Every finding on record at Aspire Senior Living Carthage

Based on interviews and record review, the facility failed to protect the rights of self-determination of all residents when the facility staff did not ensure one resident (Resident #1) received, or was offered, showers on a routine basis per his/her reasonable preference. The facility census was 116. Review of the facility's policy titled Resident Showers, dated 10/01/25, showed the following:-It is the practice of this 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 and based upon resident safety;-Partial baths may be given between regular shower schedules as per facility policy;-The certified nurse aide (CNA) will observe the skin for any changes while performing bathing and inform the nurse of any changes;-Assist the resident to the shower room and bring all necessary supplies. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 12/31/23;-Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness or paralysis or partial paralysis on one side of the body), anxiety disorder, and major depressive disorder(a serious medical mood disorder). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/10/26 showed the following:-Cognition intact;-The residents did not reject care during the assessment period;-The resident was dependent on staff for showers/bathing, personal hygiene and shower/bathing transfers. Review of the resident's care plan, reviewed/updated 01/25/26, showed the following:-The resident required staff assistance to complete daily activities of care safely due to left sides hemiplegia post CVA (stroke);-Encourage resident to wash, rinse, and dry body parts that are within their physical ability to do;-The resident had confusion/forgetfulness and needed cueing/reminders;-The resident required two staff for transfers and a mechanical lift;-Bathe per schedule. The resident refused bathing/showers, hygiene cares. The resident may take bed baths;-Make the bathing process pleasant by ensuring non-hurried atmosphere give assistance as needed;-Observe resident changes in ability to perform care. During an interview on 07/28/26, at 10:53 A.M., the resident said the following:-He went over two weeks without a shower earlier in July 2026;-He/she would like to have more showers;-The staff says he/she refused showers but they just don't want to give them. Review of the resident's comprehensive CNA shower review showed the following:-The resident refused a shower on 07/02/26;-The resident received a shower on 07/18/26, 07/20/26, and 07/28/26. Review of the resident's bathing task, dated July 2026, showed the following:-The resident received a bath/shower on 07/20/26 and 07/22/26;-The resident refused on 07/25/26. Review of the resident's nurses' notes, dated 07/02/26 to 07/18/26, showed staff did not document regarding showers given or refused by the resident. Review of the resident's record showed staff did not document a shower provided or offered from 07/02/26 to 07/18/26 (15 days). During an interview on 07/27/26, at 4:45 P.M., CNA B said the following:-The residents were generally scheduled to get showers two times a week;-He/she thought residents got showers;-The CNA's were supposed to document on the CNA shower sheets when they give or attempt to give a shower and give it to the nurse after they complete it. During an interview on 07/28/26, at 4:54 P.M., CNA C said the following:-The residents get showers two times a week;-The CNAs document on a shower sheet when they give or attempt to give a shower. They should let the nurse know if the resident refused. During an interview on 07/28/26, at 9:44 A.M., CNA D said the following:-The residents were supposed to be offered a shower two times a week. If they refused the CNAs try to offer another time;-The resident refused showers sometimes, but staff still offer them;-The CNA documented on a shower sheet and on the computer if a resident refused and if a shower was given. During an interview on 07/27/26, at 1:31 P.M., Licensed Practical Nurse (LPN) A said the following:-He/she thought residents were getting showers;-The CNAs were responsible for giving residents showers;-The CNAs fill out a shower sheet after giving a shower. They should document if a resident refused. During an interview on 07/28/26, at 11:02 A.M., the Assistant Director of Nursing (ADON) said the following:-Residents should be offered at least two showers a week;-Staff should offer another shower the next shift if a resident refuses;-When a resident is given a shower, the CNA documented on a shower review sheet and in the medical record under tasks. They should also document if a resident refuses a shower;-The CNA gives the shower sheet to the nurse. Complaints #3097712, #3117921

Based on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed to ensure wound care was completed and documented for three residents (Resident #1, #2, and #3) with skin abrasions, including pressure ulcer, surgical wounds, blisters, skin tears, and venous wounds; failed to ensure topical treatment was completed for two residents (Resident #5 and #6) with rashes. The facility census was 115. Review of the facility policy, dated 10/01/25, titled Wound Treatment Management, 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 the dressing change; -The facility will follow specific physician orders for providing wound care; -Treatments will be documented on the Treatment Administration Record or in the electronic health record. 1. Review of Resident #1's face sheet (a brief summary of resident), showed the following: -admitted on [DATE]; -Diagnoses included: non-pressure chronic ulcer of right lower leg limited to breakdown of skin, non-pressure chronic ulcer (open sore on the skin caused by poor blood flow or other medical conditions rather than constant body pressure) of right lower leg with fat layer exposed, peripheral vascular disease (slow and progressive condition that causes blood vessels outside of the heart and brain to narrow or block). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 07/28/26, showed the following:-Cognitively intact; -Two venous ulcers (open skin sore or chronic wound that forms on the lower leg, usually near the ankle, because damaged veins fail to return blood efficiently to the heart) present. Review of the resident's care plan, last revised 07/30/26, showed the following: -Resident had the potential for skin break down and skin tears, skin rashes related to skin fragility; -Staff should inspect skin for changes daily; -If skin breakdown occurs, treat per facility policy and notify physician; -Resident had a venous ulcer related to peripheral vascular disease; -Staff should monitor, document, report as needed signs and symptoms of infection; -Staff should complete weekly treatment documentation; -Staff should perform wound care as ordered. Review of the physician order sheet (POS) and August 2026 Treatment Administration Record (TAR) showed the following: -An order, dated 07/30/36, for right anterior shin venous wound order. Change dressing twice weekly. Clean with wound cleanser, skin prep (liquid film protective dressing) edges, calcium alginate (wound care dressing to soak up fluid) to wound bed, cover with Medipore dressing (brand of wound dressing) or equivalent every Monday and Thursday day shift.; -Staff did not document care as completed on 08/06/26 or 08/10/26; -An order dated 08/17/26, for right anterior shin venous wound order. Staff to change dressing twice weekly. Cleanse with wound cleanser, skin prep edges, apply xeroform to wound bed, cover with UNNA boot (compression bandage) or equivalent every Monday and Thursday day shift; -Staff did not document right anterior shin venous wound care as completed on 08/20/26, 08/24/26, or 08/27/26. Review of the POS and September 2026 TAR, showed the following: -An order, dated 08/17/26, for right anterior shin venous wound order. Staff to change dressing twice weekly. Cleanse with wound cleanse, skin prep edges, apply xeroform to wound bed, cover with UNNA boot or equivalent every Monday and Thursday day shift; -Staff did not document right anterior shin venous wound care as completed on 09/03/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 0814/26, for first right toe blister order. Staff to observe blister daily. Cleanse with wound cleanser and apply skin prep. May leave open to air, every day shift; -Staff did not document first right toe blister care as completed on 08/15/26, 08/16/26, 08/20/26, 08/23/26, 08/27/26, 08/28/26, or 08/29/26. Review of the POS and September 2026 TAR, showed the following: -An order, dated 08/14/26, for first right toe blister order. Staff to observe blister to daily. Cleanse with wound cleanser and apply skin prep. May leave open to air, every day shift; -Staff did not document first right toe blister care as completed on 09/01/26 or 09/03/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 08/20/26, for right posterior calf venous wound order. Staff to change dressing twice weekly. Clean with wound cleanser, skin prep edges, apply xeroform to wound bed, cover with UNNA boot or equivalent every Monday and Thursday day shift; -Staff did not document right posterior calf venous wound care as completed on 08/20/26, 08/24/26, or 08/27/26. Review of the POS and September 2026 TAR, showed the following: -An order, dated 08/20/26, for right posterior calf venous wound order. Staff to change dressing twice weekly. Clean with wound cleanser, skin prep edges, apply xeroform to wound bed, cover with UNNA boot or equivalent every Monday and Thursday day shift; -Staff did not document right posterior calf venous wound care as completed on 09/03/26. During observation and interview on 09/09/26, at 9:30 A.M., showed the following: -The resident sat in bed with bandage on the lower right leg, dated 09/08/26; -He/She said there were blisters that filled with fluid and were not open areas; -The nurse completed bandage changes, but he/she did not remember how often; -He/She saw the wound care physician weekly. 2. Review of Resident #2's face sheet showed the following: -admitted on [DATE]; -Diagnoses included: idiopathic aseptic necrosis (the death of bone tissue caused by a loss of blood supply where no clear or known cause can be found) of right femur (thigh bone), cellulitis (bacterial skin infection that affects the deep layers of the skin and underlying tissues), chronic pain. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -At risk of developing pressure ulcers/injuries; -Open lesion(s) other than ulcers, rashes or cuts. Review of the care plan, last revised 07/02/26, showed the following: -Resident had impairment to skin integrity to bilateral lower extremities related to ulcerations, lesions and diagnosis of cellulitis; -Staff should follow facility protocols for treatment of injury; -Staff should monitor and document location, size and treatment of skin injury and report abnormalities, failure to heal, signs or symptoms of infection to the physician. Review of the POS and August 2026 TAR showed the following: -An order, dated 07/22/26, with discontinued date of 08/13/26, apply unna boot (a specialized medical compression bandage wrapped from the base of the toes to just below the knee to treat lower leg wounds, ulcers, and severe swelling) to bilateral lower extremity once weekly for edema management. Clean left lower extremity with soap and water, pat dry, apply unna boots from distal to proximal ensuring even compression. Observe unna boots daily, every Wednesday evening shift; -Staff did not document bilateral lower extremity care as completed on 08/12/26; -An order, dated 08/19/26, with discontinued date of 08/26/26, staff to apply unna boot to right lower extremity once weekly for edema management. Clean left lower extremity with soap and water, pat dry, apply unna boots from distal to proximal ensuring even compression. Observe unna boots daily, every Wednesday evening shift; -Staff did not document right lower extremity care (unna boot) as completed on 08/19/26 or 08/26/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 08/04/26, for staff to monitor for skin break down under left lower extremity orthosis brace daily. May remove brace for assessment. Notify physician of any signs or symptoms of skin breakdown, infection or worsening condition every shift; - Staff did not document orthosis brace care as completed for day shift on 08/05/26, 08/06/26, 08/08/26, 08/09/26, 08/11/26, 08/12/26, 08/15/26, 08/16/26, 08/20/26, 08/22/23, 08/27/26, 08/28/26, 08/29/26, or 08/30/26; -Staff did not document orthosis brace care as completed for evening shift on 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/08/26, 08/12/26, 08/13/26, 08/14/26, 08/17/26, 08/18/26, 08/19/26, 08/20/26, 08/21/23, 08/22/26, 08/23/26, 08/24/26, 08/25/26, 08/26/26, 08/28/26, or 08/31/26; -Staff did not document orthosis brace care as completed for night shift on 08/04/26, 08/09/26, 08/16/26, 08/17/26, 08/27/26, or 08/31/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/04/26, for staff to monitor for skin break down under left lower extremity brace daily. May remove brace for assessment. Notify physician of any signs or symptoms of skin breakdown, infection or worsening condition every shift; -Staff did not document left lower extremity brace care as completed for day shift on 09/01/26; -Staff did not document left lower extremity brace care as completed for evening shift on 09/01/26, 09/02/26, 09/03/26, 09/04/26, 09/05/26, 09/06/26, 09/07/26, or 09/08/26; -Staff did not document left lower extremity brace care as completed for night shift on 09/01/26, 09/05/26, or 09/07/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 08/26/26, for staff to observe protective dressings right lower extremity three sites daily. Replace if missing or soiled. Notify physician of any signs or symptoms of infection or worsening condition every shift; -Staff did not document protective dressings right lower extremity care as completed for day shift on 08/27/26, 08/28/26, 08/29/26, or 08/30/26; -Staff did not document protective dressings right lower extremity care as completed for evening shift on 08/28/26 or 08/31/26; -Staff did not document protective dressings right lower extremity care as completed for night shift on 08/27/26 or 08/31/26; -A order, dated 08/27/26, for staff to apply protective dressing to right lower extremity three sites, change dressing twice weekly. Clean with wound cleanser, skin prep to site, xeroform, cover with bordered foam or equivalent every Monday and Thursday day shift; -Staff did not document right lower extremity protective dressing as completed on 08/27/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/26/26, for staff to observe protective dressings right lower extremity three sites daily. Replace if missing or soiled. Notify physician of any signs or symptoms of infection or worsening condition every shift; -Staff did not document right lower extremity three sites care as completed for day shift on 09/01/26; -Staff did not document right lower extremity three sites care as completed for evening shift on 09/01/26, 09/02/26, 09/03/26, 09/04/26, 09/05/26, 09/06/26, 09/07/26, 09/08/26; -Staff did not document right lower extremity three sites care as completed for night shift on 09/01/26, 09/05/26, 09/07/26; -An order, dated 08/27/26, for staff to change right lower extremity three sites protective dressing twice weekly. Clean with wound cleanser, skin prep to site, xeroform, cover with bordered foam or equivalent every Monday day shift; -Staff did not document right lower extremity three sites protective dressing as completed on 09/03/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 08/27/26, for staff to apply protective dressing to left lateral knee, change dressing twice weekly. Clean with wound cleanser, skin prep to site, xeroform, cover with bordered foam or equivalent every Monday and Thursday evening shift; -Staff did not document left lateral knee protective dressing as completed on 08/26/26 or 08/31/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/27/26, staff to change protective dressing to left lateral knee twice weekly. Clean with wound cleanser, skin prep to site, xeroform, cover with bordered foam or equivalent every Monday and Thursday day shift; -Staff did not document completion of left lateral knee dressing change as completed on 09/03/26. During observation and interview on 09/09/26, at 10:30 A.M., the resident sat in the bed with his/her lower legs open to air and no intact dressings. The resident said the nurse checks the open areas on his/her legs every few days. 3. Review of Resident #3's face sheet, showed the following: -admitted on [DATE]; -Diagnoses included: cellulitis, surgical aftercare following surgery on the digestive system, pancreatic cancer. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -At risk of developing pressure ulcers; -Lesion(s) other than ulcers, rashes or cuts. Review of the care plan, last revised 09/01/26, showed the following: -Resident had potential for skin breakdown related to skin fragility, incontinence, impaired mobility; -Staff should assess skin with daily routine care. Review of the POS and August 2026 TAR and physician order sheet showed the following: -An order, dated 08/14/26, for staff to observe abscess to scrotum daily. Ensure placement of Bactroban ointment. Replace if missing or soiled. May leave open to air (OTA). Notify physician of any signs or symptoms of infection or worsening condition every shift; -Staff did not document abscess to scrotum care as completed for day shift on 08/15/26, 08/16/26, 08/20/26, 08/24/26, 08/27/26, 08/28/26, or 08/30/26; -Staff did not document abscess to scrotum care as completed for evening shift on 08/17/26, 08/18/26, 08/19/26, 08/21/26, 08/22/26, 08/23/26, 08/25/26, 08/26/26, 08/28/26, or 08/31/26; -Staff did not document abscess to scrotum care as completed for night shift on 08/16/26, 08/17/26, 08/27/26, or 08/31/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/14/26, to observe abscess to scrotum daily. Ensure placement of Bactroban ointment. Replace if missing or soiled. May leave open to air. Notify physician of any signs or symptoms of infection or worsening condition, every shift; -Staff did not document abscess care as completed for day shift on 09/01/26 or 09/02/26; -Staff did not document abscess care as completed for evening shift on 09/01/26, 09/02/26, 09/03/26, 09/04/26, 09/05/26, 09/06/26, or 09/08/26; -Staff did not document abscess care as completed for night shift on 09/05/26. Review of the POS and August 2026 TAR and physician order sheet showed the following: -An order, dated 08/15/26, abscess of scrotum (external pouch of skin directly below the penis). Apply Bactroban (prescription antibiotic ointment) ointment daily. May leave open to air every day shift; -Staff did not document abscess of scrotum care as completed on 08/15/26, 08/16/26, 08/20/26, 08/23/26, 08/24/26, 08/27/26, 08/28/26, or 08/30/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/15/26, to apply Bactroban ointment daily to abscess of scrotum. May leave open to air, every day shift; -Staff did not document Bactroban ointment care as completed on 09/01/26, 09/02/26, or 09/07/26. Review of the POS and August 2026 TAR and physician order sheet showed the following: -An order, dated 08/19/26, for staff to observe dressing to scrotum daily. Replace if missing or soiled. Notify physician of signs or symptoms of infection or worsening condition every shift; -Staff did not document observation of dressing to scrotum as completed for day shift on 08/20/26, 08/24/26, 08/27/26, 08/30/26; -Staff did not document observation of dressing to scrotum as completed for evening shift on 08/21/26, 08/22/26, 08/23/26, 08/25/26, 08/26/26, 08/31/26; -Staff did not document observation of dressing to scrotum as completed for night shift on 08/27/26 or 08/31/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/19/26, to observe dressing to scrotum daily. Replace if missing or soiled. Notify physician of any signs or symptoms of infection or worsening condition, every shift; -Staff did not document scrotum care as completed for day shift on 09/01/26 or 09/02/26; -Staff did not document scrotum care as completed for evening shift on 09/01/26, 09/02/26, 09/03/26, 09/04/26, 09/05/26, 09/06/26, or 09/08/26; -Staff did not document scrotum care as completed for night shift on 09/05/26. Review of the POS and August 2026 TAR showed the following: -An order, dated 08/20/26, to change dressing daily to varicocele (enlargement of the veins) to scrotum. Clean with wound cleanser, skin prep edges, pack with iodoform (wound packing to prevent infection). May leave open to air or cover with gauze, every day shift; -Staff did not document varicocele to scrotum dressing change and care as completed on 08/23/26, 08/24/26, or 08/27/26. Review of the August 2026 TAR and POS showed the following: -An order, dated 08/28/26, to express abscess (apply pressure to force drainage out of opening) prior to wound treatment of varicocele to scrotum. Clean with wound cleanser, skin prep edges, pack with iodoform. May leave open to air or cover with gauze, every day shift; -Staff did not document express abscess care as completed on 08/30/26. Review of the POS and September 2026 TAR showed the following: -An order, dated 08/28/26, to express abscess prior to wound treatment to Varicocele to scrotum. Clean with wound cleanser, skin prep edges, pack with iodoform. May leave open to air or cover with gauze, every day shift; -Staff did not document express abscess care as completed on 09/01/26, 09/02/26, 09/04/26, or 09/07/26. During an interview and observation on 09/10/26, at 9:00 A.M., the resident was in bed, he/she said staff assisted with his/her needs. The nursing staff take care of his/her wounds every day. 4. During an interview on 09/10/26, at 10:00 A.M., Licensed Practical Nurse (LPN) B said the TAR shows what and when treatments are to be completed by the nurse. The order will populate for each shift an item is due. The nurse must document to show the treatment was completed each shift even if the order only said to observe the dressing each shift, it should be complete. He/She would not expect to see blank spots on the TAR. 5. During an interview on 09/10/26, at 10:55 A.M., LPN C said skin assessments and skin treatments populate on the TAR for the nurse during their shift. Each nurse is responsible for all skin treatments on their assigned hall. The nurse must document when the task is completed and should document the task even if it reads, observe the dressing. If there is no documentation, it would be considered not complete. He/She would expect nurses to document when they have completed treatments or observations. 6. During an interview on 09/10/26, at 10:45 A.M., the Unit Manager said required skin assessments and wound care populate on the nurse's TAR for each shift. Staff should document in the TAR as it shows what has been completed. He/She does not know if any staff audit the TAR's. 7. During an interview on 09/10/26, at 1:20 P.M., the Assistant Director of Nursing (ADON) said the TAR tells the nurse what needs to be completed and when it is to be completed. If the order states a treatment or observation should be completed daily and every shift, then it is expected that the nurse will complete the work on their assigned shift. Staff should document in the TAR when the task is completed and document a progress note if necessary. There should not be gaps or blank spots on the TAR. 8. During an interview on 09/10/26, at 1:50 P.M., the Director of Nursing (DON) said the TAR will populate what physician orders need completed for each shift. The nurses should document in the TAR when the task is complete. It is expected that the wounds and dressings should be observed daily but the order populates in each shift to ensure the dressing is observed that day. She would not expect to see blank spots on the TAR. Documentation shows the task has been completed. 9. During an interview on 09/10/26, at 2:00 P.M., the Administrator said wound and skin care orders populate on the nurse TAR on the shift that it is due. She is unaware of how often the ADON or DON audit the nurse TAR. She would expect staff to document their work as completed and not see a TAR with blank holes and no documentation. 10. Review of Resident #5's face sheet showed the following: -Admittd on 02/03/26; -Diagnoses included Alzheimer's disease, dementia and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No skin conditions. Review of the resident's care plan, revised 07/07/26, showed the following: -The resident had the potential for skin breakdown, skin tears, bruises, rashes related to fragile skin, incontinence and prolonged sitting or laying; -Administer medication as ordered and/or indicated for itching; -Administer ointment and/or cream to skin as ordered and/or indicated. Review of the resident's nurse's progress notes, dated 08/28/26, showed the following: -At 9:13 P.M., staff sent a picture of stomach rash to the physician; -At 9:18 P.M., the physician ordered Triamcinolone 1% cream twice a day for 10 days for the rash. Review of the resident's POS, dated 09/10/26, showed the following: -An order, dated 08/29/26, for triamcinolone acetonide topical cream 0.1%. Apply to chest and stomach rash topically two times a day for rash for ten days. Review of the resident's August 2026 TAR showed the following: -On 08/29/26 and 08/30/36, staff did not administer the triamcinolone cream treatment A.M. and P.M. doses; -On 08/31/26, staff did not administer the A.M. does of triamcinolone cream and documented 9 indicating other/see progress note. Review of the resident's nurse's progress notes showed the following: -On 08/29/26, at 8:01 A.M., triamcinolone acetonide topical cream .1%, apply to chest and stomach for rash topically two times a day for rash for 10 days, awaiting arrival; -On 08/29/26, at 3:24 P.M., triamcinolone acetonide topical cream .1%, apply to chest and stomach for rash topically two times a day for rash for 10 days, drug not available; -On 08/30/26, at 8:01 A.M., triamcinolone acetonide topical cream .1%, apply to chest and stomach for rash topically two times a day for rash for 10 days, drug not available; -On 08/30/26, at 3:51 P.M., triamcinolone acetonide topical cream .1%, apply to chest and stomach for rash topically two times a day for rash for 10 days, drug not available; -On 08/31/26, at 7:14 A.M., triamcinolone acetonide topical cream .1%, apply to chest and stomach for rash topically two times a day for rash for 10 days, awaiting arrival; -On 08/31/26, at 9:26 A.M., no skin issues identified. Review of the resident's skin assessment, dated 08/31/26, at 6:17 P.M., showed the following: -Skin warm and dry, skin color within normal limits and turgor (the skin's ability to change shape and snap back to its normal position) was not met; -New skin issue; -Location was chest and abdomen; -Additional location information was rash; -Skin issue was rash. Review of the resident's nurse's progress notes showed the following: -On 09/01/26, at 3:15 A.M., resident continues to have rash on chest and abdomen and looks to be improving; -On 09/04/26, at 6:33 A.M., a message was sent to the physician regarding the resident's rash. Received new orders. Review of the resident's POS, dated 09/10/26, showed the following: -An order, dated 09/04/26, with start date of 09/07/26, for permethrin topical cream 5%. Apply to head to toe topically one time a day for rash until 09/07/26. Apply head to toe, leave on for eight to twelve hours, rinse off after and repeat in one week. Review of the resident's nurse's progress notes showed the following: -On 09/05/26, at 2:17 A.M., the resident had a rash over upper trunk of body and arms. Treatment scheduled for this day (ivermectin and permethrin). Rash over entire upper trunk, front and back including chest and arm. Scheduled to be treated today with ivermectin and permethrin; -On 09/07/26, at 9:44 A.M., showed permethrin topical cream 5% was not available; -On 09/07/26, at 3:11 P.M., showed permethrin topical cream 5% was not available. Review of the resident's skin assessment, dated 09/07/26, at 6:17 P.M., showed the following: -Skin warm and dry, skin color within normal limits and turgor was not met; -The resident had an existing skin issue; -There were no new skin issues; -Skin issue needs review; -Location was abdomen and chest; -Additional location information was rash; -Skin issue was rash. Review of the resident's nurse's progress notes showed the following: -On 09/09/26, at 9:00 A.M., a nurse assessed the resident's rash. The resident's rash was noted to be improving with current treatment. Review of the resident's September 2026 TAR showed staff did not complete the permethrin treatment and documented 9 indicating other/see progress note. During an interview on 09/10/26, at 1:38 P.M., LPN B said the resident had a rash and staff should have administered the treatment per the physician's orders. During an interview on 09/10/26, the Unit Manager said nursing notified the physician of the resident's rash and the physician ordered cream. During an interview on 09/10/26, at 3:20 P.M., the DON said the resident had a rash and the physician ordered permethrin. Nursing staff should have administered the medication per the physician's orders. During an interview on 09/10/26, at 3:32 P.M., the Administrator said staff should have administered the resident's medications per physician's orders. 11. Review of Resident #6's face sheet showed the following: -admitted on [DATE]; -Diagnoses included dementia, diabetes and rash. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No skin conditions. Review of the resident's care plan, revised 06/26/26, showed the following: -Resident itches and picks at skin; -Apply topical treatments as ordered as needed. Review of the resident's skin assessment, dated 08/25/26, showed no new skin issues found. Review of the resident's POS, dated 09/10/26, showed the following: -An order, dated 09/07/26, with start date of 09/08/26, for permethrin topical cream 5%, apply to entire body topically one time only for rash until 09/08/26. Review of the resident's nurse's progress notes showed the following: -On 09/05/26, at 12:39 P.M., the resident had red rash to left arm and reported pain. Physician and nurse management notified and awaiting further instruction at this time; -On 09/07/26, at 6:05 P.M., the resident had rash noted to left upper arm. Photo sent to the physician and requested possible cream for the rash; Review of the resident's September 2026 TAR showed the following: -Permethrin topical cream 5%, apply to entire body topically one time only for rash until 09/08/26; -Staff did not document administration or a reason administration was not completed on 09/08/26. Review of the resident's nurse's progress notes dated 09/09/26 at 9:01 A.M., showed a nurse assessed the resident's rash. The resident's rash was improving with current treatment. The nurse would continue to monitor. Review of the resident's skin assessment, dated 09/08/26, showed the resident had no existing skin issues and no new skin issues found. During an interview on 09/10/26, at 1:38 P.M., LPN B said the resident had a rash. Nursing staff should have administered the treatment for the residents' rash per physician's orders. During an interview on 09/10/26, the Unit Manager said nursing staff notified the physician of the resident's rash and the physician ordered cream. During an interview on 09/10/26, at 3:20 P.M., the DON said the resident had a rash and the physician ordered permethrin. Nursing staff should have administered the medication per the physician's orders. During an interview on 09/10/26, at 3:32 P.M., the Administrator said if the physician ordered permethrin for the resident and staff should have administered the medication. 12. During an interview on 09/10/26, at 1:07 P.M., Certified Nursing Assistant (CNA) D said the following: -If he/she notices a resident has a new skin condition, he/she would notify the nurse; -The nurse assesses the new skin condition and notifies the physician to receive orders. 13. During an interview on 09/10/26, at 11:40 A.M., Certified Medication Technician (CMT) E said the following: -If he/she notices a new skin issue, he/she would notify the nurse; -He/She documents in the TAR if a medication is unavailable; -He/She administers medications per physician's orders. 14. During an interview on 09/10/26, at 1:38 P.M., LPN B said the following: -If he/she receives an order for medication, he/she enters the order into the electronic medical record, and this notifies the pharmacy of the new order; -If he/she entered an order in the system in the morning, the facility usually receives the medication the same day unless the pharmacy does not have the medication in stock; -If staff are unable to give the medication, they document this in the TAR, and document unavailable in a progress note and contact the pharmacy; -If the medication is unavailable for several days, the nurse contacts the physician and asks for alternative treatments; -The CMTs apply the treatments for rashes, and the nurse follows up on the treatments; -If a resident has a treatment order for a rash, the staff should administer the treatment. 15. During an interview on 09/10/26, at 11:40 A.M., LPN E, said the following: -When the nurse receives a new order for medication, they enter the order into the resident's electronic medical record which automatically sent the new order to the pharmacy; -If nurses do not enter an order into the electronic medical record before 5:00 P.M., the medication will not come until the next day; -If the medication was available in the e-kit, nurses pull the medication from there until the medication arrives at the facility; -Staff entered the orders for permethrin cream the day after the medication was ordered; -If the cream was unavailable, nursi

Based on interview and record review, the facility failed to ensure one resident (Resident #7) was treated with dignity and respect when one staff member (Licensed Practical Nurse (LPN) F) cursed at the resident. The facility census was 115.Review of the facility's policy, titled Professionalism - Customer Service, dated 10/01/25, showed the following:- It is the policy of this facility to provide professional, courteous service to our customers. Every employee is accountable for conducting themselves in a professional manner at all times. This facility strives to create an environment where the resident always comes first;-Within the facility, the customer is the resident, their family members and or the resident's responsible party;-Professionalism is defined as a way of conducting oneself that includes courtesy and respect for others;-Compassion is defined as sympathetic awareness of others' distress and a desire to alleviate it. You can show compassion for others by being kind, caring, and displaying a willingness to help;-The facility is the resident's home, and will be regarded as such. Each resident will be treated with compassion and respect at all times;-Your attitude can influence how your day goes and the outcomes you achieve. Stay positive and remove negative language;-When a resident makes a request, respond positively. For example, say Thank you for asking, let me see what I can do.-Make responding promptly and compassionately to your residents' needs your top priority;-Create an environment where residents and family members are continually greeted with a smile, and make eye contact, to show that they are valued as an individual;-Always do your best. Strive to be competent in the skills you need to do your job and to exceed your residents' expectations;-When caring for or responding to residents and family members, consider what you would want if you were in their position;-Be aware of your residents' goals and preferences for care. Provide care in accordance with their care plans;-Support the concept that residents are in control of their own choices;-Do whatever is necessary to support your residents based on their individual needs and preferences. Protect and uphold residents' rights at all times;-Do not argue or bicker with the residents you care for. If you feel yourself becoming angry or confrontational, step away from the situation for a moment. Ask a co-worker or your supervisor to assist if needed. 1. Review of Resident #7's face sheet, a document that gives a patient's information at a quick glance, showed the following:-admitted on [DATE];-Diagnoses included schizoaffective disorder (a chronic mental health condition combining symptoms of a psychotic disorder like schizophrenia with a mood disorder like depression or bipolar disorder), depression and dementia. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 06/22/26, showed the following:-Cognitively intact;-No behaviors documented. Review of the resident's care plan, revised 06/26/26, showed the following:-Resident may become verbally and physically aggressive toward staff;-He/she had delusions and hallucinations;-Resident displays impulsivity, attention seeking behavior, oppositional behavior, angry outbursts, mood liability, irritability, demanding behaviors and name calling to others;-He/she had a poor sense of social boundaries and he/she could be intrusive to others and/or hyper talkative;-He/she had poor judgement, insight and illogical thought processes. He/she could be impatient and demanding;-Interventions included: Place the resident in an area where frequent observation was possible, offer behavior-cognitive therapy, refer to social services for evaluation, talk in a calm voice when behavior is disruptive;-He/she has the potential for altered mood state and psychosocial well-being related to depression, schizoaffective disorder and anxiety;-Interventions included: Address complaints and concerns timely, encourage and allow to voice feelings and concerns, observe for changes in mood, and provide support and reassurance as needed;-The resident had behavior challenges. He/she may yell and cuss when he/she was not provided the answer or decision he/she wanted;-Interventions included: Anticipate and meet the resident's needs, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert his/her attention, and remove him/her from the situation and talk to an alternate location as needed. Review of nurse's progress notes, dated 09/05/26, at 12:11 P.M., showed the following:-The resident reported a verbal altercation with a nurse who was off duty at this time;-Due to the nature of the accusation, the Director of Nursing (DON) was immediately notified by this nurse;-The nurse notified the Administrator and the resident's guardian was called and a voicemail left;-The Administrator notified the resident's physician. Review of the facility's investigation, dated 09/10/26, showed the following:-On 09/05/26, at approximately 11:20 A.M., Resident #7 reported an allegation of verbal abuse against LPN F that occurred on the night of 09/04/26;-Witnesses included Registered Nurse (RN) G;-Resident #7 stated he/she asked LPN F for hydrogen peroxide and LPN F told the resident the facility did not have hydrogen peroxide;-The resident and LPN F argued and the resident told LPN F, fuck you, and LPN F stated fuck you too to the resident;-RN G stated he/she overheard part of the conversation between the resident and LPN F;-LPN F said something back to the resident but RN G could not hear what was said;-LPN F was suspended pending investigation. During an interview on 09/09/26, at 10:46 A.M., the resident said the following:-He/She asked LPN F for hydrogen peroxide and LPN F said a rude comment to him/her;-He/She said fuck you to LPN F and LPN F replied fuck you;-RN G witnessed the verbal altercation. During an interview on 09/10/26, at 10:58 A.M., LPN F said the following:-On 09/04/26, at approximately 10:30 P.M. to 10:45 P.M., the resident was sitting near the nurse's station on his/her walker;-RN G was at the nurse's station;-The resident asked for hydrogen peroxide, and he/she (LPN F) told the resident that he/she did not believe the facility had any hydrogen peroxide;-The resident told him/her that he/she could use what he/she wanted because this was their home and then said fuck you;-He/She told the resident that he/she was not going to sit and listen to that and walked away. The resident called him/her a bitch;-The resident kept arguing with him/her, and he/she (LPN F) bent down where only the resident could hear him/her and told the resident that he/she did not make enough money to get fucked and walked away;-RN G intervened, but was not close enough to hear what LPN F said;-He/She should not have responded to the resident in that manor as it was inappropriate;-He/She should have walked away and not said anything to the resident;-When this occurred, on 09/04/26, he/she did not report the incident to management, but should have called the on-call nurse;-During the investigation on 09/05/26, he/she told the Administrator and DON what he/she said to the resident;-Staff should treat residents with dignity and respect;-If he/she heard a staff member treat a resident inappropriately, he/she would separate the staff member from the resident and report the incident to the Assistant Director of Nursing (ADON) or DON. During an interview on 09/09/26, at 5:04 P.M., RN G said the following:-On 09/04/26, between 10:30 P.M. and 12:00 A.M., the resident asked him/her for hydrogen peroxide;-He/she did not know if the facility had hydrogen peroxide;-The resident then asked LPN F for hydrogen peroxide and LPN F told the resident the facility did not use hydrogen peroxide. The resident said he/she was an adult and could have what he/she wanted;-The resident and LPN F started to argue and the resident said fuck you to LPN F;-LPN F said he/she was done with the resident and walked away from the resident;-LPN F walked behind the nurse's station, bent over and said something to the resident, but he/she could not hear what LPN F said;-The resident told him/her (RN G) that he/she was a witness to what LPN F had said to him/her, but RN G did not hear what was said;-He/she did not ask the resident any follow-up questions as to what LPN said. During an interview on 09/10/26, at 1:07 P.M. Certified Nursing Assistant (CNA) D said staff should treat residents with respect, as this is the residents' home. During an interview on 09/10/26, at 1:38 P.M., LPN B said the following:-Staff should treat residents with dignity and respect;-If a resident is aggressive with staff, they should try to deescalate the situation. If that does not work, they should walk away;-Staff should not engage in a verbal altercation with residents;-If he/she heard staff curse at a resident and tell them they did not get paid enough to deal them, he/she would report the incident to the DON immediately. This could be considered abuse and/or a dignity and respect concern;-If staff observes an incident between a staff and a resident, they should follow up the resident and report any concerns to the DON. During an interview on 09/10/26, at 2:57 P.M., the Unit Manager said the following:-Staff should treat residents with dignity and respect;-If a resident becomes verbally aggressive, staff should try to redirect, walk away if necessary and get another staff member to reapproach the resident;-If he/she heard a staff member use curse words toward a resident, and say they don't get paid enough to deal with the resident, he/she would consider this a dignity and respect issue or possible abuse. During an interview on 09/10/26, at 3:20 P.M., the DON said the following:-During the investigation, LPN F reported to him/her that he/she (LPN F) told the resident that he/she (LPN F) did not make enough money to get fucked;-The comment made by the LPN was inappropriate;-RN G should have asked the resident follow-up questions when the resident told him/her that he/she was a witness to what LPN F said;-RN G should have reported the incident to him/her (DON). -He/she expects staff to treat residents with dignity and respect;-If a resident becomes verbally aggressive, staff should tell the resident their language is inappropriate. If the resident continues to escalate, staff need to separate themselves from the situation and walk away. 7. During an interview on 09/10/26, at 3:32 P.M., the Administrator said the following:- It is inappropriate for staff to use curse language toward a resident and to say they do not get paid enough to deal with them;-He/she expects staff to treat residents with dignity and respect;-If a resident becomes verbally aggressive, staff should not respond poorly and should attempt to keep the situation professional;-If a resident continues to be verbally aggressive, staff should walk away and find another staff member to reapproach the resident. 31888779; 3188889

Based on observation, interview and record review, the facility failed to ensure the residents had a clean and comfortable environment when the shower in the shower room had black substance in the corner of the shower stall. The facility census was 119.Review of the facility's policy titled, Cleaning Bathrooms, dated 01/30/24, showed the following:-The purpose is to ensure facility bathrooms are clean and sanitary;-The procedure is to spray shower walls and floor surface with bathroom cleaner. Spread and wipe around shower walls and faucet with clean, wet rag. Use hand-held shower hose to rinse shower. Be sure all hair is removed from drain plate. Wipe dry;-Use a clean mop, clean water, and floor cleaner to mop bathroom floor working from the farthest side of the bathroom to the doorway. Staff should make sure the mop is wrung out properly to prevent puddles of water on the floor.The facility did not provide a cleaning schedule or logs for cleaning the resident shower rooms.1. Observations on 07/17/26, at 11:35 A.M., of the resident shower room between the 400 and 500 hall, showed the following:-A resident used the key hanging on the door to enter the shower room. He/she left a few minutes later;-The shower door was locked with a key hanging on the middle of the door;-The shower stall had a blackish film/residue covering the tile and grout/caulking lines in the left corner going up the wall and towards the drain. It covered approximately a foot and a half square foot mostly on the grout/caulking but also on the tile;-The shower head sprayer dripped water onto the shower floor.During an interview on 08/03/26, at 12:12 P.M., a resident's family member said the following:-On 07/15/26, he/she visited his/her family member. The resident needed to use the bathroom, and he/she went with him/her to the shower room at the end of the 400 hall;-When they walked by the shower area on the way to the toilet, there was what appeared to be black mold In the back left hand corner of the shower;-He/she could not be sure that it was mold but it looked like black grime and he/she did not think staff should shower residents in there;-He/she asked the resident about the black substance and the resident said it was there when he/she last showered;-The family member did not know when the resident last received a shower.During an interview on 07/17/26, at 12:31 P.M., Certified Nursing Assistant (CNA) C said the following: -He/she noticed a black residue or substance in the corner of the shower in the shower room between 400 and 500 hall;-He/she first saw the black substance about a week ago when he/she gave a resident a shower;-He/she thought the substance was caused from a resident dying their hair black or brown;-He/she did not report it to anyone and did not attempt to clean it;-He/she did not think much of it.Observations of the eyewash station and shower on 400 hall on 07/17/26, at 11:43 A.M., showed the following: -The housekeeping supervisor turned on the eyewash station and blackish water came out of the pipe that drained onto the left corner of the shower;-The left corner of the shower had a blackish substance on the grout lines and tile of the left corner of the shower;-The shower sprayer continued to drip into the shower. During an interview on 07/17/26, at 11:43 A.M., the Housekeeping Supervisor said the following: -The housekeeping staff were supposed to mop and clean the shower rooms daily;-Staff should have cleaned the shower room between the 400 and 500 halls yesterday;-He/she looked at the black substance in the corner of the shower and thought it could be mold;-The eyewash station drained into that corner of the shower. The residents emptied drinks such as soda or coffee in the eye wash station. He/she thought that might be what caused the black build-up in the corner of the shower;-He/she did not realize the black build-up had gotten so bad;-He/she did not keep track of the staff who were responsible for cleaning the shower, and did not have a log that showed staff completed the cleaning;-Housekeeping Aide B was responsible for cleaning the shower this morning;-He/she would not feel comfortable with a resident taking a shower in that shower due to the black substance;-He/she did not know how long the black substance had been in the shower. During an interview on 07/17/26, at 11:47 A.M., Housekeeping Aide B said the following:-He/she cleaned the 400/500 shower room that morning and could not get the black substance off the tile and grout;-He/she thought it looked really bad this morning;-He/she did not let anyone know that he/she could not clean it;-When he/she cleaned the shower on 07/15/26, he/she did not remember the black substance looking as bad as it did now.During an interview on 07/17/26, at 11:25 A.M., Licensed Practical Nurse (LPN) A said the following:-Some of the residents use the shower room bathroom and they would be able to see into the shower area;-He/she did not know the 400/500 shower had black grime in the corner until now; -He/she thought it looked like mold but he/she could not be sure;-He/she would not want to use the shower due to the black build up;-He/she thought housekeeping staff cleaned the shower rooms daily and did not understand how the shower could get that dirty if the housekeeping staff cleaned it daily.During an interview and observation on 07/17/26, at 11:35 A.M., the Assistant Director of Nursing (ADON) said the following:-He/she could see the black substance on the tile and grout in the left corner of the shower;-He/she did not know what the black substance was, but would not want to take a shower in there;-The housekeeping staff cleaned the shower rooms;-Residents on 400 hall would sometimes use the bathroom in the 400 shower room and would be able to see the mold. During an interview on 07/17/26, at 2:19 P.M., the Director of Nursing (DON) said the following: -He/she noticed the blackish build up and grime in the 400/500 shower room yesterday;-He/she showed the housekeeping supervisor the black grime and build-up in the shower and thought housekeeping staff would address it;-The residents pour drinks down the eye station drain and it drained onto the floor in left corner of the shower;-The housekeeping staff were supposed to clean the shower room daily to prevent build-up;-He/she did not know the shower head continuously dripped. During an interview on 07/17/26, at 2:30 P.M., the Maintenance Supervisor said the following:-The residents had been dumping drinks such as tea and coffee down the eye wash station drain. Staff told residents not to pour drinks down the eyewash station drain but they did it anyway;-He/she was not sure the reason housekeeping staff did not properly clean the shower;-If staff cleaned it daily, there would not be so much of the black substance on the grout and caulking;-He/she did not know how long the shower had been like that or how long the shower head had been dripping;-When he/she saw the shower three to four weeks ago, there was no black grime in the corner. During an interview on 07/17/26, at 2:39 P.M., the Administrator said the following:-He/she expected the housekeeping staff to clean the showers daily;-When staff noticed the black substance on the tile and grout in the shower, they should have immediately told housekeeping staff so they could address it;-If the staff are unable to get the shower clean, they should close that shower until it can be cleaned properly;-The Housekeeping Supervisor should ensure the housekeeping staff cleaned the showers properly.3096046

Based on record review and interview, the facility failed to provide care per standards of practice when staff failed to obtain physician orders to monitor, flush, and obtain blood from an implanted vascular access port (small device placed under the skin, usually in the chest, to provide long term access to a vein) and failed to include the implanted vascular access port on the resident care plan for one resident (Resident # 1). The facility census was 111.Review of the facility policy titled admission Orders, undated, showed the following:-The physician must provide written and/or verbal orders for the resident's immediate care and needs;-The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission.Review of the facility policy titled Accessing and De-accessing an Implanted Vascular Access Port, undated, showed the following:-It is the policy of the facility to ensure that implanted vascular access ports are accessed and de-accessed consistent with current standards of practice;-The nurse will obtain and verify the physician order for the use of an implanted port;-The nurse shall be validated with a competency assessment prior to accessing or de-accessing an implanted port for the first time;-Aseptic technique (method that prevents contamination) will be used when accessing and de accessing the port,-If not routinely used, implanted ports will be flushed and locked every one to two months or as per physician orders.Review of the facility policy titled Comprehensive Care Plan, undated, showed the following:-It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services identified in the resident's comprehensive assessment and meet professional standards of quality;-The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be furnished, the resident's goals for admission, desired outcomes, and preferences for future discharge; and qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out interventions.1. Record review of Resident #1's face sheet (document that gives a resident's information at a quick glance) showed the following:-admission date of 12/24/25;-Diagnoses included chronic kidney disease and hepatorenal syndrome (rapid deterioration in kidney function in individual's with cirrhosis (late-stage liver disease characterized by scarring in the liver tissue)).Review of resident's care plan, dated 12/29/25, showed the following:-Resident had limited physical mobility;-Resident had liver disease related to cirrhosis. (Staff did not care plan related to an implanted port.)Review of the resident's December 2025 Physician Order Sheet (POS) showed staff did not document orders for flushing, monitoring, or drawing blood from the resident's port.Review of the resident's nursing admission note, dated 12/24/25, showed staff did not address the resident's implanted port.Review of the resident's January 2026 POS showed staff did not document orders for flushing, monitoring, or drawing blood from the resident's port.Review of a resident re admission summary, dated [DATE], showed staff did not address the resident's implanted port.Review of the resident's February 2026 POS showed the following:-An order, dated 02/05/26, for a complete blood count (CBC - blood test to measure the number and size of different cells in the blood), complete metabolic panel (CMP - a blood test to evaluate metabolism (how your body uses food and energy) and the balance of certain chemicals in the body);-An order, dated 02/14/26, for a statim (STAT - immediate) CMP;-An order, dated 02/15/26, for a CMP on 02/16/26;-An order dated 02/20/26, for a CMP.Review the resident's nursing notes, dated 02/05/26 to 02/19/26, showed staff did not document regarding issues with obtaining the lab. Review of the resident's nursing progress note dated 02/20/26, at 6:07 P.M., showed resident lethargic and had poor fluid intake. Physician notified and requested IV fluids via currently accessed port.Review of the resident's February 2026 POS showed the following:-An order, dated 02/20/26, to flush implanted port with 10 milliliters (ml) normal saline every four weeks one time a day every month on the 20th for a diagnosis of hepatorenal syndrome;-An order, dated 02/20/26, to administer sodium chloride 0.9% (solution used to replenish fluids and electrolytes) 400 ml bolus (single, large dose of medication) one time only related to metabolic encephalopathy (condition where the brain has trouble working due to a chemical or metabolic problem);-An order, dated 02/20/26, to administer sodium chloride 0.9% intravenous (IV) 100 ml per hour every shift related to metabolic encephalopathy. Administer via port at 100 ml every hour for 48 hours.(Staff did not document orders regarding monitoring or blood draws from the implanted port.)Review of the resident's nursing progress notes showed staff did not complete additional documentation regarding the resident's implanted port. During an interview on 03/24/26, at 12:18 P.M., Licensed Practical Nurse (LPN) A said the following:-An implanted port was the responsibility of a Registered Nurse (RN);-The resident had an implanted port upon admission to the facility;-A resident with an implanted port should have physician orders to flush and draw blood from it;-The phlebotomist from the lab does the lab draws for residents;-The lab tried multiple times but was unable to obtain sufficient blood to get results for the resident;-An RN accessed the resident's port to obtain blood due to the lab technician was unable to.During an interview on 03/24/26, at 1:40 P.M., LPN B said the following:-The lab come out to obtain a blood sample, but they were unable to;-The lab was not allowed to draw blood from an implanted port;-He/she did not know if the resident1 had a port;-The Director of Nursing (DON) was responsible for the care of implanted ports;-There should be physician orders for the care and to assess of a port;-An implanted port should be included on the care plan.During an interview on 03/24/26, at 11:12 A.M., RN C said the following:-The DON was responsible for flushing of implanted ports;-There should be physician orders for the care of implanted ports;-The admission nursing assessment should include a resident that had an implanted port;-Implanted ports should be included on the care plan;-A port should be monitored for infection or discomfort;-The resident should have orders to access the port for flushing and obtaining blood;-The lab had difficulty obtaining a blood sample, so he/she obtained it from the port;-He/she did not obtain an order to draw blood from the port, but he/she thinks the previous nurse did.During an interview on 03/24/26, at 2:00 P.M., the DON said the following:-An implanted port should be accessed by an RN only;-He/she was responsible for the care of implanted ports;-There should be an order for flushing and drawing blood from a port;-The lab was unable to obtain a good blood specimen from the resident;-A facility RN obtained blood from the resident's port but it was hemolyzed (blood cells become damaged or destroyed);-RN C then drew a blood sample from the port and they obtained results;-The resident came to the facility with a port, but did not initially have orders for the care of it;-A resident admitted with any kind of port should have the information included in the admission assessment;-The DON reported seeing only one order, dated 02/20/26, for the resident's port to be flushed.During an interview on 03/24/26, at 3:30 P.M., the Assistant Director of Nursing (ADON) said the following:-An RN can access an implanted port to obtain a blood sample;-A physician order was required to draw blood or flush a port;-A resident admitted with an implanted port should have that included in the admission assessment;-The orders to care for an implanted port should be obtained upon admission;-It is important to monitor port for patency (open, unobstructed) and to flush monthly;-The lab was unable to obtain an adequate sample, so RN C accessed the port for a blood sample;-He/she was unsure why the lab was unable to obtain a sample during that time;-A resident should have an implanted port included on the care plan;-The nurses and MDS Coordinator were responsible for updating care plans;-All updates and changes are discussed in the morning meeting so the care plan can be updated.During an interview on 03/26/26, at 9:25 A.M., the Administrator said the following:-He/she expected staff to follow policies and procedures related to implanted ports;-An implanted port should be included in an admission assessment;-The resident should have orders for care, monitoring, and blood draws from an implanted port; -An implanted port should be included on the resident care planComplaint #2749284

Based on interview and record review, the facility failed to ensure colostomy (surgical procedure that brings one end of the large intestine out through the abdominal wall) site care was provided per standards of practice when staff failed to obtain physician orders for the routine colostomy care/changes, failed to routinely assess the colostomy site, failed to document resident removed of the colostomy bag, and failed to document care of the colostomy for one resident (Resident # 1). Staff also failed to routinely assess the colostomy site and failed to document monitoring colostomy self-care for one resident (Resident # 2). The facility census was 111. Review of a facility policy titled Ostomy (surgical opening in an organ of the body) Care, dated October 2025, showed the following:-It is the policy of the facility to ensure residents who require ostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences;-Ostomy care will be provided by licensed nurses under the orders of the attending physician;-A licensed nurse will determine the actual type of ostomy through physical assessment, medical record review, and collaboration with the attending physician;-The frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's person-centered care plan;-Direct care staff members will observe and respond to any signs of the resident's discomfort about the ostomy or it's care;-The surrounding skin of the ostomy will be monitored for excoriation, abrasion, and breakdown;-Interventions to prevent complications or promote dignity associated with the ostomy will be included in the care plan. Review of a facility policy titled Documentation in the Medical Record, dated October 2025, showed Licensed staff shall document all assessments, observations, and services provided in the resident's medical record.1.Review of Resident #1's face sheet (document that gives resident's information at a quick glance) showed the following:-admission date of 03/12/25;-Diagnoses included muscle weakness, cognitive communication deficit (communication impairment), and neuromuscular dysfunction of the bladder (nerve damage causing loss of bladder control).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/21/26, showed the following:-Severe cognitive impairment;-Resident had no behavior symptoms or rejection of care;-Resident had an indwelling catheter (a sterile tube inserted into the bladder to drain urine) and ostomy;-Dependent on staff for showers, toileting, bed mobility, and transfers.Review of the resident's care plan, revised 01/23/26, showed the following:-Resident exhibits combativeness with care and especially colostomy care;-Resident should have abdominal binder;-Staff should change colostomy bag every three days;-Staff should obtain onesies to discourage resident from removing the bag.Review of the resident's monthly summary note, dated 03/01/26, showed the following: -Resident alert, unable to voice needs, and staff anticipated needs;-Resident had a suprapubic catheter in place which was patent (open) to dependent drainage;-Resident was full assistance with activities of daily living (ADL's - fundamental, self-care tasks such as bathing, dressing, mobility, and toileting) and transfers. (Staff did not address the resident's colostomy or colostomy care in the assessment.)Review of the resident's March 2026 Physician Order Sheet (POS) showed an order, dated 01/09/26, for a colostomy change every 24 hours as needed.(Staff did not document an order for routine colostomy care.)Review of the resident's nursing admission assessment note, dated 03/06/26, showed the following: -The resident had a flat, non-tender abdomen with bowel sounds present;-Resident denied indigestion, nausea, vomiting, diarrhea, constipation, or bowel incontinence. (Staff did not address the resident's colostomy or colostomy care in the assessment.)Review of the resident's skin check, dated 03/14/26, showed the following: -Skin warm and dry;-Skin color and turgor normal;-Resident did not have an external device;-No skin issues identified. (Staff did not address the resident's colostomy.)Review of the resident's skin check, dated 03/23/26, showed the following: -Skin warm and dr;-Skin color and turgor normal;-No skin issues identified.(Staff did not address the resident's colostomy.)Review of the resident's skin check, dated 03/28/26, showed the following: -Skin warm and dry;-Skin color and turgor normal.(Staff did not address the resident's colostomy.)Review of the resident's March 2026 Treatment Administration Record (TAR) showed the following: -An order, dated 01/09/26, for a colostomy change every 24 hours as needed;-Staff did not document completion of the colostomy changes during the month of March 2026.Review of the resident's March 2026 progress notes showed staff did not document behavior of resident removing colostomy bag, assessment of stoma (surgically created opening on the surface of the abdomen that connects to an internal organ) and changing of the colostomy wafer.Review of the resident's April 2026 POS showed an order, dated 01/09/26, for a colostomy change every 24 hours as needed. (Staff did not document an order for routine colostomy care.)Review of the resident's skin check, dated 04/04/26, showed the following: -Skin warm and dry;-Skin color and turgor normal. (Staff did not address the resident's colostomy.)Review of the resident's skin check, dated 04/12/26, showed the following: -Skin warm and dry;-Skin color and turgor normal;-No skin issues identified. (Staff did not address the resident's colostomy.)Review of the resident's skin check, dated 04/20/26, showed the following : -Skin warm and dry;-Skin color and turgor normal;-No skin issues identified. (Staff did not address the resident's colostomy.)Review of the resident's care plan, revised 04/21/26, showed the following additions to the care plan:-Resident will have urinary diversion managed as evidenced by appropriate amount, type, color, odor of drainage, stoma the correct size, pink, free of breakdown or infection, and the surrounding skin free of breakdown, rash, or infection;-Resident had a colostomy and would remove the bag and throw it.Review of the resident's nursing progress note, dated 04/29/26, showed colostomy removed prior to shower. The stoma was pink, moist, and viable. Appliance applied and secured with no leaks noted upon placement. Resident tolerated well.Review of the resident's April 2026 TAR showed the following:-An order, dated 01/09/26, for a colostomy change every 24 hours as needed;-Staff did not document completion of the changes in the month of April 2016. Review of the resident's April 2026 progress notes showed no further notes of resident removing colostomy bag, no additional assessments of stoma, and no documentation of changing of the colostomy wafer.During an interview on 04/29/26, at 11:45 A.M., Certified Nurse Assistant (CNA) A said the following:-The resident had a colostomy; -The nurse was responsible for the care of a colostomy;-The resident removed the colostomy bag frequently and did not like it on;-The resident did not have a colostomy bag on currently;-Staff would place a brief on the resident to prevent leakage from the uncovered ostomy site.During an observation on 04/29/26, at 11:50 A.M., the resident was lying in bed while two aides prepared him to transfer to a shower chair. Resident was noted to have a brief on with the stoma partially visible out of the top of a brief. No wafer or colostomy bag was in place. The resident was noted to have tubing from a suprapubic catheter out of the brief with scattered brown colored fecal matter on the tubing. During an interview on 04/29/26, at 12:02 P.M., Certified Medication Technician (CMT) B said the following:-The resident had a colostomy but would remove it;-The staff would replace the bag when he/she removed it;-The resident had an abdominal binder but would not wear it.During an interview on 04/29/26, at 12:48 P.M., Licensed Practical Nurse (LPN) D said the resident was noncompliant with the use of an ostomy bag. The staff would apply a bag, and the resident would take it off. The nurses should document when the resident removed the ostomy bag as it is a behavior. The physician had been notified of the resident's noncompliance and ordered an abdominal binder, but the resident refused to wear it. The staff have tried to cover the ostomy with a brief.During an interview on 04/29/26, at 2:10 P.M., CNA E said the resident had never worn an ostomy bag. The resident wore a brief, and he/she was constantly wiping the resident due to no ostomy bag.During an interview on 04/29/26, at 2:30 P.M., the Assistant Director of Nursing (ADON) said the resident pulled the ostomy bag off and was getting it changed constantly. He/she did not know if the resident utilized an abdominal binder. The staff should document in the progress notes when the resident removed the ostomy bag. The staff try to distract the resident and keep his/her pants pulled up over the ostomy site. The resident had a suprapubic catheter, and it could cause an infection if the ostomy site is not covered.During an interview on 04/29/26, at 3:15 P.M., Registered Nurse (RN) F said the resident should have an order to have the ostomy changed.During an interview on 04/29/26, at 3:20 P.M., LPN G said the resident had weekly skin assessments completed that should address ostomy site. He/she removed ostomy bags at times. They have tried multiple interventions and notified the guardian. He/she had an as needed order to change the colostomy if it was removed, but no routine orders. He/she should have a routine order for changing the colostomy. He/she could possibly get an infection if the ostomy site is uncovered due to the suprapubic catheter.During an interview on 04/29/26, at 3:30 P.M., LPN H said the resident did not like the colostomy bag on, so the staff will check and reapply if it is missing. He/she should have an order to change the colostomy wafer every three days and as needed.During an interview on 04/29/26, at 3:40 P.M., the Director of Nursing (DON) said the resident had been resistive to care at times depending on the staff. He/she had taken the colostomy bag off and thrown it. The aides should notify the nurse so it can be replaced when this occurs. He/she should have an order for routine changes and assessment of the colostomy. He/she is at risk for an infection when the colostomy bag is not in place due to having a suprapubic catheter.2. Review of Resident # 2's face sheet showed the following:-admission date of 12/11/24;-Diagnoses included vascular dementia (decline in mental skills caused by decreased blood flow to the brain), lung cancer, and colon cancer.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Resident had an ostomy;-Independent for toileting, dressing, bed mobility, and transfers;-Required minimal staff assistance with showers.Review of the resident's care plan, revised 01/06/26, showed resident had behavior problems related to verbal aggression, combativeness, and hallucinations.Review of the resident's March 2026 POS showed the following:-An order, dated 01/06/26, for a colostomy change as needed;-An order, dated 01/06/26, for a colostomy change every three days;-An order, dated 01/06/26, for independent colostomy care with staff support as needed.Review of the resident's March 2026 TAR showed the following:-An order dated 01/06/26, for a colostomy change as needed. (Staff did not document completion by staff or resident for the month);-An order dated 01/06/26, for colostomy change every three days. Staff documented care provided as ordered. Review of the resident's nursing skin check, dated 03/05/36, showed the following: -Skin warm and dry with normal color and turgor;-Resident does not have an external device;-No skin issues identified.(Staff did not address the resident's colostomy.)Review of the resident's nursing progress note, dated 03/06/26, showed resident had a colostomy that he/she cared for independently. (Staff did not document an assessment of the colostomy area.)Review of the resident's nursing skin check, dated 03/12/26, showed the following: -Skin warm and dry with normal color and turgor.;-No skin issues identified. (Staff did not address the resident's colostomy.)Review of the resident's nursing skin check, dated 03/19/26, showed the following: -Skin warm and dry with normal color and turgor;-No skin issues identified.(Staff did not address the resident's colostomy.)Review of the resident's nursing skin check, dated 03/26/26, showed the following:-Skin warm and dry with normal color and turgor;-No skin issues identified. (Staff did not address the resident's colostomy.)Review of the resident's nursing progress note, dated 03/06/26, showed resident had a colostomy that he/she cared for independently. (Staff did not document an assessment of the colostomy area.)Review of the resident's electronic medical record for March 2026 showed staff did not document an assessment of the colostomy site.Review of the resident's April 2026 POS showed the following:-An order, dated 01/06/26, for a colostomy change as needed;-An order, dated 01/06/26, for a colostomy change every three days;-An order, dated 01/06/26, for independent colostomy care with staff support as needed.Review of the resident's April 2026 TAR showed the following:-An order dated 01/06/26, for a colostomy change as needed. (Staff did not document completion by staff or resident for the month);-An order dated 01/06/26, for colostomy change every three days documented as completed as ordered.Review of the resident's nursing progress note, dated 04/10/26, showed the following: -The resident is alert and oriented but at times had some forgetfulness and or confusion;-Resident had a colostomy and cared for it independently.(Staff did not document an assessment of the colostomy area.)Review of the resident's nursing progress note, dated 04/16/26, showed resident continued to be confused per baseline during a post fall neurological assessment. (Staff did not document an assessment of the colostomy area.)Review of the resident's weekly skin observation, dated 04/16/26, showed no new skin issues. (Staff did not document regarding the colostomy area.)Review of the resident's nursing progress note, dated 04/17/26, showed resident alert and oriented with some forgetfulness. Resident had a colostomy present. (Staff did not document an assessment of the colostomy area.)Review of the resident's nursing progress note, dated 04/24/26, showed the resident was usually alert and oriented. The resident had a colostomy and provided care independently. (Staff did not document an assessment of the colostomy area.)Review of the resident's care plan, revised 04/29/26, showed staff added the resident had a self-care performance deficit related to limited mobility and required some staff assistance.Review of resident electronic medical record for April 2026 showed staff did not document an assessment of the colostomy site.During an interview on 04/29/26, at 10:30 A.M., the resident said he/she took care of the colostomy and changed the bag. The staff would help if he/she asked. During an interview on 04/29/26, at 12:02 P.M., CMT B said the resident cared for his/her own colostomy. The CNA's check it every shift to make sure it's good. During an interview on 04/29/26, at 2:30 P.M., the ADON said the resident cared for his/her own ostomy site. He/she would ask the nurse if assistance was needed with it. The resident was on hospice, and the hospice nurse should be assessing the ostomy site.During an interview on 04/29/26, at 3:15 P.M., RN F said the resident cared for his/her own ostomy. The staff provide the supplies, and he/she takes care of it.During an interview on 04/29/26, at 3:20 P.M., LPN G said the resident tried to change his/her own ostomy. The nurse had helped at times with the colostomy. He/she thought the resident would report any changes to the ostomy site to the nurse.During an interview on 04/29/26, at 3:40 P.M., the DON said the resident asked the nurse for scissors and supplies when it was time to change the colostomy. Nurses should be assessing the site during the weekly skin assessment. He/she did not know how the nurse could observe the site if the colostomy bag was intact during the weekly skin assessment. 3. During an interview on 04/29/26, at 12:02 P.M., CMT B said CNAs were responsible for changing the colostomy bags but did not document the change.During an interview on 04/29/26, at 12:10 P.M., LPN C said the CNAs were responsible for changing a colostomy bag and the nurses change the wafer. The nurse should document completed ostomy care in the medical record.During an interview on 04/29/26, at 12:48 P.M., LPN D said the nurse should assess the stoma of an ostomy resident every shift. The residents should have orders to change the wafer every three days. The CNAs are responsible for changing the ostomy bag and the nurses change the wafers. The nurse should document an assessment and change of an ostomy wafer. During an interview on 04/29/26, at 2:10 P.M., CNA E said CNA's change the residents ostomy bags and the nurses change the wafer. He/she usually changed bags once per shift. During an interview on 04/29/26, at 2:30 P.M., the ADON said there should be orders for assessment of an ostomy site and to change the wafer every three days. The ostomy bag should be changed at least every three days with the wafer change or if it is excessively dirty. Nurses should document the change of the resident wafer in the TAR. During an interview on 04/29/26, at 3:15 P.M., RN F said he/she was unsure how often ostomy wafers and bags should be changed. He/she thought they should be changed once a month and as needed. The ostomy site should be monitored, and assessments should be documented. He/she did not think an order was needed to assess the ostomy site. The assessment of the ostomy should be documented monthly in a progress note or the monthly nursing assessment. During an interview on 04/29/26, at 3:20 P.M., LPN G said nurses are responsible for changing the ostomy wafer and the aides change the ostomy bag. Colostomy orders should have a routine and an as needed order. The nurse should assess the colostomy site. During an interview on 04/29/26, at 3:30 P.M., LPN H said a colostomy site should be monitored daily or upon a resident complaint.During an interview on 04/29/26, at 3:40 P.M., the DON said the colostomy wafer should be changed every three days and as needed. The aides changed the colostomy bags, and the nurse is responsible for the changing of the wafer. There should be a physician order in the medical record. The nurse should assess the stoma site, surrounding skin, and the stoma. The nurse should document in the TAR when the colostomy is changed. An assessment of the site should be documented upon change of wafer or for a complaint. The order should include a note to assess the site when the colostomy is changed. Complaint # 2968998

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough weekly skin assessments and failed care plan related to skin for three residents (Resident #3, Resident #2, and Resident #4) and when staff applied treatment to skin conditions without physician's orders for two residents (Resident #3 and #4). A sample of six residents were reviewed in a facility with a census of 111. Review of the facility's policy titled Skin Assessment, dated 2024, showed the following:-It is the policy to perform a full body skin assessment as part of the systematic approach to pressure injury prevention and management;-A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse (RN) upon admission/re-admission, daily for three days, 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 include date and time of the assessment, name and position title, observations (skin conditions, how the resident tolerated the procedure), the type of wound, describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain, if resident refused the assessment and why, and information as indicated or appropriate. 1. Review of Resident #3's face sheet showed the following:-admission date of 04/25/25;-Diagnoses included Alzheimer's disease, heart failure, and major depressive disorder. Review of resident's current Physician's Order Sheet (POS) showed an order, dated 05/15/25, for staff to apply Eucerin moisturizer to face twice daily for facial rash. Review of the resident's care plan, revised 07/25/25, showed the following:-The resident has potential for skin breakdown for skin fragility;-Staff to conduct a skin audit per schedule. (Staff did not care plan regarding a facial rash) Review of the resident's physician progress note imported 08/01/25, at 6:13 A.M., for service date of 07/30/25, showed the physician documented the following:-The resident seen for follow-up of lower extremity cellulitis (infection) and edema (swelling). Diagnosis of cellulitis and atopic dermatitis;-Chronic ulcerations to lower extremities;-Treatment plan included cellulitis, bilateral lower extremities-symptomatically resolved;-Eczematous dermatitis-rash resolved;-Continue Eucerin as needed. Review of resident's current POS showed an order, dated 08/04/25, for staff to conduct weekly skin audit/ Staff to chart a zero for no new skin issues and chart a number one for new skin issues and follow up in nurses' notes. Review of the resident's progress notes and Treatment Administration Record (TAR), dated 08/04/25 through 09/06/25, showed staff did not complete a weekly skin audit with a zero or number one for the resident. Review of the resident's skin assessment on 9/07/25, at 11:50 P.M., showed Licensed Practical Nurse (LPN) E/Wound Nurse documented the resident noted to have 2 plus pitting edema (moderate level of swelling) to bilateral lower extremities. Additionally, patchy, red, raised areas observed on the medial (inner) aspects of his/her bilateral thighs. The resident has a history of cellulitis. Charge nurse notified the primary care physician regarding current skin condition and assessment findings. Review of the resident's current POS showed an order, dated 09/08/25 with an end date of 09/10/25, for cefdinir (antibiotic) 300 mg capsule twice a day for local infection of the skin and subcutaneous tissue. Review of the resident's nurse's note dated 09/08/25, at 2:21 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic charting with no signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse's note dated 09/08/25, at 4:03 P.M. showed LPN E/Wound Nurse documented the resident had two episodes of cellulitis related to bilateral lower extremities. Review of the resident's nurse's note dated 09/08/25, at 4:17 P.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotics. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse's note dated 09/09/25, at 3:22 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic charting with no signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse's note dated 09/09/25, at 1:22 P.M. showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotics, with no signs or symptoms of adverse reactions such as a rash. The resident has some redness and plus 3 non pitting edema (significant swelling) noted to lower left extremities Review of the resident's nurse's note dated 09/10/25, at 5:53 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotics. The resident has non pitting edema noted to LLE. Review of the resident's current POS showed an order, dated 09/10/25 with an end date of 09/17/25, for amoxicillin (antibiotic) one tablet twice a day for local infection of the skin and subcutaneous tissue. Review of the resident's nurse's note dated 09/11/25, at 2:10 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotics. The resident's LLE was warm to touch and edematous. Review of the resident's nurse's note dated 09/12/25, at 2:21 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic charting with no signs or symptoms of adverse reactions such as a rash. The resident's left leg was elevated with redness and swelling noted. Review of the resident's physician note imported 09/12/25, at 9:26 A.M., for a service date of 09/10/25, showed the physician documented facility staff reported increased edema and redness to the resident's left lower extremity. Review of the resident's nurse's note dated 09/13/25, at 2:40 A.M showed a nurse documented antibiotic charting for cellulitis. The resident continuec antibiotic charting with no signs or symptoms of adverse reactions such as a rash. Review of the resident's quarterly MDS assessment, dated 09/13/25, showed the following:-Severely impaired cognitive skills;-At risk for pressure ulcers;-Open lesions other than ulcer, rashes, cuts not marked. Review of the resident's nurse's note dated 09/14/25 ,at 11:05 P.M. showed a nurse documented the resident continued on antibiotic therapy for cellulitis to left lower extremities. The resident's leg remained swollen. Review of the resident's nurse's note dated 09/15/25, at 1:48 P.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic with no signs or symptoms of adverse reactions reported. Review of the resident's nurse's note dated 09/16/25, at 2:04 P.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic with no signs or symptoms of adverse reactions reported. Review of the resident's progress notes and TAR, dated 09/08/25 through 09/16/25, showed staff did not complete a weekly skin audit with a zero or number one for the resident. Staff did not document a full assessment/description of the resident's skin. Review of the resident's nurse's note dated 09/17/25, at 3:46 A.M., showed a nurse documented antibiotic charting for cellulitis. The resident continued antibiotic charting with no signs or symptoms of adverse reactions such as a rash. Review of the wound nurse note dated 09/17/25, at 9:20 A.M., showed LPN E/Wound Nurse documented the resident's wound site was fully healed upon assessment. The resident's skin was intact with complete epithelialization (new tissue) over the previous wound area. The resident's skin appeared healthy with no signs of active infection, despite treatment for cellulitis. Review of the resident's physician progress note imported 09/18/25, at 7:00 A.M., for service date of 09/17/25 showed the physician documented follow up visit for the resident's left lower extremity cellulitis. Facility nursing staff report swelling to the resident's left leg as resolved and redness much improved. Review of the resident's progress notes and treatment administration record, dated 09/18/25 through 09/29/25, showed staff did not complete a weekly skin audit with a zero or the number one for the resident. Review of the resident's nurse's note dated 09/21/25, at 12:36 A.M. showed a nurse documented the resident continued antibiotic therapy for left lower extremity cellulitis. No signs or symptoms of adverse reaction. Review of the wound nurse note dated 09/30/25, at 11:19 A.M. showed LPN E/Wound Nurse documented new report of skin issue to bilateral lower extremities. Resident noted to have two plus pitting edema to bilateral lower extremities, with an open area related to edema and fluid accumulation. It is noted that the edema is not a new concern. Medical Director to refer the resident to cardiology for further assessment and treatment. (The LPN did not document a full assessment and description of the area.) Review of the resident's progress note dated 10/09/25, at 8:32 P.M. showed a nurse documented the resident had no new open areas or skin issues. Review of the resident's progress note dated 10/11/25, at 5:22 A.M. showed a nurse documented the resident had no new open areas or skin issues. Review of the resident's progress note dated 10/13/25, at 5:15 P.M. showed a nurse documented the resident had no new open areas or skin issues. Review of the resident's progress note dated 10/15/25, at 5:06 P.M. showed a nurse documented the resident had no new open areas or skin issues. Review of the resident's nurses note dated 10/18/25, at 6:32 A.M. showed a nurse documented the resident's left arm swollen with pitting plus two edema. Staff notified the physician and awaited instructions. (Staff did not document a full assessment or description.) Review of the current POS showed an order, dated 10/19/25 with end date of 10/25/25, for cephalexin capsule 500 mg one tablet three times a day for cellulitis of left lower limb. Review of the resident's nurse's note dated 10/20/25, at 1:51 P.M., showed a nurse documented the resident continued antibiotic related to cellulitis of his/her left arm. No signs or symptoms of adverse reaction reported. Review of the resident's nurse's note dated 10/21/25, at 2:23 A.M., showed a nurse documented antibiotic charting for left arm cellulitis. The resident continued antibiotic for his/her left arm cellulitis. No signs or symptoms of adverse reactions such as a rash. The resident's left arm swelling and redness improved. Review of the resident's nurse's note dated 10/22/25, at 12:39 A.M., showed a nurse documented antibiotic charting for left arm cellulitis. The resident continued on antibiotics. Review of the resident's nurse's note dated 10/22/25, at 2:01 P.M. showed a nurse documented the resident continues on an antibiotic related to cellulitis of his/her left arm. No signs or symptoms of adverse reactions reported. Review of the resident's nurse's note dated 10/22/25, at 4:11 P.M., showed the former Director of Nursing (DON) documented the physician rounded on this day. New orders received to apply Eucerin topically to left upper extremity two times per day for eczematous dermatitis. Review of resident's current POS showed an order, dated 10/22/25, for staff to apply Eucerin cream twice a day, for rash and other nonspecific skin eruption. Review of the resident's nurse's note dated 10/23/25, at 1:36 A.M,. showed a nurse documented antibiotic charting for left arm cellulitis. The resident continued antibiotics. The resident's left arm is reddened in color with no drainage noted. Review of the resident's nurse's note dated 10/23/25, at 11:17 A.M., showed a nurse documented the resident continued antibiotic for signs and symptoms of cellulitis to his/her left arm. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse's note dated 10/24/25, at 12:09 P.M., showed a nurse documented the resident continued antibiotic for signs and symptoms of cellulitis to the left arm. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse note dated 10/25/25, at 1:37 A.M., showed a nurse documented the resident on an antibiotic for left arm cellulitis with no signs or symptoms of adverse reactions such as a rash. Review of the resident's nurses note dated 10/26/25, at 9:57 A.M., showed a nurse documented the resident completed an antibiotic for cellulitis to his/her left arm, no signs of a rash. the resident's left arm had improved. Review of the resident's nurses note dated 10/28/25, at 1:12 A.M., showed a nurse documented the resident was on an antibiotic for his/her left arm cellulitis. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurses dated 10/29/25, at 1:24 A.M., showed a nurse documented antibiotic charting for left arm cellulitis. No signs or symptoms of adverse reactions such as a rash. Review of the resident's progress notes and TAR, dated 10/18/25 through 10/30/25, showed staff did not complete a weekly skin audit or document a zero or the number one for the resident. Staff did not document a full assessment and description of the resident's skin. Review of the wound nurse note dated 10/31/25, at 8:52 A.M., showed LPN E/wound nurse documented the resident's bilateral lower extremities had declined significantly. Review of the resident's current POS showed an order, dated 11/01/25 with an end date of 11/06/25, for cephalexin capsule 500 mg three times a day for local infection of the skin and subcutaneous tissue. Review of the resident's nurse's note dated 11/02/25, at 12:55 A.M., showed a nurse documented the resident on an antibiotic for lower extremity cellulitis. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurse's note dated 11/02/25, at 6:51 P.M., showed a nurse documented the resident continued antibiotic charting for cellulitis to the lower extremities. Review of the resident's nurses note dated 11/03/25, at 11:26 A.M. showed a nurse documented the resident continued an antibiotic related to lower extremity cellulitis. No signs or symptoms of adverse reaction noted such as a rash. Review of the resident's nurses note dated 11/03/25, at 12:42 A.M. showed a nurse documented the resident on an antibiotic for lower extremity cellulitis. No signs or symptoms of adverse reactions such as a rash. Review of the resident's nurses note dated 11/03/25, at 5:24 P.M., showed LPN E/Wound Nurse documented the resident had itching to his/her lower extremities and did not keep the dressings on and caused the ulcerations to bleed. He/she notified the primary care physician with new orders received for Claritin (antihistamine) 10 mg every day. Review of the resident's nurses note dated 11/04/25, at 2:35 A.M. showed a nurse documented the resident continued an antibiotic for lower extremity cellulitis. The resident had no signs or symptoms of adverse reaction such as a rash. Review of the resident's nurses' notes dated 11/04/25, at 7:58 P.M., showed a nurse documented the resident continued antibiotic charting for cellulitis to the lower legs. Review of the resident's nurses' notes dated 11/05/25, at 2:57 A.M., showed a nurse documented the resident continued antibiotic therapy for cellulitis to his/her lower extremities. The resident had Tubi grips (a multi-purpose, elasticated tubular bandage providing continuous support for strains, sprains, swelling, and soft tissue injuries) in place to his/her left leg with no edema. The resident's skin appeared to have been scratched and bled. Review of the resident's nurses' notes dated 11/05/25, at 1:34 P.M. showed a nurse documented the resident continued Keflex (cephalexin) three time a day for lower extremity cellulitis. The nurse documented the resident had no signs or symptoms of adverse reactions noted to treatment. The resident had no abnormal rash or hives. Review of the resident's nurses note dated 11/05/25, at 5:19 P.M. showed LPN E/Wound Nurse documented the resident continued to present with a rash that appeared generalized and scattered throughout the trunk, bilateral upper extremities, and proximal bilateral lower extremities. Characteristics of the rash included red/maroon, railed papular clusters. Surrounding skin noted to be dry. Associated symptoms include itching, no drainage, heat or odor observed. Resident started on Claritin 10 mg daily for itching on 11/03/25. Staff changed the resident's shower soap, and the primary care physician is aware. Wound care physician to evaluate the rash on 11/10/25. Observation on 11/06/25, at 10:47 A.M., showed the resident was scratching him/herself behind his/her left shoulder. The resident had a red rash on his/her stomach, and it was reddened in the middle of his/her back and on the back of the left and right arm. The resident wore a long-sleeved shirt and long pants. During an interview on 11/06/25 at 10:47 A.M., Nurse Aide (NA) G said the resident also had a rash on his/her thighs and behind the knees. They put antifungal cream on the rash. All residents admitted to the facility usually admitted to the 100 hall before they might place them on the unit since they have to know where to place a resident. He/she thought the resident had a rash on the back of his/her right arm when he/she came to live on the unit. During interview on 11/06/25, at 10:41 A.M., NA F who worked on the memory care unit 500 hall, said the following:-They think the rash all over his/her back, both arms with the left arm worse, slight rash on the right arm, both legs and spots on his/her stomach was a fungus;-Both NA F and NA G put antifungal cream on the resident's rash which was itching on his/her left shoulder;-They keep the antifungal cream there on the unit;-He/she thought the resident had a rash on the back of his/her arm when he/she moved there on the unit. Observation on 11/06/25, at 10:47 A.M. showed a tube of 1% Clotrimazole Cream Antifungal cream in the resident's room drawer. Review of the resident's physician's orders dated 08/01/25 to 11/06/25, showed staff did not document an order for an antifungal cream to put on the resident's skin. During an interview on 11/06/25, at 2:38 P.M., LPN E/Wound Nurse said today (11/06/25) the resident had a clustered type of rash on his/her thigh. Staff treated the resident for itching. The resident's weekly skin assessment should had shown a rash. During an interview on 11/06/25, at 4:05 P.M. the MDS/Care Plan Coordinator said she was not aware of the resident's rash, and it should be on the resident's care plan. 2. Review of Resident #2's face sheet showed the following:-admission date of 06/06/25;-Diagnoses included orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, high blood sugar, congestive heart failure, high blood pressure, cellulitis (bacterial skin infection that causes red, swollen, warm, and painful skin that spreads quickly) of face. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitive skills intact;-At risk for pressure ulcers;-Open lesions other than ulcer, rashes, cuts not marked. Review of the resident's care plan, edited 9/10/25, showed the following:-Staff may apply moisture barrier to skin and provide incontinence care after each incontinent episode.(Staff did not care plan regarding monitoring the resident's skin for pressure ulcers, skin rashes, and cuts.) Review of the resident's progress notes, dated 09/24/25 to 10/01/25, showed the staff were to document antibiotic charting for cellulitis of the resident's nose. Review of the resident's progress notes showed the following:-On 9/24/25, the resident was on antibiotic charting for cellulitis to nose. There was no adverse effect such as rash noted;-On 9/25/25, showed the physician saw the resident and gave new orders for Rocephin (antibiotic for bacterial infection)1 gram (gm) Intramuscular (IM) for five days and doxycycline (antibiotic used for skin infections)100 milligrams (mg) for 10 days for cellulitis of the face; -On 9/26/25, showed the resident continued antibiotic with no signs/symptoms of adverse reactions. No reported rash. The nose was red and swollen;-On 9/27/25, showed the resident continued antibiotic with no signs/symptoms of adverse reactions. No reported rash. The nose was red and swollen;-On 9/30/25, showed the resident continued antibiotic with no signs/symptoms of adverse reactions. No reported rash. The nose was slightly red and no swelling;-On 10/01/25, showed the resident continued antibiotic with no signs/symptoms of adverse reactions. No reported rash. The nose was slightly red and no swelling:-On 10/03/25, showed the resident continued antibiotic with no signs/symptoms of adverse reactions. No reported rash. The nose was much normal in appearance, mild swelling and no redness;-On 10/04/25, showed the resident continued doxycycline 100mg twice a day until 10/6/25 for cellulitis to nose. Nose normal in appearance. No adverse reaction notes to antibiotic therapy, no rash. Review of the resident's progress note, dated 10/09/25, showed the physician saw the resident and gave new orders for prednisone (steroid) 20 mg every day for seven days and then 10mg every day for 7 days and then to stop. Review of the resident's Medications Administration History, dated 10/10/25 to10/16/25, showed a physician's order for prednisone tablet 20mg to administer one tablet for seven days, then stop for contact dermatitis (an inflamed skin reaction that causes an itchy, red, and sometimes bumpy or blistered rash when the skin touched an irritant or allergen). Staff administered the prednisone to the resident from 10/10/25 to 10/16/25. Review of the resident's Medications Administration History, dated 10/17/25 to 10/23/25, showed a physician's order for prednisone tablet 10mg to administer one tablet for seven days, then stop for contact dermatitis. Staff administered the prednisone from 10/17/25 to 10/23/25. Review of the resident's POS, dated 08/01/25 to 11/06/25, showed staff were to do a weekly skin audit and to record 0 for no new skin problems, 1 for new skin problems and follow up in the notes once a day every Saturday. Review of the resident's medical record showed there were no notes regarding a weekly skin audit for 08/01/25 to 11/05/25. Review of the resident's progress notes, dated 10/9/25 to 11/4/25, showed staff did not document any issues with the resident's skin for a non-specific rash. Review of the resident's progress note, dated 11/05/25, showed the wound care nurse documented the resident continued to present with a persistent rash. Multiple interventions had been attempted without noted improvement. The physician was aware of the ongoing issue. The wound care physician visit was scheduled for 11/10/25 and they were to evaluate the rash at that time. Observation on 11/05/25, at 11:45 A.M., showed the resident sat in the wheelchair in his/her room. The bedsheets had spots of blood. There were dark scabs and pimple-like red sores on the resident's outer arms. The resident began scratching him/herself at times on arms and stomach.During interview on 11/05/25, at 11:45 A.M., the resident said the following:-He/she had a rash on his/her upper back, thighs, arms, groin, stomach, and buttocks;-The physician had looked at it and gave him/her steroid medication and said it was a form of dermatitis;-He/she had this rash for the past three weeks. He/she had taken a shower and the rash came back. He/she thinks the rash is bacterial and activated by heat;-Staff had washed his/her bed sheets together with other residents' bed sheets and linens. He/she did not want his/her bed sheets washed frequently;-When he/she was on the 100 hall, he/she got a rash for three days from taking penicillin (an antibiotic). He/she used Benadryl (antihistamine for itching) cream and did take a Benadryl pill at night;-He/she was to see the physician tomorrow. He/she said his/her belly really itches and was scratching him/herself. During interview on 11/06/25, at 2:10 P.M., the resident's physician said the following:-The rash was scabies since it was all over and looked like the classic scabies;-Before, the rash was more diffuse but now it looked like scabies. It looked better but it was more spotted;-The resident had a sore in his/her nose and it got worse and turned into cellulitis in his/her face. At the time, the resident had an all over rash and thought he/she had contact dermatitis from possible laundry soap, or bath soap and they did change the soaps;-He put the resident on steroids for this;-Staff did not call him/her about the change in the rash until today, but had put the resident on Prednisone for seven days in October;-He would have liked to have been called when the resident finished the Prednisone;-He would prescribe Permethrin and Invermectin now for the resident;-Scabies broke out on the 500 hall unit and they did treat all the residents on the hall at one time;-They would isolate Resident #2 for at least a week and possibly treat the roommate;-Sometimes the test to scrape for scabies is sometimes negative result. They did try to get someone to come to the facility and do the scraping, but they did not come. 3. Review of Resident #4's face sheet showed the following:-admission date of 01/28/25;-Diagnoses included dementia without behavioral disturbance, local infection of the skin and subcutaneous tissue, pruritus (itchy skin), rash and other nonspecific skin eruption, dermatitis. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severely impaired cognition;-At risk for pressure ulcers;-Open lesions other than ulcer, rashes, cuts not marked. Review of the resident's care plan, dated 02/07/25 and edited 10/27/25, showed the following:-Potential for skin breakdown, skin tears, bruises related to self-ambulatory, confusion/forgetfulness, and skin fragility;-Approaches included inspect skin for changes daily. Review of the resident's physician's orders, dated 07/02/25 to 08/13/25, showed an order for Ivermectin (prescription medication used to treat scabies ) 3 mg three tablets (9 mg) by mouth once a day on Wednesday for dermatitis. Review of the resident's progress notes dated 08/06/25, showed LPN E/Wound Nurse, documented that nursing staff reported the resident had a rash. The resident had been previously evaluated by the physician and had received multiple treatments for the rash. This was not a new occurrence, and the rash had already been addressed with appropriate interventions. The resident was treated with oral Ivermectin and topical permethrin. The physician followed up with resident on 07/29/25 and the resident reported to the physician that he/she did not have any scratching since treatment, and resolved out rash. The condition will continue to be monitored for any changes or worsening condition. Review of the resident's progress notes, for service date 08/20/25, showed the following:-Chief complaint of rash;-The resident was seen today at request of facility staff for recurrence of diffuse rash with itching. Patient reports itching and redness to arms, legs, chest, and back. He/she resides on the memory care unit. No new lotions, soaps or medications reported;-Skin: diffuse popular erythematous rash;-Rash-suspect recurrence of scabies. Ivermectin PO (by mouth) now and Permethrin topically. Will repeat in one week. Review of the resident's physician's orders, dated 08/21/25, showed an order of Ivermectin 3 mg, three tablets (9mg) by mouth, One Time Dose. Review of the resident's physician's orders, dated 08/21/25 to 08/29/25, showed an order of Permethrin (medicated skin cream for scabies) cream 5%, thin layer, topical, One Dose, once a day on Thursday. Review of the resident's Medications Administration History, dated 08/01/25 to 08/31/25, showed staff administered the permethrin medicated cream on 08/21/25. Review of the resident's Medications Administration History, dated 08/01/25 to 08/31/25, showed staff did not administer the permethrin cream on 08/28/25 because the drug/item was unavailable. Review of the resident's physician's orders, dated 08/23/25 to 09/02/25, showed an order for Contact Isolation precautions every shift. Review of the resident's progress notes showed the following:-On 08/23/25, staff documented there was no new open areas or skin issues;-On 8/24/25, staff documented Infection Control: Isolation type Contact, Resident continued contact isolation due to rash;-On 08/26/25, staff documented the resident continued contact isolation. Resident compliant with isolation. Review of the resident's progress note, for 08/27/25 service date, showed the Nurse Practitioner (NP) documented the following:-Chief Complaint: Follow-up of rash;-Patient was seen today for follow-up of rash. Patient reports itching and redness to arms, leg, chest, and back much improved;-Skin: resolving diffuse popular erythematous rash;-Treatment Plan: Rash-symptomatically improved. Continue Permethrin topically as ordered. Review of the resident's progress notes, dated 08/30/25, showed staff documented the resident continues on contact isolation. Review of the resident's progress notes, dated 10/07/25 for service date of 10/1/25 with the NP, showed the resident's skin was normal. Review of the resident's physician order report, dated 01/08/25, showed staff were to do a weekly skin audit and to record 0 for no new skin problems, 1 for new skin problems and follow up in the notes once a day on Wednesday. Review of the resident's Medication Administration Record and the Treatment Administration Record, dated 08/01/25 to 11/05/25, showed staff did not document regarding a skin audit of the resident. Review of the resident's progress notes from 08/27/25 through 11/04/25 showed no documentation of the resident's skin and/or the rash. Review of the resident's progress note, dated 11/05/25, showed LPN E/Wound Nurse showed the resident continued to present with a persistent rash. Multiple interventions have been attempted without noted improvement. The physician was aware of the ongoing issue. Confirmation received for the wound care physician visit scheduled for 11/10/25. The resident to be evaluated for rash at that time. During interview on 11/06/25, at 10:41 A.M., Nurse Aide (NA) F who worked on the memory care unit 500 hall, said the following:-They monitor the resident's skin when they give them a shower, change their clothes, provide incontinence care, and take them to the restroom;-They report anything on the skin such as bruising and rashes to the nurse at the nursing desk;-The resident had a rash all over his/her body;-They put an antifungal cream and extra lotion on the resident's skin, and it was better; -The resident was itching and mainly complaine

Based on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving one resident (Resident #1) and failed to report the allegation in a timely fashion. The facility census was 110.Review of the facility's policy titled Abuse and Neglect, revised 04/16/24, showed the following:-The facility is committed to facilitate efforts to protect residents from abuse neglect, misappropriation of residents' property and exploitation;-In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of residence property, are reported immediately, but not later than two hours after the allegations is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegations do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency and adult protective services where state law provides for jurisdiction and long term care facilities in accordance with state law through established procedures. 1. Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 10/21/22;-Diagnoses included acute kidney failure, heart failure, anxiety disorder and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/20/25, showed the following:-Cognitive skills intact; -The resident had no behaviors. Review of the resident's care plan, revised 06/13/25, showed the following:-The resident had potential for altered mood state/psychosocial well-being related to depression and anxiety, the resident has a history of abuse;-Encourage and allow the resident to voice feelings and concerns;-Observe for changes in mood;-The resident required behavior management related to fixation on health, misconstrued truth, delusions, and hallucinations. Review of the resident's progress note dated 11/02/25, at 5:37 A.M., showed Licensed Practical Nurse (LPN) A documented the resident was confused and anxious. The resident stated he/she was dying and someone came into his/her room to rape him/her. LPN A talked with the resident to reassure him/her and the resident calmed. (The LPN did not document notifications related to the allegation of possible abuse.) Review of the resident's care plan, dated 11/02/25, showed staff added the resident had a statement of someone coming into his/her room with unwanted sexual intent. Review of the resident's progress note dated 11/03/25, at 2:08 P.M., showed a nurse documented he/she noted the previous shift's nurse note involved possible abuse at approximately 1:50 P.M., The nurse notified the Director of Nursing (DON) immediately.Review of the facility's abuse investigation showed staff initiated the investigation on 11/03/25, at 2:00 P.M. Review of the resident's progress note dated 11/03/25, at 3:19 P.M. showed the former Director of Nursing (DON) documented she and the Administrator met with the resident regarding the previous note documented by the night shift nurse. The resident denied making the reported statement and was adamant that no one had touched or harmed him/her. The resident stated he/she felt safe at the facility. The resident verbalized understanding of how to report any issues or concerns if needed. The resident has a known history of delusions and hallucinations. Staff to continue to monitor and follow the current plan of care. Review of DHSS records showed the facility reported the allegation of possible abuse on 11/03/25, at 4:15 P.M. During an interview on 11/06/25, at 8:00 A.M., LPN A said the following:-Staff should report to the supervisor and the on-call nurse immediately of an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse; -Nurses should notify the DON or on-call nurse with an allegation of abuse;-He/she assessed the resident who said he/she did not remember making the allegation of abuse statement;-He/she did not report the allegation of abuse. During an interview on 11/05/25, at 10:50 A.M. Certified Nurse Aide (CNA) B said the following:-Staff should report to the charge nurse immediately an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse. During an interview on 11/05/25, at 11:15 A.M., the former DON said the following:-Staff should report to their supervisor immediately of an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse;-Staff wrote LPN A up for not reporting the allegation of abuse;-LPN A said he/she did not notify her because the resident did not name anyone, and the resident had not been alone. During an interview on 11/06/25, at 11:45 A.M., the Administrator said the following:-Types of abuse staff should monitor include physical, mental, and sexual;-Staff should protect the resident first and report to the supervisor, her or the DON immediately of an allegation of abuse; -LPN A should had reported the allegation of abuse immediately to his/her supervisor;-She would consider the resident's statement an allegation of abuse;-The facility should report to the state within two hours of an allegation of abuse. Complaint #2659914

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to air dry dishes before stacking; failed to wear hair restraints appropriately; failed to maintain a proper air gap to prevent possible back flow; failed to maintain the ice machine and scoop; and failed to maintain food contact surfaces and nonfood contact surfaces, including the stove/oven, in a manner that would prevent possible contamination of food. These concerns had the potential of affecting any of the residents. The facility census was 111. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Staff to wash, scrub, rinse, and sanitize equipment/utensils. Staff to allow items to air dry. -Remove first rack to drain board when wash and rinse cycle is complete and allow dishes to air dry; Observation on 03/24/25, beginning approximately 10:00 A.M., of the kitchen area showed the following items wet nesting (trapping water between them and preventing the ability for items to air dry): -Four small, clear plastic bowls; -Sixty-two plastic plate covers; -Ninety-four plastic bowls; -One hundred and ten plastic trays; -One hundred and thirteen white ceramic plates. Observation on 03/28/25, at approximately 10:50 A.M., showed the following items wet nesting: -Fifty-two plastic trays; -Ninety-four ceramic plates. During an interview on 03/28/25, at approximately 11:20 P.M., Dishwasher F said the following: -He/she waits as long as he/she can before stacking dishes to make sure they are dry; -He/she was trained to dry the dishes completely before putting them away; -Sometimes staff run short on time and get in a hurry. During an interview on 03/28/25, at approximately 1:35 P.M., Dietary Aide (DA) G said the following: -The dishes can never be stacked wet because it could cause bacteria to grow; -Dishes are only to be put away when they are completely dry; -He/she thinks sometimes the dishwashers get in a hurry. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said dishes need to be air dried before putting them away or it could cause growth or contamination. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -Staff should always let all the dishes air dry before putting them away; -Dishes are not to be left wet and stacked. During an interview on 03/28/25, at approximately 1:10 P.M., [NAME] J said the following: -Dishes have to be dry before being put away; -Staff should not wet-nest or use a cloth to dry dishes. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said dishes cannot be stacked while still wet. During an interview on 03/28/25, at approximately 2:50 P.M., the Dietary Manager (DM) said kitchen staff knows dishes cannot be put away while wet due to possible bacteria growth. During an interview on 03/28/25, at approximately 3:45 P.M., the Director of Nursing (DON) said dishes cannot be put away while still wet. Dishes have to be completely dry because of the potential of bacteria to grow. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said kitchen staff are aware that dishes are to be air dried before being put away. Staff have been trained on this and should be following the training. 2. Review of the 2022 Food Code, issued by the FDA, showed the following information: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. -Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. Review of the facility policy titled Use of Gloves and Hairnets, dated 08/15/09, showed staff to wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. Observation on 03/26/25, at approximately 12:00 P.M., showed the following: -The activity director walked into the kitchen, with no hairnet; -His/her hair was approximately two-three inches below the shoulders in length; -He/she grabbed a glass, walked over to the ice machine, scooped out ice, and left the kitchen. Observation on 03/27/25, at approximately 12:05 P.M., showed the following: -Cook L walked in and passed through the kitchen wearing no hairnet; -His/her hair was flowing and moving as he/she walked; -He/she went into the back of the kitchen and into a bathroom to grab a hair net; -He/she walked into the middle of the kitchen and while reading the bulletin board put on the hair net. Observation on 03/27/25, at approximately 12:10 P.M., showed hairnets located in the staff bathroom, that is in the back of the kitchen. Staff did not hairnets readily available at the kitchen entrances. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -Hairnets were kept in the bathroom; -Everyone should have a hairnet on before coming into the kitchen. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -Everyone has to have on a hairnet; -Anyone coming into the kitchen should have a hairnet on; -The hairnets need to be up by the front door. During an interview on 03/28/25, at approximately 2:15 P.M., DA K said he/she will clock-in, which is in another part of the building, and then he/she comes through the kitchen, and the hairnets are kept in the bathroom, During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -He/she said they always have a hairnet on while in the kitchen; -When asked about seeing him/her during an earlier observation, he/she said they all have to come through the kitchen to grab a hairnet; -The box of hairnets are kept in the bathroom. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -Staff should have hairnets on when cooking or preparing food or just in the kitchen; -He/she expected all staff to always have on their hairnets. During an interview on 03/28/25, at approximately 3:45 P.M., the DON, said the following: -He/she has not seen where the hairnets are kept, but thinks they are somewhere in the back of the kitchen; -He/she will ask for a hairnet if needed; -No one should walk through the kitchen to get a hairnet. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said no one should go into the kitchen without a hairnet on. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said hairnets were mandatory prior to entering the kitchen. He/she expected any staff, from any department, to put on a hair net before they go into the kitchen. 3. Review of the 2022 Food Code, issued by the FDA, showed the following information: -An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch; -Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by back flow. Review of the facility policy titled Ice Chest and Ice Machines, dated 11/14/16, showed staff to install proper air gaps where the condensate lines meet the waste lines. Observation on 03/28/25, at approximately 10:50 A.M., showed the two-door refrigerator's drainpipe was laying directly on the floor drain. There was no visible air gap between the drainpipe and floor drain. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -The drain hose from under the refrigerator used to be up higher and not actually on the drain, itself; -He/she was not sure what happened and why it was no longer up, off the drain. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she was not aware of any air gap requirement. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said they knew there should be an air gap present. He/she was unsure what the size of air gap needed to be. During an interview on 03/28/25, at approximately 2:50 P.M., DM said he/she did not know about the drainpipe air gaps. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -He/she did not realize there was an issue with the air gap and would expect the air gap size to meet the requirement. 4. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Wash ice scoops in the dish machine or with a detergent solution; -Rinse with clear water, followed by immersion in 100 parts per million (ppm) chlorine solution for sanitation; -If any of the components are noted to have a lime and/or calcium build-up, soak in de-lime solution until no scale is observed; -After de-liming, repeat the machine washing, or the manual wash, rinse and sanitizing steps; -Ice scoops should be kept in a closed/covered container on or next to the ice bin and should be cleaned daily. Observation on 03/24/25, beginning approximately 10:00 A.M., showed the following: -The ice machine had a thick build-up of calcium or lime substance lining the outside rim of the door, around the edges of the inside of the door, and outside ledges and rims of the ice machine; -The removable blue plastic ice scoop bin had approximately 1/2 inch of standing water; -There was a black, slimy substance in the water in the ice scoop bin; -There were no drain holes in the ice scoop container bin to allow the water to escape. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F said the following: -He/she was not sure who cleaned out the ice machine and ice scoop; -He/she will wash the scoop once in a while. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she was unsure who cleaned the ice machine or the ice scoop bin. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said he/she was unsure who was to clean the ice machine or ice scoop bin. He/she has not cleaned either and did not know how often they should be cleaned. During an interview on 03/28/25, at approximately 2:50 P.M., the DM, said he/she did not realize the ice scoop bin did not have a way for the water to drain. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said he/she would expect staff to keep the ice scoop bin clean and sanitized on a regular schedule. During an interview on 03/28/25, at approximately 4:10 P.M., the |Administrator said it was an issue for water to be trapped in the ice scoop bin. The lime issue has been an ongoing issue. 5. Review of the 2022 Food Code, issued by the FDA, showed the following information: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces; -Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests Review of the facility policy titled, Cleaning Schedules, dated 08/10/18, showed to prevent the spread of bacteria that may cause food borne illnesses the DM should establish the frequency of equipment cleaning and the DM should supervise adherence to the cleaning schedule and inspect the kitchen weekly for cleanliness. Review of the kitchen's cleaning schedule titled, Weekly Kitchen Checklist, undated, showed the following task to be completed: -Clean all freezers and refrigerators, interior and exterior, including floors of walk-ins. -Clean walls: sanitize handles, doorknobs, etc.; -Clean ovens and grate on stove top; -Polish all stainless-steel surfaces. Review of a checklist titled Daily Kitchen Checklist, undated, showed the following: -All dishes, pots, pans and utensils are cleaned and stored properly after each meal and snack; -All work counters are cleaned and sanitized after use; -Can opener is clean and sanitized after each use; -Steam table is clean and sanitized after each use; -Sweep floors after meals and mop daily; -Oven spills are cleaned, and ovens turned off; -Food service employees wear hair restraints; -Clean ice machine exterior; -Clean mixer after each use; -Clean microwave and toaster. Observation of the kitchen, on 03/24/25, beginning at approximately 10:00 A.M., showed the following: -The standing mixer had dried food particles on the outside; -The puree machine had a greasy film on it; -Steam table sides and top prep area were covered in a grease and lint substance; -The bottom shelves of the prep table, to the left of the steam table, were covered in a grease and lint substance; -The toaster oven on counter was covered in a grease and lint substance; -The bottom shelves under counter had a layer of food crumbs and was covered in a grease and lint substance; -The prep area on the back wall was dirty with a grease film; -The can opener had dried food particles on it and was covered with a grease film; -The stand mixer had dried food on it and was covered with a grease film; -The walk-In refrigerator's ceiling, walls, and fan were covered in a growth of a white/silvery substance; -The refrigerator had a soured smell; -The walk-In freezer's ceiling, walls, and fan were covered in a growth of a white/silvery substance. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F, said the following: -He/she thought there was a cleaning schedule; -He/she knew to clean his/her own area; -The DM also came around and cleaned a lot. During an interview on 03/28/25, at approximately 1:35 P.M.,DA G said everyone usually cleans the area where they work. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said the following: -Everyone cleans their own areas; -He/she will clean up any messes he/she makes while cooking; -They all take turns sweeping and mopping. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -He/she believed there was a cleaning list to follow on the wall; -He/she did refer to it, sometimes; -Staff were expected to clean the areas they were working in; -All the other area's are split between staff to clean; -The deep cleaning is done by whoever has time. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said the following: -There was a cleaning schedule that was to be followed; -Kitchen staff were expected to take care of their own areas. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -Staff follow a cleaning schedule which was a check list; -Specific tasks are not assigned to anyone; -Whoever gets to it was supposed to do it; -After doing the task, staff are supposed to initial, but no one does. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -He/she does have a cleaning schedule that staff are expected to follow; -Each staff were to clean their own areas and then they all have additional areas to clean; -He/she expected staff to be following the cleaning schedule. -He/she will be going over each duty with kitchen staff to ensure the cleaning duties are covered. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said the following: -The kitchen should be clean and free of debris; -There was a cleaning schedule that staff should follow; -There should not be any clutter, food, or trash anywhere; -Prep areas should be cleaned and sanitized. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator, said the following: -Staff were expected to follow a cleaning schedule; -He/she expected a cleaning schedule to be posted for all staff to follow; -He/she expected staff to be cleaning all walls, vents, windows, pipes, and all that is attached to the walls; -Everything should be cleaned on a regular schedule; -The walk-ins should be wiped down and cleaned. 6. Review of the facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following for the oven, range, and grill: -Spray with oven cleaner and let stand according to directions; -Wipe off loosened grease and dirt; -Wash and rinse; -Let air dry. Observation on 03/24/25, beginning approximately 10:40 A.M., showed the following: -The top edges of the doors on the stove were covered in a grease and lint substance; -The stoves knobs and just behind the knobs were covered in a grease and lint substance; -The stove's hood (back, top, and sides) were covered in a grease and lint substance; -The electrical components on backside of the stove, coming from the ceiling, were covered in a grease and lint substance; -The two motors, sitting on the backside of the stove, were covered in a grease and lint substance. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said he/she cleaned the area as he/she was working and he/she tried to keep the stove and oven clean. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she tried to clean up as he/she cooked. He/she was not sure who was responsible to deep clean the stove. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -The oven needed to be cleaned following every use; -He/she was unsure of how often the oven or stove top were cleaned; -He/she was not sure who is assigned to clean the oven. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -He/she had a cleaning schedule that staff were expected to follow; -Each staff were to clean their own areas and then they all have additional areas to clean; -He/she expected the cooks to clean the stove, oven, and hood; -He/she expected them to be degreased, as well, on a regular basis, for a deep-clean. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -Staff were expected to follow a cleaning schedule and he/she expected one to be posted for all staff to follow; -All area, including the stove, hood, and oven, were to be cleaned on a daily schedule.

Based on observation, interview, and record review, the facility failed provide a sanitary environment in the kitchen when staff failed to ensure all areas in the kitchen were kept clean. This could have the potential to affect all of the residents. The facility had a census of 111. Review of the 2022 Food Code, issued by the FDA, showed the following information: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests Review of the facility policy titled Cleaning Schedules, dated 08/10/18, showed to prevent the spread of bacteria that may cause food borne illnesses the Dietary Manager (DM) should establish the frequency of equipment cleaning, supervise adherence to the cleaning schedule, and inspect the kitchen weekly for cleanliness. Review of the kitchen cleaning schedule titled Weekly Kitchen Checklist,: undated, showed the following task to be completed: -Clean all freezers and refrigerators, interior and exterior, including floors of walk-ins; -Clean walls: sanitize handles, doorknobs, etc. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Floors: Sweep floor after each meal service; mop using disinfecting detergent solution, as needed, and at least once daily and change mop and water when becomes gray; -Ice Machines: Monthly wash machine, inside and outside, including legs and handle; -Walls and Ceilings: Walls and ceilings should be free of chipped and/or peeling paint. Wash thoroughly at least twice a year. Heavily soiled surfaces should be cleaned frequently and as required. 1. Observation on 03/24/25, beginning at approximately 10:00 A.M., of the kitchen showed the following: -Ceiling vents with grease and lint substance covering the surface; -The wall next to ice machine had a grease and lint substance covering the surface; -The wall behind the steam table had a grease and lint substance covering the surface; -Trim over the doors (entry to kitchen, office, bathroom and dry storage area) had a grease and lint substance covering the surface; -The window pane over the sink was dirty and difficult to see through; -The window sill and wall section just below was covered in a grease and lint substance; -The air conditioner unit and plastic panels holding the air conditioner in, located in the window, was covered in a grease and lint substance covering the surface; -The cabinets front & sides were covered in a grease and lint substance; -The bottom shelves under the counter had a layer of food crumbs and was covered in a grease and lint substance; -The prep area on the back wall had a grease film; -The wall switch plate cover, near dishwashing area, was covered with a grease film; -The metal slats on the 2-door refrigerator were covered with a grease film; -The top of the dishwasher was covered with a grease film. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F said the following: -He/she tried to clean his/her own area; -He/she did clean the walls in the dishwashing area; -The DM also came around and cleaned a lot; -He/she was unsure who was responsible to clean what areas. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -Everyone usually cleaned the area where they worked; -He/she was not sure who does what, as far as cleaning. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -He/she believed there is a cleaning list to follow; -Staff were to clean the area they work in and the other areas were split; -The deep cleaning was done by whoever had time. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said the following: -There was a cleaning schedule that was to be followed; -Kitchen staff were expected to take care of their own areas. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -Staff follow a cleaning schedule; -Specific tasks were not assigned to anyone; -Whoever gets to it was supposed to do it; -After doing the task, staff were supposed to initial, but no one does. During an interview on 03/28/25, at approximately 2:50 P.M., DM said the following: -He/she did have a cleaning schedule that staff were expected to follow; -Each staff were to clean their own areas and then they all had additional areas to clean. During an interview on 03/28/25, at 3:50 P.M., the Regional Nurse Consultant said the following: -The kitchen should be clean and free of debris; -There was a cleaning schedule that staff should follow; -There should not be any clutter, food, or trash anywhere and prep areas should be clean. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -Staff were expected to follow a cleaning schedule and he/she expected one to be posted for all staff to follow; -Expected staff to clean all walls, vents, windows, pipes, and all that is attached to the walls on a regular schedule.

Based on observation, interview, and record review, the facility failed to complete a risk/benefit review. document alternatives attempted prior to bed rail use, and failed to obtain informed consent prior to the use of bed side rails for six residents (Residents #266, #26, #53, #41 #28, and #59); failed to address and/or timely address the use of bed side rails in the residents' care plans for three residents (Resident # 266, #28, and #59); failed to conduct an initial safety gap check prior to side rail use for three residents (Residents #41, #28, and #59); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 111. Review of the facility policy titled Resident Beds and Bed Safety Rails Program, dated 10/28/19, showed the following: -The scope was to maintain beds and perform bed safety rails audits; -Preventative maintenance should be conducted on all beds and bed safety rails annually; -Bed Safety Rails Audit should be performed when it is determined that the use of bed rails is an appropriate application for the resident; -Initial and annual training should be conducted on all staff that are designated to perform the bed safety rails audits and should be used during initial and annual training as a reference. Review of the facility policy titled Bedrail Use, dated 10/26/22, showed the following: -Bed rails are used to enable a resident to become more functionally independent, and when the medical condition of the resident requires the use of a bedrail; -Bed rails could be considered a form of physical restraint; therefore, the need for bedrails should be identified in the resident assessment, and the plan of care; -Bed rails may be used to help a resident position or turn. Instructions should be provided to the resident as needed; -The interdisciplinary team should determine if the benefits outweigh the risk of a bedrail; -Possible hazards and clinical benefits of the bedrail use should be explained to the resident and guardian, during the admission process and upon initial implementation; -Continued use of bedrails requires documentation of the presence of a medical symptom, which would necessitate the use of bedrails, or that the bedrails assist the resident with mobility and transfer abilities and that clinical benefits still outweigh the risks of use; -Complete an Enabler/Assistive Device/Side Rail Review and Evaluation upon admission, readmission, upon initially implementing side rail, and with significant change; -Side rails should be addressed in the care plan; -Evaluation for entrapment risk should also be completed when mattress or bed type are changed; -The resident and the resident representative should give informed consent to the use of the device, prior to its use. 1. Review of Resident #266's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included alcohol dependence with alcohol-induced dementia, alcohol-induced mood disorder, anxiety, and nicotine dependence. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 03/20/25, for siderails to promote independence with bed mobility. Review of the resident's electronic medical record (EMR) showed staff did not document risk informed consent, signed by the resident or guardian, completed prior to the use of the bed side rails. Review of the resident's care plan, revised 03/24/25, showed the following: -Potential for falls; -Required assistance to complete daily activities of care safely. (Staff did not care plan related to the resident's side rail use.) Observations on 03/24/25, at 1:25 P.M., and on 03/25/25, at 10:05 A.M., showed quarter bedrails to each side of the resident's bed in place and in the upright position. 2. Record review of Resident # 26's face sheet showed the following information: -admitted [DATE]; -Diagnoses included clavicle (collarbone) fracture, presence of right artificial hip joint, and mechanical loosening of artificial hip joint. Review of the resident's admission MDS), dated [DATE], showed the following: -Cognition intact -Required substantial assistance for dressing, toilet use, and personal hygiene; -Required extensive assistance for bed mobility and transfer. Review of the resident's current POS showed an order, dated 02/04/25, for siderails to promote independence with bed mobility. Review of the resident's EMR showed staff did not document risk informed consent, signed by the resident or guardian, completed prior to the use of the bed side rails. Review of the resident's care plan, revised 02/17/25, showed the following: -The resident required side rail used as an enabler related to mobility and positioning; -Bed side rail use will be reviewed on admission and quarterly by the restorative nurse. Observation on 03/24/25, at 11:00 A.M., showed quarter bed side rails to each side of the resident's bed in place and in the upright position. The resident said that the bed side rails have been on the bed since admission and does not remember any staff reviewing the risks and benefits for use or obtaining consent to use the side rails. 31464 3. Review of Resident #53's face sheet showed the following information: -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure with excess carbon dioxide (CO2) in the bloodstream, chronic obstructive pulmonary disease (COPD - breathing disorder), sleep apnea (disrupted breathing cycle during sleep), morbid obesity, pain, generalized anxiety disorder, and depression. Review of the resident's admission MDS, dated [DATE], showed the following information: -Cognition intact; -No functional limitation in range of motion for upper extremities; -Required partial to moderate assistance to roll left to right, sit to lying, and lying to sitting on the side of the bed. Review of the resident's POS, current as of 03/31/25, showed an order, dated 02/11/25, for siderails to promote independence. Review of the resident's care plan, dated 03/26/25, showed the following: -Required staff assistance to complete daily activities of care safely related to diagnosis of respiratory failure and COPD; -Required siderail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if rails in need of repair, observe for appropriate lateral/vertical space of rails, observe for proper functioning, observe mattress for appropriate size for bed, and observe resident's freedom of movement; -Siderail use will be reviewed on admission and quarterly by restorative nurse. Review of the resident's medical records showed staff did not document completion of a risk assessment or informed consent prior to the use of side rails. Observation on 03/24/25, at 12:15 P.M., showed the resident rested in bed. Grab bars were in the raised position on each side of the bed. During an interview and observation on 03/27/25, at 12:13 P.M., the resident demonstrated his/her ability to use the grab bars on either side of the bed. He/she said the side rails were already on the bed on his/her admission. Staff did not discuss with him/her any risks associated with the use of side rails. The resident said he/she did want the side rails for mobility and repositioning. Observation on 03/28/25, at 9:52 A.M., showed the resident rested in bed. Grab bars were in the raised position on each side of the bed. 17056 4. Review of Resident #41's face sheet showed the following information: -admitted [DATE]; -Diagnoses included paraplegia (condition characterized by partial or complete paralysis of the lower half of the body), anxiety disorder, depression, and vascular dementia with psychotic disturbance (involves cognitive decline and psychotic symptoms like delusions (belief that is persistently held despite evidence to the contrary) and hallucinations (sensory experiences that occur with an external stimuli)). Review of the resident's Physical Restraint Record of Informed Consent, dated 07/12/24, showed the resident and a witness signed on 07/10/24 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's care plan, dated 07/12/24, showed the following information: -Resident required side rail use as enabler related to promoting self mobility/positioning. -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 03/26/25 with no new approaches or changes. Review of the resident's face sheet showed the resident readmitted to the facility on [DATE]. Review of the resident's POS, dated 03/28/25, showed an order, dated 02/06/25, for siderails to promote independence with bed mobility. Review of the resident's 5 day MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Total dependence on staff for bed mobility, chair to bed transfers, and toileting hygiene; -The resident did not have any physical restraints. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation on 03/26/25, at 9:45 A.M., showed the resident in bed with small grab bars (near the resident's head and shoulders) on both sides of the bed in the up position. Observation and interview on 03/28/25, at 2:04 P.M., showed the resident in bed with small grab bars on both sides of the bed in the raised position. The resident said the bed came with the grab bars. Sometimes the resident will use them to pull up in bed. During an interview on 03/28/25, at 12:48 P.M. , the Corporate Nurse said the resident did not have a side rail assessment prior to 03/26/25 because he/she was newer. During an interview on 03/31/25, at 10:09 A.M., Restorative Nursing Assistant (RNA) M said the resident used his/her grab bars during care. The resident can turn by self and grabs the bar. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident had paraplegia and used the grab bars for bed mobility. The resident's grab bars were added to his/her careplan with the start date of 07/12/24. She reviewed the care plan on 03/26/25. Typically, she reviewed care plans when she completed the MDS assessment. During an interview 03/31/25, at 3:59 P.M., the Director of Nursing (DON) said the resident had been in and out of the facility several times. They did not have a siderail assessment or informed consent for his/her side rails. The gap measurements do not have a date on the form, but they should have a date. Staff completed the gap measurements on 03/24/25. 5. Review of Resident #28's face sheet showed the following information: -admitted [DATE]; -Diagnoses included osteoporosis (condition in which bones become weak and brittle) and depression. Review of the the resident's Physical Restraint Record of Informed Consent, dated 11/02/23, showed the resident and a witness signed on 11/02/23 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's care plan, dated 01/24/24, showed the following information: -Required side rail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 02/05/25 with no new approaches or changes. Review of the resident's side rail evaluation, dated 02/08/24, showed the following information: -Resident needs side rails due to weakness; -Side rails will assist the resident with security, safety, bed mobility, transfers; -Bilateral side rails are recommended; -Benefit to side rails are to serve as enabler to promote independence and to serve as assistive device for bed mobility to increase ADL participation; -Provide assistance as required and/or needed with bed mobility; -Provide assistance as required and/or as needed with transfers and toileting; -Side rail use risks and benefits discussed/education listed on form; -Form completed by nursing; -The form did not show any signature or consent for the side rails. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Total dependence on staff for toilet hygiene, transfer for bed to chair; -Maximum assistance for bed mobility; -No physical restraint used. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation on 03/24/25, at 4:25 P.M., showed the resident in bed with grab bars on both sides of the bed in the raised position. Review of the resident's POS, dated 03/28/25, showed an order, dated 03/26/25, for side rails to promote independence with bed mobility. Review of the resident's Enabler/Assistive Device Review, undated on signed hard copy, dated 03/26/25 in the electronic medical record, showed the following information: -Resident required assist of one staff with bed mobility; -Interdisciplinary team recommended enabler/assistive device; -Type of device was grab bar; -Reason for recommendation was to assist with bed mobility; -Other alternatives tried included bed in low position; -Therapy has assessed the use of assistive device; -It had been determined that the clinical benefits of the device outweighed the clinical risk of the deice. The resident and/or, if applicable, resident representative had been informed and agreed with the use of this device; -Resident signed the bottom of the form; -Plan of care updated accordingly. Observation and interview on 03/28/25, at 2:07 P.M., showed the resident in bed with grab bars (rails) on both sides of the bed in the raised position. The resident said he/she had the rails when he/she got the bed. No one asked him/her if the resident wanted rails. The resident does use the rails to roll over. During an interview on 03/28/25, at 2:07 P.M., the resident's family member said the bed had the grab bars when the resident got the bed. During an interview on 03/31/25, at 9:26 A.M., Certified Nurse Aide (CNA) N said the resident used the grab bars when he/she rolled in bed. During an interview on 03/31/25, at 10:09 A.M., RNA M said the resident used his/her grab bars. He/she could use the grab bars and pull his/herself up in the bed. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident had grab bars and used them. He/she typically didn't get out of bed. The resident wanted to stay in bed. The resident used them to move around in bed. The resident's siderails were added to the care plan on 01/24/24. During an interview on 03/31/25, at 3:59 P.M., the DON said the resident should have an earlier physician order for the side rails. The care plan and side rail evaluation provided was probably the earliest they have. The Assistive Device Review had a date of 03/26/25 in the computer. The facility printed off and retained a hard paper copy for the consent signature. 6. Review of the resident's face sheet showed the following information: -admitted [DATE]; -Diagnoses included major depressive disorder and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the the resident's Physical Restraint Record of Informed Consent, dated 05/12/21, showed the resident and a witness signed on 05/12/21 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's side rail evaluation, dated 09/17/23, showed the following information: -Side rail use assessment-functional status; -Reason resident needed side rails was ambulation with assistance; -Side rails will assist resident with transfers and mobility; -Recommended for both sides of the bed; -Benefit to side rails for resident was to serve as enabler to promote independence; -Additional interventions for side rail use was to provide assistance as required and/or needed with bed mobility; -Side rail use risks and benefits discussed/education listed on form; -Form completed by nursing; -The form did not show any signature or consent for the side rails. Review of the resident's care plan, dated 09/18/23, showed the following information: -Required side rail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 02/10/25 with no new approaches or changes. Review of the resident's progress note dated 09/20/23, at 12:43 P.M., showed staff educated the responsible party on risks versus benefits of enabler use, including potential for harm/death and increased mobility/independence, and verbalized informed consent. Review of the resident's physician order sheet, dated 03/28/25, showed an order, dated 10/25/23, for siderails to promote independence with bed mobility. Review of the resident's Side Rail Evaluation, dated 02/15/24, showed the following information: -Reason resident needed side rails was due to weakness; -Side rails would assist resident with bed mobility, transfers, safety, and security; -Benefit to side rails for resident was to serve as an enabler to promote independence, the resident and/or resident representative had expressed desire for side rails while in bed, and to serve as assistive device for bed mobility to increase ADL participation; -Additional interventions for side rail use included encourage and/or assist resident to keep bed in lowest position while in bed, provide assistance as required and/or needed with bed mobility, and provide assistance as required and/or as needed with transfers and toileting; -Side rail use risk and benefits discussed/education listed on form; -Form completed by nursing. -The form did not show any signature or consent for the side rails. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation and interview on 03/25/25, at 10:46 A.M., showed the resident in bed with small grab bars on both sides of the bed, in the up position. The resident said he/she used them to move in bed. He/she liked and wanted to keep them. Review of the resident's Enabler/Assistive Device Review, undated on signed hard copy, dated 03/26/25 in the electronic medical record, showed the following information: -Resident's mobility status, included bed mobility as independent with one staff assist; -Type of device/enable recommended was grab bars; -Reason for recommendation was to assist with bed mobility and assist with transfers in /out of bed; -Other alternatives that had been attempted included bed in low position; -Therapy had assessed the resident for the use of assistive device; -It had been determined that the clinical benefits of the device outweighed the clinical risk of the device. The resident and/or, if applicable, resident representative have been informed and agreed with the use of this device. -The resident signed the form; -Staff documented the plan of care had been updated accordingly. Observation and interview on 03/28/25, at 2:34 PM., showed the resident in bed with grab bars on both sides of the bed in the raised position. The resident said the rails were on the bed when he/she first got the bed. The resident said he/she did use them to move in bed. During an interview on 03/31/25, at 9:26 AM., CNA N said the resident used the grab bars when he/she rolled in bed. The grab bars stayed in the up position. During an interview on 03/31/25, at 10:09 A.M., RNA M said the resident turned on the call light if he/she needed assistance. He/she did not know for sure if the resident used the grab bars or not. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident's side rails were added to his/her care plan on 09/18/23. The resident had the grab bars and used them. He/she liked to stay in bed, but could self position. During an interview on 03/31/25, at 3:59 P.M., the DON said the assessments provided for the resident were all they had. They would realize they didn't have certain pieces, such as the order, care plan, or the evaluation/assessment. She completed the resident's enabler/assessment on 03/26/25. Gap measurements should have a date on the form for when they are completed. 7. During interviews on 03/27/25, at 1:30 P.M., and on 03/31/25, at 10:09 A.M., RNA M said he/she did not do anything with side rails. He/she did not do any measurements or monitoring of any kind. The new beds come with the side rails (grab bars). He/she was not involved in the assessment for them or gap measurements. During an interview on 03/28/25, at 1:45 P.M., LPN B said all the beds on 100 hall have side rails on them all the time. They never take them off as far as he/she knew. He/she did not do any kind of bed side rail assessment form and thought the admission nurse or management took care of bed side rail information, orders, and consents for bed side rails. During an interview on 03/28/25, at 1:55 P.M., LPN E said that if a resident needed help with ambulation, bed mobility, was incontinent, or have had recent falls that nurses do an enabler assessment form for the bed side rails. The nurse will put in a physician order and obtain consent from either the resident or the guardian. Staff measured from the headboard to the mattress and from the mattress to the rails. The previous Director of Nursing (DON) was responsible for making sure the bed side rails measurements were done. Now, LPN E and the DON were responsible for making sure it got done. LPN E would notify maintenance if the rails were loose and/or needed them placed. During an interview on 03/31/25, at 10:40 A.M., Registered Nurse (RN) O said the beds already have the grab bars on them at admission. The admitting nurse should be completing the enabler assessment. If not the admitting nurse, the unit manager or medical records should be doing the assessment. It should be completed within 24 hours of admission. Therapy does an evaluation to see if grab bars are needed or not. Whoever completed the enabler assessment should also get consent. They should be completed within 24 hours of admission. That same staff should explain the risks/benefits of the grab bars. The nurse completed the assessment, unit manager, or medical records can get the gap measurements. Anyone can get the measurements. The same person who does the assessment should be getting the gap measurements. When they do the evaluation, the grab bars can be removed. Other things they would try before the grab bars was low bed or elevate head of the bed. Many residents come in the facility and want the grab bars. The grab bars should be added to the care plan. It should be added typically once the evaluation is completed and the grab bars are determined as appropriate. Gap measurements should be done by policy. He/she thought that was quarterly. During an interview on 03/28/25, at 1:25 P.M., the Rehabilitation Director said that therapy staff do an evaluation for positioning, bed mobility, and transfers for bed side rail usage and notify the nurse if they require a bed side rail. Therapy staff do not complete a side rail evaluation form, did not put in the orders, did not get consent and did not complete any gap measurements. The Rehabilitation Director said nurses do all of that. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said she added to the care plan who they give her as names that have side rails or grab bars. She was not involved in the assessment of the grab bars/side rails, consents, or the gap measurements. If on 100 hall, all beds have grab bars on them at admission. On other halls, it depended. Typically, they admit a resident straight to 100 hall. Then, they move them from 100 to another hall. It is a different bed. It just depended on the bed whether it had side rails already. She did not know the time period from when they have the grab bars to when she was told about them. Typically, she reviewed care plans when she completed the MDS assessment. They used to have a restorative nurse who did the gap measurements, consents, and assessments. She assumed the previous DON took over those responsibilities. During an interview on 03/31/25, at 3:59 P.M., the DON said most of the residents who came in to 100 hall, came in with grab bars. Therapy would evaluate and say if okay to have the grab bars. Therapy didn't give them a piece of paper that said they were needed to promote bed mobility/transfers. Observation would be done, and orders entered/care plan updated. They had been discussing risks/benefits on the enabler form, but when they changed computer systems, it got dropped. Assessment and informed consent was on that form. Gap measurements were a separate form. CNA P was responsible for the gap measurements. LPN E kept track of the measurements after CNA P got them. When a grab bar was put on, staff should have the order in place prior to putting on the grab bars. Physical therapy should evaluate the grab bars before they come on. Gap measurements should be completed when grab bars are put on. Consent form and measurement form should be done at the same time. Staff should do gap measurements any time there is a change in structure, or change in anything. Assessments should be completed on initiation of the grab bar, and then either quarterly or annually. They would realize they didn't have certain pieces, such as the order, care plan, or the evaluation/assessment. Gap measurements should have a date on the form for when it is completed. All of the enabler/assessments were completed on 03/26/25. During an interview on 03/31/25, at 4:51 P.M., the Administrator said side rail assessments should be completed on admission. They should be discussing them with the resident and family on admission. Staff should update the care plan on admission and get consent signed if they want them or declination if they don't want them. Gap measurements should be completed on admission or upon initiation of the side rails. Staff should quarterly/annually update the care plan as needed. Staff should get physician orders for side rails/grab bars. If there is no change in the bed or mattress, they should not need gap measurements again. But, maintenance staff should be doing safety checks per policy.

Based on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment for one resident (Resident #52), whose room contained multiple areas of wall, door, and ceiling damage. A sample of 21 residents was reviewed. The facility census was 111. Review of a facility policy entitled Repair Requisition (TELs (electronic application) Work Order System), dated 07/06/15, showed the following: -Purpose was to assist in the prompt repair of equipment, or facility plant features, that may be broken or have failed; -TELs Work Order Requests are used as a communication tool and are not intended to be a permanent record of equipment service; -Requests for repairs to equipment, or the building, should be communicated via the TELs Work Order System to the maintenance department, using the TELs app on each computer. The Maintenance supervisor should check Work Order requests each day and plan to work accordingly; -Once repairs are complete, the Maintenance Supervisor should record the repair on the TELs Work Order System as appropriate. 1. Review of Resident #52's face sheet (gives basic profile information at a glance) showed the following: -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD - breathing disorder with acute exacerbation), emphysema (lung disease), insomnia, obstructive sleep apnea, dependence on supplemental oxygen, and anxiety disorder. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/13/25, showed mild cognitive impairment. Review of the resident's care plan, last reviewed 12/27/24, showed the staff to address complaints and concerns timely and encourage/allow to voice feelings and concerns. Observation and interview on 03/24/25, at 12:32 P.M., showed the following: -The resident pointed at the room door, closet doors, walls, and ceiling and said, The walls and doors look like crap, and the ceiling has water damage. He/she also pointed out the large loops of television cable on the floor next to the bed and chest of drawers; -The room door was scraped from the hinge edge to the doorknob. The scarpe was 1 to 2 inches in width; -Approximately 6 inches from the lower edge of the closet door was a jagged 2 to 3 inch hole punched through the exterior surface, with several cracks extending outward from the hole; -The closet doors showed three circular pieces of plastic of two sizes attached to the exterior; -Two areas of apparent water damage to the corner of the ceiling over the resident's bed; -Five small holes in the ceiling over the resident's bed; -Six holes/anchors in the wall between the tv/nightstand and the corner of the wall; -Four holes/anchors in the wall between the overbed light and the corner of the wall. During an interview on 03/31/25, at 11:54 A.M., the Maintenance Assistant said the facility used the electronic TELs application system. Any staff can send a repair/work order request to maintenance, and the system alerts them with new messages. Sometimes the staff just tells them directly of repairs needed. The Maintenance Assistant said they usually wait until a room is empty/vacated to do wall repairs, due to the smell/fumes. He was not aware of the wall, door, or ceiling damage or excess coiled cable in the resident's room. During an interview on 03/31/25, at 12:08 P.M., Certified Medication Technician (CMT) D said staff can either tell maintenance directly or put in a repair request on the electronic system regarding wall or door damage. During an interview on 03/31/25, at 12:14 P.M., Licensed Practical Nurse (LPN) C said any staff can put in a work order for the maintenance department through the electronic system or can just tell them directly. The LPN was not aware of a request for repairs in the resident's room. During an interview on 03/31/25, at 12:24 P.M., the Maintenance Director said staff should put in a work order on the electronic system to request repairs. He said the facility did have a pipe issue with resulting ceiling damage on 07/29/24. He was not aware of ceiling water damage or wall/door damage in the resident's room. He had not received a work request for those items. During an interview on 03/13/25, beginning at 4:06 P.M., the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant said any staff can request repairs by entering a work order into the electronic system. Maintenance staff check the requests daily and the system alerts them to new requests.

Based on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to obtain and document physician orders for the use of supplemental oxygen for one resident (Resident #53) of four sampled residents. The facility census was 111. Review of the facility's policy titled Advanced Care Procedures: Oxygen Administration, dated 12/08/05, showed the following: -Oxygen should be administered under the orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without physician's order; however, the order should be obtained immediately after the crisis is under control; -Obtain physician's orders for the rate of flow and route of administration of oxygen (i.e., by tank, concentrator, nasal cannula, mask, etc.). 1. Review of Resident #53's face sheet showed the following information: -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure with excess carbon dioxide (CO2) in the bloodstream, chronic obstructive pulmonary disease (COPD - breathing disorder), sleep apnea (disrupted breathing cycle during sleep), chronic atrial fibrillation (irregular heart function), and bronchitis. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/03/25, showed the following information: -Cognition intact; -On oxygen therapy, continuous on admission; -Received oxygen therapy while a resident. Review of the resident's care plan, dated 03/26/25, showed the following: -Diagnoses included COPD and respiratory failure; -Resident required staff assistance to complete daily activities of care safely related to diagnosis of respiratory failure and COPD; -Resident received oxygen therapy. Administer oxygen therapy as ordered, change tubing per protocol, ensure that supply is available at all times, observe for changes in symptoms that may indicate worsening respiratory status, notify provider of change, and provide with humidification. Review of the resident's Physician Order Sheet (POS), current as of 03/31/25, showed an order, dated 02/16/25, to change resident's oxygen tubing every week on Sunday. Staff did not document orders for oxygen use that specified the flow rate or route. Observation on 03/25/25, at 12:15 P.M., showed resident rested in bed with oxygen in use at 3 liters per minute (lpm) via nasal cannula. Observation and interview on 03/28/25, at 9:52 A.M., showed the resident rested in bed with oxygen in use at 3 lpm via nasal cannula. The resident confirmed the liter flow should be set to 3 lpm. The resident said he/she used the oxygen continuously due to COPD and recent bronchitis. During an interview on 03/31/25, at 12:08 P.M., Certified Medication Tech (CMT) D said only the nurses can adjust oxygen settings. Certified nurse aides (CNAs) are not supposed to adjust the oxygen liter flow, but they can assist the residents with the nasal cannula placement. During an interview on 03/31/25, at 12:12 P.M., Licensed Practical Nurse (LPN) B said the nurse should obtain an order for a resident's supplemental oxygen use and enter the order into the electronic medical record (EMR). The nurse should set the liter flow on the oxygen concentrator and/or portable tank. CNAs are not supposed to adjust oxygen settings. During an interview on 03/31/25, at 12:14 P.M., LPN C said the nurse should put an oxygen order in the EMR. The facility usually puts in a standing order for as needed oxygen to maintain the oxygen saturation above the percentage given by the physician. The nurses start oxygen at 2 to 3 lpm and assess the effectiveness. During an interview on 03/31/25, at 4:40 P.M., the Director of Nursing (DON), the Regional Nurse Consultant (RNC), and the Administrator said staff should obtain a physician's order for a resident's use of supplemental oxygen. The order should include the liter flow and route (nasal cannula, mask).

Based on observations,interviews, and record review, the facility failed to ensure food was properly stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 115 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Review of the Dietary Service Manual, dated 08/10/18, showed the following: -Kitchens and dining areas should be kept clean, free from litter, and rubbish, and protected from rodents, roaches, flies, and other insects; -Utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and should be free from breaks, corrosion, open seams, cracks, and chipped areas; - Items in storage rooms should not be stored within 18 inches of sprinkler heads, and should be kept at least 6 inches from the floor; -Open food items should be covered, labeled, and dated. Opened dry goods should be kept in tightly sealed containers. 1. Observations during the tour of the kitchen on 10/23/23, at 10:05 A.M., showed the following: -In the pantry, there was a large container of oatmeal dated 10/8 to 11/8. The plastic lid was left ajar; -In the walk-in refrigerator, there was an opened and undated 10-pound box of sausage patties. The box stated to keep frozen 0 to 10 degrees Fahrenheit(F); -In the walk-in freezer, there were unopened boxes of food products placed into plastic crates on the floor. A large unopened cardboard box of beef was also noted on the floor without being raised. An opened and undated 3-gallon container of strawberry ice cream was stored on a shelf, with the lid ajar. Observations during the tour of the kitchen on 10/25/23, at 10:28 A.M., showed the following; -In the walk-in freezer, there was an opened and undated 20 lb. box of sugar cookie dough. There was an opened and undated 3-gallon container of strawberry ice cream with the lid ajar; -There were two knife storage boxes, with four knives in each. These were secured to the sides of two cupboards, near a kitchen sink and potential backsplash. The knife handles were observed with dirt and dark discoloration. The storage boxes were noted to have dried dirt and debris on all exposed sides and on the cupboard walls behind them; -There were tongs, ladles, and whisks that hung inside cupboard doors that were observed with dried debris on the handles. The cupboards were observed with dried food and dirt on the storage shelves; -Two large pitchers of tea were observed on the kitchen counters next to a kitchen sink without any lids or covers; -Pantry floors were observed with large areas of built-up dirt. Observations during the tour of the kitchen on 10/26/23, at 1:30 P.M., with the Dietary Supervisor (DS) and Registered Dietitian (RD) showed the following: -Three large pitchers of tea were observed on the kitchen counters next to a kitchen sink without any lids or covers; -The two knife storage boxes, with four knives in each, were again observed with dirt and debris; -Tongs, ladles, and whisks were observed inside cupboard doors with dried food and debris on the handles. The cupboards were observed with dirt and dried food on the shelves; -Pantry floors with visible areas of visible dirt built-up; -The 3-gallon containers of ice cream were again observed with lids ajar. During an interview on 10/26/23, at 1:44 P.M., with the DS and RD confirmed that the pitchers of tea should have been covered. The knife storage boxes and cupboard utensils should have been properly cleaned before stored. The maintenance department was supposed to clean and strip the floor wax in the pantry, but had been too busy lately. They confirmed all bins should have securely placed lids during storage, and that the ice cream should not have lids ajar. The DS and RD were unaware the box of sausages specified it should be kept frozen.

Based on observations, interviews, and record review, the facility failed to keep one out of six medication carts secured; failed to remove expired calibration solution from one out of the two medication rooms; and failed to removed two expired covid tests. These failures had the potential for resident medications to be tampered with, glucometers to be calibrated inaccurately, and for expired covid tests and medications which may be less effective be used. The facility census was 115. 1. Review of the Storage and Expiration of Medication, Biological, Syringes, and Needles policy, with a revision date of 10/31/16, showed the facility should ensure that all medications and biologicals are securely stored in a locked cabinet/cart or a locked medication room that is inaccessible by residents or visitors. During observations on 10/25/23, from 11:09 A.M. to 11:20 A.M., a medication cart sitting between the 100 and 200 halls by the nurses' station was unlocked and unattended. At 11:09 AM, this surveyor opened a drawer that contained medication, then closed the drawer, and continued to observe the cart. At 11:11 AM, multiple staff walked past the medication cart. At 11:16 AM, Resident # 22 ambulated with a walker past the unlocked medication cart. At 11:18 AM, the Director of Nursing (DON) walked by the unlocked cart and went into the nurses' station. At 11:20 AM, the Staff Development nurse locked the cart. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 08/13/23, showed the resident indicated the resident either would not answer the mental status question or the answer was nonsensical. During an interview on 10/25/23, at 11:20 A.M., the Staff Development Nurse showed the medication cart was unlocked and she locked it. The medication cart should be kept locked to keep unauthorized people out of it. There were medications in the cart that could hurt a resident if they got a hold of it. A resident could get in the cart if it was unlocked and get something a resident should not get. 2. Review of the Storage and Expiration of Medication, Biological, Syringes, and Needles policy, with a revision date of 10/31/16, showed the facility should ensure that medications and biologicals that have an expired date should be stored separate from other medications until destroyed or returned to the pharmacy. Observation and interview on 10/25/23, at 12:41 P.M., with Licensed Practical Nurse (LPN) 1 in the medication room showed the following: -Seven boxes of recalibrate assure dose that had an expiration date of 09/20/23. LPN 1 said the recalibrate assure dose was expired and should not be in there. If an expired recalibration solution was used it could cause an inaccurate reading when calibrating the glucometer. If the glucometer had been calibrated inaccurately the residents could get inaccurate blood sugar results and may get too much insulin or too little insulin; -Two covid tests with expiration dates of 06/22/23. LPN 1 said the two covid tests kits expired on 06/22/23, however they were not using that brand any longer. The expired covid tests should be thrown away. 3. During an interview on 10/26/23, at 10:00 A.M., the Director of Nursing (DON) said her expectations were that medication should be checked for expiration dates. Med techs checked each cart each day for expired medications. Expired assure plus calibration solution could potentially give staff a false reading and be out of range. If the solution was expired staff could get a false reading and if too high could give insulin when the resident really did not need insulin.

Based on observations, interviews, and record review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) reflective of the resident's status at the time of the assessment for one resident (Resident #16) out of a total sample of 34 residents. The facility census was 115. 1. Review of the Centers for Medicare and Medicaid (CMS)'s RAI 3.0 Manual, revised October 2023, showed in the coding instructions for wandering that the frequency of the behavior during the seven day look back period should be coded. Review of the Resident's #16's Admission Record, found in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included dementia, depression, anxiety, and schizophrenia (a chronic brain disorder - symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation). Review of the resident's quarterly MDS assessment located in the MDS tab in the EMR, with an assessment reference date (ARD) of 06/05/23, showed the following: -Significantly impaired cognition; -Independent with bed mobility, transfers, walk in room and corridor, locomotion on and off unit; -Assessed to not wander, nor have physical or verbal behavioral symptoms directed toward others. Review of the resident's annual MDS assessment located in the MDS tab in the EMR, with an ARD of 08/28/23, showed the following; -Significantly impaired cognition; -Continued to be independent with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Assessed to not wander, nor have physical or verbal behavioral symptoms directed toward others. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, dated 02/11/17, showed the following: -Resident has diagnosis of schizophrenia; -Resident refuses psych meds and lab monitoring; -Resident will get in to other resident belongings, turn off their oxygen concentrators, and throw their clothing through the doorway into the hall. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, dated 01/06/23, showed the following: -Dementia Unit needed related to wandering in and out of resident rooms; -Resident takes other resident belongings and staff belongings. Resident will take pictures off the wall; -Resident may not be able to attend activities in the general population. It causes resident increased agitation and behaviors. During observations on 10/23/23, at 11:38 A.M., on 10/24/23, at 9:05 A.M., and on 10/25/23, at 4:05 P.M., showed the resident wandered on the secure unit. The resident observed wandering in and out of other residents' rooms and throughout the unit. Staff were observed frequently redirecting the resident. During an interview on 10/26/23, at 10:28 A.M., MDS Coordinator (MDSC) said the following: -The resident had been care planned for his/her behaviors and did not have any new ones; -The Resident Assessment Instrument (RAI) indicated to code for any new behaviors so they can be care planned, but if the resident is only observed with already existing and known behaviors, then she would not capture that information on the MDS; -Since the resident had only the long-standing behaviors, they would not be captured on more recent assessments; -The care plan for the resident was currently accurate for her behaviors. During an interview on 10/26/23, at 11:37 A.M., Nursing Assistant (NA) revealed the resident wandered on the secured unit all the time. This was the resident's normal behavior. The resident also liked to go into other residents' rooms and take clothing that he/she thinks is his/hers. During an interview on 10/26/23, at 11:42 A.M., Licensed Practical Nurse (LPN) 2 said the resident wandered all of the time, at least on a daily basis. The resident might watch television or do something for a short period of time, but still spent most of his/her time wandering the unit and into other resident rooms. During an interview on 10/26/23, at 12:00 PM, the Director of Nursing (DON) said the MDSC had not documented the resident's behaviors or wandering because they were not new behaviors for the resident. The DON said the MDSC had to reread the RAI. The resident had always been a busy pacer in the facility, but now that he/she was on the secured unit he/she wandered even more.

Based on interviews and record review, the facility failed to ensure a Level 1 PreAdmission Screening and Resident Review (PASRR) was completed for one resident (Resident #15) of one sampled resident reviewed for PASARR failure to complete a Level 1 screen which prevents the completion of an in-depth evaluation (Level II PASRR) and possible identification of appropriate services. The facility census was 115. Review of the PreAdmission Screening Resident Review policy, revised on 06/09, showed the following: -The process for PASRR included a Level I and/or Level II would be added to the admission checklist as one of the documents required prior to or at the time of admission; -The original documents for Level I and/or Level II determination would be placed in the medical chart behind the social services tab and a copy would also be placed in the residents financial file in the business office; -The intent of a preadmission screening was to ensure that all individuals with a diagnosis of mental illness had appropriate placement in a facility, their medical needs outweigh their mental needs, and they received appropriate services for their condition; -The nursing facility was responsible for ensuring a Level I screening was completed, submitted, and had a Level I determination on or before admission. 1. Review of Resident #15's Admission Record, found in the Admission Tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (a chronic brain disorder that affects less than one percent of the U.S. population), anxiety, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), panic disorder, and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment comlpeted by facility staff) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/01/23, showed the resident had no cognitive impairment. Review of the resident's Care Plan located in the Care Plan tab of the EMR, dated 09/11/23, showed the following: -Potential for altered mood state/psychosocial well being related to schizophrenia, anxiety, bipolar, and depression; -Resident to have no decline in mood state/psychosocial well being; -Interventions included psychological counseling at various facilities, medication management, and monitoring for mood changes. During an interview on 10/23/23, at 2:06 P.M., the reisdent said he/she had mental issues, was schizophrenic, and was on medication for that condition. The resident said she had been in and out of many different facilities, but had been at this facility several years and it was his/her home. The resident said he/she worked outside the facility several days a week. Review of the PASRR section of the resident's hard copy chart showed a PASRR was not in the chart. Review of the resident's EMR showed there was no PASRR in the record. During an interview on 10/26/23, at 9:00 A.M., Licensed Practical Nurse/Medical Records (LPN) 5 said he/she did not see a PASRR in the hard copy chart for the resident. LPN 5 said he/she was not sure what a PASRR was for. During an interview on 10/26/23, at 9:10 A.M., the Financial Specialist said after reviewing the financial records for the resident, he/she did not find a PASRR that had been completed for the resident. He/she would call the guardian and the facility that the resident had come from. A PASRR was completed for every resident to ensure the resident was at the correct level of care and the facility would be able to meet a resident's needs. The PASRR would be kept in the resident's financial records if the resident had one. Whoever did the job before him/her did not obtain the required PASSR and the resident should have a completed PASRR in the financial records. During an interview on 10/26/23, at 12:03 PM, the Director of Nursing (DON) said every resident had to have a Level I PASRR completed before being admitted to the facility. When a Level I PASRR was completed, it was sent to an outside company that determined if a resident needed a Level II. The DON said a diagnosis of schizophrenia would trigger a PASRR Level II to be completed. A Level II PASRR determined what services the resident needed from the facility, what has worked in the past, and what the resident needed now. The DON said the resident should have a PASRR completed.

Based on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for one resident (Resident #21) out of a total sample of 32 residents when the resident had a physician order for oxygen use and the facility failed to develop a care plan related to oxygen usage. The facility census was 115. Review of the Nursing Management Manual Policy, effective 08/15/18, under the Quality of Life section with a Person Centered Care Plan policy title, showed the following: -The purpose of a person-centered plans of care was to care approaches and goals specific to the resident's needs; -Comprehensive plan of care should be reviewed quarterly and the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) Coordinator should ensure the care plan interventions were entered outside of routine care which would provide the Certified Nursing Assistants (CNA) with individualized information needed to meet the residents care needs; -The care plan team should develop a comprehensive care plan for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. 1. Review of the Resident #21's quarterly Minimum Data Set (MDS), located in the MDS tab in the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 09/12/23, showed the following: -admitted on [DATE] and readmitted on [DATE]; -Cognition was intact; -Diagnoses included anxiety, asthma (a disease that affects the lungs causing repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing), and chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems); -Resident had shortness of breath on exertion and when lying flat; -Utilized oxygen therapy. Review of the resident's EMR Physician Orders showed the following, -An order, dated 09/06/23, for oxygen at two liters per nasal cannula as needed for shortness of breath. Changing all oxygen tubing every week on Fridays. Respiratory assessment for shortness of breath and albuterol sulfate (a quick relief inhaler) as needed for shortness of breath. Review of the resident's EMR Care Plan tab showed a comprehensive care plan dated 09/06/23. Staff did not care plan the resident's oxygen use. Observation on 10/24/23, at 9:32 A.M., showed the resident was sitting in a wheelchair in the dining room area. The resident was drinking coffee and had oxygen at 2L per nasal cannula. During an interview on 10/24/23, at 9:33 A.M., the resident revealed he/she had been in the hospital a few weeks ago and he/she now used oxygen as he/she needed it. During an interview on 10/26/23, at 1:01 P.M., the MDS Coordinator said if a resident was on oxygen, he/she would make a care plan reflecting the oxygen use. A problem for respiratory would be initiated and oxygen would be one of the interventions. The MDS Coordinator confirmed there was no care plan for oxygen use and there should be. He/she did not know why he/she did not establish a care plan for the oxygen use. The care plan should include interventions like oxygen saturations, changing the O2 tubing, vital signs, and physician orders for oxygen use. 27104

Based on record review, observation, and interview, the facility failed to ensure two residents (Residents #40 and #59) out of two residents observed out of a sample of 32 residents were positioned appropriately at the dining table to ensure the residents could access their food without difficulty and at a comfortable position. This had the potential for the residents to have nutritional issues and a negative dining experience. The facility census was 115. Review showed the facility did not provide a policy related to dining and positioning. 1. Review of Resident #40's facility provided quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 09/15/23, showed the following: -admitted [DATE]; -Cognition was moderately impaired, made poor decisions, and supervision was required; -Resident required limited assistance with one person assist with eating. 2. Review of Resident #59's facility provided quarterly MDS, with an ARD of 07/27/23, showed the following: -admitted [DATE]; -Cognition severely impaired; -Required supervision for eating and required setup help only. 3. Observation on 10/24/23, at 1:03 P.M., in the dining room in the secured unit showed Resident #40 and Resident #59 were seated in their wheelchairs at the dining table. Both residents were observed where their chins were level with the top of the dining table. Both were also observed having to reach above their heads with their eating utensils in order to reach their food. Observation on 10/25/23, at 12:15 P.M. showed Resident 340 and Resident #59 were seated in their wheelchairs at the dining room table in the secured unit eating lunch. Their chins were level with the top of the table. Resident #40 had all of his/her food in bowls and was reaching up above his/her head with his/her spoon so he/she could access the food in his/her bowl in order to feed him/herself. He/She then was observed to reach up and take the bowl and put it in his/her lap so he/she could feed him/herself without having to reach above his/her head. Resident #59 was observed in his/her wheelchair at the dining table with his/her chin level to the dining table, reaching above his/her head with his/her eating utensils in order to access her food so he/she could feed herself. 4. During an interview on 10/25/23, at 12:20 P.M., with Certified Nursing Assistant (CNA) 1 and Licensed Practical Nurse (LPN) 2, both confirmed the Resident #40 and Resident #59's wheelchairs were either too low or the table was too high in order for them both to be able to feed themselves without difficulty. They confirmed both of the residents' chins were level with the table, and they had to reach up in order to be able to reach their food on their plates and in their bowls. CNA 1 confirmed Resident #40 often reaches up and gets her bowl and holds it close to him/her so he/she can feed him/herself without reaching. They both confirmed it could possibly be a potential for him/her to spill hot food on him/her when reaching up for his/her bowls. 5. During an Interview on 10/26/23, at 11:00 A.M., the Director of Nursing (DON) said she was not aware Resident #40 and Resident #59 sat so low at the dining table and had to reach up above their heads to access their food in order to feed themselves.

Please refer to event ID NWD012. MO 950 Based on interview and record review, the facility failed to protect residents from misappropriation of resident property when narcotic medications of five residents (Resident #20, #21, #22, #23, and #24) went missing while in the possession of facility staff. The facility census was 90.

Based on observations, interviews and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being for two residents (Resident #1 and #11) when the facility failed to accurately assess, notify the physician and administer pain medications when the residents experienced significant pain not controlled by their current medication regimen. The facility failed to appropriately identify, assess, implement individual interventions, and monitor the effectiveness of the interventions for one resident (Resident #10) with an open wound. The facility failed to monitor a resident's skin for skin breakdown and failed to treat the skin breakdown for one resident (Resident #6) who developed painful excoriation and an open area. A sample of 17 residents was selected for review in a facility with a census of 99. 1. Record review of the facility's policy titled Pain Management and Assessment dated 1/5/10, showed the following: -The detection of the presence of pain, determining the frequency and intensity of pain, and identification of effective pain management interventions can help to avoid adverse outcomes that impact the resident's functional status and quality of life; -Pain assessment presents unique problems in the elderly, as these residents may exhibit physiologic, psychologic and cultural changes associated with aging; -A pain management regimen will be developed that includes both pharmacological and non-pharmacological interventions per the assessment process and the effectiveness of regime will be reviewed routinely and will be revised if goals are not met. Goals per pain management for most residents should be to achieve a consistent level of comfort while maintaining as much function as possible; -Pain can cause suffering and is associated with inactivity, social withdrawal, depression, and functional decline; -It is important to consider the resident's emotional, social and spiritual factors involved in influencing their pain symptom perception; -Most residents with moderate to severe pain will require regularly dosed pain medications, and some will require additional as needed pain medications for breakthrough pain; -Ongoing pain assessment: The alert resident should be asked to describe their pain on a scale of 1-10, with zero being no pain and ten being the most severe pain. It is helpful to ask the resident their expectations for pain relief, can they live with the pain at the current level, and if not, how much relief is needed to live comfortably; -Have the resident show the location and radius (extending or radiating) of the pain; -Non-pharmacological pain management interventions were included in the policy; -If the resident's pain is not controlled by the current treatment regime, the physician should be notified; -The resident's response to pain medication should be documented in the Medication Administration Record [REDACTED] -The consultant pharmacist may be consulted to assist with the management of a resident's pain when needed; -The interdisciplinary care team should develop a plan of care for the resident with pain, and evaluate the effectiveness of the plan periodically. Record review of the facility's policy titled Pain Assessment, dated 10/01/10, showed the following information: -Painful conditions in long-term care residents include [MEDICAL CONDITION] joint disease (also know as [MEDICAL CONDITION] - caused by the breakdown of cartilage in one or more joints), [MEDICAL CONDITION] (brittle or fragile bones), fractures, muscle pain/stiffness, and immobility; -Residents with a history of chronic pain typically may not receive adequate pain management; -Staff should believe the resident's report of pain and document a description of the pain; -Pain is not a normal part of aging, residents do not have to bear pain and elderly persons are not likely to become addicted to pain medications; -Principles of pain management in the elderly include the staff should always believe the resident's reports of pain, the staff should be compulsive in assessing a resident's pain and observe on all shifts and the staff should use medications and non-medication interventions when possible. 2. Record review Resident #11's face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/17/16, showed the following staff assessment of the resident: -Cognitively intact; -Extensive to limited staff assistance required for most activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Received as needed (PRN) pain medication; -The interview for pain assessment showed the resident had frequent pain at a pain level of eight out of ten and the pain made it hard for the resident to sleep at night and limited the resident's daily activities. Record review of the residents' physician's admission History and Physical, dated 11/11/16, showed the following: -The resident had a motor vehicle accident [AGE] years ago which caused multiple fractures of the left femur (thigh bone), knee and hand. Surgical repair with open reduction and internal fixation (refers to a surgical procedure to fix a severe bone fracture, or break to realign the bone fracture into the normal position) of knee and thigh, and amputation of the left fourth and fifth fingers; -Mentally alert; -Polyarthralgia (pain in more than one joint and is always associated with arthritic pain); -[DIAGNOSES REDACTED]. Record review of the resident's November 2016 admission physician's orders [REDACTED]. -[MEDICATION NAME] (an anti-anxiety medication) 0.5 milligram (mg) tablet, give one tablet every six hours as needed for anxiety; -[MEDICATION NAME] (a narcotic-like pain reliever, used to treat moderate to severe pain) 50 mg tablet, give one tab every six hours as needed for pain rated at one to five on the pain scale; -[MEDICATION NAME] 50 mg tablet, give two tablets to equal 100 mg, every six hours as needed for pain rated six to ten on the pain scale; -An order dated 11/18/16, for [MEDICATION NAME] HCL (an opioid/narcotic pain medication) 20 mg tablet twice daily for pain. Record review of a nurse's note dated 11/11/16, at 2:15 A.M., showed the resident had a pain patch ([MEDICATION NAME], a skin patch designed to be used only for opioid-tolerant patients. A patient is opioid-tolerant if oral narcotics have already been used for severe pain) on his/her left shoulder on admission to the facility. Record review of a fax, dated 11/11/16, to the resident's physician from the facility staff showed the following: -The resident requested a [MEDICATION NAME]. The resident had a [MEDICATION NAME] when admitted from the hospital; -The physician's response written on the faxed request showed a new order for artificial tears. -The physician did not respond to the request for a [MEDICATION NAME] Patch or additional pain medications. Record review of the resident's quarterly MDS, dated [DATE] showed the following changes: : -Received a scheduled pain medication, a PRN pain medication and non-medication interventions; -The interview for pain assessment showed the resident had occasional pain at a pain level of six out of ten and the pain continued to made it hard for the resident to sleep at night and limited the resident's daily activities. Record review of the resident's comprehensive care plan, dated 2/24/17, showed the following: -A goal of not having unrelieved pain for 90 days as evidenced by no moaning, groaning, or facial grimaces. -Interventions directed staff to coordinate with the resident's physician to manage pain medication for optimum control of pain. -Observe for the effectiveness of medications. -Administer pain medication as ordered. -Attempt to measure the resident's pain level using the pain scale. Record review of the residents March 2017 MARs showed the following: -On 03/01/17 at 10:30 P.M., the resident's pain was rated as a 10. Staff did not document administering additional pain medication. -On 03/03/17 at 10:30 P.M., the resident's pain was rated as a 10. Staff did not document administering additional pain medication. -On 03/06/17 at 10:30 P.M., the resident's pain was rated as a 10. Staff did not document administering additional pain medication. -On 03/11/17 at 10:30 P.M., the resident's pain was rated as a 9. Staff did not document administering additional pain medication. During interviews on 3/22/17, at 9:25 A.M and 3/24/17, at 9:25 A.M., the resident said the following: -He/She had been at the facility since November 2016; -He/She used a motorized scooter to get around; -He/She was in constant pain every day; -He/She had chronic pain most of his/her life due to a car accident when he/she was young and multiple surgeries to repair the damage from the accident; -He/She built up a tolerance to pain medications due to being on them for so many years; -He/She received [MEDICATION NAME] at 7:00 A.M. and 7:00 P.M., and within three to four hours of taking the medication he/she had breakthrough pain; -He/She had a physician's orders [REDACTED]. [MEDICATION NAME] upset his/her stomach and did not help the pain. He/She told the charges nurses since he/she was admitted to the facility he/she did not want to take [MEDICATION NAME] for those reasons. He/She took [MEDICATION NAME] on occasion when he/she was having a really bad day. He/She had an order for [REDACTED].>-Nursing staff asked him/her to rate the pain every day, but he/she did not see the purpose since staff did nothing when he/she rated the pain as a 10 out of 10; -Prior to admission, he/she lived on his/her own and took [MEDICATION NAME] and [MEDICATION NAME] (a narcotic pain medication) three times daily for pain control. This allowed him/her to work and be functional; -While in the hospital he/she had a [MEDICATION NAME]. He/she asked the nurse to talk with the physician about prescribing a patch, but he/she did not know if the nurse talked to the physician. He/she had not had a [MEDICATION NAME] since admission; -He/she received physical therapy when he/she was first admitted . The therapist used cold packs and ultrasound to help relieve the pain which helped for a short time. After therapy ended the staff did not offer non-medication interventions; -He/she did not ask for pain medications between doses of [MEDICATION NAME] because there was not anything effective available for him/her to take. He/she said she,she just hurts between doses; -He/she asked for the [MEDICATION NAME] often to help deal with the anxiety caused by being in pain; -Pain limited his/her daily activities and interrupted his/her sleep regularly; -He/she could not take a step without pain. He/she dreaded waking up because there was nothing he/she could do to help the pain. He/she had worked hard all his/her life but felt lost, ready to give up, and he/she had no purpose. Observations of the resident throughout the survey, 03/21/17 - 03/27/17, showed the resident spent most of the days laying on his/her bed. The resident grimaced when he/she moved his/her legs. He/She rode a scooter outside during the scheduled smoke breaks. Record review of the facility's form titled Pain Interview and Reviews dated 12/1/17, 12/8/17, 12/16/17, 12/22/16, 1/8/17, 2/2/17, and 2/17/17, showed the following: -On a scheduled pain medication regime; -Received PRN pain medications; -No non-medication intervention administered; -Occasional pain, rated at 8 out of 10 present at the time of the assessment interview; -Pain limited the resident's daily activities and made it hard for the resident to sleep; -Pain intensity rated at 8 out of 10; -Staff documented the pain regimen and plan of care reviewed and currently meets the residents' needs. Review of the resident's medical record showed staff did not document Pain Interview and Reviews for March 2017. Record review of the physician's progress notes, dated 2/17/27 and 2/28/17, showed no documentation regarding the resident's pain. Record review of the resident's March 2017 physician's orders [REDACTED]. During an interview on 3/24/17, at 9:40 A.M., Licensed Practical Nurse (LPN) F said the following: -Staff documented a pain score each shift based on a scale of 1-10. The number documented was the highest level of pain the resident experienced during the shift; -Staff did not document a pain level when administering a pain medication; -When a resident's pain was not controlled with the current pain medication regimen, he/she would notify the resident's physician; -Resident #11 had chronic pain for many years; -Since the resident's admission, the resident had reported [MEDICATION NAME] upset his/her stomach and did not help with the pain; -He/she had not reported the [MEDICATION NAME] upset the resident's stomach and did not help with pain to the resident's physician; -The resident often asked for the PRN [MEDICATION NAME]. Pain made the resident nervous and anxious; -He/she did not know why the physician did not respond to the faxed request on 11/11/16 for a [MEDICATION NAME] or pain medication; -He/she did not know if nursing staff followed-up with the physician regarding the fax. During an interview on 3/24/17, at 10:00 A.M., Certified Nurse Aide (CNA) A said the following: -The resident often said he/she was hurting or was having a bad day; -When the resident got up from the bed to get on the scooter he/she grimaced and groaned; -He/She had not told the nurse the resident was having pain and groaning. The CNA said the resident saying it was a bad day was typical. During an interview on 3/24/17, at 3:00 P.M., CNA J said the following: -Whenever the resident changed positions he/she grimaced and groaned; -The resident often said his/her back hurt; -CNA J told the charge nurse whenever the resident complained of pain; -The resident did not ask for a pain medication when he/she complained about pain. CNA J did not know if the resident had a physician's orders [REDACTED]. During an interview on 3/24/17, at 11:55 A.M., the physical therapist said the following: -Therapy worked with the resident when the resident first came to the facility; -The resident complained of pain often in his/her knee. She used ultrasound and stretching exercises to try to relieve the resident's pain; -Pain medication was the best option for the resident's pain control due to the resident's history of multiple fractures, surgeries and chronic pain. Non-pharmacological interventions would not be effective in relieving the resident's chronic pain except for a short duration of time; -She discharged the resident from therapy when the resident stopped making progress. During an interview on 3/24/17 at 3:40 P.M., the resident's physician said: -He had seen the resident one time since the resident's admission in November 2016; -The resident suffered multiple fractures in a motor vehicle accident [AGE] years ago; -The resident was dependent on pain medication; -He was not aware [MEDICATION NAME] upset the resident's stomach; -He had not talked with the resident about what pain medications the resident took prior to coming to the facility; -He did not know why he ordered artificial tears in response to a fax asking about a [MEDICATION NAME]; -The nursing staff did not inform him the resident had breakthrough pain; -He expected the nursing staff to notify him if he needed to alter a resident's pain medication regimen. 3. Record review of Resident #1's face sheet (admission data) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's Pain Interview and Reviews dated 12/23/16, 12/29/16, 01/06/17 and 01/18/17, showed the following information: -The resident received pain medications on an as needed basis; -The resident did not receive any non-medication interventions to treat his/her pain; -The resident did not report pain reported at the time of the review, but reported he/she had occasional pain; -Staff documented the pain regimen and plan of care currently met the residents'. needs. Record review of the physician's progress notes showed the following: -On 02/12/17, the resident continued to complain of painful knees. [DIAGNOSES REDACTED]. -On 03/03/17, the resident's condition was unchanged and both knees continued hurting with arthritis. Record review of the resident's care plan, dated 01/06/17, showed staff identified the resident's potential for pain was related to the [DIAGNOSES REDACTED]. -Coordinate with the physician to manage pain medication for optimum pain control; -Observe for effectiveness of medication; -Observe for non-verbal signs of pain, including facial expressions, pulling away and fighting; -Observe for factors that increase or decrease pain; -Attempt to measure the resident's pain level using the pain scale from 0-10; -Keep the resident and family informed of pain regimen; -Administer medications as ordered by the physician. Record review of the resident's March 2017 MAR indicated [REDACTED] -An order dated 12/22/16, [MEDICATION NAME] (a narcotic pain medication) 10-325 mg to be given by mouth every six hours as needed for pain; -On 03/23/17, the physician prescribed [MEDICATION NAME] 7.5/325 mg, one tablet by mouth routinely twice a day for pain; -On 03/24/17, the physician increased the [MEDICATION NAME] to 10/325 mg, one tablet by mouth routinely to three times a day for pain. Additionally, the physician prescribed Tylenol 325 mg, give two tablets by mouth every six hours as needed for pain or fever. -The 6:30 A.M. pain administration entries showed staff documented a zero (indicating no pain) for 23 of the 26 days. On 03/09/17 and 3/25/17 staff documented a six and on 03/26/17 staff documented an eight; -The 2:30 P.M. pain administration entries showed staff documented the resident reported pain daily from 03/04/17 through 03/10/17 and on 03/14/17, 03/20/17, 03/22/17, 03/23/17 and 03/24/17; -The 10:30 P.M. pain administration entries showed staff documented the resident reported pain on 03/03/17, 03/04/17, 03/10/17, 03/11/17 and 03/22/17. -The resident did not receive pain medication on 03/21/17; -Directed staff to chart the highest degree of pain by scale of 0-10 for the shift. During an interview on 03/21/17, at 3:30 P.M., the resident said the following: -When he/she asked for pain medication at midnight last night and the night shift nurse told the resident the facility was completely out of the resident's pain medications; -At approximately 9:00 A.M., LPN C told the resident the pharmacy had not delivered his/her medications when he/she asked for a pain medication this morning -LPN C told the resident the emergency medication kit had pain medications in it; -He/She called staff at approximately 11:30 A.M. this morning asking for his/her pain medications a second time; -LPN C told the resident he/she forgot to get the resident's pain medication earlier this morning; -LPN C told the resident that he/she was planning on giving the resident the pain medication before his/her physical therapy session; -LPN C administered the resident's pain medication at 1:30 P.M. During an interview on 03/22/17, at 9:10 A.M., the resident said the following: -The resident asked for a pain pill at 8:30 P.M. last night; -The staff told the resident the facility was out of his/her pain medications; -The staff offered the resident a Tylenol for his/her knee pain when the resident rated the pain at ten on the one to ten scale; -The staff did not follow-up on the effectiveness of the Tylenol for his/her knee pain; -This morning the resident rated his/her knee pain at 15 and asked for pain medication; -I don't understand how they could run out of my medications, it makes me disgusted. Record review of the resident's nurses' notes completed by the Assistant Director of Nursing (ADON) showed the following information: -On 03/22/17, at 2:05 P.M., the resident was sitting up in the recliner and was tearful. The resident reported to the ADON he/she was upset because he/she did not have any pain medications available and his/her knee had been hurting earlier this morning. The resident reported he/she had pain medication earlier this morning, but did not have any pain medication this past weekend. The resident received pain medication one time each day over the past three to four days. -On 03/22/17, at 5:00 P.M., the charge nurse notified the physician about the resident's current pain medication regimen and redness to the resident's right leg. The physician prescribed pain medication twice a day for the resident; -On 03/23/17, at 3:29 P.M., the resident became tearful and reported he/she was having pain. The resident said he/she received Tylenol, but the Tylenol does not help the pain. The resident was able to repeat the orders and instructions given to him/her yesterday for the routine pain medications twice a day and Tylenol for breakthrough pain. The resident reported these pain medications are not enough. During an interview on 03/22/17, at 3:40 P.M., LPN C said the following: -The pharmacy delivers refilled medications every night; -There are currently two residents, including Resident #1, who are out of medications; -Staff gave Resident #1 Tylenol instead of the narcotic pain medication since the facility does not have the resident's pain medication available; -The staff should document the resident's highest level of pain for the entire shift; -The nursing staff should administer pain medications for a resident having breakthrough pain and notify the physician; -The resident's MAR indicated [REDACTED] -There is no documentation of the resident receiving pain medication on 03/21/17. During an interview on 03/23/17 at 10:10 A.M., the social services director (SSD) said on 03/22/17, he/she spoke with the resident who became tearful and expressed concerns about his/her pain medications. The SSD spoke with LPN C about the resident's concerns and the LPN said he/she would notify the resident's physician. During an interview on 03/24/17, at 10:13 A.M., the ADON said the following: -The pharmacy delivers medications every night; -She was unaware of any residents not having their medications available; -On 03/22/17, she spoke with Resident #1 who was crying and in pain; -The resident said the facility was out of her pain medications over the weekend; -The resident said his/her knees were hurting again. The ADON and LPN C evaluated the resident's legs and found concerns of possible [MEDICAL CONDITION] (bacterial skin infection) in the residents' legs; -LPN C did not tell the ADON the resident was out of his/her pain medications; -On 03/22/17, Resident #1 was in obvious pain; -Staff should notify the physician when a resident has breakthrough pain (severe pain that erupts while a resident is already medicated with a long acting pain medication and the nurse should document the complaint in the nurse's notes; -A resident should never have uncontrolled pain, it creates more fear and is upsetting to the resident. 4. During an interview on 3/27/17, at 2:30 P.M., the DON said the following: -Nursing staff should assess residents for pain each shift, using a scale of 1-10 for alert and oriented residents or a nonverbal scale for residents who were not alert and oriented; -Nursing staff should rate residents' pain when administering a PRN pain medication; -Nurses should notify the physician when a resident's pain medication was not effective; -Staff should offer non-pharmacological interventions for pain such as distraction, reposition, massage, cold packs and use pillows to make comfortable to help relieve pain. Staff should document in the nurses notes whenever a non-pharmacological intervention is used. 5. Record review of the facility's policy titled Skin Infection Guidelines, dated 10/01/10, showed the following: -Certified Nursing Assistant (CNA) will conduct body inspections of residents at risk for pressure sores on a daily basis. Results of inspection will be documented on the body audit sheet or in Smart Charting beside the appropriate resident's name. A skin concern identified by the CNA will be reported to assigned licensed nurse immediately. The CNA will document the nurse it was reported to on the body audit sheet or report changes recorded in Smart Charting. All body audit sheets will be shared with the assigned licensed nurse and the licensed nurse will submit the body audit sheets to the DON or designee. The body audit sheets will be reviewed by the treatment nurse or designee for new skin concerns and findings will be presented at the Quality Assurance (QA) skin sub-committee. Treatment nurse or designee will review for appropriate measures taken and report at morning meetings; -Licensed nurses will conduct body inspection of residents at risk for pressure sores on a weekly basis per schedule. The DON will ensure that a weekly schedule is developed and implemented. The licensed nurse will document findings of the inspection on the MAR, which is individualized for each resident. Any skin concerns identified by the licensed nurse will be reported to the designated treatment nurse immediately for evaluation and treatment orders. If the treatment nurse is unavailable, the nurse identifying the concern should evaluate the wound and notify the physician for initial treatment orders. Any skin concerns identified will be presented at the morning meeting. Weekly results will be reviewed at the QA skin sub-committee meeting; -CNA body audit records will be maintained in the DON's office for 90 days in a QA binder if manual sheets and reviewed by the DON if electronic. Record review of the facility's Wound and Skin Management Protocol dated 10/01/10, showed the following skin management: -Perineal excoriation: Diaper rash or red bottom is the erosion of skin caused by excessive moisture and/or irritation in urine and feces. Suggested treatment: Cleanse area and apply protective ointment as needed; -Skin Tears: Abrasions, suture lines, cuts, or lacerations. Suggested treatment included cleanse area and cover with transparent dressing or protective ointment. If the skin is too fragile, then cover the tear with foam dressing and secure it with a retention bandage. Change the dressing 3 times per week or as needed. Record review of the facility's policy titled Change in Medical Condition of a Resident dated 11/28/16, showed the following: -Notification of the physician, legal representative, or interested family member, should occur promptly when there is a change in the resident's condition; -Change in condition is defined as: An accident involving the resident which results in injury and has the potential for requiring a physician intervention; A significant change in the resident's physical, mental or psychosocial status; A need to alter treatment significantly; A decision to transfer or discharge the resident from the facility; -Examples of a change in condition may include: overall deterioration of condition, accidents or incidents resulting in suspected injury, decline in Activities of Daily Living (ADL- dressing, grooming, bathing, eating, and toileting) skills, new behavioral problems, new pressure ulcer or wound, or new pain; -In a non-emergency situation, contact the physician and legal representative/family during normal office and daylight hours no later than the next day. -Document the symptoms and observations associated with the change in condition, the date and time of contact with the physician and family member/legal representative. Notes should include comments on the care provided by nursing personnel; -The 24 hour shift report serves as a reminder to report any change in condition to the oncoming shift and to notify a physician and/or family member; -Further assessment may be warranted with certain permanent changes in condition; -A change of condition may prompt an update to the MDS within 14 days of determining the change of condition exists; -The plan of care may be altered to reflect a change in condition where new goals and approaches are developed. 6. Review of Resident #10's medical record showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. (a progressive movement disorder), chronic pain (pain persisting for a long time or recurrent) , major [MEDICAL CONDITION] (a persistent depressed mood), and anxiety disorder (increased anxiety that interferes with daily life). Record review of the resident's quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Cognitively intact; -Weight of 501 pounds (lbs); -Extensive staff assistance required for transfers, bed mobility, bathing, dressing, and personal cares; -At risk for pressure ulcers; -No pressure ulcers or open [MEDICAL CONDITION] on the skin. Review of the resident's medical record dated 12/01/16 through 03/27/17 showed staff did not document a wound assessment or management of a wound. Record review of the residents' MAR, dated 12/01/16 through 03/24/17, showed a nurse documented a weekly skin audit. The nurse did not document new wounds on the resident. Record review of the daily New Skin Audit Report Roster, completed by CNA's, showed the following: -On 12/07/16, staff identified a new skin problem and notified the nurse; -On 12/15/16, staff identified a new skin problem and notified the nurse; -On 12/20/16, staff identified a new skin problem and notified the nurse. Record review of the resident's nurses' notes showed the following: -From 12/16/16 through 12/28/16, staff did not document skin breakdown; -On 12/29/16, the physician gave a new order for a dressing to the resident's posterior thigh (side not specified); -From 12/30/16 through 12/31/17, staff did not document skin breakdown. Record review of the December 2016 treatment administration record (TAR) showed the following: -An order to apply a thin layer of [MEDICATION NAME] (a topical antibiotic cream) to the the residents bilateral posterior thighs and buttocks open areas, followed by zinc oxide twice a day. Staff initialed the treatment 52 of 56 times; -An order to cleanse the moisture associated excoriation on the resident's left posterior thigh with wound cleanser, pat dry, apply Ilex (a skin protectant paste) to the open area, cover Ilex with Vaseline, cover the area with superabsorbent dressing and secure with tape; -Observe the dressing to the left posterior thigh every shift and replace the dressing if soiled or missing. Record review of the daily New Skin Audit Report Roster, dated 01/05/17, showed staff identified a new skin problem and notified the nurse. Record review of the resident's nurses' notes showed the following -From 01/01/17 through 01/10/17, staff did not document skin breakdown; -On 01/11/17, staff documented the resident had a moisture related rash to the inner groin and healing excor

Based on interview and record review the facility failed to provide care and services to inform or request permission for one resident's (Resident #39's) court appointed guardian prior to allowing the resident to leave the facility for an extended period of time (10 days). Resident #39 has a guardian and a known history of drug/[MEDICAL CONDITION] with his/her significant other. The resident's significant other asked to take the resident on a leave of absence for 10 days. Staff did not inform the resident's guardian or physician before allowing the resident's significant other to take him/ her from the facility. Additionally, staff called the resident's physician to inform him/her that the resident was leaving the facility, but did not report who would be providing care for the resident or where the resident was going. The resident left the faciity on [DATE], and on 12/20/13 went from the significant other's home to the emergency room . The resident tested positive for [MEDICATION NAME] and [MEDICATION NAME]. The hospital admitted the resident to the intensive care unit with [DIAGNOSES REDACTED]. Interviews with the resident's guardian and physician both showed that had they known, they would not have approved the resident leaving the facility. The facility census was 106. Record review of Resident #39's hospital records showed the following information: -The hospital admitted the resident in January of 2013 for an intertrochanteric fracture ([MEDICAL CONDITION]), altered mental status, and questionable Weirnicke's [MEDICAL CONDITION] (presence of neurological symptoms caused by [MEDICAL CONDITION] of the central nervous system commonly regarded as a condition peculiar to malnourished people with alcohol misuse); -History of alcoholism. Record review of the resident's history and physical dated, 6/13/13, showed the following information: -Prior to the hospital admission the resident was allegedly unresponsive for two days; -Required mechanical ventilation. Record review of the resident's medical record showed on 6/27/13, the hospital made a motion for emergency guardianship based on assessment and medical evaluation. The court documents showed the resident had poor judgment, required constant supervision, and was unable to manage his/her affairs. The resident lived with a significant other prior to the hospital admittance on 6/13/13. The court appointed the resident an emergency guardian on 6/27/13. Record review of the resident's health record showed on 6/28/13, the resident was served with a notice of hearing for guardianship. Further review showed the resident was appointed an attorney for representation on the same date. Record review of the resident's medical record showed on 7/16/13, the hospital social services department documented the hospital notification of the emergency guardianship approval for the resident. The court appointed the public administrator (PA) to make decisions for the resident through the guardianship hearing. The hospital Social Services department documented notification of the admission coordinator of the facility to the change in the resident's guardianship status. Record review of the hospital's discharge summary, dated 7/17/13, showed the following information: -Poor social support; -Requires a guardian and long term care placement; -The hospital physician documented the resident's significant other believed the resident was too intoxicated and drug the resident out in the yard. A passerby observed the resident in the yard and notified 911 and the resident was transferred to the hospital where it was deemed he/she required inpatient care and mechanical ventilation. Record review of the hospital's patient transfer form, dated 7/17/13, showed the following information: -Guardian; -Altered mental status secondary to [MEDICAL CONDITION]; -[MEDICAL CONDITION] (term that means brain disease, damage, or malfunction); -[MEDICAL CONDITION]; -Brainstem stroke; -Poor social support. Record review of the resident's facility face sheet, dated 7/17/13, showed the staff failed to identify a court appointed guardian for the resident. Record review of the facility nurse's note, dated 7/17/13, at 3:34 P.M., showed the resident arrived at the facility and the facility staff admitted the resident. Record review of the facility preference/return to the community review, dated 7/22/13, at 1:48 P.M., showed the Social Services Director (SSD) documented the resident had no legal guardian or legally authorized representative. Record review of the facility social admission review, dated 7/22/13, at 1:52 P.M., showed the SSD failed to identify a legal guardian. During an interview on 12/26/13, at 1:30 P.M., the SSD said he does not review the resident's chart to complete this assessment. He said he would ask the resident. He said he does not review the chart prior to completing scheduled assessments, but that he reviewed the face sheets. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment completed by facility staff, on 7/31/13, showed staff documented the resident had no guardian or legally authorized representative. Record review of the resident's permanent medical record showed on 8/7/13, the Twenty-ninth Judicial Circuit Court of Jasper County Missouri declared the resident incapacitated and granted the Jasper County Public Administrator (PA) as the resident's guardian. Record review of the resident's care plans showed staff failed to identify the PA, guardian, or legal representative since admission to the facility on [DATE]. Record review of the facility nurses' notes, dated 10/7/13, showed the following: -At 5:44 P.M., staff documented the resident acted different from his/her normal behavior, and the resident had slurred speech and laughed more than normal. Staff documented the resident's significant other and another male had been in earlier that day and stayed with the resident for approximately 30 minutes. Staff said the visitors took the resident outside to smoke. Staff questioned the resident and asked if his/her significant other had brought him/her something. The resident shook his/her head yes. Staff documented the resident admitted to drinking alcohol (whiskey); -At 6:31 P.M., staff documented the physician said the significant other should not be allowed back into the facility. Staff documented contacting the facility managers. During an interview on 12/26/13, at 1:30 P.M., SSD said he was not aware of the resident's significant other bringing the resident alcohol, or the physician's order not allowing the significant other back in the facility building. He said the nursing department did not notify him of the event and he did not review the nurses' notes. During an interview on 12/26/13 at 2:12 P.M., Licensed Practical Nurse (LPN) A said he/she noticed the resident was acting differently following a visit from the resident's significant other. He/she discussed with registered nurse (RN) D the difference in the resident's behavior and LPN A contacted the resident's physician regarding the resident saying the significant other brought him/her alcohol. The resident's physician said the significant other should not be allowed to have contact with him/her. LPN A made a note in the resident's medical record regarding the conversation with the physician. He/she discussed the order with RN D who contacted the acting Director of Nursing (DON) regarding the events and the physician order. LPN A wrote out a note and put it in the SSD's mailbox to make him/her aware of the situation. He/she is not aware of what happened regarding the situation from there. During an interview on 12/26/13, at 2:20 P.M., the Assistant Director of Nursing (ADON) (previous interim DON) said she was the acting DON in October. Nursing staff notified her of the resident's alcohol misuse in the building. Staff had said the resident's significant other brought in the alcohol. She was unaware of the physician's order for the significant other to refrain from the building. She said normally the staff would have discussed it in the next morning meeting, but was not sure whether or not they discussed the alcohol use situation. Record review of the facility's quality of life form, dated 10/30/13, and received on 10/31/13, showed the person who completed the form was the court appointed PA. The SSD documented that he faxed a quality of life form to the RP and awaited a response. During an interview on 12/26/13, at 1:30 P.M., SSD said after review, he discovered that he had contacted the significant other about the quality of life form. He said the significant other contacted the PA office. The staff at the PA office then called the facility and had the form faxed to their office for completion. He said he did not review the face sheet or question why the PA office contacted him and did not know why he sent the information to the PA's office. Record review of the facility social service review, dated 10/30/13, showed the SSD failed to complete the legal status portion of the assessment. Record review of the resident's quarterly MDS dated , 10/30/13, showed staff documented the resident had no guardian or legally authorized representative. Record review of the facility nurse's note, dated 11/22/13, at 5:37 P.M., showed the resident transferred to the hospital for medical evaluation and treatment for [REDACTED]. Record review of the nurse's note, dated 11/25/13, at 10:48 P.M., showed the facility staff readmitted the resident to the facility following a hospital stay. Record review of the facility face sheet, dated 11/25/13, showed the facility staff failed to identify guardianship of the resident. Record review of the facility nurse's note, dated 12/12/13, at 12:20 P.M., showed the resident's significant other (who the physician ordered not to be in the building) arrived at the facility to take the resident out on a leave of absence. Staff documented the significant other signed and collected the resident's medications, clothing, and said he/she would return the resident in twelve days. Record review of the nurse's notes for the month of December 2013, showed no physician order to allow the resident to leave the facility for a twelve-day period, and showed no request to the PA for a leave of absence. Record review of the physician's orders for the month of December 2013, showed no physician order to allow the resident to leave the facility for a twelve-day period with medications. Record review of the hospital emergency room notes, dated 12/20/13, showed the following information: -Presented to the hospital after the resident's significant other called 911 following a change in the resident's level of consciousness; -The resident was unable to answer questions; -The resident's significant other said the resident was cognitively intact when the resident was discharged from the nursing facility to his/her care; -The significant other said the resident had a waxing and waning (increase and decrease) in orientation; -The significant other said the resident developed diarrhea and complained of abdominal pain; -The resident had a low blood pressure; -The resident was oriented to self, only; -Acute kidney failure. Record review of the resident's hospital history and physical dated 12/20/13, showed the following information: -[MEDICAL CONDITIONS]; -Diarrhea; -History of stroke; -History of alcoholism; -Episodes of altered mental status; -Positive drug screen for [MEDICATION NAME]; -Positive drug screen for [MEDICATION NAME]; -Brought into the hospital by his/her significant other when he/she had an increase in his/her confusion; -admitted the resident to the intensive care unit. Record review of a typed and signed statement by the SSD, dated 12/20/13, showed the following information: -The significant other had contacted the SSD regarding a twelve-day leave of absence; -The SSD asked nursing to contact the physician and get a discharge order for a twelve-day leave of absence; -The SSD received a phone call from the resident's son who said the resident had been admitted to the hospital; -The SSD and the son discussed guardianship, and SSD told the son that the resident did not have a guardian; -The SSD received the son's contact information and went to file the information; -The SSD said when he went to file the information, the contact information and the resident's face sheet varied. The resident's face sheet had the significant other listed as the responsible party, and the contact information showed the PA was the guardian and responsible party; -The SSD documented that if he had remembered that the resident had a PA, the normal protocol would be to have the family member contact the PA for all leave of absences; -The SSD documented that due to just looking at the face sheet SSD did not think of any other person's involvement with the resident. During an interview on 12/20/13, at 3:48 P.M., the PA said the hospital had contacted him/her and reported that his/her resident was admitted to the hospital on [DATE] through the emergency room . The PA said the resident somehow ended up out of the facility on a twelve day pass. He/she said he/she would never have allowed a twelve day pass for any resident. The PA said the most he/she had ever allowed a resident for a pass was seven days. The PA said the facility never notified him/her or asked for permission for the resident's leave from the facility. The PA said records showed on 10/14/13, the PA's office spoke with the SSD to setup a care plan meeting. (The SSD at the facility said he was unaware the resident had a court appointed guardian). During an interview on 12/20/13, at 4:56 P.M., the SSD said they keep the guardian paperwork in the front of the chart behind the face sheet. He said the resident's guardian paperwork was not in the chart because the chart was thinned more than once. He said the resident was discharged and re-admitted on [DATE] so the chart was thinned at that time. He said he does not review the face sheets on re-admits. During an interview on 12/26/13, at 1:30 P.M., SSD said he had documented the resident as being his/her own person and thought that information was correct at the time of the statement. He said he did not realize there was a problem with the face sheet on 12/20/13. During an interview on 12/20/13, at 6:45 P.M., the business office manager (BOM) said the newly admitted residents that arrive during normal business hours from 8:00 A.M., to 5:00 P.M., personal information is entered by him. He said if the resident is admitted after business hours the nurses have a demographic page to complete with basic information like the date of birth, social security number, gender, name, and resident number. He said he entered the other information on the next business day. He said he enters the guardian information off of the hospital face sheet and he gets the rest of the information when the contract for care is signed. He said the nursing staff never gave him the hospital discharge summary or the emergency guardianship paperwork. Record review of the typed and signed statement by the Director of Nursing (DON), dated 12/20/13, showed the following: -The DON assisted the significant other with medication review; -The DON called the SSD and verified the resident had permission to go with the significant other on a leave of absence; -The DON verified the significant other on the face sheet (which still listed him/her as the responsible party); -The DON assisted the significant other with signing the resident out of the building. During an interview on 12/23/13, at 9:15 A.M., the primary care physician (PCP) said he had recently taken over the resident's care due to her regular PCP was out for an extended amount of time. He said he did not really know much about the resident. He said the facility did contact him for a leave of absence, but he was unaware for how long. He said he expected the facility to notify the responsible party or guardian prior to the resident being released from the facility. He said he has never had any problems with that process. He said he was unaware of the resident's history or the situation prior with the significant other, but said if he had been aware, he would have not let the resident leave with the significant other. He said he would not have placed the resident in a home with the history of the significant other dragging the resident out to the yard and leaving him/her there inebriated while he/she required medical attention. During an interview on 12/23/13 at 1:15 P.M., LPN B said he/she would look at the contact information on the face sheet to determine the contact person for a resident. Upon admit to the facility, DPOA or guardian information is included in the admission paperwork from the hospital. When a resident is going out of the facility on pass, he/she would contact the physician and request an order for [REDACTED]. During an interview on 12/23/13, at 1:20 P.M., the DON said the face sheet information is filled out by whoever entered the information. She said that usually falls on the financial department. She said there was no policy previous to this event, but one had just been implemented and staff in-services were currently being completed to have face sheet and guardianship status reviewed daily. She said all information sent from the hospital will be reviewed daily in the clinical meeting that consisted of the DON the assistant director of nursing (ADON), and the medical records nurse. She said staff are now expected to document in the nurses' notes when the physician was contacted, how long the resident will be gone, and physician permission for the leave of absence. She said she was unaware of the history between the resident and his/her significant other. She said she expected SS to review the RP or guardian status with care plan reviews. She said the guardianship papers should be transferred to a new chart on a new admission or re-admission. During an interview on 12/23/13 at 1:22 P.M., LPN C said when a resident admits to the facility, the paperwork for DPOA or guardianship will come as part of the admission packet from the hospital. If no paperwork comes, he/she would contact the resident or the family to determine if there is a DPOA or guardian for decisions. If it is determined the resident has a guardian, he/she would contact the guardian and request copies of the paperwork. If the resident has a guardian, the guardian should be contacted regarding permission for the resident to go on a pass. He/she would contact the resident's physician regarding the resident going out for a pass. During the phone call, he/she would relay the length of the pass to the physician along with obtaining orders for medications to be sent out with the resident. Record review of the facility face sheet, dated 12/24/13, showed staff listed the PA as the responsible party and guardian. Record review of the facility nurse's note, dated 12/25/13, at 12:45 A.M., showed facility staff readmitted the resident at approximately 8:00 P.M., the previous evening on 12/24/13. Staff documented the PA said the resident's significant other is not allowed to see the resident at this point. During an interview on 12/26/13, at 1:30 P.M., SSD said he was not aware the resident had a court appointed guardian prior to 12/20/13, when the resident admitted to the ICU. During an interview on 12/26/13, at 1:30 P.M., the administrator said staff did not notify him of the physician order for [REDACTED]. MO 474 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on 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. During the onsite visit, the facility trained staff on proper communication of residents ' responsible parties. The nurse management team reviewed all residents ' clinical records to ensure they listed the correct responsible parties. The facility implemented a Quality Assurance plan to monitor and ensure the residents ' responsible parties stayed correctly listed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit on 12/26/13, the severity of the deficiency was lowered to a "G" level. This statement does not denote that the facility has complied with State law Section 198.026.1 RSMo.

Based on observation, interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-for residents when staff failed to accurately assess the skin condition of two residents (Resident #3 and #12) with venous stasis ulcers (due to poor circulation). On 12/19/12, one resident (Resident #3) developed a fever, with redness, pain and warmth in his/her left lower leg. Staff delayed administering the ordered antibiotic for over 24 hours. The nurse aides also reported a rash on the resident's back and groin area. Nurses did not further assess or report the areas to the physician. By 12/22/12, the resident had swelling, redness and blisters on his/her left lower leg. The resident also had dark discoloration of the entire sacral (lower back) region with a general decline in condition. The resident was sent to the hospital for infection of the leg that had spread to his/her blood (sepsis). The resident required surgical removal of necrotic (dead) skin, subcutaneous tissue and tendon from the heel. The resident also had a large saddle type sacral decubitus ulcer that came close to, but spared, the anus that required surgical removal of skin and a significant amount of subcutaneous tissue that exposed muscle at the base of the wound. Staff also failed to appropriately and accurately assess, monitor, and treat pain for these same two residents (Resident #3 and #12) whom staff were aware experienced pain when staff treated and dressed extensive, deep tissue wounds. Staff did not pre-medicate the residents before scheduled dressing changes or stop the process when the residents expressed pain verbally and with noticeable body language. Nineteen residents plus six additional residents were chosen for review in a facility with a census of 107. 1. Record review of Resident #3's recent quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment to be completed by facility staff, dated 10/24/12 showed the following information: -Stroke; -High blood pressure; -Dementia; -Has unclear speech and is rarely/never understood; -Clear understanding of others; -Sometimes responds adequately to simple, direct communication only; -Has behavioral symptoms not directed toward others (e.g., verbal/vocal symptoms like screaming, disruptive sounds or physical symptoms like rummaging or scratching self) at least 4 to 6 days a week; -[MEDICAL CONDITION] ([MEDICAL CONDITION] - causes decreased blood flow to legs and feet); -Diabetes; -Generalized pain; -Independent bed mobility; -One person limited assistance needed with transfers; -One person extensive assistance needed with ambulation in and out of room; -One person limited assistance needed with dressing, toileting, bathing and personal hygiene; -Not able to stabilize balance without human assistance; -Functional limitation in Range of Motion (ROM) of arm and leg of one side; -Utilizes a walker or wheelchair for mobility; -Always continent of bowel and bladder; -At risk for developing pressure ulcers; -No venous and arterial ulcers present. Record review of the December 2012 Medication Administration Record [REDACTED] -Tylenol 325 mg (milligram) caplet. Give two caps every four hours PRN (as needed) for pain; --[MEDICATION NAME] (non-narcotic pain medication) 50 mg tablet. Give two tabs Q (every) four hours PRN pain. Record review of the nurses notes dated 12/19/12, at 3:42 P.M., showed staff found the resident on the floor in his/her room. Aside from a small red scraped area to the resident's right posterior shoulder, no other new red bruised or open areas were noted related to the fall. Neuro (neurological) checks (checks to determine signs of [MEDICAL CONDITION]) were within normal limits. Left lower leg very red, painful and warm to the touch. Physician notified of the fall and leg problem. The resident's temperature at one point showed 101.5 degrees. Record review of the December 2012 MAR indicated [REDACTED].M. for generalized pain. Staff did not administer medication for pain relief following the 3:42 P.M., assessment. Record review of the nurses notes dated 12/19/12, at 6:53 P.M., showed Late Entry: At approximately 5:00 P.M., spoke with the physician and gave an update of the resident's left leg redness and temperature earlier this day. Physician ordered lab blood work for the morning and to start [MEDICATION NAME] 100 mg (antibiotic) administered BID (twice daily) for 10 days. The nurse documented "No [MEDICATION NAME] available in the E-kit (emergency kit), faxed order to pharmacy in hopes they will bring antibiotic in delivery this shift." Record review of the nurses notes dated 12/20/12, at 2:03 P.M., showed antibiotic had not been received from the pharmacy at this time. As needed (PRN) [MEDICATION NAME] (pain medication) administered for pain, leg remains red and weepy (seeping serum from pores). Record review of the December 2012 MAR indicated [REDACTED]. According to physician orders [REDACTED]. Staff documented one pain assessment on 12/20/12, at 6:30 A.M.. Staff recorded the resident's pain as"0" (no pain - on a scale of 1 to 10). Record review of the December 2012 MAR indicated [REDACTED].M. (28 hours since ordered). At 9:08 A.M., staff documented [MEDICATION NAME] 50 mg tablet was effective to reduce pain but pain is still present to bilateral lower extremities. Physician notified. During an interview on 01/11/13, at 2:55 P.M., LPN G said he/she received the order from the physician to start the antibiotic but it was not available in the E-Kit (Emergency Kit). LPN G said he/she faxed the pharmacy but the medication never arrived. LPN G did not call the pharmacy. Observation of the facility E-Kit on 01/11/13, at 3:00 P.M., showed [MEDICATION NAME] listed as one of the antibiotics held in the E-Kit stock. Record review of the E-kit log sheet showed LPN G never broke the lock to look inside the box for the antibiotic. During an interview on 01/14/13, at 1:45 P.M., the Pharmacy consultant said the pharmacy shut their phones off at 5:00 P.M. and an answering service takes after hour calls. The pharmacy does make after hour deliveries. A fax arrived from LPN G on 01/19/12, at 5:26 P.M., but it was not viewed by pharmacy staff until the next morning. The antibiotic was filled and delivered that afternoon. The resident received the first dose at 9:00 P.M. on 12/20/12. During an interview on 01/10/13, at 1:35 P.M., the facility medical director said he would expect staff to administer an ordered antibiotic on the same day. Record review of the nurses notes on 12/22/12, at 2:50 A.M., showed staff assisted the resident to bed at 11:30 P.M. Staff noted swelling and redness to lower left leg, with blisters present. Resident has a dark discoloration of the buttocks, appearance is deep purple bruising color, entire saddle (sacral region, triangular-shaped bone at the bottom of the spine) is discolored. Resident is combative and not cooperating with staff. There is no evidence staff notified the physician of this new development at that time. Record review of the nurses notes dated 12/22/12, at 7:00 A.M., showed staff notified the physician of the resident's decline in condition. Respirations shallow and the resident now required oxygen, extremities cold to the touch, resident's level of conscious decreased and not responding appropriately to questions. [MEDICAL CONDITION] (a spreading bacterial infection just below the skin surface) left lower leg continues to weep and be painful. Resident sent to the hospital. Record review of the December 2012 MAR indicated [REDACTED]. Record review of the resident's skin monitoring form titled, "CNA Resident's Daily QA Body Audit forms" (provided to surveyors for review) showed from 12/16/12 to 12/22/12, staff identified and reported a rash on areas of the resident's under arm, back and groin. On 12/19/12, staff reported to the charge nurse of the resident's reddened left lower leg. On 12/21/12 and 12/22/12, staff reported to the charge nurse of the resident's left lower leg redness with swelling and oozing pus. Record review of the December 2012 nurses notes did not show the nurses completed any followed-up assessments of the rash identified by the CNAs on the Body Audit Forms. Nurses notes and POS showed they physician had not ordered any treatments for the rash identified. On 12/21/12, nursing documented no rash observed. During interview on 01/10/13, at 5:45 P.M., the Director of Nurses (DON) said all CNAs should use the skin audit tool every shift and submit this to the charge nurse. New areas identified should be assessed by the nurse. The charge nurse communicates with the treatment nurse for wound care. LPN C (the wound nurse) views the skin audit sheets every morning. If there are new skin issues, LPN C notifies the physician. Record review of the hospital History and Physical assessment dated [DATE], showed the resident was admitted to hospital #1 due to difficulty breathing. The resident's entire leg red, tender, swollen with weeping blisters. [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) were administered and the resident transferred to hospital #2. Among the [DIAGNOSES REDACTED]. Record review of an Operative/Procedure Note dated 12/26/12, showed the following information: -Resident admitted to hospital #2 on 12/22/12, with severe [MEDICAL CONDITION] of his/her left lower leg with necrotic (dead) tissue in the foot. Resident also developed a large sacral decubitus ulcer and necrotic tissue on his/her foot, especially the heel; -Surgically removed necrotic skin, subcutaneous tissue and tendon from the heel. Wound measured 8 x 5 cm; -Surgically removed new necrotic skin from the outer portion of the foot. Wound measured 3 x 2 cm; -The wound on the inner portion of the foot measured 8 x 5 cm and had necrosis of the entire base of the wound as well as a new area of skin and subcutaneous tissue that was necrotic which measured 3 x 3 cm. Subcutaneous tissue, tendon and skin was surgically removed from these areas; -The resident had a large saddle type sacral decubitus ulcer that came close to, but spared, the anus. The right side of the involved area of skin was 20 cm in length, the left side was 16 cm in length and the [MEDICATION NAME] diameter was 12 cm. Skin and a significant amount of subcutaneous tissue were removed exposing muscle at the base of the wound. The surgical area involved measured 20 x 12 cm. Record review of the nurses notes dated 01/03/13, showed palliative orders now in place and Hospice service referral made. Resident to transfer back to the facility today. Record Review of the POS [REDACTED].M., showed the resident in pain and kicked at the nurse when he/she touched the resident's left lower leg. Dressings were changed this morning per RN (Registered Nurse). Resident is on palliative care and will reassess tomorrow to see if pain is better controlled. Resident/family has deferred assessment. When a resident is dying, the skin, like other body organs, becomes vulnerable to impairment and pressure-related injuries. At this time, palliative wound care should be the focus while providing skin care, repositioning as tolerated, minimizing/eliminating friction and shear forces, minimizing pain, etc., in order to promote comfort and honor resident's wishes during the end-of-life process. Record review of the nurses notes dated 01/03/13, showed the resident returned to the facility at 7:00 P.M. The admitting nurse documented observation of a very large dressing to the coccyx (tail bone) area and another very large dressing to the left lower extremity from the knee down. Record review of the January 2013 physician order [REDACTED]. -On 01/03/13, [MEDICATION NAME] (narcotic pain medication) 20 mg/ml (milligrams per milliliters) give 0.25 to 0.50 ml SL (under the tongue) every two hours as needed for pain; -[MEDICATION NAME] (a combination of a narcotic with Tylenol) 5-325 tablet. Give one to two tablets every four hours as needed for pain. Record review of the resident's care plan reviewed and updated on 01/03/13, showed the following information: -Resident not to have unrelieved pain x 90 days; -No moaning, groaning, or facial grimaces; -Coordinate with the physician to manage pain medication for optimum control of pain; -Observe for effectiveness of medication; -Observe for non-verbal signs of pain (ex. Facial expressions, pulling away, fighting); -Observe for factors that increase/decrease pain; -Observe for intolerable pain. Record review of the January 2013 Physician order [REDACTED]. -01/04/13, Observed dressings daily and replace if missing or soiled; -01/04/13, Change stasis ulcers (due to poor circulation) left lower extremity dressings every other day and as needed. Replace if missing or soiled. Clean stasis ulcers with warm water/soap, rinse, apply Hydroferra Blue (sterile antimicrobial sponge wound dressing) cut to size for all ulcers. Cover with 4 x 4, secure with gauze wrap and coban (self-adherent elastic wrap) for protection. -01/08/13, Pain assessment - chart highest degree of pain by scale 0 - 10 for your shift. Chart every shift. Record review of the website <http://www.[MEDICATION NAME].com> showed the following information: -[MEDICATION NAME] Blue is a simple, safe, effective and proven moist wound dressing proven effective against a variety of microorganisms [MEDICAL CONDITION] ([MEDICAL CONDITION], is a resistant bacterial infection difficult to treat.[MEDICAL CONDITION] has developed a resistance to the [MEDICAL CONDITION] anti-infective, [MEDICATION NAME] broad-spectrum antibiotic). -[MEDICATION NAME] Blue is highly absorptive. Must be moistened with sterile saline or sterile water, squeezed out and secured to the wound bed with an appropriate secondary dressing.-Dressings should be changed every 1 to 3 days following good wound care practice. Record review of the nurses notes dated 01/04/13, at 2:39 P.M., showed the wound nurse assessed and documented a descriptive narration of the resident's wounds. The nurse documented completing the treatments to all areas as ordered. The resident was noncompliant with wound care. Record review of the January 2013 MAR indicated [REDACTED].M.). On 01/04/13, staff administered [MEDICATION NAME] 20 mg/ml 0.05 ml SL for pain at 6:53 P.M. (four hours after the treatment). Staff did not assess for or record the resident's pain level at any time on 01/04/13. Record review of the nurses notes dated 01/04/13, at 6:53 P.M., showed the resident very anxious. Staff administered [MEDICATION NAME] (antianxiety) to calm. Staff also documented at 6:54 P.M., the resident complained of hurting and administered [MEDICATION NAME] for pain. Staff did not follow up on the medication effectiveness until 2:29 A.M., (approximately 7.5 hours) the following morning on 01/05/13. Record review of the January 2013 TAR showed staff did not complete the treatment as scheduled on 01/06/13. LPN C initialed he/she completed the treatment on 1/8/13. There was no other staff initials or documentation to show staff changed the dressing from 01/03/13 (readmitted ) to 01/08/13 (the order directed staff to change dressings every other day). Record review of the nurses notes dated 01/07/13, at 11:11 A.M., showed staff administered [MEDICATION NAME] 5-325 tablets for resident complaint of pain. Staff followed up at 12:38 P.M., and documented the medication was effective. Nursing did not document anything further in the record. Record review of the January 2013, medication record showed the staff administered two [MEDICATION NAME] 5-325 tablets on 01/07/13, at 11:10 A.M. Staff administered [MEDICATION NAME] to the resident on 1/8/13 at 1:34 A.M. Staff did not initial they administered any [MEDICATION NAME] or [MEDICATION NAME] to the resident since that time. Record review of the January 2013 MAR indicated [REDACTED]. During an interview on 01/08/13, at 3:45 P.M., CNA W entered the room as the resident was yelling out. CNA U and CNA V assist with repositioning the resident up in bed. After repositioning, the resident stopped yelling out. CNA U said he/she turned the resident every two hours but the resident puts him/herself back on his/her back. Staff have used a wedge to prop him/her on his/her side but the resident is noncompliant and often throws it out of bed. The resident also has removed the dressing and packing from his/her bottom. He/she does what he/she wants. Observation and interview on 01/09/13, showed the following information:-At 8:50 A.M., licensed practical nurse (LPN) C did not wash his/her hands or use hand sanitizer. He/she removed a pair of scissors from his/her uniform pocket. LPN C did not sanitize the scissors. He/she used the scissors to cut multiple [MEDICATION NAME] blue packages into two pieces. -At 9:00 A.M., LPN C entered the resident's room and set up the wound supplies on the bedside table. LPN C set up a basin with soapy water. He/she washed his/her hands and applied gloves. CNA D was in the room with the resident. CNA D washed his/her hands and applied gloves. The LPN and CNA removed the blanket covering the resident's legs and the resident cried out, "Owe!" LPN C said" His/her leg actually hurts more than his/her bottom". LPN C did not assess the resident for pain prior to starting the treatment;-At 9:05 A.M., LPN C used the scissors and began to cut off the soiled gauze wrap dressing from the resident's lower left leg and foot. The resident winced and cried out, "Oh, Oh, Owe!" CNA D said, " I know hurts" and instructed the resident to breathe through his/her mouth and out through his/her nose, As LPN C began to pull off the soiled gauze wrap the resident winced, pulled his/her left leg up toward his/her chest and cried out, "Owe, Oh!" LPN C said, " I'm sorry," and removed the soiled outer gauze wrap dressing. CNA D remarked to the nurse about the resident, " He/she's not digging this." -The resident had a large crater-like full thickness ulcer on his/her anterior left foot that extended down the side of the foot and across the ankle near the arch of the foot. The wound bed had scattered areas of necrosis, and yellow slough (dead tissue). The ulcer had various depths, the wound edges were white, red and raw with several areas of necrosis migrating into the larger wound. The resident's left outer foot had multiple areas present. The first area near the resident's heel was an irregular shaped full thickness ulcer with a crater-like appearance. The wound bed had necrosis, and yellow slough. The wound edges were red and raw and had various depths. The second area near the top of the resident's left foot was a quarter-sized full thickness ulcer. The wound bed was white with red wound edges. The ulcer had a slight crater-like appearance. The resident's upper leg and shin had several dime-sized scabbed areas. (For the full description of the tissue involvement see the 12/26/12 Operative/Procedure Note above). -LPN C wet a cloth in a basin of warm water and wrung the water over the resident's foot. The resident winced and cried out, "Wow, oh, ow!" and pulled his/her foot up toward his/her chest. CNA D told the resident not to touch the area. The resident cried out,"Ow!" CNA D said to the resident, " I know it hurts." LPN C started to pull off the underlying dressing from the wound bed. CNA D stood by the bed and coached the resident to breath in and out and said, " Try to keep your mind off of it." The DHSS surveyor stopped the procedure and asked LPN C if the resident had pain medication prior to the treatment. The LPN said he/she was not sure but would check and see. LPN C said the resident "often refused pain medication." LPN C turned to the resident and said, " Do you want me to get you something for pain?" The resident nodded and stated clearly, "I do." -At 9:08 A.M., LPN C stepped out of the resident's room to check with the resident's charge nurse LPN E about pain medication for the resident. LPN E said the resident had not had any type of pain medication since 1/8/13 at 1:34 A.M. LPN C did not tell LPN E how much pain the resident was in and the nurses did not discuss which pain medication would be most beneficial to the resident. LPN E removed two tablets of [MEDICATION NAME] 5-325 from the medication cart, entered the resident's room and administered the medication to the resident. LPN C told the resident he/she would wait a few minutes before continuing the treatment. LPN C said the [MEDICATION NAME] usually took approximately 20-30 minutes to start working. LPN C said the [MEDICATION NAME] was fast-acting. -At 9:17 A.M., (approximately 9 minutes) LPN C did not reassess the resident's pain. LPN C said to the resident, " You want me to finish?" The resident said,"Yeah." LPN C said,"Ok, I am gonna finish." LPN C did not stop the treatment and give the [MEDICATION NAME] time to take effect. He/she wet the cloth and wrung out water over the resident's leg and foot. LPN C removed the underlying dressing from the wound bed. -At 9:21 A.M., LPN C continued the treatment and dripped warm soapy water over the open areas of the resident's left leg and foot. The resident cried out loudly,"Ow, Oh!" LPN C said,"Okay, I am stopping."-At 9:25 A.M., LPN C did not reassess the resident's pain and began to rinse the resident's foot. The resident lay in bed breathing rapidly with shoulder muscles twitching as he/she grabbed on to the CNA's arm. The resident pointed at LPN C and growled. The LPN continued the treatment and the resident, still holding the CNA's arm, pulled back his/her foot and shouted out, " Oh, oh god!" LPN C said, " It will be all right." The resident said, "What are you doing?" LPN C said, "You okay?" The resident gasped, " WOW!" The DHSS surveyor asked the LPN if the leg was infected and the LPN said he/she believed the resident [MEDICAL CONDITION] (a resistant bacteria) in the foot. -At 9:30 A.M., LPN C used a plastic measuring tool sheet (a 4 x 6 inch transparent device used to measure the size of pressure ulcers, wounds or skin conditions of any kind) to measure the resident's outer foot. LPN C laid the plastic tool across the wound on the resident's anterior foot and said it measured 10.2 x 5.6 centimeters (cm). LPN C laid the plastic tool against the wound bed and said the depth was 0.6 cm. LPN C did not use a cotton tipped applicator to measure the depth of the wound at various portions of the wound and did not assess the area with a cotton tipped applicator for undermining or tunneling. -LPN C used a plastic measuring tool and measured the first area on the resident's outer left foot and heel as 7.0 x 9.7 x 0.1 cm. -LPN C used a plastic measuring tool and measured the second area on the resident's outer left foot as 2.4 x 1.4 x 0.3 cm. LPN C also measured three areas on the resident's left shin. Without removing gloves, the LPN use a marker from the treatment table to record the wounds dimensions then laid the marker back on the table and washed hands and regloved. The LPN repeated this process multiple times during the treatment without sanitizing the marker between wound measurements. -At 9:45 A.M., LPN E entered the resident's room and asked the resident if the pain was better. The resident said,"Yeah, Oh Yeah". -At 9:48 A.M., LPN C wet the cut pieces of [MEDICATION NAME] blue in a basin of normal saline. LPN C had CNA D wash his/her hands and change gloves to help hold the resident's leg. LPN C placed the pieces of [MEDICATION NAME] blue on the resident's foot and lower leg. The resident showed no verbal or nonverbal signs of pain when the [MEDICATION NAME] blue was placed. The resident said,"Ow!" when the 4 x 4 gauze was placed over the [MEDICATION NAME] Blue and when the CNA lifted the resident's leg. -At 9:50 A.M., LPN C started to wrap the resident's left leg and foot with a gauze Kling wrap and the resident cried out, " Oh, Oh, Ow!" and stuck his/her hand out with the palm facing the nurse to indicate for him/her to stop. The staff said, "Ok" and stopped wrapping the leg. LPN C did not assess the resident's pain at that time. -At 9:52 A.M., the resident told the staff to keep going. LPN C did not assess the resident's pain at that time and finished wrapping the resident's leg. When asked about the Vaseline gauze, LPN C said he/she completed the treatment the day before yesterday (1/7/13) and he/she did not put the Vaseline gauze on the resident. Record review of the January 2013 TAR showed from 01/03/13 (readmission) to 01/08/13, staff did not provide treatment to the resident's lower left leg stasis ulcers. During an interview on 01/10/13, at 12:00 P.M., the resident's physician said if a resident is showing facial grimacing and flinching, pain should be addressed. Resident #3 is straight forward with his/her pain. If showing these signs the nurse should stop the treatment. Staff should treat each resident on an individual bases in regards to pain. During an interview on 01/10/13, at 1:35 P.M., the facility medical director said staff should ask the resident if they are in pain or observe for non-verbal signs of pain such as grimacing. If a resident has a treatment such as debridement or packing a wound, he would expect staff to pre-medicate for pain. During an interview on 01/10/13, at 3:00 P.M., RN C said he/she made a big mistake not medicating Resident #3 for pain prior to his/her treatment. I know the treatment hurts him/her. [MEDICATION NAME] was not administered because it does not sustain. It was obvious he/she was in pain due to the non-verbal signs. It would have been appropriate to stop the treatment until the pain medication had a chance to be effective. Scissors should be sanitized. During interview on 01/10/13, at 5:45 P.M., the Director of Nurses (DON) and the administrator said the following: -The administrator said staff should complete a pain assessment prior to providing a treatment. The first step should be to ask the resident if they are in pain. If the resident cannot speak, staff should use the nonverbal pain assessment. If a resident complained of pain during a treatment, the nurse should stop and reassess the resident for pain. The nurse should move on to another treatment until the pain medication has had time to take effect. -The DON new admissions with new areas are assessed by LPN C and treatments are initiated by contacting the physician for orders. -LPN C works Monday to Friday and the charge nurse is responsible for treatments when LPN C is not working. The charge nurse should review the TAR and know their residents. -The DON said he/she does not assess resident wounds weekly. "We rely heavily on LPN C." -The administrator said LPN C has not had any formal training on wound care and said the Assistant Director of Nurses (ADON) assessed resident wounds at times. 2. Record review of the facility's policy on Pain Management and assessment dated [DATE], showed in part the following information: -Pain is any type of physical pain or discomfort in any part of the body; -Pain is very subjective, pain is whatever the experiencing person says it is and exists whenever he or she says it does; -Pain can cause suffering and is associated with inactivity, social withdrawal, depression, and functional decline; -Elderly residents often suffer acute and chronic pain and may have more than one source of pain; -Most residents with moderate to severe pain will require regularly dosed pain medications, and some will require additional PRN (as needed) pain medications for breakthrough pain; -If the resident is unable to communicate pain symptoms, the nurse should use staff assessment observation. This assessment is based upon behavior that indicates pain, such as non-verbal sounds, verbal complaints, facial expressions, and protective body movements; -Document pain (1-10) on the MAR, or use verbal descriptors scale for documentation on the MAR; -The nurse should determine whether the resident can participate in the numeric scale assessment of pain or requires the verbal descriptor scale upon admission and choose the method accordingly; -A pain assessment should be completed through resident interviews unless the resident is unable to participate. The assessment should (follow the Pain Assessment Interview or staff observation) include the presence of pain, pain frequency, effect on function, and intensity. The pain assessment (UDA) should be conducted upon admission/re-admission, when new or worsening pain is evidenced, and per the RAI process. An on-going assessment of pain utilizing either a numeric scale of 0 - 10 or a verbal descriptor scale will be conducted daily and with evidence of new or worsening pain; -The resident's response to pain medication should be documented in the MAR; -The consultant pharmacist may be consulted to assist with the management of a resident's pain when needed; -The interdisciplinary care plan team should develop a plan of care for the resident with pain, and evaluate the effectiveness of the plan periodically. 3. Record review of Resident #12's quarterly MDS assessment dated [DATE], showed the following information:-High blood pressure, anxiety, diabetes and [MEDICAL CONDITION] disorder; -Clear understanding of others;-Independent with cognitive decision-making -No behavioral symptoms -One person extensive assistance needed with transfers, dressing, toileting, bathing and personal hygiene; -Not able to stabilize balance without human assistance; -Functional limitation in ROM of leg on one side; -Utilizes a walker or wheelchair for mobility; -Scheduled and as needed pain regimen;-Presence of occasional pain. -At risk for developing pressure ulcers; -No venous and arterial ulcers present. Record review of the care plan developed on 09/05/12 and last reviewed by staff on 01/03/13, showed the following information: -Staff should coordinate with the physician to manage and control the resident's pain; -Staff should observe for the pain medications effectiveness, for non-verbal signs of pain, factors that increase/decrease pain and measure the resident's pain level using the pain scale. -Potential for skin breakdown due to limited mobility and incontinence. Record review of the facilities form titled Nursing Admission Review dated 01/03/13, showed the following information: -The resident was readmitted to the facility from the hospital after having an above the knee (right) amputation; -admitted with a surgical wound; -Resident was experiencing pain and [MEDICATION NAME] 5/325 was listed as the medication/intervention. -Skin was thin, fragile and poor turgor (late sign in dehydration. It occurs with moderate to severe dehydration.) Record review of the physician's orders [REDACTED]. Observations and interview on 01/08/13, beginning at 4:45 P.M., showed the following information: -The resident said he/she was admitted to the nursing home in September after he/she had a stroke and was here to regain strength and needed help walking again; -He/she had a brace on left leg due to leg trouble. -He/she said something happened to his/her right foot and just recently had that leg amputated (Record review showed the resident had venous stasis ulcers); -Resident was in bed on his/her back on a regular mattress; -The resident said he/she was hurting from a "big wound" on his/her bottom; -He/she said the staff were in earlier "messing" with it; -The resident was flinching, making facial grimaces and continued saying his/her bottom was really hurting; -The resident said staff did not give him/her any pain medication prior to the staff messing with the wound on his/her bottom; -The resident's call light was behind his/her p

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J." A monitoring visit was completed on 01/30/13. 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 this time. The treatments for six residents were observed and medical records reviewed. The following information was gathered: - Staff were following their immediate plan of correction for wound care. - Skin assessments for all of the resident's wounds were completed. - All residents had weekly wound tracking completed. - Training has been provided to the facility's designated wound nurse. - The facility ' s corporate wound care specialist has been involved with skin audits and training for the staff. - Surveyors observed that some of the wounds had improved. -When providing wound care, staff also conducts resident pain assessments. They monitor the resident or ask the resident if there is any pain during the wound treatment procedures. If there is pain, treatment is provided for the resident, and follow-up is done afterward to see if the pain intervention was appropriate. -Surveyors observed that when providing treatment to one demented resident, the resident flinched when the nurse removed the dressing. Staff stopped and medicated the resident with sublingual [MEDICATION NAME], waited, then proceeded with the treatment. - Surveyors spoke with one of the residents in the deificient practice regarding pain control. He/she said that he still has pain but staff were better about asking him/her if he is pain before treatments. 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 "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.

Based on observation, interview and record review, the facility failed to ensure staff accurately assessed the skin condition of residents to identify pressure ulcers, failed to accurately monitor, document and track the progress of the pressure ulcers, and ensure new ulcers did not develop for at least six residents (Resident #2. #3, #4, #8, #9 and #12) that staff identified as having a history of pressure ulcers and/or at risk for developing pressure ulcers. Resident #3 acquired an unstagable pressure ulcer to his/her right outer ankle. The treatment nurse was not aware of this ulcer prior to 1/9/13. Resident #4 acquired an unstagable pressure ulcer to his/her outer right 5th toe. The treatment nurse was not aware of this ulcer prior to 1/9/13. Resident #8 acquired a Stage III pressure ulcer to his/her outer right ankle. Resident #9 acquired a Stage II pressure ulcer to right buttock and acquired an unstageable pressure ulcer on the resident's ankle. The treatment nurse was not aware of this ulcer prior to 1/9/13. On 1/8/13, Resident #12 acquired four Stage 2 pressure ulcer to the coccyx(tailbone) and buttock that declined in status in less than 24 hours on 1/9/13, to a Stage III. The treatment nurse had not assessed the resident until five days after the resident readmitted to the facility (1/3/13). Staff failed to provide treatments as ordered by the physician for four residents (Resident #2, #3, #8 and #9). Staff failed to consistently follow the treatment plan for one resident (Resident #2) for the placement of pressure relieving devices and failed to follow infection control standards during pressure ulcer care for three residents (Resident #3, #8 and #12). Staff failed to follow their policy and ensure a trained registered nurse assessed the pressure ulcers at least weekly as part of the Interdisciplinary Team review. Nineteen (19) residents were sampled. The facility had a census of 107. Federal guidelines define the following: -Unstageable-Slough and/or Eschar (dead tissue), known but not stageable due to coverage of wound bed by slough and/or eschar. -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II pressure ulcer - Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III pressure ulcer - Full thickness tissue loss. Subcutaneous fat (under the skin) 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 (opening underneath the lip of the boarder) or tunneling (A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). -Stage IV pressure ulcer - 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. 1. During the entrance conference at the beginning of the survey on 01/07/13, the surveyors requested a list of residents the facility had identified with pressure ulcers. The administrator presented a list containing five residents (Resident #2, #5, #8 and #9) who were chosen by the survey team for review. (Staff sent the fifth resident listed to the hospital before the survey team could observe his/her skin.) While surveyors accompanied staff on skin assessments on 1/9/13, three more residents (Resident #3, #4 and #12) were identified with pressure ulcers. Record review of a typed form entitled Residents with Pressure Ulcers, dated 1/14/13, showed the facility now listed 14 residents with pressure ulcers. 2. Record review of Resident #3's recent quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment to be completed by facility staff, dated 10/24/12 showed the following information: -Stroke; -[MEDICAL CONDITION] ([MEDICAL CONDITION] - causes decreased blood flow to legs and feet); -Diabetes; -Generalized pain; -Dementia; -Sometimes responds adequately to simple, direct communication only; -Has behavioral symptoms not directed toward others (e.g., verbal/vocal symptoms like screaming, disruptive sounds or physical symptoms like rummaging or scratching self) at least 4 to 6 days a week; -Independent bed mobility; -One person limited assistance needed with dressing, transfers, toileting, bathing and personal hygiene; -Functional limitation in Range of Motion (ROM) of arm and leg of one side; -Utilizes a walker or wheelchair for mobility; -Always continent of bowel and bladder; -At risk for developing pressure ulcers. Record review of the resident's care plan last reviewed and updated on 01/04/13, showed the following information: -Inspect skin for changes daily; -Determine ulcer stage and condition of ulcer; -Assess and treat pain if present; -Observe for signs and symptoms of infection; -Provide incontinent care after each episode; -Treatment as ordered; -Pressure reducing air mattress; -Resident is non-compliant with wound care, removes dressings; -Resident is non-compliant with repositioning; -Resident refuses wound care; -Resident combative with staff when performing ADLs (activities of daily living). Record review of the December 2012 nurses notes showed on 12/22/12, at 2:50 A.M., Resident to bed at 11:30 (A.M./P.M. unknown), is lethargic. Resident has a dark discoloration of the buttocks, appearance is deep purple bruising color, entire saddle (sacral region, triangular-shaped bone at the bottom of the spine) is discolored. Resident is combative and not cooperating with staff. Record review of physicians orders dated 12/22/12, showed an order to apply moisture barrier topically to sacral saddle every shift. Record review of the nurses notes dated 12/22/12, at 3:03 A.M., showed the nurse documented moisture barrier applied topically to fragile skin on sacral area. Record review of the nurses notes dated 12/22/12, at 7:00 A.M., showed staff notified the resident's physician of the resident's decline in condition. Respirations shallow and now requires oxygen, extremities cold to the touch, resident's level of conscious decreased and not responding appropriately to questions. Resident sent to the hospital. Record review of hospital #2 History and Physical assessment dated [DATE], showed the Resident was admitted to a hospital #1 due to difficulty breathing. Staff assessed the resident's left leg, administered antibiotics and transferred the resident to hospital #2. Among the [DIAGNOSES REDACTED]. Record review of hospital #2 nurses notes dated 12/24/12, showed nursing noted skin sloughing on the resident's backside and applied [MEDICATION NAME] (foam dressing). The nurse documented the dressing application was painful for the resident. Record review of the hospital's Operative/Procedure Note dated 12/26/12, showed the following information: -Resident admitted to Hospital #2 on 12/22/12, with severe [MEDICAL CONDITION] of his/her left lower leg with necrotic tissue in the foot. Resident also developed a large sacral decubitus ulcer and necrotic (dead) tissue on his/her foot, especially the heel. The resident also has renal (kidney) failure; -The resident had a large saddle type sacral decubitus ulcer that came close to, but spared, the anus. The right side of the involved area of skin was 20 cm in length, the left side was 16 cm in length and the [MEDICATION NAME] diameter was 12 cm. Skin and a significant amount of subcutaneous tissue were removed exposing muscle at the base of the wound. The surgical area involved measured 20 x 12 cm. Record review of hospital #2 nurses notes dated 01/03/13, showed palliative orders now in place and Hospice service referral made. Resident to transfer back to the facility today. Record Review of the POS [REDACTED].M., showed the resident in pain and kicked at the nurse. Dressings were changed this morning per RN (Registered Nurse). Resident is on palliative care and resident/family has deferred assessment. When a resident is dying, the skin, like other body organs, becomes vulnerable to impairment and pressure-related injuries. At this time, palliative wound care should be the focus while providing skin care, repositioning as tolerated, minimizing/eliminating friction and shear forces, minimizing pain, etc., in order to promote comfort and honor resident's wishes during the end-of-life process. Record review of the hospital transfer form dated 01/03/13, showed the resident returned to the facility with a primary [DIAGNOSES REDACTED]. Record review of the facility nurses notes dated 01/03/13, showed the resident arrived back to the facility at 7:00 P.M. The admitting nurse documented observation of a very large dressing to the coccyx (tail bone) area and another very large dressing to the left lower extremity from the knee down. Record review of the January 2013 physician order [REDACTED]. -01/04/13, Observed dressings daily and replace if missing or soiled; -01/09/13, Clean unstagable pressure ulcer on coccyx with normal saline, pack with Hydroferra Blue (sterile antimicrobial sponge wound dressing) cut to size. Cover with 4 x 4's, secure with [MEDICATION NAME] film (Transparent film dressings designed for protecting skin and wound sites. Frame style allows customization of shape and size to fit any site. Unique sacral shape is designed for challenging and difficult-to-dress areas). Observe area and change dressing daily; -01/09/13, Change right outer ankle Stage II wound dressing every Tuesday and Friday. Observe area daily x 90 days. Clean area of right outer ankle with wound cleanser, apply [MEDICATION NAME] Absorbant (transparent dressing with absorbant foam pad). May secure edges with [MEDICATION NAME] (adhesive wipe). Record review of the nurses notes dated 01/04/13, at 2:39 P.M., showed the wound nurse assessed and treated the resident's coccyx as ordered. Resident was noncompliant with wound care. Record review of the Wound Flow Record dated 01/04 /13, showed the following information: Wound (8) Evaluation: -admitted with venous stasis ulcer (a necrotic crater-like lesion of the skin of the lower leg caused by chronic venous congestion) 24.0 cm x 11.0 cm x 6.2 cm (3.0 tunneling) to coccyx; -Has adipose (fatty) tissue present in wound bed with heavy amount of green, tan, yellow and bloody exudate (drainage) noted; -Wound bed extends from coccyx to top of rectal opening with a depth change from superficial to undermining of adipose (fatty) tissue; -Wound has both granulation (new tissue growth) and necrotic tissue present; -Area surrounding wound bed is denuded (removal of top layer of skin); -Undermining noted to the top and left of coccyx; -Epidermis (outer layer of skin) along wound margin is loose and movable, exposing fascia (a structure of connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding some structures together, while permitting others to slide smoothly over each other); -Resident has intermittent fecal incontinence which soils dressing. (Section for date of surgical debridement left blank) Observation on 01/09/13, showed the resident in bed on his/her back. Observation between 8:50 A.M. and approximately 10:35 A.M., showed the following information:-At 8:50 A.M., licensed practical nurse (LPN) C did not wash his/her hands or use hand sanitizer. He/she removed a pair of scissors from his/her uniform pocket. LPN C did not sanitize the scissors. He/she used the scissors to cut two large pieces of [MEDICATION NAME] roll and to cut multiple Hydroferra Blue packages into two pieces. He/she used his/her thumbnail to puncture a hole in the foil safety seal on the container of sterile normal saline, then poured the (now contaminated) normal saline into a product spray bottle that was labeled wound cleanser. LPN C said the bottle had wound cleanser in it at one time, but now it does not, he/she poured the normal saline into the spray bottle to make it easier. -At approximately 10:02 A.M., LPN C observed a dressing covering the resident's right outer ankle. LPN C said he/she did not apply that dressing and was not aware the resident had an area to be treated on his/her right outer ankle. LPN C removed the dressing, visibly soiled with bloody drainage, to reveal an irregular shaped dark scabbed area. LPN C used a plastic measuring tool and measured the area as 1.3 cm x 0.9 cm x 0.1 cm. LPN C cleaned the area with normal saline, applied [MEDICATION NAME] around the edges of the wound and covered it with a [MEDICATION NAME] absorbant dressing. -At 10:15 A.M., LPN C and CNA D turned the resident on his/her side. The resident wore an incontinent brief which was visibly soiled. The LPN said the resident had no areas on his/her coccyx before transferring to the hospital (on 12/22/12) and said "he/she came back from the hospital like this." CNA D asked the resident if he/she was still in pain (prior pain medication administered at 9:08 A.M. while in the process of treating the resident's left leg and foot). The resident showed no verbal and/or nonverbal signs of pain. The LPN and CNA removed the resident's incontinent brief and exposed a large dressing covering the resident's coccyx. The dressing was visibly soiled and the bottom edge of the dressing closest to the anal opening was heavily saturated with feces. LPN C removed the dressing from the resident's coccyx. LPN C said the area on the resident's coccyx was a "stasis ulcer" because of [MEDICAL CONDITION]. The area on the resident's coccyx was a football shaped crater that covered the resident's right and left coccyx and up the midline coccyx. The area presented as a full thickness pressure ulcer with necrotic tissue present, and yellow slough in the wound bed. The pressure ulcer had a red wound edge with undermining present along a ridge between 8 and 11 o'clock. -At 10:24 A.M., LPN C sprayed the pressure ulcer with the normal saline, and patted the area dry with 4 x 4 gauze. LPN C used a plastic measuring tool sheet (a 4 x 6 inch transparent device used to measure the size of pressure ulcers, wounds or skin conditions of any kind) to measure the resident's coccyx pressure ulcer. LPN C laid the plastic tool across the length of the wound on the resident's coccyx, then placed his/her gloved finger at the end of the tool and directly in the wound bed, then moved the measuring tool down and finished the measurement. LPN C said the measuring tool only measured up to 13 cm, he/she placed his/her finger on the area of the wound at 13 cm then moved the tool down to finish. LPN C then measured the width. LPN C said the wound measured 20.0 cm x 8.5 cm. LPN C used a cotton tipped applicator to measure the depth of the wound. He/she placed the applicator in the center of the wound and said the depth measured 4.8 cm. LPN C said the wound does have undermining, not tunneling, just a "cleft". LPN C used an applicator and went under the area of undermining. LPN C moved the applicator back and forth and said the deepest part was 2.7 cm at 9 o'clock.-At 10:31 A.M., LPN C did not re-cleanse the wound bed after he/she touched the area during the measuring. LPN C placed the cut pieces of the Hydroferra Blue in the wound bed, covered the pieces with 4 x 4 gauze then covered the entire coccyx pressure ulcer with two large piece of [MEDICATION NAME]. 2. Record review of Resident #8's most recent quarterly MDS dated [DATE], showed the following information: -Moderately impaired cognitive skills for daily decision making; -Requires one person limited assistance with bed mobility and transfers; -Does not ambulate; -Requires extensive assistance with dressing; -Requires one person physical assistance with bathing; -Has impairment of functional Range of Motion (ROM) of arm and leg on one side of the body; -Uses a wheelchair for mobility; -Incontinent of bowel and bladder; -[MEDICAL CONDITION] (other than [MEDICAL CONDITION]); -[MEDICAL CONDITION] disorder; -[MEDICAL CONDITION]; -Diabetes; -Mental [MEDICAL CONDITION]; -Generalized pain; -At risk for developing pressure sores; -One venous or arterial ulcers present. Record review of the resident's skin monitoring form titled,"CNA Resident's Daily QA Body Audit forms" (provided to surveyors for review) showed the following: -From 12/12/12 to 01/02/13, staff did not identify any pressure ulcers on the resident. -On 01/03/13, staff identified an area of treatment to the resident's left outer ankle/foot. Record review of the Wound Flow Record dated 01/04/13, showed the following information: -Acquired left ankle Stage III pressure ulcer; -Pressure sore identified on 01/03/13; -Pressure sore measured 1.4 cm x 1.2 cm x 0.3 cm with slough and yellow drainage present. Record review of the January 2013 POS showed an order dated 01/03/13, for staff to change dressing to Stage III wound site on left outer ankle every other day. Apply Hydroferra Blue, cover with [MEDICATION NAME] plus pad, may secure edges with [MEDICATION NAME]. Observe area daily for 90 days. Replace dressing if soiled or missing PRN. Record review of the resident's care plan last reviewed on 01/03/13 and updated on 01/06/13, showed the following information: -Encourage to use proper fitting shoes; -Inspect skin for changes daily; -Skin audits per schedule and PRN; -Observe for signs and symptoms of infection; -Differentiate type of ulcer (i.e., stasis, pressure, surgical, diabetic, venous, arterial ulcer); -Physician in facility on 01/03/13 and ordered antibiotic for [MEDICAL CONDITION]; -Wound culture obtained on 01/03/13; -Hydroferra Blue treatment to pressure ulcer; -Culture received on 01/06/13. Antibiotic order changed to [MEDICATION NAME]. Record review of the nurses notes dated 01/03/13, at 3:29 P.M., showed the wound bed is dry with light yellow slough noted. Area surrounding wound is red with [MEDICAL CONDITION] (swelling) noted and painful to the touch. Implemented treatment for [REDACTED]. Physician notified while at the facility and assessed the wound. Wound bed at this time is moist with yellow slough noted on previous dressing. Wound margin has granulation tissue present. Foot remains red and painful. Received order to culture wound, continue treatment ordered. Start antibiotic therapy for [MEDICAL CONDITION]. Care Plan updated. Record review of the nurses notes dated 01/06/13, at 9:52 A.M., showed preliminary report received for wound culture which started growing [MEDICAL CONDITION] (MRSA - is a resistant bacterial infection difficult to treat.[MEDICAL CONDITION] has developed a resistance to the [MEDICAL CONDITION] anti-infective, [MEDICATION NAME] broad-spectrum antibiotic). Physician was notified and ordered the current antibiotic discontinued and begin administering [MEDICATION NAME] (antibiotic) 500 mg qid (four times daily) for one week for the wound infection. Record review of the nurses notes dated 01/08/13, showed the physician reviewed the wound culture report and ordered staff to begin administering [MEDICATION NAME] (antibiotic) 600 mg bid (twice daily) for 10 days. During an interview on 01/08/13, at 4:38 P.M. a Certified Nurse Assistant (CNA) K said the aides do "body audits" on residents daily during showers and complete a report sheet identifying skin issues. These monitoring sheets are handed to the charge nurse every shift for review. Record review of the January 2013 TAR showed staff did not complete the treatment to the resident's ankle on 01/05/13 and did not observe the dressing on the evening of 01/05/13 and 01/07/13 as ordered. Observation and interview on 1/9/13 at 1:23 P.M., showed the following information:-LPN C did not wash his/her hands or use hand sanitizer. He/she removed a pair of scissors from his/her uniform pocket. LPN C did not sanitize the scissors. He/she opened a package of Hydroferra Blue, removed it from the package with his/her hands and used the scissors to cut a of a piece of Hydroferra blue to size. -LPN C and CNA D wheeled the resident into the shower room. LPN C washed his/her hands and applied gloves. LPN C removed the resident's socks and shoes. The resident said, "My foot is hurting, my toenails need to be cut, they need a foot doctor. My feet are swelling up too honey". LPN C removed the soiled dressing from the resident's left outer ankle;-The resident had a silver dollar-sized pressure sore on his/her left outer ankle. The pressure ulcer had a yellow wound bed with flaky, dry skin surround the ulcer, heel and foot. LPN C measured the area as 3.0 cm x 2.0 cm x 0.3 cm. He/she cleansed the area, placed the piece of Hydroferra blue directly into the wound bed and covered the area as ordered. During an interview on 01/10/13, at 1:35 P.M., the resident's physician (who is also the facility medical director) said the resident has a congenital malformation of the foot which has had sores on it in the past. The area on her ankle showed up all of the sudden as a minor Stage I pressure ulcer. I expect the CNAs and the charge nurses to communicate on wounds. Staff should identify if wounds not getting better with current treatment. There should not be any lag time between identification of a wound and treating the wound. During an interview on 01/10/13, at 2:25 P.M., LPN C said the following: -2:25 P.M., Body audits were done on each shift. If I become sick, I call the DON to make sure treatments get done. If the TAR has an "N" or "R" posted of the day a treatment was to be completed, the treatment was not done. If I do not get to a treatment, I make a list for the charge nurses to complete. I get pulled to the floor a lot. I rarely pass a treatment along unless it is a twice a day treatment like creams or powders. Nurses have to sign off they observed dressings every shift. There seems to be a lack of communication with the nurses and I don't know why treatments are getting missed. If new skin problems are found on a resident, I explain to the charge nurse what we are going to do to treat it. The charge nurses are not present during weekly skin assessments. If I find or see a change in a resident's skin condition, I invite the charge nurse to see the resident and the change. In daily clinical meetings we discuss new skin issues. We have wound meetings every Friday. Nine out of ten times, either the DON or ADON are present. I have not been provided with special training but had a nurse from another facility show how they do treatments. Wounds are treated according to a formulary protocol. I am not confident yet as to how to measure wounds. I did not see Resident #3 before he/she went to the hospital in December. I changed and renamed his/her coccyx ulcer from vascular to pressure ulcer. I am not happy with finding new problem areas of skin yesterday that I was not aware of. -3:00 P.M., I made a big mistake not medicating Resident #3 for pain prior to his/her treatment. I know the treatment hurts him/her. [MEDICATION NAME] was not administered because it does not sustain. It was obvious he/she was in pain due to the non-verbal signs. It would have been appropriate to stop the treatment until the pain medication had a chance to be effective. -3:07 P.M., Scissors should be sanitized. During an interview on 01/10/13, at 10:40 P.M., LPN J said he/she did not treat or observe the resident's foot because LPN C provided the treatments. LPN J said he/she receives body skin audits from the CNAs' and they circle the resident's foot on the document to indicate treatment completed. LPN J said his/her responsibility was not to treat the wound but to observe the dressing is in place. If the date on the dressing is old, then I would do the treatment. 4. Record review of Resident #12's quarterly MDS assessment dated [DATE], showed the following information:-Clear understanding of others;-Independent with cognitive decision-making -One person extensive assistance needed with transfers, dressing, toileting, bathing and personal hygiene; -At risk for developing pressure ulcers. Record review of the care plan developed on 09/05/12 and last reviewed by staff on 01/03/13, showed the resident had potential for skin breakdown due to limited mobility and incontinence. Record review of the facility's form titled, Resident Risk Review for Pressure Ulcers, dated 01/03/13, showed the resident was at risk for pressure ulcers. Record review of the facility's form titled, Nursing Admission Review, dated 01/03/13, showed the resident's skin was thin, fragile with poor turgor; Record review of the weekly wound record dated 01/08/13, showed LPN C noted the following information: -Type of wound: pressure; -Whether admitted with the pressure ulcer or acquired at the facility was not checked; -Location of body: coccyx (center area, upper left buttock, upper right buttock and lower right buttock) -Original identification date: 01/08/13; -Original wound stage: Stage II times four; -Tissue character: granulation tissue; -Peri -wound skin (skin around the wound) : clear; -Exudate: yellow small amount. -Measurements: -Center area, Stage II, measured 2.1 x 2.0 x 0.2;-Upper left buttock, Stage II, measured 2.4 x 3.5 x 0.2;-Upper right buttock, Stage II, measured 0.3 x 1.5 x 0.2;-Lower right buttock, Stage II, measured 0.7 x 1.4 x 0.2. Record review of the nurses notes dated 01/08/13, at 4:05 P.M., showed LPN C noted the following:-The resident had complaint of pain to coccyx, resident was assessed. -The resident has Stage II pressure ulcers x 4 to coccyx area. -Superficial excoriation noted with top layers of epidermis missing, area surrounding wounds are blanchable at this time. -Wound beds have granulation tissue present with [MEDICATION NAME] (new growth of skin) noted to wound margins. -Small amount of exudate noted with cleaning, no signs of infection or odor noted at this time. -Responsible party notified. Physician notified. Observation and interview on 01/9/12 at 7:15 A.M., showed the following information:-LPN C entered the resident's room and set up the wound care supplies. -LPN C rolled the resident onto his/left side. LPN C removed the resident's incontinence brief. The brief was heavily saturated with urine. LPN C removed the soiled dressing on the resident's coccyx. -LPN C said he/she definitely has some "dark areas"-The resident had two large egg-shaped/sized pressure ulcers; one on the inner aspect of his/her right buttock and one on the inner aspect of his/her left buttock. The ulcers met in the middle at the midline coccyx. The midline coccyx had a quarter-sized dark purple-black area. Both buttock wound beds were yellow and white with a bright red wound edge. The wound beds had a slight crater-like appearance. The left buttock pressure sore had an irregular shaped area on the bottom edge at the 7 o'clock position that extended inward toward the center of the pressure sore. The area had the appearance of another pressure ulcer formation;-LPN C said yesterday (01/8/13), was the first time he/she had seen the resident's buttock and coccyx. The areas looked different than yesterday, "looks worse".-LPN C did not provide incontinence care before starting the pressure ulcer treatment. LPN C cleansed the areas with moistened 4x4 gauze. -LPN C used a plastic measuring tool sheet to measure the resident's pressure ulcer. He/she said yesterday (1/8/13) the area was a Stage II, he/she will leave it at a Stage II. The surveyor asked LPN C about the darkened area on the midline coccyx. LPN C said, "The skin is sloughing off of the dark area, will call the center a Stage III."-Yesterday it was several Stage II ulcers, today it was "one wound". Measured the area 3.1 x 9.8 x 0.3. LPN C said now it was a Stage III;-At 7:28 A.M., LPN C did not re-cleanse the wound bed after he/she touched the area during the measuring. LPN C placed a dressing over the pressure ulcer. LPN C laid the soiled incontinence brief against the resident's skin and exited the room. Record review of the physician's orders [REDACTED]. Record review of the nurses notes dated 01/09/13, at 8:34 P.M., showed LPN C noted the area to the resident's coccyx now considered a Stage III, wound margin has small amount of necrotic tissue that is sloughing with purple discoloration noted to surrounding tissue at top of coccyx. Previous documentation of four Stage II pressure ulcers have combined into one Stage III with denuded skin surrounding original ulcerations. Wound bed surrounding coccyx area has granulation tissue present. Small amount of serosanguinous (blood and serum mixed) exudate noted with cleaning, no odor noted at this time. LPN C did not address an assessment of the residents level of pain. Record review of the weekly wound record dated 01/09/13, showed LPN C noted the following information: -Type of wound: pressure; -Whether admitted with the pressure ulcer or acquired at the facility was not checked; -Location of body: coccyx -Original identification date: 01/09/13; -Original wound stage: Stage II; -Current wound stage: Stage III; -Tissue character: granulation tissue. LPN C did not indicate the presence of slough and necrosis. -Peri-wound skin: clear; LPN C did not indicate the skin was denuded. -Exudate: pink-yellow small amount. During an interview on 1/9/13 at 1:00 P.M., LPN H said the following:-Regarding Resident #12, LPN H was his/her charge nurse. The resident did not have any areas on his/her coccyx before going to the hospital and did not have any areas when he/she was readmitted ;-On 1/8/13, he/she did not receive any report about the resident's coccyx. He/she has not seen the resident's coccyx. He/she knew there was a treatment ordered;-LPN H said he/she did not know on 1/8/13, the resident had four Stage II pressure ulcers;-This morning (1/9/13), he/she did not receive any information in report about the pressure ulcers, only that his/her pain medication had been increased;-He/she was not aware the resident's pressure ulcer was now a Stage III. 5. Record review of Resident #9's quarterly MDS assessment dated [DATE], showed the following information: -Severely impaired cognition; -Long and short term memory problems; -Total assistance of staff for Bed mobility, eating and bathing; -Extensive assistance of two staff for transfers, dressing and personal hygiene; -Can only stabilize when transferring from the bed to the wheelchair; -Always incontinent of bowel and bladder; -Only able to stabilize with staff assistance when transferring from bed to wheelchair; -At risk for pressure ulcers has Stage II; -[DIAGNOSES REDACTED]. Record review of the care plan developed on 01/20/12 and reviewed on 10/31/12, showed the following information: -Potential for pain; -Totally incontinent of bowel and bladder; -Impaired cognition; -Potential for skin break down due to skin fragility, incontinence of bowel and bladder; -Staff should follow physician orders, inspect skin for changes daily, skin audit per schedule, provide incontinent care, turn and reposition per schedule. -Activities of daily living, staff should observe for skin changes and report to charge nurse. Record review of the physician orders [REDACTED]. -On 01/02/13, reopened Stage II on right and left heels, cleanse with wound cleanser, dry, apply Tegraderm foam adhesive and secure edges with [MEDICATION NAME] every Monday and Thursday and as needed; -Observe bilateral heel dressing and replace dressing if missing or soiled. Record review of the January 2013 TAR showed staff did not complete the treatment to the residents left or right heel as ordered on [DATE] and 01/07/13. Observation on 01/09/13, at 3:10 P.M., showed the following information: -The resident lay in bed with heel protectors on both feet. Staff just completed incontinent care and the resident lay on his/her left side. LPN C entered and placed the treatment supplies on a clean towel on the resident's bedside table and assessed

Based on interview and record review the facility failed to identify, assess, document and notify the physician, in a timely manner, regarding an acute (sudden) change of condition as evidenced by an initial pulse of 130, respiratory rate of 38 and oxygen saturation of 82% for one resident (Resident #5) of 16 selected for sample, who had a recent history of pneumonia,[MEDICAL CONDITION] (a bacterial infection in the bloodstream or body tissues), and acute [MEDICAL CONDITION] (a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon [MEDICATION NAME] becomes dangerously high) that required mechanical ventilation (a machine to help patients breathe when they are unable to breathe sufficiently on their own). This deficient practice resulted in an extended hospitalization for acute [MEDICAL CONDITION] (the sudden loss of the ability of the kidneys to remove waste and concentrate urine without losing electrolytes), dehydration and respiratory acidosis. The facility's census was 91. According to The A.D.A.M. Medical Encyclopedia, respiratory acidosis is a condition that occurs when the lungs cannot remove all of the carbon [MEDICATION NAME] the body produces. This disrupts the body's acid-base balance causing body fluids, especially the blood, to become too acidic. Acute respiratory acidosis is a severe condition in which carbon [MEDICATION NAME] builds up very quickly and before the kidneys can return the body to a state of balance. Symptoms may include confusion, easily fatigued, lethargy, shortness of breath and sleepiness. Severe respiratory acidosis is a medical emergency; seek immediate medical help. Record review of the facility's Change in Medical Condition of Residents policy, dated 11/01/01, showed the following information: -Standard: Notification of the physician should occur promptly, according to federal regulations, when there is a change in the resident ' s condition; -Examples of a change in condition includes: Respiratory distress, temperature elevation or fall, onset of confusion, new memory loss, pulse below 40 or above 104, drop or elevation in blood pressure, loss of appetite; -Process: Assess the change in condition and determine whether it is an emergency medical situation or a non-emergency situation; -Contact the physician (in an emergency) at the time the event occurs whatever time of the day or night; -In a non-emergency call during normal office and daylight hours. If a non-emergency situation occurs after 5:00 P.M. or on a weekend, the physician is contacted the next day or at the schedule requested by the physician, but no later than the next day; -When possible, non-emergency calls are consolidated with routine calls; -The Director of Nursing may be consulted for assistance determining the urgency of calls; -Documenting the change of condition: Nurses notes should include documentation of the symptoms and observations associated with the change in condition, and the date and time contact with the physician; -Notes also should include comments on the care provided by nursing personnel. 1. Record review of Resident #5's current medical record showed on 02/03/11 staff readmitted the resident to the facility, from the hospital. The resident's readmission [DIAGNOSES REDACTED]. Record review of the 14 day Minimum Data Set, a federally mandated comprehensive assessment instrument, completed by facility staff, dated 2/14/11, showed the following information: -Clear speech-distinct and intelligible words; -Makes self understood; -Understands others; -Short and long term memory problems; -Dependent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -[DIAGNOSES REDACTED]. Record review of the care plan, last updated 02/03/11, showed staff did not develop or initiate interventions related to pneumonia and or respiratory problems. Record review of the February 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 02/04/11 an order for [REDACTED]. -On 02/16/11 an order for [REDACTED]. According to the 2001 Certified Nursing Assistant (CNA) training manual, the normal ranges for pulse, respirations and blood pressures, in adults are as follows: -Pulse-50-100 beats per minute; -Respirations-14-20 breaths per minute; -B/P - Systolic (top number) between 100 to 150 mm Hg (millimeters of mercury); -B/P - Diastolic (bottom number) between 60 to 90 mm Hg. According to Mosby's Manual of Diagnostic and Laboratory Tests, normal oxygen saturation values, in the elderly, should be equal to or greater than 95% and is a critical value when equal to or less than 75%. Record review of the nurses' notes, dated 02/21/11, showed the following information: -At 1:09 A.M. the aide notified the nurse of the resident's abnormal pulse, respirations and oxygen saturation (a measurement of [MEDICATION NAME] blood expressed as a percentage): pulse 130, respirations 38 and oxygen saturation of 82% on room air. The nurse assessed the resident and found his/her pupils were dilated, apical pulse (the heart rate when measured with a stethoscope placed over the heart) rate was 98, respirations were shallow at 32 and oxygen saturation was 75%. The resident was moving his/her arms and trying to push away the nurse. After the nurse administered two L of oxygen to the resident, his/her oxygen saturations increased to 85%. The nurse increased the oxygen to three L and the resident's oxygen saturation increased to 87%. The resident's pulse remained at 100 and his/her nail beds were pink with sluggish refill. The nurse documented he/she would continue to monitor the resident's condition; -At 2:27 A.M. the resident's apical pulse was difficult to hear and his/her radial pulse (heartbeat felt over the radial artery (located close to the inside part of the wrist near the thumb)) was 80 and thready (weak). The nurse observed no cyanosis (a bluish or grayish discoloration of the skin due to lack of oxygen to the area from prolonged pressure or vascular insufficiency) in the resident's fingers and no mottling (a marbled-like pattern on skin caused by pooling blood) was present. The resident's respirations were 36 and he/she was "not moving much air;" -At 11:08 A.M. staff will transfer the resident to the emergency room (ER) for evaluation due to difficulty swallowing food and medications; -At 2:51 P.M. staff called the ER to follow-up on the resident's status after he/she was transferred to the ER due to a decline in health. ER staff informed the facility the resident was admitted to the hospital. Record review of the resident's current medical record showed staff did not document anything regarding the resident's acute significant decline in condition, including notification of the physician of the resident's abnormal vital signs and/or respirations, from 2:27 A.M. until the staff sent the resident to the ER at or near 11:08 A.M.; eight hours and forty-one minutes later. During an interview on 05/05/11, at 2:10 P.M., Registered Nurse (RN) L said on 02/20-02/21/11 he/she worked from 2:00 P.M.-2:00 A.M. Between 1:00 A.M. and 2:00 A.M. on 02/21/11 an aide notified the nurse of the resident's abnormal vital signs. The nurse said he/she administered a breathing treatment to the resident, and attempted to listen to his/her lungs. The nurse was unable to assess the resident's lungs because the resident pushed him/her away. The RN said when he/she rechecked the resident's pulse and oxygen saturation, the resident's oxygen saturation was still low. The nurse administered oxygen to the resident. The nurse said before he/she left the facility, at the end of his/her shift, the resident's oxygen saturation increased to 90% but he/she did not document the increase in the nurses' notes. RN L said he/she told LPN K to check on the resident because he/she had a change in condition. He/she also reported to LPN K that he/she did not notify the physician of the resident's change in condition because he/she "was doing what nurses do, assessing and intervening." During an interview on 05/05/11, at 5:05 P.M., RN L said after he/she thought about the incident, he/she remembered he/she did attempt to notify the physician. On 02/21/11, the nurse contacted the physician about another resident; when RN L said he/she wanted to talk about Resident #5, the physician hung up. The RN said when he/she called the physician, the resident's oxygen saturations had already increased to 90%. Record review of the 2/2011 MAR indicated [REDACTED]. Staff documented the resident received the treatment at 1:00 A.M. for 15 minutes, at 5:00 A.M. for 20 minutes and 9:00 A.M. for 20 minutes. Record review of the hospital's switchboard log book, provided by facility staff, dated 02/20-02/21/11, showed on 02/21/11, at 1:34 A.M., facility staff requested the switchboard operator to contact the resident's primary care physician. The switchboard operator called the physician on his/her cell phone but did not receive a response. The operator then called the physician on his/her home phone and transferred the call to the facility. According to the hospital's switchboard log book, facility staff did not document notifying the physician at any other time. During an interview conducted on 05/05/11, at 2:00 P.M., Licensed Practical Nurse (LPN) K said on 02/21/11 he/she worked from 2:00 A.M.-6:00 A.M. At shift change, RN L told LPN K the resident was not doing as well as RN L thought he/she should have been and the resident was removing the oxygen. RN L did not inform the LPN he/she needed to notify the physician. The LPN was under the impression he/she was waiting for the physician to return a call placed by RN L, but he/she did not know why the RN called the physician. The physician did not call. LPN K said, during his/her shift, the resident was able to answer questions and his/her oxygen saturations stayed between 93-95% on two L of oxygen. When he/she assessed the resident, he/she heard wheezes but did not think the resident was in respiratory distress. LPN K said he/she did not think there was a need to document the assessment. He/she did not think anything abnormal was going on with the resident; the resident may have acted a little different but not enough to document. During an interview on 05/05/11, at 11:30 A.M., LPN J said on 02/21/11 he/she worked as the charge nurse on the day shift (6:00 A.M.-2:00 P.M.). He/she said the resident had a change in level of consciousness; he/she only opened his/her eyes and did not attempt to mimic words. The nurse said the resident had a fever and his/her blood pressure was low. The resident also continued on two L oxygen per NC and his/her saturations were above 90%. The nurse attempted to administer Tylenol, to the resident, for fever, but the resident would not open his/her mouth. LPN J said he/she attempted to notify the physician of the resident's refusal to take medication by mouth at 6:30 A.M. and 8:00 A.M. but the physician did not return the call. Staff transferred the resident from the bed into his/her wheelchair and wheeled him/her into the dining room for breakfast. The resident would not eat. LPN J asked the DON to assess the resident. The Director of Nursing (DON) noticed the resident's skin was pale and clammy. The LPN said the DON told staff they should transfer the resident to the hospital. LPN J said he/she and LPN K did not actually know what was wrong with the resident; they just knew he/she was not himself/herself. During an interview conducted on 05/05/11, at 11:37 A.M., the DON said she was positive staff contacted the physician of the resident's change in condition; they just did not document it. The DON said she expected staff to notify the physician if a resident's oxygen saturation dropped and document the notification. The DON said when she entered the facility on 02/21/11, she assessed the resident per LPN J's request, then notified the medical director of the resident's change of condition who instructed staff to transfer the resident to the hospital. During an interview on 05/05/11, at 10:20 A.M., LPN I said on 02/21/11 he/she worked at the facility and performed wound care on the resident. He/she said staff were attempting to feed the resident breakfast but the resident was having difficulty swallowing; he/she would chew and chew but not swallow. The LPN did not remember anything else. During an interview on 05/05/11, at 4:25 P.M. the DON said staff contacts the resident's primary physician by paging him/her through the hospital paging system. During an interview conducted on 05/05/11, at 5:05 P.M., the administrator said, if it is not documented, then it was not done. During an interview on 05/05/11, at 4:53 P.M., the resident's primary physician said he/she expected staff to notify him/her if a resident had a change in condition such as decreased oxygen saturation, abnormal vital signs and coughing. The physician did not remember if staff notified him/her of the resident's change of condition on 02/21/11. During an interview conducted on 05/05/11, at 5:24 P.M., the facility's medical director said he did not remember facility staff notifying him of another physician's resident's change in condition. He said if a medical issue with a resident occurs on the night shift, staff should notify the RN on-call for guidance. Record review of the unplanned discharge instruction sheet, undated, provided by facility staff on 05/06/11, included the following information: -Call the DON at the time of decline; -Call the physician and obtain orders to transfer to the emergency room (ER); -If an emergency, call 911; -Document completely, in the nurses' notes, including the reason for discharge, who was notified and the condition of the resident at the time of discharge. During an interview conducted on 05/06/11, at 9:05 A.M., the DON said staff did not contact her, by phone, on 02/21/11 regarding the resident's change in condition. She said either she or the Assistant DON was the nurse on-call but she did not know which one. Record review of the Emergency Medical Services (EMS) preliminary patient report, dated 02/21/11, showed EMS staff documented the resident's pupils were non-reactive and he/she had an initial oxygen saturation of 81% on two L of oxygen. Staff applied 15 L of oxygen per mask, to the resident, and obtained vital signs. The resident's blood pressure was 84/56, pulse 110, oxygen saturation 92% on 15 L of oxygen per mask. Record review of hospital A's ER physician record, dated 02/21/11, dated 11:29 A.M., showed the resident's chief complaint was gradual weakness that started two days ago. Facility staff reported the resident was not eating or drinking and was less active today (02/21/11). The ER physician documented the resident presented to the ER with severe generalized (all over) weakness, slow to respond, was alert but confused, had decreased breath sounds and a fast heart rate at 109. Record review of hospital A's physician's history and physical (H&P) examination note, dated 02/21/11, showed the following information: -Over the last three or four days the resident had gradually deteriorated; he/she was not eating and his/her mentality was quite sluggish. Staff were unable to care for the resident and transferred him/her to the ER. Upon admission, the resident's blood pressure was 81/56. With this condition, the resident was admitted to the Intensive Care Unit (ICU) for further treatment; -Physician examination showed the resident was short of breath, respirations 36, blood pressure 79/55, pulse 101 and oxygen saturation 93% on two L of oxygen. The resident lung sounds were diminished (decreased) with rhonchi (low pitched, snore-like sounds caused by airway secretions and airway narrowing) and wheezing on both sides; -Laboratory results showed abnormal arterial blood gases (a test that measures the levels of oxygen and carbon [MEDICATION NAME] in the blood to determine how well your lungs are working) and elevated creatinine (a test that helps determine kidney function), Blood Urea Nitrogen (BUN) (a test that helps determine kidney function) and White Blood Cell (WBC) (a blood test that helps diagnose infection) count; -[DIAGNOSES REDACTED]. -Hospital (hospital A) staff to stabilize the resident in ICU then transfer to another hospital's(hospital B) ICU for further treatment including [MEDICAL TREATMENT]. Record review of Hospital B's H&P, dated 02/24/11, showed upon arrival, staff had to emergently intubate the resident. The resident was nonresponsive, had a blood pressure of 86/45, heart rate in the low 100's, oxygen saturation 91%. A chest x-ray showed a left lower lobe infiltrate (an abnormal substance that has accumulated in the lungs) and effusion (a collection of fluid into a part of the pleural cavity, which is the space between the lung and chest wall). [DIAGNOSES REDACTED]. The resident was transferred to Hospital C on 3/10/11. Record review of Hospital C's discharge summary showed an admission date of [DATE]. The resident required additional hospitalization in order to return to his/her prior level of function before returning to the facility on [DATE]. At the time of the survey, the violation was determined to be at the immediate jeopardy level "J." Based on record review, observation and interview, completed during the onsite (annual and extended survey) visit, it was determined the facility had implemented corrective actions to address and lower the violation at that time. During the onsite visit, the facility staff performed re-assessments on all residents to ensure no residents were experiencing an acute change in condition. The facility performed inservices on policy and procedure regarding change in condition and notification of physician by the charge nurse, as well as, if the attending facility physician cannot be reached, the facility medical director will be contacted; new staff will be inserviced at the time of hire. The facility will monitor compliance through clinical meeting and all inconsistencies will be addressed as appropriate. The violation was lowered to a D level. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.