/She should change his/her gloves and hand sanitize in between dirty and clean. 4. Review of Resident #27's quarterly MDS, dated [DATE], showed the following: -Cognitively intact;-Requires substantial/maximum staff assistance for rolling left and right, sit to lying and lying to sitting on side of bed;-Dependent on staff for toileting hygiene;-Range of motion limitations one side upper and lower body;-Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 08/05/25, showed the following: -The resident had an ADL self-care performance deficit; -Requires substantial/maximum staff assistance for rolling left and right, sit to lying and lying to sitting on side of bed;-Dependent on staff for toileting hygiene;-The resident has bladder incontinence related to cerebral vascular accident;-Clean peri-area with each incontinent episode. Observation on 08/13/25, at 3:42 A.M., showed the following: -CNA E washed his/her hands and applied gloves;-CNA E performed an incontinence check on the resident;-The resident was in bed sleeping and observed to have two incontinent products in place;-CNA E removed both incontinent products and the inner product was wet with urine;-CNA E performed frontal peri-care with a washcloth and then placed the soiled washcloth on the resident's bedside table;-CNA E assisted the resident to turn on his/her right side and performed peri-care the resident's buttocks and anal area with a washcloth placed on the resident's bedside table;-CNA E placed the soiled washcloth on the resident's floor;-Wearing soiled gloves, CNA E pulled the resident's top sheet up to cover the resident, adjusted the bed with the bed control, picked up the soiled washcloth and opened the resident's door by the door handle;-CNA E removed his/her gloves after placing the soiled washcloth in the linen cart and walked down the hall to the clean linen closet;-CNA E did not perform hand hygiene after removing gloves and went into another resident's room to answer a call light;-With soiled hands, CNA E moved the resident's table back within reach after lowering the resident's bed;-CAN E did not clean the bedside table or floor where he/she placed soiled washcloths. During an interview on 08/13/25 at 6:04 A.M, CNA E said the following:- Hands should be washed before and after peri-care, any time you put on gloves, any time you provide any care, pretty much all the time;-Gloves should be changed all the time, when dirty and after every resident care performed and gloves removed before leaving the room;-Hands should be washed or hand sanitizer used after gloves are removed;-A washcloth that has been used for peri-care should not be placed on a resident's bedside table or on the floor;-He/She realized that he/she had put the washcloth being used for peri-care on the bedside table and on the floor after the act had occurred;-He/She should have cleaned the resident's bedside table and floor with disinfectant and did not;-He/She should have removed his/her gloves after performing peri-care and washed hands or used hand sanitizer before touching the resident's sheets, bed controls and door handle and did not. During an interview on 08/14/25 at 4:22 P.M., the Director of Nursing (DON) said the following:-She would expect staff to wash their hands before and after cares;-She would expect staff to change their gloves when going from dirty to clean;-She would expect staff to perform hand hygiene in between glove changes with soap and water or hand sanitizer;-Staff should not touch items such as clothing, linens, bed controls, doorknobs, or other items after completing resident cares like peri-care;-Dirty linens should be placed in a dirty linen container in a clear bag; they should not be placed on the floor, on a wheelchair or any other surface;-If soiled linen is placed on a surface, she would expect staff to clean that surface immediately after with Sani-wipes.During an interview of 08/14/25 at 4:40 P.M., the Administrator said the following:-Staff should not be touching items such as clothing, linens, bed controls, doorknobs, etc. with dirty gloves;-Dirty linens should not be placed on the floor, on the resident's wheelchair or on a bedside table if they are soiled or have been used to provide peri-care;-Dirty linens should be placed in a bag and taken to the utility room or to a linen cart;-If soiled linen is placed on a surface, she would expect it to be cleaned and sanitized immediately after, with the appropriate chemicals.

Based on observation, interview and record review, the facility failed to maintain a safe, clean, and homelike environment for three residents (Resident #64, Resident #10, Resident #30) in a sample of 24 residents and one additional sampled resident (Resident #55). The facility census was 55. Review of the facility policy, Resident Environmental Quality, revised 09/01/2021, showed the following: -It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public;-Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents;-Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment;-All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. 1. Observation on 08/11/25 at 1:08 P.M. in Resident #10's room showed the following:-A wet and soiled blanket laid across the windowsill; -A wet and soiled blanket laid on the floor under the air conditioning unit/window;-Chipped paint on the wall in between the windowsill and the air conditioning unit;-An electrical outlet on the wall under the window and above the floor. During an interview on 08/11/25 at 1:08 P.M., the resident said the following:-He/She would like his/her window caulked because water leaks everywhere and gets all of his/her items on the window side of the bed wet;-He/She had reported the leak to maintenance a few times and they still have not fixed it;-There was a blanket in the window and on the floor because everything gets wet when it rained; -An electrical outlet was directly under the window in the wall and the water runs down the wall;-The paint on the wall was chipped from the water damage. During an interview on 08/13/25 at 4:54 A.M., Certified Nurse Aide (CNA) C said the following:-All of the windows and air conditioning units leaked;-Many residents have complained about their windows and air conditioning units leaking;-He/She and other staff have complained and reported it to maintenance several times because of the safety/fall risk for residents and well as the electrical outlets being low on the wall;-He/She has told maintenance about it more than ten times; the leaks had been going on for months. 2. Observation on 08/11/25 at 3:15 P.M. in Resident #64's room showed the following:-A 1/2 - 1 inch gap between the two sliding glass doors to the outside (vertical gap from top of the door to the bottom of the door) showing no seal; -Grass and weeds were present in the opening and the heat from outside was coming into the room; -There were several blinds broken and missing from the sliding glass door;-There were cobwebs all around the window/blinds. During an interview on 08/11/25 at 3:15 P.M., the resident said the following:-Grass and bugs come in through the gap in the door;-He/She reported this to maintenance, and they never come in to do anything about it, so he/she had to clean it up;-He/She was in the facility for rehab with double pneumonia and was trying to get off of oxygen after all of his/her respiratory issues. The gap in the door was letting heat in the room and outside elements such as the grass and weeds blowing in as well as bugs made his/her respiratory issues worse.3. Observation on 08/11/25 at 1:52 P.M., in occupied room [ROOM NUMBER] showed the following: -Multiple gouges in the wall behind the resident's bed, approximately six to eight inches long, showing the paint color beneath the top layer of paint;-Wallpaper peeling away from the windowsill exposing the drywall between the gaps;-Numerous ants crawling on the windowsill;-Caulk around the window frame, with openings in the caulk the approximate size of a pencil eraser;-White, unpainted spackle repaired area on the wall near the main doorway. 4. Observation on 08/14/25 at 1:00 P.M., in Resident #55's room showed multiple rolled up towels in the resident's windowsill. During an interview on 08/13/25 at 10:00 A.M. and 08/14/25 at 1:00 P.M., the resident said the following: -He/She puts the towels in the windowsill because when it rained, the window leaked;-The towels stopped the rain;-Maintenance was aware of the problem and has tried to fix the window numerous times. 5. Observations on 8/13/25 between 11:35 A.M. and 4:00 P.M., during the Life Safety Code tour, showed the following:-The wall behind occupied 107-B bed headboard with gouged marks in the sheet rock;-In occupied room [ROOM NUMBER], window shades with broken horizontal blinds; -In occupied room [ROOM NUMBER], two 1-inch unsealed holes in wall of the alcove area;-In occupied room [ROOM NUMBER], sliding shades with broken vertical blinds;-In occupied room [ROOM NUMBER], window shades with broken horizontal blinds;-In occupied room [ROOM NUMBER], window shades with broken horizontal blinds. During an interview on 8/14/25 at 1:45 P.M., the Maintenance Director said the following:-He was aware of some of the identified areas;-All staff are to monitor for environmental concerns. The facility used a system called angel rounds (monthly). It was designed to identify issues throughout the facility;-Maintenance is notified of environmental issues by a log kept at the nurse station, and he checks it on an ongoing basis. Staff also notify him in person; -He prioritizes the list for repairs and would expect items to be repaired within a day depending on the item's priority. He was the main maintenance person and had one other individual that helped him. It could be challenging to complete repairs and keep the list up to date. During an interview on 08/14/25 at 4:22 P.M., the Director of Nursing (DON) said the following:-She would expect that if a resident complained about water coming in from their window or around the air conditioning unit on the floor causing items to get wet, that staff report it to maintenance, the water be removed, and if any personal items are/were damaged, she would try to replace them or take care of them if they were soiled;-She would expect maintenance to fix the sliding glass door and ask the resident if he/she was okay with staying in that room until it was fixed if the resident had respiratory issues;-She would not expect a resident to clean their own floor if there were insects and grass coming in from the unsealed door; that was staff's job. During an interview on 08/14/25 at 4:40 P.M., the Administrator said the following:-If a resident complained that water was coming in from his/her window when it rained, or around the air conditioning unit on the floor causing personal items to get wet, she would expect staff to clean it up first, replace or restore the items, and contact plant operations for a permanent fix;-She expected the door to be sealed if a resident has a sliding glass door in his/her room that does not seal, and the resident has respiratory issues.

Based on observation, interview, and record review, the facility failed to ensure staff provided personal privacy and treated one resident (Resident #4), in a review of 17 sampled residents, with dignity and respect when providing personal care. Staff provided a bed bath to the resident with the resident's privacy curtain and door open while talking to other residents in the hallway. The facility census was 56. Review of the facility policy, Promoting/Maintaining Resident Dignity, last revised 10/01/23, showed the following: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality; -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; -The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences; -When interacting with a resident, pay attention to the resident as an individual; -Explain care or procedures to the resident before initiating the activity; -Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered; -Groom and dress residents according to resident preferences: -Speak respectfully to residents; avoid discussions about residents that may be overheard; -Maintain resident privacy; -Each resident will be provided equal access to quality of care regardless of diagnosis, severity of condition or payment source. 1. Review of Resident #4's Care Plan, last revised 11/18/24, showed the following: -The resident's autonomy and dignity will be honored; -The resident has the right to be treated with consideration, respect, and dignity; -He/She had an activities of daily living (ADL) performance deficit and impaired vision and required assistance with all care; -He/She was dependent on staff for personal hygiene, showering/bathing, toileting hygiene and dressing; -He/She had a communication problem; -He/She sometimes had a hard time making his/her needs known. -Request clarification from him/her to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 12/21/24, showed the following: -Cognition severely impaired; -Dependent on staff for toilet hygiene and upper/lower body dressing; -Dependent on staff for showering/bathing. Observation on 2/26/25 at 7:23 A.M., showed the following: -Certified Medication Technician (CMT) L entered the resident's room and did not knock, introduce himself/herself, or pull the privacy curtain or bedroom door closed; -The resident did not wear any clothing or undergarments and sat fully exposed on his/her bed with his/her legs bent and crossed in front of him/her; -The resident sat in the middle of his/her bed facing the hallway. The door to the room was open and the privacy curtain was not pulled to provide privacy to the resident from the hallway; -Another resident was outside of the resident's room in the hallway. The entire front side of the resident's body was exposed to the resident in the hallway as the other resident looked in and talked to CMT L, who was in the resident's room; -CMT L filled a plastic tub with soapy water and sat it on the bedside table near the resident's bed; -CMT L provided a bed bath for the resident. The door to the resident's room remained open and the privacy curtain was not pulled. Another resident walked in the hallway by the resident's doorway. CMT L said, What's up? to the other resident and began having a conversation with the resident in the hallway as he/she provided the bed bath for Resident #4; -The resident was left completely exposed with no covering during the entire bed bath; -CMT L saw another resident in a wheelchair in the hallway and said, What are you doing?; -CMT L completed the bed bath, removed his/her gloves, left the resident exposed in the bed when he/she went over to the resident's sink to wash his/her hands and put on new gloves; -CMT L assisted the resident to dress in an incontinence brief, shorts, socks, and shirt, exposing all of the resident's body and genitalia to anyone in the hall. During an interview on 2/27/25 at 2:15 P.M., CMT L said the following: -He/She did not recall having the curtain/door open while providing care for the resident (on 2/26/25); -He/She did not recall having conversations with other residents walking by the resident's room while providing care; -He/She felt this would have been an invasion of the resident's privacy. During an interview on 2/27/25 at 2:10 P.M., Registered Nurse J said he/she expected staff to close the privacy curtain and the resident's room door to provide privacy when providing care. During an interview on 2/27/25 at 3:15 P.M., the Director of Nursing said she expected staff to ensure privacy for the resident or any other resident when providing personal care by closing the door, pulling the privacy curtain, and only exposing the area of the resident that they are working with. During an interview on 2/27/25 at 4:00 P.M., the Administrator said the following: -She expected staff to treat residents with dignity and respect; -She expected staff to provide residents with privacy.

Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions to prevent unintended weight loss for one resident (Resident #26), in a review of 17 sample residents, who had a 8.61% weight loss in one month. The facility census was 56. Review of the facility policy, Weight Monitoring, last revised 9/1/22, showed the following: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; -The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. -Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: a. Identified causes of impaired nutritional status b. Reflect the resident's personal goals and preferences c. Identify resident-specific interventions d. Time frame and parameters for monitoring e. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition-related problems are identified. f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. g. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. -Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. -Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) -Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. c. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager, or the nursing department may initiate this process. d. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. e. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. f. The interdisciplinary plan of care communicates care instructions to staff. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/16/24, showed the following: -Cognition was severely impaired; -Understood others and was able to make himself/herself understood; -Severely impaired vision; -Required supervision or touch assist for eating; -Height was 68 inches; weight was 159 pounds; -No weight loss. Review of the resident's Care Plan, revised on 11/13/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit, he/she was blind, and required guidance; -When the resident was eating, explain placement of items and feed if necessary; -The resident was able to feed himself/herself with tray set up due to him/her being blind; -He/She repeatedly asks for food and drink; -He/She would eat either in his/her room or in the main dining area. -Instruct him/her to eat in an upright position, to eat slowly, and to chew each bite thoroughly. (The resident's care plan did not address weight loss or identify interventions to prevent weight loss.) Review of the resident's weight record, dated 1/08/25, showed the resident weighed 159.1 pounds. Review of the resident's Physician Progress Note, dated 1/21/25, showed the following: -Protein calorie malnutrition (an individual does not eat enough protein and calories to meet nutritional needs); -Encourage increased oral intake; -On house supplement (a fortified nutritional shake that provides calories and protein) and Remeron 15 milligrams (mg) at bedtime for appetite stimulant. Review of the resident's Physician Progress Note, dated 1/24/25, showed the following: -The resident gets up readily for snacks; -The resident had a very good appetite and seemed to always want to eat. Review of the resident's weight record, dated 02/06/25, showed the resident weighed 145.4 pounds (a weight loss of 13.7 pounds; a 8.61% weight loss in one month). Review of the resident's nutritional assessment, dated 02/10/25, showed the Registered Dietician (RD) documented the following: -Regular diet with regular consistency; -Nectar thickened liquids; -Meal intake 50-100%; -Weight on 02/06/25 was 145 pounds; -Loss of 5% or more in the last month or loss of 10% in the last six months; -Nutritional requirements: 1848 kilocalories (kcal), 66 grams of protein, and 1980 ml fluids; -The resident with fair to good oral intake with meals. Significant weight loss noted. Will add 60 milliliter (ml) med pass supplement (house supplement) three times a day to support nutritional needs and promote weight gain. Review of the resident's Physician's Orders, dated February 2025, showed the following: -Mirtazapine (Remeron) 15 mg, take one tablet my mouth at bedtime for depression, obsessive compulsive disorder, and anxiety (original order dated 8/17/24); -2.0 House Supplement (nursing), give 60 ml three times a day for weight loss (original order dated 2/10/25). Review of the resident's Care Plan, revised on 2/10/25, showed no documentation the facility developed a care plan to address the resident's weight loss. The care plan did not include documentation the resident had weight loss and did not include listed interventions to prevent further weight loss and promote weight gain. Review of the resident's Medication Administration Record (MAR), dated February 2025, showed the following: -On 02/13/25 at 2:00 P.M., staff documented 0 mls of the 2.0 House Supplement was administered; -On 02/14/25 at 9:00 A.M., staff documented 0 mls of the 2.0 House Supplement was administered; -On 02/14/25 at 2:00 P.M., staff documented 0 mls of the 2.0 House Supplement was administered. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -Understood others and was able to make himself/herself understood; -Severely impaired vision; -Required supervision or touch assist for eating; -It was very important to the resident to have snacks in between meals; -Height was 68 inches; weight was 145 pounds. (Based on this information, the resident's calculated body mass index (BMI; a calculated measure of weight relative to height) was 22. Normal/healthy BMI is 18.5 to 24.9); -Weight loss of 5% or more in last month or loss of 10% or more in last six months; -On physician prescribed weight loss program. (Note: The physician's progress notes, dated 1/21/25, identified the resident had protein calorie malnutrition. Staff was to increase the resident's oral intake and provide supplements/medications to increase appetite. The resident was not on a prescribed weight loss program.) Review of the resident's MAR, dated February 2025, showed the following: -On 02/24/25 at 9:00 A.M., staff documented 0 mls of the 2.0 House Supplement was administered; -On 02/24/25 at 2:00 P.M., staff documented 0 mls of the 2.0 House Supplement was administered. Review of the resident's MAR, dated 02/27/25 at 9:00 A.M., showed Registered Nurse (RN) J charted 0 mls of the 2.0 House Supplement was administered. During an interview on 02/27/25 at 2:10 P.M., RN J said the following: -The resident sometimes refused his/her house supplement; -The resident didn't like the taste of the house supplement; -He/She charted it as 0 mls administered if the resident didn't drink the supplement. During an interview on 2/27/25 at 2:15 P.M., the resident said the following: -He/She did not refuse a milkshake this morning; -He/She would like to have a milkshake. Observation on 2/24/25 at 12:50 P.M., showed the following: -The resident sat on the side of the bed with his/her meal tray on the over-the-bed table in front of him/her. There were no staff in the resident's room; -The resident said he/she was blind and asked multiple times what food items were on his/her tray. The resident's tray included chicken strips, mixed vegetables, a cup of tortilla chips, a cup of fruit cocktail, a glass of thickened water and a glass of thickened juice. -The resident touched around his/her tray feeling for the food and for his/her drink glass with juice. -The resident said he/she could not find the juice and asked for assistance to find it on his/her tray. -The resident said he/she liked chicken but could not see it to enjoy it; -The resident ate 100% of the fruit cocktail and chips with his/her hands. The resident did not eat any of his/her chicken or mixed vegetables; -The resident asked for more chips and called out, Hello. More chips. Hello, nurse. Observation on 2/24/25 at 1:05 P.M., showed the resident lay in bed. His/Her meal tray sat on the over-the-bed table next to his/her bed. The chicken and the mixed vegetables remained on the resident's tray. The resident called out, hello. During interview on 2/24/25 at 1:05 P.M., the resident said he/she had no way to ask for help. He/She did not have a call light, or if he/she had one, he/she didn't know where it was. He/She couldn't call for help and would like for someone to come by his/her room periodically and ask if he/she needed something. He/She wished he/she had a menu of the items served for the meals so he/she could pick out his/her own food. He/She would like a choice in what he/she ate, but no one had asked him/her what he/she would like. He/She would like peanut butter and jelly sandwiches and grilled cheese. (These items were listed as an alternate the residents could request on the resident's meal ticket, however, the resident was blind and could not read the ticket). Observation on 2/24/25 at 1:30 P.M., showed CMT F took the resident's tray from his/her room and told the resident he/she would get the resident a snack. The resident lay in bed. Observation on 2/24/25 at 1:39 P.M., showed the resident lay in bed. The resident did not have any food or drink in his/her room. The resident said he/she would like more chips and something to drink. Observation on 2/24/25 at 1:42 P.M., showed the resident lay in bed. The resident called out, Nurse. Nurse. Hello. The resident did not have any food or drink in his/her room. No staff was in the hallway to respond to the resident. Observation on 2/24/25 at 2:55 P.M. showed the following: -The resident lay awake in bed; -No cup or fluids were available for the resident in his/her room. During an interview on 2/24/25 at 2:55 P.M., the resident said the following: -He/She thought there ought to be a way to get a hold of someone when he/she needed something; -He/She would like more food; -He/She was thirsty and would like something to drink. Observation on 2/25/25 at 11:40 A.M., showed the following: -The resident lay awake in bed; -The resident's water pitcher, which contained regular water (not thickened) was on the bedside table, and not within his/her reach. A small bendable straw was down inside the pitcher. During an interview on 2/25/25 at 11:40 A.M., the resident said the following: -He/She was hungry and thirsty; -He/She would like a milkshake. Observation on 2/25/25 at 11:45 A.M., showed CMT E poured a 4 ounce mighty milkshake (a fortified, frozen shake, used to add calories and protein to the diet) into a clear cup with a straw and handed it to the resident. (The mighty milkshake was not the same as the house supplement.) During an interview on 2/25/25 at 11:45 A.M., the resident said the straw was broken and he/she was not getting anything out through the straw. Observation on 2/25/25 at 11:45 A.M. showed CMT E told the resident he/she would get him/her a new straw and left the room. CMT E did not return with a new straw. Observation on 2/25/25 at 11:45 A.M. showed the following: -The resident repeatedly sucked through the straw and continued to say, This isn't working. This is broken; -The resident consumed approximately 50% of the shake before giving up on the broken straw and lying back down on the bed. Observation on 2/26/25 at 7:00 A.M. showed the resident called out, Hello, can I have some food please? Hello, can I have something to drink please? During an interview on 2/26/25 at 7:00 A.M., the resident said he/she would like something to eat and drink. Observation on 2/26/25 at 7:05 A.M., showed the following: -Licensed Practical Nurse (LPN) N brought the resident a small cup of koolaide and the resident drank it very quickly and asked where the food was; -LPN N told the resident he/she would bring it as soon as he/she got it. Review of the resident's dietary tray card for breakfast on 2/26/25 at 8:00 A.M., showed the following: -Regular, Finger Foods; -No pork; -Nectar thick liquids; -Provide assistance at meals; -Wants peanut butter and jelly for breakfast; -The resident was to receive corn flakes, French toast sticks, sausage links, juice of choice, coffee or hot tea, and milk of choice. Observation on 2/26/25 at 7:50 A.M., showed the following: -CMT F brought the resident's breakfast tray to the resident's room and sat it down on his/her bedside table; -The resident's breakfast tray included French toast, a bowl of oatmeal, a sausage patty, and juice. (The resident did not receive a peanut butter and jelly sandwich, corn flakes, milk, or coffee with his/her breakfast meal.); -The resident asked where his/her food and drink were and grabbed all around the plate and tray to find his/her food and drink; -He/She found his/her juice and drank it quickly, spilling it all over the blanket; -CMT F poured the syrup on the resident's French toast but did not explain where things were on the resident's tray; -CMT F left the room; -The resident felt around the plate to locate his/her food and got syrup all over his/her hands; -He/She ate his/her food very quickly; -He/She consumed 100% of the meal. Observation on 2/26/25 at 8:12 A.M., showed the following: -The resident was in bed; -The resident said, Nurse, can I get some more food? Can I get some toast and coffee? -CMT L was in the room assisting the resident's roommate. He/She went to the resident, removed the resident's tray, and said, You ate it all!; -The resident said, Nurse, can I get some coffee, please? Where can I get some coffee? Hello? Nurse, can I get some coffee?; -CMT L told the resident that he/she would get him/her some coffee when he/she was finished feeding the resident's roommate some grapes; -The resident asked, Can I get some grapes? Where is the food at? I'm so hungry!; -CMT L said, You just finished breakfast; -The resident said, Well, I'm still hungry! -CMT L said, Let's get up and I'll see about getting you a snack; -The resident said, Can I get some coffee? I don't want to get up; -CMT L finished assisting the resident to get dressed; the resident continued to say, I'm hungry. Can I get some food?; -CMT L assisted the resident to transfer into his/her wheelchair and pushed the resident to the dining room; -The resident said, I'd like breakfast and coffee; -CMT L said, You already ate; -The resident said, I'd like some more; -CMT L got the resident some coffee with cream and sugar from the dining room area and sat it in front of him/her on the table; -CMT L did not get the resident anything to eat. Observation on 2/26/25 at 8:34 A.M., showed the following: -The resident sat at the dining room table and said, Nurse, can I get something to eat or drink? I'm hungry; -The resident did not have any food in front of him/her; -Housekeeper M told the resident that he/she would get him/her a peanut butter and jelly sandwich; -Corporate RN delivered a peanut butter and jelly sandwich to the resident's old room (resident moved rooms during the survey) and sat it on a bedside table; -Staff did not bring any food to the resident who was in the dining room. Observation on 2/26/25 at 8:45 A.M., showed the following: -Corporate RN walked up to the resident in the dining room and asked how he/she was doing; -The resident asked for food; -Corporate RN told the resident the kitchen staff would get food for him/her; -The Registered Dietician (RD) brought the resident a cookie. Observation on 2/26/25 at 8:55 A.M., showed the following: -The resident ate all of his/her cookie and asked for another snack; -Corporate RN asked kitchen staff to get the resident another snack. Observation on 2/26/25 at 9:00 A.M., showed the following: -The resident ate cheese crackers off of a small saucer at the dining room table; -Crackers were scattered all around the outside of the plate. Observation on 2/26/25 at 1:45 P.M., showed the following: -The resident lay in bed awake and said, Nurse, I'm hungry. I'd like something to eat. Is there anymore food?; -The Assistant Director of Nursing (ADON) was in the resident's room providing a treatment for the resident's roommate. The ADON said, Wait, I'm helping your roommate; -The resident said, I've been waiting for quite some time; -The ADON said, How about some popcorn; -The resident said, Where is it?; -The ADON said, I'll have to get it; -Housekeeping M brought the resident some popcorn (no drink). The resident shoved the popcorn into his/her mouth one bite after the other very quickly; -The resident ate all of his/her popcorn and asked for more to eat. During an interview on 2/26/25 at 2:30 P.M., the resident said he/she would like a snack and a drink. Observation on 2/26/25 at 2:40 P.M., showed the RD brought the resident thickened water and a fig [NAME] bar for a snack. During an interview on 2/27/25 at 1:30 P.M., the resident's family member and power of attorney (POA) said the resident was thinner and had lost weight. During an interview on 3/11/25 at 9:40 A.M., the RD said the following: -She was not aware the resident was constantly asking for food and drink; -The resident asked her for a snack every once in a while, and she would get the resident whatever he/she asked for, which was usually something sweet like a danish or an alternate like an oatmeal cream pie; -The resident would also ask her for juice or coffee, and she would make sure it was thickened (nectar thick liquids); -She expected staff to give the resident food and drink that he/she liked, like sweets, to promote weight gain related to his/her weight loss; -She looked at her notes and the resident's weight was documented on 2/6/25; -Once the weight was put into the system, it triggered a list that she printed out, then made recommendations, and gave it to the Administrator and Director of Nursing; -She added a note on 2/10/25 and recommended a House Supplement three times daily for the resident; -She did not recall discussing the resident or his/her weight loss with the interdisciplinary team (IDT); -The IDT met every morning and discussed anyone on the list, so she was sure they discussed the resident at that time; -She did not recall the last time the IDT discussed the resident; -She was not aware staff were documenting that the resident did not consume his/her house supplement; -She could not see the resident refusing or not consuming his/her house supplement unless he/she was not feeling well that day; -She followed up monthly to ensure interventions were effective. During interview on 3/12/25 at 9:26 A.M., the Director of Nursing said the following: -She was not aware the resident asked for more food and drinks. She knew the the resident frequently said, Nurse, nurse but she was not aware of anything else; -She was not aware staff documented the resident did not consume all of his/her house supplement. She would have expected staff to have notified her; -She looked at the resident's medical record and was seeing now that the resident had a 14 pound weight loss. She would have expected staff to notify her of the resident's weight loss; -The IDT met daily and weekly to discuss interventions and to determine if interventions were successful. She did not recall discussing the resident's weight loss in the IDT meetings.

Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for three residents (Residents #5, #14, and #30), in a review of 17 sampled residents. Staff failed to follow physician's orders for oxygen therapy and immunizations/vaccinations for Resident #5, failed to pack a wound as ordered for Resident #14, and failed to apply a soft hand splint for Resident #30. The facility census was 56. Review of the facility policy, Medical Provider Orders, revised 4/7/22, showed the following: -The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements staff should contact the ordering provider for clarification of the order prior to implementation of the order. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 01/10/25, showed the following: -His/Her cognition was severely impaired; -He/She had impaired range of motion (ROM) in both his/her upper and lower extremities; -He/She was dependent on staff for activities of daily living (ADLs), including dressing. Review of the resident's Physician's Orders, dated February 2025, showed the following: -Nursing to apply soft palm splint to right hand as tolerated; -On 01/29/25, an order was obtained to administer Tdap (vaccine protects against tetanus (infection of the nervous system), diphtheria (serious bacterial infection), and pertussis/whooping cough (highly contagious respiratory infection), Prevnar 20, and a COVID booster. Review of the resident's medical record showed no evidence staff administered the Tdap vaccination, Prevnar 20, or COVID booster as ordered. Review of the resident's care plan, last reviewed on 02/23/25, showed the following: -His/Her cognitive function was impaired related to dementia; -He/She was dependent on staff with dressing; -He/She required a soft palm splint related to contracture of his/her right hand. Observation on 02/24/25 at 12:00 P.M., showed the following: -The resident's right hand was contracted; -He/She sat at the dining room table in his/her Broda (special tilt in space seating) chair with no soft palm guard on his/her right hand. Observation on 02/25/25 at 12:00 P.M., showed the following: -The resident's right hand was contracted; -He/She sat at the dining room table in his/her Broda chair with no soft palm guard on his/her right hand. Observation on 02/25/25 at 3:35 P.M., showed the following: -The resident lay in his/her bed without a soft palm guard on his/her contracted right hand; -No palm guard was visible in the resident's room. Observation on 02/26/25 at 6:00 A.M., showed the following: -The resident lay in his/her bed with no soft palm guard on his/her contracted right hand; -No palm guard was visible in the resident's room. Observation on 02/26/25 at 7:30 A.M. showed the following: -The resident's right hand was contracted; -Staff assisted the resident to the dining room for breakfast. Staff did not put a soft palm guard on the resident's contracted right hand; -No palm guard was visible in the resident's room. During an interview on 02/26/25 at 3:40 P.M., the Therapy Director said the following: -The resident should have a soft palm splint on the right hand to avoid his/her nails digging into the palm of the resident's contracted right hand; -She had educated staff and placed the palm guards in the resident's room prior to survey; -She was not aware staff did not use the soft palm guard. During an interview on 02/26/25 at 4:30 P.M., Certified Nurse Assistant (CNA) B said the resident had a soft hand guard that was suppose to be used on the contracted right hand, but he/she didn't know where it was. During an interview on 02/27/25 at 11:30 A.M., the Corporate Registered Nurse (RN) said the physician entered the orders for the vaccinations (Tdap, Pertussis, Prevnar 20, and COVID booster) as a routine order, therefore, the order did not generate into the nurse administration record to be given, and consequently staff did not administer the vaccinations. Administrative staff should have discovered the order in the chart review, but did not. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -One or more unhealed pressure ulcers; -Three stage 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; -Received application of non-surgical dressings. Review of the resident's Physician Order, dated February 2025, showed the following: -Right ischial (lower half of the hip bone) wound: Cleanse with normal saline, skin prep (a film-forming skin protectant) to peri wound, lightly pack wounds with Vashe (wound cleanser solution) soaked one solid length of gauze roll, cover with bordered foam, change twice a day and as needed if removed or soiled. Do not use multiple pieces of gauze. Every day and evening shift; -Coccyx (tailbone): Cleanse with normal saline, skin prep to peri wound, lightly pack wounds with Vashe soaked one solid length of gauze roll, cover with bordered foam, change twice a day and as needed if removed or soiled. Do not use multiple pieces of gauze. Every day and every evening shift. Review of the resident's Treatment Administration Record (TAR), dated 2/25/25, showed Licensed Practical Nurse (LPN) N provided the treatment to the resident's right ischium and coccyx on the evening shift. During an interview on 2/26/25 at 3:20 P.M., LPN N said the following: -The resident's wounds should be packed with gauze; -Last night (2/25/25), the wounds had some drainage so he/she just used a 4x4 gauze to cover the wounds to stop the drainage and covered them with the bordered foam dressing. Observation on 2/26/25 at 1:45 P.M., showed the Assistant Director of Nursing (ADON) entered the resident's room to perform treatment to the resident's pressure ulcers. The ADON removed bordered foam dressings from the resident's right ischium and coccyx. There was no packing in either of the resident's wounds. During an interview on 2/26/25 at 1:45 P.M., the ADON said there was an order for the pressure ulcers to be packed twice daily, so she was not sure why staff (LPN N) did not pack the pressure ulcers last night. During an interview on 2/27/25 a 10:10 A.M., the Physician Assistant said the following: -He expected staff to follow the physician orders; -The wound could worsen if staff did not pack the wound and follow the orders. During an interview on 2/27/25 at 3:15 P.M., the Director of Nursing (DON) said she expected staff to pack the wound packed as ordered. 3. Review of Resident #5's Care Plan, last reviewed/revised on 01/08/25, showed the following: -He/She required oxygen therapy as needed while in bed; -Administer oxygen as ordered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was intact; -Diagnoses included heart failure, stroke, hemiplegia (inability to move one side of the body), and anxiety; -No evidence to show the resident used oxygen during the previous seven-day look back period. Review of resident's Physician's Orders, dated February 2025, showed the following: -Apply oxygen at 2 liters (L) per nasal cannula continuously while in bed; -May titrate up oxygen to 3 liters to keep oxygen saturation level above 90% every shift (original order dated 12/18/24). Observation on 02/26/25 at 5:50 A.M., showed the resident lay in bed with oxygen via nasal cannula in place in his/her nostrils. The resident's oxygen concentrator was set to deliver 4.5 liters of oxygen per minute. Observation on 02/26/25 at 4:20 P.M., showed the resident lay in bed with oxygen nasal cannula in place in his/her nostrils. The resident's oxygen concentrator was set to deliver 4.5 liters of oxygen per minute. During an interview on 02/26/25 at 2:00 P.M., CNA B said the following: -CNAs were allowed to place oxygen on residents; -He/She applied the resident's oxygen and turned on the machine (on 2/26/25); -He/She knew what the resident's oxygen was supposed to be set at because he/she had worked with this resident a long time. Review of resident's progress notes, dated 02/26/25, showed no documentation the resident complained of shortness of breath and/or any other respiratory symptoms that warranted an increase in the resident's oxygen level. Observation on 02/27/25 at 9:00 A.M., showed the resident lay in bed with oxygen nasal cannula in place in the resident's nostrils. The resident's oxygen concentrator was set to deliver 4.5 liters per minute. During an interview on 02/27/25 at 9:15 A.M., RN H said the following: -The resident's oxygen was supposed to be set on 2 liters at night and as needed for shortness of breath or decreased oxygen saturation; -Licensed nurses were responsible for applying oxygen. He/She did not receive report that the resident required an increase in oxygen level; -The resident should not have oxygen set on 4.5 liters per minute. Review of resident's progress notes, dated 02/27/25, showed no documentation the resident complained of shortness of breath and/or any other respiratory symptoms that warranted an increase in the resident's oxygen level. During an interview on 02/27/25 at 11:20 A.M., the DON said the following: -Licensed nursing staff were responsible for applying oxygen on the residents; -CNAs could monitor and ensure oxygen was properly placed in the nose, but they were not to apply oxygen; -She expected staff to follow physician's orders as written. During an interview on 2/27/25 at 2:15 P.M., the resident's Physician's Assistant said the following: -He expected staff to follow orders as written and/or be notified if any changes were needed; -The resident's oxygen was ordered for 2 liters; -He expected staff to follow the resident's physician order, because 4.5 liters per minute was too much; -He consistently educated staff that more oxygen was not always better, and they should follow the orders and titrate as needed; -He was not notified that the resident required more oxygen than what was ordered. During an interview on 02/27/25 at 4:02 P.M., the Administrator said she expected staff to follow physician orders as written. 50189

Based on observation, interview, and record review, the facility failed to provide three residents (Residents #102, #14, and #12), who relied on staff to assist with their activities of daily living (ADLs), in a review of 17 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 56. Review of the facility's policy, Oral Care, last reviewed/revised 09/01/21, showed it was the practice of the facility to provide oral care to residents in order to prevent and control plaque associated oral diseases. (The policy did not address how often staff were to provide assistance with oral care.) Review of the facility's policy, Providing Nail Care, reviewed/revised 9/1/21, showed the following: -Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care; -Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis; -Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. 1. Review of the Resident #102's Face Sheet showed the following: -He/She admitted to the facility on [DATE]; -His/Her diagnoses included stroke and dysphagia (difficulty swallowing). Review of the resident's Care Plan, dated 02/24/25, showed no documentation related to the type of assistance the resident required for oral hygiene. Observation on 02/24/25 at 2:49 P.M., showed the resident's left (dominant) hand/arm was flaccid (inability to move) and was in a brace. The resident's breath was odorous and there was a white substance around his/her mouth. The resident had his/her natural teeth. There were no oral hygiene products (toothpaste, toothbrush) located in the resident's room. During an interview on 02/24/25 at 2:49 P.M., the resident said the following: -He/She was unable to move his/her dominant left hand and needed assistance with oral hygiene; -None of the staff had assisted him/her with oral hygiene since he/she admitted to the facility on [DATE]. During an interview on 02/26/25 at 7:10 A.M., the resident said none of the staff helped him/her with oral care since he/she was admitted and his/her mouth was starting to taste pretty bad. Observation on 02/26/25 at 7:10 A.M., showed the resident's mouth was dry with a white substance around his/her gum line. Observation on 02/26/25 at 7:25 A.M., showed Certified Nurse Assistant (CNA) B did not assist the resident with oral hygiene as part of morning care before assisting the resident to the dining room for breakfast. There were no oral hygiene products located in the resident's room. During an interview on 02/26/25 at 7:30 A.M., CNA B said he/she did not assist the resident with oral hygiene, because the resident did not have any oral care supplies in his/her room as the resident was recently admitted . He/She had not worked for a few days and did not know why there were no supplies in the resident's room. Staff was supposed to provide oral care every morning. During an interview on 02/27/25 at 9:15 A.M., Registered Nurse (RN) H said CNAs and/or the nurse should provide oral care for residents, including residents with no teeth, every eight hours and/or shiftly. During an interview on 02/27/25 at 11:30 A.M., the Director of Nursing (DON) said CNAs should assist residents with oral care at a minimum with morning care. During an interview on 2/27/25 at 4:00 P.M., the Administrator said she expected staff to provide oral care in the morning, in the evenings, and as needed. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -Cognition intact; -No rejection of care; -Dependent on staff for all ADLs. Review of the resident's Care Plan, revised on 2/24/25, showed the following: -He/She was dependent on staff for all ADLs; -He/She was able to make his/her needs known and wanted to make care decisions; -Check nail length and trim and clean on bath day and as necessary. Observation on 2/24/25 at 3:05 P.M. showed the resident lay awake in bed. The resident's fingernails were very long. During an interview on 2/24/25 at 3:05 P.M., the resident said the following: -His/Her nails were way too long and needed to be cut; -Staff usually cut his/her nails; they had not done this though for a while. Observation on 2/25/25 at 2:45 P.M. showed the resident lay in bed. The resident's fingernails were very long. 3. Review of the Resident #12's Face Sheet showed the resident's diagnoses included stroke, cognitive communication deficit, disorganized schizophrenia (mental disorder characterized by hallucinations, delusions, and disorganized thinking and behavior), Parkinson's disease (neurodegenerative disease affecting both motor and non-motor systems), and need for assistance with personal cares. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She required supervision or touch assistance with personal hygiene and bathing. Review of the resident's Care Plan, revised 10/30/24, showed the following: -Required supervision/cues with cares due to diagnosis of schizophrenia, to ensure he/she had completed ADLs appropriately; -Staff to check nail length, trim and clean them on bath day and as necessary. Observation on 2/24/25 at 1:15 P.M., showed some of the resident's fingernails were long, jagged, and had brown debris under the nails. Observation on 2/25/25 at 11:27 A.M., showed some of the resident's fingernails were long, jagged, and had brown debris under the nails. Observation on 2/26/25 at 5:53 A.M., showed some of the resident's fingernails were long, jagged and had brown debris under the nails. Observation on 2/26/25 at 12:50 P.M., showed some of the resident's fingernails were long, jagged and had brown debris under the nails. Observation on 2/27/25 at 9:00 A.M., showed some of the resident's fingernails were long, jagged and had brown debris under the nails. During an interview on 2/27/25 at 11:15 A.M., CNA D said the following: -All staff were responsible for providing nail care; -CNAs should check residents' nails on shower days; -The resident does his/her own showers with staff supervision; -CNA D checked residents' nails on shower days and cleaned and cut them if needed. During an interview on 2/27/25 at 2:20 P.M., CNA B said the following: -A typical shower consisted of checking residents' nails; -He/She gave the resident a shower on 2/26/25 and did not notice the resident's nails needed to be cut. 4. During an interview on 2/27/25 at 2:10 P.M., RN J said he/she expected the aides to provide nail care with shower at least twice a week. During an interview on 2/27/25 at 10:00 A.M., the Assistant Director of Nursing (ADON) said aides should provide nail care on shower days and as needed. During an interview on 2/27/25 at 3:16 P.M., the DON said the following: -CNAs should complete nail care or at least check the residents' nails with showers; -Staff should completed nail care when needed and when the nails are soiled, broken or uneven. During an interview on 2/27/25 at 4:00 P.M., the Administrator said she expected staff to clean and trim/file nails on shower days and as needed. 45563 49528

Based on observation, interview, and record review, the facility failed to provide evidence the facility offered the pneumococcal vaccination to three residents (Residents #5, #29, and #36), in a review of 17 sampled residents, and failed to provide education to each resident or resident representative regarding the benefits and potential side effects of the pneumococcal vaccination. The facility census was 56. Review of the facility policy, Pneumococcal Vaccine, dated 9/1/21, showed the following: -It is the facility policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with Centers for Disease Control and Prevention (CDC) guidelines and recommendations; -Each resident will be assessed for pneumococcal immunization upon admission, self-report of immunization shall be accepted, any additional efforts to obtain information shall documented, including efforts to determine date of immunization or type of vaccine received; -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized, following assessment for any medical contraindications the immunization may be administered in accordance with physician-approved standing orders; -Prior to offering the pneumococcal immunization, each resident or the resident's representative will received education regarding the benefits and potential side effects of the immunization; -The individual receiving the immunization, or the resident's representative, will be provided with a copy of the CDC's current vaccine information statement relative to that vaccine; -If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding; -The resident/representative retains the rights to refuse the immunization, a consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record; -The type of pneumococcal vaccine offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations; -Usually only one pneumococcal polysaccharide vaccination (PPSV) is needed in a lifetime, however, based on an assessment and practitioner recommendation, additional vaccines may be provided; -The resident's medical record shall include documentation that indicates at a minimum, the following: A. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; B. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Review of the CDC's recommendations for pneumococcal vaccine timing, dated 04/01/22, showed the following: -CDC recommends pneumococcal vaccination for adults [AGE] years old or older; -For adults who have never received a pneumococcal vaccine, or those with unknown vaccination history, one dose of PCV 15 (15-valent pneumococcal conjugate vaccine) or PCV 20 (20-valent pneumococcal conjugate vaccine) should be administered; -If PCV 20 is used, their pneumococcal vaccinations are complete; -If PCV 15 is used, follow with one dose of PPSV 23 (23-valent pneumococcal polysaccharide vaccine) with a recommended interval of at least one year; -For adults who have previously received PPSV 23 but who have not received any pneumococcal conjugate vaccine (PCV), one does of PCV 15 or PCV 20 may be administered with an interval of at least one year; -For adults [AGE] years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, who have previously received PCV13 at any age, it is recommended to receive one dose of PPSV 23 at or after [AGE] years of age (at least one year after PCV13 was received). Their pneumococcal vaccinations are complete; -For adults [AGE] years or older with an immunocompromising condition who have previously received a PCV13 at any age, CDC recommends two doses of PPSV 23 before age [AGE] years and one dose of PPSV 23 at the age of 65 or older. Administer a single dose of PPSV23 at least 8 weeks after the PCV13 was received. -If the patient was younger than [AGE] years old when the first dose of PPSV23 was given and has not turned [AGE] years old yet, administer a second dose of PPSV23 at least five years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to [AGE] years of age. -Once the patient turns [AGE] years old and at least five years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations. 1. Review of Resident #5's face sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was over [AGE] years old; -His/Her diagnoses included unspecified organ and tissue transplant with rejection. Review of the resident's vaccination record showed the following: -The resident received PPSV 23 on 02/05/22; -There was no documentation to show the resident received any other pneumococcal vaccinations prior to or after administration of PPSV 23; -There was no documentation to show the facility offered the PCV 20 vaccination to the resident per CDC guidelines. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 01/22/25, showed the resident was up to date with pneumococcal vaccinations. Review of the resident's medical record showed no documentation the facility offered the resident the pneumococcal vaccination, and no documentation the facility provided education to the resident regarding the benefits and potential side effects of the vaccination. 2. Review of Resident #29's face sheet showed the following: -admitted on [DATE]; -Diagnoses included cancer of the hypopharynx (the lower part of the throat) and chronic obstructive pulmonary disease (COPD); Review of the resident's admission MDS, dated [DATE], showed the resident was not up to date on his/her pneumococcal vaccinations. Staff documented the reason the resident did not receive the vaccination was because it was not offered. Review of the resident's Medication Administration Record (MAR), dated 11/15/24, showed the resident was to receive the PPSV23 vaccine. There was no documentation staff administered the vaccine. Review of the resident's significant change in status MDS, dated [DATE], showed the resident was not up to date on his/her pneumococcal vaccinations. Staff documented the reason the resident did not receive the vaccination was because it was not offered. Review of the resident's immunization record, located in the electronic medical record, showed no documentation the resident received a pneumococcal vaccine prior to or after admission to the facility. Review of the resident's medical record showed no documentation the facility offered the resident the pneumococcal vaccination, and no documentation the facility provided education to the resident regarding the benefits and potential side effects of the vaccination. During an interview on 2/27/25 at 2:59 P.M., the Corporate Registered Nurse (RN) said he could not locate any documentation staff administered the PPSV23 vaccine to the resident. During an interview on 2/27/25 at 3:16 P.M., the Director of Nursing (DON) said she was not aware the resident had not received the pneumococcal vaccine. 3. Review of Resident #36's Face Sheet showed the following: -admitted to the facility on [DATE]; -He/She was over [AGE] years old; -His/Her diagnoses included adult failure to thrive. Review of the resident's vaccination record showed the following: -The resident received Prevnar 13 (PCV13) on 12/12/14; -There was no documentation to show the resident received any other pneumococcal vaccinations prior to or after administration of the PCV13 vaccination. Review of the resident's quarterly MDS, dated [DATE], showed the resident was up to date with pneumococcal vaccinations. Review of the resident's medical record showed no documentation the facility offered the resident the pneumococcal vaccination, and no documentation the facility provided education to the resident regarding the benefits and potential side effects of the vaccination. 4. During an interview on 2/27/25 at 4:02 P.M., the Administrator said she expected staff to follow the Centers for Disease Control and Prevention (CDC) guidelines for determining the administration of pneumococcal vaccines.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for two residents (Residents #405 and #102), in a review of 17 sampled residents. The facility census was 56. Review of the facility's policy, Baseline Care Plans, last reviewed 09/01/21, showed the following: -The facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; -A baseline care plan would be developed within 48 hours of a resident's admission; -The admitting nurse, or supervising nurse on duty, should gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable; -Interventions should be initiated that addressed the resident's current needs that may include, but not limited to any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; -Once established, goals and interventions should be documented in the designated form; -The summary should include the initial goals of the resident, a summary of the resident's medication and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 1. Review of Resident #405's hospital medical records, dated 2/10/25, showed the following: -The resident had an unstageable pressure injury (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable tissue that accumulates on the surface of a wound) or eschar (dead tissue within a wound)) to the sacrum (the large, triangle shaped bone at the base of the spine that connects the spine to the pelvis); -The resident had an unstageable pressure injury to the right hip; -The resident had an unstageable pressure injury to the right elbow. Review of the resident's undated face sheet showed the following: -admitted on [DATE]; -Diagnosis included metabolic encephalopathy (a change in how the brain works due to an underlying condition). Review of the resident's Progress Notes, dated 2/13/25 at 1:36 P.M., showed the Director of Nursing (DON) documented the resident arrived on a stretcher, with a surgical dressing in place from a pacemaker placement. The resident had a wound on this/her sacrum that measured 14 x 8 x 0.1 (no unit of measure provided), with the wound bed comprised of less than 3% slough. Both of the resident's legs were contracted. Review of the resident's Physician Order Sheet, dated February 2025, showed the following: -No added salt diet, mechanical soft texture, regular/thin liquids consistency (original order dated 2/13/25); -Right hip superior, clean with normal saline, pat dry, apply Santyl (an ointment that removes dead tissue from a wound), every day shift for unstageable wound (original order dated 2/13/25); -Weekly skin assessment, every day shift, every Friday, if there are any new skin issues, identify on skin assessment (original order dated 2/13/25) -Weekly weights for four weeks from admission, then monthly weights (original order dated 2/13/25). -Clean with normal saline, pat dry, apply dry dressing daily, one time a day for sacrum (original order dated 2/14/25); -Clean with normal saline, pat dry, apply Santyl right hip one time a day for unstageable wound (original order dated 2/14/25). Review of the resident's Care Plan, dated 2/14/25, showed the care plan included the resident's rights. The care plan did not include the type of assistance the resident required for activities of daily living (ADLs), his/her diet, pressure ulcers present on admission, weekly weights, incontinence, or any refusal of care. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/15/25, showed the following: -Cognitively intact; -No behaviors or rejection of care; -Impairment of both lower extremities; -Required set up and clean up assistance with eating; -Required maximum assistance with toileting, showering/bathing, lower body dressing, and personal hygiene; -Required supervision/touching assistance with upper body dressing; -Was dependent on staff for putting on/taking off footwear and all mobility (rolling in bed, sitting up, lying down, standing, and all transfers); -Was always incontinent of bowel and bladder; -Had two stage III pressure ulcers (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Undermining and tunneling may also occur) and one unstageable pressure ulcer on admission; -Was on a mechanically altered diet. Review of the resident's Physician Order Sheet, dated February 2025, showed the following: -Right hip, clean with normal saline/wound cleanser, pat dry, apply calcium alginate once daily, abdominal (ABD) pad and cover site dressing, every day shift for right hip (original order dated 2/19/25); -Sacrum, clean with wound cleanser/normal saline, pat dry, apply calcium alginate, ABD pad and cover site dressing, every day shift (original order dated 2/19/25). Review of the resident's care plan, dated 2/21/25, showed staff added the following to the resident's care plan: -The resident required enhanced barrier precautions for chronic wounds; -The resident had a stage III pressure ulcer on his/her right hip, a stage III pressure ulcer on his/her sacrum and an unstageable pressure ulcers on his/her left heel related to his/her impaired mobility. -Staff did not updated the care plan to include the type of assistance the resident required for ADLs, his/her diet, weekly weights, incontinence, or any refusal of care. Observation on 2/25/25 at 12:16 P.M., showed the Corporate Registered Nurse (RN) delivered the resident's meal tray and asked if the resident wanted help to eat. The resident initially refused, but then agreed. Certified Medication Technician (CMT) F attempted to feed resident. Observation on 2/25/25 at 12:21 P.M., showed CMT F left the resident's room. CMT F said the resident refused to eat any of his/her meal. Observation on 2/26/25 at 5:57 A.M., showed Certified Nurse Assistant (CNA) O and CNA P provided incontinence care to the resident. Observation on 2/26/25 at 7:53 A.M. showed CMT L assisted the resident to eat his/her breakfast. Observation on 2/26/25 at 9:19 A.M. showed the Assistant Director of Nursing (ADON) attempted to provide wound care to the resident, who refused. During interviews on 2/26/25 at 3:02 P.M. and 2/27/25 at 12:41 P.M., RN J said the following: -The resident had been refusing most cares, including getting out of bed, since his/her arrival to the facility; -The resident had been refusing to get up since he/she admitted , so staff had not been able to obtain an accurate weight; -Today was the first day he/she had seen the resident out of bed and in a wheelchair; -The resident required a mechanical lift for transfers; -The resident required assistance from staff to eat, but could drink on his/her own. Observation on 2/27/25 at 12:19 P.M., showed CNA B assisted the resident to eat his/her lunch During an interview on 2/27/25 at 1:01 P.M., CNA B said the resident had been refusing most of his/her cares since arriving to the facility. During an interview on 2/27/25 at 1:04 P.M., the Physician Assistant said the following: -He/She was not aware staff did not obtain the resident's weight, but they likely did not weigh the resident due to the resident's refusal and resistance to cares; -He/She would have expected staff to obtain and document the resident's weights. In the case the resident refused, he/she would have expected the staff to document the refusal make other attempts to obtain the resident's weight. During an interview on 2/27/25 at 3:16 P.M., the Director of Nursing (DON) said if the resident refused, she would expect staff to properly document and provide education to the resident. 2. Review of Resident #102's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -Diagnoses included stroke, dysphagia (difficulty swallowing), and anxiety. Review of a nursing progress note, dated 02/26/25 at 2:44 P.M., showed the resident admitted to the facility on [DATE] after he/she suffered a cerebral infarction (stroke) with left side (dominant) paresis (inability to move one side of the body). His/Her arm was in a brace and he/she worked with physical therapy, occupational therapy, and speech therapy. During an interview on 02/24/25 at 2:49 P.M., the resident said the following: -He/She was unable to move his/her dominant left hand and needed assistance with oral hygiene; -He/She required assistance with transfers. Observation on 02/24/25 at 2:49 P.M., showed the resident was unable to move his/her left arm. The resident wore a brace on his/her left arm/wrist. Observation on 02/26/27 at 7:30 A.M., showed two staff transferred the resident from the bed to the wheelchair with a gait belt. Review of the resident's care plan, completed on 2/23/25, showed the facility did not address the resident's care needs including transfer status, assistance needed for oral care, use of a left arm/hand brace, or therapy services. During an interview on 2/27/25 at 9:15 A.M., RN H said the nurse who completed a resident's admission should complete an initial/baseline care plan. The care plan should be based on the nurse's initial assessment and the resident's initial care needs should be included on the baseline care plan. He/She was unsure why the baseline care plan was not completed for Resident #102. 3. During interviews on 02/27/25 at 11:30 A.M. and 3:16 P.M., the DON said completion of a baseline care plan had always been an expectation of the admitting nurse, but was not included on the checklist to ensure it was completed. She was unsure of the time frame requirement for a baseline care plan to be completed. During an interview on 2/27/25 at 4:02 P.M., the Administrator said she would expect baseline care plans to be done following guidelines and regulations and completed within 48 hours of a resident's admission. 45563 50189

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #26 and #4), in a review of 17 sampled residents, had call lights within reach. The facility census was 56. Review of the facility policy, Call Lights: Accessibility and Timely Response, last revised September 2021, showed the following: -The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance; -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -All residents will be educated on how to call for help by using the resident call system; -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; -Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (Examples include touch pads, larger buttons, bright colors, etc.); -With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/16/24, showed the following: -Cognition was severely impaired; -Required partial to moderate assistance from lying to sitting on side of bed; -Required partial to moderate assistance with transfers; -Required substantial to maximal assistance with walking 10 feet - once standing, the ability to walk at least 10 feet in a room, corridor, or similar space; -Used a manual wheelchair. Review of the resident's care plan, last revised 02/10/25, showed the following: -He/She had an activities of daily living (ADL) self-care performance deficit; -He/She was blind and required guidance; -He/She was impulsive and had a history of falls/at risk for falls related to confusion, decreased balance, and blindness; -Be sure his/her call light is within reach or attached to his/her person; -Staff to do frequent rounds and to toilet and lay down after meals; -Anticipate and meet his/her needs; -He/She was to be laid down after meals. Observation on 2/24/25 at 12:50 P.M., showed the following: -The resident sat on the side of the bed with his/her meal tray on the over-bed-table in front of him/her. There were no staff in the resident's room; -The resident said he/she was blind and asked multiple times what food items were on his/her tray; -The resident touched around his/her tray feeling for the food and for his/her drink glass with juice; -The resident said he/she could not find the juice and asked for assistance to find it on his/her tray; -The resident asked for more chips and called out, Hello. More chips. Hello, nurse.; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. During interview on 2/24/25 at 1:05 P.M., the resident said he/she had no way to ask for help. He/She did not have a call light, or if he/she had one, he/she didn't know where it was. He/She was blind, so staff would have to put the call light somewhere he/she could find it and access. He/She couldn't call for help and would like for someone to come by his/her room periodically and ask if he/she needed something. Observation on 2/24/25 at 1:42 P.M., showed the resident lay in bed. The resident called out, Nurse. Nurse. Hello! No staff was in the hallway. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/24/25 at 2:04 P.M., showed the resident lay in bed. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/24/25 at 2:55 P.M. showed the following: -The resident lay awake in bed; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. During an interview on 2/24/25 at 2:55 P.M., the resident said the following: -He/She never had a call light to use; -He/She asked where the call light was located; -He/She wished he/she had a call light; -He/She thought there ought to be a way to get a hold of someone when he/she needed something. Observation on 2/25/25 at 11:40 A.M. showed the following: -The resident lay awake in bed; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/25/25 at 12:17 P.M. showed the following: -The resident was in bed; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/25/25 at 2:30 P.M. showed the following: -Certified Medication Technician (CMT) F and the Social Services Director (SSD) assisted the resident to the bathroom and then back into his/her wheelchair; -The resident wore a t-shirt and an incontinence brief and did not wear any pants; -The resident said he/she was very cold and would like a blanket and would like to lay back down; -CMT F covered the resident with a blanket and told him/her that he/she would have to get his/her pants from the shower room and left the room; -CMT F left the room around 2:40 P.M. and did not return with the resident's pants; -The resident sat in his/her wheelchair near the middle of the room with a blanket. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. During an interview on 2/25/25 at 3:05 P.M., the resident said he/she would like to go to bed. Observation on 2/25/25 at 3:05 P.M. showed the resident called out, Hello, can I please go to bed now? The SSD talked to the resident and said she was working on getting the resident's belongings moved to his/her new room and staff would lay him/her down once they got his/her bed cleaned and made. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/25/25 at 3:35 P.M. showed the resident still slumped down in his/her wheelchair. The resident was not wearing pants and was covered with a blanket. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/25/25 at 4:50 P.M. showed the resident remained slumped down in his/her wheelchair. The resident's legs were stretched out in front of him/her, and he/she was covered with a blanket. The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/25/25 at 5:15 P.M. showed the following: -The resident lay on the floor in front of his/her wheelchair; -His/Her blanket lay behind him/her on the floor; -The resident was curled up on his/her left side. The resident was not wearing pants and his/her t-shift was pulled over his/her knees. During an interview on 2/25/25 at 5:15 P.M., the resident said he/she had been asking to lay down, so he/she put one knee down and then the next to lay himself/herself down (on the floor). During an interview on 2/27/25 at 1:30 P.M., the resident's family member and power of attorney (POA) said the resident could use the call light to call for help if he/she remembered. During an interview on 2/27/25 at 2:10 P.M., Registered Nurse (RN) J said the following: -The resident was blind so he/she usually hollered if he/she needed anything; -He/She thought the resident had a call light, but he/she was not sure; -He/She expected for the resident's call light to be within the resident's reach at all times. During an interview on 2/27/25 at 2:20 P.M., CMT L said the resident's call light should be within reach at all times. During an interview on 2/27/25 at 10:00 A.M., the Assistant Director of Nursing (ADON) said resident should have his/her call light within reach at all times. During an interview on 2/27/25 at 3:15 P.M., the Director of Nursing (DON) said she expected the resident's call light to be within reach at all times. During an interview on 2/27/25 at 4:00 P.M., the Administrator said she expected all residents' call lights to be within reach. 2. Review of Resident #4's Care Plan, last revised 11/18/24, showed the following: -He/She has an ADL performance deficit and impaired vision and required assistance with all care; -Encourage him/her to use bell to call for assistance; -He/She was at risk for falls, gait/balance problems, was legally blind and had decreased safety awareness: -Be sure his/her call light is within reach and encourage him/her to use it for assistance as needed; -He/She has a communication problem; -He/She sometimes had a hard time making his/her needs known. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition severely impaired; -Required substantial/maximal assistance for transfers; -Frequently incontinent of urine. Observation on 2/24/25 at 2:55 P.M. showed the following: -The resident sat awake on his/her bed; -The resident's call light hung on the wall in between the beds in the room and was not within the resident's reach. During an interview on 2/24/25 at 3:00 P.M., the resident said the following: -When asked if he/she was able to use the call light, the resident said, Yes, yes, yes; -He/She shook his/her head back and forth, side to side when asked if he/she knew where the call light was. Observation on 2/26/25 at 5:55 A.M., showed the following: -The resident lay on his/her back in bed. The resident was awake and made screaming noises; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. Observation on 2/26/25 at 7:23 A.M., showed the following: -The resident sat in bed; -The resident's call light hung on the wall between the two beds in the room and was not within the resident's reach. During an interview on 2/26/25 at 8:40 A.M., Certified Nurse Assistant (CNA) B said the resident was able to use the call light. During an interview on 2/27/25 at 3:15 P.M., the DON said she expected the resident to have his/her call light within reach at all times. During an interview on 2/27/25 at 4:00 P.M., the Administrator said she expected the resident to have his/her call light within reach at all times.

Based on interview and record review, the facility failed to ensure four residents (Resident #2, #3, #4, and #5) in a review of five sampled residents were treated with respect and dignity, when residents reported staff cursed at them when responding to the residents and their needs. The residents reported the comments made them feel bad, worthless, upset, and less than human. The facility census was 53. Review of the facility policy for Resident Rights with a revision date of 9/3/22 showed the following: -The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; -The resident has the right to a dignified existence. 1. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 11/8/24 showed the following: -Able to make self understood and able to understand others; -Alert and oriented able to make decisions; -Diagnosis of schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). During an interview on 12/9/24 at 11:30 A.M., the resident said the following: -There were several staff members who said fuck, shit, and damn around him/her and raised their voices when around the residents; -He/She had reported this to the staff, but nothing had been done about it; -He/She did not like staff using these words, it made him/her feel bad and worthless. 2. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Diagnoses of depression and schizophrenia. During an interview on 12/9/24 at 12:30 P.M., the resident said the following: -There were some staff members who were very disrespectful in how they treated and talked to him/her; -Staff frequently said fuck when speaking to him/her and what the fuck do you want?. This made him/her feel ignorant; -It did not do any good to report this, nothing was ever done. 3. Review of Resident #4's comprehensive MDS dated [DATE] showed the following: -Able to make self understood and able to understand others; -Alert and oriented with some difficulty with decision making; -Diagnoses of schizophrenia, depression, and anxiety. During an interview on 12/9/24 at 11:15 A.M., the resident said the following: -There were some staff members, mainly on the evening and night shifts, that said fuck, damn, shit when taking care of him/her; -He/She did not like it when the staff used these words; -It upset him/her when staff talked like this. 4. Review of Resident #5 quarterly MDS dated [DATE] showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Diagnosis of anxiety. During an interview on 12/9/24 at 3:00 P.M., the resident said the following: -There were some staff members on the evening and night shifts that talked to him/her in a rough and degrading manner; -The staff said fuck, damn, shit and what the fuck do you want? when answering his/her call light; -The way staff talked to him/her made him/her feel less than human; -He/She had reported this to the nurses, but nothing had been done about it. During an interview on 12/9/24 at 3:45 P.M., Licensed Practical Nurse (LPN) A said there were some staff members who talked in a rough manner. During an interview on 12/9/24 at 4:11 P.M., the Director of Nursing (DON) and the facility Administrator said the following: -They expected staff to not use foul language in front of the residents and to treat and speak to them with respect and dignity. After the surveyor shared the words and comments residents reported staff were directing to them, both the DON and administrator felt these described a dignity issue. MO246121

Based on interview and record review, the facility failed to ensure one resident (Resident #1) in a review of five sampled residents was free from verbal abuse. The resident reported staff cursed at him/her when responding to the resident and his/her needs. The resident said the verbal abuse made him/her feel angry and upset. The facility census was 53. Review of the facility policy for Abuse, Neglect and Exploitation with a revision date of 8/23/22 showed the following: -It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of the facility policy for Resident Rights with a revision date of 9/3/22 showed the following: -The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included anxiety and depression. Review of the resident's psychosocial assessment dated [DATE] showed the following: -Moderate impairment in cognition; -Has some delusions and showed signs of depression. Review of the resident's care plan for Residents' Rights dated 12/05/24 showed the following: -The resident's autonomy and dignity will be honored in the personal choices that he/she makes; -The resident has the right to be treated with consideration, respect, and dignity. During an interview on 12/9/24 at 12:00 P.M., the resident said the following: -A couple of days ago, a staff member was providing him/her care and called him/her a fucking bitch and told him/her to shut the fuck up then the staff member walked out of his/her room; -This made him/her angry and upset that a staff member would talk to him/her this way; -He/She did not know the person's name; -His/Her family member was on the telephone with him/her when the staff member talked to him/her this way. During an interview on 12/9/24 at 12:00 P.M., the resident's sister, [NAME] said the following: -He/She was talking on the phone with Resident #1 when he/she heard someone at the facility say fucking bitch and shut the fuck up; -He/She did not know who the person was; -It sounded like this person was in the resident's room when this was said. During an interview on 12/9/24 at 3:45 P.M., Licensed Practical Nurse (LPN) A said there were some staff members who talked in a rough manner. During an interview on 12/9/24 at 4:11 P.M., the Director of Nursing (DON) and the facility Administrator said the following: -They expected staff to not use foul language in front of the residents and to treat and speak to them with respect and dignity. After the surveyor shared the words and comments the resident reported staff directed at him/her, both the DON and administrator felt these described a dignity issue, rather than verbal abuse. MO246121

Based on interview and record review, the facility failed to safely transfer one cognitively intact resident (Resident #157), who had a diagnosis of quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), in a review of 17 sampled residents. Per the resident's interview, two unidentified staff (only identified by gender) failed to maintain control of the resident during a mechanical lift transfer, causing the resident's legs to hit the lift. When the resident was over the bed, staff hit the emergency release instead of the lowering button, and the resident dropped to the bed with his/her legs bent underneath him/her. During assessment, staff identified the resident had skin tears to both of his/her legs. The resident had pain and swelling in his/her legs and was sent to the hospital for evaluation. The resident was diagnosed with bilateral leg fractures consistent with the described incident. Staff failed to safely transfer two residents (Residents #12 and #36) in the mechanical lift when staff did not maintain control of the residents during the transfer. The wheels on the mechanical lift did not function properly during the transfers and staff forcefully pushed the lifts causing the residents to swing while suspended in the mechanical lift. The facility failed ensure the mechanical lifts utilized to transfer residents were maintained in good repair to ensure resident safety during transfers. The facility census was 54. The administrator was notified of the Immediate Jeopardy (IJ) on 8/23/24 at 5:00 P.M. which began on 8/5/24. The IJ was removed on 8/27/24 as confirmed by surveyor onsite verification. Review of the facility policy, Safe Resident Handling/Transfers, dated 09/01/21, showed the following: -The facility is to ensure that residents are handled and transferred safely to prevent or minimize risks for injury; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves; -Dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used; -Resident lifting and transferring will be performed according to the resident's individual plan of care; -Staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly; -Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy; -Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 1. Review of Resident #157's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 06/17/24, showed the following: -Cognitively intact; -Limited range of motion in bilateral upper and lower extremities; -Dependent on staff for all transfers. Review of the resident's Face Sheet, dated August 2024, showed the following diagnoses: -Quadriplegia; -Need for assistance with personal care; -Other abnormalities of gait and mobility. Review of the resident's undated Care Plan showed the following: -The resident was unable to ambulate; -The resident was dependent on staff for all activities of daily living, including transfers; -Two staff were to use a Hoyer lift for transfers, and to use proper safety precautions. Review of the resident's Physician Orders, dated August 2024, showed oxycodone (a narcotic pain medication used to treat moderate to severe pain) 10 milligram (mg) tablet, give 10 mg every six hours as needed for pain. Review of the resident's Medication Administration Record (MAR), dated August 2024, showed staff administered oxycodone 10 mg as needed on 08/02/24 at 1:35 P.M. for a pain level of eight (on a scale of one to ten with a ten being the most pain). Review of the resident's MAR on 08/05/24 showed staff administered oxycodone 10 mg at 4:51 A.M. for a pain level of six. Review of the resident's Progress Note, dated 08/05/24 at 12:08 P.M. showed the MDS Coordinator/Licensed Practical Nurse (LPN) S was made aware of two skin tears on the resident's shins. He/She measured and assessed the skin tears. Review of the resident's Weekly Skin Check, dated 08/05/24, showed the following: -Skin tear to the front of the right lower leg; -Skin tear to the front of the left lower leg. During an interview on 08/28/24 at 5:33 A.M., Certified Nurse Assistant (CNA) V said the following: -He/She worked with the resident on 08/05/24; -He/She noticed both the resident's legs were swollen and there was a skin tear on the left lower leg; -He/She asked the resident what happened, and the resident said it must have happened when staff were rolling him/her in bed, but he/she could not say exactly when it happened; -He/She notified the wound nurse of the swelling, skin tear and what the resident reported happened. During an interview on 08/23/24 at 10:00 A.M., the wound nurse said the following: -On 08/05/24, staff notified him/her of skin tears on the resident's legs; -The staff told him/her the resident's legs hit the wall when staff rolled the resident onto his/her side while in bed; -He/She did not ask the resident what happened or initiate any further investigation or reporting. Review of the resident's medical record showed no documentation to show the resident obtained the skin tears as a result of staff rolling him/her into the wall while in bed. Review of the resident's MAR on 08/05/24 showed staff administered oxycodone 10 mg at 1:54 P.M. for a pain level of five. Review of the resident's MAR on 08/06/24 showed staff administered oxycodone 10 mg at 12:45 A.M. for a pain level of five. Review of the resident's Progress Note, dated 08/07/24 at 11:30 A.M., showed the Director of Nursing (DON) documented a CNA (CNA N) notified him/her that the resident's bilateral lower extremities appeared to look different. The DON assessed the bilateral lower extremities and found no bruising, abrasions, cuts or tears. The DON noticed swelling to the resident's right knee. The DON notified the nurse practitioner (NP) who was in the building at the time. The NP assessed the resident, found no signs of recent trauma, like bruising, but ordered x-rays (a photographic, or digital image, of the inside of the body) of the bilateral lower extremities to rule out fractures. The resident was cognitively intact, alert and oriented, and was asked about recent falls or other injuries and the resident denied experiencing any incidents. During an interview on 08/23/24 at 4:10 P.M., CNA N said the following: -He/She worked with the resident on 08/07/24; -He/She had worked with the resident prior to 08/07/24, but it had been a few days; -Prior to 08/07/24, he/she had not noticed anything abnormal with the resident's legs; -He/She notified the DON that the resident's legs were swollen and the left leg was curved different and did not appear normal; -He/She asked the resident what happened, and the resident said he/she did not know. Review of the resident's Physician Progress Note, dated 08/07/24, showed the resident was seen for complaints of right knee pain and left leg pain. The resident's right knee was swollen and his/her left leg was slightly deformed and bowed out. The resident was sent to the emergency room after x-ray results, which showed fluid on the right knee and a fracture of the left lower leg. Review of the resident's x-ray results, dated 08/07/24, showed the following: -Comminuted (caused by trauma) fracture of the left medial femoral condyle (the lower portion of the femur, or thigh bone); -Relatively nondisplaced (still in correct position or alignment) comminuted oblique fracture (a type of broken bone, where the bone is broken at an angle and the break goes all the way through the bone) at the proximal diaphyseal aspect of the tibia (the upper portion of the lower leg bone, closest to the knee); -Moderate-sized suprapatellar effusion (swelling around the knee) with a nondisplaced oblique fracture at the proximal diaphyseal aspect of the tibia; -Relatively nondisplaced fracture at the distal diaphyseal aspect of the femur (the lower portion of the upper leg bone, closest to the knee); -A CT Scan (a diagnostic imaging procedure that uses x-rays and computer technology to produce more detailed images of inside the body) was recommended for full assessment. Review of the resident's MAR on 08/07/24 showed staff administered oxycodone 10 mg at 11:13 P.M. for a pain level of four. Review of the resident's MAR on 08/08/24 showed staff administered oxycodone 10 mg at 11:35 P.M. for a pain level of six. Review of the resident's Progress Note, dated 08/08/24 at 4:52 P.M., showed the resident had a deformity in the left lower extremity that was bowed out. The NP wanted the resident sent to the emergency room for a CT scan to rule out pathological fractures of the left lower extremity and right lower leg, including the tibia (bone of the lower leg) and femur (bone of the upper leg, or thigh). The resident will need an orthopedic consult. Emergency Medical Services (EMS) called at this time to transport to the emergency room . Review of the resident's MAR on 08/08/24 showed staff administered oxycodone 10 mg at 5:20 P.M. for a pain level of six. Review of the resident's Progress Note, dated 08/08/24 at 6:45 P.M. showed the facility received orders from the NP to send to the resident to the emergency room for a bone density scan (a low-dose x-ray that measures calcium and other minerals in your bones to determine bone strength). Staff administered as needed pain medication (oxycodone) for six out of ten back pain. The EMS team left the facility with the resident. Review of the EMS Report, dated 08/08/24, showed the following: -Primary impression: extremity pain; -Chief complaint: leg pain for two days; -Extremities assessment: bilateral whole legs, motor function absent, pain, and swelling; -Narrative: the resident reported his/her legs had been swollen and hurting for a couple days. Review of the resident's hospital orthopedic consultation note, dated 08/12/24, showed the following: -The resident was not able to move his/her legs, but had the ability to detect pain in the legs; -The resident reported pain in the right leg at the kneecap and around the left lower leg; -The resident reported being moved with a Hoyer lift, when his/her knees torqued (twisted) after his/her legs were caught during movement; -X-rays were taken and the resident was found to have nondisplaced fractures of the right distal femur and left proximal tibia. Review of the resident's hospital x-ray records, dated 08/13/24, showed the following: -A comminuted mildly displaced fracture through the proximal tibial metadiaphysis of the left leg; -A comminuted mildly displaced fracture through the fibular neck of the left leg; -A mildly displaced supracondylar fracture of the distal femur of the right leg and may have intra-articular extension (the fracture continues into the joint space, indicating a more serious injury); -A mild valgus (an outward angle) of the femoral condyles in relationship to the distal femur of the right leg. Review of the resident's hospitalist discharge note, dated 08/14/24, showed the following: -The resident complained of bilateral leg pain; -Imaging demonstrated fractures; -Orthopedics saw the resident and recommended conservative (no surgery) management given his/her paraplegia; -The resident reported his/her legs were twisted at the nursing home, while in a lift; -It is felt this was when the fractures occurred. During interview on 08/22/24 at 5:46 P.M., the resident said the following: -He/She did not have movement in his/her extremities, but did have feeling; -He/She was sent to the hospital due to increased pain and fractures; -He/She reported two CNAs (only identified by gender) transferred him/her with a Hoyer lift and had problems with the lift, as it was being wonky to rotate around. The sling attachment that rotated his/her body and the legs of the lift were not moving smoothly, making the transfer feel unstable; -As the staff turned him/her in the lift, his/her legs hit one side of the lift. As the staff spun him/her the other way, his/her legs hit the other side of the lift; -When the staff went to lower him/her to the bed, the staff used the emergency release and lowered the resident quickly onto the bed with his/her legs bent underneath his/her body; -After this occurred, the staff repositioned him/her; he/she did not notice any pain; -No other staff came in that day to check on him/her. He/she did not report this to any staff as he/she was not experiencing pain; -The nurse practitioner came to see him/her on 8/7/24, the day before he/she was sent to the hospital (the resident was sent to the hospital on 8/8/24), two or three days after the incident occurred. He/She told the NP his/her legs hit the Hoyer lift during a transfer; -The wound nurse noticed skin tears on both of his/her lower legs a day or two before the NP saw him/her; -He/She told the NP and the DON on 08/07/24 about his/her legs hitting the Hoyer lift during the transfer. During interviews on 08/22/24 at 7:50 A.M. and 11:50 A.M., the Administrator said she didn't think the facility had any incidents or injury of unknown origin reports in the month of August. At 11:50 A.M., the Administrator provided a report which indicated one witnessed fall involving another resident and no injuries of unknown origin. During an interview on 08/23/24 at 10:44 A.M., the NP said the following: -A CNA told him/her the resident wanted to talk to him/her about pain in his/her right knee (on 8/7/24); -Upon examination, he/she noticed extreme swelling and tenderness in the resident's right knee, and the resident complained of pain in the left leg, which he/she then noticed was bowed out; -He/She ordered an x-ray to rule out a fracture; -He/She asked the resident what happened and if the resident had sustained any injuries from his/her wheelchair, staff, or transfers; all of which the resident denied; -He/She received results of the x-ray the next day (8/8/24); -The x-ray showed fractures, but he/she could not identify if they were old or new fractures; -He/She notified the facility staff to send the resident to the hospital for further evaluation due to the fractures; -He/She would not consider the resident's injuries to be of unknown origin; he/she would call it a pathological (indicative of or caused by a disease) fracture due to the resident's quadriplegia; -He/She denied the resident having any known calcium, vitamin, or bone deficiency, but wanted to get the resident tested ; -He/She explained the comminuted fracture could be caused by the twisting or turning of the limb, which could occur with any transfer or wrong movement; -He/She recalled the resident saying, during his/her evaluation on 08/07/24, that sometimes when the staff is doing a transfer, his/her leg swing back and forth. During an interview on 08/23/24 at 11:23 A.M., the DON said the following: -On 08/07/24, CNA N was caring for the resident. Around 10:00 A.M., CNA N asked him to assess the resident due to the resident's leg not appearing normal. He assessed the resident and found swelling of the right knee, but did not see any bruising or abrasions. He questioned the resident as to what happened and the resident denied anything happening. He also asked CNA N to leave the room and again asked the resident what happened, and the resident denied any injuries. He then notified the NP who was in the building, and asked him/her to assess the resident. The NP ordered x-rays; -The following day he was notified of the x-ray results, sent the results to the NP, and received orders to send the resident to the hospital for further evaluation; -He also questioned CNA N (who provided care for the resident on 8/7/24) who denied any injuries or accidents occurring; -He did not feel the resident's injury was an injury of unknown origin because both the staff and resident denied anything happening and he asked multiple times. He was also told the fracture was an old fracture, and there were no new fractures that he was made aware of. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had limited range of motion in both lower extremities; -The resident was dependent on staff for all transfers. Review of the resident's undated Care Plan showed the following: -The resident was dependent on staff for all transfers and required a full body lift transfer; -Staff were to support the resident's body and legs during a full body lift transfer; -Transfer status: the resident required a hoyer lift with the assistance of two staff. Observation on 08/21/24 at 2:05 P.M., showed the following: -CNA N and CNA Q transferred the resident from the shower chair to the bed with a Hoyer lift (mechanical lift); -CNA N operated the lift, while CNA Q controlled the resident's body; -Once the resident was lifted out of the chair and was suspended in the air in the Hoyer lift sling, CNA Q let go of the resident's body, walked away from the resident and went to the far side of the bed. The resident was suspended over the floor in the room; -CNA N pushed the Hoyer lift forcefully with the resident in lift. CNA N said the wheels on the lift were sticking. The resident swung uncontrolled side to side until CNA N grabbed the Hoyer sling to steady the resident. During an interview on 08/22/24 at 4:05 P.M., CNA Q said staff should always keep control of the resident during a mechanical lift transfer. He/She let go of the resident during the transfer on 08/21/24 to make room to move the resident from the shower chair to the bed. The other CNA (CNA N) put his/her hand on the resident to steady him/her. 3. Review of Resident #36's annual MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had limited range of motion in upper and lower extremities on one side; -The resident was dependent on staff for all transfers. Review of the resident's undated Care Plan showed the following: -The resident was dependent on staff for all transfers; -Transfer status: the resident required a hoyer lift with the assistance of two staff. Observation on 08/21/24 at 2:49 P.M., showed the following: -CNA Q and CNA O transferred the resident from his/her wheelchair to the bed with a Hoyer lift; -CNA O operated the lift, while CNA Q controlled the resident's body; -While CNA O lifted the resident in the Hoyer lift; the Hoyer lift made creaking and popping sounds. The lifting motion was jerking and bouncing the resident; -Once the resident was lifted out of the chair, CNA Q let go the resident's body, walked away from the resident and went to the far side of the bed The resident was suspended over the floor in the room; -CNA O kicked the wheels and legs of the Hoyer lift and pushed it forcefully while pushing the resident in the lift to the bed. The resident swung uncontrolled forward and backward and side to side, over the floor, until CNA O was able to grab the sling and steady the resident. During an interview on 08/22/24 at 4:05 P.M., CNA Q said staff should always keep control of the resident during a mechanical lift transfer. He/She let go of the resident during the transfer on 08/21/24 to make room to move the resident from his/her wheelchair to the bed. The other CNA (CNA O) put his/her hand on the resident to steady him/her. During an interview on 09/11/24, at 5:36 P.M., the DON said he expected two staff to be present during a Hoyer lift transfer. One staff was to work the lift and the other staff was to maintain contact with the resident during the transfer. 4. During an interview on 08/22/24 at 1:51 P.M., CNA M said some of the lifts were hard to use. The Hoyer lift legs didn't always roll or move freely. Sometimes staff had to kick or jerk the lift to get the wheels to move, which could be unsafe for the residents as the transfers were not smooth. During an interview on 08/22/24 at 4:05 P.M., CNA Q said the following: -The Hoyer lifts had malfunctioned on him/her before. The legs and wheels got stuck on one of the lifts and made it hard to use; -He/She has had a resident's legs get caught when transferring with the Hoyer lift, however, he/she immediately lowered the resident down and repositioned the resident prior to continuing the transfer; -He/She had never had any resident injured during a hoyer transfer. During interview on 08/23/24 at 9:06 A.M. and 9:40 A.M., CNA O said the following: -One of the Hoyer lifts was hard to use due to the wheels sticking; -He/She had not reported the wheels sticking because the lift was still useable, just hard to use. During an interview on 08/23/24 at 9:57 A.M., CNA N said two of the Hoyer lifts had issues with the legs sticking and the wheels not rolling. During an interview on 08/23/24 at 9:32 A.M., CNA M said the following: -The facility had three Hoyer lifts; -Staff could not use one of the Hoyer lifts because the battery was broken, and the other two Hoyer lifts were hard to use due to the legs and wheels sticking, but staff had to use them. During interviews on 08/23/24 at 11:23 A.M., the DON said the following: -The facility had three Hoyer lifts and one was not working due to a battery issue; -Staff had not notified him of any issues with or difficulty using the other two Hoyer lifts; -He expected staff to notify him and maintenance staff if they had concerns with the functionality of the Hoyer lifts. During an interview on 09/11/24, at 5:36 P.M., the DON said following survey exit, one Hoyer lift was taken out of service because it would lower quickly when the red emergency button was pushed. During an interview on 09/11/24, at 2:10 P.M., the Administrator said she expected the the Hoyer lifts to work properly. If there were issues with the caster wheels, electric or charging components, loose parts, or other malfunctions, the equipment should be taken out of service. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO240516 MO241013

Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the residents' needs in the event of an emergency for two residents (Residents #25 and #157), in a review of 17 sampled residents. The residents' care plans directed for four staff to lower the resident to the ground with a sling and drag the residents out of the building to safety on a lift pad in the event on an emergency evacuation. The facility staffing showed three or less staff worked on the night shift on seven days between 7/12/24 and 8/26/24. Insufficient staff to evacuate the resident had the potential to cause serious injury, harm or death in the event of an emergency requiring an emergency evacuation. The facility assessment identified five staff were needed on the night shift to meet the residents' needs. The facility failed to ensure at least five staff worked on the night shift on 19 days between 7/12/24 and 8/26/24. The facility failed to provide sufficient staff to ensure two residents (Residents #23 and #49) received showers as scheduled. The facility census was 54. The administrator was notified of the Immediate Jeopardy (IJ) on 08/28/24 at 5:40 P.M. which began on 07/12/24. The IJ was removed on 08/29/24 as confirmed by surveyor onsite verification. Review of the facility policy, Nursing Services and Sufficient Staff, revised 09/01/21, showed the following: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans; -Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. 1. Review of the Facility Assessment, dated 08/02/24, showed the assessment identified five staff were needed for the night shift (two Licensed Practical Nurses (LPN) and three Certified Nurses Assistants (CNA)). 2. Review of the facility time record (Daily Punches), dated 07/01/24 through 08/26/24, and the Detailed Census Report showed the following: -On 07/12/24, the facility census was 56. Four staff (two CNAs, one Registered Nurse (RN) and one LPN) were in the building on the night shift from 12:01 A.M. through 6:38 A.M. (a total of six hours and 37 minutes); -On 07/14/24, the facility census was 55. Four staff (one CNA, one RN and two LPNs) were in the building on the night shift from 11:00 P.M. through 7:00 A.M. (a total of eight hours); -On 07/17/24, the facility census was 55. Three staff (one CNA, one RN and one LPN) were in the building on the night shift from 1:08 A.M. through 5:23 A.M. (a total of four hours and 15 minutes -On 07/21/24, the facility census was 56. Three staff (one RN and two LPNs) were in the building on the night shift from 12:53 A.M. through 6:01 A.M. (a total of five hours and eight minutes); -On 07/23/24, the facility census was 56. Four staff (two CNAs and two LPNs) were in the building on the night shift from 11:00 P.M. through 4:15 A.M. (a total of five hours and 15 minutes); -On 07/24/24, the facility census was 56. Four staff (two CNAs, one RN and one LPN) were in the building on the night shift from 12:05 A.M. through 6:05 A.M. (a total of six hours); -On 07/30/24, the facility census was 54. Three staff (one CNA and two LPNs) were in the building on the night shift from 12:38 A.M. through 6:27 A.M. (a total of five hours and 49 minutes); -On 08/02/24, the facility census was 54. Four staff (one RN, one LPN and two CNAs) were in the building on night shift from 11:55 P.M. through 6:56 A.M. (a total of seven hours and one minute); -On 08/08/24, the facility census was 55. Four staff (two LPNs and two CNAs) were in the building on the night shift from 11:00 P.M. through 6:14 A.M. (a total of seven hours and 14 minutes); -On 08/10/24, the facility census was 54. Two staff (one LPN and one CNA) were in the building on the night shift from 11:00 P.M. through 4:40 A.M. (a total of five hours and 40 minutes); -On 08/11/24, the facility census was 54. Two staff (the Assistant Director of Nursing (ADON) and one CNA) were in the building on the night shift from 11:00 P.M. through 3:54 A.M. (a total of four hours and 54 minutes); -On 08/14/24, the facility census was 53. Four staff (one RN, two LPNs and one CNA) were in the building on the night shift from 11:00 P.M. through 7:00 A.M. (a total of eight hours); -On 08/16/24, the facility census was 53. Four staff (three CNAs and one LPN) were in the building on night shift from 11:00 P.M. through 6:32 A.M. (a total of seven hours and 32 minutes); -On 08/17/24, the facility census was 52. Four staff (two CNAs, one Trained Medication Aide (TMA) and one LPN) were in the building on the night shift from 12:25 A.M. through 6:54 A.M. (a total of six hours and 29 minutes); -On 08/19/24, the facility census was 52. Three staff (one CNA, one RN and one LPN) were in the building on the night shift from 11:00 P.M. through 6:49 A.M. (a total of seven hours and 49 minutes); -On 08/21/24, the facility census was 53. Two staff (one RN and one LPN) were in the building on the night shift from 11:00 P.M. through 12:12 A.M. A CNA began work at 12:12 A.M. so three staff were in the building from 12:12 A.M. until 6:32 A.M. (a total of seven hours and 32 minutes); -On 08/24/24, the facility census was 53. Four staff (two RNs and two CNAs) were in the building on the night shift from 11:00 P.M. through 6:30 A.M. (a total of seven hours and 30 minutes); -On 08/25/24, the facility census was 53. Four staff (one RN and three CNAs) were in the building on the night shift from 11:00 P.M. through 6:11 A.M. (a total of seven hours and 11 minutes); -On 08/26/24, the facility census was 52. Three staff (one RN, one LPN and one CNA) were in the building on the night shift from 11:00 P.M. through 5:43 A.M. (a total of six hours and 43 minutes). 3. Review of Resident #25's admission record, dated 09/28/21, showed the resident's diagnoses included obesity, contracture (permanent tightening of muscles, tendons, ligaments or skin that limits movement in a joint or body part) of knee, unsteadiness on feet, generalized muscle weakness, and the need for assistance with personal care. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/14/24, showed the following: -Cognitively intact; -The resident had functional limitations in range of motion (ROM) with upper extremity impairment on one side and lower extremity impairment on both sides; -The resident needed maximal assistance with lying to sitting on the side of the bed, sit to stand, and chair/bed to chair transfer; -The resident was 60 inches tall and weighed 302 pounds. Review of the resident's care plan, revised 07/31/24, showed the following: -Emergency evacuation - the resident had a bariatric bed and required assistance from staff for transfers; -Staff use bariatric sling at bedside; -Place bariatric sling under resident, put bed in lowest position and assist to floor times four staff and slide resident to safety. During interviews on 08/20/24 at 12:43 P.M , 08/27/24 at 3:49 P.M. and 08/28/24 at 11:43 A.M., the resident said the following: -There were not always four staff members working on the night shifts; -If staff had to physically move him/her out of the building it would take at least four staff members to do so. -The resident assumed he/she would be evacuated by wheelchair. The resident's electric wheelchair was not working during the survey and he/she did not have a manual wheelchair available the first couple days of the survey. During an interview on 08/27/24 at 3:31 P.M., Trained Medication Aide (TMA) W said it would take four people to use a blanket to get the resident out of the building safely. During an interview on 08/27/24 at 5:38 P.M., LPN C/Infection Preventionist (IP) said the resident would require four staff to move him/her from his/her bed, to the floor, onto a sheet and to drag him/her to safety. During an interview on 08/27/24 at 3:40 P.M., LPN B said the resident would require four staff to transfer him/her to the floor and pull him/her out with a sheet. 4. Review of Resident #157's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for all transfers. Review of the resident's Face Sheet, dated August 2024, showed the resident's diagnoses included quadriplegia (paralysis or loss of normal motor function that affects all of a person's limbs). Review of the resident's undated Care Plan showed the following: -The resident was dependent on staff for all activities of daily living, including transfers; -Unable to ambulate; -Ensure to use Hoyer lift for transfers, use proper safety precautions; -Emergency Evacuation: the resident is dependent on staff for transfer. Place sling under the resident, place bed in the lowest position, four staff to assist resident to the floor, and slide to safety. During an interview on 08/27/24 at 5:38 P.M., LPN C/IP said the resident would require four staff to move him/her from his/her bed, to the floor, onto a sheet and to drag him/her to safety. 5. Review of Resident #23's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for all ADLs. Review of the resident's undated Care Plan showed the resident required one to two staff assistance for bathing. Review of the resident's undated Kardex showed his/her showers/bathing were scheduled for Monday and Thursday evenings. Review of the resident's Shower Sheets, for June 2024, showed the resident received a shower/bathing on 06/03/24. Review showed no documentation the resident refused or received a shower/bathing on 06/04/24 through 6/30/24 (27 days). (The facility did not provide any additional shower sheets for June 2024.) Review of the resident's Shower Sheets for July 2024 showed the following: -The resident received a shower/bathing on 07/01/24, 07/04/24, and 07/08/24; -No documentation the resident refused or received a shower/bathing on 07/09/24 through 07/14/24 (six days); -The resident received a shower/bathing on 07/15/24; -No documentation the resident refused or received a shower/bathing on 07/16/24 through 07/21/24 (six days); -The resident received a shower/bathing on 07/22/24; -The resident refused a shower/bathing on 07/25/24; -The resident received a shower/bathing on 07/29/24 (seven days after his/her last documented shower/bathing). Review of the resident's Shower Sheets for August 2024 showed the following: -The resident received a shower/bathing on 08/01/24, 08/05/24, and 08/08/24; -The resident refused a shower/bathing on 08/12/24; -The resident received a shower/bathing on 08/15/24 (seven days after his/her last documented shower/bathing). Review of the resident's 30-day Point of Care documentation for bathing for 08/15/24 showed the the resident received a partial bed/towel bath. Review of the resident's Shower Sheets showed the resident received a shower/bathing on 08/19/24. Review of the resident's 30-day Point of Care documentation for bathing showed no entry for 08/19/24. Observation on 08/20/24 at 3:14 P.M. showed the resident's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. During an interview on 08/20/24 at 3:14 P.M., the resident said the following: -He/She has had to wait up to four hours for staff to answer his/her call light; -The staffing on the weekends was always short; there never seemed to be enough staff; -Usually there was only one CNA on the weekends; -It could take staff a minimum of one hour to answer his/her call light on the weekends; -He/She was supposed to get showers two times per week, in the evening, but he/she typically only received one; -His/Her showers were scheduled two times a week, on Monday and Thursday evenings, after 4:00 P.M.; -Staff was supposed to provide him/her a shower yesterday (08/19/24), but did not; -Staff tell him/her they can't give him/her a shower due to not having enough staff; -He/She has not had a shower in three weeks; -He/She was emotional and had tears in his/her eyes, and said he/she feels like a grease ball and is embarrassed by his/her greasy hair. Observation on 08/21/24 at 7:48 A.M. showed the resident's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. During interview on 08/21/24 at 7:48 A.M., the resident said he/she had not received a shower. It was not his/her shower day, so he/she would have to wait one more day until his/her scheduled shower day. Observation on 08/22/24 at 9:31 A.M. showed the resident's hair was very oily and unclean. His/Her was clumped in strands and shiny. During interview on 08/22/24 at 9:31 A.M., the resident said the following: -He/She was scheduled to get a shower later this evening; -He/She was tearful and said, Just look at my hair, it is disgusting and it was unacceptable. During interviews on 08/29/24 at 11:52 A.M. and 5:41 P.M., the resident said the following: -He/She did not receive a shower on Monday (08/26/24); the staff did not attempt or offer; -He/She had refused showers in the past, but had not in the past month; -Every time he/she asked staff for a shower, during the past month, staff told him/her there was not enough staff to complete his/her shower; -He/She had absolutely not received a shower in the last four weeks, other than the previous week (08/23/24) when he/she had to complain to the Director of Nursing (DON); -He/She remembered refusing on 08/12/24, after review of Shower Sheets, but denied receiving any showers, other than on 08/23/24; -He/She asked staff today if he/she would get his/her scheduled shower, and staff replied, I don't know. 6. Review of Resident #49's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for showers and required minimal assistance with other personal hygiene. Review of the resident's undated Kardex showed his/her showers were scheduled for Monday and Thursday. He/She required assistance from one staff. Review of the resident's Shower Sheets for July 2024 showed the following: -The resident received a shower on 07/17/24; -The resident refused a shower on 7/24/24, 07/27/24 and 07/31/24; -The resident only received one of the nine scheduled showers/baths he/she was scheduled to receive. Review of the resident's Shower Sheets for August 2024 (through 08/29/24), showed the following: -The resident received a shower on 08/03/24 (17 days after his/her last documented shower on 07/17/24); -No documentation the resident refused or received a shower on 08/04/24 through 08/13/24 (10 days); -The resident received a shower on 08/14/24 and 08/17/24; -The resident refused his/her shower on 08/21/24; -No documentation the resident received a shower after 08/21/24. During an interview on 08/20/24 at 3:30 P.M. and 08/29/24 at 1:20 P.M., the resident said the following: -He/She received a shower yesterday (08/28/24), but prior to that it had been one week since his/her last shower; -He/She wanted two showers a week and was scheduled to get two showers per week; -He/She was lucky to get one shower a week, and some weeks he/she didn't get a shower at all; -He/She has refused showers in the past, but denied any recent refusal; -Staff told him/her they were unable to complete showers due to not having enough staff; -The resident became upset and said he/she felt disgusting when he/she did not receive his/her scheduled showers; -It regularly took staff at least an hour to answer his/her call light. Sometimes, it took staff up to four hours to answer his/her call light. The weekends, especially Sundays, were the worst. During an interview on 08/29/24 at 12:09 P.M. and 08/29/24 at 1:34 P.M., CNA N said the following: -Most residents were scheduled for showers two times per week; -Some residents refused on their scheduled shower days, then asked for a shower on a different day. When this happened, he/she tried to accommodate the resident, but his/her first priority was completing the scheduled showers for that day; -He/She could not finish his/her tasks in his/her scheduled eight hour; -There had been times in the past were he/she would be responsible for an entire hall with 25 residents by himself/herself; -There was no extra help passing food trays, which would free him/her up to start assisting dependent residents who needed help with meals or needed to be fed 7. During an interview on 08/27/24 at 3:40 P.M., LPN B said the following: -The minimum staffing on the night shift was four staff; -At times, there were only three staff on the night shift and occasions where it was lower than that because staff did not come into work as scheduled. During an interview on 08/28/24, at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -The facility preferred to staff two licensed nurses and three certified nurse assistants on the night shift; -He has worked on the night shift on 8/11/24; it was only him and one CNA during that shift. During an interview on 08/27/24 at 5:33 P.M., CNA V said the following: -He/She primarily worked on the night shift; -There was not always enough staff to complete tasks (providing care and transferring residents) safely and in a timely manner; -Sometimes he/she had to wait and/or find help, so it delayed him/her from getting things done timely and could force some staff to do things unsafely; -There are usually three CNAs scheduled, but typically there was only one or two CNAs who actually came in to work. During an interview on 09/18/24 at 12:40 P.M., the former staffing coordinator said the following: -He/She was the staffing coordinator from February 2024 until July 2024; -The position was then assigned to the LPN C/IP C in July 2024; he/she continued to help LPN C/IP with staff scheduling after July 2024; -He/She was not aware of the Facility Assessment (related to staffing); -In March 2024, he/she followed a staffing chart and was instructed there needed to be at least five staff working the night shift, and there should never be less than four staff to cover the shift; -He/She knew there should be two nurses, one TMA and two CNAs to cover the night shift; -When a staff called in (to report they were not coming into work as scheduled), he/she made phone calls to find staff to work; -Sometimes, staff would not call in, but would show up very late to their shift; -So many staff called in (did not report to work) in the middle of the night that he/she asked the staff to call the facility and let a manager know they would not be working their scheduled shift; -No one was really monitoring to ensure staffing was covered. During an interview on 09/18/24 at 12:40 P.M., LPN C/IP said the following: -He/She was the hired in May to be the Nurse Manager during the day; -When he/she was hired, there was no structure and he/she was not told what job he/she was responsible to do; -He/She was in charge of nursing functions and was not in charge of staffing; -In July 2024, the facility down-sized the positions and cut the staffing coordinator's position and assigned that duty to the DON; -He/She volunteered to help with coordinating the staffing, but did not have access to on-boarding and had no idea how to even contact the staff; -The facility's staff phone list was outdated, and he/she had no way to access the staff's phone numbers; -The facility did not provide any written guidance on what to do if staff called in (did not work their scheduled shift); -Ultimately, it was the DON's responsibility to ensure there was sufficient staffing; -Staffing was always scheduled at the bare minimum, so there were issues if staff did not come to work as scheduled; -The administration knew the facility's staffing was at the bare minimum and there was a chance there would not be enough staffing to cover the shifts; -Nothing was done to address only two staff working on the night shift, because the facility did not know about it (prior to the recertification survey); -He/She did not know what the facility did to ensure sufficient staffing. During an interview on 09/18/24 at 3:33 P.M., the DON said the following: -He started working for the facility in mid-May; -The former staffing coordinator was responsible for making sure there was an adequate number of staff to work; -In mid-August 2024, the staffing coordinator's position was cut; -The staffing was handed over to LPN C/IP and the DON, but LPN C/IP took care of the staffing; -If staff called-in (to report they would not work their scheduled shift), there was a two-hour policy, but the staff did not respect that time frame and would call in at the last minute. Sometimes, staff would not come to work and would not call-in; -Sometimes there was not enough staff to cover the shift at the beginning of the shift, and the nurse manager would have to try to find someone to fill in; -The DON would ensure compliance; -The facility made sure the schedule was filled to ensure there was sufficient staff in case a staff member called in and could not work; -It would require three staff members at the minimum working the night shift; -He was aware of the Facility Assessment, but could not remember what the needs break down included for staffing. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO240480 MO240379 47008 50189 50675

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #23 and #49), who were dependent on staff to complete their activities of daily living (ADLs), in a review of 17 sampled residents, were provided the necessary care to maintain good personal hygiene. Staff failed to assist and provide the residents showers per their shower schedule. The failure caused one resident to be tearful and embarrassed about his/her hygiene. A second resident became emotional and had tears in his/her eyes, saying he/she feels like a grease ball and was embarrassed by his/her greasy hair. The facility census was 54. Review of the facility policy, Resident Showers, dated 09/01/21, showed the following: -It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice; -Residents will be provided showers as per request or as per facility schedule protocols (per the Kardex the residents are to receive at least two showers a week) and based upon resident safety; -Partial baths may be given between regular shower schedules as per facility policy; -Assist the resident with showers as needed. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/22/24, showed the following: -Cognitively intact; -Limited range of motion in bilateral (both) lower extremities; -Dependent on staff for all ADLs. Review of the resident's undated Care Plan showed the following: -The resident had an ADL self-care performance deficit related to obesity and history of stroke; -One to two staff assistance required for bathing; -If the resident refused to get out of bed for a shower, negotiate a time to return and try again. If resident continued to refuse, offer a bed bath in place of a shower. -The resident's care plan did not include how often the resident was to receive a shower/bathing. Review of the resident's undated Kardex showed his/her showers/bathing were scheduled for Monday and Thursday evenings. Review of the resident's Shower Sheets for June 2024 showed the resident received a shower/bathing on 06/03/24. Review showed no documentation the resident refused or received a shower/bathing on 06/04/24 through 6/30/24 (27 days). (The facility did not provide any additional shower sheets for June 2024.) Review of the resident's Shower Sheets for July 2024 showed the following: -The resident received a shower/bathing on 07/01/24, 07/04/24, and 07/08/24; -No documentation the resident refused or received a shower/bathing on 07/09/24 through 07/14/24 (six days); -The resident received a shower/bathing on 07/15/24; -No documentation the resident refused or received a shower/bathing on 07/16/24 through 07/21/24 (six days); -The resident received a shower/bathing on 07/22/24; -The resident refused a shower/bathing on 07/25/24; -The resident received a shower/bathing on 07/29/24 (seven days after his/her last documented shower/bathing). Review of the resident's Shower Sheets for August 2024 showed the following: -The resident received a shower/bathing on 08/01/24, 08/05/24, and 08/08/24; -The resident refused a shower/bathing on 08/12/24; -The resident received a shower/bathing on 08/15/24 (seven days after his/her last documented shower/bathing). Review of the resident's 30-day Point of Care documentation for bathing for 08/15/24 showed the the resident received a partial bed/towel bath. Review of the resident's Shower Sheets showed the resident received a shower/bathing on 08/19/24. Review of the resident's 30-day Point of Care documentation for bathing showed no entry for 08/19/24. Observation on 08/20/24 at 3:14 P.M. showed the resident's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. During interview on 08/20/24 at 3:14 P.M., the resident said the following: -His/Her showers were scheduled two times a week, on Monday and Thursday evenings, after 4:00 P.M.; -Most weeks, he/she only received one shower; -Staff was supposed to provide him/her a shower yesterday (08/19/24), but did not; -Staff always told him/her they did not have enough staff to provide a shower; -His/Her last shower was three weeks ago; -He/She was emotional and had tears in his/her eyes, and said he/she feels like a grease ball and is embarrassed by his/her greasy hair. Observation on 08/21/24 at 7:48 A.M. showed the resident's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. During interview on 08/21/24 at 7:48 A.M., the resident said he/she had not received a shower. It was not his/her shower day, so he/she would have to wait one more day until his/her scheduled shower day. Observation on 08/22/24 at 9:31 A.M. showed the resident's hair was very oily and unclean. His/Her was clumped in strands and shiny. During interview on 08/22/24 at 9:31 A.M., the resident said the following: -He/She was scheduled to get a shower later this evening; -He/She was tearful and said, Just look at my hair, it is disgusting and it was unacceptable. During interviews on 08/29/24 at 11:52 A.M. and 5:41 P.M., the resident said the following: -He/She did not receive a shower on Monday (08/26/24); the staff did not attempt or offer; -He/She had refused showers in the past, but had not in the past month; -Every time he/she asked staff for a shower, during the past month, staff told him/her there was not enough staff to complete his/her shower; -He/She had absolutely not received a shower in the last four weeks, other than the previous week (08/23/24) when he/she had to complain to the Director of Nursing (DON); -He/She remembered refusing on 08/12/24, after review of Shower Sheets, but denied receiving any showers, other than on 08/23/24; -He/She asked staff today if he/she would get his/her scheduled shower, and staff replied, I don't know. 2. Review of Resident #49's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Limited range of motion on one side of both upper and lower extremities; -Dependent on staff for showers and required minimal assistance with other personal hygiene. Review of the resident's undated Care Plan showed he/she needed extensive assistance with ADLs due to impaired mobility related to previous stroke. The resident's care plan did not include how often the resident was to receive a shower/bathing. Review of the resident's undated Kardex showed his/her showers were scheduled for Monday and Thursday. He/She required assistance from one staff. Review of the resident's Shower Sheets for July 2024 showed the following: -The resident received a shower on 07/17/24; -The resident refused a shower on 7/24/24, 07/27/24, and 07/31/24. Review of the resident's Shower Sheets for August 2024 showed the following: -The resident received a shower on 08/03/24 (17 days after his/her last documented shower on 07/17/24); -No documentation the resident refused or received a shower on 08/04/24 through 08/13/24 (10 days); -The resident received a shower on 08/14/24 and 08/17/24; -The resident refused his/her shower on 08/21/24; -No documentation the resident received a shower after 08/21/24. During an interview on 08/29/24 at 1:20 P.M., the resident said the following: -He/She received a shower yesterday (08/28/24), but prior to that it had been one week since his/her last shower; -He/She wanted two showers a week and was scheduled to get two showers per week; -He/She usually only received one shower a week, and some weeks he/she didn't get a shower at all; -Staff told him/her they were unable to complete showers due to not having enough staff; -The resident emotional and had tears in his/her eyes, and said he/she feels like a grease ball and is embarrassed by his/her greasy hair.; -He/She had refused in the past, but had not refused in the past month. 3. During an interview on 08/29/24 at 12:06 P.M., Certified Nurse Assistant (CNA) R said the following: -Most residents were scheduled for showers two times per week; -If a resident refused, the resident must sign the shower sheet, indicating they refused; -Some residents refuse all day long, then ask to shower the next day, if this happened, he/she would try to get the resident showered, but must complete the scheduled showers first. During an interview on 08/29/24 at 12:09 P.M., CNA N said the following: -Staff fill out a shower sheet for every scheduled shower; -Most residents were scheduled for showers two times per week; -Some residents refused on their scheduled shower days, then asked for a shower on a different day. When this happened, he/she tried to accommodate the resident, but his/her first priority was completing the scheduled showers for that day. During an interview on 09/11/24, at 5:36 P.M., the DON said the following: -Staff were to complete shower sheets, and document if a resident refused; -If a resident refused, the CNA needed to notify the nurse, and the nurse was supposed to speak to the resident. If the resident continued to refuse, staff were to notify the physician and family/guardian and document those actions in the resident's medical record; -Staff were to encourage bathing and document it accurately; -It would never be okay for a resident to go three to four weeks without a shower. During an interview on 08/29/24 at 6:43 P.M., the Administrator said she expected staff to give residents two showers per week. The residents should not have greasy or dirty appearing hair.

Based on observation, interview, and record review, the facility failed to ensure staff utilized Enhanced Barrier Precautions as required by facility policy when providing care and treatment to three residents (Residents #38, #46 and #12), who had wounds or an indwelling medical device, in a review of 17 sampled residents. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to track infections in the facility by organism and location. The facility failed to complete Tuberculin Skin Tests (TST) and/or annual evaluations as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for eight of eight new employees reviewed. The facility census was 54. Review of the facility policy, Enhanced Barrier Precautions, reviewed 06/15/24, showed the following: -It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi drug-resistant organisms (a microorganism that is resistant to one or more classes of antibiotics or antifungals) (MDRO); -Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; -All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; -The facility will have the discretion on how to communicate to staff which residents required the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -An order for enhanced barrier precautions will be obtained for residents with any of the following: -1. Wounds e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.; -2. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; -3. MDRO's for which EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDRO's; 4. Additional epidemiologically important MDRO's may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA); -Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care); b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room; e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; f. Provide education to residents and visitors; -High-contact resident care activities include: dressing; bathing; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes); and wound care (any skin opening requiring a dressing); -Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility; -Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility policy, Infection Prevention and Control Program, revised 05/15/23, showed the following: -This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines; -Standard Precautions: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. 1. Review of the Resident #38's admission record showed the following: -Original admitted [DATE]; -Readmitted [DATE]; -The resident's diagnoses included methicillin resistant staphylococcus aureus infection (a type of bacteria that is resistant to many antibiotics) (MRSA) and infection and inflammation reaction due to other internal prosthetic devices, implants, and grafts; -The onset of the MRSA infection was 07/30/24. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/02/24, showed the following: -The resident had an infection which was classified as an MDRO; -The resident had an intravenous (IV) (a tube inserted into a vein) and was receiving IV antibiotics. Review of the resident's Physicians Order Summary, dated 07/01/23 through 08/31/24, showed the following: -IV peripherally inserted central catheter (PICC) line (a long, thin tube that is inserted into a vein in the arm or upper body and ends in a large vein near the heart) located in right upper arm; monitor insertion site and surround skin for signs and symptoms of infection or bleeding every shift; -IV PICC flush with 10 milliliter (ml) saline before infusion, then flush with 10 ml saline after infusion, one time a day for before and after infusion; -Vancomycin (antibiotic) intravenous solution. Use 500 ml/hour intravenously one time a day related to methicillin resistant staphylococcus aureus infection. Review of the resident's Care Plan, revised 07/31/24, showed the resident has a PICC line in his/her left forearm due to a diagnosis of MRSA. The resident was receiving vancomycin until 08/30/24; the care plan did not address Enhanced Barrier Precautions. Observation on 08/22/24 at 9:31 A.M. showed the following: -LPN W gathered supplies from the medication storage room to administer medication through the resident's PICC line; -He/She washed his/her hands and donned (put on) gloves and entered the resident's room; -There was no signage/instruction outside the resident room regarding PPE; -LPN W did not wear a gown and no PPE, including a gown was available in the hallway outside of the resident's door or in his/her room; -LPN W cleaned the resident's PICC line port with an alcohol pad and administered 10 ml saline into the PICC line; -He/She then started the resident's scheduled vancomycin IV infusion; -He/She removed his/her gloves and threw them in the resident's trash can, washed his/her hands with soap and water and left the room. During an interview on 09/10/24 at 12:15 P.M., LPN W said he/she used standard precautions when administering IV medication. He/She did not wear a gown while administering IV medication through the resident's PICC line. He/She was unaware of any EBP practice used at the facility. During an interview on 08/29/24 at 11:29 A.M., the Infection Preventionist (IP) said she was new to her position. She would look at the hospital discharge paperwork to see if the resident had an infection upon readmission to the facility. The resident was on an antibiotic vancomyocin and was having trouble breathing. The facility would use standard precautions unless the resident had a diagnosis which required droplet or contact precautions. The IP said he/she did not know what EBP was and had not received training. 2. Review of Resident #46's Admission Record, dated 05/24/24, showed the resident's diagnoses included acquired absence of leg below the knee and MRSA infection. Review of the resident's Care Plan, revised on 7/26/24, showed the following: -He/She had a surgical wound requiring a wound vac (is a medical treatment that helps wounds heal by using a vacuum to remove fluid and bacteria from the wound); -There was no documentation regarding EBP. Review of the resident's weekly wound assessment, dated 08/28/24, showed the following: -Date of onset: 05/21/24; -Wound site: left BKA stump lateral; -Surgical wound; -The wound measured two centimeters (cm) in length, 13 cm in width and 0.5 cm in depth; -The amount of drainage was documented as large (more than 75 percent (%) drainage); -The type of drainage was documented as serosanguineous (thin, watery, pale, red/pink drainage). Review of the resident's Physician Order Summary, dated 08/29/24, showed the following: -Continue wound vac therapy to the left BKA, twice weekly changes; cleanse with soap and water place a nickel thick layer of Santyl (ointment used to remove damaged tissue) over wound bed then place black granulation foam (a foam dressing used with the wound vac to aid and promote wound healing by removing excess exudates (fluids)) down place gauze over blistered areas before placing drape down, every day sift every Monday and Friday (order start date 08/26/24). Observation on 08/29/24 at 10:25 A.M., showed the following: -The wound care nurse gathered supplies and donned gloves, but no gown, and entered the resident's room; -The Assistant Director of Nursing (ADON) was already in the room and wore gloves, but no gown; -There was no signage/instruction regarding EBP outside the resident's room; -There was no PPE, including gowns available outside of the resident's door or inside the resident's room; -The resident sat in his/her wheelchair with his/her left BKA wound open to air; -The ADON placed two paper chux (absorbent material) on the floor underneath and in front of the resident's wheelchair; -The wound nurse cleaned the resident's left BKA wound using two 4x4's soaked in Vashe wound solution (a solution intended for cleansing, irrigating, moistening and removing matter from wounds); -The wound nurse applied a nickel sized amount of Santyl to the resident's left BKA wound; -The ADON cut a piece of granulated foam to place on top of the resident's left BKA wound; -The ADON kneeled down on the paper chux in front of the resident's left BKA wound and covered the wound with the cut piece of granulated foam; -The wound nurse placed a piece of clear wound tape over the granulated foam as the ADON held the foam in place on top of the resident's left BKA wound; -The wound nurse cut a small hole in the middle of the piece of clear wound tape that covered the granulated foam and the resident's left BKA wound; -The ADON adhered a 30 inch drain tube attachment on top of the small hole which was cut in the piece of clear wound tape; -The ADON attached the 30 inch drainage tube and connected it to a portable vacuum pump; -The ADON turned on the portable vacuum pump; -When the ADON started the suction on the portable wound vac, there was clear drainage immediately seen in the tube connected between the wound and the pump; -The wound nurse took off her gloves and put them in a plastic trash bag in the resident's room; -The ADON took off his gloves and put them in a plastic trash bag in the resident's room. During an interview on 08/29/24 at 10:59 A.M., the wound nurse said the following: -Staff change the resident's wound dressing two times a week and as needed; -She did not wear a gown while performing the resident's dressing change; -She and the ADON should have worn gowns when performing the resident's dressing change, but the facility had not started the EBP program; -The facility was working toward starting an EBP program. During an interview on 08/29/24 at 11:06 A.M., the ADON said the following: -Staff use PPE when a resident is positive for COVID-19; -He did not wear a gown today when helping with the resident's dressing change, because the wound was not draining; -He would not use a gown when changing the resident's dressing because there was not enough drainage; -There was no EBP practice in the facility. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed the resident had two unstageable pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) with suspected deep tissue injury (DTI) (a type of pressure injury that occurs when prolonged pressure or shear forces damage the tissue beneath the skin). Review of the resident's undated Care Plan showed the following: -The resident had actual impairment to skin integrity; -No documentation regarding EBP. Review of the resident's Physician Order Sheet, dated August 2024, showed the following: -Cleanse left ischial (hip/sitting bone) and right buttock with soap and water, pat dry, and apply barrier cream twice daily; -May apply barrier cream as needed to redness or excoriation after episodes of incontinence; -Wound order: for the left buttock, left ischial and right buttock, cleanse with soap and water, pat dry, then cover with silicone border dressing (a foam dressing used to assist wound healing of moderately exudating wounds). Change dressing every three days on Monday, Wednesday and Friday. Ordered date 07/09/24. Review of the resident's Progress Notes, dated 08/09/24 at 10:25 A.M. showed the following: -Left ischial (hip/sitting bone) wound measured 15 centimeters (cm) x 10 cm x 0 cm; -Left buttock wound measured 14.5 cm x 13.5 cm x 0 cm; -Right buttock measured 11.5 cm x 9 cm x 0 cm.; -This was the last documented measurement assessment. Review of the resident's Progress Notes, dated 08/19/24 at 3:42 P.M. showed the following: -Nutrition/Dietary quarterly review; -Skin: pressure injury with suspected DTI to left ischial area, was worse. Pressure injury with suspected DTI to right buttock area, was resolved. Pressure injury with suspected DTI to left buttock, was improved. There was a new Stage II (Define) (partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) pressure ulcer to the left thigh. Observation on 08/20/24 at 3:44 P.M. and 08/21/24 at 9:42 A.M. showed no signs for EBP on or near the resident's room door. Observation on 08/21/24 at 2:20 P.M. showed the following: -No signs for EBP on or near the resident's room door; -The wound nurse performed wound care on the resident; -The wound nurse sanitized his/her hands, donned clean gloves and wore a mask but no gown; -The wound nurse removed the old dressing and cleansed the area with soap and water; -The wound nurse removed soiled gloves and sanitized his/her hands before donning clean gloves to complete dressing change; -The resident's bottom was reddened and had purple coloration and was not blanchable on bilateral buttocks and ischium. The resident also had a small open wound on the lower left buttock, near the thigh; -The wound nurse applied barrier cream and silicone border dressing. During an interview on 08/21/24 at 2:20 P.M. and 08/29/24 at 10:59 A.M., the wound nurse said the following: -The resident had multiple areas of DTI, on bilateral buttocks and ischium; -The resident had a small Stage II wound on the back of the left upper thigh, near the buttock. -The facility had not started the EBP program; -The facility was working toward starting an EBP program. During an interview on 08/29/24 at 11:29 A.M., the IP said the following: -If a resident's wound was not infected, staff could perform the dressing change without wearing full PPE; -Staff would wear gloves during the dressing change; -Staff should wear gown and gloves if there was an infection in the wound and the staff could wear eye protection at their own discretion; -She was not aware of an EBP practice at the facility. She was aware staff used standard precautions when completing a dressing change. During an interview on 08/23/24 at 10:48 A.M., the Director of Nursing (DON) said the facility had not initiated the EBP program because they were not totally prepared at this time. He was not sure what precautions should be taken or the resident population in which EBP should be practiced. During an interview on 09/11/24, at 5:36 P.M., the DON said the following: -He was told by corporate that the facility did not have to implement EBP yet, they had three months to implement; -With EBP, staff will be expected to wear gown and full PPE for wound care. 4. Review of the facility policy, Water Management Program, dated 09/01/21, showed the following: -It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems; -1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing: -a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-born pathogens grow and spread. Education is consistent with each team member's role; -b. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials; -2. The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder; -3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems; -4. Data to be used for completing the risk assessment may include, but are not limited to: -a. Water system schematic/description; -b. Legionella environmental assessment; -c. Resident infection control surveillance data (i.e. culture results); -e. Rounding observation data; -f. Water temperature logs; -g. Water quality reports from drinking water provider (i.e. municipality, water company); -h. Community infection control surveillance data (i.e. health department data); -5. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder; -6. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan; -7. Testing protocols and control limits will be established for each control measure: -a. Individuals responsible for testing or visual inspections will document findings; -b. When control limits are not maintained, corrective actions will be taken and documented accordingly; -c. Protocols and corrective actions will reflect current industry guidelines (i.e. ASHRAE, OSHA, CDC); -8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible; -9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness; -12. The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed, such as when any of the following events occur: -a. Data review shows control measures are persistently outside of control limits; -b. A major maintenance or water service change occurs (including replacing tanks, pumps, heat exchangers, distribution piping, or water service disruption from the supplier to the building); -c. One or more cases of disease are thought to be associated with the facility's systems, or; -d. Changes occur in applicable laws, regulations, standards, or guidelines; -13. In the event of an update to the water management program, the water management team shall: -a. Update the water system schematic/description, associated control points, control limits, and any pre-determined corrective actions; -b. Train those responsible for implementing and monitoring the updated program; -14. Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years; -15. The water management team shall report relevant information to the QAPI Committee. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grows well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the facility's water temperature log, dated 07/01/24, of the hot water temperatures showed the following: -Laundry, 108.2 degrees F. (no documentation any action was taken); -room [ROOM NUMBER], 105.3 degrees F. (no documentation any action was taken); -ORC unit, room [ROOM NUMBER], 106.3 degrees F. (no documentation any action was taken). Review of the water temperature log, dated 07/08/24, showed the temperature of the hot water in ORC unit room [ROOM NUMBER] was 107.1 degrees F. (no documentation any action was taken). Review of the water temperature log, dated 07/18/24, of the hot water temperatures showed the following: -room [ROOM NUMBER], 106.3 degrees F. (no documentation any action was taken); -room [ROOM NUMBER], 108.1 degrees F. (no documentation any action was taken); -Kitchen, 105.6 degrees F. (no documentation any action was taken); -Laundry, 105.2 degrees F. (no documentation any action was taken); -room [ROOM NUMBER], 107.4 degrees F. (no documentation any action was taken); -ORC 6, 105.1 degrees F. (no documentation any action was taken). Review of the water temperature log, dated 07/23/24, of the hot water temperatures showed the following: -room [ROOM NUMBER], 105.3 degrees F. (no documentation any action was taken); -room [ROOM NUMBER], 108.9 degrees F. (no documentation any action was taken); -Kitchen, 105.5 degrees F. (no documentation any action was taken); -room [ROOM NUMBER], 106.7 degrees F. (no documentation any action was taken); -ORC 8, 105.4 degrees F. (no documentation any action was taken). During an interview on 08/22/24 at 6:14 P.M. and 09/11/24 at 4:15 P.M., the maintenance director said the following: -He measured the water temperatures weekly to ensure they were between 105 degrees F and 120 degrees F; -He had only checked the hot water temperatures; -There was no water committee at the facility; -He had never been to a water management meeting; -He had never flushed the whirlpool tub, which was located on the 400 hallway, because it was behind a locked door and was not being used; -Currently, there was no water testing conducted to detect Legionella bacteria; -There was no water flow diagram for the building; -He did not check for bio-film in the building; -He took no action if water temperatures were under 110 degrees F. If the water temperature falls under 105 degrees F, he checks to make sure the mixing valve was working correctly for the hot water. Observations on 08/27/24 between 3:13 P.M. and 3:55 P.M. showed the following: -room [ROOM NUMBER], the cold water temperature was 80.2 degrees F; -room [ROOM NUMBER], the cold water temperature was 79.7 degrees F; -room [ROOM NUMBER], the cold water temperature was 84.0 degrees F; -room [ROOM NUMBER], the cold water temperature was 80.0 degrees F; -room [ROOM NUMBER], the cold water temperature was 80.5 degrees F; -room [ROOM NUMBER], the cold water temperature was 82.9 degrees F. During an interview on 09/11/24, at 5:36 P.M., the DON said the following: -The facility does not have a Water Management Committee that he was aware of; -The facility is expected to follow ASHRAE or CDC guidelines for legionella he does not think the facility has reviewed the guidelines. During an interview on 08/29/24 at 6:43 P.M., the Administrator said she expected a Legionella program to be followed and to include a water management team and to be compliant with ASHRAE guidelines. 5. Review of the facility policy, Infection Prevention and Control Program, revised 05/15/23, showed the following: -This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines; -The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases; -All staff are responsible for following all policies and procedures related to the program; -A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards; -The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee; -An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program; -Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program; -The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program; -The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program. Review of the facility provided, Infection Control Log, for August 2024, showed the following: -Resident #25 was ordered macrobid (antibiotic) 100 milligrams (mg) twice daily for seven days on 08/02/24 for a urinary tract infection (UTI). There was no documentation of the organism being treated or the location (mapping), and no follow up documented after the antibiotic was completed; -Resident #48 was ordered ceftriaxone (antibiotic) two grams daily via IV on 08/06/24 for an infection in his/her left leg. There was no documentation of the organism being treated or the location (mapping); -Resident #48 was ordered linezolid (antibiotic) 600 mg, one tablet twice daily for 21 days on 08/07/24 for an infection in his/her left leg. There was no documentation of the organism being treated or the location (mapping); -Resident #48 was ordered flagyl (antibiotic) 500 mg twice daily for 42 days on 08/07/24 for an infection in his/her left leg. There was no documentation of the organism being treated or the location (mapping); -Resident #38 was ordered vancomycin (antibiotic) 500 mg daily via IV for 30 days on 08/07/24 for bacteremia (infections of the blood). There was no documentation of the location (mapping); -Resident #6 was ordered azithromycin (antibiotic) 250 mg daily for 10 days on 08/20/24 for a bacterial infection. there was no documentation of the location (mapping); -Resident #13 was ordered bactrim DS (antibiotic) 800 - 160 mg twice daily for seven days on 08/21/24 for a leg leg wound, there was no documentation of the organism being treated or the location (mapping); no follow up documented after the antibiotic was completed; -Resident #38 was ordered rifampin (antibiotic) 600 mg daily until 08/31/24 on 08/21/24 for an infection and inflammatory reaction, there was no documentation of the organism being treated or the location (mapping); -Resident #38 was ordered vancomycin 500 mg daily via IV until 08/30/24 on 08/21/24 for MRSA, there was no documentation of the the location (mapping). During an interview on 08/22/24 at 04:30 P.M., the IP said she only downloaded a list of residents on antibiotics daily. She just makes sure the antibiotic was okay for the type of infection and did not track the organism or location of residents with infections. During an interview on 08/23/24 at 10:48 A.M., and 09/11/24 at 5:36 P.M., the DON said the following: -He expected the IP to have a map for infections; -He expected the IP to complete a follow up on the residents who have completed a course of antibiotics; -He expected the IP to contact physicians to document what organism is being treated when a resident is prescribed an antibiotic and to document the physicians response; -He expected IP to track infections and antibiotic use and communicate trends and concerns to the DON, the physician, and medical director if needed. 6. Review of the facility policy, Employee Tuberculosis Testing, implemented 09/01/21, showed the following: -Tuberculosis (TB) screening and testing is conducted in this facility for the purpose of early identification, evaluation, and treatment of employees with latent TB infection (LTBI) or TB disease; -Policy Explanation and Compliance Guidelines: 1. Follow state or local requirements regarding TB screening and testing of employees. In the absence of state or local requirements, follow CDC recommendations below; 2. New Staff Screening: a. At the time of employment, all new staff shall undergo pre-placement screening for TB, including an individual risk assessment, TB symptom screen, and a TB test. b. All new staff shall receive two Mantoux TB Skin Tests given two weeks apart (two-step testing) unless: i. A previously positive TB skin test reaction or positive TB blood test is reported, OR ii. Evidence of completion of adequate therapy for active TB is reported, OR iii. Two negative TB skin tests within the past twelve months, the more recent within the last three months, can be documented, OR iv. The employee has previously received the BCG vaccine. In this case, the employee shall be tested using a blood test (i.e. IGRA). c. All initial and follow-up TB tests shall be administered and interpreted (48-72 hours for skin tests) by a trained healthcare provider on our staff or any licensed physici

Based on observation, interview, and record review, the facility was not administrered in a manner to ensure the well-being of each resident. From October, 2023- the facility had six changes in the licensed nursing home administrator position, which is responsbile for the overall oversight and supervision of employees and resident care. An allegation of verbal abuse was not reported to the state agency. Sufficient nursing staff were not present to ensure the health and safety of residents. Mechanical equipment was not maintained in a safe manner. Nurse aides were not trained to perform job functions and ongoing inservice training was not completed. The facility census was 54. 1. Record review of administrator records received by the licensure and certification unit showed the following: Administrator A worked at the facility from 10/13/23-4/9/24. Administrator B worked at the facility from 4/11/24-5/20/24. Administrator C worked at the facility from 5/20/24-5/28/24. Administrator D worked at the facility from 5/28/24-6/30/24. Administrator C worked at the facility from 6/30/24-8/19/24. Administrator E began working at the facility on 8/19/24. 2. During the resident group interview on 08/21/24 at 1:00 P.M., eleven residents, Residents #14, #20, #13, #10, #11, #9, #21, #7, #18, #28 and #54, said they were only able to get money from their resident fund account Monday through Friday. Resident #54 said the facility does not have someone for banking at the facility on the weekends. He/she has been told in the last couple weeks that they do not have staff here on the weekend for them to get money out, so they have to get whatever they would need for the weekend out on Fridays. During an interview on 08/21/24 at 11:00 A.M., the Regional Business Office Manager said the following: -The administrator was responsible for handing out resident money when residents requested; -The cash envelope was held in the administrator's office; -The facility did not have banking hours on Saturday. During an interview on 08/21/24 at 2:09 P.M., the administrator said she was not aware the facility needed to provide access to resident funds on the weekends. 3. Review of Resident #49's admission MDS, dated [DATE], showed the following: -Required supervision with ADLs; -Required maximum assistance from one staff to stand and to transfer to the toilet; -The resident did not walk and used a wheelchair. Review of the resident's Care Plan for ADLs, dated 6/4/24, showed the following: -The resident required extensive assistance from one staff for ADLs due to impaired functional mobility from a previous stroke that with right sided weakness; -Encourage the resident to participate to the fullest extent possible with each interaction. Review of the resident's Nurses Note, dated 8/02/24 at 2:29 P.M., showed LPN B documented that at 2:00 A.M., the resident put on the call light. CNA A went into the resident's room to check what the resident needed. CNA A told the nurse the resident threw a bottle at him/her. LPN B and CNA A went to the resident's room. The resident told LPN B that he/she would kill CNA A with a gun because CNA A went to his/her room and made fun of him/her that he/she should be walking to use the bathroom. LPN B notified the DON, Assistant Director of Nursing (ADON), and the nurse manager. During an interview on 8/12/24 at 12:00 P.M., the resident said the following: -On 8/2/24 during the midnight shift, he/she turned on the call light to get some help to go to the bathroom; -CNA A answered the call light and called him/her a nasty mother fucker and refused to take him/her to the bathroom; -He/She cursed back at the aide and told him/her to get out of his/her room and threw a plastic bottle at the staff. Review of the resident's Progress Note, dated 08/02/24 at 5:15 P.M., showed the Social Services Designee (SSD) documented he/she went to resident's room to follow up on both events of yesterday. The resident was still upset at the CNA from last night and he/she did not want that CNA in his/her room ever again. During an interview on 8/12/24 at 11:30 A.M., the SSD said the following: -On 8/9/24 around 5:00 P.M., she went to the resident. The resident told her that on 8/2/24 when he/she rang the call light to go to the bathroom, CNA A answered the light and told him/her that he/she was a nasty ass mother fucker who needs to stop pissing all over himself/herself; -The resident was very upset; -She reported what the resident said to the DON, but the DON had an emergency and she didn't know if he did anything about it; -She was in a hurry to leave the facility and does not remember if she told the regional nurse; -She did not get the impression that the resident was accusing the staff member of abuse, but staff should not curse at residents so she saw that this could be verbal abuse; -She should have reported this to the Director of Operations (the acting administrator at the time of this investigation). Review of the resident's Social Services Progress Note, dated 8/9/24 at 5:27 P.M., showed the SSD documented he/she went to resident's room to check on him/her. The resident was in the process of calling the state. He/She was upset because he/she heard that CNA A was in the building. The SSD spoke to the DON who was focusing on a situation with another resident, but would check into this. The SSD then contacted the administrator (Director of Operations). During an interview on 8/12/24 at 3:43 P.M., the DON said the following: -On 8/9/24, the SSD told him the resident said CNA A had cursed at him/her during an incident between the resident and CNA A on 8/2/24; -He was working the floor and had an emergent situation he was handling at the time; -He told the SSD to inform the regional nurse; -He assumed the SSD had reported this allegation to the regional nurse. During interviews on 8/12/24 at 10:30 A.M. and 8/21/24 at 9:43 A.M., the regional nurse said the following: -On 8/2/24, CNA A left a note under the DON's door saying the resident cursed at him/her and threw a plastic bottle at him/her; -She had the SSD go to the resident to see what was wrong; -The SSD reported the resident had experienced a loss in his/her family and was somewhat distraught and angry and thought that the incident could have been from this grief; -The SSD offered support to the resident; -She did not hear anything else; -She had let the DON know about the situation, but there was no investigation done since it was not employee to resident abuse. It was a resident behavior; -No one reported to her the resident said CNA A cursed at him/her. During interviews on 8/12/24 at 10:30 A.M. and 8/21/24 at 8:45 A.M., the Director of Operations said the following: -He had heard about a situation that occurred on 8/2/24 between the resident and CNA A, but since the resident had cursed at the aide, there was no abuse and he thought the SSD had taken care of the situation; -The SSD told him the resident admitted he/she had cursed at the employee and also threw a plastic bottle at the employee, but nothing was said about CNA A cursing at the resident; -He was not aware of any accusations of CNA A cursing at the resident; -If he had been made aware of the allegation of the staff cursing at the resident, he would have investigated the allegation and notified the state agency. 4. Review of the Facility Assessment, dated 08/02/24, showed the assessment identified five staff were needed for the night shift (two Licensed Practical Nurses (LPN) and three Certified Nurses Assistants (CNA)). Review of the facility time records, dated 07/01/24 through 08/26/24, and the Detailed Census Report showed during nineteen (19) shifts, the facility did not have sufficient nursing staff on duty as identified in the assessment. On 8 of the shifts- three or less nursing staff were on duty to provide the necessary care and services. Review of Resident #25's care plan, revised 07/31/24, showed the following: -Emergency evacuation - the resident had a bariatric bed and required assistance from staff for transfers; -Staff use bariatric sling at bedside; -Place bariatric sling under resident, put bed in lowest position and assist to floor times four staff and slide resident to safety. During interviews on 08/20/24 at 12:43 P.M , 08/27/24 at 3:49 P.M. and 08/28/24 at 11:43 A.M., Resident #25 said the following: -There were not always four staff members working on the night shifts; -If staff had to physically move him/her out of the building it would take at least four staff members to do so. Interviews with multiple nursing staff showed it would take four people to get Resident #25 out of the building safely. Review of Resident #157's undated Care Plan showed the following: -The resident was dependent on staff for all activities of daily living, including transfers; -Unable to ambulate; -Ensure to use Hoyer lift for transfers, use proper safety precautions; -Emergency Evacuation: the resident is dependent on staff for transfer. Place sling under the resident, place bed in the lowest position, four staff to assist resident to the floor, and slide to safety. During an interview on 08/27/24 at 5:38 P.M., LPN C/IP said Resident #157 would require four staff to move him/her from his/her bed, to the floor, onto a sheet and to drag him/her to safety. Review of Resident #23's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for all ADLs. Review of Resident #23's undated Care Plan showed the resident required one to two staff assistance for bathing. Observation on 08/20/24 at 3:14 P.M. showed Resident #23's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. During an interview on 08/20/24 at 3:14 P.M., Resident #23's said the following: -He/She has had to wait up to four hours for staff to answer his/her call light; -He/She was supposed to get showers two times per week, in the evening, but he/she typically only received one; -Staff tell him/her they can't give him/her a shower due to not having enough staff; -He/She has not had a shower in three weeks; -He/She was emotional and had tears in his/her eyes, and said he/she feels like a grease ball and is embarrassed by his/her greasy hair. Observation on 08/21/24 at 7:48 A.M. showed the resident's hair was very oily and unclean. His/Her hair was clumped in strands and appeared shiny. Observation on 08/22/24 at 9:31 A.M. showed the resident's hair was very oily and unclean. His/Her was clumped in strands and shiny. During interview on 08/22/24 at 9:31 A.M., the resident said the following: -He/She was scheduled to get a shower later this evening; -He/She was tearful and said, Just look at my hair, it is disgusting and it was unacceptable. Review of Resident #49's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for showers and required minimal assistance with other personal hygiene. Review of Resident #49's Shower Sheets for July 2024 showed the following: -The resident only received one of the nine scheduled showers/baths he/she was scheduled to receive. Review of Resident #49's Shower Sheets for August 2024 (through 08/29/24), showed the following: -The resident received a shower on 08/03/24 (17 days after his/her last documented shower on 07/17/24); -No documentation the resident refused or received a shower on 08/04/24 through 08/13/24 (10 days); -The resident received a shower on 08/14/24 and 08/17/24; -The resident refused his/her shower on 08/21/24; -No documentation the resident received a shower after 08/21/24. During an interview on 08/20/24 at 3:30 P.M. and 08/29/24 at 1:20 P.M., Resident #49 said the following: -He/She was lucky to get one shower a week, and some weeks he/she didn't get a shower at all; -The resident became upset and said he/she felt disgusting when he/she did not receive his/her scheduled showers; -It regularly took staff at least an hour to answer his/her call light. Sometimes, it took staff up to four hours to answer his/her call light. The weekends, especially Sundays, were the worst. During an interview on 08/27/24 at 3:40 P.M., LPN B said the following: -The minimum staffing on the night shift was four staff; -At times, there were only three staff on the night shift and occasions where it was lower than that because staff did not come into work as scheduled. During an interview on 08/28/24, at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -The facility preferred to staff two licensed nurses and three certified nurse assistants on the night shift; -He has worked on the night shift on 8/11/24; it was only him and one CNA during that shift. During an interview on 08/27/24 at 5:33 P.M., CNA V said the following: -He/She primarily worked on the night shift; -There was not always enough staff to complete tasks (providing care and transferring residents) safely and in a timely manner; -Sometimes he/she had to wait and/or find help, so it delayed him/her from getting things done timely and could force some staff to do things unsafely; -There are usually three CNAs scheduled, but typically there was only one or two CNAs who actually came in to work. During an interview on 09/18/24 at 12:40 P.M., the former staffing coordinator said the following: -He/She was the staffing coordinator from February 2024 until July 2024; -The position was then assigned to the LPN C/IP C in July 2024; he/she continued to help LPN C/IP with staff scheduling after July 2024; -He/She was not aware of the Facility Assessment (related to staffing); -In March 2024, he/she followed a staffing chart and was instructed there needed to be at least five staff working the night shift, and there should never be less than four staff to cover the shift; -He/She knew there should be two nurses, one TMA and two CNAs to cover the night shift; -When a staff called in (to report they were not coming into work as scheduled), he/she made phone calls to find staff to work; -Sometimes, staff would not call in, but would show up very late to their shift; -So many staff called in (did not report to work) in the middle of the night that he/she asked the staff to call the facility and let a manager know they would not be working their scheduled shift; -No one was really monitoring to ensure staffing was covered. During an interview on 09/18/24 at 12:40 P.M., LPN C/IP said the following: -He/She was the hired in May to be the Nurse Manager during the day; -When he/she was hired, there was no structure and he/she was not told what job he/she was responsible to do; -He/She was in charge of nursing functions and was not in charge of staffing; -In July 2024, the facility down-sized the positions and cut the staffing coordinator's position and assigned that duty to the DON; -He/She volunteered to help with coordinating the staffing, but did not have access to on-boarding and had no idea how to even contact the staff; -The facility's staff phone list was outdated, and he/she had no way to access the staff's phone numbers; -The facility did not provide any written guidance on what to do if staff called in (did not work their scheduled shift); -Ultimately, it was the DON's responsibility to ensure there was sufficient staffing; -Staffing was always scheduled at the bare minimum, so there were issues if staff did not come to work as scheduled; -The administration knew the facility's staffing was at the bare minimum and there was a chance there would not be enough staffing to cover the shifts; -Nothing was done to address only two staff working on the night shift, because the facility did not know about it (prior to the recertification survey); -He/She did not know what the facility did to ensure sufficient staffing. During an interview on 09/18/24 at 3:33 P.M., the DON said the following: -He started working for the facility in mid-May; -The former staffing coordinator was responsible for making sure there was an adequate number of staff to work; -In mid-August 2024, the staffing coordinator's position was cut; -The staffing was handed over to LPN C/IP and the DON, but LPN C/IP took care of the staffing; -The facility made sure the schedule was filled to ensure there was sufficient staff in case a staff member called in and could not work; -It would require three staff members at the minimum working the night shift; -He was aware of the Facility Assessment, but could not remember what the needs break down included for staffing. During an interview on 08/23/24 at 11:23 A.M., 09/11/24 at 4:51 P.M. and 09/18/24 at 3:33 P.M., the Director of Nursing (DON) said the following: -He started as the DON in mid-May 2024, three and one half months ago; -The former staffing coordinator was responsible for making sure there was an adequate number of staff to work; -In mid-August 2024, the staffing coordinator's position was cut; -The staffing was handed over to Licensed Practical Nurse (LPN) C/Infection Preventionist (IP) and the DON, but LPN C/IP took care of the staffing; -Sometimes there was not enough staff to cover the shift at the beginning of the shift, and the nurse manager would have to try to find someone to fill in; -It would require three staff members at the minimum working the night shift; -He was aware of the Facility Assessment, but could not remember what the needs break down included for staffing; -He had not been in the role long enough to ensure all the policies were implemented. During an interview on 08/20/24 at 12:34 P.M. and 08/28/24 at 1:45 P.M., the Administrator said the following: -She started at the facility on 08/19/24 as the administrator; she was working at the facility for about a month before she took the role of administrator; -She was new to the administrator role at the facility; -The corporate team at the facility was also new in the last two weeks to the facility; -The facility could not use agency staffing because of payment issues with the previous company. 5. Review of equipment checks provided by an outside vendor, dated April 2023, showed the following: -Three mechanical lifts in service; -Invacare RPL450-2, functional, hardware good, pass inspection; -Proactive Medical Protekt 600, functional, hardware good, battery low needs charged, pass inspection; -Invacare RPL600-2, functional, hardware good, scale calibrated, pass inspection; -Next inspection due April 2024. -Review showed the vendor did not complete an inspection after the April 2023. Observation of the facility mechanical lifts on 08/23/24 at 1:51 P.M. showed mechanical lifts in the storage hall, the Proactive Medical Protekt 600 and the Invacare RPL600-2, neither had a maintenance tag on them. A handwritten note was posted on the Proactive Medical Protekt 600 lift that noted, Do not use. Battery dead. Observation on 08/27/24 at 3:31 P.M. showed an additional mechanical lift, the Invacare RPL-450-2 was available in the storage hall. Observation on 08/27/24 at 3:49 P.M. of the Invacare RPL450-2 lift showed the following: -Marred legs with black buildup; -Wheels with dirt buildup and rust on the wheel covering and the wheel-lock; -Popping and creaking when raising and lowering the lift bar, without a resident in the lift. Observation on 08/27/24 at 3:57 P.M. of the Invacare RPL-600-2 lift showed the following: -Marred legs with black buildup; -Wheels with dirt buildup and rust on the wheel covering and the wheel-lock; -Marred lift arm and sling attachment point with chipping paint. Observation on 08/21/24 at 2:05 P.M., showed Certified Nurse Assistant (CNA) N and CNA Q transferred Resident #12 from the shower chair to the bed with a mechanical lift. CNA N lifted the resident out of the chair with the mechanical lift and pushed the lift forcefully with the resident in lift. CNA N said the wheels on the lift were sticking. Observation on 08/21/24 at 2:49 P.M., showed CNA Q and CNA O transferred Resident #36 from his/her wheelchair to the bed with a mechanical lift; -While CNA O raised the resident in the lift, the lift made creaking and popping sounds. The lifting motion jerked and bounced the resident in the lift sling; -Once the resident was lifted out of the chair, CNA O kicked the wheels and legs of the lift and pushed it forcefully to the bed. During an interview on 08/22/24 at 1:51 P.M., CNA M said some of the lifts were hard to use. The lift legs don't always roll or move freely. Sometimes staff had to kick or jerk the lift to get the wheels to move. During an interview on 08/22/24 at 4:05 P.M., CNA Q said the mechanical lifts had malfunctioned on him/her before. The legs and wheels got stuck on one of the lifts and made it hard to use. During interview on 08/23/24 at 9:06 A.M. and 9:40 A.M., CNA O said the following: -One of the mechanical lifts was hard to use due to the wheels sticking; -He/She had not reported the wheels sticking because the lift was still useable, just hard to use. During an interview on 08/23/24 at 9:57 A.M., CNA N said one of the mechanical lifts was broken; the battery did not work. The other two lifts had issues with the legs sticking and the wheels not rolling. During an interview on 08/23/24 at 9:32 A.M., CNA M said the following: -The facility had three mechanical lifts; -Staff could not use one of the lifts because the battery was broken, and the other two lifts were hard to use due to the legs and wheels sticking, but staff had to use them. During interviews on 08/23/24 at 11:23 A.M., the Director of Nursing (DON) said the following: -The facility had three mechanical lifts and one was not working due to a battery issue; -Staff had not notified him of any issues with or difficulty using the other two mechanical lifts; -He expected staff to notify him and maintenance staff if they had concerns with the functionality of the lifts. During an interview on 08/29/24, at 10:31 A.M., the Maintenance Director said the following: -The facility had three mechanical lifts; -One lift was just taken out of service because there was a problem with the battery connection; the battery wasn't holding a charge; -Staff had not reported any other issues regarding the Hoyer lifts to him; -Staff should tag the equipment for repair and communicate it needed to be repaired in the maintenance request book. During an interview on 09/11/24, at 2:10 P.M., the Administrator said the following: -She expected the mechanical lifts to work properly; -If there were issues with the wheels, electric or charging components, loose parts, or other malfunctions, the equipment should be taken out of service and maintenance made aware to make the needed repairs; -The Maintenance Director was responsible to ensure maintenance was completed on the mechanical lifts; -The Maintenance Director was responsible to complete repairs or coordinate with outside contractors if staff could not do the repairs in house; -During department head rounds, staff were supposed to identify areas that needed to be repaired, and the staff would let maintenance know if repairs were needed to the building, furniture or equipment. 6. Record review of employee training records showed existing and new employees did not all receive orientation and ongoing training to meet the needs of residents. During an interview on 08/23/24 at 11:23 A.M., 09/11/24 at 4:51 P.M. and 09/18/24 at 3:33 P.M., the Director of Nursing (DON) said the following: -He started as the DON in mid-May 2024, three and one half months ago; -He was aware of the Facility Assessment, but could not remember what the needs break down included for staffing; -He was responsible for staff education but did not know there was a check list for new hire orientation; -He did not have many records of previous education/training (prior to his employment); -All he had was what the corporate staff had provided for the education fairs, and the binder provided for review; -He had not been in the role long enough to ensure all the policies were implemented. During an interview on 08/20/24 at 12:34 P.M. and 08/28/24 at 1:45 P.M., the Administrator said the following: -She started at the facility on 08/19/24 as the administrator; she was working at the facility for about a month before she took the role of administrator; -She was new to the administrator role at the facility; -The corporate team at the facility was also new in the last two weeks to the facility. MO 240379 MO 240480 MO 240516 MO 240331

Based on observation, interview, and record review, the facility failed to ensure non-food contact surfaces in the kitchen were clean, failed to ensure an air gap at the ice machine drain, and failed to store food items off of the floor. The facility census was 54. Review of the the facility's policy, Sanitation Inspection, last reviewed/revised on 9/1/21, showed the following: -It is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations; -Inspections will be conducted but not limited to dry storage, main production area, food preparation area, and general dietary observations. Review of the facility's policy, Food Safety Requirements, implemented on 9/1/21, showed the following: -It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -Food safety practices shall be followed throughout the facility's entire food handling process; -Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms; -Dry food storage - Keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. 1. Observations in the kitchen on 8/20/24 at 12:00 P.M. and on 8/21/24 at 7:55 A.M., showed the following: -The closed fire drop curtain at the serving window, located next to and above the steam table where staff served the meals, had buildup of a yellow grease and dust/debris; -The electrical junction box and metal conduit, located between clean plate cover table and the coffee maker, was soiled with an oily substance and dust/debris; -The electrical receptacle box and metal conduit, located behind the coffee maker, was soiled with an oily substance and dust/debris. During an interview on 8/21/24 at 8:50 A.M., the Dietary Manager said the following: -The dietary department was responsible for cleaning the fire drop curtain on the kitchen side and electrical boxes/conduit surfaces; -He did not know about the identified areas; -Moving forward he expected the identified areas to be cleaned weekly. During an interview on 8/21/24 at 10:25 A.M., the Registered Dietician said she expected the identified surfaces to be clean and free of grease and dust/debris. 2. Observation on 8/20/24 at 3:15 P.M., of the ice machine located in the kitchen, showed an approximately-inch plastic drainpipe exited the ice machine, and ran along the wall and into the floor drain well approximately 1-inch. There was no air gap above the floor drain well. During an interview on 8/21/24 at 9:57 A.M., Maintenance Staff Member K said the following: -The maintenance department is responsible for the kitchen ice machine drainage and maintaining the proper drainpipe air gap; -He did not know the plastic drain pipe was inside the floor drain well and below the floor surface; -The maintenance department monitored the ice machine drainage monthly; -He expected a proper ice machine air gap to be maintained. 3. Observation on 8/20/24 at 3:20 P.M., in room [ROOM NUMBER] (emergency supply room), showed the following: -One 5-pound bag of instant non-fat dry milk sat on the floor; -Two 1-pound bags of vanilla pudding and pie filling sat on the floor; -One box of vanilla wafers sat on the floor. During an interview on 8/21/24 at 8:50 A.M., the Dietary Manager said the following: -The dietary department was responsible for maintaining the food storage in room [ROOM NUMBER]; -He monitored the room one/two times per week; -He did not know about the identified items on the floor; -He expected food items in room [ROOM NUMBER] to be stored above the floor. During an interview on 8/21/24 at 10:25 A.M., the Registered Dietician said she expected food items to be stored off of the floor.

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, received necessary care and services in accordance with professional standards of pactice when staff failed to obtain laboratory tests and administer lactolose (a liquid medication used to treat liver failure by removing ammonia from the blood, a waste product normally processed in the liver and removed through the urine. Ammonia build up in the blood can be very dangerous and can be toxic to the brain) as ordered by the resident'sphysician. The resident, with known liver disease, became lethargic and dehydrated (loss of more fluid than taken in, the body does not have enough water and other fluids to carry out its normal functions) with an elevated blood level of ammonia, critially elevated levels of sodium and chloride (minerals required for normal body function) and elevated kidney function laboratory tests indicating severe dehydration and kidney failure. The resident was hospitalized as a result. The facility census was 61. Review of the facility policy, Medication Administration, dated 9/1/22, showed the following: -Medications are administered by licensed nurses, or other staff who were legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice; -Review the Medication Administration Record (MAR) to identify medication to be administered; -Remove the medication from the source; -Administer medication as ordered in accordance with manufacturer specificaions; -Observe the resident consumption of the medication; -Sign the MAR after administration; -Report and document any adverse side effects or refusals; -Correct any discrepancies and report to the nurse manager. Review of the facility policy Notification of Changes, dated 9/1/21, showed the following: -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there was a change requiring such notification; -Circumstances requiring notification included accidents, significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and circumstances that required a need to alter treatment; -For residents incapable of making decisions, the representative would make any decisions that had to be made. 1. Review of Resident #1's Physician Order Sheet (POS), dated 2/15/23, showed the following: -Diagnoses of chronic kidney disease stage 3 (kidney failure), chronic viral hepatitis C (a viral infection that attacks the liver and leads to inflammation, spreads by contact with contaminated blood and can lead to serious liver damage), and cirrhosis of the liver (liver damage leading to scarring and liver failure); -Lactulose (liquid medication used to treat liver failure by removing ammonia from the blood) 10 grams (gm)/15 milliliters (ml) give 30 ml three times daily related to liver failure, cirrhosis of liver. Review of the resident's annual Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/16/24, showed the following: -Severely impaired cognition; -No hallucination or delusions; -Required substantial (staff assisting with more than half of the effort) with wheelchair mobility, toileting, personal hygiene. Review of the resident's POS dated 3/5/24 showed an order to obtain Complete Blood Cell Count (CBC, a laboratory blood test used for diagnostic purposes) and Comprehensive Metabolic Panel (CMP, a laboratory blood test use for diagnostic purposes that included electrolytes and liver function tests). Review of the resident's laboratory results dated [DATE] showed the following: -CMP specimen was hemolyzed (clotted blood in the tube rendering the specimen unusable); -Attempts to contact the nurse were unsuccessful, report sent to advise lab was unable to perform testing due to specimen hemolyzed. Please contact lab if redraw was needed stat (immediate) or make a new requisition for redraw on the next routine lab day. Review of the resident's care plan revised 3/13/24 showed the following: -Activities of Daily Living (ADLs) self-care deficit, his/her functional ability varied. Staff should encourage the resident to participate to the fullest extent possible, monitor/document and report any changes, any potential for improvement, reasons for self-care deficit, and declines in function; -Medications taken related to liver failure. Staff should monitor frequently for signs and symptoms of neurologic impairment. If neurologic compromise was noted, urgent treatment was necessary. Review of the resident's MAR dated 4/13/24 showed staff documented at 9:00 A.M. and 2:00 P.M. lactulose 30 ml not administered, see progress notes (nurses' notes). Review of the resident's nurses notes dated 4/13/24 showed no staff documentation regarding lactulose not administered at 9:00 A.M. and 2:00 P.M. and no documentation staff notified the resident's physician lactulose was not administered. Review of the resident's MAR showed staff documented the following: -On 4/14/24 at 2:00 P.M. lactulose 30 ml not administered, resident refused; -On 4/15/24 at 9:00 A.M. and 2:00 P.M. lactulose 30 ml not administered, resident refused; -On 4/17/24 at 9:00 P.M. lactulose 30 ml not administered, resident sleeping. Review of the resident's nurses notes showed no documentation staff notified the resident's physician lactulose was not administered on 4/14/24, 4/15/24 and 4/17/24. Review of the resident's vital signs record dated 4/20/24 at 9:08 A.M. showed staff documented the resident's blood pressure (measurement of how forcefully blood circulates against the walls of the blood vessels), was 175/126 mmHg (millimeters of mercury, a measurement of pressure, normal blood averages 120/80, indicates potential hypertensive, high blood pressure, crisis). Review of the resident's nurses notes showed no additional staff assessment of the resident's condition and no documentation staff notified the resident's physician of the resident's elevated blood pressure. Review of the resident's nurses note dated 4/21/24 showed Licensed Practical Nurse (LPN) A documented at 10:31 A.M. the resident was up in the wheelchair, was lethargic and his/her left arm was edematous (abnormally swollen with fluid). The resident was not responding to any stimuli, stared into space, pupils were fixed. Jerking motion noted while up in the wheelchair. LPN A called the physician. Blood pressure 135/110 (indicating high blood pressure), pulse 91 beats per minute (normal less than 80 at rest), respirations 18 breaths per minute, (normal range 10-18) temperature 97.5 degrees (normal 98.6 degrees). Review of the resident's vital signs record dated 4/21/24 at 11:42 A.M. showed staff documented the resident's blood pressure was 135/125 mmHg (indicating high blood pressure). Review of the resident's nurses notes dated 4/21/24 showed LPN A documented the following at 11:57 A.M. the physician's exchange (triage team) returned the telephone call and said they had no record of the resident. It was noted in the resident's medical record lactulose medication had not been given for four days. A dose was given at that time. The nurses note did not indicate the resident's physician was notified lactulose was not given for four days. Review of the resident's record showed no additional staff assessment of the resident and no documentation staff notified the resident's physician of the resident's condition. Review of the resident's MAR dated 4/22/24 showed staff documented at 2:00 P.M. lactulose 30 ml not administered, with no documentation indicating the reason why staff did not administer the resident's lactose. Review of the resident's vital signs record dated 4/24/24 showed staff documented the following: -At 8:47 A.M. blood pressure 177/100 mmHg (indicating high blood pressure); -At 9:43 P.M. blood pressure 100/73 mmHg. Review of the resident's nurses note dated 4/24/24 at 10:13 P.M., showed staff documented at 9:40 P.M. the resident had a hard time breathing, assessment revealed the resident used accessory muscles to breath (indicating respiratory distress), supplemental oxygen was applied at 2 liters (measurement of oxygen delivered through a tube inserted in the nose), blood pressure was 100/73, pulse 83, respirations 20. Resident was unresponsive to voice, touch, or pain. Staff called the physician, orders received to send the resident to the emergency department. Review of the resident's emergency room laboratory results dated [DATE] showed the following: -Sodium (mineral or electrolyte required in the blood for proper body function) level 169, critical level result (laboratory test with normal range 135-145, indicating dehydration or excessive lack of water. The most serious symptoms of dehydration are brain dysfunction, confusion, muscle twitching, seizures, coma and death); -Chloride (mineral or electrolyte required in the blood for proper body function) level 134, critical level (laboratory test with normal range 97-110, indicating dehydration or excessive lack of water); -Creatinine (laboratory blood test, normal 0.6 - 1.10) 2.66 high result (indicating kidney disease, not filtering waste from the blood effectively); -Blood Urea Nitrogen (BUN, laboratory blood test, normal 6 - 25) 80 high result (indicating kidney disease, could also indicate dehydration). Review of the resident's hospital laboratory results dated [DATE] showed ammonia level of 79 (normal less than 50, high ammonia blood levels are life threatening and can lead to confusion, disorientation, excessive sleepiness, change in consciousness, tremors, coma and death). During interview on 5/2/24 at 2:35 P.M. Certified Nurse Assistant (CNA) B said the resident could transfer with assistance, walk short distances and used a wheelchair for mobility. He/She was talkative and asked for water and sodas frequently. The resident went downhill, became sleepy and tired, drowsy and slept all the time. This went on for a week before staff sent the resident out to the hospital. During an interview on 5/2/24 at 2:45 P.M. Certified Medication Technician (CMT) C said the resident refused the lactulose at times, staff had to mix the lactulose with coffee or something to hide the taste and then the resident would take the medication. The resident was more lethargic the few days before he/she was transferred to the hospital. The resident missed several doses of lactulose before transfer to the hospital. During an interview on 5/2/24 at 1:45 P.M. LPN A said the following: -The resident was usually friendly and outspoken; -On 4/21/24 the resident was lethargic with an unclear voice, elevated blood pressure and not feeling well or acting normal. It was noticed on 4/21/24 the resident's lactulose bottle was full and staff had not administered the medication as ordered. Several doses were missed. LPN A called the physician's answering service with no call back. LPN A informed the Assistant Director of Nurses (ADON) who instructed LPN A to administer the resident's lactulose and watch the resident. The resident did wake up slightly following the lactulose administration. LPN A did not send the resident to the hospital, did not document any follow up assessments, or attempt to notify the physician again. He/She was not aware the resident was transferred to the hospital three days later. He/She should have sent the resident to the emergency room for treatment on 4/21/24. During an interview on 5/2/24 at 9:25 A.M. and 1:10 P.M. the Assistant Director of Nursing (ADON) said the following: -The CMP laboratory test ordered 3/7/24 was not done, no repeat blood draw was completed and the test was not completed as ordered; -The resident had a change in condition, was unresponsive and sent out to the emergency roiagnom on [DATE]. During an interview on 5/2/24 at 2:50 P.M. the Director of Nursing said the following: -Staff should ensure the resident received the lactulose and all medications as ordered. The resident would take the medication if mixed with something to hide the taste. Staff should know to work with the resident and not miss any doses of the lactulose. The resident had liver disease and missed doses of lactulose could cause the resident increased lethargy and drowsiness; -Staff should have ensured the CMP ordered 3/7/24 was redrawn and followed up to ensure the results were received. The charge nurse was responsible for laboratory follow up and reporting results to the physicians; -Staff should have notified her when the resident had a change in condition with additional symptoms of lethargy. During an interview on 5/2/24 at 3:00 P.M. the Administrator said the following: -Staff should follow the physician's orders and ensure laboratory tests were completed as ordered and follow up completed regarding the results. Staff should ensure medications were administered as ordered and if medication was not given or laboratory tests were not obtained staff should notify the physician; -If a resident had a decline or significant change in condition, staff should seek help immediately from the physician or send the resident to the emergency room for evaluation and treatment; -Staff should avoid prolonging a residents' illness by not getting treatment. Staff should monitor and assess residents, administer medications as ordered and follow the physicians' orders. During an interview on 5/16/24 at 7:50 A.M. the resident's physician said the resident was confused and refused medication at times. If staff were aware of ways to encourage the resident to take his/her medications, those suggestions should be shared with all staff. The resident had liver disease and had an elevated ammonia level as a result. The lactulose should help control the ammonia level. A level of 79 might cause the resident some increased lethargy and confusion, although the resident's ammonia level ran higher than normal. No staff had informed him on 4/21/24 the resident was not responding to any stimuli, stared into space, pupils were fixed and he/she had jerking motion with blood pressure of 135/110. The DON and ADON had his direct number and should have notified him directly of these changes in the resident's condition. The resident's emergency room laboratory results indicated the resident was dehydrated on hospital admission. He might have sent the resident to the hospital sooner than 4/24/24 if staff had notified him of the resident's condition on 4/21/24 and kept him informed of his/her condition and decline. Earlier treatment might have prevented the resident's further decline. MO235276

Refer to ZNHX13 Based on interview and record review, the facility failed to obtain and administer pain medication in a timely manner after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, and failed to ensure the medication was available for administration for two residents (Resident #1 and #2), in a sample of eleven residents. Resident #1 had an order for morphine sulfate (a narcotic medication used to treat severe pain), and oxycodone (a narcotic medication used to relieve moderate to severe pain) for pain, and Lyrica (a medication used to treat nerve and muscle pain). The facility failed to obtain Resident #1's morphine sulfate and oxycodone, resulting in the resident having increased pain, becoming angry and upset and ultimately self-discharging from the facility. Additionally, facility staff documented administering Resident #1's Lyrica on 1/3/24 at 9:00 P.M. when it had not been administered. Resident #2 had an order for hydrocodone acetaminophen (a narcotic medication with a Tylenol additive used to relieve moderate to severe pain) for pain. The facility failed to obtain Resident #2's hydrocodone/acetaminophen resulting in the resident having increased pain and staying in bed more where he/she maintained a position that he/she thought would help with his/her pain. Facility staff documented administering Resident #2's hydrocodone/acetaminophen when the medication was not available to administer or obtained through the facility's Pyxis (emergency kit/automated medication dispensing system). The facility census was 63. Review of the facility's policy, Pain Management, dated 9/1/21, showed the following: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -The facility will utilize approach for recognition, assessment, treatment and monitoring of pain; -In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain the facility shall recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; -Evaluate the resident for pain upon admission, during ongoing scheduled assessments and when a significant change in condition or status occurs; -Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences; -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, or other health care professionals and the resident/and the resident's representative, will develop, implement, monitor, and revise necessary interventions to prevent or manage each individual resident's pain at the beginning at admission; -Facility staff will notify the nurse practitioner (NP) if the resident's pain is not controlled by the current treatment regime. Review of the undated facility's policy, Controlled Substance Prescriptions, showed the following: -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe; -A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long-term care facility residents; -Verbal orders for controlled medications are permitted for CII controlled drugs (certain narcotics, stimulants, and depressant drugs, some examples are morphine, and oxycodone) only in emergency situations. Verbal orders for controlled medications received by facility should be noted in the resident's medical record and nursing facility staff must confirm that the prescriber or the prescriber's employee has communicated the order to the pharmacy; -Incomplete prescriptions and verbal orders for controlled substances may not be edited or changed by the facility nursing staff. Controlled substance prescriptions from physician assistants, nurse practitioners, and agent of the physician who are authorized to prescribe controlled drugs are valid if they comply with requirements listed (date the prescription is issued or verbal order taken, full name and address of the resident, name of medication, strength of medication, dose of medication and dosage form, quantity prescribed, route of administration, duration of therapy or number of refills, diagnoses or indication for use and name, address and Drug Enforcement Administration (DEA) registration number ( a unique identifier provided by the drug enforcement agency to medical practitioners allowing them to prescribe dispense and administer drugs defined to be controlled dangerous substances) of the prescriber); -For emergency-controlled substance orders, the nurse will review the emergency kit list for available medications prior to contacting the prescriber. The nurse will communicate to the prescriber the emergency medications available to provide appropriate care to the patient; -New orders for controlled substances communicated to the nurse verbally or orally by the prescriber via telephone are entered into the physician order sheet/telephone sheet or entered into the electronic medical records system; -The prescriber or prescriber's employee or agent prepares a written prescription and faxes the complete prescription (containing all required elements) to the pharmacist directly, or in instances of an emergency situation, the prescriber orally/verbally communicates the order directly to the pharmacist of a quantity sufficient for emergency situation; -In order to communicate CII orders orally/verbally between prescriber and pharmacist, the prescription must meet the DEA's criteria of an emergency situation. Conformance with such a criteria must be discussed between the prescriber and pharmacist and documented on the prescription; -Immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user; -No appropriate alternative treatment is available, including administration of a drug which is not a controlled substance under schedule II; and it is not reasonably possible for the prescribing practitioner to provide a written prescription to be presented to the person dispensing the substance prior to dispensing; -Only after verifying that the above communication has occurred and the pharmacy and facility receive a complete prescription, the nurse reviews the emergency kit list to assess the contents. After finding the medication on the list the nurse unlocks the container, or enters the secured cabinet, or breaks the seal, and removes the required medication if it is available in the emergency kit. 1. Review of Resident #1's face sheet, undated, showed the following: -admitted to the facility was 12/28/23; -Diagnoses included fusion of spine, cervical region (surgery that joins two or more of the vertebrae in your neck), generalized anxiety disorder and major depressive disorder. Review of the resident's nursing note, dated 12/28/23 at 6:08 P.M., showed the resident was admitted to the facility from the hospital. The resident had a motor vehicle accident (MVA) and had surgery done on C1 and C2 vertebrae (the first two vertebrae of the cervical spine located at the neck and at the base of the skull). He/She was alert and oriented. The resident said he/she experiences jerky like movements at times and can voice when and where he/she has pain, as well as using descriptive words for his/her pain. Review of the resident's physician order sheets (POS) dated December 2023 showed the following: -Morphine 30 mg extended release (ER) by mouth in the morning and one tablet before bedtime for pain (order start date 12/28/23) -Oxycodone 10 mg one tablet by mouth every three hours as needed for severe pain for up to six days (order start date 12/28/23); -Lyrica 150 mg one capsule by mouth in the morning and one capsule before bedtime (order start date 12/28/23); -Methocarbamol (used to treat muscle spasms and pain) 500 milligrams (mg) by mouth every eight hours as needed for muscle spasms (order start date 12/29/23). Review of the resident's nursing note dated 12/29/23 at 12:11 P.M., showed staff spoke with the pharmacy and notified them that an updated script due to hard copy script received from the hospital was only valid for two doses of morphine. Spoke with the physician's office and made aware a prescription was needed. Review of the resident's nursing note dated 12/29/23 at 8:16 P.M., showed a prescription for morphine 30 mgER on e tablet in the morning and at bedtime was needed from the physician. Review of the resident's nursing note dated 12/29/23 at 8:17 P.M. showed a prescription was needed from the physician for pregabalin (Lyrica) 150 mg one capsule in the morning and at bedtime. Review of the resident's medication administration record (MAR) dated 12/29/23 showed the resident reported no pain in the morning, no pain in the evening, and the resident's pain level was a 6 (on a pain scale from 0 to 10 with 0 being no pain and 10 the worst pain) at night. Review of the resident's MAR dated December 2023 showed the following: -On 12/29/23 there was no evidence facility staff administered the resident's morphine sulfate 30 mg at bedtime; -On 12/29/23 there was no evidence facility staff administered the resident's Lyrica 150 mg at bedtime. Review of the resident's nursing note dated 12/30/23 at 3:38 A.M., showed the resident reports unrelieved pain with intense muscle spasms. The NP was also notified that the resident had no more morphine and only two of the as needed (PRN) oxycodone left at this time. Orders to give methocarbamol (used to treat muscle spasms and pain) 500 milligrams (mg) now and start new tizanidine (used to treat muscle spasms) 4 mg every six hours as needed. Review of the resident's nursing note dated 12/30/23 at 5:36 A.M., showed staff administered methocarbamol 500 mg and administration was effective. Review of the resident's MAR dated December 2023 showed the following: -On 12/30/23 there was no evidence facility staff administered the resident's morphine sulfate 30 mg in the morning or at bedtime; -On 12/30/23 there was no evidence facility staff administered the resident's Lyrica 150 mg in the morning or at bedtime. Review of the resident's nursing note, dated 12/30/23 at 4:26 P.M., showed staff spoke with the NP multiple times this shift to make sure he/she was aware of the missed medication (morphine). At this time no solution has been achieved. The physician has been notified. Tylenol has been offered and the resident has refused. Review of the resident's MAR dated 12/30/23 showed the resident was assessed and had no pain in the morning, evening or at night. Review of the resident's nursing note dated 12/31/23 at 1:24 A.M. showed the resident denied presence of pain now but wanted to call 911 due to the lack of his/her pain medication. Review of the resident's nursing note dated 12/31/23 at 10:45 P.M. showed the resident's morphine for pain control was just delivered. Review of the resident's MAR dated 12/31/23 showed pain a 1 in the morning and in the evening, and no pain at bedtime. Review of the resident's MAR dated December 2023 showed the following: -There was no evidence facility staff administered the resident's Lyrica 150 mg in the morning or at bedtime on 12/31/23 (a total of five missed doses between 12/28/23 and 12/31/23) -There was no evidence the facility staff administered morphine sulfate in the morning or at bedtime on 12/31/23 as ordered (the resident missed five consecutive doses of his/her routinely scheduled morphine between 12/28/23 and 12/31/23). Review of the facility's Controlled Drug Receipt/Record/Disposition Form dated 12/31/23 showed 30 tablets of morphine sulfate 30 mg were delivered and facility staff signed out the first dose on 1/1/24 at 9:00 A.M. Review of the resident's MAR dated January 2024 showed staff administered the resident's morphine sulfate 30 mg in the morning of 1/1/24 at 9:00 A.M. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 1/1/24, showed the following: -Cognitively intact; -Received scheduled and as needed (PRN) medications for pain; -Received non-medication intervention for pain; -Frequent presence of pain; -Pain effect on sleep frequent; -Pain frequently interferes with therapy activities; -Pain frequently interferes with day-to-day activities; -Pain intensity severe. Review of the resident's physical therapy evaluation dated 1/1/24, untimed, showed the following: -Diagnoses included fusion of spine, cervical, muscle weakness and unsteadiness on feet; -Frequency three times a week; -The resident presents from hospital following C1-C2 fusion following a MVA with resulting hemiparesis (muscle weakness or partial paralysis that can affect one side of the body) to left upper extremity and lower extremity. The resident had the ability to express wants and ideas, understands others and follows one step directions independently; -He/She was alert and oriented while appearing agitated due to report of lack of care since in the facility and wanting to return home. The resident had good participation throughout evaluation while demonstrating use of crutches and manual wheelchair with bilateral lower extremities; -Unsteady upon standing while recommended supervision assistance throughout due to occasional muscles spasms in left lower extremity and working on greater development of lower extremity motor control. Review of the resident's care plan dated 1/1/24 showed the care plan did not address pain. Review of the resident's nursing note dated 1/1/24 at 11:58 A.M., showed spoke with the resident's physician office regarding Lyrica. The office must have a request from the pharmacy before they will send a script from the physician. The nurse spoke with the pharmacy, and they will send over the request. The resident was notified of the pharmacy and physician notification. Review of the resident's MAR dated 1/1/24 showed no pain in the morning, evening, or at night. Review of the resident's MAR dated 1/2/24 showed pain a 3 in the morning, a 3 in the evening, and none at bedtime. Review of the resident's MAR dated January 2024 showed the following: -There was no evidence staff administered Lyrica 150 mg twice a day as ordered on 1/1/24 or on 1/2/24; -Staff documented they administered Lyrica 150 mg on 1/3/24 in the morning and at bedtime, and on the morning of 1/4/24. Review of the facility's Controlled Drug Receipt/Record/Disposition Form dated 1/2/24 showed 30 capsules of pregabalin (Lyrica) 150 mg were delivered to the facility. Facility staff signed out the first dose on 1/3/24 at 9:00 A.M. Facility staff signed out the next dose on 1/4/24 at 9:00 A.M. Facility did not sign out the bedtime dose on 1/3/24 as ordered. Review of the resident's nursing note dated 1/4/24 at 1:35 P.M., the resident was discharged home today. During an interview on 1/24/24 at 10:15 A.M., the resident's pharmacy clinician said Lyrica 150 mg was not in the facility Pyxis pool (an automated medication dispensing system). The resident's Lyrica 150 mg was dispensed on 1/2/24, but not delivered to the facility until 1/3/24 at 8:53 A.M. It is a narcotic, so facility staff must call the pharmacy to notify them of the order. The order was put in the electronic medical record on 12/28/23, but the pharmacy was not notified of the order until 1/2/24. During interview on 1/17/24 at 3:40 P.M. the resident said the following: -He/She was at the facility for a short time. He/She was traumatized by his/her stay at the facility due to the uncontrolled pain in his/her neck and surgical area. He/She had excruciating pain while at the facility; -He/She rated his/her pain a 10 or higher on a scale of 0 to 10 (0 being none and 10 being the worst pain possible) most of the time while he/she was in the facility; -He/She did not receive his/her pain medications as ordered and because of this he/she could not eat, sleep, or participate in therapy as he/she should. When he/she did receive his/her pain medication it was late; -He/She went home too early following surgery, but he/she had no other choice because of the intense pain and lack of pain control at the facility. During an interview on 1/18/24 at 9:45 A.M. and 11:10 A.M. and on 1/24/24 at 4:00 P.M. Licensed Practical Nurse (LPN) A said the following: -On 1/2/24 at around 12:00 P.M., the resident requested his/her oxycodone for breakthrough pain, but it had run out. He/She forgot to put in a nursing note regarding the pain. The resident rated his/her pain an 8 (on a 0-10 scale with 0 being none and 10 being the worst pain). The medication did not come in till the next day; -On 1/3/24 at 9:00 P.M., he/she documented/initialed on the MAR that he/she administered the resident's Lyrica, if he/she did not sign out the Lyrica on the narcotic sheet, he/she did not administer the medication. The resident may have been asleep. He/She should have put in a nursing note on why he/she didn't administer the medication. During interview on 1/24/24 at 11:43 A.M. the assistant director of nursing (ADON) said a narcotic cannot be accessed through the Pyxis system without a prescription, same as an order at the pharmacy for a narcotic, it cannot be filled without a prescription from the physician, Lyrica 150 mg and morphine 30 mg was not available in the facility Pyxis. During an interview on 1/18/24 at 11:30 A.M. and at 5:15 P.M., the director of nursing (DON) said the following: -Resident #1 had a prescription for two doses of morphine and a few doses of his/her PRN oxycodone when he/she was admitted to the facility, and the resident's primary physician was to refill the narcotics after his/her admission. The nurses at the facility had been communicating with the resident's physician office that a prescription was needed for the resident's pain medications; -The resident was upset and frustrated that he/she did not have his/her pain medications, but he/she did not feel the resident's pain was uncontrolled. If the resident's pain was uncontrolled, the facility would have sent the resident back to the hospital. During an interview on 1/18/24 at 2:30 P.M. the resident's physician said he/she was not notified that Resident #1 needed a prescription refill for narcotics, he/she was out of town at the time. There was no good reason for the facility not getting Resident #1's Lyrica filled. The facility basically needed to make a phone call to the pharmacy to get it taken care of. The resident should have received his/her medication as ordered. 2. Review of Resident #2's undated, medical diagnosis sheet showed the resident had a diagnoses that included unspecified abdominal pain. Review of the resident's care plan, revised 1/29/23, showed the following: -The resident had pain related to recent surgery on his/her bowels, he/she is able to make his/her needs known and has as-needed pain medications; -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; -Administer analgesia (medications that relieve different types of pain) as per orders, give/offer one-half hour before treatments or cares, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to cares. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Utilized a walker and a wheelchair; -Received scheduled and as-needed pain medications; -Described pain as moderate; -Received an opioid (a pain medication used to treat moderate to severe pain) routinely. During an interview on 01/18/24 at 2:40 P.M., the resident said the following: -He/She had chronic pain in his/her low back from a motor vehicle accident years ago; -His/Her pain scale level was usually between a three and a four on a 0-10 pain scale even with pain medication use; -He/She used to take hydrocodone/acetaminophen 10/325 mg by mouth four times daily as needed for pain, but his/her physician changed the medication to four times daily routinely so he/she could sleep better and not have to ask for pain medications in the night; -He/She did not receive any pain medication from 9:00 P.M. on 01/12/24 until 9:00 A.M. on 01/17/24; -His/Her pain was a seven on the 0-10 pain scale when he/she did not get the pain medication; -He/She stayed in bed a lot more when he/she did not get the pain medication, because he/she would hurt more when he/she moved. Review of the resident's nursing progress notes showed staff documented on 01/09/24 at 2:39 P.M., physician at the facility and new orders received to discontinue Norco 10/325 (hydrocodone) PRN (as needed) and start Norco 10/325 mg by mouth four times a day. Review of the resident's January 2024 physician order sheet (POS) showed the following: -Hydrocodone/acetaminophen oral tablet 10/325 mg by mouth every four hours PRN (as needed) for pain, discontinued on 01/09/24; -Hydrocodone/acetaminophen oral tablet 10/325 mg by mouth, scheduled four times a day for pain, scheduled for 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M., start date 01/09/24. Review of the resident's controlled drug receipt/record/disposition form for his/her hydrocodone/acetaminophen 10/325 mg, one tablet by mouth every four hours as needed for pain, showed the count went to a zero balance on 01/12/24 at 9:00 P.M. (the facility had used all of the resident's supply of medication at this time and no medication remained). Review of the resident's January 2024 MAR showed staff documented on 01/13/24, 9:00 A.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, administered as ordered. Review of the pharmacy log for the facility Pyxis system, dated January 2024, showed hydrocodone/acetaminophen 10/325 mg was available in the Pyxis system at the facility, quantity was seven and it was last dispensed on 1/4/24. Review of the account of medications removed from the facility Pyxis system showed staff removed no hydrocodone/acetaminophen from the emergency system for the resident on 1/13/24. Review of the facility's Controlled Drug Receipt/Record/Disposition Form showed there was no hydrocodone/acetaminophen 10/325 mg, one tablet by mouth four times a day, dispensed from the pharmacy to the facility for the resident on 1/13/24. During an interview on 1/18/24 at 9:45 A.M., 11:10 A.M. and 4:30 P.M., LPN A said the following: -He/She documented/initialed that he/she administered Resident #2's hydrocodone/acetaminophen 10/325 mg one tablet on 1/13/24 at 9:00 A.M. on the MAR. He/She went to the narcotic cart (which is another cart) to get the medication and it was not available; -He/She forgot to go back and change the MAR to show the medication was not available. He/She did not administer the medication like the documentation indicated he/she had; -He/She could not access the Pyxis for the medication because it was a new prescription and they were required to put a code in to access the medication. Review of the resident's nursing progress notes showed staff documented on 01/13/24 at 11:04 A.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, resident medication on the way from RX (pharmacy). Review of the resident's January 2024 MAR showed staff documented on 01/13/24 at 12:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's nursing progress notes showed staff documented on 01/13/24 at 4:30 P.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, pharmacy contacted, waiting on delivery. Review of the resident's January 2024 MAR showed staff documented on 01/13/24 at 5:00 P.M., hydrocodone/acetaminophen table 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's January 2024 MAR showed staff documented on 01/13/24, 9:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, administered as ordered. Review of the facility's Controlled Drug Receipt/Record/Disposition Form showed there was no hydrocodone/acetaminophen 10/325 mg, one tablet by mouth four times a day, dispensed from the pharmacy to the facility for the resident on 01/13/24. Review of the account of medications removed from the facility Pyxis system showed no hydrocodone/acetaminophen was removed from the emergency system for the resident on 1/13/24. During an interview on 1/18/24 at 5:00 P.M., LPN C said he/she documented/initialed that he/she administered Resident #2's hydrocodone/acetaminophen 10/325 mg one tablet on 1/13/24 at 9:00 P.M. on the MAR. He/She went to the narcotic cart to get the medication and it was not available. He/She forgot to go back and change it on the MAR. He/She did not administer the medication. The resident said he/she was having pain but he/she told the resident it was out of his/her control. He/She did not have the medication to administer. Review of the resident's January 2024 MAR showed staff documented on 01/14/24 at 9:00 A.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's nursing progress notes showed staff documented on 01/14/24 at 9:13 A.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, waiting on prescription from physician, call made, pharmacy contacted. Review of the resident's January 2024 MAR showed staff documented on 01/14/24 at 12:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's January 2024 MAR showed staff documented on 01/14/24, 5:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, administered as ordered. Review of the facility's Controlled Drug Receipt/Record/Disposition Form showed there was no hydrocodone/acetaminophen 10/325 mg, one tablet by mouth four times a day, dispensed from the pharmacy to the facility for the resident from 01/13/24 through 01/14/24. Review of the account of medications removed from the facility Pyxis system showed staff had removed no hydrocodone/acetaminophen from the emergency system for the resident on 1/14/24. Staff could not have administered the resident's medication on 1/14/24 at 5:00 P.M. as the resident did not have a supply of the medication that had been delivered from the pharmacy and none had been pulled from the Pyxis system. Review of the resident's nursing progress notes showed staff documented 01/14/24 at 6:33 P.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, pending physician's prescription and pharmacy delivery. Review of the resident's January 2024 MAR showed staff documented on 01/14/24 at 9:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's nursing progress notes showed staff documented on 01/14/24 at 9:16 P.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, resident medication is waiting on a prescription, faxed the resident's physician Friday night and awaiting for prescription to be signed to send medication. Review of the resident's January 2024 MAR showed staff documented on 01/15/24 at 9:00 A.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's January 2024 MAR showed staff documented on 01/15/24 at 12:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's nursing progress notes showed staff documented 01/15/24 at 12:12 P.M., spoke with the physician's office staff, made aware that the pharmacy said they had not received a prescription for the Norco (hydrocodone) that was written on 01/09/24. Office staff said their policy is they wait to receive a prescription request from the pharmacy. Informed that the resident was in a lot of pain since he/she has been out of the medication. Review of the resident's January 2024 MAR showed staff documented on 01/15/24 at 5:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's nursing progress notes showed staff documented on 01/15/24 at 6:07 P.M., hydrocodone/acetaminophen 10/325 mg, give one tablet by mouth four times a day for pain, waiting on physician. Review of the resident's January 2024 MAR showed staff documented on 01/15/24 at 9:00 P.M., hydrocodone/acetaminophen tablet 10/325 mg, give one tablet by mouth four times a day for pain, medication unavailable. Review of the resident's January 2024 MAR, from 1/13/24 at 9:00 A.M. to 1/15/24 at 9:00 P.M., showed staff documented the resident's hydrocodone/acetaminophen medication was not available for administration nine times and had documented the medication was given three times when record review and interview showed the medication had not been administered, the medication was not available or pulled from the Pyxis system. The resident missed a total of 12 doses of the ordered pain medication. Review of controlled drug receipt/record/disposition form for the resident's hydrocodone/acetaminophen 10/325 mg, one tablet by mouth four times daily, showed the pharmacy dispensed the medication to the facility on [DATE] (no time indicated); the form showed staff gave the first dose on 01/16/24 at 7:00 A.M. During an interview on 01/23/24 at 3:20 P.M., the pharmacy technician said the following: -No hydrocodone/acetaminophen 10/325 mg tabs were pulled from the facility's Pyxis on 01/13/24, 01/14/24, and 01/15/24 for the resident; -New orders for a narcotic medication cannot be transmitted by the facility's electronic medical record (EMR). Facility staff will notify the pharmacy of a new order for a narcotic and the pharmacy will contact the provider's office to obtain the written prescription. During an interview on 1/18/24 at 4:30 P.M., LPN A said Resident #2 went without his/her hydrocodone for multiple days, staff communicated with the physician's office and pharmacy about the issue. The resident stayed in bed more during this time because of the pain. During an email correspondence on 1/25/24 at 7:39 A.M., the ADON said hydrocodone/acetaminophen 10/325 mg was available in the facility Pyxis. During an interview on 1/18/24 at 11:30 A.M. and at 5:15 P.M. the DON said the following: -Facility staff communicated with the physician's office several times regarding Resident #2's hydrocodone needing a new prescription and refill, she called the resident's physician office herself on 1/15/24 and explained the resident was still waiting on his/her medication and they needed it now. The prescription was finally filled. The resident was without the medication for several days. The resident ran out of the medication on 1/13/24 and it was not refilled until 1/16/24; -She would expect for each resident's pain medications/narcotics be administered as ordered to assure pain control; -The facility had ongoing issues with

Based on interview and record review, the facility failed to follow professional standards of practice for two residents(Resident #1 and Resident #2) out of seven sampled. Staff failed to notify the physician when Resident #2, who is dependent upon oxygen, had oxygen levels fall below the recommended range as ordered by the physician, causing the resident to become incoherent and having difficulty breathing and required hospitalization . Staff also failed to document the change in condition for Resident #1 and failed to monitor and document the resident's oxygen saturation (SPO2 levels). Staff failed to follow professional standards for Resident #1, when the resident experienced a change in the ability to swallow and staff used to a syringe to give the resident food and fluids without the order from the physician or consulting speech therapy. The facility census was 65. Review of the facility undated policy for Oxygen Administration showed: -Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; -Oxygen is administered under orders of a physician, except in the case of an emergency; -Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy; -The resident's care plan shall identify the interventions for oxygen therapy such as they type of oxygen delivery system, when to administer, equipment settings, monitoring of the SPO2 (oxygen saturations) levels and/or vital signs and complications associated with the use of oxygen; -Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them such as ventilatory depression (slowed respiratory rate) associated with elevated carbon dioxide levels; -Staff shall notify the physician of any changes in the resident's condition, including changes in vital sighs, oxygen concentrations, or evidence associated with the use of oxygen. Review of the facility's undated policy for Documentation in the Medical Record showed: -Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation; -Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record; -Record descriptive and objective information based on first-hand knowledge of assessment, observation, or service provided; -Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care. Review of the facility's undated policy for Noninvasive Ventilation (CPAP, BIPAP) showed: -It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice; -CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea; -BiPAP or bi-level positive airway pressure, is a similar respiratory therapy intervention that delivers inhalation pressure and exhalation pressure to provide a patent airway; -Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). Review of the facility policy for Notification of Changes dated 9/01/21 showed: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification; -Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 1. Review of Resident #2's comprehensive Minimum Data Set (MDS), a comprehensive assessment instrument completed by staff,d dated 10/5/23 showed: -Able to make self understood and able to understand others; -Able to make decisions; -Dependent upon staff for Activities of Daily Living (ADL's); -Receives continuous oxygen, use of BiPAP or CPAP not marked; -Diagnoses of atrial fibrillation (irregular heartbeat), coronary artery disease (CAD is caused by plaque buildup in the wall of the arteries that supply blood to the heart), heart failure, hypertension, diabetes, asthma and chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems). Review of the care plan for oxygen therapy with a revision date of 10/12/23 showed: -The resident is on oxygen therapy and will refuse to wear oxygen; -Goal: the resident will have no signs or symptoms of poor oxygen absorption; -Interventions in part of: administer oxygen as ordered; monitor for signs and symptoms of respiratory distress and report to the physician; position resident to facilitate ventilation/perfusion (ability to breath) Review of the care plan for COPD with a revision date of 10/25/23 showed: -The resident has COPD; -Goal: the resident will display optimal breathing patterns daily; -Interventions in part of : administer oxygen as ordered; monitor of signs and symptoms of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, cyanosis (a bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), somnolence ( a state of drowsiness or strong desire to fall asleep); monitor and document and report. Review of the care plan for use of BiPAP with a revision date of 11/7/23 showed: -The resident uses a BiPAP, has been non-compliant with wearing it. -Goal: the resident will use the BiPAP nightly with minimal risk of complications; -Interventions in part of : Encourage the resident to wear the CPAP when he/she sleeps; explain the risk vs benefit of wearing the BiPAP as per physician orders; monitor for respiratory difficulty, decreased oxygen saturation; staff to check to ensure the resident has the CPAP on when sleeping. Review of the Physician Order Sheet (POS) dated December 2023 showed: -BiPAP at bedtime, apply at night and document any refusals with an order date of 10/27/22; -Oxygen O2 at 3 liters per minute (LPN) via nasal cannula as needed for SOB or to keep O2 sats above 90%. May titrate up to 4 LPN to keep O2 sats above 90% with an order date of 10/25/23; -Respiratory Therapy to evaluate and treat as recommended; -Ipratropium-Albuterol (combination is used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) solution 0.5-2.5 milligrams (mg) inhale every 4 hours as needed for SOB or wheeze via nebulizer with a start date of 10/25/23; -Trelegy Ellipta Inhalation aerosol powder (used to treat COPD), one puff orally daily for SOB with a start date of 10/26/23. Review of the Medication Administration Record (MAR) dated December 2023 showed: -Ipratropium-Albuterol (combination is used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) solution 0.5-2.5 milligrams (mg) inhale every 4 hours as needed for SOB or wheeze via nebulizer with a start date of 10/25/23 not documented as given 12/1/23 through 12/9/23; -CPAP, as needed, not documented as done 12/1/23 through 12/9/23; -No documentation of SPO2 or respiratory rate. Review of the nurses notes dated 12/03/2023 1:30 showed: -Residents family called the desk phone requesting that someone go and check on the resident. He/She stated that he/she had just gotten off the phone with the resident and he/she sounded confused and may need to go to the hospital. This nurse went to assess the resident after hanging up with the family member and findings are as follows: Temperature. 97.4, Blood pressure 100/68, Pulse 90 bpm, Respirations 20, O2 was at 96% via nasal cannula. Resident was alert and orientated to person, place, time, and events able to respond to questions appropriately and is able to voice his/her own needs. Will continue to monitor. Review of the nurses notes from 12/03/23 - 12/12/23, showed no documentation the staff continued to monitor the resident. During an interview on 12/12/23 at 10:55 A.M. Certified Nurse Aide (CNA) A said: -He/she checked on the resident shortly after 3:00 P.M. on 12/9/23; -The resident usually knows him/her by name, but this day, the resident was very confused and did not know his/her name, the resident kept calling him/her [NAME], he/she does not know who that is; -The resident had been very incontinent of urine with brown stains on the bed linen; -His/her breakfast and lunch had been split onto the floor; -This was unusual for the resident to spill food; -He/she and LPN A cleaned the resident up; -The resident had his/her oxygen on; -He/she kept calling out for a [NAME] and [NAME], he/she does not know who that is; -After supper, the resident's FM came in to see the resident and said that he/she was concerned due to the resident had not called him/her all day; -He/she could not find LPN A; -LPN B tried to contact LPN A but could not find him/her, so LPN B called 911; -The resident kept saying I can't breath, I need to go to the hospital. During an interview on 12/12/23 at 2:50 P.M. LPN B said: -On 12/9/23 around 7:00 P.M. CNA A came to him/her and said that he/she could not find LPN A; -Resident #2 was having difficulty breathing and FM A was with the resident and wanted the resident to be sent to the hospital; -He/she had not taken care of the resident on this day and attempted to call for LPN A who said that he/she would be to the hall soon, but LPN A did not return to the hall for over a half hour; -He/she checked on the resident who was very confused and his/her O2 sats were 94% with the oxygen on; -He/she called 911 for the ambulance and the resident was sent to the hospital. During an interview on 12/13/23 at 9:45 A.M. FM A said: -He/she came to the facility on [DATE] around 7:30 P.M. because he/she was very concerned about the resident; -The resident usually calls him/her several times a day, and he/she had not heard from the resident; -When he/she arrived in the room, the resident was very confused and CNA A said that the resident had not eaten, that breakfast and lunch food was on the floor and that the resident had been combative with him/her; -This is not like the resident, who usually eats all of his/her food and is very pleasant; -He/she asked to see the nurse and CNA A went to find the nurse but could not find him/her, LPN B came into the room and said he/she was calling for the resident's nurse; -The resident was holding the BiPAP mask in his/her hand and was trying to put the mask on, but could not; -The resident was very cold to touch and said that he/she was cold; -After about 30 minutes, he/she told CNA A and LPN B that if they did not call 911 then he/she would, about this time, LPN A showed up and the resident was taken to the hospital and admitted to the ICU. -He/she had not received a phone call all day from the facility. Review of the nurses notes dated 12/09/2023 at 11:05 P.M. signed by Licensed Practical Nurse (LPN) A showed: - Resident had to have CPAP placed throughout the day. Resident O2 was fluctuating between 60-94% on 3L due to the resident is non compliant with wearing the oxygen. The resident kept dropping food throughout the day. The resident's aide reported the resident does not ever drop food. The Resident locked him/herself out of his/her phone due to being confused. Resident cleaned up with aide and charge nurse. Resident kept saying he/she could not breath when rolling. Charge nurse awaited until oxygen was in 90% to exit room. Resident's family member came when charge nurse was rounding on another hall. The Resident's family member insisted to another nurse, that he/she would like for the resident to go to hospital. Resident charge nurse immediately spoke to family member and the resident was picked up by 4 paramedics and sent to local hospital for COPD. Review of the medical record for 12/9/23 showed no documentation of the resident's vital signs, oxygen levels, the physician of the change of condition. During an interview on 12/11/23 at 1:48 P.M. LPN A said: -He/she applied the BiPAP during the day shift on 12/9/23 due to the resident kept taking his/her oxygen off and the O2 sats would drop into the 60's. The resident was confused and kept dropping his/her food at meal time. -When he/she was making rounds on another hall, FM A came to the facility and insisted the resident to the hospital; -LPN B called the ambulance and sent the resident to the hospital; -He/she had documented in the resident's medical record the events of the day. During an interview on 12/12/23 at 10:00 A.M. Physician A said: -He/she or the on call physician should have been notified of the oxygen levels dropping and the application of the BiPAP to keep the oxygen levels up; -He/she can not find any documentation of the on call physician being notified of the oxygen levels dropping, the increased confusion. During an interview on 12/13/23 at 10:00 A.M. LPN A said: -On 12/9/23, he/she had put on the BiPAP to bring the resident's carbon monoxide levels down as he/she had not worn the BiPAP during the night and was having some shortness of breath, was very confused; -As long as the resident had the BiPAP on, his/her oxygen levels was 96%; -He/she did not notify the physician due to applying the BiPAP was working and there was not need to call the physician; -He/she was on break when LPN B called for him/her; -He/she responded quickly when LPN B called and said FM A was there wanting the resident to be sent to the hospital; -The resident has a behavior of removing his/her oxygen and BiPAP mask and the resident's oxygen levels will drop if he/she doesn't keep the masks on; -He/she did notify the Director of Nursing about the resident's behavior of not keeping the oxygen on; -He/she thinks the oxygen levels are documented on the MAR. During an interview on 12/13/23 at 11:30 P.M. the Assistant Director of Nursing said: -The resident frequently takes his/her oxygen off and will remove the BiPAP mask; -This is a behavior for him/her and he/she is aware of the consequences. During an interview on 12/13/23 at 11:30 A.M., the DON said: -She was notified by LPN A after the resident had sent the resident to the hospital that he/she had put the BiPAP on the resident during the day; -LPN B had called her after he/she had sent the resident to the hospital; -She would expect the nurses to document the resident's oxygen saturation at least daily and more often if the resident was having difficulty; -The physician or the physician on call should have been notified of the increase in confusion and disorientation and the difficulty of keeping the oxygen levels above 90%; -She would have expected this information to be documented with individual notes, vital signs should have been taken and documented as well as the O2 levels; -The family should have been called to notify them of the change of condition. During an interview on 12/18/23 at 10:15 A.M. Nurse Practitioner (NP) A said: -He/she was the NP on call for 12/9/23 and he/she did not receive a phone call from the facility for Resident #2; -If he/she would have received a phone call regarding a change in condition for Resident #2, he/she would have given the order to send the resident to the hospital. 2. Review of Resident #1's quarterly MDS dated [DATE] showed: -The resident was able to sometime make him/her self understood and usually understood others; -Unable to make decision; -Totally dependent upon staff for ADL's; -Receives a mechanically altered diet; -Has a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising); -Incontinent of bowel and bladder; -On isolation; -Received speech therapy; -Diagnoses of COVID 19, dysphagia (difficulty swallowing), Friedreich ataxia (is a rare inherited disease that causes progressive damage to the nervous system and movement problems), seizure disorder, anxiety and depression. Review of the care plan for nutrition with a revision date of 10/12/23 showed: -The resident has a potential nutritional problem related to dysphagia, he/she needs to be fed; -Goal: The resident will maintain adequate nutritional status; -Interventions in part: feed him/her meals, serve diet as ordered. Review of the POS for December 2023 showed: -Regular mechanical soft texture, regular/thin consistency, the resident requires assistance with all meals for diet. Review of the speech therapy notes dated 12/1/23 showed: -Resident seen for one on one dysphagia session in room. The resident with severe difficulty swallowing this date. Speech Language Therapist (SLP) trialed alternate modes (cup, sip, spoon) and reduced amounts to assess if any modifications would reduce the residents overt signs or symptoms of aspiration. No clinician or resident modifications sufficient to reduce overt cough, multiple swallows, watery eyes, and audible gulping in relation to amount trialed. SLP conferred with staff to establish a plan of care. Staff educated on the decline of swallow, the resident is not receptive to modifications at this time; significant skill and medical decline this date. Review of the nurses notes dated 12/04/2023 at 8:13 T A.M. signed by Licensed Practical Nurse (LPN) C showed: - Resident is having difficulty with regular diet. Resident diet changed to pureed. Speech therapy working on barium swallow test. Review of the nurses notes dated 12/05/2023 at 8:01 A.M. showed: - Resident in room and speech therapy. Report given resident not swallowing properly. Resident observed eating well in room per ADON. Resident physician called and family. Awaiting return call. v/s 120/79-123-98% resident eating food and fluids well. Review of the SLP note dated 12/5/23 at 2:57 P.M. signed by SLP A showed: -Resident not able to use straw to intake liquids this date. The resident continued to demonstrate overtly signs and symptoms of aspiration this dated via clinician controlled cup sip this date. Premature posterior spillage noted with delayed swallow initiation with multiple tongue movements to propel bolus. The resident gulping during oral transit and pharyngeal phase. The resident with cough two times on thin liquid. SLP withheld further trials and recommended a modified barium swallow to assess residents safety with liquids. ADON, charge nurse and meal aid called SLP to resident's room during breakfast and resident continued to exhibit premature spillage into the pharynx (throat) (observed via resident;'s open mouth posture and mastication) prior to oral initiation of the swallow. SLP educated staff on physiology of swallow and origin of concerns but staff dismissive and all stated she's fine despite SLP's concerns. The resident supine in bed with head of bed raised to 60 degrees for intake during this session. SLP educated staff on ensuring the resident is properly positioned in chair prior to meal intake due to concerns for safety of swallow. Review of the nurses notes dated 12/05/2023 at 7:39 P.M. signed by LPN D showed: -Resident observed in room yelling while in bed. Nurse readjusted resident position in bed. Resident fed chocolate pudding, applesauce, water and chocolate ensure through a piston syringe, resident swallows slowly but tolerated well. Resident in bed resting. Prefers light to be on, call light in reach, bed in lowest position and fall mat on floor by bedside. Will continue to monitor throughout shift. Review of the SLP note dated 12/6/23 signed by SLP A showed: -SLP assessed the resident's safety with liquids via straw. The resident unable to pull liquids through stray. SLP trialed small amount of preferred drink via spoon. The resident with no swallow reflex. SLP modified approach to be 2 cc's via straw. Liquid noted to fall back past the back of throat and then the resident initiated a swallow with gurgling, wet, gulping six times before a week singular cough. Further by mouth (PO) trials withheld due to concerns for safety. Nurse in attendance for session and verbalized that this was abnormal foe the resident. SLP recommended considering sending the resident to hospital due to difficulty swallowing/severe aspiration risk. Review of the nurses notes dated 12/06/2023 at 12:11 P.M. showed: -Per speech therapy request this nurse called to lunch table for swallowing difficulty for patient. Resident offered a small amount of cool soda which he/she held in his/ her mouth then a gargling sound noted with delayed swallowing reflex. Resident has had minimal intake for past 2 meals. Notified physician office, reviewed med list, and will be sending information to provider. Resident appears lethargic, dry lips and mucosa, low tone for bilateral upper extremities. Resident does not appear to cry as he/she normally does when he/she is hungry or in need of care. Resident heart rate tachy but regular rate and rhythm. Resident O2 sat 96% on room air. Review of the nurses notes dated 12/7/23 at 1:13 P.M. signed by LPN C showed: - Resident still struggling with eating. This nurse fed resident and it was hard for resident to swallow. Resident was able to get down about 4 bites of oatmeal pureed and about 5 bites of pudding before resident was exhausted. Drops of water with a straw was given to help with hydration. Therapy also came and tried to assist with feeding. Resident was up in the chair for this. Review of the SLP notes dated 12/7/23 at 3:07 P.M. signed by SLP A showed: -Nursing reported that the resident choked on small amount of liquid via syringe and consumed three bites of breakfast and half a cup of pudding. Resident unable to use a straw. Attempted fluids with a cup, with the resident holding fluids at back of throat with gulping swallows. Awaiting orders for a modified barium swallow to assess the swallow. During an interview on 12/11/23 at 11:20 A.M. LPN C said: -The resident had been sent to the hospital on 12/7/23 due to not eating or drinking for several days; -The resident did not have a swallow reflux and was unable to swallow; -He/she had been to the hospital several times over the last couple of days due to concern of aspiration (sucking food or fluids into the airway) and dehydration; -Speech therapy was working with the resident and was concerned about his/her swallow and wanted a modified barium swallow (is an X-ray procedure performed in the Radiology department that looks at the anatomic structures in your head and neck area to make sure they are working properly while you are chewing, drinking and swallowing) done and was waiting for the orders to do the test. During an interview on 12/11/23 at 3:50 P.M. LPN D said: -The resident had not been eating or drinking well. -He/she fed the resident via a 90 cc (Centimeter) syringe, he/she have the resident applesauce, pudding and water through the syringe. The resident was able to swallow this better than using a straw. During an interview on 12/12/23 at 9:40 A.M. SLP A said: -He/she had been working with the resident on the resident's swallow technique; -The resident had a difficult time swallowing foods and fluids due to his/her disease process; -The resident's swallow had deteriorated rapidly to where he/she began to cough with foods and fluids; -He/she had asked for a modified barium swallow to assess the resident's swallow and was waiting for physician orders; -He/she was notified that the nursing staff had used a syringe to feed the resident food and fluid; -After this the resident had an increase in the cough with any attempt to administer fluids or food; -He/she could see an increase in the delay of the swallow; -He/she would not have recommended using a syringe to give foods or fluids to the resident because of the delay in the swallow reflex and the possibility of aspiration or choking. During an interview on 12/12/23 at 10:25 A.M. Physician A said: -He/she would not have recommended using a syringe to give fluids or food to the resident. During an interview on 12/13/23 at 11:30 A.M. the DON said: -Using a syringe to give food or fluids to a resident is not acceptable method of feeding; -Staff were desperate to get food and fluids into the resident; -She would not have expected staff to use a syringe. MO228525 MO228602

Refer to ZNHX12 Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff failed to provide incontinence care per the facility's perineal care policy/procedure and to wash their hands when they removed contaminated gloves while performing post-incontinence care for Resident #2 and #4. The facility census was 70. The administrator was notified on 11/08/23 at 4:45 P.M. of an Immediate Jeopardy (IJ) which began on 11/07/23. The IJ was removed on 11/09/23 as confirmed by surveyor on-site verification. Review of the facility policy, Glucometer Disinfection, revised 09/01/21, showed the following: -The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood-borne diseases to residents and employees; -Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects; -The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; -The glucometers should be disinfected with a wipe pre-saturated with EPA registered healthcare disinfectant that is effective against human immunodeficiency virus/HIV (a virus that targets the immune system and can be spread through contact with infected blood), Hepatitis C and Hepatitis B (a serious liver infection caused by a virus that most commonly spread by exposure to infected body fluids) virus; -Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use; -Procedure: h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive; i. Retrieve two disinfectant wipes from container; j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions, allow the glucometer to air dry. Review of the facility policy, Blood Glucose Monitoring, dated 09/01/21, showed the following: -It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders; -Policy explanation and compliance guidelines: 3. The nurse will will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; -Procedure: 2. Obtain needed equipment and supplies: gloves, glucometer, alcohol pads, gauze pads, single use auto-disabling lancet, blood glucose testing strips; -The policy did not address placing a barrier between the glucometer and other items while in use. Review of the Evencare G2 glucometer manufacturer/guidelines for disinfecting the piece of equipment showed the following: -To disinfect the meter, clean the meter with one of the following validated disinfection wipes listed below: a. Dispatch Hospital Cleaner Disinfectant Towels with bleach; b. Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; c. Clorox Healthcare Bleach Germicidal and Disinfectant wipes; d. Medline Micro-Kill Bleach Germicidal Bleach wipes; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean; -Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow to air dry. 1. Review of Resident #1's face sheet showed the following: -Diagnosis of diabetes mellitus with hyperglycemia (a group of diseases that result in too much sugar in the blood); -Diagnosis of unspecified viral Hepatitis C. Review of the resident's November 2023 physician order sheet showed an order for Humalog insulin (medication injected for elevated blood sugar), inject subcutaneously before meals related to type II diabetes mellitus with hyperglycemia:. If blood sugar is 61-150 = no insulin, blood sugar 151-200 = 3 units, 201 - 250 = 5 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units, greather than 400 give 15 units and contact physician, with an order start date of 02/13/22. Review of the resident's November 2023 medication administration record (MAR) showed the following: -Resident receives a blood glucose test three times a day at 6:00 A.M., 11:00 A.M., and 4:00 P.M.; -Staff document the blood sugar results on page seven of the MAR; -Page 1 of the MAR listed the resident with diagnosis of Hepatitis C. Observation on 11/07/23 at 5:49 A.M., showed the following: -Registered Nurse (RN) A took a glucometer out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bed without placing a barrier between the glucometer and the mattress; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and the top of the medication cart and removed his/her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the glucometer with bare hands. 2. Review of Resident #2's face sheet showed a diagnosis of diabetes mellitus. Review of the resident's November 2023 physician order sheet showed an order for Lispro insulin (medication injected for elevated blood sugar) inject subcutaneously before meals and at bedtime related to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes): if blood sugar is 0 -150 = no insulin, blood sugar 151-200 = no insulin, 201 - 250 = 6 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units and call physician/nurse practitioner, with an order start date of 06/15/23. Review of the resident's November 2023 MAR showed the resident received a blood glucose test four times a day at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M. Observation on 11/07/23 at 6:11 A.M., showed the following: -RN A took the same glucometer he/she used to check Resident #1's blood sugar out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the resident's blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bedside table without placing a barrier between the glucometer and a magazine on the bedside table; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and top of the medication cart and removed his/ her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the used glucometer with bare hands; -No disinfection wipes were available for use on the medication cart. During interviews on 11/07/23 at 5:50 A.M. and 7:05 A.M., and 11/08/23 at 2:10 P.M., RN A said the following: -He/She cleans the glucometer with alcohol wipes if there were no sanitizer (disinfectant) wipes on the cart; -He/She had given the sanitizer wipes to another staff member earlier in the shift and did not have any sanitizer wipes on his/her medication cart; -Sanitizer wipes were in central supply, but central supply was generally locked at night and he/she did not have a key to central supply; -When cleaning a glucometer, you should clean it with alcohol wipes or sanitizer wipes, make it wet and then let it air dry; -When he/she takes a glucometer into a resident room, he/she should place a barrier, such as a paper towel, so he/she did not place the equipment on a dirty surface; -He/She did not place a barrier between the glucometer and mattress for Resident #1 or between the glucometer and bedside table for Resident #2 when he/she obtained the residents' blood sugars but should have; -He/She used the same glucometer for the residents on A hall and D hall; -He/She was not aware of any residents with an infectious disease such as viral hepatitis; -If a resident has an infectious disease, they should have their own glucometer. During an interview on 11/08/23 at 2:18 P.M., Licensed Practical Nurse (LPN) G said the following: -He/She believed each hall had its own glucometer to use for multiple residents; -The A hall had four residents who have routine blood glucose monitoring; -MicroKill One sanitizers were available on the medication cart and could be used to sanitize the glucometer; -He/She usually cleaned the glucometer in between each resident with alcohol wipes; -He/She thought the night shift staff disinfected the glucometer each night with the sanitizer wipes; -He/She was unsure if anyone at the facility had Hepatitis C; -He/She was unsure what the manufacturer's recommendations were for disinfecting the glucometer. During an interview on 11/08/23 at 4:00 P.M., the Director of Nursing (DON) said the following: -She expected staff to follow the facility policy for cleaning a multi-use glucometer after each use; -She expected staff to clean the glucometer with sanitizer wipes; -She would not expect staff to know off of the top of their head if a resident they were obtaining a blood sugar on had an infectious disease such as hepatitis C; -All of the residents' diagnoses are listed in the resident health record; -If staff disinfected a glucometer properly, staff could use a multi-use glucometer on a resident that has Hepatitis C, and then other residents; -Extra sanitizer wipes were available in central supply and the 11-7 shift had access to the central supply with a key; -Alcohol wipes were not acceptable to disinfect a multi-use glucometer; -There were two residents at the facility that had Hepatitis C. During an interview on 11/08/23 at 3:50 P.M., the administrator said the following: -He expected staff to clean a multi-use glucometer properly after use and to disinfect the glucometer per manufacturer's recommendations and company policy; -He expected staff to follow infection control policies to ensure no infection was passed to another resident; -If a resident had diagnosis of Hepatitis C, he expected staff to follow company policy for glucometer use, follow infection control policies and then follow proper cleaning to be able to use the glucometer for multiple residents. 3. Review of the facility policy, Perineal Care, revised 09/01/21, showed the following: -Policy explanation and compliance guidelines: -Perform hand hygiene and put on gloves; Apply other personal protective equipment as appropriate; -If perineum is grossly soiled, turn resident on side, remove fecal material with toilet paper, then remove and discard; -Cleanse buttocks and anus, front to back; vagina to anus in females and scrotum to anus in males, using a separate washcloth or wipes; -Dry thoroughly; -Re-position resident in supine (laying on back) position. Change gloves if soiled and continue with perineal care; -Cleanse perineal area using separate washcloth or wipes for each area; -Change gloves if soiled and continue with perineal care; -If using soap, rinse after washing; -Reposition as desired and cover resident; -Remove gloves and discard. Perform hand hygiene. Review of the facility hand washing policy, dated 9/1/21, showed the following: -All staff would perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene was the general term for cleaning the hands by handwashing with soap and water or use of an antiseptic hand rub, also known as an alcohol-based hand rub (ABHR); -Staff would perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene was indicated and would be performed under conditions listed in, but not limited to the attached hand hygiene table which included; -ABHR with 60-95% alcohol was the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they were visibly dirty, before eating, and after using the restroom. Review of the facility hand hygiene table, dated 2021, showed the following: -Hands should be cleaned with soap and water when hands were visibly dirty, and hands were visibly soiled with blood or there body fluids; -Hands should be cleaned with ether soap and water or ABHR (ABHR is preferred) between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves, before performing resident care procedures, when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions, and whenever in doubt. Review of Resident #2's electronic medical record (EMR) showed he/she had the following diagnoses: -Overactive bladder (condition of the bladder that causes a frequent and sudden urge to urinate that may be difficult to control); -Urinary tract infections (UTI, an infection involving the urinary tract system); -Dysuria (painful urination). Review of the resident's care plan, last revised on 8/24/22, showed the following: -He/She was on diuretic (a substance that promotes an increased production of urine) therapy; -He/She was incontinent of bowel and bladder and had a history of UTIs; -He/She had a self-care deficit with performance of activities of daily living (ADLs) due to decreased strength and limited mobility; -Staff were to assist the resident with cleaning the perineal area after each incontinence episode. Review of resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/19/23, showed the resident's cognition was intact, he/she was frequently incontinent of bowel and bladder, and did not have a history of rejecting care. Observation on 11/7/23 at 5:37 A.M., showed the following: -The resident was incontinent; his/her incontinence brief was saturated with orange colored urine and urine was on the bed pad located under the resident; -With a soapy, wet bath towel and gloved hands, Certified Nurse Assistant (CNA) J cleaned urine from resident's perineal area, abdominal fold and thighs. He/She wiped the resident's left groin multiple times, right groin, and genital area, but did not use a different cloth surface after each wipe. CNA J walked over to the resident's sink, rinsed the towel with water and walked back over to the resident to rinse the resident's groin and genitalia with the same towel. With the same gloves, CNA J obtained a clean brief from resident's bedside storage. CNA J assisted the resident onto his/her left side, placed an incontinence brief under the resident, and without cleansing urine from the resident's buttock and thigh areas, CNA J assisted the resident onto his/her right side to pull the brief through, then assisted the resident to his/her back and attached the clean brief. With the same gloves, CNA J opened the resident's door to his/her room to discard trash; -CNA J had not changed gloves when he/she went from a dirty process to a clean process and touched the resident's bedside storage, clean brief, the resident and the resident's door with the gloves. During an interview on 11/7/23 at 5:45 A.M., the resident said staff had last changed his/her incontinence brief and provided care at approximately 8:00 P.M. on 11/6/23. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should change the surface of the cloth with every wipe. He/She did not realize he/she used the same surface of the cloth and did not change cloths when needed. Resident #2 did not like to be awakened during the night for staff to check for incontinence, so he/she changed him/her in the morning. Resident #2's bed pad was not wet, therefore he/she did not change the pad. 4. Review of Resident #4's diagnoses showed he/she had the following: -Overactive bladder; -Recent UTI (10/10/23). Review of the resident's care plan, last revised on 10/25/23, showed the following: -He/She had an ADL self-care performance deficit and was dependent on staff for all ADLs, including personal hygiene and toileting; -He/She was frequently incontinent of bladder related to an overactive bladder; -He/She wore adult briefs; -Staff were to assist the resident with cleaning his/her perineal area after each incontinence episode. Review of the resident's admission MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She was dependent on staff with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She did not reject care. Observation of the resident, on 11/7/23 at 5:53 A.M., showed the resident lay in his/her bed and had been incontinent of bladder. The resident's incontinence brief was saturated. With gloved hands, CNA J cleaned urine from the resident's perineal area, lower abdomen, buttocks, and thighs. CNA J wiped the resident's left groin, right groin and genital area multiple times with a wet, soapy bath towel. He/She did not change the cloth surface after each wipe. CNA J assisted the resident onto his/her left side and wiped the right and left buttocks multiple times. He/She did not change the surface of the cloth after each wipe. CNA J rinsed the towel with water and rinsed the resident's buttocks areas, groin and genitalia, but did not change the surface of the cloth after each wipe. With the same gloves, CNA J obtained barrier cream from the resident's bedside table and placed it on the resident's buttocks, obtained a clean brief from resident's bedside storage area and placed it on the resident. CNA J removed his/her gloves and without performing hand hygiene, he/she grabbed the resident's door knob, opened the door, and exited the room to discard trash. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should not have touched any clean items with contaminated gloves. During an interview on 11/9/23 at 10:30 A.M., the DON said she would expect staff to remove gloves and wash their hands before touching any clean items. Hands were to be washed with soap and water when visibly soiled and after removal of gloves. Staff were expected to remove gloves and wash their hands after applying barrier cream and before touching any clean items. She expected staff to change the surface of the cloth after each wipe when providing incontinence care. Staff should not use the same surface multiple times before changing surfaces. She expected staff to clean all areas of the perineum with wash cloths and/or wipes. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO225546 MO226124

Refer to ZNHX12. Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and to communicate with outside agencies (e.g. sate surveyors) regarding any matter. Review of the facility's policy, Resident and Family Grievances, dated 9/2/22, showed the following: -The facility would support each resident's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; -The facility would not retaliate or discriminate against anyone who filed a grievance or participated in investigation of grievances. Review of the facility policy, Promoting/Maintaining Resident Dignity, revised 09/01/22, showed the following: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident' individuality; -When interacting with a resident, pay attention to the resident as an individual; - Respond to requests for assistance in a timely manner. 1. Review of confidential Resident #900's face sheet showed the resident was his/her own responsible party. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, showed the following: -Adequate hearing and clear speech; -Able to make self understood and able to understand others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:00 P.M., the resident said the following: -Staff do not come in and take care of him/her when he/she needed help; -He/She has complained to the management staff about the lack of response to his/her call light, and then the staff will take even more time to answer the call light. He/She has waited up to an hour for staff to come in and assist him/her; -He/She feels that staff will punish him/her for talking with the State Agency (SA) and the staff will take longer to answer the call light or refuse to give him/her medication; -He/She has tried to voice his/her concerns to management, but feels that nothing is done about these concerns and then staff will ignore him/her when he/she needs help; -He/She has filed grievances, but has not received any resolution to his/her grievances; -He/She needs help to get in and out of bed at times and help to use the bathroom. When he/she has complained about staff members to management, these staff members will then ignore him/her and refuse to help him/her. He/She has been told (specified staff member), if he/she talks with the SA or calls the abuse and neglect hotline, that he/she can look for another place to live. 2. Review of confidential Resident #700's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understands others; -Cognitively intact. During a confidential interview on 11/07/23 at 7:30 A.M., the resident said the following: -He/She feared repercussions from staff simply for talking to the SA; -He/She felt like the repercussions would be that staff would ignore him/her more than they already do, and that it will take a really long time to answer his/her call light now, longer than usual which was at times a really long time. 3. Review of confidential Resident #800's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understood others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:36 P.M., the resident said the following: -He/She would not complain due to real fear of retaliation from staff; -The retaliation was real, the resident would not explain, but turned his/her head away and would not talk further. 4. Review of Resident #10's face sheet showed an admitted [DATE]. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 9/25/23, showed the following: -Cognitively impaired; -Understood others and able to make others understand; -No behaviors or rejection of care; -Dependent on staff for bed mobility; -No falls in the last month prior to admission; -One non-injury and one injury fall since admission or prior assessment. Review of the resident's fall risk assessment, dated 10/30/23, showed he/she had had two falls in the last 30 days and was high risk for falls. Review of the resident's care plan, last revised on 10/30/23, showed the following: -History of traumatic event; -Further traumatization will be avoided; -Required assist of one staff for activities of daily living (ADL), including transfers; -Dependent on staff for meeting emotional, intellectual, physical and social needs; -Increased risk for falls due to impaired mobility and will throw self on the floor due to having a difficult time making needs known; -Low bed; -Fall mattress/mat next to bed when in bed; -Resident required prompt response to all requests for assistance. Review of a video/audio recording (received anonymously), date stamped 10/31/23, showed the following: -On 10/31/23 at 4:20 A.M., Resident #10 was observed on the floor by a confidential resident. Resident #10 can be heard saying, Can you help me get back into the bed, I rolled off the bed. Can you help me; -On 10/31/23 at 4:29 A.M., a video of a hallway with a male voice, repeatedly yelling out for help; -On 10/31/23 at 4:33 A.M., a female staff member observed standing at the doorway of Resident #10 and saying, I need you to stay on the mat and be quiet; the staff member was identified as Certified Nurse Assistant (CNA) H by a confidential resident. During an interview on 11/8/23 at 11:00 A.M., the resident said the following: -In the last two weeks, he/she fell out of bed, yelled for help and when unidentified staff initially arrived, they told him/her to be quiet and stay on the mat. He/She asked for help to get back into bed and the same unidentified staff refused to assist him/her. This made him/her feel helpless and upset. During interview on 11/7/2023 at 2:15 P.M. CNA H said the following: -He/She did not necessarily recall the resident being on the floor the night of 10/30/23 or early morning of 10/31/23 as he/she was not assigned that hall, however the resident is always on the mat; -He/She did not tell the resident to be quiet or that he/she would have to stay on the mat. During an interview on 11/9/23 at 1:00 P.M. and 1:20 P.M., the Director of Nursing said the following: -She would not expect staff to ignore a resident's call light or request for help. She would expect staff to assist the residents when they request help; -Residents should not fear retaliation for voicing concerns or complaints. -She would expect staff to respond to resident's needs promptly; -She would not expect staff to tell a resident to be quiet, stay on the fall mat and then leave without assisting them back to bed, and had not heard of that happening; -It would be a dignity/respect issue if staff told a resident to be quiet, left them wet for extended periods of time or did not answer call lights timely. During an interview on 11/9/23 at 1:10 P.M., the Administrator said the following: -Residents should not fear any retaliation against them if they brought any concerns to any staff members; -He would find it unacceptable for any staff member to retaliate against a resident for voicing concerns. MO225143 MO227066 MO226198 MO226300 MO226124

Refer to ZNHX12. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room . Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. The facility failed to provide adequate supervision and monitoring for Resident #15, who resided on a locked dementia unit and was on a pureed diet, when staff placed a peanut butter and jelly sandwich down on a table near the resident. The resident picked the sandwich up and ate it without staff knowledge. The facility census was 70. 1. During email communication on 11/28/23, at 12:49 P.M., the facility administrator said the facility did not have a Low-Air Loss mattress policy. Review of the undated operation manual for the Proactive medical product, Protekt Aire 6000 mattress, showed the following: -The Protekt Aire 6000 pump and mattress are intended to reduce the incidence of pressure ulcers while optimizing comfort; -Pressure range is 20 - 55mmHg adjustable and should be selected by a using the person's weight guide listed on the panel providing pressure range options; -Weight range option settings are: 80 pounds, 130 pounds, 180 pounds, 230 pounds, 280 pounds, 340 pounds, 400 pounds and 450 pounds. Review of Resident #6's face sheet showed diagnoses included morbid obesity (a condition when weight exceeds 100 pounds over recommended weight) and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/03/23, showed the following: -Adequate hearing, clear speech, makes self understood and understands others; -Cognitively intact; -No mobility impairment; -Toileting hygiene, dependent (helper does all of the effort, resident does none of the effort to complete the activity); -Mobility: roll left and right, substantial/maximum assist; -Bed rails not used. Review of the resident's progress notes showed staff documented the following: -On 10/28/23 at 2:17 A.M., staff documented at 2:00 A.M., Certified nursing assistant (CNA) B went to the resident's room to answer the call light. The resident needed to use the bed pan. When the resident finished with bed pan, he/she activated call light and CNA B went to the resident's room to remove the resident from the bed pan. In the process of cleaning the resident, the resident pushed himself/herself toward the edge of the bed whereby CNA B was telling the resident not to move too far toward the edge of bed but the resident was not listening. In the process, the resident slid out of the bed and CNA B tried to pull the resident back in the bed with linen, but the resident lost balance and fell where he/she hurt his/her scalp and had a laceration. CNA B asked Licensed Practical Nurse (LPN) C to come to the resident's room due to a fall. LPN C found the resident bleeding from his/her head, cleansed the resident's head and put a pressure dressing on the injury to stop the bleeding. Assessment revealed no injuries to legs or feet, two lacerations on nose and head. The resident was transferred back to bed via Hoyer lift (a mechanical lift used to transfer a resident from one surface to another) and the physician was called with an order to send to the emergency room for evaluation; -On 10/28/23 at 9:15 A.M., the resident returned from the emergency room with sutures to his/her forehead and a brace to his/her right hand to be worn while awake and remove while sleeping. Review of the resident's emergency room records, dated 10/28/23, documented the resident's assessment showed tenderness over his/her right clavicle (collarbone), pain at the base of his/her right thumb, a four centimeter laceration between his/her eyebrows, a one centimeter laceration on the bridge of his/her nose. Review of the resident's care plan, revised 10/21/23, showed the following: -At risk for falls; -Goal: will not sustain serious injury through the review date; -Resident had a fall on 10/28/23 at 2:07 A.M. and went to emergency room due to head laceration, has sutures in his/her forehead and two black eyes; -Anticipate and meet the resident's needs; -Resident has an activity of daily living (ADL) self-care performance deficit, is obese and weak; -Bed mobility assist times one to two; -Toilet use: change in bed. -Personal hygiene assist as needed with one to two staff. Review of the resident's November 2023 physician order sheet showed the following: -May have brace on right hand while awake and remove while sleeping with a start date of 10/28/23; -Remove sutures to forehead in 10 days with a start date of 10/28/23. Observation on 11/07/23 at 6:30 A.M., showed the following: -The resident lay awake in his/her bed; -The resident had purple and yellow bruising below both eyes: -A healing laceration was noted on the bridge of his/her nose and on his/her forehead between his/her eye brows; -The resident was wearing a splint on his/her right hand/thumb; -Low air loss mattress at alternating setting, set at 450 pounds (residents documented weight in his/her electronic health record was 269 pounds). Observation on 11/07/23 at 9:15 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During interviews on 11/07/23 at 6:30 A.M. and 9:15 A.M., the resident said the following: -The day he/she fell out of bed, CNA B was cleaning him/her up after having to use the bed pan; -CNA B had his/her hand on the resident's right hip and was looking at the resident's bottom to see if he/she had cleaned everything ok; -CNA B pushed his/her bottom too far and he/she fell out of bed; -He/She was sent to the emergency room for stitches and x-rays; -The hospital told him/her that he/she had a broken nose, but did not break his/her thumb; -He/She had black eyes since the fall; -He/She got a new bed that had side rails on them after he/she fell ; -His/Her mattress was pretty firm and could be softer; -When he/she got too close to the edge of the mattress the edge crumpled. During an interview on 11/07/23 at 2:50 P.M. and 11/20/23 at 3:40 P.M., CNA B said the following: -He/She cared for Resident #6 on the night he/she fell out of bed; -The resident asked to use the bedpan and he/she placed the resident on the bed pan; -After the resident was finished, he/she removed the resident from the bed pan; -After providing incontinence care, he/she applied barrier cream on the resident's buttocks; -The resident kept moving toward the edge of the bed on the left side; -He/She asked the resident to stop moving toward the edge of the bed, but he/she continued to move and started to slide out of the bed; -He/She used the turn sheet to attempt to reposition the resident and stop him/her from sliding, but the resident fell out of bed; -When the resident fell to the floor, he/she noticed there was blood on the resident's face; -He/She got the nurse to provide care and the resident was sent to the hospital; -If two staff had provided incontinent care for the resident, he/she would not have fallen out of bed. During an interview on 11/07/23, at 2:56 P.M., LPN C said the following: -He/She was the charge nurse for the resident the night he/she fell out of bed; -CNA B reported the resident had pushed against CNA B when providing care and started to slide toward the edge of the bed; -The resident slid out of the bed and fell to the floor; -The resident received a laceration to his/her scalp and nose and was sent to the emergency room for treatment; -Side rails were applied to the resident's bed after the fall; -The resident had a low air loss mattress due to skin breakdown in the past; -The air mattress should be set to the resident's weight; -Anyone can check to make sure the setting on the air mattress is correct, all nurses should check that; -If the air mattress was set too high it could have been a factor in the fall. Observation on 11/08/23 at 9:12 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the Director of Nursing (DON) said the following: -Resident #6 was sent to the hospital during the night shift after a fall from his/her bed during incontinence care and received two lacerations; -The wound care nurse and central supply is in charge of checking the air mattresses to make sure the setting are correct, but any nurse should also monitor to make sure settings are correct; -If the air mattress was at maximum fill at 450 pounds, that could have been a potential factor in Resident #6 falling out of bed; -She would have expected CNA B to stop the incontinence care/repositioning and get additional help for Resident #6 when the resident began pushing himself/herself toward the edge of the bed and when CNA B was telling the resident not to move too far toward the edge of bed and the resident was not listening; -There was adequate staff the night of Resident #6's fall out of bed to provide two people for the resident's care. 2. Review of the facility policy titled, Meal Supervision and Assistance, last revised January 2023, showed the following: -Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/ her preference and with adequate supervision and assistance to prevent accidents. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary; -Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident' environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff; -The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time. Review of Resident #15's comprehensive MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -Difficulty making self understood and sometimes understands others; -Unable to make decisions; -Requires limited assistance with ADL's and feeding; -Diagnoses of stroke and dementia; -No swallow disorder and no speech therapy marked; -Alteration in diet left blank. Review of the registered dietician progress note, dated 9/19/23, showed the resident was on a pureed diet. Review of the resident's care plan, dated 10/11/23, showed no care plan for nutrition, the resident's diet, or swallow problems. Review of the resident's physician's order sheet, dated 11/2023, showed an order for a pureed diet. Observation on 11/6/23 at 12:43 P.M., showed: -Resident #15 sat at a table in the dining room on the locked dementia unit; -The resident was served a tray of pureed food; -The resident said the food was terrible and ate the pudding; -Another resident said that he/she was still hungry. During an interview on 11/6/23 at 12:45 P.M., CNA M said: -Resident #15 does not like the pureed food; -He/She does not know why the resident was on a pureed diet, but he/she was not suppose to have solid food. Observation on 11/6/23 at 12:50 P.M. showed: -CNA M went to the kitchen and returned with two peanut butter and jelly sandwiches wrapped in plastic wrap; -CNA M placed one wrapped sandwich on the table, where Resident #15 sat; the sandwich was within the resident's reach; CNA M unwrapped the second sandwich and handed it to another resident; -Resident #15 picked up the wrapped sandwich, removed the plastic wrap and began to eat the sandwich; -CNA M and Registered Nurse (RN) A stood in the dining room where Resident #15 sat and ate the sandwich; -Neither CNA M or RN A noticed the resident had eaten the sandwich. During an interview on 11/7/23 at 10:45 A.M., CNA M said: -The resident was on a pureed diet and was to be monitored closely for taking food and choking. Staff are to observe the resident closely; -He/She was unaware the resident ate the peanut butter and jelly sandwich; he/she wondered what had happened to the sandwich and why there was plastic wrap on his/her tray. During an interview on 11/7/23 at 7:00 A.M., Registered Nurse (RN) A said: -He/She was unaware the resident ate a peanut butter and jelly sandwich; -The resident was on a pureed diet; -The resident was not safe to eat regular food; he/she could have choked. During an interview on 11/7/23 at 10:30 A.M. the DON said: -Resident #15 has a diagnosis of dysphagia (difficulty swallowing; Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all) with orophangeal dysphagia (difficulty initiating a swallow); -Resident #15 should be monitored closely because he/she does not like the pureed food and will take food off other resident's trays; -Staff should monitor the residents and ensure they eat foods that are ordered for them. 3. Review of Resident #5's care plan, last revised 2/1/23, showed the following: -He/She had an ADL self-care performance deficit related to his/her diagnosis of Friedreich's ataxia (an inherited disorder that affects some of the body's nerves); -He/She required assistance of two with Hoyer lift transfers. Review of the resident's physician's orders, dated November 2023, showed an order for Hoyer lift assist of two for all transfers (2/1/23). During an interview on 11/7/23 at 6:00 A.M., CNA J said the resident should be a two person transfer with a Hoyer lift, but he/she transferred the resident with only one person because the resident was so small. Technically he/she was supposed to use two staff for Hoyer transfers. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the DON said the following: -Under no circumstances should a Hoyer lift transfer be completed with only one staff. She expected all Hoyer lift transfers be completed with two staff. MO226653 MO227065 MO226124

Based on interview and record review, the facility failed to ensure systems were in place to clearly document residents' choice for code status. The facility also failed to clearly communicate the choice of code status to direct care staff so staff knew immediately what actions to take in the event of an emergency for four residents (Residents #2, #3, #4, and #5) in a review 79 residents. This had the potential to result in a resident who wished to be full code status not receiving cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) in the event of an emergency, or residents receiving CPR who wished to be a do-not-resuscitate (DNR) (when a person elects to not have CPR attempted on them if their heart or breathing stops). The facility census was 79. The administrator was notified on [DATE] at 11:10 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility policy, titled Advanced Directives, revised [DATE], showed the following: -Upon admission, the resident will be provided with written information concerning the right to formulate an advance directive if he or she chooses to do so; -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative; -Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advance directives; -The resident will be given the option to accept or decline the assistance and care will not be contingent on either decision; -Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive; -A resident will not be treated against his or her own wishes; -In accordance with current omnibus budget reconciliation act (OBRA) definitions and guidelines governing advance directives, our facility has defined advance directives as preferences regarding treatment options and include, but are not limited to: a. Advanced Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated; c. Durable Power of Attorney (DPOA) for Health Care (i.e. Medical Power of Attorney) - a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated; e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy or representative has directed that no cardiopulmonary resuscitation or other life-sustaining treatments or methods are to be used; -The director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of the facility admission checklist, showed items to be obtained and orders entered, included a resident's code status order and signature. The form showed columns to indicate the item had been obtained, had not been obtained, the item was not applicable and a section for comments and follow up. 1. Review of Resident #2's medical record showed he/she had a representative (DPOA) and there was no code status identified on his/her face sheet or physician orders. His/Her admitted was [DATE]. During an interview on [DATE] at 4:20 P.M., the resident said when he/she died , he/she would prefer that staff just let him/her go and not perform CPR. During an interview on [DATE] at 10:15 A.M., Registered Nurse (RN) C said the following: -When he/she admits a resident, he/she reviews hospital discharge records for a resident's code status and/or calls the resident's physician to obtain a code status order; -Each resident's electronic health record should have an identified code status; -He/She was the admitting nurse for the resident; -Upon review of the resident's electronic health record on [DATE], along with the surveyor, RN C confirmed the resident's electronic health record did not include an identified code status; -He/She did not realize a code status had not been obtained or addressed; -Staff should be able to locate a resident's code status in the resident's electronic health record, on the face sheet, or on the physician orders; -In the event of an emergency, and no code status is listed, he/she would begin CPR. 2. Review of Resident #3's medical record showed he/she was his/her own person and there was no code status identified on his/her face sheet or physician orders. His/Her admitted was [DATE]. During an interview on [DATE] at 3:45 P.M., the resident said he/she wanted to live, and if he/she stopped breathing, he/she wanted everything done to save him/her. During an interview on [DATE] at 10:30 A.M., Licensed Practical Nurse (LPN) G said the following: -He/She could recall the resident's admission; it occurred at shift change; -Graduate Practical Nurse (GPN) K had started the admission and then told him/her that he/she (LPN G) needed to finish the admission, He/She thought all he/she needed to complete was an admission assessment and that all other information had been obtained; -He/She though the Assistant Director of Nursing (ADON) had been the one to enter the resident's orders, including the code status. He/She had not checked to see that that information had been collected; -The facility used an admission checklist to complete resident admission that had a list of things that was to be obtained during the admission process. The admission list included code status. He/She did not see this resident's admission checklist. Once completed, the admission nurse turns this form into the Director of Nursing (DON); -Each resident's electronic health record should have an identified code status and it should be located on the face sheet and physician orders; -Upon review of the resident's electronic health record on [DATE] with the surveyor, LPN G confirmed the resident's electronic health record did not contain an identified code status; -In the event of an emergency, and no code status is listed, he/she would begin CPR. During an interview on [DATE] at 12:05 P.M., GPN K said the following: -He/She had received the resident's admission paperwork from the admissions staff right at shift change; -When his/her shift ended, the resident had not yet arrived at the facility; -He/She had not played any part in the resident's admission other than to tell LPN G to expect an admission on his/her shift, but he/she did not know an arrival time. 3. Review of Resident #4's medical record showed he/she had a representative. There was no code status identified on his/her face sheet or physician orders. His/Her admitted was [DATE]. During an interview on [DATE] at 8:28 A.M., the resident's representative said he/she was the resident's guardian and that the facility had not discussed the resident's code status with him/her. The resident would not want CPR done if he/she stopped breathing. During an interview on [DATE] at 12:02 P.M., LPN Supervisor E said the following: -He/She was the admitting nurse for the resident; -He/She uses the admission checklist when completing resident admissions; -He/She could not recall if he/she obtained the resident's code status at admission; -All residents should have an identified code status; -Staff can locate a resident's code status in their electronic health record on the face sheet or on the physician orders; -If no code status is listed and there is an emergency, then staff should start CPR. 4. Review of Resident #5's medical record showed he/she had a (DPOA) and there was no code status identified on his/her face sheet or physician orders. His/Her admitted was [DATE]. During interview on [DATE] at 5:10 P.M., the resident's DPOA said the following: -The facility did not go over anything regarding code status on admission; -The resident should be a full code. Review of the resident's care plan, dated [DATE], showed it stated the following: -I have a living will or other advanced directive: health care agent; I will have my desires and wishes followed according to my signed directive; Facility will place my advanced directive in my medical record. Review of the resident's medical record showed no documentation of an advanced directive. During a phone interview on [DATE] at 11:55 A.M., LPN I said the following: -He/She believed he/she was the admitting nurse for the resident. As the admitting nurse, it would be his/her responsibility to obtain the resident's code status and to do that, he/she would look through any hospital discharge paperwork, ask the resident or ask the family, and obtain the physician order for the code status; -If a resident elected a DNR status, the order needed to be entered into the resident's electronic health record right away; -If a resident elected a full code status, the order did not have to be entered; -He/She could not recall anything about the resident's code status at the time of admission; -All residents should have an identified code status; -Staff can locate a resident's code status in their electronic health record on the face sheet or on the physician orders; -If no code status is listed for a resident and there is an emergency, he/she would start CPR. During an interview on [DATE] at 4:20 P.M., Nurse Aide (NA) X said he/she was not CPR certified, did not know where to locate a resident's code status and would not know the first thing about doing CPR. During an interview on [DATE] at 3:25 P.M. Certified Medication Technician (CMT) M said the following: -He/She would search for a resident's code status in the electronic health record on the face sheet; -He/She would initiate CPR if the code status wasn't indicated or found in the health record; -He/She had CPR training in the past, but his/her certification had expired. During an interview on [DATE] at 3:50 P.M., CMT W said the following: -He/She is CPR certified; -A resident's code status should be in his/her electronic health record; -He/She would not start CPR if he/she does not know a resident's code status. During an interview on [DATE] at 3:55 P.M., CMT V said the following: -He/She is CPR certified; -A resident's code status should be in his/her electronic health record; -He/She would not initiate CPR on a resident without knowing the resident's code status. During an interview on [DATE] at 6:35 A.M., CMT S said the following: -He/She is CPR certified; -A resident's code status should be in his/her electronic health record; -If code status is unknown, he/she would not initiate CPR; -He/She would not want to bring somebody back that did not want CPR. During an interview on [DATE] at 6:35 A.M. Registered Nurse (RN) R said the following: -He/She was CPR certified; -He/She would check the face sheet on the electronic health record for a resident's code status; -If the code status was not indicated, he/she would start CPR. During an interview on [DATE] at 10:45 A.M., the admission staff said the following: -The clinical nurse is to get the orders for the resident's code status at admission; he/she had not been told that this was his/her responsibility to obtain that information; -He/She obtains hospital discharge records or transfer records on the resident and shares those documents with the clinical nurse/admitting nurse and also uploads those records in the resident's electronic health record for anyone to review; -He/She starts the demographics of the resident face sheet, including weight, payer source, previous address and any special emergency contacts; he/she does not enter code status information. During an interview on [DATE] at 5:20 P.M., the social services director said the following: -She had been working on a binder for resident code status for over a month, but had not been able to complete the binder due to interruptions; -Staff were to locate a resident's code status in the resident's electronic health record, either on the face sheet or the physician orders; -Each resident should have an identified code status; -It was not her responsibility to obtain a resident's code status at the time of admission, that would be the responsibility of the admitting nurse. During an interview on [DATE] at 11:30 A.M., the Director of Nursing (DON) said the following: -Resident code status should be on the resident's face sheet and on their physician order sheets in their electronic health record; -Social Services was responsible to get the information at admission if the admission is during business hours. If the admission is after business hours, the admitting charge nurse is responsible for collecting this information from the resident's physician; -The facility admission checklist is an internal tool that staff use on a resident's admission and turn into the DON for final review to ensure all items have been addressed. The checklist is then filed away, these forms would not be available for the surveyor to review because they were internal documents; -Medical records staff was responsible to enter the code status in the resident's electronic health record; -The expectation is for staff to identify code status in the electronic health record, on the resident face sheet and/or the physician order sheet; -If a resident did not have a code status listed, staff should start CPR. During an interview on [DATE] at 8:15 A.M., the administrator said the following: -She expects every resident's electronic medical record to include an elected code status; -The social worker is responsible for gathering the code status information; -The admitting charge nurse could also gather that information if the social worker is not available; -If a code status is not known at the time of admission, she expects staff to follow up with the resident or resident's representative to obtain that information; -Medical records is responsible for scanning the advanced directive documentation into the resident's electronic medical record; -In the event of an emergency, she expects staff to look for a resident's code status in the electronic medical record. If a code status cannot be identified, she would expect staff to start CPR while other staff call the resident's emergency contact for clarification. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one resident (Resident #1) who resided on the locked dementia unit. The resident had a diagnosis of dysphagia (difficulty swallowing, taking more time and effort to move food from the mouth to the stomach) and was identified by the facility as a choking risk. The resident had an order to receive a mechanical soft diet and, per his/her physician orders, staff were to supervise and cue the resident due to unsafe eating habits (eating too fast and not completely chewing food). On [DATE], the resident obtained oatmeal pies as well as half a peanut butter sandwich without staff knowledge from an unsupervised snack cart. Certified Nurse Assistant (CNA) A was the only staff member on the unit for 15 residents. CNA A initially noticed the resident coughing in the hallway while CNA A passed dinner trays to residents in the dining room. When the resident was no longer able to cough, CNA A performed a finger sweep without result. CNA A then left the resident alone (no other staff in the area), and went to the locked door of the unit, unlocked the door and yelled at staff, that he/she needed help. CNA A returned to the resident and performed two Heimlich thrusts (a first aid procedure where abdominal thrusts are given and used to treat upper airway obstructions) while the resident sat in the wheelchair. Half an oatmeal cream pie came out of the resident's mouth. Staff responded to the call for help and suctioned the resident's mouth without success. The resident expired at the facility. The facility census was 79. The administrator was notified on [DATE] at 3:18 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility policy titled, Meal Supervision and Assistance, last revised [DATE], showed the following: -Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/ her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary; -Accidents refers to any unexpected or unintentional incident, which may result in injury or illness to a resident.; -Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas; -Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristics of an individual resident that influences the likelihood of an accident; -Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident' environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff; -The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time; -Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; -Be careful to provide portions of food easy for the resident to chew. 1. Observation on [DATE] at 1:05 P.M., of the nurses office of the secured, locked unit showed the following: -The door to the nurses office was open; -Just inside the nurses office and to the right, two sandwiches, two packages of saltine crackers and an individual cup of applesauce sat on an overbed table; -Staff identified the sandwiches as being for residents, one was a meat sandwich and one was a peanut butter sandwich; -Residents were going in and out of the nurses office to use the restroom and get ice and water from a cart in the nurses office. 2. Observation on [DATE] at 11:14 A.M., of the secured, locked unit showed the following: -The nursing office door was open; staff were initially nowhere to be seen; -Just inside the nurses office and to the right, was an overbed table with two packages of saltine crackers on the table; -An open bag of corn chips and an open bag of cookies sat on the nurses desk; -The door beside the nursing office was propped open; inside was a refrigerator; on top of the refrigerator was a large jar of peanut butter, a half loaf of bread, and a meal tray with partially eaten food. Staff identified this room as the snack room and said the door did not fully latch or lock and the meal tray must have been left over from last night's supper; -Residents were in the day area just adjacent to both of these rooms and walked up and down the hall. 3. Observation on [DATE] at 6:30 A.M., of the secured, locked unit showed the following: -The nursing office door was open; staff were at the opposite end of the hallway; -The door beside the nursing office was open and not pulled shut; -Residents were in the day area just adjacent to these rooms and walking up and down the hall. 4. Observation on [DATE] at 2:28 P.M., of the secured, locked unit showed the following: -The door beside the nursing office was open and not pulled shut; inside was a refrigerator; on top of the refrigerator were wrapped packages of cookies. Staff said the door still did not lock but maintenance staff had been made aware; -Residents were in the day area just adjacent to this room and walked up and down the hall. 5. Review of Resident #1's undated face sheet showed he/she had diagnoses that included cerebral infarction (stroke) and dysphagia. Review of the resident's hospice binder showed an admission note and orders, dated [DATE], that included an order for mechanical, chopped, diet. Review of the resident's medication review report showed the following: -May have diet liberties for holidays and special events. May omit diet restrictions, except for texture modifications, on special occasions, order date of [DATE]; -Registered dietitian consult as needed, order date of [DATE]. Review of the resident's facility progress notes, showed dietary/nutritional services notes as follows: -On [DATE] at 11:02 A.M., new admission assessment, resident on hospice, mechanical soft diet, feeds self with supervision. Review of the resident's facility progress notes, showed dietary/nutritional services notes as follows: -On [DATE] at 11:53 A.M., mechanical soft diet, feeds self with supervision. Review of the resident's hospice interdisciplinary plan of care revision/physician order, dated [DATE], showed the resident may have pleasure foods. Review of the resident's facility care plan, last revised [DATE], showed the following: -Behaviors: The resident has attempted to get in the nurses cart. The resident will remain safe through the next review date. Monitor his/her locomotion, ensure he/she is in appropriate places, redirect when attempting to get into nurses cart; -Activities of daily living (ADL): Has a self-care performance deficit, is able to ambulate short distances and uses wheelchair for long distances. The resident needs meal tray set up for eating, ensure he/she is at meals; -Cognition: The resident has impaired cognitive function/dementia or impaired thought process. Cue, reorient and supervise as needed; -Nutritional: Provide and serve diet as ordered. Review of the resident's facility progress notes showed the following: -On [DATE] at 2:20 P.M., the resident was seen eating lunch, chewing, and coughing up food; -On [DATE] at 10:11 A.M., this writer contacted and spoke with hospice. The resident does have orders for pleasure foods, but still remains on mechanical soft diet, resident is noted to be noncompliant. New order obtained for the resident to have appropriate foods cut up and encourage to chew slowly and not stuff food in his/her mouth. Review of the resident's [DATE] physician orders (POS) showed the following: -Resident is to be up in wheelchair in the dining room for all meals for supervision and cueing due to unsafe eating habits (eating too fast and not completely chewing food), order date of [DATE]. Review of the resident's facility care plan dated [DATE] showed it had not been updated and was not resident specific to the resident regarding his/her diet order or need for supervision and cueing due to unsafe eating habits. Review of the resident's medication review report showed the following: -Speech therapy (ST) evaluation for dysphagia; ST recommends pureed diet at this time per speech evaluation, order date of [DATE]; -Dietary order for regular diet, pureed texture, order date of [DATE]. Review of the resident's Speech Therapy Evaluation and Plan of Treatment, dated [DATE], showed the following: -Diagnoses included cerebral infarction and dysphagia; -Plan of Treatment: Resident and caregiver goals: Resident to consume the least restrictive diet consistency with decreased risk of aspiration; -Resident referral and history: The resident was referred for dysphagia services after observation of the resident demonstrating decreased ability forming bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing), and removal of food from the oral cavity. Prior the resident took solids as mechanical soft/chopped textures; -Chart review and resident interview: Medical factors included swallowing precautions, current intake of solids was pureed consistency and the resident required supervision at mealtime prior to onset; -Clinical bedside assessment of swallowing: The resident required supervision/assistance at mealtime due to swallowing safety 91 - 100 percent (%) of the time; -Assessment summary: Resident presents with oral dysphagia; due to the documented physical impairments and associated functional deficits, the resident is at risk for aspiration; -Recommend solids of puree consistencies. Review of the resident's hospice binder showed his/her hospice plan of care, dated [DATE], included staff was to provide feeding assistance, assist and cue with eating and he/she was on a mechanical soft, pleasure food diet. Review of the resident's [DATE] physician orders (POS) showed the following: -Regular diet, mechanical soft consistency; order date of [DATE]. Review of the resident's facility progress notes showed staff documented the following: -On [DATE] at 4:13 P.M. at approximately 4:35 P.M., this writer was called to the hall by a staff member because the resident didn't look right. The resident was in his/her wheelchair. This writer assessed the resident and the resident was unresponsive. Staff put the resident in bed and applied oxygen at two liters per nasal cannula. Resident is a do not resuscitate (DNR) under the care of hospice. Call placed to hospice at approximately 4:45 PM. Director of Nursing (DON) and Administrator made aware. During an interview on [DATE] at 1:20 P.M. and [DATE] at 2:16 P.M., CNA A said: -He/She took care of the resident on [DATE]; -The resident was on hospice and had a suction machine in his/her room due to being a choking risk; -The resident was to receive a pureed diet with thickened liquids and could have candy and soda; no resident should eat alone and they all should be monitored; -He/She was on the hall by him/herself as the Certified Medication Technician (CMT) had left the hall to get some applesauce; -Resident #1 had been sitting by him/her in the hall; -Two other residents began to yell at each other and he/she got up and responded to them; -When he/she returned back where he/she was sitting, Resident #1 had a peanut butter and jelly sandwich and half of it was gone; -He/She took the half of the sandwich from the resident and told the resident that he/she was going to choke. The resident then took two oatmeal cream pies from the side of his/her wheelchair and he/she took them away from the resident; -The supper meal trays were delivered from the kitchen, so he/she got up to begin passing the trays and looked back and saw Resident #1 had a third oatmeal cream pie and had half of it in his/her hand. The resident was coughing and then he/she stopped coughing and his/her color was not good, his/her color was pale gray and white; -He/She did a couple of finger sweeps and was not able to remove anything from the resident's mouth. He/She then went to the locked door, opened the door and yelled at the therapy staff and called for help STAT (immediately); -When he/she returned back to Resident #1, the resident remained in the wheelchair and was not coughing, so he/she did a couple of Heimlich maneuver thrusts and a couple of pieces of the oatmeal cream pie came out of the resident's mouth. The resident took a breath and his/her color was better; -When RN B arrived, the resident was breathing. RN B tried to suction the resident and got large amounts of thick phlegm. The resident then took a deep breath and slumped over onto his/her right arm and the resident was gone (died ); -The resident could self-propel in his/her wheelchair; -Snacks for residents were sometimes left on a table tray in the nursing office when dietary delivered them to the hall; -Peanut butter sandwiches and oatmeal cream pies were frequent snack items dietary brought for residents; -He/She had passed out oatmeal cream pies to other residents that day, but had not given Resident #1 a snack because he/she had requested a coke and a candy bar; -The resident had to have gotten the peanut butter and jelly sandwich and oatmeal cream pies from the nursing office; -The resident was constantly grabbing food and stuffing it in his/her mouth; -If the resident saw food, he/she was going to get it; -The resident would try and get into the hot cart that dietary brought meals down in because he/she knew there was food in the cart. The resident would try and get in the nursing cart because he/she knew that is where his/her cigarettes and candy bars were kept. During an interview on [DATE] at 12:05 P.M., Physical Therapy Assistant U said observation on [DATE] showed: -He/She had been sitting in the therapy department outside the secured, locked unit's doors on [DATE] when CNA staff came to the door and yelled that he/she needed help and needed a nurse; -He/She ran to the front nurses station to get the nurse, Registered Nurse (RN) B and they returned to the unit; -When he/she got back to the unit, he/she saw CNA A doing the Heimlich maneuver on Resident #1 in the hallway outside of the resident's room; the resident was in his/her wheelchair; -He/She helped stabilize the resident's trunk while RN B got a suction machine from the resident's room and brought it into the hallway; -He/She also tried to administer the Heimlich but was unsuccessful, nothing was coming up. He/She could not tell if the resident was able to take a breath; -He/She was then instructed to monitor the other residents while CNA A performed a finger sweep of the resident's mouth and a white goopy substance was removed; -He/She was later told the resident had passed away. During an interview on [DATE] at 11:54 A.M. and [DATE] at 12:42 P.M., Certified Medication Technician (CMT) L said the following: -He/She was in the front of the facility when a therapist came up to the desk and said staff on the locked memory care unit needed a nurse, there was a resident choking; -When he/she got to the locked memory care unit, CNA A was doing the Heimlich maneuver on Resident #1. CNA A was sweating, so he/she took over and continued to do the Heimlich maneuver. The resident had what looked like vomit (did not say how he/she knew this was vomit) down the front of his/her shirt; it was white and thick in color and consistency, like bread; -RN B began to suction the resident; -The resident's hands went blue in color and he/she was limp; -He/She called the resident's hospice provider, RN B said that the resident had expired; -He/She had worked in the unit for the past month and a half and had always known the resident to be on a pureed diet; -He/She had not handed out any resident snacks; -He/She thought peanut butter and jelly sandwiches and oatmeal cream pies were part of the snacks that dietary delivered. Sometimes those snacks were left in the nursing office and the door to the nursing office was usually left open; -The resident could self-propel anywhere he/she wanted to go in his/her wheelchair; -The resident was always trying to take everyone's food. During interviews on [DATE] at 5:00 P.M. and [DATE] at 4:39 P.M., RN B said on [DATE] he/she observed the following: -He/She was working the 200 and 400 halls and responded to the locked memory care unit when CMT L came to the kitchen door and said that the CNA on the locked memory care unit had yelled to therapy staff that he/she needed help and was calling for a nurse; -When he/she got back to the locked memory care unit, Resident #1 was slumped over in his/her wheelchair by his/her room and leaning to his/her right side; he/she had a brown emesis on his/her gown; -Resident #1 was pale with a very weak, faint pulse but no response; -He/She checked Resident #1's pulse at the neck and the wrist; he/she did not check for a blood pressure or check his/her pupils; -The resident had oxygen in his/her room. He/She put the oxygen on the resident as high as it would go; -CNA A said the resident had something in his/her mouth and that he/she had tried to remove it, but couldn't as the resident tried to bite him/her; -CNA A said the resident took food from the nurse's station; -He/She tried to suction the resident, but only got saliva; -The resident expired. During an interview on [DATE] at 3:18 P.M., the administrator and Chief Executive Officer (CEO) said the following: -Resident snacks should be locked up and not within reach of residents until they are passed out to residents; -Staff should be monitoring residents while they are eating snacks. During an interview on [DATE] at 7:25 A.M., the Dietary Supervisor said the following: -He/She had been the dietary supervisor for two weeks; -He/She thought the resident was a pureed diet and that is all he/she had ever prepared to send the resident; -Snacks he/she sent to the unit for the resident would have been applesauce, pudding and blended cake; -Peanut butter or peanut butter and jelly sandwiches and oatmeal cream pies were snack items dietary delivered to the halls for residents. He/She did not deliver the snacks, so he/she did not know where the snacks were placed when delivered. Those items would not have been appropriate for a pureed diet. During an interview on [DATE] at 11:20 A.M., Graduate Practical Nurse (GPN) K said the following: -The resident had behaviors that included grabbing and snatching of food when he saw it; this could be from other residents' trays or even from the hot cart when dietary delivered the meals; -He/She knew the resident was to be up in his/her wheelchair for meals, but had not been instructed to sit with the resident, supervise or monitor him/her; -He/She could not recall the specific diet the resident was supposed to receive. During an interview on [DATE] at 7:30 A.M., LPN Supervisor E said the following: -The resident liked food and was constantly trying to take food when he/she saw it and would try and get the hot cart open when dietary brought the meal trays to the unit. The resident knew the hot cart contained food; -The resident was on a mechanical soft diet but had been having problems with chewing and swallowing, so he/she had down graded the resident's diet to a pureed diet; -He/She had not obtained an order for the pureed diet because he/she thought if you down graded the diet you did not have to; -There should always be staff around when residents are eating a meal or snack so they can be monitored. During an interview on [DATE] at 2:22 P.M., the resident's hospice nurse said the following: -The resident had been on a regular diet but at some point, LPN Supervisor E told him/her the resident was on a pureed diet due to choking. The facility had down graded the resident's diet and he/she thought staff was to be monitoring the resident when the resident ate. He/She had been told the resident pocketed food; -The resident had behaviors that included stealing food from others; -The resident could propel him/herself in a wheelchair and could get to things he/she wanted. Review of the resident's death certificate showed the disease, injury or complication that caused the resident's death included aspiration. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO223484

Based on interview and record review, the facility failed to ensure a resident with pressure ulcers and skin conditions received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and worsening of pressure ulcers and skin conditions for one resident (Resident #6). On 8/15/23, staff documented the resident had open areas to the left great toe, right rear thigh and left rear thigh. No measurements or staging of the wounds was documented. On 8/16/23 staff obtained treatment orders for the wound on the left toe. On 8/25/23, staff documented the resident had open areas, identified as pressure, to the right gluteal fold and right hip. On 8/26/23 staff obtained treatment orders for the wounds to the buttocks and right hip. On 8/31/23, the resident was seen by a wound care consultant nurse in the facility who documented an acute unstageable pressure ulcer to the right hip, chronic unstageable pressure ulcer to the right buttock, an acute stage 3 pressure ulcer to the genitalia, a chronic [NAME] Grade (a tool used to identify diabetic ulcers) 2 diabetic ulcer to the left foot, a chronic unstageable pressure ulcer to the left hip, an acute [NAME] Grade 1 diabetic ulcer to the left great toe and an acute, unstageable pressure ulcer to the left lower leg. The resident required emergent treatment in the hospital due to the wounds where the physician identified possible wound infection to the left foot that may represent osteomyelitis and cellulitis of the right gluteal fold and sepsis, and documented the resident was critically ill and if he/she did not acutely intervene upon those illnesses, the resident's life was in danger and facility neglect was suspected. Staff also failed to complete dressing changes as ordered for Resident #7 and the resident's wounds were reported to have declined four days after admission. The resident's provider, discharged the resident back to the hospital because the facility did not have qualified staff to care for wounds. The facility census was 79. The administrator was notified on 10/11/23 at 2:00 P.M. of an Immediate Jeopardy (IJ) which began on 08/31/23. The IJ was removed on 10/12/23 as confirmed by surveyor on-site verification. Review of the Facility Assessment, last revised 8/25/22, showed the following: -New admissions begin with the referral process. The Director of Nursing (DON) will review the referral upon receipt and look for any diagnoses, conditions or symptoms. If an issue is identified, the DON will discuss with the Administrator and any other discipline that may be involved to determine our ability to meet the needs of the resident. During this evaluation we will review, as necessary, medications, treatments, equipment needs, capability and capacity of staff as required. New admission clinical needs are evaluated by using the clinical admission grid; -We provide care that is appropriate and seeks to meet all standards of quality; -Services and care offered based on residents' needs include: skin integrity, pressure injury prevention and care, skin care, wound care Review of the facility policy titled, Medical Provider Orders, revised 4/7/22, showed the following: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of the facility policy titled, Skin Assessment, revised 9/1/22, showed the following: -It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment; -Policy Explanation and Compliance Guidelines: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury; -Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title; b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.); c. Document type of wound; d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain); e. Document if resident refused assessment and why; f. Document other information as indicated or appropriate. Review of the facility policy titled, Wound Treatment Management, revised 9/1/22, showed the following: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -The facility will follow specific physician orders for providing wound care; -Treatments will be documented on the Treatment Administration Record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing; b. Changes in the characteristics of the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer). 1. Review of the facility Matrix (identifies residents and specific conditions- including those with pressure ulcers), dated 8/29/23 and completed by facility staff, showed no residents identified with a pressure ulcer. 2. Review of Resident #6's face sheet showed the following: -admitted was 12/28/22; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (also known as a stroke; CVA) affecting the dominant side, diabetes, contracture of muscle (tightening or shortening of a muscle), moderate protein calorie malnutrition and need for assistance with personal cares. Review of the resident's care plan, last revised 1/13/23, showed the following: -The resident has an activities of daily living (ADL) self-care performance deficit and a history of CVA with right sided weakness. Staff should assist to the extent needed to accomplish task; bathing/showering: assist times one; report any changes to the nurse. The resident required assist times one to two for bed mobility and dressing, assist times one to two for personal hygiene/oral care, assist times one for toilet use, assist times one to two for transfers; -Has diabetes mellitus- he/she will have no complications related to diabetes through the review date; -Monitor/document/report as needed (PRN) any signs and symptoms of dry skin or poor wound healing; -Monitor/document/report PRN any signs or symptoms of infection to any open areas including redness or pus formation; -Has potential for impairment to skin integrity. Will maintain or develop clean and intact skin by the review date; keep body parts from excessive moisture, ensure he/she is clean and dry; -Has bladder/bowel incontinence, will remain free from skin breakdown due to incontinence. Review of the resident's Braden Scale (a score for predicting pressure ulcer risk) assessment form, dated 6/2/23, completed by facility staff, showed the following: -Sensory perception - ability to respond meaningfully to pressure-related discomfort: slightly limited - responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in one or two extremities; -Moisture - very moist, skin is often but not always moist; -Activity -chair fast, ability to walk severely limited or non-existent, cannot bear own weight and/or must be assisted into chair or wheelchair; -Mobility - slightly limited, makes frequent though slight changes in body or extremity position independently; -Friction and Sheer - moves feebly or requires maximum assistance. During a move, skin probably slides to some extent against sheets, chairs, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down; -Score: 15 (low risk for pressure ulcers). Review of the resident's weekly skin check, dated 6/26/23 at 5:58 A.M., showed the following: -Observations: Site: no documentation; -Facility staff documented in the notes section the resident had no open areas noted, skin intact; -Staff checked the box indicating there were no new wounds identified during this skin check. Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/21/23, showed the following: -Severe cognitive impairment; -The resident required extensive assistance of one staff member with bed mobility; -The resident was dependent on one staff member for personal hygiene; -Always incontinent of bowel and bladder; -The resident required total dependence of one staff member for bathing; -The resident was at risk for pressure ulcers; -The resident did not have any pressure ulcers at a stage one or higher; -The resident did not have any unhealed pressure ulcers or injuries; -The resident had no wounds or skin problems; -No application of dressings to feet; -Not on a turning/repositioning program; -The resident had a pressure relieving device for his/her chair and bed. Review of the resident's August 2023 physician order sheets (POS) showed orders for the following: -Protective barrier cream to buttocks, posterior thighs and genitalia every day shift to promote wound healing, start date of 1/28/23; -Collagenase ointment (a prescription medicine that removes dead tissue from wounds so they can start to heal), apply to left thigh topically every day shift for wound care, start date of 8/9/23. Review of the resident's electronic health record (EHR) showed no weekly skin assessment for the resident since 6/26/23. Review of the resident's weekly skin check, dated 8/15/23 at 6:22 A.M., showed the following: -Site - left toe(s); type: wound; no documentation of measurement for length, width or depth or wound stage; -Site - right thigh (rear); type: wound; no documentation of measurement for length, width or depth or wound stage; -Site - left thigh (rear); type: wound; no documentation of measurement for length, width or depth or wound stage; -Facility staff documented in the notes section the resident had wounds on the left toes, right thigh (rear), left thigh and the resident had dry feet; -Staff checked the box indicating there were no new wounds identified during this skin check. Review of the resident's progress note, dated 8/15/23 at 6:30 A.M., showed the resident had a wound on the left great toe, back of his/her thigh and on the left buttock. Review of the resident's August 2023 Medication Administration Record (MAR) showed on 8/15/23, the administration box for the ordered Collagenase ointment, apply to left thigh topically every shift for wound care, was blank, indicating the treatment was not completed. There was no documentation to show why the treatment was not completed as ordered Review of the resident's progress note, dated 8/16/23 at 2:12 A.M., showed the following: -This morning the nurse aide was providing care and found an open area to the left toe, also buttock and thigh; -Nurse did an assessment and found no drainage at this time, called the medical director (physician) and order received to clean wound with wound cleanser, apply Santyl (an ointment used to remove dead tissue from wounds to promote healing) then calcium alginate (a wound dressing that is highly absorbent and helps with maintaining a moist healing environment) and border dressing (a foam dressing with an adhesive edge); -Treatment started right away, resident to remain on monitoring for new skin issues. Review of the resident's weekly skin check, dated 8/16/23 at 2:21 A.M., showed the following: -Facility staff documented in the notes section the resident had wounds on the left toes, wound on the buttock, wound on the thigh and the resident had dry feet; -Staff completed no documentation of the type of wound, specific measurements, location (no documentation to indicate which buttock or thigh) or the status of the wounds (such as drainage or signs of infection); -Staff did not indicate if there were any new wounds identified during this skin check. Review of the resident's August 2023 POS showed an order for Santyl ointment, apply to left great toe topically every day shift for wound care, cleanse with wound cleanser, pat dry, apply Santyl, then calcium alginate, cover with border dressing- start date 8/16/23. Review of the resident's physician progress note, completed by the Nurse Practitioner (NP) dated 8/17/23, showed he/she documented the resident had a wound on his/her buttocks, but would not let the NP see or assess it today. The wound nurse ordered Santyl. Review of the resident's August 2023 MAR showed the following: -On 8/20/23, the administration box for the ordered Collagenase ointment, apply to left thigh topically every shift for wound care, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered; -On 8/20/23, the administration box for the ordered Santyl ointment, apply to left great toe topically every day shift for wound care, cleanse with wound cleanser, pat dry, apply Santyl, then calcium alginate, cover with border dressing, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered. Review of the resident's EHR showed no documentation of a weekly skin assessment on 8/22/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -The resident required extensive assistance of one staff member with bed mobility and personal hygiene; -The resident required extensive assistance of two staff members with transfers and dressing; -The resident was dependent on one staff member with locomotion on and off the unit and with toilet use; -Frequently incontinent of bowel and bladder; -The resident was dependent on one staff member for bathing; -Functional limitation in range of motion; upper and lower extremity impairment on one side; -No rejection of cares; -The resident was at risk for pressure ulcers; -The resident did not have any pressure ulcers at a stage one or higher; -The resident did not have any unhealed pressure ulcers or injuries; -The resident had no wounds or skin problems, including feet; -No application of dressings to feet; -Not on a turning/repositioning program; -The resident had a pressure relieving device for his/her chair and bed; -No documentation to show the resident was on hospice. Review of the resident's progress note, dated 8/25/23 at 8:59 A.M., showed the following: -During morning cares, noted to have an open area to the right buttock and right hip; -Assess for pain and injury; -Physician, Director of Nursing, and family member notified. Review of the resident's weekly skin check, dated 8/25/23 at 9:00 A.M., showed the following: -The resident had a right gluteal fold wound, type of wound was pressure (facility staff did not document the length, width, depth or the stage of the pressure ulcer); -The resident had a right trochanter (hip) wound, type was pressure (facility staff did not document the length, width, depth or the stage of the pressure ulcer); -Notes indicate open areas; -Staff did not indicate if there were any new wounds identified during this skin check; -There was no documentation of skin concerns to the resident's toe, thigh or buttocks. Review of the resident's August 2023 POS showed orders for the following: -Collagenase ointment, apply to right buttock topically every day shift for wound care, start date of 8/26/23; -Skin prep wipes, apply to right hip topically every day shift for wound care, start date of 8/26/23. Review of the resident's August 2023 MAR showed the following: -On 8/26/23, the administration box for the ordered Collagenase ointment, apply to left thigh topically every shift for wound care, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered; -On 8/26/23, the administration box for the ordered Collagenase ointment, apply to right buttock topically every day shift for wound care, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered; -On 8/26/23, the administration box for the ordered Santyl ointment, apply to left great toe topically every day shift for wound care, cleanse with wound cleanse, pat dry, apply Santyl, then calcium alginate, cover with border dressing, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered; -On 8/26/23, the administration box for the ordered protective barrier cream to buttocks, posterior thighs and genitalia every day shift to promote wound healing, was blank, indicating the treatment had not been completed. There was no documentation to show why the treatment had not been completed as ordered. Review of the resident's Wound Care Plus progress note, dated 8/31/23, showed the following: -The resident was being seen for evaluation and management of multiple wounds; -The resident was not on hospice services; -Narrative note: New consult received for multiple wounds. Right buttock, left plantar foot, left second toe wounds positive for bacteria per Moleculight (portable imaging device that detects bacteria in wounds). Resident unable to tolerate debridement (the removal of damaged tissue) today. Right buttock and left plantar foot wounds with strong, malodorous and purulent (thick, white, yellow or brown fluid and is a sign of infection) drainage. Left foot edematous (abnormally swollen with fluid) and erythematous (redness of the skin). Right buttock and left plantar foot wound culture obtained. Due to resident's malnutrition and severity of wounds, recommend transfer to hospital as soon as possible for further workup to rule out osteomyelitis (infection of the bone) and sepsis (life-threatening complication of an infection, usually produces an elevated white blood cell count (WBC) white blood cells protect against illness and disease). Assistant Director of Nursing (ADON) updated on resident's condition; -Physical exam: lower extremity assessment - no off-loading device in use for the left or right extremity. Encouraged air mattress and bilateral Prafo boots (prevents pressure ulcers from developing on the back of the heel and allows current ulcers to heal); - Wound Assessment(s): -Wound #1, right hip, is an acute, unstageable pressure injury, obscured full-thickness skin and tissue loss, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 2 centimeters (cm) length x 4.2 cm width x 0.2 cm depth, with an area of 8.4 square (sq) cm and a volume of 1.68 cubic cm. The resident reports a wound pain level of 5/10 (pain scale with 10 being the worst pain imaginable). Wound bed has 1-25 percent (%) eschar (dead tissue that sheds or falls off from health skin), 76-100% epithelialization (the restoration of damaged epithelium (thin tissue forming the outer layer of the body's surface)). The periwound skin exhibited scarring. The periwound skin was dry/scaly. Unable to determine depth. (The facility had identified a concern with the resident's right hip on 8/25/23 and treatment order obtained on 8/26/23, but no measurements were documented for monitoring); -Wound #2, right buttock, is a chronic, unstageable pressure injury, obscured full-thickness skin and tissue loss, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 cm length x 4.5 cm width x 0.2 cm depth, with an area of 27 sq cm and a volume of 5.4 cubic cm. There is a moderate amount of purulent drainage noted which has a strong odor. The resident reports a wound pain of level 5/10. Wound bed has 76-100% slough, 1-25% eschar and 1-25% epithelialization. The periwound skin exhibited callus (hard, thickened skin), scarring and maceration (when the skin has been exposed to moisture for too long). The periwound skin was moist. Periwound skin presents with signs and symptoms (s/s) of infection. Confirmation description and treatment plan: Signs and symptoms present, culture and sensitivity (C&S) pending, topical antibiotics prescribed. Unable to determine depth. (The facility had identified a concern with the resident's right buttock on 8/25/23 and treatment order obtained on 8/26/23, but no measurements were documented for monitoring); -Wound #3, genitalia, is an acute, Stage III pressure injury pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1 cm length x 0.5 cm width x 0.2 cm depth, with an area of 0.5 sq cm and a volume of 0.1 cubic cm. Wound bed has 1-25% eschar. The periwound skin exhibited scarring. The periwound skin was dry/scaly. Affects 90% of the skin; -Wound #4, left plantar foot is a chronic, [NAME] Grade 2 diabetic ulcer (deep ulcer extended to ligament, tendon, joint capsule, bone or deep fascia), and has received a status of not healed. Initial wound encounter measurements are 8 cm length x 6 cm width x 0.2 cm depth, with an area of 48 sq cm and a volume of 9.6 cubic cm. Tendon, bone and adipose are exposed. There is a large area of epithelialization. The periwound skin exhibited edema and erythema. The periwound skin was friable (easily crumbled), denuded (the loss of epidermis caused by prolonged moisture and friction) and moist. The temperature of the periwound skin is warm. Periwound skin presents with s/s of infection. Confirmation description and treatment plan is: Signs and symptoms present, topical antibiotics prescribed. Unable to determine depth, affects 10% of the skin. The secondary diagnosis for this wound is pressure ulcer; -Wound #5, left hip is a chronic, unstageable pressure injury, obscured full-thickness skin and tissue loss, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 5 cm length x 2.5 cm width x 0.2 cm depth, with an area of 12.5 sq cm and a volume of 2.5 cubic cm. There is a moderate amount of serous (thick, clear to yellow) drainage. The resident reports a wound pain of level 5/10. Wound bed has 1-25% slough, 76-100% eschar, 1-25% epithelialization. The periwound skin exhibited scarring. The periwound skin was friable and dry/scaly. Periwound skin presents with s/s of infection. Confirmation description and treatment plan is: Signs and symptoms present, C&S pending, topical antibiotics prescribed. Unable to determine depth; -Wound #6, left plantar second toe is an acute, [NAME] Grade 1 diabetic ulcer (superficial ulcer on the outer layer of the skin) and has received a status of not healed. Initial wound encounter measurements are 1 cm length x 2 cm width x 0.2 cm depth, with an area of 2 sq cm and a volume of 0.4 cubic cm. The resident reports a wound pain of level 5/10. Wound bed has 1-25% eschar and 51-75% epithelialization. The periwound skin exhibited callus. The periwound skin was dry/scaly. Periwound skin presents with s/s of infection. Confirmation description and treatment plan is: Signs and symptoms present, C&S pending, topical antibiotics prescribed; -Wound #7, left medial (toward the middle or center), lower leg is an acute, unstageable pressure injury, obscured full-thickness skin and tissue loss, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 1 cm length x 1 cm width x 0.2 cm depth, with an area of 1 sq cm and a volume of 0.2 cubic cm. There is a moderate amount of serous drainage noted. Wound bed has 1-25%, pink, granulation, 1-25% eschar and 1-25% epithelialization. The periwound skin exhibited scarring. The periwound skin was friable and moist. Affects 80% of skin, suspected deep tissue injury (SDTI) and unable to determine depth; -Assessment: Pressure Versus Non-Pressure Screening Questions: Is the resident or the resident's affected body part immobile?: Yes Was the resident or the resident's affected body part immobile recently (last 2 weeks) prior to the wound developing?: Yes Evaluate the location of the ulcer. Did the nursing staff note it is directly from positioning (i.e. bed, chair, shoe, device)?: Yes Observe the resident in actual supine, side lying, sitting and with their devices (i.e. splints, braces, etc). Did the nursing staff determine the specific area of breakdown was consistent with applied external force?: Yes Preliminary impression of this skin breakdown/ulceration is as follows: The ulcers are consistent with pressure as the primary etiology. -Wound and Skin Evaluation: I certify the resident was located at the Skilled Nursing Facility during the encounter; Visit Type: Initial Visit. Review of the resident's progress notes, dated 8/31/23, showed the following: -At 2:11 P.M., Wound Care Plus (an outside resource for wound treatment) nurse practitioner assessed the resident and gave an order to send the resident to the emergency room for evaluation and treatment related to wound treatment; -At 2:45 P.M., the resident was transported to the hospital. Review of the resident's hospital paperwork showed the following: -admitted [DATE]; -Presented from long term care facility; unable to obtain history from caregiver; registered nurse (RN) at facility reported was seen by wound care that day and referred to the emergency department for additional evaluation; -History and physical: skin: multiple wounds, skin breakdown noted to genitalia, bilateral hips, plantar aspect of the left foot with exposed bone; -Diagnoses included multiple open wounds and osteomyelitis of the left foot; -Active wound areas included dorsal left (did not specify where), right buttocks, anterior (near the front) proximal (near the center) right upper leg and anterior left proximal upper leg; -Assessment and plan: suspected osteomyelitis of the left foot, multiple open wounds, cellulitis (bacterial infection involving the inner layers of the skin) of the right gluteal (buttocks)/ischial (sitting bone) soft tissue and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death); -The resident had an elevated WBC of 21.1 (normal is 4.5 to 11); -An x-ray of the resident's left foot showed findings of a wound over the medial forefoot that may reflect developing osteomyelitis and there was soft tissue swelling noted; -The resident is critically ill. If I (the physician) do not acutely intervene upon these illnesses, the resident's life is in danger; -The resident required four different intravenous (IV) antibiotics for suspected infection of the skin/soft tissue, wounds, bone/joint and for cellulitis; -Required a wound vacuum (wound vac) (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) to his/her left foot; -Sacral (below the spine and above the tailbone) decubitis ulcer with infection - right ischial (the curved bone that makes up the bottom of the pelvis) gangrene (dead tissue caused by an infection or lack of blood flow); -Left lower extremity multiple wounds with sepsis from necrotic/gangrenous wounds; -Required surgical treatment - underwent excisional debridement with removal of all non-viable soft tissue and bone to the left foot, left hip and right ischium; -Concur with suspected neglect. During an interview on 9/1/23 at 12:05 P.M., certified nurse assistant (CNA) P said the following: -He/She cared for the resident routinely; -The resident always had socks on so he/she never observed his/her feet, so he/she was not sure if the resident had any wounds on his/her feet; -The resident had a dressing on his/her bottom and other places on his/her body, but he/she never observed the wounds; -The resident didn't have an air mattress or heel protectors. During interview on 9/5/23 at 6:40 A.M., CNA O said the following: -He/She was told the resident was on hospice and was getting his/her showers from the hospice nurse, so he/she could not remember the last date he/she gave the resident a shower; -The last shower he/she can recall, the resident had no skin issues at that time; -CNA staff are to fill out shower sheets when showers are completed, turn them in to the charge nurse and then it gets turned in to the DON. During interview on 9/5/23 at 7:00 A.M. and 2:15 P.M., Licensed Practical Nurse (LPN) J said the following: -He/She can only recall a wound on the resident's bottom; -If a wound is discovered, he/she would complete the skin assessment in the electronic health record and measurements should be included in the assessment; -He/She had not had any formal wound training. During interview on 9/5/23 at 7:

Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff failed to provide incontinence care per the facility's perineal care policy/procedure and to wash their hands when they removed contaminated gloves while performing post-incontinence care for Resident #2 and #4. The facility census was 70. The administrator was notified on 11/08/23 at 4:45 P.M. of an Immediate Jeopardy (IJ) which began on 11/07/23. The IJ was removed on 11/09/23 as confirmed by surveyor on-site verification. Review of the facility policy, Glucometer Disinfection, revised 09/01/21, showed the following: -The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood-borne diseases to residents and employees; -Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects; -The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; -The glucometers should be disinfected with a wipe pre-saturated with EPA registered healthcare disinfectant that is effective against human immunodeficiency virus/HIV (a virus that targets the immune system and can be spread through contact with infected blood), Hepatitis C and Hepatitis B (a serious liver infection caused by a virus that most commonly spread by exposure to infected body fluids) virus; -Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use; -Procedure: h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive; i. Retrieve two disinfectant wipes from container; j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions, allow the glucometer to air dry. Review of the facility policy, Blood Glucose Monitoring, dated 09/01/21, showed the following: -It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders; -Policy explanation and compliance guidelines: 3. The nurse will will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; -Procedure: 2. Obtain needed equipment and supplies: gloves, glucometer, alcohol pads, gauze pads, single use auto-disabling lancet, blood glucose testing strips; -The policy did not address placing a barrier between the glucometer and other items while in use. Review of the Evencare G2 glucometer manufacturer/guidelines for disinfecting the piece of equipment showed the following: -To disinfect the meter, clean the meter with one of the following validated disinfection wipes listed below: a. Dispatch Hospital Cleaner Disinfectant Towels with bleach; b. Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; c. Clorox Healthcare Bleach Germicidal and Disinfectant wipes; d. Medline Micro-Kill Bleach Germicidal Bleach wipes; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean; -Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow to air dry. 1. Review of Resident #1's face sheet showed the following: -Diagnosis of diabetes mellitus with hyperglycemia (a group of diseases that result in too much sugar in the blood); -Diagnosis of unspecified viral Hepatitis C. Review of the resident's November 2023 physician order sheet showed an order for Humalog insulin (medication injected for elevated blood sugar), inject subcutaneously before meals related to type II diabetes mellitus with hyperglycemia:. If blood sugar is 61-150 = no insulin, blood sugar 151-200 = 3 units, 201 - 250 = 5 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units, greather than 400 give 15 units and contact physician, with an order start date of 02/13/22. Review of the resident's November 2023 medication administration record (MAR) showed the following: -Resident receives a blood glucose test three times a day at 6:00 A.M., 11:00 A.M., and 4:00 P.M.; -Staff document the blood sugar results on page seven of the MAR; -Page 1 of the MAR listed the resident with diagnosis of Hepatitis C. Observation on 11/07/23 at 5:49 A.M., showed the following: -Registered Nurse (RN) A took a glucometer out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bed without placing a barrier between the glucometer and the mattress; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and the top of the medication cart and removed his/her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the glucometer with bare hands. 2. Review of Resident #2's face sheet showed a diagnosis of diabetes mellitus. Review of the resident's November 2023 physician order sheet showed an order for Lispro insulin (medication injected for elevated blood sugar) inject subcutaneously before meals and at bedtime related to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes): if blood sugar is 0 -150 = no insulin, blood sugar 151-200 = no insulin, 201 - 250 = 6 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units and call physician/nurse practitioner, with an order start date of 06/15/23. Review of the resident's November 2023 MAR showed the resident received a blood glucose test four times a day at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M. Observation on 11/07/23 at 6:11 A.M., showed the following: -RN A took the same glucometer he/she used to check Resident #1's blood sugar out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the resident's blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bedside table without placing a barrier between the glucometer and a magazine on the bedside table; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and top of the medication cart and removed his/ her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the used glucometer with bare hands; -No disinfection wipes were available for use on the medication cart. During interviews on 11/07/23 at 5:50 A.M. and 7:05 A.M., and 11/08/23 at 2:10 P.M., RN A said the following: -He/She cleans the glucometer with alcohol wipes if there were no sanitizer (disinfectant) wipes on the cart; -He/She had given the sanitizer wipes to another staff member earlier in the shift and did not have any sanitizer wipes on his/her medication cart; -Sanitizer wipes were in central supply, but central supply was generally locked at night and he/she did not have a key to central supply; -When cleaning a glucometer, you should clean it with alcohol wipes or sanitizer wipes, make it wet and then let it air dry; -When he/she takes a glucometer into a resident room, he/she should place a barrier, such as a paper towel, so he/she did not place the equipment on a dirty surface; -He/She did not place a barrier between the glucometer and mattress for Resident #1 or between the glucometer and bedside table for Resident #2 when he/she obtained the residents' blood sugars but should have; -He/She used the same glucometer for the residents on A hall and D hall; -He/She was not aware of any residents with an infectious disease such as viral hepatitis; -If a resident has an infectious disease, they should have their own glucometer. During an interview on 11/08/23 at 2:18 P.M., Licensed Practical Nurse (LPN) G said the following: -He/She believed each hall had its own glucometer to use for multiple residents; -The A hall had four residents who have routine blood glucose monitoring; -MicroKill One sanitizers were available on the medication cart and could be used to sanitize the glucometer; -He/She usually cleaned the glucometer in between each resident with alcohol wipes; -He/She thought the night shift staff disinfected the glucometer each night with the sanitizer wipes; -He/She was unsure if anyone at the facility had Hepatitis C; -He/She was unsure what the manufacturer's recommendations were for disinfecting the glucometer. During an interview on 11/08/23 at 4:00 P.M., the Director of Nursing (DON) said the following: -She expected staff to follow the facility policy for cleaning a multi-use glucometer after each use; -She expected staff to clean the glucometer with sanitizer wipes; -She would not expect staff to know off of the top of their head if a resident they were obtaining a blood sugar on had an infectious disease such as hepatitis C; -All of the residents' diagnoses are listed in the resident health record; -If staff disinfected a glucometer properly, staff could use a multi-use glucometer on a resident that has Hepatitis C, and then other residents; -Extra sanitizer wipes were available in central supply and the 11-7 shift had access to the central supply with a key; -Alcohol wipes were not acceptable to disinfect a multi-use glucometer; -There were two residents at the facility that had Hepatitis C. During an interview on 11/08/23 at 3:50 P.M., the administrator said the following: -He expected staff to clean a multi-use glucometer properly after use and to disinfect the glucometer per manufacturer's recommendations and company policy; -He expected staff to follow infection control policies to ensure no infection was passed to another resident; -If a resident had diagnosis of Hepatitis C, he expected staff to follow company policy for glucometer use, follow infection control policies and then follow proper cleaning to be able to use the glucometer for multiple residents. 3. Review of the facility policy, Perineal Care, revised 09/01/21, showed the following: -Policy explanation and compliance guidelines: -Perform hand hygiene and put on gloves; Apply other personal protective equipment as appropriate; -If perineum is grossly soiled, turn resident on side, remove fecal material with toilet paper, then remove and discard; -Cleanse buttocks and anus, front to back; vagina to anus in females and scrotum to anus in males, using a separate washcloth or wipes; -Dry thoroughly; -Re-position resident in supine (laying on back) position. Change gloves if soiled and continue with perineal care; -Cleanse perineal area using separate washcloth or wipes for each area; -Change gloves if soiled and continue with perineal care; -If using soap, rinse after washing; -Reposition as desired and cover resident; -Remove gloves and discard. Perform hand hygiene. Review of the facility hand washing policy, dated 9/1/21, showed the following: -All staff would perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene was the general term for cleaning the hands by handwashing with soap and water or use of an antiseptic hand rub, also known as an alcohol-based hand rub (ABHR); -Staff would perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene was indicated and would be performed under conditions listed in, but not limited to the attached hand hygiene table which included; -ABHR with 60-95% alcohol was the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they were visibly dirty, before eating, and after using the restroom. Review of the facility hand hygiene table, dated 2021, showed the following: -Hands should be cleaned with soap and water when hands were visibly dirty, and hands were visibly soiled with blood or there body fluids; -Hands should be cleaned with ether soap and water or ABHR (ABHR is preferred) between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves, before performing resident care procedures, when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions, and whenever in doubt. Review of Resident #2's electronic medical record (EMR) showed he/she had the following diagnoses: -Overactive bladder (condition of the bladder that causes a frequent and sudden urge to urinate that may be difficult to control); -Urinary tract infections (UTI, an infection involving the urinary tract system); -Dysuria (painful urination). Review of the resident's care plan, last revised on 8/24/22, showed the following: -He/She was on diuretic (a substance that promotes an increased production of urine) therapy; -He/She was incontinent of bowel and bladder and had a history of UTIs; -He/She had a self-care deficit with performance of activities of daily living (ADLs) due to decreased strength and limited mobility; -Staff were to assist the resident with cleaning the perineal area after each incontinence episode. Review of resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/19/23, showed the resident's cognition was intact, he/she was frequently incontinent of bowel and bladder, and did not have a history of rejecting care. Observation on 11/7/23 at 5:37 A.M., showed the following: -The resident was incontinent; his/her incontinence brief was saturated with orange colored urine and urine was on the bed pad located under the resident; -With a soapy, wet bath towel and gloved hands, Certified Nurse Assistant (CNA) J cleaned urine from resident's perineal area, abdominal fold and thighs. He/She wiped the resident's left groin multiple times, right groin, and genital area, but did not use a different cloth surface after each wipe. CNA J walked over to the resident's sink, rinsed the towel with water and walked back over to the resident to rinse the resident's groin and genitalia with the same towel. With the same gloves, CNA J obtained a clean brief from resident's bedside storage. CNA J assisted the resident onto his/her left side, placed an incontinence brief under the resident, and without cleansing urine from the resident's buttock and thigh areas, CNA J assisted the resident onto his/her right side to pull the brief through, then assisted the resident to his/her back and attached the clean brief. With the same gloves, CNA J opened the resident's door to his/her room to discard trash; -CNA J had not changed gloves when he/she went from a dirty process to a clean process and touched the resident's bedside storage, clean brief, the resident and the resident's door with the gloves. During an interview on 11/7/23 at 5:45 A.M., the resident said staff had last changed his/her incontinence brief and provided care at approximately 8:00 P.M. on 11/6/23. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should change the surface of the cloth with every wipe. He/She did not realize he/she used the same surface of the cloth and did not change cloths when needed. Resident #2 did not like to be awakened during the night for staff to check for incontinence, so he/she changed him/her in the morning. Resident #2's bed pad was not wet, therefore he/she did not change the pad. 4. Review of Resident #4's diagnoses showed he/she had the following: -Overactive bladder; -Recent UTI (10/10/23). Review of the resident's care plan, last revised on 10/25/23, showed the following: -He/She had an ADL self-care performance deficit and was dependent on staff for all ADLs, including personal hygiene and toileting; -He/She was frequently incontinent of bladder related to an overactive bladder; -He/She wore adult briefs; -Staff were to assist the resident with cleaning his/her perineal area after each incontinence episode. Review of the resident's admission MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She was dependent on staff with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She did not reject care. Observation of the resident, on 11/7/23 at 5:53 A.M., showed the resident lay in his/her bed and had been incontinent of bladder. The resident's incontinence brief was saturated. With gloved hands, CNA J cleaned urine from the resident's perineal area, lower abdomen, buttocks, and thighs. CNA J wiped the resident's left groin, right groin and genital area multiple times with a wet, soapy bath towel. He/She did not change the cloth surface after each wipe. CNA J assisted the resident onto his/her left side and wiped the right and left buttocks multiple times. He/She did not change the surface of the cloth after each wipe. CNA J rinsed the towel with water and rinsed the resident's buttocks areas, groin and genitalia, but did not change the surface of the cloth after each wipe. With the same gloves, CNA J obtained barrier cream from the resident's bedside table and placed it on the resident's buttocks, obtained a clean brief from resident's bedside storage area and placed it on the resident. CNA J removed his/her gloves and without performing hand hygiene, he/she grabbed the resident's door knob, opened the door, and exited the room to discard trash. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should not have touched any clean items with contaminated gloves. During an interview on 11/9/23 at 10:30 A.M., the DON said she would expect staff to remove gloves and wash their hands before touching any clean items. Hands were to be washed with soap and water when visibly soiled and after removal of gloves. Staff were expected to remove gloves and wash their hands after applying barrier cream and before touching any clean items. She expected staff to change the surface of the cloth after each wipe when providing incontinence care. Staff should not use the same surface multiple times before changing surfaces. She expected staff to clean all areas of the perineum with wash cloths and/or wipes. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO225546 MO226124

Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff failed to provide incontinence care per the facility's perineal care policy/procedure and to wash their hands when they removed contaminated gloves while performing post-incontinence care for Resident #2 and #4. The facility census was 70. The administrator was notified on 11/08/23 at 4:45 P.M. of an Immediate Jeopardy (IJ) which began on 11/07/23. The IJ was removed on 11/09/23 as confirmed by surveyor on-site verification. Review of the facility policy, Glucometer Disinfection, revised 09/01/21, showed the following: -The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood-borne diseases to residents and employees; -Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects; -The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; -The glucometers should be disinfected with a wipe pre-saturated with EPA registered healthcare disinfectant that is effective against human immunodeficiency virus/HIV (a virus that targets the immune system and can be spread through contact with infected blood), Hepatitis C and Hepatitis B (a serious liver infection caused by a virus that most commonly spread by exposure to infected body fluids) virus; -Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use; -Procedure: h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive; i. Retrieve two disinfectant wipes from container; j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions, allow the glucometer to air dry. Review of the facility policy, Blood Glucose Monitoring, dated 09/01/21, showed the following: -It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders; -Policy explanation and compliance guidelines: 3. The nurse will will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy; -Procedure: 2. Obtain needed equipment and supplies: gloves, glucometer, alcohol pads, gauze pads, single use auto-disabling lancet, blood glucose testing strips; -The policy did not address placing a barrier between the glucometer and other items while in use. Review of the Evencare G2 glucometer manufacturer/guidelines for disinfecting the piece of equipment showed the following: -To disinfect the meter, clean the meter with one of the following validated disinfection wipes listed below: a. Dispatch Hospital Cleaner Disinfectant Towels with bleach; b. Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; c. Clorox Healthcare Bleach Germicidal and Disinfectant wipes; d. Medline Micro-Kill Bleach Germicidal Bleach wipes; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean; -Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow to air dry. 1. Review of Resident #1's face sheet showed the following: -Diagnosis of diabetes mellitus with hyperglycemia (a group of diseases that result in too much sugar in the blood); -Diagnosis of unspecified viral Hepatitis C. Review of the resident's November 2023 physician order sheet showed an order for Humalog insulin (medication injected for elevated blood sugar), inject subcutaneously before meals related to type II diabetes mellitus with hyperglycemia:. If blood sugar is 61-150 = no insulin, blood sugar 151-200 = 3 units, 201 - 250 = 5 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units, greather than 400 give 15 units and contact physician, with an order start date of 02/13/22. Review of the resident's November 2023 medication administration record (MAR) showed the following: -Resident receives a blood glucose test three times a day at 6:00 A.M., 11:00 A.M., and 4:00 P.M.; -Staff document the blood sugar results on page seven of the MAR; -Page 1 of the MAR listed the resident with diagnosis of Hepatitis C. Observation on 11/07/23 at 5:49 A.M., showed the following: -Registered Nurse (RN) A took a glucometer out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bed without placing a barrier between the glucometer and the mattress; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and the top of the medication cart and removed his/her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the glucometer with bare hands. 2. Review of Resident #2's face sheet showed a diagnosis of diabetes mellitus. Review of the resident's November 2023 physician order sheet showed an order for Lispro insulin (medication injected for elevated blood sugar) inject subcutaneously before meals and at bedtime related to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes): if blood sugar is 0 -150 = no insulin, blood sugar 151-200 = no insulin, 201 - 250 = 6 units, 251 - 300 = 8 units, 301 - 350 = 10 units, 351 - 400 = 12 units and call physician/nurse practitioner, with an order start date of 06/15/23. Review of the resident's November 2023 MAR showed the resident received a blood glucose test four times a day at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M. Observation on 11/07/23 at 6:11 A.M., showed the following: -RN A took the same glucometer he/she used to check Resident #1's blood sugar out of the top drawer of the medication cart; -RN A put on a pair of gloves after using alcohol based hand sanitizer; -RN A cleaned the glucometer with an alcohol pad, assembled equipment to test the resident's blood glucose level and entered the resident's room; -RN A sat the glucometer directly on the resident's bedside table without placing a barrier between the glucometer and a magazine on the bedside table; -RN A performed the finger stick procedure and placed a drop of the resident's blood on a test strip in the glucometer; -RN A obtained the results and left the resident's room; -RN A removed the test strip from the glucometer with a gloved hand and placed the strip and lancet device in the biohazard sharps container on the medication cart; -RN A placed the glucometer on top of the medication cart without placing a barrier between the glucometer and top of the medication cart and removed his/ her gloves; -RN A cleaned the glucometer with two individual packaged alcohol pads and placed the glucometer in the top drawer of the medication cart; -RN A performed hand hygiene with hand sanitizer; -RN A did not clean the meter with one of the disinfection wipes as suggested by the glucometer's manufacturer and cleaned the used glucometer with bare hands; -No disinfection wipes were available for use on the medication cart. During interviews on 11/07/23 at 5:50 A.M. and 7:05 A.M., and 11/08/23 at 2:10 P.M., RN A said the following: -He/She cleans the glucometer with alcohol wipes if there were no sanitizer (disinfectant) wipes on the cart; -He/She had given the sanitizer wipes to another staff member earlier in the shift and did not have any sanitizer wipes on his/her medication cart; -Sanitizer wipes were in central supply, but central supply was generally locked at night and he/she did not have a key to central supply; -When cleaning a glucometer, you should clean it with alcohol wipes or sanitizer wipes, make it wet and then let it air dry; -When he/she takes a glucometer into a resident room, he/she should place a barrier, such as a paper towel, so he/she did not place the equipment on a dirty surface; -He/She did not place a barrier between the glucometer and mattress for Resident #1 or between the glucometer and bedside table for Resident #2 when he/she obtained the residents' blood sugars but should have; -He/She used the same glucometer for the residents on A hall and D hall; -He/She was not aware of any residents with an infectious disease such as viral hepatitis; -If a resident has an infectious disease, they should have their own glucometer. During an interview on 11/08/23 at 2:18 P.M., Licensed Practical Nurse (LPN) G said the following: -He/She believed each hall had its own glucometer to use for multiple residents; -The A hall had four residents who have routine blood glucose monitoring; -MicroKill One sanitizers were available on the medication cart and could be used to sanitize the glucometer; -He/She usually cleaned the glucometer in between each resident with alcohol wipes; -He/She thought the night shift staff disinfected the glucometer each night with the sanitizer wipes; -He/She was unsure if anyone at the facility had Hepatitis C; -He/She was unsure what the manufacturer's recommendations were for disinfecting the glucometer. During an interview on 11/08/23 at 4:00 P.M., the Director of Nursing (DON) said the following: -She expected staff to follow the facility policy for cleaning a multi-use glucometer after each use; -She expected staff to clean the glucometer with sanitizer wipes; -She would not expect staff to know off of the top of their head if a resident they were obtaining a blood sugar on had an infectious disease such as hepatitis C; -All of the residents' diagnoses are listed in the resident health record; -If staff disinfected a glucometer properly, staff could use a multi-use glucometer on a resident that has Hepatitis C, and then other residents; -Extra sanitizer wipes were available in central supply and the 11-7 shift had access to the central supply with a key; -Alcohol wipes were not acceptable to disinfect a multi-use glucometer; -There were two residents at the facility that had Hepatitis C. During an interview on 11/08/23 at 3:50 P.M., the administrator said the following: -He expected staff to clean a multi-use glucometer properly after use and to disinfect the glucometer per manufacturer's recommendations and company policy; -He expected staff to follow infection control policies to ensure no infection was passed to another resident; -If a resident had diagnosis of Hepatitis C, he expected staff to follow company policy for glucometer use, follow infection control policies and then follow proper cleaning to be able to use the glucometer for multiple residents. 3. Review of the facility policy, Perineal Care, revised 09/01/21, showed the following: -Policy explanation and compliance guidelines: -Perform hand hygiene and put on gloves; Apply other personal protective equipment as appropriate; -If perineum is grossly soiled, turn resident on side, remove fecal material with toilet paper, then remove and discard; -Cleanse buttocks and anus, front to back; vagina to anus in females and scrotum to anus in males, using a separate washcloth or wipes; -Dry thoroughly; -Re-position resident in supine (laying on back) position. Change gloves if soiled and continue with perineal care; -Cleanse perineal area using separate washcloth or wipes for each area; -Change gloves if soiled and continue with perineal care; -If using soap, rinse after washing; -Reposition as desired and cover resident; -Remove gloves and discard. Perform hand hygiene. Review of the facility hand washing policy, dated 9/1/21, showed the following: -All staff would perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene was the general term for cleaning the hands by handwashing with soap and water or use of an antiseptic hand rub, also known as an alcohol-based hand rub (ABHR); -Staff would perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene was indicated and would be performed under conditions listed in, but not limited to the attached hand hygiene table which included; -ABHR with 60-95% alcohol was the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they were visibly dirty, before eating, and after using the restroom. Review of the facility hand hygiene table, dated 2021, showed the following: -Hands should be cleaned with soap and water when hands were visibly dirty, and hands were visibly soiled with blood or there body fluids; -Hands should be cleaned with ether soap and water or ABHR (ABHR is preferred) between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves, before performing resident care procedures, when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions, and whenever in doubt. Review of Resident #2's electronic medical record (EMR) showed he/she had the following diagnoses: -Overactive bladder (condition of the bladder that causes a frequent and sudden urge to urinate that may be difficult to control); -Urinary tract infections (UTI, an infection involving the urinary tract system); -Dysuria (painful urination). Review of the resident's care plan, last revised on 8/24/22, showed the following: -He/She was on diuretic (a substance that promotes an increased production of urine) therapy; -He/She was incontinent of bowel and bladder and had a history of UTIs; -He/She had a self-care deficit with performance of activities of daily living (ADLs) due to decreased strength and limited mobility; -Staff were to assist the resident with cleaning the perineal area after each incontinence episode. Review of resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/19/23, showed the resident's cognition was intact, he/she was frequently incontinent of bowel and bladder, and did not have a history of rejecting care. Observation on 11/7/23 at 5:37 A.M., showed the following: -The resident was incontinent; his/her incontinence brief was saturated with orange colored urine and urine was on the bed pad located under the resident; -With a soapy, wet bath towel and gloved hands, Certified Nurse Assistant (CNA) J cleaned urine from resident's perineal area, abdominal fold and thighs. He/She wiped the resident's left groin multiple times, right groin, and genital area, but did not use a different cloth surface after each wipe. CNA J walked over to the resident's sink, rinsed the towel with water and walked back over to the resident to rinse the resident's groin and genitalia with the same towel. With the same gloves, CNA J obtained a clean brief from resident's bedside storage. CNA J assisted the resident onto his/her left side, placed an incontinence brief under the resident, and without cleansing urine from the resident's buttock and thigh areas, CNA J assisted the resident onto his/her right side to pull the brief through, then assisted the resident to his/her back and attached the clean brief. With the same gloves, CNA J opened the resident's door to his/her room to discard trash; -CNA J had not changed gloves when he/she went from a dirty process to a clean process and touched the resident's bedside storage, clean brief, the resident and the resident's door with the gloves. During an interview on 11/7/23 at 5:45 A.M., the resident said staff had last changed his/her incontinence brief and provided care at approximately 8:00 P.M. on 11/6/23. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should change the surface of the cloth with every wipe. He/She did not realize he/she used the same surface of the cloth and did not change cloths when needed. Resident #2 did not like to be awakened during the night for staff to check for incontinence, so he/she changed him/her in the morning. Resident #2's bed pad was not wet, therefore he/she did not change the pad. 4. Review of Resident #4's diagnoses showed he/she had the following: -Overactive bladder; -Recent UTI (10/10/23). Review of the resident's care plan, last revised on 10/25/23, showed the following: -He/She had an ADL self-care performance deficit and was dependent on staff for all ADLs, including personal hygiene and toileting; -He/She was frequently incontinent of bladder related to an overactive bladder; -He/She wore adult briefs; -Staff were to assist the resident with cleaning his/her perineal area after each incontinence episode. Review of the resident's admission MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She was dependent on staff with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She did not reject care. Observation of the resident, on 11/7/23 at 5:53 A.M., showed the resident lay in his/her bed and had been incontinent of bladder. The resident's incontinence brief was saturated. With gloved hands, CNA J cleaned urine from the resident's perineal area, lower abdomen, buttocks, and thighs. CNA J wiped the resident's left groin, right groin and genital area multiple times with a wet, soapy bath towel. He/She did not change the cloth surface after each wipe. CNA J assisted the resident onto his/her left side and wiped the right and left buttocks multiple times. He/She did not change the surface of the cloth after each wipe. CNA J rinsed the towel with water and rinsed the resident's buttocks areas, groin and genitalia, but did not change the surface of the cloth after each wipe. With the same gloves, CNA J obtained barrier cream from the resident's bedside table and placed it on the resident's buttocks, obtained a clean brief from resident's bedside storage area and placed it on the resident. CNA J removed his/her gloves and without performing hand hygiene, he/she grabbed the resident's door knob, opened the door, and exited the room to discard trash. During an interview on 11/7/23 at 1:40 P.M., CNA J said he/she should not have touched any clean items with contaminated gloves. During an interview on 11/9/23 at 10:30 A.M., the DON said she would expect staff to remove gloves and wash their hands before touching any clean items. Hands were to be washed with soap and water when visibly soiled and after removal of gloves. Staff were expected to remove gloves and wash their hands after applying barrier cream and before touching any clean items. She expected staff to change the surface of the cloth after each wipe when providing incontinence care. Staff should not use the same surface multiple times before changing surfaces. She expected staff to clean all areas of the perineum with wash cloths and/or wipes. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO225546 MO226124

This deficiency is uncorrected. For previous examples, refer to Statement of Deficiencies dated 10/12/23. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room . Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. The facility failed to provide adequate supervision and monitoring for Resident #15, who resided on a locked dementia unit and was on a pureed diet, when staff placed a peanut butter and jelly sandwich down on a table near the resident. The resident picked the sandwich up and ate it without staff knowledge. The facility census was 70. 1. During email communication on 11/28/23, at 12:49 P.M., the facility administrator said the facility did not have a Low-Air Loss mattress policy. Review of the undated operation manual for the Proactive medical product, Protekt Aire 6000 mattress, showed the following: -The Protekt Aire 6000 pump and mattress are intended to reduce the incidence of pressure ulcers while optimizing comfort; -Pressure range is 20 - 55mmHg adjustable and should be selected by a using the person's weight guide listed on the panel providing pressure range options; -Weight range option settings are: 80 pounds, 130 pounds, 180 pounds, 230 pounds, 280 pounds, 340 pounds, 400 pounds and 450 pounds. Review of Resident #6's face sheet showed diagnoses included morbid obesity (a condition when weight exceeds 100 pounds over recommended weight) and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/03/23, showed the following: -Adequate hearing, clear speech, makes self understood and understands others; -Cognitively intact; -No mobility impairment; -Toileting hygiene, dependent (helper does all of the effort, resident does none of the effort to complete the activity); -Mobility: roll left and right, substantial/maximum assist; -Bed rails not used. Review of the resident's progress notes showed staff documented the following: -On 10/28/23 at 2:17 A.M., staff documented at 2:00 A.M., Certified nursing assistant (CNA) B went to the resident's room to answer the call light. The resident needed to use the bed pan. When the resident finished with bed pan, he/she activated call light and CNA B went to the resident's room to remove the resident from the bed pan. In the process of cleaning the resident, the resident pushed himself/herself toward the edge of the bed whereby CNA B was telling the resident not to move too far toward the edge of bed but the resident was not listening. In the process, the resident slid out of the bed and CNA B tried to pull the resident back in the bed with linen, but the resident lost balance and fell where he/she hurt his/her scalp and had a laceration. CNA B asked Licensed Practical Nurse (LPN) C to come to the resident's room due to a fall. LPN C found the resident bleeding from his/her head, cleansed the resident's head and put a pressure dressing on the injury to stop the bleeding. Assessment revealed no injuries to legs or feet, two lacerations on nose and head. The resident was transferred back to bed via Hoyer lift (a mechanical lift used to transfer a resident from one surface to another) and the physician was called with an order to send to the emergency room for evaluation; -On 10/28/23 at 9:15 A.M., the resident returned from the emergency room with sutures to his/her forehead and a brace to his/her right hand to be worn while awake and remove while sleeping. Review of the resident's emergency room records, dated 10/28/23, documented the resident's assessment showed tenderness over his/her right clavicle (collarbone), pain at the base of his/her right thumb, a four centimeter laceration between his/her eyebrows, a one centimeter laceration on the bridge of his/her nose. Review of the resident's care plan, revised 10/21/23, showed the following: -At risk for falls; -Goal: will not sustain serious injury through the review date; -Resident had a fall on 10/28/23 at 2:07 A.M. and went to emergency room due to head laceration, has sutures in his/her forehead and two black eyes; -Anticipate and meet the resident's needs; -Resident has an activity of daily living (ADL) self-care performance deficit, is obese and weak; -Bed mobility assist times one to two; -Toilet use: change in bed. -Personal hygiene assist as needed with one to two staff. Review of the resident's November 2023 physician order sheet showed the following: -May have brace on right hand while awake and remove while sleeping with a start date of 10/28/23; -Remove sutures to forehead in 10 days with a start date of 10/28/23. Observation on 11/07/23 at 6:30 A.M., showed the following: -The resident lay awake in his/her bed; -The resident had purple and yellow bruising below both eyes: -A healing laceration was noted on the bridge of his/her nose and on his/her forehead between his/her eye brows; -The resident was wearing a splint on his/her right hand/thumb; -Low air loss mattress at alternating setting, set at 450 pounds (residents documented weight in his/her electronic health record was 269 pounds). Observation on 11/07/23 at 9:15 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During interviews on 11/07/23 at 6:30 A.M. and 9:15 A.M., the resident said the following: -The day he/she fell out of bed, CNA B was cleaning him/her up after having to use the bed pan; -CNA B had his/her hand on the resident's right hip and was looking at the resident's bottom to see if he/she had cleaned everything ok; -CNA B pushed his/her bottom too far and he/she fell out of bed; -He/She was sent to the emergency room for stitches and x-rays; -The hospital told him/her that he/she had a broken nose, but did not break his/her thumb; -He/She had black eyes since the fall; -He/She got a new bed that had side rails on them after he/she fell ; -His/Her mattress was pretty firm and could be softer; -When he/she got too close to the edge of the mattress the edge crumpled. During an interview on 11/07/23 at 2:50 P.M. and 11/20/23 at 3:40 P.M., CNA B said the following: -He/She cared for Resident #6 on the night he/she fell out of bed; -The resident asked to use the bedpan and he/she placed the resident on the bed pan; -After the resident was finished, he/she removed the resident from the bed pan; -After providing incontinence care, he/she applied barrier cream on the resident's buttocks; -The resident kept moving toward the edge of the bed on the left side; -He/She asked the resident to stop moving toward the edge of the bed, but he/she continued to move and started to slide out of the bed; -He/She used the turn sheet to attempt to reposition the resident and stop him/her from sliding, but the resident fell out of bed; -When the resident fell to the floor, he/she noticed there was blood on the resident's face; -He/She got the nurse to provide care and the resident was sent to the hospital; -If two staff had provided incontinent care for the resident, he/she would not have fallen out of bed. During an interview on 11/07/23, at 2:56 P.M., LPN C said the following: -He/She was the charge nurse for the resident the night he/she fell out of bed; -CNA B reported the resident had pushed against CNA B when providing care and started to slide toward the edge of the bed; -The resident slid out of the bed and fell to the floor; -The resident received a laceration to his/her scalp and nose and was sent to the emergency room for treatment; -Side rails were applied to the resident's bed after the fall; -The resident had a low air loss mattress due to skin breakdown in the past; -The air mattress should be set to the resident's weight; -Anyone can check to make sure the setting on the air mattress is correct, all nurses should check that; -If the air mattress was set too high it could have been a factor in the fall. Observation on 11/08/23 at 9:12 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the Director of Nursing (DON) said the following: -Resident #6 was sent to the hospital during the night shift after a fall from his/her bed during incontinence care and received two lacerations; -The wound care nurse and central supply is in charge of checking the air mattresses to make sure the setting are correct, but any nurse should also monitor to make sure settings are correct; -If the air mattress was at maximum fill at 450 pounds, that could have been a potential factor in Resident #6 falling out of bed; -She would have expected CNA B to stop the incontinence care/repositioning and get additional help for Resident #6 when the resident began pushing himself/herself toward the edge of the bed and when CNA B was telling the resident not to move too far toward the edge of bed and the resident was not listening; -There was adequate staff the night of Resident #6's fall out of bed to provide two people for the resident's care. 2. Review of the facility policy titled, Meal Supervision and Assistance, last revised January 2023, showed the following: -Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/ her preference and with adequate supervision and assistance to prevent accidents. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary; -Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident' environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff; -The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time. Review of Resident #15's comprehensive MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -Difficulty making self understood and sometimes understands others; -Unable to make decisions; -Requires limited assistance with ADL's and feeding; -Diagnoses of stroke and dementia; -No swallow disorder and no speech therapy marked; -Alteration in diet left blank. Review of the registered dietician progress note, dated 9/19/23, showed the resident was on a pureed diet. Review of the resident's care plan, dated 10/11/23, showed no care plan for nutrition, the resident's diet, or swallow problems. Review of the resident's physician's order sheet, dated 11/2023, showed an order for a pureed diet. Observation on 11/6/23 at 12:43 P.M., showed: -Resident #15 sat at a table in the dining room on the locked dementia unit; -The resident was served a tray of pureed food; -The resident said the food was terrible and ate the pudding; -Another resident said that he/she was still hungry. During an interview on 11/6/23 at 12:45 P.M., CNA M said: -Resident #15 does not like the pureed food; -He/She does not know why the resident was on a pureed diet, but he/she was not suppose to have solid food. Observation on 11/6/23 at 12:50 P.M. showed: -CNA M went to the kitchen and returned with two peanut butter and jelly sandwiches wrapped in plastic wrap; -CNA M placed one wrapped sandwich on the table, where Resident #15 sat; the sandwich was within the resident's reach; CNA M unwrapped the second sandwich and handed it to another resident; -Resident #15 picked up the wrapped sandwich, removed the plastic wrap and began to eat the sandwich; -CNA M and Registered Nurse (RN) A stood in the dining room where Resident #15 sat and ate the sandwich; -Neither CNA M or RN A noticed the resident had eaten the sandwich. During an interview on 11/7/23 at 10:45 A.M., CNA M said: -The resident was on a pureed diet and was to be monitored closely for taking food and choking. Staff are to observe the resident closely; -He/She was unaware the resident ate the peanut butter and jelly sandwich; he/she wondered what had happened to the sandwich and why there was plastic wrap on his/her tray. During an interview on 11/7/23 at 7:00 A.M., Registered Nurse (RN) A said: -He/She was unaware the resident ate a peanut butter and jelly sandwich; -The resident was on a pureed diet; -The resident was not safe to eat regular food; he/she could have choked. During an interview on 11/7/23 at 10:30 A.M. the DON said: -Resident #15 has a diagnosis of dysphagia (difficulty swallowing; Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all) with orophangeal dysphagia (difficulty initiating a swallow); -Resident #15 should be monitored closely because he/she does not like the pureed food and will take food off other resident's trays; -Staff should monitor the residents and ensure they eat foods that are ordered for them. 3. Review of Resident #5's care plan, last revised 2/1/23, showed the following: -He/She had an ADL self-care performance deficit related to his/her diagnosis of Friedreich's ataxia (an inherited disorder that affects some of the body's nerves); -He/She required assistance of two with Hoyer lift transfers. Review of the resident's physician's orders, dated November 2023, showed an order for Hoyer lift assist of two for all transfers (2/1/23). During an interview on 11/7/23 at 6:00 A.M., CNA J said the resident should be a two person transfer with a Hoyer lift, but he/she transferred the resident with only one person because the resident was so small. Technically he/she was supposed to use two staff for Hoyer transfers. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the DON said the following: -Under no circumstances should a Hoyer lift transfer be completed with only one staff. She expected all Hoyer lift transfers be completed with two staff. MO226653 MO227065 MO226124

Based on observation, interview and record review, the facility failed to routinely assess pain, obtain and administer pain medication timely after pain was identified, failed to notify the physician the resident did not have pain medication available for administration and failed to plan care with interventions to address the resident's pain for one resident (Resident #4) a 14 sampled residents. Resident #4 had a bacterial infection of the knee and osteoarthritis and was to receive physical therapy. The failure to have pain medication for the resident caused pain with therapy and a delayed the resident's progress with therapy. The census was 70. Review of the facility policy for Pain Management dated 9/1/21 showed: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain; -In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated, evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition occurs, and manage or prevent pain, consistent with comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. -Facility staff shall observe for nonverbal indicators which may indicate the presence of pain. -Staff shall be aware of verbal descriptors a resident may use to report or describe their pain; -The facility shall utilize a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professions and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individuals resident's pain beginning at admission; -The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal; -Non-pharmacological interventions and pharmacological interventions shall be included; -Facility staff shall reassess resident's pain management for effectiveness and/or adverse consequences. 1. Review of Resident #4's admission record showed: -admitted to the facility 7/13/23; -Diagnoses included arthritis due to bacterial infection in the right knee, pyogenic arthritis (pyogenic, or septic arthritis is a serious and painful infection of a joint), pain in the right knee and osteoarthritis. Review of the resident's comprehensive care plan initiated 7/13/23, showed no care plan to address the resident's pain or arthritis. Review of the resident's physician's orders sheet (POS) dated July 2023 showed the following: -Pain monitoring every shift, 1-10 scale (one being little to no pain and 10 being excruciating pain); -Gabapentin (a medication used to treat nerve pain) 300 milligrams (mg) one capsule at bedtime for nerve pain; - Acetaminophen tablet 325 mg, give 2 tablets by mouth every six hours as needed for general discomfort; -Hydrocodone-acetaminophen (narcotic medication), 5-325 mg, one tablet every six hours as needed for pain. Review of the resident's physical therapy (PT) notes dated 7/14/23, and signed by Physical Therapist A, showed the resident was alert and oriented with a history of right knee septic arthritis with further deconditioning (reversible changes in the body brought about by physical inactivity and disuse) and increased pain levels upon light movement of the right knee. Review of the resident's PT notes dated 7/18/23, signed by Physical Therapist A, showed the resident reported that staff bent his/her right knee yesterday when attempting to get him back into bed. Pain today a 7 out of 10 in the right knee. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/20/23 showed: -The resident is alert and oriented, able to make self understood and able to understand others; -Requires extensive assistance of one staff member for activities of daily living (ADL's); -Occasional mild pain. Review of the resident's physician progress note dated 7/25/23 showed: -The resident is going to need some extensive therapy. He/She is not able to bear weight; -He/She is having some increased pain. Order for Tramadol (used for the short-term relief of severe pain) 50 mg every eight hours as needed. Review of the resident's POS for July 2023 showed an order for Tramadol Hcl tablet 50 mg, give one tablet every eight hours as needed. Review of the resident's Medication Administration Record (MAR) dated July 2023 showed: -Pain monitoring every shift for pain; -There was no documentation staff assessed the resident's level of pain for dates 7/14/23 through 7/31/23; -Tramadol Hcl tablet 50 mg one tablet every 8 hours as needed for pain related to osteoarthritis; -There was no documentation staff administered Tramadol Hcl 50 mg. on any dates; -Hydrocodone-acetaminophen 5-325 mg one tablet every six hours as needed for pain scale of 1-10, documented as given one time on 7/18/23 for a pain level of 5; -Acetaminophen 325 mg take two tablets every six hours as needed for pain documented as administered on 7/19/23 with a pain level of 9; on 7/23/23 with a pain level of a 5, and 7/31/23 with a pain level of 5. Review of the resident's MAR dated August 2023 showed: -Pain monitoring every shift; -There was no documentation staff assessed the resident for pain from 8/1/23 through 8/10/23; -On 8/11/23 through 8/15/23, staff documented every shift the resident had a no pain (0); -There was no documentation staff administered any Tramadol Hcl tablet 50 mg one tablet every 8 hours as needed for pain; -There was no documentation staff administered hydrocodone-acetaminophen 5-325 mg one tablet every six hours as needed for pain; -There was no documentation staff administered acetaminophen 325 mg take 2 tablets every six hours as needed for pain. Review of the resident's PT notes dated 8/2/23 signed by PT A, showed the resident was unable to lift his/her left lower extremity long enough due to right knee pain. Review of the resident's PT notes dated 8/4/23 signed by PT A, showed the resident was unable to tolerate standing greater than 15 minutes today due to right knee pain. Review of the resident's PT notes dated 8/8/23 signed by PT A, showed stand by assistance, but unable to ambulate due to soreness in the right knee today. During an interview on 8/15/23 at 3:00 P.M. Physical Therapist A said: -The resident has had a lot of right knee pain since admission and has not been able to complete some therapy due to the pain in the right knee; -He/She continues to complain of knee pain during therapy and has said that he/she asked for pain medication and has not received any; -By not receiving the pain medication, this delayed the resident's progress in therapy. During an interview on 8/15/23 at 10:30 A.M. Resident #4 said the following: -He/She has a lot of pain in the right knee; -He/She had asked for pain medication and staff told him/her there was no prescription for the Tramadol or the hydrocodone-acetaminophen and the medication was not available; -Staff gave him/her Tylenol, but it only dulled the pain at times; -There have been times when he/she cannot sleep or participate in therapy due to the pain in his/her knee. During an interview on 8/14/23 at 10:30 A.M., the Medical Director/Physician A said: -The resident told him that he/she has not had any pain medication since he/she has been at the facility; -He ordered Tramadol a few weeks ago for the resident due to the resident's increase in pain; -The resident should have hydrocodone-acetaminophen 5-325 mg available; -The resident said that he/she asked for a pain pill last night and only got Tylenol which did not touch his/her pain. Observation and interview on 8/14/23 at 2:00 P.M. showed the following: -Licensed Practical Nurse (LPN) B looked in the medication cart and could not find the resident's Tramadol or hydrocodone-acetaminophen medications; -He/She said the medications were not in the medication cart or in the medication room; -He/She would have to call pharmacy. During an interview on 8/15/23 at 10:00 A.M. LPN C said the following: -The resident did not have Tramadol or hydrocodone-acetaminophen because the facility did not have a written prescription signed by the physician to send to the pharmacy for the medication to be filled; -A prescription should have been sent by the hospital but it was not; -He/She did not know why the prescription had not been obtained. During an interview on 8/15/23 at 11:10 A.M. Pharmacist A said: -The pharmacy did not have a prescription for the hydrocodone-acetaminophen for the resident so the pharmacy cannot send the medication; -The pharmacy had not been notified of the order for the Tramadol so the medication has not been sent to the facility. During an interview on 8/15/236 at 11:46 A.M. Medical Director/Physician A said: -He was at the facility on 8/14/23 to make rounds and see the resident; -He was not aware the pharmacy needed a prescription for the hydrocodone-acetaminophen or he would have given one yesterday; -He would expect the facility to contact him and request a prescription for narcotic pain medication upon receiving the order for the narcotic for pain. During an interview on 8/15/23 at 5:15 P.M. the Director of Nursing said: -She was not aware that the resident did not have pain medication; -She would have expected the nurses to obtain a prescription for the pain medication upon admission to the facility and ensured the resident had his/her pain medication. During an interview on 8/15/23 at 5:15 P.M. the Administrator said she would expect staff to administer medications as ordered by the physician. MO222958

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #2), of 14 sampled residents, received care and services to prevent weight loss. Staff failed to obtain weights per facility protocol or document intake per facility policy. The facility to failed carry through with recommendations from the Registered Dietitian, notify the physician and dietitian with further weight loss, and failed to update the resident's care plan timely when new weight loss was identified. Resident #1 had a 15% weight loss in six months and a 33% weight loss since his/her admission in October of 2022. Resident #2 had a 15% weight loss in six months. The facility census was 92. Review of the facility's policy for Weight Monitoring dated 6/2/22 showed: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; -The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: -Identifying and assessing each resident's nutritional status and risk factors; -Evaluating/analyzing the assessment information; -Developing and consistently implementing pertinent approaches; -Monitoring the effectiveness of interventions and revising them as necessary; -A weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. Newly admitted residents will have their weight monitored weekly for four weeks. Residents with significant weight loss/weight gain should be weighed weekly until stable. If clinically indicated monitor weight daily until stable; -The medical provider should be informed of a significant change in weight and may order nutritional interventions; the medical provider should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. The registered dietitian or dietary manager should be consulted to assist with interventions. Observations pertinent to the resident's weight status should be recorded in the medical record. Review of the facility's Weight Assessment and Intervention policy dated 9/2008 showed: -The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents; -Nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter; -Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; -The dietician will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month - 5% weight loss is significant; greater than 5% is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe. Six months - 10% weight loss is significant; greater than 10% is severe; -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the following: -The resident's target weight range (including rationale if different from ideal body weight); -Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; -The relationship between current medical condition or clinical situation and recent fluctuations in weight; -Whether and to what extent weight stabilization or improvement can be anticipated; -The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss; -Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, dietician, consultant pharmacist, and the resident or resident's legal surrogate; -Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and the time frames and parameters for monitoring and reassessment; -Interventions for undesirable weight loss shall be based on careful considerations of the resident choice and preferences, nutritional and hydration needs of the resident, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing, or digestion, the use of supplements and/or feeding tubes, and end of life decisions and advance directives. Review of the facility policy for Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol dated 8/2017 showed: -Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current status - weight, food/fluid intake, and pertinent laboratory values, and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition: -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake; -The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions. 1. Review of Resident #1's electronic medical record titled Weights and Vital Signs, showed staff documented the resident weighed 95# on 10/20/22 and 87# on 10/26/22 (8# loss in six days). Review of the resident's care plan for nutrition dated 11/1/22 showed the following: -The resident has potential for nutritional problem, he/she needs to be fed. At risk for weight loss; -The resident will have no significant weight loss of 5% in 30 days or 10% in 180 days; -Monitor/document/report as needed any signs or symptoms of dysphagia (difficulty swallowing), pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals - initiated on 11/1/22; -Offer routine snacks and hydration, initiated on 11/1/22; -Provide and serve diet as ordered, initiated on 11/1/22. Review of the resident's electronic medical record titled Weights and Vital Signs showed staff documented the following weights: -11/2/22 -90.2# -No weight documented for the week of 11/7/22; -11/16/22 - 89.9#; -No weight documented for the week of 11/21/22; -11/29/22-88.0# -12/6/22-88# - No weights documented for the weeks of 12/12/22, 12/19/22, 12/26/221/2/23; -1/10/23-74# -1/18/23-80# (Further weight loss since 10/26/22 of 7#). Review of the resident's Registered Dietician progress note on 1/24/23 showed: -Diet order of mechanical soft with 2.0 supplement three times daily (TID); -Height 66 weight 74#; Body Mass Index (a weight-to-height ratio, calculated by dividing one's weight in kilograms by the square of one's height in meters and used as an indicator to obesity and underweight) 11.9 (normal range for an adult female is 18.5 to 25.9; -Estimated nutritional needs of 34 kilograms (35) = 1190 kcals, 34 (1.2) = 41 grams protein and 1020 milliliters of fluid; -Resident is on a mechanical soft diet with fair oral intake. 2.0 supplement three times a day with medication pass. Weight loss to 74#; BMI 11.9 - low. Would add house supplement with lunch & supper. Encourage good oral intake and provide assist as needed. Monitor weekly until weights are stable. Review of the resident's electronic medical record titled Weights and Vital Signs showed staff documented the resident's weight as 78# on 1/25/22, (further loss of two pounds in seven days). Review of the resident's care plan for nutrition showed an update on 1/29/23 to give supplements as ordered. Review of the resident's medical record titled Weights and Vital Signs showed staff documented the following weights: -No weight documented for the week of 1/3/23 -2/1/23-80# -2/10/23-78# -2/15/23-76# Review of the resident's medical record from 1/24/23 through 2/17/23 showed no documentation staff notified the resident's physician of the resident's weight loss or RD recommendations. There was no documentation of the resident's food or fluid intake. Review of the resident's RD progress note dated 2/17/23 showed: -Resident continues on weekly weights with overall fluctuations (the resident's medical record showed staff did not consistently assessed the resident's weight weekly). Currently 76#. On a mechanical soft diet with fair to good intake per staff; -House supplement added last month as appropriate. No wounds reported. No labs for review. Would continue nutrition interventions and weekly weights. Review of the resident's electronic medical record titled Weights and Vital Signs showed staff documented the following weights: -2/22/23-79# -3/10/23-74# Review of the resident's electronic medical record from 2/17/23 through 4/5/23, showed the following: -Missing weekly weights during the weeks of 3/1/23, 3/15/23, 3/22/23, and 3/29/23; -No evidence staff notified the resident's physician of the RD's recommendations or of the resident's weight loss. There was no documentation of the resident's food or fluid intake. Review of the resident's RD progress note dated 4/5/23 showed: -Resident's March weight down to 74#. On a mechanical soft diet with 90 ml 2.0 supplements TID and house supplement with lunch & supper. Fair to good oral intake reported. No wounds reported. No recent labs. Would add double entree with lunch to increase calories; monitor weekly weights until stable. Review of the resident's care plan dated 11/1/22 showed no update related to the RD's recommendation to add double entree at lunch. Review of the resident's medical record titled Weights and Vital Signs showed staff documented the resident weighed 70# on 4/10/23, (weight down 25 pounds since 10/22/22). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/10/23 showed: -The resident admitted to the facility on [DATE]; -Dependent upon staff for eating; -Diagnoses of stroke and malnutrition; -Weights: On 10/27/22 87 pounds (#), on 12/19/22 87 #, on 2/27/23 79#, and 4/10/23 79#. Review of the resident's medical record titled Weights and Vital Signs showed staff documented the following weights: -5/1/23-70#; -6/8/23-63# Review of the resident's weights on 6/8/23 showed a 19% weight loss in six months; 10% weight loss in three months; a 10% weight loss in one month and an overall 33% weight loss since admission on 10/22/22. Review of the resident's physician's order sheet (POS) dated June 2023, showed the following: -Weekly weights, notify physician with a weight gain or loss of three pounds or more in one week ordered on 4/19/23; -Regular diet, mechanical soft texture; -Ready Care/Med Pass 2.0 (a high calorie drink), 90 milliliters (ml) three times a day ordered on 10/26/22; -House supplement two times a day with lunch and dinner ordered on 10/26/22. Review of the resident's discharge MDS dated [DATE], showed the resident was discharged to the hospital with a weight of 79#. Review of the resident's Medication Administration Record and the Treatment Administration Record for April 2023, May 2023 (one weight obtained 5/1/23), and June 2023 (one weight obtained on 6/8/23), showed staff did not obtain weekly weights and did not document why staff did not obtain the weekly weights. There was no documentation to show staff notified the resident's physician of the resident's weights or of the resident's weight change, or of the RD's recommendations. Review of the resident's nurses notes dated 6/20/23 at 2:45 P.M., showed the resident was noted to have altered mental status. Call placed to physician with orders to send the resident to the emergency room . Review of the resident's hospital discharge summary 7/12/23, showed the following: -Severe protein-calorie malnutrition; -Weight of 69#. During an interview on 8/15/23 at 11:46 A.M. and 8/23/23 at 8:20 A.M., the resident's physician/facility Medical Director said he would have expected weekly weights to be done and to be notified of the resident's weight loss. The discussion of a feeding tube or hospice services should have been discussed due to the continued weight loss and disease process. 2. Review of Resident #2's medical record labeled Weights and Vital Signs showed staff documented the resident's admission weight as 160# on 1/3/23. Review of Resident #2's nutritional care plan dated 1/13/23 showed: -The resident has potential for nutritional problem. He/She will stuff food in his/her mouth. He/She is at risk for aspiration/weight/fluid imbalance, has a history of malnutrition, and weight fluctuates (gains/losses) month to month; -The resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs or symptoms of malnutrition; -Interventions include a sippy cup for fluids, initiated 1/13/23, monitor what he/she is eating, if not feed him/her or give cues, initiated 1/13/23; monitor/document/report as needed any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, or holding food in the mouth. Several attempts at swallowing, refusing to eat. Appears concerned during meals, monitor/record/report to physician as needed signs or symptoms of malnutrition, 1/13/23, emaciation (cachexia - muscle mass loss with or without fat mass loss), significant weight loss: more than 5 % in one month, more than 10% in 6 months initiated 1/13/23; offer snacks and hydration, provide and serve diet as ordered, initiated 1/13/23. Review of the resident's RD progress note dated 1/24/23, showed the resident was admitted on a mechanical soft diet, no bread related to dysphagia (difficulty swallowing). No wounds. Would continue diet and monitor weight trends. Review of the resident's medical record labeled Weights and Vital Signs showed staff documented the following weights: -2/17/23 - 146#; -3/10/23 - 135#, (loss of 11 pounds in one month); -No weights documented for April 2023. Review of the resident's RD progress note dated 4/5/23 showed the resident's March weight was down to 136#, BMI 18.4 low. On a mechanical soft diet with no bread, fair to good intake reported. No labs for review. No wounds reported. Would discontinue no bread restrictions. Monitor weekly weights until stable. Review of the resident's medical record labeled Weights and Vital Signs showed staff documented the following weights: -No weights documented for May 2023; -6/8/23 - 147#; -No weight documented for July 2023. -There was no evidence staff assessed weekly weights until stable as recommended by the RD. Review of the resident's quarterly MDS dated [DATE] showed: -admitted to the facility on [DATE]; -Requires extensive assistance of one staff member for eating; -Diagnoses of stroke and malnutrition; -Weights: 1/2/23 160#; 2/27/23 147 #, 4/21/23 147#; 7/21/23 147#. Review of the resident's medical record labeled Weights and Vital Signs showed staff documented the resident's weight on 8/9/23 as 124# (loss of 23 pounds in 19 days). Review of the resident's medical record from 4/5/23 through 8/14/23 showed no documentation of weekly weights, no documentation of the resident's intake, no documentation of the physician notification of weight loss or any further RD progress notes. During an interview on 8/25/23 at 4:30 P.M. Certified Nurse Aide (CNA) E said: -He/She does the monthly weights and will do the weekly weights when a nurse tells him/her to; -He/She documents the weights on a spreadsheet and used to give the list to the former Assistant Director of Nursing (ADON), but the ADON had not been at the facility for several months; -He/She writes the weights down on paper now and hands them to the nurses now; -No one has told him/her to get weekly weights on any of the residents. During an interview on 8/14/23 at 2:00 P.M. and 8/15/23 at 5:15 P.M.,the Director of Nursing (DON said the following: -Staff do not document the resident intakes; -Staff should document the percentage of the nutritional supplements consumed on the Medication Administration Record (MAR); -The facility has not had an RD at the facility for several months. -She would expect weights to be done on time, following the facility policy and the physician's orders; -Weights should be reported to the DON or ADON for any weight loss; -The residents who have had a weight loss should be reported to the physician, the responsible party and consult with the RD. MO220317

This deficiency is uncorrected. For previous examples, refer to Statement of Deficiencies dated 10/12/23. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room. Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. The facility failed to provide adequate supervision and monitoring for Resident #15, who resided on a locked dementia unit and was on a pureed diet, when staff placed a peanut butter and jelly sandwich down on a table near the resident. The resident picked the sandwich up and ate it without staff knowledge. The facility census was 70. 1. During email communication on 11/28/23, at 12:49 P.M., the facility administrator said the facility did not have a Low-Air Loss mattress policy. Review of the undated operation manual for the Proactive medical product, Protekt Aire 6000 mattress, showed the following: -The Protekt Aire 6000 pump and mattress are intended to reduce the incidence of pressure ulcers while optimizing comfort; -Pressure range is 20 - 55mmHg adjustable and should be selected by a using the person's weight guide listed on the panel providing pressure range options; -Weight range option settings are: 80 pounds, 130 pounds, 180 pounds, 230 pounds, 280 pounds, 340 pounds, 400 pounds and 450 pounds. Review of Resident #6's face sheet showed diagnoses included morbid obesity (a condition when weight exceeds 100 pounds over recommended weight) and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/03/23, showed the following: -Adequate hearing, clear speech, makes self understood and understands others; -Cognitively intact; -No mobility impairment; -Toileting hygiene, dependent (helper does all of the effort, resident does none of the effort to complete the activity); -Mobility: roll left and right, substantial/maximum assist; -Bed rails not used. Review of the resident's progress notes showed staff documented the following: -On 10/28/23 at 2:17 A.M., staff documented at 2:00 A.M., Certified nursing assistant (CNA) B went to the resident's room to answer the call light. The resident needed to use the bed pan. When the resident finished with bed pan, he/she activated call light and CNA B went to the resident's room to remove the resident from the bed pan. In the process of cleaning the resident, the resident pushed himself/herself toward the edge of the bed whereby CNA B was telling the resident not to move too far toward the edge of bed but the resident was not listening. In the process, the resident slid out of the bed and CNA B tried to pull the resident back in the bed with linen, but the resident lost balance and fell where he/she hurt his/her scalp and had a laceration. CNA B asked Licensed Practical Nurse (LPN) C to come to the resident's room due to a fall. LPN C found the resident bleeding from his/her head, cleansed the resident's head and put a pressure dressing on the injury to stop the bleeding. Assessment revealed no injuries to legs or feet, two lacerations on nose and head. The resident was transferred back to bed via Hoyer lift (a mechanical lift used to transfer a resident from one surface to another) and the physician was called with an order to send to the emergency room for evaluation; -On 10/28/23 at 9:15 A.M., the resident returned from the emergency room with sutures to his/her forehead and a brace to his/her right hand to be worn while awake and remove while sleeping. Review of the resident's emergency room records, dated 10/28/23, documented the resident's assessment showed tenderness over his/her right clavicle (collarbone), pain at the base of his/her right thumb, a four centimeter laceration between his/her eyebrows, a one centimeter laceration on the bridge of his/her nose. Review of the resident's care plan, revised 10/21/23, showed the following: -At risk for falls; -Goal: will not sustain serious injury through the review date; -Resident had a fall on 10/28/23 at 2:07 A.M. and went to emergency room due to head laceration, has sutures in his/her forehead and two black eyes; -Anticipate and meet the resident's needs; -Resident has an activity of daily living (ADL) self-care performance deficit, is obese and weak; -Bed mobility assist times one to two; -Toilet use: change in bed. -Personal hygiene assist as needed with one to two staff. Review of the resident's November 2023 physician order sheet showed the following: -May have brace on right hand while awake and remove while sleeping with a start date of 10/28/23; -Remove sutures to forehead in 10 days with a start date of 10/28/23. Observation on 11/07/23 at 6:30 A.M., showed the following: -The resident lay awake in his/her bed; -The resident had purple and yellow bruising below both eyes: -A healing laceration was noted on the bridge of his/her nose and on his/her forehead between his/her eye brows; -The resident was wearing a splint on his/her right hand/thumb; -Low air loss mattress at alternating setting, set at 450 pounds (residents documented weight in his/her electronic health record was 269 pounds). Observation on 11/07/23 at 9:15 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During interviews on 11/07/23 at 6:30 A.M. and 9:15 A.M., the resident said the following: -The day he/she fell out of bed, CNA B was cleaning him/her up after having to use the bed pan; -CNA B had his/her hand on the resident's right hip and was looking at the resident's bottom to see if he/she had cleaned everything ok; -CNA B pushed his/her bottom too far and he/she fell out of bed; -He/She was sent to the emergency room for stitches and x-rays; -The hospital told him/her that he/she had a broken nose, but did not break his/her thumb; -He/She had black eyes since the fall; -He/She got a new bed that had side rails on them after he/she fell; -His/Her mattress was pretty firm and could be softer; -When he/she got too close to the edge of the mattress the edge crumpled. During an interview on 11/07/23 at 2:50 P.M. and 11/20/23 at 3:40 P.M., CNA B said the following: -He/She cared for Resident #6 on the night he/she fell out of bed; -The resident asked to use the bedpan and he/she placed the resident on the bed pan; -After the resident was finished, he/she removed the resident from the bed pan; -After providing incontinence care, he/she applied barrier cream on the resident's buttocks; -The resident kept moving toward the edge of the bed on the left side; -He/She asked the resident to stop moving toward the edge of the bed, but he/she continued to move and started to slide out of the bed; -He/She used the turn sheet to attempt to reposition the resident and stop him/her from sliding, but the resident fell out of bed; -When the resident fell to the floor, he/she noticed there was blood on the resident's face; -He/She got the nurse to provide care and the resident was sent to the hospital; -If two staff had provided incontinent care for the resident, he/she would not have fallen out of bed. During an interview on 11/07/23, at 2:56 P.M., LPN C said the following: -He/She was the charge nurse for the resident the night he/she fell out of bed; -CNA B reported the resident had pushed against CNA B when providing care and started to slide toward the edge of the bed; -The resident slid out of the bed and fell to the floor; -The resident received a laceration to his/her scalp and nose and was sent to the emergency room for treatment; -Side rails were applied to the resident's bed after the fall; -The resident had a low air loss mattress due to skin breakdown in the past; -The air mattress should be set to the resident's weight; -Anyone can check to make sure the setting on the air mattress is correct, all nurses should check that; -If the air mattress was set too high it could have been a factor in the fall. Observation on 11/08/23 at 9:12 A.M., showed the resident lay awake in bed with the low air loss mattress at alternating setting, set at 450 pounds. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the Director of Nursing (DON) said the following: -Resident #6 was sent to the hospital during the night shift after a fall from his/her bed during incontinence care and received two lacerations; -The wound care nurse and central supply is in charge of checking the air mattresses to make sure the setting are correct, but any nurse should also monitor to make sure settings are correct; -If the air mattress was at maximum fill at 450 pounds, that could have been a potential factor in Resident #6 falling out of bed; -She would have expected CNA B to stop the incontinence care/repositioning and get additional help for Resident #6 when the resident began pushing himself/herself toward the edge of the bed and when CNA B was telling the resident not to move too far toward the edge of bed and the resident was not listening; -There was adequate staff the night of Resident #6's fall out of bed to provide two people for the resident's care. 2. Review of the facility policy titled, Meal Supervision and Assistance, last revised January 2023, showed the following: -Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/ her preference and with adequate supervision and assistance to prevent accidents. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary; -Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident' environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff; -The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time. Review of Resident #15's comprehensive MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -Difficulty making self understood and sometimes understands others; -Unable to make decisions; -Requires limited assistance with ADL's and feeding; -Diagnoses of stroke and dementia; -No swallow disorder and no speech therapy marked; -Alteration in diet left blank. Review of the registered dietician progress note, dated 9/19/23, showed the resident was on a pureed diet. Review of the resident's care plan, dated 10/11/23, showed no care plan for nutrition, the resident's diet, or swallow problems. Review of the resident's physician's order sheet, dated 11/2023, showed an order for a pureed diet. Observation on 11/6/23 at 12:43 P.M., showed: -Resident #15 sat at a table in the dining room on the locked dementia unit; -The resident was served a tray of pureed food; -The resident said the food was terrible and ate the pudding; -Another resident said that he/she was still hungry. During an interview on 11/6/23 at 12:45 P.M., CNA M said: -Resident #15 does not like the pureed food; -He/She does not know why the resident was on a pureed diet, but he/she was not suppose to have solid food. Observation on 11/6/23 at 12:50 P.M. showed: -CNA M went to the kitchen and returned with two peanut butter and jelly sandwiches wrapped in plastic wrap; -CNA M placed one wrapped sandwich on the table, where Resident #15 sat; the sandwich was within the resident's reach; CNA M unwrapped the second sandwich and handed it to another resident; -Resident #15 picked up the wrapped sandwich, removed the plastic wrap and began to eat the sandwich; -CNA M and Registered Nurse (RN) A stood in the dining room where Resident #15 sat and ate the sandwich; -Neither CNA M or RN A noticed the resident had eaten the sandwich. During an interview on 11/7/23 at 10:45 A.M., CNA M said: -The resident was on a pureed diet and was to be monitored closely for taking food and choking. Staff are to observe the resident closely; -He/She was unaware the resident ate the peanut butter and jelly sandwich; he/she wondered what had happened to the sandwich and why there was plastic wrap on his/her tray. During an interview on 11/7/23 at 7:00 A.M., Registered Nurse (RN) A said: -He/She was unaware the resident ate a peanut butter and jelly sandwich; -The resident was on a pureed diet; -The resident was not safe to eat regular food; he/she could have choked. During an interview on 11/7/23 at 10:30 A.M. the DON said: -Resident #15 has a diagnosis of dysphagia (difficulty swallowing; Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all) with orophangeal dysphagia (difficulty initiating a swallow); -Resident #15 should be monitored closely because he/she does not like the pureed food and will take food off other resident's trays; -Staff should monitor the residents and ensure they eat foods that are ordered for them. 3. Review of Resident #5's care plan, last revised 2/1/23, showed the following: -He/She had an ADL self-care performance deficit related to his/her diagnosis of Friedreich's ataxia (an inherited disorder that affects some of the body's nerves); -He/She required assistance of two with Hoyer lift transfers. Review of the resident's physician's orders, dated November 2023, showed an order for Hoyer lift assist of two for all transfers (2/1/23). During an interview on 11/7/23 at 6:00 A.M., CNA J said the resident should be a two person transfer with a Hoyer lift, but he/she transferred the resident with only one person because the resident was so small. Technically he/she was supposed to use two staff for Hoyer transfers. During an interview on 11/7/23 at 10:30 A.M. and 11:00 A.M., 11/8/23 at 1:20 P.M. and 11/21/23 at 10:49 A.M., the DON said the following: -Under no circumstances should a Hoyer lift transfer be completed with only one staff. She expected all Hoyer lift transfers be completed with two staff. MO226653 MO227065 MO226124

Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and to communicate with outside agencies (e.g. sate surveyors) regarding any matter. Review of the facility's policy, Resident and Family Grievances, dated 9/2/22, showed the following: -The facility would support each resident's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; -The facility would not retaliate or discriminate against anyone who filed a grievance or participated in investigation of grievances. Review of the facility policy, Promoting/Maintaining Resident Dignity, revised 09/01/22, showed the following: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident' individuality; -When interacting with a resident, pay attention to the resident as an individual; - Respond to requests for assistance in a timely manner. 1. Review of confidential Resident #900's face sheet showed the resident was his/her own responsible party. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, showed the following: -Adequate hearing and clear speech; -Able to make self understood and able to understand others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:00 P.M., the resident said the following: -Staff do not come in and take care of him/her when he/she needed help; -He/She has complained to the management staff about the lack of response to his/her call light, and then the staff will take even more time to answer the call light. He/She has waited up to an hour for staff to come in and assist him/her; -He/She feels that staff will punish him/her for talking with the State Agency (SA) and the staff will take longer to answer the call light or refuse to give him/her medication; -He/She has tried to voice his/her concerns to management, but feels that nothing is done about these concerns and then staff will ignore him/her when he/she needs help; -He/She has filed grievances, but has not received any resolution to his/her grievances; -He/She needs help to get in and out of bed at times and help to use the bathroom. When he/she has complained about staff members to management, these staff members will then ignore him/her and refuse to help him/her. He/She has been told (specified staff member), if he/she talks with the SA or calls the abuse and neglect hotline, that he/she can look for another place to live. 2. Review of confidential Resident #700's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understands others; -Cognitively intact. During a confidential interview on 11/07/23 at 7:30 A.M., the resident said the following: -He/She feared repercussions from staff simply for talking to the SA; -He/She felt like the repercussions would be that staff would ignore him/her more than they already do, and that it will take a really long time to answer his/her call light now, longer than usual which was at times a really long time. 3. Review of confidential Resident #800's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understood others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:36 P.M., the resident said the following: -He/She would not complain due to real fear of retaliation from staff; -The retaliation was real, the resident would not explain, but turned his/her head away and would not talk further. 4. Review of Resident #10's face sheet showed an admission date of 9/15/23. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 9/25/23, showed the following: -Cognitively impaired; -Understood others and able to make others understand; -No behaviors or rejection of care; -Dependent on staff for bed mobility; -No falls in the last month prior to admission; -One non-injury and one injury fall since admission or prior assessment. Review of the resident's fall risk assessment, dated 10/30/23, showed he/she had had two falls in the last 30 days and was high risk for falls. Review of the resident's care plan, last revised on 10/30/23, showed the following: -History of traumatic event; -Further traumatization will be avoided; -Required assist of one staff for activities of daily living (ADL), including transfers; -Dependent on staff for meeting emotional, intellectual, physical and social needs; -Increased risk for falls due to impaired mobility and will throw self on the floor due to having a difficult time making needs known; -Low bed; -Fall mattress/mat next to bed when in bed; -Resident required prompt response to all requests for assistance. Review of a video/audio recording (received anonymously), date stamped 10/31/23, showed the following: -On 10/31/23 at 4:20 A.M., Resident #10 was observed on the floor by a confidential resident. Resident #10 can be heard saying, Can you help me get back into the bed, I rolled off the bed. Can you help me; -On 10/31/23 at 4:29 A.M., a video of a hallway with a male voice, repeatedly yelling out for help; -On 10/31/23 at 4:33 A.M., a female staff member observed standing at the doorway of Resident #10 and saying, I need you to stay on the mat and be quiet; the staff member was identified as Certified Nurse Assistant (CNA) H by a confidential resident. During an interview on 11/8/23 at 11:00 A.M., the resident said the following: -In the last two weeks, he/she fell out of bed, yelled for help and when unidentified staff initially arrived, they told him/her to be quiet and stay on the mat. He/She asked for help to get back into bed and the same unidentified staff refused to assist him/her. This made him/her feel helpless and upset. During interview on 11/7/2023 at 2:15 P.M. CNA H said the following: -He/She did not necessarily recall the resident being on the floor the night of 10/30/23 or early morning of 10/31/23 as he/she was not assigned that hall, however the resident is always on the mat; -He/She did not tell the resident to be quiet or that he/she would have to stay on the mat. During an interview on 11/9/23 at 1:00 P.M. and 1:20 P.M., the Director of Nursing said the following: -She would not expect staff to ignore a resident's call light or request for help. She would expect staff to assist the residents when they request help; -Residents should not fear retaliation for voicing concerns or complaints. -She would expect staff to respond to resident's needs promptly; -She would not expect staff to tell a resident to be quiet, stay on the fall mat and then leave without assisting them back to bed, and had not heard of that happening; -It would be a dignity/respect issue if staff told a resident to be quiet, left them wet for extended periods of time or did not answer call lights timely. During an interview on 11/9/23 at 1:10 P.M., the Administrator said the following: -Residents should not fear any retaliation against them if they brought any concerns to any staff members; -He would find it unacceptable for any staff member to retaliate against a resident for voicing concerns. MO225143 MO227066 MO226198 MO226300 MO226124

Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and to communicate with outside agencies (e.g. sate surveyors) regarding any matter. Review of the facility's policy, Resident and Family Grievances, dated 9/2/22, showed the following: -The facility would support each resident's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; -The facility would not retaliate or discriminate against anyone who filed a grievance or participated in investigation of grievances. Review of the facility policy, Promoting/Maintaining Resident Dignity, revised 09/01/22, showed the following: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident' individuality; -When interacting with a resident, pay attention to the resident as an individual; - Respond to requests for assistance in a timely manner. 1. Review of confidential Resident #900's face sheet showed the resident was his/her own responsible party. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, showed the following: -Adequate hearing and clear speech; -Able to make self understood and able to understand others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:00 P.M., the resident said the following: -Staff do not come in and take care of him/her when he/she needed help; -He/She has complained to the management staff about the lack of response to his/her call light, and then the staff will take even more time to answer the call light. He/She has waited up to an hour for staff to come in and assist him/her; -He/She feels that staff will punish him/her for talking with the State Agency (SA) and the staff will take longer to answer the call light or refuse to give him/her medication; -He/She has tried to voice his/her concerns to management, but feels that nothing is done about these concerns and then staff will ignore him/her when he/she needs help; -He/She has filed grievances, but has not received any resolution to his/her grievances; -He/She needs help to get in and out of bed at times and help to use the bathroom. When he/she has complained about staff members to management, these staff members will then ignore him/her and refuse to help him/her. He/She has been told (specified staff member), if he/she talks with the SA or calls the abuse and neglect hotline, that he/she can look for another place to live. 2. Review of confidential Resident #700's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understands others; -Cognitively intact. During a confidential interview on 11/07/23 at 7:30 A.M., the resident said the following: -He/She feared repercussions from staff simply for talking to the SA; -He/She felt like the repercussions would be that staff would ignore him/her more than they already do, and that it will take a really long time to answer his/her call light now, longer than usual which was at times a really long time. 3. Review of confidential Resident #800's face sheet showed the resident was his/her own responsible party. Review of the resident's quarterly MDS showed the following: -Adequate hearing and clear speech; -Ability to make self understood and understood others; -Cognitively intact. During a confidential interview on 11/6/23 at 1:36 P.M., the resident said the following: -He/She would not complain due to real fear of retaliation from staff; -The retaliation was real, the resident would not explain, but turned his/her head away and would not talk further. 4. Review of Resident #10's face sheet showed an admitted [DATE]. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 9/25/23, showed the following: -Cognitively impaired; -Understood others and able to make others understand; -No behaviors or rejection of care; -Dependent on staff for bed mobility; -No falls in the last month prior to admission; -One non-injury and one injury fall since admission or prior assessment. Review of the resident's fall risk assessment, dated 10/30/23, showed he/she had had two falls in the last 30 days and was high risk for falls. Review of the resident's care plan, last revised on 10/30/23, showed the following: -History of traumatic event; -Further traumatization will be avoided; -Required assist of one staff for activities of daily living (ADL), including transfers; -Dependent on staff for meeting emotional, intellectual, physical and social needs; -Increased risk for falls due to impaired mobility and will throw self on the floor due to having a difficult time making needs known; -Low bed; -Fall mattress/mat next to bed when in bed; -Resident required prompt response to all requests for assistance. Review of a video/audio recording (received anonymously), date stamped 10/31/23, showed the following: -On 10/31/23 at 4:20 A.M., Resident #10 was observed on the floor by a confidential resident. Resident #10 can be heard saying, Can you help me get back into the bed, I rolled off the bed. Can you help me; -On 10/31/23 at 4:29 A.M., a video of a hallway with a male voice, repeatedly yelling out for help; -On 10/31/23 at 4:33 A.M., a female staff member observed standing at the doorway of Resident #10 and saying, I need you to stay on the mat and be quiet; the staff member was identified as Certified Nurse Assistant (CNA) H by a confidential resident. During an interview on 11/8/23 at 11:00 A.M., the resident said the following: -In the last two weeks, he/she fell out of bed, yelled for help and when unidentified staff initially arrived, they told him/her to be quiet and stay on the mat. He/She asked for help to get back into bed and the same unidentified staff refused to assist him/her. This made him/her feel helpless and upset. During interview on 11/7/2023 at 2:15 P.M. CNA H said the following: -He/She did not necessarily recall the resident being on the floor the night of 10/30/23 or early morning of 10/31/23 as he/she was not assigned that hall, however the resident is always on the mat; -He/She did not tell the resident to be quiet or that he/she would have to stay on the mat. During an interview on 11/9/23 at 1:00 P.M. and 1:20 P.M., the Director of Nursing said the following: -She would not expect staff to ignore a resident's call light or request for help. She would expect staff to assist the residents when they request help; -Residents should not fear retaliation for voicing concerns or complaints. -She would expect staff to respond to resident's needs promptly; -She would not expect staff to tell a resident to be quiet, stay on the fall mat and then leave without assisting them back to bed, and had not heard of that happening; -It would be a dignity/respect issue if staff told a resident to be quiet, left them wet for extended periods of time or did not answer call lights timely. During an interview on 11/9/23 at 1:10 P.M., the Administrator said the following: -Residents should not fear any retaliation against them if they brought any concerns to any staff members; -He would find it unacceptable for any staff member to retaliate against a resident for voicing concerns. MO225143 MO227066 MO226198 MO226300 MO226124

Based on observation, interview and record review, the facility failed to have a system in place for the administrator to ensure the facility van, used to transport residents to and from appointments including dialysis, was inspected and licensed for the safe and legal transport of residents. The facility had not paid personal property tax on the facility van for 2021 or 2022 and the van had not been inspected and licensed for two years. The van was not taken out of use and the facility continued to transport residents in the van including three residents (Resident #9, #11 and #12), of 12 sampled residents which the facility transported to dialysis. The administrator was not aware the facility van was not appropriately inspected or licensed until the van driver was ticketed by police for expired plates. The facility also failed to have a system in place for the administrator to ensure there were sufficient funds to disperse as a refund to one resident, (Resident #3). The facility issued the resident a refund check on [DATE] in the amount of $5460.00 which was returned due to insufficient funds. The facility census was 77. The Administrator was notified on [DATE] at 1:30 P.M of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility policy for Transportation dated [DATE] showed: -The community can assist with arranging and providing transportation for residents to and from medical appointments; -Should it become necessary for the facility to provide transportation, the Social Service Designee (SSD) or charge nurse (CN) will be responsible for the arranging of the transportation. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff dated [DATE] showed: -Alert and oriented and able to answer questions; -Extensive assistance of one staff member for Activities of Daily Living (ADLs); -Diagnoses of end stage renal disease (ESRD, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of the resident's Physician Order Sheet (POS) dated ,d+[DATE] showed an order for dialysis on Tuesday, Thursday and Saturday. During an interview on [DATE] at 2:00 P.M. Resident #9 said: -He/She goes to dialysis three days a week; -He/She used to use the facility van until this week, when he/she went on a Medicaid transport van on Saturday. 2. Review of Resident #11's quarterly MDS dated [DATE] showed: -Unable to answer questions appropriately or make decisions appropriately; -Extensive assistance of one staff member for ADLs; -Diagnoses of ESRD. Review of the resident's POS for ,d+[DATE] showed an order for dialysis Monday, Wednesday and Friday. Review of nurses notes dated [DATE] at 12:26 P.M. showed the resident to be transferred to a local hospital to under go dialysis. Resident lethargic, easy to arouse. Review of the nurses notes [DATE] at 10:23 P.M. showed resident returned back from the hospital at 7:00 P.M., no dialysis was done at the hospital. During an interview on [DATE] at 10:00 A.M. Resident #11 said: -He/she is more short of breath than he/she normally is; -He/she is suppose to have dialysis three times a week, but has not received any dialysis in a few days. 3. Review of Resident #12's quarterly MDS dated [DATE] showed: -Alert and oriented and able to answer questions appropriately; -Dependent upon two staff members for ADLs -Diagnoses of ESRD. Review of the resident's POS dated ,d+[DATE] showed an order for dialysis on Monday, Wednesday and Friday. 4. Observation on [DATE] at 12:30 P.M. showed the facility van parked in the parking lot with license plates dated 2021. During an interview on [DATE] at 3:55 P.M. the Administrator said the following: -She was made aware of the license plates being expired on [DATE] when an employee who drives the van received a ticket for expired plates; -She contacted the corporate office on [DATE] to see if they had received information on renewal of the license plates and she heard back from the corporate office today; -She was told that licensing the facility van was handled at the facility level; -She could not find an insurance card for the van, there was none in the van, she had contacted the corporate office for information on the insurance; -She checked the county assessor to see if the taxes had been paid for the year and found the taxes had not been paid for two years; -She had contacted the corporate office today for assistance on renewing the license plates; -The van has been transporting residents to appointments since the van driver received the ticket; -She will inform the Director of Nurses (DON) the van is not to be used and to find other transportation for the resident with dialysis and physician appointments. During an interview on [DATE] at 4:30 P.M. the DON said: -There were three residents who receive dialysis and one resident who had a wound doctor appointment; -She will work on finding other methods of transportation. During an interview on [DATE] at 10:00 A.M. the DON said: -Resident #9 receives dialysis on Tuesday, Thursday and Saturday. She was able to set up Medicaid transportation, and the resident will not miss any dialysis appointments. He/she went to dialysis on Thursday before the van was no longer able to be used; -Resident #11 is private pay and she has not been able to set up any transportation. The resident does not have any family that lives in the area to help with transportation. She had contacted the dialysis clinic for possible alternative placement for the resident; -Resident #12 receives dialysis on Monday, Wednesday and Friday and will miss one appointment, but Medicaid transportation has been set up and will start on Monday. During an interview on [DATE] at 8:00 A.M. the Medical Director said: -He was informed of the facility van being unlicensed on [DATE] and for his permission to send the residents via ambulance to dialysis if other transportation could not be found; -He has been told the facility owes transportation companies money and they will not transport until they receive payment. During an interview on [DATE] at 11:00 A.M. the Administrator said the van's insurance has been expired since December of 2022. She has notified the corporate offices to get the insurance updated. Observation on [DATE] at 9:00 A.M. showed the van parked at the facility with license plates dated 2021. During an interview on [DATE] at 9:00 A.M. the Administrator said: -The van was inspected on Monday, the checks were given to the county assessor on Monday, but there is a problem with the names on the van title and the personal property taxes. The names do not match, she has contacted the corporate office and they are trying to figure out the problem. The van was not in use. -Resident #11 has not had dialysis since last Friday. There was no transportation that will take him/her. The DON has contacted all outside transportation companies and no one will take the resident due to out standing bills that have not been paid by the corporation. During an interview on [DATE] at 9:15 A.M. the Medical Director said: -Resident #11 was sent to the hospital on [DATE] and should have received dialysis there, but did not; -The nursing staff need to monitor the resident closely for any signs of shortness of breath, if the resident displays any shortness of breath, then he/she needs to be sent back to the hospital; -The DON is trying to find someone to transport the resident, but is not having any luck as the facility owes money to transport companies and they will not transport. During an interview on [DATE] at 10:00 A.M. the Administrator said: -Resident #11 still has not had dialysis, she is working with sister homes to see if they can transport the resident if an appointment can be made for today. During an interview on [DATE] at 1:00 P.M. the DON said: -The dialysis provider the resident goes to does not have any appointments available for today. The physician has been contacted and if the resident develops shortness of breath, the resident is to go to a local hospital for treatment. 5. Review of the undated facility policy for Conveyance of Resident Funds showed: -Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death as applicable. -The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or tot he resident's estate (individual or probate jurisdiction per state), as applicable within thirty(30) days from the date of the resident's discharge from the facility or death. Review of Resident #3's medical record showed the resident was admitted to the facility on [DATE] and expired on [DATE]. During an interview on [DATE] at 10:50 A.M. the Administrator said the following: -She was informed on [DATE] by the prior Business Office Manager (BOM) Resident #3's refund check, dated for [DATE] in the amount of $5,460.00 had not cleared the bank; -The former BOM said he/she had contacted the corporate office and they were reissuing a check; -The new check should be at the facility in a week. During an interview on [DATE] at 9:20 A.M. the Corporate BOM said; -The first refund check that was issued [DATE] was returned due to insufficient funds; -The previous BOM contacted the corporate office and they re-issued a new check on [DATE] and that check was given to the family on [DATE]; -She is aware that refunds should be issued within 30 days. During an interview on [DATE] at 3:00 P.M. the Administrator said: -She expects bills to be paid in a timely manner by the corporation so the facility can provide services to the residents uninterrupted and per physician's orders; -She expects that when a refund check is issued it does not get returned for insufficient funds, that refunds are issued within the 30 day time frame. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious ,jeopardy level K. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO217264 MO217926

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), received his/her psychotropic medication (a medication used to treat psychosis or behaviors), per physician's orders and failed to communicate laboratory testing to the physician required to refill the medication. The facility also failed to administer the resident's insulin as ordered by the physician. As a result of these failures, the resident felt depressed and worthless. The resident left the facility without staff knowledge, walked along multi-lane roads including an interstate highway, to a grocery store. The resident relayed he/she planned to walk to the store to eat a meal and then walk out into oncoming traffic and commit suicide. The census was 77. The Administrator was notified on 5/5/23 at 1:30 P.M of the Immediate Jeopardy (IJ), which began on 5/4/23. The IJ was removed on 5/12/23 as confirmed by surveyor onsite verification. Review of the facility policy for Medication Reorder dated 9/21 showed: -It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biological's in a timely manner to meet the needs of the residents; -The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biological's in order to meet the needs of each resident; -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; -Each time a nurse is administering medications and observes six (6) or less doses left of one kind, that nurse will order the medication. Review of the facility policy for Laboratory Services and Reporting dated 9/21 showed: -The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law; -The facility must provide or obtain laboratory services to meet the needs of its residents; -All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record; -Promptly notify the ordering physician, physician assistance, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Review of Resident #1's Level One Prescreen Form (a pre-admission screening form to determine if a resident has a series mental illness and is appropriate for nursing home placement), dated 7/21/21, showed the resident rarely or never had the capability to make decisions or displays consistent unsafe/poor decision making or requires total supervision requiring reminders, cues or supervision at all times. Review of the care plan for psychotropic medication dated 6/16/22 showed the following: -The resident received psychotropic medications, had diagnosis of bipolar (a brain disorder that causes changes in a person's mood, energy, and ability to function) and schizophrenia (a serious mental disorder in which people interpret reality abnormally); -The resident will be/remain free from psychotropic drug related complications; -Administer medication as ordered by the physician, monitor for side effects and effectiveness; monitor/record occurrence of target behavior symptoms such as pacing or wandering; -The resident has diabetes. He/She receives daily insulin; -The resident will have no complications related to diabetes; -Monitor blood glucose per physicians orders; diabetes medication as ordered by the physician; -Monitor/document for side effects and effectiveness. Review of the resident's care plan addressing depression dated 4/17/23 showed: -The resident uses antidepressant medication related to depression; -The resident will be free from discomfort or adverse reactions related to antidepressant therapy; -Administer medication as ordered by the physician. Monitor/document side effects and effectiveness; -Monitor/document/report as needed adverse reactions to antidepressant therapy such as change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal. Review of the Brief Interview for Mental Status (BIMS, an evaluation used to determine level of orientation) dated 3/29/23, showed the resident scored a 7, indicating the resident had severe cognitive impairment. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff dated 4/15/23 showed: -Alert and oriented and able to answer some questions appropriately; -No wandering or behaviors; -Mood: Has trouble falling asleep, feeling tired daily, trouble concentrating daily with a mood severity code of 8, (mild depression); -Independent with ambulation, and required oversight when off the unit; -Diagnoses included depression, bipolar disorder and schizophrenia. Review of the resident's physician orders sheet (POS) dated April 2023 showed: -Humulin N Kwik Pen (a medication for diabetes), subcutaneous (sub q, under the skin) 100 Units/ml (milliliters), inject 30 units daily with a start date of 4/18/23; -Glargine Insulin (a medication for diabetes), 100 units/ml, inject 15 units sub q daily with a start date of 3/13/23; -Admelog Solostar (a medication for diabetes), 100 units/ml inject per sliding scale; -Clozapine 100 mg, take three tablets at bedtime (HS), (review of the website Drugs.com showed Clozapine is an antipsychotic medication that works by changing the actions of chemicals in the brain. Clozapine is used to treat schizophrenia in adults after other treatments have failed. Clozapine is also used to reduce the risk of suicidal behavior in adults with schizophrenia or similar disorders. Frequent medical tests are necessary while using this medication. Clozapine should not be suddenly stopped. It is important to follow the physician's dosing instructions very carefully. If a dose is missed for more than two days in a row, call the physician before taking the medication again. Get the prescription refilled before you run out of medicine completely. A mandatory requirement for use includes regular monitoring of white blood cell count and absolute neutrophil count (white blood cell count). Review of the resident's Medication Administration Record (MAR) dated April 2023 showed: -Clozapine 100 mg, give 3 tablets at HS documented as not given on 4/10/23, 4/15/23, 4/28/23, 4/29/23 and a 9 documented on 4/30/23, indicating to check nurses notes and documented as medication was not available; -Glargine solution 100 units/ml give 15 ml at HS documented as not given on 4/12/23, 4/15/23, 4/16/23, 4/27/23 and 4/28/23; -Humulin N KwikPen sub q 100 units/ml, give 25 units at HS documented as not given on 4/1/23, documented as not available on 4/11/23, not documented as given on 4/12/23 and discontinued on 4/17/23; -Humulin N Kwik Pen sub q 100 units/ml given 30 units sub q at HS with a start date of 4/18/23 documented as not available on 4/28/23. Review of the nurses notes dated 4/1/23 through 4/30/23 showed no documentation of physician notification or why staff did not administer the Clozapine or the insulins as ordered. Review of the resident's MAR dated May 2023 showed Clozapine 100 mg, give three tablets at HS documented with a 9 on 5/1/23 and 5/2/23 with no documentation in the nurses notes as to why staff did not administer the medication. Review of the resident's nurses notes dated 5/2/23 at 3:18 P.M. signed by Licensed Practical Nurse (LPN)/Unit Manager (UM) A, showed the resident's Clozapine to be delivered once recent labs are sent to pharmacy as they are needed in order to refill medication; will be sent to them per physician's nurse. Observation of the medication cart on the locked behavior unit on 5/4/23 at 3:00 P.M. with LPN C showed: - Humulin N Kwik Pen 100 units/ml, give 30 units at HS dated filled on 4/26/23 with 90 ml left in the pen; - Glargine solution 100 units/ml give 15 ml at HS, with 3 ml's in the pen, dated 4/19/23 as filled, the pen was full - There was no Clozapine medication on the cart. During an interview on 5/4/23 at 3:15 P.M. Pharmacist A said: -He/She is the pharmacist who fills the resident's medication; -The pharmacy last sent Clozapine 100 mg on 3/20/23. The pharmacy only sends one card of the medication at a time for a 30 day supply of the medication as the medication required blood work to be done before the medication can be refilled. The pharmacy had not received any lab work or physician authorization for the medication to be filled. -The pharmacy had not received any communication from the facility for the need of the medication to be refilled; -The pharmacy computer will indicate when the physician has given the approval to fill the Clozapine; -The Glargine insulin was last refilled on 4/19/23 for a 20 day supply, half of this medication should have been used out of the prefilled pen; -Humulin N Kwik Pen was last filled on 4/26/23 for a 10 day supply, there should only be very little left in the prefilled pen. During an interview on 5/4/23 at 2:00 P.M. the Family Member (FM) A said: -The resident has bipolar disorder and has been suicidal in the past. The resident takes Clozapine for this. The resident told him/her, he/she had not received the Clozapine for over a week. The resident also said he/she had not been getting his/her insulin; -He/She talked with someone at the facility and was told the Clozapine had not been refilled and the resident had not received the medication. During an interview on 5/4/23 at 3:30 P.M. Licensed Practical Nurse (LPN)/Unit Manager (UM) A said: -He/She passed medications on 5/2/23 and did not find any Clozapine on the medication cart to give to the resident; -He/She called the pharmacy and was told they were waiting on the necessary lab work and the approval from the physician to refill the Clozapine; -He/She called the physician's office and they said they had received the necessary lab work earlier and was sending the approval to the pharmacy; -He/She gave the resident a shower earlier in the day on 5/2/23, the resident seemed upset and unhappy. The resident said staff did not care about him/her and that he/she felt depressed; -He/she knew the resident needed his/her blood sugar checked before lunch on 5/3/23, but could not find the resident; -The resident was found at a local grocery store and brought back by the police. He/she was sent to the hospital for evaluation. During an interview on 5/4/23 at 3:30 P.M., LPN B said: -He/she was told on 5/3/23 the resident could not be found; -He/She and another staff member got into a car and drove to a local grocery store and found the resident in the grocery store diner with the local police; -The resident was very upset and crying; -The local police brought the resident back to the facility; -The resident said he/she was very unhappy, he/she had not been getting his/her medication and did not want to be at the facility any more. The resident felt staff did not care about him/her. Review of the resident's local psychiatric hospital admission notes dated 5/3/23 showed the resident presents from the emergency room from the nursing home. The resident was sent due to suicidal ideation. The resident said he/she was going to walk in front of a vehicle because he/she had been neglected at the nursing home. The resident said he/she has not been getting his/her psychiatric medications as prescribed. Review on 5/10/23 at 11:00 A.M. of the resident's discharge orders dated 5/9/23 from the local psychiatric hospital showed an order for Clozapine 300 mg at HS. During an interview on 5/10/23 at 10:36 A.M. the resident said the following: -He/She came back to the facility (following hospitalization ), on 5/9/23 around 3:00 or 4:00 P.M. and he/she did not receive his/her Clozapine last night; -He/She had not been receiving the Clozapine prior to going to the hospital; -He/She did not feel anyone would miss him/her as they did not care if he/she got his/her medication; -He/She had walked out the front door and crossed the street to get to the interstate, he/she walked along the interstate trying to get a ride. When no one picked him/her up, he/she walked up the interstate to the next exit and crossed over the over pass and went into a local grocery store that had a diner. He/She got something to eat. He/She was going to wait until the store closed, then walk out in front of a car because no one at the facility cared about him/her. Observation on 5/10/23 at 11:00 A.M. of the medication cart on the locked behavior unit showed no Clozapine. During an interview on 5/10/23 at 11:00 A.M. LPN/UM A said: -The resident had an order for Clozapine 300 mg at HS from the hospital; -He/she did not know why the medication was not delivered; -He/she called the pharmacy and ordered the medication. During an interview on 5/10/23 at 2:00 P.M. the Director of Nursing said: -The resident had a standing order for a Complete Blood Count (CBC) to be done weekly for the use of Clozapine; -In March the facility changed laboratory companies and the pharmacy can no longer see the lab work on the electronic medical record, the nurses have to fax the pharmacy the blood work. She cannot find where the latest blood work was sent to the pharmacy or the physician; -She would expect the nurses to send the laboratory findings to the physician for review and then send to the pharmacy for the medication to be filled; -She would expect the nurses to reorder the medication when needed and to call the pharmacy when the medication is not delivered. During an interview on 5/11/23 at 3:00 P.M. the Administrator said: -Resident #1 had exited the facility without staff knowledge on 5/3/23; -The resident was upset because he/she had not been receiving his/her medication, felt that no one would miss him/her and no one would care that he/she was gone; -She would expect the nurses to administer medication as prescribed by the physicians or the psychiatrist; -She would expect the staff to send lab work to the physician for review. During an interview on 5/4/23 at 12:30 P.M. and 5/5/23 at 8:00 A.M. Physician A said: -He was the resident's physician; -He had been made aware the resident had left the facility unattended and unknown to the staff and the resident had been admitted to a psychiatric hospital; -He was not aware the resident's Clozapine had not been given as ordered; -Clozapine was a very dangerous medication, it is not a medication that should be disrupted or altered; -The resident and other residents had told him they had not been receiving their medication as ordered; -He would expect the facility administer medication as ordered by the physician and psychiatrist, and obtain any necessary lab work to continue a medication. He would also expect the facility to notify a physician or the psychiatrist when a resident misses their medication. -If the medication is not administered as it is ordered, it could lead to depression and suicidal thoughts. MO217921 MO217937 MO217945 MO217698 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious ,jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to protect one resident (Resident #2) from staff verbal abuse of 12 sampled residents. The resident was in pain and requested ordered pain medication. Licensed Practical Nurse (LPN) D yelled and cursed at the resident and called the resident a dope head and drug seeking in front of other residents. The resident reported LPN D's actions made him/her feel humiliated and embarrassed. The facility census was 77. Review of the facility policy for Abuse, Neglect and Exploitation dated 9/1/21 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition of Verbal Abuse - means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/26/23 showed: -Alert and oriented and able to answer questions; -Able to make self understood and able to understand others; -Vision and hearing is adequate; -Independent with mobility, requires assistance of one staff member for dressing, personal hygiene and toilet use; -Diagnoses of heart failure. During an interview on 5/4/23 at 2:00 P.M. the Administrator said she had been informed on 4/27/23 by Licensed Practical Nurse (LPN) B the resident was upset. She went to the resident and the resident told her that on 4/25/23 on the evening shift, he/she had asked LPN D several times for his/her pain medication. The staff on the evening shift could not find LPN D and when they did, LPN D came to his/her room and began yelling at the resident and using curse words towards the resident. Other staff members heard LPN D verbally abusing the resident and removed LPN D from the resident's room. During an interview on 5/4/23 at 3:20 P.M. LPN B said the following: -He/she was doing a treatment on the resident's leg 4/27/23 on the day shift, when the resident told him/her that he/she was very upset that no one had come to speak with him/her about LPN D from a couple of nights ago; -The resident said he/she was in pain and needed a pain pill, staff could not find LPN D, and when they did, LPN D came into his/her room and began to yell and scream at him/her. LPN D called the resident drug seeking. He/She felt verbally abused and humiliated. Other residents over heard this as well; -Certified Medication Technician (CMT) B came and told LPN D to leave the resident's room. During an interview on 5/5/23 at 2:10 P.M. CMT B said the following: -LPN D had been leaving the facility several times on the evening shift on 4/25/23; -CMT B was passing the bedtime medications on 4/25/23 around 7:00 P.M. when Resident #2 asked for a pain pill; -He/She did not have the particular medication on the medication cart, this was on the nurse's cart; -He/She could not find LPN D in the facility. Another staff member went outside to find LPN D and when LPN D came back into the building, he/she went to the resident's room and began to yell and curse at the resident. LPN D called the resident a drug seeker and a dope head; -CMT B told LPN D this was inappropriate and to give the resident a pain pill. The nurse finally gave the resident a pain pill around 9:00 P.M.; -The resident was angry and upset by the incident. During an interview on 5/5/23 at 2:45 P.M. the Activity Director said the following: -He/She was working the evening shift on 4/25/23. LPN D would disappear and staff would have to go out to his/her car and tell him/her to come into the facility; -Around 8:45 P.M. Resident #2 wanted a pain pill, LPN D could not be found; -A staff member went outside and LPN D was in his/her car, the staff member told LPN D he/she needed to come in and give the resident a pain pill; -LPN D came into the facility and began yelling and told the resident it was not time for his/her pain pill, then proceeded to yell at the resident that he/she was a drug seeker and a dope head; -He/she told LPN D to lower his/her voice and not to use the words that he/she was using. During an interview on 5/5/23 at 2:15 P.M. LPN E said: -He/She was the nurse on the 300 hall on the night of 4/25/23; -He/She overheard a commotion on the 100 hall after supper where Resident #2 resides but could not understand what was being said, the voices were loud and angry; -CMT B came and asked if he/she could give the resident a pain pill after supper and he/she could not get into LPN D's medication cart, he/she did not have the key; -LPN D had taken several long breaks that evening and was difficult to find; -LPN D came in from outside and gave the resident a pain pill around 9:00 P.M. During an interview on 5/5/23 at 11:30 A.M. Resident #2 said the following: -On 4/25/23 on the evening shift, he/she had asked CMT B for a pain pill. The CMT said a nurse had to give the pain pill. He/She waited a long time, then rang his/her call light again for the pain pill. CMT B said LPN D was in the facility, he/she would go find him/her; -The resident said the pain was an 8 out 10, with 10 being severe pain; -When LPN D came to his/her room, Resident #2 was in pain, LPN D began to yell and curse at him/her calling him/her drug seeking and left his/her room; -He/She got out of bed and went out into the hallway. LPN D was talking with another resident about him/her and saying that he/she was always asking for a pain pill, that he/she was drug seeking and a dope head. He/She yelled at LPN D and said I want my pain pill now. LPN D yelled at him/her that he/she did not need the pills. He/She yelled at LPN D again, I want my pain pill. CMT B came and told LPN D to leave the resident alone and get his/her pain medication. Finally LPN D got his/her pain medication; -He/she felt humiliated by what LPN D said and was embarrassed other residents heard what LPN D said about him/her. During an interview on 5/12/23 at 4:00 P.M. the Administrator said: -She considered the incident with Resident #2 verbal abuse; -She would expect the staff to talk calmly with the residents and not to yell and scream at residents. MO217645

Based on observation, interview and record review, the facility failed to ensure a system was in place for the administrator to have knowledge of, and access to payment status and funds for essential services, including Internet service and trash service, to ensure there is no disruption in services. The facility's Internet bill had not been paid. This caused a disruption in Internet service from approximately 5:00 P.M. on 12/13/22 until 1:00 P.M. on 12/14/22. As a result, staff were unable to access the facility's electronic medication administration records (only accessible with Internet service), and failed to administer morning medications on 12/14/22 to at least 27 residents as a result of non-payment for the service. The administrator was without access to funds to prevent a disruption of services including Internet and trash disposal. The facility census was 104. The administrator was notified on 12/14/21 at 7:07 P.M. of the Immediate Jeopardy (IJ), which began on 12/13/22. The IJ was removed on 12/15/22, as confirmed by surveyor onsite verification. Review of the facility's Emergency Procedure - Utility Outage policy, dated August 2018, did not include how the facility would address issues if there was loss of Internet services (services that enable the facility to access resident's medical records and ability to administer medications). 1. During an interview on 12/13/22 at 1:40 P.M., the Business Office Manager (BOM) said the following: -If he/she received a bill at the facility he/she sent it to the third party billing company for payment; -He/She had gotten late notices for nonpayment for the electric bill, trash pickup and for linen purchases. He/She sent those notices to the third party billing company; -12/7/22 was the last time the trash was picked up at the facility. Trash disposal services quit picking up the trash because of non-payment for service. During an interview on 12/14/22 at 1:35 P.M. and 5:15 P.M., the administrator said the following: -The facility was without Internet service, but it was working now. Internet service went out between 4:30 P.M. - 5:00 P.M. on 12/13/22. She had Medication Administration Records (MARs) printed for the staff and some of the staff used their personal hotspots (a feature on a wireless device used to connect to the Internet) to connect to the Internet so they could give medications; -On the evening of 12/13/22 she was on the phone with the facility's Information Technology (IT) company to find out the problem with the Internet, they told her it was technical difficulties; -Today (12/14/22), when the Internet was still not working after 12:00 P.M. and not all staff had hotspots, Corporate Nurse H called a sister facility to get MARs printed for today; -At 9:50 A.M. Corporate Nurse H called her and told her a sister facility was printing MARs for the staff; -The administrator arrived at the sister facility to pick up the MARs between 11:00 A.M. and 11:30 A.M., at 11:05 A.M. she got a call from the IT company telling her the Internet was up and running; -The facility had difficulty getting the Internet rebooted and running. The facility did not have access to the Internet until about 1:00 P.M. on 12/14/22; -She did not have all MARs printed yesterday (12/13/22) for today (12/14/22) because she anticipated that the Internet would be working; -The BOM sends a copy of the bills for her to sign off on to be paid, through a messaging system. She signs off on them and forwards them on to the corporate office and she doesn't know what happens after that; -If she gets a disconnect notice she sends it to the corporate office and they send it to the third party billing company; -She does not have access funds to pay any of the bills for the facility, everything goes through the third party billing company. During an interview on 12/14/22 at 2:17 P.M., Resident #5 said he/she had not gotten any of his/her medications yet for the day. During an interview on 12/14/22 at 2:35 P.M., Certified Medication Tech (CMT) E said the following: -He/She was responsible for the 300 hall and there were 27 resident that had not had their medicine; -He/She could not pass medications to the residents since the beginning of his/her shift (7:00 A.M.), because the Internet was not available and he/she did not have a hotspot to access it; -He/She was given paper MARs at 1:30 P.M. to be able to administer medications. During an interview on 12/14/22 at 2:40 P.M., CMT I said the following: -He/She was responsible for the 400 and 500 halls and there were some residents that got their medications, but not all of them; -He/She used another employees hotspot to access the Internet, but he/she did not have a hotspot and could not finish passing medications. During an interview on 12/14/22 at 3:04 P.M., Licensed Practical Nurse (LPN) F said there were some residents that did not get their insulin because he/she could not access their electronic MARs. During an interview on 12/14/22 at 4:31 P.M. Corporate Nurses A and B said the following: -After making a phone call they found out the disruption in Internet service was due to non-payment; -Because of the third party billing company the facility used, the facility did not see all the bills; -The facility was having problems with the third party billing company paying the facility bills; -The BOM did not notify the administrator or the corporate office of past due notices; -The facility had never received an aging report (a record of overdue invoices from a specific time period that is used to measure the financial health of a company) from the third party billing company. Observation on 12/14/22 at 1:27 P.M. showed three trash dumpsters at the back of the building. All three were overflowing with waste, so much so the lids could not close. There was a heaping pile of trash bags to the side of a dumpster and cardboard boxes piled to the side of another dumpster. During an interview on 12/14/22 at 2:45 P.M., the Dietary Manager said: -The facility trash has not been picked up from approximately 12/7/22 through 12/14/22; -Trash was piled around and above the dumpsters. Dietary staff take kitchen trash bags out and place them on the existing pile. During an interview on 12/14/22 at 3:00 P.M., the Maintenance Director said: -Facility trash was picked up on Monday, Wednesday and Friday of each week; -The trash company has not picked up facility trash since 12/7/22; -Trash piled outside created an opportunity for attracting rodents to the area. During an interview on 12/14/22 at 4:15 P.M., the trash company representative said the facility did not have trash picked up because of non-payment for the service. During an interview on 12/21/22 at 4:18 P.M., the medical director said the following: -The facility had a lot of problems with non-payment with vendors such as laboratory and imaging; -His physician group had a meeting with the facility's chief operating officer (COO) to address the issues of non-payment to vendors; -He did not have sufficient resources available when trying to provide care for the residents when the facility did not pay their vendors; -He was very frustrated he did not hear from the facility on 12/14/22 until 4:30 P.M. about residents missing morning medications. He should have been notified immediately. MO208894 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy (IJ) level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure one resident (Resident #2), received all of his/her physician ordered medications in a review of 14 residents. Resident #2, with a diagnosis of seizures (abnormal electrical activity in the brain that happens quickly), did not receive his/her evening and/or bedtime medications on his/her day of admission (10/28/22) and did not receive any medications on 10/29/22 including the medication Keppra (medication used to control seizures). The resident became unresponsive and was sent to the hospital in a postictal state (a period that begins when a seizure subsides and ends when the patient returns to baseline) and had to be emergently intubated. The resident had physician orders for medication to prevent seizures and the facility did not have the medication available for administration. The resident missed three total doses of scheduled antiseizure medication. The facility census was 104. The Administrator was notified on 12/12/22 at 1:20 P.M. of the Immediate Jeopardy (IJ), which began on 10/28/22. The IJ was removed on 12/12/22, as confirmed by surveyor onsite verification. Review of the facility's Medication Reconciliation policy, revised 4/7/22, showed the following: -Medication reconciliation refers to the process of verifying that the resident's current medication list matches the medical provider's orders for the purposes of providing the correct medications to the resident at all points throughout his/her stay; -Medication reconciliation involves collaboration with the resident/resident representative and multiple disciplines, including admission liaisons, licensed nurses, medical providers, and pharmacy staff; -Pre-Admission Process: obtain current medication list from the referral source (hospital, home health, hospice or primary care provider), obtain current medication/admission orders, forward to the nursing unit accepting the resident; -Admission Process: compare orders to hospital records, etc. obtain clarification orders as needed, transcribe orders in accordance with procedures for admission orders, order medications from the pharmacy in accordance with facility procedures for ordering medications, obtain a home list of medications from the resident/resident representative. Place on chart for the medical provider to review and revision of medication regimen, if warranted. Review of the facility's Medical Provider Orders policy, revised on 4/7/22, showed the following: -The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order; -If using electronic medication records, input the medication and/or treatment order according to the electronic health record instruction and facility policy; -Validate the new order in the electronic medication administration record and treatment administration record; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -Written transfer order (sent with a resident by a hospital or other health care facility) should be implemented without further validation if it is signed and dated by the resident's current attending medical provider. 1. Review of Resident #2's undated face sheet showed the following: -The resident admitted to the facility on [DATE] from the hospital; -The resident was his/her own responsible party; -The resident's pharmacy was the pharmacy used by the facility; -The resident had diagnoses that included metabolic encephalopathy (damage or disease from another health condition that affects the brain and can lead to an altered mental state and confusion), autistic disorder (a complicated condition that includes problems with communication and behavior), seizures, and mild intellectual disabilities. Review of the resident's hospital discharge summary list of medications, dated 10/28/22, included the following: -Keppra (used to prevent seizures) 750 milligram (mg) tablet, take one tablet by mouth two times daily for seizures; -Guanfacine (used to treat high blood pressure) 2 mg tablets, take one tablet by mouth two times daily; -Nadolol (used to treat high blood pressure) 80 mg tablet, take one table by mouth daily; -Tizanidine (muscle relaxant) 4 mg tablet, take one tablet by mouth every eight hours; -Diazepam 5 mg tablet, take one tablet by mouth two times daily. Administer in the morning and at lunch time; -Diazepam 10 mg tablet, one tablet by mouth daily at bedtime; -Lamotrigine (used to treat seizures) 150 mg tablet, take one tablet by mouth daily; -Polyethylene glycol 17 gram powder in packet, take one packet by mouth daily; -Seroquel (used to treat mental/mood disorders) 200 mg tablet, take one tablet by mouth three times daily; -Temazepam (used for insomnia) 15 mg capsule, take one capsule by mouth daily at bedtime; -Melatonin (used for insomnia) 5 mg tablet, take one tablet by mouth daily at bedtime; -Note to stop taking fluconazole (an antifungal medication) 150 mg tablet. Review of the resident's hospital discharge summary dated 10/28/22, showed the following: -The resident was non-verbal at baseline; -The resident had been in the hospital from 10/6/22 - 10/28/22 for neuroleptic malignant syndrome (life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs); -The records also showed medication adjustments to control the resident's seizures; -He/She had not had any recent seizures on Keppra 750 mg twice daily and Lamotrigine 150 mg daily; -His/Her discharge condition was stable with a good prognosis. Review of the resident's undated physician order sheet showed the following: -The resident was admitted on [DATE]; -Diazepam 10 mg give one table by mouth at bedtime for anxiety, start date was 10/29/22; -Diazepam 5 mg give one tablet by mouth two times a day for anxiety, start date was 10/29/22; -Fluconazole tablet 150 mg, give one tablet by mouth one time a day every seven days for infection for four weeks until finished, start date was 10/29/22; -Guanfacine HCI tablet 2mg, give 2mg by mouth two times a day for hypertension (high blood pressure), start date was 10/29/22; -Hydroxyzine HCl 25 mg, give two tablets by mouth every eight hours as needed for anxiety and itching, start date was 10/29/22; -Lamotrigine 150 mg tablet, give one tablet by mouth one time a day for seizures and bipolar disorders, start date was 10/29/22; -Nadolol 80 mg tablet, give one tablet by mouth one time a day for hypertension, start date was 10/29/22 (This same order was listed three times on the physician order sheet); - Seroquel 200 mg, give one tablet by mouth every eight hours for schizophrenia, bipolar disorder and depression, start date was 10/29/22; -Temazepam 15 mg capsule, give one capsule by mouth at bedtime for insomnia, start date was 10/29/22; -Tizanidine 4 mg tablet, take one tablet by mouth every eight hours as needed for muscle spasm, start date was 10/29/22; -Tizanidine 4 mg tablet, take one tablet by mouth three times a day for muscle relaxant, start date was 10/29/22 (This same order was listed two times on the physician order sheet); -No order for Keppra. Review of the resident's medication administration record (MAR), dated October 2022, showed the following: -Diazepam 10 mg tablet, give one tablet by mouth at bedtime for anxiety. Start date was 10/29/22, the MAR showed 6 (hospitalized ) on 10/29/22, 10/30/22 and 10/31/22; -Diazepam 5 mg tablet, give one tablet by mouth two times a day for anxiety. The start date was 10/29/22, the MAR showed 9 (other/see progress notes) on 10/29/22, 10/30/22 and 10/31/22; -Diazepam solution 1mg/1ml, give 5 ml by mouth every four hours as needed for anxiety, start date was 10/29/22 and the boxes for 10/29/22, 10/30/22 and 10/31/22 were blank; -Fluconazole 150 mg tablet, give one tablet by mouth one time a day every seven days for infection for four weeks until finished. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Lamotrigine 150 mg tablet, take one tablet by mouth one time a day for seizures and bipolar disorders. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Nadolol 80 mg give one tablet by mouth one time a day for hypertension. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; (This same order was on the MAR three times. One to be given at 7:00 A.M. and two orders to be administered at 8:00 A.M.) -Temazepam 15 mg, give one capsule by mouth at bedtime for insomnia. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Guanfacine 2 mg tablet, give 2 mg by mouth two times a day for hypertension. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Seroquel 200 mg tablet, give one tablet by mouth every eight hours for schizophrenia, bipolar disorder and depression. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Tizanidine 4 mg tablet, give one tablet by mouth every three times a day for muscle relaxant. The start date was 10/29/22, the MAR showed 9 on 10/29/22, 10/30/22 and 10/31/22; -Benadryl Allergy 25 mg capsule, give one capsule by mouth every six hours as needed for allergies, start date was 10/29/22 and the boxes for 10/29/22, 10/30/22 and 10/31/22 were blank; -Hydroxyzine HCl (used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg tablet, give two tablets by mouth every eight hours as needed for anxiety and itching, start date was 10/29/22 and the boxes for 10/29/22, 10/30/22 and 10/31/22 were blank; -No documentation staff administered Keppra. Review of the facility's medication inventory for the Pyxis (an automated medication dispensing system), dated 12/15/22, showed the following: -A quantity of 10 Seroquel 25 mg tablets were available; -There were no other medications available that the resident was ordered to receive. Review of the resident's progress notes, dated 10/28/22 at 9:20 P.M., showed the following: -The resident was admitted to the facility from the hospital; -The resident did not respond verbally to any questions Licensed Practical Nurse (LPN) D asked during his/her assessment of the resident; -It was reported to LPN D that the resident was trying to get out of bed. Review of the resident's progress notes, dated 10/29/22, showed the following: -At 7:56 A.M., the resident was very agitated. The resident couldn't stay in his/her bed or wheelchair and was always wandering around the room and unit with an unsteady gait requiring one on one supervision. The Director of Nurses (DON) was made aware of the resident's state. The resident kept yelling for help, one on one care provided this shift; -At 8:02 A.M., the resident required one on one care, he/she was agitated and wandering the hallway with unsteady gait. The resident was constantly trying to roll out of bed. One on one care was provided and the resident calmed down; -At 8:22 P.M., LPN P charted that at approximately 7:00 P.M. the resident was in the dining room slouched over in a chair. The LPN assessed the resident, the resident did not respond to verbal or physical stimuli. The LPN called 911 and the resident was transported to the hospital and the nurse practitioner was made aware; -There was no documentation correlated to the MAR as to why the resident did not receive medications scheduled for 10/29/22. Review of the resident's hospital records, dated 10/29/22 and 10/30/22 showed the following: -The resident was admitted to the emergency room (ER) on 10/29/22 at approximately 7:40 P.M.; -The nursing home staff could not provide any information about the resident or if he/she had missed any medications -The resident was very positictal and confused; -Given the resident's underlying issues the physician anticipated it would take him/her quite some time to return back to baseline and it may warrant admission for prolonged postictal state; -The resident had seizure activity in the emergency room and had to be intubated (a tube inserted into the resident's trachea to keep it open so air can get through); -The resident's Keppra levels were less than two micrograms (mcg)/ml and the normal range is 10.0 - 40.0 mcg/ml; -The resident was in the Intensive Care Unit (ICU) where his/her seizure medications were restarted and no more seizures were witnessed; -The likely cause of the resident's seizures was from not taking his/her medication. During an interview on 12/7/22 at 2:18 P.M., the resident's guardian said the following: -The resident's seizures were under control before he/she left the hospital and was admitted to the facility on [DATE]; -The only seizures the resident had in the past was when he/she did not get his/her medication; During an interview on 12/6/22 at 1:03 P.M., 12/12/22 at 2:14 P.M., LPN D said the following: -He/She was the admitting nurse for the resident; -It is the responsibility of the admitting nurse to enter all orders and medications for the new resident; -He/She got the medication list from the resident's hospital records; -He/She called the facility family nurse practitioner (FNP) and went over the resident's medications; -He/She must not have seen Keppra on the hospital records, so it did not get on the resident's MAR; -The facility did not have a Pyxis to pull medications from at the time the resident was admitted to the facility. During an interview on 12/8/22 at 2:49 P.M. LPN P said the following: -The resident wandered the hallways on his/her shift; -He/She was checking on other residents and went back to the dining room and found the resident unresponsive and unable to sit up in the chair; -He/She did not take any vital signs on the resident because the cart was down the hall. The resident was breathing and had a pulse. LPN P stayed with the resident until the emergency medical services (EMS) arrived; -When the EMS arrived they took the resident's vital signs, assessed him/her and then took the resident to the hospital. During an interview on 12/7/22 at 9:15 A.M. and 12:23 P.M. and 12/8/22 at 2:42 P.M., the DON said the following: -It was LPN D's responsibility to enter the resident's order and verify them with the physician; -She would expect LPN D to chart if he/she verified the medications with the physician; -The resident's medications had probably not been reviewed by another nurse; -The staffing coordinator was on call the weekend the resident was admitted and she isn't qualified to review medications because she is not a nurse; -Ultimately it would have been her responsibility to check the medications of the new admit, but it did not get done. During an interview on 12/7/22 at 3:45 P. M., the administrator said the following: -It was the responsibility of the weekend nurse manager to check orders for new admits; -If medications were not available in the Pyxis the staff should call the physician for new orders; -She would have expected staff to administer the resident's medications when they arrived from the pharmacy at 3:27 P.M. on 10/29/22; -She did not know why it took so long for the resident's medication to arrive to the facility. During an interview on 1/9/23 at 2:26 P.M. the Pharmacy Director (from the pharmacy the facility utilized for medication deliveries) said the following: -The facility did not start processing orders for the resident until approximately 3:30 A.M. on 10/29/22; -The pharmacy did not start processing the orders for the resident until 8:00 A.M. on 10/29/22; -The pharmacy makes deliveries Monday -Friday at noon and 7:00 P.M. and Saturday and Sunday at 3:00 P.M.; -If the facility needed medication after hours (7:00 P.M. Monday - Friday) they have been in-serviced to put the orders in their electronic medication administration program and then call the pharmacy number to let them know they need the medications stat. The pharmacy would usually get the medications to the facility within four hours. If it was medications that needed a physician approval, the pharmacy would call the physician and get the approval for the medications for the stat order; -Even if the facility Pyxis did not have the medications available there should have been an emergency kit with medications available for the resident. During an interview on 12/21/22 at 4:18 P.M., the Medical Director said the following: -He is finding out way later about new admissions than he would like. He would like to be notified when the facility is anticipating a new resident's arrival so he can be better prepared to meet their needs and medication needs; -He was very frustrated that he was not notified about the resident and not having medications available for him/her. -In this instance his team should have heard about it immediately; -He needed to know about emergent issues immediately, not hours later; -He said clinically if there was a lag of starting medications for the resident it would have contributed to him/her having a seizure at the facility; -The resident didn't have protection he/she needed because the facility did not have his/her medications available. MO209255 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to properly identify and treat a deep tissue injury for one resident (Resident #3), who was at risk for developing pressure ulcers, in a review of 18 sampled residents. The facility census was 92. Review of the facility's policy, Pressure Injury Prevention and Management, revised 3/3/22, showed the following: -This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate; -After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Review of the National Pressure Injury Advisory Panel (NPIAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Injury Advisory Panel 2019 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual 3.0, Version 1.17.1, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue) or bruising. May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. May adhere to the base of the wound or present in clumps throughout the wound; -Eschar: dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissues and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. 1. Review of Resident #3's face sheet showed the following: -Diagnoses include: diabetes mellitus (a group of diseases that result in too much sugar in the blood), COVID-19 (1/18/23), peripheral vascular disease/PVD (a systemic disorder that involves the narrowing of peripheral blood vessels) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's weekly skin check, dated 12/27/22, showed no open areas noted and skin intact with no new wounds identified (there were no previous wounds noted). Review of the resident's January 2023 physician order sheet (POS) showed a treatment order for skin prep wipes (a topical skin protectant), apply to both heels and left ankle every day and evening shift; order date of 5/27/22. No indication of a treatment for the resident's buttocks or coccyx (also known as the tailbone, a triangular arrangement of bone that makes up the very bottom portion of the spine). Review of the resident's January 2023 treatment administration record (TAR) showed the following: -A treatment of skin prep wipes, apply to both heels and left ankle every day and evening shift; -No indication of a treatment for the resident's buttocks or coccyx. Review of the resident's 1/1/23 treatment administration record (TAR) showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the evening shift. Review of the resident's 1/2/23 - 1/4/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day shift. Review of the resident's weekly skin check, dated 1/4/23, showed no open areas noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's care plan, revised on 1/6/23, showed the following: -Resident is at risk for skin problems related to PVD; -Monitor extremities for signs and symptoms of injury, ulcers, coldness of extremity, pallor (a pale appearance), blistering, burning, bruising or other skin lesions; -Resident has activities of daily living - self-care deficit: bed mobility: requires assist of one, dressing: requires assist of one, personal hygiene: requires assist of one, toilet use: requires assist of one; -Resident is incontinent and is at risk for skin breakdown; -No indication on care plan that the resident has any current skin problems or is at risk for pressure ulcer development. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/23, showed the following: -Severe cognitive impairment; -No behaviors or rejection of cares; -Extensive assist of one staff for bed mobility, transfers, and personal hygiene; -Total dependence of one staff for toileting; -Always incontinent of bowel and bladder; -At risk for pressure ulcer development; -No unhealed pressure ulcers or foot ulcers; -No applications of treatments or dressings to any area. Review of the resident's 1/7/23 - 1/8/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day shift. Review of the resident's 1/9/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day or evening shift. Review of the resident's 1/10/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's weekly skin check, dated 1/11/23, showed no skin concerns noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's 1/13/23 - 1/14/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day or evening shift. Review of the resident's 1/15/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's weekly skin check, dated 1/18/23, showed no skin concerns noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's 1/19/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/20/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the evening shift. Review of the resident's 1/21/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/22/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/23/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day or evening shift. Review of the resident's nursing progress notes 1/1/23 - 1/23/23 showed the following: -No documented skin concerns or skin related issues; -On 1/23/23 at 11:23 P.M., staff documented the resident was transported to a local emergency room for evaluation related to increased shortness of breath and low oxygen saturation. Review of the resident's hospital admission record for 1/24/23 showed the resident arrived at the hospital at 12:01 A.M. on 1/24/23. Review of the resident's hospital wound/skin assessment records, dated 1/24/23 at 8:00 A.M., showed the following: -Pressure injury on coccyx right; left; medial (center) was present on admission with wound bed assessment deep purple/eschar/deep pink/beefy red, scant exudate (drainage), measuring 8 centimeters length and 10 centimeters width and no depth, staging of a suspected deep tissue injury; -Pressure injury on left heel was present on admission with wound bed deep purple and dusky, no exudate, measuring 7 centimeters length and 7 centimeters width with depth, staging of a suspected deep tissue injury, peri-wound (area surrounding the wound) is boggy (soft and mushy); -Pressure injury on right foot; lateral (side away from the middle); proximal (closer to center) was present on admission with wound bed assessment deep purple, no exudate, measuring 3 centimeters length and 4 centimeters width with no depth, staging of a suspected deep tissue injury, peri-wound is boggy; -Pressure injury on right foot; lateral; medial was present on admission with wound bed deep purple, no exudate, measuring 2 centimeters length and 2 centimeters width with no depth, staging of a suspected deep tissue injury, peri-wound intact; -Pressure injury on right foot; lateral; distal (farther away from the center) was present on admission with wound bed deep purple, no exudate, measuring 3 centimeters length and 3 centimeters width with no depth, staging of a suspected deep tissue injury; -Pressure injury on right outer ankle was present on admission with wound bed deep purple, no exudate, measuring 3 centimeters length and 2 centimeters width with no depth, staging suspected deep tissue injury, peri-wound intact. During an interview on 2/2/23, at 2:40 P.M., Certified Medication Technician (CMT) F said Resident #3 had breakdown on his/her bottom and feet and was unsure what the treatments were for the breakdown. During an interview on 2/2/23, at 8:17 P.M., Certified Nursing Assistant (CNA) H said he/she did remember working with Resident #3 and he/she had breakdown on his/her bottom, but was not sure about the treatment being provided. During an interview on 2/3/23, at 10:06 A.M., CMT/CNA G said the following: -He/She remembers working with Resident #3; -The resident had been going downhill and had declined recently; -The resident had a hole on his/her bottom about the size of a golf ball that staff were putting cream on; -He/She felt like the wound nurse was aware of the area since staff were putting cream on the resident's bottom; -He/She thinks there was a treatment to the resident's feet, but he/she was not sure. During an interview on 2/15/23, at 9:39 A.M., CMT K said it had been reported to him/her that the resident had a diaper rash, but he/she was not sure how long or what treatment was being performed. He/She was not aware of any other skin issues with the resident. During an interview on 2/14/23, at 9:44 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She feels like the resident had some chaffing on his/her bottom and had a cream applied to his/her bottom; -He/She was not sure if the wound nurse was aware of the resident's breakdown. During an interview on 2/14/23, at 3:08 P.M., LPN I said he/she was aware of a treatment of skin prep to the resident's heels that had some bruising he/she thought, but was unaware of any concerns with the resident's bottom. During an interview on 2/14/23, at 8:37 P.M., Registered Nurse (RN) E said the following: -The resident had a small area of breakdown on his/her bilateral buttocks; -He/She was not aware of any issues with the resident's feet; -He/She reported the bottom breakdown to the wound nurse earlier that week, but did not document in the resident progress notes when reported; -When there is a skin issue staff tells the wound care nurse and she determines a treatment and does the treatments; -The wound care nurse does all of the weekly skin assessments. During an interview on 2/3/23, at 11:28 A.M., the wound care/treatment nurse said the following: -Skin assessments are done on every resident weekly; -Resident #3 had a pressure a ulcer on his/her bottom that was just noticed the day he/she was transferred to the hospital; -She had not evaluated or assessed the reported pressure ulcer and did not document anything about it; -She was going to assess the resident the day the resident went to the hospital but did not; -He/She was made aware of the pressure ulcer the morning the resident went to the hospital; -There was nothing wrong with the resident's feet, the skin prep treatment was for protection; -The resident did not have breakdown or bruises on either foot. During an interview on 2/7/23 at 2:00 P.M. the Director of Nursing (DON) and administrator said: -They would expect the resident's skin was inspected by a nurse when a staff member informs them of skin breakdown; -They would expect the nurse to document skin breakdown, notify the physician and obtain a treatment order; -The nurses can do a treatment when the wound nurse is not available. During an interview on 2/10/22 at 8:30 A.M. the Medical Director said he expected the facility to follow their policy for skin integrity, to inspect and document any break in the skin and to notify the physician for treatment orders. During an interview on 2/16/23, at 5:00 P.M., the resident's physician said the following: -He was unaware the resident had skin breakdown prior to transfer to the hospital; -He would have expected to have been notified about the breakdown to give orders for a treatment; MO213076 MO213230

Based on interview and record review, the facility failed to properly identify and treat a deep tissue injury for one resident (Resident #3), who was at risk for developing pressure ulcers, in a review of 18 sampled residents. The facility census was 92. Review of the facility's policy, Pressure Injury Prevention and Management, revised 3/3/22, showed the following: -This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate; -After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Review of the National Pressure Injury Advisory Panel (NPIAP), prevention and treatment of pressure ulcers: quick reference guide, [NAME] DC: National Pressure Injury Advisory Panel 2019 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual 3.0, Version 1.17.1, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue) or bruising. May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. May adhere to the base of the wound or present in clumps throughout the wound; -Eschar: dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissues and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. 1. Review of Resident #3's face sheet showed the following: -Diagnoses include: diabetes mellitus (a group of diseases that result in too much sugar in the blood), COVID-19 (1/18/23), peripheral vascular disease/PVD (a systemic disorder that involves the narrowing of peripheral blood vessels) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's weekly skin check, dated 12/27/22, showed no open areas noted and skin intact with no new wounds identified (there were no previous wounds noted). Review of the resident's January 2023 physician order sheet (POS) showed a treatment order for skin prep wipes (a topical skin protectant), apply to both heels and left ankle every day and evening shift; order date of 5/27/22. No indication of a treatment for the resident's buttocks or coccyx (also known as the tailbone, a triangular arrangement of bone that makes up the very bottom portion of the spine). Review of the resident's January 2023 treatment administration record (TAR) showed the following: -A treatment of skin prep wipes, apply to both heels and left ankle every day and evening shift; -No indication of a treatment for the resident's buttocks or coccyx. Review of the resident's 1/1/23 treatment administration record (TAR) showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the evening shift. Review of the resident's 1/2/23 - 1/4/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day shift. Review of the resident's weekly skin check, dated 1/4/23, showed no open areas noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's care plan, revised on 1/6/23, showed the following: -Resident is at risk for skin problems related to PVD; -Monitor extremities for signs and symptoms of injury, ulcers, coldness of extremity, pallor (a pale appearance), blistering, burning, bruising or other skin lesions; -Resident has activities of daily living - self-care deficit: bed mobility: requires assist of one, dressing: requires assist of one, personal hygiene: requires assist of one, toilet use: requires assist of one; -Resident is incontinent and is at risk for skin breakdown; -No indication on care plan that the resident has any current skin problems or is at risk for pressure ulcer development. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/23, showed the following: -Severe cognitive impairment; -No behaviors or rejection of cares; -Extensive assist of one staff for bed mobility, transfers, and personal hygiene; -Total dependence of one staff for toileting; -Always incontinent of bowel and bladder; -At risk for pressure ulcer development; -No unhealed pressure ulcers or foot ulcers; -No applications of treatments or dressings to any area. Review of the resident's 1/7/23 - 1/8/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day shift. Review of the resident's 1/9/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day or evening shift. Review of the resident's 1/10/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's weekly skin check, dated 1/11/23, showed no skin concerns noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's 1/13/23 - 1/14/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed each indicated day for the day or evening shift. Review of the resident's 1/15/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's weekly skin check, dated 1/18/23, showed no skin concerns noted, skin intact and no new wounds identified (there were no previous wounds noted). Review of the resident's 1/19/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/20/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the evening shift. Review of the resident's 1/21/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/22/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day shift. Review of the resident's 1/23/23 TAR showed a scheduled twice a day treatment of skin prep wipes to both heels and left ankle was not completed for the day or evening shift. Review of the resident's nursing progress notes 1/1/23 - 1/23/23 showed the following: -No documented skin concerns or skin related issues; -On 1/23/23 at 11:23 P.M., staff documented the resident was transported to a local emergency room for evaluation related to increased shortness of breath and low oxygen saturation. Review of the resident's hospital admission record for 1/24/23 showed the resident arrived at the hospital at 12:01 A.M. on 1/24/23. Review of the resident's hospital wound/skin assessment records, dated 1/24/23 at 8:00 A.M., showed the following: -Pressure injury on coccyx right; left; medial (center) was present on admission with wound bed assessment deep purple/eschar/deep pink/beefy red, scant exudate (drainage), measuring 8 centimeters length and 10 centimeters width and no depth, staging of a suspected deep tissue injury; -Pressure injury on left heel was present on admission with wound bed deep purple and dusky, no exudate, measuring 7 centimeters length and 7 centimeters width with depth, staging of a suspected deep tissue injury, peri-wound (area surrounding the wound) is boggy (soft and mushy); -Pressure injury on right foot; lateral (side away from the middle); proximal (closer to center) was present on admission with wound bed assessment deep purple, no exudate, measuring 3 centimeters length and 4 centimeters width with no depth, staging of a suspected deep tissue injury, peri-wound is boggy; -Pressure injury on right foot; lateral; medial was present on admission with wound bed deep purple, no exudate, measuring 2 centimeters length and 2 centimeters width with no depth, staging of a suspected deep tissue injury, peri-wound intact; -Pressure injury on right foot; lateral; distal (farther away from the center) was present on admission with wound bed deep purple, no exudate, measuring 3 centimeters length and 3 centimeters width with no depth, staging of a suspected deep tissue injury; -Pressure injury on right outer ankle was present on admission with wound bed deep purple, no exudate, measuring 3 centimeters length and 2 centimeters width with no depth, staging suspected deep tissue injury, peri-wound intact. During an interview on 2/2/23, at 2:40 P.M., Certified Medication Technician (CMT) F said Resident #3 had breakdown on his/her bottom and feet and was unsure what the treatments were for the breakdown. During an interview on 2/2/23, at 8:17 P.M., Certified Nursing Assistant (CNA) H said he/she did remember working with Resident #3 and he/she had breakdown on his/her bottom, but was not sure about the treatment being provided. During an interview on 2/3/23, at 10:06 A.M., CMT/CNA G said the following: -He/She remembers working with Resident #3; -The resident had been going downhill and had declined recently; -The resident had a hole on his/her bottom about the size of a golf ball that staff were putting cream on; -He/She felt like the wound nurse was aware of the area since staff were putting cream on the resident's bottom; -He/She thinks there was a treatment to the resident's feet, but he/she was not sure. During an interview on 2/15/23, at 9:39 A.M., CMT K said it had been reported to him/her that the resident had a diaper rash, but he/she was not sure how long or what treatment was being performed. He/She was not aware of any other skin issues with the resident. During an interview on 2/14/23, at 9:44 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She feels like the resident had some chaffing on his/her bottom and had a cream applied to his/her bottom; -He/She was not sure if the wound nurse was aware of the resident's breakdown. During an interview on 2/14/23, at 3:08 P.M., LPN I said he/she was aware of a treatment of skin prep to the resident's heels that had some bruising he/she thought, but was unaware of any concerns with the resident's bottom. During an interview on 2/14/23, at 8:37 P.M., Registered Nurse (RN) E said the following: -The resident had a small area of breakdown on his/her bilateral buttocks; -He/She was not aware of any issues with the resident's feet; -He/She reported the bottom breakdown to the wound nurse earlier that week, but did not document in the resident progress notes when reported; -When there is a skin issue staff tells the wound care nurse and she determines a treatment and does the treatments; -The wound care nurse does all of the weekly skin assessments. During an interview on 2/3/23, at 11:28 A.M., the wound care/treatment nurse said the following: -Skin assessments are done on every resident weekly; -Resident #3 had a pressure a ulcer on his/her bottom that was just noticed the day he/she was transferred to the hospital; -She had not evaluated or assessed the reported pressure ulcer and did not document anything about it; -She was going to assess the resident the day the resident went to the hospital but did not; -He/She was made aware of the pressure ulcer the morning the resident went to the hospital; -There was nothing wrong with the resident's feet, the skin prep treatment was for protection; -The resident did not have breakdown or bruises on either foot. During an interview on 2/7/23 at 2:00 P.M. the Director of Nursing (DON) and administrator said: -They would expect the resident's skin was inspected by a nurse when a staff member informs them of skin breakdown; -They would expect the nurse to document skin breakdown, notify the physician and obtain a treatment order; -The nurses can do a treatment when the wound nurse is not available. During an interview on 2/10/22 at 8:30 A.M. the Medical Director said he expected the facility to follow their policy for skin integrity, to inspect and document any break in the skin and to notify the physician for treatment orders. During an interview on 2/16/23, at 5:00 P.M., the resident's physician said the following: -He was unaware the resident had skin breakdown prior to transfer to the hospital; -He would have expected to have been notified about the breakdown to give orders for a treatment; MO213076 MO213230

Based on observation, interview, and record review, the facility failed to appropriately transfer one resident (Resident #1), who required assistance with transfers, using a gait belt. Staff failed to use a gait belt when transferring Resident #1 on 7/23/22. Both the staff member and the resident fell to the floor during the transfer and the staff member landed on top of the resident. Staff failed to document and investigate the fall or ensure interventions were put in place to prevent reoccurrence. On 7/27/22, staff obtained a physician order for X-rays of the resident's ankle and foot as well as a venous Doppler of the resident's leg left leg, due to [CONDITION(S)] (swelling caused by fluid trapped in the body's tissues) and pain. On 7/28/22, another staff member attempted to transfer the resident without using a gait belt. Both the staff member and the resident fell to the floor. The resident was sent to the emergency room and admitted to the hospital for treatment of a femoral neck (top of the thigh bone) fracture, humerus (upper arm) fracture, knee dislocation, acute pain, and acute blood loss. A sample of six residents was selected for review. The facility census was 104. The administrator was notified on 8/23/22 at 2:38 P.M. of an Immediate Jeopardy (IJ) which began on 7/23/22. The IJ was removed on 8/24/22 as confirmed by surveyor onsite verification. Review of the facility's Fall Prevention Program policy revised 9/21/21 showed the following: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; -A fall is an event in which an individual unintentionally comes the rest on the ground, floor, or other level, but not as a result of an overwhelming external force (resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere; -The facility uses a standardized risk assessment for determining a resident's fall risk; -When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program; -Each resident's risk factors and environmental hazards when developing the resident's comprehensive plan of care; -Interventions will be monitored for effectiveness; -The plan of care will be revised as needed; -When any resident experiences a fall, the facility will: a. Assess the resident; b. Complete a post fall assessment; c. Complete an incident report; d. Notify the physician and family; e. Review the resident's care plan and update as indicated; f. Document all assessments and actions; g. Obtain witness statements in the case of injury. Review of the facility's Use of Gait Belt policy revised 5/4/22 showed the following: -It is the policy of the facility to use gait belts (a device put on a resident who has mobility issues, by a caregiver prior to that caregiver moving the resident. Residents may have problems with balance and a gait belt may be used to aid in their safe movement) with residents that cannot independently ambulate or transfer for the purpose of safety; -Gait belts will be available for staff to use; -All employees will receive education on the proper use of gait belts during orientation and annually; -It will be the responsibility of each employee to ensure they have it available for use at all times when at work; -Any and all repairs needed or issues with gait belts will be reported to the supervisor immediately for replacement; -Failure to use a gait belt properly may result in termination. 1. Review of Resident #1's annual Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/15/22 showed the following: -Diagnoses included stroke, [CONDITION(S)] (one-sided paralysis), diabetes, [CONDITION(S)], anxiety, and depression; -Cognition was intact; -Required limited assistance of one staff for bed mobility, transfers, and hygiene; -No falls since the previous assessment. Review of the resident's care plan revised 5/23/22 showed the following: -The resident had a self-care performance deficit (deficiency or failing) related to a history of stroke with left sided weakness, contracted left elbow, hand, and left contracted foot. The resident used a wheelchair for locomotion and fatigues easily; -Assistance of one staff for transfers; -Monitor/document/report as needed, any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function; -The resident was at risk for falls due to history of stroke with left sided weakness. The resident would attempt to transfer himself/herself; -Be sure the call light is in reach and encourage him/her to use it for assistance as needed; -Ensure the resident wore appropriate footwear; -Keep the resident's wheelchair near the bed; -Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Alter or remove any possible causes if possible. Educate resident/family/caregivers/Interdisciplinary team as to causes. During an interview on 8/22/22 at 3:31 P.M. Certified Nurse Aide (CNA) B said towards the end of July (exact date unknown), Resident #1 asked to be changed so CNA B changed the resident while the resident was in bed. CNA B tried to transfer the resident to the wheelchair. The resident's foot got caught and both the resident and CNA B fell to the floor. CNA B landed on the resident during the fall. CNA B had another aide help get the resident up off the floor. The resident complained of his/her leg hurting. CNA B reported this to the charge nurse at the time. CNA B did not remember the name of the aide that assisted him/her to get the resident off the floor or the name of the nurse he/she reported the fall to. CNA B wrote a statement about the incident which he/she gave to the charge nurse. CNA B made a copy of the statement and placed it in the Director of Nurses (DON)'s box. CNA B said he/she did not use a gait belt during the transfer with Resident #1. During an interview on 8/24/22 at 1:38 P.M. Licensed Practical Nurse (LPN) F said he/she was not the charge nurse, but he/she was working on 7/23/22 when Resident #1 fell . It was about 7:00 P.M., right as LPN F was finishing his/her shift. LPN F could not recall who the charge nurse was at the time. LPN F collected statements from CNA B and the other staff involved, but was unsure who the other staff member was. LPN F placed the statements in the former DON's mailbox. LPN F also called and notified the former DON that evening before he/she left. LPN F did not assess Resident #1 or call his/her physician as this would have been the charge nurse's responsibility. LPN F's only involvement was collecting the statements and notifying the former DON. During an interview on 8/23/22 at 4:00 P.M. the former DON said she became aware Resident #1 fell on [DATE], a Saturday, during a transfer with CNA B when the former DON found a written statement from CNA B the following Monday, 7/25/22. The former DON did not recall who the charge nurse was at the time. The former DON did not think CNA B used a gait belt during the transfer, but she wasn't certain. The former DON said she thought she got a statement from the charge nurse as well and had a file on the incident that she left in the facility. The former DON instructed CNA B to use two staff when transferring Resident #1 in the future after the fall on 7/23/22. The former DON expected staff to transfer Resident #1 with a gait and expected two staff to transfer Resident #1 with a gait belt after his/her fall on 7/23/22. The former DON said there should have been a nurse's note made by the charge nurse regarding Resident #1's fall on 7/23/22. The former DON did not know if the charge nurse completed an investigation or conducted an assessment of Resident #1 after the fall on 7/23/22. Record review showed no documentation the resident fell on [DATE]. During an interview on 8/23/22 at 5:50 P.M., the Regional Director of Operations said she could not locate the file the former DON said she had made regarding Resident #1's fall on 7/23/22. Review of the resident's physician order sheet (POS) for July 2022 showed an order dated 7/27/22 for venous Doppler (a special ultrasound technique that evaluates blood as it flows through a blood vessel) of the left leg for diagnoses of [CONDITION(S)]/pain and an order for an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body) of the ankle and foot for diagnoses of [CONDITION(S)], pain, status post injury. Review of the resident's nurse's note dated 7/28/22 at 2:22 P.M. showed the resident was transferring from the bed with the assistance of a CNA. The resident pivoted in the opposite direction and fell to the floor. The resident said he/she hit his/her head and back. 911 was called and responded and the resident was in route to the hospital. Review of the resident's Incident Report, dated 7/28/22 at 2:22 P.M., showed the following: -The incident occurred in the resident's room; -The resident was transferring from bed with the assistance of a CNA. The resident pivoted in the opposite direction and fell to the floor. The resident said he/she hurt his/her head and back. 911 called and responded and the resident was transported to the hospital via Emergency Medical Services (EMS). Review of the resident's Fall Risk Assessment Worksheet dated 7/28/22 at 3:22 P.M. showed the following: -The resident was a high risk for falls; -The resident had two falls in the last 30 days; -The resident's cognitive status had changed in the last 90 days. Review of the resident's discharge information from the hospital, dated 8/4/22, showed the resident's discharge diagnoses from the hospital was femoral neck fracture, humerus fracture, knee dislocation, and acute blood loss [CONDITION(S)] (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). Observation on 8/22/22 at 10:48 A.M. showed the resident had dark purple bruising to his/her left arm from the elbow up to his/her shoulder. During interviews on 8/22/22 at 10:48 A.M., and 8/23/22 at 3:03 P.M., the resident said the following: -He/She had a fall when transferring with staff out of bed. Their feet got tangled together and they both fell to the floor. The staff member fell on top of the resident; -The resident said the fall shook him/her up and caused some pain. The staff member did not use a gait belt during the transfer; -The resident said he/she fell again a few days later with a different staff member during a transfer. Both the resident and the staff member landed on the floor. The staff member did not use a gait belt during this transfer. The resident had to be transferred to the emergency room ; -His/Her first fall was with CNA B. CNA B was a large, heavyset person, and CNA B landed on top of the resident. CNA B's knee landed on the resident's left thigh and the resident hit his/her head on the floor. CNA B yelled for help and another aide came in and assisted CNA B to get the resident off the floor. The nurse never came and assessed Resident #1 after this fall. Other staff, who the resident could not recall the names, did come and talk with him/her about it a few days later, trying to figure out what happened; -A few days later the resident fell again, this time during a transfer with CNA A on 7/28/22. The resident was sent to the emergency room . During an interview on 8/22/22 at 1:45 P.M., the resident's significant other said he/she thought the first fall occurred on 7/22/22 or 7/23/22, when the resident was being transferred by a staff member. The staff member ended up landing on top of the resident. He/She found out about the fall from the resident. The resident's significant other spoke to the administrator about the fall on the following Monday. The resident's significant other said he/she is at the facility each day for several hours and staff never used a gait belt when transferring the resident. The only staff who ever used a gait belt when transferring the resident was therapy staff. During an interview on 8/23/22 at 2:45 P.M. Resident #6 said he/she was Resident #1's roommate and Resident #6 was in the room and observed Resident #1 fall while being transferred by CNA B (on 7/23/22). Both CNA B and Resident #1 fell to the floor. Resident #1 did complain of pain. CNA B and another aide assisted Resident #1 off the floor. Review of the undated statement from CNA A (referring to the fall on 7/28/22) showed the following: -At approximately 2:00 P.M. the resident was wheeled to his/her room by his/her significant other who had asked CNA A to change the resident; -Prior to the transfer CNA A locked the wheelchair and was going to the stand the resident on his/her right side which was his/her strong side; -During the transfer both CNA A and the resident lost their balance and fell to the floor; -The resident isn't steady on his/her feet; -CNA A was in front of the resident and the resident was holding onto CNA A's left side; -As CNA A and the resident stood from the wheelchair, the resident leaned towards his/her left side and CNA A and the resident fell to the floor; -The resident fell on the floor on his/her left side; -CNA A immediately checked to see if the resident was injured and got the nurse and notified the Assistant Director of Nursing (ADON), nurse manager, and administrator of the incident; -The resident complained of pain in his/her left thigh and arm; -EMS was called to send the resident to the emergency room for evaluation. During an interview on 8/22/22 at 1:14 P.M. CNA A said on 7/28/22 around 2:00 P.M. he/she attempted to transfer Resident #1 from the wheelchair to the bed. The resident was a stand and pivot transfer. CNA A did not use a gait belt during this transfer. Resident #1 lost his/her balance and leaned to one side. Resident #1 had his/her arm around CNA A's shoulder. CNA A had a hold on the resident's pants and under his/her armpit. Resident #1 pivoted in the opposite direction of the bed. Both CNA A and Resident #1 landed on the floor. CNA A was able to get up and got the charge nurse who assessed the resident and sent the resident to the emergency room . CNA A said a few days prior to 7/28/22, Resident #1 fell with another aide, CNA B. CNA B was transferring the resident and ended up falling on him/her. CNA A said CNA B wrote out a statement about the incident so the administrator should know about it. During an interview on 8/22/22 at 1:40 P.M. CNA C said Resident #1 fell during a transfer with a staff member and then a few days later fell again with a different staff member. The resident required assistance of one staff and a gait belt at that time. CNA C said the resident was being transferred by CNA B when the first fall occurred. During an interview on 8/22/22 at 3:26 P.M. CNA D said he/she was not aware of Resident #1 falling prior to 7/28/22. Sometimes CNA D transferred Resident #1 using a bear hug method because sometimes the resident would complain about the gait belt. During an interview on 8/22/22 at 4:05 P.M. Licensed Practical Nurse (LPN) E said Resident #1 had swelling in his/her left leg and had complained of pain. LPN E received an order on 7/27/22 to obtain an X-ray and a venous Doppler of the left leg and foot. The tests were scheduled for the following Friday, but before the tests were obtained the resident ended up going to the emergency room after a fall on 7/28/22. LPN E was not aware of the resident having a fall prior to 7/28/22. During an interview on 8/22/22 at 2:15 P.M. the Director of Nursing (DON) and the administrator said they expected staff to utilize a gait belt with residents who required manual assistance for transfers and staff should have used a gait belt when assisting Resident #1 with transfers. The DON and administrator expected staff to complete an assessment of the resident after a fall occurred, complete an incident report, contact the physician, and document all findings. During an interview on 8/22/22 at 2:57 P.M., the administrator said she was not aware of the resident having any fall prior to 7/28/22. No one had reported anything about it to her. During an interview on 8/23/22 at 4:15 P.M. Resident #1's physician and the facility's medical director, said he was not sure if the facility notified him of Resident #1's fall on 7/23/22. The physician would expect staff to follow the facility protocol following a resident fall, including obtaining vital signs and neurological checks if the resident hit their head. The resident may need to be seen emergently. If there was no injury from the fall, the physician would expect increased monitoring for any changes and the physician would expect to be notified of any changes. The physician did order some imaging tests for Resident #1 which were not able to be obtained prior to the resident's second fall. The physician was notified after the resident's second fall. The resident was sent to the emergency room and admitted to the hospital with fractures. The physician was aware there were issues and problems related to documentation in the facility. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to implement the facility policy addressing Cardiopulmonary Resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood) requirements for staff and to monitor to ensure CPR certified staff were scheduled and present in the facility 24 hours a day, seven days a week. This failure affected 77 residents who were identified as full code status (CPR required in the event of cardiac or respiratory arrest). Further review showed the facility failed to ensure the facility transporter, who transported four sampled residents (Residents #5, #101, #25 and #64) and two additional residents (Resident #47 and #54) in the facility van, all of which had elected a full code status,was trained and certified to provide CPR. Additionally, the facility failed to ensure a system so the medical record accurately and consistently indicated residents' code status for 20 residents (Resident #79, #30, #55, #25, #50, #59, #19, #88, #28, #457, #101, #94, #51, #89, #60, #20, #509, #5, #76 and #507) in a review of 56 sampled residents and for seven additional residents (Resident #92, #68, #84, #16, #17, #21 and #54). The facility census was 109. The administrator was notified on [DATE] at 2:45 P.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the facility's policy, CPR, dated [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advanced directives. In accordance to these rights, the facility will implement guidelines regarding cardiopulmonary resuscitation; -The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate (DNR) order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity (discoloration of skin due to blood pooling), decapitation, transection or decomposition); -CPR certified staff will be available at all times; -Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or refortification is also acceptable. 1. Review of Certified Medication Technician (CMT) K's American Health Care Academy CPR certification card showed the following: -He/She successfully completed the requirements in accordance with American Health Care Academy's curriculum; -Issue date [DATE]. Renewal date [DATE]. During interview on [DATE] at 8:42 A.M. CMT K said his/her CPR class was held online with no hands-on skills portion. 2. Review of Licensed Practical Nurse (LPN) F's National CPR Foundation's certification card showed the following: -He/she was now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. During an interview on [DATE] at 9:42 A.M., LPN F said the following: -He/She thought he/she had a valid CPR certification that was good until the end of August or September; -He/She had taken an on-line CPR class; there was no hands on portion for this class. 3. Review of the Wound Nurse's National CPR Foundation's certification card showed the following: -He/She was now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. (Same course with no hands-on skills training) 4. Review of Registered Nurse (RN) EE's National CPR Foundation's certification card showed the following: -He/She was now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. (Same course with no hands-on skills training) 5. Review of LPN DD's National CPR Foundation's certification card showed the following: -He/She was now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. (Same course with no hands-on skills training) 6. Review of LPN FF's National CPR Foundation's certification card showed the following: -He/She was now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. (Same course with no hands-on skills training) 7. Review of Transportation Driver/Housekeeping Aide YY's employee file showed no documentation regarding CPR certification. During interview on [DATE] at 11:55 A.M. Transportation Driver/Housekeeping Aide YY said the following: -He/She was CPR certified approximately six years ago; -He/She transported newly admitted residents and residents who are readmitted from the hospital and all [CONDITION(S)] residents; -He/She doesn't know the code status of the residents he/she transports; -If a resident became unresponsive he/she would pull over and give CPR; -He/She did not remember the correct respirations to compressions ratio. 8. Review of Central Supply Staff/Certified Nurse Aide (CNA) XX's employee filed showed no documentation regarding CPR certification. During interview on [DATE] at 12:47 P.M. Central Supply staff/CNA XX said the following: -He/She filled in and transports residents if the Transportation Driver/Housekeeping Aide YY can't go; -He/She was not CPR certified; -Transportation Driver/Housekeeping Aide YY was the main transporter. 9. During an interview on [DATE] at 2:42 P.M., the DON said the following: -Receptionist O arranges transportation for residents to appointments; -Central Supply Staff/CNA XX and Transportation Driver/Housekeeping Aide YY provide transportation to residents since they have a Class E licenses; -Central Supply Staff/CNA XX only transported residents a handful of times; -Transportation Driver/Housekeeping Aide YY was usually the one who transported residents. During interviews on [DATE] at 2:47 P.M. and 3:07 P.M., Receptionist O said the following: -Transportation Driver/Housekeeping Aide YY transported Resident #64 to and from a pre-operation appointment on [DATE] and to and from a surgery on [DATE]. Transportation Driver/Housekeeping Aide YY also transported the resident to a follow up appointment on [DATE] or [DATE]. The resident had another follow up appointment on [DATE]. Transportation Driver/Housekeeping Aide YY would be driving the resident to and from this appointment. -No other staff go with Transportation Driver/Housekeeping Aide YY when he/she transports Resident #64 to and from these appointments; -He/She did not know if Transportation Driver/Housekeeping Aide YY was CPR certified, and did not know the code status of the residents Transportation Driver/Housekeeping Aide YY transported; -Transportation Driver/Housekeeping Aide YY started transporting Resident #5 to and from vascular appointments about three weeks ago. Transportation Driver/Housekeeping Aide YY transported the resident to and from the appointments once a week; -Transportation Driver/Housekeeping Aide YY started transporting Resident #47 to and from [CONDITION(S)] appointments a couple months ago. Transportation Driver/Housekeeping Aide YY took Resident #47 to [CONDITION(S)] three times a week. During an interview on [DATE] at 12:47 P.M. the Regional Director of Operations said no residents had been transported by the facility since last Thursday, [DATE]. During an interview on [DATE] at 1:47 P.M. and 6:12 P.M., the Transportation Driver/Housekeeping Aide YY said he/she transported Resident #5 (full code status) to his/her wound clinic appointment on the morning of [DATE]. Sometime between noon and 4:00 P.M. the DON something to him/her about a CPR class being held the following week at the facility and wanted him/her to attend. The Transportation Driver/Housekeeping Aide YY said the DON never told him/her that he/she couldn't continue transporting residents to outside appointments. The Transportation Driver/Housekeeping Aide YY said on [DATE] at about 4:00 A.M. he/she picked up Resident #54 (full code status) from a [CONDITION(S)] appointment and returned him/her to the facility. Transportation Driver/Housekeeping Aide YY said he/she had transported Resident #54 many times during the time he/she had been the transport driver. The resident did not always have alternate transportation so he/she would make sure the resident got to his/her [CONDITION(S)] appointments and returned to the facility. On [DATE] the Transportation Driver/Housekeeping Aide YY said he/she took Resident #101 to a [CONDITION(S)] appointment in another community and while he/she was there the DON called him/her and yelled at him/her to return immediately. The Transportation Driver/Housekeeping Aide YY said he/she couldn't just leave the resident there so he/she waited for the resident to finish with their appointment and then returned with the resident back to the facility. The Transportation Driver/Housekeeping Aide YY said he/she had also transported Resident #25 to and from [CONDITION(S)] appointments. The Transportation Driver/Housekeeping Aide YY said he/she had been transporting residents for about a year. During an interview on [DATE] at 5:15 P.M. the DON said she educated the Transportation Driver/Housekeeping Aide YY regarding transporting residents. She said she told him/her he/she could not transport any more residents until he was CPR certified. She said she talked to him/her on [DATE] and she believed she texted him/her no more transportation until CPR certified at the end of day on [DATE]. During interview on [DATE] at 10:39 A.M., the Staffing Coordinator/CMT Z said the following: -He/She has been the staffing coordinator for nine months; -He/She was responsible for the nursing schedule; -He/She was not aware which staff were CPR certified; -He/She was not allowed to have access to whether or not staff was CPR certified; -He/She does not schedule staff to ensure CPR certified staff coverage on all shifts. During an interview on [DATE] at 9:15 A.M. the RN/Corporate Nurse said the following: -He was not aware the CPR certification had to have the hands-on piece for proper certification; -He was not aware some staff' CPR certifications were not valid; -The administrator had thought there was a waiver for CPR certification due to COVID. During interview on [DATE] at 12:18 P.M. the DON said the following: -The Staffing Coordinator/CMT Z was responsible for the nursing schedule; -When the facility has HR (Human Resources) in the building they are responsible for getting copies of staff CPR cards; -They have not had HR in the building recently; -Recently she has been trying to collect CPR cards; -Licensed nurses should be CPR certified; -She did not know that CPR online training was not acceptable; -She did not know if Transportation Driver/Housekeeping Aide YY was CPR certified; -The Transportation Driver/Housekeeping Aide YY takes residents to and from [CONDITION(S)] and will transport if scheduled outside transportation fails to arrive; -She didn't know the Transportation Driver/Housekeeping Aide YY needed to be CPR certified. During interview on [DATE] at 12:00 P.M. the administrator said the following: -He was aware of the requirement for CPR certified staff on all shifts; -He did not know if it was the facility's expectation that all licensed nurses should be CPR certified; -There were full code residents in the facility; -There should be CPR certified staff coverage on all shifts; -He does not know what the requirements are regarding CPR certification requirements for the transporter; -He had not thought about whether or not the transporter should be CPR certified. 10. Record review of Resident #79's face sheet showed the resident had elected to be a Do Not Resuscitate -DNR (staff would not provide CPR/life support with cessation of breathing/heartbeat). Record review of the resident's care plan, dated [DATE], showed the resident's code status was a full code (resident would want CPR and life support measures). Record review of the resident's [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -An individual sheet for the resident, with his/her name at the top of the sheet, with resident specific information; -In the upper right corner of the page, a box for code status to be written/filled in; -The code status box for this resident indicated the resident had elected a full code status; -The code status' were not consistent and it was unclear what code status the resident had elected or what staff should do in the event of an emergency. 11. Record review of Resident #92's face sheet showed the resident had elected to be a full code. Record review of the resident's [DATE] POS showed the resident elected to be a full code status. Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -An individual sheet for the resident, with his/her name at the top of the sheet, with resident specific information; -In the upper right corner of the page, a box for code status to be written/filled in; -The code status box for this resident indicated the resident had elected a code status of DNR; -The code status' were not consistent and it was unclear what code status the resident had elected or what staff should do in the event of an emergency. 12. Record review of Resident #30's care plan, dated [DATE], showed the resident's code status was a full code. Record review of the resident's face sheet on [DATE], showed the resident had elected to be a full code. The resident's face sheet was updated on [DATE] to show the resident had elected a DNR status after being admitted to hospice services. Record review of the resident's [DATE] POS showed the resident elected to be a full code status; on [DATE] his/her code status changed to a DNR after being admitted to hospice services. Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -An individual sheet for the resident, with his/her name at the top of the sheet, with resident specific information; -In the upper right corner of the page, a box for code status to be written/filled in; -The code status box for this resident indicated the resident had elected a full code status. Record review of the A Hall report book, on [DATE] at 11:00 A.M. and [DATE] at 9:15 A.M. showed the following: -The same individual sheet for the resident, with his/her name at the top of the sheet, with resident specific information; -In the upper right corner of the page, the box for code status still indicated the resident was a full code status; -The code status box had not been updated with the resident's change to DNR code status when he/she elected hospice services; -The code status' were not consistent and it was unclear what code status the resident had elected or what staff should do in the event of an emergency. Review of the resident's care plan, dated [DATE], on [DATE], showed the resident's code status was a full code; the resident's care plan had not been updated to show the change to the DNR code status, therefore the code status' were not consistent and it was unclear what code status the resident had elected or what staff should do in the event of an emergency. 13. Record review of Resident #55's face sheet showed the resident had elected to be a full code. Record review of the resident's [DATE] POS showed the resident elected to be a full code status. Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not consistent/identified in the book. 14. Record review of Resident #68's face sheet showed the resident had elected to be a full code. Record review of the resident's [DATE] POS showed the resident elected to be a full code status. Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -An individual sheet for the resident, with his/her name at the top of the sheet, with resident specific information; -In the upper right corner of the page, a box for code status to be written/filled in; -The code status box for this resident was blank; No indication of full code or DNR status was completed for this resident; -The resident's code status was not consistent/identified in the book. 15. Record review of Resident #25's face sheet showed the resident had elected to be a full code. Record review of the resident's [DATE] POS showed the resident elected to be a full code status. Record review of the A Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not consistent/identified in the book. 16. Review of Resident #50's face sheet showed it did not include a code status. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -No code status; -admitted to Heartland Hospice on [DATE]. Review of the resident's care plan, dated [DATE] showed the following: -Advanced directives: Resident was a full code; -Resident chose hospice services ([DATE]). 17. Record review on [DATE] at 12:30 P.M. of the nurse report book at the nurse's station for the D Hall and Isolation Hall showed blank pages with resident names for those halls. Residents on the even side of the halls (Residents #89, #60, #20, #509, #54, #5, #76 and #507) had nothing written in the box labeled Code Status. There was no evidence of a binder designated for resident code status information at the nurse's station. 18. Record review of Resident #5's care plan, reviewed on [DATE], showed the resident elected to be a full code. Record review of Resident #5's [DATE] POS showed the resident elected to be a full code. Review of the D Hall and Isolation Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not identified in the book. 19. Record review of Resident #20's [DATE] POS showed the resident elected to be a full code. During an interview on [DATE] at 4:20 P.M. the resident said he/she was a full code and wanted everything done to help him/her if his/her heart would stop. Record review of the resident's care plan, reviewed on [DATE], showed the resident elected to be a full code. 20. Record review of Resident #60's undated face sheet showed the resident elected to be a full code. Record review of the resident's care plan, reviewed on [DATE], showed the resident elected to be a full code. Review of the D Hall and Isolation Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not identified in the book. 21. Record review of Resident #76's [DATE] POS showed the resident elected to be a full code. Review of the D Hall and Isolation Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not identified in the book. 22. Record review of Resident #89's care plan, reviewed on [DATE], showed the resident elected to be a full code. Review of the resident's [DATE] POS showed the resident elected to be a full code. Review of the D Hall and Isolation Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not identified in the book. 23. Record review of Resident #509's [DATE] POS showed the resident elected to be a full code. Record review of the resident's current care plan showed the resident elected to be a full code. Review of the D Hall and Isolation Hall report book, on [DATE] at 3:59 A.M. showed the following: -Individual sheets for each resident that resided on this hall, with his/her name at the top of the sheet, with resident specific information; -The book did not contain an individual sheet for the resident to identify his/her code status; -The resident's code status was not identified in the book. 24. Record review of Resident #507's [DATE] POS showed the resident elected to be a full code. Record review of the resident's current care plan showed the resident elected to be a full code. 25. Record review of the D Hall report book, on [DATE] at 4:51 A.M. showed individual sheets for each resident. In the upper right corner there was a box for code status to be written. There was no indication of full code or do not resuscitate (DNR) status completed for residents #28, 457, 101, 94, 51, 17, 16, and 84. Record review on [DATE] at 12:30 P.M. of the nurse report book at the nurse's station for the D Hall and Isolation Hall showed blank pages with resident names for those halls. Residents on the even side of the halls (Residents #89, #60, #20, #509, #54, #5, #76 and #507) had nothing written in the box labeled Code Status. There was no evidence of a binder designated for resident code status information at the nurse's station. 26. During interview on [DATE] at 4:00 A.M. CNA CCC said the following: -A resident's code status could be found in the computer system where the resident face sheet and care plan was; -Code status could also be found in a book at the nursing station; -He/She would probably use the book at the nursing station to check a resident's code status because it was quicker. During interview on [DATE] at 10:00 A.M. CNA I said the following: -He/She did not know how to find a resident's code status; -He/She would have to yell for the nurse and hope they heard him/her in the event of an emergency. During interview on [DATE] at 4:30 A.M. CNA S said he/she was not sure who was a DNR or full code and that it was against HIPAA (Health Insurance Portability and Accountability Act of 1996 - a law to protect protected health information) for him/her to know that information. In the case of an emergency he/she would call for the nurse. During interview on [DATE] at 5:18 A.M. CNA R said resident code status was in the computer. If there was an emergency he/she would call the nurse. He/She was unsure what residents were full code or DNR. During an interview on [DATE] at 8:47 P.M. CNA M said he/she did not know what code status meant. CNA M said he/she did not know what full code or DNR meant. He/She would call for help in an emergency. During an interview on [DATE] at 9:40 P.M. CNA G said if a resident was unresponsive he/she would check if they were breathing, run to the nurse's station and call a nurse/staff STAT (an abbreviation of the word statum meaning right away) to the resident's room. He/She would go back immediately to the resident's room and start CPR without knowing the resident's code status. CNA G said the residents had a red dot on their door if their code status was do not resuscitate (DNR) and a black dot if they were a full code, but since the pandemic the residents had been moved around so much the dots were not used anymore. During an interview on [DATE] at 9:45 P.M. CNA BB said he/she did not know the code status of the residents and did not know how to find it. During an interview on [DATE] at 1:25 P.M., LPN QQ said the following: -He/She would look for a resident's code status in the computer if he/she was near a computer, otherwise he/she would look in the report book at the nursing station if he/she was sitting there; -The report book was a red binder that had a sheet of paper for each resident on a specific hall and that paper indicated specific things for the resident, including their code status; -He/She thought social services was responsible for ensuring the resident code status was in the computer correctly and that the page in the report book was placed at admission and kept accurate. During an interview on [DATE] at 4:24 A.M. LPN AA said he/she had a binder with a list of residents and their code status at the nurses station at the end of the 500 hall. 27. Observation on [DATE] at 4:30 A.M. showed no binder with resident's code status at the nurse's station at the end of the 500 hall. 28. Review of a white binder (located in the window of the nursing room) on [DATE] at 9:58 A.M. showed the following: -The book contained face sheets, telephone order sheets and either green sheets of paper (full code) or red sheets of paper (DNR) for residents; -It did not include documents for Resident's #50 or #59 or for Resident's #19, #21 and #88 who were full code status. 29. Observation on [DATE] at 4:30 P.M. showed no red code status book at the 100 Hall nurses' station, on the crash cart or in in the therapy room. 30. During observation on [DATE] at 2:15 P.M. there was no code status book on any of the four crash carts or at the central nurses station, ORC nurses station or Freedom hall nurses station. 31. During interview on [DATE] at 4:30 A.M. LPN DD said he/she would find the code status on the electronic record. During an interview on [DATE] at 9:49 P.M. LPN II said since the COVID-19 pandemic there had been a lot of room changes for the residents and their code status had not been updated outside their rooms. It used to be a red dot indicated DNR and a green dot indicated full code. These should be on the resident's name plaque outside each room. If he/she did not know the code status of a resident he/she would go to the computer to look. During an interview on [DATE] at 1:30 P.M. LPN NN said if he/she needed to know the code status of a resident he/she would look in the resident's electronic record under the miscellaneous documents tab. During interview on [DATE] at 2:23 P.M. LPN FF said the following: -The resident code status was listed in the computer; -Individual code status for each resident was not written anywhere; -Individual code status for each resident was not given in report; -In a crisis he/she checks the computer for the resident's code status. During interview on [DATE] at 9:55 A.M. Registered Nurse (RN) X said the following: -He/She would look at the electronic record for a resident's code status; -He/She was unsure if the code status book was still used. During interview on [DATE] at 4:00 P.M. and [DATE] at 12:15 P.M. the DON said the following: -There was no indication in the resident rooms about code status due to frequent room changes; -Resident code status was located in the electronic health record; -Each resident's code status was also located in the red books at the nurses' station and on each crash cart; -The CNAs get report from their nurses about resident code status; -The CNA was expected to yell for help if a resident was unresponsive. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #30), in a review of 56 sampled residents and one additional resident (Resident #459) received the necessary services in accordance with professional standards of practice. Staff failed to ensure a system was in place to continuously monitor functionality of a Life Vest (a wearable cardioverter defibrillator (a device designed to detect life-threatening rapid heart rhythms and automatically deliver a treatment shock to restore a normal rhythm) worn by a patient at risk for sudden [CONDITION(S)]) for Resident #459. The facility also failed to complete weekly and daily weights, failed to provide treatments as ordered to large surgical wounds to the resident's left foot and left inner ankle, failed to provide interventions to aid in wound healing, failed to communicate a recommendation from the wound care center to the resident's physician to start [MEDICATION(S)] (an antibiotic) to treat a wound infection in the resident's left foot, failed to communicate weight loss related to nutrition for wound healing along with excessive fluid imbalance related to monitoring congestive heart failure, for one resident (Resident #459). The resident was not started on antibiotics for the wound infection which resulted in hospitalization for [CONDITION(S)] on [DATE]. The resident expired on [DATE] from severe [CONDITION(S)]. The facility failed to assess and provide physician ordered treatments for non-pressure related wounds and care in accordance with current accepted standards of practice for one resident (Resident #30). The facility census was 109. The administrator was notified on [DATE] at 4:20 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by the surveyor onsite verification. Review of the facility's policy, Life Vest (Wearable Defibrillator), dated [DATE], showed the following: -It is the policy of this facility to establish procedures for the safe use of wearable defibrillators; -The resident's medical record shall include the following information related to the wearable defibrillator: name and contact information of the manufacturer, name and contact information of the ordering cardiologist or specialist and product pamphlet or web address to access product pamphlet for operating instructions and/or troubleshooting information; -Staff responsible for the care of the resident with orders for a wearable defibrillator shall receive education on the use of the device. This education shall include, but is not limited to: purpose of the device and how it works, application and care of the garment, application of and operating instructions of the monitor, how to respond to alarms, when to notify attending or ordering physician and when to notify manufacturer for replacement; -Education of staff may be provided by product representative or by supervisory staff using educational materials provided on the product's website: the staff development coordinator or designee shall maintain copies of sign in sheets to verify education has been provided and a nurse shall be designated to serve as the facility's resource for any questions or concerns related to the use of the device; -Each resident who has orders for a wearable defibrillator will receive education on its use. This education shall include, but is not limited to: purpose of the device and how it works, application and care of the garment, application of and operating instructions of the monitor, how to respond to alarms, when to notify nurse while in facility, when to notify ordering physician (when providing discharge instructions) and when to notify manufacturer for replacement (such as when alerted by device or in response to certain alert codes); -Education of the resident may be provided by product representative, facility staff, or educational materials provided on the product's website. Facility staff are responsible for documenting education and documentation of return demonstration; -The resident shall be monitored for compliance with use of the wearable defibrillator, instances of alerts and/or vibrations, and any signs or symptoms of adverse outcomes associated with the use of the device. All monitoring efforts shall be documented in the resident's medical record. Review of the facility's policy, Wound Treatment Management, dated [DATE], showed the following: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse; -Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing; b. The dressing has dislodged; c. The dressing is soiled otherwise, or is wet; -Dressings will be applied in accordance with manufacturer recommendations; -Treatment decisions will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage; ii. Surgical iii. Incidental (i.e. skin tear, medical adhesive related skin injury); iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxsis); b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury); ii. Size - including shape, depth, and presence of tunneling and/or undermining; iii. Volume and characteristics of exudate; iv. Presence of pain; v. Presence of infection or need to address bacterial bioburden; vi. Condition of the tissue in the wound bed; vii. Condition of peri-wound skin; c. Location of the wound; d. Goals and preferences of the resident/representative; -Guidelines for dressing selection may be utilized in obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. The guidelines are to be used to assist treatment decision making; b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances; c. The facility will follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Treatments will be documented on the Treatment Administration Record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing; b. Changes in the characteristics of the wound; c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1. Review of Resident #459's face sheet, showed the resident was admitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated [DATE], showed the following: -Incision wounds to left foot and left medial foot; -Weight 200 pounds (lbs), taken on [DATE]. Review of the resident's Nurses Notes, dated [DATE], showed the following: -The resident was admitted to the facility at 7:00 P.M.; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Full code (cardiopulmonary resuscitation to be started if heart or lungs cease to function) and is on a life vest (personal defibrillator worn by a patient at risk for sudden [CONDITION(S)]). Review of the resident's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], to weigh the resident on admission and weekly for four weeks; -No order to direct staff to monitor the life vest; -No order for an antibiotic. Review of the resident's Admission Assessment, dated [DATE]-[DATE], showed the following: -The resident was admitted from the hospital; -He/She required extensive physical assistance with bed mobility, transfers, dressing, toilet use, and hygiene; -Dependent with bathing; -Weight 200 lbs. Review of the resident's Physician Orders, dated [DATE], showed the following: -[MEDICATION(S)] cream 1 % (cream used to prevent infection and aid in wound healing), apply to left foot topically every day shift for wound. Cleanse wound on left foot, apply [MEDICATION(S)] cream and cover with dry dressing then ace wrap. -Resident is on a life vest. Review of the resident's [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no evidence staff were to monitor the resident's life vest. Review of the resident's TAR, dated [DATE], showed the following: -[MEDICATION(S)] cream 1%, apply to left foot topically on wound and cover with dry dressing then ace wrap daily; -There was no documentation to show staff completed the treatment. Review of the resident's care plan, revised on [DATE], showed the following focus areas: -The resident has a full code status; -No indication of focus area, goals or interventions/tasks to address the life vest. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover the wound with Xeroform (fine mesh gauze dressing impregnated with [MEDICATION(S)] and 3% Xeroform ([MEDICATION(S)] tribromophenate)-an antimicrobial) dressing, secure with absorbent pad and secondary dressing, and apply ace wrap every day shift for the wound on the left foot. Review of the resident's TAR, dated [DATE], showed the following: -[MEDICATION(S)] cream 1%, apply to left foot topically on wound and cover with dry dressing then ace wrap daily; -The Xeroform treatment (ordered on [DATE]) was not listed on the TAR. -There was no documentation to show staff completed ordered treatment to the resident's left foot on [DATE]. Review of the resident's TAR, dated [DATE], showed the following: -[MEDICATION(S)] cream 1%, apply to left foot topically every day shift, for wound, clean wound on left foot, apply [MEDICATION(S)] cream and cover with dry dressing, then ace wrap; -Completed; -Discontinued [DATE]; -The Xeroform treatment (ordered on [DATE]) was not listed on the TAR. Review showed no evidence staff completed the ordered treatment on [DATE]. Review of the resident's Nurses Notes, dated [DATE], showed the following: -The resident was seen by traveling wound care service for wound assessment; -The resident was noted to have tendons exposed (to left foot wounds) with areas of necrosis (dead tissue) noted; -Orders for Santyl with calcium alginate (a dressing that absorbs drainage), cover with pad, and kerlix and secure with tape. Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #1 left, anterior foot (mid) is an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 28 cm length, 17 cm width, 0.8 cm depth and tendon is exposed. There was a moderate amount of sero-sanguineous (a thin, watery fluid that is pink in color due to the presence of a small amount of red blood cells) drainage noted. Wound bed has ,d+[DATE]% slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), ,d+[DATE]% bright red granulation (part of the healing process where connective tissue and capillaries form). The periwound skin color was normal; -Wound #2 left, medial ankle was an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 2.2 cm length, 8.5 cm width, 0.8 cm depth. There was a moderate amount of sero-sanguineous drainage noted. Wound bed has ,d+[DATE]% slough, and ,d+[DATE]% bright red granulation. The periwound skin color was normal, and periwound was moist; -Wound Orders: -Wound #1 left, anterior foot (mid): Cleanse wound and peri-wound with saline. Apply skin protectant to peri-wound. Apply calcium alginate to wound base. Apply Santyl to wound base, cover with super absorbent pad, wrap with roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal; -Wound #2 left, medial ankle: Cleanse wound and peri-wound with saline. Apply skin protectant to peri-wound. Apply calcium alginate to wound base, apply Santyl to wound base, cover with super absorbent pad, wrap with roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. Review of the resident's [DATE] POS showed the following:-An order dated [DATE], for Santyl ointment 250 unit/gram, apply to left foot and inner ankle topically to promote wound healing. Cleanse area with normal saline, apply Santyl, cover with calcium alginate, absorbent pad, kerlix (rolled gauze) and secure with tape daily; -No order for antibiotic treatment; -Resident is on a life vest; -No order to direct staff to monitor the life vest. Review of the resident's [DATE] MAR and TAR showed no evidence staff were to monitor the resident's life vest. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the following: -Moderate cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive physical assistance of one staff member for bed mobility, toilet use, and bathing; -Weight 200 lbs; -Incontinent of bowel and bladder; -Did not transfer or walk. Review of the resident's medical record showed no documentation staff obtained a weekly weight for the week of [DATE]-[DATE]. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Care Plan, dated [DATE], showed the following: -The resident plans to return home with home health; -Activities of daily living (ADL) deficit related to decreased strength, back pain, and leg impairments; -Non-weight bearing to the left side; -Requires assistance of one for bed mobility, dressing, hygiene, and toilet use; -Transfer with assist of two staff members with a mechanical lift; -Wears a life vest and is full code status; -Congestive heart failure; -Encourage adequate nutrition; -Give cardiac medications as ordered; -Monitor potassium, sodium, blood urea [MEDICATION(S)], and creatinine; -Monitor/document/report as needed any signs or symptoms of congestive heart failure: dependent [CONDITION(S)] of the legs and feet, periorbital (around the eyes) [CONDITION(S)], shortness of breath on exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea(sensation of breathlessness in the recumbent position, relieved by sitting or standing), weakness and/or fatigue, increased heart rate, lethargy and disorientation; -Monitor/document/report as needed any signs or symptoms of [MEDICATION(S)] (drug that stimulate the heart muscle.) toxicity: fatigue, muscle weakness, anorexia, nausea, yellow halos around objects; -Monitor/document/report as needed any signs or symptoms of [CONDITION(S)] (deficiency of potassium in the bloodstream) in residents receiving diuretic therapy: fatigue, muscle weakness, diminished appetite, nausea and vomiting and [CONDITION(S)], monitor potassium levels; -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease with range of motion withdrawal or resistance to care which could be related to pain; -Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. -Resident has actual impairment to skin integrity of the left lower leg; -Encourage good nutrition and hydration in order to promote healthier skin; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks out of blood vessels into nearby tissues) and any other notable changes or observations; -The resident's care plan did not address weight loss as a problem area for the resident. Review of the resident's TAR, dated [DATE], showed no evidence staff completed the ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Registered Dietitian (RD) note, dated [DATE], showed the following: -Weight 200 lbs.; -Consumes 51%-75% of most meals; -No labs; -Stage II (partial-thickness loss of skin with exposed dermis) on coccyx and open wound to foot and heel; -Recommend multivitamin with minerals and 500 milligrams (mg) of vitamin C two times daily. Review of the resident's medical record showed no evidence staff communicated the RD's recommendations to the resident's physician. Observation on [DATE] at 12:10 P.M., showed the following: -The resident lay in bed visiting with his/her family member; -The resident was wearing a white vest under his/her gown; -The vest was noted to have a pack in a black holder that was sitting on the resident's bedside table with the battery removed and sitting next to the black holder; -An additional battery sat on the charger on the bedside table. During interview on [DATE], at 12:12 P.M., the resident said the following: -The vest was something to help his/her heart; -The resident was not sure how long the battery had been out of the vest, but the unit had not been working for a few days; -The resident's family member called someone to check on it, and they were out yesterday, but the vest did not get fixed. Observation on [DATE] at 2:23 P.M. showed the batteries for the resident's life vest remained on the resident's bedside table. During interview on [DATE] at 1:25 P.M., Certified Nurse Assistant (CNA) VV said the following: -He/She was aware the resident wore a life vest; -He/She knew what a life vest was; it shocked a resident who is out of heart rhythm; -The charge nurses and the director of nursing (DON) monitored the life vest; the monitoring was above his/her pay grade; -He/She had not had any training at this facility for the life vest; -The battery should be in the vest and a back-up battery on the charger; -He/She thought the life vest was working, but he/she hadn't checked it; the nurses check the vest. During an interview on [DATE], at 1:46 P.M., Licensed Practical Nurse (LPN) WW (charge nurse) said the following: -He/She knew the resident wore a life vest; -He/She knew what a life vest was; it monitored cardiac condition and heart rate; -He/She did not know how to monitor the life vest to see if it was functioning; -He/She has not had any training on the life vest; -He/She felt like it would be the charge nurses' responsibility to monitor the vest for proper functioning; -He/She was not working with the resident on [DATE] so he/she was unsure if the life vest was working; -There should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She did not see a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 2:48 P.M. and 6:13 P.M., LPN II said the following: -He/She admitted the resident (on [DATE]), and on admission the resident wore the life vest; -The purpose of the life vest was to help the heart beat when it slowed down or when in [CONDITION(S)] fibrillation; -The vest was functioning if the machine showed a green circle; -If something was not working on the life vest, it beeped and then staff checked on it; -He/She attended a life vest in-service early last year; -The nurse was responsible for making sure the life vest was functional; -Staff document their monitoring to ensure the life vest was functioning on the MAR; -He/She looked in the computer and noted there was nowhere for staff to document they checked the life vest; -He/She was off the day before, but the life vest was working the last time he/she worked; -He/She had not checked on the resident today to see if the life vest was working; he/she was not in charge of the resident at the time of the interview; -If there was a problem with the life vest, he/she would have documented it in the nurse's notes. During an interview on [DATE] at 3:51 P.M., the resident's nurse practitioner said the following: -She was aware the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -She would expect nursing to monitor the resident for chest pain, shortness of breath or any cardiac symptoms; -She would expect nursing to monitor to make sure the vest was working; -She would expect the life vest to be fully functional at all times; -The DON would be responsible for making sure everyone was trained on the life vest; -If the life vest was not fully functional, or if the battery was removed, the resident could potentially go into [CONDITION(S)] which could lead to death. Observation on [DATE] at 4:58 P.M. showed the battery was in place in life vest. During interview on [DATE] at 4:58 P.M., the resident said staff put the battery in the life vest about 30 minutes ago. During an interview on [DATE], at 5:16 P.M., the therapy director said the following: -She was helping reposition the resident for a treatment about 4:30 P.M.; -At that time, she saw the battery for the life vest on the bedside table; -After the battery is put in, the screen will light up and you see the green circle circling the body; -The vest would not be functional if the battery was not connected; -The purpose of the life vest is it will shock the resident if he/she goes back into a-fib. Observation on [DATE] at 5:28 P.M. showed the life vest alarming with the message to check belt. The DON and therapy director repositioned the electrodes, cleansed the electrodes, and repositioned the belt numerous times with the alarm still sounding. Observation on [DATE] at 6:45 P.M. showed the life vest was functioning and not alarming. During an interview on [DATE], at 12:31 P.M., RN J said the following: -He/She had called the life vest company because during the evening on [DATE], the unit kept giving an error message to check the electrodes and check belt; -He/She along with LPN II kept rearranging the electrodes and belt with no solution; -The life vest representative gave instruction over the phone on how to do a manual download, and said the unit was functioning after the download; -On [DATE] at approximately 6:30 P.M., a representative from the life vest company was at the facility and checked the life vest because they were told it was not working; -The life vest had been working until then; -On [DATE] at approximately 8:37 P.M., the alarm on the unit started sounding; -He/She tried to resolve the issue by following the screen prompts; -He/She notified the life vest company and the representative instructed him/her how to reset the unit; -The machine was still having issues and provided an error code; -The life vest representative said to remove the battery, and at that time, the resident would not be protected and the company would send someone out; -He/She removed the battery and sat it in front of the battery charger on the bedside table; -He/She contacted the resident's physician on [DATE] at 8:47 P.M. to let him know the battery had been taken out of the unit; -There was no particular monitoring system in place for the life vest; -Staff was supposed to monitor to make sure the life vest was functioning properly; -The life vest was a defibrillator to be used if the resident had another episode of a-fib; -You can tell if the life vest is working if there are three green circles going around; -The life vest company provided training when they came and checked the life vest; -The facility has not provided any training on the life vest prior to the resident's admission; -He/She made a nurses note with the details of [DATE] but it must not have saved as there was no nurse's note in the resident's medical record; -He/She made a late entry in the progress notes to indicate the problems of [DATE]; -He/She did not make the DON aware of the life vest issues because she was hard to get a hold of. During an interview on [DATE], at 1:30 P.M., the medical director said the following: -He was aware the resident had a life vest; -The resident's cardiologist recommended the life vest after a recent hospitalization ; -He was made aware of the malfunctioning life vest, but was told a representative had been called; -He was not made aware of the battery being removed; -If he had known the life vest was not going to be functional for an extended period of time, a plan for monitoring the resident's cardiac condition would have been put in place with a potential re-hospitalization ; -It would be the facility's responsibility to make sure staff know how the life vest works; -If the life vest was not fully functional, the resident could experience symptoms such as dizziness, [CONDITION(S)] (a temporary loss of consciousness/[CONDITION(S)]), another episode of a-fib or potentially death. During an interview on [DATE] at 6:15 P.M. and 6:30 P.M., the DON said the following: -She was aware the resident had a life vest; -The life vest was used for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -You can tell the life vest is functioning by looking at the connection and the machine; -If the screen on the unit is blank, it is not functioning; -She had training on the life vest in 2020; -The charge nurse was responsible for checking to make sure the life vest was functioning properly; -There should be an order to check the life vest and a space on the MAR/TAR to check to show monitoring was completed; -If there was not a space on the MAR/TAR for monitoring the life vest, it would be indicated on the care plan; -Staff have been trained on the life vest (in 2020 prior to the resident's admission); -The battery has to be in the pack for the life vest to be functional; -She noticed the battery was not in the pack between 8:00 A.M. and 9:00 A.M. on [DATE] and she put the battery back in the life vest; -Staff did not notify her over the holiday of any issues with the life vest; -The life vest representative came the facility (on [DATE] at approximately 6:30 P.M.) and gave new leads and a new life vest for the resident and the vest is fully functional at this time. During an interview on [DATE] at 2:16 P.M., the administrator said the following: -He was aware a resident was admitted with a life vest; -He was not sure what a life vest was other than it was something clinical; -He was unsure if the life vest for the resident was functioning. Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #1 left, anterior foot (mid) is an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 28 cm length, 27 cm width, 0.8 cm depth, tendon is exposed. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has ,d+[DATE]% slough, ,d+[DATE]% bright red granulation. The periwound skin color is normal, with scarring present and moist; -Wound #2 left, medial ankle is an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 3 cm length, 8 cm width, 0.8 cm depth. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has ,d+[DATE]% bright red granulation. The periwound skin color is normal, with scarring, and was moist; -Wound Orders: -Wound #1 left, anterior foot (mid): Cleanse wound and peri-wound with saline, apply skin protectant to peri-wound, apply calcium alginate to wound base, apply Santyl to wound base, cover with super absorbent pad, wrap with roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal; -Wound #2 left, medial ankle: Cleanse wound and peri-wound with saline, apply skin protectant to peri-wound, apply calcium alginate to wound base, apply Santyl to wound base, cover with super absorbent pad, wrap with roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. Review of the resident's weight record, dated [DATE], showed the resident weighed 176.2 lbs (weight loss of 23.8 lbs since [DATE]). Review of the resident's medical record showed no evidence staff notified the registered dietician or the resident's physician of the resident's 28.8 lb weight loss. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Cardiologist appointment rescheduled to [DATE]; -New orders for daily weights, blood pressure, pulse, and oxygen saturation orders given by the cardiologist added to the resident's orders. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -New order for [MEDICATION(S)] (medication used to treat high blood pressure) HCL extended release 24 hour beads, 360 mg; -Obtain pulse, blood pressure, oxygen saturation, and weights daily. Review of the resident's TAR, dated [DATE], showed the resident weighed 176.2 lbs. Review of the resident's Nurses Notes, dated [DATE], showed the following: -The resident's life vest had blue dye coming from it; -Staff notified the resident's physician who said it was because the life vest activated and shocked the resident; -The resident's pulse was 132; -The resident was sent to the emergency room and returned to the facility with a new order for [MEDICATION(S)] (medication for irregular heart beats). Review of the resident's TAR, dated [DATE], showed staff did not complete the Santyl and calcium alginate treatment to the resident's left foot due to the resident was hospitalized . Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #1 left, anterior foot (mid) is an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 19 cm length, 20 cm width, 0.8 cm depth, tendon is exposed. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has ,d+[DATE]% slough, ,d+[DATE]% bright red granulation. The periwound skin color is normal with scarring, and was moist; -Wound #2 left, medial ankle is an acute full thickness surgical wound and has received a status of not healed. Wound measurements are 3 cm length, 8 cm width, 0.8 cm depth. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has ,d+[DATE]% bright red granulation. The periwound skin color is normal with scarring, and periwound was moist; -Wound Orders: -Wound #1 left, anterior foot (mid): Cleanse wound and peri-wound with saline, apply skin protectant to peri-wound, apply calcium alginate to wound base, apply Santyl to wound base, cover with super absorbent pad, wrap with roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled remo

Based on observation, interview and record review the facility failed to adequately assess, provide ordered treatments, and provide preventative measures for one resident (Resident #459) who was admitted with a Stage II pressure ulcer on his/her coccyx. Facility staff failed to complete ordered treatments, did not provide a pressure reducing air mattress until 13 days after admission and did not notify the nurse practitioner when the resident refused to turn in bed due to pain from his/her wounds. The facility failed to provide adequate pain relief which resulted in non-compliance with the resident for turning and repositioning. The facility also failed to monitor nutrition and provide interventions to aid in wound healing. The facility failed to monitor and report signs and symptoms of infection which resulted in hospitalization for [CONDITION(S)] on [DATE]. The facility also failed to communicate the recommended treatments to the physician to obtain orders for the treatments as new wounds developed and wounds deteriorated, which resulted in no treatments done for the wounds. The resident was admitted to the hospital with [CONDITION(S)], a Stage IV ulcer on his/her coccyx, multiple pressure areas on his/her back and an unstageable ulcer on his/her right heel. The resident expired as a result of [CONDITION(S)] on [DATE]. The facility also failed to adequately assess and identify wounds, or communicate them to the physician for one resident (Resident #27). The facility failed to consistently reposition the resident off his/her back. The facility census was 109. The administrator was notified on [DATE] at 4:57 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated [DATE], showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [CONDITION(S)] (redness). Presence of blanchable [CONDITION(S)] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from healthy skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer). Review of the Resident Assessment Instrument (RAI) manual, a manual directing the completion of the Minimum Data Set (MDS) a federally mandated assessment, dated [DATE], showed the following: -Moisture Associated Skin Damage (MASD) is also referred to as maceration and includes incontinence-associated [CONDITION(S)], intertriginous [CONDITION(S)], periwound moisture-associated [CONDITION(S)], and peristomal moisture-associated [CONDITION(S)]; -Moisture exposure and MASD are risk factors for pressure ulcer/injury development. Provision of optimal skin care and early identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -MASD without skin erosion is characterized by red/bright red color (hyperpigmentation), and the surrounding skin may be white (hypopigmentation). The skin damage is usually blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present; -MASD with skin erosion has superficial/partial thickness skin loss and may have hyper- or hypopigmentation; the tissue is blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. Necrosis is not found in MASD; -If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury; -If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis is present, code the skin damage as a pressure ulcer. Review of the facility's policy Pressure Injury Prevention and Management, dated [DATE], showed the following: -Facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers/injuries; -Pressure Ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -Facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate; -Licensed nurses will conduct a pressure injury risk assessment on all residents upon admission/readmission, weekly for four weeks, then monthly or whenever the resident's condition changes significantly; -Risk factors include but are not limited to: -Impaired/decreased mobility and decreased functional ability; -Co-morbid conditions; -Drugs that may affect healing; -Impaired diffuse or localized blood flow; -Exposure of the skin to urinary and fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; and -The presence of a previously healed pressure ulcer; -Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury and findings will be documented in the resident's record; -Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record; -The staging of pressure ulcers will be clearly identified to ensure correct coding on the MDS; -Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task; -Training in the completion of the pressure ulcer risk assessment, full body skin assessment, and pressure ulcer assessment will be provided as needed; -After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions; -Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure ulcer assessment; -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure ulcer present. Basic or routine care interventions could include, but are not limited to: -Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); -Minimize exposure to moisture and keep skin clean, especially of fecal contamination; -Provide appropriate, pressure-redistributing, support surfaces; -Maintain or improve nutrition and hydration status, where feasible; -Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure ulcer present: -Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue; -Interventions will be documented in the care plan and communicated to all relevant staff; -Registered Nurse unit manager or designee will review all relevant documentation regarding skin assessments, pressure ulcer risks, progression towards healing and compliance at least weekly, and document a summary of findings in the medical record; -The attending physician will be notified of: -The presence of a new pressure injury upon identification; -The progression towards healing, or lack of healing, of any pressure ulcers weekly; -Any complications (such as infection, development of a sinus tract, etc.) as needed; -Any changes to the facility's pressure ulcer prevention and management processes will be communicated to relevant staff in a timely manner; -Interventions on a resident's plan of care will be modified as needed, considerations include: -Changes in resident's degree of risk for developing a pressure ulcer; -New onset or recurrent pressure ulcer development; -Lack of progression towards healing; -Resident non-compliance; -Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1. Review of Resident #459's face sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated [DATE], showed the following: -Pressure ulcer to coccyx (tailbone) present on admission to the hospital, and on discharge from the hospital; -Weight 200 lbs. (pounds) taken on [DATE]; -Resident wanted coccyx wound dressing to be changed at the new facility. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -House barrier cream after incontinent episodes and as needed; -Weekly skin assessment on Saturdays; -Weigh resident on admission and weekly for four weeks; -Assess pain level every shift; -Acetaminophen (pain reliever) 325 mg (milligrams), 2 tablets by mouth every six hours as needed for pain/fever; -[MEDICATION(S)] (medication for anxiety) 0.5 mg by mouth every eight hours as needed for anxiety; -[MEDICATION(S)] (narcotic pain medication) ,d+[DATE] mg 1 tablet by mouth every six hours as needed for pain. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Resident admitted to the facility at 7:00 P.M.; -Stage II pressure ulcer on coccyx; -Incontinent of bowel and bladder. Review of the resident's Admission Assessment, dated [DATE]-[DATE], showed the following: -Resident admitted from the hospital; -Requires extensive physical assistance with bed mobility, transfers, dressing, toilet use, and hygiene; -Dependent with bathing; -Coccyx wound; -Weight 200 lbs. Review of the resident's Braden (skin risk assessment), dated [DATE], showed the following: -Sensory Perception, 3, responds to verbal commands, but cannot always communicate discomfort or the need to be turned or has a sensory impairment which limits the ability to feel pain or discomfort over half of the body; -Moisture, 3, occasionally moist, skin is occasionally moist, requiring and extra linen change approximately once a day; -Activity, 1, bedfast; -Mobility, 3, makes frequent though slight changes in body or extremity position independently; -Nutrition, 3, adequate, eats over half of most meals, eats a total of four servings of protein, occasionally will refuse a meal, but will usually take a supplement when offered; -Friction and Shear, 2, potential problem, moves feebly or requires minimum assistance, during a move skin probably slides to some extent against sheets, chair, restraints or other devices, maintains relatively good position in chair or bed most of the time but occasionally slides down; -Scored 15, at risk. Review of the resident's POS, dated [DATE], showed Santyl Ointment 250 unit/gram (a gel applied for removal of dead tissue) cleanse wound on buttocks Stage II pressure ulcer with wound cleanser, apply Santyl and cover with bordered dressing daily. Review of the resident's Weekly Skin Check, dated [DATE], showed the resident had a Stage II pressure ulcer to the resident's coccyx. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed the following: -Santyl to coccyx Stage II pressure ulcer, clean wound with wound cleanser, apply Santyl and cover with bordered dressing daily: There was no documentation to show staff completed the treatment; -The house barrier cream ordered on [DATE], was not included on the resident's TAR. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess pain every shift; -No documentation the resident's pain level was assessed on the day shift; -Evening shift documented the resident's pain at a 5 on a ,d+[DATE] scale; -[MEDICATION(S)] ,d+[DATE] mg every six hours as needed for pain, not administered; -Tylenol 650 mg every six hours as needed, not administered. Review of the resident's MAR, dated [DATE], showed the following: -Assess pain every shift; -Day shift documented the resident's pain at a 10 on a ,d+[DATE] scale with 10 being the worst pain imaginable: -Evening shift documented the resident's pain at a 10 on a ,d+[DATE] scale; -[MEDICATION(S)] ,d+[DATE] mg every six hours as needed for pain, not administered; -Tylenol 650 mg every six hours as needed, not administered. Review of the resident's MAR, dated [DATE], showed the following: -Assess pain every shift; -[MEDICATION(S)] administered for a pain level of 5 at 5:20 P.M., charted as effective at 8:20 P.M. Review of the resident's TAR, dated [DATE], showed the following: -Santyl to coccyx Stage II pressure ulcer, clean wound with wound cleanser, apply Santyl and cover with bordered dressing daily; -There was no documentation to show staff completed the Santyl treatment to the coccyx. Review of the resident's TAR, dated [DATE], showed the following: -Treatment order for Santyl to coccyx Stage II pressure ulcer, clean wound with wound cleanser, apply Santyl and cover with bordered dressing daily, documented as completed; -Treatment order for Santyl to coccyx Stage II pressure ulcer, clean wound with wound cleanser, apply Santyl and cover with bordered dressing daily, discontinued on [DATE]. Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #3 coccyx is an acute moisture associated skin damage (MASD) and has received a status of not healed. Wound measurements are 8 cm length, 8 cm width, 0.1 cm depth, no drainage noted. Wound bed has ,d+[DATE]% epithelialization (a process of covering denuded skin). The periwound skin exhibited excoriation (act of abrading or wearing off the skin ) dry/scaly, and ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) present. -Wound Orders: -Wound #3 coccyx: Cleanse wound with soap and water, pat dry, apply moisture barrier of facility choice, follow product instruction. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Resident seen by traveling Wound Care service for wound assessment; -Resident noted to have tendons exposed with areas of necrosis (dead tissue) noted; -Orders for Santyl with calcium alginate (a dressing that absorbs drainage), cover with pad, and kerlix and secure with tape; -Note did not specify the location of the wound this note addressed and was not consistent with the Wound Care Center Progress Noted dated [DATE]. Review of the resident's POS, dated [DATE], did not include a treatment order to the pressure ulcer on the resident's coccyx. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the coccyx. Review of the resident's MAR, dated [DATE], showed no pain medication administered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the following: -Moderate cognitive impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -No behaviors or rejection of care; -Requires extensive physical assistance of one staff member for bed mobility, toilet use, hygiene, and bathing; -Physical transfers from bed to chair did not occur; -Occasionally incontinent of bladder; -Always incontinent of bowel; -Received as needed pain medication; -Not on scheduled pain medications; -Pain is present frequently, -Resident rated pain a 7 on a ,d+[DATE] scale (0=no pain, 10 worst pain you can imagine); -Weighs 200 pounds (lbs.); -One Stage II pressure ulcer present on admission; -No Moisture Associated Skin Damage (MASD); -Pressure reducing device for chair and bed. Review of the resident's POS, dated [DATE], showed the resident was to be non-weight bearing to the left side. Review of the resident's Care Plan, dated [DATE], showed the following: -Resident plans to return home with home health; -ADL deficit related to decreased strength, back pain, and leg impairments; -Non-weight bearing to the left side; -Requires assistance of one for bed mobility, dressing, hygiene, and toilet use,; -Transfer with assist of two staff members with a mechanical lift; -Encourage adequate nutrition; -Resident complains of pain in his/her back; -Administer analgesia (pain medication) as per orders. Give/offer ,d+[DATE] hour before treatments or care; -Anticipate the need for pain relief and respond immediately to any complaint of pain; -Monitor/record/report to nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy,constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing); -Monitor/record/report to nurse other signs of pain: loss of appetite, refusal to eat and weight loss; -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease with range of motion withdrawal or resistance to care which could be related to pain; -Resident has actual impairment to skin integrity of the left lower leg, back and coccyx; -Encourage good nutrition and hydration in order to promote healthier skin; -May use a draw sheet or lifting device to move resident; -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks out of blood vessels into nearby tissues) and any other notable changes or observations. Review of the resident's Braden Scale, dated [DATE], showed the following: -Sensory Perception, 4, no impairment; -Moisture, 3, occasionally moist, skin is occasionally moist, requiring and extra linen change approximately once a day; -Activity, 2 chair fast, ability to walk severely limited or non-existent, cannot bear own weight and/or must be assisted into chair or wheelchair; -Mobility, 3, makes frequent though slight changes in body or extremity position independently; -Nutrition, 3, adequate, eats over half of most meals, eats a total of 4 servings of protein, occasionally will refuse a meal, but will usually take a supplement when offered; -Friction and Shear, 1, problem, requires moderate to maximum assistance in moving, complete lifting without sliding against sheets is impossible; -Scored 16, at risk. Review of the resident's Nurses Note dated [DATE] at 12:35 A.M., showed resident crying out, when asked what was wrong the resident replied, I hurt, resident rates pain an 8 on a ,d+[DATE] scale. Review of the resident's TAR, dated [DATE], did not include a treatment order for the resident's pressure ulcer on his/her coccyx. Review of the resident's MAR, dated [DATE], showed the following: -[MEDICATION(S)] administered at 12:35 A.M. for a pain level of 8 (carried over from [DATE]), charted as effective at 1:42 A.M.; -[MEDICATION(S)] administered at 6:30 A.M. for a pain level of 8, charted as effective at 1:15 P.M. -Day shift pain level assessed at a 3, no additional Tylenol or [MEDICATION(S)] administered; -Evening shift pain level assessed at a 3, no additional Tylenol or [MEDICATION(S)] administered. Review of the resident's Weekly Skin Check, dated [DATE], showed the staff documented no new areas. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the resident's coccyx. Review of the resident's MAR, dated [DATE], showed no pain medication administered. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the resident's coccyx. Review of the resident's MAR, dated [DATE], showed the following: -Evening shift pain level assessed at a 3; -No medication given for pain. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order for the resident's pressure ulcer on his/her coccyx. Review of the resident's MAR, dated [DATE], showed the following: -[MEDICATION(S)] administered at 12:24 A.M. (overnight on [DATE]) for pain level of 5; -Pain level not documented for night shift. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order for the pressure ulcer on the resident's coccyx. Review of the resident's MAR, dated [DATE], showed the following: -[MEDICATION(S)] administered at 5:25 P.M. for pain level of 7; -Pain medication documented as effective at 8:22 P.M. Review of the resident's Registered Dietitian note, dated [DATE], showed the following: -Weight 200 lbs.; -Consumes 51%-75% of most meals; -No labs; -Stage II on coccyx and open wound to foot and heel (surgical wounds); -Recommend multivitamin with minerals and 500 mg of vitamin C two times daily. Review of the resident's medical record showed no evidence staff communicated the facility dietitian's recommendations to the physician. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order for the resident's pressure ulcer on his/her coccyx. Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #3 coccyx is an acute partial thickness MASD and has received a status of not healed. Wound measurements are 8.5 cm length, 8.5 cm width, 0.3 cm depth, with a moderate amount of sanguineous drainage noted. Wound bed has ,d+[DATE]% epithelialization, 26%-50% eschar (a type of necrotic tissue that is dryer than slough, adheres to the wound bed, and has a spongy or leather-like appearance). The periwound skin exhibited excoriation, moist, and ecchymosis present. -Wound Orders: - Wound #3 coccyx: New order, cleanse wound and peri-wound with saline, apply skin protectant to peri-wound, apply calcium alginate to wound base, apply Santyl to wound base, cover with bordered gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. (Review of the RAI manual showed necrotic tissue is not present in MASD, and should be coded as pressure). Review of the resident's medical record showed no evidence the treatment order recommended for the coccyx wound on [DATE] was communicated to the physician, placed on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Nurses Notes, dated [DATE], showed the following: -Resident moved closer to the nurses' station; -Needs a low air loss mattress, will add; -Resident has a video visit on [DATE] at 10:30 A.M. and will need current vital signs and weight. Review of the resident's MAR, dated [DATE], showed staff administered [MEDICATION(S)] at 9:06 A.M. for a pain level of 8, charted effective at 1:21 P.M. Review of the resident's Nurse Practitioner Note, dated [DATE], showed the following: -Wounds noted to the thoracic (pertaining to the chest) region of the spine, and coccyx; -No pain reported; -Prescription for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed no evidence the treatment order for medi-honey and calcium alginate was carried through to the POS or the TAR. Review of the resident's POS, dated [DATE], showed it did not include a treatment order to the wound on the coccyx, or the three wounds on the resident's back. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the wound on the coccyx or the three wounds on the resident's back. Review of the resident's weight record, dated [DATE], showed the resident lost 23.8 lbs. down from 200 lbs. on [DATE], and now weighed 176.2 lbs. Review of the resident's medical record (Nurses Notes, Dietician Notes, Physician Notes, and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no new orders to address the weight loss. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Obtain pulse, blood pressure, oxygen saturation, and weights daily. Review of the resident's Braden Scale, dated [DATE], showed the following: -Sensory Perception, 2, very limited, responds only to painful stimuli, cannot communicate discomfort except by moaning or restlessness or has sensory impairment which limits the ability to feel pain or discomfort over half of the body; -Moisture, 1, constantly moist, skin is kept moist almost constantly by perspiration, urine, etc., dampness is detected every time resident is moved or turned; -Activity, 1, bedfast; -Mobility, 2, very limited, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently; -Nutrition, 3, probably inadequate, rarely eats a complete meal and generally eats only about half of the food offered; -Friction and Shear, 1, problem, requires moderate to maximum assistance in moving, complete lifting without sliding against sheets is impossible; -Scored 9, very high risk; -The Braden score showed an increase in the risk of pressure ulcer development, and decline in function from the previous assessment. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Cardiologist appointment rescheduled to [DATE]; -New orders for daily weights, blood pressure, pulse, and oxygen saturation orders given by the cardiologist added to the resident's orders. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the resident's coccyx or the three wounds identified on the resident's back. Review of the resident's Medication Administration Records, dated [DATE], showed the following: -Pain assessed at a 4 on evening shift, no Tylenol or [MEDICATION(S)] administered; -[MEDICATION(S)] administered at 10:58 P.M. for a pain level of 7, charted effective on [DATE], at 2:31 A.M. Review of the resident's Nurse Notes, dated [DATE], at 10:58 P.M., showed the resident complained of butt pain. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the wound on the coccyx or the three wounds on the resident's back. Review of the resident's Medication Administration Records, dated [DATE], showed the following: -Evening shift documented a pain level of 5; -No Tylenol or [MEDICATION(S)] administered; Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the resident's coccyx or the three wounds on the resident's back. Review of the resident's MAR, dated [DATE], showed the following: -Day shift documented a pain level of 5, -No documentation staff administered Tylenol or [MEDICATION(S)]. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order to the pressure ulcer on the resident's coccyx or the three wounds on the resident's back. Review of the resident's MAR, dated [DATE], showed the following: -Day shift did not document a pain score; -Evening shift documented a pain level of 5, no documentation staff administered Tylenol or [MEDICATION(S)]. Review of the resident's POS, dated [DATE], showed the following: -Skin-Prep (Skin Protectant wipe), apply to to right heel topically one time a day to right heel and cover with border gauze to promote wound healing; -Skin-Prep (Skin Protectant wipe), apply to upper/middle/right back topically one time a day to middle upper back right side and cover with foam to promote wound healing; -Santyl ointment 250 unit/gram, apply to medial coccyx topically to promote wound healing, cleanse area with normal saline, pat dry, apply nickel thick amount of Santyl, cover with calcium alginate, then gauze, and cover with bordered gauze daily. Review of the resident's TAR, dated [DATE], showed it did not include a treatment order for the pressure ulcer on the resident's coccyx or the three wounds on the resident's back. Review of the resident's MAR, dated [DATE], showed the following: -Day shift pain score documented at a level of 10, no documentation staff administered Tylenol or [MEDICATION(S)]; -Evening shift documented a pain level of 10, [MEDICATION(S)] and [MEDICATION(S)] administered at 3:14 P.M. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Resident screaming out for help repeatedly; -Turned and repositioned each time; -Pain medications given with little effect; -Resident keeps asking to remove things from his/her buttocks, but it is a wound. Review of the resident's Wound Care Center Progress Note, dated [DATE], showed the following: -Wound #3 coccyx is an acute pressure ulcer and has received a status of not healed. Wound measurements are 9 cm length, 9 cm width, 1.8 cm depth, bone is exposed. Undermining has been noted at 12:00 and ends at 3:00 with a maximum distance of 2.5 cm. There is a moderate amount of sanguineous drainage noted. Wound bed has ,d+[DATE]% slough. The wound is deteriorating. The periwound skin exhibited excoriation, periwound moist, and ecchymosis present; - Wound #4 right heel is an acute full thickness (no identification if due to pressure), and has received a status of not healed. Wound measurements are 2 cm length, 3 cm width, 0.1 c

Based on observation, interview, and record review the facility failed to ensure one resident (Resident #555) was free from sexual abuse by Certified Nurse Assistant (CNA) FFF. Resident #555 reported CNA FFF raped him/her. The resident said CNA FFF put his/her genitalia in the resident's mouth and rectum. The resident was fearful. The facility census was 109. The administrator was notified on 10/4/21 at 4:57 P.M. of the Immediate Jeopardy (IJ) which began on 5/23/21. The IJ was removed on 10/4/21 as confirmed by the surveyor onsite verification. CNA FFF was suspended on 5/23/21 from the building pending investigation and terminated. Review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 9/1/21, showed the following: -It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal guidelines within prescribed timeframes; -The facility shall develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -1. Screening: The facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries; -2. Training: New employees will be educated on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Additional education will be provided as situations arise; -3. Prevention: The facility will provide resident, families and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur; -4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of a mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; ii. Sexual abuse is the non-consensual sexual contact of any type with a resident; -5. Alleged violations: A situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property; -6. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below; -7. Protection: The facility will protect residents from harm during an investigation; -8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences; -Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: -Any owner, operator, employee, manager, agent or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation; -When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident; b. Remove the accused employee from resident care area; c. Notify the Director of Nursing Services and Administrator; d. Notify the attending physician, resident's family/legal representative, and Medical Director; e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions; f. Document actions taken in the medical record; g. Complete an incident report and initiate an investigation; 2. The Director of Nursing Services, Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than two hours after discovery or forming the suspicion; b. Obtain statements from direct care staff; c. Suspend the accused employee pending completion of the investigation; d. Follow up with appropriate agencies, during business hours, to confirm the report was received; e. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service; 3. The Administrator should follow up with government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final as required by the state. 1. Review of Resident #555's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/21, showed the following: -Moderate cognitive impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Able to express ideas and wants, understood; -No acute mental status changes; -No hallucinations, delusions, or behaviors; -Requires extensive physical assistance of one person for bed mobility, transfers, eating, dressing, toilet use, and hygiene; Review of the resident's Nurses Notes, dated 5/23/21 at 5:00 P.M., showed the following: -Resident accused certified nurse assistant (CNA) of improperly touching him/her; -Director of Nursing (DON) called. CNA sent home and suspended till investigation complete. Review of the resident's Nurses Notes, dated 5/23/21 at 6:00 P.M., showed the police arrived at the front door of the facility and explained the resident's Family Member A called and wanted police to investigate. Review of the resident's Nurses Notes, dated 5/23/21 at 7:52 P.M., showed the following: -Resident's Family Member A called the facility to notify of allegations brought forth by the resident; -Nurse was notified and went to check on resident; -Resident said he/she didn't want to talk to the nurse about the allegation, but said, they raped me; -He/She then said, it was the boy/girl (resident identified gender); -Resident safety was verified; -CNA was escorted out of the building; -Administrator/DON notified; -Nurse Practitioner notified; -Police arrived at the facility to investigate; -Emergency Medical Service (EMS) arrived and transported the resident to the hospital. Review of the facility's investigation, undated, showed the following: -During the afternoon shift on 5/23/21, Certified Medication Technician (CMT) Z took a call from the resident's Family Member A; -Family Member A alleged the resident was raped; -Nursing supervisor, Licensed Practical Nurse (LPN) B, was notified; -LPN B immediately went to the resident's room to check the safety of the resident; -Resident reportedly said he/she was raped by the boy/girl (resident identified gender). -LPN B asked if it occurred this shift, and the resident said, Yes.; -Resident declined to provide additional information at that time; -CNA FFF was the only other staff person of the gender identified by the resident in the building during the shift; -LPN B contacted the DON and CNA FFF was suspended immediately pending the outcome of the investigation; -LPN B returned to resident's room to further assess the situation; -Resident said he/she did not want to speak to LPN B, but only to his/her Family Member A; -LPN B contacted the DON again, and while on the phone, the police entered the facility; -Police requested to speak to the resident, and the resident was subsequently sent to the hospital for the administration of a rape kit; -LPN B spoke to resident's Family Member A about the incident while police were at the facility; -The administrator arrived at the facility and began conducting an investigation; -Upon speaking to nursing staff, Resident #555 did not leave his/her room throughout the 3 -11 shift on 5/23/21; -Administrator spoke to the resident's roommate, Resident #75, who said he/she knew who CNA FFF was and he/she did not witness anything inappropriate or hurtful between CNA FFF and his/her roommate; -Interviewed five additional alert and oriented residents, Resident #99, #41, #600, #601, and #602; -All residents indicated knowing CNA FFF and he/she was never inappropriate with them; -All residents questioned said CNA FFF never hurt them; -All staff who worked on the evening shift were interviewed, no concerns were expressed, outside of the police being on campus; -Informed resident's Family Member A an investigation was being conducted; -LPN B said there were no signs of blood on the sheet or anything abnormal with the bedding or room; -Interview with CNA FFF on 5/25/21 in the morning showed CNA FFF said he/she worked on 5/23/21, on the C hall, between 3:00 and 3:30 P.M. He/She assisted the resident from his/her wheelchair to his/her bed, checked to see if he/she was dry, and passed ice water. CNA FFF said he/she dropped off the resident's dinner tray and then picked up his/her dinner tray; -Conclusion: Based upon staff and resident interviews, the facility cannot validate abuse. The results of the rape kit have not been provided to the facility. The facility was unable to provide the detailed notes from the investigation on the staff who were interviewed or if they asked CNA FFF when they questioned him/her if he/she touched Resident #555 sexually or exhibited any other inappropriate behavior. Review of the resident's Hospital Face Sheet showed the resident arrived at the emergency roiagnom on [DATE] at 8:05 P.M. Review of the resident's Emergency Department Provider Notes, dated 5/23/21, showed the following: -The resident arrived with EMS (emergency medical services) and police department after possible sexual assault at the facility; -EMS said the resident began having pain in his/her genitalia after an incident that occurred at approximately 5:00 P.M.; -Resident reports he/she was sexually assaulted today by an aide at the facility; -Resident also reports his/her arm was twisted today by the aide who assaulted him/her; -Police asked all bedding to be bagged, and gown bagged separately; -Positive for dysuria (painful or difficult urination); -Diaper cream covering majority of perineum, no obvious signs of bruising, injury, tear or blood; -Speculum exam with scant white genital discharge; -Cooperative and consented to exam; -Rape kit collected; -Complains of dysuria, urine without infection confirmed by labs, pelvic exam without concerning lesion/finding; -Clinical Impressions: alleged assault; -For full details see Sexual Assault Nurses Note (SANE) note; -Resident was admitted to the hospital until they could confirm he/she would be safe at the nursing facility. Review of the resident's SANE note, dated 5/23/21, showed the following: -Presented to the Emergency Department with complaint of genital pain and possible sexual assault; -Resident said he/she was tired and his/her aide (identified by first name of CNA FFF) laid him/her down; -He/She went to sleep; -CNA FFF (resident identified CNA FFF by first name), pulled his/her cover off and took his/her clothes off; -CNA FFF (resident identified CNA FFF by first name), told him/her to eat and twisted his/her arms trying to get him/her to eat; -Resident said he/she did not know what CNA FFF was wearing but it stinked (stunk); -He/She was raped without his/her consent; -Resident said CNA FFF took his/her clothes off, and that he/she came into his/her room naked; -Genital and anal swabs collected. During an interview on 5/24/21, at 6:00 P.M., CNA I said the following: -On 5/23/21 around 4:00 P.M., Resident #555 was upset, he/she asked the resident what was wrong; -The resident said CNA FFF raped him/her; -LPN B walked into his/her room, and the resident told both of them that CNA FFF raped him/her; -The resident got upset and said we didn't believe him/her. During an interview on 6/3/21, at 3:15 P.M., LPN B said the following: -The resident said CNA FFF raped him/her; -The police showed up ten minutes later, and would not let him/her talk to or examine the resident; -The police called EMS and sent the resident to the hospital; -He/She notified the DON. During an interview on 5/24/21, at 6:15 P.M., the DON said the following: -LPN B texted him/her on 5/23/21, at 5:41 P.M. that said call me, it's urgent; -LPN B reported the allegations made by the resident; -She instructed him/her to suspend CNA FFF from the building pending investigation; -When she got there the police did not permit her or any staff to speak to the resident. During an interview on 5/24/21, at 2:30 P.M., the resident's roommate, Resident #75, said the following: -He/She was not in his/her room on 5/23/21 from 4:00 P.M. until after dinner; -When he/she came back to the room, he/she could tell Resident #555 was upset by his/her body language, but he/she did not say anything; -CNA FFF was rough with him/her when CNA FFF cleaned the resident in his/her perineal region, the CNA wipes repeatedly, was rough, and it hurt. During an interview on 5/25/21, at 1:57 P.M., the resident's Family Member A said the following: -The resident told him/her that the resident called Family Member B, and said CNA FFF raped him/her and the staff didn't believe him/her, they laughed at him/her; -He/She called the police so they could make sure the resident was okay; -The resident told him/her that CNA FFF exposed himself/herself to him/her, and tried to put his/her genitalia in the resident's mouth and in his/her rectum; -The resident was not one to complain or stand up for himself/herself, he/she was more the type to just keep things to himself/herself. During an interview on 5/25/21, at 3:30 P.M., Family Member B said the following: -Right after it happened, the resident called him/her and was upset; -He/She said CNA FFF raped him/her; -He/She said someone came into the room and saw it and they were laughing at him/her. Observation of and interview with the resident on 6/3/21, at 2:20 P.M., showed the following: -The resident said, CNA FFF (said CNA FFF's first name) raped me; -He/She told one of the nurses and they didn't do anything; -They laughed at me, clarified staff laughed at him/her; -An employee told him/her not to call the police, he/she would take care of it; -Then the employee told him/her that CNA FFF was suspended; -When asked if CNA FFF hurt the resident, he/she motioned and pointed to his/her buttocks, and then to his/her arm; -When asked details of what happened, the resident was visually upset, put his/her head down into his/her hand, and his/her eye watered; -The resident said he/she did not want to talk about it because he/she had to think about what happened; -The resident said afterward CNA FFF washed himself/herself up in the sink when he/she finished; -It made him/her feel terrible; -Throughout the interview, the resident would get upset, put his/her head in his/her hands, and his/her voice would get softer. During an interview on 5/24/21, at 5:35 P.M., Staffing Coordinator Certified Medication Technician (CMT) Z said the following: -He/She heard about the allegations made against CNA FFF by the resident around 4:30 P.M.; -The resident told his/her Family Member A who called about 6:00 P.M.; -The resident has said CNA FFF was rough with care before; -CMT Z had tried to keep CNA FFF off C hall. During an interview on 5/25/21, at 4:00 P.M., the administrator said the following: -Residents in the facility's care should not experience abuse or neglect; -The facility prohibits abuse and neglect; -All allegations of abuse and neglect are investigated as the facility policy directs; -All staff are educated on hire and annually on prevention, identification, and reporting abuse; -The facility was unable to substantiate abuse for this investigation; -The CNA was terminated based on care concerns uncovered by the investigation. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s). MO 5 MO 9 MO 1 MO 8 MO 1

Based on observation, interview and record review, the facility failed to assess, monitor, and treat pain and failed to ensure pain medication was available when needed for two residents (Resident #2 and #80) of 56 sampled residents, and one additional sampled resident (Resident #459). Resident #459 experienced pain with wounds and the lack of pain relief contributed to a deterioration in his/her condition. The facility census was 109. Review of the facility's policy, Pain Management, dated 9/1/21, showed the following: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain; -Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility shall: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain); c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences; 2. Facility staff shall observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g. limping), skin color, vital signs (e.g. increased heart rate, respirations, and/or blood pressure), perspiration; b. Loss of function or inability to perform activities of daily (ADLs) (e.g. rubbing a specific locations of the body, or guarding a limb or other body parts); c. Fidgeting, increased or recurring restlessness; d. Facial expressions (e.g. grimacing, frowning, fright or clenching of the jaw); e. Behavior such as: resisting care, distressed pacing, irritability, depressed mood or decreased participation in unusual physical and/or social activities; f. Difficulty eating or loss of appetite; g. Weight loss h. Difficulty sleeping ([CONDITION(S)]); i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming); j. Decline in activity level; k. Skin conditions; 3. Facility staff shall be aware of verbal descriptors a resident may use to report or describe their plan. Descriptors include but are not limited to: a. Heaviness or pressure; b. Stabbing; c. Throbbing; d. Hurting or aching; e. Gnawing; f. Cramping; g. Burning; h. Numbness, tingling, shooting or radiating; i. Spasms; j. Soreness, tenderness, discomfort, pins and needles; k. Feeling rough, tearing or ripping; -Pain Assessment: 1. The facility shall utilize a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: a. History of pain and its treatment (including non-pharmacological, pharmacological, and alternative medicine (CAM) treatment and whether or not each treatment has been effective); b. Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident; c. Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post [CONDITION(S)], venous and arterial ulcers, and [CONDITION(S)]); d. Identifying key characteristics of the pain: i. Duration of pain; ii. Frequency; iii. Location; iv. Timing; v. Pattern (e.g. constant or intermittent); vi. [CONDITION(S)] of pain; e. Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms); f. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain; g. Impact of pain on quality of life (e.g., sleeping, functioning, appetite and mood); h. Current prescribed pain medications, dosage and frequency; i. The resident's goals for pain management and his/her satisfaction with the current level of pain control; j. Physical and psychosocial issues that might be causing or exacerbating the pain; k. Additional symptoms associated with pain (e.g. nausea, anxiety); -Pain Management and treatment: 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary; 2. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal; 3. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment; 4. Factors influencing the choice of treatments include: a. The cause, location and severity of the resident's pain; b. The resident's current medical condition; c. The resident's current medications; d. The resident's desired level of relief and tolerance for adverse consequences (e.g. partial pain relief for fewer significant adverse reactions); e. Potential benefits, risks and adverse consequences of medications f. Available treatment options; g. Resident's elected hospice benefit; 5. Non-pharmacological interventions may include but are not limited to: a. Environmental comfort measures (e.g. adjusting room temperature, smoothing linens, comfortable seating or assistive devices); b. Loosening any constrictive bandage, clothing or device; c. Applying splinting (e.g., pillow or folded blanket); d. Physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning); e. Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility; f. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain; 6. Pharmacological interventions shall follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team shall develop a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate [MEDICATION(S)] therapy for pain; b. Consider evidence-based practice tools to assist in the assessment of the resident's pain; c. Consider administering medication around the clock instead of PRN or combining longer acting medications with PRN medications for breakthrough pain; d. Utilized the most effective and least invasive route for [MEDICATION(S)] administration (e.g., oral, rectal, topical, injection, infusion pump and/or transdermal); e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved; f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects; g. Review clinical conditions which may require several analgesics and/or adjuvant medications. Documentation will clarify the rationale for a treatment regimen and acknowledge associated risks; h. Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturer's guidelines to optimize their effectiveness and minimize their adverse consequences; i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen; j. Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with more advanced, complex or poorly controlled pain; 7. Monitoring, Reassessment and Care Plan Revision: a. Facility staff shall reassess resident's pain management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, [CONDITION(S)], respiratory depression, pruritus, nausea, vomiting, addition and falling asleep or drowsiness) at established intervals; b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated; c. If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team shall work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. Review of an In-Service Education Record, dated 7/22/21, showed the following: -Subject: Medication pass and sleeping resident; -All residents are to be awakened for medications, nursing assessments and treatments. Review of an undated In-Service Education Record regarding the facility Medication Unavailable Policy, showed the policy stated the following: - 1. If Meds are not available for administration: A. Search Medication cart; B. Obtain Medication from Emergency box if med is stocked, and notify the Pharmacy of the Missing medication; C. If med is not stocked immediately call the pharmacy to obtain medication; D. If pharmacy cannot deliver due to weather, a order to soon is triggered, the medication is not covered by insurance or the medication cannot be delivered within the ordered time frame, notify the MD and follow step #2 or #3; E. Notify MD if med cannot be given in the time frame ordered, and document MD response; -2. If the MD orders an available substitute medication and orders to DIC old: A. D/C current order, transcribe new order; B. Administer Medication; C. Notify the Pharmacy of new order; D. Document response in the Nurses Notes; -3. If the MD states to hold the medication until it is delivered: A. Hold current medication order and order time; B. When medication arrives transcribe as a new order and a new administration time, complete telephone order; C. Notify pharmacy of the new order; -4. If a Medication is not delivered the day that it is ordered you must: a. Call the Pharmacy to ascertain the status; b. Document the response; c. If the Medication is again not delivered the Administrator/DON must be notified for prompt intervention; -5. If you STAT order a medication: a. Call the pharmacy and report that a STAT order has been faxed; b. Give STAT info over phone and verify they received the info and will be sent out; -6. ALL new admissions send orders to be STAT. Call Rx for follow up they received stat order; -7. All Pharmacy concerns will be communicated to the DON for follow up. 1. Review of Resident #459's face sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's Hospital discharge records, dated 8/27/21, showed the following: -Pressure ulcer to coccyx (tailbone) present on admission to the hospital, and on discharge from the hospital; -Incision wounds to left foot and left medial foot; -Resident wanted coccyx wound dressing to be changed at the new facility. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess pain level every shift; -Acetaminophen (pain reliever) 325 mg (milligrams), 2 tablet by mouth every six hours as needed for pain/fever; -[MEDICATION(S)] (medication for anxiety) 0.5 mg by mouth every eight hours as needed for anxiety; -[MEDICATION(S)] (narcotic pain medication) 5-325 mg 1 tablet by mouth every six hours as needed for pain. Review of the resident's Nurses Notes, dated 8/27/21, showed the following: -Resident admitted to the facility at 7:00 P.M.; -Full code and is on a life vest (personal defibrillator worn by a patient at risk for sudden [CONDITION(S)]); -Stage II (partial-thickness loss of skin with exposed dermis) pressure ulcer on coccyx. Review of the resident's Admission Assessment, dated 8/27/21-8/28/21, showed the following: -Resident admitted from the hospital; -Requires extensive physical assistance with bed mobility, transfers, dressing, toilet use, and hygiene; -Dependent with bathing; -Coccyx wound. Review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess pain every shift; -On 8/28/21, no documentation staff assessed the resident's pain level on the day shift; -On 8/28/21, evening shift documented the resident's pain at a 5 on a 1-10 scale, [MEDICATION(S)] and Tylenol not administered; -On 8/29/21, day shift documented the resident's pain at a 10 on a 1-10 scale with 10 being the worst pain imaginable, [MEDICATION(S)] and Tylenol not administered; -On 8/29/21, evening shift documented the resident's pain at a 10 on a 1-10 scale, [MEDICATION(S)] and Tylenol, not administered. Review of the resident's Nurses Notes, dated 9/1/21, showed the following: -Resident seen by traveling Wound Care service for wound assessment; -Resident noted to have tendons exposed with areas of necrosis (dead tissue) noted to the left foot wound. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -No behaviors or rejection of care; -Requires extensive physical assistance of one staff member for bed mobility; -Physical transfers from bed to chair did not occur; -Received as needed pain medication; -Not on scheduled pain medications; -Pain was present frequently, -Resident rated pain a 7 on a 0-10 scale (0=no pain, 10 worst pain you can imagine); -One Stage II pressure ulcer present on admission; -Surgical wounds. Review of the resident's MAR, dated 9/2/21, showed no pain medication administered. Review of the resident's Care Plan, dated 9/3/21, showed the following: -Resident complains of pain in his/her back; -Administer [MEDICATION(S)] (pain medication) as per orders. Give/offer 1/2 hour before treatments or care; -Anticipate the need for pain relief and respond immediately to any complaint of pain; -Monitor/record/report to nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing); -Monitor/record/report to nurse other signs of pain: loss of appetite, refusal to eat and weight loss; -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease with range of motion or resistance to care which could be related to pain; -Resident has actual impairment to skin integrity of the left lower leg, back and coccyx; -May use a draw sheet or lifting device to move resident; -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the resident's Nurses Note dated 9/3/21 at 12:35 A.M., showed resident crying out, when asked what was wrong resident replied I hurt, resident rates pain an 8 on a 1-10 scale. Review of the resident's MAR, dated 9/3/21-9/9/21, showed the following: -9/3/21, day shift pain level assessed at a 3, no additional Tylenol or [MEDICATION(S)] administered; -9/3/21, evening shift pain level assessed at a 3, no additional Tylenol or [MEDICATION(S)] administered. -9/4/21, no pain medication administered; -9/5/21, evening shift pain level assessed at a 3 no medication given for pain. -9/6/21, Pain assessment not documented for night shift. Review of the resident's Nurse Practitioner Note, dated 9/9/21, showed three wounds noted to the [MEDICATION(S)] (pertaining to the chest) region of the spine, one to the left heel, left ankle, and coccyx; -No pain reported. Review of the resident's Nurse Notes, dated 9/10/21, at 10:58 P.M., showed the resident complained of butt pain. Review of the resident's MAR, dated 9/10/21-9/14/21, showed the following: -9/10/21 pain assessed at a 4 on evening shift, no Tylenol or [MEDICATION(S)] administered; -9/11/21, evening shift documented a pain level of 5, no Tylenol or [MEDICATION(S)] administered; -9/12/21, day shift documented a pain level of 5, no documentation Tylenol or [MEDICATION(S)] administered; -9/13/21, day shift did not document a pain score; -9/13/21, evening shift documented a pain level of 5, no Tylenol or [MEDICATION(S)] administered. -9/14/21, day shift pain score documented at a level of 10, no Tylenol or [MEDICATION(S)] administered; -9/14/21, evening shift documented a pain level of 10, [MEDICATION(S)] and [MEDICATION(S)] administered at 3:14 P.M. Review of the resident's Nurses Notes, dated 9/14/21, showed the following: -Resident screaming out for help repeatedly; -Turned and repositioned each time; -Pain medications given with little effect; -Resident keeps asking to remove things from his/her buttocks but it is a wound. The resident's medical record showed no physician notification after the resident's pain medication was given with little effect, or any other interventions used to relieve his/her pain. No new physicians orders were given in regards to the resident's pain. Review of the resident's Wound Care Center Progress Note, dated 9/15/21, showed the following: -9/15/21-wound culture collected from the left foot reviewed, moderate growth of e. coli (bacteria found in the environment, foods, and intestines of people and animals that can cause necrosis of soft tissue) and pseudomonas (type of bacteria found commonly in the environment, which can cause infection in the blood, lungs, and wounds); -Report obtained from staff nurse regarding resident reports no significant changes to resident condition since last visit by wound team. -New order for [MEDICATION(S)] (antibiotic) 500 mg by mouth two times daily for ten days for wound infection; -Wound to coccyx deteriorated; -New wounds to back and heel. Review of the resident's record (Nurses Notes, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Records, dated 9/15/21-9/16/21, showed the following: -9/15/21, no Tylenol or [MEDICATION(S)] administered; -9/16/21, day shift pain assessed at a 10, no Tylenol or [MEDICATION(S)] administered on day shift; -9/16/21, night shift documented a pain level of 3, no Tylenol or [MEDICATION(S)] administered on night shift. Review of the resident's Nurses Notes, dated 9/16/21, showed the following: -Resident seen by traveling wound care service; -Coccyx wound with foul odor and copious amount of exudate that is purulent (a type of fluid that is released from a wound. Often described as being milky in appearance, it's almost always a sign of infection); -Wound was cultured and awaiting lab results; -Wounds to upper back were caused by life vest; -Resident is declining in function, appetite is poor, only wants to lay on his/her back, non-compliant with offloading pressure, and resident is sleeping more. Review of the resident's Nurse Practitioner Note, dated 9/16/21, showed the following: -The resident has multiple wounds including a wound to the left heel, left ankle, three to the [MEDICATION(S)] region of the back and coccyx; -Wounds managed by traveling wound center; -The resident has pressure areas noted to the [MEDICATION(S)] spine; -Pain reported, in multiple areas of wounds, burning at times, severity of pain depends. Review of the resident's Medication Administration Records, dated 9/17/21-9/19/21, showed the following: -9/17/21, day shift documented a pain level of 4, no [MEDICATION(S)] or Tylenol administered; -9/17/21, evening shift documented a pain level of 4, no [MEDICATION(S)] or Tylenol administered; -9/18/21, resident did not receive any Tylenol or [MEDICATION(S)]; -9/19/21, [MEDICATION(S)] administered at 4:58 A.M. (Night shift carry over from 9/18/21), and effectiveness is not documented; -9/19/21, day shift pain assessed at a 9, no documented Tylenol or [MEDICATION(S)] administered on day shift; -9/19/21, evening shift documented a pain level of 9, no Tylenol or [MEDICATION(S)] administered on evening shift; -9/19/21, night shift documented a pain level of 3, no Tylenol or [MEDICATION(S)] administered on night shift. Review of the resident's Nurses Notes, dated 9/19/21, at 4:58 A.M. showed staff documented administration of [MEDICATION(S)]. The record did not include documentation of effectiveness. Review of the resident's MAR, dated 9/20/21-9/22/21, showed the following: -9/20/21, evening shift documented a pain level of 4, no pain medication administered. -9/21/21, [MEDICATION(S)] administered at 1:02 A.M. (Night shift carry over from 9/20/21), documentation did not include effectiveness of the medication; -9/21/21, evening shift pain level not documented, no pain medication administered on day shift, evening shift or night shift. - 9/22/21, showed day shift pain assessed at a 7, [MEDICATION(S)] administered, effectiveness documented as unknown. Review of the resident's Nurses Notes, dated 9/22/21, showed the Nurse Practitioner wrote an order to send the resident to the emergency room for [CONDITION(S)] work up. Review of the resident's Hospital Emergency Department Provider Notes, dated 9/22/21, showed the following: -Resident sent from the nursing facility with a recent wound culture from his/her buttocks showing multiple organisms; -Complaining of buttocks pain and wound; -[MEDICATION(S)] (narcotic pain medication) 50 micrograms, administered enroute to the hospital; -[CONDITION(S)] (rapid heart beat), heart rate noted to be 170; -Deep decubitus ulcer (pressure ulcer) to his/her superior buttocks, obviously infected. During an interview on 9/28/21 at 1:45 P.M., Licensed Practical Nurse (LPN) WW said the following: -The resident's coccyx wound went from a non-painful wound to very painful, large, and with slough; -The resident would scream when you turned him/her or had to do dressing changes, especially when the wound had more odor and drainage; -Had pain medication ordered as needed; -The pain medication was effective at times, but not as effective when the wound showed signs and symptoms of infection; -He/She did not know if anyone reported the increased pain to the physician or nurse practitioner. During an interview 9/29/21 at 2:45 P.M., and 10/7/21 at 12:57 P.M., facility LPN Wound Nurse, said the following: -The resident admitted to the facility with the wound on the coccyx and surgical wounds to the left foot and ankle; -Pain was an issue for the resident and increased during treatments; -He/She was not sure when or if the physician or FNP was contacted about the resident's pain. During an interview on 9/29/21 at 4:06 P.M., the resident's spouse said the following: -He/She was with the resident almost every day for most of his/her stay from 8/27/21-9/22/21; -The resident did not want to turn every time because he/she would have so much pain; -He/She did not know pain medication could be every 6 hours, the resident and he/she did not know to ask for it; -The resident never refused any pain medication when they offered it when he/she was there. During an interview on 9/28/21 at 5:00 P.M., the DON said the following: -If a resident has pain, pain medications would be administered as ordered; -If a pain medication was ineffective then the physician should be notified; -Residents with treatments that can be painful should be pre-medicated 30 minutes to an hour before completing the resident's treatment. During an interview on 9/29/21 at 2:15 P.M., the resident's Nurse Practitioner said the following: -She first saw the pressure ulcer on the coccyx on 9/9/21; -The wound had necrosis and was not MASD (moisture-associated skin damage); -Three wounds were found on the resident's back that day, two of them were unstageable because they were slough covered, and one wound on the resident's back was a Stage II, they were caused from pressure from the life vest; -Residents with pain from wounds are generally medicated prior to dressing changes; -Pain can contribute to loss of appetite, non-compliance with turning and repositioning. During an interview on 10/14/21 at 1:00 P.M., the resident's physician/medical director said: -Staff are expected to notify a physician for deterioration of a wound or condition, and pain not being controlled; -The physician did not recall being notified about Resident #459's pain not being controlled; -Uncontrolled pain can lead to non-compliance with turning and repositioning, and loss of appetite. 2. Review of Resident #80's medical record showed he/she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 7/20/21, showed the following: -The resident was on pain medication therapy related to acute pain due to right leg amputation; -Administer medications as ordered; -Pain management as needed; -Respond immediately to any complaint of pain; -Monitor and record pain characteristics. During an interview on 8/23/21 at 1:30 P.M., the resident said the following: -He/She was almost always in pain, this was phantom pain from his/her right leg being amputated; -Most of the staff never ask him/her to rate his/her pain; -He/She was too old to have to deal with having pain; -Some staff ask him/her to rate the pain, but when he/she does, he/she just usually says a number and requested pain medication, most of the time they do not bring it to him/her.; -Tylenol was all they gave him/her and that was not helpful; he/she also thought he/she was to watch his/her Tylenol consumption and not take too much; -He/She thought he/she was supposed to have something stronger for pain, but they never offered it to him/her. During an interview on 8/24/21 at 9:40 A.M. the resident said he/she was in pain and had been asking staff for pain medication and had not received any yet. During an interview on 8/24/21 at 9:50 A.M., the DON said the following: -She was responsible for the resident's as needed medications; -She was not sure what interventions the resident had available for pain; -She would speak with the resident and review the orders. Record review of the resident's August 2021 POS showed the following orders: -Tylenol 325 mg, give 650 mg every eight hours as needed for pain/fever rated one to five; order date of 6/25/21; -Oxycodone-acetaminophen ([MEDICATION(S)]) (narcotic pain relief) 10/325 mg, one tablet every four hours as needed for pain rated a six to ten; original order date of 6/25/21; -Assess pain every shift for pain monitoring. Record review of the resident's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol 325 mg, give 650 mg every eight hours as needed for pain/fever rated one to five; order date of 6/25/21; -Oxycodone-acetaminophen 10/325 mg, one tablet every four hours as needed for pain rated a six to ten; original order date of 6/25/21; -Assess pain every shift for pain monitoring; -On 8/24/21, day shift, staff documented the resident's pain score as a 4. During an interview on 8/24/21 at 10:00 A.M. the DON said the following: -She had looked at the resident's orders and saw he/she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident did not have a [MEDICATION(S)] supply available; -The resident had reported pain to her but refused Tylenol and wanted something stronger; -She would have to look into the matter. Review of the resident's medical file (nursing notes), showed the DON documented the following: -On 8/24/2021 at 10:28 A.M., the resident requested pain medication. After reviewing orders pharmacy was called. The pharmacist did not see the order on their system. When checking the electronic medical record she did see the order for his/her [MEDICATION(S)]. Alternative offered and resident refused. Will check back with pharmacy in order to pull from Pyxis; -On 8/24/2021 at 4:05 P.M., the resident refused Tylenol. Review of a physician/nurse practitioner encounter note, dated 8/25/21, showed the following: -The resident has chronic phantom pain related to below the knee amputation in February 2021; -He/She reported pain was worse at night; -He/She reported pain was tolerable with his/her [MEDICATION(S)]; -Described as aching, on-going throughout the day and night. Observation on 8/25/21 at 8:25 A.M. showed Trained Medication Aide (TMA) BBB preparing and administering the resident his/her scheduled medications. While administering the resident his/her medications, he/she did not ask the resident to rate his/her pain. After administering the resident's medications, TMA BBB documented on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/25/21 at 8:32 A.M., TMA BBB said the following: -He/She had documented the resident's pain score of zero because he/she did not look to be in distress; -The resident had not voiced any concern of pain; -He/She had not asked the resident if he/she was in pain; -A lot of times, he/she just went on the resident's appearance and documented the pain score. During an interview on 8/25/21 at 8:55 A.M. the resident said the following: -He/She was in pain; -TMA BBB had not asked him/her to rate his/her pain; if he/she would have, he/she would have rated it a five or six; -If staff offered him/her Tylenol, he/she was not going to take it; it did not work; -He/She needed something stronger. Record review of the resident's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol 325 mg, give 650 mg every eight hours as needed for pain/fever rated one to five; order date of 6/25/21; -Oxycodone-acetaminophen 10/3

Based on observation, interview and record review, the facility failed to ensure gradual dose reductions (GDRs; the stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discontinued) were attempted or the physician documented the rationale for not attempting a GDR on antipsychotic medications (medications that affects brain activities associated with mental processes and behavior) for two residents (Residents #59 and #91) of 56 sampled residents. The facility also failed to identify side effects of antipsychotic medication for sampled Resident #8. The facility census was 109. Review of the facility's policy, Use of [CONDITION(S)] Drugs, dated 9/1/21, showed the following: -Residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication; -1. A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. [CONDITION(S)] drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics; -2. The indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches, will be determined by: a. Assessing the resident's underlying condition, current signs, symptoms, expressions and preferences and goals for treatment; b. Identification of underlying causes (when possible); -3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team; -4. The indications for use of any [CONDITION(S)] drug will be documented in the medical record; a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility; b. For [CONDITION(S)] drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician; i. [CONDITION(S)] medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed; ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation; -5. Residents and/or representatives shall be educated on the risks and benefits of [CONDITION(S)] drug use, as well as alternative treatments/non-pharmacological interventions; -6. Residents who use [CONDITION(S)] drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs; -7. Residents who use [CONDITION(S)] drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the [CONDITION(S)] drugs; -8. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN (as needed) or as per facility policy; -9. PRN orders for all [CONDITION(S)] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days); a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order; -10. The effects of the [CONDITION(S)] medications on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis, such as; a. Upon physician evaluation (routine and as needed); b. During the pharmacist's monthly medication regimen review; c. During MDS review (quarterly, annually, significant change), and; d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care; -11. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record; -12. Use of [CONDITION(S)] medications in specific circumstances: a. Acute or emergency situations (i.e., acute onset or exacerbation of symptoms or immediate threat to health or safety of resident or others): i. A clinician in conjunction with the IDT shall evaluate and document the situation to identify and address any contributing and underlying causes of the acute condition and verify the need for a [CONDITION(S)] medication; ii. Use of the [CONDITION(S)] medication shall be consistent with #9 above, regarding PRN orders; iii. Continued use of the medication shall be consistent with procedures for gradual dose reductions; b. Enduring conditions (i.e. non-acute, chronic or prolonged); i. The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented; ii. An evaluation shall be documented to determine that the resident's expressions or indications of distress are: 1. Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medications(s) are discontinued; 2. Not due to environmental stressors alone, that can be addressed to improve the symptoms or maintain safety; 3. Not due to psychological stressors, anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed; and 4. Persistent, and negatively affect his or her quality of life; c. New admissions: i. The facility shall identify the indication for use, as possible, using pre-admission screening and other pre-admission data; ii. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. Review of the facility's policy, Gradual Dose Reduction of [CONDITION(S)] Drugs, dated 9/1/21, showed the following: -Residents who use [CONDITION(S)] drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; -1. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use [CONDITION(S)] drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions; -2. Within the first year in which a resident is admitted on a [CONDITION(S)] medication or after the prescribing practitioner has initiated a [CONDITION(S)] medication, the facility will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated; -3. After the first year, a GDR will be attempted annually, unless clinically contraindicated; -4. The timeframes and duration of attempts to taper any medication shall depend on factors including the coexisting medication regimen the underlying causes of symptoms, individual risk factors, and pharmacological characteristics of the medication; a. Tapering shall be consistent with accepted standards of practice; b. Some medications (e.g., antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences; c. Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or otherwise modified include: i. During monthly medication regimen review by the pharmacist; ii. When the physician or prescribing practitioner evaluates the resident's program; iii. During the quarterly MDS review by the interdisciplinary team; -5. GDR will be documented on the [CONDITION(S)] Dose Reduction History form; -6. For any individual who is receiving a [CONDITION(S)] medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and b. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior; -7. For any individual who is receiving a [CONDITION(S)] medication to treat a disorder other than expressions or indications of distress related to dementia (for example, [CONDITION(S)], [CONDITION(S)], depression with psychotic features, or another medical condition, other than dementia which may cause [CONDITION(S)]), GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: a. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rational for why any attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; or b. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; -8. Rationale for clinical contraindications may be documented on the Clinically Contraindicated Dosage Reduction form; -9. Use of [CONDITION(S)] medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented, unless the other types of [CONDITION(S)] medications are clinically indicated; -10. Other medications which may affect brain activity such as central nervous system agents, mood stabilizers, anticonvulsants, muscle relaxants, anticholinergic medications, antihistamines, NMDA receptor modulators, and over the counter natural or herbal products must also only be given with a documented clinical indication consistent with accepted clinical standards of practice. 1. Review of the Resident #8's admission Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 5/20/21, showed the following: -His/Her diagnoses included Alzheimer's, [CONDITION(S)], depression, and cognitive communication deficit; -The resident wandered daily; -He/She had severe cognitive impairment; -He/She rarely made self understood; -The resident required extensive assistance of one staff member for toileting, bathing, dressing and personal hygiene. Review of the resident's physician order sheet dated 6/7/21, showed the following: -The resident's diagnoses included Alzheimer's disease (no diagnoses listed for [CONDITION(S)] or any mental illness); -[MEDICATION(S)] (an anti psychotic medication) 0.25 milligram (mg) tablet once daily for agitation (start date 6/5/21); -Monitor antipsychotic medications for dry mouth, constipation, blurred vision, disorientation/confusion/ difficulty urinating, [CONDITION(S)] (low blood pressure), dark urine, yellow skin, nausea/vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue.) Review of the resident's undated care plan showed the following: -The resident wandered; -He/She often walked into other residents rooms, lay in their bed and may take items; -He/She has been aggressive with staff and residents; -He/She often hits furniture or walls when walking; -His/Her safety will be maintained through the review date; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books; -Identify pattern of wandering: Is the wandering purposeful, aimless, or escapist, is the resident looking for something, does it indicate the need for more exercise; -Intervene as appropriate; -The resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, difficulty making decisions, impaired decision making, long term memory loss; -Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion; -The resident's care plan did not address antipsychotic medications. Review of the resident's pharmacy note dated 7/31/21, showed the following: -The medical record review completed; -No new recommendation. Review of the resident's physician order sheet dated August 2021, showed the following: -[MEDICATION(S)] 0.25 milligram (mg) tablet once daily for agitation (start date 6/5/21); -[MEDICATION(S)] discontinued on 8/15/21; -On 8/16/21 [MEDICATION(S)] 0.25 mg tablet once daily related to Alzheimer's. Review of the resident's MAR dated 8/1/21 to 8/31/21, showed the following: -Antipsychotic medications-monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, [CONDITION(S)], dark urine, yellow skin, nausea/vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of the mouth or tongue) three times daily every morning, evening and night; -Staff indicated no every morning, evening and night that no adverse reactions noted. Observation on 8/23/21 at 11:07 A.M. showed the resident with involuntary tongue movement, his/her tongue protruded in and out of his/her mouth. Observation on 8/23/21 at 11:52 A.M. showed the following: -The resident walked in the hall; -The resident's tongue protruded in and out of his/her mouth, he/she smacked his/her lips and his/her jaw moved sideways. Observation on 8/23/21 at 4:47 P.M. showed the following: -The resident wandered up and down the hall; -The resident's tongue protruded in and out of his/her mouth, he/she smacked his/her lips and his/her jaw moved sideways. Observation on 8/24/21 at 8:20 A.M. showed the following: -Resident wandered from room to room; -He/She had involuntary tongue movement, protruding his/her tongue in and out of his/her mouth. Observation on 8/25/21 at 6:05 A.M. showed the following: -Resident walked in his/her room; -The resident's tongue protruded in and out of his/her mouth, he/she smacked his/her lips and his/her jaw moved sideways. Observation on 8/26/21 at 8:20 A.M. showed the following: -Resident walked the hall; -The resident's tongue protruded in and out of his/her mouth, he/she smacked his/her lips and his/her jaw moved sideways. Review of the resident's medical record showed no gradual dose reduction records found for the resident's [MEDICATION(S)]. Review of the resident's pharmacy note dated 8/27/21, showed the following: -The medical record review completed; -See note. During an interview on 8/31/21 at 7:40 P.M., the resident's representative said the resident did not have lip smacking, tongue protruding or irregular jaw movement before the resident admitted to the facility. The facility failed to provide pharmacy recommendation notes after multiple requests. 2. Review of Resident #59's care plan dated 2/17/21, showed the following: -Behavior: Resident will become agitated/ combative at times with cares; -Medication review as indicated; -Medications as ordered. Notify Medical Director (MD) of adverse reactions, worsening clinical condition. Review of progress notes dated 4/28/21 showed: - Medication Record Review (MRR) complete; - See report. (No report found in medical record.) Review of the pharmacist recommendation letter to the physician, dated 4/1/21 through 4/29/21 showed the following: -The resident has been taking [MEDICATION(S)] 2.5 mg daily since 10/31/20 without a GDR. Could we attempt a dose reduction at this time to verify the resident is on the lowest possible dose?; -Document not signed or dated by the physician but rationale of: The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated related to (blank). A follow through notation read: note written to physician. Review of the resident's progress notes dated 5/31/21, showed: - MRR complete; - See report. Review of the pharmacist recommendation letter to the physician dated 5/31/21, showed the following: -The resident has been taking [MEDICATION(S)] DR 125 mg times eight at bed time since 11/4/20 without a GDR. Could we attempt a dose reduction at this time to verify the resident is on the lowest possible dose?; -Response dated and signed by the physician 6/11/21 showed no clinical rationale marked but response of no change. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No [CONDITION(S)] behaviors or wandering; -Received anti-depressant, anti-anxiety and anti-psychotic last seven days. Review of the resident's progress notes, dated 7/1/21, showed; - MRR complete; - See report. Review showed no report located in the resident's medical record. Review of the resident's progress notes dated 7/31/21, showed: - MRR complete; - See report. Review showed no report located in the resident's medical record. Review of the resident's Physician Order Sheet (POS) dated 8/21, showed the following: -Diagnoses included Alzheimer's disease, manic ([CONDITION(S)]) [CONDITION(S)] disorder; -[MEDICATION(S)] Sodium capsule Delayed Release Sprinkle 125 mg (eight caps) by mouth at bedtime (11/4/20); -[MEDICATION(S)] XR (antidepressant) 150 milligram (mg) by mouth daily (9/19/19); -[MEDICATION(S)] (anti-anxiety) 2.5 mg one by mouth daily (10/31/20). Observations of the resident showed the following: -On 8/23/21 at 11:30 A.M. the resident sat in the dining room with lip smacking and right arm tremor noted; -On 8/23/21 at 4:13 P.M. the resident sat in the dining room. Lip smacking and right arm tremor noted; -On 8/24/21 at 8:40 A.M. the resident sat in a chair in the dining room with lip smacking and right arm tremor noted. At 4:21 P.M. the resident ambulated down the hall and continued with lip and arm movements; -On 8/25/21 at 11:55 A.M. the resident sat in the dining room with lip smacking and arm movements; -On 8/26/21 at 11:50 A.M. the resident sat in the dining room and continued with movements. 3. Review of a pharmacy note for Resident #91, dated 5/31/21, showed: - MRR complete; - See report. The facility failed to provide any reports referenced by the pharmacy note after multiple requests. Review of the resident's care plan dated 7/8/21, showed the following: -Received anti-anxiety, antidepressant and psychoactive medications; -Resident will remain free from discomfort or adverse reactions related to medication therapy; -Monitor for side effects shiftly, for safety, and occurrence of target behaviors. Review of the resident's annual MDS, dated [DATE] showed the following: -No [CONDITION(S)] behaviors or wandering; -Received anti-depressant, anti-anxiety and anti-psychotic last seven days. Review of a pharmacy note dated 7/31/21, showed: - MRR completed; - See report. Review showed no report found in the resident's medical record. Review of the resident's POS dated 8/21, showed the following: -Diagnoses included Alzheimer's disease, generalized anxiety disorder, major depression, dementia with behaviors; -Monitor behaviors shiftly; -[MEDICATION(S)] (used for anxiety) 0.5 mg by mouth at bedtime (8/4/20); -[MEDICATION(S)] 0.5 mg by mouth one time daily for anxiety at 10:00 A.M. (8/5/20); -[MEDICATION(S)] HCL 75 mg- take two tablets two times daily for depression (8/4/20). Review of the resident's medical record showed there were no GDR's for the above medications since the resident's admission on 8/4/20. During interview on 9/22/21 at 9:06 A.M. the DON said the following: -Nursing staff assess residents for medication side effects (specifically tardive dyskinesia (T.D.): uncontrolled, involuntary movements); -They should be assessing for constant moving of extremities, involuntary movements, mouth movements, lip pursing/involuntary movements; -The assessment should be documented in the Medication Administration Record; -He/She was not aware of the resident's continual lip smacking and right arm tremor; -He/She was not sure if the issue had been reported to the physician; -He/She would consider this to be tardive dyskinesia; -He/She did not have any GDR's for Resident #91 in the last 12 months. 4. During an interview on 9/23/21 at 10:30 A.M., the Director of Nurses (DON) said the following: -She expected staff to monitor residents on antipsychotic medications for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, [CONDITION(S)], dark urine, yellow skin, nausea/vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of the mouth or tongue) three times daily every morning, evening and night.; -She would expect staff to notify the resident's physician with any signs of any resident's tongue protruding in and out of his/her mouth, smacking of lips and jaw moving sideways. During an interview on 10/14/21 at 1:00 P.M. the medical director (also resident #8's physician), said if there were new findings of tardive dyskinesia he would expect staff to notify him or the nurse practitioner so medications could be adjusted.

Based on observation, interview, and record review, the facility failed to comprehensively assess pain and intervene when one resident (Resident #3) of six sampled residents exhibited pain during a treatment. The facility census was 112. 1. Record review of the facility's Pain Management Policy and Procedure, dated 9/4/17, showed the following: -Policy: The intent of this policy is to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management; -Definition of Pain: Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (National Institute of Nursing Research, 1994); -It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations and emotions. Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. McCaffery & Beebe, 1989; -Procedures: Upon admission, readmission, and quarterly and with significant change in condition, residents will be evaluated for pain; -Residents who are cognitively impaired and unable to verbally express pain will be assessed utilizing the recommended pain evaluation which is specific for cognitively impaired residents. The assessment will include interviews with legal representatives/family, if possible, to identify any resident specific behaviors that may indicate the resident is experiencing pain from history. Examples of possible indicators of pain include, but are not limited to the following: Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming); Facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw); -Ongoing evaluations of residents for pain will be completed by staff at least three times daily and documented as the fifth vital sign on the residents' Medication Administration Record [REDACTED] -Based on the evaluation, the interdisciplinary team, resident physician and the resident and/or representative, will develop, implement, monitor and revise as necessary interventions to prevent or manage the residents pain; -Pharmacological interventions utilized will consider factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the resident's desired level of relief and tolerance for adverse consequences; -Ongoing evaluation of the resident's pain levels using both verbal and non-verbal signs will continue and be utilized as the basis for revision of the comprehensive care plan; -If a resident's pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated. 2. Record review of Resident #3's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Required total assist of staff with bed mobility transfer, dressing, eating, toileting, and personal hygiene; -One Stage III pressure ulcer (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible) and three unstageable pressure ulcers; -No pain or hurting; -Hospice care. Record review of the resident's care plan, dated 2/20/18, showed the following: -Problem: Had a decline, failure to thrive, multiple pressure ulcers and elected hospice care; -Goal: Dignity will be maintained and he/she will be comfortable over the next 90 days; -Approach: Please monitor him/her for pain and administer pain medications as ordered by physician; -Problem: Pain; -Goal: Verbalize reduction in pain; -Approach: Assess effects of pain on the resident; -His/her pain is unique and believable and administers pain medication as ordered; -Assess past effective and ineffective pain relief measures; -Monitor and record any complaints of pain and: location, frequency, effect on function, intensity, alleviating factors, aggravating factors; -Monitor and record any non-verbal signs of pain: (e.g., moaning, guarding grimacing, etc.) -Position for comfort with physical support as necessary. Record review of the resident's physician orders, dated 3/01/18 through 3/31/18, showed the following: -Pain assessment every shift, pain scale 1-10 (one being the least amount of pain and 10 being the greatest amount of pain); -[MEDICATION NAME] ([MEDICATION NAME]) (narcotic used to treat moderate to severe pain) 5 mg, by mouth or under the tongue every four hours as needed for pain; -[MEDICATION NAME] ([MEDICATION NAME]) 325 mg, two tablets every four hours as needed for pain; -Apply Duoderm (a commonly used [MEDICATION NAME] dressing used to treat pressure ulcers, it has gel-like properties to absorb excretions from the wound and protect the wound debris and potentially infection causing bacteria) to right buttock/gluteal every three days and as needed; -Cleanse left bunion (a bony bump that forms on the joint at the base of your big toe) and left medial (inside) ankle ulcers with wound cleanser and apply Xeroform (an occlusive dressing which means the dressing prevents air from reaching the wound) with dry dressings every day and as needed; -Cleanse right knee and left shin with wound cleanser and apply Xeroform with dry dressing every day and as needed; -Cleanse left knee with wound cleanser and apply Xeroform and dry dressing every other day; -Cleanse left hip ulcer with wound cleanser and skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) and then apply Santyl (a sterile enzymatic [MEDICATION NAME] ointment) with Vaseline; -Cleanse left heel ulcer with wound cleanser, skin prep, and apply Santyl with Vaseline guaze (non-adherent primary dressing that maintains a moist wound bed for autolytic healing) and dry dressing every day and as needed; -Cleanse right 5th toe and apply Xerofom daily; -Cleanse right middle back; apply Duoderm every three days for protection. Record review of the resident's wound notes, dated 3/8/18 at 9:00 A.M., showed the following: -UTD (unable to determine stage) pressure ulcer left hip, full thickness measure 1 cm x 1 cm x 0.1 cm with 100% slough, deferred wound edges with peri-wound intact with small serous exudate; -UTD pressure ulcer to coccyx, measures 6 cm x 3 cm x 1.4 cm with 80% pink granulation tissue and 20% slough to wound med, undermined (tunneling) 1.6 cm and moderate serosanguinous (blood and liquid part of blood/serum) exudate; -Stage III pressure ulcer left heel, measures 4 cm x 3 cm x 0.1 cm with minimal serosanguinous exudate, 50% pink tissue with 30% necrotic tissue and 20% yellow to wound bed, the area declined; - New diabetic ulcers to left foot; -Left bunion diabetic ulcer, measures 2 cm x 2.5 cm x .01 cm with scant serous (fluid resembling serum) exudate; -Right fifth toe is presenting as a diabetic ulcer, measures 3.5 cm x 3 cm x .01 cm with 80% yellow tissue and 20% necrotic tissue with minimal serosanguinous exudate. Record review of the wound list provided by the administrator, showed the following: -On 3/13/18, the area on the right side of the resident's back had measured 4.5 cm x 6 cm x 0.1 cm; -There was no further information provided. Record review of the resident Medication Administration Record, [REDACTED] -On 3/14/18 at 8:00 A.M., the pain assessment scheduled for each shift was blank; -At 8:00 A.M., [MEDICATION NAME] 0.25 mg was given for pain (no description of pain or scale) and there was no results if the medication was effective documented; -At 11:15 A.M., [MEDICATION NAME] 0.25 mg was given for pain and the result was effective. During an interview on 3/14/18 at 9:25 A.M., the resident said: -He/she had lots of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction); -He/she thought he/she was wet and had not been turned or repositioned; -His/her butt and waist was hurting and his/her back felt sore. During an interview on 3/14/18 at 10:02 A.M., the hospice volunteer said: -He/she had been in the resident's room since 9:20 A.M. and had called for staff 20 to 25 minutes ago; -CNA A asked what he/she needed and the hospice volunteer said the resident would like a wheelchair because his/her back hurt and CNA A said he/she would be back. Observation on 3/14/18 at 10:02 A.M., showed: -Certified Nurse Assistant (CNA) A came in the resident's room and said he/she just returned from break; -The hospice volunteer said the resident's back was hurting and CNA A said the resident got pain medication earlier; -The resident was in bed on the right side of his/her back with his/her legs bent and toward the right and he/she was not turned or repositioned. Observation on 3/14/18 at 10:35 A.M. showed the following: -Licensed Practical Nurse (LPN) C and CNA A turned the resident on his/her back and the resident moaned out in pain; -The staff did not ask the resident about his/her pain; -LPN C washed around the resident's wounds and the resident yelled out ow; -LPN C said sorry; -The resident moaned out while the nurse packed the resident's pressure ulcer on his/her coccyx and said oh my gosh; -LPN C was cleansing the unstageable pressure ulcer on the resident's right outer foot and the resident said not so hard and the LPN said I'm just wiping; -LPN C was placing foam on the right outer foot ulcer and the resident yelled out oh yeah; -LPN C said he/she could have [MEDICATION NAME] every hour and he/she normally gives it to him/her because he/she normally has pain during dressing changes; -LPN C gave pain medication one hour before he/she did the dressing change; -CNA A turned the resident to his/her right side and he/she moaned out; -CNA A washed the resident left lower leg and the resident said ow; -The resident said his/her pain rated a 9 (pain scale of 0 (lowest)-10 (highest); -The resident had facial grimacing and moaning when the aide moved his/her leg so the nurse could change his/her shin dressing; -LPN A removed the dressing from the resident's left foot and the resident yelled out no, oh goodness; -LPN A cleansed the left foot ulcer and the resident yelled out ow, ow, ow, that hurts; -CNA A rolled the resident toward the left side and the resident moaned out ohhhh; -CNA A placed the blue boot on the resident's feet and the resident said it's hurting. -Staff did not address the resident's pain. During an interview on 3/14/18 at 3:42 P.M., the resident said he/she was having pain which was a 10 and he/she hurt really bad. He/she would like better pain management and needed more information on pain management. During an interview on 3/14/18 at 3:25 P.M., LPN E said: -The resident's wound treatments caused pain; -The resident should always have pain medication prior to his/her wound treatments and staff should make sure the medication was effective before the treatment was started. During interview on 3/14/18 at 3:59 P.M., the Assistant Director of Nursing (ADON) said: -He/she had in-serviced staff on pain management; -Staff was to assess the resident's pain using a pain scale of 1-10 or facial scales; -The staff was to document where the resident's pain was; it was not appropriate to write effective for results; -Staff was to follow up with the same scale used to assess the resident's pain; -If a resident was having any pain with treatment, staff was to medicate the resident 20 minutes prior to the treatment and if it was not effective the nurse contacts the resident's physician. During interview on 3/14/18 at 4:12 P.M., the DON said: -If a resident was in pain he/she would expect staff to give pain medication right before the treatment due to [MEDICATION NAME]'s short life span; -If a resident was experiencing pain during a treatment he/she would expect staff to stop the treatment and see if they had any other medications; -If no other medication was available he/she would expect staff to notify the resident's physician to let him/her know the pain medication was not working. During interview on 3/15/18 at 12:31 P.M., the administrator said the following: -He/she would have expected staff to stop the resident's treatment if they had pain and medicate; -The resident should have been medicated prior to his/her treatment and staff should follow up with effectiveness. During interview on 3/20/18 at 4:18 P.M., the resident's physician said the following: -He/she would have expected staff to administer [MEDICATION NAME] 1/2 hour prior to providing wound care; -Staff should have contacted him/her and he/she would have given an order for [REDACTED].>-The resident was hospice and the least we can do is keep them comfortable. MO 8

Based on observation, interview and record review the facility failed to provide services to promote the highest practicable well being for one resident (Resident #16) in a review of 21 sampled residents and one additional resident (Resident #59). The facility failed to comprehensively assess pain, provide scheduled pain medication in a timely manner, administer PRN (as needed) pain medication or notify the physician after scheduled pain medication was ineffective and the resident exhibited pain for Resident #16. Facility staff failed to notify the physician when Resident #59 refused medications including [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]) and experienced increased hallucinations. The facility census was 116. 1. Review of the facility's policy, Pain Management, revised 9/2011 showed the following: Policy: Staff will implement the facility Pain Management Program including Evaluation/Re-evaluation for the patients/residents experiencing either acute or chronic pain; Definition of pain: Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (National Institute of Nursing Research, 1994. It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations and emotions. Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. McCaffery and Beebe, 1989; Procedures: 1.Upon admission, re-admission, quarterly and with a significant change in condition complete Section E of the Nursing Data Collection Tool; -If pain is triggered, initiate a pain management care plan which includes non-pharmacological and pharmacological interventions for the resident's pain relief; -Interventions should be specific for the resident based on the information collected during the evaluation and interview process; -Initiate the Pain Flow Sheet for ongoing documentation of PRN medication administration and effectiveness; -Document pain as the fifth vital sign, evaluating or checking with the resident for the presence of pain during the morning, afternoon, evening medication pass and PRN; 2. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool. Initiate the Pain Flow Sheet as determined by resident need, following documentation parameters set forth above; 3. Obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. This information should be incorporated into the development of the resident's pain management care plan; 4. Utilize the standard: -Numeric rating scale (0-10); -Verbal descriptor scale (mild, moderate, severe, very severe-horrible); -Staff evaluation of pain or possible pain in cognitively impaired or non-verbal residents using non-verbal sounds, vocal complaints, facial expressions, protective body movements; -Pain Assessment for Advanced Dementia (PAINAD), for those who have end stage dementia; 5. Consider a pain specialist consultation if pain management continues to be ineffective. 2. Review of the facility's policy, Medication Management Program, revised 9/2011 showed the following: -Medications are administered no more than one hour before or one hour after the designated time; -If the resident is unable to take the medication or refuses it, the authorized licensed/certified staff member circles his/her initials on the Medication Administration Record (MAR) and documents the reason refused or not given on the designated area of the MAR, (physician is notified as necessary.) 3. Review of Resident #16's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/17 showed the following: -Severely impaired cognition; -Minimal depression; -No rejection of care; -Totally dependent on two staff for bed mobility and dressing; -Totally dependent on one staff for eating, toilet use, personal hygiene and bathing; -Functional limitation of range of motion on one side, both upper and lower extremities; -Scheduled pain medication; -No observed or documented pain indicators; -Feeding tube. Review of the resident's care plan revised 8/2/17 showed the following: -The resident is at risk for pain/discomfort related to decreased mobility and [DIAGNOSES REDACTED]. It causes pain and stiffness, especially in the hip, knee, and thumb joints); -Administer medications. Evaluate, record, report effectiveness and any adverse side effects; -Assess effects of pain on the resident (disturbances in sleep, activity, psychosocial, etc.); -Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge; -Handle gently and try to eliminate any environmental stimuli; -Monitor and record any non-verbal signs of pain (i.e. crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.); -Position for comfort with physical support as necessary. Review of the resident's undated Central Information Tool showed the following: -Pain Management Program-unmarked by staff; -Pain interventions: blank; -Behavior: Resident yells a lot, screams; -Interventions: Assess for pain, approach calmly and talk to him/her quietly. Review of the resident's July 2017 physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Pain assessment every shift: pain scale 1-10; -[MEDICATION NAME] (muscle relaxing medication) 4 milligrams (mg) per tube twice daily; -[MEDICATION NAME] (muscle relaxer and an antispastic medication) 20mg per tube three times a day; -[MEDICATION NAME] (narcotic pain medication) 5/325 mg give one tablet per tube every eight hours; -Tylenol (pain medication) solution 160 mg/ 5 milliliters (ml) give 20.3 ml per tube as directed as needed for pain/elevated temperature; -[MEDICATION NAME] (anti-convulsant medication also used to treat panic episodes)0.5 mg per tube twice daily as needed; -Up in geri-chair (reclining wheelchair) daily-resident's door to be open at all times except during personal care. Review of the resident's July 2017 Medication Administration Record (MAR) showed the following: -July 7: 11- 7 shift, 7-3 shift and 3-11 shift pain assessments blank; -July 8: 11-7 shift pain assessment blank. Review of the resident's MAR showed on 7/10/17 the resident's pain assessments changed from shiftly to scheduled at 8:00 A.M., 2:00 P.M. and 10:00 P.M. Review of the resident's July 2017 MAR showed the following: -July 10: 11-7 shift and 3-11 shift pain assessments blank; -July 13: 11-7 shift pain assessment blank; -July 14: 11-7 shift and 3-11 shift pain assessments blank; -July 15: 3-11 shift pain assessment blank; -July 16: 11-7 shift pain assessment blank; -July 17: 11-7 shift, 7-3 shift and 3-11 shift pain assessments blank; -July 18: 11-7 shift, 7-3 shift and 3-11 shift pain assessments blank. Review of the resident's MAR on 7/10/17 showed the resident's pain assessments changed from shiftly to scheduled at 8:00 A.M., 2:00 P.M. and 10:00 P.M. Review of the resident's July 2017 MAR showed the following: -July 19: 8:00 A.M. pain assessment blank; -July 22: 8:00 A.M. and 2:00 P.M. pain assessments blank; -July 25: 8:00 A.M., 2:00 P.M. and 10:00 P.M. pain assessments blank; -July 26: 8:00 A.M. and 2:00 P.M. pain assessments blank; -July 27: 8:00 A.M., 2:00 P.M. and 10:00 P.M. pain assessments blank; -July 28: 8:00 A.M., 2:00 P.M. and 10:00 P.M. pain assessments blank; Review of the resident's pain flow sheet on 7/28/17 at 10:00 A.M. showed the following: -Site/location of pain: leg; -Characteristics: aching; -Frequency: almost constantly; -Current intensity: 9; -Non-verbal indicators: vocal complaints of pain; -Precipitating/aggravating factors: unknown; -Non-medication intervention: positioning; -Medication: Tylenol solution 20.3 ml; -After intervention intensity: 2, acceptable. Review of the resident's July 2017 MAR showed the following: -July 29: 2:00 P.M. pain assessment blank; -July 30: 8:00 A.M., 2:00 P.M. and 10:00 P.M. pain assessments blank. Review of the resident's August 2017 physician's orders [REDACTED]. -Pain assessment every shift: pain scale 1-10; -[MEDICATION NAME] 4 mg per tube twice daily; -[MEDICATION NAME] 20mg per tube three times a day; -[MEDICATION NAME] 5/325 mg give one tablet per tube every eight hours; -Tylenol solution 160 mg/ 5 milliliters (ml) give 20.3 ml per tube as directed as needed for pain/elevated temperature. Continuous observation on 8/1/17 from 7:34 A.M. to 8:34 A.M. showed the following: -A sign beside the resident's door which read, Resident's door to be open at all times except personal care signed by the Director of Nursing (DON); -The door to the resident's room was shut; -The resident yelled out, Hey, hey continuously; -Several different staff members passed by the resident's room; -Staff did not respond to the resident's cries. Continuous observation on 8/1/17 from 9:00 A.M. to 9:20 A.M. showed the following: -The door to the resident's room was shut; -The resident yelled out, Ah, ah! continuously; -Certified Nurse Aide (CNA) KK and CNA W sat in the dining room across the hall from the resident's room; -Staff did not respond to the resident's cries. Review of the resident's MAR dated 8/1/17 showed the following: -Pain scale at 8:00 A.M. 3; -Pain scale at 2:00 P.M. 7; -Pain scale at 10:00 P.M. 0; -[MEDICATION NAME] 5/325 mg one tablet per tube every eight hours scheduled at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Review of the resident's MAR dated 8/1/17 showed the following: -Facility staff did not administer PRN Tylenol for pain; -No evidence facility staff re-evaluated the resident's pain after the pain scale at 8:00 A.M. or 2:00 P.M. Review of the resident's Controlled Substances Proof of Use form dated 8/1/17 showed the following: -Staff signed out the resident's 6:00 A.M. dose of [MEDICATION NAME] 5/325 mg as administered at 6:00 A.M.; -Staff signed out the resident's 2:00 P.M. dose of [MEDICATION NAME] 5/325 mg as administered at 3:30 P.M.; -The resident's scheduled [MEDICATION NAME] 5/325 mg doses were administered 9 hours and 30 minutes apart; -Staff failed to administer the resident's scheduled [MEDICATION NAME] 5/325 mg every eight hours as ordered. During interview on 8/1/17 at 4:14 P.M. the resident said the following: -When I'm having pain the staff tell me ok; -I holler out when I'm hurting. Observation on 8/1/17 at 4:26 P.M. in the resident's room showed the following: -The resident lay in bed; -The resident exhibited facial grimacing and cried out; -The resident was drawing up his/her right leg. Observation on 8/1/17 at 4:29 P.M. in the resident's room showed the following; -CMT II entered the resident's room; -The resident said, I'm in pain; -The resident complained of right leg pain. During interview on 8/1/17 at 4:34 P.M. CMT II said the following: -He/she told Licensed Practical Nurse (LPN) S the resident was hurting now; -LPN S gave the resident [MEDICATION NAME] 5/325 mg at 3:30 P.M. and it takes at least 30 minutes to one hour for the medication to work. During interview on 8/1/17 at 4:42 P.M. LPN S said the following: -The resident can say if he/she is having pain; -The resident will say his/her leg hurts; -He/she gave the resident's 2:00 P.M. [MEDICATION NAME] 5/325 mg at 3:30 P.M. today; -He/she did not give the resident's [MEDICATION NAME] 5/325 mg at 2:00 P.M. because he/she had to work both halls; -He/she was told he/she had two hours before and two hours after the scheduled time to administer medication. Observation on 8/1/17 at 4:44 P.M. in the resident's room showed the following: -The resident continued to complain of right leg pain; -CNA SS lowered the head of the resident's bed; -The resident cried when staff removed the pillow from between his/her legs; -CNA SS removed the resident's soiled shirt; -The resident cried out, It hurts, it hurts; -LPN S said, I know; -CNA SS and LPN S pulled the resident up in bed; -The resident yelled out an expletive; -The resident cried loudly when staff attempted to straighten his/her legs. Review of the resident's MAR dated 8/1/17 showed no PRN Tylenol was administered by staff. Observation on 8/2/17 at 2:53 P.M. in the resident's room showed the following: -The resident sat up in his/her geri-chair; -The resident yelled out; -The resident told CNA RR his/her leg was hurting; -CNA RR and CNA X transferred the resident from the geri-chair to the bed using the mechanical lift; -The resident exhibited facial grimacing and began to cry; -CNA RR asked, What's the matter? -The resident cried; -The resident exhibited facial grimacing and cried out during pericare; -The resident exhibited facial grimacing and yelled, Please! During interview on 8/2/17 at 3:05 P.M. CNA X said the following: -The resident screams and cries all the time; -He/she never knows when the resident is having pain; -The resident screams when they touch his/her left leg. Observation on 8/2/17 at 3:11 P.M. showed the following: -CNA RR told LPN S the resident was having pain; -LPN S said, I'm getting ready to give him/her scheduled pain medication now. I haven't given it yet. Observation on 8/2/17 at 3:16 P.M. in the resident's room showed the following: -The resident lay on his/her back in bed; -The resident exhibited facial grimacing and continued to cry out. Observation on 8/2/17 at 3:22 P.M. showed the following: -The resident lay on his/her back in bed; -The resident exhibited facial grimacing and continued to cry out; -LPN S stood at the medication cart across the hall; -LPN S said, I'm coming; -The resident yelled, Ah! Observation on 8/2/17 at 3:23 P.M. showed the following: -LPN S entered the resident's room; -The resident continued to cry out; -The resident continued to exhibit facial grimacing and grabbed at his/her left arm and right hand; -The resident complained of his/her leg hurting; -LPN S flushed the resident's feeding tube and administered pain medication. Review of the resident's Controlled Substances Proof of Use form dated 8/2/17 showed the following: -Staff signed out the resident's 6:00 A.M. dose of [MEDICATION NAME] 5/325 mg as administered at 5:00 A.M.; -Staff signed out the resident's 2:00 P.M. dose of [MEDICATION NAME] 5/325 mg as administered at 3:19 P.M.; -The resident's scheduled [MEDICATION NAME] 5/325 mg doses were administered 10 hours and 19 minutes apart; -Staff failed to administer the resident's scheduled [MEDICATION NAME] 5/325 mg every eight hours as ordered. Review of the resident's MAR dated 8/2/17 showed facility staff did not administer PRN Tylenol for pain. During interview on 8/2/17 at 3:30 P.M. LPN S said the reason the resident's pain medication was late was because he/she was working on the other hall. Observation on 8/3/17 at 5:01 A.M. in the resident's room showed the following: -The resident's door was shut; -The resident exhibited facial grimacing and cried out. Observation on 8/3/17 at 5:04 A.M. in the resident's room showed the following: -CNA R entered the resident's room; -The resident yelled out, Hey, hey, hey, hey!; -CNA R said, If you need to cry it out you can; -CNA R left the resident's room and shut the door. Continuous observation on 8/3/17 from 5:09 A.M. to 5:27 A.M. in the resident's room showed the following: -The resident continued to cry out; -The resident yelled, My leg hurts! During interview on 8/3/17 at 5:20 A.M. LPN Q said the following: -The resident can communicate pain to staff; -His/her pain is usually generalized pain; -He/has orders for PRN [MEDICATION NAME] also; -The crying, moaning and yelling out is a behavior; -He/she has scheduled pain medication. During interview on 8/3/17 at 5:22 A.M. CNA R said the following: -The resident can communicate pain; -His/her pain is usually foot, leg or hip; -The resident prefers to have the door shut; -If staff talk to the resident he/she calms down; -When he/she cries out staff leave him/her alone; -When staff bother him/her it makes it worse. Observation on 8/3/17 at 5:29 A.M. showed LPN Q entered the resident's room with the resident's morning medications including scheduled [MEDICATION NAME] 5/325mg. Review of the resident's MAR dated 8/3/17 showed no evidence staff administered any PRN pain medication or re-evaluated the resident's pain after the scheduled [MEDICATION NAME] 5/325 mg was administered at 5:29 A.M. Continuous observation on 8/3/17 from 6:03 A.M. to 6:18 A.M. showed the following: -The resident lay on his/her back in bed; -His/her legs were drawn up towards his/her chest; -The resident exhibited facial grimacing and cried out; -The resident's face was red; -He/she cried out loudly, Ah, ah! Observation on 8/3/17 at 10:05 A.M. in the resident's room showed the following: -The resident lay in his/her bed; -The resident cried out; -The resident said, I hurt all over. During interview on 8/3/17 at 10:13 A.M. the resident's family member said the following: -He/she visits the resident every weekend; -He/she thinks the resident has leg cramps; -The resident has pain; -The resident exhibits pain by yelling and crying out; -The resident can't move around without assistance; -If staff will give the resident Tylenol, the resident will verbalize pain relief; -If he/she rubs the resident's legs and feet it helps the pain. During interview on 8/3/17 at 11:35 A.M. LPN H said the following: -The resident is having pain when he/she is grabbing his/her leg; -The resident can tell staff if he/she is having pain; -He/she yells during repositioning; -He/she has ordered Tylenol PRN and [MEDICATION NAME] every eight hours on schedule for pain control. During interview on 8/3/17 at 4:45 P.M. the Director of Nursing (DON) said the following: -She would expect staff to assess for pain in a resident that is crying out or yelling; -She would expect staff to administer PRN pain medication if indicated even for facial grimacing; -She would expect staff to try non-medication interventions if a resident continues to cry/yell after pain medication is administered; -She would expect staff to administer medication within one hour before or after the scheduled time. During interview on 8/16/17 at 11:55 A.M. the resident's physician said the following: -She would expect staff to perform a pain assessment if the resident is yelling, crying out or exhibits facial grimacing; -She would expect staff to notify her if the resident complains of or exhibits pain after scheduled pain medication is administered because the resident might need a change in pain medication; -If PRN pain medication is available she expect staff to administer it as needed. 4. Review of the Resident #59's care plan revised 12/19/16 showed the following: -Resident has periods when he/she experiences hallucinations, paranoia, or delusions; -Approach the resident in a calm and reassuring manners. Redirect resident's behaviors and use medication if needed; -Resident is at risk for adverse consequences related to receiving antipsychotic and antidepressant medication for treatment of [REDACTED]. -Monitor the resident's behavior and response to medication; -Quantitatively and objectively document the resident's behavior. Review of the resident's Quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -No acute mental status change; -No inattention or disorganized thinking; -No hallucinations or delusions; -No rejection of care, medications, treatments, etc.; -[DIAGNOSES REDACTED]. Review of the resident's June 2017 physician's orders [REDACTED]. -Aspirin [MEDICATION NAME] Coated (EC) 81 milligrams (mg) take one tablet by mouth once daily; -[MEDICATION NAME] (antidepressant medication) XL 150 mg by mouth every morning; -[MEDICATION NAME] (anti-psychotic medication) 100mg take two tablets by mouth at bedtime for [MEDICAL CONDITION]; -[MEDICATION NAME] (medication used to treat constipation) 10 grams (gm)/15 milliliter (ml) take 30ml by mouth three times daily; -[MEDICATION NAME] Dry Mouth Oral Rinse swish and spit 15 ml by mouth three times daily; -[MEDICATION NAME] ( medication used to treat symptoms of [MEDICAL CONDITION] or involuntary movements due to the side effects of certain psychiatric drugs) 2mg take one tablet by mouth twice daily; -[MEDICATION NAME] (blood pressure medication) 10mg take one tablet by mouth once daily; -[MEDICATION NAME] (medication used to treat various types of [MEDICAL CONDITION] disorders and also used to treat manic episodes related to [MEDICAL CONDITION] disorder ([MEDICAL CONDITION])) ER 750 mg by mouth at bedtime. Review of the resident's nurses' notes dated 6/20/17 untimed showed the resident made sexual comments to a nurse. Review of the resident's June 2017 MAR showed staff circled the [MEDICATION NAME] doses on 6/22/17, 6/23/17, 6/24/17, 6/25/17, 6/26/17, and 6/27/17 as not administered. Review of the back of the June 2017 MAR showed staff failed to document the reason the [MEDICATION NAME] doses were not administered on 6/22/17, 6/23/17, 6/24/17, 6/25/17, 6/26/17, and 6/27/17. Review of the resident's Behavior/Intervention Monthly Flow Record dated 6/23/17 showed the following: -Behavior: hallucinations, paranoia and delusions; -Day shift: two episodes; Evening shift: two episodes; -Intervention: Encourage to rest; -Outcome: Improved; -Behavior: socially inappropriate statements/behaviors; -Evening shift: two episodes; -Intervention: Encourage to rest; -Outcome: Improved. Review of the resident's Behavior/Intervention Monthly Flow Record dated 6/26/17 showed the following: -Behavior: hallucinations, paranoia and delusions; -Day shift: one episode; -Intervention: Redirect; -Outcome: Improved. Review of the resident's Behavior/Intervention Monthly Flow Record dated 6/28/17 showed the following: -Behavior: hallucinations, paranoia and delusions; -Day shift: three episodes; -Intervention: Redirect; -Outcome: Improved; -Behavior: socially inappropriate statements/behaviors; -Day shift: two episodes; -Intervention: Redirect; -Outcome: Worsened. Review of the resident's Behavior/Intervention Monthly Flow Record dated 6/29/17 showed the following: -Behavior: hallucinations, paranoia and delusions; -Day shift: three episodes; -Intervention: Encourage to rest; -Outcome: Improved; -Behavior: socially inappropriate statements/ behaviors; -Intervention: Redirect; -Outcome: Improved. Review of the resident's June 2017 nurses' notes showed no evidence staff notified the resident's physician of the resident not receiving six doses of [MEDICATION NAME] or other ordered medications. Review of the resident's MAR dated 7/20/17 showed the following: -[MEDICATION NAME] 200mg dose circled by staff as not administered; -[MEDICATION NAME] ER 750mg dose circled by staff as not administered; -[MEDICATION NAME] 2mg 8:00 P.M. dose circled by staff as not administered. Review of the back of the resident's MAR dated 7/20/17 showed the following: -All night time medications refused; -Resident said they make him/her feel bad. Review of the resident's MAR dated 7/23/17 showed the following: -Aspirin EC 81mg dose circled by staff as not administered; -[MEDICATION NAME] XL 150mg dose circled by staff as not administered; -[MEDICATION NAME] 10mg dose circled by staff as not administered; -[MEDICATION NAME] 2mg 8:00 A.M. and 8:00 P.M. dose circled by staff as not administered; -[MEDICATION NAME] Dry Mouth Oral Rinse 15ml 8:00 A.M., 1:00 P.M. and 8:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 10gm/15ml 30ml 8:00 A.M., 12:00 P.M. and 8:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 200mg dose circled by staff as not administered; -[MEDICATION NAME] ER 750mg dose circled by staff as not administered. Review of the back of the resident's MAR dated 7/23/17 showed the resident refused all morning medications. Review of the resident's MAR dated 7/24/17 showed the following: -Aspirin EC 81mg dose circled by staff as not administered; -[MEDICATION NAME] XL 150mg dose circled by staff as not administered; -[MEDICATION NAME] 10mg dose circled by staff as not administered; -[MEDICATION NAME] 2mg 8:00 A.M. dose circled by staff as not administered; -[MEDICATION NAME] Dry Mouth Oral Rinse 15ml 8:00 A.M. and 1:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 10gm/15ml 30ml 8:00 A.M. and 12:00 P.M. doses circled by staff as not administered. Review of the back of the resident's MAR dated 7/24/17 showed the resident refused all morning medications. Review of the resident's MAR dated 7/25/17 showed the following: -Aspirin EC 81mg dose circled by staff as not administered; -[MEDICATION NAME] XL 150mg dose circled by staff as not administered; -[MEDICATION NAME] 10mg dose circled by staff as not administered; -[MEDICATION NAME] 2mg 8:00 A.M. dose circled by staff as not administered; -[MEDICATION NAME] Dry Mouth Oral Rinse 15ml 8:00 A.M. and 1:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 10gm/15ml 30ml 8:00 A.M. and 12:00 P.M. doses circled by staff as not administered. Review of the back of the resident's MAR dated 7/25/17 showed the resident refused all morning medication. Review of the resident's MAR dated 7/26/17 showed the following: -Aspirin EC 81mg dose circled by staff as not administered; -[MEDICATION NAME] XL 150mg dose circled by staff as not administered; -[MEDICATION NAME] 10mg dose circled by staff as not administered; -[MEDICATION NAME] 2mg 8:00 A.M. and 8:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] Dry Mouth Oral Rinse 15ml 8:00 A.M., 1:00 P.M. and 8:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 10gm/15ml 30ml 8:00 A.M. and 12:00 P.M. doses circled by staff as not administered; -[MEDICATION NAME] 200mg dose circled by staff as not administered; -[MEDICATION NAME] ER 750mg dose circled by staff as not administered. Review of the back of the resident's MAR dated 7/26/17 showed the following: -Resident refused all evening medications except stool softener; -Nurse is aware. Review of the resident's July 2017 nurses' notes showed no evidence staff notified the resident's physician of the resident's medication refusals. Review of the resident's nurses' notes dated 8/2/17 untimed showed the following: -Resident noted to be talking to him/herself; -When asked who he/she is talking to, the resident replied he/she is hearing voices; -Will continue to monitor. Review of the resident's nurses' notes dated 8/3/17 untimed showed the following: -Resident is noted to be walking up and down the halls swinging his/her arms talking to him/herself; -No one with him/her; -He/she will tell staff I'm hearing voices. During interview on 8/3/17 at 12:00 P.M. the Administrator said the following: -The resident made a sexual abuse allegation against CNA LL; -The resident said it happened on 8/2/17 while he/she was visiting with Resident #69; -Allegedly CNA LL placed his/her hand on the resident's back and the resident felt it was in a sexual nature; -The resident is a paranoid [MEDICAL CONDITION] and has refused medications for several days. During interview on 8/3/17 at 1:50 P.M. Resident #69 said the following: -His/her roommate fell yesterday; -Resident #59 was in the room after his/her roommate fell ; -Resident #59 has been talking to him/herself more lately and acting strange; -CNA LL was trying to walk by Resident #59 in the doorway ; -As CNA LL was walking by Resident #59, Resident #59 said don't touch me! -Nothing inappropriate happened; -CNA LL was trying to get into the room to help his/her roommate. During interview on 8/3/17 at 1:10 P.M. CMT J said the following: -Circling initials on the MAR means the medication was not administered; -If a resident refuses medication, he/she circles his/her initials, writes the reason for refusal on the back of the MAR and notifies the charge nurse; -The resident refused medications for a few days and was acting different; -He/she reported medication refusals to the nurse; -LPN I was one of the nurses he/she reported the refusals to. During interview on 8/3/17 at 1:20 P.M. LPN I said the following: -No staff reported to him/her that the resident was refusing medications; -He/she would expect the CMTs to report medication refusals; -If a medication is refused the CMT should circle his/her initials and write the reason why the medication was not administered on the back of the MAR; -He/she would notify the physician if a resident missed more than two doses of medication; -It was very important to notify the physician if a resident refuses [MEDICATION NAME] because it is a very important medication. During interview on 8/3/17 at 4:45 P.M. the DON said the following: -She would expect the CMT to notify the charge nurse if a resident refuses medication; -She would expect the charge nurse to notify the physician if a resident refuses a medication several times during the shift; -She would expect staff to notify the physician if a resident refuses [MEDICATION NAME] after one hour. During interview on 8/16/17 at 11:55 A.M. the resident's physician said the following: -She would expect staff to notify her if a resident refused medication; -Staff did not notify her about the resident refusing medication; -The resident was transferred to the hospital's psychiatric unit on 8/4/17 for hallucinations and threatening to harm a staff member.

Based on observation, interview and record review, the facility failed to ensure the safety of one dependent resident (Resident #1), of three residents sampled. The resident had a history of [REDACTED]. The resident required total assistance with bathing. The facility bathed the resident using a lift bath trolley (bath/shower bed). The manufacturer's operating instructions directed staff to use the two safety straps on the bath trolley when bathing a resident. Facility staff failed to ensure the bath trolley was maintained with two straps to secure the resident and while in the process of bathing , the resident arched his/her body and fell off the bath trolley onto the floor. The resident sustained a maxillary fracture and complete avulsion of a tooth. The facility census was 104. 1. Review of the facility's Lift Bath Trolley Operating and Daily Maintenance Instructions, dated 1996, provided by the Director of Nursing (DON), showed the following: -Equipment was intended for lift and transferring residents to and from hygiene sites under supervision of trained skilled nursing staff in accordance with the instructions outlined in the manual; - Always make sure the equipment is handled by trained staff; - The lift bath trolley is moved with care and the safety straps are secured; - The safety straps are in good condition and properly fastened; -The lift bath trolley has two foldable handle bars as standard equipment, during transport and bath lower the handle bar that is placed at the longest distance from the resident's waist; - The lift bath trolley has two safety straps as standard equipment, the chest and hip strap; - When transferring the resident from bed: -Choose the appropriate end of the lift bath trolley to act as back support and fasten the pillow there; -Attach the hip strap to the knob and pass it straight over the stretcher so that it hangs over the floor; -When resident is on the lift bath trolley fasten the chest strap; -Raise the stretcher a little, pull out the hip strap and fasten it. Lower the handle bar. 2. Review of the facility's Repairs/Maintenance Log, dated 12/31/13, showed straps to shower bed missing. The job was noted as completed on 01/03/13 and initialed by the maintenance supervisor. 3. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 01/24/12, showed the following: -Comatose; -Total dependence of one person with bed mobility and bathing; -Total dependence of two persons with transfers; -Impairment of upper and lower extremities; -Height 6 foot and 1 inch; -149 pounds. Review of the resident's care plan, updated 11/14/12, showed problems including activities of daily living self care performance deficit related to injury. The resident was struck by a car and was dependent with all care. The resident was to be shampooed and showered per schedule. The resident required a mechanical lift for transfers. He/she was incontinent of bowel and staff was to provide peri care after each incontinent episode. He/she was totally dependent on staff to provide a bath. The resident was totally dependent on staff for repositioning and turning in bed and dependent on staff for dressing. Mouth guard daily. The resident was at risk for falls: Side rails as ordered by physician and staff was to anticipate and meet the resident's needs. (The care plan did not identify how staff was to shower the resident or address the resident's spasms/uncontrolled movements.) Review of the resident's physician progress notes [REDACTED]. The result of the accident caused the resident to suffer a severe TBI (traumatic brain injury) as well as multiple fractures. The physician would be managing the resident monthly for rehab and [DIAGNOSES REDACTED] needs. Review of the resident's physician orders [REDACTED]. Review of the resident's nurse notes dated 1/28/13 at 11:00 A.M, showed: CNA's (certified nurse aides) notified the charge nurse the resident was going to receive his/her shower. At approximately 11:00 A.M., the charge nurse was notified the resident was on the floor in the shower room with bleeding from his/her mouth. The charge nurse entered the shower room and observed the resident on his/her back on the floor with fresh blood on his/her mouth. The ADON (assistant director of nursing) was kneeling beside the resident with a cold compress and applied the compress to the resident's mouth, his/her mouth was cleaned out and the charge nurse was unable to determine the extent of his/her mouth damage. The resident was moaning. Orders were received to transfer the resident stat to the emergency room (ER). Review of the resident's nursing progress note dated 01/28/13 showed an unidentified person was called to the shower room at 11:25 A.M. and observed the resident on the floor on his/her back. Two CNA's were with the resident. It was stated the resident had been belted onto the stretcher (bath bed) and the resident arched his/her back and moved slightly, flipping his/her head first onto the floor, called 911 stat. Review of the resident's Physician/NP/PA Communication and Progress Note dated 01/28/13 at 11:45 A.M. showed staff called regarding facial trauma. The problem/symptom started at 11:25 A.M. The problem/symptom had gotten worse as the resident had a non reactive left pupil and blood from the mouth. Pertinent medical history included previous brain trauma July 2012. The resident had mental status and neurological changes. The resident had increased pain and moaning. The problem could have been trauma to the resident's mouth and the resident appeared to be in pain. New orders were received to transfer stat. Review of the resident's ER discharge instructions dated 1/28/13 showed [DIAGNOSES REDACTED]. History: fell in shower and quadriplegic. Follow up with oral surgeon in one day , (call to be seen for non-displaced maxillary fracture with avulsion of right central and lateral incisors and chipped left central incisor -all upper teeth). During interview on 2/11/13 at 11:00 A.M., the resident's guardian said he/she wanted the resident to have oral surgery, however, the resident had another scheduled surgery and he/she was afraid too many surgeries would be hard on the resident. The resident had a surgical procedure to have a Baclofen pump placed to help decrease his/her [DIAGNOSES REDACTED] on 2/8/13. Interview on 2/6/13 at 11:28 A.M., CNA A said this was his/her second time giving the resident a shower. He/she had no idea the resident had spasms or arched his/her back. The CNA went to reach for the water faucet and the resident went off the bath bed face first. The bath bed strap was attached to the resident, the strap was very long. He/she was shown by another CNA how to give the resident a bath using the bath bed. There was only one strap to use on the resident. Interview on 2/6/13 at 11:45 A.M., showed RA (restorative aide) B said the resident was in the bath bed when he/she had a spasm and the bed bath belt (strap) popped off. The RA tried to brace the resident's fall. The resident flipped over and hit the floor face first. When the resident had his/her spasm the belt popped off. When he/she starting working at the facility in July of 2012 there was only one strap used on the bath bed and after the resident fell another strap was added. The bar on the bed bath was supposed to come down when the resident was being transported, but the bar could not be used due to the resident's legs being contracted. He/she was trained by another aide on how to use the bath bed. Interview on 2/7/13 at 8:39 A.M., showed the maintenance supervisor said he/she did monthly inspections on equipment, including the shower bed. The shower bed had always had one strap. He/she had been working at the facility for three years and there had only been one strap on the shower bed. There was a second strap added to the shower bed after Resident #1 fell out of the shower bed, (the maintenance man had no explanation as to why the second strap was added after the fall). He/she would not comment on the CNA requesting a second strap for the shower bed in December 2012. He/she had just printed out the lift bath trolley manual on 1/6/13 (after the fall). During interview on 2/6/13 at 4:25 P.M., the Director of Nursing said there had been no policy and procedure regarding the use of the lift bath trolley or training prior to the resident's incident of falling off the lift bath trolley. Complaint #MO

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "K". A monitoring visit was completed on 11/17/2011. Based on observation, record review and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. the severity of the deficiency was lowered to a "H" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations

tical service failed to p Based on observation, interview and record review the facility failed to provide pharmaceutical services that could supply accurate acquisition, receipt and dispensing of medications to meet the needs of facility residents. Facility residents, including six (Resident #70, #71,#56, #80, #81 and #30) of fifteen sampled residents, did not receive numerous ordered medications over multiple days and one additional resident (Resident #83), did not receive the optimal antibiotic to treat his/her condition when the pharmacy failed to have ordered antibiotics available for administration. Resident #70 missed multiple doses of medications for hypertension, chronic renal disease, dialysis and muscle spasms. The resident had an episode of hypertension, leg spasms, and abnormal blood work as a result of missing the medications. Resident #71 missed multiple psychiatric medications and was subsequently hospitalized as a result due to increased agitation and behaviors. Another resident, (Resident #80) observed with tremors in both upper extremities, did not receive medication ordered to address his/her tremors. This medication had been ordered 10/25/11 and had not been received at the time the resident was discharged from the facility 10/29/11. The resident relayed his/her tremors had not improved and the tremors were wearing him/her out. Resident #81, a resident with recent hip and ankle fractures, did not receive his/her change in ordered pain medication for 26 hours. The resident reported his/her pain control was much improved once the the new pain medication was received and administered. Resident #30 missed his/her blood thinning medication so prevent blood clots resulting in sub therapeutic laboratory values. The census was 104. 1. Review of Resident #70's annual minimum data set (MDS), a federally mandated assessment instrument required to be completed by staff dated 10/03/11 showed the following: -The resident's cognition was intact; -The resident received dialysis. Review of the resident's 10/01/11 physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medication that included: - Senispar (decreases level of para[DIAGNOSES REDACTED] in people with chronic kidney disease and are on dialysis, decreases calcium and phosphorous)( 60 mg (milligrams) by mouth every day at 8:00 A.M.; - Metoprolol (hypertension) 100 mg ER (extended release) one by mouth two times a day at 8:00 A.M. and 8:00 P.M.; - Renal cap softgels (Nephrocaps) (renal vitamin used to treat vitamin deficiency in people with chronic kidney disease and those undergoing dialysis) one by mouth every evening at 6:00 P.M.; - Renvela (reduces blood levels of phosphorous in people with chronic kidney disease undergoing dialysis) 800 mg's three tablets by mouth three times a day at 8:00 A.M., 11:30 A.M., and 6:00 P.M.; - Clonidine (hypertension) 0.3 mg by mouth three times a day at 8:00 A.M., 1:00 P.M., and 8:00 P.M.; -Trazodone (depression) 50 mg by mouth three times a day at 8:00 A.M., 1:00 P.M., and 8:00 P.M.; -Hydralazine (hypertension) 100 mg's by mouth four times a day at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.; -Cymbalta (depression) 60 mg's by mouth daily at 8:00 A.M.; -Levothyroxine ([DIAGNOSES REDACTED]) 100 mcg (micrograms) by mouth daily at 7:00 A.M.; -Lisinopril (hypertension) 20 mg by mouth daily at 8:00 A.M.; -Poly-iron (Niferex) (iron deficiency anemia) 150 mg by mouth daily at 8:00 A.M.; -Rifampin (bacterial antibiotic used to eliminate bacteria that causes [DIAGNOSES REDACTED]) 300 mg by mouth daily at 8:00 A.M.; -Verapamil (hypertension) ER 240 mg by mouth daily at 9:00 A.M.; -Famotidine (treat/prevent ulcers) 20 mg by mouth daily; -Flexeril (muscle relaxer) 10 mg by mouth three times a day. Review of the resident's medication administration sheets (MAR), dated 10/01/11 through 10/31/11 showed the following: -On 10/04/11 and 10/05/11 at 9:00 A.M., staff documented (back of the medication administration sheet) all the resident's morning medications were not available and staff told the nurse; -On 10/18/11 at 9:00 A.M., staff documented the resident was LOA (leave of absence) and all the resident's morning medications were not available; -Staff initialed/circled the resident's 8:00 A.M. dose of Niferex on 10/01/11, 10/04/11, and 10/05/11 (circled entries indicates medication not given); -Staff initialed/circled the resident's 8:00 A.M. dose of Rifampin on 10/01/11, 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/09/11, 10/10/11, and 10/11/11; -Staff documented (on back of the medication administration sheet) on 10/07/11 at 8:00 A.M., the Rifampin was not available/on delivery; -On 10/10/11 at 8:00 A.M., staff documented the Rifampin was not available/reported to nurse; -On 10/11/11 at 8:00 A.M., staff documented the Rifampin was not available/would re-order; -Staff initialed/circled the resident's 9:00 A.M. dose of Verapamil on 10/01/11, 10/04/11, and 10/05/11; -Staff initialed/circled the resident's 8:00 A.M. dose of Metoprolol on 10/01/11, 10/04/11, 10/05/11, 10/08/11, 10/12/11, and 10/13/11; -On 10/08/11 at 8:00 A.M., staff documented (on the back of the medication administration sheet) the Metoprolol was not available; -Staff initialed/circled the resident's 8:00 P.M. dose of Metoprolol on 10/04/11, 10/06/11, 10/07/11, and 10/12/11; -On 10/06/11 at 8:00 P.M., staff documented (on back of the medication administration sheet) the Metoprolol was not available, pharmacy notified, and nurse practitioner aware; -Staff initialed/circled the resident's 6:00 P.M. dose of Nephrocaps on 10/08/11 and 10/15/11; -On 10/08/11 at 8:00 A.M. and 10/15/11 at 5:00 P.M. (on the back of the medication administration sheet), the Nephrocaps were not available; -Staff initialed/circled the resident's 6:00 A.M. dose of Flexeril on 10/04/11, 10/05/11, 10/12/11, 10/18/11, and 10/19/11; -On 10/04/11 at 6:00 A.M. staff documented (on back of medication administration sheet) the Flexeril was not given/not available, and the pharmacy was aware; -On 10/05/11 at 6:00 A.M., staff documented the Flexeril was not available; -On 10/12/11 at 6:00 A.M., staff documented the Flexeril not given/not available; -On 10/18/11 at 6:00 A.M., staff documented the Flexeril was not given/not available; -On 10/19/11, at 6:00 A.M., staff documented the Flexeril was not given/not available, and the pharmacy was aware; -Staff initialed/circled the resident's 4:00 P.M. dose of Flexeril on 10/04/11, 10/05/11, 10/06/11, 10/12/11, and 10/18/11; -On 10/05/11 at 4:00 P.M., staff documented (back of medication administration sheet) the Flexeril was not there and faxed pharmacy again; -Staff initialed/circled the resident's 10:00 P.M. dose of Flexeril on 10/04/11, 10/05/11, 10/06/11, 10/12/11, and 10/13/11; -On 10/13/11 at 10:00 P.M., staff documented (back of medication administration sheet) the medication was not there/faxed to pharmacy/confirmation obtained; -Staff initialed/circled the resident's 8:00 A.M. dose of Renvela on 10/01/11, 10/04/11, 10/05/11, 10/12/11, and 10/13/11; -Staff initialed/circled the resident's 11:30 A.M. dose of Renvela on 10/04/11, 10/05/11, 10/12/11, and 10/13/11; -Staff initialed/circled the resident's 6:00 P.M. dose of Renvela on 10/04/11 and 10/12/11; -Staff initialed/circled the resident's 8:00 A.M. dose of Clonidine on 10/01/11, 10/04/11, 10/05/11, 10/08/11, 10/09/11, 10/12/11, and 10/13/11; -Staff initialed/circled the resident's 1:00 P.M. dose of Clonidine on 10/01/11, 10/04/11, 10/05/11, 10/08/11, and 10/12/11; -Staff initialed/circled the resident's 8:00 A.M. dose of Trazodone on 10/01/11, 10/04/11, 10/05/11, and 10/13/11; -Staff initialed/circled the resident's 1:00 P.M. dose of Trazodone on 10/04/11 and 10/05/11; -Staff initialed/circled the resident's 8:00 P.M. dose of Trazodone on 10/04/11; -Staff initialed/circled the resident's 8:00 A.M. dose of Hydralazine on 10/01/11, 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/09/11, 10/10/11, 10/11/11, 10/12/11, and 10/13/11; -On 10/07/11 at 8:00 A.M., staff documented (back of medication administration sheet) the Hydralazine was not available/nurse aware; -On 10/10/11 at 8:00 A.M., staff documented the Hydralazine was not available and reported to the nurse; -On 10/11/11 at 8:00 A.M., staff documented the Hydralazine was not available and would order from the pharmacy; -Staff initialed/circled the resident's 12:00 P.M. dose of Hydralazine on 10/01/11, 10/04/11, 10/05/11, 10/07/11, 10/11/11, and 10/13/11; -On 10/07/11 at 12:00 P.M., staff documented (back of medication administration sheet) the medication was not available and the nurse was aware; -Staff initialed/circled the resident's 5:00 P.M. dose of Hydralazine on 10/01/11, 10/04/11, 10/05/11, 10/06/11, 10/07/11, 10/08/11, 10/09/11, 10/10/11, and 10/11/11; -On 10/06/11 at 5:00 P.M., staff documented (back of the medication administration sheet) the Hydralazine was not given; -On 10/10/11 at 5:00 P.M., staff documented the Hydralazine was not available and reported to the nurse; -Staff initialed/circled the resident's 9:00 P.M. dose of Hydralazine on 10/02/11, 10/04/11, 10/07/11, and 10/11/11; -Staff initialed/circled the resident's 8:00 A.M. dose of Senispar on 10/01/11, 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/09/11, 10/10/11, and 10/11/11; -On 10/07/11 at 8:00 A.M., staff documented (back of medication administration sheet) the Senispar was not available and the nurse was aware; -On 10/10/11 at 8:00 A.M., staff documented the Senispar was not available and reported to the nurse; -On 10/11/11 at 8:00 A.M., staff documented the Senispar was not available and would be ordered from the pharmacy; -Staff initialed/circled the resident's Famotidine on 10/04/11, 10/05/11, 10/07/11, 10/08/11, 10/09/11, 10/10/11, and 10/11/11; -On 10/07/11 at 8:00 A.M., staff documented (back of medication administration sheet) the Famotidine was not available and the nurse was aware; -On 10/10/11 at 8:00 A.M., staff documented the Famotidine was not available and reported to the nurse; -On 10/11/11 at 8:00 A.M., staff documented the Famotidine was not available and would be ordered from the pharmacy; -Staff initialed/circled the resident's 8:00 A.M. dose of Cymbalta on 10/01/11, 10/04/11, 10/05/11, 10/12/11, and 10/15/11; -On 10/12/11 at 9:00 A.M., staff documented (back of the medication administration sheet) the Cymbalta was not available/not given, and would be re-ordered; -Staff initialed/circled the resident's 7:00 A.M. dose of Levothyroxine on 10/01/11, 10/04/11, and 10/05/11; -At 6:00 A.M. (unable to read the date), staff documented (back of medication administration sheet) the Levothyroxine was not available/not given; -Staff initialed/circled the resident's 8:00 A.M. dose of Lisinopril on 10/01/11, 10/04/11, 10/05/11, and 10/15/11. Review of the resident's nurse's notes dated 10/13/11 showed the following: -At 3:30 P.M., the dialysis nurse contacted the facility and notified staff the resident's blood pressure was elevated and to verify the resident's medications, and the last time the resident received his/her medications; -Staff reviewed the resident's medication administration sheet with the dialysis nurse at that time. During interview on 10/21/11 at 11:20 A.M. and 10/27/11 at 10:45 A.M., the dialysis nurse said the following: -The resident's blood pressure before dialysis on 10/13/11 was 200 (systolic) over 109 (diastolic) (Lipincott, a comprehensive manual for all types of nursing care shows normal blood pressure readings range from 95-140 systolic over 60-90 diastolic) and 214/108 after dialysis; -The resident told dialysis staff he/she had not been getting his/her medications; -The resident's phosphorous (mineral in the body that helps filter out waste in the kidneys) level was elevated; -The phosphorus level was drawn on 10/11/11; -The level was 7.0 (Mosby's Diagnostic and Laboratory Test Reference 6 th Edition Copyright 2003 showed normal phosphorous level was 3-4.5 mg/dl (milligrams per deciliter); -In September 2011, the resident's phosphorous level was 5.1; -If someone was not getting his/her phosphorous binding medications it could elevate the phosphorus level; -If the resident was not getting his/her Renvela and Senispar (phosphorous binding medications), it could affect the resident's laboratory values. Review of the resident's nurse's notes dated 10/13/11 and 10/14/11 showed the following: -On 10/13/11 at 3:58 P.M., the resident returned to the facility from dialysis; -Staff checked the resident's blood pressure and obtained a reading of 218/116; -Staff notified the nurse practitioner of the resident's blood pressure reading at the time, the report received from the dialysis clinic, and the resident did not take his/her blood pressure medications prior to going to dialysis; -The nurse practitioner directed staff to administer the resident's medication at that time (Clonidine, Hydralazine, Verapamil, Lisinopril, Niferex, Rifampin, Flexeril, Trazodone, and Senispar; -At 5:15 P.M., staff checked the resident's blood pressure and obtained a reading of 204/110; -At 4:30 P.M., staff checked the resident's blood pressure and obtained a reading of 200/100; -At 4:45 P.M., staff checked the resident's blood pressure and obtained a reading of 190/98; -At 5:15 P.M., staff checked the resident's blood pressure and obtained a reading of 188/96; -At 6:00 P.M., staff checked the resident's blood pressure and obtained a reading of 180/94; -At 6:30 P.M., staff checked the resident's blood pressure and obtained a reading of 172/96; -At 7:15 P.M., staff checked the resident's blood pressure and obtained a reading of 160/94; -At 8:00 P.M., the resident's Metoprolol (Toprol) and Cymbalta was delivered from the pharmacy and given for 8:00 P.M. scheduled dose; -The resident's blood pressure reading was 150/90; -At 9:00 P.M., staff checked the resident's blood pressure and obtained a reading of 148/88; -Staff administered the resident's Hydralazine, Clonidine, and Trazodone; -At 10:00 P.M., staff checked the resident's blood pressure and obtained a reading of 148/88; -At 11:00 P.M., staff checked the resident's blood pressure and obtained a reading of 150/88; -On 10/14/11 at 1:30 A.M., staff administered Ativan (anxiety) for resident complaint of agitation and Hydrocodone (narcotic analgesic) for resident complaint of pain. Review of the resident's monthly record of vital signs/weights dated 09/16/10 through 09/21/11 showed the resident's blood pressure readings ranged from 132 to 200 systolic over 60-98 diastolic. During interview on 10/21/11 at 11:05 A.M., the resident said the following: -He/She did not get his/her medications for a few days; -He/She would asked staff about his/her medications when staff did not stop to give the resident his/her medications; -Staff would tell him/her they had to wait for the pharmacy to get the medications; -Staff said the pharmacy did not deliver anyone's medications; -His/Her blood pressure was really high, 200/100 or something; -He/She had a headache when his/her blood pressure was elevated; -His/Her laboratory values were elevated at dialysis; -He/She had spasms in his/her left leg when he/she did not get his/her Flexeril; -Staff did not check on the resident when the resident did not get his/her medications. During interview on 10/21/11 at 10:20 A.M., the Director of Nurses (DON) said staff had not been monitoring the resident's blood pressure when the resident did not receive his/her medications (prior to 10/13/11). During interview on 10/21/11 at 11:30 A.M., the resident's primary care physician/facility Medical Director said the following: -It was not okay for residents including Resident #70 to miss doses of medications; -Residents could not miss diabetic and high blood pressure medications; -Resident #70 could have had a stroke due to his/her elevated blood pressure. 2. Review of Resident #71's quarterly MDS dated [DATE] showed the following: -The resident's cognition was intact; -The resident had displayed no behaviors. Review of the resident's physician order [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer Clozapine (antipsychotic) 250 mg at bedtime using 100 mg tablets (two whole tablets and one half tablet to equal 250 mg). Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's bedtime dose of Clozapine on 10/01/11, 10/05/11, 10/06/11, 10/07/11, 10/08/11, and 10/09/11; -Staff left the bedtime dose slot blank on 10/04/11; -Staff documented on the back of the medication administration sheet the following: -On 10/06/11 at 8:00 P.M., staff documented the medication was not available/charge nurse notified; -On 10/07/11 at 8:00 P.M., staff documented the medication was not available/pharmacy and charge nurse aware; -On 10/09/11 at 8:00 P.M., staff documented the medication was not available. Review of the resident's nurse's notes dated 10/10/11 at 5:00 A.M. showed the following: -The resident was irritated and anxious throughout the night; -Staff tried to redirect the resident seven times to relax and sleep; -At 4:00 A.M., the resident became combative and yelling; -The resident was on a rampage around the facility; -The resident attacked staff two times; -The resident said he/she was hearing voices; -Staff contacted the paramedics to pick up the resident. Review of the resident's physician's orders [REDACTED]. Review of the resident's history and physical from an area hospital dated 10/10/11 showed the following: -Reason for admission: Exacerbation of psychosis; -The resident had reportedly gotten increasingly aggressive at the facility; -The resident reportedly missed his/her medications for two days last week due to a change in pharmacies; -Since then, the resident's behaviors had gradually escalated to the point of hospital admission; -Family reported the resident usually did not have aggression; -Family said the resident had always been pleasant and functioned at a higher level. During interview on 10/26/11 at 1:35 P.M., the DON said the following: -The resident took antipsychotic medications; -The antipsychotic medications were not available through the pharmacy, so the resident missed doses; -The resident had behaviors due to missed doses of medication; -The resident was sent to the psychiatric hospital for evaluation/treatment. Review of the resident's nurse's notes dated 10/21/11 (no time documented) showed the resident returned to the facility from the hospital. Review of the resident's physician's orders [REDACTED]. -The physician directed staff to administer medications that included Clozapine 25 mg (10 tablets to equal 250 mg) at bedtime (9:00 P.M.) and Haldol (antipsychotic) 5 mg's at bedtime (9:00 P.M.). Review of the resident's medication administration sheet dated 10/01/11 through 10/31/11 showed the following: -Staff initialed/circled the resident 9:00 P.M. dose of Clozapine on 10/21/11; -Staff initialed/circled the resident's 9:00 P.M. dose of Haldol on 10/21/11; -Staff documented on the back of the medication administration sheet that the Clozapine and Haldol were not available, charge nurse notified, medications on delivery, pharmacy called at 10:15 P.M. 3. Review of Resident #56's 14 day MDS dated [DATE] showed the following: -The resident had [DIAGNOSES REDACTED]. -The resident's cognition was intact. Review of the resident's physician's orders [REDACTED]. -The physician directed staff to administer medications that included the following: -Bystolic (hypertension) 5 mg daily at 9:00 A.M.; -Lasix (fluid pill) 40 mg daily at 9:00 A.M.; -Neurontin (seizures) 300 mg two capsules two times a day at 9:00 A.M. and 9:00 P.M.; -Apresoline (hypertension) 50 mg three times a day at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; -Polysaccharide Iron (anemia) 150 mg daily at 9:00 A.M.; -Synthroid ([DIAGNOSES REDACTED]) 200 mcg (micrograms) daily at 6:00 A.M.; -Lisinopril (hypertension) 40 mg daily at 9:00 A.M.; -Levetiracetam (seizures) 750 mg two times a day at 9:00 A.M. and 9:00 P.M.; -Lansoprazole disintegrating (acid reflux) 30 mg at bedtime (9:00 P.M.); -Risperidone (antipsychotic) 1 mg at bedtime (9:00 P.M.); -Duloxetine (Cymbalta) (depression) 60 mg daily at 9:00 A.M. Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's 9:00 A.M. dose of Bystolic on 10/14/11; -Staff initialed/circled the resident's 9:00 A.M. dose of Lasix on 10/09/11 and 10/14/11; -Staff initialed/circled the resident's 9:00 P.M. dose of Neurontin on 10/17/11; -Staff initialed/circled the resident's 6:00 A.M. dose of Apresoline on 10/15/11, 10/16/11, and 10/17/11; -Staff initialed/circled the resident's 2:00 P.M. dose of Apresoline on 10/13/11, 10/14/11, 10/15/11, 10/16/11, and 10/17/11; -Staff initialed/circled the resident's 10:00 P.M. dose of Apresoline on 10/15/11, 10/16/11, and 10/17/11; -On 10/15/11 (no time documented), staff documented on the back of the medication administration sheet the resident Apresoline was held due to a blood pressure reading of 108/60; -On 10/16/11 staff documented twice (no times documented) on the back of the medication administration sheet the resident's Apresoline was held due to a blood pressure reading of 110/46 and a pulse of 48 (Lipincott, a comprehensive manual for all types of nursing care showed a normal pulse range was 60-80 beats per minute) and the second entry staff documented the resident's Apresoline was held due to a blood pressure reading of 11/60; -On 10/17/11 (no time documented), staff documented the resident's Apresoline was not given due to being re-ordered/manager aware; -The DON wrote on the front of the medication administration sheet (not dated) the nurse planned to hold the resident's blood pressure medication because the resident's blood pressure was low, but the medication was not available and re-ordered on [DATE], 10/15/11, and 10/16/11; -Staff initialed/circled the resident's 9:00 A.M. dose of Polysaccharide Iron on 10/09/11; -Staff initialed/circled the resident's 6:00 A.M. dose of Synthroid on 10/14/11, 10/16/11, and 10/17/11; -On 10/14/11 at 6:00 A.M., staff documented on the back of the medication administration sheet the resident's Synthroid was not here/not given; -On 10/17/11 (no time documented), staff documented on the back of the medication administration sheet the resident's Synthroid was not given/being re-ordered; -Staff initialed/circled the resident's 9:00 A.M. dose of Lisinopril on 10/14/11; -Staff initialed/circled the resident's 9:00 A.M. dose of Duloxetine on 10/09/11 and 10/14/11; -Staff initialed/circled the resident's 9:00 P.M. dose of Levetiracetam on 10/17/11; -Staff initialed/circled the resident's 9:00 P.M. dose of Lansoprazole disintegrating on 10/17/11; -Staff initialed/circled the resident's 9:00 P.M. dose of Risperidone on 10/17/11. Review of the resident's nurse's notes dated 10/17/11 at 6:00 A.M. showed the resident was out of two 6:00 A.M. medications. Review of the resident's physician order [REDACTED]. Review of the resident's MAR indicated [REDACTED]. During interview on 10/20/11 at 3:45 P.M. and 10/21/11 at 10:30 P.M., the DON said the following: -If there had been a physician's orders [REDACTED]. [REDACTED]. -The resident's Apresoline was not available anyway. 4. Review of Resident #80's 14 day MDS dated [DATE] showed the assessed the resident as follows: -Resident is cognitively intact (BIMS score of 14); -Resident has no memory problems; -Resident can make needs known. Record review of the resident's plan of care, last updated 10/17/2011, showed the facility staff were instructed to: -Educate resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medication; -Administer medication as ordered by MD (Medical Doctor). Monitor for side effects and effectiveness, s/e (side effects) notify MD as needed. Record review of the resident's Physician order [REDACTED]. Record review of the resident's MAR, dated 10/2011, showed the medication Requip was added on 10/26/11. - Doses dated on 10/27 at 8:00 A.M., 12:00 P.M. and 4:00 P.M. were all circled indicating medication not available; - Doses dated on 10/28 at 8:00 A.M., 12:00 p.m. and 4:00 p.m. were all circled indicating medication not available. - Doses dated on 10/29 at 8:00 a.m, 12:00 P.M. and 4:00 P.M. were not documented as given. During interview on 10/29/11 at 10:25 A.M. the resident said the following: -He/She was leaving the facility and going to residential care that same day; -He/She had not received medications ordered by his/her physician while residing at the facility including a heart medication which was missed for two days and a new medication ordered by the physician last Tuesday (10/25/11) for tremors; -The nurse practitioner visited Thursday (10/27/11) and was shocked the medication was not there; -Staff told him/her the medication "Was not in yet"; -He/She has never received the ordered medication; -His/Her tremors were a bit worse and the tremors, "Wear me out". Observation on 10/29/11 at 10:25 A.M. showed the resident sitting on the seat of his/her wheeled walker accompanied by his/her family member. The resident had noticeable tremors of bother upper arms. During interview on 10/29/11 at 10:35 A.M. Licensed Practical Nurse (LPN) Q said the facility had recently changed pharmacy providers and there were problems with the new pharmacy. The pharmacy did not get the Requip (an antiparkinson agent), ordered for the resident and the resident was leaving the facility 10/29/11. During an interview on 10/29/2011 at 2:00 p.m. the DON said they never received the medication from the pharmacy to give to the resident after several follow up faxes and phone calls. 5. Review of Resident #81's 14 day MDS dated [DATE] showed the facility assessed the resident as follows: -Cognitively intact; -[DIAGNOSES REDACTED]. -The resident presented with pain and received prn pain medications. During interview on 10/29/11 at 11:30 A.M. the resident said the following: - He/She had recently fractured his/her hip and ankle; -Initially he/she received Vicodin for pain control, but had seen his/her orthopaedic surgeon recently and the order was changed to Percocet; -Percocet worked better for pain relief; -The Percocet was not available, and it took awhile to get the medication; -He/She did well with the Percocet. Review of a physician's prescription dated 10/24/11 showed the following: -Percocet 7.5/325 mg one to two by mouth every four to six hours as needed for pain; -Facility staff confirmed the order at 2:00 P.M.. Review of the resident's nurse's notes dated 10/25/11 through 10/26/11 showed the following: -At 1:10 P.M. the resident was admitted to the facility and orders were verified. Has script for Percocet, faxed to the pharmacy and also called; -At 2:30 P.M. resident complains of pain, given Vicodin, explained Percocet order faxed to the pharmacy earlier; -At 7:00 P.M. resident alert and oriented, complains of pain in left hip/groin area, prn Vicodin given at 5:30 P.M., pain rated an eight on a scale of one to ten regarding pain; -On 10/26/11 at 10:00 A.M. pharmacy notified of medications not available for new resident, will be delivered before 12:00 P.M.. Review of the resident's physician's orders [REDACTED]. -The resident presented with [DIAGNOSES REDACTED]. -Oxycodone/APAP (Percocet, a narcotic analgesic) 7.5-325 one to two tablets by mouth every four to six hours as needed for pain, order dated 10/26/11. Review of the resident's MAR indicated [REDACTED].M., (26 hours after the medication had been ordered). During interview on 10/29/11 at 2:20 P.M. the DON said the order for the resident's Percocet was sent by 2:00 P.M. and was supposed to be at the facility at 6:00 P.M. that same night. The facility was then told by the pharmacy it would not be available until 6:00 P.M. the next day. The facility called the pharmacy again and were able to get the Percocet the next day by 4:00 P.M.. The facility gave the resident ordered Ativan (antianxiety) and Vicodin to help calm the resident down. 6. Review of resident #30's annual MDS dated [DATE], showed the facility assessment of the resident included the following: -Intact Cognition, clear speech, adequate hearing and vision; -[DIAGNOSES REDACTED]. -Resident's medications include insulin, antidepressants and anticoagulants. Review of the resident's history and physical dated 9/30/11 showed [DIAGNOSES REDACTED]. -Atria fibrillation (a turbulent blood flow through the top of the heart that can cause emboli or small clots to form); Coronary artery disease. Review of the MAR indicated [REDACTED] -Reverse of the MAR indicated [REDACTED].M.) "Coumadin three 3 mg med unavailable"; -No mention on the MAR indicated [REDACTED]. Review of the resident's physician order [REDACTED]. -10/3/11 order to start Coumadin three 3 mg daily; -10/16/11 continue Coumadin 3 mg daily, recheck INR in one week; -10/17/11 increase Coumadin dose to four 4 mg daily, recheck INR in one week. Review of Laboratory report for bleeding time INR (international normalized ratio: are measures of the extrinsic pathway of coagulation <http://en.wikipedia.org/wiki/Coagulation>. This test is also called "ProTime INR" and used to determine the clotting tendency of blood, in the measure of Coumadin dosage) showed the following results: -On 10/11/11 INR was 1.28, (after not receiving the medication for two days); -On 10/24/11 INR was 2.80; -Laboratory normals listed for emboli prevention and prophylaxis INR range should be 2.0-3.0. Review of resident's nurses notes from 9/25/11 through 10/24/11 showed no mention of physician notification of the resident missing two doses of Coumadin. 7. Review of Resident #83's physician's orders [REDACTED]. During interview on 10/29/11 at 12:33 P.M. the DON said the resident needed an antibiotic for a urinary tract infection last Friday (10/21/11), and the nurse practitioner had to go to a fifth choice of an antibiotic before the pharmacy had a medication available to give. Interview on 10/26/11 at 12:15 P.M. and 10/31/11 at 3:50 P.M. showed the medical director's/resident's physician's nurse practitioner said the following: -She could not recall the date she was first informed of medication supply problems; -She was not involved in meetings, discussion, or review of new pharmacy transition, policy and procedures; -Resident #83 had a high white blood cell count (indicating infection) this month (October 2011); -The resident was bariatric and had a wound, she had the facility obtain a urine sample to check for infection; -She wanted to cover the resident with an antibiotic before the culture and sensitivity (C&S), on

This deficiency is uncorrected for previous examples please refer to the statement of deficiencies dated 9/02/11. Based on interview and record review the facility failed to ensure three (Resident #77, #78 and #79) of 15 sampled residents and five additional residents (Resident #1, #72, #73, #75 and #76) were free of significant medication errors when the facility pharmacy failed to provide residents' ordered medications for facility staff to administer over multiple days for numerous medications. This resulted in multiple omissions of medications which should not be discontinued/stopped abruptly due to the potential for negative outcomes. The census was 104. 1. Review of Mosby's Nursing Drug Reference 2011 24 th Edition copyright 2011 showed the following information regarding medications: -[MEDICATION NAME]-do not discontinue product abruptly; may cause precipitate [MEDICAL CONDITION] (chest pain); -[MEDICATION NAME]-comply with dosage schedule even if feeling better; -Do not discontinue product abruptly or withdrawal symptoms may occur: anxiety, increased blood pressure; headache, [MEDICAL CONDITION], increase pulse, tremors, nausea, sweating; -[MEDICATION NAME]-do not discontinue medication quickly after long term use; may cause nausea, headache, malaise; -[MEDICATION NAME]-do not discontinue medication quickly after long term use; may cause nausea, headache, malaise; -[MEDICATION NAME]-do not discontinue product abruptly; -[MEDICATION NAME]-compliance with dosage schedule/duration is necessary; -[MEDICATION NAME]-comply with all areas of medical regimen including product therapy; -Do not discontinue abruptly; chest pain may occur; -[MEDICATION NAME]-product must be continued for prescribed time in prescribed method to be effective; -[MEDICATION NAME]-do not discontinue medication abruptly; -[MEDICAL CONDITION], nausea, headache, [DIAGNOSES REDACTED], and [MEDICAL CONDITION](elevated heart rate) will occur; -[MEDICATION NAME]-avoid abrupt withdrawal of this medication because EPS (extra pyramidal symptoms) (movement disorders) may a result; -[MEDICATION NAME]-avoid abrupt withdrawal of this medication or EPS may result; -[MEDICATION NAME]-do not discontinue abruptly, severe cardiac reactions may occur; -[MEDICATION NAME]-do not discontinue quickly, abrupt withdrawal may precipitate [MEDICAL CONDITION]; -Levetiracetam-do not discontinue medication quickly, withdrawal [MEDICAL CONDITION] may occur; -[MEDICATION NAME]-avoid abrupt withdrawal, EPS may result; -[MEDICATION NAME]-if discontinued abruptly, parkinsonian crisis, [DIAGNOSES REDACTED] may occur; -[MEDICATION NAME]-do not discontinue quickly, [MEDICAL CONDITION] may result; -[MEDICATION NAME]-do not discontinue medication quickly, hallucinations, [DIAGNOSES REDACTED], [MEDICAL CONDITION](fast pulse) will occur; -[MEDICATION NAME]-avoid abrupt withdrawal, EPS may result; -[MEDICATION NAME]-not to discontinue abruptly, [MEDICAL CONDITION] could occur; -[MEDICATION NAME]-do not discontinue abruptly; -[MEDICATION NAME]-do not stop abruptly; -[MEDICATION NAME]-must be continued on a daily basis; -[MEDICATION NAME]-do not discontinue medication quickly; -[MEDICATION NAME]-do not skip dose; -QVAR-do not discontinue product abruptly; -Atrovent-compliance necessary with number of inhalations. 2. Review of Resident #1's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] ([MEDICAL CONDITION] hormone) 88 mcg daily at 6:00 A.M.; -[MEDICATION NAME] (blood thinner) 75 mg daily at 6:00 A.M.; -[MEDICATION NAME] (antipsychotic) 15 mg every evening at 5:00 P.M. Review of the resident's medication administration sheet (MAR) dated 10/01/11 through 10/31/11 showed the following: -Staff initialed/circled the resident's 6:00 A.M. dose of [MEDICATION NAME] on 10/04/11; -Staff initialed/circled the resident's dose of [MEDICATION NAME] on 10/04/11 and 10/14/11; -On 10/04/11 and 10/13/11 at 6:00 A.M., staff documented on the back of the medication administration sheet the resident's 6:00 A.M. medication was not here/not given; -Staff initialed/circled the resident's 5:00 P.M. dose of [MEDICATION NAME] on 10/14/11, 10/15/11, 10/16/11, 10/17/11, and 10/18/11; -On 10/17/11 at 5:00 P.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available; -Staff checked the STAT (emergency) kit and called the pharmacy. 3. Review of Resident #72's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] (antidepressant) 10 mg daily at 9:00 A.M.; -[MEDICATION NAME] (anticonvulsant) sprinkles 125 mg four capsules two times a day at 9:00 A.M. and 9:00 P.M.; -[MEDICATION NAME] (antiparkinson) 25/100 three times a day at 9:00 A.M., 2:00 P.M., and 9:00 P.M.; -[MEDICATION NAME] ([MEDICAL CONDITION]) 300 mg three times a day at 9:00 A.M., 2:00 P.M., and 9:00 P.M.; -[MEDICATION NAME] (skeletal muscle relaxant) 20 mg four times a day at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -[MEDICATION NAME] (antipsychotic) 0.5 mg at bedtime (9:00 P.M.); -[MEDICATION NAME] (depression) 50 mg at bedtime (9:00 P.M.). Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/09/11, 10/10/11, 10/15/11, and 10/16/11; -On 10/15/11 and 10/16/11 (no time documented), staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not given/unavailable; -Staff initialed/circled the resident's 9:00 A.M. and 9:00 P.M. dose of [MEDICATION NAME] on 10/09/11 and 10/10/11; -Staff initialed/circled the resident 9:00 A.M., 2:00 P.M., and 9:00 P.M. dose of [MEDICATION NAME] on 10/10/11; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/10/11; -Staff initialed/circled the resident's 2:00 P.M. and 9:00 P.M. dose of [MEDICATION NAME] on 10/09/11 and 10/10/11; -Staff initialed/circled the resident's 12:00 A.M. dose of [MEDICATION NAME] on 10/05/11, 10/08/11, 10/09/11, and 10/10/11; -On 10/05/11 and 10/09/11 at 12:00 A.M., staff documented on the back of the medication sheet the [MEDICATION NAME] was not here; -Staff initialed/circled the resident's 6:00 A.M. dose of [MEDICATION NAME] on 10/05/11, 10/08/11, 10/09/11, and 10/10/11; -On 10/06/11 and 10/09/11 at 6:00 A.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not here; -Staff initialed/circled the resident's 12:00 P.M. dose of [MEDICATION NAME] on 10/08/11, 10/09/11, and 10/10/11; -On 10/10/11 at 12:00 (not indicate A.M. or P.M.), staff documented the [MEDICATION NAME] was not here; -Staff initialed/circled the resident's 6:00 P.M. dose of [MEDICATION NAME] on 10/08/11, 10/09/11, and 10/10/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/09/11 and 10/10/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/10/11; -On 10/10/11 (no time documented), staff documented all 6:00 P.M. and 9:00 P.M. medications were not given/not available. 4. Review of Resident #73's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] (antipsychotic) 15 mg two times a day at 9:00 A.M. and 9:00 P.M.; -[MEDICATION NAME] (antiemetic) 4 mg three times a day at 9:00 A.M., 1:00 P.M., and 5:00 P.M.; -[MEDICATION NAME] (antidiarrheal) 2.5 mg two tablets four times a day at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.; -[MEDICATION NAME] ([MEDICATION NAME]) (anti-[MEDICAL CONDITION]) 400 mg two times a day at 9:00 A.M. and 9:00 P.M. Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11, 10/14/11, 10/15/11, 10/16/11, and 10/17/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/04/11, 10/14/11, and 10/15/11; -The 9:00 P.M. slot on 10/05/11 was left blank; -On 10/14/11, 10/15/11, and 10/16/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not available; -On 10/17/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available, re-faxed order; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/07/11, 10/08/11, 10/09/11, and 10/10/11; -Staff initialed/circled the resident's 1:00 P.M. dose of [MEDICATION NAME] on 10/07/11, 10/08/11, 10/09/11, and 10/10/11; -Staff initialed/circled the resident's 5:00 P.M. dose of [MEDICATION NAME] on 10/09/11, 10/10/11, 10/11/11, 10/13/11, and 10/15/11; -On 10/07/11 at 9:00 A.M. and 1:00 P.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available; -On 10/08/11 at 9:00 A.M., 1:00 P.M., and 5:00 P.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available; -On 10/10/11 at 8:00 A.M. and 12:00 P.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available (at 8:00 A.M.-on order/at 12:00 P.M.-nurse aware); -Staff initialed/circled the resident's 9:00 A.M. and 1:00 P.M. dose of [MEDICATION NAME] on 10/13/11; -Staff initialed/circled the resident's 5:00 P.M. dose of [MEDICATION NAME] on 10/06/11 and 10/15/11; -On 10/13/11 at 9:00 A.M. and 1:00 P.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not available and had been re-ordered; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11 and 10/10/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] ([MEDICATION NAME]) on 10/04/11, 10/05/11, 10/06/11, and 10/08/11; -On 10/06/11 at 9:00 P.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not available, pharmacy notified, nurse practitioner aware; -On 10/10/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME] was not available, reported to the nurse. 5. Review of Resident #75's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] (antipsychotic) 1 mg two times a day at 8:00 A.M. and 8:00 P.M.; -[MEDICATION NAME] (skeletal muscle relaxant) 20 mg three times a day at 8:00 A.M., 4:00 P.M., and 8:00 P.M.; -[MEDICATION NAME] ([MEDICAL CONDITION]) 900 mgs three times a day at 8:00 A.M., 4:00 P.M., and 8:00 P.M.; -[MEDICATION NAME] (depression) 30 mg daily at 8:00 A.M.; -[MEDICATION NAME] (reflux) 20 mg at 7:00 A.M.; -[MEDICATION NAME] ([MEDICAL CONDITION]) 200 mg two times a day at 8:00 A.M. and 8:00 P.M.; -Levetiraceta ([MEDICAL CONDITION]) 1000 mg two times a day at 8:00 A.M. and 8:00 P.M. Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME] on 10/07/11, 10/08/11, 10/09/11, 10/10/11, 10/11/11, 10/12/11, 10/14/11, 10/17/11, and 10/19/11; -On 10/05/11, 10/07/11, 10/10/11, 10/12/11, 10/17/11, 10/18/11, and 10/19/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not available; -On 10/05/11, staff documented the nurse was informed; -On 10/07/11, staff documented the nurse was aware; -On 10/10/11, staff documented the medication was on order; -On 10/12/11, staff documented the medication would be re-ordered and staff would inform the nurse; -On 10/17/11, staff documented the medication re-ordered/reported to nurse; -On 10/18/11 and 10/19/11, staff documented the nurse was aware; -Staff initialed/circled the resident's 7:00 A.M. dose of [MEDICATION NAME] on 10/11/11 and 10/12/11; -On 10/11/11 and 10/12/11 at 6:00 A.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was unavailable and not given; -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME] on 10/07/11, 10/08/11, 10/09/11, 10/10/11, 10/15/11, and 10/17/11; -On 10/07/11 at 9:00 A.M. and 10/08/11 at 8:00 A.M., staff documented on the back of the medication sheet the [MEDICATION NAME] was not available and the nurse was aware; -On 10/10/11 at 9:00 A.M., staff documented the medication was not available and on order; -On 10/17/11 at 8:00 A.M., staff documented the medication was not available and re-ordered; -Staff initialed/circled the resident's 8:00 A.M. dose of Levtiraceta on 10/13/11; -On 10/13/11 at 8:00 A.M., staff documented on the back of the medication administration sheet the medication was not available; -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME] on 10/17/11; -On 10/17/11 at 8:00 A.M., staff documented on the back of the medication administration sheet the medication was not available; -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME] on 10/05/11 and 10/19/11, and the 4:00 P.M. dose on 10/04/11; -On 10/04/11 at 4:00 P.M., staff documented on the back of the medication administration sheet the medication was not given/not available; -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME] on 10/05/11, 10/07/11, 10/09/11, 10/11/11, and 10/13/11; -On 10/07/11 at 8:00 A.M., staff documented on the back of the medication sheet the medication was not available and the nurse was aware; -On 10/10/11 at 8:00 A.M., staff documented the medication was on order and not available; -On 10/0811 and 10/09/11 at 8:00 A.M., staff documented the medication was not available and the pharmacy was called; -On 10/11/11 at 8:00 A.M., staff documented the medication was not given/not available, and the pharmacy was called; -Staff initialed/circled the resident's 4:00 P.M. dose of [MEDICATION NAME] on 10/04/11; -On 10/04/11 at 4:00 P.M., staff documented on the back of the medication administration sheet the medication was not available and the nurse was aware. 6. Review of Resident #76's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medication that included the following: -[MEDICATION NAME] (depression) 60 mg daily at 9:00 A.M.; -[MEDICATION NAME] 120 mg CD (hypertension) one daily at 9:00 A.M.; -[MEDICATION NAME] (hypertension) 100 mg ER daily at 9:00 A.M.; -Micro K (potassium supplement) 20 meq daily at 9:00 A.M.; -Vitamin C (vitamin supplement) 500 mg daily at 9:00 A.M.; -[MEDICATION NAME] (abnormal heart rhythms) 0.125 mg daily at 9:00 A.M.; -[MEDICATION NAME] (diabetes) 500 mg two times a day at 9:00 A.M. and 9:00 P.M.; -[MEDICATION NAME] (hypertension) 100 mg three times a day at 9:00 A.M., 1:00 P.M., and 9:00 P.M.; -[MEDICATION NAME] (Alzheimer's) 4.6 mg/24 hours apply one patch at bedtime (9:00 P.M.); -On 10/03/11, the physician directed staff to administer [MEDICATION NAME] (antibiotic) 875 mg two times a day for seven days and Acidophilus (digestion) two times a day for seven days; -On 10/07/11, the physician directed staff to administer Vitamin D (vitamin supplement) 50,000 unit weekly for eight weeks; -[MEDICATION NAME] (hypertension) 160 mg daily at 9:00 A.M.; -[MEDICATION NAME] 40 mg daily at 9:00 A.M. Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/04/11 and the 9:00 A.M. dose on 10/05/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/04/11 and the 9:00 A.M. and 1:00 P.M. dose on 10/05/11; -Staff initialed/circled the resident's 9:00 P.M. dose of [MEDICATION NAME] on 10/12/11 and 10/18/11; -On 10/12/11 at 9:00 P.M., staff documented on the back of the medication administration sheet the [MEDICATION NAME] was not here and the nurse was made aware; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11, 10/12/11, and 10/13/11; -On 10/12/11 and 10/13/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the medication was not available and would re-order from the pharmacy; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] (hypertension) on 10/05/11, 10/06/11, 10/07/11, 10/08/11, 10/09/11, and 10/10/11; -On 10/0711, 10/08/11, 10/09/11, and 10/10/11 at 9:00 A.M., staff documented on the back of the medication administration sheet the medication was not available; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/05/11; -Staff circled/initialed the resident's 9:00 A.M. dose of [MEDICATION NAME], multivitamin, and vitamin C on 10/05/11; -On 10/05/11 at 9:00 A.M., staff documented on the back of the medication administration sheet that all the resident's medications on 10/05/11 were not given/pharmacy did not bring; -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/04/11, 10/05/11, 10/06/11, and 10/07/11; -On 10/05/11 at 9:00 A.M., staff documented on the back of the medication administration sheet that all the resident's morning medications were not available/told nurse; -On 10/07/11 at 9:00 A.M., staff documented on the back of the medication sheet the the resident's [MEDICATION NAME] was not available/told nurse; -Staff initialed/circled the resident's 9:00 A.M. dose of Acidophilous on 10/04/11; -Staff initialed/circled the resident's 8:00 dose of vitamin D on 10/14/11 (the medication was ordered on [DATE] to be given weekly for eight weeks); -ON 10/14/11 at 8:00 A.M., staff documented on the back of the medication administration sheet the medication was not here/reported to nurse; -There was no documentation showing the had received any doses of the medication. 7. Review of Resident #77's admission MDS dated [DATE] showed the resident had [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] (hypertension) 5 mg daily at 8:00 A.M.; -[MEDICATION NAME] (tremors) 1 mg daily at 8:00 A.M.; -[MEDICATION NAME] (hypertension) 12.5 mg daily at 8:00 A.M.; -[MEDICATION NAME] ([MEDICAL CONDITION] hormone) 0.05 mg daily at 6:00 A.M.; -[MEDICATION NAME] (reflux) 20 mg daily at 6:00 A.M.; -[MEDICATION NAME] (cholesterol) 145 mg daily at 4:00 P.M.; -[MEDICATION NAME] ([MEDICAL CONDITION]) 125 mg two times a day at 8:00 A.M. and 8:00 P.M.; -[MEDICATION NAME] (depression) 30 mg at bedtime (8:00 P.M.); -[MEDICATION NAME] 60 mg at bedtime. Review of the resident's MAR (portion dated October 2011 and a portion not dated) showed the following: -Staff initialed/circled the resident's 8:00 A.M. dose of [MEDICATION NAME], on 10/07/11; -On 10/07/11 at 8:00 A.M., staff documented on the back of the medication administration sheet the resident's [MEDICATION NAME], was not available, pharmacy called/nurse aware; -Staff initialed/circled the resident's 6:00 A.M. dose of [MEDICATION NAME] on 10/07/11; -Staff initialed/circled the resident's 8:00 P.M. dose of [MEDICATION NAME] on 10/07/11 and 10/08/11; -Staff initialed/circled the resident's 8:00 P.M. dose of [MEDICATION NAME] and [MEDICATION NAME] on 10/07/11; -On 10/07/11 at 8:00 P.M., staff documented on the back of the medication administration sheet the resident's 60 mg dose was not available, and the charge nurse/pharmacy was aware. 8. Review of Resident #78's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] (hypertension) 20 mg daily at 9:00 A.M.; -[MEDICATION NAME] (fluid) 40 mg two times a day at 9:00 A.M. and 9:00 P.M.; -QVAR (corticosteroid for wheezing, shortness of breath, breathing problems) inhaler 40 meq four times a day at 9:00 A.M., 1:00 P.M., 5;00 P.M., and 9:00 P.M.; -[MEDICATION NAME] Diskus ([MEDICAL CONDITION]) one puff (inhaled) two times a day at 9:00 A.M. and 9:00 P.M.; -[MEDICATION NAME] Nebulizer ([MEDICAL CONDITION]) 0.083% four times a day at 9:00 A.M.,1:00 P.M., 5:00 P.M., and 9:00 P.M.; -Atrovent ([MEDICAL CONDITION]) one vial per nebulizer four times day at 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Review of the resident's MAR for October 2011 showed the following: -Staff initialed/circled the resident's 9:00 A.M. dose of [MEDICATION NAME], and [MEDICATION NAME] Diskus on 10/04/11; -Staff initialed/circled the resident's 9:00 A.M., 1:00 P.M., and 5:00 P.M. dose of QVAR inhaler on 10/04/11; -Staff initialed/circled the resident's 5:00 P.M. dose of [MEDICATION NAME] Nebulizer on 10/04/11; -On 0/04/11 (no time documented), staff documented he resident's 9:00 A.M., 1:00 P.M., and 5:00 P.M. medications were not available. 9. Review of Resident #79's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -The physician directed staff to administer medications that included the following: -[MEDICATION NAME] (hypertension) 5 mg daily at 9:00 A.M.; -[MEDICATION NAME] (enlarged prostate) 5 mg daily at 9:00 A.M.; -[MEDICATION NAME] (difficult urination/enlarged prostate) 0.8 mg daily at 10:00 A.M. Review of the resident's MAR indicated [REDACTED] -Staff initialed/circled and wrote not available on the resident's 9:00 A.M. dose of [MEDICATION NAME] on 10/14/11; -Staff documented on the back of the medication administration sheet the [MEDICATION NAME] and [MEDICATION NAME] was unavailable, faxed to the pharmacy, and on delivery; -Staff initialed/circled the resident's 10:00 A.M. dose of [MEDICATION NAME] on 10/26/11; -Staff documented on the back of the medication administration sheet the medication was unavailable, on order, and reported. During interview on 10/20/11 at 12:20 P.M., the administrator said the following: -The facility switched pharmacy providers on 10/03/11; -There had been problems with medication deliveries that affected 40-50 % of the residents. Interview with the administrator on 10/26/11 at 12:15 P.M. showed she said the following: -The new pharmacy policy and procedures had not been reviewed by the medical director; -She spoke to the medical director about several specific missing medications; -It had been 28 days since the new pharmacy took over, the facility was still "having trouble" getting medications for residents; -The nurses and DON were doing daily audits of non-available medications, and following up by fax and a phone call to pharmacy. The DON was keeping and tracking this information; -Was informed one week before the pharmacy change over by the old pharmacy. During interview on 10/29/11 at 11:00 A.M. the facility administrator said the following: -The facility changed pharmacy providers the first week of October 2011, the change out occurred 10/4/11; -The roll out has not gone well; -There have been multiple omissions of resident medications by the pharmacy, some medication comes to the facility in packaging from the pharmacy with no medication in the packaging; -Staff have to contact the pharmacy, fax the pharmacy, then call the physician to advise a medication is not available, revising the physician orders [REDACTED]. This takes a tremendous amount of nursing time that nurses should spend with resident care, nurses spend all day begging for medications from the pharmacy; -The current pharmacy has no experience providing medications for the long term care setting and needs. Interview with the facility medical director on 10/26/11 at 1:33 P.M. showed he said the following: -He was informed of new pharmacy by the facility immediately before the switch, and could not recall how many days; -He had not reviewed the new pharmacy policy and procedures; -He was not involved in meetings, discussion, or review of the new pharmacy transition, policy and procedures; -One resident had to be sent to the hospital for psychiatric care after missing several doses of [MEDICAL CONDITION] medications due to unavailability by the pharmacy; -When informed of unavailable medications, he handled these case by case such as monitoring labs, alternate available medications, monitoring vital signs; --The facility notified other resident's physicians when medications were not available; - There were multiple cases. Complaint # MO and #MO

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to administer one of 23 sampled residents (Resident #14) his/her prescribed laxative/stool softener numerous times in one month, failed to note reason(s) medication was not administered, and failed to monitor the results of the medication's use so that the resident did not develop fecal (bowel) impaction (hard stool in the rectum) with loss of blood. The facility census was 112. 1. Review of Resident #14's Physician order [REDACTED]. Review of Resident #14's admission minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 05/10/11, showed the following: -Always continent of bowel and bladder; -Not on a toileting program; -No constipation present. Review of bowel elimination record dated 06/01/11 through 06/03/11, showed the following: -On 06/01/11, resident had a medium bowel movement (BM) two times; -On 06/02/11, resident had a small BM, and medium BM; -On 06/03/11, resident had a large BM. During interview on 09/08/11 at 2:20 P.M., the Medical Records director said no elimination records for May were available. Review of Physician order [REDACTED]. Review of the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Resident to receive [MEDICATION NAME] (medication to induce bowel movements or to loosen the stool, most often taken to treat constipation) 17 grams (cap filled to line) twice a day; -Staff did not administer the medication thirteen out of 58 opportunities, and staff provided no documentation as to why medication was not given. Review of hospital records dated 06/03/11, showed the following: -admitted for rectal bleeding; -Schedule for colonoscopy in A.M.; -GI consult noted resident had two episodes of large, bright red blood per rectum (150-200 cc each, clots mixed with blood) earlier today. Review of surgical notes dated 06/04/11, showed the following: -Large stool in the rectum (probably from previous fecal impaction); -Stool removed manually; -Very large brown colored stool in the [MEDICATION NAME] colon; -A few medium sized irregular ulcers in the rectum, probably stercoral (fecal) ulcers (the cause of bleeding), in a patient with a history of constipation; -A large quantity of clotted blood was found in the rectum. During interview on 09/02/11 at 7:45 A.M., Licensed Practical Nurse (LPN) M said the facility has a log book that staff record residents BM's in and that the nurse is to check the log daily to see if a resident needs a laxative. During interview on 09/02/11 at 8:55 A.M., LPN X said he/she checked the BM list and notified the medication nurse to give the resident something if they have not had a BM in three days. During interview with Director of Nursing (DON) on 09/02/11 at 9:20 A.M., she said she expected staff to give any resident that has not had a bowel movement in three days a laxative. If the resident did not have an order for [REDACTED]. Complaint MO 030

Based on observation, interview and record review, the facility failed to provide services to promote healing of pressure sores and to prevent infection and the development of additional pressure sores for two of 23 sampled residents (Residents #1, and #14) by failure of staff to periodically assess each pressure sore, failure to request prompt changes in treatment for [REDACTED]. The facility identified nine residents with pressure sores. The facility census was 112. 1. Review of the nursing admission assessment dated [DATE] showed Resident #1 had a pressure sore on his/her right and left ischium (hip), redness to his/her coccyx (tailbone), and redness on his/her left outer foot. The facility staff failed to document the measurements of these wounds. Review of the physician's orders [REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 05/15/11, showed the following: -Long and short term memory loss; -Severely impaired in his/her cognitive skills needed for daily decision making; -Required extensive assistance of two or more staff for mobility in bed; -At risk for pressure sore development; -Two unstageable pressure sores (slough and /or eschar covered wound bed) present on admission, largest measured 2.5 centimeters by 2.5 centimeters, and most severe tissue type of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps.) Review of the care plan dated 05/06/11, showed the following: - Facility staff assessed the resident at risk for complications secondary to wounds and admitted with three unable to stage wounds on his/her left hip and two on his/her right hip; - The care plan had been clarified on 06/25/11 to show two pressure sores on the right hip and a new pressure sore on the resident's coccyx. -The care plan had been updated on 07/28/11 to include pressure sores on the right lateral foot (one noted as proximal and one noted as distal); -The care plans directed facility staff to assess the resident's skin weekly and as needed and to measure on a weekly basis. Review of the Braden scale (assessment instrument used to assess residents at risk for pressure sore development) dated 05/25/11 showed the resident score a 10 (score of 12 or less indicates high risk for development). Review of the wound notes dated 06/10/11, showed the following: -Left hip pressure sore measured 2.9 centimeters (cm) in length by 2.6 cm in width, and unable to determine depth; -Right hip (distal) pressure sore measured 0.5 cm by 0.5 cm; -Right hip (proximal) pressure sore measured 1.0 cm by 1.4 cm; -Coccyx pressure sore measured 2.0 cm by 2.0 cm; -Will obtain Specialized Wound Management (SWM) consultation. Review of the physician's orders [REDACTED]. Review of the nurses notes dated 06/17/11, showed the resident had been seen by SWM, see their progress notes. Review of the Specialized Wound Management progress notes dated 06/17/11, (one week after the facility noted they would seek consultation), showed the following: -Left hip pressure sore measured 2.9 cm by 2.6 cm, unable to determine wound bed and thick yellow necrosis (dead tissue) at the center of the wound. Sharp debridement completed and removed devitalized (dead) tissue; -Right hip (distal) measured 0.5 cm by 0.5 cm, unable to determine wound bed and yellow necrosis ; -Right hip (proximal) measured 1.0 cm by 0.4 cm, unable to determine wound bed and yellow necrosis. -Stage One (an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues) on the coccyx; -Nursing reported the areas had been treated with [MEDICATION NAME] but did not improve, treatment was changed to Santyl and [MEDICATION NAME]. Review of the nurses notes dated 06/22/11, showed the resident had been seen by SWM nurse, see their progress notes. Review of the Specialized Wound Management progress note dated 06/22/11, showed the following: -Left hip pressure sore measured 2.5 cm by 2.8 cm, unable to determine wound bed and thick yellow necrosis at the center of the wound; -Right hip (distal) measured 1.5 cm by 1.5 cm by 0.2 with pink granulation tissue in the wound bed; -Right hip (proximal) measured 1.3 cm by 0.8 cm, unable to determine wound bed depth and yellow necrosis, wound status declined; -Unstageable pressure ulcers to bilateral hips, apply Santyl and [MEDICATION NAME], cover with dry dressing and change everyday and as needed. The ulcer on the right hip was a healing Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) ; -Follow up in one week. Review of the wound nurse notes dated 06/28/11, showed the resident had been seen by the SWM nurse, see their progress notes. Review of the medical record showed no progress note from the SWM nurse dated 06/28/11. Review of requested progress notes received from SWM by fax on 9/09/11, showed no follow up record for 6/28/11. Review of the wound notes dated 07/06/11, showed the resident had been seen by the SWM nurse, see their progress note. Review of the SWM nurse note dated 07/06/11 showed the following: -Left hip pressure sore measured 2.5 cm by 2.5 cm and unable to determine the depth. The wound had thick yellow necrosis at the center of the wound bed. Sharp debridement completed and removed devitalized tissue. The wound status was unchanged; -Right hip (distal) pressure sore measured 1.1 cm by 1.2 cm by 0.3, healing Stage III and the wound had improved. -Right hip (proximal) pressure sore measured 1.0 cm by 1.0 cm by 0.3 cm and the pressure sore had improved -Sacrum pressure sore measured 3.0 cm by 3.0 cm by 0.2 cm and this was a new pressure sore described as a Stage III; -Apply Santyl to wounds on bilateral hips and coccyx (sacral) area and cover with dry dressing. (The pressure sore on the right hip (distal) had increased in size from the last measurements in the chart on 06/10/11, the resident now had a Stage III pressure sore on his/her coccyx which had previously been assessed as a Stage I.) -Follow up in one week. Review of the wound nurse notes dated 07/13/11 showed the following: -Left hip pressure sore measured 2.5 cm by 3.6 cm and unable to determine depth of the wound -Right hip (distal) pressure sore measured 0.8 cm by 0.8 cm by 0.2 cm -Right hip (proximal) wound measure 0.5 cm by 0.4 cm, by 0.2 cm -Sacrum pressure sore measured 3.0 cm by 2.8 cm by 0.2 cm and described as a Stage III. Review of the wound nurse notes dated 07/20/11 (two weeks after prior follow up visit), showed the resident had been seen by the SWM nurse. Review of the Specialized Wound Management progress notes dated 07/20/11, showed the following: -Left hip pressure sore measured 2.0 cm by 4.0 cm and unable to determine the depth. Deep tissue injury noted at 6:00 o'clock location that measured 3.0 cm by 4.0 cm with dark intact skin. Sharp debridement completed and removed devitalized tissue. The wound status had declined; -Right hip (distal) pressure sore measured 0.7 cm by 0.5 cm by 0.2 cm; -Right hip (proximal) pressure sore measured 0.2 cm by 0.2 cm by 0.2 cm; -Sacrum wound measured 4.4 cm by 3.5 cm with deep tissue injury at 12:00 o'clock location. The wound had declined in status; -Apply Santyl and [MEDICATION NAME] to pressure sores on bilateral hips and coccyx (sacral) area and cover with foam dressing. (The pressure sore on the left hip had increased in width and the pressure sore on the coccyx had increased in total size since the last measurement on 07/13/11. Both of these are pressure sores now have deep tissue injury to them.) Review of the wound nurse notes dated 07/29/11, showed the resident had been seen by the SWM nurse, see their progress notes. Review of the Specialized Wound Management progress notes dated 07/29/11, showed the following: -Left hip pressure sore measured 4.7 cm by 4.7 cm, the wound bed was not visible due to yellow and black necrosis. The wound had declined and treatment changed to Dakin's Solution ( used to kill germs and prevent germ growth in wounds); -Right hip (distal) pressure sore measured 0.2 cm by 0.5 cm by 0.2 cm; -Right hip (proximal) pressure sore measured 0.2 cm by 0.2 cm by 0.1 cm; -Sacrum wound measured 4.5 cm by 3.0 cm; -Right lateral foot proximal pressure sore measured 1.5 cm wide by 1.0 cm deep and this was a new wound; -Right foot lateral distal pressure sore measured 1.7 cm wide by 1.5 cm deep and this was a new wound; -Both foot pressure sores were unstageable; -Apply Santyl and [MEDICATION NAME] to pressure sores on right hip and coccyx (sacral) area and cover with foam dressing. (The pressure sore on the left hip had increased in size since the last measurement on 07/20/11. The resident also developed a new pressure sore on the lateral and proximal side of the right foot.) Review of the wound notes dated 08/03/11, showed the resident had been seen by the SWM nurse today, see their notes. Review of the Specialized Wound Management progress notes dated 08/03/11, showed the following: -Left hip pressure sore measured 5.2 cm by 5.0 cm, the wound bed was not visible due to yellow and black necrosis. The wound was no better and would continue Dakin's to control bacterial load; -Right hip (distal) pressure sore measured 0.1 cm by 0.3 cm by 0.1 cm; -Right hip (proximal) wound measured 0.1 cm by 0.3 cm by 0.1 cm; -Sacrum pressure sore measured 4.0 cm by 1.8 cm; -Right lateral foot proximal pressure sore measured 1.2 cm wide by 2.6 cm deep; -Right foot lateral distal pressure sore measured 1.4 cm by 1.8 cm. (The pressure sore on the left hip had increased in size and the pressure sore on the proximal side of the right foot had increased in size.) Review of the wound notes dated 08/10/11, showed the resident had been seen by the SWM nurse today, see their notes. Review of the Specialized Wound Management progress notes dated 08/10/11, showed the following: -Left hip pressure sore measured 4.7 cm by 4.7 cm the wound bed was not visible due to yellow and black necrosis. -Right hip pressure sores healed; -Sacrum 2.5 cm by 2.0 cm; -Right lateral foot proximal pressure sore measured 1.5 cm by 1.0 cm; -Right foot lateral distal pressure sore measured 1.7 cm by 1.5 cm. Review of the care plan updated 08/10/11 showed the two pressures on the right hip were healed. Review of the wound notes dated 08/17/11, showed the resident had been seen by the SWM nurse today, see their notes. Review of the Specialized Wound Management progress notes dated 08/17/11, showed the following: -Left hip pressure sore measured 6.0 cm by 5.0 cm with bone exposed at the center of the wound. The wound had declined in status; -Right hip proximal remained healed however there was a deep tissue injury noted that measured less than 1 cm in diameter and wounds healed; -Sacrum 3.5 cm by 2.2 cm; -Right lateral foot proximal pressure sore measured 1.5 cm by 1.0 cm; -Right foot lateral distal pressure sore measured 1.7 by 1.5 cm. (The pressure sore on the coccyx had increased in size from the last measurement on 08/10/11.) Review of the wound notes dated 08/19/11, showed the following: -Right hip distal pressure sore open 0.5 cm by 0.5 cm by less than 0.2 cm and stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink bed without slough. May also present as an intact or open/ruptured blister). During interview on 08/30/11 at 9:45 A.M., LPN CC said the weekly wound measurements would be documented on the back of the treatment sheet or on another sheet that would describe the wound, measurements, etc. He/she said the facility would start to use a graphing tool to track any wounds. He/she reviewed the resident ' s chart and could find neither of these in his/her chart. He/she said he/she had started doing wound treatments and monitoring in the past week. Observation on 08/31/11 at 10:50 A.M., showed the following: -SWM nurse and wound nurse in the resident's room to complete assessment of the pressure sores; -Left hip pressure sore measured 6.5 cm by 7.5 cm by 0.1 cm with 3 cm of tunneling at 12:00 o'clock noon and 2.5 cm of tunneling at 9:00 o'clock; -Sacrum pressure sore measured 3.0 cm by 2.0 cm; -Right hip (proximal) 0.2 by 0.6 cm by 0.1 cm and described the area as superficial; -Right hip (distal) 0.3 cm by 0.3 cm by 0.2 cm and and described the area as superficial; -Right lateral foot (proximal) 1.3 cm by 1.0 cm; -Right lateral foot (distal) 1.6 cm by 1.5 cm with black eschar. During interview on 09/02/11 at 10:00 A.M., LPN CC said he/she would call SWM and get any progress notes on Resident #1. During interview on 09/08/11 at 3:45 P.M. the Director of Nursing said he/she would talk to LPN CC and see if the progress notes on Resident #1 had been received at the facility. During interview on 09/09/11 at 10:53 A.M., the Director of Nursing said he/she would follow up on the status of the progress notes from SWM on Resident #1. During interview on 09/09/11 at 12:00 noon, the Administrator said SWM nurses were not to replace the treatment nurse and that hospice also saw and assessed the resident. The administrator said the skin assessments from the chart said on 05/10/11 and 05/23/11, the skin on the resident's hips was not intact, the skin assessments did not address the condition of the skin on the resident's coccyx. 2. Review of Resident #14's admission notes dated 05/03/11, showed the following: -Resident alert and oriented times three; -Resident able to make needs known; -Had ulcers to bilateral heels; -All toes were necrotic (premature death of living tissue); -Coccyx reddened but not opened; -(No measurements of wound documented). Review of Resident #14's admission MDS assessment dated [DATE], showed the following: -BIMS (Brief Interview for Mental Status), score of 15 which indicated he/she was cognitively intact in his/her ability for daily decision making; -Required extensive assistance of one with bed mobility, transfers, toilet use and personal hygiene; -Functional limitation in range of motion for lower extremity; -At risk for pressure ulcers; -Five unstageable pressure ulcers at time of admission; -Four pressure ulcers with necrotic tissue. Review of the medical record showed there was not a care plan available to direct staff in providing care including interventions for pressure sore treatment and/or prevention, and facility staff were not able to locate a care plan after requested by surveyor. Review of skilled nursing flow sheet dated 05/13/11, showed three open areas on coccyx, one approximately nickel size and two approximately dime sized. Review of SWM, specialized wound management, (an outside wound consultation company) notes dated 05/18/11 through 06/08/11, showed the following: -Saw on 05/18/11 for ulcers on bilateral heels only. -Saw on 05/24/11 for area on buttocks, noted as shearing force from draw sheet. The left buttocks measured 7.0 centimeters (cm) by 4.5 cm and the right buttock measured 8.0 cm by 4.0 cm. -Saw on 06/03/11 for wound on sacrum extending across both buttocks measuring 11.0 cm by 16.0 cm with undetermined depth, pink with yellow and black necrosis, and scant yellow exudate. During interview on 08/30/11 at 9:45 A.M., LPN M said the following: -Was not aware of who was responsible for measuring wounds; -Measured some and the floor nurse did some; -Wound measurements should be in treatment book if done. 3. Review of facility policy dated 09/19/10, showed the following: -Skin shall be inspected with each bath and during care; -The licensed nurse shall inspect the resident's skin weekly and PRN; -Areas identified shall have the Initial Wound assessment Form completed to identify underlying causes or barrier to healing; -A Wound Condition Report shall be completed to begin weekly tracking of wound healing Complaint MO 030