Every finding on record at Aspire Senior Living Jonesburg

Based on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #3) when staff failed to utilize two staff members while using a mechanical lift, the mechanical lift tipped over, which resulted in left femoral fractures, right femur fractures, a bruise to the forehead, and a T12 compression fracture (occurs when the 12th thoracic vertebra) required hospitalization. Facility staff failed to utilize two staff for bed mobility for one dependent resident (Resident #1) which resulted in a femur fracture. Facility staff failed to utilize two staff in a manner to assure resident safety for one resident (Resident #2) out of three sampled residents. The facility census was 63.1. Review of the facility's Safe Resident Handling and Transfers policy, dated 10/1/25, showed residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Staff will be educated on the use of safe handling/transfer practices and to include use of mechanical lift devise upon hire, annually and as the need arises or changes in equipment occur. Staff members are expected to maintain compliance with safe handling/transfer practices, failure to maintain compliance may lead to disciplinary action up to and including termination of employment.2. Review of Resident #3's Annual MDS, dated [DATE], showed staff assessed the residents as severely cognitively impaired and dependent on staff to transfer to and from a bed to a chair (or wheelchair).Review of the resident's care plan, dated 04/09/26, showed the resident had limited physical mobility related to contractures, stroke and weakness and required assistance from one staff for locomotion. The care plan did not provide directions to staff for transfer assistance.Observation on 04/30/26 at 12:15 P.M., showed the Social Service Director (SSD) and CNA D entered the resident room to provide care to the resident. CNA D operated the lift and transferred the resident from the bed over to the wheelchair, while the SSD stood next to the wheelchair. The resident swung in the air during the transfer from the bed to the chair.During the interview on 04/30/26 at 12:20 P.M., the SSD said staff are educated to use two staff when transferring a resident with a mechanical lift. He/She said one staff should be operating the lift and the other staff would be either by the bed or the wheelchair to safely to lower the resident. He/She said he/she did notice the resident was moving a little bit while elevated in the sling above the floor without being guided.During an interview on 04/30/26 at 12:22 P.M., CNA D said two staff members are required to transfer a resident when using a mechanical lift. He/She said one person operates the lift and the other stands by the wheelchair and guides the resident while lowering into the chair. He/She said he/she was not trained on one staff guiding the resident during a transfer.Review of the resident's progress notes, dated 05/2/26 at 6:00 A.M., showed staff documented a CNA called for the nurse to come to the resident's room. Resident on floor next to his/her bed with mechanical lift turned onto its side next to roommate's bed. Staff documented approximate four-centimeter bruise to the residents' mid forehead with small amount of blood draining. Resident complained of lower extremity pain with no injury noted at this time. Emergency Medical services in route, residents taken to hospital. Review of the resident's hospital progress note, dated 05/02/26, showed staff documented the resident fell from mechanical lift which resulted in a facture of femoral shaft, left, a fracture of proximal end of right femur, a bruise to the forehead, T12 compression fracture, fracture of neck of right femur, nondisplaced spiral fracture of shaft of left femur (thighbone cracked by twisting force, creating a corkscrew pattern). During an interview on 05/12/26 at 9:08 A.M., the Administrator said CNA E utilized the mechanical lift by himself/herself when the resident became combative and the mechanical lift flipped over. The resident was sent to the hospital.During an interview on 05/12/26 at 9:10 A.M., The Director of Nursing (DON) said the resident was sent to the hospital because he/she suffered a bruise to the forehead.During an interview on 05/12/26 at 10:08 A.M., CNA E said he/she got the resident up and resident was in mechanical lift extended above his/her chair and he/she tried to brush the resident's hair. He/She said the resident started to flail his/her arms and mechanical lift tipped over. CNA E said he/she tried to stop the mechanical lift from tipping over but could not. CNA E said he/she did not utilize the break on the mechanical lift and did not have another staff member in the room to help him/her and should have. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 02/20/26, showed staff assessed the resident as cognitively intact and dependent on staff to transfer to and from a bed to a chair (or wheelchair), turning and repositioning.Review of the resident's care plan, dated 01/15/25, showed staff assessed the resident had an activity of daily living (ADL) self-care performance deficit related to left side weakness and required two staff for transferring, turning and repositioning.Review of the facility report, dated 04/21/26, showed the Certified Nurse Aide (CNA) A documented he/she repositioned the resident by rolling him/her towards the wall, when he/she heard a pop. The resident immediately expressed pain, stating ow and reported his/her leg hurt.Review of the facility's Skilled Nursing Facility to Hospital Transfer Form, dated 04/23/26, showed the diagnosis for admission was pain in the left knee.Review of the resident's progress notes, dated 04/24/26, showed staff documented the nurse at the hospital reported the resident admitted for fractured femur.During an interview on 04/30/26 at 10:38 A.M., CNA A said during the repositioning of the resident, he/she heard a pop noise and the resident yelled out in pain. He/She said he/she knew he/she should have asked for assistance, but the other staff members were busy.During an interview on 04/30/26 at 10:49 A.M., LPN B said he/she did not recall if CNA A reported the incident to him/her because he/she was busy assisting a new admission. He/She said he/she did see the resident on 04/21/26 between 9:30 to 10:00 P.M. and he/she did complain about pain in his/her legs, but upon assessment, did not see any injuries. He/She said he/she did not contact the physician since the resident had a history of leg pain.4. Review of Resident #2's Quarterly MDS, dated [DATE], showed the resident dependent on staff to transfer from bed to a chair (or wheelchair).Review of resident's care plan, dated 04/09/26, showed staff assessed the resident had limited physical mobility related to Alzheimer's and total dependent on staff for locomotion.Observation on 04/30/26 at 12:00 P.M., showed CNA C entered the resident's room to provide care. He/She transferred the resident from the bed to the chair with a mechanical lift with a hospice employee. CNA C operated the mechanical lift while the hospice employee stood over by the resident's wheelchair. The resident swung in the air, without staff guidance, while being transferred from the bed to the chair.During an interview on 04/30/26 at 12:11 P.M., CNA C said he/she would open the legs, the other staff should be guiding the resident. He/She did see the resident swing in the air. He/She should have told him/her to guide the resident. CNA said the concern is the resident could fall if other staff do not hold onto the resident 5. During an interview on 04/30/26 at 10:49 A.M., Licensed Practical Nurse (LPN) B said two staff members are required when transferring a resident with a mechanical lift. He/She said the purpose for two staff was for one person to operate the lift and the other would guide the resident to safely transfer the resident.During an interview on 04/30/26 at 1:14 P.M., the administrator said there should be two staff members when transferring a resident with a mechanical lift. He/She said the concern with not using two staff members is the potential for residents to sustain injury.During an interview on 05/12/26 at 9:08 A.M., the Administrator said the expectation is two staff members should be present when using a mechanical lift to avoid injury. Complaint #2993245Incident #3001682

Based on interview and record review, facility staff failed to notify the physician after a change in condition for one resident (Resident #1) out of one sample residents when staff assisted the resident with positioning, heard a pop and the resident complained of pain. The facility census was 63.1. Review of the facility's Notification of Changes policy, dated 01/30/24, showed the facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 2. Review of the resident's care plan, dated 01/15/25, showed the resident had an Activity of Daily Living (ADL) self-care performance deficit related to a diagnosis of left sided paralysis and required two staff for transferring.Review of the facility report, dated 04/21/26, showed the Certified Nurse Aide (CNA) A documented he/she repositioned the resident by rolling him/her towards the wall, when he/she heard a pop. The resident immediately expressed pain, stating ouch and reported his/her leg hurt. The CNA immediately reported the incident to the charge nurse. The CNA documented the following morning, the resident was observed in his/her wheelchair and continued to report pain, so he/she again, reported the incident from the prior night to the charge nurse. The report did not contain documentation the physician was notified after the incident.Review of the resident's progress notes, dated 04/22/26, showed staff documented during the morning shift change report resident sitting in wheelchair by housekeeping office, anytime staff approached the resident, resident began yelling and cussing his/her left hip hurt. Staff documented the behavior was usual for resident to yell and cuss when in pain. The notes did not contain documentation staff contacted the physician after a change in condition. During an interview on 04/30/26 at 10:38 A.M., CNA A said he/she during the evening on 04/21/26, rolled the resident towards the wall, he/she heard a pop noise and the resident yelled out in pain. He/She immediately reported it to the Licensed Practical Nurse (LPN) B.During an interview on 04/30/26 at 10:49 A.M. LPN B said he/she did not recall if CNA A reported the incident to him/her because he/she was busy assisting a new admission. He/She said he/she did see the resident on 04/21/26 between 9:30 to 10:00 P.M. and he/she did complain about pain in his/her legs, but upon assessment, did not see any injuries. He/She said he/she did not contact the physician since the resident had a history of leg pain.During an interview on 04/30/26 at 1:14 P.M., administrator said he/she expected staff to contact the physician if the resident had a change in condition. He/She said the nurse should have contacted the physician after CNA A reported hearing a popping noise and the resident was in pain. 2993245

Based on interview and record review, facility staff failed to meet professional standards of practice when staff failed to complete weekly skin assessments for one resident (Resident #1) out of three sampled residents. The facility census was 62.1. Review of the facility's policy titled Skin Integrity, dated 01/30/24, showed the medical record will contain all documentation regarding assessment of skin.Review of the facility's policy titled Skin Observation, undated, showed a full body, or head to toe, skin observation will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter;The facility did not provide a policy for following physician's orders.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/25/25, showed staff assessed the resident with moderate cognitive impairment.Review of the resident's care plan, dated 12/29/25, showed staff assessed the resident with impaired cognition and at risk for skin breakdown and pressure ulcers.Review of the resident's Physician's Order Sheet (POS), dated 10/03/25, showed an order for weekly skin assessments every Friday on the evening shift.Review of the resident's nurse's notes, dated 12/21/25, showed staff documented a deep tissue injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration) on the resident's sacrum.Review of the resident's POS, dated 12/29/25, showed an order for weekly skin assessments every Monday on the night shift.Review of the resident's weekly skin assessment, dated December 2025, showed staff did not document they assessed the resident's skin on 12/05/25, 12/12/25, and 12/19/25.Review of the resident's POS showed orders:-On 01/02/26: Miconazole Nitrate Vaginal Cream 4% (an antifungal medication), mix with barrier cream (a skin protectant) and apply to buttock every shift and as needed;-On 01/02/26: Skin prep (a skin protectant) wipes to left heel every shift.Observation on 01/0526 at 9:45 A.M., showed the resided in bed on a low air loss mattress.During an interview on 01/05/26 at 12:45 P.M., the MDS nurse said he/she does not see any weekly skin assessments completed for the resident from 11/28/25 through 12/21/25. The MDS nurse said the resident has an order for weekly skin assessments and they should have been completed during that time. The MDS nurse said the charge nurse is responsible to complete them and he/she does not know why they were not done. The MDS nurse said if something is not documented it was not completed, and staff are expected to follow all physician's orders.During an interview on 01/05/26 at 1:22 P.M., Registered Nurse (RN) A said the resident has a DTI on his/her sacrum and a pressure ulcer on his/her left heel. RN A said the DTI was found on 12/21/25 prior to the resident going to the hospital and the left heel has been an ongoing issue but he/she did not know the date it was found. RN A said both wounds were facility acquired. RN A said both wounds should be documented on the resident's skin assessment. RN A said prior to this most recent hospital stay on 12/22/25 the resident had multiple behaviors and was non-complaint with cares such as repositioning and wearing heel protectors. RN A said the charge nurse is responsible to complete the weekly skin assessments and document them in the resident's chart. RN A said he/she knows the resident has an order for weekly skin assessments and the computer system automatically triggers the charge nurse to complete them. RN A he/she does not know why all the skin assessments were not completed but said they should have been. RN A said all physician's orders should be followed as this is what directs a resident's care. RN A said if an order is not followed it could lead to potential resident harm, like in this case wounds.During an interview on 01/05/26 at 1:58 P.M., the Director of Nursing (DON) said he/she expects staff to follow physician's orders as this is what directs a resident's care. The DON said the charge nurse is responsible to complete the weekly skin assessments on all residents and document them in the resident's chart. The DON said he/she was not aware the resident did not have a skin assessment documented from 11/28/25 through 12/21/25. The DON said if it is not documented it was not completed. The DON said the resident is non-compliant and if he/she refused a skin assessment the charge nurse should have documented that, as not documenting is not acceptable. The DON said the consequences of not following physician's orders can lead to potential outcomes or harm to the resident.During an interview on 01/05/26 at 2:20 P.M., the Administrator said he/she expects staff to follow all physician's orders as this is what tells the staff how to care for the resident and provide proper treatment or medications. The Administrator said the charge nurse is responsible to complete the weekly skin assessments and document them in the resident's chart timely. The Administrator said if something is not documented he/she can't say if it was completed or not. The Administrator said she was not aware staff didn't complete skin assessments on this resident from 11/28/25 through 12/21/25. The Administrator said staff should have completed and documented skin assessments per the physician's orders. The Administrator said not documenting the assessments is not acceptable. The Administrator said the consequences of not completing assessments can result in potential outcomes for the residents such as wounds like this. The Administrator said the DON, MDS, or himself/herself are responsible to oversee the nurse's and ensure things are completed and documented as ordered. The Administrator said he/she did not know why the assessments were not completed per the physician's orders but should have been. Complaint #2700450

Based on interview and record review, facility staff failed to notify one resident's (Resident #1) out of one sampled resident representative in a timely manner when staff assessed the resident with an open area to the knee and bone protruding through the skin. The facility census was 59. The administrator was notified on 11/18/25 of Past Non-Compliance, which occurred on 10/06/25 when nursing staff failed to notify Resident #1's Power of Attorney (POA) of a change in condition to an old fracture to the right knee with new bone protrusion. Nursing staff completed in-service training on when and who to notify after a change in condition on 10/10/2025. 1. Review of the facility's policy titled Notification of Changes, dated 10/01/25, showed the purpose is to ensure the facility promptly informs the resident and notifies the resident representative when there is a change requiring notification. The facility must inform the resident and/or notify the resident's legal representative when there is a change requiring such notification. Circumstances requiring notification include; potential to require physician intervention, circumstances that require a need to alter treatment including new treatment, discontinuation of current treatment due to acute condition or exacerbation of chronic conditions.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/16/25, showed staff assessed the resident as follows:-Severe Cognitive impairment;-Lower extremity impairment both sides;-Dependent on staff for transfers, toileting, and hygiene;-Diagnoses of Non-Alzheimer's Dementia.Review of the resident's nurse notes, dated 10/05/25 at 12:41 A.M., showed staff documented a 0.5 centimeter (cm) open area to the right knee with a white center, no odor or drainage noted. The nurse's note did not contain documentation the resident's representative had been notified of the open area to the knee. Review of the resident's nurse note, dated 10/06/25 at 1:22 A.M., showed staff documented a pink tinge drainage from the right knee dressing. Dressing removed, area cleansed, pinpoint hole noted with large amount of pink tinged drainage. Bone protruding under skin. New dressing applied. Resident yells out it hurts often, even when care is not being done. The nurse note did not contain documentation staff notified the resident representative of change in condition. Review of the resident's nurses note, dated 10/06/25 at 8:08 A.M., showed the assistant director of nursing (ADON) documented he/she notified the resident's physician the right femur fracture bone protruded through the skin and current pain management is not effective, new orders received. The nurse note did not contain documentation staff notified the resident representative of change in condition. Review of the resident's nurses note, dated 10/07/25 at 1:31 P.M., showed a new order for Keflex (antibiotic) 500 milligrams (mg) three times a day for five days due to wound.Review of the resident's nurses note, dated 10/07/25 at 3:33 P.M., showed the MDS coordinator documented he/she spoke with the resident's representative about the resident's status, discharge from Medicare services, and antibiotic due to wound infection.During an interview on 11/17/25 at 2:06 P.M., the DON said he/she is unsure why the charge nurse did not notify the resident's representative when the femur bone protruded through the resident's skin, but they should have. The resident's representative should have been notified as soon as possible. During an interview on 11/18/25 at 12:02 P.M., the ADON said when a resident has a change in condition the resident representative should be contacted as soon as possible. He/She said he/she does not have a good reason why the resident representative was not notified after the doctor was contacted for the resident's change in condition. He/She said he/she was so worried about the resident that is slipped his/her mind.During an interview on 11/18/25 at 1:20 P.M., the administrator said staff is expected to notify the resident representative promptly or immediately with a change in condition. Each situation is different but after a resident is assessed staff should notify the representative if there is a change. Complaint #2642026

Based on observation, interview and record review, facility staff failed to use standardized recipes to prepare foods for service to all residents and serve food in accordance with the nutritionally calculated menus. Facility staff failed to provide menus with the food items and portion sizes to be served for all diet types utilized by the facility and failed to record substitutions made to the menus. These failures have the potential to affect all residents. The facility census was 59. 1. Review of the facility's policy titled Food Service to Residents, dated 01/30/24, showed food will be prepared and served in a manner that meets the individual needs of the resident. Review of the facility's policy titled Menus, dated 01/30/24, showed the policy directed staff that the menus must: -Meet the nutritional needs of the residents in accordance with established national guidelines;-Be prepared in advance;-Be followed;-Reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups. Review of the facility's policy titled Food Substitutions, dated 01/30/24, showed the dietary manager will make food substitutions as appropriate or necessary, he/she will consult the dietitian as necessary prior to making a substitution, and all substitutions are to be noted on the menu and filed in accordance with established dietary policies. Review of the residents' diet cards showed the residents' diet types included regular, minced and moist (a diet in which the foods consist of very soft, small moist lumps that does not require more than minimal chewing ability) and pureed. Review of the menus posted on the dietary manager's door, showed a four-week cycle of contracted vendor prepared menus for a regular diet type. Observation on 08/27/25 at 7:45 A.M., showed the kitchen did not contain visible menus for the minced and moist and pureed diet types, standardized recipes for staff to use in food preparation, or a menu substitution log. Review of the breakfast menu dated 08/27/25 (Week 1, Day 4), showed the menus directed staff to provide the residents on a regular diet with: -Four ounces (oz.) of hot cereal or six oz. of cold cereal;-Breakfast sandwich which consisted of two slices of bread and two oz. of protein; and-A four oz. fresh fruit cup. Review showed the menu did not contain documentation of any substitutions made to the menu. Observation of the breakfast meal service on 08/28/25 at 7:45 A.M., showed [NAME] M served the residents who received regular diets four oz. of hot cereal or six oz. of cold cereal, one oz. of scrambled eggs, and two oz. of diced potatoes. Observation showed the cook did not prepare, serve or offer the residents the breakfast sandwich or the fresh fruit cup as indicated by the menus. Observation showed the cook did not prepare, serve or offer the residents an additional protein and fruit source. Observation of the breakfast meal service on 08/28/25 at 7:45 A.M., showed [NAME] M served the residents who received minced and moist diets four oz. of hot cereal, one oz. of scrambled eggs, and two oz. of diced potatoes. Observation showed the cook did not prepare, serve or offer the residents the breakfast sandwich or the fresh fruit cup as indicated by the menus. Observation showed the cook did not prepare, serve or offer the residents an additional protein and fruit source. Observation of the breakfast meal service on 08/28/25 at 7:45 A.M., showed [NAME] M served the residents who received pureed diets four oz. of hot cereal, three oz. of pureed scrambled eggs and two oz. of pureed sausage. Observation showed the cook did not prepare, serve or offer the residents a pureed breakfast sandwich, pureed fruit or an additional pureed starch. During an interview on 08/27/25 at 8:28 A.M., [NAME] M said the breakfast served is different from the menus, because the dietary manger had been mixing and matching food items to make menus due to something with the food orders and possibly being over budget. The cook said the dietary manager told him/her to substitute the breakfast menu with the food items he/she served the residents, but he/she did not tell him/her how much to serve of each item. The cook said the only menus they had were the menus posted on the dietary manager's door and he/she did not have documentation of the substitutions made to the menu. The cook also said they did not have any recipes to use to prepare the resident meals, so they just made things how they think they should be made. During an interview on 08/27/25 at 1:15 P.M., the dietary manager said staff are expected to serve the menus as planned unless otherwise directed and staff should call him/her for direction if they do not have something they need to make the meal. The dietary manager said he/she did not direct the staff to not serve the breakfast as directed by the menu and staff did not contact him/her about needed substitutions to the breakfast meal. The dietary manger said substitutions to the menu should be approved and documented, but he/she did not know staff substituted the breakfast menu so he/she did not have documentation of the substitutions. The dietary manager said if substitutions are made, there should be food items to cover all food types indicated on the menu to meet the residents' nutritional needs. The dietary manager said, based on the original breakfast menu and what staff served the residents, staff should have served the residents on regular and minced and moist diets an additional protein source and a fruit source and the residents on a pureed diet should have received a pureed starch and fruit source. The dietary manager said he/she did not have menus for minced and moist and pureed diets, nor did he/she have standardized recipes available for staff to use to prepare meals. The dietary manager said he/she had repeatedly asked the dietician and facility management about the menus and recipes because he/she knew they should have them. The dietary manager said the registered dietician told him/her the menus and recipes were in the contracted menu computerized program, but he/she had not been trained how to use the program and did not know how to access the menus and recipes. During an interview on 08/28/25 at 10:38 A.M., the administrator said staff are expected to prepare food in accordance with the standardized recipes and serve it in accordance with the planned menus, which included the food items and portion sizes for modified textured diets. The administrator said if staff do not have what they need to prepare a meal, they should notify the dietary manager or him/her to get what they need or contact the registered dietician to figure out a substitution. The administrator said staff did not contact him/her about a need to substitute the breakfast menu on 08/27/25. The administrator said, if staff make substitutions to the menu, the substitutions should be of equal nutritional value and documented. The administrator said the dietary manager is responsible to ensure the dietary staff have the menus and recipes to prepare the meals and that staff serve the meals accordingly. The administrator said when they got the new spring/summer menus in, he/she asked the dietary manager if he/she had all the menus and recipes needed and the dietary manager said that they did, so he/she had no idea that the dietary staff did not have recipes or menus for minced and moist and pureed diets because the dietary manager did not know how to retrieve them from the computerized program. The administrator said if the department heads do not know how to do something, they should come to him/her for help. The administrator said he/she does a kitchen sanitation inspection on to two times a month, but he/she does not look for the menus and recipes when he/she does his/her inspections.

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use and ensure the use of food in a first-in, first-out manner. Facility staff failed to ensure dishes were clean and air dried prior to stacking in storage to prevent the growth of foodborne pathogens. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to maintain kitchen surfaces and equipment clean and in good repair to prevent potential contamination. These failures have the potential to affect all residents. The facility census was 59. 1.Review of the facility's policy titled Storage of Food in Refrigeration, dated 01/30/24, showed: -Store raw meats on the bottom shelves to prevent contamination of other perishable items; -Food being returned to storage after cooking or preparation must be covered; -All containers must be labeled with the contents and date the food item was placed in storage; -Food items that remain sealed from the supplier may be held until the expiration date if unopened. Review of the facility's policy titled Food Safety, dated 01/30/24, showed: -A purpose of the policy is to ensure the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness; -The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety; -For food brought into the facility that has been prepared by others, the facility is responsible to: a. Store visitor food in such a way to clearly distinguish it from food used by or prepared by the facility; b. Ensure safe food handling once the food is brought to the facility, including safe temperatures of food and handling of leftovers; c. Clearly identify what food has been brought in by visitors for residents and guests when served; d. Food brought in must be dated, stored in the resident's room, and discarded after three days; e. Store bought items in original wrapping or container unopened; f. Food may not be stored in the facility kitchen/refrigerator. Observations on 08/25/25 at 10:10 A.M., showed the reach-in refrigerator labeled as #1 contained: -An opened and undated bag of uncooked hot dogs stored inside an undated plastic resealable bag stored on the top shelf over containers of ready-to-eat and leftover prepared food items; -An unopened package of uncooked ham and an opened and undated package of sliced turkey breast stored inside an undated plastic resealable bag on the top shelf over containers of ready-to-eat and leftover prepared food items. Observation showed liquid from the turkey package dripped on a container of tossed salad stored below the turkey; -An opened and undated bag of precooked bacon pieces stored in an undated plastic resealable bag opened to the air on the second shelf. Observations on 08/25/2025 at 10:26 A.M., showed the reach-in freezer labeled as #3 contained: -An undated case of beef patties opened to the air; -An undated and unlabeled plastic resealable bag which contained two uncovered burritos, a grocery store bag and an undated and unlabeled unidentifiable packaged food item. Observations on 08/25/2025 at 10:30 A.M., showed three dented six pound eight ounce (oz.) cans of diced pears and a dented six pound 10 oz. can of fancy tomato sauce stored on a shelf with the in-use food supply in the dry goods pantry. Observation showed the dent on the can of tomato sauce located on the top edge seal of the can. Observations on 08/27/25 at 9:08 A.M., showed the reach-in refrigerator labeled as #1 contained: -An opened and undated bag of uncooked hot dogs stored inside an undated plastic resealable bag and a case of uncooked ham stored on the top shelf above containers of shredded cheese, vanilla pudding and chocolate puddings; -Containers of leftover prepared brown gravy, peas and turkey with gravy stored above the containers of shredded cheese and puddings; -Opened and undated one gallon containers of mayonnaise, enchilada sauce, sweet and sour sauce, and fresh sauerkraut. Observation showed the container of sauerkraut with a delivery sticker dated 01/23/25 and the exterior of the container excessively soiled with mold-like debris. Observation on 08/27/25 at 9:17 A.M. showed two opened and undated five pound containers of peanut butter stored on the shelf above the microwave. Observation showed the top exterior excessively soiled with peanut butter residue. During an interview on 08/27/25 at 9:22 A.M., the dietary manager (DM) said raw foods should be stored below ready-to-eat and prepared foods and prepared foods should be stored above raw foods and below ready-to eat foods to avoid cross-contamination. The DM said opened and leftover prepared food items should be labeled with the date the item is opened or made to prevent staff from serving spoiled food. The DM said staff should use all of one food item before they open another to ensure food is used in a first in, first out manner. The DM said he/she is responsible to monitor food storage and he/she should look at it every day, but he/she had not done so and he/she had not been able to do a lot of his/her duties due to some staffing issues. Observation on 08/27/25 at 9:46A.M., showed an undated container of sugar, removed from its original packaging, stored below the cook's food preparation counter and scoop stored uncovered on top of the container. Observation on 08/27/25 at 10:22 A.M., showed the reach-in refrigerator labeled as #2 contained: -Opened and undated 46 oz. bottles of nectar consistency thickened apple juice, orange juice and iced tea; -An opened and undated 46 oz. bottle of honey consistency thickened cranberry juice; -An opened and undated 32 oz. carton of honey consistency thickened dairy beverage; -An opened and undated 32 oz. carton of half and half with a use by date of 08/24/25; -An unopened 32 oz. carton of half and half with best by date of 08/17/25; -An opened and undated 12 oz. bottle of wing sauce with a best by date of 06/09. Observation showed the year of the best by date worn off of the bottle; -An uncovered pitcher of cranberry juice dated 08/26/25; -An undated plastic resealable bag of leftover pizza slices; -An unlabeled bottle of a factory prepared coffee drink. During an interview on 08/27/25 at 10:25 A.M., [NAME] M said the coffee drink bottle belonged to an employee and employee food items should not be stored in the refrigerator with resident food. During an interview on 08/27/25 at 10:30 A.M., the DM said opened and prepared food items should be labeled, dated and stored in sealed containers. The DM said staff are expected to discard food that is past its expiration date and if it does not have an expiration date then the best by or use by dates would be considered the expiration date and staff should dispose of those items if they are past the best by or use by dates. The DM said if an expiration date or best by date on a food item is not legible then it should also be discarded. The DM said the bottle of wing sauce, bag of pizza and coffee drink bottle belonged to staff and staff food should not be stored with the resident food. The DM said he/she told staff to store their food in his/her office refrigerator. Observation on 08/27/25 at 10:45 A.M., showed the reach-in freezer labeled as #3 contained: -An undated case of beef patties opened to the air; -An undated and unlabeled plastic resealable bag which contained two uncovered burritos, a grocery store bag under the burritos and an undated and unlabeled unidentifiable packaged food item. During an interview on 08/27/25 at 10:45 A.M., the DM said the food plastic resealable bag belonged to a resident. The DM said the bag should have been labeled with the resident's name and the date it was received. The DM said he/she did not know what the unlabeled packaged food item was or how old it was, staff should not have stored the grocery bag with the items because it is contaminated, the burritos should be wrapped to prevent contamination from the other items in the bag and he/she did not know how old the burritos were. Observation on 08/27/25 at 11:15 A.M., showed the dry goods storage pantry contained: -An opened and undated 25 pound bag of sugar; -An opened and undated 50 pound bag of flour; -An undated bag of egg noodles opened to the air; -A dented six pound eight oz. can of diced peaches and two dented six pound 10 oz. cans of fancy tomato sauce stored on a shelf with the in-use food supply. Observation showed a dent on one of the two cans of tomato sauce located on the top edge seal of the can. During an interview on 08/27/25 at 4:15 P.M. the DM said dented cans should be disposed of and not stored with the in-use food supply. The DM said staff are trained on food storage requirements upon hire and as needed. During an interview on 08/28/25 at 10:55 A.M., the administrator said opened and prepared food items should be stored sealed in appropriate containers, labeled with what it is and dated with the opened or made date. The administrator said uncooked foods should be stored below prepared and ready-to-eat foods and prepared foods should be stored above uncooked foods and below ready-to-eat foods to prevent cross-contamination. The administrator said staff should use all of one food item before they open another to ensure food is used in a first-in,first-out manner and dented cans should be discarded and not be stored with the in-use food items. The administrator said staff food should not be stored with the resident food supply and outside food items brought in for residents should be stored in sealed containers dated with the date received, labeled with the resident's name, and not stored with anything that could be contaminated, like a grocery store bag, to prevent cross-contamination. The administrator said staff are expected to dispose of items past their best by or use by dates or if they cannot read what the best by or use by date is. The administrator said scoops used to dispense food should be stored in clean covered containers. The administrator said staff are trained on food storage requirements upon hire and as needed and the DM is responsible to monitor food storage daily. The administrator said he/she did not know the DM had not monitored the food storage daily. 2. Review of the facility's policy titled Dish Washing, dated 01/30/24, showed the policy did not contain direction for staff related to the drying and storage of dishes. Observations on 08/25/25 at 10:10 A.M., showed five metal sheet pans and 14 metal food preparation pans of various sizes stacked together wet on the shelf below the cook's station food preparation table. Observation also showed five of the 14 wet stacked food service pans contained food debris on the inside and another two of the pans had soap residue on the inside. Observation on 08/27/25 at 2:50 P.M., showed Dietary Aide (DA) O washed dishes in the mechanical dishwashing station. Observation showed the DA stacked sanitized plates and plate covers from the clean side of the station while wet and then put them in storage. Observations on 08/27/25 at 3:00 P.M., showed 18 metal food service pans of various sizes stacked together wet on the shelf below the cook's station food preparation table. Observation also showed eight insulated plate covers stacked together wet and stored upside down on the shelf by the ice machine. During an interview on 08/27/25 at 3:15 P.M., the DM said staff should ensure dishes are clean and allow the dishes to air dry before they put them away and staff are trained on this requirement. The DM said he/she is responsible to monitor dish washing and storage daily, but he/she had not done so daily due to staffing issues. During an interview on 08/28/25 on 11:18 A.M., the administrator said staff should ensure the dishes are clean, without food residue, and allow the dishes to air dry before they put them away. The administrator said staff are trained on dish washing and storage procedures and the DM is responsible to monitor dish storage after each meal's wash. 3. Review of the facility's policy titled Hand Hygiene, dated 01/30/24, showed: -Handwashing will be regarded by this facility as the single most important means of preventing the spread of infection; -Staff will follow the facility's established hand hygiene procedures to prevent the spread of inspection and disease to other staff, residents and visitors; -Hands should be washed for at least 20 seconds using soap and water when staff come on duty, whenever hands are visibly soiled, after handling items potentially contaminated with blood, body fluids, excretions, or secretions, before and after glove use, and upon completion of duty; -The policy did not provide direction to staff on the proper procedure for washing their hands with soap and water. Review of the facility's policy titled Food Safety, dated 01/30/24, showed: -A purpose of the policy is to ensure the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness; -Staff should have access to proper hand washing facilities with available soap, hot water and disposable towels and/or heat/air drying methods. The use of disposable gloves is not a substitute for proper hand washing; -Hands must be washed before putting on and after removing gloves as well as between tasks and between handling soiled and clean dishes; -The policy did not provide direction to staff on the proper procedure for washing their hands with soap and water. Observations on 08/27/25 at 8:56 A.M. and 9:08 A.M., showed DA N washed soiled dishes in the mechanical dishwashing station and then washed his/her hands at the handwashing sink. Observation showed when the DA washed his/her hands, he/she scrubbed his/her hands with soap for three seconds, rinsed his/her hands and turned the faucet off with his/her bare hands. Observation showed the DA then put away sanitized dishes from the clean side of the station. Observations on 08/27/25 at 3:06 P.M. and 3:08 P.M., showed DA O washed soiled dishes in the mechanical dishwashing station. Observation showed, without performing hand hygiene, he/she put away sanitized dishes from the clean side of the station. Observation on 08/27/25 at 3:10 P.M., showed DA N entered the kitchen from outside and washed his/her hands in the handwashing sink. Observation showed when the DA washed his/her hands, he/she scrubbed his/her hands with soap for three seconds and turned the faucet off with his/her bare hands. During an interview on 08/27/25 at 3:10 P.M., DA N said staff should scrub their hands with soap for at least 20 seconds when they wash their hands, and he/she thought he/she had just scrubbed his/her hands with soap for 30 seconds but guessed he/she got in too much of a hurry. The DA said he/she did not know he/she should not turn the faucet off with his/her bare hands, but it would make sense not to do so since the faucet is turned on with dirty hands. During an interview on 08/27/25 at 3:11 P.M., DA O said staff should wash their hands between tasks and anytime they get dirty. The DA said he/she should have washed his/her hands between handling the dirty and clean dishes, but he/she forgot to do so because he/she was stressed out and overwhelmed. During an interview on 08/27/25 at 4:15 P.M., the DM said staff should wash their hands with soap and water when they enter the kitchen, between tasks and after they touch anything dirty. The DM said, when staff wash their hands, they should scrub their hands with soap for at least 30 seconds before they rinse and turn the faucet off with a paper towel to prevent recontamination of their hands. The DM said all staff are trained on hand hygiene upon hire and as needed so they should know better. During an interview on 08/28/25 at 11:39 A.M., the administrator said staff should perform hand hygiene anytime they enter the kitchen, between tasks and after they touch something dirty. The administrator said, when staff wash their hands, they should scrub their hands with soap for 30 seconds before they rinse and turn the faucet off with a paper towel because the faucet is dirty. The administrator said staff are trained on hand hygiene upon hire, annually and as needed. 4. Review of the facility's policy titled Cleaning, dated 01/30/24, showed: -The purpose of this policy is to ensure a clean and sanitary dietary environment; -All equipment, food contact surfaces and utensils shall be cleaned whenever contamination may have occurred; -All food surfaces will be cleaned at the end of each food preparation session; -Refrigerator units must be cleaned; -Wall surfaces that become splattered during the food preparation process must be cleaned daily; -The policy did not contain information specifically related to the cleaning and maintenance of freezers, gasket seals, vents, fans, the steam table, and the ice machine. Observations on 08/25/25 at 10:08 A.M. and 08/27/25 at 9:00 A.M., showed the kitchen did not contain a visible cleaning or maintenance schedule. 5. Observations on 08/25/25 at 10:08 A.M. and 08/27/25 at 9:30 A.M., showed a piece of foil, which contained an accumulation of dirt and food debris, on the windowsill below the air conditioner unit in the food preparation area. During an interview on 08/27/25 at 3:45 P.M., the DM said staff put the foil on the windowsill to protect it from the air conditioner condensation. The DM said staff should check the windowsill daily and ensure it is cleaned as needed. The DM said he/she did not notice the accumulation of dirt and food debris on the foil. During an interview on 08/28/25 at 11:23 A.M., the administrator said the dietary staff are responsible to ensure the kitchen surfaces are routinely cleaned and the DM should monitor the cleanliness of the kitchen daily. The administrator said he/she recently directed the dietary staff to replace the foil on the windowsill since it was dirty and he/she did not know staff did not replace it as directed. 6. Observation on 08/25/25 at 10:08 A.M., showed the steam table wells contained a white sediment buildup and food debris floating in the water and the top of the water with an oily film layer. Observation on 08/27/25 at 9:30 A.M., showed the steam table wells contained a white sediment buildup and food debris floating in the water and the top of the water with an oily film layer. Observation also showed dark mold-like specks along the sides of two of the wells. During an interview on 08/27/25 at 9:30 A.M., [NAME] M said staff take the steamtable outside weekly to drain and clean it and they had last cleaned the steamtable wells on 08/18/25. During an interview on 08/27/25 at 9:35 A.M., the DM said the white sediment buildup is calcium deposits that accumulates quickly due to the facility's hard water. The DM said the steamtable should be drained and cleaned daily, but it is currently cleaned once a week because staff must take it outside and tip it over to dump out the water. The DM said staff must take the steamtable outside to drain and clean it because the wells will no longer drain through the drainpipe due to calcium buildup. The DM said he/she had not tried to remove the calcium deposits from the drain manually or chemically, but he/she had notified maintenance staff on multiple occasions about the drain issue and they had not fixed it to date. During an interview on 08/27/25 at 3:45 P.M., the maintenance assistant said every time the DM reports that the steam table will not drain, he/she goes to the kitchen and manually unclogs the drain. The maintenance assistant said the facility does have hard water that creates a buildup of calcium deposits, but he/she felt the steam table drain issues were related to the staff not cleaning it often enough. The maintenance assistant said dietary staff had not reported any current issues with the steam table drain and he/she did not know it would not drain as designed. During an interview on 08/28/25 at 11:23 A.M., the administrator said the steam table wells should be drained and cleaned after each meal, but at least once a day. The administrator said if something is in need of repair, staff should notify the maintenance staff and if they have notified maintenance staff and the issue is not taken care of, they should notify me. The administrator said no one reported any issues with the draining of the steam table to him/her and he/she did not know staff were only cleaning the steam table once a week. 7. Observation on 08/25/25 at 10:18 A.M., showed the gasket seal on the kitchen chest freezer torn in multiple areas and an excessive accumulation of ice built up on the lid, interior walls and food items stored inside the freezer. Observation on 08/27/25 at 10:53 A.M., showed the gasket seal on the kitchen chest freezer torn in multiple areas and an excessive accumulation of ice built up on the lid, interior walls and food items stored inside the freezer. Observation also showed the exterior of the chest freezer with multiple scratches, dents and areas of rust. During an interview on 08/27/25 at 10:53 A.M. the DM said the gasket seal and ice buildup had been an on-going issue for months. The DM said maintenance staff have repaired it several times, but the repairs do not last long. The DM said he/she also reported the disrepair of the freezer to the administrator and corporate staff. During an interview on 08/27/25 at 3:45 A.M., the maintenance assistant said maintenance staff make repairs to the chest freezer the best they can when dietary staff let them know there is an issue. The maintenance assistant said no one had reported any recent issues with the chest freezer to maintenance staff. The maintenance assistant said they have worked on the freezer multiple times in the past and make the repairs the best they can, but the freezer is old. During an interview on 08/28/25 at 11:23 A.M., the administrator said if something is in need of repair, staff should notify the maintenance staff and if they have notified maintenance staff and the issue is not taken care of, they should notify me. The administrator said he/she knew about the poor condition of the chest freezer and intended to replace it, but he/she forgot. 8. Observation on 08/25/25 at 10:40 A.M. and 08/27/25 at 11:11 A.M., showed six ceiling vents and a small tabletop fan, which were located over food preparation and dishwashing stations in the kitchen, with a buildup dirt and debris. During an interview on 08/27/25 at 3:45 P.M., the DM said the maintenance staff are responsible to clean the kitchen vents and fans and he/she did not know how often they were expected to clean them. During an interview on 08/28/25 at 11:23 A.M., the administrator said the dietary staff are responsible to clean the kitchen vents and fans and they should clean them at least monthly. The administrator said he/she did not know dietary staff thought maintenance staff were responsible to clean them and were not cleaning them. 9. Observation on 08/27/25 at 9:08 A.M., showed the gasket seals torn on the doors to the reach-in refrigerators labeled as #1 and #2. During an interview on 08/27/25 at 9:22 A.M., the DM said he/she did not know about the torn seals on the refrigerators. The DM said he/she is responsible to monitor food storage, which would include the condition of the refrigeration units, and he/she should look at it every day, but he/she had not done so and he/she had not been able to do a lot of his/her duties due to some staffing issues. During an interview on 08/28/25 at 11:23 A.M., the administrator said if there are issue with the refrigerators, staff should document the issue in the maintenance binder to notify maintenance staff. The administrator said the DM is responsible to monitor food storage, which would include the condition of the storage areas daily. The administrator said he/she did not know about the torn gasket seals on the refrigerators or that the DM had not monitored the food storage daily. 10. Observation on 08/27/25 at 4:00 P.M., showed a utility cart with an ice chest stored in the dining room. Observation showed the scoop to dispense the ice from the chest stored uncovered in a container previously used for manufacturer packaged ice cream. Observation showed the container did not contain a description or emblem to indicate the container was not a single-service container. Observation also showed the ice scoop for the ice machine stored in an uncovered container with an accumulation of white sediment, debris and water. During an interview on 08/27/25 at 4:15 P.M. the DM said scoops used to dispense ice should be stored in clean covered containers and staff should clean ice machine scoops and bins daily. The DM said upon review of the ice machine's scoop bin, he/she did not believe staff cleaned the scoop and the bin daily as directed. The DM also said he/she did not know they could not reuse the ice cream containers for other food things. During an interview on 08/28/25 at 10:55 A.M., the administrator said scoops used to dispense ice should be stored in clean covered containers and staff should not reuse ice cream containers to store food or food-contact items. The administrator said dietary staff are responsible to clean the ice scoops and bins daily and the DM should monitor their cleanliness daily. The administrator said he/she did not know the issues with the ice scoops and bins or that the DM had not monitored them daily.

Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain resident rooms. Staff failed to clean and maintain wheelchairs for four residents (Resident #5, #6, #16, and #58) of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Maintenance, dated 01/30/24, showed it is the job of all staff to identify areas of concern regarding the maintenance of the building. Preventive maintenance will occur throughout the year. Review of the facility policy titled Maintenance Work Request, dated 01/30/24, showed when a resident, staff member, or family member recognizes the need for maintenance services, a Maintenance Work Request form will be completed by a staff member. Maintenance personnel will review all Maintenance Work Requests daily, Monday through Friday, and prioritize work to be done. All Maintenance Work Requests will be completed within five days of receipt, unless the work needed is of an urgent nature, in which case it will be done as soon as possible. If parts or supplies must be purchased to complete a job, permission to do so must be secured from the administrator in a timely manner. 2. Observation on 08/25/25 at 11:02 A.M., showed resident occupied room [ROOM NUMBER] drywall damaged between bed A and the electrical outlet at the height of the recliner chair and headboard of bed. 3. Observation on 08/25/25 at 3:15 P.M., showed resident occupied room [ROOM NUMBER] doorframe, wall and door with black marks and missing paint. Observation showed the bathroom door to the room had chipped and missing paint. 4. Observation on 08/26/25 at 11:26 A.M., showed resident occupied room [ROOM NUMBER]-bathroom wall and door with missing drywall and paint. Two large missing areas of plaster above bed B with missing paint on the walls by the beds. Plaster sprayed on ceiling in bathroom over sprayed down the wall. Door and doorframe to room has missing and chipped paint. 5. Observation on 08/26/25 at 11:54 A.M., showed resident occupied room [ROOM NUMBER] closet door base trim missing, the bathroom door with a patched hole unpainted and areas of unpainted wall between the beds. Observation showed the bathroom wall with unpainted drywall patch and a cracked window. 6. Observation on 08/26/25 at 2:44 P.M., showed resident occupied room [ROOM NUMBER]-bathroom ceiling with two large water and cracks. 7. Observation on 08/26/25 at 3:08 P.M., showed resident occupied room [ROOM NUMBER] had a broken plastic skid plate on the door, base trim by the bathroom door is peeled away from the wall and missing paint above the base trim. 8. During an interview on 08/28/25 at 1:35 P.M., Certified Nurse Aide (CNA) J said if something needs fixed, staff write it down in the maintenance book at the nurse's station, and then maintenance will sign off on it when it is fixed. The CNA said he/she has noticed missing plaster on the ceilings, and damaged doors and drywall, but can't remember the room. The CNA said the damage he/she has seen in the rooms is not homelike. The CNA said he/she had not filled out a maintenance request this month. The CNA said he/she doesn't really pay attention that much to the walls and doors and she doesn't look up at the ceilings. 9. Review of the facility Maintenance Book, dated August 2025, showed three maintenance tickets for the month of August, each signed as completed by the Maintenance Director. During an interview on 08/28/25 at 2:30 P.M., Licensed Practical Nurse (LPN) F said staff should write things that need fixed in the maintenance book at the nurse's station. The LPN said he/she has seen the damaged walls and doors in the rooms and has not reported it this month. The LPN said he/she has seen the rubber base trim coming off the walls and reported it a long time ago, it has been that way for a while. During an interview on 08/28/25 at 3:58 P.M., the Director of Nursing (DON) said staff should put things that need to be fixed in the maintenance log. The DON said he/she has noticed some of the damage in the rooms. The DON said the administrator is responsible to make sure maintenance request are followed up on. The DON said he/she has completed maintenance request, but does not remember what for and he/she does not remember the specific rooms she seen things in as she is in and out of so many rooms every day. The DON also said she does not look at the ceilings when she goes in rooms. During an interview on 08/28/25 4:43 P.M., the maintenance director said staff should submit a work order in the book at nurse's station. The maintenance director said he/she looks at the book every day and completes the requests. The maintenance director said he/she signs and dates the work orders the day it is completed. The maintenance director said he/she thinks the administrator goes through and looks at work orders in the book. The maintenance director said he/she leaves all work orders in the book, even after completed. The maintenance director said the three work orders in the book for august is all he/she has had for august. The maintenance director said he/she had not been told about missing ceiling plaster, base trim off walls and he/she hasn't got back to painting the patches on the doors, and walls. During an interview on 08/28/2025 at 5:02 P.M., the administrator said he/she has a maintenance book at nurse's station that staff can write concerns in. The administrator said maintenance should check the book daily, and once done with work orders, maintenance need to sign off on it. The administrator said he/she is responsible to make sure maintenance is completing work orders. The administrator said staff has reported damage to the walls, doors, and ceilings in the resident's rooms. The administrator said he/she told corporate, he/she needed a new window, for the cracked window, and he/she has let it fall through the cracks. 10. Review of the facility policy titled Wheelchair Maintenance and Cleaning, dated 05/01/25, showed daily, nursing staff will wipe down high-touch areas (armrests, seat belts, brakes, and push handles) using facility-approved disinfectant wipes. Spills, body fluids, or visible soil must be cleaned immediately. Weekly housekeeping staff will perform a more thorough cleaning of all wheelchair surfaces, including seat cushions, frames, footrests, and wheels. 11. Observation on 08/25/25 at 8:14 A.M., showed Resident #5 sat in his/her wheelchair in the dining room. Observation showed the lower part of the wheelchair had built up dirt and food debris. The front of the wheelchair had an orange pool noodle taped to the front and the tape dirty and peeled away. During an interview on 08/26/25 at 10:03 A.M., the resident said he/she has never seen anyone clean his/her wheelchair. He/She said it bothers him/her the wheelchair has dirt and food debris all over.12. Observation on 08/25/2025 at 3:37 P.M., showed Resident #6 sat in his/her wheelchair in the day room. Observation showed the foot pedals and wheels covered in dried food. The frame had a buildup of an unknown dark substance.Observation on 08/26/2025 at 10:43 A.M., showed the resident's wheelchair foot pedals and wheels covered in dried food. The wheelchair frame had a buildup of an unknown dark substance, the brake had a clump of hair and dried food on the wheelchair cushion. 13. Observation on 08/28/25 at 8:32 A.M., showed Resident #16 in his/her wheelchair in the dining room. Observation showed the wheelchair frame with built up dirt and debris.14. Observation on 08/26/25 at 12:47 P.M., showed Resident #58 in his/her wheelchair in the dining room. Observation showed the lower part of the wheelchair with built up dirt and debris.15. During an interview on 08/28/25 at 2:02 P.M., CNA J said the night shift CNAs are supposed to clean the wheelchairs. He/She said he/she is not sure how often, but he/she thinks there is a wheelchair cleaning schedule in the shower book at the nurse's station. He/She said he/she is unsure why they are not cleaned.During an interview on 08/28/25 at 2:46 P.M., LPN F said the CNAs on the night shift are supposed to clean the wheelchairs. He/She said he/she thought so many wheelchairs are supposed to get cleaned every night, but he/she is unsure of the actual schedule. He/She said he/she expects staff to wipe off food splatter and debris if they see it on the wheelchairs. He/She said he/she has noticed dirty wheelchairs and have passed the information along to night shift nurse in report.During an interview on 08/28/25 at 2:30 P.M., the Housekeeping Manager said he/she tries to clean wheelchairs when he/she has some spare time. He/She said he/she will take the wheelchairs to the shower room and wipe them down with a spray and bleach cleaner. He/She said he/she is unaware of any wheelchair cleaning schedule; he/she just tries to help clean them when he/she can. He/She was not aware that in the policy it said housekeeping is to do a deep cleaning of the wheelchairs weekly.During an interview on 08/28/25 at 4:04 P.M., the DON said the night shift CNAs are responsible for cleaning the wheelchairs weekly. He/She said he/she was not aware that per policy housekeeping is to clean them weekly. He/She said he/she is not sure why wheelchairs are not getting cleaned. He/She said it is the charge nurse's responsibility to ensure the night shift aides are cleaning them.During an interview on 08/28/25 at 5:15 P.M., the administrator said night shift aides are to wipe the wheelchairs down while the residents sleep every night. He/She said housekeeping does deep clean the wheelchairs. He/She said it is the DON's responsibility to ensure wheelchairs are getting clean.

Based on interview and record review, facility staff failed to review and revise the care plan for three residents (Resident #6, #38 & #55) with diagnoses and/or activity preferences out of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Comprehensive Care Plan, dated 01/30/24, showed each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing, medical, physical, mental, and psychosocial needs identified in the comprehensive assessment. The comprehensive care plan will be developed by the interdisciplinary team using the Minimum Data Set (MDS), a federally mandated assessment tool, to assess the resident's clinical condition as well as cognitive and functional status and the use of services. The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 2. Review of Resident #6's Significant Change MDS, dated [DATE], showed staff documented activities of interest as follows: -Snacks between meals;-Staying up past 8 P.M.;-Listening to music;-Being around animals such as pets;-Participating in favorite activities;-Spending time outdoors. Review of the resident's care plan, revised 08/19/25, showed the care plan did not contain guidance for activities of interest.During an interview on 08/28/25 at 1:35 P.M., Certified Nursing Aide (CNA) J said the residents' activities of interest should be on the care plan. The CNA said the MDS Coordinator is responsible for updating resident care plans. During an interview on 08/28/25 at 2:30 P.M., Licensed Practical Nurse (LPN) F said the resident's activities of interest should be care planned. The LPN said the MDS Coordinator is responsible to put information in care plan, he/she takes information from morning meetings.During an interview on 08/28/25 at 3:23 P.M., the MDS Coordinator said he/she has not done activities of interest for resident care plans before. The MDS Coordinator said the resident's activities of interest is important to their care. During an interview on 08/28/25 at 3:58 P.M., the Director of Nursing (DON) saidCare plan is for resident care. Anything that pertains to that resident should go on care plan. MDS coordinator is responsible to create and update care plans. During an interview on 08/28/25 at 5:02 P.M., the administrator said the resident's activity preferences should be on the care plan. 3. Review of Resident #38's Annual MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, diagnosis of diabetes mellitus, and received insulin.Review of the resident's Physician Order Sheet (POS), dated August 2025, showed an order for Insulin Aspart injection pen, inject 36 units once a day. Review of the resident's care plan, dated 08/13/25, showed the care plan did not contain direction for diabetes.During an interview on 08/28/25 at 1:42 P.M., Restorative Aide/CNA J said diabetes should be on the care plan so staff know if a resident is a diabetic in case the resident is acting different, their sugar may be low, and staff can alert the nurse. During an interview on 08/28/25 at 2:51 P.M., LPN F said diabetes should be recorded on the care plan, so staff know what to watch for, or if they get insulin, in case their blood sugars drop. During an interview on 08/28/25 at 3:23 P.M., the MDS Coordinator said care plans should include diagnoses such as diabetes and whether a resident requires insulin. He/she did not know the diagnosis was not on the care plan, he/she said it used to be. During an interview on 08/28/25 at 3:58 P.M., the DON said care plans are used for resident care and anything that pertains to the resident like diagnoses, diabetes, or if they use insulin. The DON said the MDS Coordinator is responsible for creating and updating care plans, and he/she is responsible for making sure he/she does it. During an interview on 08/28/25 at 5:09 P.M., The Administrator said diabetes should be listed on the care plan, because they have special diets and may use insulin. He/she said the DON would be responsible for ensuring care plans are updated since he/she oversees the MDS coordinator. 4. Review of Resident #55's MDS, dated [DATE], showed staff assed the resident as: -Received as needed pain medication;-Had pain occasionally over the last five days;-Pain affected sleep over the last five days;-Pain occasionally affected the resident's day to day activities over the last five days;-Pain score of 5 (What does this mean?);-Received Opioid medication seven out of seven days in the seven day look back period. Review of the resident's POS, dated August 2025, showed an order for pain monitoring, assess for pain every shift, Acetaminophen 325 milligrams, give two tablets every four hours as needed for general discomfort, Tramadol (pain medication) 50 mg, give one tablet every six hours as needed for pain. Review of the resident's care plan, dated 04/17/25, showed the care plan did not contain direction for pain management, to include pharmacological and non-pharmacological interventions.During an interview on 08/28/25 at 1:35 P.M., CNA J said a resident's individualized care for pain, should be on a care plan. During an interview on 08/28/25 at 2:30 P.M., LPN F said pain management should be care planned, with alternative ways to manage pain.During an interview on 08/28/25 at 3:23 P.M., the MDS Coordinator said pain should be addressed on the care plan with interventions. The MDS Coordinator said medication as an intervention, and non-medication interventions should be on care plan. During an interview on 08/28/25 at 3:58 P.M., the DON said pain should be on resident's care plan, with medication and non-medication interventions.During an interview on 08/28/25 at 5:02 P.M., the administrator said pain should be on the care plan with interventions for pain relief.

Based on interview and record review, facility staff failed to document the required neurological checks (an assessment completed to determine if the nervous system is impaired) and update the plan of care with interventions after falls for four residents (Resident #6, #21, #25 and #34) out of 24 sampled residents. Staff failed to update the fall risk assessment for three residents (Resident #21, #25, and #34) out of 24 sampled residents. The facility census was 59. 1. Review of the facility policy titled Fall Incident Reporting and Neurological Checks Policy, undated, showed the purpose is to ensure timely, accurate reporting and monitoring following any resident fall in order to promote safety, identify causes, prevent recurrence, and promptly detect and manage potential injuries, especially head trauma. All resident falls, whether witnessed or unwitnessed, must be immediately reported, documented, and followed by a comprehensive assessment, including neurological checks when head trauma is suspected, or the fall was unwitnessed. The procedure is as follows: -Notify the licensed nurse immediately if unlicensed staff discover the fall; -Complete an incident report immediately including date, time, and location of fall, circumstances leading up to the fall (witnessed/unwitnessed), description of event and findings on assessment, interventions provided and resident response, notifications made (physician, family, Director of Nursing (DON)); -Enter progress note in resident's medical record. Neurological checks (assessments) are required for any fall with head strike (witnessed or suspected), any unwitnessed fall, and residents on anticoagulant therapy regardless of apparent injury. The frequency for neurological checks are every 15 minutes for one hour; every 30 minutes for two hours; every one hour for four hours; every four hours for 24 hours; and every eight hours for an additional 72 hours as indicated (per physician order or facility protocol). Assess and document level of consciousness/alertness, orientation and speech, pupils (size and reaction), limb strength and movement, vital signs (blood pressure, pulse, respirations), pain, nausea/vomiting, headache, dizziness, or changes in behavior; any abnormal findings must be immediately reported to the physician. Post-fall follow up includes update the resident's care plan with new interventions; and all staff will receive training on fall response, incident reporting, and completion of neurological assessments annually and upon hire. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/25/25, showed: -Severe cognitive impairment;-Used a wheelchair;-Had not fallen. Review of the resident's medical record showed staff documented: -Fall Note, dated 06/4/25, resident fell out of wheelchair. Staff went to push wheelchair forward and resident fell forward. Head impacted on front of nurses' station. Abrasion to scalp in hairline. Review showed staff did not complete any neurological checks after the fall;-Fall Note, dated 08/12/25, staff documented while making rounds found resident on the floor next to the bed laying on his/her right side. Small abrasion to right upper forehead and right upper eyebrow. Review of the resident's 72-hour neurological checks documentation showed staff did not document 4 out of the 15 required neurological checks. Review of the resident's Care Plan, revised 08/19/25, showed staff did not document fall interventions for the falls on 06/04/25 or 08/12/25. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Short and long-term memory problems;-Used a wheelchair;-Had falls since admission or prior assessment and had one fall with no injury. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 07/14/25 with no injuries. Review showed the medical record did not contain documentation staff completed neurological checks. Review of the resident's Physician Order Sheet (POS), dated August 2025, showed an order to complete quarterly fall risk assessments with a start date of 07/29/25. Review of the residents medical record did not contain documentation staff completed the quarterly fall risk assessment. Review of the resident's care plan, dated 8/27/25, showed staff did not document additional fall interventions after the 07/14/25 fall. 4. Review of Resident #25's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired;-Used a wheelchair;-Had not fallen since admission or prior assessment. Review of the resident's POS, dated August 2025, showed an order to complete quarterly fall risk assessment with state date of 01/9/2025. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with no injury on 07/14/25. The medical record did not contain documentation of neurological checks or an updated fall risk assessment. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with no injury on 08/04/25. The medical record did not contain seven of 15 neurological checks or an updated fall assessment. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with no injury and complained of pain on 08/07/25. The medical record did not contain documentation of neurological checks or an updated fall risk assessment. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with no injury on 08/17/25. The medical record did not contain documentation of neurological checks or an updated fall risk assessment. Review of the resident's care plan, dated 07/31/25, showed staff did not document the resident's falls and did not provide interventions. 5. Review of Resident #34's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired;-Used a wheelchair;-Had a fall prior to admission and since admission. Review of the resident's medical record showed an admission Fall Assessment, dated 07/13/25, showed a score of 17. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with no injury and complaints of shoulder pain on 08/17/25. The medical record did not contain documentation of neurological checks or an updated fall risk assessment. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with a scalp abrasion and bruise to right middle finger on 08/8/25. The medical record did not contain documentation of a neurological checks. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall with 08/22/25. The medical record did not contain documentation of a neurological checks. Review of the resident's care plan, dated 07/01/25, showed resident is high risk for fall related to confusion, unaware of safety needs; with a goal of resident will not sustain serious injury through the review dates. Staff did not document any interventions and did not list any new interventions after the falls. 6. During an interview on 08/27/25 at 4:46 P.M., the Director of Nursing (DON) said if the neurological checks are not in the system under evaluations, then they were not done. During an interview on 08/28/2025 at 2:02 P.M., Licensed Practical Nurse (LPN) E said if a resident falls, he/she initiates neurological checks if the resident cannot say whether they hit their head. LPN E said the neurological checks should be completed every 15 minutes times four, then 30 minutes times four, then hourly times four, then every four hours times four, then every eight hours for 72 hours. The LPN said all fall follow up charting for 72 hours should be in the progress notes. LPN E said staff keep a report sheet at the nurses' desk that lets him/her know if there has been any falls and the date, so he/she knows if the neurological checks need to be continued. LPN E said if neurological checks are not completed the resident could have a brain bleed or something because the residents on the memory care unit cannot really communicate all that well, so he/she cannot really tell by talking to the residents. LPN E said he/she has noticed that the neurological checks are not always done, but sometimes there is only a Certified Medication Technician (CMT) on the unit that does not have access to the charting. LPN E said the care plans should be updated with interventions after every fall, and it is the MDS Coordinator who updates the care plan, the nurses do not. LPN E said the MDS Coordinator is told about falls during the morning meetings, but he/she has been pulled to another facility recently to work as well, and he/she has missed some morning meetings. LPN E said he/she should let the DON know if there are missing neurological checks so he/she can follow up and he/she does not know if he/she did that. During an interview on 08/28/25 at 3:23 P.M., the MDS Coordinator said as far as he/she knows the nurses can update the care plans, and the care plans should be updated after every fall. He/she said the nurses should document an intervention within an hour of the fall. The MDS Coordinator said he/she takes his/her computer to the morning meetings to update the care plans at that time, and he/she puts the orders in for nursing to do the quarterly fall assessments. The MDS Coordinator believes the DON has in-serviced nursing staff about updating the care plans after falls. He/she did not know the resident's care plans were not updated, and he/she has been covering at a sister facility as well. During an interview at 08/28/25 at 3:58 P.M., the DON said the nurses should document an intervention in the care plan after a fall, and they have been told that. The DON said the nursing staff does not update the care plans because they think they do not know how. The MDS Coordinator is responsible for care plans, and he/she is responsible for overseeing the MDS Coordinator. The DON did not know the residents' care plans were not updated after the falls and they should be. The DON said for unwitnessed falls neurological checks should be completed every 15 minutes times four, every 30 minutes times four, every hour times four, then every four hours times four, then every eight hours for 72 hours. The DON said only nurses are allowed to chart the neurological checks, so if there is a CMT working he/she should notify the nurse out on the floor to complete the neurological checks. He/she said there is a list of residents at the nurses' desk that have had falls and need neurological checks, and it is important to complete them because the resident could have a brain bleed or a fracture, especially on the memory care unit where the residents cannot communicate as well. The DON said staff talk about falls in the morning meetings, and that he/she is responsible for checking to make sure the neurological checks are completed, and he/she did not know they were not being done. During an interview on 08/28/25 4:58 P.M., the Administrator said for unwitnessed falls nursing staff are expected to do neurological checks and treat the resident as if they hit their head; and they should do them for a total of 72 hours. He/she said staff should be completing them to ensure there are not any neurological issues. The Administrator said if there is only a CMT working on the memory care unit, they should contact the nurse on the floor to complete the neurological checks. The Administrator said care plans should be updated after falls, and the charge nurses can do that, he/she does not know why staff are not doing it, it is not only on the MDS Coordinator, and the nurses have been told repeatedly. He/she said the DON would be responsible for ensuring charting and care plans are updated, and he/she did not know neurological checks were not being completed and care plans were not being updated.

Based on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for four residents (Residents #1, #5, #41 and #55) out of five sampled residents. The facility staff failed to implement appropriate infection control procedures to prevent the spread of communicable diseases when staff failed to screen four staff (Nurse Aide (NA) S, Registered Nurse (RN) P, Certified Medication Technician (CMT) Q and NA R) out of 8 staff sampled for tuberculosis (TB), a contagious, air-borne bacterial infection primarily affecting the lungs, in accordance with facility policy. The Facility census was 59.1. Review of the facility's Hand Hygiene Policy, dated 01/30/24, showed hands should be washed for at least twenty seconds using soap and water under the following conditions:-Before having direct contact with a resident;-After having direct contact with a resident;-After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin;-After handling items potentially contaminated with blood, body fluids, excretions, or secretions;-Before putting on gloves;-After removing gloves.Review of the facility's Standard Precautions Policy, dated 01/30/24, showed hands must be washed between any task that has the possibility of transferring bacteria from resident to resident. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/26/25, showed staff assessed the resident as cognitively intact, required substantial/maximal assist with toileting, dressing, and bed mobility, and always incontinent of bowel and bladder. Observation on 08/28/25 at 10:10 A.M., showed Certified Nurse Aide (CNA) L entered the resident's room to perform perineal care and assist the resident out of bed. The CNA washed hands and applied gloves, performed perineal care and with the same soiled gloves and applied a clean brief to resident. CNA L removed his/her gloves, did not wash his/her hands and applied new gloves. The CNA dressed the resident, removed his/her gloves and walked out of the room. The CNA did not wash hands before he/she left the resident's room. Observation showed the CNA re-entered the residents room, transferred the resident to a wheelchair, combed the resident's hair and cleaned his/her glasses. During an interview on 08/28/25 at 10:28 A.M., CNA L said he/she should have washed his/her hands between gloves changes and before leaving the room. He/She said he/she usually washes his/her hands in the dirty utility room. The CNA said he/she is unsure why he/she did not wash hands between gloves changes and before leaving resident's room. He/She said that not washing hands is a risk for contamination. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, impairment to upper and lower extremities, dependent on staff for bed mobility and toileting, and always incontinent of bowel and bladder. Observation on 08/27/25 at 2:47 P.M., showed NA I entered the resident's room washed his/her hands and applied gloves. He/She transferred the resident to bed with a mechanical lift. NA I performed perineal care and with the same soiled gloves put a clean brief under the resident and applied cream to the resident's buttock. NA I wiped the cream off of his/her soiled gloves onto the resident's clean brief, rolled the resident to his/her back, latched the brief, adjusted the resident's dress, and reattached the mechanical lift sling to the Hoyer with the same soiled gloves on. NA I removed his/her gloves and did not wash hands before he/she left the resident's room with a trash bag in hand went to another resident's room. 4. Review of Resident #41's Quarterly MDS, dated [DATE] showed staff assessed the resident as severe cognitive impairment, impairment to upper and lower extremities, dependent for bed mobility and toileting, and always incontinent of bowel and bladder. Observation on 08/27/25 at 2:27 P.M., showed NA I entered the resident's room, washed his/her hands and applied gloves. NA I cleansed stool from a round pillow with wipes, removed his/her gloves and did not wash his/her hands before he/she left the room to get new sheets. NA I returned to the room washed hands, applied gloves, and cleansed stool from the resident's buttocks. The NA wiped stool off his/her gloves and continued to wipe the resident. The NA put cream on his/her soiled gloves, applied it to the resident's buttocks, put a clean sheet under the resident, performed perineal care and applied cream to the resident. During an interview on 08/27/25 at 3:07 P.M., NA I said he/she should have changed gloves and washed hands between dirty to clean cares, before applying cream to buttock, and before leaving the resident's room. He/She said he/she felt that he/she could wipe his/her soiled gloves off with a wipe and it would be okay. He/She said he/she did that. He/She said the risk of not changing gloves or performing hand hygiene is cross contamination. 5. Review of Resident #55's Quarterly MDS, dated [DATE], showed staff assed the resident as cognitively intact, always incontinent of bowel of bladder, required maximal assistance from staff for bed mobility, and dependent on staff for personal hygiene, dressing and bathing. Observation on 08/27/2025 at 10:19 A.M. showed CNA H entered the resident's room to provide perineal care. The CNA washed his/her hands, applied gloves, wiped loose stool from the resident's buttocks and removed the resident's soiled brief. CNA H removed his/her right glove and put a new glove on without performing hand hygiene. Observation showed the resident had another loose stool. The CNA wiped the resident buttocks and placed a clean brief under the resident. The CNA removed his/her gloves, grabbed bags of soiled linens, opened the resident's door, exited the room and did not wash his/her hands. The CNA walked down the hall to the dirty utility room, opened the door, discarded the soiled linens, grabbed a clean incontinence pad and sheets for the resident's bed and returned to the resident's room, where he/she washed his/her hands. 6. During an interview on 08/28/25 at 3:06 P.M., Licensed Practical Nurse (LPN) F said staff should wash their hands upon entering a resident's room, apply gloves, perform care, change gloves from dirty to clean, and wash their hands before they leave the room. The LPN said it is not okay to wipe soiled gloves off with a wipe, apply cream to a glove and then put it on the resident. The LPN said it is an infection control concern. During an interview on 08/28/25 at 4:31 P.M., the Director of Nursing (DON) [NAME] if staff get stool on their gloves, staff should remove their gloves, wash their hands and put on clean gloves. Staff should change their gloves from dirty to clean tasks and is not acceptable to wipe stool off of gloves and then use the same gloves to apply cream to a resident. Staff are expected to wash their hands before they leave a resident's room, and they are not washing their hands and changing their gloves that is an infection control concern. During an interview on 08/28/25 at 5:37 P.M., the administrator said he/she expects staff to wash their hands upon entering the room and when they apply clean gloves. He/She said once gloves are soiled, he/she expects staff to remove the gloves and wash their hands before applying new gloves. He/She said it is not acceptable to use soiled gloves to apply cream to a resident or touch other things in the residents' rooms. 7. Review of the facility's Employee Tuberculosis Screening Policy, dated 01/30/24, show upon employment, the employee will receive 0.1 milliliter of Tuberculin Units intradermally (under the skin) on the forearm; this is step one. The employee is then instructed to return for the TB reaction reading in forty-eight to seventy-two hours. The Employee is not to have resident contact until after the results of the first skin test have been obtained. If the first skin test is negative, a second skin test is given within fourteen days after the original test; this is step two. If the second test is negative, a screen will be performed annually thereafter. 8. Review of NA S's personnel records showed a hire date of 01/28/25. Review of the NA's personnel record did not contain documentation staff administered the second TB test. During an interview on 08/28/2025 at 10:24 A.M., the DON said he/she can't saywhy the NA did not receive a two-step TST, it just got overlooked. 9. Review of RN P's personnel records showed a hire date of 02/10/25. Review of the RN's personnel record did not contain documentation staff administered the second step TB test. 10. Review of CMT Q's personnel records showed a hire date of 08/16/25, and the first day he/she worked on the floor as 08/16/25. Review showed the records contained documentation of a negative two-step TST with the first step administered on 08/15/25 and results not read until 08/18/25. Review of the CMT's personnel record did not contain documentation staff administered the CMT's second step TB test. During an interview on 08/28/2025 at 10:24 A.M., the DON said he/she had no answer for why the CMT worked the floor before his/her first step had been read. 11. Review of NA R's personnel records showed a hire date of 02/20/25, and the first day he/she worked on the floor as 02/25/25. Review showed the records contained documentation of a negative two-step TST with the first step administered on 02/20/25 and read on 08/22/25. Review of the NA's personnel record did not contain documentation staff administered the second step TB test. During an interview on 08/28/25 at 10:07 A.M., the BOM said payroll showed NA R's first date he/she worked on the floor as 02/25/25. During an interview on 08/28/2025 at 10:24 A.M., the DON said the NA's second step test was just overlooked.

Based on observation, interview and record review, facility staff failed to provide care and services in a dignified manner, when staff propelled one resident (Resident #55) of a sample of 24 residents, down the hall backwards in a mechanical chair and left one resident (Resident #6) of a sample of 24 residents, in the dayroom with clothes soiled with food debris. The facility census was 59.1. Review of the facility's policy titled, Protecting, Promoting and Ensuring Resident Rights-Facility Responsibility, undated, showed each resident has the right to a dignified existence. All staff will be advocates for resident rights. Review of the facility's policy titled, Resident Rights, undated, showed staff should ensure that resident rights are respected, protected, and promoted. Staff should inform residents of their rights and provide an environment in which they can be exercised. Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. This facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. 2. Review of Resident #55's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/19/25, showed staff assed the resident as: -Cognitively intact; -Used a wheelchair; -Dependent on staff members to propel him/her in a wheelchair. Observation on 08/25/25 at 12:18 P.M., showed Nurse Aide (NA) I pulled the resident out of his/her room backwards in a mechanical chair, and then pulled the resident down the full length of the hallway, to the administrator's office. The resident yelled and cussed while staff pulled him/her down the hall backwards. During an interview on 08/28/2025 at 11:33 A.M., the resident said staff dragging him/her down the hall backwards, bothered him/her. The resident said it embarrassed him/her and made him/her feel unsafe because he/she doesn't know if the staff is going turn the chair over. During an interview on 08/28/25 at 1:35 P.M., Certified Nurse Aide (CNA) J said staff should not pull a resident down the hall in a mechanical chair backwards, it's not safe and it's degrading. During an interview 08/28/25 at 2:30 P.M., Licensed Practical Nurse (LPN) F said staff should not pull a resident down a hall backwards in a mechanical chair, it is unsafe, and residents can't see where they are going. It's not dignified. During an interview on 08/28/25 at 3:58 P.M., the Director of Nursing (DON) said staff should never pull a resident down the hallway backwards, it is a dignity issue. The DON said staff should propel the resident forward so they can see where they are going. During an interview on 08/28/25 at 5:02 P.M., the administrator said he/she did see the NA pull the resident backward down the hallway to his/her office. The administrator said he/she told the NA his/her actions were not appropriate and undignified. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed: -Severe cognitive impairment;-Impairment to one side of upper extremities;-Impairment to both sides of lower extremities;-Used a wheelchair;-Dependent on staff members for eating, bathing, personal hygiene and to propel wheelchair 150 feet;-Diagnosis of Dementia. Observation on 08/26/25 at 10:43 A.M., showed the resident in a wheelchair in the dayroom by the nurse's station with dried food debris down the front of his/her shirt. Observation showed five other unidentified residents were in the dayroom with the resident. Observation on 08/26/25 at 2:24 P.M., showed the resident in his/her wheelchair, in the dayroom with pureed meat on both pant legs. Observation showed other residents in the dayroom. Observation on 08/27/25 at 9:34 A.M., showed LPN F propelled the resident out of the dining room and to the dayroom with other unidentified residents. The LPN left the dayroom. Observation showed food dribbled out of his/her mouth, down his/her chin, and down the front of his/her shirt. Observation showed Resident #8 wiped Resident #6's mouth and chin. Observation at 9:38 A.M., showed NA I wiped the resident's mouth and shirt. The NA then left the resident in the dayroom with food stains down the front of his/her shirt. Observation at 10:32 A.M., showed the resident is still in his/her wheelchair in the dayroom, with other unidentified residents. Observation on 08/27/25 at 2:29 P.M., showed the resident in his/her wheelchair in the dayroom with other unidentified residents after lunch. Observation showed the resident has brown liquid down the front of his/her shirt and on pants. Observation on 08/28/25 at 9:45 A.M., showed the resident in a wheelchair, in the dayroom after breakfast, with other unknown residents. The resident has a brown liquid food substance on his/her face and his/her mouth and down the front of his/her shirt. During an interview on 08/28/2025 at 1:35 P.M., CNA J said the resident's cognition is severely impaired. The CNA said food on a resident's shirt and pants is not dignified and the resident should be changed. The CNA said it's not dignified for another resident to wipe food from this resident's face. During an interview on 08/28/25 at 2:30 P.M., LPN F said staff should change the resident clothes if they have food debris on them. The LPN said it is not dignified for the resident to sit in the dayroom with food on his/her clothes. The LPN said the resident is severely cognitively impaired. During an interview on 08/28/25 at 3:58 P.M., the DON said the resident has severe cognitive impairment. The DON said it is not dignified to leave the resident in the dayroom, with food on his/her clothes. The DON said staff should have changed him/her and not left him/her like that. During an interview on 08/28/25 at 5:02 P.M., the administrator said it is not dignified to leave the resident in the dayroom, with food on the front of his/her clothes. The administrator said staff should have taken the resident to his/her room and changed his/her clothes.

Based on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code - Cardiopulmonary resuscitation ((CPR) an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) on the face sheet, and/or Physician Order Sheet (POS) for five residents (Resident #20, #25, #34, #42 and #53) out of 24 sampled residents. The facility census was 59.1. Review of the facility policy titled Basic Life Support/CPR, dated [DATE], showed the purpose is to ensure this facility is able to, and does provide, emergency basic life support when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR and the resident's advance directives. Potential rescuers will initiate CPR, in addition to calling 911, unless a valid DNR order is in place; and the facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the resident's advance directives and any related physician order, such as code status. 2. Review of Resident #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, dated 08/25, showed staff documented the resident's code status as Full Code (provide CPR). Review of the resident's face sheet (a summary document that provides essential patient information), undated, showed staff did not document the resident's code status. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the resident did not have a physician order for code status. Review of the resident's medical record showed an advance directive dated [DATE]. Review showed the resident to be a full code. 3. Review of Resident #25's Significant Change MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, dated [DATE], showed staff documented the resident's code status as DNR. Review of the resident's face sheet, undated, showed staff did not document the resident's code status. Review of the resident's POS, dated [DATE], showed the resident did not have a physician order for code status. Review of the resident's medical record showed a signed DNR form dated [DATE]. 4. Review of Resident #34's admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, dated [DATE], showed staff documented the resident's code status as DNR. Review of the resident's face sheet, undated, showed staff documented the resident's code status as DNR. Review of the residents POS, dated [DATE], showed the resident did not have a physician order for code status. Review of the resident's medical record showed a signed DNR form dated [DATE]. 5. Review of Resident #42's MDS tracking record, dated [DATE], showed the resident was admitted to the facility on [DATE]. Review of the resident's face sheet, undated, showed staff did not document the resident's code status. Review of the resident's POS, dated [DATE], showed the resident did not have a physician order for code status. Review of the resident's medical record showed a signed DNR form dated [DATE]. 6. Review of Resident #57's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, dated [DATE], showed staff documented the resident's code status as DNR. Review of the resident's face sheet, undated, showed staff did not document the resident's code status. Review of the resident's POS, dated [DATE], showed the resident did not have a physician order for code status. Review of the resident's medical record showed a signed DNR form dated [DATE]. 7. During an interview on [DATE] at 1:57 P.M., Certified Nurse Aide (CNA) C said the code status would be in the chart, on the resident's face sheet, or he/she can ask the nurse; and it would also be on the care plan. CNA C said residents have color coded dots next to their name plates by their rooms and he/she would know from that as well. During an interview on [DATE] at 2:02 P.M., Licensed Practical Nurse (LPN) E said code status is found on the resident's Medication Administration Record (MAR), or there is a book at the nurse's desk that has code statuses. LPN E said the code status should be on the care plan, and there should be a physician order; and nursing is responsible on admission to enter the order. If the resident changes their code status, then the Social Services Director (SSD) lets him/her know, and he/she puts the order in the computer; and the face sheets updates when the order is put in. LPN E said he/she was not aware the residents did not have an order for their code status, and it would be important to have that so staff would know what to do if a resident were to code. He/she said staff would have to start CPR because without an order it would be assumed they are a Full Code. LPN E said without an order CPR may be done on someone who did not want it, or not done on someone who did want CPR. During an interview on [DATE] at 3:58 P.M., the Director of Nursing (DON) said there are color coded dots outside the resident's door, and their code status should be in the charting and on the face sheet. The DON said there should be an order and the nurse who admits the resident is responsible for entering the order. The DON said without an order staff could end up doing CPR on someone who does not want it, or not do it on someone who does want it. The DON said the SSD goes through the book to make sure it is updated, he/she did not know the residents were missing physician orders and ultimately it is his/her responsibility to ensure there are orders for code status. During an interview on [DATE] at 4:58 P.M., the administrator said there are color coded dots on the name plate, the code status can be found on the face sheet, and there should be a physician order. The nurses put the orders in the computer; and the DON is responsible to ensure the nurses are putting the orders in. The Administrator said without an order for code status staff could do CPR on someone who does not want it, or not do CPR for someone who does want it; and he/she did not know residents were missing code status orders. He/she said the SSD and admission Coordinator go over it on admission with the advanced directive and give the information to the nurses to put in the computer.

Based on observation, interview, and record review, facility staff failed to obtain signed consent for bed rail use and failed to assess three residents (Resident #2, #5 and #15) out of four sampled, for bed rail use. The facility census was 59. 1. Review of the facility's policy titled Bed Rail, dated 01/30/2024, showed bed rails are adjustable metal or rigid plastic bars that attached to the bed. Examples of bed rails include grab bars, assist bars, side rails, and safety rails. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. The Facility should maintain evidence that is has provided sufficient information so that the resident or resident representative could make an informed decision. The Facility will assess the resident's need for bed rails, documentation in the resident's record will reflect this assessment and related information. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/28/25, showed staff assessed the resident as follows: -Moderate cognitive impairment;-Lower extremity impairment on one side;-Dependent with toileting, and transfers;-Dependent with rolling left and right, sit to lying, and lying to sitting on bed side.Review of the resident's bed rail assessment, dated 07/14/25, showed the assessment did not contain recommendations for turn bars or assist bars.Review of the resident's medical record showed the record did not contain a signed informed consent from the resident or resident representative for the use of bed rails.Observation on 08/25/25 at 11:02 A.M., showed the resident in bed with both bed rails in the upright position. Observation on 08/26/25 at 8:25 A.M., showed the resident in bed with both bed rails in the upright position.Observation on 08/27/25 at 8:45 A.M., showed the resident in bed with both bed rails in the upright position.Observation on 08/28/25 at 8:34 A.M., showed the resident in bed with both bed rails in the upright position. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-Upper and Lower Extremity impairment on both sides;-Dependent with bed mobility, toileting, and transfers.Review of the resident's bed rail assessment dated [DATE], showed the assessment did not contain recommendations for turn bars or assist bars.Review of the resident's medical record showed the record did not contain a signed informed consent from the resident or resident representative for the use of bed rails.Observation on 08/25/25 at 11:13 A.M., showed the resident in bed with assist bars in the upright position on both sides. Observation on 08/26/25 at 8:29 A.M., showed the resident in bed with assist bars in the upright position on both sides. Observation on 08/27/25 at 8:50 A.M., showed the resident in bed with assist bars in the upright position on both sides. Observation on 08/28/25 at 8:36 A.M., showed the resident in bed with assist bars in the upright position on both sides. 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive impairment;-Upper extremity impairment on one side;-Lower extremity impairment on both sides;-Dependent with bed mobility, toileting, and transfers.Review of the resident's bed rail assessment, dated 07/30/25, showed the assessment did not contain recommendations for turn bars or assist bars. Review of the resident's medical record showed the record did not contain a signed informed consent from the resident or resident representative for the use of bed rails.Observation on 08/25/25 at 11:32 A.M., showed the resident in bed with assist bars in the upright position on both sides.Observation on 08/26/25 at 8:31 A.M., showed the resident in bed with assist bars in the upright position on both sides.Observation on 08/27/25 at 8:51 A.M., showed the resident in bed with assist bars in the upright position on both sides.Observation on 08/28/25 at 8:38 A.M., showed the resident in bed with assist bars in the upright position on both sides. 5. During an interview on 08/28/25 at 2:33 P.M., Licensed Practical Nurse (LPN) F said charge nurses sometimes complete the assessments, but usually the therapy department completes them. The LPN said he/she is unsure who is responsible to obtain informed consent. During an interview on 08/28/25 at 11:25 A.M., the MDS Coordinator said the therapy department is responsible for completing bed rail assessments, and he/she did not know why the residents' assessments did not indicate assist bars. He/She said it is the MDS coordinators responsibility to ensure bed rail assessments are completed accurately by the therapy department. He/She said he/she has never completed a bed rail consent. The MDS coordinator said the older charting system prompted staff to complete the consent, but this one does not. During an interview on 08/28/25 at 11:38 A.M., the Director of Therapy said he/she started completing bed rail assessments in January 2025. He/She said the assessment states whether assist bars are indicated at this time or recommended, and he/she questioned this because if the resident already has the assist bars, then why would they need to be recommended or indicated. He/She said the MDS Coordinator is responsible for obtaining bed rails consents. During an interview on 08/28/25 at 4:12 P.M., the Director of Nursing (DON) said residents should have consents for bed rails use. He/She said the bed rail assessment did make it sound like the residents did not utilize assist bars. He/She said it is the DON's responsibility to oversee and ensure that everything is obtained and charted accurately. During an interview on 08/28/25 at 5:19 P.M., the administrator said he/she was not aware that bed rail consents needed to be obtained. He/She said he/she knows therapy discusses bed rails with the charge nurses, but he/she is unsure who completes the bed rail assessment. He/She said it is the DON's responsibility to oversee the bed rail assessments.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments and regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #2, #3, #5, and #15) out of four sampled residents. The facility census was 59.1. Review of the facility's policy titled Bed Rail, dated 01/30/24, showed assess the resident for risk of entrapment from bed rails prior to installation. Ensure the bed's dimensions are appropriate for the resident's size and weight. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. The facility must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. After installation of bed rails; it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident's choices. Review of the facility's policy titled Bed and Bed rail Maintenance to reduce/prevent entrapment, dated 1/30/24, showed this facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/28/25, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Lower extremity impairment on one side; -Dependent with rolling left and right, sit to lying, and lying to sitting on bed side. Review of the resident's electronic medical record (EMR), showed the record did not contain an entrapment risk assessment for the use of bed rails, or a maintenance inspection to ensure the bed rails were properly secured to the resident's bed. Observation on 08/25/25 at 11:02 A.M., showed the resident in bed with both bed rails in the upright position. Observation on 08/26/25 at 8:25 A.M., showed the resident in bed with both bed rails in the upright position. Observation on 08/27/25 at 8:45 A.M., showed the resident in bed with both bed rails in the upright position. Observation on 08/28/25 at 8:34 A.M., showed the resident in bed with both bed rails in the upright position. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively Intact; -Required substantial/maximal assistance with bed mobility and transfers; -Dependent with toileting. Review of the resident's EMR, showed the record did not contain an entrapment risk assessment for the use of bed rails, or a maintenance inspection to ensure the bed rails were properly secured to the resident's bed. Observations on 08/26/25 at 3:25 P.M., showed the resident in bed with a half bed rail up on the right side. Observation on 08/27/25 at 10:34 A.M., showed the resident in bed with a half bed rail up on the right side. Observation on 08/28/25 at 1:30 P.M., showed the resident in bed with a half bed rail up on the right side. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Upper and Lower Extremity impairment on both sides; -Dependent with bed mobility, toileting, and transfers. Review of the resident's EMR, showed the record did not contain an entrapment risk assessment for the use of bed rails, or a maintenance inspection to ensure the bed rails were properly secured to the resident's bed. Observation on 08/25/25 at 11:13 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/26/25 at 8:29 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/27/25 at 8:50 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/28/25 at 8:36 A.M., showed the resident in bed with both assist bars in the upright position. 5. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive impairment; -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Dependent with bed mobility, toileting, and transfers. Review of the resident's EMR, showed the record did not contain an entrapment risk assessment for the use of bed rails, or a maintenance inspection to ensure the bed rails were properly secured to the resident's bed. Observation on 08/25/25 at 11:32 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/26/25 at 8:31 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/27/25 at 8:51 A.M., showed the resident in bed with both assist bars in the upright position. Observation on 08/28/25 at 8:38 A.M., showed the resident in bed with both assist bars in the upright position. 6. During an interview on 08/28/25 at 2:33 P.M., Licensed Practical Nurse (LPN) F said in the old charting system staff were asked for the entrapment measurements, but the new system does not prompt staff to add the measurements. The LPN said he/she did not know who was responsible to complete the assessments, and he/she did not know the assessments should be completed on a regular basis. During an interview on 08/28/25 at 11:25 A.M., the MDS Coordinator said staff does not complete entrapment assessments or measurements. He/She said maintenance puts the assist bars on the bed and nothing is done after that. He/She said the importance of entrapment assessments is to make sure the resident doesn't get entangled in the assist bar. He/She said he/she would expect entrapment measurements completed if assist bars are on the bed. During an interview on 08/28/25 at 11:38 A.M., the Therapy Director said therapy does not complete entrapment assessments. He/She said only bed rails larger than assist bars require measurements. During an interview on 08/28/25 at 12:31 P.M., the Maintenance Director said he/she puts the bed rail on the bed after the resident has been assessed. He/She said he/she doesn't complete any type of measurements with the bed rails. The maintenance director said he/she does not regularly inspect the beds to ensure the bed rails are working properly. He/She said he/she was not aware areas of entrapment should be measured. During an interview on 08/28/25 at 4:12 P.M., the Director of Nursing (DON) said the facility does not have entrapment assessments or measurements, just bed rail assessments. He/She said maintenance is responsible for putting the bed rails on the beds. He/She said not doing entrapment assessments and measurements could put the resident at risk for injury. During an interview on 08/28/25 at 5:19 P.M., the administrator said he/she is unsure who completes entrapments assessments. He/She said maintenance puts the bed rails on the bed. He/She said, I'll be honest I didn't even know there was an entrapment assessment. He/She said he/she does not see an assist bar as a bed rail. He/She said the risk of not doing entrapment assessments is the resident getting trapped in the bed rail, breaking a bone, dying, or suffocation. He/She said he/she is not sure how often bed rails should be measured or checked but should probably be quarterly and as needed.

Based on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 59.1.Review of the facility's policy titled Nurse Staffing Information, dated 01/30/24, showed the facility must post resident census daily at the beginning of each shift in a clear and readable format.2. Review of facility's August daily nurse staffing sheets showed the sheets did not contain a facility census on 08/07, 08/08, 08/12- 08/15, 08/18, 08/19, and 08/25- 08/28/25. 3. Observation on 08/25/25 at 11:49 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census.Observation on 08/26/25 at 10:13 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census.Observation on 08/27/25 at 8:49 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census.Observation on 08/28/25 at 08:35 A.M., showed the facility nurse staff posting located by the nurses' station did not contain a facility census. 4. During an interview on 08/28/25 at 3:00 P.M. Licensed Practical Nurse (LPN) F said the night shift charge nurse fills out the daily staffing sheet. He/She said the daily staffing sheet should include the census, number of staff, and how many hours worked. He/She was not aware the census was not being put on the sheet. He/She said the Director of nursing (DON) oversees that they are getting done daily.During an interview on 08/28/25 at 4:23 P.M., the DON said the night shift charge nurse fills out the daily staffing sheets. He/She said it should include the number of staff, hours worked, date, and census. He/She said he/she was not aware that the census line has been blank. He/She said it is his/her responsibility to ensure the forms are filled out correctly. During an interview on 08/28/25 at 5:25 P.M., the administrator said the night shift charge nurse fills out the daily nurse staffing sheet. He/She said it should include the census, date, total staff and hours worked. He/She said he/she was not aware that census was not being filled out daily. He/She said the DON oversees that the staffing sheet is being completed.

Based on record review and interview, facility staff failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe a resident to resident altercation between two residents (Resident #1, and Resident #2) when Resident #1 slapped Resident #2. The facility census was 56. 1. Review of the facility's abuse, neglect, exploitation or mistreatment policy, dated 1/30/24, showed the purpose of the policy is to ensure all alleged violations related to mistreatment, exploitation, neglect, or abuse are thoroughly investigated and reported to the proper authorities within the required time frames. All alleged violations of abuse, neglect, exploitation or mistreatment are reported immediately, but not later than two hours after the allegation is made to the administrator of this facility and to other officials to include State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities. 2. Review of the facility's investigation form, dated 1/22/25, showed staff documented after the noon meal Resident #1 hit Resident #2. Review showed a typed anonymous note left under the administrator's door on 1/24/25 at 7:30 A.M. Review of the anonymous note left under the administrator's door, undated, showed the following Resident #1 had slapped Resident #2 on 1/22/25 in the afternoon, and wanted to bring it to your attention since we were not sure if it had been reported. Review of the facility investigation did not contain documentation staff reported the altercation to DHSS with in the two hour time frame. 3. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/16/25, showed staff assessed the resident as severe cognitive impairement, with a diagnosis of dementia. Review of resident's progress notes, dated 1/22/25 through 1/24/25, did not contain documentation staff reported to DHSS of the resident to resident altercation with the two hour timeframe. 4. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident with a mild cognitive impairement and a diagnosis of dementia. Review of resident's progress notes, dated 1/22/25 through 1/24/25, did not contain documentation staff reported to DHSS of the resident to resident altercation with the two hour timeframe. During an interview on 1/30/25 at 10:41 A.M., Certified Nurse Assistant (CNA) A said Resident #1 and Resident #2 were in another resident's room when he/she heard yelling coming from the room. CNA A said he/she went to room and he/she saw Resident #1 slap Resident #2 in the face. He/she said the residents were immediately separated and he/she reported this to Registered Nurse (RN) A. During an interview on 1/30/24 at 1:27 P.M., the administrator said she came in on 1/24/25 at approximately 7:45 A.M., and saw a note left under her door about an altercation between Resident #1 and Resident #2. She immediately started investigating. She said it seemed the charge nurse had dropped the ball, because the charge nurse thought social services had reported it to her. During an interview on 2/3/25 at 9:07 A.M., RN A said he/she was the charge nurse at the time of the incident but didn't see what happened. RN A said he/she heard staff say, They hit each other, He/She said when staff were seen going up the hall to talk to the administrator he/she assumed they were reporting this to her. RN A said he/she did not follow up with staff to see what actually happened between the two residents. RN A said, I take responsibility, I did not report this to the administrator. During an interview on 2/3/25 at 9:42 A.M., the administrator said she expects staff to report any incident of resident altercations. The administrator said she expected staff to report any incident of violence within the required timeframe so it could be reported to the state timely. MO00248498

Based on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free from verbal and physical abuse when Certified Nursing Assistant (CNA A) threatened Resident #1 with rough treatment. The facility census was 60. The administrator was notified on 12/24/24 of past Non-Compliance which occurred on 12/24/24. On 12/24/24, staff notified the administrator they witnessed CNA A telling Resident #1 he/she would manhandle the resident if the resident did not cooperate with care. Staff immediately suspended CNA A, assessed the resident for injuries, and notified the required parties and agencies. The administrator terminated CNA A on 12/26/24. The administrator in-serviced all staff, on abuse and neglect policies and procedures by 12/30/24. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, dated 1/30/24, showed the purpose is to ensure each resident's right to be free from abuse, neglect, and corporal punishment of any type by anyone. Review showed abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Willful is defined as the individual acting deliberately, not that the individual intended to inflict harm or injury. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/24, showed staff assessed the resident as follows: -Cognitive intact; -Diagnosis of Parkinson's disease, wedge compression fracture of the vertebra, pain, and vertigo; -Depressed mood several days of the week; -Moderate assistance needed to transfer from a bed to a chair, and go from sitting to standing position; -Impairment to both legs. Review of the resident's plan of care, dated 11/1/24, showed staff assessed the resident as follows: -Weakness and delayed response from Parkinson's disease; -Chronic pain due to compression fractures; -Risk of falling due to impaired balance and weakness; -Ability to transfer, walk in room, walk in corridor, toilet, maintain personal hygiene, has deteriorated due to progression of Parkinson's disease. Review of the facility's investigation summary, dated 12/24/24, showed staff documented the social worker observed CNA A threatening the resident with being manhandled and handling Resident #1 in an aggressive manner on 12/24/24. Review showed staff documented the resident said CNA A had handled him/her in a rough manner and him/her, he/she would manhandle him/her after the resident told CNA A he/she could not stand. Review showed the social worker documented he/she heard CNA A tell the resident twice he/she would manhandle the resident and witnessed CNA A handling the resident in an aggressive manner. Review showed staff documented CNA A was suspended pending inestigation, and terminated 12/26/24. Review of the administartor written statement, dated 12/24/24 at 8:50 A.M. showed the administrator documented with the BOM present showed the resident said CNA A told him/her to get up, grabbed his/her legs, sat him/her up on the side of the bed and told him/her to stand. The resident told the CNA he/she couldn't stand, so the aide grabbed him/her and put him/her in the wheelchair. The aide then pushed him/her in the bathroom and asked him/her to hold the railing. When the resident said he/she couldn't grab the railings, the CNA grabbed him/her again and put him/her on the toilet. The resident said the CNA told him/her, he/she was going to be manhandled after he/she told the aide he/she could not stand. The resident said the aide was rough with him/her. During an interview on 1/3/25 at 10:42 A.M., the social worker said he/she was in the room of the resident assisting the resident's roommate when CNA A came in to assist Resident #1. Resident #1 said you are hurting me to CNA A, so CNA A stepped away, but when he/she returned CNA A told the resident we are going to try again, but if you don't try I'm going to manhandle you. Then CNA A grabbed the resident from the front under the resident's arms and moved him/her abruptly to his/her wheelchair causing the locked wheelchair to rock. CNA A then moved the wheelchair to the bathroom and tried to gey the resident to hold the grab bars, but the resident could not reach the grab bars, so CNA A said I'm going to have to manhandle you again. CNA A then lifted the resident up from the chair by yanking his/her pants and abruptly pushed him/her torso down on the toilet seat without allowing the resident to pivot his/her feet. The social worker said he/she asked CNA A to leave. During an interview on 1/3/25 at 11:09 A.M., CNA A said he/she worked with the resident a few times and the resident could pivot his/her feet and stand with assistance. CNA A said the resident was resisting him/her as he/she was trying to get the resident out of bed, so he/she said to the resident, you have to help me or I will need to manhandle you. CNA A said he/she did not know why he/she said this, and it was not OK for him/her to do so. CNA A said he/she bear-hugged the resident to get him/her up from bed and placed the resident in the wheelchair. CNA A said he/she then took the resident to the bathroom and the resident was unable to hold the grab bar so he/she bear-hugged the resident again and lowered him/her to the toilet. During an interview on 1/3/25 at 11:47 A.M., the resident said the CNA who came in the room, him/her to get up. The resident said he/she told the CNA he/she cannot get up and the CNA said I'll just manhandle you. The resident said the CNA grabbed him/her under the arms, stood him/her up at the side of the bed and then shoved him/her back down on the bed. The resident did not remember how he/she got in the wheelchair. The resident said, I don't remember what happened in the bathroom, because I was crying so hard. MO00247019

Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the resident was ready for discharge from the hospital. The facility census was 62. 1. Review of the facility's Transfer and Discharge policy, undated, showed staff were directed to: -Ensure resident rights are protected when the facility can no longer provide care or services needed; -The facility must notify the resident at least thirty days prior to the anticipated transfer; -A transfer or discharge will not be done except when the safety of individuals in the facility is endangered, due to the clinical or behavioral status of the resident, and as documented/confirmed by a physician; -Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility informs the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family/representative in selecting the new residence; -The notice must include: -Specific location to which the resident is to be transferred or discharged ; -Explanation of the right to appeal the transfer or discharge to the State; -Information on how to obtain an appeal form; -Information on obtaining assistance in completing and submitting the appeal hearing request and; -Name, address (mail and email) and telephone number of the representative of the Office of the State Long-Term Care Ombudsman. 2. Review of Resident #1's Discharge Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/18/24, showed an admitted [DATE] and discharge date of [DATE]. Review of the resident's progress notes, dated 10/18/24, showed staff documented the resident was issued an immediate discharge and will not be returning to the facility. The Director of Nursing (DON) and administrator provided the resident with the letter of immediate discharge. Staff documented referrals were sent to other facilities, but did not contain documentation the resident was provided with acceptance of admission to an alternative facility. Review of the resident's Immediate Discharge Notice, undated, showed staff documented the reason for the immediate discharge as facility staff unable to provide adequate care to the resident and ensure safety of others in the facility. Review showed the immdediate discharge would be effective immediately on 10/18/24. The notice did not include documentation of the appeal process, specific location where the resident will be discharged or transferred to, or the Office of the State Long-Term Care Ombudsman contact information. During an interview on 10/19/24 at 4:30 P.M., the resident's family member said the resident was at the hospital and the facility is refusing to take the resident back. He/She said the facility administrator called and said the resident hit someone. He/She said that why they are not taking the resident back. The family member said the facility did not provide a discharge notice. He/She said the resident is at a local hospital ER and is ready for discharge but there is nowhere for him/her to go. The resident is just sitting in theER on a gurny and they said it could be four days or so until they find a bed for him/her. During an interview on 10/19/24 at 5:15 P.M., the administrator who said the facility issued an emergency discharge notice to the resident in person and the family by phone. The administrator said they sent the emergency discharge to the hospital and had the hospital as the discharge location. During an interview on 10/19/24 at 5:30 P.M., the administrator said she would not be taking the resident back. MO00243813

Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, lighting, and sink countertops in good repair. The facility census was 60. 1. Review of the facility's Physical Environment policy, undated, showed: -The facility will provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public; -Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents; -Maintain all mechanical, electrical, and patient care equipment in safe operating condition; -The policy did not contain direction or guidance to report facility repairs or routine inspection of the facility. 2. Observation on 08/20/24 at 10:55 A.M., showed occupied resident room [ROOM NUMBER] on the secured unit with a gap in the flooring between the room and hallway. Observation on 08/20/24 at 11:06 A.M., showed occupied resident room [ROOM NUMBER] bathroom on the secured unit with a large piece of tile missing from the floor in front of the toilet. Observation on 08/20/24 at 11:11 A.M. showed occupied resident room [ROOM NUMBER] with multiple brown stains to the floor next to the toilet. Observation on 08/20/24 at 11:17 A.M., showed occupied resident room [ROOM NUMBER] bathroom with dark brown stains to the toilet bowl. Observation on 08/20/24 at 11:39 A.M., showed occupied resident room [ROOM NUMBER] with a section of baseboard peeled back from the wall next to the bathroom and a fall mat frayed and cracked. Observation showed gap is in the threshold between the room and the hallway. Observation on 08/21/24 at 08:26 A.M., showed occupied resident room [ROOM NUMBER] on the secured unit with a gap in the floor between the room and hallway. Observation on 08/21/24 at 08:27 A.M., showed occupied resident room [ROOM NUMBER] bathroom on the secured unit with a large piece of tile missing from the floor in front of the toilet. Observation on 08/21/24 at 08:28 A.M. showed occupied resident room [ROOM NUMBER] with multiple brown stains to the floor next to the toilet. Observation on 08/21/24 at 08:30 A.M., showed occupied resident room [ROOM NUMBER] bathroom with dark brown stains to the toilet bowl. Observation on 08/22/24 at 10:43 A.M., showed occupied resident room [ROOM NUMBER]'s sink vanity top had a large strip ripped off the front under the sink. The edges were rough to the touch and had stained particle board exposed. Observation on 08/22/24 at 11:00 A.M., showed the light in the bathroom between room [ROOM NUMBER] and 402 did not turn on. 3. During an interview on 08/22/24 at 1:06 P.M., Nurse Aid (NA) I said he/she writes repair requests in the maintenance log book located at the nurses desk. During an interview on 08/22/24 at 1:17 P.M., Licensed Practical Nurse (LPN) H said staff are directed to write down repair requests in the maintenance log book at the nurses desk. During an interview on 08/23/24 at 8:19 A.M., the Housekeeping Supervisor said he/she reports broken or malfunctioning items to maintenance by writing it down in a log book, Maintenance normally gets the repairs done quickly. During an interview on 08/23/24 at 8:23 A.M., the Maintenance Supervisor said staff put repair requests in the a log book located at both nurses desk. He/She said he/she is responsible for the repairs but intimately the administrator is responsible. He/She said he/she was not aware of the repairs needed in the resident's rooms. He/She does rounds of the building everyday. During an interview on 08/23/24 at 9:56 A.M., the administrator said maintenance has a binder with work requests to go by when doing repairs. Staff meet every morning to make sure the repairs are being finished. Maintenance is responsible for the repairs but he/she is ultimately responsible to make sure they repairs are finished.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy for three residents (Resident #27, #50, and #163) of three sampled residents who discharged to the hospital. The facility census was 60. 1.Review of the facility's Bed Hold policy, undated, showed the following: -The facility will notify all residents, and/or their representative of the bed hold policy guidelines upon admission to the facility, at the time of transfer to the hospital or leave and at the time of non-covered therapeutic leave; -If the resident or representative wants to hold the bed, a signed authorization of the bed hold selection notice must b e obtained with each physician approved hospitalization ; -Signed authorization must be received within 48 hours of the transfer or leave, if it occurs during the week and by the first business day following the transfer if it occurs on a weekend or holiday. 2. Review of Resident #27's medical record showed the resident discharged to the hospital on 05/22/24. Review showed the record did not contain documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #50's medical record showed the resident discharged to the hospital on 07/26/24. Review showed the record did not contain documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 4. Review of Resident #163's medical record showed the resident discharged to the hospital on 06/02/24, 06/24/24 and 07/18/24. Review showed the record did not contain documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 5. During an interview on 08/22/24 at 11:37 A.M., the administrator said bed hold paperwork is printed off and sent with the resident on discharge to the hospital and do not make copies for the medical record. During an interview on 08/23/24 at 8:38 A.M., Registered Nurse (RN) K said nurses are responsible to complete bed holds when a resident goes to the hospital. He/She is not sure they are being done. During an interview on 08/23/24 at 9:26 A.M., the Director of Nursing (DON) said there is a bed hold book at the nurse station for the charge nurses to pull a sheet from when a resident is discharged to the hospital but a signed copy is not kept for the record. He/She said he/she is not sure if the nurses are sending them with the resident but the hospital does call and ask if the facility is holding the bed. During an interview on 08/23/24 at 9:54 A.M., the administrator said the nurse is supposed to send the bed hold with the resident to the hospital on discharge and thought they had a binder at the nurse station. He/She said the nurse is supposed to make copies and keep a log when one is completed or sent out with the resident. He/She said he/she is responsible to ensure the bed holds are completed and was not aware the bed holds were not signed or copied for the medical record.

Based on interview and record review, facility staff failed to follow up with one resident's (Resident #1) physician in the absence of laboratory orders to monitor the effect of the resident's anticoagulant (medication that thins the blood) medications, and failed to obtain a stop date for the [MEDICATION NAME] (blood thinner) injection. The physician failed to order routine [MEDICATION NAME] time (PT, a blood test to measure how long it takes blood to clot) and international normalized ratio (INR, a standardized measure of the clotting ability of blood, used to monitor the risk of bleeding when taking anticoagulation medication) tests for the resident, and failed to provide a stop date for the [MEDICATION NAME] injection. Staff continued to administer the anticoagulant medications in the absence of orders to monitor the effect of the medication. These failures placed the resident at risk for significant adverse side effects including the risk of serious injury or death, such as [MEDICAL CONDITION] or stroke and resulted in a PT flagged as high at 75.7 seconds and an INR flagged as critically high at 8.1. The facility census was 49. The administrator was notified on 7/16/19 at 2:50 P.M of an Immediate Jeopardy (IJ) which began on 7/10/19. The IJ was removed on 7/13/19, as confirmed by surveyor onsite verification. 1. Review of the facility's policies, showed the policies did not contain guidance for monitoring the usage of anticoagulant medications. Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment tool used by staff, dated 02/15/19, showed staff assessed the resident as follows: - Impaired cognition; - [DIAGNOSES REDACTED]. - No anticoagulant administered over the seven day review period. Review of the resident's nurses notes showed staff documented: -On 06/28/19: Received an order to obtain D-DIMER (test to identify harmful blood clots) results, new orders received to send to the hospital emergency room for evaluation, family and ambulance called for transport; -On 06/29/19: Resident left the facility via ambulance. Review of the resident's hospital discharge record, dated 07/01/19, showed: -Discharge [DIAGNOSES REDACTED]. -Medication order for [MEDICATION NAME] injection 75 milligrams (mg) once daily; start date 07/02/19 with no end date; -Medication order for [MEDICATION NAME] (blood thinner) tablet 5 mg once daily; start date 07/02/19; -Discharge summary: Venous Doppler showed positive acute [MEDICAL CONDITION] to left lower extremity and patient was started on a [MEDICATION NAME] regimen with [MEDICATION NAME] bridge. Patient will continue the [MEDICATION NAME] regimen with [MEDICATION NAME] bridge on an outpatient basis at his/her nursing home. Adjustments for INR will be made at the nursing home. Review of the resident's physician order [REDACTED]. Additional review of the physician order [REDACTED]. - [MEDICATION NAME] injection 75 mg one time daily, with a start date of 07/01/19 and end date as open ended; - [MEDICATION NAME] tablet 5 mg one time daily, with a start date of 07/01/19 and end date as open ended Additional review of the resident's POS, dated (MONTH) 2019, showed the POS did not contain a PT/INR laboratory order to monitor the use of the resident's anticoagulant medications. Review of the resident's plan of care, revised on 03/05/19, showed staff did not update the plan of care to reflect the resident's use of anticoagulant medications beginning on 07/02/19, and did not contain parameters for monitoring the effect of the anticoagulant medications. Review of the resident's medication administration record (MAR), dated (MONTH) 2019, showed staff documented they administered the following medications: [REDACTED] -[MEDICATION NAME] syringe 75 mg once daily at 9:00 [NAME]M., from 07/04/19 thru 07/10/19; -[MEDICATION NAME] ([MEDICATION NAME]) tab 5 mg once daily at 5:00 P.M., from 07/02/19 thru 07/10/19. Additional review of the resident's MAR, dated (MONTH) 2019, showed the MAR did not contain a PT/INR laboratory order to monitor the use of the resident's anticoagulant medications. Review of the resident's nurses note, dated 07/10/19 at 11:02 P.M., showed staff documented they were called to the resident's room by staff. Resident had dark red large thick blood coming from rectal area. Resident was verbal and denied any complaint of pain or discomfort. 911, Director of Nursing (DON), and family member notified. Ambulance transported the resident to the hospital. Review of the resident's hospital emergency department medical records, dated 07/10/19, showed hospital staff documented: -Per daughter, the resident started vomiting about an hour ago and was found to be bleeding by his/her nursing home nurse. The patient had blood in her vomit and stool, and the vomit was coffee ground color. The patient has swollen eyes and is currently taking anticoagulants; -PT value of 75.7 seconds, (reference normal range between 9.5 - 11.6 seconds); -INR value of 8.1, (reference normal range between 0.9 - 1.1); -[DIAGNOSES REDACTED]. -[DIAGNOSES REDACTED]. During an interview on 07/13/19 at 2:30 P.M., Licensed Practical Nurse (LPN) B said the nurses are responsible for ensuring residents using [MEDICATION NAME] have PT/INR lab orders in place, and said he/she did not realize the resident did not have PT/INR lab orders. LPN B said if a resident is using [MEDICATION NAME] and there are not PT/INR lab orders, a nurse should call the resident's physician to clarify why the resident does not have lab orders. During an interview on 07/13/19 at 11:13 [NAME]M., the Director of Nursing (DON) said he/she was aware the resident was taking both [MEDICATION NAME] and [MEDICATION NAME]. The DON said he/she did not realize the resident did not have PT/INR laboratory orders in place until the resident was sent to the emergency roiagnom on [DATE]. The DON said nursing staff are responsible to ensure residents using [MEDICATION NAME] have PT/INR lab orders in place, and said he/she would expect for the nurses to contact the doctor to find out why the resident does not have PT/INR orders. During an interview on 07/13/19 at 12:28 P.M., the facility Medical Director (MD) said he/she knew the resident was ordered [MEDICATION NAME] when discharged from the hospital on [DATE]. The MD said he/she waited to order the PT/INR because he/she was scheduled to see the resident on 07/09/19 and was planning to cut the [MEDICATION NAME] dosage in half or to discontinue the medication. The MD said he/she knew the resident's PT/INRs were in normal range at the hospital which is why he/she was not concerned about ordering a PT/INR within a couple days after being discharged from the hospital. The MD said he/she had a conflict in his/her schedule on 07/09/19 and rescheduled to visit the resident on 07/11/19. During an interview on 07/15/19 at 4:04 P.M., the hospital Nurse Practitioner (NP) said the resident started taking the [MEDICATION NAME] and [MEDICATION NAME] while he/she was admitted in the hospital from 06/29/19 through 07/01/19, due to a [DIAGNOSES REDACTED]. The NP said he/she would have expected for the resident's physician to order a PT/INR within a day or two after being discharged from the hospital on [DATE]. The NP said the [MEDICATION NAME] bridge typically takes up to five days to reach it's therapeutic range and is typically not administered after five days. During an interview on 07/15/19 at 4:12 P.M., the facility's MD said he/she was aware the resident was discharged from the hospital on [DATE] with an order for [REDACTED]. The MD said the facility staff did fax the hospital discharge orders to him/her when the resident was readmitted to the facility, but must have overlooked the [MEDICATION NAME] injection order. The MD said [MEDICATION NAME] is not typically continued upon being discharged from the hospital and must have assumed it was discontinued prior to the resident's re-admission to the facility. The MD said if he/she was aware the resident was on [MEDICATION NAME] and [MEDICATION NAME], he/she would have ordered the PT/INR no later than 07/05/19 and provided a stop date for the [MEDICATION NAME]. The MD said the facility staff did not communicate with him/her from 07/01/19 through 07/09/19 about the resident not having PT/INR orders or about not having a stop date for the [MEDICATION NAME]. During an interview on 07/16/19 at 3:03 P.M., LPN D said he/she was aware the resident was taking both [MEDICATION NAME] and [MEDICATION NAME], but said he/she was not aware the resident did not have PT/INR orders in place. The LPN said it is the nurse's responsibility to communicate with the resident's physician related to ordering PT/INRs and to clarify medication orders. LPN D said if a resident is taking [MEDICATION NAME] and [MEDICATION NAME] and the resident does not have a PT/INR order in place, a nurse should contact the resident's doctor to clarify why PT/INRs have not been ordered. The LPN said he/she was not aware the resident's [MEDICATION NAME] did not have stop date and should have clarified the order with the resident's physician. During an interview on 07/16/19 at 3:17 P.M., the Director of Nursing (DON) said he/she was not aware the resident's [MEDICATION NAME] injection did not have a stop date and said a nurse should have contacted the resident's physician to clarify the [MEDICATION NAME] order. The DON said it is the nurse's responsibility to communicate with the resident's physician related to clarifying medication orders. The DON said he/she did not communicate with the resident's physician from 07/01/19 through 07/10/19, and said he/she was unsure if any other nurses communicated with the physician. During an interview on 07/16/19 at 4:03 P.M., the Administrator said he/she was not aware the resident was on [MEDICATION NAME] and [MEDICATION NAME] without PT/INR orders in place. The Administrator said he/she would trust the MD and the nursing staff to have necessary laboratory orders in place to monitor the anticoagulants. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy (IJ) level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 258

Based on observation, interview and record review, facility staff failed to provide appropriate care and services to prevent the development of pressure ulcers for two residents (Residents #2 and #3), and failed to provide treatments after the development of facility acquired pressure ulcers for one resident (Resident #3), out of 17 sampled residents. The facility census was 84. 1. Review of the facility's Pressure Ulcer, Care and Prevention of pressure ulcer policy, dated 3/2012, showed the following: - Purpose: To prevent and treat further breakdown of pressure sores; - treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending Physician and for implementing measures to prevent pressure ulcers; - Equipment; - Skin lotion; - Elbow protector; - Heel protector; - Pressure reducing mattress; - Pressure reducing chair pad; - Foot cradle; - Pillows; - Guidelines; 1. Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; 2. Apply skin lotion gently to dry skin; 3. Change bed linen promptly whenever wet or soiled; 4. Keep sheets dry, free of wrinkles and debris; 5. Use pressure-reducing devices to relieve pressure; 6. Turn the resident every two hours and position with pads or pillows to protect bony prominences; 7. Active and passive range of motion may be ordered by the Physician to improve circulation; 8. Whenever possible, teach the resident to change his/her own position at regular intervals and shift his/her weight in wheelchair; 9. Use elbow and heel protectors if needed; 10. Use bed cradle to relieve pressure of bed clothing, if needed; 11. Assist resident at meal times to assure adequate nutrition; 12. Offer fluids frequently for adequate hydration. 2. Review of the National Pressure Ulcer Advisory Panel "Updated Staging System" document showed they defined Pressure Ulcers as follows: Stage II: Partial thickness-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled or sero-sanginous (a pink colored drainage containing blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Stage III: Full thickness skin loss-Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (tissue destruction underlying the area along the wound edges) and tunneling (course or pathway that can extend from any direction from the wound). Stage IV: Full thickness tissue loss-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (black, hard, dead tissue) may be present. Often includes undermining and tunneling. Unstageable: Full thickness skin or tissue loss - depth unknown-Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknown-Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 3. Review of Resident #3's MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for bed mobility, transfers, dressing, toileting and personal hygiene; -[DIAGNOSES REDACTED]. -At risk for the development of pressure ulcers; -One Stage II (full thickness skin loss) pressure ulcer present upon admission; -One Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer present upon admission; -Required ulcer care. Review of the resident's comprehensive care plan dated 6/29/12 showed staff planned the following interventions for pressure ulcers: -Provide regular diet and milk with meals; -Assess the condition of the skin surrounding the pressure ulcer; -Assess the pressure ulcer for location, stage, size, granulation tissue (collagen-rich tissue that fills the wound bed causing it begin to heal) and epithelization (the last layer of skin to form before the wound is healed) weekly; -Report any signs of further breakdown, document weekly skin assessment; -Encourage to lay down in a.m. or p.m.; -Low air loss mattress to bed; -Float heels; -Provide treatment as ordered; -Turn and reposition as resident allows. Review of the resident's MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for bed mobility, transfers, dressing, toileting and personal hygiene; -[DIAGNOSES REDACTED]. -At risk for the development of pressure ulcers; -One Stage II pressure ulcer present upon admission; -Required ulcer care. Review of the Weekly Pressure Wound Report showed staff documented the following assessments about the resident's right heel pressure ulcer: -8/1/12- Right heel Stage II pressure ulcer acquired at the facility on 7/31/12, measured 2.1 cm (length) x 1.7 cm (width) x 0.5 cm (depth), drainage, wound gel and a dry dressing was ordered by the physician daily. -8/23/12-Right heel Stage II pressure ulcer measured 2.4 cm x 2.1 cm x less than 0.5 cm., drainage, [MEDICATION NAME] (antibiotic) ointment with dressing was ordered by the physician daily. -9/19/12-Right heel Stage II pressure ulcer measured 1.5 cm x 1.4 cm with less than 0.4 cm, drainage, treatment ordered was alginate dressing with dry dressing daily. -10/17/12- Right heel Stage II pressure ulcer measured 2.3 cm x 3.2 cm x 0.2 cm, drainage, slough (dead tissue that may have a yellow or white appearance), treatment ordered was alginate dressing with dry dressing daily. -10/24/12-Right heel Stage II pressure ulcer measured 2.3 cm x 3.0 cm x 0.2, treatment ordered was alginate dressing with dry dressing daily. -11/21/12-Right heel Stage II pressure ulcer measured 1.5 cm x 2.2 cm x 0.2 cm, drainage, treatment ordered was wound gel to base and dry dressing daily. -12/20/12-Right heel Stage II pressure ulcer measured 1.2 cm x 1.7 cm x 0.2 cm, slough now resolved, treatment ordered was Santyl (enzymatic ointment that removes dead tissue) ointment and dry dressing daily. -1/2/13-Right heel Stage II pressure ulcer measured 1.9 cm x 1.5 cm x 0.2 cm, treatment ordered was wound gel, unnaboot (cast-like zinc saturated compression wrap) with dry dressing daily. -1/17/13-Right heel Stage II pressure ulcer measured 2.3 cm x 3.1 cm x 1.0, five percent adherent yellow slough at four to seven o'clock, 95% pink granulation tissue, ulcer deteriorated and tunneling is documented as present, treatment ordered was Santyl and dry dressing daily. -1/22/13-Right heel Stage II pressure ulcer measured 2.5 cm x 3.3 cm x 0.3 cm, ulcer deteriorated, treatment ordered was Santyl and dry dressing daily. Observation on 1/22/13 at 7:00 P.M. showed the resident in his/her wheelchair in the hallway. The resident did not have on heel protectors and a dried brownish/red drainage soiled the resident's right sock. Observation on 1/22/13 at 8:30 P.M. showed CNA N entered the room to assist the resident into bed from the wheelchair. CNA N and RN O transferred the resident into bed by the mechanical lift. CNA N cleansed the resident and alerted the charge nurse to assist with an ostomy bag. Neither CNA N or RN O offered or encouraged the use of heel protectors or positioned the resident's heel onto a pillow to prevent further pressure to the pressure ulcer. Further, the resident's pressure ulcer was exposed and did not have a treatment in place. Observation on 1/22/13 at 10:45 P.M. showed the resident lay in bed without his/her heels positioned a pillow or heel protectors in place. Staff did not place heel protectors on the resident's heels or place his/her heels on a pillow to prevent further pressure from occurring. Further the resident's pressure ulcer was exposed and did not have a treatment in place. Review of the Treatment Administration Record (TAR) dated 1/22/13 at 11:30 P.M. showed staff did not sign their initials to show they completed the treatment for [REDACTED]. Observation on 1/22/13 at 11:40 P.M. showed the resident lay in bed without his/her heel protectors in place or heels positioned on a pillow to prevent further pressure from occurring. Staff did not place heel protectors on the resident's heels or place them on a pillow to prevent further pressure from occurring. Observation on 1/24/13 at 10:05 A.M. showed Licensed Practical Nurse (LPN) C and the Assistant Director of Nursing (ADON) entered the room to provide a treatment to the resident's right heel pressure ulcer. LPN C removed the soiled dressing. The pressure ulcer was oblong in shape on the bottom of the right heel. The wound bed was covered in approximately 95-100% yellow slough and measured approximately 0.3 cm in depth indicating a Stage III pressure ulcer as defined by the NPUAP Pressure Ulcer Stages. Just below the open area the resident's skin had a purple/blue hue and was boggy indicating a deep tissue injury as defined by the NPUAP Pressure Ulcer Stages. This area measured approximately 2 cm x 1 cm the skin was loose near the wound bed. During an interview on 1/24/13 at 10:20 A.M. the resident said staff did not put on the heel protectors or prop his/her heels on a pillow prior to him/her developing the pressure ulcer on the right heel. Further, the resident said staff are not consistent with applying the heel protectors or propping his/her heels since the development of the pressure ulcer. During an interview on 1/24/13 at 11:00 A.M. CNA H said she/he has cared for the resident for a long time. CNA H said the resident has not refused to place his/her heels on a pillow or use of the heel protectors while in bed. During an interview on 1/24/13 at 10:30 A.M. the Assistant Director of Nursing (ADON) said the resident's ulcer was caused by "pressure" and was facility acquired. Further, the resident's pressure ulcer started out as a blister that opened and they now considered it a "Stage II" pressure ulcer. The ADON said staff are instructed to encourage the resident to wear heel protectors and "float heels (prop the feet upon a pillow to avoid the heels from touching the bed)" while in bed. The ADON said staff currently assessed the pressure ulcer as "adherent slough tissue in the wound bed with serosanguinous drainage." The ADON said the resident's heel should have a treatment dressing on at all times. 4. Review of Resident #1's Braden Scale (an assessment used to predict pressure ulcer risk), dated 8/28/12, showed staff assessed the resident with a score of 17 (assessment lists scores of 15 to 18 as mild risk for the development of pressure ulcers). Review of the resident's Head to Toe Skin Assessments showed staff assessed the resident as follows: -On 9/04/12- Denuded (Stripped of its covering, bare) skin to buttocks- no open areas noted. Zinc cream continued; -On 9/12/12- "Continue with denuded areas to buttocks"; -On 9/18/12- "Buttocks remains with excoriation, slowly improving". Review of the resident's Treatment Administration Record (TAR), dated 10/01/12 to 10/31/12, showed staff were directed to complete the following: -(Started 9/26/12) Apply [MEDICATION NAME] spray (a topical wound care spray)topically each shift to left heel; -Apply [MEDICATION NAME] lotion (a moisturizing lotion) topically once daily; -Apply Baza antifungal moisture barrier cream topically to groin and buttocks each shift. Review of the resident's Head to Toe Skin Assessments showed staff documented the following assessments: -On 10/05/12- Open area to right buttock. -On 10/09/12- Continue with treatment to right buttock. Review of the resident's Treatment Administration Record (TAR), dated 10/01/12 to 10/31/12, showed staff were directed to complete the following: -On 10/09/12- cleanse open areas to left buttock with peri spray, apply zinc (a barrier cream), three times daily and as needed until healed, then discontinue. Review showed staff documented the following assessments: -On 10/11/12-Staff first documented an assessment of a Stage II pressure ulcer right buttock, surrounding denuded (the top layer of skin removed) areas, measured 3.8 centimeters (cm) in length by 3.1 cm in width by 0.3 cm in depth, red and yellow with a moderate amount of drainage; -On 10/11/12- Staff first documented an assessment of a Left buttock pressure ulcer measuring 2.8 cm in length by 2.5 cm in width by 0.2 cm in depth, red with no drainage. Staff did not document the stage of the pressure ulcer. Review of the resident's nurse's notes showed staff documented the following: -On 10/12/12- Staff first noted a "half dollar size open area" on the resident's coccyx (tailbone). The physician ordered staff to apply [MEDICATION NAME] (a self-adhesive, non-breathable wound dressing), and change every three days and as needed until healed, then discontinue. Review of the resident's Treatment Administration Record (TAR), dated 10/01/12 to 10/31/12, showed staff were directed to: -Cleanse the coccyx wound with wound cleanser, apply [MEDICATION NAME], change every three days and as needed until healed, then discontinue. Staff discontinued the treatment on 10/24/12; -On 10/13/12 staff added- Cleanse the right heel with wound cleanser, apply hydrogel (a wound dressing) and dry dressing, change daily until healed, then discontinue. Staff did not document an assessment to monitor for improvement or decline of this newly identified pressure ulcer. -On 10/17/12 staff documented to continue current treatment to the Stage II wound (no location identified). The wound measured 4.6 cm in length by 3.5 cm in width by 0.3 cm in depth, red and yellow with a moderate amount of drainage. Review of the resident's Head to Toe Skin Assessments showed on 10/17/12, staff documented to continue with treatment to coccyx and right heel. Staff did not document information to show assessment of the previously identified left and right buttocks pressure ulcers. Review of the resident's nurse's notes showed staff documented the following: -On 10/18/12, staff assessed the open area on the resident's right buttock increased in size and now measured 4.6 cm in length by 3.5 cm in width by 0.3 cm in depth. Staff documented the physician changed the treatment to a [MEDICATION NAME] dressing treatment. Staff documented they provided the resident with a pressure reducing mattress, and a cushion in his/her wheelchair. Staff documented the resident preferred to lay on his/her back despite being encouraged to lay on his/her side, and frequently refused to get out of bed. Staff did not document assessments of the left buttock, coccyx, or right heel pressure ulcers to show on-going monitoring for improvement or decline. Review of the resident' Head to Toe Skin Assessments, dated 10/23/12, showed staff documented, "Continue to coccyx and right heel." Review of the resident's Treatment Administration Record (TAR), dated 10/24/12 showed staff were directed to cleanse the coccyx wound with wound cleanser, apply hydrogel with dry cover dressing three times daily and as needed. Staff did not document assessments of the right or left buttock, coccyx, or right heel pressure ulcers to show on-going monitoring for improvement or decline. Review of the resident's Head to Toe Skin Assessments, dated 10/30/12, showed staff documented, "Continue with treatment to buttocks". Review of the resident's TAR, dated 11/01/12 to 11/30/12, showed staff directed to: - [MEDICATION NAME] lotion- apply topically once daily; - Baza antifungal moisture barrier cream- apply topically to groin and buttocks each shift; - [MEDICATION NAME] spray- apply topically each shift to left heel; - Coccyx wound- cleanse with wound cleanser, apply hydrogel with dry cover dressing three times daily and as needed; - Right heel- cleanse with wound cleanser, apply hydrogel and dry dressing, change daily until healed, then discontinue; - 11/01/12- Staff documented the Stage II pressure ulcer to right buttock, was "slowly improving", continue with hydrogel three times daily, measured 4.6 cm in length by 3.3 cm in width by 0.3 cm in depth, red and yellow with no drainage; -11/01/12- Staff documented the unstageable area on the resident's right heel, measured 3.5 cm in length by 3.5 cm in width by undetermined depth, dry adherent (connected) slough/scabbed over area right heel. Continue with hydrogel treatment daily. "Improving". -Staff did not document assessments of the left buttock or coccyx pressure ulcers to show on-going monitoring for improvement or decline. Review of the resident's Head to Toe Skin Assessments, dated 11/06/12, showed staff documented to "Continue with treatment to buttocks and heel". Review of the resident's TAR, dated 11/07/12, showed staff documented an assessment of the stage II pressure ulcer on the resident's right buttock, which measured 4.2 cm in length by 3.3 cm in width by 0.3 cm in depth, red and yellow with no drainage. "Hydrogel treatment continued to buttock wound. Improving". Staff did not document assessments of the left buttock, coccyx, or right heel to show ongoing monitoring for improvement or decline of the areas. Review of the resident's Head to Toe Skin Assessments, dated 11/12/12, showed staff documented, "continue with treatment to buttocks and heel." Review of the resident's TAR, dated 11/16/12, showed staff documented the resident's right buttock was a Stage II pressure ulcer, measured 0.6 cm in length by 0.9 cm in width by 0.1 cm in depth, pink and red with no drainage, 100 percent (%) granulation. Peri wound skin pink and intact. Staff did not document an assessment of the resident's left buttock, coccyx, or right heel to show ongoing monitoring for improvement or decline of the areas. Review of the resident's Head to Toe Skin Assessments, dated 11/20/12, showed staff documented, "continue with treatment to buttocks". Review of the resident's TAR, dated 11/01/12 to 11/30/12, showed staff documented the following: - 11/21/12- Stage II pressure ulcer right buttock, increased in size and now measured 1.5 cm in length by 2.1 cm in width by 0.1 cm in depth; pink, red and yellow with no drainage; small amount yellowish slough without drainage; wound base red granulated tissue. Staff did not document an assessment of the resident's left buttock, coccyx, or right heel to show ongoing monitoring for improvement or decline of the areas. - 11/27/12- Stage II pressure ulcer right buttock, measuring 1.5 cm in length by 1.8 cm in width by 0.1 cm in depth, red and yellow with no drainage, buttock wound with decreased amount adherent slough, increased red granulated tissue noted, area continues to improve. Staff did not document an assessment of the resident's left buttock, coccyx, or right heel to show ongoing monitoring for improvement or decline of the areas. Review of the resident's nurse's notes showed staff documented the following: - 11/28/12- Stage II to right buttock healing, measured 1.5 cm in length by 1.8 cm in width by 0.1 cm in depth. Hydrogel treatment. Staff provided a "pressure mattress" but the resident preferred to lie on his/her back. Staff encouraged the resident to reposition on side. Plan of care update. Review of the resident plan of care, showed staff updated it on 11/28/12 with the following: -Right buttock 1.5 centimeters (cm) in length by 1.8 cm in width by .1 cm in depth. However, staff did not document interventions to direct staff on the plan to improve the pressure ulcer and prevent new areas from developing. Review of the resident's Braden Scale Assessment, dated 12/01/12, show staff assessed the resident with a score of 15. Review of the resident's Minimum Date Set (MDS), a federally mandated assessment instrument, dated 12/01/12, showed facility staff assessed the resident as follows: - Able to recall two out of three words on the Brief Interview for Mental Status; - Did not reject care; - Totally dependent and required two plus persons physical assistance for bathing activity; - Required extensive assistance and two plus persons physical assistance for transfers, toilet use and hygiene; - Required extensive assistance and one person physical assistance for dressing; - Impairment on both sides of his/her lower extremities; - Frequently incontinent of bladder; - Occasionally incontinent of bowel; - [DIAGNOSES REDACTED]. - At risk for developing pressure ulcers; - One or more unhealed pressure ulcers Stage I (intact skin with non-blanchable redness of a localized area, usually over a bony prominence) pressure ulcer or higher; - Two Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough (non-viable tissue)) pressure ulcers; - Date of oldest Stage II pressure ulcer- 9/26/12; - Most severe tissue type for any pressure ulcer- granulation (pink or red tissue with shiny, moist granulated appearance); - No pressure ulcers present on the prior assessment; - Pressure relieving device for chair and bed; - Turning/repositioning program; - Ulcer care; - Applications of ointments/medications other than to feet. Review of the resident's physician's orders [REDACTED]. - Regular diet with large meat portions at lunch and dinner; - 12/03/12- Discontinue hydrogel to coccyx. Discontinue hydrogel to right heel. Discontinue [MEDICATION NAME] treatment to bilateral heels; - New treatment- left ankle wound- cleanse with wound cleanser and apply unaboot (heel protection boot) with dry cover dressing daily until healed, then discontinue; - Right heel wound - cleanse with wound cleanser, apply zinc cream daily until healed, then discontinue; - Coccyx wound- cleanse with wound cleanser, apply zinc cream three times daily and as needed until healed, then discontinue; - May apply zinc cream to skin excoriation (superficial skin breakdown) three times daily. Review of the resident's TAR, dated 12/01/12 to 12/31/12, showed staff documented the following: - 12/05/12- New treatment in progress wound to coccyx/right buttock much improved. Measures 0.8 cm in length by 1.0 cm in width, no depth. Stage II red granulated tissue without drainage. Right heel red, zinc treatment. Staff recorded "No open areas. - 12/10/12- Right heel and coccyx wounds healed- Right heel wound healed 12/10/12; - Coccyx wound healed 12/10/12; - May apply zinc cream to skin excoriation three times daily. Review of the resident's POS, dated 1/01/13 to 1/31/13, showed the physician directed staff to: - Provide a regular diet with large meat portions at lunch and dinner; - Nutritional Shake as needed; - May apply zinc cream to skin excoriated three times daily as needed; - 1/07/13- Apply zinc cream to buttocks three times daily and as needed; Review of the resident's TAR, dated 1/01/13 to 1/31/13, showed staff are directed to: - May apply zinc cream to skin excoriated three times daily as needed; - 1/07/13- Apply zinc cream to buttocks three times daily and as needed [MEDICATION NAME] (preventative); - 1/07/13- New treatment initiated for buttocks/coccyx excoriation. No open areas, area 3.0 cm in length by 3.0 cm in width, red; Review of the resident's plan of care, updated 1/10/13, showed staff planned the following interventions: - Provide a regular diet; - Weigh weekly; - Provide nutritional shakes he/she kept in room; - Provide health shakes three times daily; - Apply moisture barrier to skin; - Provide incontinence care after each incontinent episode; - Provide staff assistance for toileting; - Report any signs of skin breakdown (sore, tender, red or broken areas); Review of the resident's TAR, dated 1/01/13 to 1/31/13, showed staff are directed to: - 1/11/13- No significant change to buttock and coccyx excoriation. Treatment continued; Review of the resident's nurse's notes showed staff documented the following: - 1/17/13- Buttocks excoriated. New treatment order noted. Review of the resident's POS, dated 1/01/13 to 1/31/13, showed staff are directed to: - 1/21/13- Discontinue [MEDICATION NAME] lotion and zinc; - 1/23/13- Cleanse coccyx wound with wound cleanser, apply [MEDICATION NAME] (a sterile wound dressing), change every three days and as needed until healed, then discontinue. Staff did not document an assessment of the coccyx including measurements to show ongoing monitoring for improvement or decline of the area. Review of the resident's TAR, dated 1/01/13 to 1/31/13, showed staff were directed to: - 1/23/13- Cleanse coccyx wound with wound cleanser, apply [MEDICATION NAME], change every three days and as needed until healed, then discontinue. Review of the resident's plan of care showed staff did not update the resident's plan of care with new interventions regarding the resident's increased risk for pressure ulcers, and current history of pressure ulcers until 1/23/13. Review of the resident's plan of care, updated 1/23/13, showed staff documented the following: - Resident has a pressure ulcer on coccyx; - Apply pressure relieving mattress to bed; - Assess and record the condition of the skin surrounding the pressure ulcer; - Assess the pressure ulcer for location, stage, size, presence of granulation tissue and epithelization (regrowth of skin over a wound) weekly; - Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown; - Regular diet, large portions at lunch and supper; - Keep clean and dry as possible. Minimize skin exposure to moisture; - Keep linens clean, dry and wrinkle free; - Maintain the head of the bed at the lowest degree of elevation possible; - Observe and report signs of [MEDICAL CONDITION]; - Treatment- clean coccyx wound with wound cleaner, apply [MEDICATION NAME], change every three days; - Turn and reposition every two hours and as needed. Observation on 1/23/13 at 9:22 A.M. showed the resident in his/her bed, on his/her back with the head of the bed elevated approximately 45 degrees. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/23/13 at 11:40 A.M. showed the resident in his/her bed, on his/her back with the head of the bed elevated approximately 45 degrees. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/23/13 at 11:42 A.M. showed Licensed Practical Nurse (LPN) C and the Assistant Director of Nursing (ADON) provide treatment on the resident's wound on his/her coccyx. Observation showed the resident's coccyx wound was open to air without barrier cream or a dressing. Observation showed a circular, open area on the resident's coccyx, measuring approximately 1.0 cm in length by 1.0 cm in width, with a dry, red wound bed. Further observation showed two additional areas, approximately nickel sized, that appeared newly healed, with fragile skin, near the open pressure ulcer. Observation of the resident's right heel showed a scabbed area approximately 3.0 cm in length by 0.5 cm in width. During an interview on 1/23/13, at 11:42 A.M., the ADON said she would notify the Physician to obtain an order for [REDACTED]. During an interview on 1/23/13 at 12:00 P.M., LPN C said the following: - The resident acquired his/her pressure ulcers at the facility; - The wound on the resident's coccyx was healed, but has opened back up again; - Staff are directed to turn and reposition the resident every two hours and apply zinc to the resident's buttocks; - The resident was non-compliant with turning and repositioning; - Staff were directed to elevate the resident's heels by placing a pillow under his/her legs. Observation on 1/23/13 at 1:07 P.M. showed the resident in his/her bed, on his/her back with the head of the bed elevated approximately 45 degrees. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/23/13 at 3:18 P.M. showed the resident in his/her bed, on his/her back with the head of the bed elevated approximately 45 degrees. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/23/13 at 3:27 P.M. showed the resident in his/her bed, on his/her back with the head of the bed elevated approximately 45 degrees. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/23/13 at 6:05 P.M. showed the resident in his/her bed, on his/her back. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/24/13 at 7:45 A.M. showed the resident in his/her bed, on his/her back. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. Observation on 1/24/13 at 9:30 A.M. showed the resident in his/her bed, on his/her back. Observation showed a pillow under the resident's calves and knees with his/her heels resting on the mattress of the bed. During an interview on 1/24/13 at 9:32 A.M., Certified Nurse Aide (CNA) F said the following; - Staff were directed to turn and reposition the resident every two hours; - The resident used to wear heel protector boots, but was non-compliant with wearing them; - The resident was non-compliant with turning and repositioning; - The resident got out of bed approximately two days each week; - Staff were directed to elevate the resident's heels off of the mattress with a pillow. During an interview on 1/24/13 at 11:20 A.M., the Director of Nursing said the following: - Staff assessed resident's skin when they admitted a resident to the facility; - The resident had areas of excoriation on his/her buttocks upon admission on 8/24/12; - She would consider the resident at high risk for pressure ulcers due to the resident's compromised skin areas and his/her incontinence; - The resident used to get out of bed and use his/her motorized wheelchair, but has been declining in health for approximately three to four weeks; - Staff should provide the resident with a pressure reducing mattress and apply barrier cream to his/her buttocks; - Staff provided low air loss mattresses if a resident has a Stage III (full thickness tissue loss) or greater pressure ulcer. During an interview on 1/24/13 at 11:35 A.M., the ADON said the following: - The resident has had a decline in health beginning approximately one month ago; - The resident had been refusing to get out of bed and has not been eating well; - The resident had the same pressure relieving mattress on his/her bed as other residents; - The resident used to to wear heel protector boots, but was non-compliant with wearing them; - Staff should "float" the resident's heels by elevating them off of the mattress; - She would expect staff to develop a care plan addressing the resident's risk and history of developing pressure ulcers on his/her heels and buttocks.