Every finding on record at Aspire Senior Living New Florence

Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 50. 1. Review of the facility's Infection Preventionist (IP) Policy, undated, directed staff to designate a qualitied individual (s) to be responsible for implanting programs and activities to prevent and control infections. During an interview on 09/25/25 at 8:05 A.M., the administrator said the Assistant Director of Nursing (ADON) was the infection preventionist and left the facility September 9, 2025. The administrator said at this time the facility does not have an IP.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 50.1. Review of the facility's policy titled, Antibiotic Stewardship, undated, showed the purpose is to develop and implement protocols to optimize the treatment of infections by ensuring the residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduced the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Develop, promote, and implement a facility wide system to monitor the use of antibiotics.Review of the facility's antibiotic stewardship program showed staff did not have a process in place to track and trend antibiotic usage.During an interview on 09/25/25 at 8:05 A.M., the administrator said the Assistant Director of Nursing (ADON) started a few months ago along with her and the Director of Nursing. The ADON was the infection preventionist and was to work on getting a process started for the Antibiotic Stewardship. The administrator said the ADON left September 9th, and it is still unknown what has or hasn't been done because he/she did not leave any of the information at the facility.

Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis bacteria (TB)) was completed in accordance with their policy and on file for five employees (Dietary D, Certified Medication Technician (CMT) E, Housekeeper F, Social Services, and Certified Nursing Assistant (CNA) G) out of ten employee files reviewed. Facility staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and/or annual PPD tests were completed and documented as per the facility policy for three residents (#2, #14, and #18) out of six sampled residents. Facility staff failed to provide wound care in a manner to reduce the risk of infection for two residents, (Residents #6 and #30) out of three sampled residents. The facility census was 50.1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed:-The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.-Facilities must have water management plans and documentation that, at a minimum, ensure each facility:*Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;*Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;*Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.Review of the facility's Water Management and Legionella Risk Reduction policy, reviewed 2023, showed:-At least annually, the facility will conduct a Water Program Review;-At the time of the Water Management Review the Water Management Program Team will update the process flow diagram, associated control points, control limits and corrective actions if needed;-Control measures and limits should be established for each control point;-Facility specific control points for hazardous conditions included ice machines, the main kitchen, the satellite kitchen, sinks, tubs, showers and toilets.Review of the facility's Water Program Review dated, 06/19/25, showed the assessment did not contain any additional details. Review showed the facility specific program did not contain control measures or control limits for the identified hazardous conditions control points.Observation on 09/23/25, during the facility tour showed the facility equipped with multiple spas, an unused satellite kitchen and multiple showers in resident bathrooms.Observation on 09/22/2025 at 11:02 A.M., showed room [ROOM NUMBER] bathroom sink with water brown. During an interview on 09/24/25 at 11:25 A.M., Housekeeper C said he/she ran water in resident rooms daily for about 30 seconds. Housekeeper C said he/she had seen brown water in the past in sinks that were not used regularly.During an interview on 09/24/25 at 11:45 AM the maintenance director said he/she and the water committee, which also included the administrator and dietary manager, were responsible for the water management program. The maintenance director said he/she had reviewed Centers for Disease Control (CDC) documents describing risks and it was his/her understanding there were no identified risks in the facility. The maintenance director said housekeeping staff ran the water for two minutes in every room monthly, but it was not documented. The maintenance director said the water should not be brown.During an interview on 09/24/25 at 2:30 PM the administrator said corporate staff were responsible for establishing the water management program. The administrator said he/she just started about one month ago and had not reviewed the water management program in depth. The administrator said the program should include facility specific control measures and corrective actions for identified potentially hazardous conditions.2. Review of the facility's policy titled, Employee Tuberculosis Screening, dated 01/30/24, showed the following guidance:- Tuberculosis screening is a part of the pre-employment medical examination and in general, all employees in this long-term care facility are to comply with established tuberculosis screening procedures;- A two-step Mantoux test (used to determine if a person has been infected with TB) is given unless the employee has documentation of a previous positive reaction;- Upon employment, the employee will receive 0.1 milliliters of Tuberculin Units of PPD which is considered step one;- The employee is instructed to return for the TB reaction reading in 48 to 72 hours. The employee is not to have any resident contact until after the results of the first skin test have been obtained;- If the first skin test is negative, a second skin test is given within 14 days after the original test. 3. Review of Dietary D's employee file showed:- Hire date of 05/01/25;- The file did not contain documentation the second PPD administered.4. Review of CMT E's employee file showed:- Hire date of 08/14/25;- The file did not contain documentation of a PPD test.5. Review of Housekeeper F's employee file showed:- Hire date of 05/01/25;- The first PPD administered on 08/20/25 and the second PPD administered 08/29/25, after the employee's hire date. 6. Review of Social Services employee file showed:- Hire date 06/20/25;- The first PPD administered on 08/21/25 and did not contain a read date;- The file did not contain documentation the second PPD administered.7. Review of CNA G's employee file showed:- Hire date 08/12/25;- The file did not contain documentation the second PPD administered. 8. During an interview on 09/25/25 at 1:10 P.M., the Director of Nursing (DON) said he/she started working at the facility a month ago and is currently responsible for employee PPD testing. The DON said the facility previously had an assistant DON who was responsible for employee PPD testing upon hire and annually. The DON said he/she has had problems finding employee PPD records since working at the facility. The DON said when a new employee gets hired, he/she would expect for the employee to receive the two-step PPD test prior to working on the floor with residents and would expect for the employee to receive a PPD screening annually. 9. During an interview on 09/25/25 at 1:15 P.M., the administrator said he/she expects new employees to receive the two-step PPD test prior to working on the floor with residents and would expect for the employee to receive a PPD screening annually.10. Review of the facility policy Mantoux testing - Residents (Tuberculosis Screening), undated, showed the policy directs staff as follows:-Residents will be screened for tuberculosis infections upon their admission to the facility and at intervals appropriate for the regional;-Upon admission, residents/guests should receive the PPD two-step screening. If screening was done by the transferring hospital, it must have occurred within 30 days prior to nursing home admission. The facility should obtain documentation of the results of X-Rays and PPD tests.11. Review of Resident #2's medical record showed an admission date of 06/02/25. Review showed the immunization record did not contain documentation a first or second step TB test administered. 12. Review of Resident #14's medical record showed an admission date of 06/09/25. Review showed the immunization record did not contain documentation a first or second step TB test administered.13. Review of Resident #18's medical record showed an admission date of 02/06/25. Review showed the immunization record did not contain documentation a first or second step TB test administered.During an interview on 09/25/25 at 1:43 P.M., the DON said a 2 step TB should be completed on admission and an annual screening should be done. The DON said he/she is not sure why they weren't done, but the new infection preventionist will be responsible to do this process moving forward. During an interview on 09/25/25 at 8:05 A.M., the administrator said she is not sure why TB's are not completed. She said TB's are currently top priority right now, because it was found that records were not being kept up to date. The administrator said if the TB's are done, they would be uploaded into the system.14. Review of the Facility's Hand Hygiene policy, undated, showed the following:-Staff will follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents, and visitors;-Hands should be washed for at least twenty seconds using soap and water under the following conditions:--Before having direct contact with a resident;--After having direct contact with a resident;--Before providing invasive procedures;--Before handling clean or soiled dressings, gauze pads, etc.; --After handling used dressings, contaminated equipment, etc.;--After contact with blood, bodily fluids, excretions, secretions, mucous membranes, or non-intact skin;--After handling items potentially contaminated with blood, body fluids, excretions, or secretions;--Before putting on gloves;--After removing gloves;-Hand sanitizers containing at least 60% alcohol maybe used when soap and water is not readily available.15. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 9/15/25 showed staff assessed the resident as follows:-Cognitively intact;-At risk for developing pressure ulcers/injuries;-One unhealed stage II pressure injury.Review of the residents Physician order sheet (POS), date 09/24/25, showed staff are directed to apply skin prep to residents right heal for skin protection two times a day for wound/skin management.Review of the resident's care plan, dated 7/10/25, showed the resident is at risk for impairment to skin integrity due to incontinence and requiring assistance with activities of daily living (ADLs).Observation on 09/24/2025 at 12:04 P.M., Registered Nurse (RN) A entered the resident's room to perform right heel wound care. He/She placed a gown and gloves on, placed a barrier, and cleaned the wound with skin prep. He/She left the residents room with the gown and gloves on, went to the treatment cart, removed gloves, replaced without hand hygiene, grabbed gauze from the cart, and came back in the resident's room. He/She cleaned the resident's bloody right toe. He/She removed gloves and replaced them without performing hand hygiene.16. Review of Resident #30's quarterly MDS, dated [DATE] showed staff assessed the resident as cognitively intact, has a diagnosis of heart failure and diabetes mellitus.Review of the resident's POS, dated 09/2025, showed the following:-Cleanse left lower leg blister with wound cleanser and dry gauze, apply wound gel and Abdominal pad, wrap with kerlix wrap every day/shift and as needed for wound/skin management;-Cleanse right lower leg blister with wound cleanser and dry gauze, apply wound gel and Abdominal pad, wrap with kerlix wrap every day/shift and as needed for wound/skin management.Observation on 09/24/2025 at 11:07 A.M., RN A entered the resident's room to perform wound care on bilateral lower leg wounds. He/She placed on a gown and gloves. He/she placed the barrier and clean wound supplies on the bed between the resident's legs. He/She placed the residents bandaged legs on top of the clean barrier with the clean supplies in the middle between the resident legs. He/She cut the right lower leg bandage off the resident's leg with scissors and placed the soiled bandage, scissors on the clean barrier and placed the uncovered leg wound on the clean barrier. With the same soiled gloves, RN A removed the bandage from the left leg with scissors and wound cleaner, discarded the bandages and scissors on top of the clean barrier and then placed the uncovered leg wound on the top of the clean barrier. RN A opened the clean supplies and then placed the open supplies back on the clean barrier. He/She left the residents room with his/her gown and gloves on. He/She removed his/her gloves in the hallway and then removed two tongue suppressors from the treatment cart. He/She replaced his/her gloves without performing hand hygiene. He/She used a tongue suppressor to apply the resident's cream to the wound on the left side, placed the abdominal pad on the wound, and then placed the leg back on the same barrier. He/She then lifted the resident's leg, picked up the gauze from the barrier, and wrapped the left leg with the roll of gauze. He/She removed his/her gloves and replaced his/her gloves without performing hand hygiene. He/She cleans the right wound with wound cleaner, used the tongue suppressor to apply the cream to the right leg wound, placed the abdominal pad on the wound and then placed the leg back down on the barrier. With the same gloves he/she wraps gauze around the leg. He/She put the soiled scissors and placed them in the top drawer of his/her treatment cart without cleaning or disinfecting them.During an interview on 09/25/25 at 1:09 P.M., the DON said his/her expectation is that staff clean their hands between clean and dirty tasks, before applying gloves, any times gloves are removed, and any time gloves become soiled or are in contact with fluids. He/She said he/she expects staff to use a clean barrier for wound care supplies and expects staff to place dirty bandages, used supplies and trash during wound care in a trash bag. He/She said trash and/or used wound care supplies should never be placed on clean barriers. He/She said staff should remove PPE before exiting a resident's room and should not wear dirty gloves/gowns in the hallways. He/She said hand hygiene and glove changes during would care are important to prevent the spread of infections. He/She said he/she expects staff to provide care for each wound individually with clean gloves to prevent cross contamination.During an interview on 09/25/25 at 1:15 P.M., the Administrator said he/she expects staff to change gloves and perform hand hygiene any time they go from one task to another or from clean to dirty tasks. He/She said residents with multiple wounds should have care completed separately to prevent cross contamination. He/She said personal protective equipment (PPE) should be removed and hand hygiene performed before exiting a resident room. He/She said he/she expects staff to place all wound care supplies on a clean barrier and all used items should be placed in a trash bag and not on the clean surface of the barrier. He/She said this is to help prevent the spread of infections. During an interview on 10/02/25 at 10:02 A.M., RN A said staff are expected to wash hands before starting a wound treatment and should change gloves and wash hands when going from dirty to clean tasks and should remove gloves and wash hands before leaving the residents room. He/She said clean barriers help prevent the spread of infection. He/She said he/she should have kept the barrier clean and all used supply items should have been placed in a trash bag. He/She said he/she typically uses a trash bag and does not place dirty items on his/her clean barrier, but didn't use one during the wound care because he/she forgot it in the treatment cart. He/She said dirty or used items can increase the risk for infection or the transfer of bacteria. He/She said residents with multiple wounds should have wounds treated separate as per the orders. He/She said the mistakes made during wound care were due to nerves.

Based on observation, interview, and record review, facility staff failed to complete an entrapment assessment for two residents (Resident #2 and #38) of two sampled residents with bed rails. The facility census was 50. 1. Review of the facility's policy titled, Bed/Assist Bars Use in Long-Term Care, dated 09/17/25, showed staff are directed: -Nursing/Therapy staff must perform a risk assessment prior to implementation that considers entrapment risk;-Findings and rationale must be documented in the resident's care plan;-Ensure proper positioning to minimize entrapment and injury risk. 2. Review of Resident #2's comprehensive minimum data set (MDS), a federally mandated assessment tool, dated 06/26/25, showed staff assessed the resident as:-Cognitively intact;-Diagnoses of a seizure disorder or epilepsy;-Bed rails not used as restraint in bed.Observation on 09/23/25 at 2:42 P.M., showed the resident in bed with bilateral U bars in the upright position. Review of the resident's medical record did not contain an entrapment assessment.3. Review of Resident #38's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-Diagnoses of multiple sclerosis;-Impairments on both sides of upper and lower extremities;-Bed rails not used as restraints in bed.Observation on 09/24/25 at 8:24 A.M., showed the resident in bed with one quarter length bed rail in the upright position. Observation on 09/25/25 at 7:50 A.M., showed the resident in bed with one quarter length bed rail in the upright position.Review of the resident's medical record did not contain an entrapment assessment.During an interview on 09/25/25 at 12:45 P.M., the Maintenance Director said he/she is responsible for completing entrapment assessments on bed rails and should complete the entrapment assessments for any new bed rails and then two times a year after the initial installation. The Maintenance Director said he/she completed entrapment assessments on the resident's bed rails, but did not document the assessments. The Maintenance Director said he/she should have documented the entrapment assessments and said he/she got busy which is why they were missed being documented. During an interview on 09/25/25 at 12:55 P.M., the administrator said the Maintenance Director is responsible for completing entrapment assessments on bed rails to ensure there is nothing loose or to ensure there are no gaps. The administrator said an entrapment assessment should be completed when installing a new bed rail and then he/she would expect for the bed rail to be checked monthly.

Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed maintain resident rooms, common areas, medical device equipment and the exterior of the building clean and in good repair. Facility census was 50.1.Review of the facility's External Environmental Services policy, dated 01/30/2024, directed staff to keep building exterior in good repair.2.Review of the maintenance records showed they did not contain documentation related to spa remodels.3.Review of the proposal for roof repairs, dated 08/12/25, showed the proposal did not contain approval signatures.4. Observation on 09/23/25 during the Life Safety Code tour showed:-The mansard roof on the north side of the facility contained multiple missing shingles which exposed the wood decking. Observation showed rotted decking material and two holes which exposed the attic space;-Two wall corners in the 100 hall spa behind the toilet contained cracks which spanned from the floor to the ceiling. Observation showed there was a gap between the tile floor and the baseboard behind the toilet;-The wall in resident room [ROOM NUMBER] contained a large rectangular hole which exposed the wall cavity below the resident's desk.During an interview on 09/24/25 at 11:45 A.M., the maintenance director said he/she was responsible for ensuring the facility interior and exterior repairs are completed. The maintenance director said he/she was aware of the holes in the roof, the cracks in the spa walls and the hole in resident room [ROOM NUMBER]. The maintenance director said the facility was under new ownership since May and he/she was working with corporate staff to get roof repaired and have two spas remodeled. The maintenance director said he/she did not know the status of repair or remodel plans. The maintenance director said the hole in resident room [ROOM NUMBER] had been there for quite a while but he/she had not had a chance to make repairs.During an interview on 09/24/25 at 2:30 P.M., the administrator said the maintenance director was responsible for keeping the facility in good repair. The administrator said he/she was aware of the roofing and spa issues but did not know the status of bids or repairs since corporate staff were working on these issues. The administrator said he/she was not aware of the hole in resident room [ROOM NUMBER].

Based on interview and record review, the facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program which included documentation and implementation of on-going systemic issues with resolution. The facility census was 50.1. Review of the facility's Quality Assurance and Performance Improvement Plan, undated, showed, it is the purpose of this facility-wide performance improvement process to include identifying and implementing opportunities to improve the quality of resident care and quality of life, as well as other measures of organizational performance. Meeting quarterly with key personal attending to coordinate this program. Review of the Performance Improvement Program, dated 09/03/25, showed, area of concern: QAPI has not been previously done.Review of the facility's records showed staff did not provide documentation of a QAPI/QA program.During an interview on 09/25/25 at 7:59 A.M., the administrator said there is no information on a QAPI/QA program to provide, and the facility is going to have to start this from scratch.

Based on interview, and record review, facility staff failed to ensure care plans were reviewed and revised with changes in the resident's needs for seven residents (Resident #5, #14, #16, #19, #23, #38 and #41) out of 13 sampled residents. The facility census was 50.R 1. Review of the facility's policy titled, Care Plan Policy undated, showed the care plan is designed to identify each resident's strengths, needs, goals and preferences and to guide the delivery of quality, coordinated care that promotes the highest practicable physical, mental, and psychosocial well-being. Review showed:-Care plans shall be written in clear, measurable, and actionable terms, identifying specific interventions and goals;-Care plans shall be reviewed and revised quarterly, annually, and with any significant change in status;-Revisions must reflect changes in resident condition, treatment, preferences, or goals;-All updates, reviews, and revisions must be dated, timed, signed, and clearly documented.2. Review of Resident #5's Annual minimal data set (MDS), a federally mandated assessment tool, dated 08/12/25, showed staff assessed the resident as follow:-Cognitively intact;-Used a wheelchair,-Upper extremity impairments on both sides;-Lower extremity impairments not assessed. Review of the resident's progress notes, dated 06/01/25, showed staff documented the resident had an unwitnessed fall.Review of the resident's progress notes, dated 06/16/25, showed staff documented the resident had an unwitnessed fall.Review of the resident's care plan, dated 07/10/25, showed staff assessed the resident at risk for falls related to history of falls. Review showed the care plan did not contain new interventions after each of the resident's falls. 3. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:-Cognition moderately impaired;-On hospice care. Review of the resident's Outside the Hospital Do-Not-Resuscitate (DNR) Order, dated 06/02/25, showed the residents representative signed the order for the resident to be a DNR.Review of the resident's physician order sheet (POS), dated September 2025, showed the resident with an DNR order.Review of the resident's care plan, dated 07/05/2025, showed staff assessed the resident to remain a full code. Review showed the residents care plan did not reflect the residents correct advanced directives. During an interview on 09/25/25 at 1:35 P.M., the Director of Nursing (DON) said patient centered out comes, change in conditions and personal needs should be on resident's care plans. During an interview on 09/25/25 at 1:39 P.M., the administrator said the care plan coordinator from another facility is responsible for care plans at this time and has been covering this area since she has been here as the administrator. During an interview on 09/29/25 at 9:52 A.M., the care plan coordinator said he/she works approximately one and half days each week in the facility. He/She said the residents care plan should list the correct advanced directives for a resident and said if he/she does not have a residents DNR orders at the time of admission, then the resident will be listed as a full code. The care plan coordinator said he/she should have updated the residents care plan once the DNR orders were confirmed. 4. Review of Resident #16's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition not assessed;-Did not contain documentation of a fall since admission. Review of the resident's nursing progress notes, 07/21/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/11/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's care plan, last revised 04/09/25, showed staff did not review or revise the care plan to reflect the resident falls or fall interventions. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately cognitively impaired;-Two or more falls since admission. Review of the resident's nursing progress notes, 06/21/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 07/14/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/16/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/29/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's care plan, last revised 04/07/25, showed staff did not review or revise the care plan to reflect the resident falls or fall interventions. 6. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment;-One sided impairment to the upper and lower extremity;-Diagnosis of a stroke and complete paralysis and partial weakness.Review of the resident's progress notes, dated 08/30/25, showed the resident had an unwitnessed fall that caused bruising to right knee, right ankle, and down the outside of his/her right calf.Review of the resident's care plan, dated 06/18/25, showed staff did not review or revise the care plan to reflect the resident falls or fall interventions7. Review of Resident #38's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact;-Used an indwelling catheter.Review of the resident's nursing progress notes, dated 08/31/25, showed staff documented the residents foley catheter removed.During an interview on 09/22/25 at 2:50 P.M., the resident said he/she used to have a catheter but no longer has one. Review of the resident's care plan, dated 08/01/25, showed the resident at risk for infection related to a urinary catheter and the resident will remain free from catheter-related trauma through review date. Review showed staff did not update the care plan to reflect the removal of the residents foley catheter.During an interview on 09/25/25 at 1:35 P.M., the DON said patient centered out comes, change in conditions and personal needs should be on resident's care plans. During an interview on 09/25/25 at 1:39 P.M., the administrator said the care plan coordinator from another facility is responsible for care plans at this time and has been covering this area since she has been here as the administrator. During an interview on 09/29/25 at 9:52 A.M., the care plan coordinator said he/she works approximately one and half days each week in the facility. The care plan coordinator said any changes to a resident using a catheter, whether the catheter is new or removed should be listed on the care. 8. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows;-Severe cognitive impairment;-Used a wheelchair;-Moderate assistance with toileting, showering/bathing, lower body dressing, sit to stand, and chair/bed-to-chair transfer;-Diagnosis of dementia and Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors, slow movement, stiffness, and loss of balance).Review of the resident's nursing progress notes, 07/30/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/04/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/07/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 08/22/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's nursing progress notes, 09/18/25, showed staff documented the resident had an unwitnessed fall. Review of the Resident's Care plan, dated 07/10/25, showed staff did not review or revise the care plan to reflect the resident falls or fall interventions.During an interview on 09/25/25 at 1:35 P.M., the DON said he/she would expect safety interventions and detailed interventions for falls to be on the resident's care plan. The DON said patient centered out comes, change in conditions and personal needs should be on resident's care plans.During an interview on 09/25/25 at 1:39 P.M., the administrator said the residents care plan should be updated after falls with or change in conditions with interventions. The administrator said the care plan coordinator from another facility is responsible for care plans at this time and has been covering this area since she has been here as the administrator. The administrator was not sure why the care plans are not up to date with falls and fall interventions. During an interview on 09/29/25 at 9:52 A.M., the care plan coordinator said he/she works approximately one and half days each week in the facility. The care plan coordinator said he/she believes the nursing staff should be documenting new falls and interventions on the resident's care plan, and that nursing staff has not made him/her aware of residents falls to include on the care plans. He/She said that new falls with new interventions should be included in the care plans.

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan to reflect the care needs for three residents (Resident #2, #30, and #41) out of 13 sampled residents. The facility census was 50.1. Review of the facility's policy titled, Care Plan Policy, undated, the care plan is designed to identify each resident's strengths, needs, goals, and preferences and to guide the delivery of quality, coordinated care that promotes the highest practicable physical, mental, and psychosocial well-being. Review showed:-Care plans shall be written in clear, measurable, and actionable terms, identifying specific interventions and goals;-Care plans shall be reviewed and revised quarterly, annually, and with any significant change in status;-Revisions must reflect changes in resident condition, treatment, preferences, or goals;-All updates, reviews, and revisions must be dated, timed, signed, and clearly documented.2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 06/09/25, showed staff assessed the resident as cognitively intact and receives hospice services.Review of the resident's Physician's Order sheet (POS), dated 06/09/25, showed an order for hospice services.Review of the resident's care plan, dated 09/16/25, showed the care plan did not contain documentation of the resident's Hospice care. 3. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;-Has an indwelling catheter (tube inserted int the urinary tract to drain urine form the bladder).Review of the resident's care plan, dated 07/24/25, showed the care plan did not contain documentation of the resident's catheter.4. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and does not receive hospice services.Review of the resident's POS, dated 09/10/25, showed an order for hospice services.Review of the resident's care plan, dated 06/18/25, showed the care plan did not contain documentation of the resident's Hospice care. 5. During an interview on 09/25/25 at 1:25 P.M., the Director of Nursing (DON) said hospice residents come with their own set of care, so it is important this is care planned. The DON said resident catheter should be care planned also, and is important staff know for infection prevention and care. During an interview on 09/25/25 at 1:29 P.M., the administrator said the care plan coordinator from another home is responsible for care plans and the care plan meetings. He/She comes to the building two to three times a week. The administrator said he/she has been covering the care plan process for as long as she has been in the building. The administrator was not aware these things were not on the resident's care plan. During an interview on 09/29/25 at 9:52 A.M., the care plan coordinator said he/she works approximately one and half days each week. The care plan coordinator said hospice should be included on the resident's care plans, along with any changes to a resident using a catheter, whether the catheter is new or removed.

Based on interview and record review, facility staff failed to ensure Certified Nurse Aid (CNA) G, nurse aid (NA) H and CNA I received a minimum of 12 hours of ongoing education annually. The facility census was 50.1. Review of the Facility's Nurse Aide Regular In-Service Training policy, dated 01/20/24, showed the in-service training must be sufficient to ensure the continuing competence of the nurse aides but must be no less than 12 hours per year, include dementia training and resident abuse prevention training, and for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.Review of the facility's Resident Matrix, dated 09/22/25, showed staff documented 16 residents who resided in the facility with diagnoses of dementia and/or Alzheimer's disease.Review of the facility's records, showed the staff did not provide documentation CNA G, NA H, and CNA I completed or were provided with dementia and/or Alzheimer training.During an interview on 09/24/2025 at 2:40 P.M., the Director of Nurse (DON) said the facility does not have the required 12-hour trainings set up or implemented for NA staff. He/She said the facility got new ownership in May and they have yet to implement the NA 12-hour trainings. He/She said the old ownership did not leave any documentation that education was being completed previous to the ownership change.During an interview on 09/25/25 at 1:15 P.M., the administrator said he/she expects NA's to receive 12 hours of continued education yearly. He/She was not aware that NA's were not getting the education. He/She said the DON is responsible for the continued education, but he/she is new, he/she is the new administrator, and the facility came in new ownership a few months ago.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #22, #38, and #49) out of three sampled residents. The facility census was 50.1. Review of the facility's policy titled, Bed Hold Policy Guidelines, undated, showed the facility will notify residents and/or their representative of the bed hold policy guidelines. The bed hold notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #22's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 05/01/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party. 3. Review of Resident #38's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 08/12/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party.4. Review of Resident #49's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and did not document a return date. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party.5. During an interview on 9/25/25 at 1:00 P.M., the Director of Nursing (DON) said he/she started at the facility about a month ago and is uncertain about the facility's bed hold policy.During an interview on 09/25/25 1:02 P.M., the administrator said when a resident is discharged to the hospital or therapeutic leave, the discharging nurse is responsible to provide the bed hold policy and obtain the resident's or residents representative signature. The administrator said he/she is not sure if this process is currently happening or not. The administrator said he/she would expect for the resident or resident's representative to be notified of the facility's bed hold policy each time a resident is discharged to the hospital.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 46. 1. Review of the facility's Registered Nurse policy, dated 01/30/25, showed except when waived, the facility must use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. 2. Review of the Facility Assessment, revised 05/15/25, showed the facility is to staff at least one RN at least eight hours per day, seven days a week. 3. Review of the facility's RN Staffing assignments, dated 06/01/25 through 06/30/25, showed staff did not provide the services of an RN for eight consecutive hours per day on 06/11/25, 06/13/25, and 06/22/25. 4. Review of the facility's RN Staffing assignments, dated 07/01/25 through 07/14/25, showed staff did not assign an RN to work on 07/04/25, 07/07/25, 07/12/25, and 07/13/25. 5. During an interview on 07/14/25 at 1:12 P.M., the Staffing Coordinator said he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily, but the facility only has one RN on staff other than the Director of Nursing (DON). He/She said the RN was scheduled off on 07/04/25, 07/07/25, 07/12/25, and 07/13/25, he/she reached out to the DON to cover, but the DON was unable to cover the shifts. During an interview on 07/14/25 at 1:43 P.M., the interim DON said he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily, and the DON should ensure the requirement is met. He/She said he/she assumed the interim DON role on 07/14/25 and was not aware the Staffing Coordinator did not assign an RN to work on 07/04/25, 07/07/25, 07/12/25, and 07/13/25. During an interview on 07/14/25 at 1:52 P.M., the administrator said he/she is aware of the requirement to have an RN in the facility eight consecutive hours daily, the Staffing Coordinator is expected to schedule an RN, and the DON should ensure the requirement is met. He/She said he/she just returned from vacation and was not sure why there was not an RN in the building on 07/04/25, 07/07/25, 07/12/25, and 07/13/25. Intake#1775987

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information to include the facility name, current date, resident census, total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, daily. Facility staff failed to keep the required daily staffing records. The facility's census was 46.1. Review of the facility's Nurse Staffing Information policy, dated 01/30/25, showed staff are directed as follows:-Post the following information daily: facility name, current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nurse Aides (CNA), and the resident census;-Post the nurse staffing data as specified above daily at the beginning of each shift, in a clear and readable format, and in a prominent place readily accessible to residents and visitors;-Maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. 2. Review of the facility's Nurse Staffing records on 07/14/25, showed the facility did not contain the daily nurse staffing information for:-May 2025;-June 2025;-07/01/25 through 7/14/25. 3. Observation on 07/14/25 at 9:50 A.M., 10:00 A.M., and 12:45 P.M., showed facility staff did not post the required nurse staffing information in the facility. 4. During an interview on 07/14/25 at 12:48 P.M, the interim Director of Nursing (DON) said the staffing coordinator is responsible to post the daily nurse staffing sheet. During an interview on 07/14/25 at 1:12 P.M., the Staffing Coordinator said he/she was not aware it was his/her responsibility to post the daily nurse staffing sheet and was not familiar with all the information required to be posted. During an interview on 07/14/25 at 1:43 P.M., the interim DON said he/she did not know why the nurse staffing sheet was not posted daily. He/She said the required staffing sheets should be retained for 18 months, and he/she was not sure why there was no record since 05/01/25 when the new company took over. During an interview on 07/14/25 at 1:52 P.M., the administrator said the staffing coordinator is responsible to post the nurse staffing sheet daily, and him/her or the DON to ensure it gets done. He/She said he/she had not realized the nurse staffing sheet was not being done daily. He/She said the records should be maintained for 18 months. Intake# 1775987

See event ID PY0C12. Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51.

Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51. 1. Review of the facility's policy titled, Physician Orders, dated 02/2022, showed staff are directed to follow physician's orders. Physician's orders will be entered into the electronic medical record (EMR) as soon as practicable once received from the physician. Orders will be carried out as per the physician. Review of the facility's Fall Risk Reduction policy, dated 10/2011, showed if the fall is un-witnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks and continue for seventy-two hours. Schedule for Neurological Assessment Following Potential Head injury every fifteen minutes times four, every sixty minutes times four, every four hours times four, every shift for seventy-two hours. Review showed it did not contain direction for staff regarding not performing Neurological Assessments following a potential head injury if the resident is at the end of life. 2. Review of Resident #1's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/20/24, showed staff assessed the resident as severely cognitively impaired and did not contain documentation of a fall since admission or rejection of care. Review of the podiatrist's orders, dated July 2024, showed: -On 07/17/14: Keep Mepitel dressing (a thin transparent dressing) and Steri-Strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day. -On 07/22/24: Cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled; Review of the resident's Physician Order Sheet (POS), dated 07/01/2024 to 08/31/2024, showed the POS did not contain: -Orders to keep Mepitel dressing and Steri-strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day; -Orders to cleanse wound on the great toe and left lateral food with saline or wound cleansers, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the resident's Treatment Administration Record (TAR), dated July 2024, showed: -On 7/13/24: Paint the left foot incision with Betadine daily, cover with a 4x4 gauze, wrap with gauze and ACE wrap daily every evening for surgical wound to left foot. Review showed the TAR did not contain documentation staff provided wound care on 07/14/24, 07/18/24, 07/25/24, and 07/26/24; -Review showed the TAR did not contain contain the podiatrist's orders to cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the Podiatrist progress notes, dated 07/31/24, showed he/she placed a call placed to nursing home to discuss why patient presented today without proper bandages and proper wound care. He/She explained that patient was at risk for further amputation due to now infected wounds not being properly cared for in facility. Review of the resident's podiatrist orders, dated 07/31/24, showed an order to Apply Betadine to the incision site and to the great toe wound, apply Aquacel AG (a wound dressing that combines hydrofiber technology with ionic silver to treat wounds), cover both sites with gauze, cover with rolled gauze and ACE bandage daily. Foot is to stay wrapped and covered at all times. Doxcycline Monohydrate (used to treat infections) 100 milligram (mg) by mouth two times a day for ten days. Further review of the resident's Treatment Administration Record (TAR), dated July 2024, showed an order dated 7/31/24 to check the left foot each shift, ensure dressing/ace wrap in place, clean and dry, and change dressing once daily and as needed. The TAR showed it directed staff to do the treatment on an as needed basis and not daily per the podiatrist's orders. Review showed the TAR did not contain documentation staff provided wound care on 07/31/24. Review of the Podiatrist office note, dated 10/23/24, showed the physician documented the resident's wound not bandaged. The wound was infected. Review of the resident's medical record, dated, 08/19/24, showed staff documented the resident had an unwitnessed fall. Review of the resident's neurological Assessment Flow Sheet, dated 08/19/24 through 08/23/24, showed the flow sheet did not contain documentation of neurological assessments or vital signs as directed by the facility's policy, for the dates of 08/19/2024 through 08/23/2024. During an interview on 10/23/24 at 12:03 P.M., LPN A said staff are directed to assess the resident after an unwitnessed fall, or a witnessed fall with head injury, and complete neurological checks for seventy-two hours. The LPN said staff would document the neurological checks on a form. Staff should continue neurological checks even if the resident is towards the end of his/her life. During an interview on 10/25/24 at 1:08 P.M., Licensed Practical Nurse (LPN) A said he/she did not know why the wound care was not completed as ordered. He/She said if a wound care treatment was not completed, staff are too report to the DON. He/She said he/she did not know if the resident's wound became infected, due to the treatments not being completed according to physician orders. During an interview on 10/25/24 at 1:25 P.M., the Director of Nursing (DON) said the resident's family member would take the resident to his/her appointments without informing staff, so staff may not have known to ask if there were new orders from the Podiatrist. He/She did not know who or why the sutures were removed and would need to look in to it. Staff are directed to assess the resident, ensure resident safety, notify the physician, family and himself/herself after a fall. The DON said if the fall is unwitnessed, or a witnessed fall with head injury, staff are directed to perform neurological checks for seventy-two hours. The hospice nurse was in the resident's room from the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, so staff did not perform neurological checks. The resident's daughter signed a comfort measure form, so staff did not conduct a neurological assessment from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24. During an interview on 10/25/24 at 1:26 P.M., the administrator said the resident's family member took the resident to his/her doctor appointments and he/she did not know if the family member provided staff with any new orders. He/She said staff may not have known the resident went to a podiatrist appointment if the residents family member did not tell facility staff. If a resident had a unwitnessed fall, or witnessed fall with head injury, staff are directed to ensure resident safety, conduct an assessment, notify the physician, family, and DON, and start and neurological and vital checks to be completed for seventy-two hours. Staff are educated to follow fall protocol. The staff did not complete neurological checks during the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, since the hospice nurse was with the resident. The staff did not perform neurological checks from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24 because of the resident's state of medical condition it was the towards the end of his/her life. 4. During an interview on 10/25/24 at 1:08 P.M., LPN A said nurses are responsible to update physician orders as soon as received. The LPN said staff are expected to follow the prescribed orders and should document completed treatments on the TARS. The LPN said if a treatment is missing from the TAR it should be reported to the DON. LPN A said The DON was responsible for ensuring orders are transcribed accurately. During an interview on 10/25/24 at 1:25 P.M., the DON said the charge nurse is responsible for contacting the physician to obtain a verbal order or the wound care nurse should document the orders in the wound care book. The DON said the nurses are responsible for transcribing orders in the residents' medical records. The DON said if staff questioned the orders, they would need to clarify with the physician or other provider. There is no auditing system in place to ensure the orders are transcribed accurately in the resident's medical record. If staff did not follow wound care orders, there is the potential a wound could become infected. He/She said he/she did notice staff did document providing treatments on the TAR. He/She said he/she had not had an opportunity to review why there were undocumented treatments, so he/she did have a reason why. He/She said staff have to select to add the order to the TAR or the order will not transfer over to the TAR. He/She said During an interview on 10/25/24 at 1:26 P.M., the administrator said the nurse would get the orders from the wound care nurse, or physician, based on what was observed. He/She said the orders are transcribed by the nurse into the resident's medical record. He/She said if the nurse had questions about the orders, he/she would clarify with the nurse practitioner or the physician. He/She said there was no audit in place to ensure the orders were transcribed accurately into the resident's medical record. He/She said the staff were expected to double check the information being entered for accuracy. He/She said when a resident goes to an appointment outside the facility, they do have communication with the physician. He/She said the resident, family member, or attendant were given paperwork to give to the physician's office, which included, the facility fax number to fax over new physician orders. He/She said if staff did not follow wound care orders, there was a potential to cause an infection in the wound. MO00243904

Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51. 1. Review of the facility's policy titled, Physician Orders, dated 02/2022, showed staff are directed to follow physician's orders. Physician's orders will be entered into the electronic medical record (EMR) as soon as practicable once received from the physician. Orders will be carried out as per the physician. Review of the facility's Fall Risk Reduction policy, dated 10/2011, showed if the fall is un-witnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks and continue for seventy-two hours. Schedule for Neurological Assessment Following Potential Head injury every fifteen minutes times four, every sixty minutes times four, every four hours times four, every shift for seventy-two hours. Review showed it did not contain direction for staff regarding not performing Neurological Assessments following a potential head injury if the resident is at the end of life. 2. Review of Resident #1's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/20/24, showed staff assessed the resident as severely cognitively impaired and did not contain documentation of a fall since admission or rejection of care. Review of the podiatrist's orders, dated July 2024, showed: -On 07/17/14: Keep Mepitel dressing (a thin transparent dressing) and Steri-Strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day. -On 07/22/24: Cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled; Review of the resident's Physician Order Sheet (POS), dated 07/01/2024 to 08/31/2024, showed the POS did not contain: -Orders to keep Mepitel dressing and Steri-strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day; -Orders to cleanse wound on the great toe and left lateral food with saline or wound cleansers, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the resident's Treatment Administration Record (TAR), dated July 2024, showed: -On 7/13/24: Paint the left foot incision with Betadine daily, cover with a 4x4 gauze, wrap with gauze and ACE wrap daily every evening for surgical wound to left foot. Review showed the TAR did not contain documentation staff provided wound care on 07/14/24, 07/18/24, 07/25/24, and 07/26/24; -Review showed the TAR did not contain contain the podiatrist's orders to cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the Podiatrist progress notes, dated 07/31/24, showed he/she placed a call placed to nursing home to discuss why patient presented today without proper bandages and proper wound care. He/She explained that patient was at risk for further amputation due to now infected wounds not being properly cared for in facility. Review of the resident's podiatrist orders, dated 07/31/24, showed an order to Apply Betadine to the incision site and to the great toe wound, apply Aquacel AG (a wound dressing that combines hydrofiber technology with ionic silver to treat wounds), cover both sites with gauze, cover with rolled gauze and ACE bandage daily. Foot is to stay wrapped and covered at all times. Doxcycline Monohydrate (used to treat infections) 100 milligram (mg) by mouth two times a day for ten days. Further review of the resident's Treatment Administration Record (TAR), dated July 2024, showed an order dated 7/31/24 to check the left foot each shift, ensure dressing/ace wrap in place, clean and dry, and change dressing once daily and as needed. The TAR showed it directed staff to do the treatment on an as needed basis and not daily per the podiatrist's orders. Review showed the TAR did not contain documentation staff provided wound care on 07/31/24. Review of the Podiatrist office note, dated 10/23/24, showed the physician documented the resident's wound not bandaged. The wound was infected. Review of the resident's medical record, dated, 08/19/24, showed staff documented the resident had an unwitnessed fall. Review of the resident's neurological Assessment Flow Sheet, dated 08/19/24 through 08/23/24, showed the flow sheet did not contain documentation of neurological assessments or vital signs as directed by the facility's policy, for the dates of 08/19/2024 through 08/23/2024. During an interview on 10/23/24 at 12:03 P.M., LPN A said staff are directed to assess the resident after an unwitnessed fall, or a witnessed fall with head injury, and complete neurological checks for seventy-two hours. The LPN said staff would document the neurological checks on a form. Staff should continue neurological checks even if the resident is towards the end of his/her life. During an interview on 10/25/24 at 1:08 P.M., Licensed Practical Nurse (LPN) A said he/she did not know why the wound care was not completed as ordered. He/She said if a wound care treatment was not completed, staff are too report to the DON. He/She said he/she did not know if the resident's wound became infected, due to the treatments not being completed according to physician orders. During an interview on 10/25/24 at 1:25 P.M., the Director of Nursing (DON) said the resident's family member would take the resident to his/her appointments without informing staff, so staff may not have known to ask if there were new orders from the Podiatrist. He/She did not know who or why the sutures were removed and would need to look in to it. Staff are directed to assess the resident, ensure resident safety, notify the physician, family and himself/herself after a fall. The DON said if the fall is unwitnessed, or a witnessed fall with head injury, staff are directed to perform neurological checks for seventy-two hours. The hospice nurse was in the resident's room from the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, so staff did not perform neurological checks. The resident's daughter signed a comfort measure form, so staff did not conduct a neurological assessment from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24. During an interview on 10/25/24 at 1:26 P.M., the administrator said the resident's family member took the resident to his/her doctor appointments and he/she did not know if the family member provided staff with any new orders. He/She said staff may not have known the resident went to a podiatrist appointment if the residents family member did not tell facility staff. If a resident had a unwitnessed fall, or witnessed fall with head injury, staff are directed to ensure resident safety, conduct an assessment, notify the physician, family, and DON, and start and neurological and vital checks to be completed for seventy-two hours. Staff are educated to follow fall protocol. The staff did not complete neurological checks during the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, since the hospice nurse was with the resident. The staff did not perform neurological checks from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24 because of the resident's state of medical condition it was the towards the end of his/her life. 4. During an interview on 10/25/24 at 1:08 P.M., LPN A said nurses are responsible to update physician orders as soon as received. The LPN said staff are expected to follow the prescribed orders and should document completed treatments on the TARS. The LPN said if a treatment is missing from the TAR it should be reported to the DON. LPN A said The DON was responsible for ensuring orders are transcribed accurately. During an interview on 10/25/24 at 1:25 P.M., the DON said the charge nurse is responsible for contacting the physician to obtain a verbal order or the wound care nurse should document the orders in the wound care book. The DON said the nurses are responsible for transcribing orders in the residents' medical records. The DON said if staff questioned the orders, they would need to clarify with the physician or other provider. There is no auditing system in place to ensure the orders are transcribed accurately in the resident's medical record. If staff did not follow wound care orders, there is the potential a wound could become infected. He/She said he/she did notice staff did document providing treatments on the TAR. He/She said he/she had not had an opportunity to review why there were undocumented treatments, so he/she did have a reason why. He/She said staff have to select to add the order to the TAR or the order will not transfer over to the TAR. He/She said During an interview on 10/25/24 at 1:26 P.M., the administrator said the nurse would get the orders from the wound care nurse, or physician, based on what was observed. He/She said the orders are transcribed by the nurse into the resident's medical record. He/She said if the nurse had questions about the orders, he/she would clarify with the nurse practitioner or the physician. He/She said there was no audit in place to ensure the orders were transcribed accurately into the resident's medical record. He/She said the staff were expected to double check the information being entered for accuracy. He/She said when a resident goes to an appointment outside the facility, they do have communication with the physician. He/She said the resident, family member, or attendant were given paperwork to give to the physician's office, which included, the facility fax number to fax over new physician orders. He/She said if staff did not follow wound care orders, there was a potential to cause an infection in the wound. MO00243904

Based on observation, interview and record review, facility staff failed to follow applicable laws and regulations when the staff failed to screen four staff (Licensed Practical Nurse (LPN) D, Certified Nurse Assistant (CNA) J, Dietary Aide (DA) L, and DA M) of 10 staff sampled for Tuberculosis ((TB) a bacterial infection that affects the lungs). The facility staff failed to ensure dietary staff performed hand hygiene as often as necessary using approve techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility's policy titled TB Testing and Screening-Employee, revised December 2010 showed: -All employees and volunteers of eight or more hours per month will receive a Mantoux two-step test, a skin test that can help determine if someone has TB; -Employees and volunteers will received the first step TB test prior to resident contact. 2. Review of LPN D's personnel file showed: -First step TB placed 07/05/24 and read 07/08/24; -The file did not contain a second step TB test. Review of LPN D's time card showed his/her first day worked as 07/08/24. 3. Review of CNA J's personnel file showed: -First step TB placed 08/07/24 and read 08/09/24; -The file did not contain a second step TB test. Review of CNA J's time card showed his/her first day worked as 08/07/24. 4. Review of DA L's personnel file showed: -First step TB placed 08/07/24 and read 08/09/24; -The file did not contain a second step TB test. Review of DA L's time card showed his/her first day worked as 08/09/24. 5. Review of DA M's personnel file showed: -First step TB placed on 05/24/24 and read on 05/27/24; -Second step TB placed on 06/07/24 and read on 06/10/24. Review of DA M's time card showed his/her first day worked as 05/20/24. During an interview on 09/04/24 at 10:12 A.M., the administrator said the former Minimum Data Set (MDS) nurse had been responsible to complete and monitor employee TB tests. The administrator said he/she hired a new MDS nurse this week who will be responsible for completing TB tests after he/she finishes orientation. The administrator said he/she has not asked the new MDS nurse to start the TB testing yet as he/she is new. The administrator said he/she did not know new hire TB tests were not completed timely and he/she did not know why as the staff member responsible for completing them quit two weeks ago and will not respond to phone calls. During an interview on 09/06/24 at 11:03 A.M., the MDS nurse said he/she started at the facility this week and had not been instructed to complete the employee TB screenings. 6. Review of the facility's Glove and Hand Washing Procedures policy, dated 2011, showed: -All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines; -All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between all tasks. Hand washing should occur at a minimum of every hour; -Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual residents; -Hands are washed before donning gloves and after removing gloves; -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surfaces, such as door handles and equipment; -Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, remove gloves and wash hands again; -When gloves must be changes, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedures is always wash, glove, remove, rewash, and re-glove; -The proper procedure for washing hands is as follows: a. Turn on the water as hot as comfortable; b. Wet hands and apply soap; c. Scrub hands with soap 15 to 20 seconds or more; d. Rinse hands thoroughly; e. Dry hands with a paper towel or air dryer; f. Turn off the faucet with a paper towel. Observation on 09/05/24 at 9:44 A.M., showed [NAME] P entered the kitchen and washed his/her hands as the handwashing sink. Observation showed the cook scrubbed his/her hands with soap for two seconds when he/she washed his/her hands and then turned the faucet off with his/her bare hands. Observation showed the cook then continued to prepare zucchini for service to residents at the lunch meal. Observation on 09/05/24 at 9:58 A.M., showed DA Q entered the kitchen and washed his/her hands at handwashing sink. Observation showed the DA scrubbed his/her hands with soap under running water when he/she washed his/her hands. Observation on 09/05/24 at 10:05 A.M., showed, when DA R washed his/her hands at the handwashing sink, the DA used paper towels to turn off the faucet and then used the same paper towels to dry his/her hands. Observation on 09/05/24 at 10:11 A.M., showed DA R entered the kitchen from taking out trash and washed his/her hands at the handwashing sink in mechanical dishwashing station. Observation showed, after the DA washed his/her hands, he/she dried his/her hands with paper towels, used the same paper towels to turn off the faucet and then reused the same paper towels to continue to dry his/her hands. During an interview on 09/05/24 at 10:12 A.M., DA R said a paper towel is used to turn off the faucet so you do not get your hands dirty again. The DA said he/she did not think about that when he/she used the same paper towel he/she used to turn off the faucet to dry his/her hands that he/shed would make his/her hands dirty again. Observation on 09/05/24 at 10:30 A.M., showed when DA S washed his/her hands at the handwashing sink, the DA scrubbed his/her hands with soap for three seconds. Observation showed the DA also turned the faucet off with a paper towel and then used same paper towel to dry his/her hands. During an interview on 09/05/24 at 10:31 A.M., DA S said a paper towel is used to turn off the faucet so you do not make your hands dirty again. The DA said different paper towels should be used to turn off the faucet and dry hands, but he/she just did not think about it when he/she used the same paper towels. The DA also said, when staff wash their hands, they should scrub their hands with soap for three minutes and he/she did not know why he/she did not do so. Observation on 09/05/24 at 10:34 A.M., showed DA Q washed his/her hands at the handwashing sink, the DA spread soap on his/her hands and then scrubbed his/her hands with soap under running water. During an interview on 09/05/24 at 10:36 A.M., DA Q said staff should scrub their hands with soap for 15 seconds out of the water when they wash their hands and he/she did not realize that he/she did not do so. Observation on 09/05/24 at 10:45 A.M., showed [NAME] P used the manual can opener to open a can of pasta sauce with gloved hands and poured the sauce into a pan. Observation showed the cook removed his/her soiled gloves and then, without performing hand hygiene, donned new gloves and put away sanitized dishes from the mechanical dishwashing station. Observation showed the cook then loaded soiled dishes with gloved hands, removed his/her soiled gloves and washed his/her hands at the handwashing sink in the mechanical dishwashing station. Observation showed, when the cook washed his/her hands, the cook spread soap on his/her hands and then scrubbed his/her hands under running water. Observation showed the cook donned new gloves and then continued to prepare food items for service to residents at the lunch meal. Observation showed the cook put pot holders on over his/her gloves, removed the pot holders and then continued to prepare food items with the same gloved hands. Observation showed the cook then removed his/her soiled gloves and, without performing hand hygiene, put away sanitized dishes from the clean side of the mechanical dishwashing station. During an interview on 09/05/24 at 10:55 A.M., [NAME] P said staff should wash their hands when they get dirty. The cook said staff should scrub their hands with soap for 15 seconds when they wash their hands, turn the faucet off with a paper towel and use a different paper towel to dry their hands. The cook said he/she did not know why he/she used the same paper towels to that he/she used to turn off the faucet to dry his/her hands other than he/she was in a hurry. The cook said he/she did not know that he/she needed to scrub his/her hands with soap out of the water when he/she washed his/her hands or that hand hygiene should be done between glove changes. During an interview on 09/05/23 at 2:18 P.M., the Certified Dietary Manager (CDM) said staff should perform hand hygiene when they enter the kitchen, before they prepare food, between glove changes, between tasks and after they touch anything dirty. The CDM said staff should scrub their hands with soap for 15 seconds, out of the water, and turn the faucet off with a paper towel when they wash their hands. The administrator said staff should not dry their hands with the same paper towel used to turn off the faucet because it would recontaminate their hands. The CDM said all staff are trained on proper hand hygiene procedures upon hire and as needed. During an interview on 09/06/24 at 1:25 P.M., the administrator staff should perform hand hygiene when the enter the kitchen, after they touch anything dirty, after glove use and between tasks. The administrator said staff should scrub their hands with soap for 20 to 40 seconds, out of the water, and turn the faucet off with a paper towel when they wash their hands. The administrator said staff should not dry their hands with the same paper towel used to turn off the faucet and all staff are trained on proper hand hygiene procedures upon hire. 48982

Based on record review and interview, facility staff failed to maintain an accurate accounting system for resident fund bank statement matched the reconciliation for March 2024 to July 2024, and failed to provide quarterly bank statements to the residents. The facility held funds for 25 residents. The facility census was 54. 1. Review of the facility's policy titled Resident Trust Fund, undated, showed: -Upon written request of the resident or responsible party, the facility must hold, safeguard, manage, and account for the resident's personal funds through the Resident Trust Fund; -Transactions are to be entered daily or as they occur so that the balance for each resident can be accessed at anytime during the day; -Resident statements will be sent out quarterly. 2. Review of the facility's bank statements, dated March 2024 through July 2024, showed the statements did not contain monthly reconciliation. 3. Review of the facility's bank statements, dated 09/06/24, showed the facility bank statements showed they did not contain first quarter bank statements. 4. During an interview on 09/05/24 at 4:53 P.M., the administrator said the facility's accounting records have not been getting reconciled monthly and residents have not been getting their quarterly bank statements since the former BOM retired in February 2024. The administrator said no quarterly statements have been sent out in 2024. The administrator said the Corporate Accounts Receivable (AR) is responsible to reconcile the accounts, and the Corporate BOM is responsible to complete and email the quarterly statements to him/her for distribution. The administrator said he/she has not gotten quarterly statements to distribute this year but did contact corporate to ask for them. During an interview on 09/06/24 at 12:00 P.M., the Corporate AR said the Corporate BOM is responsible to send the quarterly statements to the Administrator for distribution. The Corporate AR said he/she is not sure if the statements had been sent or not for this year. The Corporate AR said accounts should be reconciled monthly but he/she said due to the transition it did not happen as it should have said the ball got dropped. The Corporate AR said he/she reconciled the accounts this week and sent them to the Administrator as he/she completed them. During an interview on 09/06/24 at 12:45 P.M., the Corporate BOM said he/she is responsible to complete the quarterly bank statements and email the statements to the administrator to distribute to the resident or their responsible party. The Corporate BOM said he/she took this role about a month ago and he/she sent the second quarter statements to the Administrator today. The Corporate BOM said he/she is not sure if the first quarter statements were sent or not because he/she had not been responsible for them at that time. The Corporate BOM said it took him/her extra time to send the second quarterly statements because he/she had to sort the information out. The Corporate BOM said the statements sent today were late and should have been sent in July.

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #5, #31, #44, and #48) out of 15 sampled residents. The facility census was 54. 1. Review of the facility's policy titled Comprehensive Care Plans Policy and Procedure, revised [DATE], showed: -The comprehensive care plan contents include areas identified through the Minimum Data Set (MDS) (a federally mandated assessment tool) process, the resident's medical condition, and other risk or problem areas identified through assessment; -Care plan is to be updated quarterly and as needed to reflect the resident's current needs, goals, and interventions. 2. Review of Resident #5's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognition impairment; -Received hospice services. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed an order for hospice services with a start date of [DATE]. Review of the resident's care plan, revised [DATE], showed the care plan did not contain direction for hospice services. Observation on [DATE] at 12:40 P.M., showed hospice staff visited the resident. 3. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's POS, dated [DATE], showed an order for staff not to perform Cardiopulmonary Resuscitation (CPR) with a start date of [DATE]. Review of the resident's care plan, revised [DATE], showed staff documented the resident as both a full code (to perform CPR) and to not perform CPR. 4. Review of Resident #44's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Had pressure ulcers. Review of the resident's POS, dated [DATE], showed an order for moon boots (pressure relief boot) to be on at all times except while bathing. Review of the resident's care plan, revised [DATE], showed the care plan did not contain direction for moon boots. Observation on [DATE] at 8:00 A.M., showed the resident in bed and did not have moon boots on his/her feet. Observation on [DATE] at 6:00 A.M., showed the resident in bed and did not have moon boots on his/her feet. Observation on [DATE] at 8:50 A.M., showed the resident in bed and Licensed Practical Nurse (LPN) A performed a skin treatment to both of the resident's heels and did not put the resident's moon boots on him/her. During an interview on [DATE] at 1:13 P.M., LPN A said he/she knows the resident has orders for moon boots but he/she forgot to put the boots on the resident. Observation on [DATE] at 9:10 A.M., showed the resident in bed and did not have moon boots on his/her feet. 5. Review of Resident #48's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Had behaviors; -Received hospice services. Review of the resident's POS, dated [DATE], showed orders on: -[DATE] for Hospice Services; -[DATE] for Wander guard, check placement each shift. Review of the resident's elopement assessment, dated [DATE], showed staff assessed the resident as an elopement risk. Review of the resident's nurse's notes, dated [DATE], showed LPN C documented the resident's family member expressed concerns about the resident wandering because the resident had previously eloped from a different facility. LPN C documented he/she contacted the resident's physician and obtained orders for a wander guard. Review of the resident's weights showed showed staff documented: -[DATE]: 130.0 pounds (lbs); -[DATE]: 126.4 lbs; -[DATE]: 120.6 lbs; -[DATE]: 118.2 lbs. Review of the resident's care plan, revised [DATE], showed it did not contain direction for staff in regard to the resident's cognitive status, elopement risk, wandering, wander guard placement, weight loss, or hospice services. Observation on [DATE] at 5:00 P.M., showed the resident wandered the dining room in his/her wheelchair. Observation on [DATE] at 6:45 A.M., showed the resident ambulated in the hall and wandered into another resident's room. Observation on [DATE] at 7:25 A.M., showed the resident ambulated with staff to the assisted table in the dining room. Observation showed the resident stood up and wandered away. CNA F assisted the resident back to the table and sat him/her down. Observation showed CNA F walked away and the resident stood up and wandered away from the table through the dining room. Observation showed CNA F assisted the resident back to the table and sat him/her down. Observation showed CNA G assisted the resident to drink his/her juice. Observation on [DATE] at 9:35 A.M., showed the resident hollered out incoherently. During an interview on [DATE] at 6:40 A.M., LPN B said the resident wanders in his/her wheelchair or ambulates through the facility. LPN B said the resident has attempted to go out the door and wears a wander guard. During an interview on [DATE] at 9:10 A.M., the administrator said the resident receives hospice care. 6. During an interview on [DATE] at 8:45 A.M., the MDS Coordinator said he/she is responsible to update all care plans and he/she started at the facility about a week ago, is still in orientation. The MDS Coordinator had not reviewed all the resident's care plans. The MDS Coordinator said care plans should be updated quarterly and as needed with any changes. The MDS Coordinator said he/she receives changes in resident conditions each morning at the facility meeting. The MDS Coordinator said the DON talks to the charge nurse prior to the meeting and brings any concerns or changes to the meeting. The MDS Coordinator said he/she updates the care plans as needed after each meeting. The MDS Coordinator said a care plan's purpose is to drive the resident's care needs and direct staff on how to care for a resident. He/She said care plans should be individualized and match the resident's POS. The MDS Coordinator said a care plan should contain things such as moon boots, code status, wandering, elopement risk, hospice services, cognitive level, the amount of assistance a resident requires, behaviors, special equipment used, skin interventions, and weight loss. During an interview on [DATE] at 11:18 A.M., LPN B said he/she has access to the resident care plans. LPN B said the purpose of a care plan is to show staff how to care for a resident and any special devices they need. LPN B said a care plan should be individualized and match the POS. LPN B said he/she would expect a care plan to have weight loss interventions, skin interventions, any special devices a resident uses, code status, cognitive level, wandering, elopement risk, behaviors, and the amount of care a resident requires. During an interview on [DATE] at 11:24 A.M., CNA I said he/she has access to the care plans. The care plan is what shows staff how to care for a resident. During an interview on [DATE] at 12:30 P.M., the DON said the MDS Coordinator is responsible to update the care plans. The DON said the prior MDS Coordinator walked out two weeks ago, and had not answered her phone since. The DON said the care plan should be individualized and match the POS. The DON said the purpose of a care plan is to let staff know how to take care of a resident, to show a resident's preferred choices, and interest. The DON said he/she would expect the care plan to have things such as how much assistance a resident needs, how the resident transfers, code status, weight loss, moon boots, elopement risk, wandering, any behaviors, cognitive level, and any special equipment such as a wander guard. The DON said he/she talks to the charge nurse each morning then takes any changes or issues to the morning meeting to be discussed. The DON said the MDS Coordinator attends the meeting and will update the care plan if needed after it. The DON said the care plan should be updated quarterly and as needed with any changes. The DON said each quarter the care plan team meets with the resident and/or family and go over the care plan to ensure it is updated correctly.

Based on interview and record review, facility staff failed to complete pre-employment screenings Criminal Background Check (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nursing Aide (CNA) Registry for six employees (Housekeeper N, Dietary Aide (DA) K, Licensed Practical Nurse (LPN) D, CNA J, DA L, and CNA I) of 10 employees sampled. The facility census was 54. 1. Review of the facility's policy titled Recruitment and Hiring, revised March 2024, showed: -The facility will follow all state and federal laws regarding hiring practices; -The Human Resources (HR) department will process all pre-hire screenings within one or two business days of receiving documentation from the hiring manager; -CBC; -EDL verification; -FCSR verification; -Verify all license and certification; -Review showed the policy did not contain direction for staff in regard to checking the CNA registry. 2. Review of Housekeeper N's personnel file showed: -Date of hire 04/26/23; -Did not contain documentation of a CNA registry verification. Review of the housekeeper's timecard showed his/her first day worked as 05/01/23. 3. Review of DA K's personnel file showed: -Date of hire 07/10/23; -Did not contain documentation of a CNA registry verification. Review of the DA's timecard showed his/her first day worked as 07/13/23. 4. Review of LPN D's personnel file showed: -Date of hire 07/08/24; -Did not contain documentation of a FCSR, EDL or CNA registry verification. Review of the LPN's timecard showed his/her first day worked as 07/08/24. 5. Review of CNA J's personnel file showed: -Date of hire 08/07/24; -Did not contain documentation of a CNA registry verification. Review of the CNA's timecard showed his/her first day worked as 08/07/24. 6. Review of DA L's personnel file showed: -Date of hire 08/07/24; -Did not contain documentation of a CNA registry verification. Review of the DA's timecard showed his/her first day worked as 08/09/24. 7. Review of CNA I's personnel file showed: -Date of hire 08/14/24; -Did not contain documentation of a FCSR, EDL or CNA registry verification, Review of the CNA's timecard showed his/her first day worked as 08/14/24. 8. During an interview on 09/04/24 at 10:12 A.M., the administrator said the former Business Office Manager (BOM) had been responsible to complete the pre-employment screenings for new hires. The administrator said the former facility BOM retired in February, and the facility has not had a BOM since. The administrator said after the facility BOM retired the corporate HR is responsible to complete the pre-employment screenings. During an interview on 09/06/24 at 12:18 P.M., the Administrator said he/she did not know the screenings had not been completed and did not know why they had not been completed. The Administrator said the corporate HR person is new and had only been with the company for one month.

Based on record review and interview, facility staff failed to provide refunds of personal funds to residents from the facility operating account within 30 days for six residents (Resident #212, #209, #211, #207, #208, and #210) who were discharged from the facility. The facility census was 54. 1. Review of the facility's policy titled Resident Trust Fund, undated, showed upon written request of the resident (or responsible party), the facility must hold, safeguard, manage, and account for the resident's personal funds. 2. Review of the facility's-maintained Account Receivable Aging report, dated 09/05/24, showed resident's with personal funds held in the facility operating account: -Resident #212 had a balance of $5671.11 with a discharge date of [DATE]. -Resident #209 had a balance of $78.80 with a discharge date of [DATE]; -Resident #211 had a balance of $3126.00 with a discharge date of [DATE]; -Resident #207 had a balance of $6922.04 with a discharge date of [DATE]; -Resident #208 had a balance of $630.00 with a discharge date of [DATE]; -Resident #210 had a balance of $5604.00 with a discharge date of [DATE]; During an interview on 09/04/24 at 2:10 P.M., the administrator said the former Business Office Manager (BOM) retired in February of this year and the facility has not had a BOM since. The administrator said corporate is responsible to complete bank reconciliations and any Aging Reports. During an interview on 09/05/24 at 2:38 P.M., the administrator said he/she did not know the facility still held funds for the discharged residents. The administrator said he/she did not know why residents who were no longer at the facility had an outstanding balance because the corporate team took on this responsibility after the previous BOM retired. The administrator said corporate is responsible to file the proper paperwork and ensure the discharged resident's money is returned. During an interview on 09/06/24 at 12:00 P.M., the Corporate Accounts Receivable (AR) said he/she is responsible for reviewing the AR report. The Corporate AR said the AR report should be reviewed monthly for outstanding balances and credits. He/She said this had not been done due to the transition from the previous BOM to the corporate team. The corporate AR said any outstanding balances and credits should be investigated, and after it is investigated the money should be refunded within 30 days. The corporate AR said he/she is currently working on refunding the outstanding balances and said the ball got dropped.

Based on interview and record review, facility staff failed to notify one resident's (Resident #1) family and physician in a timely manner when staff identified the residents second and third toes on his/her right foot swollen, red, white, macerated, draining serosanguinous fluid (contains or relates to both blood and the liquid part of blood (serum) which resulted in the resident being sent to the hospital and his/her second right toe amputated. The facility census was 50. 1. Review of the facility policy change of condition, revised February 2019, showed staff are directed to observe, record, and report any condition change to the attending physician to ensure proper treatment will be implemented. Review showed staff are directed to notify the resident's responsible party. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/27/23, showed staff assessed the resident's diagnoses included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), cellulitis (infection of the deep tissues of the skin and muscle) of the right lower limb, diabetes mellitus (group of diseases that result in too much sugar in the blood), diabetic neuropathy, and dementia. Review of the resident's plan of care, updated 1/17/24, showed staff assessed the resident with impaired skin integrity due to history of rashes and sores on feet and toes. Review showed staff identified the resident diagnosed with diabetes mellitus. Review showed staff documented interventions to monitor, document, and report as needed any signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation. Review showed staff are to check the residents skin for breaks and treat promptly as ordered by doctor. Review of the resident's nurses notes, dated 2/22/24 at 6:26 A.M., showed staff documented the resident with a blister like reddened are on his/her right foot great toe. Review showed staff covered the area with a dressing. Review of the resident's nurses notes, late entry for 2/25/24 at 6:45 A.M., created 2/28/24 at 2:38 P.M., showed Licesned Practical Nurse (LPN) C documented the resident's right foot second toe red and swollen. Review showed LPN C documented he/she reported to the day shift nurse to consult physicain with condition and addtitional orders. Review of the resident's nurses notes, late entry for 2/25/24 at 2:58 P.M., created 2/28/24 at 3:04 P.M., showed LPN A documented the resident right foot toes blisters opened, foul odor, and purulent (containing or producing pus) drainage present. Review showed the nurses note did not contain documentation staff notified the doctor or family of the change in condition. Review of the resident's nurses notes, dated 2/28/24 at 4:29 P.M., showed LPN C documented the residents second and third toes on right foot swollen, red, white, macerated, draining serosanguinous fluid and very foul odor. Review showed LPN C documented the bulb of toes completely open and macerated (the softening and breaking down of skin). Review showed the wound nurse consulted and advised to send the resident to the emergency room for evaluation and rule out osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection). Review of the resident's emegency room paperwork, dated 2/28/24 showed hospital staff documented primary diagnosis as Type 2 diabetes mellitus with diabetic foot infection with redness, swelling, and drainage noted to right 2nd toe. Review of the hospital medical records, dated 2/29/24 through 03/02/24, showed staff documented an impression of cellulitis around the foot particularly around the 2nd and 3rd toes, ulceration along the distal aspect and plantar aspect of the 2nd toe, and necrotic (the death of body tissue) tissue on the 2nd toe with probable osteomyelitis and septic arthritis. Review showed hospital staff documened the final diagnoses included type 2 diabetes mellitus with foot ulcer, type 2 diabetes with diabetic peripheral angioplasty (disease of the blood vessels) with gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), other acute osteomyelitis of the right ankle and foot, gangrene and cellulitis of the right toe. Review showed the operation notes, dated 3/2/24, amputation of the second toe of the right foot and debridement (removal) of necrotic wounds on the third toe of the right foot. During an interview on 3/11/24 at 10:45 A.M., LPN A said he/she observed foul, purulent-looking drainage on 2/25/24, and he/she noticed blisters on the resident's three toes on the right foot had popped and were draining. LPN A said he/sh planned on calling the doctor but got busy and forgot. During an interview on 3/11/24 at 2:17 P.M., the Director of Nursing (DON) said he/she is not aware of staff calling the residents doctor after LPN A observed the residents toes on 2/25/24 until 2/28/24. During a telephone interview on 3/12/24 at 9:48 A.M., the resident's family member said when the resident went to the hospital on 2/28/24, hospital staff found the resident had a staph infection in his toes and removed the 2nd toe on his/her right foot. During a telephone interview on 3/12/24 at 12:29 P.M., LPN C said he/she worked the overnight shift from 2/24/24 to 2/25/24. LPN C said when he/she observed the resident's foot at 5:00 A.M. on 2/25/24 the 2nd toe on the right foot was red, angry, and swollen. LPN C said he/she told the day shift nurse to call the doctor about the toe and get an order. LPN C said on 2/25/24, the 2nd toe appeared like it needed a treatment order from a physician. LPN C said when he/she removed the resident's right sock on 2/28/24, the right sock had drainage saturated on it which smelled terrible, the whole top of the foot was red, the pads on the bottom of the 2nd and 3rd toe were visibly open, and both toes were dripping serosanguinous drainage. LPN C said he/she came in early in the morning on 2/28/24 and the wound nurse was on-site at the time, so he/she asked the wound nurse to look at the resident's toes. LPN C said later in the day, he/she discovered the wound nurse had left without examing the resident's toes. LPN C said he/she observed the foot and then called the wound nurse and the physician to update them on the condition. The LPN said the wound nurse and physician advised sending the resident out to the emergency room for evaluation and treatment. During a telephone interview on 3/12/24 at 3:11 P.M., the resident's physician said if staff observed a resident's toes with foul-smelling purulent drainage, he/she expected staff to notify him/her of this on the same day. During a telephone interview on 3/14/24 at 8:57 A.M., LPN A said he/she forgot to notify the resident's family about the toe on 2/25/24 because he/she was so busy that day. During a telephone interview on 3/20/24 at 9:27 A.M., the DON said given the condition of the resident's foot as observed by LPN A on 2/25/24, he/she would have expected staff to notify both the physician and family as soon as possible. He/She did not know why staff failed to do so. MO00232536 & MO00232506

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for four residents (Residents #2, #3, #6, and #7) out of 15 sampled residents. For Resident #2, facility staff failed to prevent the development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (dead tissue- tan, brown, or black) in the wound bed) on the coccyx, with the wound bed infected [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus -a bacteria that is resistant to certain antibiotics). For Resident #3, facility staff failed to prevent the development of an unstageable heel pressure ulcer and a Stage IV (full thickness tissue loss) pressure ulcer on the right buttocks. For Resident #6, the facility staff failed to assess a facility acquired Stage II (partial-thickness tissue loss) pressure ulcer on the coccyx. For Resident #7, facility staff failed to prevent and accurately assess the development of a facility acquired Stage II pressure ulcer on the buttock. Staff failed to document complete information on skin assessments, failed to provide weekly skin assessments to monitor potential problem areas or detect areas of altered skin integrity before they worsened, and failed to update the resident's plan of care with new interventions to prevent pressure ulcers, after a decline in health. The facility census was 65. 1. Review of the facility's Nursing Services Department Policy and Procedure Manual, dated 9/2004, regarding Pressure Sore Care, showed the following: Purpose- To present information of pressure sores and/ or prevent deterioration of existing pressure sores; Causes; 1. Moisture from perspiration, urine, feces and/or vaginal discharge; 2. Inadequate nutrition; 3. Inadequate fluid intake; 4. Impaired circulation; 5. Lack of cleanliness; 6. Improper or careless transferring causing bruising or other injury; 7. Wrinkles, lumps, crumbs, etcetera, in bedding and chairs; 8. Fragile skin caused by the aging process; 9. Skin touching skin; 10. Pressure on bony prominence; Warning Signals- Direct care givers are to observe daily for the following signs of potential decubitus (pressure ulcer) signs and report accordingly and licensed nurse will do a comprehensive skin assessment weekly; 1. Redness or a darker, deeper bruise-like color; 2. Heat; 3. Tenderness; 4. Pain or discomfort; 5. Cracks in skin; 6. Excessive dryness; 7. Sores, cuts or abrasions; Report any changes of condition to the charge nurse; Prevention; 1. Frequent application of lotion, or approved ointment to skin surfaces with special attention to pressure prone areas; 2. Frequent turning and/or repositioning every two hours or as specified on the individualized plan of care; 3. Use of anti-pressure devices; - Air mattress to bed; - Specialty mattress to bed; - Air cushion to wheelchair; 4. Backrubs to stimulate circulation and relax muscles; 5. Keep resident clean and dry; 6. Encourage adequate food and fluid intake; 7. Careful handling of resident during care and transferring; 8. Straighten and tighten sheets and chair pads frequently; 9. Pad skin-on-skin areas with soft material; Procedure; 1. Observe turning/positioning plan as defined in the Resident Plan of Care; 2. Observe reddened or pressure sore prone areas; 3. Wash skin area with approved cleanser; 4. Apply lotion, or approved ointment; 5. Place clean linen on bed if necessary; 6. Tighten linen (must be free from wrinkles); 7. Position resident according to plan of care; 8. Report any abnormalities to Charge Nurse; Treatment- To be done by licensed personnel or Rehabilitation Therapist; Objective- To promote healing of existing pressure sores to protect an area from contamination; 1. Newly reported pressure ulcers are to be assessed as soon as reasonably possible with EZ graph (skin assessment form) completed; 2. Notify physician of pressure sore and obtain treatment orders (refer to Clinical Practice Quick Reference Guide to assist with assessment and treatment options); 3. If pressure ulcer is assessed as Stage II (partial thickness skin loss involving epidermis, dermis, or both, and presents as an abrasion, blister or shallow crater) or greater, a nutritional consult is to be initiated; 4. Treatment summaries for pressure sores are to be completed on the EZ graph weekly and should include; a. Location; b. Size- width, length, and depth; c. Stage I (non-blanchable [DIAGNOSES REDACTED] (redness) of intact skin), stage II, stage III (full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down, but not through underlying connective tissue), or stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure); d. Appearance of wound; i. Signs and symptoms of infection; ii. Any granulating tissue (new connective tissue) noted; iii. Color of wound tissue and surrounding tissue; e. Continuation of current treatment or new treatment order; **COMPLETE ABOVE ON EACH PRESSURE SORE** 5. Notify physician if no improvement after two weeks of treatment. 2. Review of the facility's E-Z Graph Wound Assessment System form shows staff are directed to document wound location, treatments being used, measurements, wound characteristics, and staff interventions to prevent the development of additional wounds, or the worsening of current wounds. Review showed staff are directed to document the location of the wound by placing the dot in the center of the graph over the wound and aim the top of the graph towards the resident's head. 3. Observation on 11/25/13 at 3:30 P.M. showed Resident #2 up in his/her wheelchair in his/her room. During an interview at that time, the resident said he/she acquired a wound on his/her tailbone while at the facility. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/29/13, showed staff assessed the resident as: - Able to recall two out of three words without cueing, on the Brief Interview for Mental Status; - Poor appetite or overeating, two to six days; - Rejection of care, not exhibited; - Extensive assistance and two plus persons physical assist for transfers; - Extensive assistance and one person physical assist for dressing, toilet use and hygiene; - Physical help and one person physical assist for bathing activity; - Impairment on one side, upper and lower extremities; - Indwelling catheter; - Occasionally incontinent of bowel; - [DIAGNOSES REDACTED]. - Occasional mild pain; - Weight- 129 pounds (lbs); - At risk for developing pressure ulcers; - No pressure ulcers; - Pressure relieving device to bed and chair; - Turning/repositioning program; - Nutrition or hydration intervention to manage skin problems. Review of the resident's plan of care, updated 8/29/13, showed staff are directed as follows: - Resident will be assisted as needed with Activities of Daily Living (ADL's); - One aide as needed to help resident: roll over in bed, transfer from one place to another, propel the wheelchair, get dressed and undressed; - Provide pericare after resident has an accident; - May apply a protective barrier as needed; - Resident wears pull-ups and need staff to change these; - 2/19/13- Gel cushion; - 5/11/13- No pressure ulcers, is still at some risk, assist with bed mobility; - 8/04/13- Open area to coccyx; - 8/05/13- At risk, anti-pressure devices chair, bed, toilet, treat with Replicare (a [MEDICATION NAME] wound dressing), monitor for signs and symptoms of infection and for healing; - 8/05/13- Weight 128.6 lbs- stomach issues, nausea, emesis (vomiting), feeds self, appetite poor- fair, eating smaller portions; - 8/29/13- add supercereal at breakfast due to weight loss; - At risk for skin breakdown; - Anti-pressure mattress on the bed, wheelchair cushion; - Help in and out of easy chair; - Nurse will do Braden Scale (a tool used for predicting pressure ulcer risk) quarterly and as needed; - Pericare, protective ointment; - Monitor skin, float heels, follow nutritional plan. Review of the resident's plan of care, updated 11/20/13, showed staff are directed as follows: - Resident will be assisted as needed with ADL's; - One to two aides as needed to help resident: roll over in bed, transfer from one place to another, propel the wheelchair, help resident get dressed and undressed; - Resident does not wear briefs or pull-ups; - Pericare; - Anti-pressure bed, cushion in wheelchair, soft easy chair; - Braden Scale, pericare, protective ointment; - Monitor skin, float heels, follow nutritional plan; - Resident had an ulcer debrided (dead tissue removed) on tailbone area, it was not big before, but now it is bigger; - Treat this per physician's orders [REDACTED]. - Change position every two hours in bed and chair; - 10/10/13- Bed bath only. No baths or showers due to pressure ulcer; - 10/10/13- Went to wound clinic. New order protein supplement three times daily; - 10/10/13- Culture and X-ray, treatment changed; - 10/14/13- [MEDICATION NAME] (an antibiotic) times ten days; - 10/30/13- Treat ulcer on bottom as ordered by physician. Tylenol (a nonopioid [MEDICATION NAME]) as needed; - 10/31/13- Wound clinic, treatment changed; - 11/01/13- Resident tends to pick at dressing; - 11/13/13- Due to sore on bottom resident has not been sitting in his/her recliner much, but rather resting in bed; - 11/13/13- Turn every two hours; - 11/13/13- Resident needs to change position every two hours in bed and at other times to relieve discomfort. Keep physician informed of changes in pain; 11/20/13- Roho (a pressure relieving cushion). Further review of the resident's care plans showed staff did not update the resident's plan of care regarding the resident's increased risk for developing pressure ulcers due to depression and non-compliance with repositioning, as described by staff. Review of the resident's Nursing Comprehensive Assessment, Braden Risk Assessment Scale (a tool used for predicting pressure ulcer risk), dated 7/29/13 showed staff assessed the resident with a score of 17. Review showed if staff assess a resident with a score of 18 or less and/or a history of pressure ulcers, staff are directed to initiate a preventative program and care plan. Review of the resident's E-Z Graph Wound Assessment System form, dated 8/10/13, showed staff documented the following: - Location- Right buttock; - Treatment- Replicare; - Stage II; - Pink wound base; - No drainage, odor, eschar, undermining (the wound is open underneath the boarder) or tunneling (a tunnel of tissue). Further review showed staff did not document the measurements of the wound or interventions to prevent the development of additional pressure ulcers, or the worsening of the current pressure ulcer, as directed. Review of the resident's nurse's notes showed staff documented the following: - 9/13/13- Resident noted with dime sized open area with pink center, appears like the top layer of skin has been sheared off; - Treatment received for Replicare; - Resident seems more depressed not wanting to watch television, eat, is losing weight and only wants to lie down. Review of the resident's E-Z Graph Wound Assessment System form, dated 9/19/13, showed staff documented the following: - Location- Right and left buttocks; - Treatment- Replicare; - Wound on right buttock measured 2.2 centimeters (cm) in length by 1.0 cm in width; - Wound on left buttock measured 2.3 cm in length by 1.5 cm in width; - Pink wound base, left and right buttocks wounds; - No drainage, odor, eschar, undermining or tunneling; - Interventions include anti-pressure mattress and chair cushion, turning and repositioning every two hours, and dietary supplements. Further review showed staff did not document the stage of the wounds on the resident's right or left buttocks. Review of the resident's E-Z Graph Wound Assessment System form, dated 9/26/13, showed staff documented the following: - Location- Coccyx; - Treatment- Allevyn (a wound dressing) non-adhesive; - Wound base pink/yellow; - Drainage- moderate serous (clear, thin, watery fluid); - Periwound clear; - Eschar/slough present; - No odor, undermining or tunneling; - Interventions include anti-pressure mattress and chair cushion, positioning device, turning and repositioning every two hours, treatment changed, and dietary supplements. Further review showed staff did not document the measurements or the stage of the wound. Review of the resident's Physician order [REDACTED]. - 8/04/13- Replicare apply to coccyx, change every three days; - 9/26/13- Allevyn non-adhesive to coccyx, change every three days and as needed. Review of the resident's physician's notes, dated 9/27/13, showed the physician documented, " He/she has developed a sore on his/her sacrum or coccyx area during the last month, I am told. He/she needs circulating mattress bed and change positions every two hours round the clock. The tape is making him/her sore and he/she needs to see physical therapy for sitz bath and get the area cleaned up. We should stop using tape of any kind. Physical therapy may be able to help get a foam cushion to keep pressure off his/her sacrum and coccyx. The bandage will need to be changed at least twice a day for now. Will use silver [MEDICATION NAME] (a chemical compound wound treatment) for now and wash it between changes. Previously the bandage was changed every three days. On palpation, the ulcer does not seem to go deeply. The skin is loose, but it is draining a significant amount. I am going to get a culture today. " Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/09/13, showed staff assessed the resident as: - Able to recall two out of three words without cueing, on the Brief Interview for Mental Status; - Feeling down, depressed or hopeless, never or one day; - Poor appetite or overeating, seven to eleven days; - Rejection of care, not exhibited; - Total dependence and two plus persons physical assist for bathing activity; - Extensive assistance and two plus persons physical assist for transfers, dressing, toilet use and hygiene; - Extensive assistance and one person physical assist for eating; - Physical help and one person physical assist for bathing activity; - Impairment on one side, upper and lower extremities; - Frequently incontinent of bladder; - Continent of bowel; - [DIAGNOSES REDACTED]. - Frequent moderate pain; - Weight- 110 lbs; - At risk for developing pressure ulcers; - One unstageable pressure ulcer, due to non-removable dressing/device, not present on admission; - Slough; - Pressure relieving device to bed and chair; - Turning/repositioning program; - Nutrition or hydration intervention to manage skin problems; - Ulcer care; - Application of non-surgical dressing other than to feet; - Application of ointment/medications other than to feet. Review of the resident's Braden Scale showed a score of 12 or less represents a high risk for developing pressure ulcers. Review showed staff assessed the resident with the following scores: - 10/10/13- 11; - 10/09/13- 12; - 10/14/13- 12. Review of the resident's E-Z Graph Wound Assessment System form, dated 10/02/13, showed staff documented the following: - Location- Buttocks; - Wound base red/white; - No drainage; - Periwound- [DIAGNOSES REDACTED]tous. Further review showed staff did not document the treatment, measurements or stage of the wound; drainage, odor, eschar/slough, undermining or tunneling. Review of the resident's Nursing Flow Sheet Report, dated 10/03/13, showed staff documented the resident's wound on the coccyx with redness. Further review showed staff documented on 10/09/13 the resident had a fluid filled area to the coccyx draining yellowish fluid, wound had yellow/green slough, treatment performed per order. Review of the resident's Nursing Admission History/Assessment, dated 10/02/13, showed staff documented a wound on the resident's coccyx with a white area above the wound. Review showed staff documented the resident with "complaints of pain on his/her bottom, hurting when sitting in wheelchair, has treatment of [REDACTED]. Review of the resident's Physician order [REDACTED]. - Discontinue Replicare and Allevyn; - 10/09/10- Wet to dry dressing twice daily and follow up with primary care physician for wound care referral; - 10/09/13- Wet to dry dressing twice daily until healed- Discontinued 10/10/13; - 10/09/13- Wound specialist consult; - 10/10/13- Culture and sensitivity of coccyx wound, X-ray of coccyx, change treatment to pack tunnel with [MEDICATION NAME] AG (an antimicrobial dressing), cover with Hydrogel (a non-adherent, water-based dressing) impregnated gauze, then cover with Allevyn non-adhesive and cover two times per week- Discontinued 10/24/13; - 10/10/13- No shower or bath; - 10/10/13- Cleanse coccyx wound with normal saline then pat dry, apply Zinc (a protective barrier cream) cream to periwound. May replace dressing as needed. Keep dressing dry. Vitamin C 500 milligrams (mg) twice daily protein supplement three times daily, wound care specialist; - 10/17/13- Continue dressing change as previously ordered. See at wound clinic next Thursday 10/24/13. Written order wound clinic; - 10/24/13- Discontinue [MEDICATION NAME] AG and Hydrogel dressing change. Do daily dressing change with Mesalt rope gauze (a dressing used to debride and cleanse wounds) and cover with gauze; - 10/31/13- Remove dressing and packing from coccyx wound, clean with wound cleanser, then obtain swabs of wound for culture and sensitivity. Do not refrigerate specimen. Report culture sensitivity to wound clinic. Change wound dressing to [MEDICATION NAME] AG rope, cover with Allevyn non-adhesive foam and tape two times per week. Check outer foam dressing each shift and change if at least 50 percent (%) saturated with drainage. Antifungal extra thick to any maceration around wound perimeter every shift and as needed. Review of the resident's Treatment Administration Record (TAR), dated 10/01/13 to 10/31/13, showed staff provided the following treatments: - 10/10/13- Coccyx- Pack tunnel with [MEDICATION NAME] AG, cover with Hydrogel impregnated gauze, then cover with Allevyn non-adhesive and cover two times per week, Clean wound with normal saline and pat dry. Apply Zinc cream to periwound- Discontinued 10/19/13. Review of the resident's physician's notes, dated 10/04/13, showed the physician documented, "At the bottom of his/her tailbone, he/she does have a clear hole about 2.0 cm in length by 1.0 cm wide. It has a light yellow eschar." Review of the resident's physician's notes, dated 10/09/13, showed the physician documented the following: Chief complaint, "My ass hurts". Very small ulcer is present with a very large dressing. Pressure ulcer. "I would think is a stage II." Refer to wound specialist, pain specialist, and psychiatric evaluation. Review of the resident's Wound Care Specialists form, dated 10/10/13, showed the wound clinic staff documented the resident's wound was a stage III, measuring 1.4 cm in length by 1.6 cm in width by 2.1 cm in depth. Review of the resident's Wound Care Specialists form, dated 10/17/13, showed the wound clinic staff documented the resident's wound was a stage III, measuring 1.2 cm in length by .6 cm in width by 4.2 tunneling. Review of the resident's Wound Care Specialists form, dated 10/24/13, showed the wound clinic staff documented the resident's wound was a stage III, measuring .9 cm in length by .7 cm in width by 5 cm in depth. Review of the resident's Wound Care Specialists form, dated 10/31/13, showed the wound clinic staff documented the resident's wound was a stage III, measuring .9 cm in length by .6 cm in width by 4.6 cm in depth. Review of the resident's radiology report, dated 10/31/13, showed the nurse practitioner documented, "Within the subcutaneous tissues at the end of the sacrum there is a soft tissue lesion which contains air. This lesion measures approximately 3.9 cm in length by 1.6 cm in width by 3.3 cm in depth and is most consistent with abscess which appears to communicate with the skin surface." Review of the resident's nurse's notes showed staff documented the following: - 10/13/13- Certified Nurse Aide's (CNA) and this Licensed Practical Nurse (LPN) unable to satisfy resident with constantly turning his/her, positioned his/her pillows; - Each time resident changed his/her position rolling over positioning pillow; - 10/24/13- Wound care clinic report was increased purulent (pus) drainage, tunneling at 10:00 o'clock to 12:00 o'clock, 5 cm deep. Review of the resident's Braden Scale, dated 11/13/13, showed staff assessed the resident with a score of 15. Review showed a score of 12 or less represents a high risk for developing pressure ulcers. Review of the resident's E-Z Graph Wound Assessment System form, dated 11/13/13, showed staff documented the following: - Location- Sacral Area; - Stage IV; - Wound base pink; - Drainage small serous. Review showed staff did not document the treatments, measurements of the wound, periwound, odor, eschar/slough, undermining or tunneling; or interventions to prevent the development of additional pressure ulcers, or the worsening of the current pressure ulcer, as directed. Review of the resident's POS, dated 11/01/13 to 11/30/13, showed orders directing staff to provide the following: - 11/06/13- Dakins (a solution used to eliminate germs and prevent germ growth) .25 percent (%) one-half (1/2) strength- change dressing to sacral ulcer twice daily. Soak Dakins (1/2 strength) in one-fourth (1/4) inch gauge and pack wound. Place dry dressing over gauze. Dakins only to be used for three days unless otherwise directed; - 11/21/13- Clean sacral wound then apply Collagen AG (an antimicrobial dressing) then use plain packing gauze to hold in Collagen. Change every other day. Cover with dry gauze and tape. Change outer dressing daily and as needed. Review of the resident's TAR, dated 11/01/13 to 11/30/13, showed staff provided the following treatments: - 10/10/13- Coccyx- Pack tunnel with [MEDICATION NAME] AG, cover with Hydrogel impregnated gauze, then cover with Allevyn non-adhesive and cover two times per week. Clean wound with normal saline and pat dry. Apply Zinc cream to periwound- Discontinued 10/19/13. - 11/20/13- Clean sacral wound then apply Collagen AG then use plain packing gauze to hold Collagen in. Change every other day and as needed, then cover with dry gauze, change outer dressing daily and as needed- Discontinued 11/29/13; - 11/29/13- Clean sacral wound with wound cleanser then cover with four by four gauze and tape, change dressing daily and as needed. Further review of resident's TAR, dated 11/01/13 to 11/30/13, showed staff documented administering the following: - 11/11/13 (12:00 A.M.)- [MEDICATION NAME] (an opioid [MEDICATION NAME]) 5/352 mg- bottom pain; - 11/12/13 (10:00 P.M.)- [MEDICATION NAME] 5/325 mg- Complaint of buttock pain; - 11/14/13 (9:30 P.M.)- Tylenol 325 mg- sacral pain; - 11/23/13 (12:00 A.M.)- [MEDICATION NAME] 5/325 mg- complaint of buttock/leg/hip pain; - 11/24/13 (9:30 P.M.)- Tylenol 325 mg- complaint of sacral pain. Review of the resident's physician's notes, dated 11/07/13, showed the physician documented the resident "was admitted from emergency room to hospital on [DATE] with an infected wound with [MEDICAL CONDITION]. The nurse there described it as .5 cm in length by .5 cm in width, open to the coccyx with 2.5 cm tunnel at the 12:00 o'clock area and a small amount of purulent drainage with mild odor, which patient is aware of. He/she is complaining of pain." Review of the resident's nurse's notes showed staff documented the following: - 11/01/3- Talked with resident about turning and repositioning in bed and about the turn schedule; - To be turned every 30 to 45 minutes; - 11/09/13- Cleansed sacral are with wound cleanser. Pus like drainage approximately one tablespoon came out of orifice. Recleansed area with wound cleanser. Repack with dry dressing then applied Opsite (a transparent film dressing) on top. Previous dressing was saturated when taken off. Observation on 11/26/13 at 11:30 A.M. showed the resident up in his/her wheelchair in his/her room. Observation on 11/26/13 at 2:40 P.M. showed the resident in his/her bed lying on his/her right side. Observation on 11/26/13 at 5:15 P.M. showed the resident up in his/her wheelchair in his/her room. Observation on 11/27/13 at 6:27 A.M. showed the resident in his/her bed on his/her back. Observation on 11/26/13 at 9:45 A.M. showed the resident lay in bed. CNA K positioned the resident on the left side and LPN G removed the old dressing with a minimal amount of brown drainage. Observation showed a circular open area approximately 1.0 cm in length near the coccyx. LPN G used a cotton swab and placed it down the tunnel of the wound and it measured 3.0 cm in depth. During an interview on 11/26/13 at 9:43 A.M., the Director of Nursing (DON) said the charge nurse who is on duty on Wednesday evenings assesses residents' wounds. During an interview on 11/26/13 at 9:45 A.M., LPN G said the following: - Staff should perform weekly skin assessments to monitor residents' skin; - The resident acquired the pressure ulcer on his/her coccyx while at the facility; - The resident had a change in condition with depression and decreased appetite, which increased his/her risk for developing pressure ulcers; - The resident's wound is currently a stage III; - The resident goes to the wound clinic. During an interview on 11/27/13 at 6:20 A.M., CNA I said the following: - Staff turn and reposition residents at high risk for pressure ulcers, every hour to one and one-half (1/2) hours; - If a resident refuses to turn and reposition, staff should encourage the resident to reposition; - Staff should monitor residents' skin for redness and skin breakdown every time they perform care for a resident; - If staff notice a change in a resident's skin they should notify the charge nurse immediately. During an interview on 11/27/13 at 8:50 A.M., CNA H said the following: - Staff apply a barrier cream to the resident's periarea after each episode of incontinence; - Prior to the resident developing the pressure ulcer, the resident had a change in condition and became more lethargic and had decreased appetite; - Staff encourage the resident to turn and reposition, but the resident "does not like to face the wall". During an interview on 11/27/13 at 10:55 A.M., the DON said the following: - The resident was more mobile when he/she first came to the facility; - Staff provided a pressure relieving mattress on the resident's bed and wheelchair; - The resident goes to the wound clinic for treatment; - Staff attempt to reposition the resident, but he/she "scoots over", - Staff are suppose to monitor resident's skin during care, and if the resident's skin is reddened or staff notice any changes to the resident's skin, they are suppose to report the information to the charge nurse; - Staff write changes to resident's care in the CNA book, then transfer the information to the easy graph; - The resident's pressure ulcer was a stage III, but became larger after [MEDICATION NAME]; - The resident acquired the pressure ulcer at the facility. During an interview on 11/27/13 at 12:57 P.M., LPN F said the following: - The resident developed the pressure ulcer on his/her coccyx in August; - The resident was non-compliant with turning and repositioning; - The resident was up in his/her wheelchair "all the time" during the time when he/she developed the pressure ulcer on his/her coccyx; - He/she thinks the pressure ulcer became larger when staff removed the Replicare, and some of the skin around the wound came off with the treatment; - Staff should complete every section of the EZ graph form, including the stage, measurements, characteristics and staff interventions; - If a resident is non-compliant with turning and repositioning, staff should document the resident's behaviors, and re-educate the resident on the risks of being non-compliant with turning and repositioning. 2. Review of Resident 3's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/22/13 showed the facility staff assessed the resident as follows: -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -Uses wheelchair; -Weight is 146; -At risk for the development of pressure ulcers; -Pressure reducing devices on chair and bed. Review of the resident's Significant Change MDS assessment dated [DATE] showed the facility staff assessed the resident as follows: -Required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene; -Catheter for the last seven days; -Weight 109 lbs.; -One Stage III pressure ulcer; -One unstageable pressure ulcer due to coverage of wound bed by slough or eschar; -Stage III measured 0.5 cm x 0.7 cm x 4.0 cm (depth); -Ulcer care. Review of the comprehensive care plan dated 11/26/13 directed staff on the following interventions for pressure ulcers: -I have an anti-pressure mattress on my bed and in my wheelchair seat; -The nurse aids watch my skin for breakdown during direct personal care and during my baths. They will alert my nurse if anything is found; -Follow my nutritional plan; -My feet are floated in bed, but i do not leave them there, I move around; -I have an ulcer on my right buttock and heels. These are to be treated per my physician's orders [REDACTED]. Review of the resident's initial E-Z Graph Wound Assessment System form showed staff documented they found a blister on the left heel: On 5/26/13 staff documented: - Location- Left heel blister; - Treatment- OpSite (transparent dressing); - Pink wound base; white and brown; -Length, width and depth- not documented; - No drainage, odor, eschar, undermining or tunneling. Review showed staff documented the blister on the left heel in the approximate center of the graph. Further review showed staff did not document the measurements of the blister or stage on the EZ graph form. On 6/6/13 staff documented: - Location- Left heel; - Treatment- Allevyn Adhesive; - Pink wound base- pink, yellow and brown; -Length, width and depth- not documented; - Odor and eschar - yes; -Drainage- serous. Review showed staff documented the blister on the left heel in the approximate center of the graph. Further review showed staff did not document the measurements of the wound or use the color code system as indicated on the EZ graph form. On 6/14/13 staff documented: - Location- Left heel; - Treatment- Allevyn Adhesive; -Stage- unstageable; -Measurements: 2.0 cm x 3.5 cm and nothing documented for depth; - Pink wound base- black - Odor- no -Eschar - yes; -Drainage- serosanguinous. Further review of the EZ graph form showed staff did not use the color coded system as indicated on the EZ form. Further review showed staff did not document interventions to prevent the development of additional pressure ulcers, or the worsening of the current pressure ulcer, as directed. On 6/20/13 staff documented: - Location- Left heel; - Treatment- Santyl and [MEDICATION NAME]; -Stage- unstageable; -Measurements: 2.5 cm x 3.0 cm and nothing documented for depth; - Pink wound base-not documented - Odor- no -Eschar - yes; -Drainage- not documented. Review of the EZ graph form showed staff did not document interventions to prevent the development of additional pressure ulcers, or the worsening of the current pressure ulcer, as directed. On 7/11/13 staff documented: - Location- Left heel; - Treatment- Santyl and [MEDICATION NAME] powder; -Stage; not documented -Measurements: 2.0 cm x 2.5 cm and nothing documented for depth; - Pink wound base- yellow and brown; - Odor- yes; -Eschar - yes; -Drainage; moderate. Further review of the EZ graph form showed staff did not use the color coded system as indicated on the EZ form. Further review showed staff did not document the worsening of the current