Every finding on record at Aspire Senior Living Joplin

Based on interview, and record review, the facility failed to provide care per standards of practice when staff failed to complete ordered daily weights, failed to notify physician as ordered regarding excess weight gain, failed to document and monitor the resident's fluid restriction and intake, and failed to care plan new intervention for one resident (Resident #1) with a diagnosis of congestive heart failure (CHF - impaired heart function) contributing to the resident's hospitalization with severe hyponatremia (low sodium), hypervolemia (fluid overload), abdominal distention, and lower extremity edema. The facility census was 111. Review of the facility policy titled Notification of Changes, dated January 2024, showed the following:-The purpose is to ensure resident and/or representative notification of specific changes during the resident's stay at the facility;-The facility must immediately inform the resident, consult with the resident physician, and notify the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status or decision to transfer a resident from the facility. Review of the facility policy titled Fluid Restriction, dated January 2024, showed the following:-It is the policy of the facility to ensure that fluid restrictions are followed in accordance with physician orders;-The nurse will obtain and verify the physician order for fluid restriction and an order written to include the breakdown of fluid per 24-hour period and will be recorded on the medication record;-The food and nutrition department will be notified by facility communication methods of the fluid restriction. 1. Review of Resident #1's face sheet (a general information sheet) showed the following: -admission date of 02/05/26;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema), congestive heart failure (CHF - impaired heart function), chronic kidney disease (CKD - damaged kidneys), stage 3B (moderately reduced kidney function), and diabetes mellitus (metabolic disease). Review of the resident's current Physician's Order Sheet (POS) showed the following:-An order, dated 02/09/26, for Lasix (diuretic - medication to decrease fluid in the body) tablet 20 milligrams (mg), give 1 tablet by mouth in the morning for edema (swelling).-An order, dated 02/23/26, for a daily weight in the morning for CHF. Call heart clinic for weight gain of 3 pounds overnight or 5 pounds in one week. Review of the resident's care plan, dated 04/17/26, showed staff did not care plan regarding the resident's diagnosis of CHF, his/her diuretic (medication to decrease fluid in the body) medication, or ordered daily weights. Review of the resident's weight showed the following: -On 02/24/26, a weight of 157.0 pounds;-On 02/26/26, a weight of 172.0 pounds. Review of the resident's progress notes showed staff did not document notification of the resident's physician or heart clinic regarding the 15-pound weight gain in two days. Review of the resident's weight showed the following: -On 02/27/26, at 7:30 A.M., a weight of 172.3 pounds;-On 02/27/26, at 11:06 A.M., a weight of 172.0 pounds;-On 02/28/26, a weight of 172.8 pounds;-On 03/01/26, a weight of 171 pounds;-On 03/02/26, a weight of 171.4 pounds;-On 03/03/26, a weight of 168.4 pounds. Review of the resident's medical record, dated 03/04/26, showed staff did not document a weight obtained or a resident refusal of weight check. Review of the resident's weight on 03/05/26 showed a weight of 170 pounds. Review of the resident's medical record, dated 03/06/26, showed staff did not document a weight obtained or a resident refusal of weight check. Review of the resident's weight on 03/07/26, at 6:46 A.M., showed a weight of 176.0 pounds. (A six-pound increase in two days.) Review of the resident's weight on 03/07/26, at 12:44 P.M., showed the resident was reweighed and showed a weight of 174.0 pounds. (A four-pound increase in two days.) Review of the resident's progress notes showed staff did not document notification of the resident's physician or heart clinic of the four-pound weight gain in two days. Review of the resident's medical record, dated 03/08/26, showed staff did not document a weight obtained or a resident refusal of weight check. Review of the resident's weight showed the following: -On 03/09/26, a weight of 174.5 pounds;-On 03/10/26, a weight of 171.0 pounds;-On 03/10/26, at 10:40 P.M., showed a weight of 174.3 pounds;-On 03/11/26, a weight of 178.5 pounds (a 3.8-pound increase in one day.) Review of the resident's progress note dated 03/11/26, at 12:48 P.M., showed the following: -Resident had over three-pound weight gain in one day;-Resident had visible fluid filling up in his/her right shoulder, so much so that there looked to be a softball of fluid on resident's right shoulder;-Nurse Practitioner (NP) aware of change in shoulder and that it was painful to the touch;-Resident said NP planned on draining it; -No extra diuretic dose sought out from physician for weight gain due to explanation of it. Review of the resident's progress note dated 03/11/26, at 10:33 P.M., showed the physician ordered prednisone (steroid medication) 40 milligrams (mg) daily for 5 days and blood sugar checks three times daily with standard insulin (medication to control blood sugar) sliding scale for administration while on prednisone. Review of the resident's current POS showed the following orders:-An order, dated 03/11/26, for prednisone 20 mg tablets, give 2 tablets one time a day for corticosteroids for 5 days;-An order, dated 03/11/26, for blood sugar check three times a day for five days due to on prednisone.(Staff did not include the insulin sliding scale on the POS.) Review of the resident's March 2026 Medication Administration Record (MAR) showed the following:-Staff documented prednisone administered as ordered except on 03/14/26 when staff noted it not administered due to vital signs out of parameters for administration (no parameters for administration noted the physician's order);-Blood glucose checks documented as completed as ordered. Review of the resident's record showed staff did not document weights from 03/12/26 through 03/15/26. Review of the resident's weight on 03/16/26 showed a weight of 173.6 pounds. Review of the resident's progress note, dated 03/16/26, showed the following: -The occupational therapist assistant documented during therapy session the resident looked distended in abdominal region;-Resident said he/she had increased difficulty in breathing and said, My lungs feel like they are filling with fluid;-Nursing staff notified, and nebulizer (breathing medication) administered;-NP notified. Review of the resident's weight on 03/17/26 showed a weight of 172 pounds. Review of the resident's progress note, dated 03/17/26, showed the following: -Orders received from NP for labs and chest x-ray due to shortness of breath;-Orders entered;-Chest x-ray results sent to NP tonight with new orders for cefdinir (antibiotic) 300 mg twice daily for 10 days;-Diuretics were increased on dayshift per order. Review of the resident's current POS showed the following orders:-An order, dated 03/17/26, for cefdinir 300 mg capsule, give 1 capsule two times a day for pneumonia for 10 days;-An order, dated 03/17/26, for torsemide (medication to treat excess fluid retention) 40 mg tablet, give one tablet once daily for edema (swelling from fluid retention). Review of the resident March 2026 MAR showed staff administered the cefdinir and torsemide as ordered. Review of the resident's weight on 03/18/26 showed a weight of 176 pounds (a four-pound weight gain. Review of the resident's progress note, dated 03/18/26, showed the following: -A noted 4-pound weight gain overnight from 172 lbs. to 176 pounds;-Staff attempted to reach heart clinic but got no response. Staff left a message;-Resident remains stable and eating breakfast in dining room;-Staff will continue to monitor. Review of the resident's weight showed the following: -On 03/19/26, a weight of 176.6 pounds;-On 03/20/26, a weight of 176.6 pounds;-On 03/21/26, a weight of 172.4 pounds. Review of the resident's medical record, dated 03/22/26, showed staff did not document a weight obtained or a resident refusal of weight check. Review of the resident's weight showed the following -On 03/23/26, a weight of 171.6 pounds.-On 03/24/26, a weight of 170.8 pounds. Review of the resident's medical record, dated 03/25/26, showed staff did not document a weight obtained or a resident refusal of weight check. Review of the resident's weight on 03/26/26, showed a weight of 174.4 pounds (an increase of 3.6 pounds). Review of the resident's progress notes, dated 03/26/26, showed staff did not document notification of the resident's physician or heart clinic of 3.6-pound weight gain. Review of the resident's weights showed the following: -On 03/27/26, a weight of 174.2 pounds.-On 03/28/26, a weight of 174.1 pounds.-On 03/29/26, a weight of 173.4 pounds.-On 03/30/26, a weight of 173.2 pounds.-On 03/31/26, a weight of 173.0 pounds.-On 04/01/26, a weight of 185 pounds (a 12-pound weight gain in one night.) Review of the resident's progress notes showed staff did not documentation of notification of the physician or heart clinic of 12 pounds weight gain in one day. Review of the resident's weight on 04/02/26, showed a weight of 189 pounds (a four-pound weight gain). Review of the resident's progress notes showed staff did not document notification of the physician or heart clinic of four-pound weight gain in one day. Review of the resident's progress note, dated 04/02/26, showed the resident admitted to the hospital due to labs out of normal limits. Review of the resident's hospital discharge note, dated 04/10/26, showed the following:-The resident was a direct admit from the neurology clinic due to severe hyponatremia (low sodium), lower extremity edema, right shoulder effusion (accumulation of excess fluid), and pain;-Resident reported over the last week his/her legs were swelling, he/she was weaker, and had increased shortness of breath;-Resident admitted from neurologist due to sodium level of 122 (normal sodium levels are 135 to 145) and significant swelling to the belly, swelling to right shoulder, and weakness to the lower extremities;-Resident discharged back to the facility on [DATE] with diagnoses of urinary tract infection, CKD, stage 4 (severely decreased kidney function), severe hyponatremia, hypervolemia (fluid overload), abdominal distention, lower extremity edema, and CHF. Review of the resident's progress note, dated 04/10/26, showed resident readmitted today from the hospital. Resident alert and orientated and on a regular diet. Resident on 1500 ml fluid restriction. Review of the resident's April 2026 MAR showed staff did document the order for fluid restriction. Review of resident's April 2026 intake and output record showed staff did not document intake for the resident. Review of the resident's weights showed no readmission weight on 04/10/26. Review of the resident's progress note, dated 04/11/26, showed resident alert and oriented with no signs of difficulty breathing or shortness of breath noted and no oxygen or cough. Head of the bed elevated to 30 degrees. No cough. Review of the resident's record, dated 04/11/26, showed staff did not document a weight for the resident. Review of the resident's weight on 04/12/26, showed a weight of 188.0 pounds. Review of the resident's progress note, dated 04/12/26, showed resident reported difficulty breathing. Tachypnea (rapid, shallow breathing) present. Resident reported orthopnea (shortness of breath that occurs when lying flat). Nurse observed orthopnea and tachypnea present. Shortness of breath noted. Nurse observed shortness of breath (while sitting and lying flat. (Staff did not document physician notification or interventions implemented.) Review of the resident's record showed staff did not document a weight on 04/13/26. Review of the resident's weight on 04/14/26, showed a weight of 197.8 pounds (an increase of 9.8 pounds in two days). Review of the resident's progress notes showed staff did not document notification of the physician or heart clinic of 9.8 pounds weight gain. Review of the resident's dietary profile, dated 04/14/26, showed the resident was on a regular diet with no fluid restriction. Review of the resident's weight on 04/15/26, showed a weight of 197.0 pounds. Review of the resident's weight on 04/16/26, showed a weight of 199.4 pounds (an increase of 2.4 pounds in one day.) Review of the resident's progress notes showed staff did not document notification of the physician or heart clinic of 2.4 pounds weight gain in one day. Review of the resident's progress note, dated 04/16/26, showed the resident reported shortness of breath and shortness of breath with exertion. Head of the bed elevated to facilitate breathing. Resident declined to attempt to lay flat for assessment of shortness of breath when lying flat. Resident stated that he/she was already short of breath, why would I want to make it worse. (Staff did not document physician notification.) Review of the resident's progress note, dated 04/17/26, showed the resident reported he/she had been having increased anxiety and shortness of air. Resident continued to wake up throughout the night. Physician notified and placed a new order for Ativan (used to treat anxiety) 0.5 mg, 1 tab every 6 hours as needed. During an interview on 06/01/26, at 11:21 A.M., Registered Nurse (RN) G said the following:-Aides were responsible for obtaining weights but the nurse can help;-The nurse should make a list of all weights needed daily;-The nurse should notify the physician if there is a large change in weight;-The nurse should see how the resident was weighed and recheck if the weight appeared to be off;-The physician should be notified if a CHF patient has a weight gain of two pounds in a day or five pounds in a week. During an interview on 06/01/26, at 11:54 A.M., Licensed Practical Nurse (LPN) I said aides were responsible for obtaining weights. The resident was a daily weight, and the physician should be notified for a weight gain of three pounds overnight or five pounds in a week. During an interview on 06/01/26, at 12:20 P.M., the Dietary Manager said the following:-The nurse provided a diet communication form for a change in diet or fluid restriction;-The diet change should automatically be updated in the chart;-The diet communication should indicate what fluids a resident on fluid restriction is allowed;-He/she could not remember if the resident was on fluid restriction. During an interview on 06/01/26, at 2:36 P.M., LPN C said the weights due for the day pop up on the nurses' MAR. The aides will obtain weights and the nurse, or the aide will document them. The physician should be notified if a CHF resident gains three pounds in 24 hours or five pounds in 72 hours. He/she could not recall if the physician was notified for the resident's weight gain, but they should have been. During an interview on 06/01/26, at 2:53 P.M., RN J said the following:-The aides help with daily weights, and the restorative aide does weekly and monthly weights;-Fluid restriction orders should be included on the MAR;-Staff should be monitoring the resident fluid intake;-The nurse is responsible for making sure the weights are completed;-The nurse should complete a daily list of weights that are needed;-The physician should be notified if a CHF resident gains three pounds in 24 hours or five pounds in a week;-He/she thought the Nurse Practitioner (NP) was notified of the residents weight gain but was unsure if it was documented;-The physician or NP should have been notified, and the nurse should have completed a progress note;-They did make some medication changes for the resident. During an interview on 06/01/26, at 3:16 P.M., the Assistant Director of Nursing (ADON) said the following:-Aides or nurses should chart the weights daily;-CHF residents should have orders indicating when to call the physician for weight changes;-Nursing and kitchen staff should monitor intake and output for residents on fluid restriction;-The physician should have been notified of the fluid restriction order upon the resident return from the hospital. During an interview on 06/01/26, at 3:44 P.M. the Director of Nursing (DON) said the following: -The restorative aide received a list of weights and was responsible for completing them;-The weights should be entered into the medical record;-The nurse should notify the physician if a CHF resident has a three-pound weight gain in one day;-The nurse should reweigh the resident and possibly check the wheelchair if the weight is off. During an interview on 06/16/26, at 9:22 A.M., the attending physician said the following:-He/she would expect staff to notify him/her of a weight change of three pounds in a day or 15 pounds in a week;-He/she should have been notified of the weight gain, but was not;-Staff should be rechecking weights if they have that amount of weight gain;-He/she did not think that the weight gain of 12 pounds in one day or 42 pounds in a 6-week period would be correct;-Staff should be following orders for fluid restrictions;-Increased fluid could have resulted in weight gain;-He/she should be notified if a resident had shortness of breath. During an interview on 06/01/26, at 4:47 P.M., the Administrator said staff should be following physician orders. Residents should be monitored after a change of condition, the physician should be notified, and all information documented in a progress note. Complaint #3022586 and #3025981

Based on interview and record review, the facility failed to establish and maintain a complete infection control program when staff failed to have processes in place to ensure all residents were screened for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when staff failed to complete a two-step test TB test for three residents (Resident #1, #3, and #4). The facility census was 111.Review of the facility policy titled Resident Screening for Tuberculosis, dated October 2025, showed the following:-The facility screens residents for tuberculosis in accordance with the state requirements as part of the overall infection prevention and control program;-Prior to or at the time of admission, all new residents will receive TB screening and testing in accordance with the state requirements;-All initial and follow-up TB tests shall be administered and interpreted (48 to 72 hours for skin tests) by a trained healthcare provider on staff, or any licensed physician;-All current residents previously TB test negative will be re-rescreened in accordance with the state requirements;-Nursing staff are responsible for initial and repeat resident screening, documentation of the results, and documentation of any assessments or symptoms of TB disease. Review of the State of Missouri Code of Regulations 19 CSR 20-20.100 showed the following:-Long-term care residents are required to have the initial test of a Mantoux PPD (purified protein derivative - skin test that is used to test for TB) two-step tuberculin test within one month prior to or one week after admission;-If the initial test is negative, zero to nine millimeters (mm), the second test, which can be given after admission, should be given one to three weeks later;-All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/05/26;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema), congestive heart failure (CHF - impaired heart function), and diabetes mellitus (metabolic disease). Review of the resident's current Physician's Order Sheet (POS) showed the following orders:-An order, dated 02/05/26, for aplisol solution (TB test solution) 5 units per 0.1milliliters (ml), inject 0.1 ml intradermally (under the skin) one time only for admission, give step one in left arm and record in immunization tab;-An order, dated 02/05/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm;-An order, dated 02/05/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission second step, give step two in right arm and record in immunization tab;-An order, dated 02/05/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm;-An order, dated 02/06/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission second step, give step two in right arm and record in immunization tab;-An order, dated 04/10/26, for aplisol solution 5 units per 0.1ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab;-An order dated 04/10/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm;-An order dated 04/10/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission second step, give step two in right arm and record in immunization tab;-An order, dated 04/10/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm. Review of the resident's February 2026 Treatment Administration Record (TAR) showed the following:-An order, dated 02/05/26, for aplisol solution 5 units per 0.1ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab, documented as completed;-An order, dated 02/05/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission second step, give step two in right arm and record in immunization tab, not documented as completed;-An order, dated 02/08/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm, documented as completed;-An order, dated 02/12/26, for aplisol solution 5 unit per 0.1 ml, inject 0.1 ml intradermally one time only for admission second step, give step two in right arm and record in Immunization tab, documented as resident sleeping;-An order, dated 02/15/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm, documented as completed. Review of the resident's February 2026 progress notes showed staff did not document related to tuberculosis screening or tuberculosis testing. Review of the resident's April 2026 MAR showed the following:-An order, dated 04/10/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab, documented as completed;-An order, dated 04/13/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm, documented as completed. Review of the resident's April 2026 progress notes showed staff did not document related to tuberculosis testing. Review of the resident's current immunizations record, reviewed on 05/27/26, showed no entries related to tuberculosis screening or tuberculosis testing. Review of the resident's record showed staff did not have TB results noted. 2. Review of Resident #3's face sheet showed the following:-admission date of 04/30/26;-Diagnoses include COPD and neck cancer. Review of the resident's current POS showed the following orders:-An order, dated 04/30/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab;-An order, dated 04/30/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step two in right arm and record in immunization tab;-An order, dated 04/30/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm;-An order, dated 04/30/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm;-An order, dated 05/01/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab;-An order, dated 05/01/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step two in right arm and record in immunization tab. Review of the resident's April 2026 MAR showed the order, dated 04/30/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab, not documented as completed. Review of the resident's April 2026 progress notes staff did not document related to tuberculosis screening or tuberculosis testing. Review of the resident's May 2026 MAR showed the following:-An order, dated 05/01/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab, documented as completed;-An order, dated 05/01/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step two in right arm and record in immunization tab, documented as completed on 05/15/26;-An order, dated 04/30/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm, documented as completed on 05/04/26;-An order, dated 04/30/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm, documented as completed on 05/17/26. Review of the resident's May 2026 progress notes showed staff did not document related to tuberculosis screening or tuberculosis testing. Review of the resident's current immunizations record showed an entry dated 05/15/26 for a TB skin test administered. No results were documented. Review of the resident's record showed staff did not have TB results noted. 3. Review of Resident #4's face sheet showed the following:-admission date of 03/04/36;-Diagnoses include stroke and CHF. Review of the resident's current POS showed the following orders:-An order, dated 03/04/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step one in left arm and record in immunization tab;-An order, dated 03/04/26, for aplisol solution 5 units per 0.1 ml, inject 0.1 ml intradermally one time only for admission, give step two in right arm and record in immunization tab;-An order, dated 03/04/26, to read TB results and record in immunization [NAME] time only for reading step one in left arm;-An order, dated 03/04/26, to read TB results and record in immunization [NAME] time only for reading second step in right arm; Review of resident's March 2026 and April 2026 progress notes showed staff did not document related to tuberculosis screening or tuberculosis testing. Review of the resident's current immunizations record showed one entry, dated 03/04/26, for a TB skin test administered with negative results. (Staff did not document a step two test documented as completed with results.) 4. During an interview on 05/28/26, at 1:12 P.M., Licensed Practical Nurse (LPN) C said the following:-An order for a TB test is entered for day of admission for a two-step TB test;-A TB test is done on admission, and another one is done 10 days later;-If there is not enough time to complete the test, he/she will pass it on to the next shift;-Nurses should document the induration (redness or swelling at TB injection site) and if the test was positive or negative when read;-The TB results should be entered into the immunizations tab in the resident electronic chart. During an interview on 05/28/26, at 1:52 P.M., the LPN E said the following:-admission nurse should be completing TB test upon admission;-Residents should receive a two-step TB test;-The nurse should be document results in the immunization tab of the resident electronic chart;-TB result documentation should include where the test was administered on the body, induration, and the result should indicate positive or negative;-Some of the resident TB tests have not been completed. During an interview on 06/01/26, at 11:21 A.M., Registered Nurse (RN) G said the following:-Residents are given a TB test upon admission and then again 10 days later;-If the TB test is not done on the day of admission it might get missed;-It can easily be missed if not done on day of admission;-The oncoming nurse will do the TB test if the admitting nurse does not have time;-A notification on the MAR pops up when it is time to read the test;-The nurse should document the site, the result, and the induration;-He/she was unsure where the results populate on the resident chart. During an interview on 06/01/26, at 2:53 P.M., RN J said the admission nurse should put in the order and complete a TB test. Residents require a two-step TB test upon admission. During an interview on 06/01/26, at 3:16 P.M., the Assistant Director of Nursing (ADON) said the following: -Residents should have a TB test upon admission and nurses should read it 48 to 72 hours later;-The TB test should be completed again a week later;-Nurses should document results in the immunization tab in the electronic medical record;-The results should include induration and result of positive or negative;-The admission nurses are responsible for completing TB tests;-He/she thinks they are getting done but does not know who monitors this. During an interview on 06/01/26, at 3:44 P.M., the Director of Nursing (DON) said the following:-The Staff Development Coordinator was responsible for reviewing TB tests but quit;-There was a problem with TB testing upon admission. During an interview on 06/01/26, at 4:47 P.M., the Administrator said staff should be completing resident TB tests. Complaint #3022586

Based on interview and record review, facility staff failed to ensure a resident's wishes regarding a Do Not Resuscitate (DNR- an order signed by a physician that instructs healthcare providers not to perform cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped) if a resident's breathing or heart stops) order was honored when staff performed CPR for one resident (Resident #1). The facility census was 111. Review of the facility's policy titled, Basic Life Support/CPR, revised [DATE], showed the following:-The purpose of the policy is to ensure that properly trained personnel are available to provide basic life support to residents requiring emergency care prior to the arrival of emergency personnel, and subject to accepted professional guidelines, resident advance directive (written instructions recognized under state law relating to the provision of care if the resident is incapacitated), and physician orders;-Potential rescuers will initiate CPR unless a valid DNR order is in place;-The facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services (EMS) in accordance with the resident's advance directive or any related physician order, and in the absence of an advance directive or DNR order;-Facility policy will address how resident preferences and physician orders related to CPR and other advance directive issues are communicated throughout the facility so that staff know immediately what action to take or not take when an emergency arises. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of [DATE];-The face sheet did not indicate code status;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema), congestive heart failure (CHF - impaired heart function), and diabetes mellitus (metabolic disease). Review of the resident's care plan, dated [DATE], showed the resident's code status was a DNR. Review of the resident's current Physician's Order Sheet (POS) showed an order, dated [DATE], for DNR. Review of an Outside Hospital Do Not Resuscitate Order (OHDNR) showed the resident signed the order on [DATE] and a physician signature dated [DATE]. Review of the resident's progress note dated [DATE], at 10:41 A.M., showed the following: -The resident was found in the dining room unresponsive at approximately 8:45 A.M.;-DNR status was verified after CPR initiated;-The resident's time of death called by this nurse and wound nurse at approximately 8:51 A.M.;-Staff notified family friend and coroner;-Funeral home picked resident up at approximately 10:29 A.M.;-Resident out of facility at approximately 10:35 A.M. During an interview on [DATE], at 11:32 A.M., Certified Nurse Aide (CNA) B said the following:-He/she observed the resident sitting in the dining room after breakfast;-A housekeeper attempted to move the resident out of the dining room, and he/she went limp;-He/she called for a nurse and tried to wake the resident up;-The resident's lips were blue and he/she appeared to not take a breath for a while;-Another CNA and a hospice nurse came into the dining room and started CPR;-LPN C entered the dining room and advised the CNA and hospice nurse to stop CPR as the resident was a DNR;-The resident code status can be found in a binder at the nurses' station or in the plan of care;-CPR should not be done on a resident with a DNR order. During an interview on [DATE], at 1:12P.M., Licensed Practical Nurse (LPN) C said the following:-A resident's code status appeared in the medical record and in a code status book at the nurse station;-The resident was found unresponsive with his/her heart stopped in the dining room;-He/she was called to the dining room by an aide;-An aide and a hospice nurse had started CPR on the resident by the time he/she arrived to assist;-He/she went to check the resident's code status and saw the resident was a DNR;-He/she returned to the dining room and informed the aide and hospice nurse to stop CPR;-CPR should be given to a resident until the code status is confirmed. During an interview on [DATE], at 11:15 A.M., CNA A said the following;-The resident's code status can be found at the nurses' station;-He/she does not know anywhere else the code status could be located;-He/she would get the nurse right away for an unresponsive resident. During an interview on [DATE], at 12:02 P.M., CNA D said the following:-If a resident was found unresponsive, staff should notify the charge nurse and verify the resident's code status;-He/she was unsure where to find a resident code status but would ask the nurse. During an interview on [DATE], at 1:52 P.M., LPN E said the following:-He/she would stay with an unresponsive resident and have someone check code status;-He/she would not start CPR until the code status was known;-CPR should not be given to a resident with a DNR order;-A resident's code status can be found in the chart or a code book at the nurse station. During an interview on [DATE], at 3:20 P.M., CNA F said the following:-Code status can be found in a book at the nurses' station;-He/she would start CPR immediately on an unresponsive resident until confirmation of a DNR order;-He/she would yell for help and have another staff check the resident code status. During an interview on [DATE], at 11:46 A.M., Certified Medication Technician (CMT) H said the following:-The nurse will let the aides know a resident code status or they can find it in a code book at the nurses' station;-The CNAs and CMTs are not allowed to initiate CPR;-He/she would get a nurse if a resident was found to be unresponsive;-CPR should not be given to a resident with a DNR order. During an interview on [DATE], at 11:54 A.M., LPN I said the following:-Code status can be found on the care plan or a book at the nurses' station;-CPR should not be given to a resident without knowing code status;-Administering CPR to a DNR resident would be against physician orders. During an interview on [DATE], at 11:21 A.M., Registered Nurse (RN) G said the following:-Resident code status can be found on the resident profile page and in a binder at the nurses' station;-CPR should not be started before checking residents code status;-A resident with a DNR order should not be given CPR. During an interview on [DATE], at 2:53 P.M., RN J said the following:-Code status can be found in on the medication administration record, resident orders, and in the code binders at the nurse station;-Nurses should check code status prior to starting CPR;-CPR should not be administered to a DNR resident. During an interview on [DATE], at 11:15 A.M., the Social Services Director (SSD) said the following:-The admission nurse assessed a residents code status on admission;-He/she reviewed code status monthly, ensured an order was in place, and entered code status in the care plan;-Code status was reviewed monthly, quarterly, annually, and upon a change in condition;-He/she printed DNR orders on purple paper and placed them in the code status folders at both nurse stations. During an interview on [DATE], at 3:16 P.M., the Assistant Director of Nursing (ADON) said the following:-The resident code status was indicated in a book on both halls and should be listed on the care plan;-The SSD was responsible for updating the code status in the book;-CNAs should not initiate CPR;-Staff should yell for help for an unresponsive resident, check the code book, and initiate CPR if indicated;-CPR should not be given to a resident with a DNR order. During an interview on [DATE], at 3:44 P.M., the Director of Nursing (DON) said the following:-He/she heard the resident went down in the dining room and a hospice nurse was present;-CPR was started on the resident, but was stopped after learning of DNR order;-CNA's should contact the nurse and not initiate CPR;-Code status should be checked in the code book at the nurses' station;-CPR should not be given to a resident with a DNR. During an interview on [DATE], at 4:47 P.M., the Administrator said a resident's code status should be honored. Staff should check the resident's code status prior to starting CPR. Complaint #3022586 and #3025981

Based on interview and record review, the facility failed to ensure residents only self-administered medication after it had been determined to be clinically appropriate when one resident (Resident #2) self-administered insulin injections independently without an assessment to determine competency or a physician order to allow for self-administration and failed to include self-administration of medication on the resident's care plan. The facility census was 111. Review of a facility policy titled Medication Self-Administration, dated 01/30/24, showed the following:-The purpose of the policy is to establish uniform guidelines concerning resident self-administration of medications;-Residents are not permitted to administer medications unless their primary physician writes an order for self-administration of the medication and the interdisciplinary team determines the resident Is able to safely self-administer medications;-An evaluation/assessment of the resident's ability to self-administer medications will be conducted and documented;-The physician order must be signed and dated prior to self-administration;-The staff charge nurse will counsel the resident on the proper use of medications initially as well as often as necessary and the resident medical record will reflect all counseling;-Self-administration of medications will be reflected on the resident's care plan and reviewed quarterly as well as with any clinical change in status. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/22/24;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive, incurable lung disease that causes severe breathing difficulties by obstructing airflow, primarily through bronchitis or emphysema) and diabetes mellitus (metabolic disease). Review of the resident's care plan, revised 01/28/26, showed the following:-Resident required assistance to complete daily activities of care safely;-Resident had fluctuation of blood sugar results with diabetes mellitus and noncompliance with diet;-Administer medications per order and evaluate, record, and report effectiveness and adverse side effects.(Staff did not care plan regarding the resident self-administering his/her insulin.) Review of the resident's medical record showed the staff did not have documentation of a self-administration of medication assessment for the resident. Review of the resident's progress note, dated 03/23/26, showed the following: -The resident requested to self-administer his/her insulin;-Resident observed giving self insulin injection using proper technique;-Staff will continue to draw insulin up as directed;-Resident care planned to self-administer when he/she requests to do so. (Staff did not document physician notification to obtain a physician's order.) Review of the resident's progress note, dated 04/08/26, showed the following: -Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) note;-Resident was an insulin dependent diabetic and had requested to self-inject insulin after the nurse sets it up;-Nurse present and observes injection with proper technique to inject, secure the safety sheath to cover needle, and dispose of needle in sharps container. (Staff did not document physician notification to obtain a physician's order.) Review of the resident's current Physician's Order Sheet (POS) showed an order, dated 05/05/26, for insulin glargine (long-acting insulin used to treat diabetes) solution 100 units per milliliter (ml), inject 60 units subcutaneously (beneath the skin) one time a day for diabetes. (Staff did not document an order for self-administration of medications.) Review of the resident's May 2026 Medication Administrator Record (MAR) showed insulin glargine documented as administered by staff. Review of the resident's May 2026 progress notes showed no further documentation related to self-administration of insulin. During an interview with on 05/28/26, at 10:28 A.M., the resident said the following:-He/she checked his/her own blood sugar and self-administered insulin injections;-Staff provided his/her with a glucometer and supplies to check blood sugars;-He/she showed the staff the blood sugar result;-The staff prepared the insulin injection based upon the blood sugar result and allowed him/her to inject the insulin. During an interview on 06/01/26, at 11:21 A.M, Registered Nurse (RN) G said the following:-Residents require a physician order to self-administer medications;-The nurse should monitor residents who self-administer medication during administration;-Blood sugar checks and insulin administration are not typically able to be self-administered by residents;-He/she does blood sugar checks and insulin administration for the resident. During an interview on 06/01/26, at 2:36 P.M., Licensed Practical Nurse (LPN) C said the following:-He/she was unsure if a resident required a physician order to self-administer medication;-The resident had self-administration of medication included on the care plan;-He/she would draw up the medication and monitor the resident if he/she requested to self-administer insulin. During an interview on 06/01/26, at 2:53 P.M., RN J said the resident administered his/her own insulin injections. The nurse will draw up the correct dosage and give the resident the syringe. The resident was care planned to self-administer medications. During an interview on 06/01/26, at 3:16 P.M., the Assistant Director of Nursing (ADON) said he/she was unaware if the resident administered his/her own medication. A resident that self-administered medication should have a physician order and the information should be included in the care plan. During an interview on 06/01/26, at 3:44 P.M., the Director of Nursing (DON) said residents require a physician order to self-administer medications. The resident self-administers his/her own insulin after the nurses pull up the correct dose. He/she should have a physician order, and it should be included in the care plan. During an interview on 06/01/26, at 4:47 P.M., the Administrator said residents should have a physician order to self-administer medication. The care plan should be updated to include resident self-administration of medications. Complaint # 3022586

Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when a nurse reinitiated an order for Naltrexone (medication used to treat alcohol and opioid disorders) without a physician order for one resident (Resident # 5). The facility census was 111.Review of the facility policy titled Medication Administration, dated October 2025, showed medications are administered by licensed nurses, or other staff legally authorized to do so, as ordered by a physician and in accordance with professional standards of practice. 1. Review of Resident #5's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/22/26;-Diagnoses included alcohol abuse. Review of the resident's current Physician Order Sheet (POS) showed the following:-An order, dated 04/22/26, for Naltrexone tablet 50 milligrams (mg), give 0.5 tablet by mouth in the morning for alcohol abuse. The order was discontinued on 04/23/26;-An order, dated 04/22/26, for hydrocodone-acetaminophen tablet 5-325 mg, give one tablet by mouth every eight hours as needed for pain. Review of the resident's April 2026 Medication Administration Record (MAR) showed an order, dated 04/22/26, for Naltrexone tablet 50 mg, give 0.5 tablet by mouth in the morning for alcohol abuse. Staff did not document as administered Review of the resident's nursing progress note, dated 04/22/26, showed resident admitted to skilled rehabilitation on this date. Resident's Naltrexone was discontinued per physician. Hydrocodone 5-325 mg every 8 hours as needed was added for pain. Review of the resident's care plan, dated 04/24/26, showed staff did not care plan the resident's history of alcohol abuse or the use of naltrexone, or pain medication. Review of the resident's current POS showed an order, dated 04/25/26, for Naltrexone tablet 50 mg, give 0.5 tablet by mouth one time a day due to alcohol abuse. Review of the resident's order progress note, dated 04/25/26, showed the following: -The order for Naltrexone oral tablet 50 mg, give 0.5 tablet by mouth one time a day due to alcohol abuse has a possible drug interaction with the following orders: hydrocodone-acetaminophen tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain;-Naltrexone may decrease the pharmacologic effects of hydrocodone-acetaminophen tablet 5-325 mg. Coadministration of naltrexone and hydrocodone-acetaminophen tablet 5-325 mg may precipitate withdrawal symptoms in individuals who are physically dependent on opioids;-Naltrexone therapy should be suspended in patients receiving intermittent opioid treatment. Review of the resident's April 2026 MAR showed the following:-An order, dated 04/25/26, for Naltrexone tablet 50 mg, give 0.5 tablet by mouth one time a day. Staff documented the Naltrexone was administered on 04/25/26 and 04/26/26;-An order, dated 04/22/26, for hydrocodone-acetaminophen tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed. Staff documented hydrocodone-acetaminophen as administered on 04/25/26 at 12:11 A.M. and 5:48 P.M Review of the resident's deleted (due to a reason of incomplete documentation) nursing progress note, dated 04/27/26, showed Naltrexone was discontinued per physician order on the day of admission. Please see admission note this nurse submitted on resident's day of admission [DATE]). Per physician this medication was discontinued. This medication was reactivated without physician's consent or orders to do so. This nurse has now discontinued Naltrexone again. During an interview on 05/28/26, at 1:12 P.M., Licensed Practical Nurse (LPN) C said the following:-The physician must be contacted for any order;-The physician is contacted for a new order, the nurse enters it into the electronic health record, and a progress note is entered regarding the order. During an interview on 05/28/26, at 1:12 P.M., LPN E said the following:-The nurse should contact the physician to obtain a new order;-The new order should be put into the electronic medical record;-The nurse should document a progress note about the reason for contacting the physician, the orders received, and notification to the resident and family;-An LPN reactivated an order without physician approval;-The LPN said he/she reactivated the order due to feeling the resident needed it due to alcohol abuse;-He/she discontinued the order as the physician discontinued the order on admission due to ordering narcotic pain medication. During an interview on 06/01/26, at 11:21 A.M., Registered Nurse (RN) G said nurses should not be writing orders without contacting the physician. Nurses should follow physician orders. During an interview on 06/01/26, at 11:54 A.M., Certified Medication Technician (CMT) H said staff should follow physician orders. It is not ok to write your own orders for residents. During an interview on 06/01/26, at 2:36 P.M., LPN C said the following:-Resident came to the facility with an order for Naltrexone but it was discontinued that day;-He/she did not believe the nurse called the physician for a new Naltrexone order;-The physician should be contacted for all orders, and those orders should be followed. During an interview on 06/01/26, at 2:53 P.M., RN J said the resident's Naltrexone was discontinued on admission due to the physician starting pan medication. He/she did not know why it had been restarted. During an interview on 06/01/26, at 3:16 P.M., the Assistant Director of Nursing (ADON) said nurses should not be writing own orders. Nurses should always contact the physician for orders and follow those orders. During an interview on 06/01/26, at 3:44 P.M, the Director of Nursing (DON) said the following:-He/she discovered the Naltrexone order incident while reviewing progress notes;-The restarting of the Naltrexone was a medication error. During an interview on 06/01/26, at 4:47 P.M., the Administrator said staff should be following physician orders. Nurses should not be writing orders without contacting the physician. During an interview on 06/16/26, at 9:22 A.M., the attending physician said the following:-The Naltrexone was discontinued due to initiating narcotic pain medication;-The Naltrexone and pain medication cannot be given together;-He/she would not and did not restart the Naltrexone;-The resident could become sick and have diarrhea and nausea if the two medications were given together;-He/she was not notified the Naltrexone had been restarted or administered;-The initiation and administration of Naltrexone would be considered a medication error. Complaint #3022586

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect, when staff did not assist one resident (Resident #4) to leave the dining room to have a soiled brief changed before mealtime. The facility census was 111. Review of a facility policy titled Resident Rights, dated January 2024, showed the following:-The purpose of the policy is to ensure resident rights are protected, respected, and promoted;-The facility will treat each resident with dignity and care for each resident in a manner and environment that promotes quality of life;-The resident has the right to live in the facility and receive services with reasonable accommodation of needs and preferences. 1. Review of Resident #4's face sheet showed the following:-admission date of 03/04/36;-Diagnoses included stroke and congestive heart failure (CHF - impaired heart function). Review of the resident's care plan, dated 03/18/26, showed the following:-Impaired physical mobility;-Assist resident in performing tasks;-Resident dependent on one to two staff for toileting;-Dependent on two staff for transfer;-Resident had bowel incontinence;-Staff should check and change brief as needed. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 03/19/26 showed the following:-Resident cognitively intact;-Resident dependent on staff for toileting, mobility, and showering;-Incontinent of bladder and bowel. Observation and interview on 05/28/26, at 2:55 P.M., showed the following: -The resident rested in bed watching television;-He/she said a few days ago in the dining room he/she had pooped in his/her pants. He/she had asked Certified Nurse Aide (CNA) F to return to the room to get changed prior to eating;-CNA F told the resident to wait and he/she did not want to take him/her back to the room;-CNA F accused the resident of trying to trick staff to help him/her with a brief change;-The resident said he/she felt embarrassed due to smelling bad and having a soiled brief;-The resident was crying in the dining room and CNA D took him/her to the room to change and brought him/her back to the dining room for lunch;-The resident started crying during when telling of the event. During an interview on 05/28/26, at 12:02 P.M., Certified Nurse Assistant (CNA) D said the following: -He/she observed CNA F assist the resident into the dining room;-He/she observed the resident had a large bowel movement. He/she stated the resident had bowel coming out of the brief;-He/she overheard the resident ask CNA F to go back to the room and have the brief changed;-CNA F told the resident they should eat and shut up;-CNA D assisted the resident back to the room to change briefs after CNA F left the resident at the table;-He/she reported the incident to the Director of Nursing (DON) or Assistant Director of Nursing (ADON). During an interview on 06/01/26, at 11:46 A.M., Certified Medication Technician (CMT) H said the following: -A resident should not eat with a soiled brief;-He/she would take the resident to the room to change and then return them to the dining room to eat. During an interview on 05/28/26, at 1:12 P.M., Licensed Practical Nurse (LPN) C said the following:-CNA's should take residents to be changed and then bring them back to dining room if soiled;-Residents should be treated with dignity and respect and it was not ok to tell a resident to shut up. During an interview on 05/28/26, at 1:52 P.M., LPN E said the following: -Residents should be taken back to the room to get changed and then returned to the dining room;-Residents should not be soiled in the dining room or told to shut up. During an interview on 06/01/26, at 11:54 A.M., LPN I said the following:-Residents should be treated with dignity and respect;-Residents should be changed if they are soiled;-He/she would take the resident from the dining room to change them and bring them back. During an interview on 06/01/26, at 11:21 A.M., Registered Nurse (RN) G said -Providing dignity and respect to residents included assuring a resident is clean and changed;-A resident should not wait to be changed after a meal;-Staff should take a resident to the room to be changed and return them to the dining area. During an interview on 06/01/26, at 2:53 P.M., RN J said the following:-A resident should be changed if found to be soiled in the dining room;-Residents should be provided with dignity and respect by keeping them clean. During an interview on 06/01/26, at 3:16 P.M., the ADON said the following: -Incontinence care should be provided every two hours and as needed;-A resident should not be allowed to eat with a soiled brief;-Any staff could assist the resident to the room to change and return them to the dining area;-An aide should not refuse to change a resident until after lunch as it could affect their dignity. During an interview on 06/01/26, at 3:44 P.M., the DON said the following: -Staff should treat residents with kindness, empathy, and meet their needs;-Staff should change a soiled resident prior to eating;-It would affect the resident's dignity to eat in the dining room with a soiled brief. During an interview on 06/01/26, at 4:47 P.M., the Administrator said the following:-Residents should be treated with dignity and respect;-Incontinence care should be provided every two hours and as needed;-A resident should not be allowed to eat with a soiled brief;-Staff should take the resident to be changed when requested;-Eating in the dining room with a soiled brief could affect the resident's dignity. Complaint #2981469 and #3022586

Based on record review and interview, the facility staff failed to ensure all residents were free of significant medication errors when staff failed to administer insulin for two residents (Resident #1 and #6) per physician order. The facility census was 111.Review of a facility policy titled Medication Administration, dated October 2025, showed the following:-Medications are administered by licensed nurses, or other staff legally authorized to do so, as ordered by a physician and in accordance with professional standards of practice;-Obtain and record vital signs and hold medication when vital signs are outside of the prescribed physician standards;-Sign the Medication Administration Record (MAR) after medication administration;-Report and document any adverse side effects or refusals. Review of a facility policy titled Medication Errors and Drug Reactions, dated January 2024, showed the following:-The purpose is to establish guidelines for reporting and recording of medication errors to safeguard the resident;-All medication errors must be promptly reported to the Director of Nursing (DON), physician, pharmacist, resident, and the Administrator;-A medication error is the observed, identified preparation, or administration of the medications which are not in accordance with the prescribers order. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/05/26;-Diagnoses included diabetes mellitus (metabolic disease). Review of the resident's care plan, dated 02/16/26, showed the following:-Resident had diabetes mellitus;-Resident had potential nutritional problems related to diabetes mellitus with insulin;-Administer medications as ordered and monitor and document side effects and effectiveness. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 02/14/26, for insulin glargine (long-acting insulin to treat diabetes) solution 100 units per milliliter (ml), inject 10 units subcutaneously (under the skin) one time a day for diabetes. Review of the resident's March 2026 MAR showed on 03/02/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented to see progress note. Review of the resident's progress note, dated 03/02/26, showed staff did not document an indication for holding the medication or notification to the physician of medication not administered. Review of the resident's March 2026 MAR showed on 03/03/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented to see progress note. Review of the resident's progress note, dated 03/03/26, showed staff did not document an indication for holding the medication or notification to the physician of medication not administered. Review of the resident's March 2026 MAR showed on 03/06/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented to see progress note. Review of the resident's progress note, dated 03/06/26, showed staff did not document an indication for holding the medication or notification to the physician of medication not administered. Review of the resident's March 2026 MAR showed on 03/07/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented to see progress note. Review of the resident's progress note, dated 03/07/26, showed staff did not document an indication for holding the medication or notification to the physician of medication not administered. Review of the resident's March 2026 MAR showed on 03/09/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented as a resident refusal. Review of the resident's progress notes, dated 03/09/26, showed staff did not document notification to the physician of the refusal. Review of the resident's March 2026 MAR showed on 03/11/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented as a resident refusal. Review of the resident's progress notes, dated 03/11/26, showed staff did not document notification to the physician of the refusal. Review of the resident's March 2026 MAR showed on 03/12/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/12/26, showed staff did not document an indication for holding the medication or notification to the physician. Review of the resident's March 2026 MAR showed on 03/17/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 171 milligram per deciliter (mg/dL) (normal pre-meal blood sugar range is 80 mg/dL to 130 mg/dL, or less than 180 mg/dL after eating), and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/17/26, showed staff did not document notification of the physician. Review of the resident's March 2026 MAR showed on 03/22/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 177 mg/dL and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/22/26, showed staff did not document notification of the physician. Review of the resident's March 2026 MAR showed on 03/25/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/25/26, showed staff did not document an indication for holding the medication or notification of the physician. Review of the resident's March 2026 MAR showed on 03/26/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/26/26, showed staff did not document an indication for holding the medication or notification to the physician. Review of the resident's March 2026 MAR showed on 03/27/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 185 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/27/26, showed staff did not document notification of the physician. Review of the resident's March 2026 MAR showed on 03/28/26, staff did not indicate a blood sugar reading and did not document medication administration. Review of the resident's progress notes, dated 03/28/26, showed staff did not document an indication for holding the medication or notification to the physician. Review of the resident's March 2026 MAR showed on 03/30/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 162 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/30/26, showed staff did not document notification of the physician. Review of the resident's March 2026 MAR showed on 03/31/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 153 mg/dL and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 03/31/26, showed staff did not document notification of the physician. Review of the resident's April 2026 MAR showed on 04/01/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented resident refused. Review of the resident's progress notes, dated 04/01/26, showed staff did not document notification of the physician of the resident's refusal. Review of the resident's medical record showed the resident out of the facility at the hospital from [DATE] to 04/10/26. Record review of the resident's current POS showed an order, dated 04/10/26, for insulin glargine solution 100 units per ml, inject 15 units subcutaneously one time a day for diabetes. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's April 2026 MAR showed on 04/10/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 89 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/20/26, showed staff did not document notification of the physician. Review of the resident's April 2026 MAR showed on 04/12/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading , and documented hold, see progress report. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/12/25, showed staff did not document indication for holding the medication or notification of the physician. Review of the resident's April 2026 MAR showed on 04/13/26, staff did not administer insulin as ordered, indicated a blood sugar reading of not applicable, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/13/25, showed staff did not document notification of the physician. Review of the resident's April 2026 MAR showed on 04/14/26, staff did not administer insulin as ordered, did not indicate a blood sugar reading, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/14/26, showed did not document notification of the physician. Review of the resident's April 2026 MAR showed on 04/15/26, staff did not administer insulin as ordered, indicated a blood sugar reading of not applicable, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/15/26, showed staff did not document notification to the physician. Review of the resident's April 2026 MAR showed on 04/16/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 176 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 04/16/26, showed staff did not document notification of the physician. 2. Review of Resident # 6's face sheet showed the following:-admission date of 05/11/26;-Diagnoses included diabetes mellitus. Review of the resident's care plan, dated 03/04/26, showed the following:-Resident had diabetes mellitus;-Diabetes medication as ordered by doctor;-Monitor/document for side effects and effectiveness. Record review of the resident's current POS showed an order, dated 05/11/26, for Lantus (long-acting insulin for diabetes) subcutaneous solution pen-injector 100 units per ml, inject 48 unit subcutaneously two times a day for diabetes. Review of the resident's May 2026 MAR showed on the morning of 05/12/26, staff did not administer insulin as ordered, blood sugar documented as 76 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/12/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/13/26, staff did not administer insulin as ordered, no blood sugar documented, and staff documented resident refused. Review of the resident's progress notes, dated 05/13/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/16/26, staff did not administer insulin as ordered, blood sugar documented as 87 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/16/26, showed staff did not document notification to the physician. Review of the resident's May 2026 MAR showed on the morning of 05/17/26, staff did not administer insulin as ordered, blood sugar documented as 85 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/17/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/18/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 68 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/18/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/19/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 95 mg/dL, and documented no insulin required. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/19/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/20/26, staff did not administer insulin as ordered, blood sugar documented as 74 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/20/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/21/26, staff did not administer insulin as ordered, blood sugar documented as 63 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/21/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/22/26, staff did not administer insulin as ordered, blood sugar documented as 80 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/22/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the evening of 05/22/26, staff did not administer insulin as ordered, blood sugar documented as 133 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/22/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/23/26, staff did not administer insulin as ordered, blood sugar documented as 117 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/23/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the evening of 05/22/26, staff did not administer insulin as ordered, blood sugar documented as 129 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/22/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/24/26, staff did not administer insulin as ordered, blood sugar documented as 83 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/24/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/25/26, staff did not administer insulin as ordered, blood sugar documented as 118 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/25/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the morning of 05/26/26, staff did not administer insulin as ordered, blood sugar documented as 159 mg/dL, and staff documented resident refused. Review of the resident's progress notes, dated 05/26/26, showed staff did not document notification to the physician. Review of the resident's May 2026 MAR showed on the morning of 05/27/26, staff did not administer insulin as ordered, blood sugar documented as 72 mg/dL, and staff documented vital signs outside of parameters to be given. (The insulin order did not contain parameters indicating to hold medication.) Review of the resident's progress notes, dated 05/27/26, showed staff did not document notification of the physician. Review of the resident's current POS showed, on 05/27/26, the previous insulin order discontinued, and a new order, dated 05/27/26, for Lantus subcutaneous solution pen-injector 100 units per ml, inject 42 unit subcutaneously two times a day for diabetes and hold for blood sugar less than 120 mg/dL. Review of the resident's May 2026 MAR showed on the morning of 05/28/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 133 mg/dL, and documented no insulin required. (Order showed to hold medication for blood sugar less than120 mg/dL) Review of the resident's progress notes, dated 05/28/26, showed staff did not document notification of the physician. Review of the resident's May 2026 MAR showed on the evening of 05/28/26, staff did not administer insulin as ordered, indicated a blood sugar reading of 122 mg/dL, and documented no insulin required. (Order showed to hold medication for blood sugar less than 120 mg/dL) Review of the resident's progress notes, dated 05/28/26, showed staff did not document notification of the physician. 3. During interviews on 06/01/26, at 11:21 A.M. and 12:23 P.M., Registered Nurse (RN) G said the following:-The nurse should notify the Nurse Practitioner (NP) if a resident refused medications;-The physician should be notified and a progress note initiated if a resident did not receive ordered medication; -Long-acting insulin should not be held without an order;-He/she may hold long-acting insulin if blood sugar is below 100 mg/dL, but would notify the physician;-Staff should follow physician orders. During an interview on 06/01/26, at 2:09 P.M., Certified Medication Technician (CMT) H said he/she would notify the nurse of a resident refusing medication. The nurse will try to administer the medication and if not mark it as a refusal. During an interview on 06/01/26, at 2:36 P.M., Licensed Practical Nurse (LPN) C said nurses should be following physician orders. During an interview on 06/01/26, at 2:52 P.M., RN J said the physician should be notified of a resident's insulin being held. During an interview on 06/01/26, at 3:16 P.M., the Assistant Director of Nursing (ADON) said nurses should make a progress note if insulin is held and indicate why held and notification to the physician. Staff should be following physician orders. During an interview on 06/01/26, at 3:44 P.M., the Director of Nursing (DON) said staff should follow physician orders. During an interview on 06/01/26, at 4:47 P.M., the Administrator said staff should be following physician orders. During an interview on 06/16/26, at 9:22 A.M., the attending physician said staff should not be holding long-acting insulin. He/she should be notified if a blood sugar result was really low and then he/she will decide if it should be held or not. Complaint #3022586

Based on observations, interviews, and record review, the facility failed to ensure nurse aides (NA) were certified within the required time frame when four NAs (NA A, NA B, NA C, and NA D) continue to work with residents beyond four months without being certified. The facility census was 106.Review of the facility policy titled, Policy, Hiring of Non-Certified Nurse Aides(Missouri), undated, showed the following:-To establish guidelines for recruitment, hiring, training, supervision, and certification of individuals who are not yet certified Nurse Aides (CNAs) but employed as nurse aides and trains at the facility;-The facility may hire individuals who are not currently certified as CNAs to work as nurse aides trainees, provided they meet the state and federal requirements. The trainees must complete an approved CNA training program and pass a state exam within the required timelines;-The facility may not permit trainees to continue working in resident care if they fail to meet the certification timelines or exam requirements.1. Review of the facility's hiring records showed NA A was hired on 08/06/25.During an interview on 02/10/26, at 2:37 P.M., NA A said the following:-He/she was hired in August 2025 as an NA. He/she has been working as an NA at the facility since then;-He/she had completed his/her classes two months ago but had not tested to become certified;-He/she was not sure who was in charge of making sure they get tested.Review of the facility records and DHSS records showed NA A did not have a current CNA certification. 2.Review of the facility's hiring records showed NA B was hired on 08/20/25.During an interview on 02/10/26, at 2:41 P.M., NA B said the following:-He/she was hired in August or September of 2025 and had worked as an NA full time since that time;-He/she finished classes around two months ago;-He/she tried to take the certification test last month but the facility where it was held canceled. It has not been rescheduled by the facility;-He/she was not sure who was in charge of making sure the testing/training gets completed. The person who used to be in charge of it left the facility about a month ago.Review of the facility records and DHSS records showed NA A did not have a current CNA certification. 3.Review of the facility's hiring records showed NA C was hired on 08/13/25.During an observation on 02/10/26, at 2:45 P.M., NA C was working on the hall assisting a resident in a wheelchair.During an interview on 02/10/26, at 2:49 P.M., NA C said the following:-He/she was hired in September as a nurse aide, and he/she had been working full time as a nurse aide ever since;-He/she had finished the training in October or November but has not passed the test to get certified yet;-He/she was scheduled to go take the test later this month.Review of the facility records and DHSS records showed NA A did not have a current CNA certification. 4. Review of the facility's hiring records showed NA D was hired on 09/16/25.During an interview on 02/11/26, at 3:58 P.M., NA D said the following:-He/she was hired in September 2025 as a full time NA;-He/she just started taking classes. He/she was not sure why it took so long;-He/she had not tested and is not certified yet.Review of the facility records and DHSS records showed NA A did not have a current CNA certification. 5. During an interview on 02/19/26, at 9:26 A.M., the Director of Nursing (DON) said the following:-He/she was not aware of how long some of the NAs had been working at the facility;-He/she did not realize that some of the NAs had been working at the facility for longer than four months until recently;-There used to be a staffing coordinator to track the NAs certification but he/she was fired about a month ago;-He/she was not sure why the certification testing did not get completed.During an interview on 02/19/26, at 9:38 A.M., the Administrator said the following:-He/she was not aware of what some of the start dates were for the NAs working at the facility;-The facility had a staff member that was in charge of making sure that the NAs were getting certified, but he/she was fired last month. Nobody had been tracking it since then.#2733099 and #2741180

Based on observation, interview, and record review the facility failed to have procedures in place to ensure the accurate dispensing and documentation of medication administration when staff left medication in a resident's room unsupervised for one resident (Resident #1) and when six medication cups with medication in them were left not administered in the medication cart labeled with room numbers for four residents (Resident #2, #3, #4, and #5) or unlabeled. The census was 106.Review of the facility's policy titled, Medication Self-Administration, dated 01/30/24, showed the following:-The purpose is to establish uniform guidelines concerning resident self-administration of medications. The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident;-Residents are not permitted to administer or retain any medication in their room unless their primary physician writes an order for self-administration, or the medication and the interdisciplinary team determines the resident is safely able to self- administer;-An evaluation/assessment of the resident's ability to self-administer medications will be conducted and documented. The interdisciplinary recommendations will be discussed with the with the resident's primary physician;-The physician's order must be signed and dated prior to self-administration;-Medications stored in the resident's room must not be accessible to other residents;-Medications will remain in the original container in which they were dispensed and will be properly labeled in accordance with the facility's established policies and procedures;-Self-administration of the medication will be reflected on the resident's care plan and will be reviewed at least quarterly.Review of the facility's policy titled, Storage of Medications, dated 01/30/24, showed the following:-The purpose is to ensure that medications are stored in a safe, secure, and orderly manner;-Medications are stored in an orderly manner in cabinets, drawers, or carts.Review of facility's policy titled, Resident-Centered Medication Pass, dated 01/30/24, showed the facility was to allow administration of medications according to a resident's schedule/routine while ensuring the safe and accurate administration of all medications.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/03/25;-Diagnoses included Type 2 diabetes mellitus (a chronic metabolic disorder where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond properly to insulin) with other skin ulcer, non-pressure chronic ulcer of other part of left foot with unspecified severity, hypertensive heart and chronic kidney disease with heart failure (represents a critical, interlinked cardiorenal syndrome where chronic high blood pressure causes thickening of the heart muscle and reduces kidney function), and lymphedema (a chronic swelling, usually in the arms or legs, caused by a buildup of protein-rich lymph fluid due to damaged or blocked lymph vessels).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/19/26, showed the following:-The resident was cognitively intact;-The resident required moderate assistance for transfers.Review of the resident's care plan, dated 12/17/25, showed the following:-The resident had functional urinary incontinence due to urinary retention. Provide medications for urinary retention as ordered and monitor for effectiveness;-The resident has hypertension (high blood pressure). Administer medications per orders and evaluate/record/report effectiveness side effects;-The resident received antidepressant medication due to a diagnosis of depression. Assess/record effectiveness of drug treatment;-The resident had a history of diabetic foot ulcers and hyperglycemia (high blood sugars) related to diabetes. Administer medications, insulin and oral medications per orders;-The resident receives antianxiety medication for anxiety.Review of the resident's Physicians Orders Sheet (POS) showed no order for self-administration of medication.Review of the resident's medication administration audit, dated 02/10/26, showed the following:-A current order for amlodipine besylate (treats blood pressure and chest pain) 5 milligram (mg) tablet, give one tablet orally one time a day. Documented on 02/10/26 at 10:57 A.M., by Certified Medication Technician (CMT) E as administered on 02/10/26, at 10:53 A.M.;-A current order for bupropion HCL XL (antidepressant) 300 mg tablet, give one tablet orally in the morning. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26, at 10:53 A.M.;-A current order for metformin HCL (oral medication used to treat diabetes) 500 mg tablet, give one tablet orally two times a day. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:54 A.M.;-A current order for metoprolol tartrate (treats high blood pressure) 100 mg tablet, give one tablet orally two times a day. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:54 A.M.;-A current order for gabapentin (anticonvulsant medication) 300 mg capsule, give one capsule orally three times a day related to type 2 diabetes mellitus with neuropathy. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:55 A.M.;-A current order for desvenlafaxine succinate ER oral tablet extended release 24-hour 50 mg (used to treat depression), give three tables by mouth in the morning. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:53 A.M.;-A current order for multi vitamin tablet, give one tablet by mouth on time daily. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26, at 10:54 A.M., -A current order for Jardiance (used to improve glucose control with type 2 diabetes) 25 mg tablet, give one tablet orally one time a day for diabetes mellitus. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:53 A.M.;-A current order for magnesium oxide 400, give tablet orally two times a day related to magnesium deficiency. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:54 A.M.;-A current order for ferrous sulfate (iron supplement) 325 mg tablet, give orally one time a day for iron deficiency. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:53 A.M.; -A current order for loratadine (for allergies) 10 mg tablet, give one tablet orally one time daily. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:53 A.M.; -A current order for Vitamin D3 microgram (mcg) tablet (supplement), give one tablet orally one time a day. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26. at 10:55 A.M.;-A current order for B12 500 mcg tablet (supplement), give one tablet orally one time a day for wound healing. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26, at 10:55 A.M.; -A current order for buspirone HCL (anxiety medication) 10 mg tablet, give one tablet orally two times a day. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26, at 10:53 A.M.;-A current order for pantoprazole SOD (stomach acid reducer), give one tablet two times a day. Documented on 02/10/26, at 10:57 A.M., by CMT E as administered on 02/10/26 at 10:53 A.M.Observations of the resident's room on 02/10/26, at 11:38 A.M., showed the following:-A medicine cup on the resident's bedside table in the middle of the room;-The medicine cup contained approximately 10 to 15 pills;-The resident was in the room, but there were no staff present;-The resident began taking the medication at 11:51 A.M.During an interview on 02/10/26, at 11:34 A.M., the resident said the following:-CMT E often leaves his/her medication on the bedside table and leaves because it takes him/her a long time to take the medication. He/she takes the medication one pill at a time;-CMT E brought the medication for the resident about 30 minutes ago and left them on the table. The resident needed to use the bathroom before he/she began taking them;-The medication sat on the bedside table the whole time he/she was in the bathroom;-CMT does not generally come back and check to make sure he/she has taken them.During an interview on 02/10/26, at 1:24 P.M., CMT E said the following:-He/she left the resident's medication on his/her bedside table today;-He/she was administering the resident's morning medication around 11:15 A.M. The resident and him/herself both needed to use the bathroom. He/she planned to come back and check on the resident to make sure he/she had taken the medication;-He/she did go back, and check and the resident had taken the medication, but he/she was unsure of what time that was;-He/she was aware that he/she was not supposed to leave resident medication in the room. The staff were supposed to watch the resident take the medication;-He/she was not sure what time he/she documented that the medication was administered but thought it was sometime around 11:15 A.M.;-He/she was not sure how he/she would know for sure what time the medication was taken by the resident;-The Medication Administration Record (MAR) should not be checked off until the resident has taken the medication.During an interview on 02/13/26, at 11:39 A.M., Certified Nurse Aide (CNA) F said the following:-He/she had gone into the residents' rooms and found medication cups with medication in them sitting on the resident's bedside table at least a few times and there was no staff with the resident;-He/she could not recall any specific residents because it has been different ones;-He/she tried to have them take it prior to him/her leaving the room;-He/she tells the nurse;-He/she does not think they were supposed to leave medication in the room unsupervised.During an interview on 02/13/26, at 2:37 P.M., CMT I said the following:-He/she never leaves medication with a resident. He/she waits for the resident to take the medication as per the facility policy;-If the resident cannot take it then, the staff should lock it up and try later or dispose/destroy it.During an interview on 02/13/26, at 2:01 P.M., Registered Nurse (RN) H said the following:-He/she saw that CMT E had left medication in a medicine cup on the resident's table earlier this week. He/she told CMT E that he/she could not leave medication in a resident room. CMT E should have waited for the resident to be ready to take the medication and witnessed him/her taking it;-The staff would not know what time or if the resident took the medication;-Staff should stay with the resident until they finish taking medication;-Staff should never leave medication in a resident's room unsupervised;-If the resident refuses the medication, then it should be destroyed.During interviews on 02/19/26, at 9:26 A.M. and 3:30 P.M., the Director of Nursing (DON) said the following:-The staff should stay and wait for the resident to take medication;-It should not be left in the resident room;-The person administering the medication will not know what time the medication was taken if they leave it in the room.During an interview on 02/19/26, at 9:38 A.M., the Administrator said the following:-It is not appropriate for staff to leave medication in a resident's room unsupervised;-If a resident needs to use the bathroom the staff should wait and then administer when they are done;-The time documented in the computer should reflect the actual time the medication was administered.2. Review of Resident #2's face sheet showed the following:-admission date of 01/02/26;-Diagnoses included hypertensive heart and chronic kidney disease without heart failure with stage 1 chronic kidney disease (a condition where chronic high blood pressure causes both left ventricular hypertrophy/heart damage and kidney dysfunction, even if the heart is not failing), Guillain-Barre syndrome (a rare, life-threatening autoimmune disorder where the immune system attacks peripheral nerves), mixed hyperlipidemia (an excess of lipids (LDL/bad cholesterol and triglycerides), and lumbar (lower) back pain lower extremity pain.Review of the resident's MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, dated 12/23/25 and revised on 01/14/26, shoed the following:-The resident was on anticoagulant (medication to slow blood clotting) therapy;-Administer medication as ordered by the physician and monitor for side effects and effectiveness each shift;-The resident had impaired cognitive function;-Staff should give the resident time to respond;-The resident has congestive heart failure (CHF - a chronic, progressive condition where the heart cannot pump blood efficiently, leading to fluid backup in the lungs and body), give cardiac medications as ordered.Observations on 02/19/26, at 4:30 A.M., showed the following:-RN L pointed out six medication cups with medication sitting on the counter in the locked medication room;-RN L did not know what the medication was;-The medicine cups had room numbers written on the side of five of the cups;-There were two medicine cups that had no room number on them, each containing one pill;-The medicine cup with Resident #2's room number on it had three pills;-RN L said the medication had come from the medication cart in a locked drawer.Review of the resident's Medication Administration Audit for evening shift, dated 02/18/26, showed the following-A current order for apixaban (blood thinner) tablet 5 mg, give one tablet by mouth two times a day, administered by CMT G at 7:21 P.M.:-An order for florastor (probiotic) oral capsule, give one tablet by mouth two times a day related to urinary tract infection, administered by CMT G at 7:21 P.M.,-An order for metoprolol (beta-blocker for high blood pressure, angina and heart failure), give one tablet by mouth three times a day, for administered by CMT G at 7:21 P.M.,-An order for trazodone (for insomnia), HCL oral tablet 50 mg, give one tablet by mouth at bedtime, for administered by CMT G at 7:21 P.M.Review of the resident's February 2026 MAR and Treatment Administration Record (TAR) showed staff did not document the resident had not refused medication or that the medication was not administered on 02/18/26.Review of the resident's nurses' notes showed staff did not document resident refusal of the medication on 02/18/26.During an interview on 02/19/26, at 11:15 A.M., the resident said he/she did not remember refusing any medications last night or this morning. He/she believes he/she took all his/her medications.3. Review of Resident #3's face sheet showed the following:-admission date of 12/03/25;-Diagnoses included malignant neoplasm of parietal lobe (a cancerous, abnormal growth of cells that divides uncontrollably, invades surrounding tissues, and can metastasize (spread) to other body parts), seizures, Type 2 diabetes mellitus with hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels), hyperlipidemia (an excess of lipids (cholesterol and triglycerides) in the blood), essential hypertension (high blood pressure), and unspecified osteoarthritis.Review of the resident's MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, dated 12/11/25 and revised 02/09/26, showed the following:-The resident was at risk for impaired cognition due to fluctuating forgetfulness;-Staff to offer verbal cues or cares;-The resident had a seizure disorder due to a brain tumor. The resident had medications prescribed.Observations on 02/19/26, at 4:30 A.M., showed the following:-RN L pointed out six medication cups with medication sitting on the counter in the locked medication room;-RN L did not know what the medication was;-The medicine cups had room numbers written on the side of five of the cups;-The medicine cup with Resident #3's room number on it had two pills;-RN L said the medication had come from the medication cart in a locked drawer.Review of the resident's Medication Administration Audit for evening shift, dated 02/18/26, showed the following:-A current order for dexamethasone (immune system suppression) oral tablet 2 mg, give one tablet by mouth three times a day administered by CMT G at 7:24 P.M.:-A current order for levetiracetam tablet (anti-seizure medication) 500 mg. give one tablet by mouth two times a day administered by CMT G at 7:24 P.M.Review of the resident's February 2026 MAR/TAR showed staff did not document the resident had refused medication or that medication was not administered on 02/18/26.Review of the resident's nurses' notes showed staff did not document the resident refused medication on 02/18/26.During an interview on 02/19/26, at 11:19 A.M., Resident #3 said the following:-The staff sometimes leave his/her medication on his/her bedside table and then leave the room;-The staff do not return to make sure he/she took them;-He/she did not remember refusing any medication on 02/19/26.4. Review of Resident #4's face sheet showed the following:-admission date of 02/05/26;-Diagnoses included kidney failure, chronic kidney disease, shortness of breath, respiratory failure and hypoxia (deprivation of oxygen), chronic obstructive pulmonary disease (COPD - an ongoing lung condition caused by damage to the lungs), atrial fibrillation (an irregular and often very rapid heart rhythm), and benign prostatic hyperplasia (BPH - enlargement of the prostate).Review of the resident's comprehensive MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, dated 02/02/26, shoed the following:-The resident was on anticoagulant therapy;-Administer medication as ordered and monitor for side effects and effectiveness each shift.Observations on 02/19/26, at 4:30 A.M., showed the following:-RN L pointed out six medication cups with medication sitting on the counter in the locked medication room;-RN L did not know what the medication was;-The medicine cups had room numbers written on the side of five of the cups;-The medicine cup with Resident #4's room number on it had five pills;-RN L said the medication had come from the medication cart in a locked drawer.Review of the resident's Medication Administration Audit for evening shift, dated 02/18/26 night, showed the following:-A current order for calcium acetate tablet (supplement) 667 mg, give one tablet by mouth three times a day for supplement with meals, administered by CMT G at 4:33 P.M.:-A current order for colace (stool softener) oral capsule 100 mg, give one capsule by mouth two times a day for constipation, administered by CMT G at 4:33 P.M.;-A current order for apixaban (blood thinner) tablet 2.5 mg, give one tablet by mouth two times a day, administered by CMT G at 7:12 P.M.;-A current order for atorvastatin calcium tablet (treat high cholesterol), 89 mg, give one tablet by mouth at bedtime for hyperlipidemia, administered by CMT G at 7:21 P.M.;-A current order for isosorbide dinitrate (used to treat chest pain) tablet 20 mg, give one tablet by mouth three times a day for hypertension, administered by CMT G at 7:21 P.M.;-A current order for neurontin (treats nerve pain) oral capsule 300 mg, give one capsule by mouth one time a day, administered by CMT G at 7:21 P.M.;-A current order for tamsulosin HCL capsule .4 mg, gibe ne capsule by mouth one time a day for BPH administered by CMT G at 7:21 P.M.Review of the resident's February 2026 MAR/TAR showed staff did not document the resident had refused medication or the medication was not administered on 02/18/26.Review of the resident's nurses' notes showed staff document the resident refused medication on 02/18/26.5. Review of Resident #5 face sheet showed the following:-admission date of 01/06/26;-Diagnoses included atrial fibrillation, cardiomyopathy (chronic disease of the heart muscle), unspecified hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease, chronic systolic (congestive) heart failure, anxiety disorder, lymphedema (swelling), hypertension (high blood pressure), and metabolic encephalopathy (an acute or chronic, often reversible, brain dysfunction resulting from systemic illness, such as liver/kidney failure, diabetes, or toxins, rather than a direct brain injury).Review of the resident's MDS, dated [DATE], showed the resident had severe cognitive impairment.Review of the resident's care plan, dated 01/15/26, showed the following:-The resident was on anticoagulant therapy due to atrial fibrillation;-Monitor for signs and symptoms of abnormal bleeding/ bruising and protect from injury.Review of the resident's Medication Administration Audit for evening shift, dated 02/18/26 night, showed the following-A current order for apixaban tablet 5 mg, give one tablet by mouth two times a day for blood clot prevention, administered by CMT E at 7:20 P.M.;-A current order for carvedilol (used to treat high blood pressure and heart failure) tablet 12.5 mg, give one tablet by mouth two times a day for hypertension. Do not administer if blood pressure is below 110 millimeters/mercury (mm/Hg) over 60 mg/Hg, or if heart rate below 60 beats per minute (bpm), administered by CMT E at 7:20 P.M.Observations on 02/19/26, at 4:30 A.M., showed the following:-RN L pointed out six medication cups with medication sitting on the counter in the locked medication room;-RN L did not know what the medication was;-The medicine cups had room numbers written on the side of five of the cups;-The medicine cup with Resident #5's room number on it had one pill;-RN L said the medication had come from the medication cart in a locked drawer.Review of the resident's February 2026 MAR/TAR showed staff did not document the resident had refused medication or medication was not administered on 02/18/26.Review of the resident's nurses' notes showed staff did not document the resident refused medication on 02/18/26.6. During an interview on 02/19/26, at 5:30 A.M., CMT G said the following:-He/she worked on the hall and administered medications to Resident #2, Resident #3, Resident #4, and Resident #5 on the evening of 02/18/26 until around 6:10 P.M.;-He/she did not remember leaving any medicine cups on the cart with medication in them;-He/she denied pre popping pills to administer later;-He/she thought maybe a few residents could have refused and he/she left the medication in the cart;-He/she usually lets the nurse know but he/she could have forgot;-He/she could not remember specific residents that refused medication.During an interview on 02/19/26, at 3:55 A.M., Licensed Practical Nurse (LPN) K said there were multiple resident's saying they did not get medications on 02/18/26.During an interview on 02/19/26, at 4:12 A.M., RN L said the following:-There were some residents that complained to him/her that they did not get their medications on 02/18/26 in the evening/night;-He/she looked at the MAR and it looked like all their medications were administered;-He/she looked in the cart and found six cups of medications. There were four that were marked with room numbers and two that were not;-He/she did not know why they were sitting in the cart and not administered. It appeared that they were marked as administered but never given. The medications were not documented on the MAR as refusals;-He/she assumes that the CMT that worked the evening shift left them in there;-He/she informed the DON to ask what to do with the medication, but he/she had not heard yet. He/she is keeping them locked up in the medication room for now;-Medication should not be left loose in the cart if it cannot be administered.During interviews on 02/19/26, at 9:26 A.M. and 3:30 P.M., the DON said the following:-If the resident refuses to take the medication it should be destroyed and not just left in the medication cart for the next shift;-He/she was made aware of the medication cups with medication in them being left in the medication cart;-CMT G told him/her that the medication cups that were left in the medication cart were from refusals.During an interview on 02/19/26, at 9:38 A.M., the Administrator said the following:-Resident medication should not be pre popped and left in the medication cart;-If a resident refused their medication the nurse should be notified so it can be destroyed.Complaint #2733099

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to document assessment, monitoring, and physician notification of a fall with injury for one resident (Resident #1) resulting in staff on following shifts not being aware of the need of fall follow-up monitoring. The facility census was 110. Review of the facility's policy, Fall Prevention Program, dated 10/01/25, showed the following: -A ''fall refers to unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themselves or had not been intercepted by another person - this is still considered a fall. If there is a loss of balance during supervised therapeutic interventions and the resident comes to rest on the ground, floor, or next lower surface despite the clinician's effort to intercept the loss of balance, it is considered a fall; -A near miss which is also considered a fall, is when a resident would have fallen if someone else had not caught the resident from doing so; -When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 11/24/23;-Diagnoses included unspecified dementia, severe, without behavioral disturbance; chronic atrial fibrillation (rapid, irregular heartbeat), obesity, depression, insomnia, and repeated falls.Review of the resident's care plan, dated 04/22/24 and edited on 10/02/25, showed the following: -The resident is at risk of falls;-The resident required assistance to get out of bed;-Fall mat beside the bed and staff to assist with sitting in a chair in the common areas;-Encourage non-skid footwear;-Observe for changes in condition that may warrant increased supervision/assistance and notify the physician;-Remind resident to ask staff for assistance with walking;-The resident has the potential for complications due to anticoagulant (blood thinner) therapy;-Observe for abnormal bleeding, increased bleeding, hematuria (blood in urine), bleeding gums, black/tarry stools, and hematemesis (vomiting of blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/01/25, showed the following: -Moderate cognitive impairment;-Moderate assistance for transfers and walking;-The resident has had no falls since the last assessment. Review of the resident's progress note dated 12/16/25, at 2:43 P.M., showed Registered Nurse (RN) A noted the resident had a hematoma (a collection of clotted blood outside of blood vessels, pooling in tissues, organs, or spaces, often from trauma, appearing as a deep bruise but more significant) on the right side of his/her head. Certified Nursing Aide (CAN) B said the resident fell out of bed two nights ago. The resident said a female helped him/her up and back into bed. The physician was notified via text Review of the resident's medical records showed staff did not document regarding a fall, injury, physician notification, assessment, or monitoring before 12/16/25. Review of the resident's record showed staff did not document a physician visit on 12/16/25 or 12/17/25. Observations on 12/18/25, at 11:00 A.M., showed the resident had a bruise on the right side of his/her forehead. The bruise had a purple spot about the size of a marble. Around the purple was a more yellowed bruising about the size of a tennis ball. During an interview on 12/18/25, at 11:00 A.M., the resident said the following: -He/she got the bruise on his/her head when he/she fell out of bed about two nights ago. A woman came in and looked him over after the incident and helped him back into bed;-The doctor saw him yesterday;-The bruise on his head no longer hurts. He/she did not remember any other assessments. During an interview on 12/18/25, at 1:53 P.M., CNA B said the following: -He/she noticed a bruise on the resident's forehead on 12/16/25. Another staff had just gotten him/her back to his/her room and asked about the bruise;-The resident said he/she had fallen on 12/14/25 at night;-The resident did not say who helped him/her up or who assessed him/her;-He/she was not aware the resident had a fall prior to this. Generally, that is something that would be passed on in report;-He/she reported the bruise/fall to RN A;-RN A came in an assessed the resident;-RN A was also not aware the resident had a recent fall. During an interview on 12/18/25, at 3:21 P.M., RN A said the following: -On 12/16/25, CNA B made him/her aware that the resident had a bruise on his/her head;-The resident said it had happened two days ago. The resident said somebody helped him up. He/she checked neuros and checked his/her vital signs;-He/she did not see any documentation in the chart regarding a fall or where the bruise might be from. He/she started to investigate;-He/she spoke with RN D and Licensed Practical Nurse (LPN) C. They told him/her that the resident had a fall on 12/13/25 at around 10:20 P.M.;-He/she was not sure why they did not document that the resident had a fall and start fall follow-up assessments. Fall follow-up is continued for 72 hours after a fall. Since the resident hit his head, they should have done neuro checks;-The injury should be documented;-He/she reported it the Assistant Director of Nursing (ADON) on Monday (12/15/25); -He/she also reported the fall/ injury to the physician. The physician came in on 12/15/25 or 12/16/25 to assess the resident. LPN G took measurements and sent that to the physican;-The resident appeared to be doing okay based on neuro checks and vitals that he/she completed but he/she wanted the physician to be aware. During an interview on 12/18/25, at 3:45 P.M., LPN C said the following: -On 12/13/25, at around 10:20 P.M., he/she had clocked out but was waiting in the building because it was cold outside. Registered Nurse (RN) D asked for help because the resident was on the floor. RN D assessed the resident for injury and did neuro checks on him/her because he said he/she had hit his/her head during the fall;-LPN E, the resident's nurse, came into the room when RN D was assessing the resident;-He/she then assisted with getting the resident back in bed;-He/she did not know if the assessment was documented in the resident's chart but it should have been;-Staff should do an initial assessment and then fall follow-up including neuro checks for the next 72 hours. There should be an event documented;-He/she assumed that LPN E had documented the assessment and completed the fall follow-up and continued assessment per the facility's protocol because he/she was aware of the fall and was the resident's nurse for that shift. During an interview on 12/18/25, at 3:51 P.M., RN D said the following:-The resident fell out of bed on Saturday (12/13/25) night around 10:30 P.M.;-The resident yelled, and he/she responded and saw that he/she had fallen out of bed;-He/she assessed him. There was blood on floor from a skin tear on his/her hand. He/she got him cleaned up;-The resident said he/she hit his/her head;-He/she checked his/her vitals and did neuro checks;-The resident did not appear to have any injuries besides a small skin tear on his/her hand. There was no bruising or swelling on his/her head at the time and everything else was normal;-They then got him/her up and into the bed;-He/she did not document anything regarding the resident's fall or assessment;-The resident's nurse was LPN E and he/she had come to the room when he/she was assessing him/her. He/she assumed that RN E would complete the appropriate documentation;-He/she did not contact the physician or the Director of Nursing (DON)/ADON;-RN E should have contacted the physician and the DON/ADON;-The nurse for the next shift should have been notified of the fall and any needed fall follow up;-The documentation would include a fall incident note/event and a note in the progress notes. He/she also assumed LPN E would take over neuro checks, and fall follow up assessment per facility protocol;-Fall follow up lasts for 72 hours. During an interview on 12/18/25, at 4:35 P.M., LPN F said the following:-He/she worked on 12/14/25 and was caring for the resident;-The staff did not inform him/her that the resident had fallen the day before. He/she should have been notified so that he/she could do fall follow-up including assessments and documentation; -There should have been documentation of the fall and the fall follow up in the chart;-If the resident hit his head there should have been neuros completed during his/her shift;-He/she did not do any assessments, or neuro checks because he/she was not aware that the resident had fallen;-He/she did not notice a bruise on the resident's head, but he/she did not look closely at it. During an interview on 12/30/25, at 4:39 P.M., RN E said the following: -The resident had a fall out of bed on 12/13/25 around 10:30 P.M;-RN D had already assessed the resident upon his/her arrival to the resident's room;-He/she through that RN D would do the documentation because he/she had assessed the resident;-He/she should have documented the fall assessment, situation, interventions put into place, and neuro checks being done;-He/she thought that RN D was going to do the neuro checks on the resident for the rest of the shift and thought RN D gave the CNA a sheet to document the resident's vitals;-He/she did not do any further vitals or assessment of the resident for the rest of her shift;-He/she did not notify the physician or the DON/ADON;-He/she did not let the oncoming nurse for the next shift know about the fall;-He/she realizes that he/she should have let the nurse taking over his/her hall know that the resident had fallen and hit his/her head. During an interview on 12/18/25, at 4:58 P.M., LPN G said the following: -He/she first became aware of bruising on the resident's head when RN A told him/her about it and the physician asked for him/her to take measurements of it; -He/she took measurements on 12/16/25. The largest part of the bruise was about five cm long and three cm wide. It was rectangular in shape but was not a perfect rectangle. It looked like it was fading and was light purple in color. He/she sent the measurements to the physician;-He/she was not aware the resident had a fall prior to this. The physician came out to assess the resident on either 12/16/25 or 12/17/25. He/she could not remember;-The physician did not think the resident needed any further intervention;-He/she worked on 12/14/25 on the overnight shift. He/she did not notice any bruising at that time, but he/she only saw him in the room and it was dimly lit at the time; -He/she should have been notified of the resident's fall on 12/14/25 when he/she worked so that he/she could do fall-follow up assessments;-The fall should have been documented in progress notes in the chart. During interviews on 12/18/25, at 3:38 P.M. and 6:01 P.M., the ADON said the following: -He/she was not aware that the resident had a fall;-If the resident had a fall the resident should have been assessed, and it should have been documented in the chart;-If a resident hits their head during a fall the nurse should complete neuro checks;-The facility recently switched to a new electronic documentation system and some of the staff may have no known where to document the assessment/ follow up;-He/she would have expected the nurse to put in a progress note and an incident report at least on paper if they did not know where to put it in the computer;-If he/she had been aware of the fall it would have been added to the risk management list and discussed during the meeting;-The nurse is supposed to inform the oncoming nurse of any falls that took place during the shift and if there is any fall follow up needed for any residents. During an interview on 12/18/25, at 5:45 P.M., the MDS Coordinator said the following: -He/she was not made aware that the resident had a fall until today. He/she was supposed to be informed of all the falls so that he/she can update the resident's care plan and the staff can discuss interventions;-The staff should assess the resident and complete an incident report regarding the fall. Fall follow up takes place for three days. During an interview on 12/18/25, at 6:01 P.M., the Administrator said the following: -He/she would expect a resident to be assessed by the nurse following a fall and to complete fall follow up;-The ADON or the DON and physician should be notified;-The nurse should document falls assessment in the resident's record. During an interview on 12/30/25, at 9:08 A.M., the resident's physician said the following: -He was not sure when he/she was made aware of the resident's fall but he/she believed the staff would have contacted him/her if there was anything serious going on;-He/she could not recall when he/she last saw the resident or when he/she assessed the resident last;-The resident is on blood thinners and that can cause bruising to look more serious that it really is;-The staff should document assessments after a fall and should complete fall follow up for the next six to eight hours or per facility protocol even if they have to wake them up;-The facility should complete neuro checks if a resident hits their head;-If the staff did not document their assessment, then they need to do a better job of documenting and passing information on to the next shift. #2689710

Based on interview and record review, the facility failed to have a process in place that established receipt and disposition of all controlled drugs when staff failed to document medications reconciliation upon discharge for one resident (Resident #1) resulting in a card of 30 Percocet (oxycodone-acetaminophen - a brand-name prescription pain medication containing a combination of two drugs: the opioid oxycodone and the non-opioid pain reliever acetaminophen) 5-325 milligrams (mg) for one previously discharged resident (Resident #2) being sent home with the resident (Resident #1). Three residents were sampled in a facility with a census of 112.On 10/14/25, the Administrator became aware of the noncompliance that occurred on 10/10/25 related to medication being sent home with the wrong resident. The Director of Nursing (DON), who was aware of the error and did not report it timely, was terminated. The Administrator completed an investigation, implemented new audits and policies to prevent future errors, and in-serviced all staff involved with medications on the new policies. The non-compliance was corrected on 10/21/25. Review of the facility's policy titled Medications-Leave of Absence, Discharge, dated 01/30/25, showed the following:-Establish uniform guidelines concerning the release of medications to residents upon their discharge or absence from the facility;-Release of medications on discharge: Drugs which have been dispensed for individual resident use and are labeled in accordance with State and Federal law may be furnished to a resident upon his or her discharge provided that the attending physician orders such medications be sent with the resident, the resident is discharged by his or her attending physician, and the resident is discharged to a health care facility or own home;-Any medications that have been discontinued will not be forwarded to the receiving facility or provided to the resident;-The charge nurse is responsible for documenting medications provided upon discharge in the resident's medical record;-Controlled substances: All drugs classified as controlled substances must be returned to the dispensing pharmacy or destroyed in accordance with the facility's procedures governing the destruction of medications. Controlled substances may be provided for the resident upon discharge/transfer with physician orders. Medications and special information for their administration are outlined in the resident's discharge plan when the resident is discharged to home.Review of the facility's policy titled Medication Reconciliation, dated 01/30/25, showed the following:-Verify the resident's current medication regimen upon admission and/or readmission to the facility and provide an updated medication list to the next service provider at the time of discharge/transfer from the facility;-Medication reconciliation will be conducted prior to the transfer of the resident to another facility, e.g., hospital or other nursing facility. The charge nurse will contact a nurse at the receiving facility to provide this information. The time of the last dose of each medication prior to the resident's transfer will be provided as well. The name of the nurse conducting the reconciliation will be documented on the Medication Reconciliation Form and also recorded on the transfer record;-A list of medications will be provided to the resident and/or caregiver upon discharge to a private residence. The charge nurse will review this list with the resident and caregiver. Contact information for the facility discharging the resident's care will be provided so questions can be answered once the resident returns home.1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 09/18/25;-discharged to home on [DATE];-The resident was his/her own responsible party;-Diagnoses included cancer, heart disease, and chronic kidney disease.Review of the resident's Physician's Order Sheet (POS), dated 09/18/25 to 10/10/25, showed the resident did not have an order for Percocet 5-325 mg.Review of the resident's nurses' progress notes showed the following:-On 10/10/25, at 8:46 A.M., staff noted the resident planned to discharge on [DATE] between 1:00 P.M. and 3:00 P.M. per the resident's report;-On 10/10/25, at 11:30 A.M., staff noted resident discharged via facility van at 11:15 A.M. on this day. All medications sent with resident including narcotics. Medications sent with resident. Resident had no concerns with discharge instructions. Home with hospice services.Review showed the facility did not provide a discharge medication reconciliation list for the resident.2. Review of Resident #2's face sheet showed the following:-The resident admitted on [DATE] and discharged home on [DATE];-The resident was his/her own responsible party;-Diagnoses included surgical aftercare following surgery of circulatory system, weakness, and diabetes.Review of the resident's October 2025 POS showed the following:-An order, dated 10/01/25 with an end date of 10/02/25, for Percocet Schedule II tablet, 5-325 mg., 1 tablet by mouth every four hours as needed;-An order, dated 10/02/25 with an end date of 10/03/25, for Percocet Schedule II tablet, 5-325 mg., 1 tablet by mouth for a pain scale of 1 to 5 out of 10 every four hours as needed;-An order, dated 10/02/25 with an end date of 10/03/25, for Percocet Schedule II tablet, 5-325 mg., 2 tablets for pain scale of 6 to 10 out of 10 every four hours as needed.Review of the pharmacy requisition sheet, dated 10/03/25, showed 30 tablets of oxycodone-acetaminophen 5-325 mg (Percocet) for the resident delivered to the facility and signed for by a nurse on 10/04/25 at 1:45 A.M.Review of the resident's Home Discharge Medication List, dated 10/03/25, showed no Percocet 5-325 mg. sent home with the resident.Review of the resident's narcotic record sheet, dated 10/04/25, showed a quantity of 30 oxycodone 5-325 mg. tablets with no tablets administered and no medication disposition completed.3. Review of the facility's investigation, undated, showed the following:-On 10/14/25, the former Director of Nursing (DON) made the Administrator aware of possible missing narcotics found on 10/10/25 and stated a nurse discharged Resident #2's left over medication card with Resident #1;-On the evening of 10/10/25, the nurse made the DON aware of the potential missing narcotic;-The former DON failed to report the issue to the Administrator, Department of Health and Senior Services (DHSS) or any corporate team member;-The Administrator placed the former DON on suspension pending investigation and began to investigate the issue to attempt to locate the missing medication;-The Administrator confirmed Resident #2 did have that medication or one similar;-The Administrator received the report from the pharmacy that showed the medication in question was delivered after Resident #2 discharged ;-The Administrator confirmed with hospice staff Resident #2's medication was at Resident #1's home.4. During interviews on 10/29/25, at 11:13 A.M. and 2:54 P.M., Licensed Practical Nurse (LPN) A said the following:-When medications come in from the pharmacy, two nurses sign for the narcotics and add them to the narcotic book with either a new narcotic sheet or to a current narcotic sheet;-If the resident was already discharged , the nurse still signed for the medication, made a narcotic sheet and placed them in the narcotic box to be destroyed later by DON or Assistant Director of Nursing (ADON);-When a resident was discharged home with their medications, the certified medication technician (CMT) pulled a resident's medications from the medication cart and filled out the medication list with those medications. He/she added the narcotic to the medication list;-He/she checked each medication card against the medication list and checked the resident's name, medication name, dosage and route;-He/she took the medications, the medication list and the narcotic book to the resident and went over each medication one at a time and he/she and resident signed the narcotic book and medication list. He/she made a copy of the medication list for the resident and kept the original for the resident's medical chart.During interviews on 10/29/25, at 11:30 A.M. and 2:03 P.M., LPN B said the following:-If a resident discharged with their medications, he/she had the CMT pull the non-narcotic medications from the medication cart, and he/she pulled the narcotic medications;-The charge nurse reconciled the medications on a medication list and checked the orders against the medication;-The charge nurse educated the resident and resident's responsible party if available on the medication schedule and have the resident and resident's responsible party, if available, and the nurse sign for the medications. The resident and/or responsible party also signed the narcotic sheet in the narcotic book for any narcotics that were surrendered to them;-The current process when the pharmacy delivered medications was for the nurse assigned to the resident to be present and check their own residents' medications in. If the resident was discharged , then the medication was returned to the pharmacy and not accepted by the nurse. If a nurse signed for narcotics for a discharged resident, they were to report this immediately to the Administrator;-Previously, whichever nurse that was behind the desk signed for all of the medications and took the narcotics to the nurse in the unit the resident resided. The nurse signing for the medications may not know which residents not on another unit were discharged . During an interview on 10/29/25, at 2:45 P.M., CMT C said the following:-When a resident discharged , he/she gathered all their medications from the medication cart and wrote the medications down on a medication list that included the dosage, quantity and times taken per day then took them with the list to the charge nurse;-The charge nurse took care of the narcotics;-When medications came in from the pharmacy, the nurse checked them in and then gave him/her the medications that went in his/her medication cart which did not include narcotics.During an interview on 10/30/25, at 11:26 A.M., Registered Nurse (RN) D said the following:-When medication came in from the pharmacy and a resident was discharged , he/she still signed for the medication due to the pharmacy not allowing the medication to be sent back;-When he/she discharged a resident, he/she pulled all of their narcotics, took them to the resident and educated the resident on them and had the resident sign the narcotic book for them;-The charge nurse filled out a medication reconciliation sheet with the resident's medication on it and gave that to the resident as well;-When Resident #1 discharged , it was a rushed decision. The RN printed of the resident's physician's orders and went over the resident's medication with the resident and had the resident sign the narcotic book;-The resident's hospice nurse was present, and the RN asked if the hospice nurse wanted to count the narcotics with the RN, but the hospice nurse refused;-He/she did not fill out a medication reconciliation sheet for the resident but should have;-At the end of his/her shift, he/she counted with the oncoming nurse and realized a card of Percocet 5-325 mg. was missing for Resident #2 and he/she informed the former DON;-He/she called Resident #2 to see if the resident had that medication and that resident did not;-He/she called the pharmacy to ensure the medication was delivered and the pharmacy confirmed the medication was delivered on 10/04/25 and was signed or by a nurse;-He/she called hospice to see if they would visit Resident #1 and confirm that the medication was accidentally sent home with the resident. Hospice could not get ahold of the resident at that time;-He/she usually went through a resident's medication one card at a time to check the resident's medication against the medication list but did not do that do to being in a rush. He/she believed this incident could have been avoided if he/she would have confirmed each medication one card at a time.During interviews on 10/29/25, at 12:26 P.M., and on 10/30/25, at 2:46 P.M., the Interim DON said the following:-When a resident discharged , the CMT pulled the medications from their cart and the charge nurse pulled the narcotics;-The charge nurse completed a medication list and should go through one medication at a time;-The number of narcotics surrendered was placed on the back of the narcotic sheet in the narcotic book and signed for;-He/she understood Resident #1 and Resident #2's narcotics were back-to-back in the medication cart and the nurse accidently grabbed Resident #2's medication with Resident #1's;-He/she could not find a medication reconciliation sheet for Resident #1. The charge nurse should have completed one;-The charge nurse should go through each medication one at a time and confirm the medication with the resident's orders and the reconciliation sheet. If the charge nurse would have completed this process, the mistake would have been caught at that time.During interviews on 10/29/25, at 12:42 P.M. and on 10/30/25, at 2:46 P.M., the Administrator said the following:-Resident #1 was sent home with a card of Resident #2's medication;-He could not find a medication reconciliation sheet for Resident #1. The charge nurse should have completed one;-The charge nurse should go through each medication one at a time and confirm the medication with the resident's orders and the reconciliation sheet. If the charge nurse would have completed this process, the mistake would have been caught at that time;-He was notified of the medication error on 10/14/25 and let the former DON go because the former DON knew about the error on 10/10/25 and did not inform him;-Initially he called Resident #1 on 10/15/25 or 10/16/25 and their significant other said the resident had the medication.-The weekend of 10/18/25 or 10/19/25, one of the nurses said the medication came into the facility after Resident #2 was discharged and he confirmed the medication was delivered after the resident discharged ;-Resident #1's hospice company confirmed the medication was at Resident #1's home on [DATE].2641188

Based on observation, interview, and record review, the facility failed to ensure six nurse aides (Nurse Aide (NA) A, NA AA, NA V, NA W, NA X, NA Y, NA Z) of sixteen sampled NAs, completed a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 105. Review showed the facility did not provide a policy regarding nurse aide certification or training. Review of the facility provided list of current NA staff showed sixteen staff on the list. Six NA staff had been employed greater than 120 days. 1. Review of NA AA's personnel file showed the following: -Date of hire of 10/02/24 (seven months and eighteen days since date of hire); -Staff did not have documentation NA AA had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA AA not listed with an active certificate. 2. Review of NA V's personnel file showed the following: -Date of hire of 10/15/24 (seven months and five days since date of hire); -Staff did not have documentation NA V had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA V not listed with an active certificate. 3. Review of NA W's personnel file showed the following: -Date of hire of 11/15/24 (six months and five days since date of hire); -Staff did not have documentation NA W had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA W not listed with an active certificate. Observations on 05/16/25, at 10:05 A.M., showed NA W working, providing direct care to residents in the facility. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA W worked on the day shift on 05/16/25. 4. Review of NA X's personnel file showed the following: -Date of hire of 01/06/25 (four months and fourteen days since date of hire); -Staff did not have documentation NA X had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA X not listed with an active certificate. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA X worked on the day shift on 05/14/25. 5. Record review of NA Y's personnel file showed the following: -Date of hire of 01/09/25 (four months and eleven days since date of hire); -Staff did not have documentation NA Y had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA Y not listed with an active certificate. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA Y worked on the evening shift on 05/16/25. 6. Record review of NA Z's personnel file showed the following: -Date of hire of 01/12/25 (four months and eight days since date of hire); -Staff did not have documentation NA Z had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA Z not listed with an active certificate. Review of the facility's provided daily staff schedules, dated 05/11/25 through 05/20/25, showed NA Z worked on the day shift on 05/11/25. Review of the state agency CNA registry, on 05/21/25, showed the Nurse Aides not listed with an active certificate. 7. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said NA's should be certified within 120 days of hire. He/she said there were several NAs that had been at the facility longer than 120 days. During an interview on 05/19/25, at 4:55 P.M., with the Director of Nursing (DON) and Corporate Compliance, the DON said NA's that were over the 120 days of hire should only pass ice, answer call lights, and perform hospitality aide duties. NA V and NA AA were still working to get practice. During an interview on 05/20/25, on 12:34 P.M., DON said when a NA was hired they were started in classes as soon as possible. There had been backlog when she started at the facility. The NA should be fully educated within 4 months. Until the NA was certified they were assigned with a second staff member. During an interview on 05/20/25, on 2:07 P.M., Administrator said NA's should be certified within four months of hire.

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination at all times when staff failed to air dry dishes, failed to ensure the ice machine had a proper air gap, and failed to keep kitchen surfaces clean and free of food debris. The facility census was 105. 1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed dishes were to be allowed to air dry. Observations on 05/12/25, at approximately 10:55 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Twenty-two plastic trays; -Sixty-one ceramic plates; -Seventy-two plastic bowls; -Ninety medium clear plastic cups. Observations on 05/13/25, at approximately 10:50 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Six clear bowls -Eleven small clear cups; -Fourteen juice cups -Twenty-one coffee cups; -Twenty-five plastic bowls. Observations on 05/15/25, at approximately 8:20 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Two metal steam table pans; -Eighteen clear cups; -Twenty-seven coffee cups; -Fifty-seven plastic bowls. During an interview on 05/15/25, at approximately 2:00 P.M., Dietary Aide (DA) BB said he/she did not know the dishes had to be fully dried prior to being stored away. During an interview on 05/15/25, at approximately 2:10 P.M., DA CC said he/she knew dishes cannot be put away while they are still wet or there could be bacteria growth During an interview on 05/15/25, at approximately 2:25 P.M., [NAME] DD said he/she did not realize that some dishes were being put away while still wet. During an interview on 05/16/25, at approximately 1:15 P.M., the Dietary Manager said the dishes have to be completely dried before they can be put away Bacteria can start growing in a very short amount of time. During an interview on 05/16/25, at approximately 1:35 P.M., the Regional Dietary Manager said he/she has let staff know dishes must be air dried when they are removed from the dishwasher. During an interview on 05/20/25, at approximately 1:45 P.M., the Facility Corporate Nurse said he/she would expect the dietary staff to know that dishes are being fully dried, prior to being stored away. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said he/she expected staff to put the dishes up after they have fully air dried. 2. Review of the facility policy titled Ice Chest and Ice Machines, dated 11/14/16 showed staff to install proper air gaps where the condensate lines meet the waste lines. Observation on 11/12/25, at approximately 11:30 A.M., of the ice machine showed the pipe coming out of the ice machine laying directly on the floor drain. There was no air gap between the pipe and floor drain. During an interview on 05/19/25, at approximately 2:55 P.M., the Maintenance Director said maintenance was responsible for making sure there was an air gap of at least two inches. During an interview on 05/20/25, at approximately 1:50 P.M., the Director of Nursing (DON) said there must be an air gap of 2 inches. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said he/she was not aware of the ice machine not having an air gap. He/she was unsure how much of an air gap was required. 3. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Carts for food delivery and utility are to be cleaned daily by wiping with a clean cloth soaked in sanitizing solution, after each meal; -Carts for food delivery and utility are to be cleaned weekly by emptying the cart, wash (giving attention to the tray slides), rinse, sanitize, and air dry; -Dish carts and dollies are to be cleaned weekly by removing dishes, clean the cart, rinse, sanitize and air dry; -The range and grill are to be cleaned daily and the cook on each shift is responsible for keeping the stove as clean as possible during the preparation of the meal. Take out burner grids and wash in the pot and pan sink, rinse, and sanitize. Brush the burners and check for clogs by lighting burners. Remove grease tray and trap door clean; -Can openers should be cleaned after each use. Remove from base, wash blade and other moving parts, rinse, sanitize, and air dry. Review of the facility cleaning schedule showed the daily cleaning checklist, weekly cleaning checklist, and monthly cleaning checklist were blank. Observation on 05/12/25, at approximately 10:55 A.M., of the kitchen showed the following: -The wall behind the steam table had grease and food splatter present. A metal shelf on the same wall had a film of grease covering the surface; -The plate warmer, next to the steam table, was had food crumbs present and a film of grease covering the surface; -The tea maker has a film of grease covering the surface; -The wall behind the counter and cabinets had a film of grease covering the surface; -The metal prep table bottom shelf was rusty and has a moldy like substance in the corners at the legs; -The metal rolling cart was covered in food splatters and crumbs; -The teeth on the can opener had a thick, greasy substance present; -The toaster oven was covered in a layer of food crumbs; -The seal-a-meal on the counter top was covered in grease and discolored; -The convection oven had a build-up of grime and had a film of grease covering the surface; -The muffin pans and cake forms, sitting on top of the convection oven, were covered in a grease film; -The range and hood pipes going into ceiling [NAME] a mixture of grease and lint present; -The front of stove and behind the knobs had a film of grease covering the surface. During an interview on 05/15/25, at approximately 2:00 P.M., DA BB said the following: -He/she had never been asked to clean the area where he/she was stationed; -He/she had thought about cleaning the wall, but did not want to mess with anything plugged into the wall and worried it could not get wet; -He/she has never seen a cleaning schedule posted. During an interview on 05/15/25, at approximately 2:10 P.M., DA CC said the following: -He/she had never seen a cleaning schedule; -He/she cleaned up in the area, where he/she was stationed; -He/she had not had the time to do extra cleaning. During an interview on 05/15/25, at approximately 2:25 P.M., [NAME] DD said the following: -There was a cleaning schedule up on the wall, at one time, but has not seen one in a long time; -He/she usually wiped down the prep tables and areas where he/she worked; -He/she will clean the steam table and change the well water. During an interview on 05/16/25, at approximately 1:20 P.M., the Dietary Manager said he/she had already started a new cleaning schedule and a check list that will be for each area. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said the following: -All surfaces are to be cleaned daily in areas where each staff is working, then specific areas, also weekly and monthly; -He/she expected the dietary staff to keep the kitchen clean.

Based on record review and interview, the facility failed to ensure the facility's quarterly Quality Assurance Performance Improvement (QAPI) Committee meetings occurred at least quarterly and included the required staff. The facility census was 105. Review of the facility policy entitled Quality Assurance/QAPI, dated 11/28/19, showed the following: -The program monitors data, analyzes and improves its performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost; -QAPI Committee will meet quarterly and the facility QAPI team will meet at a minimum monthly. Performance Improvement Project (PIP) committees will meet weekly and report to QAPI Committee concerns. At a minimum, one PIP will be charted per year; -Input is obtained from facility staff on a monthly basis through the QAPI committees. The committees are responsible for talking to their employees before reporting findings to QAPI. Residents/Families have input through resident/family council and satisfaction surveys; -The Administrator will be the Quality Management Coordinator and responsible for QAPI process; -Monthly committee membership is interdisciplinary with at lease two non licensed staff members and one resident council member. The QAPI Monthly Committee meets monthly and maintains minutes of all activity. 1. Review of facility's QAPI Committee documentation, dated 01/23/25, showed attendance by signature which included the Administrator, Medical Director, Housekeeping Supervisor, Activities Director, two MDS (Minimum Data Set - a federally mandated comprehensive assessment tool completed by facility staff) Coordinators, Social Service Director, and Regional Quality Assurance Nurse. (The meeting did not include a designated Director of Nursing (DON) and Infection Preventionist.) Review of facility's QAPI Committee documentation, dated 04/09/25, showed attendance by signature included the Administrator, DON, and the Medical Director. (The meeting did not include the two additional required members and the Infection Preventionist.) Review showed the facility did not provide any additional QAPI Committee documentaiton for the prior 12 months. During an interview on 05/19/25, at 4:19 P.M., the Administrator said he held a QAPI meeting shortly after starting in his position with the facility around 04/01/25. Only the three attendees were available at the time. Monthly attendance should include the Administrator, DON, ADON, Medical Director, all department heads, and the pharmacist when available. The Administrator was told the previous administrator had some QAPI notes, but he was only able to locate notes for one monthly meeting.

Based on observation, record review, and interview, the facility failed to provide a comfortable and homelike environment by failing to ensure the facility was in good repair, when staff failed to maintain a window screen for two residents (Resident #76 & #90), when staff failed to repair wall damage in one resident's (Resident #5) room, and when staff failed to maintain a clean shower on 200 hall. The facility census was 105. Review showed the facility did not provide a policy related to environment repairs. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed an admission date of 06/24/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/26/25, showed the resident had moderate cognitive impairment. Review of Resident #90's face sheet showed an admission date of 09/27/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. During observation and interview on 05/12/25, at 10:15 A.M., Resident #76 and Resident #90 said they were unable to open their room window as there was not a screen on the window. They would like to open window at times to get fresh air when it was nice weather outside, but since there was not a screen flying pests would get into the room. They had told maintenance staff about the screen and were told he/she did not know when it could be replaced. The window had no screen on the exterior of the window. During an interview on 05/19/25, at 3:29 P.M., Certified Nurse Aide (CNA) F said if there were any environment concerns in the building or a resident told him/her of a problem he/she would report to maintenance through the computer system, in person, or by leaving a note on the maintenance door. He/she was not aware of any windows that residents wanted to open without a screen. During an interview on 05/19/25, at 3:45 P.M., Certified Medication Tech (CMT) G said he/she would notify maintenance or administration staff if he/she was aware of any needed repairs in resident rooms or other areas of the facility. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said he/she would notify the maintenance department if he/she was aware of any damage to the building or needed repairs for resident rooms. He/she had not reported any needed repairs. During an interview on 05/19/25, at 4:10 P.M., the Maintenance Director said there were about 30 missing screens for the whole building. He/she was aware of the residents' room being without a screen. He/she said the previous maintenance supervisor had sent an email to corporate but there had not been a response. He/she had contacted the glass company and they do not work on screens. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said if there was any environment concerns, such as missing/damaged screens, staff should notify maintenance. During an interview on 05/20/25, at 12:34 P.M., with the Director of Nursing (DON) and Corporate Compliance, the DON said staff should notify maintenance through TELLS computer system or in person of any facility repairs or work to be done. The maintenance staff should then fix the problems. The maintenance staff checked the computer system multiple times per day for work orders placed. During an interview on 05/20/25, at 2:07 P.M., Administrator said staff should enter repair requests into the TELLS system. Any staff can log into the computer and enter the repair requests. Staff should notify maintenance of outside repairs including window screens. 2. Review of Resident #5's face sheet showed an admission date of 05/15/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Observation on 05/12/25, at 11:24 A.M., showed the resident was lying in his/her bed. At the head of his/her bed was a hole in the wall that appeared to be about 1 and half inches horizontally and about 2 inches vertically. During an interview on 05/19/25, at 2:25 P.M., Licensed Practical Nurse (LPN) D said anytime he/she finds holes in a resident's walls, he/she reports it to maintenance and environmental services director. He/she has not been notified of any concerns. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said if there was any environment concerns, such as holes in the wall, staff should notify maintenance. He/she was not aware of any environment concerns at the time. During an interview on 05/20/25, at approximately 12:44 P.M., the DON and Regional Quality Assurance Nurse, said staff should notify maintenance if there are holes in the walls. During an interview on 05/20/25, at 2:07 P.M., the Administrator said maintenance staff staff should enter repairs into the TELLS system. Any staff can log in and enter the needs. 3. Observation on 05/19/25, at 10:40 A.M., of the 200 hall shower room showed to the left of the shower room, where the shower chair was located, there is a part that protrudes from the wall about a foot over and was about 2 feet tall. In between the tiles and in the corner there was grayish colored grime. The floors around the walls, one to two feet out, had gray dirty substance. During an interview on 05/19/25, at 2:25 P.M., LPN D said housekeeping is responsible for cleaning the shower rooms and the aides should also be cleaning it after giving resident's showers. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said that the housekeeping staff clean shower rooms daily and nursing staff should be disinfecting between each resident. If an area was not coming clean or required deep cleaning the housekeeping staff took care of that. If the area would not come clean, was stained, or broken staff should notify the maintenance staff. During an interview on 05/20/25, at approximately 12:44 P.M., the DON and Regional Quality Assurance Nurse said staff were to notify housekeeping when showers need cleaning and anyone can notify maintenance. During an interview on 05/20/25, at 2:07 P.M., the Administrator said shower rooms should be maintained and cleaned every day and between every resident. If something cannot be cleaned, it should be replaced or gotten rid of. Housekeeping and maintenance staff were responsible.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #76, #92, #29, and #74) . The facility census was 105. Review of the facility's policy titled Hygiene and Grooming, from the Nursing Guidelines Manual, dated October 2010, showed the following information: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Services may be provided on a varying schedule when a physician's order or physician documentation of a medical contraindication exists or when the resident needs services more frequently; -Resident preferences for time of day, type of bath, and frequency of bath should be honored to the extent possible; -Family members or social service staff may be called upon to assist when the resident refuses appropriate hygiene or grooming measure by nursing staff; -Nail care is part of grooming. 1. Review of Resident #76's face sheet (brief information sheet about the resident) showed the following information: -admission date of 06/24/23; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness one side of the body) following cerebral infarction (stroke - a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side, chronic kidney disease (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) with heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and major depressive disorder. Review of the resident's care plan, last reviewed 02/14/25, showed the following: -Resident required assistance to complete daily activities safely; -Staff should assist resident with brushing teeth, assist with hair, and assist with shaving; -Staff should bathe per schedule, twice weekly per preference; -Staff should provide assistance to gather items for bathing and assist to bathing area as needed. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/26/25, showed the following: -Moderate cognitively impairment; -Required substantial to maximal assistance with tub or shower transfer and lower body dressing; -Required partial to moderate assistance with shower or bathing and upper body dressing. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed on 04/16/25, staff documented the resident received a shower. No other showers or baths were documented for the resident. Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/13/25, at 9:32 A.M., the resident said that his/her last shower was over one week ago. He/she received showers less than once per week and would prefer a shower every day but would at least like to have a shower twice per week. 2. Review of Resident #92's face sheet (brief information sheet about the resident) showed the following information: -admission date of 10/17/24; -Diagnoses included chronic ulcer (open sores that take a long time to heal, often due to underlying health conditions or injuries) of right heel and midfoot with necrosis of bone (condition where bone tissue dies due to a lack of blood supply), acute osteomyelitis (bone infection that typically develops quickly, often within a few weeks) right ankle and foot, and repeated falls. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance of staff for bathing; -Required supervision or touching assistance of staff to dress; -Required set up assistance of staff for personal hygiene. Review of the resident's care plan, last reviewed 05/13/25, showed the following: -Resident required assistance to complete daily activities of care safely; -Staff will assist with hair as needed; -Staff will assist with setting up supplies for brushing teeth; -Staff will bath per schedule; -Make bathing process pleasant by ensuring a non-hurried atmosphere; -Resident required two staff transfer with mechanical lift due to weight bearing restrictions with foot wound. Review of the resident's shower sheet schedule titled Shower/Bath List, dated April 2025 and May 2025, showed the following: -On 04/08/25, the resident received a shower; -On 04/17/25, the resident received a shower (nine days after the last documented shower); -On 05/06/25, the resident received a bed bath (19 days after the last documented shower; Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/13/25, at 10:06 A.M., the resident said that he/she received a shower about every two weeks, and he/she would prefer a shower at least twice per week. He/she felt dirty and worried about body odor when only showered twice per month. He/she was okay with a bed bath as well. 3. Review of Resident #29's face sheet showed the following information: -admission date of 08/22/18; -Diagnoses included borderline personality disorder (mental health condition making it difficult to manage emotions, control impulses and maintain stable relationships), anxiety disorder (feelings of worry, nervousness and uneasiness), chronic pain, and major depressive disorder (severe feelings of sadness). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required supervision with showers; -Independent with dressing and personal care. Review of the resident's care plan, reviewed 03/20/25, showed the following: -Resident had urinary incontinence; -Required occasional staff assistance with adult daily activities; -Staff will assist with bathing twice per week preference. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed the following: -Staff documented the resident received a shower on 04/03/25; -Staff documented the resident received a shower on 04/14/25 (11 days after the prior shower); -Staff documented the resident received a shower on 04/28/25 (14 days after the prior shower); -Staff documented the resident received a shower on 05/01/25; -Staff documented the resident received a shower on 05/07/25 (six days after the prior shower); -Staff documented the resident received a shower on 05/12/25. (Staff did not document any other showers for the resident.) Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During observations and interviews on 05/12/25, at 11:48 A.M. and 1:17 P.M., the resident was walking down the rehabilitation hall and said he/she hasn't had a shower in over a week and his/her hair was somewhat unkept. The resident said he/she received a shower on 05/07/25, and he/she was supposed to get two showers per week. He/she asks every other day for a shower and the staff say they don't have time. 4. Review of Resident #74's face sheet showed the following information: -admission date of 03/22/24; -Diagnoses included heart disease (condition that affects the blood vessels in the heart), spinal stenosis (pressure on the spinal cord and nerve roots), osteoarthritis (weakened bones), and pressure ulcer of the sacral (triangle shaped bone at base of spine) region. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance with showers; -Required partial to moderate assistance with personal hygiene and dressing. Review of the resident's care plan, last reviewed 03/03/25, showed the following: -Resident had urinary incontinence; -Resident required assistance to complete daily activities safely; -Staff should assist resident with oral care, hair care, and bathe per schedule. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed the following: -Staff documented the resident received a shower on 04/03/25, 04/09/25, and 04/14/25; -Staff did not document shower dates for the resident in May 2025. Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/12/25, at 3:56 P.M., the resident said he/she had not received a shower since 04/14/25. He/she felt dirty. He/she would be glad to have a bed bath. 5. During an interview on 05/15/25, at 1:58 P.M., Certified Nurse Aide (CNA) J said the facility had one shower aide and he/she was on light duty. They want the aides working the halls to do showers. Several residents complain about not getting showers regularly. During an interview on 05/15/25, at 2:15 PM., CNA N said the facility used to have four shower aides and now they have one. The shower aide tries to get as many showers done as possible and the other aides help. Some residents complain about not getting showers often enough. During an interview on 05/15/25, at 2:30 P.M., CNA K said they have two shower aides, the other one quit. They now want the floor aides to give residents showers and they do not have time. In the evenings he/she was responsible for an entire hall and that doesn't leave time to give showers. During an interview on 05/15/25, at 4:32 P.M. CNA L said the following: -He/she was the only shower aide, there used to be three; -If there were two shower aides that would probably be enough, as the floor aides try to help with showers; -He/she does the first four rooms of each hall on Monday and Thursday, the next four rooms on Tuesday and Friday and the remaining rooms on Wednesday and Saturday; -He/she tried to give each resident two showers per week. During an interview on 05/19/25, at 3:29 P.M., CNA F said residents should have a shower or bed bath two times per week. He/she was not sure who made the schedule. He/she would notify the shower aide if a resident requested a shower. During an interview on 05/19/25, at 12:43 P.M., Certified Medication Tech (CMT) H said they have one shower aide and there used to be three. The Director of Nursing (DON) wants the floor aides to do showers. The aides are trying to do this and are doing better on days, but the evening staff are not offering showers. The residents are supposed to be offered two showers per week and upon request. During an interview on 05/19/25, at 12:55 P.M., CMT I said floor aides were supposed to be doing showers. Everyone has complained of not getting showers at some point. During an interview on 05/19/25, at 3:45 P.M., CMT G said the shower aide had a schedule and residents were scheduled for two times per week. During an interview on 05/16/25, at 12:40 P.M., Licensed Practical Nurse (LPN) B said they have one aide doing showers. They recently changed things and the floor aides are helping with the showers. There have been a lot of residents complaining about not getting showers. The shower aide does as many as he/she can, but he/she is only one person and the aides help as much as possible. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said residents should receive showers per their scheduled days and per resident preference. During an interview on 05/20/25, at 12:34 P.M., with the DON and Corporate Compliance, the DON said there was a shower schedule that was on a rotation based on the resident room number. She said some residents preferred three showers per week. The residents were scheduled for twice per week unless they requested more and if time allowed. The residents should not have to wait 2 to 3 weeks for bed bath or showers. The aides should be documenting whether a resident was provided or refused a shower. The aide should tell the nurses if a resident refused and the nurses should be documenting that as well. During an interview on 05/20/25, at 2:07 P.M., the Administrator said residents should be offered and provided showers a minimum of twice per week. They can have more if preferred. Staff should be documenting in the electronic health record. Staff should be documenting if a resident refused and also talk to the nurse, so the nurse can see if they can get the resident to take the bath.

Based on record review and interview, the facility failed to ensure that staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer for six residents (Residents #41, #61, #78, #1, #306, and #25). The facility census was 105. Review of the facility's policy entitled Transfer, Discharge and Therapeutic Leaves (including Against Medical Advice (AMA)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -Transfer meant the moving of a resident from the facility to another legally responsible institutional setting. Discharge meant the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident; -According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident or other residents. Emergency transfer procedures should include the following obtain physicians' order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; contact an ambulance service and provider hospital for transportation and admission arrangements; complete and send with the resident a Transfer Form which documents current diagnosis, reasons for transfer, date, time, physician, current medications, treatments, functional status, any special care needs, and care plan goals; and a copy of any advance directive, Durable Power of Attorney, Do Not Resuscitate (DNR) or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident. -The original copies of the transfer form and advance directives accompany the resident. Copies are retained in the medical record; -Document information regarding the transfer in the medical record; -A copy of resident bed hold and admission policies/transfer to hospital notice should be provided upon transfer by assigned nurse to resident and/or representative of resident. 1. Review of Resident #41's face sheet (gives basic profile information at a glance) showed an admission date of 07/11/23. Review of the resident's nurse progress notes showed the following: -On 04/11/25, staff documented the resident had weeping skin, lungs sounded coarse, and was currently on an antibiotic for pneumonia. The resident's family member was present in the facility and agreed to have the resident sent to the emergency department. -On 04/17/25, staff documented the resident returned to the facility with diagnoses of pneumonia, altered mental status, and pericardial effusion (fluid buildup in the membrane surrounding the heart). Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 04/11/25. 2. Review of Resident #61's face sheet showed an admission date of 08/26/23. Review of the resident's nurses' progress notes showed the following: -On 02/25/25, staff documented the resident had flu-like symptoms, needed supplemental oxygen, and had a low blood pressure. Staff received orders for a urinalysis and intravenous (IV) fluids to be administered. Staff were unsuccessful with two attempts to start IV for fluid and two attempts to obtain specimen for urinalysis. Staff obtained new order to send resident to the hospital. Staff noted a Bed Hold Form sent with the resident and staff called spouse to inform; -On 03/08/25, staff documented the resident returned to the facility via ambulance. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/25/25. 3. Review of Resident #78's face sheet showed an admission date of 11/24/23. Review of the resident's nurses' progress notes showed the following: -On 02/06/25, staff documented the resident was sent out to the hospital related to low pulse and reduced level of consciousness. Resident returned to the facility after hospital visit. Resident was seen for confusion and hallucinations. The hospital completed labs, CT (computed tomography) scan, chest x-ray, and physical examination. Recommended follow-up with primary care physician with no order changes. Review of the resident's medical records showed staff not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/06/25. Review of the resident's nurses' progress notes showed the following: -On 02/07/25, staff documented the resident's oxygen saturation rate was very low and resident became erratic. Staff called 911 and resident was sent out to the hospital (two copies of the face sheet and CCD were went out with the resident); -On 02/08/25, staff documented resident returned to the facility and staff clarified orders with house physician. Review of the resident's medical records showed staff did not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/07/25. Review of the resident's nurses' progress notes showed the following: -On 03/19/25, staff documented the resident fell in his/her room with no injuries noted on assessment. Staff notified all parties; -On 03/20/25, staff documented the resident was found lying next to his/her bed and was lethargic with hematoma (swollen bruise) on right rib moving into chest. Resident on monitoring noted to have blood pressure decreasing. Staff sent resident to the hospital for evaluation and treatment. Staff notified physician via fax and resident's responsible party via phone; -On 03/27/25, staff documented the resident returned to the facility post pacemaker placement with vital signs within normal limits. Review of the resident's medical records showed staff did not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 03/20/25. 4. Review of Resident #1's face sheet showed an admission date of 11/26/24. Review of the resident's census information in the medical records showed the following: -On 01/14/25, resident discharged with return expected; -On 01/15/25, resident was returned and was re-admitted to the facility. Review of the resident's progress notes showed the following: -On 01/15/25, at 6:01 A.M., the resident was noted with abnormal lab results. Staff notified physician and gave an order to send resident to hospital for evaluation and treatment. The resident was sent at 10:00 P.M. on 01/14/25. Staff called family but unsuccessful in reaching them. Staff notified management; -On 01/15/25, at 5:38 P.M., the resident came back to facility via private vehicle from hospital at 4:45 P.M. Staff notified physician. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 01/14/25. 5. Review of Resident #306's face sheet showed an admission date of 07/29/24. Review of the resident's nurse progress notes showed the following: -On 04/28/25, at 10:20 P.M., the resident had an unwitnessed fall, resulting in a head wound with active bleeding and a hematoma formation at back of the head. Resident complaining of head, neck and upper back pain. Staff sent resident to the emergency room; -On 05/01/25, at 5:40 P.M., the resident returned with family from the hospital to the facility. Review of the resident's record showed staff did not have documentation indicating the family was notified in writing of the resident's transfer or bed hold. 6. Review of Resident #25's face sheet showed an admission date of 04/27/23. Review of the resident's nurse progress notes showed the following: -On 05/08/25, at 6:19 A.M., the resident complained of abdominal pain and cramping. The resident asked to be sent to the emergency room for evaluation and treatment. Resident picked up by ambulance at 9:00 P.M.; -On 05/11/25, at 11:11 A.M., resident returned from hospital at 11:00 A.M. Review of the resident's record showed staff did not have documentation indicating the family was notified in writing of the resident's transfer or bed hold. 7. During an interview on 05/15/25, at 3:50 P.M., the Director of Nursing (DON) said when a resident was sent out to the hospital, the nurse completes a Bed Hold Policy form. The resident signs the form if able, and a copy is mailed out to the responsible party by the business office. The nurse gives the resident and a family member a verbal explanation of the transfer, but the facility does not mail out a transfer letter. During an interview on 05/15/25, at 4:04 P.M., the Regional Nurse Consultant (RNC) showed the surveyors the Bed Hold Policy form and Transition of Care/Discharge Summary that are sent with the resident to the hospital. The RNC said a phone call is made to the resident's family notifying them of the need for the transfer. The RNC was not aware of the regulatory requirement to give the resident and/or responsible party a written transfer notice along with the Bed Hold Policy, which is mailed out by the business office. During an interview on 05/15/25 at 4:41 P.M., Licensed Practical Nurse (LPN) A said he/she sends a face sheet, orders, and code status with the ambulance when the resident is sent to the hospital. He/she doesn't give anything to the resident. He/she calls the representative, but doesn't mail anything to them. During an interview on 05/16/25, at 10:47 A.M., the RNC said the facility did not have evidence of written transfer letters or bed hold notices given pertaining to Residents #41, #61, #78, #1, #306, and #25. During an interview on 05/16/25, at 12:40 P.M., LPN B said they fill out a hospital transfer form along with the face sheet, order, and code status that's given to the paramedics for transfers. He/she does not give anything to the resident or mail it to the resident's representative. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said that nursing staff should document the appropriate information in the medical record any time a resident has been transferred to the hospital. The bed hold notice should be sent with the resident. He/she did not know of a letter that was to be sent to the family related to hospital transfer. During an interview on 05/19/25, at 3:10 P.M., LPN D said the nurse prints out the resident's face sheet, Continuity of Care Document (CCD), and hospital transfer form, sets up an observation event in EMR, attaches a copy of the most recent vital signs, and nurse notes. The nurse fills in the Bed Hold form and has the resident sign it, if able. The form is sent with them to hospital. They should keep a copy of the form for the chart. LPN D did not know if a copy of the form or any other transfer letter was mailed out or given to the responsible party. During an interview on 05/19/25, at 3:25 P.M., RN M said when sending a resident out to the hospital the nurse should print out an ambulance transfer form, the Bed Hold policy (have the resident sign if able), face sheet, physician order sheet, and CCD. Staff should place a copy of all information in the front of the hard chart and document the resident's condition and transfer information in nursing progress notes. During an interview on 05/20/25, at 12:34 P.M., the DON said she expected staff to document in progress notes when a resident was sent to hospital, and the staff should send a bed hold notice with the resident. The staff should fill in information as to where the resident was being transferred and the reason on the letter, along with the bed hold notice. The written transfer notice and bed hold form should be signed by the resident if they are able to sign; otherwise staff should document that on the copy sent with the resident and make a copy to put in the resident's chart. On the next business day the information should be sent to the responsible party. The DON was not aware of the required information to be included on the transfer letter. The charge nurse will be sending it out at time with resident and Social services will send the letter by mail the next business day to the responsible party. During an interview on 05/20/25, at 2:07 P.M., Administrator said staff should send a bed hold policy with residents that transfer to the hospital and notify the family.

Based on record review and interviews, the facility failed to ensure three residents (Residents #53, #92, and #25) and/or their representative were invited to participate in the resident's quarterly care plan meeting. The facility census was 105. Review of facility policy titled Person Centered Care Plans, dated August 2018, showed the following: -Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident; -The interdisciplinary plan of care committee may consist of nursing personnel having knowledge of the resident; Activities Director; Social Services Director; Dietary Manager/Registered Dietician or other members of Food & Nutrition Service; licensed therapists; attending physician; the resident; the resident family members and/or other representatives; -The Registered Nurse, or designee, should provide a list of the resident names, dates, and times for care plan meetings, two weeks in advance, to other team members. This list also includes information as to the type of care plan review for each resident: admission, quarterly, annual or significant change in status reviews; -The Social Service Director (SSD), or designee, should inform the resident and families of the scheduled meeting, by mailing Notice of Scheduled Plan of Care Conference to family members or legal representatives, as meeting notice. Family members and legal representatives should only be invited to attend, when permitted by the resident, or when the party is legally responsible for making health care decisions for the resident; -Family participation should be recorded in the medical record; -The resident participation should be recorded in the medical record; -When the family members or legal representatives are unable to attend the meeting, a review of the plan should be conducted by the care plan designee; -Contact with the family should be made by phone; -This communication should be recorded in the electronic medical record and entered as a telephone participant. The family member's comments may be documented on the Notice of Scheduled Plan of Care Conference. 1. Review of Resident #53's face sheet (a brief information sheet about the resident), showed an admission date of 05/11/21. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 04/07/25, showed the resident was cognitively intact. During an interview on 05/13/25, at 2:25 P.M., the resident said she asked for a care plan meeting with no response from staff. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed a quarterly care plan meeting held on 04/22/25. The resident and/or the resident's representative were not listed as attendees. 2. Review of Resident #92's face sheet showed an admission date of 10/17/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. During an interview on 05/13/25, at 10:15 A.M., the resident said he/she had not been asked to a care plan meeting, but would like to be included in that meeting. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed a quarterly care plan meeting held on 04/22/25. The resident and/or the resident's representative were not listed as attendees. showed the following: 3. Review of Resident #25's face sheet showed an admission date of 04/27/23. Review of the resident's discharge assessment MDS, dated [DATE], showed the resident had moderately impaired cognition. During an interview on 05/13/25, at 9:40 A.M., the resident said he/she had never attended a care plan meeting and didn't recall being invited to one. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed staff did not document when the last care plan meeting was held. 4. During an interview on 05/15/25, at 9:31 A.M., the MDS Coordinator said they hold care plan meeting quarterly or when there's a significant change. The resident, residents' family, or representative, and hospice are notified. The family receives a letter with the date and time and this is documented in the electronic record. The resident if verbally invited. All residents have quarterly care plan meetings. During interviews on 05/15/25, at 2:45 P.M., and on 05/16/25, at 11:00 A.M., the SSD said he/she mailed a care plan meeting invitation to the power of attorney, emergency contact family, and hospice. He/she mailed a letter to the family and he/she called hospice and verbally told the resident. The form is completed in the electronic record and he/she prints it off and mails it. He/she doesn't log anything or make any notes on the people he/she calls. Sometimes he/she forgets to mail out a invitation but he/she calls instead. He/she does not make a note in the resident's record when he/she called people to invite them to the care plan meeting. He/she did not make a note when he/she verbally invites the resident. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said care plan meetings are generally held by social services and the MDS Coordinator gives the social worker a calendar of upcoming MDS assessments to help keep coordinated. The residents were invited directly by the social worker. The social worker should be sure any mailed item was received by placing a phone call to ensure aware of the meeting. The social worker should make notes of invitations in the chart. During an interview on 05/20/25, at 2:07 P.M., the Administrator said care plan meetings should have the resident and/or any responsible party invited. Care plan meetings should be attended by MDS, nurses, Social Services, and therapy department. The family should be contacted by letter and phone call. Staff should call one week from meeting to confirm attendance.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene when staff did not perform or address toenail care for three residents (Residents #84, #10, and #64) of eight residents reviewed for nail care. The facility census was 105. Review of the facility's policy entitled Hygiene and Grooming, dated 10/01/10, showed the following: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Guidelines for provision of hygiene and grooming services include shower, tub or complete bed bath, as needed; -Family members or social service staff may be called upon to assist when the resident refused appropriate hygiene/grooming measures by nursing staff; -Nail care is a part of grooming. 1. Review of Resident #84's face sheet showed the following information: -readmission date of 05/02/24; -Diagnoses included hemiplegia (muscle weakness or paralysis) affecting right dominant side, traumatic brain injury, presence of feeding tube, cognitive communication deficit, restlessness and agitation, history of blood clots, anxiety disorder, and insomnia. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/03/25, showed the following information: -Severely impaired cognition; -Rejection of care behavior not exhibited; -Dependent on others for shower/bathing and personal hygiene. Review of the resident's care plan, last updated 05/01/25, showed the following: -Required assistance to complete daily activities of care safely; -Provide nail care as needed. During an interview on 05/14/25, at 12:10 P.M., the resident's family member said the resident's toenails were in bad condition, but they were better because the family member had been working on them. He/she said staff had not corrected the condition. Observation on 05/15/25, at 9:36 A.M., showed the resident rested in bed and his/her feet were exposed. The resident's toenails appeared discolored (yellow, brown), very thick, and long. Some nails were as long as one inch and curved under. During an interview on 05/15/25, at 2:10 P.M., the Social Services Director (SSD) said the podiatrist comes to the facility every six to eight weeks. The resident was not seen previously, but was on the list to be seen with the next visit During an observation and interview on 05/19/25, at 2:55 P.M., the resident's toenails on both feet appeared discolored (yellow, brown), very thick, and long. Several nails curved under. Certified Nursing Assistant (CNA) F said the resident needed nail care. The CNA said the aides can provide residents' nail care unless the resident is diabetic or the nails are too thick or long. If the aide cannot perform nail care, they should report the status and need to the nurse. The nurse will do the nail care or request the resident be added to the list to be seen by the podiatrist on the next visit date. CNA F said the resident kicks, so most aides will not attempt toenail care. The nurse usually does the care. During an interview on 05/19/25, at 3:10 P.M., Licensed Practical Nurse (LPN) D said the resident had just changed rooms, back onto LPN D's hall. The LPN said he/she put the resident on the podiatrist list for the next visit. LPN D said the podiatrist comes to the facility every six to eight weeks and was just at the facility within the last two weeks. 2. Review of Resident #10's face sheet a showed the following information: -admission date of 01/18/18; -Diagnoses included Alzheimer's disease (gradual loss of memory), muscle weakness, dementia with other behavioral disturbances (causes problems with thinking), chronic pain, and cognitive communication deficit (impairment in the ability to receive, send, process and comprehend information). Review of the resident's quarterly assessment MDS, dated [DATE], , showed the following information: -Severely impaired cognition; -Rejection of care behavior not exhibited; -Dependent on others for shower/bathing and personal hygiene. Review of the resident's care plan, last updated 04/09/25, showed the following: -Required assistance to complete daily activities of care safely; -Provide nail care as needed. Review of the resident's skin assessments, dated May 2025, showed LPN A completed a skin assessment for the resident on 05/13/25 with no concerns noted. Observation on 05/12/25, at 11:26 A.M., showed the resident lying in bed. Both feet were visible. On the right foot, the big toenail was grown to the right, about ¾ of an inch. All the other toenails had grown over the ends of the toes. On the left foot, the big toenail was grown to the left about ¾ of an inch. The rest of the toenails [NAME] grown over the ends of each toe. During an interview on 05/15/25, at 11:05 A.M., the SSD said the podiatrist comes to the facility every third month. The podiatrist was in the building in February and May. The residents are put on the list by the nurse or the aide telling the SSD they need to see the podiatrist. He/she thought the resident was not on the list as receiving services for February or May. During an interview on 05/15/25, at 12:40 P.M., LPN B said aides do not trim the resident's nails. The social worker sets up appointments with the podiatrist that comes to the facility. He/she isn't sure how often the podiatrist comes to the facility. The resident's toenails were pretty bad. They've done his/her fingernails. The resident will only let certain people cut his/her nails and it has to be someone the resident likes. The resident does refuse cares sometimes. When he/she sees that a resident's toenails need to be cut, or are in a condition like the resident's he/she puts a note into the computer. He/she doesn't remember if he/she has told anyone about the resident's toenails. During an interview on 05/15/25, at 1:58 P.M., CNA J said the aides trim the resident's toenails unless they're diabetic, in which case the nurses do them. He/she has seen the resident's toenails and thought the nurses knew about them being long. He/she had not told a nurse about the resident's toenails being long. The resident does refuse showers. The aides should be charting if the resident is refusing showers or refusing to have the toenails trimmed. During an interview on 05/15/25, at 2:30 P.M., CNA K said he/she does know the resident's toenails are long and thick. He/she has told the nurses about the resident's nails, and he/she doesn't know if anything has been done about it. During an interview on 05/15/25, at 4:32 P.M., CNA L said the he/she was the shower aide. He/she does skin assessments and trims the resident's toenails and fingernails. If the resident is diabetic, he/she lets the nurse know and they trim the resident's nails. He/she has offered the resident a shower and he/she refuses. When the residents refuse, he/she tells the nurse. He/she has not seen the resident's toenails. During an interview on 05/15/25, at 4:41 P.M., LPN A said the shower aide trims the resident's nails unless they're diabetic. The nurse's trims the resident's nails if they have diabetes. Some resident's see a podiatrist that comes to the facility if there toenails are yellow, thick or have other issues. He/she didn't know if the resident saw the podiatrist. He/she has not seen the resident's toenails nor has he/she trimmed the resident's toenails. During an interview on 05/19/25, at 12:55 P.M., Certified Medication Technician (CMT) G said anyone can trim the resident's toenails unless the resident is diabetic or has thick toenails. In those cases the nurse or podiatrist do them. He/she has seen the resident's toenails and they're not good. The Activity Director did try to trim the resident's toenails, but he/she isn't sure how that went. 3. Review of Resident #64's face sheet showed the following information: -admission date of 08/26/24; -Diagnoses included osteoarthritis (joint disease causing breakdown of cartilage), depression (feelings of sadness), and diabetes (body doesn't produce enough insulin). Review of the resident's care plan, updated 02/26/25, showed the resident required assistance with ADL functions due to related medical issues and staff provided nail care as needed. Review of the resident's quarterly assessment MDS, dated [DATE], showed the following information: -No cognitive impairment; -Rejection of care behavior not exhibited; -Partial to moderate assistance with showers. Observations and interviews on 05/14/25, at 8:47 A.M., and on 05/15/25, at 10:55 A.M., showed the resident said his/her toenails needed to be cut. The podiatrist was at the facility the other day and the SSD was supposed to put him/her on the list to see the podiatrist and he/she was not on the list. The staff does cut his/her toenails in the shower sometimes, but they haven't in a while. He/she has thick, yellow toenails and athlete's foot. Observation of the resident's toenails showed them to be at least ¼ inch over the skin. The left pinkie toenail was long and part of it had broken off. There was some redness on the big toe on the left foot. The resident said he/she was having pain. During an interview on 05/15/25, at 11:05 A.M., the SSD said the podiatrist comes to the facility every third month. The podiatrist was in the building in February and May. The residents are put on the list by the nurse or the aide telling the SSD they need to see the podiatrist. If the resident doesn't have medical issues, the aides can cut the toenails. He/she believed the resident told him/her to put the resident on the list after the podiatrist left in May. He/she provided the list and the resident was not on the list as having been seen. During an interview on 05/15/25, at 4:41 P.M., LPN A said the shower aide trims the resident's nails unless they're diabetic. The nurse's trims the resident's nails if they have diabetes. Some resident's see a podiatrist that comes to the facility if there toenails are yellow, thick or have other issues. He/she doesn't know if the resident has long toenails since the resident has not complained to him/her. During an interview on 05/15/25, at 4:32 P.M., CNA L said the he/she was the shower aide. He/she does skin assessments and trims the resident's toenails and fingernails. If the resident is diabetic, he/she lets the nurse know and they trim the resident's nails. The resident is independent, but he/she will trim the resident's nails tomorrow. During an interview on 05/16/25, at 11:30 A.M., the resident said he/she got a shower on 05/15/25 and they did not trim his/her toenails. 4. During an interview on 05/15/25, at 2:15 P.M., CNA N said the aide doing the resident's shower is responsible for trimming the residents' toenails. If the resident is diabetic, the nurse will trim the toenails. If the resident has thick, yellow toenails the nurse's will put them on the list to be seen by the podiatrist. During an interview on 05/19/25, at 12:41 P.M., Certified Medication Tech (CMT) H said any staff can trim the resident's toenails. If they're diabetic or thick and hard, the nurse or podiatrist would do it. If they need to see the podiatrist, the nurse's put the resident on the list. It's not appropriate for the toenails to grow over the skin or around the toes. During an interview on 05/19/25, at 2:35 P.M., LPN D said the podiatrist trims the thick toenails. The nurses trim the residents' toenails that have diabetes. The nurses put the resident on the list to see the podiatrist. Any staff can trim other residents' toenails. It would not be appropriate for the toenails to be grown over the resident's skin. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said the aides are responsible for doing toenail care for residents who are not diabetic. If the resident is diabetic, the wound care nurse or other floor nurse should do the nail care. The nurses can place the resident on the list for the podiatrist, who comes to the facility every six to eight weeks. A resident can be seen and billed every 60 days. During an interview on 05/20/25, at 2:07 P.M., the Administrator said the nursing staff was responsible for doing residents' nail care. If the staff were unable to do the toenail care, they should put the resident on the podiatrist' list for the next in-house visit.

Based on observation, interview, and record review, the facility failed to ensure an environment as free from possible accident hazards when staff failed to complete an assessment for, failed to monitor, and failed to care plan smokeless tobacco use for one resident (Resident #76). The facility census was 105. Review showed the facility did not provide a smokeless tobacco policy. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 07/01/19; -Diagnosis included hemiplegia (paralysis on one side of the body) and hemiparalysis (weakness on one side of the body) following cerebral infarction (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side, memory deficit following cerebral infarction, anxiety disorder, and nicotine dependence. Review of the resident's care plan, updated 03/26/25, showed the following: -Resident had stroke resulting in left sided weakness in March 2023; -Staff should review activity of daily living (ADL) functioning as needed; -Assist with mobility needs and ADL's; -Staff should observe for change in mental function, speech, or motor function as needed. (Staff did not care plan related to use of smokeless tobacco.) During interview and observation on 05/13/25, at 9:38 A.M., the resident was seated in a wheelchair in his/her room with bedside table containing two cans of chew (tobacco) and a foam cup with used tobacco chew present. The resident said he/she used chew daily in his/her room. During observation on 05/15/25, at 12:42 P.M., the resident was in his/her room with two cans of tobacco chew and foam cup on bedside table. During observation on 05/19/25, at 9:50 A.M., the resident was in his/her wheelchair with his/her eyes closed. Three cans of tobacco chew and a foam cup for used chew was on the bedside table. Review of the resident's medical record showed no tobacco assessment or monitoring to assure resident safety to use the smokeless tobacco. During an interview on 05/19/25, at 10:00 A.M., the Registered Nurse (RN) E said residents that smoke or chew tobacco should have a tobacco assessment completed by facility staff. Chewing tobacco could be a choking hazard and he/she was unsure of facility policy for use of chew. Tobacco use should be care planned for residents that smoke or chew tobacco. During an interview on 05/19/25, at 3:29 P.M., Certified Nurse Aide (CNA) F said that he/she checked with new residents and if a smoker he/she would pass that information on during shift report. He/she said that generally a resident that smokes will tell staff when it was time for smoke break. If a resident had tobacco chew they could go outside or stay in their room. He/she did not know if the nurses complete an assessment for smoking or tobacco chew. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said residents should have safe smoking assessments if they use any tobacco products. The facility did not have a smokeless tobacco policy. The resident should have tobacco use in their care plan. During an interview on 05/20/25, at 2:07 P.M., the Administrator said that residents should have tobacco use assessments and should be care planned for use of tobacco products.

Based on interview and record review, the facility failed to safely transfer one resident (Resident #211) when staff failed to use the appropriate amount of staff assistance and a gait belt (a safety device used to provide support when transferring a person from one position to another) when transferring the resident to the bathroom resulting in a fall and subsequent [MEDICAL CONDITION]; the facility also failed to safely reposition one resident (Resident #36) when staff did not ensure all equipment was removed from the bed reulting in a skin tear to the resident's foot, sf failed to document the new skin tear, contact the physician, receive new physician's orders [REDACTED]. The surveyors chose a sample of 22 residents in a facility with a census of 107. 1. Record review of the facility's policy titled Incidents and Accident, dated August 26, 2013 showed the following: -Purpose: The resident environment remains as free of accident hazards as is possible, however, when an accident occurs, prompt response and reporting occurs; -Handling Accident Occurrences should include: The resident should not be moved unnecessarily until the condition has been assessed, assess resident injury, pain, ROM, bruising, bleeding,lacerations, assess neurological signs as appropriate, notify physician and family and obtain medical care as needed, transfer to emergency room as needed; -Remember, fractures in the elderly, particularly the immobile or contracted elderly, cannot readily be detected visually. Frequently, the elderly do not experience pain or deformity immediately after a fracture. Record review of Resident #211's face sheet (a one-page summary of important information about a resident) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/17, showed: -Moderately impaired cognitive skills; -Required extensive assistance of two staff for bed mobility, transfers, toileting and bathing; -Only able to stabilize with staff assistance when moving on and off toilet and transferring from bed to chair or wheelchair; -Used a wheelchair for mobility. -One fall with no injury. Record review of the resident's care plan, last reviewed on 11/29/17, showed: -Behaviors with episodes of aggression towards staff when assisting resident with personal cares and ADL's; -Under the section addressing falls the staff documented the resident transferred independently; -Under the section addressing activities of daily living (ADLs) staff documented the resident required extensive assistance from one staff with transfers (the care plan did not address what type of assistance the resident required when walking or toileting); -The resident exhibited aggressive behaviors toward staff members when they assisted the resident with ADLs. Record review of the resident's monthly summary, dated 12/03/17, showed the resident required extensive assistance from two staff with transfer and ADL's. Record review of the resident's weekly Hospice assessment, dated 1/22/18, showed the following: -Alert to self; -High risk for falls; -Required total care for ADLs. Record review of the resident's nurses' notes, dated 1/29/18, showed a nurse documented the following: -At 6:05 A.M. (late entry for 4:00 A.M.) a certified nurse aide (CNA) was toileting the resident, when the resident started jerking his/her arms around and stumbled. The CNA said the resident was combative, hitting and kicking. The resident fell backwards onto the floor landing between the toilet and sink, hitting his/her head on the wall. The nurse assessed the resident and found no injuries or bruises except for a slight reddened area on his/her right lateral (side) back. The resident denied pain or discomfort. The resident was confused and combative towards staff. The nurse notified the resident's physician and responsible party. The resident refused vital sign checks. -At 8:23 A.M., the interim Director of Nursing (DON) reviewed the resident for behavior resulting in a fall this morning. The physician would review the resident's medications. Social services would visit with the resident to see if there were other interventions staff could try to assist in meeting the resident's needs. The care plan was reviewed and all interventions were appropriate at this time. -At 9:58 A.M., the resident had increased pain, projectile vomiting and a temperature of 99.1 degrees Fahrenheit (F). Staff notified the physician who instructed staff to send the resident to the hospital for evaluation. Staff left a message for the resident's responsible party. Staff sent the resident to the hospital. During an interview on 2/7/18 at 10:15 A.M., CNA CC said the following: -He/she worked on the 10:00 P.M. to 6:00 A.M. shift. During his/her shift, there is only one CNA in the SCU and the charge nurse is outside the SCU. -The resident was aggressive and combative with staff, at times, during cares and was confused most of the time. When the resident was combative, he/she required extensive assistance from one to two staff for transfers. At times, the resident could transfer independently from the bed to wheel chair and walked independently in his/her room; -The resident was a high risk for falls; -Staff could look on the computer to see what care a resident required; -On 1/29/18 at approximately 12:30 A.M., CNA CC noticed the resident was incontinent. He/she walked the resident to the bathroom, as they approached the toilet the resident became agitated. The CNA assisted the resident to sit on the toilet but the resident immediately stood up (after sitting down) causing the CNA to lose his/her balance. The CNA did not fall but as the CNA attempted to stabilize himself/herself, the resident began jerking his/her arms around. The resident lost his/her balance and fell on his/her back between the toilet and sink, hitting his/her head on the wall. The CNA left the resident to get the charge nurse who was in the facility outside the SCU. The charge nurse and CNA returned to the resident's bathroom and the resident was still lying on the floor. The charge nurse assessed the resident and completed some ROM on the resident before the CNA assisted the resident off the floor and onto the toilet. After the charge nurse assessed the resident's head, CNA CC walked the resident back to his/her bed. The resident continued to very combative; -The resident laid down and the CNA checked on him/her for the next couple of hours. CNA CC thought he/she checked the resident's vital signs one time after the fall; -At approximately 4:00 A.M., the CNA found the resident standing by his/her bed. The CNA convinced the resident to go back to bed and the resident fell asleep; -CNA CC did not use a gait belt or the assistance of another staff when walking the resident to the bathroom because he/she was very strong and usually could handle the resident without the assistance of another staff. The CNA said he/she usually used a gait belt when assisting residents with transfers. -If a resident required extensive assistance of two staff with ADLs, then two staff should always assist the resident. -If he/she had help and used a gait belt when assisting the resident to the bathroom, the resident probably would not have fallen and fractured his/her hip. Record review of the resident's care plan showed on 1/29/18 staff added interventions for social services to visit with the resident and for the physician to review the resident's medications. During an interview on 1/29/18 at 1:05 P.M., CNA P and CNA Q said the following: -Both CNAs said the resident had dementia, required extensive assistance of two staff for most ADLs and was combative during cares; -CNA P said the resident woke up moaning and had a temperature of 99.1 degrees F. When we started moving him/her, he/she exhibited signs and symptoms of pain. We got the resident a drink and tried to feed him/her but the resident vomited so we stopped and reported the concerns to Licensed Practical Nurse (LPN) BB. -CNA Q said the resident was sent to the hospital this morning after a fall last night. The resident hit his/her head on the sink, began running a temperature, showed signs of pain and was throwing up. During an interview on 1/29/18 at 3:00 P.M., Licensed Practical Nurse (LPN) R said the following: -The resident required extensive assistance of two staff with most ADLs; -The resident could be combative with cares; -The resident used a wheelchair for mobility; -The resident fell this morning. The resident hit his/her head when he/she fell , began projectile vomiting and was sent to the hospital for evaluation. Record review of the resident's hospital discharge summary dated 1/30/18, showed the following information; -admitted to the hospital after a fall at the nursing home; -X-ray showed right [MEDICAL CONDITION]; -Returned to the nursing home on 1/30/18. During an interview and observations from 1/29/18-2/2/18 showed the following; -On 1/31/18 at 12:45 P.M., the resident sat in his/her wheelchair in the Special Care Unit (SCU) dining room with a family member assisting him/her with lunch. The resident was confused and unable to communicate with the surveyor. The resident's family member said the resident just returned from the hospital after a fall at the facility; the resident sustained [REDACTED]. -The resident was not verbal with any other residents or staff during the survey observations; -The resident sat in his/her wheelchair in the common area in the SCU throughout the day, slept in his/her bed after breakfast meal and ate all meals in the dining room. -The resident required assistance of two staff and a gait belt for transfers. During an interview on 1/31/18 at 12:45 P.M., RN T said the following: -The resident required extensive assist/total care with all ADLs now and prior to the fall; -The resident sustained [REDACTED]. During an interview on 2/1/18 at 10:20 A.M., CNA X said the following: -The resident was confused, alert at times, very combative during cares and required extensive assistance of two staff for transfers and toileting: -He/she heard the resident fell on the overnight shift when there was only one staff member scheduled for the SCU. -He/she heard the resident was sent out to the hospital after complaining of pain after the fall where the resident hit his/her head. During an interview on 2/1/18 at 4:15 P.M., CNA U said the resident required extensive assistance of two staff for most ADLs. During an interview on 2/2/18 at 10:35 A.M., CNA Y and CNA Z said the following: -The resident required extensive assistance of two staff for most ADLs including transfers, toileting and bathing. The resident could become very combative; -Both CNAs said they would never attempt to transfer, toilet or shower/bath the resident without two staff and the use of a gait belt. -The resident was not alert or oriented and very confused. During an interview on 2/2/18 at 10:55 A.M., CNA AA said the following: -The resident required extensive assistance from two staff with all transfers and toileting; -The resident was very confused and could become very combative during cares. -He/she heard from other staff the resident fell on the overnight shift when there was only one staff on each hall. During an interview on 2/6/18 at 4:45 P.M., the DON said the following: -After a resident falls, staff should report to the charge nurse and the charge nurse should complete a head to toe assessment including range of motion (ROM) of the resident's hip. -Staff should talk to the resident if the resident is able to communicate; -Staff should check the resident's vital signs and assess for signs and symptoms of pain; -Staff should not move the resident until the nurse asseses him/her to ensure it is safe for the resident to be moved or assisted off the floor; -The staff should use the appropriate number of staff to assist the resident and a gait belt should be used at all times to ensure safety; -Staff should never grab a resident under their arms when assisting a resident up from bed, wheelchair or up off the floor. During an interview on on 2/7/18 at 1:05 P.M., LPN BB said the following: -The resident required extensive assistance from two staff with all ADLs due to his/her combativeness; -Any resident who required extensive assist of two staff should always have two staff and a gait belt assisting him/her; -Staff should not have walked the resident to the bathroom without the required assistance of two staff and the use of a gait belt; -After a resident falls and hits his/her head, the nurse should perform a head to toe assessment including ROM and assessing for pain. The resident could not verbalize if he/she was in pain, but moaning, groaning, irritability and combativeness are signs and symptoms a resident may be in pain. -When the resident showed signs of pain and projectile vomited, staff suspected the resident may have a concussion. The nurse notified the physician and staff transferred the resident to the hospital for evaluation. During an interview on 2/13/18 at 3:25 P.M., the resident's physician said the following: -The resident has advanced dementia and was not steady on his/her feet; -There should be two staff assisting a resident who requires extensive assist of two staff for transfers and toileting; -When assisting a resident to the bathroom or off the floor after fall, staff should always use a gait belt for safety; -If a resident has a fall the staff should follow protocol and assess the resident for injury, range of motion, any skin tears, bruising, deformity, dislocated or broken bones; -The staff should assess for any pain and if it is a resident who may not be able to verbalize then signs and symptoms should be monitored closely; -The physician thought he was notified when the resident began the projectile vomiting. He sent the resident to the hospital for evaluation. 2. Record review of Resident #36's face sheet (admission data) showed the facility readmitted the resident to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. Record review of the Significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/02/18, showed the following information: -Unable to assess cognition; -Extensive assistance required by staff for bed mobility, transfers, dressing and toilet use. An observation on 1/30/18, at 9:20 A.M., showed the wound nurse and Registered Nurse (RN) M provided wound care to the resident's multiple wounds using profession standards and procedures. After all wounds were treated, both nurses positioned the resident from side to side to change soiled linen and reposition him/her in bed. The resident's urinary catheter drainage bag and tubing was positioned at the foot of the resident's bed. During repositioning, the resident's foot pushed up against the foot board lodging the catheter tubing and drainage bag between the resident's foot and foot board. The wound nurse pulled on the catheter drainage bag and tubing causing a skin tear to the bottom of the resident's right foot, that measured approximately two inches in length. During an interview on 02/02/18, at 9:45 A.M., the wound nurse said after staff identify a new skin tear the nurse would cleanse the skin tear with wound cleanser apply triple antibiotic ointment, cover with [MEDICATION NAME] (non-adherant dressing) every day or as needed until healed. Staff would complete an incident report, notify the physician and family, and document it in the nurses' notes. Staff places the new order on the physician's orders [REDACTED]. The wound nurse said she failed to follow procedures after completing the wound care causing the skin tear. During an interview on 02/02/18, at approximately 10:00 A.M., the DON said when staff discovered a new skin tear staff needed to tell the charge nurse. The charge nurse needed to assess the area, notify the physician, family, document in nurses' notes and document the new order in the resident's medical records. During an interview on 02/07/18, at approximately 1:25 P.M., RN M said they should have pulled the resident up in bed either before or after completing his/her wound treatment.

Based on observation, interview, and record review, the facility failed to provide accurate and timely assessment, treatment, intervention, and notification of physician, for one resident (Resident #1) with three unstageable pressure ulcers showing signs and symptoms of infection. This deficient practice resulted in the delay of appropriate treatment and contributed to the need for subsequent hospitalization of Resident #1. The facility failed to provide appropriate pressure ulcer precautions/pressure relief interventions for three residents with pressure ulcers (Resident #2, #3, and #4) out of seven sampled residents with facility identified pressure ulcers. The facility failed to timely identify, assess, and obtain treatment orders for three additional residents with pressure ulcers (Resident #5, #6 and #9) not initially identified by the facility. The facility census was 97. Pressure ulcer staging according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines Number 15 showed: -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is non-blanchable); -Stage II pressure ulcer (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -Stage III pressure ulcer (full thickness skin loss involving damage or death of subcutaneous (layer of skin under the top layer of skin that usually contains fatty tissue) tissue that may extend down to but not including the bone); -Stage IV pressure ulcer (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures). -Suspected Deep Tissue Injury (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). Record review of the facility's pressure ulcer policy, dated 10/1/10, showed the following information: -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; physician's orders [REDACTED]. -The physician should be encouraged to document the [DIAGNOSES REDACTED]. -Pressure ulcers will be assessed at least weekly by a trained registered nurse (RN) as part of the interdisciplinary team review; -Bed or chair bound individuals or those whose ability to reposition is impaired should be considered at risk for pressure ulcers; -Identification of additional risk factors (immobility, moisture/incontinence, and nutritional deficit) should be undertaken to direct specific preventive treatment regimes; For bed bound individuals: -Reposition at least every two hours; -Use pillows or foam wedges to keep bony prominences from direct contact; -Use devices that totally relieve pressure on the heels, heels may be floated; -Elevate the head of the bed as little and for as short a time as possible; -Use lifting devices to move rather than drag individuals during transfers and position changes; -Place at risk individuals on a pressure-reducing mattress; -Skin injury due to friction and sheer forces should be minimized through proper positioning, transferring, and turning techniques; -Consider pressure relieving mattress based on individual evaluation; For chair-bound individuals: -Reposition at least every hour; -Have patient shift weight every 15 minutes is able; -Use pressure-reducing devices for seating surfaces; -Consider pressure relieving cushion based on individual evaluation; Moisture/Incontinence: -Clean skin at time of soiling and routine intervals; -Minimize skin exposure to moisture, evaluate and treat urinary incontinence. When moisture cannot be controlled, use underpads or briefs that are absorbent and present a quick-drying surface to the skin; -Dry skin should be treated with moisturizer; Therapy: -Rehabilitation efforts should be instituted if consistent with overall goals of therapy. 1. Review of Resident #1's face sheet admission information showed the following information: -Re-admitted on [DATE]. Review of the resident's current care plan dated 3/14/17, showed the resident had a potential for skin breakdown related to limited mobility and listed the following interventions: -Follow physician orders; -Monitor nutritional intake; -Inspect skin for changes daily; -Utilize pressure-reducing mattress; -Skin audit per schedule and as needed; -Utilize pressure reducing cushion while up in wheelchair; -Provide incontinent care after each episode. Review of the resident's risk review for pressure ulcers, dated 5/17/17, showed the following: -Resident is at risk of developing pressure ulcers. Review of the resident's departmental notes, dated 5/18/17, showed the director of nursing (DON) documented the following: -Resident readmitted to the facility with an unstageable pressure ulcer, due to suspected deep tissue injury (SDTI) to his/her right heel, area maroon/purple in color to edges; -Right heel appeared to have blistered at one point, but no blister remains; -New treatment orders to resident's right heel pressure ulcer for [MEDICATION NAME] (a protective barrier wipe) and a foam dressing, change every three days and as needed; -The physician and resident's responsible party notified of wound and treatment; -Additionally, the resident's left heel has a reddened area, which is slow to blanche (whitish appearance of skin when pressure is applied), but does blanche, prevention orders in place; -No signs/symptoms of infection noted; -Resident stated the area was tender when touched. Review of the resident's wound assessment report, dated 5/18/17, showed the following: -Unstageable pressure ulcer to resident's right heel, SDTI, identified on 5/17/17, measured 2.1 centimeters (cm) by 2.9 cm, with no depth. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/17, showed the following information: -[DIAGNOSES REDACTED]. -Moderate cognitive impairment; -Resident did not reject care; -Extensive assistance of two or more staff with bed mobility, transfers, and toileting; -Frequently incontinent of bladder and bowel; -Used walker and wheelchair for mobility; -No functional limitation in range of motion; -One unstageable pressure ulcer, suspected deep tissue injury (SDTI), present on admission; -Pressure reducing devices for bed and chair; -Turning and repositioning program; -Nutrition or hydration intervention to manage skin problems; -Pressure ulcer care; -Applications of ointments or medications other than to feet. Review of the resident's departmental notes showed the following: -On 5/24/17 at 1:50 P.M., the DON documented the resident continues to have a SDTI to his/her right heel, area is smaller. Area appears to have blistered at one point, but no blister remains. New treatment orders for [MEDICATION NAME] and foam dressing change every three days and as needed. The physician and resident's responsible party notified of wound and treatment; -On 5/24/17 at 3:21 P.M., the assistant director of nursing (ADON) documented the resident had a noted weight loss this past week and a poor appetite. The resident has an unstageable wound, adding Pro-stat (a nutritional protein supplement), physician notified. Review of the resident's wound assessment report, dated 5/24/17, showed the following: -Unstageable pressure ulcer to right heel, SDTI, measured 2.0 cm by 2.7 cm, no depth, and wound status improved; Review of the resident's wound assessment report, dated 5/31/17, showed the following: -Unstageable pressure ulcer to right heel, SDTI, measured 2.0 cm by 2.4 cm, no depth, and wound status improved; Review of the resident's departmental notes showed staff documented the following: -On 6/02/17 at 9:34 A.M., the resident has a stage II pressure ulcer to his/her left buttock, started a treatment to the area. The resident's right heel now has a large blister, staff to apply [MEDICATION NAME] and [MEDICATION NAME] (a brand name) foam daily. -On 6/07/17 at 12:46 P.M., the resident's right heel now had a large blister; daily treatment order changed to clean with wound cleanser, apply [MEDICATION NAME], wrap with [MEDICATION NAME] foam, cover with ABD pad and wrap with Kerlix. Left heel treatment discontinue [MEDICATION NAME] foam and use [MEDICATION NAME] daily. Stage II to left and right buttock apply [MEDICATION NAME] dressing cover with [MEDICATION NAME], and sacral [MEDICATION NAME] for additional protection. -On 6/07/17 at 4:26 P.M., the resident's left heel blister measured 3.0 cm by 4.0 cm. -On 6/15/17 at 2:26 P.M., the resident continued to have an unstageable pressure ulcer due to SDTI to his/her right heel. The area is deep maroon purple in color to edges. Appears to have blistered at one point, but no blister remains. Treatment remains the same at this time. Will continue to monitor. Review of the resident's wound assessment report, dated 6/19/17, showed the following: -Unstageable pressure ulcer (SDTI) to the resident's right heel, measured 4.0 cm by 2.30 cm, no depth, status unchanged. -Facility staff did not document a measurement for the resident's right heel pressure ulcer for 19 days from 5/31/17 until 6/19/17. Review of the wound assessment reports, dated 5/31/17 and 6/19/17, showed the ulcer increased in length from 2 cm to 4 cm. Staff did not document notification of the physician or attempt to obtain a different treatment order. Review of the resident's departmental notes showed staff documented the following: -On 6/23/17 at 4:00 P.M., the wound nurse documented the resident continues to have an unstageable pressure ulcer due to a SDTI to his/her right heel. The area is deep maroon color to edges. Appears to have blistered at one point, but no blister remains. Wound appears smaller this week treatment remains the same at this time. Will continue to monitor. Stage II pressure ulcer to left buttock remains the same in size this week. 100% granulation tissue present. Periwound noted to have redness due to moisture. No complaint of pain with assessment and or treatment. Review of the resident's wound assessment report, dated 6/27/17, showed the following: -Right heel pressure ulcer is now a stage II, measured 2.40 cm by 1.70 cm, no depth, 100% granulation tissue to wound bed, no drainage, no infection, status improved. Review of the resident's departmental notes showed the following: -On 6/29/17 at 2:54 P.M., the wound nurse documented the resident's SDTI opened and presented as a stage II pressure ulcer to the right heel. The nurse did not document measurements of the wounds. Appeared to have blistered at one point, but no blister remained. The wound appeared smaller in size this week. Treatment remained the same at this time. Wound to left buttock was closed at this time with prevention orders for [MEDICATION NAME] in place. Will continue to monitor. -On 7/06/17 at 7:53 A.M., the wound nurse documented the resident's SDTI opened and presenting as a stage II to the right heel. The nurse did not document measurements of the wounds. Wound appears larger in length and smaller in width this week. No drainage noted. No foul odor noted. Treatment changed to [MEDICATION NAME] (a wound ointment) to the wound, cover with ABD (a sterile absorbent dressing) pad and wrap with Kerlix (a gauze rolled bandage) daily. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor. Review of the resident's wound assessment report, dated 7/6/17, showed the following: -Stage II pressure ulcer to the resident's right heel, measured 3.0 cm by 1.30 cm, no depth, 100% granulation tissue to wound bed, no drainage, no infection, status improved. Review of the resident's physician order [REDACTED]. -Order start date 7/06/17, Cleanse right heel stage II pressure ulcer with wound cleanser, apply [MEDICATION NAME] daily, cover with ABD pad and wrap with Kerlix (discontinued 8/01/17). Review of the resident's departmental notes showed the following: -On 7/12/17 at 1:50 P.M., the wound nurse documented, the resident's right heel pressure ulcer was now unstageable, due to 100% slough present to wound bed. The nurse did not document measurements of the wounds. The wound appears larger this week. No drainage noted. No foul odor noted. Treatment remains [MEDICATION NAME] to wound bed, cover with ABD pad and wrap with Kerlix daily. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor. Review of the resident's wound assessment report, dated 7/12/17, showed the following: -Right heel unstageable pressure ulcer, due to slough and eschar, measured 3.0 cm by 2.0 cm, no depth, 100% slough to wound bed, wound status deteriorated; -Facility staff did not document notification of the resident's physician of the deterioration of the resident's pressure ulcer from a stage II pressure ulcer with 100% granulation tissue in the wound bed to an unstageable pressure ulcer with 100% slough to the wound bed. Review of the resident's departmental notes showed staff documented the following: -On 7/15/17 at 4:38 P.M., the resident had a soft boot in place to his/her right lower extremity; -This is the first time staff documented the resident had a pressure relieving boot to his/her right foot since his/her admission on 5/17/17. Review of the resident's wound assessment report, dated 7/19/17, showed the following: -Right heel unstageable pressure ulcer, due to slough and eschar, measured 2.8 cm by 1.6 cm, no depth, 100% eschar to wound bed, no drainage, no infection, wound status improved; -Facility staff did not notify the physician of the change in the appearance of the resident's right heel pressure ulcer from 100% slough on the previous assessment to 100% eschar. Review of the resident's departmental notes showed staff documented the following: -On 7/20/17 at 2:42 P.M., an unstageable pressure ulcer to the resident's right heel with 100 % slough to the wound bed. The wound appears smaller in size this week. The nurse did not document measurements of the wounds. No drainage noted. No foul odor noted. Treatment remains [MEDICATION NAME] to wound bed, cover with ABD pad and wrap with Kerlix daily. No complaints of pain/discomfort noted upon assessment or treatment. Will continue to monitor. -On 7/23/17 at 4:04 A.M., the resident's pressure ulcers to his/her left/right buttock and right heel, treated by wound care nurse. -On 7/26/17 at 3:30 P.M., an unstageable pressure ulcer to the resident's right heel with 100 % eschar to wound bed, and discoloration noted to lateral side of wound. The wound is larger this week. The nurse did not document measurements of the wounds. no drainage noted, no foul odor. Treatment changed to Santyl (an enzymatic [MEDICATION NAME] ointment, used to breakdown dead tissue), cover with ABD pad and wrap with Kerlix daily. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor. Review of the wound assessment report, dated 7/26/17, showed the following: -Right heel unstageable pressure ulcer, due to slough and eschar, measured 3.30 cm by 2 cm, no depth, 100% eschar to wound bed, wound status deteriorated; Review of the resident's physician order [REDACTED]. -Order start date 8/01/17, Cleanse right heel stage II pressure ulcer with wound cleanser, apply Santyl daily, cover with ABD pad and wrap with Kerlix (discontinued 9/15/17). -The wound nurse documented he/she obtained the resident's new treatment order on 7/26/17, but this order did not appear on the physician order [REDACTED]. Resulting in a 5 day delay in the resident starting a new treatment to his/her deteriorating right heel pressure ulcer. Review of the resident's departmental notes showed staff documented the following: -On 8/02/17 at 5:26 P.M., the resident had an unstageable wound to the right heel, 100% eschar to the wound bed with discoloration noted to the lateral side of the wound. The wound is larger in size this week. The nurse did not document measurements of the wounds. No drainage or foul odor present. Treatment Santyl, cover with ABD pad and wrap with Kerlix daily. No complaint of pain or discomfort noted upon assessment or treatment, will continue to monitor. Review of the resident's wound assessment report, dated 8/2/17, showed the following: -Right heel unstageable pressure ulcer, due to slough and eschar, measured 7.0 cm by 4.0 cm, no depth, 100% eschar to wound bed, no drainage, no infection, wound status deteriorated; -Facility staff did not document notification of physician or a change in treatment/intervention when the resident's pressure ulcer doubled in size from the last assessment on 7/26/17. Review of the resident's departmental notes showed staff documented the following: -On 8/08/17 at 2:57 P.M., the resident continued to have an unstageable pressure ulcer to the right heel. The wound bed contained 75% eschar and 25 % granulation tissue present to wound bed with discoloration noted to the lateral side of the wound. Wound is smaller in size this week. No drainage or foul odor noted. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor. Review of the wound assessment report, dated 8/8/17, showed the following: Right heel unstageable pressure ulcer, due to slough and eschar, measured 5.50 cm by 4.00 cm, no depth, 75% eschar and 25% granulation tissue wound bed, no drainage, no infection, wound status improved; Review of the resident's physician progress notes [REDACTED]. -Skin, no rashes or skin breakdown, no ulcers. Review of the resident's care plan dated 8/10/17, for stage II wound to right heel showed the following intervention: -Perform wound care as ordered. Review of the resident's departmental notes showed the following: -On 8/14/17 at 2:36 P.M., the wound nurse documented the resident refused the treatment to his/her right heel, made several attempts to change the dressing and the resident said, No. The wound nurse notified the resident's charge nurse, who stated he/she would try the treatment again later. No further attempts documented. Review of the resident's wound assessment report, dated 8/16/17, showed the following: -Right heel unstageable pressure ulcer, due to slough and eschar, measured 6.0 cm by 4.1 cm, no depth, 75% eschar and 25% granulation tissue wound bed, no drainage, no infection, wound status deteriorated; Review of the resident's significant change minimum data set (MDS), dated [DATE], showed the following information: -[DIAGNOSES REDACTED]. -Unable to complete brief interview for mental status; -Resident did not reject care; -Extensive assistance of two or more staff with bed mobility, transfers, and toileting; -Frequently incontinent of bladder and bowel; -Functional limitation in range of motion of one lower extremity; -Used wheelchair for mobility; -One unstageable pressure ulcer, with eschar present, currently measures 6.0 cm by 4.10 cm, no depth; -Pressure reducing devices for bed and chair; -Nutrition or hydration intervention to manage skin problems; -Pressure ulcer care; -Application of ointments or medications other than to feet; - Turning and repositioning program not listed. Review of the resident's departmental notes, dated 8/17/17 at 12:44 P.M., showed the wound nurse documented the following: -Unstageable pressure ulcer to the resident's right heel with 75% eschar and 25% granulation tissue present to wound bed, and discoloration noted to lateral side of wound. The nurse did not document measurements of the wounds. Moon boot in place to right lower extremity. No drainage or foul odor present. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor. Review of the resident's departmental notes, dated 8/23/17 at 1:35 P.M., showed the wound nurse documented the following: -Unstageable wound to the right heel 75% eschar and 25% granulation tissue present to the wound bed with discoloration to lateral side of wound. The wound is larger in size this week. The nurse did not document measurements of the wounds. Moon boot in place to right lower extremities. No drainage or foul odor noted. No complaints of pain upon assessment or treatment. Will continue to monitor; -New Stage II pressure ulcer to the top of his/her right foot. Periwound discolored wound edges well defined. No drainage noted. Order in place for [MEDICATION NAME] daily. Will continue to monitor. Review of the wound assessment report, dated 8/23/17, showed: -Right heel pressure ulcer, unstageable due to slough/eschar, measured 5.6 cm by 4.0 cm, no depth, with 75% eschar and 25% granulation tissue to the wound bed, no drainage, no infection, wound status improved; -A new stage II pressure ulcer to right top of foot, measured 1.3 cm by 1.0 cm, no depth, with 100% granulation tissue, no drainage, no infection, physician and responsibility party notified. Review of the resident's physician order [REDACTED]. -Order start date 8/25/17, Cleanse top of right foot stage II pressure ulcer with wound cleanser, apply [MEDICATION NAME], cover with [MEDICATION NAME] plus pad, change every day and as needed (discontinued 8/31/17). -Facility staff documented in the departmental notes on 8/23/17 an order in place for [MEDICATION NAME] to the new pressure ulcer on top of the resident's right foot, but the order did not appear on the physician's orders [REDACTED]. Review of the resident's departmental notes, dated 8/31/17 at 9:00 A.M., showed the wound nurse documented the following: -Unstageable wound to the right heel. 75% eschar and 25% granulation tissue present to the wound bed with discoloration noted to the lateral side of the wound. Wound is smaller this week. Moon boot in place to the right lower extremity. No drainage or foul odor present. No complaint pain or discomfort noted upon assessment or treatment. Will continue to monitor; -Stage II pressure ulcer to the top of his/her right foot is now healed. Prevention in place for foam and wrap with Kerlix daily. Will continue to monitor. Review of the resident's wound assessment report, dated 8/31/17, showed: -Right heel pressure ulcer, unstageable due to slough/eschar, measured 5.30 cm by 3.80 cm, no depth, 75% eschar and 25% granulation tissue to the wound bed, no drainage, no infection, wound status improved. Review of the resident's physician order [REDACTED]. -Order start date 8/31/17, Prevention site top of right foot apply 2 by 2 foam, cover with ABD pad, and wrap with Kerlix change daily (discontinued 9/15/17). Review of the physician's progress notes for Resident #1, dated 9/5/17, showed the physician documented the resident had no rashes, skin breakdown or ulcers. Review of the resident's wound assessment report, dated 9/5/17, showed the following: -Right heel pressure ulcer, unstageable due to slough/eschar, measured 5.4 cm by 4.0 cm, no depth, 75% eschar and 25% granulation tissue to the wound bed, no drainage, no infection, wound status deteriorated; -Unstageable pressure ulcer to right top of foot, measured 2.5 cm by 2.2 cm, no depth, unstageable due to slough and eschar, 100% slough to wound bed, no infection, wound status deteriorated; -New pressure ulcer to the lateral side of the resident's right foot, unstageable due to slough/eschar, 1.50 cm by 1 cm, no depth, no drainage, no infection, physician and responsible party notified. -Facility staff did not ask the physician for a change in treatment to the resident's right top of foot pressure ulcer, instead staff continued a preventative 2 by 2 foam, ABD, and Kerlix treatment until 9/15/17, 15 days after the return of this unstageable pressure ulcer; -Facility staff did not obtain a treatment order for a newly developed unstageable pressure ulcer to the lateral side of the resident's right foot until 9/15/17, resulting in a 10 day delay in treatment. Review of the facility's Qliq communications (texts sent between the facility staff and the resident's physician) for Resident #1, dated 9/08/17 at 10:18 A.M., showed the wound nurse sent the following communication to the resident's physician: -The resident has three unstageable pressure ulcers to his/her right foot; -Right heel pressure ulcer with eschar present to the wound bed; -Right top of foot pressure ulcer with slough present to the wound bed; -Right foot, lateral side pressure ulcer with eschar present to the wound bed; -There is a foul odor present; - The pressure ulcers are causing the resident a great deal of pain; -The resident currently has a moon boot in place to help relieve pressure, but the resident is non-complaint with keeping it on at times, as well as, with floating his/her heel for pressure relief; -The wound nurse asked the resident's physician if he would like the resident to go to the wound clinic for suggestion of treatment and/or debridement of wound. Review of the facility's Qliq communication for Resident #1, dated 9/08/17 at 10:18 A.M., showed the resident's physician sent the following response to the wound nurse: -Let's refer to the wound clinic. Sound like it'll need debridement. -The facility was unable to provide any documentation to show the facility communicated with the resident's physician about the resident's pressure ulcers after 9/08/17. Review of the resident's physician order [REDACTED]. Review of the resident's departmental notes, dated 9/14/17 at 9:29 A.M., showed the wound nurse documented the following: -Unstageable pressure ulcer to the right heel. 75% eschar and 25% granulation tissue present to the wound bed with discoloration to the lateral side of the wound. The wound is smaller in size. The nurse did not document measurements of the wounds. Moon boot in place to right lower extremity. No drainage or foul odor noted. No complaints of pain or discomfort noted upon assessment or treatment. Will continue to monitor; -Unstageable wound to the top of the resident's right foot reopened with 100% eschar noted. Redness to periwound. Scant amount of drainage noted with a foul odor present. -Unstageable wound to the resident's right lateral foot with 100% eschar present to the wound bed. Periwound free of redness. Small amount of drainage noted. Foul odor present; -The physician notified of the condition of the wounds and resident noncompliance at times, with preventative measures, such as leaving the pressure-relieving boot on and refusing to float heels off bed; -Order received to send the resident to the wound clinic for debridement. Social services notified; -Will continue to monitor. Review of departmental notes showed on 9/14/17 at 1:41 P.M., social services documented the resident had an appointment scheduled with the wound clinic on 9/21/17. Review of the resident's wound assessment report, dated 9/14/17, showed: -Right heel pressure ulcer, unstageable due to slough/eschar, measured 5.3 cm by 4.6 cm, no depth, 75% eschar and 25% granulation tissue to the wound bed, no drainage, no infection, wound status deteriorated; -Unstageable pressure ulcer to right top of foot, measured 3.4 cm by 2.4 cm, no depth, unstageable due to slough and eschar, 100% slough to wound bed, no drainage, no infection, wound status deteriorated. -New pressure ulcer to Right lateral foot, unstageable due to slough/eschar, measured 2.0 cm by 1.9 cm, no depth, 100% eschar to the wound bed, scant amount of serosanguineous drainage, no infection, wound status deteriorated, physician and responsible party notified on 9/14/17. Review of the resident's physician order [REDACTED]. -Order start date 9/15/17, right heel, stage II pressure ulcer, cleanse with wound cleanser, apply Santyl daily, cover with ABD pad and wrap with Kerlix (discontinued 10/01/17). -Order start date 9/15/17, top of right foot, unstageable pressure ulcer, cleanse with wound cleanser, apply Santyl, cover with ABD pad and wrap with Kerlix, change dressing daily and as needed (discontinued 10/01/17). -Order start date 9/15/17, lateral side of right foot, unstageable pressure ulcer, cleanse with wound cleanser, apply Santyl, cover with ABD pad and wrap with Kerlix, change dressing daily and as needed (discontinued 10/01/17). (The treatment order to the resident's right heel pressure ulcer did not change) Review of the resident's departmental notes, dated 9/20/17 at 8:52 A.M., showed the wound nurse documented the following: -Unstageable pressure ulcer to the resident's right heel with 75% eschar and 25% granulation to the wound bed, and discoloration to the lateral side of the wound. The wound is smaller this week. Moon boot in place to the resident's right lower extremity. The resident's wound has a moderate amount of drainage and a foul odor present. No complaint of pain or discomfort noted upon assessment or treatment. Will continue to monitor; -Unstageable wound to the top of the resident's right foot, reopened 75% slough and 25% granulation tissue noted to the wound bed. Redness noted to the periwound. Small amount of drainage. Foul odor present; -Unstageable wound to the right lateral foot 100% eschar present to the wound bed. Periwound free of redness. Small amount of drainage noted, foul odor present; -Resident has appointment with the wound care clinic; -Continues to be noncompliant with some aspects of care. Refuses to elevate his/her foot off the bed at times to relieve pressure; -Will continue to monitor. Review of the resident's wound assessment report, dated 9/20/17, showed: -Right heel pressure ulcer, unstageable due to slough/eschar, measured 5.10 cm by 4 cm, 75% eschar and 25% granulation tissue to the wound bed, moderate amount of serosanguineous drainage, no infection, wound status improved; -Unstageable pressure ulcer to right top of foot, measured 2.90 cm by 1.20 cm, no depth, unstageable due to slough and eschar, 75% slough and 25% granulation tissue to wound bed, small amount of serosanguineous drainage, no infection, wound status improved. -Right top of foot, right lateral foot pressure ulcer (identified on 9/05/17), unstageable due to slough/eschar, measured 3 cm by 2.50 cm, no depth, 100% eschar to wound bed, small amount of serosanguineous drainage, no infection. During an interview on 10/04/17 at 11:00 A.M., the social service director (SSD) said the following: -On 9/04/17, nursing notified the SSD of a need to make a wound clinic appointment for Resident #1; -The SSD made the resident's appointment for (MONTH) 21, (YEAR); -The SSD did not think the resident would need signed new permission paperwork, because the resident went to the wound clinic during the previous year; -The SSD said the resident appeared more cognitively intact at the time she made the appointment; -The SSD made transportation arrangements and the resident was transported to the wound clinic on 9/21/17, but the resident could not sign (consent to treat) forms. -Without proper consent, the wound clinic refused to treat the resident; -The SSD then attempted to contact the resident's responsible party, but they did not answer the call; - The

Based on record review and interviews, the facility failed to monitor, assess, and document a painful lump and bruise on one resident's (Resident #1) leg. The resident received blood thinning medications every day and ultimately required hospital emergency treatment to stop internal bleeding, replace blood loss, and insertion of a filter to capture blood clots. Four residents were chosen for review from a facility census of 97. Record review of the facility's policy titled, Change in Medical Condition of Residents, dated 11/01/01, showed: -The purpose of the policy is to keep the physician who is in charge of medical care, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed; -Notification should occur promptly when there is a change in the resident's condition. Change in condition is defined as an accident involving the resident which results in injury and has potential for requiring physician intervention; a change in the resident's physical, mental, or psychosocial status; a need to alter treatment; a decision to transfer or discharge the resident; -Examples of a change in condition may include discovery of a lump or growth, new pain; -Nurses' notes should include documentation of the symptoms and observations associated with the change in condition, the date, and time of contact with the physician and family member/legal representative. Notes also should include comments on the care provided by nursing personnel; -Further assessments may be warranted with certain permanent changes in condition; -The plan of care may be altered to reflect a change in condition where new goals and approaches are developed. According to the National Library of Medicine, National Institutes of Health, antibiotic medications are associated with an increased risk of bleeding among patients receiving [MEDICATION NAME]. [MEDICATION NAME] has a narrow therapeutic range and requires frequent monitoring to avoid potentially life-threatening complications from both under-and over-coagulation. A wide range of drugs has been linked to an increased risk of major bleeding in [MEDICATION NAME] users. 1. Record review of Resident #1's face sheet showed: -Original admission date of [DATE]; readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the March 2016 physician's orders [REDACTED].>-[MEDICATION NAME] 4 milligram (mg), daily for anticoagulant therapy (to prevent blood clots); -[MEDICATION NAME] 75 mg, daily, for prevention of blood clots; -[MEDICATION NAME] 7.5/325 tablet, one tablet, as needed, every four hours for pain; -International Normalized Ratio (INR - a test that measures how long it takes blood to clot), monthly. Record review of the resident's care plan, reviewed on 01/08/16, showed: -Potential for bruises related to fragile skin. Inspect skin for changes daily. Assess and treat pain if present. Use gentleness when working with resident; -Potential for complications related to anti-coagulant therapy. Observe for abnormal bleeding, increased bruising, blood in the urine, petechiae (pinpoint flat round red spots under the skin surface caused by bleeding under the skin), bleeding gums, black/tarry stools and vomiting blood. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/15, showed: -No cognitive impairment; -Requires extensive staff assistance for transfers, dressing, and bathing; -Incontinent of bowel and bladder; -Occasionally had pain at a level of 4 out of 10. Record review of a PT/INR lab report, dated 02/10/16, showed: -INR: 2.9 H (high) (normal range 0.9-1.2). Suggested range for residents with a history of, or current blood clots is 2.0 to 3.0; -The physician ordered staff to recheck monthly. Record review of the resident's February 2016 Medication Administration Record [REDACTED]. The resident received one dose of as needed [MEDICATION NAME] on 02/08/16. Follow up documentation showed the medication was effective. During an interview, on 03/29/16 at 10:10 A.M., the resident said: -On 02/22/16, he/she was in bed and asked Certified Nurse Aide (CNA) E to help him/her take off his/her slacks. CNA E lifted the resident's bottom and legs by putting his/her arm under the resident's thighs and lifting up so he/she could slide the resident's slacks down. The resident felt pain in his/her thigh and cried out. The aide continued to lift the resident. The resident did not think CNA E reported the incident to a nurse because no nurse came to check on him/her. -On the same day, he/she developed a hard knot and bruise on his/her thigh in the area where he/she felt pain when CNA E lifted him/her. The knot and bruise were slightly painful at first, but then got worse over the next few days. The resident also noticed his/her leg was swelling and got bigger each day. The CNAs who cared for him/her during the following days were aware of the knot and bruise. -About a week after the knot and bruise occurred, the resident went to the emergency room due to pain. He/she returned to the facility the same day. His/her leg continued to be swollen and very painful. Staff sent him/her back to the emergency room a day later, and he/she was admitted to the hospital. He/she spent several days in the Intensive Care Unit. Record review of the resident's February 2016 MAR indicated [REDACTED]. Staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME], the medication was effective. Record review of a non-immediate communication fax to the resident's physician (from facility staff) dated 02/25/16, showed: -The resident complained of a bump, about the size of a dime, to the left outer side of his/her thigh; -Area felt firm and was painful to touch; -No redness; -Observed that morning during routine rounds; -Resident was not aware of it; -Please advise; -The physician signed the fax acknowledging he read the information; he/she gave no new orders. Record review of the resident's nurses' notes showed from 02/25/16 to 02/26/16, staff did not document an assessment of the lump including size, color, shape, surrounding tissue, and tenderness/pain. Record review of the resident's February 2016 MAR indicated [REDACTED] -On 02/26/16, day shift staff documented the resident's pain level as a 7/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective; -On 02/27/16, evening shift staff documented the resident's pain level as an 8/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective; -On 02/27/16, overnight staff documented the resident's pain as a 6/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective. Record review of the resident's nurses' notes showed: -On 02/27/16, at 1:07 P.M., a nurse documented the physician ordered [MEDICATION NAME] (antibiotic) 250 mg, twice daily, for seven days to treat a urinary tract infection. Staff notified the physician of the resident's complaints of pain in his/her left hip/thigh area. The physician did not give any orders related to the resident's left hip pain. Staff would continue to monitor. Staff did not document an assessment of the resident's left hip/thigh area. -On 02/28/16, at 9:08 P.M., a nurse documented the resident complained of leg pain near the knee. A nurse assessed the resident's leg and found a hard knot which was tender to light touch. The nurse notified the physician via fax (the facility was unable to locate a copy of the fax for review). The nurse did not document an assessment or size of the knot. Record review of the resident's February 2016 MAR indicated [REDACTED] -On 02/28/16, evening shift staff documented the resident's pain level as 10/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective. -On 02/29/16, overnight staff documented the resident's pain level as 6/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective. Record review of the resident's nurse's note dated 02/29/16, at 10:23 A.M., showed a nurse documented the resident complained about a raised area to his/her left outer thigh. The area was slightly larger and very painful if touched with no redness or warmth. Spoke with daughter and called physician who instructed staff to send the resident to the emergency room . During an interview on 03/29/16, at 10:50 A.M., a hospital pharmacist said [MEDICATION NAME] will react with [MEDICATION NAME] anticoagulants and affect the PT/INR values. Record review of the hospital Emergency Department Visit summary, dated 02/29/16, showed: -Hematoma (a solid swelling of clotted blood within the tissues) of left thigh; -Administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg/325 mg, 1-2 tablets, every 6 hours as needed for pain; -Contact the Emergency Department, or your physician for questions. Follow up as directed in your discharge/follow up instructions or Return to the Emergency Department for any new, persistent, or worsening symptoms. Record review of the resident's nurses' notes showed on 02/29/16, at 04:52 P.M., a nurse documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. Record review of the facility's Skin Audit Report, completed by Certified Nurse Assistants (CNA), each shift daily showed staff did not identify any new skin problems for the resident from 02/1/16 through 03/01/16. On 03/02/16 the report showed new skin problem noted. Record review of the resident's March 2016 MAR indicated [REDACTED] -On 03/01/16, day shift staff documented the resident's pain level as an 8/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective; -On 03/01/16, overnight staff documented the resident's pain level as an 8/10; staff did not document the location of the resident's pain. Staff administered [MEDICATION NAME]; the medication was effective; -On 03/02/16, at 12:49 A.M., staff documented they administered [MEDICATION NAME]. Staff did not document an assessment of the resident's pain level and did not document the location of the resident's pain. Follow up documentation showed the medication was not effective. Record review of nurse's note dated 03/02/16, at 2:20 A.M., showed a nurse documented the resident was sent to the hospital, per the physician, for increased swelling, and pain of the resident's left leg. The swelling extended from the resident's ankle to his/her groin. The left thigh very tight with 3+ [MEDICAL CONDITION] (a large amount of swelling resulting from fluid accumulation in body tissues), warm to touch, and normal color except for bruising mid leg. The nurse was unable to feel pulses in the resident's feet. The resident was taken to hospital by ambulance. Record review of the Hospital admission History and Physical dated 03/02/16, at 5:06 A.M., showed: -Left thigh hematoma; -Hematoma worsened from previous hospitalization ; -Hemoglobin (Hgb) (a protein molecule in red blood cells that, along with iron, transports oxygen to body tissues) dropped from 10.8 to 5.9 (normal range 12.5 - 16.0); -Hematocrit (Hct) (the number of red blood cells in a specified amount of blood) 17.8 (normal range 37.0 - 47.0%); -Acute (rapid onset) or chronic (long term) blood loss lowers the hematocrit and hemoglobin. Acute blood loss can occur from trauma with lacerations, open wounds and fractures. -INR with significant elevation today at 7.8 (normal range 0.9 - 1.2); -Past medical history of [REDACTED]. -Skin positive for bruising; -Left thigh pain; -Received packed red blood cells and fresh frozen plasma (to replace blood loss); -admitted to the ICU (Intensive Care Unit); -Vitamin K administered (used to quickly reduce the INR value); -Hold [MEDICATION NAME] and [MEDICATION NAME]. Record review of the hospital discharge summary, dated 03/02/16, showed: -Resident presented with low blood pressure from a hemorrhage in the left thigh; -[MEDICAL CONDITION] (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury); -Acute blood loss [MEDICAL CONDITION]; -Prolonged INR; -Transfused with five units of packed red blood cells; -status [REDACTED]. During an interview on 3/29/16, at 10:17 A.M., the physician said: -He thought the facility had notified him about the resident's bruise, but he was not certain; -Bleeding from a minor injury could happen quickly due to the resident taking blood thinner; -He wanted facility staff to notify him if a resident had a new area of bruising or swelling; -Some antibiotics interact with [MEDICATION NAME] and increased the risk of bleeding. During an interview on 03/28/16, at 3:25 P.M., Licensed Practical Nurse (LPN) A said nursing staff completed a Change in Condition form when new issues occur with residents. This form is completed following assessment of the resident and notification of the physician. All findings from the assessment are documented in the nurses' notes and the Change in Condition form is passed to the oncoming nurse for review during shift change report. Staff may also document on a non-emergency communication form and place this document with the shift change report. LPN A said he/she was not aware to monitor the resident for anything abnormal. During an interview on 03/29/16, at 2:35 P.M., CNA E said the following: -He/she helped the resident undress while the resident lay in bed. If the resident was in bed, it only took one person to change his/her incontinent brief; one person could lift the resident's legs and hips. -The resident never yelled out in pain when he/she changed him/her. The CNA did not notice any bruising to the resident's leg. During an interview on 03/28/16, at 3:40 P.M., CNA B said any time aides noticed a change in a resident's condition, they report it to their charge nurse. During an interview on 03/29/16, at 8:20 A.M., LPN C said he/she was aware the resident had a bruise on the leg and was on anticoagulants. During an interview on 03/29/16, at 1:34 P.M., Registered Nurse (RN) D said he/she recalled assessing a knot on the resident's hip/leg and told the resident's charge nurse about it. He/she and the nurse in charge of the resident's care assessed the area together. The raised area felt like a swollen vein measuring approximately 1/2 to 3/4 inches in diameter. RN (D) was not assigned to the resident that day and did not document about the raised area in the nursing notes. The charge nurse (not RN D) sent a fax to the physician on 02/25/16 in reference to the knot. On 02/29/16, staff sent the resident to the hospital due to pain and swelling of the leg. The resident returned the same day with no new orders. RN D did not work with the resident again until 03/02/16. When he/she assessed the resident on 03/02/16, he/she was alarmed about the amount of swelling in the resident's leg compared to the last time (02/25/16) he/she assessed it. The RN notified the physician and sent the resident to the hospital. During an interview on 03/29/16, at 3:40 P.M., CNA F said he/she did not observe the resident's leg, but heard the resident had a bruise on his/her leg. The CNA said he/she became aware of the bruise prior to the resident's hospitalization . During an interview on 03/29/16, at 3:58 P.M., LPN C said the treatment nurse (LPN G) performs the skin audits. During skin audits, the nurse looks for new problems that had not already been identified. Staff did not document on the 02/25/16 skin audit any new areas on the resident's left leg because staff had already identified it. The LPN said he/she would have documented the area in the nurses notes had it been new. Staff assessed the area every shift, but would only document it if there was a change. When the LPN saw the area, it looked like a pimple on the resident's leg. On 02/29/16, the resident told LPN C a family member talked to his/her physician and the physician would be calling the facility. When the LPN had not heard from the resident's physician, he/she contacted the physician and received orders to send the resident to the hospital. During an interview on 03/29/16, at 4:20 P.M., LPN G said he/she is the facility's wound nurse and assesses residents' open wounds and pressure ulcers. The charge nurses are responsible for tracking bruises. He/she was not aware of the resident's bruise; that is something he/she does not assess or track. During an interview on 03/29/16, at 4:44 P.M., LPN H said: -If a CNA became aware of a problem with a resident, they should notify the resident's charge nurse. A condition change is anything different happening with the resident such as a skin issues, bruising, bumps, new injuries, etc. -Staff should monitor residents who receive anticoagulants for bleeding, bruising, falls, and lab work. If a resident has an injury, staff are expected to assess and document, at least once a shift, to see if the injury becomes worse. -The physician should be notified by fax or by phone depending on the urgency or acuity of the problem. -Before the resident transferred to the hospital, he/she remembered the resident had a very odd lump, located on his/her left leg above the knee, which was tender to the touch. The lump did not feel hot, but really hurt the resident when it was touched. He/she remembered documenting on the lump once and the lump did not get any bigger or shrink in size when he/she assessed it. -The LPN said a couple of nurses, including him/her, faxed the resident's physician, but the physician was slow to respond. During an interview on 03/29/16, at 5:00 P.M., the Director of Nurses (DON) said: -When a resident takes [MEDICATION NAME], staff should look for signs and symptoms of bleeding; -Staff should follow the resident's care plan for anticoagulant therapy; -Staff should follow Medical Condition Change policy; -Staff should notify the physician of a condition change and document it in the nurses' notes; -Staff should reassess the resident and if the resident has no new change in condition or appearance, then the nurses do not have to document the assessment in nurses' the notes; -New areas of concern should be documented in the nurses' notes initially by the nurse who found and assessed it; -If the nurse does not make a notation in the nurses' notes, the next shift should make a note and the area assessed every shift. Complaint: MO 699

Based on observation, interview, and record review, the facility failed to monitor the skin of two residents (Residents #9 and #16) who had acquired pressure ulcers or were at risk for pressure ulcers. Staff performed a facility wide skin audit during the survey and found additional pressure ulcers on residents. Staff did not consistently report skin breakdown to make licensed staff aware of the new areas. Licensed staff did not consistently document, describe and stage new pressure ulcers to ensure consistent monitoring . There were 13 residents identified at a high risk for developing pressure ulcers or with actual pressure ulcers chosen for review. The facility census was 108. Federal guidelines define the following for pressure ulcers: -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable). -Stage II pressure ulcer - Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III pressure ulcer - Full thickness tissue loss. Subcutaneous fat (under the skin) may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining (opening underneath the lip of the boarder) or tunneling (A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). -Stage IV pressure ulcer - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. -Unstageable - known but not stageable due to coverage of wound bed by slough and/or eschar. 1. During the entrance conference at the beginning of the survey on 04/08/13, the surveyors requested a list of residents the facility had identified with pressure ulcers. The administrator presented a list containing 14 residents with identified pressure ulcers. The survey team chose five residents from the list for review. On the evening of 04/09/13, after discussion with surveyors, staff said they would perform a skin audit on all residents. On 04/10/13, the administrator presented a typed form titled, "List from body audits done", dated 04/09/13. Record review of the list showed six additional residents with newly identified open areas. Four of these were pressure ulcers, including Resident #16 and a new unreported pressure ulcer on the heel of Resident #9. Record review of this list, in combination with the first list presented at the beginning of the survey showed the facility now listed 18 residents with 28 pressure ulcers. 2. During record review of Resident #14's, admission MDS dated [DATE] showed the following: -Sacrolitis (an inflammation of the sacroiliac joint); -Traumatic sacral fracture (triangular-shaped bone at the bottom of the spine); -Muscle spasms; -[MEDICAL CONDITION] (a joint disease caused by cartilage loss in a joint); -Pain; -Requires extensive staff assistance of one for transfers; -Requires extensive staff assistance of one for ambulation; -Requires extensive staff assistance of one for dressing; -Requires extensive staff assistance of one for personal hygiene. Record review of the resident's care plan dated 03/15/12 showed the following: -Observe for pain during mobility; -Use positioning for support; -Observe for skin conditions during care rounds; -Registered Dietician consult PRN; -Keep linens and clothing as wrinkle free as possible; -Inspect skin daily for changes; -Utilize pressure reducing mattress; -Skin audit per schedule and PRN; -Provide incontinence care after each incontinent episode; -Turn and reposition per resident's individual turning schedule; -Observe for non-verbal signs of pain; -Observe for effectiveness of pain medication. Record review of the facility's Treatment Administration Record (TAR) for the month of April 2013 showed staff completed a skin assessment on 04/05/13 and did not identify any pressure ulcers. Record review of the facility's house wide skin audit completed on the evening of 04/09/13 showed the facility brought in nurses from a sister facility to assist in the skin audits. These nurses, LPN J and LPN K, documented observation of two pressure ulcers to the resident's coccyx/buttock region. Record review of the physician order [REDACTED].M., showed a physician order [REDACTED]. Record review of the facility's house wide skin audit completed on 04/10/13 between 8:00 A.M.-10:00 A.M., showed that the Regional Nurse Consultant and the Assistant Director of Nursing (ADON) also noted two open areas on the resident's coccyx/buttock region. Observation and interview on 04/10/13 at 3:02 P.M., showed the following: - ADON and LPN L performed wound rounds. The resident agreed to continue with the assessment. The nurses rolled the resident on her right side. -LPN L said he/she saw at least three open areas and possibly four to the resident's coccyx (tailbone). LPN L said that all of the areas were Stage II pressure ulcers. -Two pressure ulcers, one to the top of the coccyx on the left buttock, and one midline (a median plane, esp. of the body or a body part) of the coccyx on the left buttock were approximately dime sized, both with a yellow tinted wound bed. -One pressure ulcer midline of the coccyx on the right buttock was approximately pea sized, with a pink wound bed. -One pressure ulcer on the left medial (middle) coccyx/buttock was approximately half dollar sized, with a pink/red wound bed. Record review of the facility's Wound Flow Record dated 04/10/13 showed the following: -Stage II on the right buttock measured 3.9 cm X 2.5 cm. Staff described the tissue as dry; -Stage II on the right buttock measured 1.0 cm X 1.0 cm; -Stage II on the coccyx measured 1.2 cm X 1.0 cm. -Staff did not document an assessment of the fourth area. Record review of the nurse notes on 04/10/13 at 5:47 P.M., showed the following information: -Stage II sheared area above coccyx; -Stage II sheared area to right inner buttock; -Stage II sheared area to right buttock; -Very small blanchable (skin loses redness with pressure)area to red area posterior (behind) to Stage II sheared area above coccyx. The facility provided a written statement dated 04/10/13 from LPN M who wrote that upon entering room and assessing the resident's skin on the morning of 04/10/13, the resident had two [MEDICATION NAME] (A dressing that is biodegradable, non breathable and adheres to the skin so no separate taping is needed) placed on the resident's coccyx region. He/she said he/she removed the [MEDICATION NAME] dressing and applied [MEDICATION NAME] (barrier that protects against moisture and minor irritation) as ordered by the physician. The facility failed to follow the physician order [REDACTED]. Record review of the physician orders [REDACTED].M., the physician ordered a treatment for [REDACTED]. -Cleanse with wound cleanser; -Apply [MEDICATION NAME] barrier film; -Cover with a [MEDICATION NAME] (A thin, clear sterile dressing that keeps out water, dirt and germs, yet lets skin breathe) foam dressing; -Observe area daily for 90 days; -Change dressing every Wednesday and PRN. The facility provided a written statement dated 04/10/13 from the facility's regional nurse consultant who wrote that between 8:00 A.M. and 10:00 A.M., she assisted the resident back to bed from the bed side commode and provided perineal care (cleansing of the residents genitalia and surrounding skin). The regional nurse consultant said she observed that two open circular areas. The facility provided an additional written statement dated 04/10/13 from the facility's regional nurse consultant who wrote staff informed her on the afternoon of 04/10/13 that the resident had a third open area. She stated that after observing the open area this morning she went to evaluate. She said she used a warm washcloth and gently wiped. She said as she wiped, the resident's skin started to roll up and she stopped the procedure. The facility provided a written statement dated 04/10/13 from LPN L who said she observed the resident scooting down in bed at "2:45 A.M., this afternoon." According to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines #15, shear is the mechanical force that acts on a unit area of skin in a direction parallel to the body's surface. Shear is affected by the amount of pressure exerted, the coefficient of friction between materials contacting each other, and the extent to which the body makes contact with the support surface. Shearing forces are produced when adjacent surfaces slide across one another. As a result of shear, many blood vessels in the sacral area are likely to become twisted and distorted, and tissue may become ischemic and necrotic. The Federal guidelines define the following: - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. -Shear is the interaction of both gravity and friction against the surface of the skin. Friction is always present when shear force is present. Shear occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches or tears the underlying blood vessels causing damage. Observations and interviews on 04/11/13 showed the following: -At 11:32 A.M., the resident sat in bed with the head of the bed at approximately 45 degrees which would put direct pressure on the pressure ulcers. The resident said he/she had pain in his/her left hip. The resident rated his/her pain as 10 out of 10. He/she said he/she had taken three pain pills and his/her pain was unrelieved. He/she said he/she would go crazy without additional pain medication. -At 2:37 P.M., the resident sat in bed with the head of the bed at 40 degrees with a bedside table over him/her; this would put direct pressure on the pressure ulcers. -At 3:59 P.M., The resident remained in bed with the head of the bed at approximately 45 degrees which would put direct pressure on the pressure ulcers. During an interview on 04/11/13 at 3:52 P.M., LPN L said the wound bed was light pink on the large area. He/she said the other wounds present as Stage II shearing. He/she feels the treatment is appropriate due to the proximity of the wounds. LPN L said he/she did not see granulation (Formation of new tissue, usually pink to red in color) tissue or a yellow tinged wound bed. The resident scoots around which contributed to the wounds. During an interview on 04/12/13 at 12:50 P.M., the resident said that his/her pain was okay today. He/she said it hurt when he/she stood or tried to change positions. Record review of the resident's care plan on showed the following information: -Staff updated the care plan for pressure ulcers and implemented interventions on 04/10/13; -Staff did not address the resident's sliding or scooting down in the bed; -Staff did not address the resident's risk for additional shearing or place interventions to reduce the risk of shearing. 3. During an interview on 04/09/13 at 453 P.M., CNA H said CNA staff fill out the skin audit sheets on every shift and alert the charge nurses to skin issues. 4. During an interview on 04/09/13 at 5:21 P.M., CNA G said if he/she sees changes in a resident's skin he/she will fill out the skin audit sheets and report it to the charge nurse. 5. Interview on 04/12/13 at 3:00 P.M., the Director of Nursing (DON) said that the CNAs have body audits that they fill out every shift. The CNAs turn those sheets in at the end of their shift to the charge nurse to report any newly identified skin concerns. The DON expected the charge nurses to address the issues identified. CNAs were to stop any care they were performing and report a new skin area immediately to the charge nurse. The facility has a wound nurse and the wound nurse, the DON, or the ADON try to visualize the wound. She expected the nurse to assess measure, notify family and physician, and get a treatment in place. The DON said the wound nurse completes the weekly skin audits and the charge nurses will complete them if the wound nurse is out of the building. Upon identification of new skin concerns, the wound nurse or charge nurses notify her. 6. Record review of Resident #9's Quarterly MDS assessment dated [DATE], showed the following information: -Stroke; -Blood circulatory problem; -Cognition moderately impaired; -Requires physical assistance from staff for bed mobility; -Functional limitation of Range of Motion (ROM) to both legs; -At risk for developing pressure ulcers; -Has one Stage II pressure ulcer. Record review of the April 2013 TAR showed the following information: -Order dated 03/11/13: Wound - Stage II left buttock, change dressing every Monday and Thursday. Cleanse with wound cleanser and apply [MEDICATION NAME] (protective cushioned film dressing) secure with foam and adhesive. Observe area daily for 90 days; -Order dated 03/12/13: Wound Stage II (genitalia) cleanse with wound cleanser and apply [MEDICATION NAME] (medicated ointment used to treat bed sores and other skin ulcers) twice daily (BID). Leave open to air. Observe area daily for 90 days; -On 04/04/13, staff performed a skin audit on the resident and documented no additional skin problems found on the resident. Record review of the resident's care plan staff last reviewed on 4/8/13 and updated on 4/9/13, showed in part the following information: -Inspect skin for changes daily; -Determine ulcer stage and condition of ulcer; -Utilize pressure reducing mattress; -Turn and reposition per resident's individual turning schedule; -Educate resident and family regarding wound care prevention and treatment; -Cushion to wheelchair; -Remind and encourage resident to elevate legs while resting, may elevate in recliner. Record review of the nurses notes from 04/05/13 to 04/09/13, showed the following information: -On 04/05/13, at 1:25 P.M., staff documented the resident had swelling of both lower legs. TED hose (Tight, thick, elastic stockings used as a preventative measure to reduce the occurrence of emboli/blood clots in the legs) in place; -On 04/07/13, at 4:40 P.M., staff documented the resident continued to have wound to bottom with treatment in place. Staff encouraged the resident to elevate his/her legs due to swelling in his/her feet; -On 04/09/13, at 1:43 A.M., staff documented the resident's lower legs were swollen with red discoloration and the physician was aware. Record review of the resident's skin monitoring forms titled, "CNA Resident's Daily QA Body Audit" (provided to surveyors for review) showed from 04/07/13 to 04/09/13, CNAs identified the resident's feet as red and swollen but did not identify any areas of concern pertaining to the resident's heels. Observation on 04/09/13, at 1:55 P.M., showed LPN F performed treatments to a Stage II pressure ulcer on the resident's genitalia and the resident's left buttock near the coccyx (tailbone) as ordered. After completing the treatments, LPN F assisted the resident on his/her right side and left the room. The resident's socks remained on his/her feet and LPN F did not observe or assess the resident's heels. Observation of the resident on 04/09/13, from 1:55 P.M. to 4:35 P.M., showed the resident in bed on his/her right side. The resident's feet were not elevated and his/her heels were not floated off the bed. Record review of the facility's Wound Flow Record dated 04/10/13, showed staff measured and assessed a 2.0 cm (centimeter) by 3.0 cm unstageable deep tissue pressure ulcer (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) on the resident's left heel. Observation and interview on 04/10/13, at 2:15 P.M., showed the resident in a recliner in his/her room. The Assistant Director of Nurses (ADON) removed the resident's socks and revealed a quarter size red/brown unopened pressure ulcer on the left outer posterior portion of the resident's heel. The ADON cleansed the area and applied [MEDICATION NAME] (clear solution, when dries, leaves a protective barrier covering). The ADON said she would expect staff to float the resident's heels to prevent heel ulcers. Complaint MO # 395

Based on observations, record review and interviews the facility failed to implement interventions to promote optimal food intake for one resident (Resident #11) who the facility identified at risk for weight loss. The facility failed to properly engage and provide the needed assistance and encouragement to the resident during meals. The facility failed to follow their policy to fully inform the physician, family, involve the dietary manager, and notify the consultant Registered Dietitian (RD) for an assessment related to the weight loss, failed to assess or identify reasons for the weight loss or develop and implement interventions to prevent further weight loss. The resident experienced a severe weight loss of 22 pounds or 16.41% body weight in 21 days. Nineteen residents were sampled out of a facility census of 108. Federal Guidelines define suggested parameters for evaluating significance of unplanned and undesired weight loss as the following: -One month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; -Three months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; -Six months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. Record review of the facility's Weight Management Policy, dated 10/01/2010, showed the following: -Maintenance of adequate nutrition and hydration is necessary for the resident to maintain health and prevent complications such as [MEDICAL CONDITION] and pressure sores. -Suggested weight schedule: All newly admitted residents will be weighed weekly for four weeks, residents with weight loss will continue to be weighed weekly, all others monthly. -The newly recorded weight should be compared to the previous recorded weight. A significant change in weight is defined by federal regulations. -The physician should be notified of a significant change in weight and may order nutritional interventions. -Meal consumption's should be recorded and may be referenced by the interdisciplinary care team as needed. -The dietary manager, registered dietitian or the nursing department may initiate desires to explore specific meal consumption information for a resident. -The dietary manager or registered dietitian should be consulted to assist with interventions and actions recorded in the dietary progress notes. -Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. -The interdisciplinary plan of care communicates care instructions to staff. Review of "The Diet Manual", a comprehensive resource and guide for facilities (available on the Department's website), Becky Dorner and Associates, Inc, Akron, Ohio, 2006 showed the following information: -The goal of medical nutrition therapy is to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem. -Identify individuals with significant/severe weight losses: -Significant weight loss (which also included a 1-2% weight loss in one week in addition to the federal guidelines) -Review the food intake records; -Assess the risk of [MEDICAL CONDITION], identify potential causes, and document findings in the medical record; -Review the plan of care; -Interview the individual to identify possible causes and to determine appropriate interventions; -Request/implement nutrition interventions; -For residents that have 1% to 2% weight loss in a week, staff should provide individualized aggressive calorie augmentation. This may include, but is not limited to: high calorie/high protein supplement, whole milk or cream, extra mayonnaise or gravy on foods, pudding/ice cream/milk shakes/sherbet; enhanced foods (high calorie/protein), brightly colored napkins on tray to signify that this resident needs extra attention and cater to individual preferences as much as possible; -Confer with appropriate family, staff and physicians regarding intervention to be taken; -Document findings, assessment of nutritional status, and nutritional intervention in medical record (including plan of care). 1. Record review of Resident #11's face sheet (admission data) showed staff admitted the resident to the facility on [DATE], for rehabilitation. [DIAGNOSES REDACTED]. Staff documented the resident's weight was 134 pounds and height was 5 feet 11 inches. Record review of the March 2013 physician's orders [REDACTED]. Record review of the care plan, dated 03/20/2013, showed the following: -All care is related to traumatic [MEDICAL CONDITION]; -Potential for skin breakdown, monitor nutritional intake; -Potential for weight loss; -Resident not to have significant weight loss x 90 days; -Staff approaches in part include: Observe for changes in appetite, provide with food and beverage preferences, encourage to eat, offer alternate meals if refused or less than 50% of meal is consumed, provide snacks or supplements, provide cueing and prompting, encourage socialization during meal times, talk with family concerning ideas or additional approaches to avoid weight loss, involve in food activities as tolerated, consult registered dietitian as needed, keep responsible party informed and observe the resident while eating meals, snacks and foods in activities for any tolerance to foods served. Record review of the facility's Dietary Review form dated 03/21/13, completed by the dietary manager (DM) showed the resident's current weight was 134 pounds, resident was on a regular diet. The DM did not document any meal instructions or food preferences. Record review of the March weekly weight sheet showed the following information: -Staff documented admission (3/20/13) weight as 134 pounds; -On 3/27/13 staff documented on the weekly weight sheet the resident's weight was 124 pounds (10 pound weight loss in one week). According to the federal guidelines this was a severe weight loss of 7.46%. Record review of the resident's five day admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/27/13, showed the following: -The resident scored a 14 on the BIMS, which is indicative of intact cognitive skills; -The resident required extensive assistance with bed mobility, transfers, dressing, toileting hygiene and bathing. -The resident required supervision and set up assistance for eating. -The resident's weight was 134 pounds and height was 5 feet 11 inches. (Staff failed to gather the weekly weight information that was documented on 03/27/13, that showed the reisdent had a 10 pound weight loss and the current weight was 124 pounds). Record review of the care plan showed staff failed to update the care plan to reflect the resident's 10 pound weight loss on 3/27/13. Record review of the medical record showed facility staff failed to notify the physician, the registered dietitian and the dietary manager of the significant weight loss as directed by the facility's Weight Management Policy. Record review of the April weekly weight sheet showed on 04/03/13, the staff documented the resident's weight was 119 pounds (an additional five pound weight loss from the previous week). According to the federal guidelines this was a severe weight loss of 11.19%. Record review of the care plan, updated 04/03/13, showed staff added an intervention of whole milk three times daily with meals, after the weekly weight showed another five pound weight loss (15 pound weight loss since admission). Record review of the medical record showed facility staff failed to notify the physician, the registered dietitian and the dietary manager of the significant weight loss as directed by the facility's Weight Management Policy. Record review of the March 2013 meal intake record showed from 03/20/13 to 03/31/13, there were 16 meals out of 34 opportunities that staff documented the resident consumed anywhere from 0%-30%. Record review of the nurses notes from date of admission 03/20/13-03/31/13 showed the following: -Staff failed to document any concerns regarding the resident's appetite to include poor intake or refusal of meals; -Staff failed to follow the approaches listed in the residents care plan to include staff documenting that they attempted any of the following, observing for changes in appetite, provide food and beverage of preference, offer alternate meals if refused or less than 50% of meal is consumed, provide snacks or supplements, provide cueing and prompting, encourage socialization during meal times, involve in food activities as tolerated, consult registered dietitian as needed, keep responsible party informed, talk with family concerning ideas or additional approaches to avoid weight loss, and observe the resident while eating meals, snacks and foods in activities for any tolerance to foods served. During the initial tour of the facility on 04/08/13, at ??:?? P.M., showed the following: -The nurse said the resident had no weight loss concerns; -The resident had a decline in all activites; -Required maximum assistance of staff for all cares; -The resident had a unstageable pressure area to left heel; -The resident was at the facility for physical and occupational therapy for recent fracture to his/her left hip (Resident had fallen at home). Record review of the registered dietitian's (RD) review dated 04/08/13 completed at 1:28 P.M., showed the following: -Weight upon assessment was 119 pounds; -Ideal body weight 172 pounds; -No dental concerns; -Receives a regular diet and has a poor appetite. The resident had a weight loss of 15 pounds at 11% since admission. - Recommendation to add fortified foods (foods with increased calories and other nutrients) including 2 cal supplement (nutritional supplement) at medication pass daily. - Obtain and honor food preferences. - Refer to the RD as indicated. Interview and a record review on 04/09/13, at 4:15 P.M., showed the following information: -The director of nursing (DON) said restorative nurse aide (RNA) W had completed some weekly weights today and Resident #11 had weighed 112 pounds. -The DON showed the the surveyor the weight sheet where staff documented the resident's current weight of 112 pounds (another seven pound weight loss in a week or a 22 pound weight loss since admission). -The DON said she was going to have the resident re-weighed today or tomorrow and did not think the weight was accurate. During interviews and observations on 04/09/13 and 04/10/13, showed the following: -On 04/09/13, at 9:05 A.M., the resident lay in bed, had a tall thin, frail stature, his/her eyes sunken in, skin was fragile and bruised, very emaciated (The process of losing so much flesh as to become extremely thin) the resident did not have very many, if any, of his own teeth and no dentures. -The resident said the "food was bad and he/she wouldn't feed it to his/her hogs". -The resident said he/she had no appetitive and had lost a lot of weight since coming to the nursing home; -At 1:05 P.M., the resident lay in bed with a lunch tray on the bedside table. On the lunch plate there was jello, a meat cutlet, spinach, a piece of bread, milk and water; -The resident said he tried to eat the jello, just has no appetite for this food; -The staff failed to encourage or offer the resident an alternate choice of food and recorded the meal intake at 25% (The surveyor documented the resident only ate one bite of meat and two bites of jello and drank none of the beverages). -At 2:00 P.M., certified nurses aide certified nurses aide (CNA) V said the resident doesn't eat much only eats 20-25% of his/her meal, if that, and sometimes he/she will drink half of his/her milk. CNA documents what percentage the resident ate on a meal card and then transfers it on the meal intake sheet. -On 04/10/13, at 7:40 A.M., the resident lay in bed. There was no meal tray on the bedside table. -The resident said the staff had not brought breakfast yet, he/she said, "They don't give a[***]about me anymore." The resident wanted to call his/her son; -At 7:45 A.M., CNA Y brought the resident's breakfast tray that consisted of scrambled eggs, half a slice of toast, one piece of bacon, hot cereal, milk and juice. The CNA helped set up the meal tray for the resident and left the room. The CNA did not encourage the resident to eat. -At 7:54 A.M., CNA Y returned to the room and talked with the resident about calling his/her family member. The resident had not touched his/her breakfast. The CNA did not encourage the resident to eat or ask the resident if he/she wanted something else. -At 8:00 A.M., the resident ate the piece of bacon. -At 8:25 A.M., two CNAs repositioned the resident and checked the resident's heels. The CNAs did not encourage the resident to eat or offer the resident an alternate food choice. -At 8:30 A.M., the occupational therapist (OT) spoke with the resident. -The resident had only eaten half a piece of bacon, half of the half piece of toast and drank his/her juice; -At 8:40 A.M., the resident said the staff have never talked to him/her about food likes and dislikes. The resident said he/she likes meat and potatoes and "I love sweet potatoes." At home he/she just snacked throughout the day. The resident said he/she just wants to get back home so he/she can eat the foods he/she likes. -At 8:47 A.M., RNA W entered the room to weigh the resident. The RNA asked, "Didn't you want to eat, maybe lunch will be better?" The RNA did not encourage the resident to eat or offer an alternate food. -The RNA weighed the resident at 112 pounds (same weight as on 4/09/13). -The resident did not eat anymore of his/her breakfast tray. -At 9:40 A.M., the resident was sleeping and the breakfast milk was still sat on the bedside table, the carton was warm to touch; -At 10:00, 10:45 and 11:15 A.M., the resident was asleep and the same warm carton of milk was at the bedside table untouched. -At 1:00 P.M., Review of the activity calender and observation showed the facility had an ice cream social activity where multiple residents and staff gathered for ice cream in the common sitting area. -At 1:45 P.M., the resident was asleep and the ice cream social was taking place at this time. No staff came to wake the resident for the ice cream social activity. -At 1:50 P.M., the surveyor asked CNA V and CNA X (who were assigned to the resident's hall) if staff had served the resident lunch. Neither CNA said they brought or took away the resident's lunch tray. The surveyor checked the food cart and located the resident's lunch tray which had not been touched. All the food was still covered and there was a new milk unopened on the tray. -At 1:55 P.M., surveyor asked the DON to accompany the surveyor to the resident's room to get the milk that had been left since breakfast so a temperature could be taken. The temperature of the milk was 73.6 degrees Farenheit. (Whole milk was an intervention that the facility had added to the resident's diet due to the resident's weight loss). Record review on 4/10/13 of the April 2013 meal intake record showed from 04/01/13 to 04/10/13, staff documented the resident consumed anywhere from 0%-30% (that included seven refusals) for 17 meals of the 30 opportunities. Record review of the nurses notes from 04/01/13-04/10/13 showed the following: -Staff failed to document any concerns with the resident appetite to include poor intake or refusal of meals; -Staff failed to follow the approaches listed in the resident's care plan to include staff documenting that they attempted any of the following: observing for changes in appetite, provide food and beverage of preferences, offer alternate meals if refused or less than 50% of meal is consumed, provide snacks or supplements, provide cueing and prompting, encourage socialization during meal times, involve in food activities as tolerated, consult registered dietitian as needed, keep responsible party informed, talk with family concerning ideas or additional approaches to avoid weight loss, and observe the resident while eating meals, snacks and foods in activities for any tolerance to foods served. Record review of the April 2013 physicians order showed on 04/09/13, an order for [REDACTED]. Record review of the care plan, updated 04/09/13, showed staff added interventions of medication pass 30 ML two times daily and fortified foods. Record review of the resident's medical record showed staff failed to notify the dietary manager of the resident's severe weight loss as directed by the facility's Weight Management Policy. Record review of the April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff did not initial they administered the nutritional supplement until 04/10/13. During an interview on 4/10/13 at 9:05 A.M., and 4/16/13 at 10:00 A.M. the Dietary Manager said: -She became dietary manager at the end of January 2013. -She was supposed to meet with all newly admitted residents to discuss food preferences to include likes and dislikes. At this time she had only met with a few residents to discuss food preferences. -She had not met with Resident #11. -Weight meetings are held weekly; -At the meeting, the team discusses residents who have had a weight loss; -Interventions are added to the resident's care plans during the meeting; -He/she adds interventions to the Tray Cards, which are used by Dietary staff when preparing residents' meals; -The last weight meeting was on 04/03/13, and staff did not discuss any weight concerns for Resident #11 that she was aware of. -Interventions used for weight loss are fortified foods, whole milk, ice cream, shakes, supercereal, double portions; -There is a powdered mixture of butter and milk which is added to vegetables and things like mashed potatoes to make fortified foods; -Dietary staff has not been consistently adding this mixture to foods for the residents who need fortified foods. -The nursing staff should report any weight concerns with a resident. -She looked up the care plan to see what interventions had been put in place and pointed out that on 04/03/13, staff added whole milk as an intervention for the resident's weight loss. -She was not aware of the resident's first 10 pound weight loss or that Resident #11 had lost 22 pounds since admission. -Whole milk was probably not an appropriate intervention for this much of a weight loss for Resident #11. During an interview on 4/22/13 at 10:00 A.M., and 4/23/13 at 10:30 A.M. the Registered Dietitian said: -She visits the facility on a monthly basis or as needed and also consults by telephone. -She sees all new admissions; -Resident #11 was a new admission and staff had asked her to see the resident specifically. -She was not aware of Resident #11's weight loss until 04/8/13, when she was at the facility. -She did not re-weigh the resident at that time; Common practice would be to get a weight if there was a concern about the resident's weight or the accuracy of the weight recorded. -She added interventions on 04/08/13, to include fortified foods and 2 cal supplement on medication pass. -She filled out a form with her recommendations on it on 04/09/13, and the facility normally has 10 days to respond. If a resident had critical weight issues the facility should respond in 24-48 hours. -Fortified foods are any high calorie food, like a high calorie butter, whole milk, shakes, ice cream, super cereal etc. -If the facility was concerned about a resident's weight they could have contacted me over the phone. -She would have added addtional interventions besides the whole milk after the resident lost 15 pounds. -She was not aware that the resident did not have dentures and very few if any of his/her own teeth; -She was not aware of the additional seven pound weight loss discovered on 04/09/13 (making a total of 22 pounds lost or 16.46%). Observation and interview on 04/11/13, at approximately 5:30 P.M., showed the following: -The resident sat in his/her wheelchair in the dining room with his/her head down; body slumped forward. A family member sat next to the reident trying to feed the resident the macroni and cheese and barbaque little smokies. -The resident said, "The food tastes like crap". -The resident only drank his/her apple juice. -The family member said staff called him/her last night regarding the resident not eating so the family member came up to see if the resident would eat for him/her. -The family member said the resident loves vanilla wafers so he/she brought some for him/her to eat. -The family member said he/she was the resident's durable power of attorney; -The resident has lost a lot of weight and nobody from the facility had contacted him/her until last night regarding the weight loss or any other concerns. -The resident fell and broke his/her hip at home a few months ago and came to the facility for therapy. -The family member said nobody had ever asked him/her about the resident's food preferences. -Family member said the resident likes to snack throughout the day and was a meat and potatoe kind of person. -At approximately 6:00 P.M., the resident left the dining room and had only drank his/her juice and taken two bites of meat. The resident only consumed 5-10% of the meal. Staff did not encourage the resident to eat or ask the resident if he/she wanted something else. During an interview on 04/11/13, at approximately 6:15 P.M., the survey team spoke with the administrator about Resident #11 not eating, staff failing to talk with the resident about food preferences, staff failing to encourage the resident to eat or offering the resident an alternate choice of food. The administrator said these concerns would be addressed and one staff would be assigned to take care of the resident. He said Resident #11 was his a number one priority. Observation and interviews on 04/12/13, with the resident and staff showed the following information: -At 8:05 A.M., the resident lay in bed and a staff was assisting the resident with breakfast; -An IV pole was next to the bed but not attached to the resident. -The staff said the resident had just been given pain medication and was not eating much; -The resident said he/she justs wanted to go to sleep; -The administrator said the nurse had attempted earlier to connect the IV fluids for hydration and was going to make another attempt soon. -At 9:15 A.M., the resident lay in bed asleep and the IV was connected to the resident's left hand. -At approximately 12:00 P.M., the administrator said he had asked the resident if you could have anything to eat what would it be and the resident said butterscotch pudding. The administrator said a staff member was going to the store to buy the pudding for the resident. The administrator said you have to go and see Resident #11. -The resident sat up in bed, smiling, laughing and talking with a family member. -The resident said he/she was feeling alot better. -The resident had some color in his/her skin, eyes were brighter and was more alert than previous days. During an interview on 04/12/13 at 2:35 P.M., the adminstrator, DON and assistant director of nursing (ADON) said the following: -The DON said staff place newly admitted , readmitted , and residents with weight loss on a weekly weight schedule for four weeks. The facility staff place interventions and get the RD involved. The RD is available for contact at any time. The DON prints the monthly weights on the 10th of every month and she looks at the weekly weights weekly. The weekly weight team consists of the Assistant Director of Nursing (ADON), the DON and the Dietary Manager (DM). The team looks at the specific weight loss, discuss interventions, and place intervention as needed. If it is a Med Pass supplement (a convenient way to supplement calories and protein), she will add it to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The weight team writes the interventions in the certified nurse aide (CNA) communication book to alert them of any changes. If the interventions are ineffective, the team review and change the interventions as needed. The RD assists facility staff with intervention changes. The DON said the DM should have a list of "likes and dislikes" on all new residents. -The Administrator and DON said we have failure in weight loss and the dietary manager should be monitoring weights and assessing new admissions for food preferences. Interventions for weight loss should be put in place as soon as we see a change in a resident's weight.

Based on record review, observation and interview the facility failed to assess, monitor, and effectively treat one resident's (Resident #14) pain which caused the resident periodic nausea. The uncontrolled pain limited the resident's ability to fully participate in social and dining activities, and increased dependence on staff for completion of Activities of Daily (ADL). The deficient practice affected one out of a selected sample of 21 residents in a facility with a census of 103. Record review of the facility's Pain Management and Assessment Policy, effective 10/01/10, showed the following information: -Pain is any type of physical pain or discomfort in any part of the body; -Pain is very subjective, pain is whatever the experiencing person says it is and exists whenever he or she says it does; -Pain can cause suffering and is associated with inactivity, social withdrawal, depression and functional decline; -Elderly residents often suffer from acute and chronic pain and may have more than one source of pain; -Elderly residents often report pain differently due to physiological, as well as, psychological and cultural changes associated with aging; -Most residents with moderate to severe pain will require regularly dosed pain medications and some will require additional as needed pain medications for breakthrough pain; -Some residents with intermittent pain or mild pain may have orders for as needed dosing only; -The alert resident should be asked to describe their pain on a scale of one to ten; with zero being no pain and ten being the most severe pain the resident can imagine; -It is helpful to ask the resident their expectation for pain relief; can they live with the pain at the current level, if not, how much relief is needed to live comfortably; -Have the resident show you the location of the pain; -Ask the resident if anything makes the pain better; -Non-pharmacological pain management includes, but are not limited to: Positioning, decrease in pain related activities, relaxation techniques and/or heat application; -If the resident's pain is not controlled by the current treatment regime, the physician should be notified. 1. Record review of Resident #16's January 2011 physician's orders [REDACTED]. -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. These vertebrae receive the most stress and are the weight-bearing portion of the back), general [MEDICAL CONDITION] and generalized pain; -An order, dated 01/14/11, for [MEDICATION NAME] (a patch that contains an opioid pain medication that is slowly absorbed through the skin and helps to relieve moderate to severe pain for up to 3 days) 25 micrograms (mcg)/hour (hr) patch, apply one patch topically every 72 hours; -An order, dated 01/14/11, for [MEDICATION NAME] (medication used to relieve moderate to severe pain) 5 milligrams (mg)/325 mg, one tablet every six hours as needed for pain. Record review of the care plan, dated 01/14/11, showed the following information: -Potential for pain related to compression fracture affecting the first lumbar vertebra with Kyphoplasty (surgery designed to treat pain and other symptoms caused by a spine fracture), right flank (side) pain secondary to bladder stimulator implant (a surgically implanted electrical device that allows control of the bladder); -Coordinate with physician to manage pain medication for optimum control of pain; -Observe for effectiveness of medication; -Observe for non-verbal signs (facial expressions, pulling away, fighting); -Observe for factors that increase/decrease pain; -Use comfort measures as needed (back rubs, lotion to body, sponge baths, repositioning); -Observe for side effects of pain medication; -Attempt to measure resident's pain level using pain scale 1-10; -Keep resident/responsible party informed. Record review of the nurses' notes, dated 01/15/11-01/25/11, showed the following information: -On 01/16/11, at 6:08 P.M., staff documented the resident required staff encouragement to go to the dining room for the evening meal, but the resident only stayed in the dining for "about two minutes" before he/she insisted he/she lay down; -On 01/15/11, at 11:10 A.M., staff documented the resident refused to get out of bed for breakfast. The resident wants to use the wheelchair at all times and states he/she cannot walk; -On 01/17/11, at 6:16 P.M., staff documented the resident uses a wheelchair for mobility which staff propels. The resident is reluctant to leave his/her room, even to go to the dining room; -On 01/18/11, at 3:25 A.M., staff documented, at the beginning of the shift, the resident had an ice pack on his/her back; -On 01/18/11, at 8:21 P.M., staff documented the resident requested pain medication one time; -On 01/20/11, at 4:46 P.M., staff reviewed the resident's plan of care for pain. On the day shift, the resident rated his/her pain at a six, seven, eight and nine out of a total score of ten and on the evening shift the resident rated his/her pain as a zero, nine and ten out of a total score of ten. The resident has a [DIAGNOSES REDACTED]. The staff had administered 12 doses of [MEDICATION NAME] since the resident's admission on 01/14/11. Staff faxed the physician requesting an increase in the [MEDICATION NAME] to two tablets every six hours. Staff continued the resident's current plan of care; -On 01/22/11, at 1:11 P.M., staff documented the resident required skilled care due to [DIAGNOSES REDACTED]. The resident uses a [MEDICATION NAME] for routine pain management and had requested [MEDICATION NAME], for breakthrough pain, eight to ten times in the last five or six days. The resident requested a pain medication and rated his/her pain at a ten out of a total of ten. His/her facial expression is smooth without grimacing, crying, writhing in bed, constant movement of legs and sweating, and was able to hold a conversation without signs and symptoms of pain. The resident requests a lot of assistance from staff but has transferred himself/herself to the commode; -On 01/22/11, at 5:51 P.M., staff documented the resident did not seem to want to get out of bed. When the resident did get out of bed and go to the dining room, he/she immediately turned around and said he/she had to go back to bed because he/she was so sick. The staff documented this was a daily occurrence; -On 01/25/11, at 8:34 A.M., staff documented the physician wrote a new order to increase the resident's [MEDICATION NAME] to 50 mcg/hr and change every three days. Record review of the resident's current medical record from 01/20/11-01/24/11 showed no physician response or evidence staff contacted or followed-up with the physician on the 01/20/11 fax that requested an increase in the resident's [MEDICATION NAME] due to his/her high pain scale ratings. Record review of a physician's orders [REDACTED]. Record review of the nurses' notes, dated 01/25/11-01/26/11, showed the following information: -On 01/25/11, at 3:35 P.M., staff documented the resident used narcotics frequently two to three times a day. The resident rated his/her pain as a five or six out of a total score of ten with relief observed; -On 01/26/11, at 4:40 P.M., staff documented the resident had occasional episodes of pain and his/her medication, as ordered, appeared effective. Record review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -From 01/14/11-01/27/11 staff administered [MEDICATION NAME] 5mg/325mg, to the resident for breakthrough pain, 30 times; -On 01/15/11, at 12:08 P.M., staff administered [MEDICATION NAME] 5/325mg to the resident. At 12:45 P.M., staff documented the pain medication was effective at relieving the resident's pain. At 12:52 P.M., (seven minutes after the nurse documented the pain medication was effective) staff documented the resident rated his/her pain as a six out of ten; -On 01/16/11, at 9:19 P.M., staff documented the resident rated his/her pain as a nine out of ten. The MAR indicated [REDACTED] -On 01/18/11, at 12:41 P.M., staff documented the resident rated his/her pain as a seven out of ten. At 3:12 P.M., staff documented the resident rated his/her pain as a seven out of ten. Staff administered [MEDICATION NAME] 5mg/325mg, to the resident, approximately 2 ? hours after the resident initially complained of pain at a seven; -On 01/20/11, at 12:49 P.M., staff documented the resident rated his/her pain as an eight out of ten. At 1:54 P.M., Staff administered [MEDICATION NAME] 5mg/325mg, to the resident, approximately 1 hour after the resident initially complained of pain at an eight; -On 01/21/11, at 1:38 P.M., staff documented the resident rated his/her pain as a seven out of ten. At 4:59 P.M., Staff administered [MEDICATION NAME] 5mg/325mg, to the resident, approximately 3 hours and 15 minutes after the resident initially complained of pain at a seven; -On 01/22/11, at 9:25 P.M., staff documented the resident rated his/her pain as a nine out of ten. The MAR indicated [REDACTED] -On 01/23/11, at 9:23 P.M., staff documented the resident rated his/her pain as a nine out of ten. The MAR indicated [REDACTED] -On 01/26/11, at 1:03 P.M., staff documented the resident rated his/her pain as a seven out of ten. The MAR indicated [REDACTED]. Observation and interview conducted on 01/27/11, at 2:30 P.M., showed the resident in his/her darkened room, positioned in bed. The resident said he/she admitted to the facility after he/she fell at home and broke his/her back. He/she had not been without pain since arriving to the facility and staff did not always administer his/her pain medication when he/she asked for it, or when he/she complained of pain. At home, if needed, he/she could take the pain medication every four hours, but at the facility, he/she can only have it every eight hours. He/she said it was like the staff was afraid he/she would become addicted to the pain medication. The resident said when his/her pain is really bad it makes him/her nauseated and affects his/her ability to perform ADLs. He/she does not attend many activities due to the pain. The resident said he/she had pain in his/her right hip and back and rated it as an eight or a nine out of ten. During an interview conducted on 01/27/11, at 4:30 P.M., Licensed Practical Nurse (LPN) O said the resident has quite a bit of pain. The pain medications seem to help but he/she requests them frequently. The resident told the LPN that he/she really had not been free of pain since arriving at the facility. During observation and interview on 01/27/11, at 5:05 P.M., the resident asked LPN O if it was time it go to the dining room for dinner. The nurse told the resident he/she should wait about 10 minutes; staff had not served him/her yet. The LPN said the resident could not stay up long. Staff tells the resident when they have served his/her tray so he/she does not have to wait. Record review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., staff documented the resident rated his/her pain as a seven out of ten. At 4:08 P.M., staff administered [MEDICATION NAME] 5mg/325mg, to the resident, approximately three hours after the resident initially complained of pain at a seven. At 4:14 P.M., staff administered [MEDICATION NAME] 5/325mg, to the resident, for right hip pain. The resident rated his/her pain as a ten out of ten. At 5:36 P.M., staff documented the pain medication was not effective at relieving the resident's pain. The resident rated his/her pain as a ten out of ten. During an interview conducted on 01/28/11, at 12:40 P.M., Certified Nurse Aide (CNA) I said he/she had assisted the resident before but does not work on his/her hall regularly. He/she said the resident "did get up and do things." Today, the resident had not complained much about pain. The resident asks the nurse for pain medication if he/she is having pain. The CNA said the resident ate lunch in the dining room but wanted to go to bed shortly after he/she got up. The aide said he/she did not know why the resident wanted to go to bed, he/she just did. During an interview conducted on 01/28/11, at 1:16 P.M., LPN J said staff assess resident's pain every shift and about one hour after administering pain medication. If the pain medication was not effective at relieving the resident's pain, he/she notifies the physician. If an aide reports a resident is in pain, he/she assesses the resident, and according to what the resident rates his/her pain, he/she administers pain medication. Generally, if a resident's pain is less than a five, the LPN administers Tylenol and may attempt to reposition the resident. If greater than five the LPN administers a narcotic pain medication, if ordered. Some residents are depressed; their pain is actually from the depression and not actual pain. If a resident appears depressed, the LPN will administer a pain medication then notify the physician of the resident's signs and symptoms of depression. The LPN said he/she administered pain medication to Resident #16 this morning and the pain medication is effective. Now the resident usually takes one pain pill a day; when he/she was first admitted he/she requested pain medication more often. Also, the resident did not want to get out bed and go to the dining room for meals. When the resident did get up, he/she would stay up about five minutes then say he/she was sick and wanted to go back to bed. Now that staff tells the resident when they have served his/her tray, he/she eats all of his/her meals in the dining room. On 01/25/11, the LPN notified the physician about the resident requesting pain medication before it was due, so the physician wrote an order to increase the [MEDICATION NAME] to 50 mcg. During an interview conducted on 01/28/11, at 1:45 P.M., the resident said his/her pain was terrible and rated it a ten out of ten. During an interview conducted on 01/28/11, at 2:18 P.M., CNA P said if a resident complained of pain, he/she would ask the resident where they had pain then notify the nurse. During an interview conducted on 01/28/11, at 2:30 P.M., the Director of Nursing (DON) said if a resident's pain is less than a five, staff administers non-narcotic pain medication and performs other comfort measures such as repositioning or massage. If greater than five, then staff administers a narcotic pain medication, if ordered. If the resident's pain is not controlled, a pain score of five or greater after the administration of pain medication, staff notify the physician. The DON said if a resident tells an aide he/she has pain, she expects the aide to notify the nurse of the resident's complaints of pain. During an interview conducted on 01/31/11, at 1:30 P.M., LPN J said after he/she became aware of the resident's excruciating pain on Friday (01/28/11), he/she notified the physician who wrote orders for [MEDICATION NAME] (a medication used to treat pain or inflammation) 7.5mg every day and to increase the [MEDICATION NAME] to 10mg/325mg. On Sunday (01/30/11), the physician increased the resident's [MEDICATION NAME] order to 7.5mg two times a day.