Every finding on record at Aspire Senior Living Roaring River

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to complete monitoring of bowel movements per physician order and facility protocol, failed to update the care plan after a resident required hospitalization/treatment for constipation/impaction, and failed to notify the physician of multiple refusals of medications for one resident (Resident #1). The facility census was 64.Review of the facility's policy, titled Medication Monitoring, dated 2025, showed the following:-The facility takes a collaborative, systematic approach to medication management, including monitoring medication for efficacy and consequences;-Licensed nurses with periodic oversight by nurse managers, shall report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician;-Interventions shall be identified on the resident's comprehensive plan of care for the systematic monitoring of high-risk medications to facilitate early identification of adverse consequences;-Target symptoms and goals for use of the medications shall be indicated on the resident's plan of care.Review of the facility's policy, titled Bowel Protocol, undated, showed the following:-The purpose is to establish a standardized approach for assessing, developing, implementing, and monitoring bowel movement regimens for residents, ensuring the promotion of comfort, dignity, and bowel health while preventing constipation, impaction, and related complications; -It is the policy of the to ensure that each resident's bowel function is assessed and managed through an individualized, interdisciplinary plan of care;-Residents will have bowel patterns monitored routinely;-A bowel regimen will be developed when clinically indicated, with input from nursing, medical, and dietary staff, and therapy disciplines as appropriate;-Interventions will be designed to maintain or restore normal bowel function and prevent avoidable constipation, fecal impaction, or incontinence;-Documentation and communication regarding bowel function will occur routinely and be reviewed as part of clinical rounds and interdisciplinary care planning;-Upon admission and quarterly, and with any significant change, the nurse will document bowel status in the electronic medical record (EMR), which includes, but is not limited to bowel sounds, nausea, decreased oral intake and abdominal pain;-The interdisciplinary care team (IDT) will develop an individualized bowel plan of care for residents when appropriate;-A bowel regimen care plan may include interventions including high-fiber foods, adequate fluid intake, activity interventions, encouragement of ambulation or range of motion, stool softeners, laxatives, or suppositories as ordered, and/or consistent timing, positioning, and privacy;-Nursing staff will document bowel movement occurrences, continence, size, and consistency in the EMR;-Nursing staff will receive notification for residents who have no documented bowel movements in the last 72 hours via electronic Medication Administration Record (eMAR) alerts that populate daily;-If no bowel movement is documented, on day three administer 30 cubic centimeters (cc) of milk of magnesia (used to treat constipation) house stock. If no result then day four administer Biscodyl suppository (used to treat constipation) house stock. If there is no result, then on day five give a fleet enema;-The IDT will review bowel regimen effectiveness during the shift-to-shift report;-Any significant changes (impaction, ileus (a condition in which the bowel does not work correctly), dark/bloody stools, etc.) will be promptly reported to the provider and documented in the EMR; -Effectiveness of the bowel regimen will be evaluated by nursing and by the provider as clinically indicated;-Regimens will be modified as needed based on resident response, clinical condition, or medication changes;1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 01/25/19;-Diagnoses included iron deficiency anemia secondary to blood loss, noninfective gastroenteritis and colitis (inflammatory conditions of the digestive tract not caused by infections, often triggered by food sensitivities, medications or underlying diseases), gastrointestinal hemorrhage (a symptom of an underlying digestive disorder, ranging from mild to life-threatening, often caused by peptic ulcers, hemorrhoids, or cancer), and gastro-esophageal reflux disease (is the most common form of GERD, where patients experience chronic, often severe, heartburn and regurgitation, but have a normal-appearing esophagus during endoscopy).Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/20/26, showed the following:-Significant cognitive impairment;-Dependent on staff for transfers;-Incontinent of bowels;-Constipation was not present.Review of the resident's care plan, dated 12/15/25, showed the following:-Requires assistance with functional abilities due to contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff);-Due to physical debility, the resident does not sit on the toilet. He/she has incontinence of bladder and bowel. Staff to provide a bed pan often and assist with peri care;-Bowel and bladder incontinence due to mobility and cerebral palsy;-The resident may decline to take medications at times, stating it is yucky. It helps if he/she has a friend with him/her to hold his/her hand when medications are administered.Review of the resident's nurses' notes showed the following:-On 11/15/25, at 9:03 A.M., Registered Nurse (RN) D noted the lab called the facility and reported a critical hemoglobin (an iron-rich protein in red blood cells that transports oxygen from the lungs to body tissues) lab of 6.2. Resident refused to let this nurse obtain blood pressure or pulse rate. He/she was not having any pain in his/her stomach, and he/she felt okay. The resident refused to get out of bed. Staff notified the physician of these concerns and received new orders for increased Dexilant (used to treat stomach acid/GERD) to 60 milligrams daily. Staff called family and notified them of lab results and new order;-On 11/15/25, at 1:28 P.M., RN D note the resident began having reddish brown emesis (vomit) that looked like watery coffee grounds. The resident's physician was notified, and he/she ordered resident sent to the emergency room for evaluation and treatment. Staff attempted to reach the resident's power of attorney multiple times with no answer.;-On 11/18/25, at 3:52 P.M., RN A noted the resident returned to the facility from the hospital where the resident was admitted for anemia with three blood transfusions. The resident also had a non-bleeding ulcer cauterized, esophageal dilation (procedure that stretches the esophagus to make swallowing easier), and disimpaction during sedation;-The physician recommended keeping a record of bowel movements.Review of the resident's hospital record, dated 11/15/26, showed the following:-The resident has a history of chronic gastrointestinal tract (GI) blood loss, gastroparesis (the stomach has trouble clearing out its contents), recurrent constipation, large amount of stool burden;-The staff at the facility reported difficulty getting the resident to take his/her medication;-The resident had severe constipation with large fecal impaction;-The physician attempted a stool disimpaction. The resident had an extremely large ball of stool and constipation.Review of the resident's bowel elimination records showed the following: -On 12/02/25, night shift, the resident was incontinent and had a large bowel movement;-On 12/03/25, no documentation by staff; -On 12/04/25, day shift, the resident had no bowel movement;-On 12/05/25, no documentation by staff;-On 12/06/25, no documentation by staff.Review of the resident's medical record showed staff did not document physician notification regarding the residents not having bowel movements. Review of the resident's medical record showed staff did not administer interventions related to no bowel movement from 12/03/25 to 12/06/25. Review of the resident's bowel elimination records showed the following:-On 12/07/25, day shift, the resident was incontinent and had a small bowel movement (four days after the last document bowel movement);-On 12/07/25, night shift, the resident was incontinent and had a small bowel movement;-On 12/08/25, day shift, no documentation by staff. During the night shift the resident had no bowl movement;-On 12/09/25, no documentation by staff;-On 12/10/25, day shift and night shift , the resident had no bowel movement;-On 12/11/25, day shift and night shift, the resident had no bowel movement;-On 12/12/25, day shift and night shift, the resident had no bowel movement;-On 12/13/26, no documentation by staff (six days with no bowel movement).Review of the resident's medical record showed staff document physician notification of the resident not having bowel movements on 12/13/26. Review of the resident's medical record showed staff did not administer interventions related to no bowel movement until 12/13/26. Review of the resident's nurse's note dated 12/13/25, at 11:27 P.M., showed the following: -When he/she arrived at the facility it was reported that the resident did not have a bowel movement in five to six days and had been given a new order of Miralax (used to treat constipation);-The resident had been throwing up the last few nights and tonight had been throwing up coffee ground emesis;-He/she was told to contact family first before sending patient out of the facility by another nurse;-Staff reached the resident's family who asked the nurse to call the physician and see what they wanted to do with resident;-The RN spoke with the physicians on-call and explained the resident's family requested not to have resident sent out if possible. The physician confirmed it was necessary to send the resident to the hospital due to the resident's current status, vital signs, and emesis;-Arrangement made to send out resident;-Nurse called back family prior to calling emergency medical services (EMS) and explained what the physician said. Family gave the okay to send the resident;-The resident was sent to the hospital at around 10:20 P.M.Review of resident's hospital records, dated 12/13/25, showed the following:-The assessment/impression showed acute chronic blood loss anemia (upper GI bleed), stercoral colitis (inflammation inside the colon caused by fecal impaction), fecal impaction (a severe, often painful, form of chronic constipation where a large, hardened mass of stool becomes stuck in the rectum or colon, blocking normal bowel movements), Barrett's Esophagus ( condition where the normal tissue lining the esophagus changes to tissue similar to the intestinal lining, usually caused by chronic acid reflux (GERD)), cerebral palsy; and esophageal stenosis ( narrowing of the esophagus);-The resident's chief complaint was abdominal pain with associated nausea, vomiting, and constipation;-The resident said he/she had not had a bowel movement in six days at the facility;-The resident was admitted last month for an esophageal ulcer, hematemesis (vomiting blood.), and fecal impaction;-The hospital provider was able to provide a partial stool disimpaction with pain being improved;-The computed tomography (CT - noninvasive imaging test that uses X-rays and computers to create detailed 3D images of bones, soft tissues, and blood vessels, often to diagnose tumors, internal injuries, or infections) results showed moderate stool in the rectal vault and additional moderate-large amount of stool throughout the colon with no bowel obstruction.Review of the resident's February 2026 Treatment Administration Record (TAR) showed the following:-A current order to monitor bowel movements (BM) daily (the resident should have a BM every other day (QOD);-An order, dated 12/28/25, current order to give Dulcolax suppository (stool softener) if no BM every other day, check two times a day;-Staff did not document monitoring on the morning shift on 02/01/26, 02/08/26, 02/13/26, or 02/27/26, and night shift of 02/06/26, 02/09/26, and 02/11/26. Review of the resident's care plan, dated 12/15/25, showed staff did not document regarding the increased monitoring of bowel movements. Review of the resident's nurse's dated 03/03/26, at 2:00 A.M., showed the following: -RN C said resident called nurse to his/her room with complaints of pain in his/her abdominal area. Resident was in distress covered in sweat and pale. The RN called EMS to come STAT (immediately, without delay);-When EMS entered the resident began vomiting black coffee ground emesis into the trash can;-EMS viewed emesis and took the resident to the hospital;-Staff notified the resident's family and physician.During an interview on 03/24/26, at 12:42 A.M., RN A said the following:-He/she monitored the resident bowel movements. The resident had a history of getting constipated and issues with his/her GI tract/ GI bleed;-The resident was on the same bowel monitoring as the other residents prior to a couple of months ago. The staff is expected to follow the facility protocol and intervene if the resident went three days without a bowel movement. The staff can also call the physician if there are concerns;-The resident had to get treatment at the hospital due to constipation. The staff had not been consistent with monitoring the resident's bowel movements;-The resident got orders added after that for monitoring of his/her bowel movements since then;-The certified nursing aides (CNA's) document in the tasks whether the resident had a bowel movement or not and give a description (size and consistency). The CNAs were expected to document each shift;-He/she looked at the records to see if the resident had a bowel movement. If the CNA's didn't document anything then he/she asked them to confirm if the resident had one. The nurses check it off on the MAR;-The nurses give a suppository if the resident went more than a day without a bowel movement per the order;-There were also communication forms that were started recently that would allow the nurses to let each other know if the resident did not have a bowel movement that shift;-He/she thought that the interventions for the resident's constipation would be included in his/her care plan.During an interview on 03/24/26, at 1:15 P.M., the MDS Coordinator said the following:-The resident had a history of constipation that required treatment during his/her hospitalization a few months ago;-The physician added an order for monitoring due to issues monitoring his/her bowel movements;-The resident was on medication to prevent constipation and had orders for monitoring constipation by ensuring the resident was having a bowel movement every other day. The nurses give a suppository if that has not occurred;-The CNA's document in the chart if the resident has a bowel movement;-He/she was in charge of updating the care plans.During an interview on 03/24/26, at 1:36 P.M., CNA B said the following:-He/she did not know the resident had any issues with constipation;-He/she was responsible for documenting in the chart if the resident has a bowel movement. He/she did not know what happened after that.During an interview on 03/24/26, at 3:07 P.M., RN C said the following:-The nursing staff monitor the residents for bowel movements. The staff follow the facility protocols if a resident does not have a bowel movement for more than three days;-He/she could not remember the specifics of the protocol;-The resident had a history of constipation and required interventions. The nurses followed an order to monitor bowel movements and to intervene if the resident did not have one every other day;-He/she checked with the CNA's on his/her shift to see if the resident had a bowel movement;-He/she did not know why the TAR was not checked off. The nurses were responsible for ensuring the MAR/TAR was checked off every shift.During an interview on 03/24/26, at 3:21 P.M., RN D said the following:-The facility did not have the best system for monitoring bowel movements for the residents;-If a resident went more than three days without a bowel movement there was a protocol of medication the nurses were supposed to provide;-If the resident went more than five days without a bowel movement staff inform the physician;-He/she knew the resident required additional monitoring for constipation. The nurses failed to monitor the resident a few months ago and he/she required care at the hospital;-He/she checked the CNA's documentation to see if the resident had a bowel movement that shift or the prior shift. He/She would check off on the TAR that she monitored.During an interview on 03/26/26, at 3:25 P.M., Licensed Practical Nurse (LPN E) said the following:-The nurses monitor the resident every shift for bowel movements to prevent constipation due to having a history of multiple hospitalizations related to constipation;-The nurses document on the TAR what it was done. It was important to complete the monitoring because a suppository was ordered to be administered if the resident did not have a bowel movement every other day;-The nurses have a protocol for all residents regarding bowel movements and generally the nurse should intervene if the resident has not had a bowel movement in three days;-He/she did now know if anyone monitored that.During an interview on 03/26/26, at 3:48 P.M., CNA F said the following:-He/she documented in the chart if a resident had a bowel movement including the size and consistency so the nurses can track it. The nurses used that to check off the TAR;-Staff closely monitored the resident for bowel movements because he/she would get very constipated quickly and had to go to the hospital. During an interview on 03/27/26, at 12:11 A.M., Certified Mediation Tech (CMT) G said staff monitored the resident for bowel movements. The CNA's documented bowel movements and the nurse monitored them to ensure if an intervention was not required.During interviews on 03/27/26 and 3/30/26, at 8:31 A.M., the resident's physician said the following:-The resident had issues with his/her entire GI tract including the esophagus. He/she was being treated with medication for ulcers and constipation;-The resident was hospitalized a few months ago for upper GI issues and was constipated;-He/she expected staff to closely monitor the resident for constipation;-He/she gave the facility a protocol to follow if a resident does not have a bowel movement. The nurses administer Milk of Magnesia if the resident has not had a bowel movement in three days . If that is unsuccessful then the nurses administer a Dulcolax suppository on the fourth day. On the fifth if the resident is still not successful in having a bowel movement, then the nurse contacts the physician for further orders;-He/she expected the nurses would follow the orders and complete documentation such as checking off the TAR.During an interview on 03/27/26, at 11:38 A.M., the Assistant Director of Nursing (ADON) said the following:-The resident had a history of constipation that resulted in him/her going to the hospital;-The CNA documents the resident's bowel movements in the chart. The nurse should be checking that to ensure residents were having bowel movements and follow the facility protocol;-The resident had increased monitoring, and the nurses should check with the CNA and document the monitoring on the TAR by checking it off.During interviews on 03/27/26, at 11:01 A.M. and 5:14 P.M., the Director of Nursing (DON) said the following:-The resident had a history of constipation;-The resident went to the hospital in December 2025;-He/she was not aware that the resident had gone five days without a bowel movement and no added intervention being provided until after the fact;-The nurses follow the facility protocol for bowel movements. The staff intervene if a resident does not have a bowel movement in three days if they still don't have a bowel movement by day five staff call the physician. The resident went to the hospital on the sixth day and was found to be constipated and impacted;-The resident was placed on increased monitoring with an order for monitoring of bowel movements by the nurses every shift to ensure he/she was having one every other day;-The nurses checked the chart for the bowel movement documentation from the CNA's and checked that off on the TAR every shift;-He/she did not know why the task on the TAR was not checked off;-The nurses provide a suppository if the resident did not have a bowel movement every other day.During an interview on 03/27/26, at 3:18 P.M., the Administrator said the following:-He/she expected the staff to follow physician orders/ protocols and the MAR/TAR to be completed;-He/she expected staff to follow the interventions for constipation as ordered. Review of the resident's February 2026 Physician Order Sheet (POS) showed an order, dated 12/15/15, for baclofen (muscle relaxer), give five mg by mouth two times a day for muscle rigidity.Review of the resident's February 2026 Medication Administration Record (MAR) showed staff documented the resident refused the baclofen 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/25/26, and the evening on 02/04/26, 02/07/26, 02/11/26, 02/13/26, 02/14/26, 02/18/26.Review of the resident's February 2026 POS showed an order, dated 01/25/19, for Biscodyl tablet delayed release 5 mg, give two tablets orally one time a day for constipation.Review of the resident's February 2026 MAR showed staff documented the resident refused the Biscodyl on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/22/26, 02/24/26, and 02/25/26.Review of the resident's February 2026 POS showed an order, dated 12/15/25, for Carafate oral tablet (antiulcer medication), give one tablet by mouth two times a day for a gastrointestinal bleed.Review of the resident's February 2026 MAR showed staff document the resident refused the Carafate the morning of 02/3/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/22/26, 02/24/26, 02/25/26 and in the evening on 02/04/26, 02/07/26, 02/11/26, 02/13/26, 02/14/26 , and 02/18/26.Review of the resident's February 2026 POS showed an order, dated 10/18/23, for Colace capsule (stool softener), give 100 mg by mouth two times a day for constipation, dated 10/18/23.Review of the resident's February 2026 MAR showed staff documented the resident refused the Colace capsule in the morning on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/25/26 and in the evening on 02/04/26, 02/07/26, 02/11/26, 02/13/26, 02/14/26, and 02/18/26.Review of the resident's February 2026 POS showed an order, dated 12/29/26, for Dexilant Oral Capsule delayed release 60 mg, give one capsule by mouth one time a day related to gastro-esophageal reflux disease without esophagitis.Review of the resident's February 2026 MAR showed staff documented the resident refused the Dexilant oral capsule on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/22/26, 02/24/26, and 02/25/26.Review of the resident's February 2026 POS showed an order, dated 01/30/26, for ferrous sulfate (iron) oral solution, give five ml by mouth one time a day for anemia concentration of the solution 325mg/5militer (ml).Review of the resident's February 2026 MAR showed staff documented the resident refused the Ferrous sulfate oral solution on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/26, 02/24/26, and 02/25/26.Review of the resident's February 2026 POS showed an order, dated 10/05/20, for folic acid tablet, give one tablet by mouth one time a day for anemia.Review of the resident's February 2026 MAR showed staff documented the resident refused the folic acid tablet on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/22/26, 02/24/26, and 02/25/26.Review of the resident's February 2026 POS showed an order, dated 06/06/24, for metoprolol succinate ER (used to treat high blood pressure)oral tablet extended release 24-hour 25 mg, give one tablet by mouth one time a day for atrial fibrillation, hold if blood pressure is lower than 110/70 millimeters/Mercury (mm/Hg).Review of the resident's February 2026 MAR showed the staff documented the resident refused the metoprolol succinate ER [DATE], 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/22/26, 02/24/26, and 02/25/26.Review of the resident's February 2026 POS showed an order, dated 12/12/25, for Miralax powder 17gram(gm)/scoop, give one scoop by mouth one time a day for bowel regimen.Review of the resident's February 2026 MAR showed staff documented the resident refused the Miralax on 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, and 02/25/26. Review of the resident's February 2026 POS showed an order, dated 04/04/24, for pravastatin sodium (reduces cholesterol levels) oral tablet 10 mg, give one tablet by mouth in the evening for hyperlipidemia (high cholesterol).Review of the resident's February 2026 MAR showed staff documented the resident refused the pravastatin sodium on 02/04/26, 02/07/26, 02/13/26, 02/14/26, 02/18/26 and 02/21/26.Review of the resident's February 2026 POS showed an order, dated 06/26/25, for Remeron (antidepressant) oral tablet, give 7.5 mg by mouth.Review of the resident's February 2026 MAR showed staff documented the resident refused the Remeron on 02/04/26, 02/07/26, 02/11/26, 02/13/26, 02/14/26, and 02/18/26.Review of the resident's February 2026 POS showed an order, dated 10/18/23, for Senna-S tablet 8.6-50 mg, give two tablets by mouth two times a day for constipation.Review of the resident's February 2026 MAR showed staff documented the resident refused the Senna-S in the morning 02/03/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, 02/14/26, 02/16/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, and 02/25/26 and in the evening on 02/04/26, 02/07/26, 02/11/26, 02/13/26, 02/14/26, and 02/18/26.Review of the resident's medical record showed staff did not document physician notifications of the resident's medication refusals in February 2026. During an interview on 03/24/26, at 12:42 A.M., RN A said the following:-The resident refused medications;- He/she did not know how many refusals before he/she needed to let the physician know;-He/she informed the physician if the resident was consistently refusing and used his/her nursing judgment;-He/she thought the physician was aware;-The resident took medication from certain staff for better than others. They always encouraged him/her to take the medications and made multiple attempts;-He/she had not spoken to the physician about the resident's refusals of his/her medication;-He/she did not know the resident had refused his/her medication over 10 times in the month of February 2026, but he/she thinks if it was multiple days in a row, he/she would tell the physician.During an interview on 03/24/26, at 1:15 P.M., the MDS Coordinator said the following:-He/she knew the resident refused medications. He/she added it to the care plan;-The nurse informs the physician and writes a note in the chart if the refusals are consistent;-He/she did not know if the physician was notified. During an interview on 03/24/26, at 3:07 P.M., RN C said the following:-He/she knew that sometimes the resident would refuse his/her medication;-It didn't happen very often on his/her shift;-He/she believed that the physician was aware but did not remember specifically telling him/her about it;-It should be documented if there was a conversation with the physician.During an interview on 03/24/26, at 3:21 P.M., RN D said the following:-The resident had behaviors and would refuse his/her medication. The staff always encouraged the resident to take it but sometimes it did not work;-He/she did not contact the physician every time the resident refused but believed he/she was aware;-He/she was not sure how many times the resident can refuse before letting the physician know;-It would be hard to know if the resident had refused the days prior because the computer does not alert you.During an interview on 03/26/2,6 at 3:25 P.M., LPN E said the following:-The resident refused his medication sometimes and the staff would encourage him to take them;-He/she did not know if the physician was notified about the resident's refusals of medication;-He/she did not know how often the resident refused medications;-He/she would let the physician know if a resident refused medications multiple days in a row and document it in a nurse's note.During an interview on 03/27/26, at 12:11 A.M., CMT G said the following:-The resident refused medications sometimes;-He/she could generally get the resident to take them;-He/she let the nurse know if the resident did not take his/her medications and would try again later;-He/she did not know if the physician was informed the resident refused medications, but he/she thought the nurse would let the physician know and document that.During interviews on 03/27/26 and 3/30/26, at 8:31 A.M., the resident's physician said the following:-He/she knew the resident would refuse medications sometimes but did not know he/she had refused over 10 times in February 2026;-He/She did not know he/she was refusing so often;-He/she wanted to know if the resident was refusing medication so often. During an interview on 03/27/26, at 11:38 A.M., the ADON said the following:-The resident refused medication often and the staff attempted several times;-The nurses notifies the physician if the resident refuses medication more than once a day and the nurse adds a note to the chart that the resident refused. During interviews on 03/27/26, at 11:01 A.M. and at 5:14 P.M., the DON said the following:-The resident refused medication sometimes, but the physician was aware;-The staff encouraged him/her to take them. During an interview on 03/27/26, at 3:18 P.M., the Administrator said the following:-He/she knew the resident would refuse cares and medications sometimes;-He/she expected staff to contact the physician if the resident was refusing medication consistently.#2809217 and #2808816

Based on interview and record review, the facility failed to send notification in writing to the resident and/or the resident's representative of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsman (advocate for the resident in nursing facilities) within the transfer and discharge notices and bed-hold policy (the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) for two residents (Resident #1 and #5); failed to send the notification in writing of a transfer or discharge of a resident from a skilled nursing facility to an assisted living facility for one resident (Resident #75); and failed to send a copy of the transfer or discharge to the Office of the State Long Term Care Ombudsman for three residents (Resident #1, #5, #75). The facility census was 69. Review of the facility's undated policy titled Transfer and Discharge, showed the following:- It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;-Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility;- The facility may initiate transfers or discharges in the following Limited circumstances:- The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;-Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified);-Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis;-Notify resident and/or resident representative;-Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements;-Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents:-Resident status, including baseline and current mental, behavioral and functional status and recent vital signs;-Current diagnosis, allergies and reasons for transfer/discharge;-Contact information of the practitioner responsible for the care of the resident;-Resident representative information including contact information;-Current medications (including when last received), treatments, most recent relevant lab and/or radio logical findings and recent immunizations;-Special instructions or precautions for ongoing care to include precautions such as isolation or contact;-Special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions;-Comprehensive care plan goals, and;-Any other documentation, as applicable, to ensure a safe and effective transition of care.-A copy of any Advance Directive, Durable Power of Attorney, DNR or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident;-The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record;-Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand;-Document assessment findings and other relevant information regarding the transfer in the medical record;- Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer;-Provide transfer notice as soon as practicable to resident and representative;-Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list;-In case of discharge, notice requirements and procedures for facility-initiated discharges shall be followed. Review of the facility's policy, dated February 2024, titled Bed Hold Policy, showed the following:-TRANSFERS. Before and at the time Facility transfers Resident for hospitalization or therapeutic leave. Facility will provide Resident or Resident's Representative with written notice explaining the duration of the bed-hold policy;-MEDICAID. If resident's care at Facility is being paid for by Medicaid. Facility willreserve Resident's bed while the Resident is on therapeutic leave, for any period that is a Covered Service under the program for which Resident is eligible If Resident's absence from Facility exceeds the time covered or is due to hospitalization, we will automatically reserve the bed for 10 days If the resident's absence exceeds 10 days, we will continue to reserve the bed only if someone has signed this Bed Reservation Agreement agreeing to be personally responsible for the charges to reserve the bed The Bed Reservation charge will be equal to 100% the Basic Daily Rate applicable to the bed in question for each day the bed is to be reserved;- MEDICARE. If resident's care at Facility is being paid for by Medicare Facility will automatically reserve the bed for 10 days if absence Is due to a hospital leave If Resident's absence from Facility exceeds this time or is due to a therapeutic leave. we will automatically reserve or continue to reserve the bed only 1f someone has signed the Bed Reservation Agreement agreeing to be personally responsible for the charges to reserve the bed The Bed Reservation charge will be equal to 100% the Basic Daily Rate applicable to the bed in question for each day the bed is to be reserved;-PRIVATE PAY. During any time that Resident's care Is not covered by Medicaid orMedicare. Facility will reserve Resident's bed only if someone has signed this Bed Reservation Agreement agreeing to be personally responsible for the charges to reserve the bed The Bed Reservation charge will be equal to 100% the Basic Daily Rate applicable to the bed in question for each day the bed is to be reserved;-AUTOMATIC RESERVATION. If the Bed Reservation Agreement is signed we will reserve Resident's bed until: Resident returns to Facility; you notify us in writing of your intention to terminate this Agreement; or it is determined that Resident's needs cannot be met at Facility;-NO AUTOMATIC RESERVATION. If there is no signed request for a bed to be reserved automatically you may still request that the bed be reserved but must do so within 24 hours of the Resident's departure from Facility. If the bed is not reserved, Resident will be readmitted to the first available bed in a semi-private room in Facility if Resident continues to require our services and is eligible for Medicaid nursing facility services. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admitted on [DATE];-Diagnoses included: Displaced intertrochanteric fracture (common type of hip fracture) of left femur (bone of the thigh), Sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to widespread inflammation, tissue damage, and potential organ failure);-Resident had a guardian and was not his/her own responsible party. Review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff) list in the medical record showed the following:-admitted on [DATE];-discharged with return anticipated 11/03/25;-re-admitted on [DATE]. Review of the resident's nurse progress notes showed staff documented the following:-On 11/03/25, at 3:25 A.M., the resident finally agreed to go to the emergency room for evaluation and treatment post fall, ambulance transporting to hospital, Left facility via ambulance at 3:20 A.M.;-On 11/03/25, at 8:30 A.M., Residents family member was called this morning and was updated on resident status and ambulance transfer to hospital. Per family member the guardian is to be contacted;-On 11/04/25, at 8:23 P.M., the resident arrived to facility via transport at 6:59 P.M. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 11/03/25. Review of the Bed Hold Acknowledgement Form, showed the following:-On 11/03/25, resident was transferred out of the facility;-Signature below indicated that the bed hold policy was acknowledged at discharge;-Verbal consent by resident, two nurses signatures;-No bed hold policy or information related to resident bed-hold rights, policy, and duration upon transfer in the notice. 2. Review of Resident #5's face sheet showed the following: -admitted on [DATE];-Diagnoses included: Cerebral infarction (stroke), hemiplegia (complete inability to move one side) and hemiparesis (mild to moderate weakness) of right dominant side, aphasia (language disorder caused by brain damage that impairs the ability to speak, understand, read, and write) following cerebral infarction;-Resident was not his/her own responsible party. Review of the resident's MDS list in the medical record showed the following:-admitted on [DATE];-discharged with return anticipated on 10/27/25;-re-admitted on [DATE];-discharged with return anticipated on 11/14/25;-re-admitted on [DATE]. Review of the Bed Hold Acknowledgement Form, showed the following:-On 10/27/25, resident was transferred out of the facility;-Notification was made to the resident's representative;-Signature below indicated that the bed hold policy was acknowledged at discharge;-Verbal consent by resident's representative via phone;-One nurse signature;-No bed hold policy or information related to resident bed-hold rights, policy, and duration upon transfer in the notice. Review of the Bed Hold Acknowledgement Form, showed the following:-On 11/14/25, resident was transferred out of the facility;-Notification was made to the resident's representative;-Signature below indicated that the bed hold policy was acknowledged at discharge;-Verbal consent by resident's representative via phone;-One nurse signature;-No bed hold policy or information related to resident bed-hold rights, policy, and duration upon transfer in the notice. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 10/27/25 or 11/14/25. Review of the Ombudsman Letter - Month October 2025, showed the following:-Hospital 8 residents (no names or information related to location of transfer). Review of the Ombudsman Letter - Month October 2025, showed the following:-Hospital 6 residents (no names or information related to location of transfer). 3. Review of Resident #75's face sheet showed the following: -admitted on [DATE];-Diagnoses included: Bacterial infection (illness caused by harmful bacteria which can damage tissues), resistant to multiple antibiotics, unspecified psychosis (person exhibits symptoms of a mental disconnect from reality but does not meet full criteria for a specific psychotic disorder);-Resident had a guardian and was not his/her own responsible party. Review of the resident's MDS list in the medical record showed the following:-admitted on [DATE];-discharged with return not anticipated on 01/04/26. Review of the resident's nurse progress notes showed no information documented related to discharge from the facility. Review of the resident's Discharge Planning Review, dated 01/02/26, showed the following:-Resident at facility for wound care and intravenous (IV) antibiotic (medications delivered directly into the bloodstream through a vein, allowing for rapid, high-concentration treatment of severe or resistant bacterial infections);-Resident will be returning to assisted living facility;-Resident signed and nurse signed discharge and dated 01/04/26. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to the discharge to the assisted living on 01/03/26. Review of the Ombudsman Letter - Month January 2026, showed the following:-No information related to discharge to another facility. 4. During an interview on 02/23/26, at 9:50A.M., Licensed Practical Nurse A said that when sending a resident to the hospital he/she would send transfer discharge profile that included active medications, code status, resident representative information. He/she would call the responsible party and notify of transfer and bed hold and get two nurse to witness the call. He/she would keep copy in the chart. He/she did not send any written information to resident or resident representative. During an interview on 02/23/26, at 10:00 A.M., Registered Nurse B said when transferring a resident to the hospital or completing a resident discharge, he/she would send resident medication list, code status, and any pertinent lab work with the resident. He/she would contact the responsible party and verbally notify them of the transfer and of the bed hold policy. If the resident was their own person and able to sign the bed hold acknowledgement, he/she would have them sign. There was not a bed hold policy that he/she gave to the resident or representative, just a verbal notice of bed hold. He/she did not send any written information to resident or resident representative. During an interview on 02/23/26, at 10:30 A.M., Business Office Manager said the nursing staff completed the bed hold during a transfer to the hospital. The nursing staff leave a copy for him/her. He/she checked in the mornings if any residents had been transferred and asked for the bed hold if not given a copy. He/she did not send any written information to resident or resident representative. During an interview on 02/23/26, at 10:35 A.M., Social Services Director said he/she notify the ombudsman monthly of hospital discharged . The nursing staff contact the resident's family or representative by phone. He/she did not send any written information to resident or resident representative. He/she did not send any resident name information to Ombudsman. He/she only sent a list that showed the number of persons for each category, the Ombudsman requested it that way and did not need the resident's name or where they were sent to. During an interview on 02/23/26, at 10:40 A.M., Director of Nursing (DON) said the nursing staff give a bed hold to the resident and contact the family or representative by phone. If the nursing staff received a verbal response related to the bed hold from the family or responsible party, then two nurses would witness the call. The nursing staff and the DON did not send any written notice of transfer or bed hold to the family or the resident. During an interview on 02/23/26, at 1:44 PM, State Long Term Care Ombudsman said [NAME] Payne - notes that she is only required to enter numbers into her system - she did not know the regulations if needed resident names. He/she said they will soon not need any information as the facility will be required to enter into a website. During an interview on 02/24/26, at 10:00 A.M., Administrator said the nursing staff should contact the resident's representative or family by phone to notify of transfer and should receive a bed hold acknowledgment. He was not aware of any written information to be sent to the resident or representative.

Based on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed to ensure weekly skin assessments and wound care was completed and documented for four residents (Resident #30, #49, #2, #6) with skin abrasions, including skin cancer, skin tears, and venous wounds. The facility census was 69. Review of the facility policy, dated 10/01/25, titled Wound Treatment Management, showed the following:-To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;-In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;- Dressing changes may be provided outside the frequency parameters in certain situations:- Feces has seeped underneath the dressing;- The dressing has dislodged;-The dressing is soiled otherwise or is wet.-Dressings will be applied in accordance with manufacturer recommendations;-Treatment decisions will be based on etiology of the wound:- Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage;-Surgical, incidental (skin tear), atypical (Cancerous lesion);-Guidelines for dressing selection may be utilized in obtaining physician orders;-The guidelines are to be used to assist in treatment decision making;-Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances;-The facility will follow specific physician orders for providing wound care;- The effectiveness of treatments will be monitored through ongoing assessment of the wound;-Treatments will be documented on the Treatment Administration Record or in the electronic health record. Review of the facility policy, dated 10/01/25, titled Documentation of Wound Treatments, showed the following:- The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment;-The facility is in partnership with a wound company that makes weekly and as needed visits;- Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates; - The following elements are documented as part of a complete wound assessment:a. Type of wound (pressure injury, surgical, etc.) and anatomical locationb. Stage of the wound, if pressure injury (stage l, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness);-Measurements: height, width, depth, undermining, tunneling;-Description of wound characteristics;- Color of the wound bed;- Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium);- Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated);-Presence, amount, and characteristics of wound drainage/exudate;-Presence or absence of odor;-Presence or absence of pain;-Wound treatments are documented at the time of each treatment;-If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact);-Additional documentation shall include, but is not limited to:-Date and time of wound management treatments;-Weekly progress towards healing and effectiveness of current intervention;-Any treatment for pain, if present;-Modifications of treatments or interventions;-Notifications to physician and/or responsible party regarding wound or treatment. Review of the facility provided undated schedule, titled Weekly Schedule for Vital Signs and Skin Assessments, showed the following:-A binder at the nursing desk with this schedule;-6 AM TO 6 PM Halls A&B - Sunday 101A, 101B, Monday 103A, 103B, 104A, Tuesday 106A, 106B, 107A, Wednesday 109A, 109B, 110A, Thursday 114A, 114B, 115A, 115B, Friday call families regarding new orders, Saturday 120A, 120B, 121A;-6 PM TO 6 AM Halls A&B - Sunday 102A, 102B, Monday 104B, 105A, 105B, Tuesday 107B, 108A, 108B, Wednesday 110B, 111A, 111B, Thursday 116A, 116B, 117A, 117B, Friday 118A, 118B, 119A, 119B, Saturday 121B, 122A, 122B;-6 AM TO 6 PM Halls C,E,&F - Sunday 124, 125, 126, 127, Monday 129B, 130A, 130B, Tuesday 132B, 133A, 133B, Wednesday 135B, 136A, 136B, Thursday 138B, 139A, 139B, 140A, Friday call families with new orders, Saturday 144B, 145A, 145B;-6 PM TO 6 AM Halls C,E,&F - Sunday 128A, 128B, 129A, Monday 131A, 131B, 132A, Tuesday 134A, 134B, 135A, Wednesday 137A, 137B, 138A, Thursday 140B, 141A, 141B, 142A, Friday 142B, 143A, 143B, 144A, Saturday 146A, 146B, 147A, 147B. 1. Review of Resident #49's face sheet showed the following: -admitted [DATE];-Diagnoses included: Diffuse traumatic brain injury (widespread brain damage occurs when the brain moves rapidly in the skull) with loss of consciousness (temporary prolonged state of unresponsiveness), peripheral vascular disease (slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels outside the heart and brain, most commonly affecting the legs), dermatitis (skin becomes red, swollen, and sore, sometimes with small blisters, resulting from direct irritation to the skin). Review of the resident's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument, completed by facility staff), dated 12/26/25, showed the following:-Severe cognitive impairment;-Use of wheelchair;-Resident at risk of developing pressure ulcers or injuries;-No open wound were present;-Substantial to maximal assistance for toileting hygiene, showering, dressing, personal hygiene. Review of the resident's care plan, last reviewed 12/26/25, showed the following:-Resident had the potential for skin impairment related to fragile skin;-Staff should follow facility protocols for treatment of injury. Observation on 02/18/26, at 2:00 P.M., showed resident in wheelchair in room, bilateral lower legs with undated wraps. Resident was not able to verbalize if bandages were changed. Review of the Treatment Administration Record (TAR), for February 2026, showed the following:-An order with a start date of 02/12/26 and a date to discontinue of 02/19/26, shows to apply a light a two-layer compression wrap to left lower extremity twice per week (Monday and Thursday) in the afternoon for wound care;-Staff did not document treatment as completed on 02/12/26, 02/16/26, or 02/19/26;-An order start date of 02/19/26 and a date to discontinue of 02/23/26, shows to cleanse lower extremity with wound cleanser, apply a light two-layer compression wrap to left lower extremity, change twice per week;-Staff did not document as completed on 02/19/26, 02/20/26, 02/21/26, 02/22/26, or 02/23/26 (5 out of 5 days not documented). Review of the nursing progress notes, for February 2026, showed the following:-No documentation related to wound care not being provided or refused by resident;-No weekly skin assessment for noted. Review of the Assistant Director of Nursing (ADON) wound measurements list, dated 02/12/26, showed no measurements documented for the resident. Review of the Wound Physician progress notes, dated 02/19/26, showed the following:-Bilateral stasis (state of inactivity) dermatitis. Recommended elevating the legs and to cleanse the wound with wound cleanser at the time of dressing changes;-Recommended arterial and venous doppler testing. Observation on 02/19/26, at 5:32 P.M., showed the following:-Wound Physician and DON entered resident room;-DON removed undated wraps on bilateral lower legs;-Left lower leg with small areas of redness. Skin intact;-Right lower leg red with swelling and no open areas;-Recommended arterial and venous dopplers (non-invasive, painless ultrasound test evaluates blood flow through arteries and veins) and continue wrap on left side only. 2. Review of Resident #2's face sheet showed the following: -admitted on [DATE];-Diagnoses included: Congestive Heart Failure (CHF), or heart failure, (a condition in which the heart can't pump enough blood to the body's other organs), infection of right lower extremity amputation stump (remaining portion of an extremity after surgical removal), open wound right lower leg. Review of Weekly skin observation, dated 02/02/26, showed the following:-Existing skin issue - scattered bruising to bilateral upper extremity, redness to buttock, wound vac (medical device that uses suction to speed the healing of wounds) in place to right above the knee amputation stump, ulcers to left lower extremity, shin, scabs to left toes, fingers, inside of left foot and ankle. Review of the resident's care plan, date initiated 02/03/26 , showed the following:-Resident at risk for impaired skin integrity related to mobility issues;-Nursing to do a weekly skin assessment and report any issues to the physician for treatment;-Resident had wounds on bilateral lower extremities;-Staff should complete a weekly skin audit by licensed nurse;-Staff should provide wound treatment as ordered. Review of the wound care provider note, dated 02/05/26, showed the following:-Skin tear left lateral calf, first evaluation, (length x width x depth) 4.2 x 2.1 x 0.1 centimeter (cm), present on admission. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Resident at risk of developing pressure ulcers or injuries;-Resident had open lesion, surgical wound, a skin tear on admission;-Dependent on staff for toileting hygiene, showering;-Substantial to maximal assistance for dressing;-Partial to moderate assistance for personal hygiene. Review of the Treatment Administration Record, for the Month of February 2026, showed the following:-An order with a start date of 02/07/26 and date to discontinue of 02/19/26, showed to change the dressing to left lower extremity. Clean with wound cleanser, place xeroform (sterile, non-adhering petroleum based, fine-mesh gauze dressing used as primary contact layer) on lesions, ABD (thick, highly absorbent, sterile, non-woven pad used to manage large wounds with moderate to heavy drainage, often acting as a secondary dressing to cushion and protect) over and wrap with kerlix (cotton gauze bandage rolls used for wound dressing) one time a day for wound care;-Staff did not document care as completed on 02/09/26, 02/12/26, 02/13/26, or 02/15/26 (4 out of 12 days not documented);-An order start date 02/14/26 and discontinue date 02/16/26, showed to wash incision to right stump with soap and water. Maintain dry dressing to right lower stump with incision covered by xeroform and ABD. Change dressing daily for surgical wound; Acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, end stage renal disease-Staff did not document care as completed on 02/15/26 (1 out of 3 days not documented). Review of ADON wound measurements list, dated 02/12/26, showed the following:-Left calf wound 4.0 by 2.0 by 0.1 cm - improved. Observation on 02/19/26, at 5:20 P.M., showed the following:-Wound Physician and DON entered the resident's room;-Removed undated bandage from the surgical wound on the right stump. To continue the surgeon's orders;-Removed undated bandage from left lower leg. The wound had improved and a new order started for foam with border to be applied three times per week and as needed. 3. Review of Resident #6's face sheet showed the following: -admitted [DATE];-Diagnoses included: Acute and chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and causes chronically low oxygen levels or chronically high carbon dioxide levels), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), end stage renal disease (final, irreversible stage of disease where kidney function drops to less than 15% of normal). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Resident is at risk of developing pressure ulcers or injuries;-Resident had no open wounds;-Substantial to maximal assistance for toileting hygiene;-Partial to moderate assistance for showering, dressing, personal hygiene; Review of the Treatment Administration Record (TAR), for the Month of February 2026, showed the following:-An order with a start date of 02/03/26 and a discontinue date of 02/19/26, showed to cleanse the left lower extremity posterior wound with wound cleanser, apply xeroform, cover with super absorbent dressing, change three times per week (Tuesday, Thursday, and Saturday) and as needed if saturated, soiled or dislodged;-Staff did not document as completed on 02/03/26, 02/05/26, 02/10/26, or 02/12/26 (4 out 8 days not documented);-An order start date of 02/03/26 and a discontinue date of 02/19/26, showed to cleanse the right lower extremity with wound cleanser, apply fibracol (soft, absorbent, non-adherent dressing designed to maintain moist environment that promotes new tissue and rapid healing) and cover with super absorbent dressing, change three times per week (Tuesday, Thursday and Saturday) and as needed if saturated, soiled or dislodged;-Staff did not document as completed on 02/03/26, 02/05/26, 02/10/26, or 02/12/26 (4 out of 8 days not documented);-An order start date 02/20/26, showed to cleanse the right lower extremity wound with wound cleanser, apply skin prep to right lower leg daily and as needed if saturated, soiled for wound care;-Staff did not document as completed on 02/20/26, 02/21/26, or 02/22/26 (3 out of 4 days not documented). Review of the nursing progress notes, for February 2026, showed the following: -No documentation related to wound care not being provided or refused by the resident;-No weekly skin assessment noted. Review of the wound physician progress notes, dated 02/05/26, showed the following:-Venous wound of the right leg full thickness, wound size 1 x 6.2 x 0.1cm, no signs of infection;-Venous wound of the left calf full thickness, wound size 1.4 x 2.1 x 0.2cm, no signs of infection. Review of the ADON wound measurements list, dated 02/12/26, showed the resident was in the hospital.Observation on 02/18/26, at 1:00 P.M., showed the resident in a recliner in his/her room under droplet precautions. The resident's bilateral lower legs were covered by a white gauze wrap. No dates were observed on the wrap. Review of the wound physician progress notes, dated 02/19/26, showed the following:-Venous wound of the right leg full thickness, wound size length 1cm by width 5.1 cm, depth unmeasurable due to presence of dried fibrinous exudate, no signs of infection;-Venous wound of the left calf full thickness, wound size 3.1 x 0.9 x 0.2cm, no signs of infection. Observation on 02/19/26, at 5:54 P.M., showed the following:-Wound Physician and DON entered the resident's room;-DON removed undated dressing from bilateral lower legs;-Right leg with dried scabbed areas;-Left leg with area of 3.4 x 1.8 x 0.2 cm with some clear drainage and redness;-Wound physician recommended skin prep to right leg and continue current treatment plan for left leg. 4. Review of Resident #30's face sheet showed the following:-admitted [DATE];-Diagnoses include COPD, CHF, atrioventricular block first degree (mild conduction delay in the heart), cardiac arrhythmia (abnormal heart rhythm), atrial fibrillation (fast and irregular heart rhythm), chronic kidney disease, and nonrheumatic mitral insufficiency (condition where the mitral valve fails to close properly causing blood flow backward into the left atrium). Review of the resident's care plan, last revised 11/12/25, showed the following:-Resident is at risk for impaired skin integrity related to age and mobility issues;-Resident will have clean and intact skin through next review date;-Report an area of concern related to skin to the nurse;-Nursing is to do a weekly skin assessment and report any issues to my physician for treatment.Review of the resident's current physician order showed the following:An order dated 02/13/26, showed to cleanse the wound/stitches with an antibacterial soap and water using a Q-Tip. Gently remove any crust or scab from the wound working in between the sutures. Apply a thick coat of Bacitracin ointment to the wound cover with nonadherent dressing and secure with tape for two weeks every evening shift for wound care. Review of the resident's February 2026 Treatment Administration Record (TAR) showed the following: -An order dated 02/13/26, cleanse the wound/stitches with an antibacterial soap and water using a Q-Tip. Gently remove any crust or scab from the wound working in between the sutures. Apply a thick coat of Bacitracin ointment to the wound cover with nonadherent dressing and secure with tape for two weeks every evening shift for wound care. -Staff documented administering the above treatment on 02/15/26 and 02/18/26;-Staff did not document administering the above treatment on 02/13/26, 02/14/26, 02/16/26, and 02/17/26.An observation and interview with the resident on 02/17/26, at 1:55 P.M., showed the following:-The resident said he/she had skin cancer removed from the face recently and is concerned because staff should be treating and bandaging the area daily. The resident did not have a bandage on her face. Review of the resident's quarterly MDS dated [DATE], showed the following:-Moderate cognitive impairment;-Resident has open lesions requiring non-surgical dressing and application of ointments/medication;-Dependent on staff for transfers, bed mobility, and showers. 5. During an interview on 02/18/26, at 11:20 A.M., LPN A said residents have complained that wound care was not completed at times. The nurses are to complete wound care according to the physician orders. On Thursdays the ADON rounded with the Wound Physician and completed care. He/she said some days was difficult to get all of the resident care completed. 6. During an interview on 02/19/26, at 9:35 AM, RN B said the nurses were to complete the weekly wound assessments. There was a binder at the nursing station that shows which room was due for the assessment. The TAR shows when the wound care is due. The ADON follows with the wound care physician and entered any new orders into the resident's chart. He/she said that if he/she was unable to get all work done for the day he/she would pass it along to the next shift. The TAR would only show the order for the shift it was due. The treatment would show as incomplete for the next shift. He/she said that staff should chart when wound care was done, if not charted it was not done. He/she would not expect to see holes in the TAR. unless there is a note or it is passed along in report. If a resident refused treatment there is a code to document that and make a progress note. He/she said if it was a really busy day he/she would get the treatments done and try to take time to chart later. 7. During an interview on 02/19/26, at 10:39 A.M., the ADON said he/she monitors wound tracking. The wound physician comes once per week. The admission nurse should start the skin assessment. There is a weekly schedule in a binder at the nurse's desk. He/she will do wound care if working on the floor or if the scheduled staff were not able to get the wound care done. He/she said that the wound dressing should be dated, sometimes staff forget to date it but it should also be documented on the TAR. There should not be blank spots on the TAR. If it was not charted, it was not done. Some days wound care was not charted but he/she knew it was done. Sometimes a resident might refuse wound care, so he/she would not document and then would try to go back later and see if could complete the care. Staff should let the other staff know when work was not completed. He/she said that he/she was working on the floor most days that he/she worked. He/she had been completing most of the wound care daily until October when new corporation took over and then the floor nurses were scheduled to do the wound care. The wound care physician was not here on the week of 02/12/26, so the ADON completed some measurements of wounds but did not get them all done. 8. During an interview on 02/19/26, at 11:15 A.M., the Medical Director said that staff should follow physician orders and that if it was not documented he would assume it was not done. He stated it was helpful when staff date the dressing in case the documentation was forgotten. There was a risk of wounds not healing and becoming infected if care not completed. 9. During an interview on 02/19/26, at 3:45 P.M., Primary Care Physician said that she expected staff to follow the orders and if had questions that could contact her. Said if staff did not complete wound care it would not get better. If there was a noted decline in wound healing that might be a sign the care was not getting done. The staff should document according to policy, if it was not documented it was considered not done. 10. During an interview on 02/19/26, at 6:00 P.M., Wound Physician stated that overall, the wounds were improved, with only minimal changes or decline in wounds. Stated if the facility did not complete wound care there could be a decline in wound healing progression. The staff should complete wound care according to physician orders and should follow their facility protocol for charting. If there were changes in wound progress or decline during the staff's wound care they should contact the wound care provider or the resident's primary care provider to update and check if different orders recommended. 11. During an interview on 02/20/26, at 11:40 A.M., DON said floor nurses complete weekly skin assessments and should do this as scheduled. The ADON completes wound tracking and had not been able to do wound care due to more residents and busy with other infection control processes. There are standing order that can be initiated when a wound started and then notify the primary physician and wound physician if needed. The standard for wound care is to date the bandage but some concerns of the ink soaking through the dressing. The staff should always document in the TAR, even if refused there was a code for not done and the chart in the progress notes why not done. There should not be blanks on the TAR. If it was not charted it was considered not done. She should be auditing the TAR's weekly but had not had time to do that due to staffing issues. She was not sure if the wound were improving. 12. During an interview on 02/23/26, at 10:00 A.M., Administrator said staff should follow physician orders and complete resident cares. The staff should document all work done and not done. If it was not documented, it was not done.

Based on observation, record review, and interview, the facility failed to provide care per standards of practice when staff failed to ensure weekly skin assessments and wound assessments were completed and documented for five residents (Resident #40, #53, #11, #61, #25) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 69. Review of the facility policy, dated 10/01/25, titled Wound Treatment Management, showed the following:-To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change;-In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse;- Dressing changes may be provided outside the frequency parameters in certain situations:- Feces has seeped underneath the dressing;- The dressing has dislodged;-The dressing is soiled otherwise or is wet.-Dressings will be applied in accordance with manufacturer recommendations;-Treatment decisions will be based on etiology of the wound:- Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage;-Guidelines for dressing selection may be utilized in obtaining physician orders;-The guidelines are to be used to assist in treatment decision making;-Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances;-The facility will follow specific physician orders for providing wound care;- The effectiveness of treatments will be monitored through ongoing assessment of the wound;-Treatments will be documented on the Treatment Administration Record or in the electronic health record. Review of the facility policy, dated 10/01/25, titled Documentation of Wound Treatments, showed the following:- The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment;-The facility is in partnership with a wound company that makes weekly and as needed visits;- Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates; - The following elements are documented as part of a complete wound assessment:a. Type of wound (pressure injury, surgical, etc.) and anatomical locationb. Stage of the wound, if pressure injury (stage l, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness);-Measurements: height, width, depth, undermining, tunneling;-Description of wound characteristics;- Color of the wound bed;- Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium);- Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated);-Presence, amount, and characteristics of wound drainage/exudate;-Presence or absence of odor;-Presence or absence of pain;-Wound treatments are documented at the time of each treatment;-If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact);-Additional documentation shall include, but is not limited to:-Date and time of wound management treatments;-Weekly progress towards healing and effectiveness of current intervention;-Any treatment for pain, if present;-Modifications of treatments or interventions;-Notifications to physician and/or responsible party regarding wound or treatment. Review of the facility provided undated schedule, titled Weekly Schedule for Vital Signs and Skin Assessments, showed the following:-A binder at the nursing desk with this schedule;-6 AM TO 6 PM Halls A&B - Sunday 101A, 101B, Monday 103A, 103B, 104A, Tuesday 106A, 106B, 107A, Wednesday 109A, 109B, 110A, Thursday 114A, 114B, 115A, 115B, Friday call families regarding new orders, Saturday 120A, 120B, 121A;-6 PM TO 6 AM Halls A&B - Sunday 102A, 102B, Monday 104B, 105A, 105B, Tuesday 107B, 108A, 108B, Wednesday 110B, 111A, 111B, Thursday 116A, 116B, 117A, 117B, Friday 118A, 118B, 119A, 119B, Saturday 121B, 122A, 122B;-6 AM TO 6 PM Halls C,E,&F - Sunday 124, 125, 126, 127, Monday 129B, 130A, 130B, Tuesday 132B, 133A, 133B, Wednesday 135B, 136A, 136B, Thursday 138B, 139A, 139B, 140A, Friday call families with new orders, Saturday 144B, 145A, 145B;-6 PM TO 6 AM Halls C,E,&F - Sunday 128A, 128B, 129A, Monday 131A, 131B, 132A, Tuesday 134A, 134B, 135A, Wednesday 137A, 137B, 138A, Thursday 140B, 141A, 141B, 142A, Friday 142B, 143A, 143B, 144A, Saturday 146A, 146B, 147A, 147B. 1. Review of Resident #40's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE];-Diagnoses included: type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) with diabetic neuropathy (nerve damage caused by long-term high blood sugars), local infection of the skin and subcutaneous skin (under the layers of skin), pressure ulcer of sacral region stage 4 (severe, full-thickness wound extending through the skin to expose muscle, tendon, or bone), pressure ulcer of other site unstageable, osteomyelitis (serious infection of the bone marrow and bone tissue) of vertebra (one of the 33 individual, irregular bones that stack to form the spinal column), sacral (large, inverted triangle-shaped bone located at the very base of the spine, situated between the two hip bones) and sacrococcygeal region (referring to the region of the sacrum and the coccyx (the tailbone)), acquired absence (surgical removal) of left leg below knee. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/14/26, showed the following:-Cognitively intact;-Use of wheelchair;-Substantial to maximal assistance for personal hygiene, dressing;-Dependent on staff for showering, toileting hygiene;-Resident has pressure ulcer or injury;-Resident at risk for developing pressure ulcers or injuries;-Resident has two stage 3 pressure ulcers;-One stage 3 pressure was present on admission. Review of the resident's care plan, last reviewed 01/03/26, showed the following:-Resident had a pressure ulcer on coccyx and right ischial tuberosity (large, rounded bony protrusion located in the lower pelvis situated in the buttocks, support the body's weight while sitting);-Staff should assess and record wound healing, measure length, width, depth where possible (staff did not care plan how often); -Staff should assess and document status of wound perimeter, wound bed and healing progress (staff did not care plan how often);-Staff should perform all treatment per physician's orders;-If the dressing comes off or is soiled, staff should notify the wound care nurse for timely wound care. Review of the Treatment Administration Record (TAR), for the Month of January 2026, showed the following:-An order with a start date of 11/15/25 and a discontinue date of 01/13/26, showed to cleanse wound to coccyx with hypochlorous acid, apply calcium alginate to wound bed, cover with self-adhesive super absorbent dressing, change daily and as needed if soiled or missing dressing for wound care;-Staff did not document care completed on 01/01/26, 01/02/26, 01/03/26, 01/05/26, 01/06/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26, 01/12/26, or 01/13/26 (11 out of 13 days not documented);-An order with a start date of 01/03/26 and a discontinue date of 01/13/26, shows to remove old dressing with adhesive remover from the right sacrum wound, cleanse the wound with vashe (wound care solution to cleanse, irrigate, moisten acute and chronic wounds), dry, apply skin prep (fast-drying, liquid film-forming dressing applied to intact skin around a wound to form a breathable, transparent, and protective barrier) to peri-wound (skin immediately surrounding a wound). Pack the wound with vashe soaked rolled gauze ensuring tunneling at 11 o'clock is packed. Cover with an ABD then Mextra (four-layer non-adhesive dressing). Secure with medipore tape (surgical tape with gentle adhesion for fragile skin) every day for wound care;-Staff did not document care completed on 01/03/26, 01/05/26, 01/06/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26, 01/12/26, or 01/13/26 (9 out of 11 days not documented);-An order start date 01/15/26, discontinue date 02/19/26, apply hydrocolloid paste (special wound dressing used for mild draining wounds) for once daily to scrotum for wound care;-Staff did not document care completed on 01/16/26, 01/17/26, 01/18/26, 01/20/26, 01/21/26, 01/22/26, 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/28/26, 01/29/26, 01/30/26 (13 out of 17 days not documented);-An order with a start date of 01/13/26, showed to cleanse the wound to the coccyx with wound cleanser, apply calcium alginate with silver to wound bed, cover with superabsorbent gelling fiber pad, change daily and as needed if saturated, soiled, or dislodged for wound care; -Staff did not document care completed on 01/14/26, 01/16/26, 01/17/26, 01/18/26, 01/20/26, 01/21/26, 01/22/26, 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/28/26, 01/29/26, or 01/30/26 (14 out of 19 days not documented);-An order with a start date of 01/13/26, showed to cleanse the wound to the right ischium (one of pelvic bones, referred to as sit bone in the buttock) with wound cleanser, apply calcium alginate (highly absorbent, antimicrobial primary wound dressing made from seaweed-derived fibers) with silver (to help with infected or chronic wound healing) to wound bed, cover with ABD pad (thick, sterile, and highly absorbent medical dressing designed to cover and protect large, heavily draining wounds) and secure with retention tape. Change daily and as needed if saturated, soiled, or dislodged for wound care; -Staff did not document care completed on 01/14/26, 01/16/26, 01/17/26, 01/18/26, 01/20/26, 01/21/26, 01/22/26, 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/28/26, 01/29/26, or 01/30/26 (14 out of 19 days not documented);-An order with a start date of 01/23/26, showed to cleanse the wound to the right stump with wound cleanser, apply calcium with silver to wound bed, cover with bordered gauze, change daily and as needed for saturated, soiled or dislodged dressing for wound care;-Staff did not document care completed on 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/28/26, 01/29/26, or 01/30/26 (7 out of 9 days not documented). Review of the Treatment Administration Record, for February 2026, showed the following:-An order with a start date of 01/15/26 and a discontinue date of 02/19/26, showed to apply hydrocolloid paste once daily to scrotum for wound care;-Staff did not document care completed on 02/01/26, 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, or 02/15/26 (11 out of 19 days not documented);-An order with a start date of 01/13/26, showed to cleanse the wound to the coccyx with wound cleanser, apply calcium alginate with silver to wound bed, cover with superabsorbent gelling fiber pad. Change daily and as needed, if saturated, soiled, or dislodged for wound care; -Staff did not document care completed on 02/01/26, 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, or 02/23/26 (12 out of 23 days not documented);-An order with a start date of 01/13/26, showed to cleanse the wound to the right ischium with wound cleanser, apply calcium alginate with silver to wound bed, cover with ABD pad and secure with retention tape. Change daily and as needed if saturated, soiled, or dislodged for wound care; -Staff did not document care completed on 02/01/26, 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, or 02/23/26 (12 out of 23 days not documented);-An order with a start date of 01/23/26, showed to cleanse the wound to the right stump with wound cleanser, apply calcium with silver to wound bed, cover with bordered gauze. Change daily and as needed for saturated, soiled or dislodged dressing for wound care;-Staff did not document care completed on 02/01/26, 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, or 02/23/26 (12 out of 23 days not documented). Review of the wound physician progress notes, dated 02/05/26, showed the following:-Site one - stage 3 pressure wound of right ischium full thickness, 10.5 x 6.1 x 1.2 (length x width x depth), improved evidenced by decreased depth;-Site two - stage 3 pressure wound sacrum full thickness, 1.2 x 0.8 x 1.3 cm, improved evidenced by decreased surface area;-Site three - non-pressure wound of the right distal stump full thickness, 3.5 x 3.1 x 0.1 cm, not at goal due to need more time;-Site four - non-pressure wound of the left scrotum partial thickness, 1.2 x 0.6 x 0.1 cm, improved evidenced by decreased surface area. Review of the nursing progress notes, for February 2026, showed the following:-No documentation related to wound care not being provided or refused by resident. Review of ADON wound measurements list, dated 02/12/26, showed the following:-Right ischium 10.3 x 6.1 x 1.1, improved;-Sacrum 1.1 x 0.5 x 1.2, improved;-Right stump 3.6 x 3.1 x 0.1, decline slough;-Scrotum 1.2 x 0.6 x 0.1, no change. Review of the nursing weekly skin observation, dated 02/13/26, showed no new skin concerns, see wound assessments for existing skin issues and accurate measurements. Review of the wound physician progress notes, dated 02/19/26, showed the following:-Site one - stage 3 pressure wound of right ischium full thickness, 7.2 x 6.3 x 1.1 cm, improved evidenced by decreased depth;-Site two - stage 3 pressure wound sacrum full thickness, 1.3 x 1 x 0.2 cm, improved evidenced by decreased depth;-Site three - non-pressure wound of right distal stump thickness, 3 x 3.1 x 0.1 cm improved evidenced by decreased necrotic tissue and decreased surface area;-Site four - non-pressure wound of left scrotum - resolved on 02/19/26. Observation and interview on 02/18/26, at 2:55 P.M., showed the following:-RN B entered the resident's room with wound care supplies, applied a gown, and completed hand hygiene and applied gloves;-He/She pulled the resident's pant leg up over the right stump and said, that is the bandage I put on Saturday. The bandage was undated. The nurse removed the bandage and sprayed wound cleanser on gauze and cleaned an area on the end of the right stump;-The area was open and beefy red with some pink drainage. Size of the area was approximately 3 x 3 cm;-The nurse removed his/her gloves and completed hand hygiene and applied gloves;-Sprayed wound cleanser on the wound and cleaned with gauze; -Prepared calcium alginate to size of the wound bed and skin prepped the skin around the wound;-Calcium alginate and the border dressing were applied and dated 2/18/26;-The nurse assisted the resident to roll to the left side, opened his/her brief, and removed bandages on the coccyx and the right buttock;-The bandages were undated;-The coccyx area was open with no drainage;-Observation showed the right ischium area to have slight drainage and the nurse stated there was a slight odor;-The wounds were cleansed with wound cleanser;-RN B removed his/her gloves, completed hand hygiene, and applied gloves;-Skin prep was applied around the wounds and calcium alginate was prepared to size and applied to the coccyx;-Blue super absorbent border dressing was applied; -RN B applied calcium alginate to the right ischium, applied gelling fiber and an ABD pad, taped the bandage. removed gloves, removed gown, and completed hand hygiene;-The nurse did not date the two bandages on the resident's buttocks area. During an interview on 02/18/26, at 3:46 P.M., RN B said the bandage appeared to be the same as when he/she completed on Saturday (02/14/26). He/She stated there were times that the wound care did not get completed and dressing changes were not charted as completed. He/she stated there were times that there was other work that keeps him/her from getting to the wound care during the shift. Observation on 02/19/26, at 4:35 P.M., showed the following:-The wound care provider and the DON entered the resident's room and donned a gown and gloves;-The bandage, dated 02/18/26, was removed from the right stump and observation showed an area of approximately 3 by 3 cm with mild red drainage on bandage; -DON completed the wound care and did not date the bandage, saying he/she would return to date it;-The resident was assisted to roll to his/her left side;-The resident had an undated bandage on his/her coccyx and an undated bandage on the right ischial area;-DON removed the bandages and the wound care provider measured the wounds and stated the ischium area was about the same, maybe better. He/She said the coccyx area was healing well;-The wound care provider recommended staff continue same treatment;-DON completed wound care and stated would return to date bandages. 2. Review of Resident #53's face sheet showed the following: -admitted [DATE];-Diagnoses included: Arnold Chiari Syndrome (structural defect where the lower part of the brain pushes down through the base of the skull into the top of the spinal canal) with spina bifida (congenital birth defect where the spinal column does not close completely during fetal development, often leaving the spinal cord and nerves exposed or damaged), paraplegia (impairment or loss of motor and sensory function in the lower half of the body), pressure ulcer of sacral region stage 4, pressure ulcer of buttock unspecified stage, osteomyelitis (serious, often bacterial, infection of the bone that causes inflammation, severe pain, swelling, and warmth in the affected area) of vertebra (one of the 33 bones that stack to form the spine) and lumbar (low back) region. Review of the resident's annual MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Substantial to maximal assistance for toileting hygiene, showering;-Partial to moderate assistance for personal hygiene, dressing;-Resident at risk for developing pressure ulcers or injuries;-Resident two stage 4 pressure ulcers that were present on admission. Review of the resident's care plan, last reviewed 12/22/25, showed the following:-Resident had a pressure injury to the ischium and sacrum, the skin was fragile;-The nurse should perform weekly skin assessments;-Wounds followed by wound care provider;-Staff should change dressing as ordered when they are scheduled and as needed soiling and saturation;-Staff should measure and document wound progress at least once per week. Review of the Treatment Administration Record, for the Month of January 2026, showed the following:-An order with a start date of 12/12/25 and a discontinue date of 02/09/26, showed to cleanse the sacral wound with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape. Change daily and as needed, every evening shift for wound care;-Staff did not document care as completed on 01/03/26, 01/11/26, 01/17/26, 01/23/26, 01/25/26, or 01/29/26, 01/31/26 (7 of 31 days not documented);-An order with a start date of 12/12/25 with a discontinue date of 02/09/26, showed to cleanse the wound to the left ischium with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape. Change daily and as needed every evening shift for wound care;-Staff did not document care as completed on 01/03/26, 01/11/26, 01/17/26, 01/23/26, 01/25/26, or 01/29/26, 01/31/26 (7 of 31 days not documented). Review of the Treatment Administration Record, for the Month of February 2026, showed the following:-An order start date 12/12/25, discontinue 02/09/26, cleanse sacral wound with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape, change daily and as needed every evening shift for wound care;-Staff did not document care as completed on 02/06/26, 02/08/26 (2 of 8 days not documented);- An order with a start date of 12/12/25 and a discontinue date of 02/09/26, showed to cleanse the wound to the left ischium with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape. Change daily and as needed every evening shift for wound care;-Staff did not document care as completed on 02/06/26 or 02/08/26 (2 of 8 days not documented);- An order with a start date of 02/09/26, showed to cleanse the sacral wound with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape. Change daily and as needed, in the afternoon, for wound care;-Staff did not document care as completed on 02/09/26, 02/10/26, 02/15/26, 02/17/26, 02/18/26, 02/19/26, 02/20/26, 02/21/26, 02/22/26, 02/23/26, 02/24/26, 02/25/26, 02/26/26, 02/27/26, or 02/28/26 (15 out of 20 days not documented);- An order with a start date of 02/09/26, showed to cleanse the wound to the left ischium with wound cleanser, apply xeroform to wound bed, cover with ABD pad and secure with tape. Change daily and as needed in the afternoon for wound care;-Staff did not document care as completed on 02/09/26, 02/10/26, 02/15/26, 02/17/26, 02/18/26, 02/19/26, 02/20/26, 02/21/26, 02/22/26, 02/23/26, 02/24/26, 02/25/26, 02/26/26, 02/27/26, or 02/28/26 (15 out of 20 days not documented). Review of the nursing progress notes, for February 2026, showed the following:-No documentation related to wound care not being provided or refused by resident. Review of the wound physician progress notes, dated 02/05/26, showed the following:-Site one - stage 4 pressure wound sacrum full thickness, 10.5 x 5.5 x 2 cm, improved evidenced by decreased depth, decreased surface area, decreased undermining;-Site two - stage 4 pressure wound of the left ischium full thickness, 1.9 x 0.3 x 0.3 cm, improved evidenced by decreased depth, decreased surface area. Review of weekly wound observation tool, dated 02/06/26, showed the following:-The wound on the left ischium is observed to be pressure stage 4. Overall improving, measure 1.9 x 0.3 x 0.3 cm;-No other information related to full body skin assessment. Review of the ADON wound measurements list, dated 02/12/26, showed the following:-Scrotum 10.3 x 5.2 x 2.0, improved;-Left ischium 1.8 x 0.2 x 0.2, improved. During an interview on 02/17/26, at 2:00 P.M., the resident said there were times that his/her wound care did not get completed. He/she did not know if the wounds were improved or stable. The wound had been present for a long time. Review of the wound physician progress notes, dated 02/19/26, showed the following:-Site one - stage 4 pressure wound sacrum full thickness, 11.3 x 3.7 x 1.4 cm, improved evidenced by decreased depth, decreased surface area, decreased undermining;-Site two - stage 4 pressure wound of the left ischium full thickness, 5.8 x 1.3 x 0.3 cm, not at goal due to need more time. Observation on 02/19/26, at 4:10 P.M., showed the following:-Wound care provider, DON, and RN B entered resident room;-Resident did not want additional staff in the room. During an interview on 02/19/26, at 4:20 P.M., Wound Physician stated the undermining on the wound appeared worse but may be due to skin healing over the area. Overall, the surface area was improved. The resident had two wounds, one on the sacrum and one on the ischium into the groin. Recommended continue the current treatment plan. 3. Review of Resident #11's face sheet showed the following: -admitted on [DATE];-Diagnoses included: pressure ulcer of right buttock stage 3 (severe, full-thickness skin loss involving damage to subcutaneous fat, appearing as a deep, open crater), anemia ( not having enough healthy red blood cells to carry oxygen to the body's tissues), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)). Review of the resident's physician orders current as of 02/24/26 showed the following:-An order dated 01/05/26, start date 01/06/26, cleanse wound to posterior right thigh with wound cleanser; apply hydrofera blue (sterile, non-cytotoxic, absorbent foam wound dressing designed for managing bioburden and promoting healing) to wound; cover with self-adhesive super absorbent dressing; change Tuesday, Thursday, and Saturday and as needed for saturation, soiled or dislodged dressing. Review of the resident's annual MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Dependent on staff for transfers;-Substantial to maximal assistance required for personal hygiene, dressing, showering, toileting hygiene;-Had unhealed pressure ulcer or injuries;-Had one stage 3 pressure ulcer that was not present on admission. Review of the resident's care plan, last reviewed 12/23/25, showed the following:-Resident had a stage 3 pressure ulcer;-Resident had potential for impairment of skin integrity related to immobility and fragile skin;-Licensed nurse will continue with weekly skin assessment to monitor for new areas of concern;-Wound nurse to document weekly measurement and assessment of wound progress;-Wound care provider will follow wound and progression. Review of the Treatment Administration Record, for the Month of January 2026, showed the following:-An order dated 01/06/26, showed to cleanse the wound to the posterior right thigh with wound cleanser; apply hydrofera blue to wound; cover with self-adhesive super absorbent dressing. Dressing is to be changed Tuesday, Thursday, and Saturday, and as needed, for saturation, soiled or dislodged dressing;-Staff did not document treatment as completed on 01/06/26, 01/08/26, 01/10/26, 01/13/26, 01/20/26, 01/22/26, 01/24/26, or 01/29/26;-Staff did not document that 8 out of 12 dates in January were treatment completed. Review of the Treatment Administration Record, for the Month of February 2026, showed the following:-An order dated 01/06/26, showed to cleanse the wound to the posterior right thigh with wound cleanser; apply hydrofera blue to wound; cover with self-adhesive super absorbent dressing. Change Tuesday, Thursday, and Saturday and, as needed, for saturation, soiled or dislodged dressing;-Staff did not document treatment as completed on 02/03/26, 02/05/26, 02/07/26, 02/10/26, 02/12/026, 02/17/26, 02/19/26, or 02/21/26;-Staff did not document that 8 out of 9 dates in February were treatment completed. Review of the nursing progress notes showed staff documented the following:-No information related to wound care not completed. Review of ADON wound measurements list, dated 02/12/26, showed the following:-Right posterior thigh, 2.5 x 4.1 x 0.2, improved. Review of the wound physician progress notes showed the following:-On 02/05/26, Pressure wound stage 3 on right thigh, measured 2.5x4.1x0.2cm, with surface area of 10.25cm, no signs of infection, continue current treatment plan three times per week and as needed;-On 02/19/26, Pressure wound stage 3 on right thigh, measured 1.1x5.8x0.2cm, with surface area of 6.38cm, no signs of infection, continue current treatment plan three times per week and as needed. Observation on 02/19/26, at 4:00 P.M., showed the following:-Wound care provider and DON enter the resident's room and donned a gown and gloves; -Assisted the resident to roll to his/her right side;-The blue bandage with date of 02/14/26 was removed;-Observation showed an open area that was approximately 1 by 6 cm, minimal drainage, -Wound Physician stated to continue same treatment;-DON completed wound care and did not date bandage, said he/she would return to date. 4. Review of Resident # 61's face sheet showed the following: -admitted [DATE];-Diagnoses included: type 2 diabetes mellitus with hyperglycemia, peripheral vascular disease (common circulation problem where narrowed or blocked blood vessels reduce blood flow to limbs, organs, and the head, most commonly affecting the legs), pressure ulcer of sacral region stage 2 (partial-thickness skin loss involving damage to the epidermis and dermis, appearing as a shallow, open ulcer with a pink/red wound bed). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Use of walker;-Use of wheelchair;-Setup or clean-up assistance with toileting hygiene, personal hygiene, toileting hygiene;-Supervision or touching assistance with showering, dressing;-Resident at risk for developing pressure ulcer or injuries;-Resident had one stage 2 pressure ulcer present on admission. Review of the resident's care plan, last reviewed 12/18/25, showed the following:-Resident had potential for impairment to skin integrity related to fragile skin;-Staff should report any skin concerns to the physician;-Staff should complete weekly treatment documentation to include measurement of each area of skin breakdowns' width, length, depth, type of tissue and any other notable changes or observations. Review of the Treatment Administration Record, for the Month of January 2026, showed the following:-An order with a start date of 01/26/26 and discontinue date of 02/06/26, showed to cleanse with the coccyx with wound cleanser, apply fibracol (soft, absorbent, non-adherent dressing designed to maintain moist environment that promotes new tissue and rapid healing) to wound bed, cover with bordered foam dressing every night shift every two days for wound care until resolved;-Staff did not document care completed on 01/28/26 or 01/30/26 (2 out of 3 days not documented). Review of the Treatment Administration Record, for the Month of February 2026, showed the following:-An order with a start date of 01/26/26 and a discontinue date of 02/06/26, showed to cleanse the coccyx with wound cleanser, apply fibracol to wound bed, cover with bordered foam dressing every night shift every two days for wound care until resolved;-Staff did not document care completed on 02/01/26 or 02/05/26 (2 out of 3 days not documented);-An order dated 02/06/26, showed Triad hydrophilic wound dress external paste was to be applied to the coccyx topically at bedtime for wound care;-Staff did not document care completed on 02/06/26, 02/08/26, 02/12/26, 02/14/26, 02/15/26, or 02/20/26 (6 out of 17 days not documented). Review of the weekly skin observation, dated 02/03/26, showed the following:-Existing skin issue - pressure ulcer stage 2 on coccyx and bilateral upper extremities have bruises that are in the healing process. Review of the wound physician progress notes, dated 02/05/26, showed the following:-Site two - Stage 2 pressure wound coccyx partial thickness, 0.5 x 0.4 x 0.1 cm, present greater than 4 days. Review of the ADON wound measurements list, dated 02/12/26, showed coccyx area closed, resolved, continue triad. Review of the nursing progress notes showed staff documented the following:-No documentation for wound care not completed or resident refusal. Review of the wound physician progress notes, dated 02/19/26, showed the following:-Site two - Stage 2 pressure wound coccyx partial thickness, 0.3 x 0.3 x not measurable cm, depth is unmeasurable due to presence of dried fibrinous exudate (scab - acting as a natural bandage), improved evidenced by decreased surface area. Observation on 02/19/26, at 5:10 P.M., showed the following:-Wound Physician and DON entered the resident's room;-No bandage on the buttocks;-Scab observed on the buttock - continued triad. 5. Review of Resident #25's face sheet showed the following: -admitted on [DATE];-Diagnoses included: chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), severe sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, which triggers widespread inflammation, tissue damage, and organ failure) without septic shock, bacterial pneumonia (serious lung infection causing inflammation and fluid/pus accumulation in the air sacs). Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of walker;-Use of wheelchair;-Partial to moderate assistance with toileting hygiene, showering , personal hygiene, dressing;-Resident at risk of developin

Based on interview and record review, facility staff failed to post nursing staff information in a prominent, readily accessible area on a daily basis. The census was 69. Review of the facility records did not show a policy regarding posted nurse staffing. Observation on 02/17/26 at 11:05 A.M., showed a nurse staff hours posting located near the nurses' station next to the dining room window, on the wall at approximately 5 feet high, that showed the following:-Dated 02/12/26 (5 days prior);-Census 70;-Day shift: 2 Registered Nurse (RN)/Licensed Practical Nurse (LPN) = 24 hours, 12 Certified Medication Technician (CMT)/Certified Nurse Aide (CNA) = 123 hours, Total = 147 hours;-No night shift hours were listed. Observation on 02/18/26 at 10:30 A.M., showed a nurse staff hours form located near the nurses' station that showed the following:-Dated 02/18/26;-Census 69;-Day shift: 2 RN/LPN = 24 hours, 11 CNA/CMT = 108 hours, 13 total = 132 hours;-Night shift: 2 RN/LPN = 24 hours, 7 CNA/CMT = 69 hours, 9 total = 93 hours. Observation on 02/19/26 at 1:06 P.M., showed a staff hours posting located near the nurses' station that showed the following:-Dated 2/19/26;-Census 69;-Day shift: 2 nurse = 23 hours, 11 CNA/CMT = 118.5 hours, 13 total = 141.5 hours;-Night shift: 3 nurse = 27 hours 7 aides = 60 hours, 10 total = 87 hours. Observation on 02/20/26 at 2:30 P.M., showed no nurse staff hours posted. Observation on 02/23/26 at 11:00 A.M., showed no nurse staff hours posted. Observation on 02/23/26 at 1:00 P.M., showed a nurse staff hours posting located near the nurses' station on a clipboard with multiple days posting located behind the front sheet. The top sheet showed the following:-Dated 02/24/26 (for the following day);-Census 69;-Day shift: 2 RN/LPN=24 hours, 15 CNA/CMT= 143 hours, 17 total = 167 hours-Night shift: 2 nurse = 24 hours, 7 aides = 70 hours, 9 total = 94 hours. Observation on 02/24/26 at 11:00 A.M., showed a nurse staff hours posting located near the nurses' station that showed the following:-Dated 02/24/26;-Census 69;-Day shift: 2 RN/LPN=24 hours, 15 CNA/CMT= 143 9 hours, 17 total = 167 hours-Night shift: 2 RN/LPN = 24 hours, 7 CNA/CMT = 70 hours, 9 total = 94 hours. During an interview on 02/23/26 at 10:00 A.M., RN B said the nurse staff hours were posted by the night nurse. Then the administration follows up in the morning. It should include the facility census and the staff hours for each shift. During an interview on 02/23/26 at 11:30 A.M., the Director of Nurses (DON) said the night shift nurses should post the daily nurse staffing hours. Last night (02/22/26) a new contract nurse worked, the forms were located in the DON office and the nurse did not have access to the form. The form should be posted daily. During an interview on 02/24/26 at 1:55 PM, the Assistant Director of Nurses (ADON) said she was responsible for posting the nurse staff hours and it should be posted daily. The staff on each shift should make any changes as needed. She said it should be posted every day, even if she was not at work. She had shown the nurses how to complete the form using the daily schedule. During an interview on 02/24/26 at 3:24 P.M., the Administrator said the nurse staff hours should be posted daily. The DON and ADON were responsible for ensuring it was posted.

Based on observation, interview, and record review, the facility failed to have a process in place for initial and periodic bed rail safety checks, to include measurements of the bed frame and bed rails for risk of entrapment, for two residents (Residents #9, #18). The facility census was 69.Review of the facility policy, dated 09/17/25, titled Bed and Assist Bars Use in Long-Term Care, showed the following:-To ensure safe and appropriate use of bed rails, side rails, and assist bars to prevent falls, entrapment, and injury, while complying with CMS and state regulations;-Bed rails or assist bars may only be installed or used with a physician/ provider order;-Orders must specify: type of device, purpose, frequency of use, and any resident-specific precautions.-Nursing/Therapy staff must perform a risk assessment prior to implementation, considering: Fall risk, Cognitive status, Mobility level, Skin integrity, Entrapment risk;-Alternative interventions must be considered before use;-Findings and rationale must be documented in the resident's care plan;-Obtain informed consent from the resident or legal representative prior to installation; -Explain risks, benefits, and alternatives;-Only trained staff may install or adjust assist bars or bed rails;-Ensure proper positioning to minimize entrapment and injury risk;-Residents with assist bars/bed rails must be monitored for safety, comfort, and skin integrity;-Reassess necessity at least monthly or when resident condition changes;-Remove assist bars or bed rails when no longer medically necessary;-Update physician orders and care plan accordingly;-Nursing Staff: Perform assessments, ensure order is in place, monitor safety;-Physician/ Provider: Evaluate necessity, write orders, review ongoing use.-Therapists: Perform assessments, recommend safer alternatives or modifications if appropriate. Review of the facility undated form, titled Bed Rails and Turn Bars Informed Consent for Use, showed the following:-Based on the assessment and identifications of the resident's needs. bed rails may be beneficial for the following reasons:-Safety: Can serve as a safety measure by preventing falling or slipping onto floor by resident with but not limited to the following conditions: seizures, neurological or movement disorders;-Security: Can provide a sense of security if the resident is afraid of falling, his/her movement iscompromised or accustomed to sleeping in a larger bed;-Mobility Assistance: Con assist resident to reposition self in bed upward/downward or turning side-to-side. Can also assist resident with safely exiting or entering bed;Potential Risks and Negative OutcomesThe use of bed rails can present a hazard or involve potential risks to certain individuals, particularly those residents with physical limitations or altered mental status, such as delirium or dementia. Potential risks may include getting caught within the roil, getting caught between mattress and rail, strangulation, suffocation, bruising and/or skin tears caused by hitting against rails, crawling over the rails and falling from greater heights increasing risk for serious injury or death. Other potential negative outcomes may include, but ore not limited to, decline in muscle functioning, skin integrity issues, may alter resident's self-esteem, induces agitation or anxiety, feelings of isolation, decline in other areas of activities of daily living and reduced physical mobility;-It is the policy of this facility to use bedrails only after on individualized resident assessment, evaluation and core planning by on interdisciplinary team determine it beneficial and appropriate for use to treat the resident's medical symptoms, assist the resident in attaining or maintaining the highest possible physical and psychosocial well-being and after attempts at using alternatives [NAME] proven inadequate or inappropriate. In determining bed rail use, the least restrictive device, which is effective, will be used.-The facility will monitor the resident's status, frequency of use, and adjust care as needed;-The facility will have a systematic evaluation process to gradually decrease and/or eliminate the use of bed rails to ensure the resident's safety while treating the resident's medical symptoms;-What assessed medical needs for this resident would be addressed by the use of bed rails or turn bars?-What are the benefits of using bed rails or turn bars for this resident and what is the likelihood of thesebenefits?-What are the resident's potential risks from the use of bed rails or turn bars?-Ways these risks will be mitigated;-Alternatives attempted that failed to meet resident's needs;-Alternatives considered but not attempted because they were considered inappropriate;-Recommended Type of Bedrails or Turn Bars:-Full Length Rail, Left Upper and/or Lower, Right Upper and/or Lower;-Three quarter Length Rail, Left Upper and/or Lower, Right Upper and/or Lower;-One-half Length Rail Left Upper and/or Lower, Right Upper and/or Lower;-One-quarter Length Rail Left Upper and/or Lower, Right Upper and/or Lower;-Split Roil Left Upper and/or Lower, Right Upper and/or Lower;-Turn Bar Left Upper and/or Lower, Right Upper and/or Lower;-Turn bar also referred to as assist bar or cone assist bar;-Recommended Frequency of Use:-Recommended bed rails or turn bars be used only at night;-Recommended bed rails or turn bars be used at all times while resident is in bed;-Recommended bed rails or turn bars be used only when resident is asleep;-I acknowledge that I have been informed of having medical needs that would be addressed by the useof bed rails or turn bars. I certify that I have read the benefits and potential risks/negative outcomes ofbed roil use, or this information has been read and explained to me. I certify that I fully understand themedical needs, benefits and potential risks/negative outcomes of bed rail use, and the health coreprofessionals' evaluation/recommendations. Therefore: -I DO voluntarily consent to the use of bed rails or turn bars as recommended;-I DO NOT consent to the use of bed rails or turn bars as recommended and understand liabilities. Review of the facility undated form, titled Bed Rails and Mattress Safety Assessment, showed the following:-Resident name and Room number;-Date of Assessment;-Reason for Assessment:-Initial Use. Scheduled Review. Change in Mattress. Change in Bed. Change in Rail.Type of bed. Type of mattress. Type of rail;-The gap between the mattress and the lowermost portion of the bed rail can be no greater than 2.5 inches or ____ for this resident;-The gap between the inside surface of the bed rail and the mattress can be no greater than 4.5 inches or _____ for this resident;-Measure while resident ls in the bed;-Implement corrective action or do not use rail if dimensions do not meet criteria. 1. Review of Resident #9's face sheet (brief information sheet about the resident) showed the following:-admitted on [DATE];-Diagnoses included: schizophrenia (chronic, severe brain disorder that causes individuals to interpret reality abnormally, leading to hallucinations, delusions, and disorganized thinking or behavior), severe intellectual disabilities (reduced cognitive capacity), muscle weakness, discogenic back pain (dull, deep ache in the spine, often in the lower back or neck, that worsens with sitting, bending, coughing, or sneezing, but improves with lying down or extending the spine);-His/her own responsible party. Review showed a bed rail assessment signed by the resident on 11/17/25. Review of the resident's Physician Order Sheet (POS), current as of 02/24/26, showed an order, dated 11/19/25, may have enabler bars to enhance independence with bed mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/26/26, showed the following:-Cognitively intact;-Use of wheelchair;-Substantial to maximal assistance for toileting hygiene, showering;-Partial to moderate assistance with personal hygiene;-Dependent on staff for showering;-Bed rail not used as a restraint in bed. Review of the resident's care plan, last reviewed on 11/19/25, showed the following:-Resident had enabler bars to assist with independence in repositioning while in bed Review of the resident and facility records showed staff did not provide documentation of initial or periodic assessments and measurements of the rails to ensure they were placed appropriately and maintained. During an interview and observation on 02/17/26, at 3:00 P.M., showed the following;-Bilateral grab bars in the upright position on the resident's bed;-The resident said he/she used the grab bars to help with repositioning in bed. Observation on 02/19/26, at 1:20 P.M., showed the following;-Bilateral grab bars in the upright position on the resident's bed. Observation on 02/24/26, at 12:45 P.M., showed the following;-Bilateral grab bars in the upright position on the resident's bed. 2. Review of Resident #18's face sheet showed the following:-admitted [DATE];-Diagnoses included: personal history of traumatic brain injury (brain injury that is caused by an outside force), cerebellar ataxia (neurological condition caused by damage or dysfunction in the cerebellum-the brain's movement control center-leading to a loss of full control of bodily movements), dysphagia (difficulty swallowing), history of falling;-Resident was not his/her own responsible party. Review showed a bed rail assessment signed by the resident on 11/17/25. Review of the resident's POS, current as of 02/24/26, showed an order, dated 11/18/25, for enabler bars to enhance independence with bed mobility. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Dependent on staff for toileting hygiene, showering;-Substantial to maximal assistance of staff for dressing, personal hygiene;-Bed rail not used as a restraint while in bed. Review of the resident's care plan, last reviewed on 01/16/26, showed the following:-Resident used enabler bars on the bed to assist with independence in repositioning while in bed. Review of the resident and facility records showed staff did not provide documentation of initial or periodic assessments and measurements of the rails to ensure they were placed appropriately and were maintained or in good repair. During observation and interview on 02/17/26, at 3:25 P.M., the resident said he/she used the grab bar to assist with repositioning in bed. Observation on 02/18/26, at 10:00 A.M., showed the following;-Grab bars in the upright position on the resident's bed.Observation on 02/20/26, at 1:15 P.M., showed the following;-Grab bars in the upright position on the resident's bed. 3. During an interview on 02/23/26, at 11:30 A.M., RN B said there was an assessment form that nursing staff completes and has the resident sign for consent, then staff would request a physician order for the side rails. Once the assessment and physician's order were in place, the nursing staff notify maintenance staff for installation. He/she did not know if there were measurements of the bed rails. 4. During an interview on 02/23/26, at 11:35 A.M., LPN A said once the nurses have the information for a side rail or grab bar, they should complete an assessment and obtain a physician's order, as well as resident or family consent. Once ready for a side rail, nursing staff should notify maintenance for installation. He/she did not know if the maintenance staff had measurements of the side rails and mattress. During an interview on 02/23/26, at 12:45 P.M., Maintenance Director said: -When staff notify him of a bed rail request, there should be a physician's order and nurse or therapy evaluation completed;-He was recently told of the new corporation policy and given the form that contains measurements;-He had no measurements of any side rails in the building at this time;-Up until August 2025 he had been completing safety checks but no measurements and has since not been checking the monthly forms;-He was responsible for the installation of bed rails;-He did not measure the resident beds before he installed the bed rails;-He did not do entrapment assessments;-He did not have ongoing inspection process for measuring the bed frame, mattress, and bed rails, to identify areas of possible entrapment.During an interview on 02/24/26, at 2:00 P.M., the DON said the nursing staff should complete a side rail assessment and obtain resident or family consent for use of side rails. The maintenance staff would then install the bed rails and bed rail entrapment measurements should be updated at least quarterly with the care plan review. During an interview on 02/24/26, at 3:20 P.M., Administrator said that side rail and mattress measurements should be done when installing side rails and should be monitored every month or if changing out a mattress. He said the staff should use the gap measurements form.

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) worked full time and did not work as the charge nurse when the facility had an average daily occupancy of 60 or more residents. The facility census was 69. Review of the facility's undated job description, Director of Nursing (DON), showed the following:-Our mission is to transform lives through Accountability, Service, Passion, Integrity, Resilience, and Excellence;-The DON is responsible for providing leadership, oversight, and direction to the nursing department to ensure the delivery of high-quality resident care and services;-The DON collaborates with interdisciplinary teams, nursing staff, and healthcare providers to promote resident well-being, clinical excellence, regulatory compliance, and a culture of safety and professionalism;-Key Responsibilities:-Provide visionary leadership, strategic direction, and operational oversight to the nursing department, aligning nursing goals with the facility's mission, vision, and values;-Recruit, hire, train, supervise, and evaluate nursing staff, including registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), and other nursing personnel;-Foster a positive and supportive work environment, promoting teamwork, collaboration, open communication, and professional growth among nursing staff members;-Ensure the provision of resident-centered care that meets the physical, emotional, and psychosocial needs of residents, adhering to established care standards, protocols, andbest practices;-Collaborate with interdisciplinary teams to develop and implement individualized care plans, treatment regimens, and interventions based on resident assessments, preferences, and goals;-Monitor and evaluate resident outcomes, quality indicators, and clinical performance metrics, implementing quality improvement initiatives to enhance resident care and safety;-Ensure compliance with federal, state, and local regulations, as well as industry standards and accreditation requirements, related to nursing practice, resident rights, and clinical care;-Coordinate and participate in regulatory surveys, inspections, audits, and compliance reviews, addressing deficiencies and implementing corrective actions as needed;-Conduct ongoing assessments, audits, and monitoring activities to assess nursing department performance, identify areas for improvement, and ensure adherence to policies and procedures;-Develop, implement, and evaluate nursing education and training programs to enhance staff competency, skills, and knowledge in areas such as resident care, clinical procedures, infection control, and safety;-Provide ongoing education, mentoring, and professional development opportunities to nursing staff members, encouraging continuous learning and career advancement;-Collaborate with external resources, educational institutions, and professional organizations to facilitate staff training, certification programs, and continuing education initiatives; -Collaborate effectively with interdisciplinary team members, including physicians, therapists, social workers, dietary staff, and administrators, to coordinate resident care and support interdisciplinary care planning;-Communicate effectively with residents, families, healthcare providers, and external stakeholders regarding resident care plans, treatment goals, care transitions, and clinical updates;-Facilitate interdisciplinary meetings, care conferences, and case reviews to discuss resident progress, address care issues, and promote continuity of care across caresettings;-Develop and maintain nursing-related emergency preparedness plans, policies, and procedures to ensure the safety and well-being of residents and staff during emergencies or disasters;-Coordinate nursing responses to emergencies, crises, and adverse events, implementing protocols for triage, communication, evacuation, and continuity of care;-Provide leadership, guidance, and support to nursing staff members, residents, and families during challenging situations, demonstrating resilience, empathy, and effectiveproblem-solving skills;-The DON plays a pivotal role in ensuring the provision of high-quality resident care, promoting clinical excellence, regulatory compliance, and interdisciplinary collaboration within a Long-Term Care facility;-Through their leadership, expertise, and commitment to nursing excellence, the DON contributes to enhancing resident outcomes, optimizing nursing practice, and fostering a culture of safety, compassion, and professionalism. Review of the facility's nursing schedule, Daily Assignment Sheets, showed the DON as charge nurse:-On 02/08/26, night shift with a census of 70;-On 02/11/26, day shift with a census of 70;-On 02/13/26, day shift with a census of 70;-On 02/16/26, night shift with a census of 69;-On 02/17/26, scheduled night shift with a census of 69; she did not work this shift due to state survey in process;-DON scheduled to work 5 shifts out of 9 days as floor/charge nurse. During an interview on 02/18/26 at 11:20 A.M., LPN B said the DON was often filling in as a charge nurse. The LPN was unsure when the DON would have time to do the DON duties. During an interview on 02/19/26 at 10:40 A.M., the Assistant Director of Nurses (ADON) said she currently worked more than 40 hours per week and was often a charge nurse on the floor. She had not had time to complete audits on wound care and CNA charting. Both her and the DON were putting a lot of hours on the floor and not completing the DON and ADON duties. During an interview on 02/20/26 at 11:40 A.M., the DON said there have been staffing issues. There were staff that would not show up when they said they would. She has worked most weekends and one to two nights per week. She would stay until the morning meeting and then leave. They try to keep two nurses staffed for all shifts. She had not been the only nurse on the days or nights she worked. When she worked on the floor, she was still the DON. She had not had time to audit Treatment Administration Records (TARs) or Medication Administration Records (MARs) weekly due to working on the floor often. During an interview on 02/20/26 at 3:00 P.M., the Administrator said when the DON was working the floor he expected she was the nurse in charge. He was aware she was working on the floor often due to staffing challenges.

Based on observation, record review, and interview, the facility failed to provide pharmaceutical services in a manner to ensure the proper storage, destruction, and accountability of medications when the facility did not have a process in place for timely destruction and tracking of the unused medications. A sample of 11 residents' (Resident # 60, #40, #53, #100, #101, #102, #1, #10, #13, #39, #103) medications were located in the medication room waiting to be destroyed. The facility census was 69. Review of the facility policy, dated [DATE], titled Medication Destruction and Diversion Prevention Policy, showed the following:-To ensure safe, secure, and compliant destruction of discontinued, expired, or unusedmedications in accordance with Missouri regulations, Drug Enforcement Administration (DEA) rules, and Center for Medicare and Medicaid Services (CMS) requirements;-For Non-Controlled Medication Destruction Procedure:-Licensed nurse verifies discontinuation or expiration;-Place medication into drug buster container (uses activated charcoal to quickly neutralize the active ingredients of medications);-Document destruction in ledger;-Documentation Requirements;-All entries must include: Date and time, Resident Name, medication name and strength, quantity destroyed, reason for destruction, and signature and two signatures for controlled substances;-Records of destruction must be maintained for a minimum of two years and be readilyretrievable for inspection by Missouri Department of Health & Senior Services (DHSS) and other authorized agencies. During an interview with Certified Medication Technician (CMT) C and observation of the medication room on [DATE] at 12:00 P.M., showed the following:-One cardboard box, approximately 18 by 18 inches in size, located under the sink that was full of unused medication cards, bags, and liquids;-Three grocery style brown bags of unused medications located under the sink;-CMT C said that he/she had disposed of medications on the Sundays that he/she worked. He/she no longer worked on Sundays;-He/she said that he/she helped another CMT dispose of unused medications at least once in the last six months;-He/she said they do not write any information about the unused medications in any logbook but there were cameras in the medication room;-Review showed some medication dispense dates of [DATE], [DATE], and [DATE] on the top of the pile. During an interview with the Director of Nurses (DON) and observation of the medication room on [DATE] at 1:20 P.M., showed the following:-The DON removed the cardboard box and three brown bags from under the sink and pulled medications out of the box and bags;-The DON said the CMT staff should destroy non-narcotic medications at least once per week;-Each medication should be logged before being destroyed and destroyed in drug buster liquid;-She was unaware of the amount to be destroyed in the medication room;-The CMTs were responsible for the medication room;-Review of a small sample of medications pending destruction included the following:-Resident #60, Solu-Medrol injectable 12 mg (steroid that prevents the release of substances in the body that cause inflammation), dispensed [DATE];-Resident # 40, Meropenem 1gm vial (broad-spectrum antibiotic to treat severe bacterial infections), three vials, dispensed [DATE]; Apixaban 2.5 mg (blood thinner used to prevent and treat blood clots), four tablets, dispensed [DATE]; Meclizine 25 mg (used to prevent motion sickness, nausea, vomiting), Omeprazole 40 mg (used to treat acid reflux), and vitamin B complex with vitamin C, four tablets each, dispensed [DATE];-Facility stock dose of Warfarin 1 mg (prescription blood thinner that prevent harmful clots from forming or growing), three tablets, expired [DATE];-Resident #53, Gentamicin 100 mg vial (broad-spectrum antibiotic to treat severe systemic infections), one vial, dispensed [DATE];-Resident #100, Augmentin 875/125 mg (commonly prescribed antibiotic to treat various bacterial infections), 25 tablets, dispensed [DATE]; Trazadone 100mg (prescription to treat depression, anxiety, and insomnia), Duloxetine 60 mg (used to treat depression, anxiety, and chronic pain), Pantoprazole 40 mg (used to treat acid reflux), Losartan 50 mg (used to treat high blood pressure), Gabpentin 600 mg (used to treat nerve pain and manage some types of seizures), and Spironolactone 25 mg (treats high blood pressure and heart failure), two tablets each, dispensed [DATE];-Resident #101, Nitroglycerin 4 mg (used to treat chest pain), one vial, dispensed [DATE];-Resident #102, Ceftriaxone 1 gm vial (antibiotic used to treat severe bacterial infections), one vial, dispensed [DATE]; Nafcillin 2 gram, three vials with Sodium Chloride 0.9% IV reconstitution (antibiotic to treat moderate to severe infections), dispensed [DATE];-Resident #1, Gabapentin 100 mg, Eliquis (brand name of Apixaban) 5 mg, Mirtazapine 15 mg (used to treat depression), one tablet each, dispensed on [DATE];-Resident #10, Metronidazole 500 mg (used to treat wide range of infections), seven tablets, dispensed [DATE];-Resident #13, Omeprazole 40 mg tablet, dispensed [DATE];-Resident #39, Spironolactone 25mg, one tablet, dispensed [DATE];-Resident #103, Atorvastatin 40mg (used to treat high cholesterol), Carvedilol 6.25 mg (used to treat high blood pressure and chronic heart failure), Eliquis 5 mg, Sertraline 25mg (used to treat depression), one tablet each, dispensed [DATE]; During an interview on [DATE] at 2:05 P.M., the Administrator said he expects staff to dispose of medication according to pharmacy policy. The DON was responsible for the medication room. He expects unused medications to be destroyed in a timely manner. During an interview on [DATE] at 3:20 P.M., Licensed Practical Nurse (LPN) D said there was not a process for disposal of non-narcotic medications. He/she had never written any information in a logbook for destroyed non-narcotic medications. The narcotics were disposed of by the DON and a nurse and logged on the narcotic disposition sheet. During an observation and interview on [DATE] at 9:15 A.M., CMT E prepared medication for Resident #64. The resident refused the medication. The CMT took the cup of medication to the medication room and removed the drug buster liquid from under the sink and placed Tylenol 500 mg, 2 tablets, and magnesium oxide 400 mg, 1 tablet into the liquid. The CMT said he/she would notify the nurse that the resident refused. He/she did not log this information and said there was no logbook for destroyed medications.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to prepare pureed diets per approved recipes and failed to provide the approved serving size for pureed meals. The facility census was 69.Review of the facility policy titled, Pureed, revised 10/01/25, showed the following:-Pureed diet menus follow the foods on the regular menu as closely as possible and differ primarily in consistency;-Use an appropriate recipe;-Always refer to the recipe and spreadsheet for directions.Review of the facility's recipe for pureed beef stew showed the following:-Prepare according to the regular beef stew recipe;-Place the number of servings needed, from the regularly prepared recipe into the food processor;-Blend until smooth and serve two #8 scoops (four ounces (oz) per serving.Review of the facility's recipe for beef stew showed the following:-Add oil to large stockpot or saucepan or steam jacketed kettle. [NAME] meat in oil;-Add vegetables, Worcestershire sauce, half of the salt and pepper, water, and base. Bring to a simmer and cook until all ingredients are fork-tender and desired end temperature is reached;-Adjust seasoning with salt and pepper. Serve with a 6 oz spoodle (combination spoon/ladle). Observation on 02/20/26 at 10:29 A.M., showed the following:-Dietary [NAME] (DC) F began to puree the lunch meal for four puree diets;-DC F used four oz scoops to place four servings of beef stew into the processor (the recipe called for 6 ounces of beef stew per serving);-DC F said he/she did not consult a recipe during the puree process.Observation on 02/20/26 at 11:46 A.M., showed the following:-DC F used one four-ounce scoop for serving one pureed portion of beef stew.During an interview on 02/20/26 at 1:24 P.M., DC F said the following:-He/she has not been trained to prepare purees;-He/she does not consult the menu or recipe for serving sizes for puree or serve out;-He/she refers to the Dietary Manager (DM) about correct serving sizes as needed;-He/she does not prepare extra puree meals.During an interview on 02/20/26 at 2:43 P.M., the DM said the following:-Staff should use the recipe book to guide portions for puree preparation and serve out;-He has not been able to train DC F on preparing purees correctly or utilizing the recipe for correct servings;-Staff do not typically make extra puree meals. During an interview on 02/23/26 at 4:38 P.M., the Administrator said staff should follow the recipe/menu for puree meal preparation and serve out.During an interview on 02/24/26 at 8:03 A.M., the Registered Dietician (RD) said staff are expected to follow the portion size indicated on the spread sheet and menus for food preparation and serve out.

Based on observation, interview and record review, the facility failed to appropriately store and label food items, failed to discard food items when appropriate per labeling, failed to air dry dishes before stacking, and failed to check dishwasher temperatures, all to ensure proper sanitaiton and food handling practices to prevent contamination. The facility census was 69.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination.Review of the facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following:-Food shall be stored on shelves in a clean, dry area free from contaminants;-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded;-Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration;-Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers.Observation on 02/17/26 at 10:45 A.M., showed the following:-A 16-ounce (oz) box of corn starch in the dry storage area, open to air and not labeled with a date;-Inside the walk-in freezer, a large plastic bag of beef patties inside a box, a large plastic bag of waffles inside a box, and a large plastic bag of broccoli inside a box, with all of the plastic bags containing these food items open to air, exposing the food to possible contamination. During an interview on 02/20/26 at 1:24 P.M., Dietary [NAME] (DC) F said all stored food should be sealed and labeled with the date opened and use by date. No food should be open to air.During an interview on 02/20/26 at 2:05 P.M., Dietary Aide (DA) G said all stored food should be sealed, labeled with the date opened and stored in the correct place.During an interview on 02/20/26 at 2:43 P.M., the Dietary Manager (DM) said all stored food should be sealed in a proper container and labeled with the open and use by date.During an interview on 02/23/26 at 4:38 P.M., the Administrator said all stored food should be sealed and labeled with the date opened and the use by date.During an interview on 02/24/26 at 8:03 A.M., the Registered Dietician (RD) said all stored food should be sealed and dated. 2. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed the following:-Facility staff must ensure their proper storage, keeping track of when to discard perishable foods, and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated;-Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable), or discarded.Review of the facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following:-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded;-Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration;-Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers.Observation of the dry food storage area on 02/17/26 at 10:45 A.M., showed the following:-A 128 oz container of soy sauce, almost empty, with a date of 05/27/24 written on the container;-A large black plastic bin about one-third full of pinto beans. Beans was written on the container with no dates;-A large black plastic bin about half full of rice. The label had a date of 01/07/25 and use by 06/07/25.During an interview on 02/20/26 at 1:24 P.M., DC F said all food that is past the use by date or expired date should be thrown out.During an interview on 02/20/26 at 2:43 P.M., the DM said all stored food should be thrown out after its use by date.During an interview on 02/23/26 at 4:38 P.M., the Administrator said expired food should be thrown out.During an interview on 02/24/26 at 8:03 A.M., the RD said no food should be available past its use by date.3. Review of the 2022 Missouri Food Code showed dishes are required to be air dried before being stacked and stored.Review of the facility policy titled, Dishes and Utensils, revised 06/19/25, showed dishes, trays, and utensils shall be air dried before storage. Observation on 02/17/26 at 10:45 A.M., showed blue coffee cups and plastic bowls stored upside down and ready for use with water sitting in the bottom of the cups and bowls. Small plastic drinking cups were stacked and ready for use with visible water inside the cups. Observation and interview on 02/20/26 at 10:44 A.M., showed the following:-Small, stacked plastic cups ready for use contained water on the inside and on the bottom of the cups;-DA G said the cups had been sitting for a while before they were stacked, but there is not enough time for them to dry completely between breakfast and lunch serve out;-DA G said staff should not stack cups wet, but the facility does not have enough cups and must use the ones not yet dry for lunch.During an interview on 02/20/26 at 1:24 P.M., DC F said dishes should be air dried and not stacked while still wet.During an interview on 02/20/26 at 2:43 P.M., the DM said all dishes should be air dried before stacking.During an interview on 02/23/26 at 4:38 P.M., the Administrator said dishes should not be stacked while wet. They should be allowed to dry before they are stacked.During an interview on 02/24/26 at 8:03 A.M., the RD said dishes should be stacked inverted and only after they have dried.4. Review of the facility policy titled Dishwashing: Machine Operation, dated 2020, showed the following:-The dining services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food;-All dishwashing machines should be operated according to the manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high-temperature dishwashing machine that uses hot water, or a chemical-sanitizing dishwashing machine that uses chemical sanitizing solutions;-Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours; it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function;-Record log documents twice daily for either final rinse temperature or sanitizer concentration;-If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dish washing machine, check nozzles and empty bottom screen and restart the dishwashing machine;-After troubleshooting, if the dishwashing machine is not functioning, then employees should contact the DM or maintenance or outside vendor per facility guidelines to coordinate repair period, the dishwashing machine should be labeled out of a service and not utilized until the dishwashing machine is repaired;-If the dishwashing machine cannot be repaired in a timely manner, the facility will utilize the manual dishwashing procedure. Paper goods may be used as a temporary measure until the dishwashing machine was repaired.Review of the Ecolab ELT dishwashing machine specifications showed the Minimum operating temperature for wash is 120 (degrees) and for sanitizing rinse is 120 .Review of the facility's dish machine log showed staff documented the sanitation parts per million (PPM-indicates one part of solution per million parts of entire mixture) two times daily in the A.M. and the P.M. Staff did not document the temperature of the machine cycles.Observation and interview on 02/20/26, at 2:05 PM and 2:17 P.M., showed the following:- Dietary Aide (DA) G put dishes through the dishwasher. The wash cycle temperature was 115 and the rinse cycle was 144 ;-DA G said as of November of last year, staff do not log dishwasher temperatures, only the sanitizer test strip results;-DA G put dishes through another cycle and the wash temperature was 103 and the rinse temperature was 136 .During an interview on 02/20/26 at 2:43 P.M., the DM said the following:-Staff should be logging the wash and rinse cycle temperatures for the dishwasher at every meal service;-He was not sure why staff did not log the temperatures. He should be auditing the logs but had not had time;-The dishwasher wash and rinse cycles should temp at a minimum of 120 .During an interview on 02/23/26 at 4:38 P.M., the Administrator said staff should follow the manufacturer recommendations for dishwasher temperatures and log temperatures and sanitizer testing for each meal service.During an interview on 02/24/26 at 8:03 A.M., the RD said the following:-Staff should be logging dishwasher temperatures at every meal service;-Low temperature dishwashers should temp at 120 for wash and for rinse cycles.

Based on interview and record review, the facility failed to ensure all resident representatives were notified of regarding changes in condition in a timely manner when staff failed to inform one resident's (Resident #1) representative of a decline in his/her wound until two days after the decline was documented. The facility census was 64. Review of the facility policy entitled Notification of Changes, dated 10/01/25, showed the following:-This policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification;-The facility must inform the resident, consult the resident's physician, and notify, consistent with his/her authority, the resident's representative when there is a change requiring notification;-Circumstances that require notification include accidents, significant changes in resident's physical, mental, or psychosocial condition, circumstances that require a need to alter treatment such as a new treatment or discontinuation of current treatment due to adverse consequences, acute condition, and exacerbation of a chronic condition. Review of the facility policy entitled Wound Treatment Management, undated treatment decisions will be based on etiology of the wound, characteristics of the wound, location of the wound, and the goals and preferences of the resident/representative. 1. Review of Resident #1 face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 10/15/25;-Diagnoses included pressure ulcer (an area of the skin and tissue injured due to pressure on the skin for a long time) of sacral region (the triangular area at the base of your spine), age related physical debility (general weakness related to aging), dysphagia (difficulty swallowing), wedge compression fracture of the third vertebra (a type of fracture in the spine), and wedge compression fracture of the fifth vertebra;-Residents responsible party contact information listed. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/15/25, showed the following information:-The resident was cognitively impaired;-The resident required substantial/max assist for eating, toileting, showering, bathing, personal hygiene, rolling from side to side, and all transfers;-The resident used a manual wheelchair. Review of the resident's care plan, updated 10/31/25, showed the following:-The resident had a power of attorney because he/she was unable to make decisions for self;-The resident required help with bed mobility when fatigued;-The resident had a pressure injury to his/her coccyx (tailbone);-The resident often refused to reposition or turn to relieve pressure;-Staff should turn and reposition the resident every two hours and as needed. Review of the resident's Physician Orders, dated 10/15/25 to 11/07/25, showed an order, dated 10/16/25, for staff to cleanse wound to coccyx with hypochlorous acid (a disinfectant), apply skin prep (used to apply a protective film over skin that helps to prepare it for adhesives) to area cover with bordered dressing, and change dressing every three days for wound care.Review of the resident's nursing progress notes, dated 10/15/25 to 11/07/25, showed the following:-On 10/15/25, the Assistant Director of Nursing (ADON) documented a 1.4 centimeter (cm) by 0.5 cm by 0.1 cm, stage two pressure area (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the resident sacrum/coccyx;-On 10/29/25, the ADON documented a stage two pressure area to sacrum/coccyx area, dark pink with no open area;-On 11/01/25, the ADON documented a stage two pressure area to sacrum/coccyx area and resident refused treatment;-On 11/05/25, the ADON documented a 5.5 cm by 5 cm by 0.5 cm, stage four pressure area (full-thickness skin and tissue loss) to sacrum/coccyx area with necrotic (dead) tissue present. The wound has deteriorated. Staff notified physician with new orders received. (Staff did not document notification of the resident's representative of the change in the wound's condition or new orders received.) Review of the resident's Physician Orders, dated 10/15/25 to 11/07/25, showed an order, dated 11/07/25, for staff to cleanse wound to coccyx with hypochlorous acid, apply calcium alginate (highly absorbent dressing/substance) to wound bed, cover with bordered gauze, and change every day and as needed. Review of the resident's nursing progress notes dated 11/07/25, at 7:15 P.M., showed staff documented family present at bed side informed of wound to coccyx and plan for treatment. Family then went to resident's room. Fifteen minutes later family informed staff of request to send resident to emergency room for wound evaluation at 7:36 P.M., second family member arrived at bed side and requested resident transferred to emergency room. Staff notified the Administrator and ADON. Resident sent to emergency room at 7:46 P.M. During an interview on 11/13/25, at 11:00 A.M., the ADON said the following: -He/she was the wound care nurse for the facility and did the wound treatments along with the charge nurses;-He/she measured all wounds of residents who were not seen by the wound care doctor;-He/she tried to speak to all families or residents who admit with wounds;-The resident had a stage two pressure area to his/her coccyx that they admitted to the facility with;-He/she did not know if the family knew of the wound on admission;-On 11/07/25 was the only time he/she spoke to the family regarding the resident's wound;-He/she did not notify the family when he/she received a new order for wound care;-He/she did not notify the family when the wound began to decline. During an interview on 11/13/25, at 11:45 A.M., Licensed Practical Nurse (LPN) A said the following:-Any changes to wounds are to be reported to the ADON, the Director of Nursing (DON), the physician, and the family;-Staff document all wounds and changes to wounds in the nurses' notes; -Family notifications should be documented in the nurses' notes;-Nursing interventions for residents with wounds include turning and repositioning, also involving family with residents are refusing care. During an interview on 11/13/25, at approximately 1230 P.M., the DON said the following:-All residents that admit are assessed for wounds;-If a resident admits to the facility with a wound staff are to notify the wound nurse for tracking, obtain orders from physician if no orders are present, document the site, and notify family;-The admitting nurse was responsible for notifications when the resident admitted if it was within business hours. Resident condition would determine priority of notification;-He/she would expect family to be notified when a resident has a change of condition and if a resident was frequently refusing treatments. During an interview on 11/14/25, at 11:00 A.M., the Administrator said the following: -He/she was not aware that the family of the resident was not notified of the change in the residents wound until 11/07/25;-He/she expected staff to notify the physician and the resident's family if the resident has a change of condition as soon as possible. Compliant 2665566

Based on record review and interviews, the facility failed to ensure staff provided care per standards of practice when staff failed to follow physician orders regarding elevated blood glucose levels and failed to document insulin administration amounts due to elevated blood glucose levels for one resident (Resident #1) of four residents sampled. The facility census was 61. Review of the facility policy entitled Blood Glucose Monitoring, revised 01/13/23, showed the following: -Purpose of the policy was to ensure the effective and accurate monitoring of blood glucose levels for individuals with diabetes or at risk for blood glucose abnormalities; to prevent low or high blood sugar; to guide healthcare professionals, caregivers, and patients in proper blood glucose monitoring practices to ensure safe and effective management of diabetes; -Doctors and nurses are responsible for ordering and interpreting blood glucose tests, providing guidance on target glucose levels, and adjusting medications accordingly; -Caregivers are responsible for regularly checking blood glucose, following prescribed testing schedules, recording results, and seeking medical advice when necessary; -Caregivers are required to document blood glucose readings, especially for those with insulin-dependent diabetes or undergoing intensive management; -Regular review of blood glucose logs should be done by healthcare professionals to ensure that the patient is staying within the target range and making necessary adjustments to their management plan; -A comprehensive blood glucose monitoring policy ensures that patients and healthcare professionals follow standardized, evidence-based practices for managing blood glucose. It aims to reduce complications associated with diabetes, improve patient outcomes, and enhance the overall quality of care. Review of the medical director's hyperglycemic (high blood sugar levels) protocol showed to leave a message on the physician's office line if the resident's blood glucose reading was greater than 500 milligrams/deciliter (mg/dL). 1. Review of Resident #1's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with hyperglycemia, long term use of insulin, and thyroid disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 09/13/24, showed the following; -Moderately impaired cognition; -Received insulin on 7 of the last 7 days. Review of the resident's care plan, last updated 09/13/24, showed the following: -Resident had a diagnosis of diabetes; -Administer diabetes medication as ordered by doctor; -Monitor/document for side effects and effectiveness diabetes medication; -Monitor/document/report any signs/symptoms of low or high blood sugar; -Perform blood sugar checks as ordered by doctor. Review of the resident's October 2024 Physician Order Sheets (POS) showed the following: -An order, dated 08/01/24, for insulin regular human injection solution (used to treat diabetes) 100 units/milligram (u/mg). Staff to inject per sliding scale before meals and at bedtime for diabetes: -If blood glucose reading was 131 mg/dL to 180 mg/dL, administer 4 units of insulin; -If blood glucose reading was 181 mg/dL to 240 mg/dL, administer 8 units of insulin; -If blood glucose reading was 241 mg/dL to 300 mg/dL, administer 10 units of insulin; -If blood glucose reading was 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood glucose reading was 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood glucose reading was 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood glucose reading was 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -Call physician for blood sugar reading over 500 mg/dL; before meals and at bedtime for diabetes. Review of the resident's October 2024 Medication Administration Records (MAR) showed on 10/11/24, the resident's blood sugar reading at 7:07 A.M. was 505 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of resident's nurse's note, dated 10/11/24, showed staff did not document information pertaining to notification to physician regarding the resident's blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's October 2024 MAR showed on 10/15/24, the resident's blood sugar reading at 7:01 A.M. was 501 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of the resident's nurse's notes, dated 10/15/24, showed staff did not document information pertaining to notification to physician regarding the resident's blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's October 2024 POS showed the order, dated 08/01/24, for insulin regular human injection solution per sliding scale was discontinued on 10/22/24. Review of the resident's October 2024 and November 2024 POS showed the following: -An order, dated 10/25/24, for NovoLog FlexPen Injection Solution (rapid acting insulin) 100 u/ml. Inject subcutaneously (below the skin) before meals and at bedtime for diabetes per sliding scale: -If blood glucose reading was 70 mg/dL to 130 mg/dL, administer no insulin; -If blood glucose reading was 131 mg/dL to 180 mg/dL, administer 2 units of insulin; -If blood glucose reading was 181 mg/dL to 240 mg/dL, administer 4 units of insulin; -If blood glucose reading was 241 mg/dL to 300 mg/dL, administer 6 units of insulin; -If blood glucose reading was 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -If blood glucose reading was 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -If blood glucose reading was 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood glucose reading was 451 mg/dL to 500 mg/dL, administer 18 units of insulin; -If blood glucose reading was over 500 mg/dL, call physician. Review of the resident's October 2024 MAR showed on 10/27/24, the resident's blood sugar reading at 7:14 A.M. was 590 mg/dL. Staff documented option 9 - Other/See Nurse Notes. Review of the resident's nurse's note, dated 10/27/24, showed staff did not document information pertaining to notification to physician regarding a blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. Review of the resident's November 2024 MAR showed on 11/15/24, the resident's blood sugar reading at 11:00 A.M. was 517 mg/dL. Staff documented option 5 - Hold/See Nurse Notes. Review of the resident's nurse's note, dated 11/15/24, showed staff did not document information pertaining to notification to physician regarding a blood sugar reading greater than 500 mg/dL, any orders/direction received, or amount of insulin administered. During an interview on 11/21/24, at 2:50 P.M., Registered Nurse (RN) A said if a resident's blood glucose reading was greater than 500 mg/dL. he/she would give the highest level of insulin for the specific sliding scale orders, recheck the blood glucose in an hour, and call the physician if the result was not in acceptable range. The resident's blood sugar test result was often high in the morning because the resident had refused insulin at bedtime the night before. The nurse should document the test result and the amount of insulin given. During an interview on 11/21/24, at 3:00 P.M., Licensed Practical Nurse (LPN) B said if the resident's sliding scale insulin order showed to call physician if the reading was greater than 500 mg/dL, he/she would wait to give insulin until contacting the physician for orders. He/she would document the orders and the amount of insulin given. During an interview on 11/21/24, at 3:05 P.M., RN C said he/she would contact the physician if a resident's blood glucose reading was greater than 500 mg/dL, which is the facility's protocol. They can either call the physician's office or put a message through on the secure electronic system and then they obtain orders regarding the amount of insulin to give. The physician can then re-address any medication changes when they are in the facility, usually weekly. During an interview on 11/21/24, at 3:20 P.M., the Director of Nursing (DON) said the nurses should follow the physician orders for administering insulin. If the order states to contact the physician if a resident's blood glucose reading is greater than 500 mg/dL, the nurse can use the secure electronic communication application to notify the physician. The nurse could give the highest level of insulin listed for the ordered sliding scale, but should go ahead and call/notify the physician. The physicians are good about getting back to them with orders, and there is always a physician on-call. The nurse should document the blood glucose reading, any physician orders, the amount of insulin given, and any re-check results. The DON reviewed the resident's nurses' notes and the electronic communications from the facility to the physician for 10/11/24, 10/15/24, 10/27/24, and 11/15/24. The DON was unable to locate documentation or evidence pertaining to physician notification of blood sugar readings above 500 mg/dL, subsequent physician orders, or amount of insulin given. During an interview on 11/21/24, at 5:02 P.M., the Administrator said he/she would expect staff to follow physician orders regarding blood sugar checks, contacting the physician if the test result was above a specified range, and insulin administration. The nurse should document all information, including the physician notification, orders, and amount of insulin given. MO00243846

Based on observation, interview, and record review, the facility failed to provide one resident (Resident #35) with routine or emergency dental care when the resident exhibited dental concerns resulting in the having continued dental issued including pain and bleeding and causing the resident to be embarrassed by his/her teeth. A sample of 22 residents was reviewed in a facility with a census of 59. Review of the facility policy titled, Oral Hygiene, dated 03/05/24, showed: -Oral care should be provided to each resident at least twice a day unless indicated differently by a doctor or dentist and more frequently if requested by the resident; -Any acute changes in dental status should be reported to the nurse such as drainage, bleeding, redness in gums, oral lesions, painful when touched, loose or broken teeth, etc. 1. Review of Resident #35's face sheet showed: -admitted [DATE]; -Diagnoses included of delusional disorder, hemiplegia (paralysis of one side of the body), chronic pain, and multiple sclerosis (MS - a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve and spinal cord). Review of the resident's care plan, revised on 11/20/22, showed resident had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) deficit and required extensive assistance of one staff with oral hygiene. Review of the resident quarterly Minimum Data Set (MDS - a federally-mandated assessment form completed by facility staff), dated 01/18/24, showed: -Cognitively intact; -Required partial/moderate assistance with oral hygiene (helper does greater than 50% or the effort). Review of the resident's progress note dated 11/23/23, at 10:31 P.M., showed a nurse documented the following: -Resident told this nurse he/she was having mouth pain. Resident showed this nurse blood on the tag of his/her pillow and told this nurse the pain was on the left bottom side of his/her mouth. This nurse assessed the resident's mouth and noted a missing broken off tooth at the back of the left bottom side of the resident's mouth. Resident was given acetaminophen for pain. Review of the resident's medical record showed staff did not document follow-up with the physician or a dentist regarding the residents dental pain. Observation and interview on 02/26/24, at 10:37 A.M., showed the following: -The resident lay awake on his/her bed. The resident's lower sheet, near the area of the resident's head, had an orange-sized, dark-red stain. The resident's pillowcase had a dime-sized, dark-red stain on the corner; -The resident said the bedding stains were blood, probably from his/her mouth. The resident said, My teeth are bad. -The resident said his/her mouth hurt all the time, and the pain was about a 9 (on a scale of 1 to 10, with 10 being the worst pain); -The resident said he/she had was unsure of when he/she last told staff of his/her dental issues. Observation and interview on 02/27/24, at 12:50 P.M., showed the following: -The resident opened his/her mouth and showed the surveyor his/her gums. Several of the resident's upper teeth appeared to be worn down to the gum line or missing, with blackened areas to his/her teeth and gums and reddened gums. The resident's lower gum had one visible tooth in the front with the gums pulled away from the tooth at the base; -The resident said his/her gums hurt. Observation and interview resident on 02/28/24, at 12:03 P.M., showed the following: -The resident said his/her gums and mouth bled a little every night; -The resident said he/she had dental issues for several years, but he/she had not reported the issues; -The resident said, in the past, the nurse aides have asked where the blood on his/her bedding came from, and the resident pointed to his/her mouth. The resident said he/she had oral pain daily, which he/she rated an 8 out of 10 all the time. The resident said it hurts to chew his/her food. The resident said he/she thought he/she needed to have a dentist pull the rest of his/her teeth and have dentures; -The resident's right upper gum line showed a blackened partial tooth worn down to the gum line. The front upper gum line was reddened and one lower tooth with exposed gum that appeared to be hitting on the upper gum when the resident bit down. The resident said that area of the upper gum caused the worst pain; -The resident said he/she was embarrassed by how his/her mouth looked. The resident said he/she had seen a dentist in the past, but not in several months and was unsure of the time. During an interview on 02/28/24, at 1:16 P.M., Licensed Practical Nurse (LPN) A said he/she was not aware of any dental issues with the resident. During an interview on 03/01/24, at 11:14 A.M., LPN T said the following: -He/she was not aware the resident was having dental issues; -If a resident had issues with his/her teeth and gums, the nurse should pass the issue on in report to the next nurse and place the resident on the list to see the dentist. During an interview on 03/01/24, at 11:28 A.M., Certified Nurse Assistant (CNA) Q said the following: -Several months ago, the resident was having an issue with his/her teeth. The CNA recalled one of the resident's teeth fell out and the resident had blood on his/her sheet. Afterwards, the Director of Nursing (DON) had a talk with the CNAs about the need to do better oral care for the residents. The DON educated staff on notifying the nurse if a resident's mouth was bleeding or if a resident lost a tooth. During an interview on 02/29/24, at 4:26 P.M., the DON said the following: -If a resident is prescribed an anticoagulant (medication that slows blood clotting), staff should watch for signs and symptoms of bleeding, such as bleeding gums or increased bruising. -The DON was not aware of the resident's mouth bleeding; -When asked if the resident had any dental concerns, the DON said he/she thought just last week a nurse observed the resident's teeth were kind of bad. Staff asked the resident if he/she wanted to go to the dentist and the resident said no, his/her teeth were not bothering him/her. The DON did not recall which nurse made the comments; -The DON said he/she did not believe the resident was on the dental program, which sends a traveling dentist to the facility. If a resident does not have the dental program, then staff have to schedule an appointment for the resident with an outside dentist and make transportation arrangements; -The DON said he/she had not personally examined the resident's mouth; -The DON read the progress notes for each resident on a daily basis, but he/she did not see the resident's note from 11/23/23 about his/her teeth; -Based on that progress note, the nurse on-duty should have informed the DON of the issues, so the facility could follow up and ask the resident if he/she wanted to go to the dentist. The nurse should have contacted the resident's physician and asked the physician to check the resident's mouth for issues/sores; -A broken tooth could cause problems. especially if the resident was on a blood thinner; -Since this resident was on Xarelto (an anticoagulant/blood thinner), the nurse should have emailed or called the physician when he/she discovered the issue. During an interview on 03/01/24, at 3:50 P.M., the Administrator said the following: -She did not know of the resident's dental issues; -She expected staff to notify the physician of dental concerns and set up dental care as needed; -She expected the nurse aides to inform the charge nurse of any dental issues with residents. 34871

Based on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to store cleaning supplies in a separate area from food; failed to date stored food in refrigerator; failed to keep non-food contact surfaces clean and free of debris; failed to dispose of expired food items; failed to rinse dishes prior to placing them into the sanitizer in the three vat sink and sanitize at the minimum manufacturer's requirements; and failed to control flies in the kitchen. The facility's census was 59. 1. Review of the facility's policy titled, Non-Food Storage, undated, showed chemical and toxic products must be stored in a separate closet, closed cabinet, or outside of the kitchen area. Observation on [DATE], at 9:54 A.M., on [DATE], at 9:00 A.M., and on [DATE], at 8:02 A.M., of the dry food storage area showed cleaning supplies sitting on milk crates with the next table containing fresh bananas and a gold wire rack in the corner containing graham crackers, oatmeal cream pies, dry cornbread mix, french fried onions, boxes of baking soda and corn starch, rotel, and marshmallows. During an interview on [DATE], 9:23 A.M., Dietary Aide (DA) S, said cleaning supplies are kept in the locked metal cage in the dry food storage room away from food. During an interview on [DATE], at 9:33 A.M., Cook U said the cleaning supplies are stored in the chemical cage, in the janitor closet, and soaps are stored under the sinks. Chemicals should not be stored next to food. During an interview on [DATE], at 9:47 A.M., the Dietary Manger (DM) said staff are responsible for putting cleaning supplies in the proper storage area. Cleaning supplies are to be stored in the metal cage in the dry food storage room, away from food. During an interview on [DATE], at 3:27 P.M., the Administrator said staff should not be storing cleaning supplies or chemicals next to food. 2. Review of the facility's policy titled, Food Storage, undated, showed the following: -All containers must be labeled with the contents and date food item was placed in storage; -Food items that remain sealed from the supplier may be held until the expiration date if unopened. Observations on [DATE], at 9:54 A.M., on [DATE], at 9:00 A.M., and on [DATE], at 8:02 A.M., of the dry food storage area showed 15 boxes of baking soda with expiration date of [DATE] on all 15 boxes. Observation on [DATE], at 10:07 A.M., of the walk in refrigerator showed the following: -Four styrofoam to go boxes containing lettuce salad and one boiled egg cut in half, not dated, on the top shelf; -One styrofoam to go box containing lettuce salad and one boiled egg cut in half, dated ,d+[DATE], on the top shelf. Observation on [DATE], at 9:05 A.M., of the walk in refrigerator showed five styrofoam to go boxes containing brown wilted lettuce salad and one boiled egg cut in half, dated ,d+[DATE], on the top shelf. During an interview on [DATE], 9:23 A.M., DA S said kitchen staff are responsible for dating food prior to it being put in refrigerator. Kitchen staff are responsible for checking expiration dates on food and disposing of expired items. During an interview on [DATE], at 9:33 A.M., Cook U said the following: -Kitchen staff are responsible for making sure food is dated before putting in the refrigerator; -Kitchen staff are responsible for checking expiration dates of food already on shelf when putting up new products; -Staff should throw out items that are past the expiration date or not dated. During an interview on [DATE], at 9:47 A.M., the DM said the following: -Staff putting away food are responsible for dating the food prior to putting in refrigerator; -Staff should be looking at food prior to using to determine if the item has expired; -The Dietitian completes a walk-through of the kitchen monthly. During an interview on [DATE], at 3:27 P.M., the Administrator said staff should date food when stored in refrigerator and freezer. Staff should check food weekly for expiration dates. 3. Review of the facility's policy titled, Dietary Cleaning, undated, showed walk-in refrigerators and freezers must be cleaned quarterly or more often if needed. Review of the facility's Daily Cleaning Schedule showed it did not address the walk in refrigerator vents/fans. Observations on [DATE], at 10:07 A.M., on [DATE], at 9:05 A.M., and on [DATE], at 8:15 A.M., of the walk-in refrigerator showed dust build up on the cooler fans and on the left side of the cooler fan box. (The dust could fall and potentially contaminate food.) During an interview on [DATE], 9:23 A.M., DA S said kitchen staff have a weekly cleaning schedule that show the staff which areas of the kitchen he/she is responsible for cleaning. During an interview on [DATE], at 9:33 A.M., Cook U said staff have a weekly cleaning schedule showing the responsibilities of each shift. During an interview on [DATE], at 9:47 A.M., the DM said staff are responsible for cleaning the vents, walls, and floors. The kitchen staff use a weekly cleaning schedule to make sure all areas of the kitchen are cleaned. During an interview on [DATE], at 3:27 P.M., the Administrator said all kitchen staff are responsible for making sure everything in the kitchen is clean. The staff use a weekly cleaning schedule. 4. Review of the facility's policy titled, Ecolab Scout Pot & Pan Procedure, dated 2011, showed the following: -Fill the rinse sink with hot water; -Submerge washed item in hot water rinse and allow excess water to run back into rinse sink; -Submerge in sanitizer sink for one minute or as specified by product label and or local guidelines. Observation on [DATE], at 10:54 A.M., showed cook U used the electric handheld [NAME] Mixer Pro to puree food items for lunch. Cook U removed the shaft and blade of the mixer after use to wash them. Cook U used the three vat sink and submerged the shaft and blade in the wash sink, washed it, skipped the rinse sink, then dipped the shaft and blade in the sanitizer sink, pulled them out with suds still on them and put on clean surface to dry. Cook U then used the mixer, shaft, and blade again to puree the next item. During an interview [DATE], at 9:23 A.M., DA S said the following: -Cooks use the three vat sink to wash pots and pans; -The procedure for washing pots and pans in the three vat sink is to wash, rinse, put in sanitizer water and let sit for a minute, and put out to dry; -The rinse sink had not been used lately because there is no plug for the rinse sink. During an interview on [DATE], at 9:33 A.M., Cook U, said the following: -Cooks use the three vat sink to wash, rinse, and sanitize pots and pans; -Staff should rinse items, let sit in sanitizer for one minute, and sit out to dry with no suds on it; -Staff are not rinsing items currently because the sink does not have a plug; -The DM and Maintenance Supervisor are responsible for making sure the sink has a plug. During an interview, at 9:47 A.M., the DM said the following: -The cooks use the three vat sink for washing pots and pans; -The cooks should be washing items in hot soapy water, dipping in the rinse sink, making sure the item is fully rinsed, and let the item sit in the sanitizer sink for one minute; -The cook puts clean items to dry and does not put the items away till dry; -The rinse sink is currently being used as it should be. During an interview conducted on [DATE], at 3:27 P.M., the Administrator said staff should be using the three vat sink according to manufactures recommendation. 5. Review showed the facility did not provide policy regarding wall maintenance. Observations on [DATE], at 10:26 A.M., on [DATE], at 9:15 A.M., and on [DATE], at 8:07 A.M., showed a six foot line of peeling paint on the wall two feet above a food prep table located on the northwest wall of the kitchen. (The peeling paint could fall and contaminate food or food contact surfaces.) During an interview on [DATE], 9:23 A.M., DA S said staff tell the DM when staff notice paint peeling from ceiling or wall. During an interview on [DATE], at 9:33 A.M., Cook U said the staff are responsible for telling the dietary manager if they notice paint peeling on the walls. During an interview on [DATE], at 9:47 A.M., the DM said the dietitian will point out peeling paint and maintenance issues and the DM will report those issues to the Administrator. During an interview on [DATE], at 3:27 P.M., the Administrator said staff should report maintenance issues to the maintenance supervisor by word of mouth or through the maintenance notebook kept at the nurses' desk. The DM is responsible for the oversight of the kitchen. 6. Observation on [DATE], at 11:45 A.M., showed two flies buzzed around in the kitchen while staff served the lunch meal. A DA waved flies off of the drinks and desserts. A fly sat on clean serving spoon hanging from the ceiling over the meal preparation table. During an interview on [DATE], at 9:23 A.M., DA S said the pest control company comes to the facility. He/she reports to main supervisor if he/she notices pests. There are some flies. The kitchen has two bug zappers by the dishwashing door and exit door. Observation on [DATE], at 9:23 A.M. showed a bug zapper plugged in at the door located near the dishwashing area. During an interview on [DATE] at 09:33 A.M., Cook U said the facility unfortunately has flies. The flies are hard to get rid of, but staff report to the maintenance and the facility administration takes care of it. During an interview on [DATE], at 9:47 A.M., the DM said she did not think there was a problem with flies. Staff should report any pest issues to the Maintenance Supervisor or the Administrator During an interview on [DATE], at 3:27 P.M., the Administrator said the facility should not have flies in kitchen.

Based on interview and record review, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility had a census of 59. Review of the Centers for Disease Control and Prevention (CDC) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated [DATE], showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Review of the facility policy titled, Water Management Program, dated [DATE], showed the following: -To inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -The purpose of this standard is to establish minimum Legionellosis risk management requirements for building water systems; -To meet the requirement of 42 Code of Federal Regulations (CFR) 483.80 to help prevent the development and transmission of communicable diseases and infections as it relates to Legionellosis; -The program team shall include the Administrator, Maintenance Director, Infection Preventionist, and Environmental Service Director. The program team shall have knowledge of the building water system design and water management as it relates to Legionellosis; -Determine the locations in the system where control measures (heating, adding disinfectant, cleaning, etc) are required; -For each control measure at each control measure location the facility will determine the limits including but not limited to a maximum value, a minimum value, or a range of values within which a chemical or physical parameter must be monitored and maintained in order to reduce hazardous conditions to an acceptable level; -Annual cleaning (when needed) of the shower heads, quarterly monitoring of the control limits (PH and Chlorine levels); -The Water Management Team is to review and confirm that all the program elements are being implemented as designed. Review of the facility's form, titled 'Baseline and Quarter, not dated, showed the following: -Location, Sediment and Biofilm, temperature, water age, disinfectant for the ice machine, showers, tubs, hot water heaters, sinks and fire suppression system; -The document was not completed for the baseline and quarter form. 1. Review of facility records showed the following: -The facility did not document a risk assessment to identify at risk areas for Legionella growth; -The facility did not document water testing for at risk areas for Legionella; -The facility did not document facility specific measures taken to prevent the growth and/or spread of Legionella bacteria. During an interview on [DATE], at 2:56 P.M., the Infection Preventionist said she did not have anything to do with the Legionella monitoring and the Maintenance Supervisor is responsible. During an interview on [DATE], at 3:10 P.M., the Housekeeping Supervisor said the following: -He/she did not have any training on Legionella; -He/she did not know housekeeping's responsibilities regarding Legionella. During an interview on [DATE], at 3:47 P.M., Certified Nurse Aide (CNA) R said the following: -He/she did not have any training on Legionella; -He/she did not have any training regarding the importance of draining shower hoses after each use. During an interview on [DATE], at 3:50 P.M., CNA Q said the following: -He/she did not have any training on Legionella; -He/she did not have training regarding the importance of draining shower hoses after each use. During an interview on [DATE], at 3:55 P.M., the Maintenance Director said the following: -He did not test water for PH and chlorine to make sure no Legionella growth; -He did not know how often to test the water for Legionella growth; -He did not meet with the water management team to discuss Legionella; -The Administrator has studied on the Legionella program and will implement a new water plan soon. During an interview on [DATE], at 3:50 P.M., the Administrator said the following: -The facility did not do any routine Legionella testing yet; -The baseline form was not conducted yet for Legionella risks; -She started in [DATE] and revised the water management policy [DATE]; -No water management team and they have not met yet.

Based on interview and record review, the facility failed implement an antibiotic stewardship program when staff failed to adequately track eight residents currently on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections, this failure could potentially place all residents at risk of infection. The facility census was 59. Review of the facility policy titled, Infection Control, General, revised on 02/18/24, showed: -It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulation, and national guidelines; -The facility will establish and maintain an infection prevention and control program under which it: prevents, identifies, reports, investigates, and controls the spread of infection and communicable disease in the facility; conducts surveillance for early detection of infections, clusters/outbreaks, and reportable diseases and to track and trend surveillance data; and decides when and how isolation should be applied to an individual resident; -The facility is to maintain a surveillance system with the capacity to identify possible communicable disease and infections before they can spread to other persons in the facility; -To identify infections the following information regarding residents is reviewed on an ongoing basis and information is to be communicated by staff in meetings (morning meetings) to the person responsible for infection prevention and control: signs and symptoms; laboratory and other diagnostic testing orders/results; new antibiotics starts; and new admission orders; -The local health department will be notified of all reportable diseases identified and of any clusters or outbreaks of any disease in accordance with state law. All clusters and or outbreaks will be investigated to identify breaches in infection control and or opportunities to improve current practices. 1. Review showed the facility did not provide an antibiotic log. During an interview on 03/01/24, at 2:56 P.M., the Infection Preventionist (IP) said the following: -He/she reviewed the physician orders to see which residents were on antibiotics about two times per week; -He/she did not track or document culture and sensitivity results or chest x-ray results; -He/she did not follow-up with residents during antibiotic administration or after completion to determine if the antibiotic was working; -He/she logged the infections from the previous month for the quality assurance and performance (QAPI - a data-driven, meeting to improve the quality of care, life, and services for the residents) meeting with facility department heads to discuss any trends of infections in the past month; -The Director of Nursing (DON) had the antibiotic log book which contained the monthly infection log. During an interview on 03/01/24, at 3:33 P.M., the DON said the following: -Staff had not completed the antibiotic log for February 2024. The IP and DON generally completed the log at the end of each month, but they had not had time to complete the February 2024 log; -At the end of each month, the IP or DON added the resident name, antibiotic information, and type of infection to the antibiotic log at the end of each month and highlighted different types of infections on a facility room map; -The log did not include information about resident culture/sensitivities. During an interview on 03/01/24, at 3:50 P.M., the Administrator said the following: -He/she expected the the IP or DON to track resident infections in real time and record on the antibiotic log as they are happening, so the staff can monitor for infection trends in the facility. 34871

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around eight residents (Residents #54, #52, #41, #35, #2, #6, #46 and #57) and in resident common areas. The facility census was 59. Review showed the facility did not provide a pest control policy. 1 Review of Resident #54's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly minimum data sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 01/05/24, showed the following: -Moderately impaired cognitive ability; -Required supervision of staff while eating; -Dependent on staff for toileting hygiene and showers; -Substantial/maximum assistance of staff with personal hygiene and dressing. Observation and and interview on 02/26/24, at 11:15 A.M., showed the following: -Resident flat on his/her back in bed in his/her room located on the A-hall; -Multiple flies buzzed around the resident and one fly crawled on the resident's arm; -The resident said, Yes, we have flies here. My family member put a fly strip up in my other room and it had a lot of flies on it, but staff said I couldn't have it. Observation and interview on 02/27/24, at 2:20 P.M., showed the following: -The resident sat in a recliner in his/her room with his/her feet elevated. Two flies buzzed about the resident with one fly crawling on the resident's left hand and another crawling on his/her face; -The resident said the flies were bad and bothered him/her; -The resident said, Flies get on my food and who wants to eat that. 2. Review of Resident #52's face sheet showed an admitted [DATE]. Review of the resident's annual MDS, dated [DATE], showed severe impaired cognitive skills. Observation and interview on 02/26/24, at 11:59 A.M., showed the following: -The resident sat on the side of his/her bed; -A fly buzzed around the room; -The resident said oh yeah when asked if the facility had flies. Observation and interview on 02/28/24, at 12:32 P.M., showed the following: -The resident ate lunch in his/her room; -The resident said a fly just got on his/her plate and he/she just wants the flies to find another home; -The resident said he/she did not have a fly swatter in the room due to someone took it to kill the flies. 3. Review of Resident #41's face sheet showed an admitted [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had no behaviors. Observation and interview in the main dining room on 02/27/24, at 9:45 A.M., during the resident council interview a fly buzzed around. The resident said he/she had been at the facility since September 2023 and there had only been a week or two that he/she has not seen flies. 4. Review of Resident #35's face sheet showed the admitted [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed resident was cognitively intact. Observation and interview on 02/27/24, at 12:50 P.M., showed the following: -Resident lying on his/her bed in his/her room located on the A-hall; -Two to three flies buzzed around the resident; -The resident said that flies are a problem in his/her room and they bother him/her. During an interview on 02/29/24, at 4:10 P.M., Certified Medication Technician (CMT) V said the following: -He/she saw flies in a few of the resident rooms recently; -He/she saw a couple flies in the resident's room earlier today, on 02/29/24, but the resident refused showers/personal cares and that attracted the flies to his/her room. 5. Observation on 02/26/24, at 11:38 A.M. showed three flies on the window in Resident #2 and Resident #6's room. 6. Observation on 02/26/24, at 11:54 A.M., showed three flies on the exit door at end of the B hall (special care unit). 7. Observations on 02/26/24, at 12:00 P.M., showed the following: -A fly on the floor by the first dining room table in the (B Hall) special care unit dining room; -Resident #46 sat on the side of his/her bed eating lunch. A fly buzzed around the resident. 8. Observation on 02/27/24, at 12:19 P.M., showed Resident #57 sitting at the dining room table in the (B Hall) special care unit. A fly landed on his/her dining room table. The resident waved the fly away after it landed on his/her left hand. 9. Observation on 02/27/24, at 1:36 P.M., showed multiple flies buzzed around the dining room in the (B Hall) special care unit. 10. Observation on 02/28/24, at 12:47 P.M., in the hall beside the main dining room showed a 'bug' zapper not plugged in. 11. During an interview on 02/28/24, at 11:37 A.M., Certified Nurse Aide (CNA) H said the following: -The facility has a lot of flies; -The flies come in the entrance to the special care unit and the back door of the special care unit; -Flies are around the utility room located outside the entrance to the special care unit; -The facility has fly swatters in the dining room; -He/she did not know how the facility monitors the flies. 12. During an interview on 02/28/24, at 1:16 PM, Licensed Practical Nurse (LPN) A said the following: -The facility had an issue with flies; -He/she saw more flies due to the warmer weather; -The facility had some fly swatters and he/she tried kill some of the flies, when he/she could; -He/she reported the flies to the maintenance supervisor in the past, but was unsure what he/she did to fix the issue; -He/she encouraged staff to pick up food trays and trash timely and keep the rooms clean to help reduce the number of flies in the rooms and that helped. 13. During an interview on 02/29/24, at 2:56 P.M., Registered Nurse (RN) B said the following: -He/she notices flies some days more than others; -Staff should make sure trash is taken out and food trays are picked up to control the flies; -Staff should inform the housekeeping supervisor or maintenance staff know if staff notice flies. 14. During an interview on 03/01/24, at 12:15 P.M., the Director of Nursing (DON) said the following: -Flies come in the smokers door if it is open for a long period of time; -Flies gravitate toward odors; -The facility has pest control come out regularly to the facility; -She expects the flies to be controlled in the facility. 15. During an interview on 02/29/24, at 2:58 P.M., the Maintenance Supervisor said the following: -Staff report by word of mouth regarding pest issues. He did not know of any fly issues lately; -Staff should notify him if any pests or flies; -The pest control company comes to the facility monthly to treat; -There is a bug zapper on the D hall which is not plugged in. The zapper works, but a resident unplugs it. It is not effective to kill flies; -No staff or residents have informed him about fly issues; -He did not notice a fly problem in the facility; -He reports to the Administrator about calling pest control. 16. During an interview on 03/01/24, at 10:30 A.M., the Environmental Service Manager said the following: -She has seen some flies; -Staff and residents did not mention the flies as a problem; -She is not aware of preventions to keep flies from getting in the building. 16. During an interview on 02/29/24, at 3:27 P.M., the Administrator said the following: -She did not really notice a lot of flies; -Staff need to find a way to try and prevent the flies from coming in the building doors. 34906 48534

Based on interview and record review, the facility failed to implement policies to prevent possible abuse, neglect, or misappropriation of residents when the facility failed to complete a Family Care Safety Registry (FSCR - a state registry that provides multiple checks on staff including a Criminal Background Check) or a Criminal Background Check (CBC) prior to hire to ensure two staff (Certified Nursing Assistant (CNA) J and Certified Medication Technician (CMT) K), did not have a disqualifying criminal background that would prevent the staff member from working in a certified long-term care facility; failed to perform an Employee Disqualification List (EDL) check on three staff (CNA J, CNA M, and CMT K); and failed to perform a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility)) check on two staff (CNA J and Licensed Practical Nurse (LPN) L) out of a sample of ten staff members. The facility census was 59. Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated 01/01/24, showed the following: -The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -Screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries; -The facility must not employ or otherwise engage individuals who: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 1. Review of CNA J's personnel file showed the following: -Hire date of 05/23/22; -Staff did not have a documented FCSR or CBC check prior to or upon hire; -Staff did not have an EDL check prior to or upon hire; -Staff did not have a NA Registry check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the Social Services Designee (SSD) said the following: -CNA J did not have any recent FCSR, CBC, EDL, or NA Registry checks on his/her most recent hire date. He/she had these completed back in 2013 and 2016; -He/she should have completed these for the most recent hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CNA's FCSR, CBC, EDL and NA Registry checks prior to the CNA's hire date. 2. Review of CMT K's personnel file showed the following: -Hire date of 03/04/22; -Staff did not have a documented FCSR or CBC check prior to or upon hire; -Staff did not have an EDL check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the CMT's FCSR, CBC or EDL checks. The checks should have been completed prior to the CMT's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CMT's FCSR, CBC and EDL checks prior to the CMT's hire date. 3. Review of LPN L's personnel file showed the following: -Hire date of 09/01/23; -Staff did not have a NA Registry check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the LPN's NA Registry check. The check should have been completed prior to the LPN's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator the SSD should have completed the LPN's NA Registry check prior to the LPN's hire date. 4. Review of CNA M's personnel file showed the following: -Hire date of 02/01/22; -Staff did not have an EDL check prior to or upon hire. During an interview on 03/01/24, at 12:16 P.M., the SSD said he/she could not find the CNA's EDL check. The check should have been completed prior to the CNA's hire date. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the SSD should have completed the CNA's EDL check prior to the CNA's hire date. 5. During an interview on 03/01/24, at 12:16 P.M., the SSD said the following: -Prior to hiring a new employee, he/she completed a CBC, FCSR, EDL and NA Registry check and new employees were not allowed to work prior to the checks being completed; -He/she was responsible for completing these checks and the Administrator was responsible for ensuring he/she completed them. 6. During an interview on 03/01/24, at 1:31 P.M., the Administrator said the following: -The SSD completed FCSR, CBC, EDL and NA Registry checks on all new employees prior to their hire date; -These checks were important to ensure the facility did not hire a staff member that had the potential to harm the facility's residents; -The SSD was responsible for completing these checks.

Based on record review and interview, the facility failed implement a comprehensive person-centered care for each resident when staff failed to complete a comprehensive and individualized care plan, including interventions, to address the specific needs of four residents (Resident #24, #30, #31, and #38) out of a sample of 22 residents. The facility had a census of 59. Review of the facility's policy, titled Care Plans, dated 01/01/24, showed the following: -It is the policy of the facility to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs; -This facility will help develop and implement a comprehensive person-centered care plan for each resident that includes: measurable objectives and timeframes to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the resident assessment instrument (RAI) process; resident's goals, preferences, needs, strengths, and weaknesses; and services are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -The comprehensive care plan will be reviewed and revised based on changing goals, preferences, and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Review of Resident #24's face sheet (a general information sheet) showed the following: -admitted [DATE]; -Diagnoses included congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), edema (fluid retention), non-pressure chronic ulcer of lower leg, and lymphedema (swelling caused by lymphatic system blockage). Review of resident's March 2024 Physician Order Summary (POS) showed the following orders: -An order, dated 10/23/23, for staff to administer Bumex (to treat fluid retention and high blood pressure) one tablet by mouth (PO) two times a day (BID) for bilateral lower extremities (BLE) edema. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/10/24, showed the following: -Cognitively intact; -Used a diuretic (used to help remove excess fluids. Review of resident's March 2024 physician order summary sheet (POS) showed the following orders: -An order, dated 01/25/24, to elevate BLE as tolerated BID for dependent edema; -An order, dated 01/25/24, for tubigrips (bandage that provides continuous support for the management of swelling) to bilateral lower extremities. Place on in the morning and take off at bedtime BID for dependent edema. Review of the resident's current care plan. last revised on 01/17/24, showed staff did not address the use of Bumex, tubigrips, or to elevate BLE for edema. During an interview on 03/01/24, at 10:28 A.M., Registered Nurse (RN) N said the resident's legs are discolored and edematous and staff elevate as tolerated. During an interview on 03/01/24, at 10:23 A.M., Certified Nurse Assistant (CNA) R said the facility had a binder at the nurses' station that lists all residents who need tubigrips. Tubigrips are applied in the morning and removed when residents' go to bed. Sometimes residents refuse to wear them. During an interview on 03/01/24, at 10:28 A.M., RN N said the tubigrips are kept in the resident's room. A reminder of the order appears on the computer daily and that information is shared with the aides. 2. Review of Resident #30's face sheet showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included Type 2 diabetes mellitus, history of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs), history of urinary tract infections, dysuria (painful or uncomfortable urination), and muscle weakness. Review of the resident's January 2024 POS for January 2024 an order, dated 01/03/24, for staff to administer Augmentin (an antibiotic) 875/125 milligram (mg) orally two times a day for urinary tract infection for 7 days (starting on 01/03/24 and ending on 01/10/24). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident cognitively intact; -Dependent on staff for personal and toileting hygiene, showers, and upper and lower body dressing; -Always incontinent of urine; -Resident on antidepressant, opioid (narcotic pain medication), and hypoglycemic (a medication used to reduce the amount of sugar in the blood) medications. Review of the resident's January 2024 POS showed an order, dated 01/26/24, for staff to change the resident's Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) monthly related to the resident's diagnosis of acute renal failure. Review of the resident's February 2024 POS showed an order, dated 02/07/24, for staff to administer Macrobid (an antibiotic) 100 mg orally two times a day for urinary tract infection for 7 days (starting on 02/07/24 and ending on 02/14/24). Observation of the resident on 02/26/24, at 11:35 A.M., showed the following: -The resident had a urinary catheter tube running out the bottom of his/her pant leg with yellow urine present in the tubing; -The catheter tubing ran to a gravity drainage bag located on the side of the resident's wheelchair (the drainage bag was inside of a cloth dignity bag). Review of the resident's February 2024 POS showed an order, dated 02/27/24, for staff to administer Macrobid 100 mg orally two times a day for urinary tract infection for 7 days (starting on 02/27/24 and ending on 03/05/24). Review of the resident's current comprehensive care plan showed the following: -Staff did not care plan related to his/her history of frequent urinary tract infections; -Staff did not care plan related to his/her presence of a urinary catheter. During an interview on 03/01/24 at 10:44 A.M., Licensed Practical Nurse (LPN) T said if a resident had a catheter, the MDS Coordinator should update the care plan to reflect that. During an interview on 03/01/24, at 11:28 A.M., Certified Nurse Aide (CNA) Q said the following: -He/she referred to the resident care plan to see what a resident's care needs were; -He/she said it is important to know if a resident had a catheter. During an interview on 03/01/24, at 10:51 A.M., RN N said the resident gets confused and starts shaking and will say his/her urine burns. The resident's catheter and UTI's should be on the care plan. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the resident's care plan did not address the catheter. The care plan should state for staff to monitor intake and output of urine, provide proper catheter care, change the catheter monthly, and to maintain the catheter bag below the resident's bladder. 3. Review of Resident #31's face sheet showed the following information: -admitted [DATE]; -Diagnoses included congestive heart failure, left leg above knee amputation, and chronic kidney disease. Review of the resident's March 2024 POS showed an order, dated 10/30/23, to apply a tubigrip to the resident's right lower extremity upon rising and remove at bedtime for edema. Review of the resident's quarterly , dated 01/21/24, showed the following information: -Moderate cognitive impairment; -Used a diuretic. Review of the resident's current care plan, last updated 10/03/23, showed staff did not address the use of tubigrips. During an interview on 03/01/24, at 10:23 A.M., CNA R said the resident reminded staff to put on his/her tubigrip. 4. Review of Resident #38's face sheet showed the following information: -admitted [DATE] with readmitted [DATE]; -Diagnoses included Alzheimer's disease and vascular dementia. Review of the resident's February 2024 POS showed an order, dated 11/09/23, for staff to apply tubigrips to bilateral lower extremities and elevate as tolerated two times a day for dependent edema. Review of the resident's quarterly MDS, dated [DATE] , showed the following information: -Cognitive skills severely impaired; -Diuretic not marked; -Supervision or touching assistance with lower body dressing. Review of the resident's February 2024 POS showed an order, dated 12/21/23, for staff to administer furosemide (Lasix - a diuretic), 20 mg PO one time a day for edema. Observation on 02/28/24, at 12:35 P.M., showed the resident sat at the dining room table with tubigrips on both of his/her legs. Review of the resident's current care plan, last revised on 10/17/23, showed staff did not address the use of Lasix, tubigrips and the diagnosis of edema on the care plan. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said she did not put edema, Lasix and tubigrips on the resident's care plan. 5. During an interview on 02/28/24, at 11:37 A.M., CNA H said care plans show staff how to care for residents. 6. During an interview on 03/01/24, at 10:51 A.M., RN N said the following: -The MDS/Care Plan Coordinator develops the care plans; -He/she did not know the process of updating care plans; -Care plans show staff how to care for a resident; -Staff should monitor residents with edema for daily weights, medications, elevate legs, and communicate with the physician if needed; -Staff should assist a resident with tubi-grips if has an order; -Foley catheter should be on a care plan, staff should monitor every shift and as needed, measure input output, change monthly; -A resident's UTI should be on care plan, staff should monitor for pain, discomfort, confusion, altered mental status, odor appearance, and encourage the resident to drink enough water; -Staff should monitor resident's who take Lasix for lab results, potassium and edema. A resident's edema should be on the care plan. 7. During an interview on 03/01/24, at 11:17 A.M., the MDS/Care Plan Coordinator said the following: -Staff have a nurse meeting every morning; -The morning nursing meeting includes the MDS/Care Plan Coordinator, charge nurse, and RNA; -Staff discuss weight concerns, falls, behaviors and concerns that need addressed; -She updates the care plans; -Nursing staff have access to the care plans in the computer; -Care plans should include the residents assistance needed with activities of daily living, pain issues, fall risks, skin concerns, smoking, smoking, if the resident wears glasses or hearing aids; -The care plan is road map or directions with information of how to care for the resident; -Staff review the care plans quarterly with the resident and/or family and address all care areas; -Staff should monitor for swelling and elevate a resident's legs if they have edema; -Staff should monitor residents on Lasix for edema, weight gain and if wear tubigrips. 8. During interviews on 03/01/24, at 8:34 A.M. and 12:15 P.M., the DON said the following: -Staff meet daily in the morning meeting and have weekly meetings regarding residents; -Care plans should include edema, catheters, frequent UTI's anticoagulants, diabetes and Lasix. 9. During an interviewed on 03/01/24, at 1:31 P.M. and 2:20 P.M., the Administrator said she expects resident care plans to have the individualized areas for each resident. 34906 43193 49585

Based on observation, interview, and record review, facility staff failed to notify the physician of a change in condition for one resident (Resident #30) when the resident complained to a nurse of pain, and stinging and burning in his/her legs, and expressed concerns about the possibility of urinary sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to it's own tissues and organs). A sample of 22 residents were reviewed in a facility with a census of 59. Review of the facility policy titled, Resident Change in Condition, dated 01/01/24, showed the following: -The facility will keep the physician, who is in charge of the resident's medical care, informed of the resident's medical condition so they may direct the plan of care as needed; -Notification of the physician should occur promptly when there is a change in the resident's condition; -Examples of change in condition may include new pain; -Staff should document the symptoms and the observations associated with the change in condition and the date and time of contact with the physician. 1. Review of Resident #30's face sheet showed: -admitted [DATE] with readmitted [DATE]; -Diagnoses included Type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), history of sepsis, history of urinary tract infections, dysuria (painful or uncomfortable urination), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff,) dated 01/10/24, showed the following: -Resident cognitively intact; -Dependent on staff for personal and toileting hygiene, showers, and upper and lower body dressing; -Always incontinent of urine; -Resident on antidepressant, opioid (narcotic pain medication), and hypoglycemic (a medication used to reduce the amount of sugar in the blood) medications. Review of the resident's January 2024 physician orders showed the following: -An order, dated 01/03/24, for staff to administer Augmentin (an antibiotic) 875/125 milligram (mg) orally two times a day for urinary tract infection for seven days (medication to be administered 01/03/24 to 01/10/24). Review of the resident's current comprehensive care plan the resident had no plan of care related to his/her history of urinary tract infections. Review of the resident's progress note dated 01/14/24, at 4:03 A.M., showed a nurse documented the following: -The nurse took the resident his/her 4:00 A.M. pain medication and the resident said he/she was in a lot of pain and his/her legs were stinging and burning. The resident told the nurse he/she was afraid the antibiotics for the urinary tract infection (UTI) did not work and was worried about going septic. The nurse documented he/she would report this information to the day shift nurses and request a follow up urinalysis for the resident. Review of the resident's progress notes showed staff did not document follow-up physician notification or request for urinalysis regarding the resident's concerns on 01/14/24. During an interview on 02/28/24, at 11:53 A.M., the resident said he/she felt the staff could do a better job on how quickly they respond when the resident is not feeling well. Sometimes, he/she tells the staff, but the concerns do not get reported to the nurse or physician. During an interview on 03/01/24, at 10:44 A.M., Licensed Practical Nurse (LPN) T said the following: -When the night nurse documented the resident was concerned about the possibility of re-development of a urinary tract infection and complained of his/her legs stinging/burning, the night nurse should have assessed the resident and documented the assessment; -The night nurse should have passed on in report to the day nurse to call the resident's physician and ask for an order for a urinalysis; -The night nurse also could have faxed the physician; -LPN T checked the resident's record and the physician communication book, but said he/she could not find documentation that the night nurse notified the resident's physician on 01/14/24 of the resident's concerns. During an interview on 02/29/24 at 5:16 P.M., the director of nursing (DON) said the following: -On 1/14/24, the nurse should have assessed the resident for signs and symptoms of a urinary tract infection and documented that assessment, but he/she did not; -The nurse should have faxed the resident's physician to notify of the resident's signs/symptoms and request for a urinalysis, but the director of nursing could not locate a fax or notification of the physician; -If the nurse sent a fax to the physician, the physician would have seen the fax at 8:00 A.M. on the morning of 01/14/24, and responded; -The night nurse should have also reported the resident's symptoms to the day shift nurse, but the DON said he/she had no proof/documentation that the information was passed on in report.

Based on observations, record review and interviews the facility failed to ensure staff adequately assessed, monitored, and documented the nutritional status of one resident (Resident #1) who the facility identified at risk for weight loss and had a tube for feeding (tube surgical placed in the stomach to administer nutrition, hydration and medication). The facility failed to notify the consultant Registered Dietitian (RD) for an assessment related to the resident's change in nutritional intake. Staff failed to follow orders to obtain weekly weights. Staff admitted the resident to the facility on [DATE] with a weight of 215 pounds. For five days, staff did not document any nutritional intake for the resident and on 6/29/13, the family requested the resident be sent to the hospital. By 6/29/13 the resident experienced a severe weight loss of 33.4 pounds (15.5%) in four months. The hospital admitted the resident for dehydration and [MEDICAL CONDITION]. Upon the resident's return to the facility, he/she continued to lose weight and on 7/18/13 weighed 173 pounds for a severe weight loss of 42 pounds or 19.5% in five months. Staff identified only one resident with a feeding tube. Thirteen residents were sampled, five for concerns with weight loss, out of a facility census of 60. Federal Guidelines define suggested parameters for evaluating significance of unplanned and undesired weight loss as the following: -One month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; -Three months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; -Six months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. 1. Record review of Resident #1's medical record showed the following information:-Staff admitted the resident on 2/19/13;-[DIAGNOSES REDACTED]. Record review of the medical nutrition therapy notes on 2/19/13, showed the dietary manager noted the resident admitted with orders for regular puree diet and tube feeding [MEDICATION NAME] (nutritional supplement) 1.5 [MEDICATION NAME] (a single amount given at specified times), register dietitian (RD) consult. Weight 215 pounds. Record review of the RD e-mail/fax consultation (a form sent to the RD by the DM via e-mail with pertinent information, including weight, diet and reason for consult. RD handwrites her recommendation and calculations during her onsite and assessment of the resident) dated 2/20/13, showed the following information:-Reason for consult: tube;-Weight: 245 pounds (dietary noted resident weighed 215 pounds)-Diet order: [MEDICATION NAME] 1.2 120 milliliters (ML)/hour between 9:00 P.M., to 5:00 A.M., and [MEDICATION NAME] every four hours during the day; puree, thin liquid diet;-Average meal intake: 10%. Speech therapy working with resident, unable to speak but moves eyes and head. Eats very little at this time, is getting more each day. This morning breakfast was 50%;-RD recommendations (RD made recommendations and calculations on the weight of 245 pounds): Change [MEDICATION NAME] to 1.5 80 ml/hour 9:00 P.M., to 9:00 A.M., give one can of [MEDICATION NAME] 1.5 [MEDICATION NAME] three times a day. Flush tube with 50 ml of water before and after each [MEDICATION NAME] and 100 ml before and after overnight feeding. Record review of the admission minimum data set (MDS) a federally mandated assessment completed by facility staff dated 2/24/13, showed the following information:-Severely impaired cognitive decision-making skills;-Total dependence on staff for transfers, hygieine and eating;-Weight: 245 pounds. Record review of the medical nutrition therapy notes showed the DM noted the following information:-On 2/29/13, the resident's family brings in regular texture food, said resident would not eat puree. Will explain the risks. Family said they would bring the food to the kitchen to have pureed.-On 3/13/13, the resident's family still bringing in food. The DM did not note she notified the resident's physician and the RD. Record review of the nurse's notes showed the following information:-On 2/27/13, the resident refused tube feeding again today,ate a fast food cheeseburger;-On 2/28/13, the resident ate food brought in by family.-Between 2/29/13 to 3/13/13, staff made no documentation regarding the family bringing in food and/or the resident's refusal to eat the puree food. Record review of the care plan dated 3/30/13, showed the following information:-Resident has need for tube feeding for nutrition/hydration and is at risk for complications related to dysphasia;-Assess and record complications of feeding tube usage;-Weigh and monitor results per facility policy.-Staff did not include problems, goals and interventions regarding the family bringing the resident regular textured foods and/or the resident refusing the pureed diet and tube feedings. Record review of the weekly and monthly weight record showed on 3/2013, staff noted the resident weighed 215 pounds. Record review of the April 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. to 9:00 A.M., feeding discontinued. Order to continue [MEDICATION NAME] feedings three times a day. Record review of the nurse's notes showed the following information:-On 4/8/13, the resident had oral dental surgery for [REDACTED]. Resident returned to as needed charting; Record review of the weekly and monthly weight record showed the following information: -4/10/13, 200 pounds (a 15 pound wight loss in 60 days or 6.9%); -4/17/13, 200 pounds. Record review of the MAR between 4/13/13 to 4/23/13, showed the resident refused the [MEDICATION NAME] everyday. Record review of nursing notes showed the following: -Staff made no documentation between 4/18/13 to 4/23/13. Staff made no documentation they notified the physician of the resident refusing the tube feeding and weight loss;-On 4/23/13, the family nurse practitioner (FNP) gave new orders to discontinue the [MEDICATION NAME] due to resident's refusal, and for staff to weigh the resident weekly. Record review of the medical nutrition notes showed between 4/10-4/24/13, the DM did not notify the physician and the RD of the resident's weight loss. Record review of the progress notes dated 4/23/13, showed the following information:-Weight: 200 pounds;-Nurses requested the FNP discontinue the resident's tube feedings at this time since he/she always refuses the feedings. Resident also refuses to eat unless his/her family brings him/her food.-Plan: Will ask nurses to weigh the resident weekly and order a dietary consult before discontinuing his/her tube feedings. Record review of the physician's orders [REDACTED]. However, staff did not note the order to obtain a dietary consult. Record review of the medical nutrition therapy notes showed the DM noted on 4/12/13 (order to discontinue noted on 4/23/13.) discontinue [MEDICATION NAME] feedings at this time due to refusal. Weight 200 pounds. Down 15 pounds from admission (9.2% in 60 days). Add fortified (high calorie) weight management times three and supercereal (high calorie) at breakfast The DM did not note she notified the RD regarding the weight loss and DC order. Record review of the MAR indicated [REDACTED]. Record review of the careplan on 4/23/13, showed the following information:-Under problems: staff handwrote "Refusal of tube feeding";-Under goals: Staff made no revisions. The care plan still had goals for the use of tube feeding;-Under interventions: staff handwrote "DC (discontinue) tube feeding. Weigh weekly". The care plan still had interventions for the use of tube feedings.-Staff made no problems, goals and interventions regarding the family bringing the resident regular texture foods. -Staff did not list other interventions to prevent further weight loss. Record review of the monthly/weekly weight record showed the following information: -4/24/13, 203 pounds. -5/1/13, 202 pounds;-5/8/13, 204 pounds;-5/15/13, 204 pounds;-5/22/12, 206 pounds;-5/29/13, 208 pounds;-6/1/13, 208 pounds;-6/9/13, staff documented no weekly weight;-6/16/13, staff documented no weekly weight;-6/23/13, staff documented no weekly weight. Record review of the MAR indicated [REDACTED]. During an interview on 7/17/13 at 9:05 A.M., the DM said:-The restorative aide completes the monthly and weekly weights;-The DM said she could not find where staff weighed the resident in June. During an interview on 7/17/13 at 1:15 P.M., restorative nurse aide (RNA) said the following:: -He/she weighed the residents monthly and weekly; -He/she had been weighing Resident #1 weekly but his/her weight stabilized; -Dietary and nursing tell him/her which residents need weekly weights; -He/she did not know there was an order to weigh the resident weekly; -The resident was not on his/her list of residents to weigh weekly; -He/she was not sure why the resident did not get weighed in June 2013. Record review of the Meal consumption flow record showed the following information:-Between 6/1 to 6/24/13:-Breakfast: staff noted the resident ate 50% or less 13 of 24 times;-Lunch: staff noted the resident ate 50% or less 16 of 24 times and two refusals;-Dinner: staff noted the resident ate 50% or less 16 of 24 times and seven refusals/sleeping.-Between 6/25 to 6/29/13 (five days) staff noted the resident refused or was sleeping for all meals. Staff did not record any intake for the resident during these days. Record review of the nurse's notes showed the following information:-Staff did not document between 6/25/13 to 6/28/13, regarding the resident refusing meals;-On 6/29/13 at 2:30 P.M., the resident's spouse expressed frustration with resident because when he/she was here either the resident cried or slept. Spouse wished for the resident to be transported to the hospital for evaluation. Staff received orders to send resident to the hospital. Record review of the medical record showed the DM made no further notes after 4/23/13 and no further consults from the RD since the admission consult on 2/20/13. During an interview on 7/17/13 at 9:05 A.M., the DM said:-The resident was on continuous tube feedings. Prior to hospitalization (6/29/13), the resident was refusing the tube feeding. Staff received orders to discontinue the feeding and let the resident just eat the puree diet. The DM said the resident was not eating or drinking well;-The resident's family was "sneaking" food to the resident. Staff spoke to the family about it;-Prior to hospitalization , the DM said the resident did not have a "big" weight loss, she tried fortified foods and supercereal. During an interview on 7/17/13, the Director of Nursing (DON) said prior to hospitalization , the resident had been eating, was picking and choosing what he/she ate. When staff brought the resident a tray, he/she would not eat it. The resident would want the spouse to bring him/her fast food. Record review of the hospital admission history and physical dated 6/29/13 and progress note dated 7/2/13, showed in part the following information:-Resident spouse said resident had increased mental changes aside from his/her baseline;-Weight-181.6 pounds (This is 24.4 pounds, or 11.8% in 12 days. Last weight 206 pounds, 33.4 pounds or 15.5% in five months since admission to facility based on a 215 pound admission weight.);-Resident was found to be dehydrated and malnourished upon admission;-Impression and plan:-[MEDICAL CONDITION] (low iron)-no active bleeding. History of prior anemic episodes;-Severe dehydration with azotemia (build up of waste products in the body. Occurs with dehydration. Can have signs of confusion and fatigue). Resolution of dehydration and mild improvement of azotemia with intravenous fluid replacement;-[MEDICAL CONDITION] (condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function). Resumed tube feedings. Record review of the hospital transfer order dated 7/8/13, showed the following information:-Discharge diagnose: altered mental status, [MEDICAL CONDITION], dehydration and urinary tract infection [MEDICAL CONDITION];-Diet: Full diet plus [MEDICATION NAME] 1.2 at 55 ml/hour;-Please administer tube feedings scheduled and offer regular diet for comfort feedings. Can switch to [MEDICATION NAME] feeding if appropriate. Record review of the facility admission POS dated 7/8/13, showed the following information:-[MEDICATION NAME] 1.5 at 45 ml/hour continuously until [MEDICATION NAME] 1.2 available;-Diet: [MEDICATION NAME] and comfort feedings. Record review of a facility form titled Resident diet and status report food and nutrition services dated 7/8/13, showed the following information:-Diet changed on 7/8/13;-Consistency: puree;-Additional comments: may have small bites of puree foods for comfort. Record review of the readmission MDS dated [DATE], showed the following information:-Weight 173 pounds (This is a 42 pounds, 19.5% loss in 5 months since admission in 2/2013);-Loss of 5% or more in one month or 10% in 6 months: staff marked No. During an interview on 7/17/13 at 2:45 P.M., the DM said the resident's diet card said comfort foods, puree texture. The DM reviewed the hospital transfer form. The DM said she was not aware the order said regular full comfort foods. The DM said she would e-mail the RD with this information. During an interview on 7/17/13 at 3:15 P.M., the Director of nursing (DON) said she spoke with the hospital nurse and they discussed the resident having a regular consistency diet. DON changed the diet order from regular to puree. She sent the diet status form to dietary with the puree diet. The DON said she did not clarify the order change with the physician and did not consult with the RD. Record review of the admission care plan dated 7/8/13, showed the following information:-Eating assist: tube feeding;-Diet: [MEDICATION NAME] and comfort foods;-Weekly weight on Wednesday;-Staff did not mark the section: Monitor meal percents daily for 30 days;-Monitor for signs and symptoms of dehydration. Record review of the nurses notes showed the following information:-On 7/9/13 (first entry since readmission on 7/8/13): alert and calm at this time. Family here to visit. [MEDICATION NAME] 1.5 running. Assisted up to geri-chair (reclining chair with wheels) and brought out to dining room. Staff fed the resident 50% at breakfast and the family assisted the resident at lunch;-On 7/10/13, Resident fed self lunch. Record review of the RD e-mail/fax consultation dated 6/9/13, (resident readmitted on [DATE]), signed by RD on 7/9/13, showed the following information:-[DIAGNOSES REDACTED]. Last month: 208 pounds;-Diet order: [MEDICATION NAME] 1.2 and puree comfort feedings. No flush orders, hospital just wrote assure resident gets 1000 ml daily;-Recommendations: 200 ml water flush every four hours. If resident does not consume some oral fluids, we can increase flushes. Weigh weekly. Record review of the monthly/weekly weight record showed on 7/10/13 (two days after admission on 7/8/13) staff noted the resident weighed 175 pounds. Record review of the Meal consumption flow record showed the following information:-Between 7/8 to 7/11/13:-Breakfast: staff noted the resident ate 50% or less 3 of 4 times;-Lunch: staff noted the resident ate 50% or less 3 of 4 times and two refusals;-Dinner: staff noted the resident ate 50% or less 1 of 4 times and one refusal.-Between 7/12 to 7/16/13 (five days), staff noted the resident refused all meals. Record review of the nurses notes showed staff made no documentation between 7/10/13 to 7/16/13, regarding the resident's tube feedings, refusals and intake. Record review of the medical nutrition therapy notes on 7/16/13, showed the DM had not documented on the resident since 4/12/13. Observation and interview on 7/16/13, showed the following information:-At 8:25 A.M., licensed practical nurse (LPN) B set up the resident's morning medications. LPN B said the resident takes his/her medication by mouth. He/she also checked the feeding tube for placement, flushed the tube and hung a new bag of [MEDICATION NAME]. LPN B and LPN A entered the resident's room. The resident lay in the bed with a sheet covering his/her body and up over his/her head. LPN B removed a corner of the sheet and asked the resident if he/she would take his/her medications. The resident did not verbally respond to the nurse, but turned his/her head to the side and pulled the cover back over his/her head. LPN B told the resident he/she needed to check his/her tube. LPN B flushed the tube and hung a new bag of tube feeding.-At 1:25 P.M., the resident lay in bed uncovered. The resident kept his/her eyes closed and head turned to the side when spoken to. The resident's tube feeding machine was turned off and the tube feeding was disconnected from the resident;-At 1:30 P.M., LPN B said the machine was set to alarm every four hours for the nurse to do the water flush. LPN B had already done the 12:00 P.M., flush;-At 1:35 P.M., LPN B entered the room. He/she was not aware the machine was turned off and disconnected;-At 1:45 P.M., the DON said he/she would contact the physician for orders to discontinue or decrease the tube feedings and then she would update the care plan;-At 1:50 P.M., certified nurse assistant (CNA) C said in the past he/she had witnessed the resident turn off the machine and pull the tube feeding out. CNA C said the resident has not eaten anything in the last two days for any meals. CNA C thinks the resident is "just giving up". CNA C said the resident can hear you when you talk to him/her. The resident just "chooses" when to listen. Record review of the nurse's notes on 7/16/13, found resident with his/her tube feeding turned off. DON spoke with the resident's spouse. Spouse indicated the resident was not responding to him/her as he/she once was. During an interview on 7/17/13 at 9:05 A.M., the DM said:-She emails the RD consultation form with new admissions, tube feeding residents, and with any concerns;-The RD comes to the facility monthly. The RD sees new admissions, tube feeding residents and residents with any concerns; RD also sees residents quarterly when MDS assessments were due;-The RD makes her recommendations and the RD gives the recommendations to the departments responsible;-The DM checked his/her log and the resident's record. The DM said the RD saw the resident on 2/20/13 and 7/9/13. She was not aware the RD had not seen the resident at other times;-The resident should have been on the RD list monthly;-The department heads meet weekly to discuss weights. During an interview on 7/17/13, the DON said:-The restorative aide completes the monthly and weekly weights;-Staff have a weekly weight meeting;-If the RD saw a resident, she would complete a written recommendation;-She was not aware the RD had not been seeing the resident;-She was not aware the DM had not been documenting in the notes since 4/12/13;-She was not aware the charge nurse had not been documenting the resident's meal refusals and the resident's family bringing food;-She was not aware the care plan was not updated regarding the refusals and family bringing food;-She was not aware the staff had noted refusals for all meals between 7/12 to 7/17/13. During an interview on 7/17/13 at 1:25 P.M., the resident's physician and DON said the following:-The physician said the resident was a "hard one" because he/she can not tell staff what he/she wants;-Surveyors made the physician aware of concerns regarding RD not seeing the resident, refusals and lack of documentation by staff;-The DON said the physician just gave new orders to discontinue the tube feedings. If the resident was not eating, staff were to give a [MEDICATION NAME] feeding. RD consult. Record review of the nurses notes dated 7/17/13 at 1:00 P.M., showed the physician saw the resident. New orders received for nutritional support. See POS for details. Record Review of the POS [REDACTED]. If takes meals [MEDICATION NAME] TID with meals until dietary consult. Record review of the MAR indicated [REDACTED]. Record review of the nurse's notes showed staff made no further documentation since the 7/17/13 1:00 P.M. note. The nurses made no documentation regarding the resident's meal intake at the supper meal on 7/17/13 and the breakfast meal on 7/18/13 and whether they administered the ordered [MEDICATION NAME] feedings. During record review and interview on 7/18/13 at 9:15 A.M., the DON said:-She wrote the telephone order for the [MEDICATION NAME] feedings, added the order to the POS and made a note in the nurses notes. She handed the order to the charge nurses to add to the MAR;-She was not aware staff had not added the order for the [MEDICATION NAME] feedings to the MAR;-The DON added the order to the MAR.-At 9:16 A.M., the DON asked LPN B to give the resident a [MEDICATION NAME] feeding. During a telephone interview on 7/18/13 at 9:18 A.M., the charge nurse on duty on 7/17/13, LPN A, said he/she knew there was an order change. The physician wrote an order for [REDACTED]. LPN A said he/she was not given the order. He/she left around 5:00 P.M., and LPN B took over. LPN A said he/she did not give the resident any [MEDICATION NAME] feedings. During observation and interview on 7/18/13 at 9:25 A.M., LPN B was in the resident's room trying to give the resident a [MEDICATION NAME] feeding. The resident was trying to grab at the tube and pull the syringe with feeding from the nurse. LPN B said he/she did not give a [MEDICATION NAME] feeding on his/her shift last night before he/she left, but he/she passed it on to LPN G saying that was what we were gonning to be doing for the resident. LPN B said no one gave him/her an order to add to the MAR. During a telephone interview on 7/18/13 at 8:03 P.M., LPN G said:-He/she did not receive report from LPN B;-Staff never transcribed the order for the [MEDICATION NAME] feedings to the MAR; -At shift change, he/she counted the narcotics with LPN B. LPN B had to leave, so LPN G was just going to look at the report book but got busy;-He/she knew the tube feeding was discontinued. He/she assumed it was because the resident could eat;-He/she did not give the resident any [MEDICATION NAME] feeding but did flush the tube twice with water. Record review of the RD e-mail/fax consultation dated 7/18/13, showed the following information:-Reason for order: RD consult;-Last month 208, 7/16/13: 176 pounds. Today: 173 pounds;-Diet order: Regular solid foods, if no oral intake then [MEDICATION NAME] one can [MEDICATION NAME] four times a day. If the resident takes meals, [MEDICATION NAME] three times with meals until dietary consult.

Based on facility record review, hospital record reviews, and interviews with facility staff, physician, and family the facility failed to adequately assess and monitor one resident (Resident #1) after the addition of a new medication, [MEDICATION NAME] (controlled opioid [MEDICATION NAME]) when the resident had a change of condition resulting in hospitalization due to an overdose of [MEDICATION NAME]. The facility census was 58. 1. According to Mosby's Manual of Diagnostic and Laboratory Tests, normal pulse oximetry (measurement of [MEDICATION NAME] blood expressed as a percentage) value in the elderly should be equal to or greater than 95% and a critical pulse oximetry value when equal to or less than 75% Mosby's 2013 Nursing Drug Reference showed the following information; -[MEDICATION NAME] side effects include drowsiness, dizziness, confusion, headache, sedation, euphoria, [MEDICAL CONDITIONS], shock, anorexia, rash, respiratory depression, and respiratory arrest. [MEDICATION NAME] increases effects on the central nervous system when used with opioids; -[MEDICATION NAME] side effects include drowsiness, dizziness, confusion, headache, sedation, euphoria, [MEDICAL CONDITION], shock, [MEDICAL CONDITION], chest pain, hypo/hypertension, [MEDICAL CONDITIONS] anorexia, rash, respiratory depression, respiratory arrest, and apnea; -[MEDICATION NAME] ([MEDICATION NAME]) side effects include dizziness, drowsiness, confusion, headache, anxiety, fatigue, depression, poor coordination, memory impairment, orthostatic [MEDICAL CONDITION], [MEDICAL CONDITIONS], blurred vision, nausea, vomiting, anorexia, rash, [MEDICAL CONDITION], itching, and [MEDICAL CONDITION]. [MEDICATION NAME] increases effect on the central nervous system when used with opioids. 2. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/27/13, showed the following information: -Admission to the facility: 3/18/13; -[DIAGNOSES REDACTED]. -Intact cognitive skills; -Extensive assistance required for transfers, dressing, toilet use, and personal hygiene; -No therapies identified; -Surgical wound, no pressure ulcers identified. Record review of the physician visit documentation for the resident dated 3/22/13, showed the following information: -Original admit to the hospital for acute [MEDICAL CONDITION], subsequently required a [MEDICAL CONDITION] (trach), multiple [MEDICATION NAME], required ventilation and prolonged intravenous (IV) antibiotics. Resident continued to have [MEDICAL CONDITION] and a gastrostomy feeding tube. The resident no longer had tube feedings and was tolerating oral feeding. The resident was no longer short of breath. The (resident's) pain was adequately controlled, although he/she had chronic pain. The resident had increased swelling in lower legs, ankles, and feet; -Plan for treatment included to continue current medications, apply Tubi-Grips to the lower extremities, apply skin prep to the heels and float the heels, and physical and occupational therapy. Record review of the physician visit documentation for the resident dated 3/27/13, showed the following information: -Resident complained of inadequate pain control which is generalized; -Increasing pedal [MEDICAL CONDITION] with weeping of his/her skin; -Impression showed increasing pedal (foot) [MEDICAL CONDITION] with [MEDICAL CONDITION], chronic pai[DIAGNOSES REDACTED] poorly controlled, [MEDICAL CONDITION], debility, [MEDICAL CONDITION] and diabetes requiring insulin; -Plan showed to discontinue the [MEDICATION NAME] (controlled opiate [MEDICATION NAME]), change the [MEDICATION NAME] (controlled opiate [MEDICATION NAME]) to ER (extended release) 30 mg every 12 hours and [MEDICATION NAME] IR (immediate release controlled opiate [MEDICATION NAME])15 mg every 6 hours as needed, add [MEDICATION NAME] (diuretic) 40 mg daily and [MEDICATION NAME] (diuretic) 25 mg daily, and recheck of lab test ordered. Record review of the physician's orders [REDACTED]. -3/18/13, an order for [REDACTED]. -3/27/13, orders for [MEDICATION NAME] ER 30 mg every 12 hours, and [MEDICATION NAME] IR 15 mg one every 6 hours as needed; -Staff to monitor resident's pain every 12 hours; -4/4/13, an order for [REDACTED]. -4/10/13 at 1:50 P.M., a physician order [REDACTED]. Record review of the nurses' notes regarding the resident showed the following information:-3/26/13 at 9:00 P.M., staff documented the resident was seated at bedside getting a breathing treatment and oxygen at 2.5 liter (L) via nasal cannula. His/her vital signs were within normal limits for the resident. No sign or symptom of pain or anxiety at this time. Staff will continue to monitor for needs and change in condition; -3/28/13 on 6:00 P.M. to 6:00 A.M. shift, oxygen sat at 92% on 2 L oxygen via nasal cannula. Resident complained of pain all over multiple times throughout the shift and was given as needed pain medication twice during shift with good results. -3/29/13 on 6:00 A.M. to 6:00 P.M. shift, staff documented the resident received routine and as needed pain medications. The physician was to see the resident on the next visit regarding the [MEDICAL CONDITION]; -3/31/13 on 6:00 A.M. to 6:00 P.M. shift, the as needed pain medication given once this shift. Oxygen at 2.5 L to trach; -4/4/13 at 12:30 P.M., the resident complained of pain all over, mostly in his/her hips and legs. New orders received from the NP included [MEDICATION NAME] 5 mg one every 8 hours; -4/7/13, (no time documented) The resident was restless and complained of pain. The resident received pain medication as ordered with little relief. Staff would to continue to monitor; -4/8/13 at 5:05 A.M., nurse aides called the nurse to come to resident's room because the resident pulled out his/her trach, the main tube was still in. The resident's oxygen saturation was down to 88%. Oxygen was placed at 3 L vial nasal cannula. The resident refused oxygen placed on the trach. Staff would continue to monitor and pass the information on to the day shift. Oxygen sats at 94% and holding; (No nurses notes documented on 4/8/13 6:00 A.M. to 6:00 P.M. shift) -4/8/13 on 6:00 P.M. to 6:00 A.M. 4/9/13 shift) staff documented the resident had no changes that shift, rested well and had normal vital signs; -4/10/13 at 00:45 A.M., staff documented the resident had increased confusion since the new medication, [MEDICATION NAME], was started. Will notify the NP at rounds this date; (Staff did not notify the physician or the NP at that time regarding the change of condition) -4/10/13 at 7:20 A.M., staff documented the resident had increased sedation and confusion. Oxygen sat at 95% on 3 L via nasal cannula.[MEDICAL CONDITION] place. Staff repositioned resident in bed with the head and foot of bed elevated. The resident's lower extremities had [MEDICAL CONDITION] and dependent cyanosis (blue discoloration). Bilateral Tubi Grips were in place. The resident responded to his/her name. The nurse documented he/she would hold the resident's narcotics until the NP rounded that day; (Staff did not notify the physician or NP of the change in condition) -4/10/13 at 1:45 P.M., the resident had cyanosis of his/her hands and his/her oxygen sat was 74% with oxygen at 3 L via trach. Respirations with accessory muscle use (an indication of difficulty breathing), the resident opened his/her eyes to his/her name but was incontinent of urine. The inner cannula of [MEDICAL CONDITION] changed and oxygen was increased to 5 L. The nurse notified the NP and received an order to send the resident to the emergency room . Record review of the medication administration records (MAR) and the narcotic logs of medications regarding the resident showed the following information:-[MEDICATION NAME] 5 mg scheduled to be administered at 6:00 A.M., 2:00 P.M., and 10:00 P.M. given once on 4/4/13, three times on 4/5/13, three times on 4/6/13, three times on 4/7/13, three times on 4/8/13, three times on 4/9/13 and once on 4/10/13; -[MEDICATION NAME] ER 30 mg scheduled to be administered at 8:00 A.M. an 8:00 P.M. showed it was given on 4/9/13 at 8:00 P.M. and again on 4/10/13 at 8:00 A.M.; -[MEDICATION NAME] IR 15 mg every six hours as needed showed given twice on 4/9/13 the last being at midnight; -[MEDICATION NAME] 0.5 mg one every six hours as needed showed given at 9:00 A.M. on 4/9/13 and 9:00 A.M. on 4/10/13. Record review of the hospital record dated 4/10/13 regarding the resident, showed the following information: -Resident arrived in the emergency room at Cassville at 2:25 P.M.; -Resident presented with a chief complaint of drug overdose. The resident presented with altered mental status. The resident was recently started on [MEDICATION NAME] in addition to his/her other pain medications. Since that time he/she has become increasingly more lethargic and has had a decreased oral intake. This is a new problem. The current episode started yesterday and has been gradually worsening. Associated symptoms include somnolence and unresponsiveness. Pertinent negatives include resident does not experience confusion and no [MEDICAL CONDITION]. Risk factors include recent infection and change in medications. Risk factors do not include illicit drug use or resident not taking medications correctly; -Resident received intravenous (IV) [MEDICATION NAME] (a medication that reverses the effect of opioid based medications) in the emergency room at the Cassville hospital; -Resident found to be hypoxic and with bilateral pneumonia and was transferred to Mercy (hospital) in Springfield where he/she was admitted to the intensive care unit; -History given to staff at Mercy in Springfield from the facility staff showed the resident was started on [MEDICATION NAME] on 4/5/13, and he/she had been more lethargic since starting the [MEDICATION NAME]. During an interview on 4/17/13 at 8:30 A.M., the administrator said the facility received a complaint regarding the resident's medications last week and they had not completed their investigation yet. During an interview on 4/18/13 at 1:25 P.M., licensed practical nurse (LPN) D said the resident was on a lot of medications and was confused. LPN D said the day the resident was sent to the hospital his/her oxygen sats were low and he/she was very confused. During an interview on 4/18/13 at 3:50 P.M., registered nurse (RN) E said he/she was working the day the resident was sent to the hospital due to low oxygen sats. RN E said the resident had been started on [MEDICATION NAME] on the prior Friday and he/she became more confused. During an interview on 4/24/13 at 12:50 P.M., a family member said they had visited the resident two to three days before he/she was sent to the hospital and they told the staff then the resident was over-medicated. The family member said the resident nearly fell out of bed that day, but he/she caught the resident from falling out of the bed. During an interview on 4/25/13 at 1:45 P.M., the resident's physician said the resident was over-sedated and sent to the hospital. The physician said the staff should have notified him when the resident had signs and symptoms of over-sedation. He said the staff should have notified him whenever the resident had a change of condition. Complaint # MO 596

Based on observations, facility record reviews, hospital record review, and interviews with residents, staff, family and physician the facility failed to consistently provide weekly nurse skin assessments and monitoring of pressure ulcers, and failed to consistently provide the physician ordered treatments to promote healing and prevent infection of pressure ulcers for six residents including one closed record (Residents #1, #4, #5, #7, #8, and #9) identified by staff as having pressure ulcers. The facility identified seven residents with pressure ulcers with five of those seven residents having facility acquired pressure ulcers, out of a census of 58. 1. Record review of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel's Prevention and treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009 showed the following pressure ulcer classification system: -Stage I-intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage II-partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Bruising indicates suspected deep tissue injury; -Stage III-full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; -Stage IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling; -Unstageable-full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the "the body's natural cover" and should not be removed; -Suspected deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 2. During the entrance conference on 4/17/13, the facility log of pressure ulcers for the past four weeks was requested. The facility provided a list of twelve residents with wounds, no measurements were documented, no treatments documented and no comparison to show weekly assessments being done. Two of the residents were identified as having the wounds on admission, three were identified with skin tears, two were identified with venous ulcers, and five were identified with avoidable pressure ulcers documented as unstageable and one as a Stage III. At 11:30 A.M., requested from the administrator the past four weeks facility log of pressure ulcers, again. During an interview on 4/18/13 at noon, the Director of Nurses (DON) said they had not been doing weekly skin assessments. She said they started to do the weekly skin assessments on 4/15/13, and the list provided yesterday (4/17/13) was the first log. The DON said licensed practical nurse (LPN) D did the assessments. During an interview on 4/18/13 at 12:10 P.M., registered nurse (RN) E said the treatments of wounds and the wound assessments were done by LPN D and LPN H. RN E said he/she did not know where the assessments were documented. During an interview on 4/18/13 at 1:25 P.M., LPN D said he/she was hired in January 2013, as a treatment nurse. LPN D said no one was doing the wound assessments when he/she was hired. LPN D said he/she was scheduled to work the midnight shift for about 1 ? months and took him/her off doing the treatments during that time. LPN D said he/she is back on the day shift and he/she is assigned to do the treatments and the wound assessments weekly. He/she said the day nurse also does the blood sugars, insulins, and the narcotics. LPN D said if treatments are missed it is due to not enough time. LPN D said the nurse doing the treatments or the assessments calls for orders when a new area is found or the treatment needs to be changed. LPN D said he/she did wound assessments on 4/8/13 for part of the facility, and again on 4/15/13 and 4/16/13. The measurements, stages, treatments, and any additional comments should be documented on the resident body audit form in the medical records. LPN D said a wound nurse consultant comes in one time a month to help with the assessments and training. On 4/22/13, the facility provided a new pressure ulcer weekly assessment completed on 4/18/13. The new log identified six residents with pressure ulcers, measurements were documented, and all residents were identified as having the pressure ulcers on admission except for Resident #8, with a Stage II on his/her coccyx. Resident #4 was not on the log and he/she was identified with one Stage III and two unstageable pressure ulcers on the log the facility provided on 4/17/13. 3. Record review of Resident #4's 14 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/6/12, showed the following information: -The resident was admitted to the facility on [DATE]; -BIMS documented as 15, cognitively intact; -Total dependence in bed mobility, transfers and toilet use; -Extensive assistance in dressing, and personal hygiene; -Two Stage II pressure ulcers on admission. The resident 60 day MDS dated [DATE], showed no pressure ulcers now. Record review of the nurses' notes for the resident showed on 1/8/13, staff documented the resident had a Stage III pressure ulcer to coccyx noted while doing treatment for [REDACTED]. Record review of the physician orders showed on 1/8/13, the physician ordered the resident to go to the wound clinic for evaluation and treatment of [REDACTED]. Record review of the resident's reports from the Hyperbaric Medicine and Wound Center showed the following information: -On 1/21/13, resident presented for evaluation of recurrent ulcerations on his/her buttock. The resident is paraplegic and does sleep on an air mattress and has pressure relief cushion on his/her wheelchair. This began about a month ago and staff have been treating with a covering of [MEDICATION NAME]. The initial coccyx pressure ulcer measured 2.0 cm by 2.0 cm by 0.1 cm depth. -On 2/4/13, the resident also presented with a pressure ulcer on left lateral heel. The initial measurement documented at 1.8 cm by 1.9 cm by 0.1 cm depth. -On 3/4/13, the resident also presented with a pressure ulcer on his/her left ischial (lower portion of hip bone). The initial pressure ulcer measured 0.7 cm by 6.0 cm. -On 3/18/13, resident also presented with area on left lateral ankle that was eschar tissue. The initial measured area documented at 0.7 cm by 0.1 cm by 0.1 cm depth. Record review of the facility's weekly skin audits for the resident for March 2013, showed staff did not consistently perform the skin audits and staff did not record measurements on the 3/5/13 report, or on the next one completed on 3/19/13. Record review of the wound sheets for the resident on 4/15/13, completed by the wound nurse consultant and LPN D, showed the following information: -Left ischium unstageable and measuring 5.00 cm by 8.00 cm with unable to determine depth. Wound bed with 80% moist yellow slough in center with 20% beefy red moist granulation surrounding slough. The periwound had a white macerated rim measuring 0.1 cm surrounding wound bed circumferentially. Red erythemic fragile tissue surrounded the wound bed measuring 9.0 cm by 13.0 cm including the wound bed. Treatment documented to cleanse area with wound cleanser and apply silver hydrogel to wound bed, and then cover with bordered foam dressing and to repeat this three times daily. -Left heel unstageable and measuring 2.5 cm by 1.8 cm with unable to determine depth. The wound bed is 60% dry lifting yellow brown eschar, 40% moist pink granulation tissue in a triangular shaped wound. Periwound is pink fragile blanchable tissue. Treatment documented the same as above. -Coccyx a healing Stage III measuring 1.00 cm by 0.30 cm with 0.2 cm depth. Wound bed 100% dry pink granulation tissue. Periwound area described as silver pink fragile scar tissue surrounding the wound bed measuring 6 cm by 2 cm including wound bed. Treatment documented the same as above. During an observation and interviews on 4/17/13 at 3:25 P.M., LPN H did the treatments for the resident. The resident was still up in his/her electric wheelchair from the noon meal. The resident had an air mattress and foot protectors on both feet. The resident had a catheter and two staff transferred the resident from his/her wheelchair to bed using a Hoyer lift. The dressings on the resident had yesterday's date on them. The coccyx wound looked improved from the above 4/15/13 report. LPN H said the left ischium looked worse today. The left heel had an open area on outer lateral side, the back of the heel was dark red and underside of heel had an open black area. The resident said the wounds just got bad quickly, maybe about a month ago. LPN H said the resident goes to the wound clinic every two weeks now. During an interview on 4/22/13 at 11:50 A.M., the resident was in his/her electric wheelchair ready to go to the wound clinic. The resident said he/she is afraid the physician will put him/her on bed rest for awhile because of his/her wounds. 4. Record review of Resident #7's admission MDS, dated [DATE], showed the resident did not have any pressure ulcers on admission to the facility. Record review of the physician orders for the resident for the month of April 2013, showed the following information: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Weekly skin audit every Tuesday (Review of provided audits showed one on 3/5/13, that identified resident with blister like sores on his/her right heel and no measurements or treatment documented, the next audit was on 3/26/13 with both heels identified red and no measurements or treatment documented); -On 4/5/13, physician ordered heel protectors on at all times except when ambulating or transferring; -On 4/10/13, order to cleanse bilateral heels with normal saline, pat dry, apply TAO and cover with foam dressing every day and as needed. Record review of the facility log of pressure sores regarding the resident, showed the following information: -On 4/18/13, unstageable right heel pressure ulcer measured at 2.5 cm by 2.2 cm with a depth of more than 0.2 cm; -On 4/18/13, unstageable pressure ulcer left heel measured at 2.2 cm by 2.7 cm with a depth of more than 0.2 cm; -On 4/25/13, Stage III right heel measured at 3.75 cm by 3.0 cm with a depth of 0.1; -On 4/25/13, Stage III left heel measured at 3 cm by 4 cm with a depth of 0.1. During an observation and interview on 4/22/13 at 1:50 P.M., LPN H did the treatment and measurements on the resident's pressure ulcers. The resident was in bed and he/she had heel protectors on both feet and wore a sling on his/her left arm. The right heel was eschar and measured 4 cm by 2 cm. The left heel was softer eschar and measured 3.25 by 3.25. LPN H did the ordered treatment for [REDACTED]. 5. Record review of Resident #5's admission MDS, dated [DATE], showed the resident did not have any pressure ulcers on admission to the facility. Record review of the nurses' notes for the resident showed the following information:-On 2/28/13 6:00 A.M. to 6:00 P.M. shift documented the resident had a stage II area on his/her right posterior heel measuring 1.5 cm by 2.5 cm. The resident reported it was from his/her shoe. Area cleansed and [MEDICATION NAME] island applied. The resident agreed to wear non-skid socks instead of his/her shoes; -On 4/15/13 at 10:00 A.M. the resident ambulated in the hall with physical therapy staff, using a walker. Resident stated slight discomfort to heels while ambulating, discomfort enough to shorten the distance; -On 4/16/13 on 6:00 P.M. to 6:00 A.M. shift, the resident complained of pain all over. Resident states he/she is dying, heels, body aches and burning on feet. Staff documented will continue to watch the resident. Record review of the one weekly skin audit found in the resident's medical record showed the following information: -Dated 4/12/13, resident with unstageable pressure ulcer on left heel measuring 2 cm by 2 cm with a depth of more than 0.2 cm and on right heel unstageable pressure ulcer measuring 2.5 cm by 2 cm with a depth of more than 0.2 cm. Record review of the treatment administration record (TAR) for the resident showed the following information:-On 4/14/13, order for staff to cleanse the left and right heel with normal saline and apply TAO and cover with foam dressing daily until healed; -On 4/17/13, showed the last treatment completed on 4/14/13. During an observation and interview on 4/22/13 at 1:40 P.M., LPN H did the 9:00 A.M. scheduled daily treatment for [REDACTED]. The resident said his/her heels hurt. The left heel had eschar at the back and bottom of the heel and measured 2 cm by 1.5 cm. The right heel had dark sticky drainage and the edges looked macerated and red. LPN H said the right heel was worse than when he/she last saw it. The right heel measured at 3 cm by 2.5 cm by 0.25 depth. 6. Record review of Resident #9's admission MDS, dated [DATE], showed the resident did not have any pressure ulcers on admission to the facility. The resident required extensive staff assistance with bed mobility, transfers, toilet use and personal hygiene. The resident was admitted to the facility on [DATE]. Record review of the weekly skin audits for the resident showed the following information: -On 3/5/13, heels identified as clear; -Next one on 3/27/13, heels identified as clear; -On 4/2/13, heels identified as clear; -On 4/8/13, staff identified the resident had [MEDICAL CONDITION] of his/her lower legs, reddened heels, and eschar on right heel, no measurement or treatment documented; -On 4/15/13, staff identified the resident had [MEDICAL CONDITION] of his/her lower legs, reddened heels, and eschar on right heel measuring 1 cm by 1.5 cm with depth more than 0.2 cm. No treatment was documented. (The facility weekly pressure ulcer assessments completed on 4/18/13, showed the same measurements for the resident's right heel) Record review of the physician orders for the resident for April 2013, did not show any treatment ordered for the resident's right heel. During an interview on 4/22/13 at 11:50 A.M., LPN D said they need a physician's order to use A & D ointment on a resident. During an observation and interview on 4/22/13 2:45 P.M., LPN H went into the special care unit to see the resident. The resident had completed a shower and was being assisted by staff ambulating with a roller walker. The staff stated they use A & D ointment on the resident's right heel. LPN H said they do not have a treatment in the TAR for the resident's heel and they should have an order to use A & D ointment. 7. Record review of Resident #8's 30-day MDS, dated [DATE], showed the resident did not have any pressure ulcers. The resident is cognitively intact. The resident required extensive assistance in bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of the weekly skin audits for the resident showed the following information; -On 4/8/13, staff identified the resident had a reddened coccyx; -On 4/15/13, staff identified the resident had a reddened coccyx; -On 4/17/13, staff identified the resident had a Stage II pressure ulcer on his/her coccyx that measured 2 cm by 1 cm with depth more than 0.1 cm. The wound bed was identified as yellow. Record review of the facility weekly skin assessment for the resident completed on 4/25/13, showed the following information:-Stage II coccyx pressure ulcer measured 3.5 cm by 1.2 cm with depth of more than 0.1 cm; -Stage II left ischial pressure ulcer measured 1 cm by 0.75 cm with depth of more than 0.1 cm. Record review of the physician orders for the resident for April 2013, showed the following information:-On 4/18/13, treatments were ordered for coccyx and left ischium, to cleanse with normal saline and pat dry, apply petroleum dressing, cover with non-adherent dressing and cover with retention tape. Staff were to change the dressing daily and as needed until healed. During an observation and interviews on 4/22/13 at 2:25 P.M., LPN H went to do the treatment for [REDACTED]. The resident said he/she had a bowel movement and the dressing got dirty. The resident had two open Stage II pressure ulcers, one on his/her coccyx and one on his/her left ischium. The resident told LPN H the bar in his/her bed hurts him/her and the resident would like an air mattress. LPN H did the treatment for [REDACTED]. 8. Record review of the Resident #1's admission MDS, dated [DATE], showed the following information: -Admission to the facility 3/18/13; -[DIAGNOSES REDACTED]. -Intact cognitive skills; -Extensive assistance required for transfers, dressing, toilet use, and personal hygiene; -No therapies identified; -Surgical wound, no pressure ulcers identified. Record review of only weekly skin audit dated 4/8/13, found in the resident's medical record showed the following information:-Coccyx identified as reddened, heels reddened, and feet reddened; -Right and left buttocks red and [MEDICATION NAME] (protective dressing) placed. Record review of the physician orders regarding the resident showed the following information: -On 3/18/13, [MEDICATION NAME] (protective) ointment applied to buttocks daily;-On 3/22/13, physician order for [REDACTED]. (No physician order found for the [MEDICATION NAME] treatment) -On 4/10/13, resident discharged to the hospital. Record review of the resident's hospital admission records dated 4/10/13, at Mercy (hospital) in Springfield showed the following information: -Stage II pressure ulcer on the right buttock; -Bilateral lower extremity [DIAGNOSES REDACTED] (redness) and [MEDICAL CONDITION], warm to touch. During an interview on 4/22/13 at 4:50 P.M., CNA G said the resident was a two person assist to toilet. The resident stayed in his/her room a lot. The resident had breakdown on his/her bottom that was covered with a dressing. During an interview on 4/24/13 at 12:50 P.M., a family member said the resident had a pressure ulcer on his/her bottom when arrived at the hospital and the resident entered the facility with no pressure ulcer. During an interview on 4/25/13 at 1:45 P.M., the resident's physician said the staff should have notified him whenever the resident had a change of condition. Complaint # MO 596

Based on record review and interviews with the staff and the facility's medical director the facility failed to provide a safe environment for two residents (Residents #1 and #3) by preventing Resident #2 from performing nursing procedures on them. The facility had a census of 58. 1. Record review of the Internet source Encyclopedia of Nursing & Allied Health </nursing-encyclopedia Tracheostomy (trach) Care showed the following: A tracheostomy is a surgically created opening in the trachea (windpipe). A tracheostomy tube is placed in the incision to secure an airway and to prevent it from closing. Tracheostomy care is generally done every eight hours and involves cleaning around the incision, as well as replacing (or cleaning) the inner cannula of the tracheostomy tube. The goals of tracheostomy care are to maintain the patency of the airway, prevent breakdown of the skin surrounding the site, and prevent infection. Sterile technique should be used during the procedure. 2. Record review of the Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/27/13, showed the following information: -Admission to the facility 3/18/13; -[DIAGNOSES REDACTED]. -Intact cognitive skills; -Extensive assistance required for transfers, dressing, toilet use, and personal hygiene; -No therapies identified; -Surgical wound, no pressure ulcers identified. Record review of the nurses' notes, regarding the resident, showed the following information:-On 3/23/13 on the 6 P.M. to 6 A.M. shift, licensed practical nurse (LPN) B documented that evening the resident needed his/her trach suctioned. LPN B documented he/she was running busy and Resident #2 came to LPN B stating he/she needed help. LPN B followed Resident #2 to Resident #1's room where Resident #2 immediately went to Resident #1's neck to get the resident prepared for suctioning of his/her trach. LPN B documented that Resident #2 said to him/her, "We don't care and the resident needs better care". Resident #1 seemed nervous and scared. LPN B redirected Resident #2 and asked Resident #2 to leave the room. LPN B documented he/she told Resident #1 it would never happen again. LPN B fixed, suctioned and cleaned the resident's trach. Resident #1 had to be medicated for anxiety. -No further nursing documentation was entered until 3/25/13, at 9:00 P.M. -Staff did not document notification of the physician or the family of the occurrence with Resident #2 and the care of Resident #1's trach. Record review of Resident #2's physician progress notes [REDACTED]. -[DIAGNOSES REDACTED]. -Alert and oriented, able to communicate needs, and independent in ambulation and care; -Resident with multiple scars, disfigurement to face and abscess right nare. Record review of the nurses' notes, for Resident #2, showed the following information:-On 3/23/13 on the 6 P.M. to 6:00 A.M. shift, LPN B documented the resident came to him/her stating it was an emergency. LPN B followed Resident #2 to Resident #1's room where Resident #2 said the resident has to be suctioned due to mucus and we are killing him/her and he/she deserves care. LPN B assured Resident #2 the resident was fine but said we can suction the resident. LPN B was trying to get the sterile kit going and Resident #2 pulled out the resident's trach when LPN B was not looking and said, "See it's full, the resident can't breathe". LPN B was shocked. LPN B explained to Resident #2 he/she was not the nurse and he/she cannot do that. LPN B redirected Resident #2 and asked Resident #2 to leave the room. Resident #1 was wide eyed and scared, and LPN B assured him/her that was not the way care was given and that he/she was sorry. Resident #1 had to be medicated for anxiety. LPN B documented he/she directed Resident #2 to never touch Resident #1's trach. -No further nursing documentation was entered until 3/24/13, at 4:45 P.M. -Staff did not document notification of the physician or the family of the occurrence with Resident #2 and the care of Resident #1's trach. -Staff did not show in Resident #2's care plan any intervention to prevent reoccurrence. 3. Record review of the Resident #3's annual MDS, dated [DATE], showed the following information: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Resident had short and long term memory problems; -Cognitive skills severely impaired; -Required extensive assistance in transfers, dressing, toilet use, and personal hygiene; -Resident used a merry walker for his/her ambulation about the facility. Record review of the nurses' notes of Resident #2 showed the following information: -On 4/2/13 at 2:20 P.M., the Director of Nurses (DON) documented after the noon meal on 4/2/13, Resident #2 reported that he/she was putting Vaseline on another resident's face. The resident was instructed not to do that anymore as it was a treatment for [REDACTED]. At 2:20 P.M., the DON documented the social service director (SSD) reported to her that Resident #2 said in regard to the lesion on the other resident's face, "I just wanna snatch it outa there". The SSD told the resident it was possibly a nursing matter, and Resident #2 replied, "It's not a cancer, it's an ingrown hair. Vaseline will bring it to a head then we can pop it." The matter was reported to the administrator and the administrator asked to speak to Resident #2. The administrator, SSD, DON and Resident #2 talked together. The administrator directed Resident #2 not to put Vaseline on another resident's face. -No further nursing documentation was entered until 4/17/13; -Staff did not document notification of the physician or the family of the occurrence; -Staff did not show in the care plan any intervention to prevent reoccurrence. During an interview on 4/17/13, at 11:00 A.M., SSD C stated Resident #2 was treating the cancer on Resident #3's face with Vaseline. During an interview on 4/22/13 at 1:25 P.M., Resident #2 said he/she liked to help the other residents. Resident #2 said he/she watches his/her roommate and checks him/her to see if wet and then asks the staff to change the roommate if needed. Resident #2 said he/she also likes to take his/her roommate outside when it is nice. He/she said they have new rules and he/she is not to touch other residents but to tell the nurse when another resident needs something. During an interview on 4/22/13, at 5:50 P.M., LPN B said the only incident he/she knew about Resident #2 interfering with another resident's care was the incident on 3/23/13, regarding Resident #1's trach. LPN B said he/she reported it to the DON and charted it in the medical records. During an interview on 4/25/13, at 10:30 A.M., the administrator said Resident #2 may need other placement and in the meantime the staff will monitor him closely as they work on a plan for him/her. During an interview on 4/25/13, at 1:45 P.M., the medical director of the facility said he was aware Resident #2 was attempting to perform nursing procedures on other residents. He said the resident cared for all the other residents. Resident #2 may need to go to a group home, he/she is very active and provides his/her own cares.

Based on facility record review, three different hospital records, and interviews with facility staff, hospital staff, hospice staff, physicians, and family members the facility failed to provide the physician ordered care and services to one resident (Resident #1) admitted to the facility for comfort care/palliative care. Facility staff visited the resident and family at the hospital prior to his/her admission to the facility. Facility staff spoke with hospital staff and had the resident's medical records and discharge orders faxed to the facility for review prior to the facility accepting the resident for admission to the facility. The facility received the hospital physician discharge orders for intravenous medications and an order for [REDACTED]. The facility did not have a registered nurse (RN) on duty 24 hours a day and staff told the family they could not provide intravenous medications to the resident. The facility staff, three days after the resident's admission, sent him/her to a different hospital for re-evaluation, without notifying the resident's family members responsible for his/her care, resulting in unnecessary stress to the resident and family during the resident's final days of life. The facility census was 52. 1. Record review of the, "Guidelines for End-of-Life Care in Long-Term Care Facilities with emphasis on Developing Palliative Care Goals" developed by Missouri End of Life Coalition's End of Life in the Nursing Home Task Force, Missouri Department of Health and Senior Services Division of Senior Services and Regulations [DATE], showed the following information: -The World Health Organization (WHO) defines palliative care as the active total care of resident whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for residents and their families. -Principles to guide efforts at providing humane, palliative care include respecting the dignity of both the resident and caregivers, be sensitive and respectful of the resident's and families wishes, use the most appropriate measures that are consistent with resident choices, encompass alleviation of pain and other physical symptoms, assess and manage psychological, social and spiritual/religious problems, provide access to palliative care and hospice care, and respect the physician's professional responsibility to discontinue some treatments when appropriate with consideration of both resident and family preferences. -A steady state of pain control is the desired goal. Pain control is much easier and more consistent if medications are given before the resident experiences pain. A resident should not have to "earn" his or her pain medication by experiencing pain. -Anxiety and pain often go together, but it is not known if anxiety can cause pain. We do know, however, that pain often causes anxiety. -During the end of life, the resident is not the only person who may need help. The family must also cope with the emotional and psychological aspects of their loved one"s condition. The facility staff needs to expand their assessment to include the needs of family members. Often families don't know how to act when the resident can no longer carry on a conversation. -Do not stop pain medications in terminal residents. Change the route if needed. 2. Record review of the Bruner and Suddarth's Textbook of Medical-Surgical Nursing, 9th edition, copyright 2000, showed the following information regarding Behavioral Responses to Pain: -Behavioral responses to pain may include verbal statements, vocal behaviors, facial expressions, body movement, physical contact with others, or altered responses to the environment. -A person in acute pain may cry, moan, frown, immobilize a body part, clench a fist or withdraw. -The person may become angry or irritable. Sounds from a radio or television may be very annoying to the person with pain. These behaviors vary greatly from one time to the next. -Although a patient's behavioral responses may be the first indication that something is wrong, behavioral responses should not be used as a substitute for pain management except in unusual situations in which pain measurement is not possible (e.g., the person is severely mentally retarded, cognitively impaired or unconscious). 3. Record review of Taber's Cyclopedic Medical Dictionary Edition 17, showed the following information: -Vegetative state is an imprecise term indicating a resident who was previously comatose, but whose eyes are now open and give the appearance that he/she is awake. It is properly characterized as a severe dementia due to global damage to the cerebral cortex. There is complete inability to respond to stimuli or to communicate. 4. Record review of the Facility to Facility Transfer orders, completed by the hospital physician on [DATE] at 2:50 P.M., for Resident #1, showed the following information:-[DIAGNOSES REDACTED]. -No Code, DNR (Do Not Resuscitate); -Diet: NPO (Nothing By Mouth); -Nutritional Supplements: None; -Resident on bedrest; -No bladder training, No bowel training, Continue urinary catheter; -No wounds; -No oxygen; -No therapies; -No labs/Diagnostic tests; -No additional orders, Comfort Care Orders; On [DATE] at 2:55 P.M. the physician signed the Discharge/Transfer Medication Reconciliation for the resident showing the following medications to be continued: -[MEDICATION NAME] (opioid [MEDICATION NAME]) 10 mg/ml, may give ,[DATE] mg for pain or shortness of breath every hour as needed by IVP; -[MEDICATION NAME] (anti-anxiety) 2 mg/ml, may give 0XXX,[DATE] mg every hour as needed by IVP; -Sodium chloride 0.9% syringe 10 ml (normal saline flush) every 12 hours and as needed by IVP; -[MEDICATION NAME] vl (to decrease secretions) 0.2 mg/ml, give 0.2 mg/ml every four hours as needed IV; -[MEDICATION NAME] ([MEDICATION NAME]) 25 mg suppository, may give 12XXX,[DATE] mg rectally every 4 hours as needed. Record review of the Facility to Facility Transfer Orders, completed by hospital nursing staff for the resident on [DATE] at 5:28 P.M., showed the following information: -Report called to facility licensed practical nurse (LPN) A; -Resident identified to have advance directives; -Resident to have nothing by mouth, staff to provide mouth care; -Resident to receive Comfort Care; -Urinary catheter insertion date identified as [DATE]; -Date of last bowel movement [DATE]; -IV insertion dated identified [DATE], PICC line in resident ' s left arm; -Resident identified with VRE; -Discharging nurse identified and telephone number provided. Record review of the ambulance report for the resident's discharge from the hospital on [DATE], showed the following information: -Ambulance staff arrived to get the resident at 6:37 P.M.; -Resident was admitted to the hospital on [DATE], because of a low blood sugar for an unknown amount of time. The resident was diagnosed with [REDACTED]. -Resident was on a ventilator and later taken off life support and he/she was taken off the ventilator; -Ambulance arrived at the facility at 8:16 P.M. Record review of the facility admission physician orders, for the resident, filled out by LPN A on [DATE], showed the following information: -[DATE], [MEDICATION NAME] ,[DATE] mg IVP every 1 hour as needed for pain or shortness of breath for 3 days; -[DATE], [MEDICATION NAME] 0.5 -2 mg IVP every 1 hour as needed for 3 days; -[DATE], Sodium chloride 0.9% syringe 10 ml (normal saline flush) 10 ml IVP every 12 hours; -[DATE], [MEDICATION NAME] vl 0.2 mg/ml 2 ml give 0.2 mg/ml IV every 4 hours; -[DATE], [MEDICATION NAME] 25 mg suppository, one every 4 hours as needed for nausea/vomiting; -[DIAGNOSES REDACTED]. -Resident identified NPO (nothing by mouth); -Resident to continue urinary catheter; -Alert noted DNR (Do Not Resuscitate); -allergies [REDACTED]. (Medication orders were also put in the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Record review of the facility admission data collection form and the nurses' notes for the resident showed the following information: -Resident with eyes open, non-responsive, NPO, on comfort care; -History of ventilator; -IV PICC left upper arm; -Has a catheter; -On [DATE] at 3:50 A.M., staff documented resident with occasional restlessness in bed moving all extremities. Family at bedside and agree to give the resident a medication for restlessness. Staff documented giving the resident [MEDICATION NAME] 1 mg IM. At 4:40 A.M., staff documented the resident resting in bed with his/her eyes closed, family at bedside; -On [DATE] at 6:00 A.M., family requested pain medication and staff documented giving the resident [MEDICATION NAME] for signs and symptoms of pain; -On [DATE] at 9:30 A.M., staff documented giving the resident [MEDICATION NAME] 0.5 ml sublingual, at request of the family; -On [DATE] at noon, staff documented giving the resident [MEDICATION NAME] 0.5 ml sublingual at the request of the family; -On [DATE] at 2:00 P.M., staff documented the resident moving about as if in a startled reaction and the family requests [MEDICATION NAME] and [MEDICATION NAME] to be given IVP. Staff explained to the family the facility cannot give IVP routinely because they do not have a registered nurse (RN) on 24 hours around the clock. Staff documented the family became irate, and nurse (RN B) explained the resident is on [MEDICATION NAME] and [MEDICATION NAME] every hour and apparently effective, resident does not appear to be in pain. Resident does rest with his/her eyes closed and when his/her bed is bumped or the room is loud, resident becomes "stimulated" and starts involuntary movements; -On [DATE] at 1:50 A.M., staff documented the resident is unable to voice his/her needs, resident turned and repositioned every two hours. Resident resting with eyes closed; -On [DATE] at 7:30 A.M., staff documented they administered [MEDICATION NAME] for restlessness; -On [DATE] at 9:30 A.M., staff documented they administered [MEDICATION NAME] sublingual for sign and symptoms of discomfort; -On [DATE] at 1:30 P.M., staff documented they administered [MEDICATION NAME] for signs and symptoms for restlessness; -On [DATE] at 5:30 P.M., staff documented family in resident's room, resident with his/her eyes open, staring, quiet and still. Foley catheter patent and draining clear amber urine. Oral care attempted and resident resists; -On [DATE] at 7:00 P.M., staff documented friends in room, pleasant and verbalized concern over resident not eating and drinking. RN B assured friends nursing was going to contact physician tomorrow; -On [DATE] at 9:50 P.M., staff documented resident resting, quiet, calm. Family member present and requested [MEDICATION NAME]. RN B told the family member resident was calm and the medication was ordered as needed for agitation. Family member was insisting RN B administer the medication and RN B documented he/she told the family member that he/she would be back to evaluate the resident; -On [DATE] at 10:30 P.M., RN B documented while giving report to the oncoming nurse a certified nurse aide (CNA) stated the family member wanted the resident to have the [MEDICATION NAME] now. RN A asked the CNA if he/she had noticed the resident agitated and the CNA said the resident was moving his/her legs but not restless or agitated; -On [DATE] at 11:00 P.M. to 11:15 P.M., RN B documented he/she checked out the [MEDICATION NAME] to give the resident and he/she and LPN C went to the resident's room to evaluate the resident. The resident was moving his/her legs but not restless or agitated. The family member aggressively and in a threatening manner stated, "I told you two hours ago the resident needed that [MEDICATION NAME] and that's the order". RN B documented he/she felt the resident didn't need the [MEDICATION NAME] and request the family member not talk to him/her like that or he/she would have the family member removed by the police. RN B documented the family member continued in a threatening manner, RN B asked the family member if he/she was the DPOA and the family member said "no". RN B documented he/she "did give the resident [MEDICATION NAME]". RN B documented this family member is one that demands [MEDICATION NAME] and [MEDICATION NAME] be given, even if the resident is calm and resting with his/her eyes closed. The family member stated you told me you didn't want to give the resident medicine so that the resident would be alert for the physician to evaluate him/her. RN B documented he/she explained to the family member "I did not say that nor that I meant that". The family member insisted that's what I (RN B) told him/her. The family member continued angrily talking to LPN C and me (RN B); -On [DATE] at 2:05 A.M., staff documented the family member is quiet and resident was repositioned by two CNA's. No noted shortness of breath, distress or agitation of the resident. Comfort measures met; -On [DATE] at 5:30 A.M., resident noted with restlessness/agitation and family member requesting [MEDICATION NAME]. Staff documented [MEDICATION NAME] 0.5 ml sublingual given. At 6:10 A.M., staff documented the [MEDICATION NAME] effective, resident resting at this time. Resident NPO, output 250 cc; -On [DATE] at 9:15 A.M., RN D (acting director of nurses (DON) at the time) documented order to send the resident to St. Johns ER to have the resident re-evaluated. She documented the resident is "awake". RN D documented the family/friends continue to refuse to let the resident have any oral intake; -On [DATE] at 9:50 A.M., staff documented the resident taken by ambulance to Cassville Mercy Hospital ER for evaluation. Staff did not document calling the hospital the resident was admitted from (Cox South in Springfield) during the days he/she was at the facility. Staff did not document in the nurses' notes notifying the resident's facility physician with any resident or family concerns. Staff did not document notifying the family members responsible for the resident's care before sending the resident to the Mercy ER in Cassville for re-evaluation. Record review of the added facility physician orders [REDACTED]. -On [DATE], no time identified, LPN A wrote the order for [MEDICATION NAME] 1 mg sublingual every six hours for anxiety, [MEDICATION NAME] 2 mg/ml give ? ml IM (intramuscular) every four hours as needed, [MEDICATION NAME] 100 mg per 5 ml (20 mg/ml) ? ml orally every two hours as needed for pain and to discontinue the [MEDICATION NAME] and [MEDICATION NAME] IVP when the other medications arrive; -On [DATE] at 1:30 P.M., RN B wrote the order for [MEDICATION NAME] 1 mg/ ? ml give sublingual every hour as needed for agitation, [MEDICATION NAME] 10 mg 0.5 ml give sublingual every hour as needed for pain, and to discontinue the [MEDICATION NAME] every six hours and the [MEDICATION NAME] every two hours orders; -On [DATE] at 9:15 A.M., RN D wrote the order to send resident to St. Johns ER Cassville, Mercy Hospital. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Staff did not document administering any medications IVP for the resident ordered on admission; -On [DATE] at 11:00 P.M., staff documented administered [MEDICATION NAME] IM (resident arrived at the facility at 8:16 P.M.); -On [DATE] staff documented the resident received [MEDICATION NAME] IM at 3:50 A.M., and [MEDICATION NAME] sublingual at 1:00 A.M., and 8:30 A.M. Staff documented the resident received on [DATE] [MEDICATION NAME] sublingual at 1:00 A.M. (first time resident received pain medication since admission the day prior at 8:16 P.M.), then [MEDICATION NAME] sublingual at 6:15 A.M., 9:30 A.M., and at noon on [DATE]; -On [DATE] staff documented the resident received [MEDICATION NAME] sublingual once that day at 9:30 A.M. and [MEDICATION NAME] sublingual once that day at 11:30 P.M.; -On [DATE] staff documented the resident received [MEDICATION NAME] once at 5:30 A.M. (The resident had not been given any [MEDICATION NAME] sublingual (for pain) since 9:30 A.M. on [DATE], resident taken from the facility 9:50 A.M. on [DATE]) Record review of the facility initial social service history for the resident dated [DATE], filled out by social service staff (SS) E showed the following information: -[DIAGNOSES REDACTED]. -Resident's Parent A passed away the same day the resident was admitted to the facility, [DATE]; -Resident is unable to answer questions; -Resident has two living children and one deceased child; -Resident has been turned over to Social Services and public administrator; -On [DATE], added progress note, called Social Services to make a report about concerns regarding the resident and statements family members were making. Record review of the abuse/neglect hotline regarding the resident filed on [DATE] at 8:59 A.M., showed the following information: -Resident admitted to the facility late Friday afternoon ([DATE]) for "palliative care". Resident was in a diabetic coma. Since the resident has not been receiving constant [MEDICATION NAME], the resident "started to come out of it". The resident is able to get out of bed. The resident's Parent B/sibling are demanding that the resident be kept sedated and not given food/water despite no POA. They have sent people to sit by the resident's bedside to monitor what staff are giving the resident. Staff were told that they do not want the resident to live. Staff are planning to start an IV and are anticipating a fight. During an interview on [DATE] at 4:11 P.M., the resident's sibling said the resident had been in the hospital, Cox South in Springfield, for two weeks due to a low blood sugar resulting in brain damage. The resident is a diabetic. Three physicians, including a neurologist, said the resident would have no quality of life and the family decided to take the resident off life support and provide comfort measures only for the resident. The sibling said Parent B was the guardian for the resident. Parent A had a [MEDICAL CONDITION] and died on [DATE]. The facility admitted the resident on [DATE], for comfort care. Admissions Coordinator (AC) F set up the admission to the facility and he/she told the family false information prior to admission. The facility was not prepared for the resident, The facility did not have the pain medications for the resident and they were told the medications were not at the facility and coming from Arkansas. After three days at the facility, the family was told the facility had a policy requiring nutrition/hydration. The facility sent the resident to another hospital in Cassville on [DATE], without the permission of Parent B. The sibling went to the Cassville Mercy hospital and was told the resident was in protective custody and the family was not allowed to see the resident. The resident was later transferred to another hospital in Springfield, without telling the family where the resident was going. The family, with the help of Cassville family services (Senior and Disability Services), found the resident at Mercy hospital in Springfield. The family was finally allowed to see the resident and then arrangements were made to transfer the resident back to Cox South in Springfield. The sibling said the family has been in a nightmare situation, they are unable to grieve for the loss of Parent A and had been unable to allow the resident to die peacefully. During an interview on [DATE] at 10:45 A.M., Missouri Senior and Disability Services supervisor said the resident was never in state custody. The resident was disabled and Parent B was his/her guardian. During an interview on [DATE] at 1:20 P.M., the administrator said the resident was admitted for palliative care and he/she was NPO. On Monday, [DATE], the administrator said the resident looked like he/she could see the administrator. The administrator asked the resident to blink his/her eyes twice to say he/she "wanted help" and the resident did. The administrator said they sent the resident out to the hospital to be re-evaluated. The administrator said the resident's Parent A died going to the hospital to see the resident and supposedly Parent B was the POA. The administrator said someone was with the resident the whole time he/she was here and they requested medications for the resident often. The administrator said they had a hospice consult done on the weekend, then later said it was not done. The administrator said admission coordinator (AC) E saw the resident prior to his/her admission to the facility. The administrator said he/she felt the family wanted to hasten the resident's death. The administrator said the facility would not take the resident back if he/she had the order for NPO. During an interview on [DATE] at 3:15 P.M., SS E said they were contacted by Cox South in Springfield before the resident was admitted and they faxed information to review. AC E was at the hospital and saw the resident prior to the admission. The resident was to receive palliative/comfort care. They have an admission team made up of the administrator, DON, the bookkeeper, and self that evaluates acceptance of a resident to the facility. The facility was weaning the resident off the [MEDICATION NAME] and the resident was coming alive. The family was demanding the resident be sent back to Cox South. SS E said he/she reported the circumstances to family services. During an interview on [DATE] at 5:00 P.M., AC F said he/she visited the resident in the hospital with the hospital case manager. The resident's Parent A had passed away that morning. The resident's life support and feeding tube had been discontinued. The resident was in a coma. A family member was with the resident at the hospital and he/she or the case manager said the resident would need hospice services. AC F said he/she called the administrator and the hospital faxed information to review. The family expected the resident to die. The administrator and SS E saw the resident on Monday ([DATE]) and then sent the resident out for a re-evaluation. The sibling was mad when he/she arrived at the facility on [DATE], and found out the resident had been sent out. The administrator talked to the sibling. During an interview on [DATE] at 5:25 P.M., LPN A said he/she took the admission orders vegetable state", NPO, and they were to keep him/her comfortable. The orders were for IV [MEDICATION NAME] and IV [MEDICATION NAME]. LPN A notified the facility physician and received new orders since they do not have an RN on staff 24 hours a day. They had the emergency kit to use for the resident until his/her medications arrived. LPN A said the resident's eyes were alert and he/she had a tear running out of his/her right eye. LPN A said the resident would assist with turning in bed. During an interview on [DATE] at 5:30 P.M., the administrator said they do not have a policy on providing palliative care. During an interview on [DATE] at 11:50 A.M., the administrator said the first time he/she saw the resident was on Monday, [DATE]. The administrator said the staff said the resident was different after admission. During an interview on [DATE] at 11:55 A.M., SS E and AC F said the acting DON and the administrator on [DATE] evaluated the resident to determine care, and they were not comfortable with the NPO order. The resident had been climbing walls that night and the sibling arrived at the facility on [DATE], after the resident was out of the facility. The sibling was upset with the staff stating the resident was better. During an interview on [DATE] at 2:15 P.M., RN D (acting DON) said he/she called the facility physician on [DATE], to give an update on the resident. The resident had been unresponsive and was waking up and the staff were uncomfortable with what to do. RN D said the facility wanted to re-evaluate the resident instead of withholding fluids. RN D said he/she was not at the facility when the resident was admitted and staff had not contacted him/her over the week-end with any concerns about the resident or family. RN D said he/she had not reviewed the hospital records of the resident that were sent to the facility. RN D said when the ambulance arrived, the resident showed panic and fear, he/she did not know if the resident was better. During an interview on [DATE] at 2:25 RN G said on [DATE], he/she assessed the resident early and the resident was sound asleep. The report he/she received that morning was the resident was brain dead. The resident did not show any responsiveness. The resident still had some motion and his/her eyes opened. The body can be still functioning even when the brain is dead. RN D told RN G the facility was transferring the resident out. During an interview on [DATE] at 9:07 A.M., family member AA said he/she was at the hospital the day AC F visited the resident regarding admission to the facility. The palliative group at the hospital really helped the family and they also talked with AC F at the hospital. Parent A had died earlier that day. The hospital staff talked about comfort measures only for the resident and no more acute care. The resident was on [MEDICATION NAME] and was given mouth care. The hospital staff were at the nurses' station and faxing information to the facility to review. During an interview on [DATE] at 11:00 A.M., Cox South Springfield social service staff said he/she was involved with the resident and the admission to the facility. He/She said they met with AC F and the family. The facility was told the resident was to receive end of life care. The medications and the NPO order were faxed to the facility prior to their approval to send the resident to the facility. AC F called them later stating corporate had approved the admission. The orders were again sent to the facility in the ambulance transfer of the resident. The social service staff received a call on [DATE], from AC F stating the resident had a change of status and had been transferred out of the facility. He/She said they talked with the facility administrator and he/she said they must provide nutrition to the resident. The resident was unable to eat. The hospital neurologist examined the resident on his/her return and found no change in the resident's mental status. The resident died in the hospital on [DATE]. During an interview on [DATE] at 10:55 A.M., family member BB said he/she visited the resident at the facility all three days. The facility did not have the medications for the resident on arrival at the facility. Staff said the medications were coming from Arkansas. Finally, the first night there, the staff said they found some [MEDICATION NAME] and gave the resident an injection. The staff said since they did not have an RN on staff 24 hours they couldn't give the IV medications that had been ordered. The facility physician changed the medications orders. On the evening of [DATE] at 8:00 P.M., the resident was agitated and he/she requested medication for the resident. The RN at 8:30 P.M. (RN B) told him/her would see about the medication. At 9:30 P.M. requested medication and nothing done, 10:30 P.M. requested medication and nothing done, and at 11:30 P.M., the resident was moving all over the bed. During the requests for medication the RN got in the face of family member BB and said he/she will call the police to remove him/her and you are not the POA. The RN threatened family member BB again and said " he/she would determine if the resident was agitated. Family member BB said "his/her concern was for the dying resident to be comfortable" . The RN went over to the resident's bed and said "I determine if the resident needs it". The RN pinched the arms and nose of the resident to see a response and he/she rubbed hard on the resident's chest until the resident pushed his/her arm away. The RN said they were not giving the resident mediations so he/she could be re-evaluated the next morning. At the 11:30 P.M. encounter, the RN brought in an LPN also and then the RN was denying ever saying anything about a re-evaluation being done the next morning. After the shift change in the morning of [DATE], the SS E and more staff were in the resident's room and talking about a re-evaluation. He/She thought the physician was coming to the facility to re-evaluate the resident. Ambulance staff arrived and the resident was taken from the facility. When the resident's sibling arrived at the facility SS E and AC F told them the state was now involved and SS E said the resident had a urinary tract infection and that could have contributed to his/her condition. They told them to take the resident's belongings with them, as the resident would not be coming back there. When the sibling went to the Cassville hospital he/she was told they could not see the resident. The family had been told the resident could die at any time and the family continually stayed with the resident. During an interview on [DATE] at 3:50 P.M., LPN C said he/she worked during the night shift on [DATE] and [DATE] and cared for the resident. He/She was told the resident was brain dead. The resident had no response, eyes opened, and some involuntary movements. The resident's arms and feet twitched. The resident was NPO, as the resident was unable to swallow and would choke to death. During an interview on [DATE] at 9:53 A.M., Parent B said he/she found Parent A dead on their porch on [DATE]. Parent B said Parent A died of a broken heart. Parent B said he/she was unable to visit the resident after admission to the facility [DATE], because he/she could not stand to see the resident die. Parent B said they had someone with the resident all the time so he/she would not die alone. Parent B said the resident lived with him/her and he/she automatically had medical guardianship of the resident as the resident's children were under legal age. Parent B said someone called a hotline in on the family saying they were withholding food and water from the resident. Parent B said three physicians at Cox South hospital in Springfield told them the resident was pre-vegetative state and he/she would not get better. The front part of the resident's brain was destroyed, the resident still had primitive movements. They left the resident on life support for awhile to be sure. When they did met with the physicians at the hospital after deciding to take the resident off life support the physicians were very [MEDICATION NAME]. When the resident was in pain he/she moved about and pulled at his/her hair. The facility never called Parent B and never notified him/her when they removed the resident from the facility. Parent B said the cause of death on the resident's death certificate was terminal [MEDICAL CONDITION] on comfort measures, and also listed semi-vegetative state, diabetes II uncontrolled, fever, and brain damage. During an interview on [DATE] at 4:00 P.M., RN B said he/she worked the week-end the resident was at the facility. RN B said the report given was the resident was brain dead. The family wanted the resident to have IV [MEDICATION NAME] and [MEDICATION NAME] every hour and they could not do the IV medications because they do not have an RN on ,[DATE]. The resident's medications were changed to sublingual. The family called in hospice to evaluate the resident. Hospice staff came to the facility on the evening of [DATE] and he/she did not let them evaluate the resident. RN B said the administrator said to let the hospice staff see the resident but they were not to evaluate the resident until the administrator was in and assessed the resident and made that decision. On [DATE], RN B said he/she explained they couldn't give the [MEDICATION NAME] every hour. RN B said he/she could evaluate when someone was in pain. He/She said when the resident pulled his/her hair, grimace, or made throaty sounds RN B administered the pain medication. RN B said [MEDICATION NAME] was administered when the resident was moving a lot. RN B was told by the family that Parent B was very distraught. RN B did not try to phone Parent B. RN B said he/she told family the administrator and hospice would see the resident the morning of [DATE]. RN B said he/she did threaten calling the police on the family on [DATE]. RN B said he/she never c

Based on observation, interview, and record review the facility failed to complete a physical assessment in a timely manner for one resident (Resident #2) who reported to the staff that he/she fell during the night and experienced pain to his/her left hip. Subsequent radiological tests showed the resident sustained [REDACTED]. The facility failed to effectively manage one resident's (Resident #15) pain with three fractures over a three month period to promote an optimal level of comfort for the resident on a continuous basis. The facility had a capacity of 90 with a census of 57 residents. Thirteen residents plus two closed records were selected for review. 1. Review of the facility's policy and procedure for "Condition Change of the Resident (Observing, Recording, and Reporting)", revised on 01/03, showed the following information: -The purpose of the policy and procedure was to observe, record, and report any change of condition to the attending physician so proper treatment could be implemented; -The policy directed the staff to implement the outlined procedure after all resident falls, injuries, or changes in physical or mental function; -The policy directed the staff to observe the resident for a list of physical and mental abnormalities which included: the presence of swelling and discoloration, pain, or for any signs of shortening or improper position of the extremities. 2. Review of the facility's policy and procedure for "Pain Management" revised 1/03, included the following information: -The basic responsibility for pain management is the licensed nurse; -The purpose of the policy was to establish baseline data on the resident's pain status, provide assessment and monitoring for pain management, provide treatment and/or interventions for the residents with pain, and the pain level would be obtained from the resident or through observation of behavioral or visual indicators regarding pain and relief of pain; -The purpose of the procedure was upon admission (within 24 hours), readmission (within 24 hours), or onset of new pain, a pain assessment would be completed using the pain assessment form, all residents will be re-assessed quarterly or as documentation dictates for pain, pain will be measured on a 0-5 scale, Cognitively impaired residents will be assessed utilizing behavioral or visual indicators, a care plan would be formulated to include interventions for pain, notification of the physician of new pain or pain unrelieved by medication or treatment. 3. Record review of Resident #2's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by the facility staff, dated 4/07//10, showed the following [DIAGNOSES REDACTED]. Record review of the resident quarterly MDS dated [DATE], showed the following information: -Moderately impaired cognitive skills for daily decision-making; -Usually understood others and was understood by others; -Required extensive assistance for bed mobility and transfers; -Required limited assistance with ambulation; -Had an unsteady gait; -fell in the past 31 to 180 days; -Experienced mild pain less than daily; Record review of a nurse's note dated 9/16/10, showed Licensed Practical Nurse (LPN) A documented the following information: -At 6:10 A.M., a Certified Nurse Aide (CNA) reported to LPN A that Resident #2 said he/she had fallen during the night and complained of pain to his/her left hip. LPN A failed to document an assessment of the resident in response to the resident's report of fall and pain; -At 9:30 A.M., the CNA reported to LPN A the resident continued to complain of pain. LPN A documented an assessment completed at that time (over three hours since the resident's initial report of a fall and complaint of pain) showed faint bruising to the left hip. LPN A failed to document further assessment of the resident's left hip, and failed to document notification of the resident's physician of the resident's report of a fall, continued complaints of pain, and the presence of bruising to the resident's left hip; -At 11:30 A.M., the CNA reported the presence of bruising to the resident's left hand. LPN A documented an assessment of the resident's left hand showed the presence of bruising but no other structural or functional abnormalities. LPN A then documented he/she notified the resident's physician (time of notification not documented) and received an order for [REDACTED]. Record review of an undated, handwritten statement signed by LPN A, showed the following information: -On 9/16/10, at 6:00 A.M., the CNA reported the resident's report of a fall and that the resident cried out in pain at his/her left hip during care to the day shift nurse; -When the CNA toileted the resident later that morning the CNA noticed a small bruise to the resident's left hip; -At 10:00 A.M., the CNA reported bruising to the resident's left hand which was assessed by a different nurse working the day shift on 9/16/10; -LPN A obtained an order (time not specified) for an x-ray of the resident's left hip, femur, and pelvis due to the resident's continued complaints of left hip pain. Record review of a nurse's note dated 9/16/10, showed LPN R documented the following information: -At 5:00 P.M., x-ray personnel had arrived at the facility to perform an x-ray of the resident's left hip, femur, and pelvis; -The resident winced in pain upon movement of his/her lower extremity during an assisted transfer from the recliner to the bed; -At 7:20 P.M., x-ray personnel notified the facility that x-ray results showed a displaced left femoral head (hip) fracture; -At 7:30 P.M., LPN R notified the resident's family and physician of the x-ray results and received an order to transfer the resident to the hospital by ambulance for further evaluation and treatment; -At 7:55 P.M., LPN R called for an ambulance that arrived at 8:30 P.M., to transport the resident to the hospital; -At 8:55 P.M., LPN R documented the resident's vital signs upon transfer, that a neurological assessment of the resident was within normal limits, and that a physical assessment of the resident showed"notable rotation"to the resident's left lower extremity (an indication of [MEDICAL CONDITION]). During an interview with CNA D and CNA E on 10/05/10, at 12:00 P.M., CNA D said Resident #2 was in bed when he/she went into the room on the morning of 9/16/10, to wake the resident and provide A.M. care. CNA D said the slightest touch caused the resident to cry out in pain. CNA D said the resident told him/her that he/she fell during the night and crawled back to bed on his/her own. CNA E said he/she assisted CNA D with the resident's care on the morning of 9/16/10, and informed the nursing staff of the resident's report of a fall during the night and of his/her complaint of pain. CNA E said the nurse did not assess the resident at that time. CNA D said he/she and CNA E assisted the resident with A.M. care and transferred him/her to the recliner. CNA E said the resident would not bear weight on his/her left leg during the transfer from the bed to the recliner. CNA E said he/she told the nurse "two or three more times" the resident was in severe pain before the nurse assessed the resident that afternoon about 1:30 P.M. During an interview on 10/06/10, at 11:10 A.M., LPN A said CNA E reported the resident's report of a fall and complaint of pain to him/her on 9/16/10, between 6:00 A.M. and 6:30 A.M., while he/she received a shift report from the night nurse. LPN A said he/she assessed the resident after report and noted no abnormalities or complaints of pain from the resident at that time. LPN A said he/she failed to document this initial assessment in the nurses' notes. LPN A said LPN F assessed the resident again that morning (no time provided) but only assessed the resident's wrist and hand. LPN A said when he/she assessed the resident again at 11:30 A.M., the resident continued to complain of pain and exhibited bruising to his/her left hip. LPN A said he/she then wrote an order for [REDACTED]. During a telephone interview on 10/06/10, at 11:50 A.M., a representative of the x-ray company said the following: -Their company received the x-ray order for the resident from the facility on 9/16/10, at 1:04 P.M. (approximately six hours after the resident's initial report of a fall and complaint of significant pain); -The facility ordered the x-ray as "routine" (not an emergency); therefore, they assigned the work order to an x-ray technician on 9/16/10, at 4:00 P.M.; -The technician completed the x-ray for the resident at the facility on 9/16/10, at 6:06 P.M.; -The radiologist read/interpreted the x-ray on 9/16/10, at 7:56 P.M.; -The x-ray company faxed the x-ray results/report to the facility on [DATE], at 7:10 P.M. During an interview on 10/06/10, at 12:25 P.M., the Director of Nurses (DON) said he/she expected the staff to complete an assessment of the resident upon notification of a fall, change in condition, or complaint of new-onset or worsening pain. The DON said he/she expected the staff to notify the resident's physician of resident falls, changes in condition, or for complaints of new-onset or worsening pain. 4. Record review of Resident #15's 60 day Medicare MDS, dated [DATE], showed the following information: -Short and long term memory problems; -Moderately impaired cognitive skills for daily decision-making; -Usually understood by others; -Usually understands other; -Sad, pained, worried facial expressions; -Resists care; -Extensive assist of one staff member with bed mobility, ambulation in room, toilet use; -Total dependence with bathing; -Unsteady gait; -fell in past 31-180 days; -Mild pain daily. Record review of the resident's physician's orders [REDACTED]. -Generalized [MEDICAL CONDITION]; -Dementia; -The POS failed to list the wrist fracture or the shoulder fracture with the other diagnoses. Record review of the resident's POS dated October, 2010 showed the following medications for pain relief: -Tylenol Arthritis Strength 650 milligrams (mg) twice a day ordered on [DATE]; -Tylenol 325 mg two tablets every four hours as needed for pain or temperature ordered on [DATE]; -[MEDICATION NAME]/APAP (a narcotic pain medication) 5/325 mg, two tablets every four hours as needed for pain ordered on [DATE]; -[MEDICATION NAME] 200 mg two tablets every four hours as needed for pain ordered on [DATE]; -[MEDICATION NAME] 50 micrograms (mcg) [MEDICATION NAME] (a narcotic pain medication patch applied to the skin) change every 3 days ordered on [DATE]. Review of Mosby's Nursing Drug Reference, 2009, 22nd edition, states Tylenol is used for mild to moderate pain. Record review of nurse's notes showed the following information: -6/8/10 (time of note not documented), Nurse U documented the resident complained of severe pain when turned. The nurse administered Tylenol 650 mg. The nurse documented very little pain relief for the resident; -6/8/10, at 2:00 A.M., Nurse U documented the resident was awake with complaint of pain to incisional area, physician faxed. The nurse failed to document what information he/she faxed to the physician; -6/9/10, on the 10 to 6 shift, LPN R documented the resident complained of incision pain with movement. The nurse administered the resident's Tylenol 650 mg (as needed) for the pain. The nurse failed to document the amount of pain relief obtained; -6/10/10, on the 10 to 6 shift, LPN M documented he/she administered two, as needed, Tylenol (dosage not documented), for hip pain. At 2:15 A.M., the nurse documented the resident continued to be awake talking to him/herself; -6/11/10, at 12:55 P.M., showed LPN F documented he/she gave the resident two, as needed, Tylenol 325 mg for complaints of right hip pain. The amount of pain relief the resident received was not documented; -6/12/10, on the 6 to 2 shift, Nurse U documented the resident complained of pain (site not documented). Nurse U documented staff gave the resident his/her Tylenol with his/her morning medications; -6/12/10, on the 10 to 6 shift, Nurse U documented when the resident was rolled from side to side the resident screamed in pain. Nurse U documented the resident spit out the as needed Tylenol when given. Nurse U failed to document notification of the resident's physician for the pain or his/her resistance to taking oral pain medication; -6/13/10, (no time indicated), showed Nurse U documented the resident cried in pain with turning or movement. Nurse U failed to document if any pain medication were given, or if staff attempted other methods of pain relief; -6/14/10, at (unreadable time), Nurse U documented the resident cried out in pain and screamed when touched. Nurse U called the physician and obtained a new order. The nurse failed to document the new order, if the new order was started at that time, and if the resident had relief from the pain; -6/14/10, at 2:00 A.M., Nurse U documented the resident screamed with pain when turned. Nurse U administered the resident's "as needed" [MEDICATION NAME] 5/325 mg; -6/17/10, on the 6 to 2 shift, Nurse U documented the resident screamed in pain and he/she administered the "as needed" [MEDICATION NAME] for the pain. Nurse U failed to document if the pain medication was effective; -6/17/10, on the 10 to 6 shift, LPN M documented the resident moaned when staff turned him/her. LPN M failed to document if a pain medication was given or if staff used other measures to decrease the resident's discomfort; -6/25/10, at 8:45 P.M., LPN R documented the staff found the resident lying on floor with a laceration to the right side of his/her forehead. The resident moaned and complained of pain to the right shoulder and right hip The nurse failed to document if he/she notified the physician; -6/25/10, at 11:55 P.M., LPN M documented the resident spit out his/her pain medication. LPN M failed to document if he/she notified the physician of the resident's refusal to take oral pain medications; -7/06/10, at 6:50 A.M., showed LPN M documented the resident fell and obtained a small laceration to the right side of his/her eye; -7/06/10, at 9:00 A.M. LPN M documented the resident had a small bruise to his/her right shoulder and bruised puffy area at right wrist; -7/06/10, at 3:00 P.M., showed LPN R documented the resident's right eyelid was completely purple and the resident complained of pain to the right wrist with range of motion. LPN R failed to document any interventions to decrease the resident's discomfort; -7/07/10, at 12 midnight, LPN M documented the resident continued to complain of discomfort at the right wrist. LPN M failed to document any interventions to decrease the resident's discomfort; -7/08/10, at 12:30 A.M., LPN M documented the resident continued to complain of pain to his/her right wrist with movement. LPN M failed to document if staff administered pain medication or applied any other pain relief measures; -7/10/10, at 8:00 P.M., Nurse U documented staff found the resident on the floor beside his/her bed; -7/12/10, (no time indicated), Nurse U documented the resident complained of his/her right eyelid pain. Nurse U administered pain medication for complaint of pain; (the degree of pain relief not documented.) -7/17/10, at 7:30 A.M., Nurse U documented the resident moaned and rubbed his/her right shoulder. Nurse U administered "as needed" Tylenol with improvement noted by 8:15 A.M.; -7/24/10, at 4:50 P.M., showed Nurse U documented the resident received [MEDICATION NAME] for back pain. The nurse failed to document the degree of pain relief the resident received; -7/29/10, at 1:00 A.M., Nurse U documented the resident complained of pain with movement of his/her right wrist; -7/29/10, at 2:30 A.M., Nurse U administered "as needed" [MEDICATION NAME] for complaints of hip and wrist pain. The nurse failed to document the degree of relief obtained; -7/31/10, at 2:00 A.M., Nurse U documented the resident complained of pain and discomfort with movement of his/her right hand. Nurse U documented staff repositioned the hand for comfort; -8/01/10, at 12:01 A.M., Nurse U documented the resident was awake and complained of right wrist and hip pain, especially when moved. Nurse U administered "as needed" [MEDICATION NAME] 5/325 mg for the pain but failed to document the degree of pain relief obtained; -8/02/10, at 2:00 A.M., Nurse U documented when staff asked the resident if he/she hurt, the resident replied "It hurts like hell". The nurse administered "as needed" [MEDICATION NAME] 5/325 mg for the pain but failed to document the degree of pain relief obtained; -8/02/10, at 12:40 P.M., LPN A documented the resident had a right wrist fracture; -8/04/10, (time not indicated), LPN A documented the x-ray report showed a healing fracture to the ulna and the humerus (the bones in the arm); -8/06/10, (time not indicated), LPN A documented the physician visited the resident and reviewed the x-ray report. No new orders were received. The nurse failed to document if the staff informed the physician of the resident's pain and use of the as needed pain medications; -8/13/10, at 12:01 A.M., Nurse U documented the resident complained of hip pain; -8/15/10, at 12:00 A.M., Nurse U documented the resident complained of hip pain and received "as needed" [MEDICATION NAME] for the pain but failed to document the degree of pain relief obtained; -8/16/10, (time not indicated), Nurse U documented the resident complained of hip pain and received as needed [MEDICATION NAME] for the pain, but failed to document the degree of pain relief obtained; -8/20/10, at 8:45 P.M., LPN R documented the resident had increased agitation, removed his/her lap buddy (device to keep resident from rising from chair), and refused to sit down. LPN R failed to document if staff assessed the resident for pain; -8/22/10, at 3:00 A.M., Nurse U documented the resident complained of hip pain. Nurse W administered the "as needed" [MEDICATION NAME] for the pain. The nurse failed to document if the resident's pain was relieved; -8/26/10, at 3:00 A.M., Nurse U documented the resident was awake, restless and complained of hip pain. Nurse U administered "as needed" [MEDICATION NAME] 5/325 mg for the pain, but failed to document the degree of pain relief obtained; -8/29/10, at 7:05 P.M., Nurse U administered the "as needed" [MEDICATION NAME] for the resident's complaint of hip and back pain. Nurse U failed to document if the resident's pain was relieved; -8/31/10, at 11:30 P.M., LPN M documented the resident called out and he/she saw the resident lying in the floor in the hall. The LPN documented the resident complained of pain in the right shoulder and right elbow, and exhibited a small abrasion at the elbow. LPN M faxed the physician but failed to document what information he/she faxed to the physician; -8/31/10, at 1:30 A.M. LPN M documented the resident had some swelling at the right shoulder with no bruises at present. The LPN applied an ice pack to the resident's shoulder; -8/31/10, at 3:30 A.M., LPN M documented the resident's shoulder was swollen and bruised and the resident complained of discomfort when moved; -8/31/10, at 5:00 A.M., LPN M documented the resident was awake, but refused to open his/her mouth to take the as needed pain medication. The LPN failed to document notification of the physician of the presence of swelling and bruising to the resident's right shoulder, the resident's complaint of shoulder pain, and the resident's refusal to take the oral pain medication; -9/1/10, at 6:40 A.M., LPN A documented the following information: -The resident was awake, with some moaning; -The resident's right shoulder demonstrated swelling and bruising at the humerus (the bone in the upper arm); -The LPN documented he/she received an order for [REDACTED]. -Staff left the resident in bed because the resident cried out in pain when staff turned him/her to be changed; -9/1/10, at 10:10 A.M. staff documented an x-ray was taken of the right shoulder; -9/1/10, at 11:15 A.M., LPN A called the physician's office and obtained an order to send the resident to the hospital for evaluation and treatment due to [DIAGNOSES REDACTED]. -9/1/10, at 12:10 P.M., the LPN documented the resident left the facility by ambulance; -9/1/10, at 8:00 P.M., LPN R documented the resident returned to the facility with a splint (immobilizer to hold the shoulder in one position) to his/her right shoulder with no signs of pain. LPN R documented new orders were received to change the [MEDICATION NAME] to one tablet every four hours as needed for pain from every six hours: -9/2/10, at 9:40 A.M., LPN A documented staff removed the immobilizer to shower the resident. The LPN documented the shoulder was swollen and bruised and the resident complained of pain with movement The LPN failed to document any interventions to relief the pain; -9/2/10, on the 2:00 P.M. to 10:00 P.M. shift, LPN R documented the resident removed the sling and immobilizer to his/her right arm. The LPN documented the resident cried out in pain with any movement of the right arm and he/she administered the "as needed" for the pain. The LPN documented the medication was helpful, but the resident continued to have pain with any movement of the right arm and it was difficult to transfer him/her or provide care; -9/3/10, at 6:45 P.M., showed LPN V documented he/she received a new order that changed the [MEDICATION NAME]/APAP 5/325 to two tablets every four hours as needed for pain and started [MEDICATION NAME] 200 mg, two tablets every four hours as needed for pain; -9/5/10, at 11:30 A.M., Nurse U documented the resident rubbed his/her right hand and grimaced. Nurse W documented he/she administered [MEDICATION NAME] (two tablets) and noted improvement at 12:10 P.M.; -9/6/10, at midnight, showed Nurse U documented he/she administered [MEDICATION NAME], two tablets, to the resident for pain The nurse failed to document the pain site and the degree of pain relief obtained; -9/6/10, at 4:00 A.M., Nurse U documented the resident complained of pain (pain site and degree of pain not documented) and received two [MEDICATION NAME]; -9/6/10, at 6:40 A.M., LPN A documented the resident moaned in pain but refused to take oral pain medications; -9/6/10, at 12 noon, LPN A documented the resident spit out his/her medications and refused to eat; LPN A failed to document notification of the physician of the resident's pain and refusal to take oral pain medication. -9/7/10, at 7:50 A.M., LPN A documented the resident was in severe pain and refused to take his/her medications by spitting them out. The LPN documented the resident did take pain medications with much coaxing. The LPN documented the resident was resisting care; -9/7/10, (no time indicated), LPN A called the physician's office and explained the resident was in severe pain and that the resident did not see an orthopedist when at the hospital for the shoulder fracture; -9/7/10, at 1:20 P.M., LPN A documented the physician's nurse called and gave an order for [REDACTED]. -9/7/10, at 8:00 P.M., LPN R documented the resident remained in bed, was lethargic and cried out in pain with any movement. The LPN documented he/she applied the [MEDICATION NAME] to the resident's left abdomen area; -9/08/10, (no time indicated), LPN A documented the resident had not moaned out in pain; -9/08/10, on the 2:00 to 10:00 P.M., shift LPN R documented the resident's pain control was improved from the previous day, before the [MEDICATION NAME] was applied. The LPN documented the resident ate 50% of his/her meal and drank fluids for supper; -9/10/10, at 9:00 A.M., LPN A documented the resident continued to complain of right hip pain. The LPN documented the resident cringed when the leg was moved. LPN A received a new order to x-ray the right hip and pelvis. Record review of the social services progress notes dated 9/11/10, showed the social worker documented the resident had been in a lot of pain. Record review of the resident care plan, up-dated by staff on 9/10/10, showed no goals or interventions for the resident's pain. Record review of the resident's Medication Administration Records (MARs) dated June 2010, through October, 2010, showed the staff failed to measure the resident's pain level on a 0-5 scale as per the facility's policy. The dates the resident received pain medication the nurse documented some relief or helped. Record review from June, 2010 to October, 2010 showed no pain assessments in the resident's medical records to coincide with events of new or increased pain. The dates the resident received pain medication the nurse documented some relief or helped. During an interview on 10/5/10, at 5:00 A.M., Certified Medication Technician (CMT) G said the CMT's complete the pain management tracking form. He/she said the CMTs assess the residents for pain and administer pain medications if needed. CMT G said the CMT's write down a list of "as needed" pain medications they administer to the residents, and give the list to the nurses for review. CMT G said the nurses document this information in the nurse' notes. During an interview on 10/7/10, at 2:10 P.M., LPN A said when a resident complains of pain, the CMTs perform a pain assessment, administer pain medication, and complete a "prn" (as needed) slip. LPN A said the prn slip includes information on the type of pain experienced by the resident, the name medication administered, and the dosage strength of the medication administered. LPN A said the CMT's give the prn slip to the nurse who, in turn, documents the pain assessment and the administration of pain medication in the nurse's notes. LPN A said the nurses review the pain assessment tracking form daily. LPN A said if the tracking form shows several zeros and then a "number", the nurse asks the resident and/or the staff if the resident's pain control is effective. LPN A said if a resident required frequent "as needed" pain medication, the nurse sends a fax to the physician asking to make the medication routine. LPN A said if a resident had severe pain they request a hospice evaluation/placement so the hospice nurses can get stronger pain medications and to manage the pain. During an interview on 10/13/10, at 9:15 A.M., LPN M said he/she faxed the physician twice during the night of 8/31/10, when Resident #15 fell . LPN M said he/she thought the resident had a [MEDICATION NAME] before his/her shoulder was injured. LPN M said he/she did not know if there were any pain medications in the facility's emergency kit. LPN M said the nurses call the physician if a resident has no pain medication ordered. LPN M said the medical director provided the nurses with a standing order to send his/her residents to the emergency room if the nurse thinks it is needed. LPN M said all the other physicians can be called at night. During an interview on 10/13/10, at 3:45 P.M., the Director of Nursing (DON) said she expected the nursing staff to assess the residents for pain and administer pain medications to keep the resident as pain free as possible. During an interview on 10/13/10, at 4:45 P.M., Resident #15's physician said the following: -He did not want his patients to be in pain; -He expected the staff to notify him when the resident had severe pain; -He expected the staff to contact him by phone after office hours and not by a fax to his office; -The resident's family primary concern was for the resident's comfort.

Based on interview and record review the facility failed to appropriately reassess, and implement resident-specific interventions to minimize the risk of falls for two residents (Residents #14 and #15) who sustained injurious falls at the facility. The facility failed to appropriately reassess Resident #15 after seven falls, three of which resulted in fractures, and failed to integrate new and/or changed interventions into the care of Resident #15 to minimize the risk of additional falls. In addition, the facility failed to communicate among pertinent staff the installation of an air mattress to the bed of Resident #14, and failed to reassess Resident #14 for the implementation of appropriate safety interventions to minimize the risk of falls from the bed. The resident subsequently fell out of bed, sustained a laceration to his/her head and a fracture to his/her right trochanter (a bony prominence of the upper leg bone), and required emergency care. The facility has a capacity of 90 and had a census of 57 residents. Thirteen residents were selected for review along with two closed records. Review of the facility's "Fall Protocol", revised 10/05, showed the following information: -The purpose of the protocol included the following rationale: -To prepare a plan of care to reduce the potential of future falls; -Charge nurse duties after a resident fall included the following directives: -Implement interventions to prevent further falls; -Inservice staff on the new intervention; -Fall Prevention Program components included the following directive: -Resident care plan(s) will reflect the risk of falls and specific interventions to prevent falls 1. Record review of Resident #14's October 2010, physician's orders [REDACTED]. Record review of Resident #14's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by the facility staff, dated 9/21/10, showed the following information: -The facility readmitted the resident on 9/15/10, after a hospital stay; -Short-term and long-term memory intact; -Independent with cognitive skills for daily decision-making; -Required extensive assist of one person for bed mobility; -No falls in the past 180 days; -Hip fracture in the past 180 days; -Received preventative skin care and pressure ulcer care for multiple skin issues which included: -Abrasions and bruises; -Five Stage I pressure ulcers (a persistent area of skin redness without a break in the skin, that is nonblanchable); -Nine Stage II pressure ulcers (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -Open lesions on the feet; -Pressure-relieving devices used on the bed and in the chair; -Bed rails not used. Record review of a nurse's note dated 9/29/10, at 1:40 P.M., showed Licensed Practical Nurse (LPN) A documented Certified Nurse Aide (CNA) B called for a nurse to come to Resident #14's room. LPN A entered the resident's room and found the resident lying on the floor. LPN A documented the resident bled from the forehead, complained of right hip pain, and exhibited new skin tears on both elbows. LPN A documented the resident had been resting in bed on an air mattress, the air mattress had been placed in the resident's room that day, and no side rails were in use with the air mattress. LPN A summoned an ambulance and transferred the resident to the hospital emergency room (ER) for evaluation and treatment. Record review of nurses' notes dated 9/29/10, at 5:00 P.M., and 5:30 P.M., showed the resident returned to the facility on [DATE], after receiving medical care at a local hospital ER. New [DIAGNOSES REDACTED]. New physician's orders [REDACTED]. Review of an operations manual published by The ROHO Group, Inc., copyright 2006, for the brand of air mattress used for Resident #14, showed the following precautionary statement: "The use of bed frame side rails in conjunction with any SelectAir low air loss mattress system should be determined based upon facility protocol, applicable laws and regulations, and individual user safety considerations. Bed frame side rail usage is not a requirement for the functional operation of any SelectAir product, but individual safety requirements and/or facility protocol may dictate that side rails be utilized". Record review of an un-timed "Side Rail Rationale Screen" form dated 9/29/10, showed the Director of Nursing (DON) completed the 10-question form and concluded the resident required the use of full side rails raised on both sides of his/her bed for safety reasons. Record review of the nurses' notes from 9/30/10 through 10/01/10, showed LPN A documented the resident continued to rest on an air mattress and that full side rails were raised on the resident's bed. During an interview on 10/13/10, at 10:55 A.M., the Housekeeping Supervisor (HKS) said staff from the housekeeping department or the maintenance department set up air mattresses for facility residents that do not receive hospice services. The HKS said he/she and another housekeeping staff member setup and disinfected Resident #14's air mattress on the morning of 9/29/10, upon direction of Corporate Nurse (CN) C. The HKS said he/she asked CN C if side rails were required on the resident's bed with the application of the air mattress. The HKS said CN C said he/she would get back to him/her on the side rail issue and to just get the air mattress on the bed and disinfect it. The HKS said he/she and the other staff member then set up and disinfected the resident's air mattress and left the room. The HKS said CN C never provided him/her with an answer regarding the application of side rails to the resident's bed. During an interview on 10/13/10, at 2:20 P.M., LPN A said he/she worked the day shift (6:00 A.M. to 2:00 P.M.) on 9/29/10. LPN A said he/she was unaware the staff had applied an air mattress to Resident #14's bed until he/she entered the resident's room and found the resident on the floor. LPN A did not know who ordered the air mattress or when staff applied the air mattress to the resident's bed that day. LPN A said the facility had no policy and procedure available regarding the setup and use of air mattresses, or for the possible use of side rails with an air mattress. LPN A said prior to Resident #14's fall on 9/29/10, the facility had not provided the staff with any in-service education regarding air mattress use or about safety issues related to air mattress use. During an interviews on 10/11/10, at 10:30 A.M., and on 10/13/10, at 8:45 A.M., the DON said a side rail assessment had not been completed on Resident #14 prior to his/her fall out of bed on 9/29/10. The DON said a side rail assessment was completed on the resident after the resident's fall and side rails were implemented at that time. The DON said to his/her knowledge the facility had no specific policy and procedure for the use of air mattresses and had not provided any in-service education to the staff prior to 9/29/10, regarding air mattress use and side rail assessment/use with air mattresses. 2. Record review of Resident #15's 60 day MDS, dated 8/03/10, showed the following information: -Short and Long term memory problems; -Moderately impaired cognitive skills for daily decision-making; -Usually understood by others; -Usually understands other; -Resists care; -Extensive assist of one staff member with bed mobility, ambulation in room, toilet use; -Total dependence with bathing; -Unsteady gait; -fell in past 31-180 days; -Mild pain daily. Record review of the resident's October, 2010, POS showed his/her medical [DIAGNOSES REDACTED]. -Unspecified fracture, part of neck of femur/open hip; -Generalized osteoporosis; -Dementia; -Review of the resident's record did not list the wrist fracture or the shoulder fracture with the other diagnoses. Record review of nurse's notes dated 5/26/10 on the 2 to 10 shift, showed LPN R documented staff found the resident sitting on the floor next to the bed and the recliner. LPN R documented no injuries noted and the fall occurred at 4:45 P.M. LPN R documented staff notified the physician and Durable Power of Attorney (DPOA). LPN R failed to document if the notification was by a fax or a phone call. LPN R failed to document any interventions to reduce the risk of future falls. Record review of nurse's notes dated 6/4/10 at 6:00 P.M. showed Nurse U documented the resident was on the floor on B hallway. Two nurses assessed the resident. During the transfer to bed by the two nurses the resident complained of severe pain to the right hip and hand. Nurse U documented staff notified the physician at 6:15 P.M. of the fall and the pain and the physician ordered the resident to be sent to the hospital with a [DIAGNOSES REDACTED]. Record review of the nurse's notes did not indicate when the resident returned/readmitted to the facility. The next entry in the nurse's notes was dated 6/07/10 on the 10 to 6 shift, LPN M documented the use of an abduction pillow (a large foam form used to keep the hips in alignment after surgery for [REDACTED]. LPN M failed to document any interventions to reduce the risk of future falls. Record review of nurse's notes dated 6/21/10 (no time indicated), showed LPN A documented the resident tried to stand and staff applied a chair alarm. LPN A documented the resident was a high fall risk. Record review of nurse's notes dated 6/23/10 at 12:15 P.M. showed LPN A documented the resident slid out of his/her wheel chair while sitting at the dining room table waiting for lunch. LPN A documented there were no injuries noted. LPN A failed to document any interventions to reduce the risk of future falls. Record review of nurse's notes dated 6/25/10: -At 8:45 P.M. showed LPN R documented staff found the resident lying on the floor of the resident's room on his/her right side. The resident had a laceration to the right forehead and was moaning. LPN R assessed the resident and found the right hip appeared to be shortened in comparison to the left hip and leg; -At 9:00 P.M. showed LPN R notified the physician and obtained an order for [REDACTED]. -At 11:55 P.M. showed LPN M documented the resident returned to the facility. LPN M documented the resident had a small laceration on the hand and complained of discomfort in the right shoulder. LPN M documented the resident's right shoulder and elbow had bruising started. Staff received an order to stop giving the medication Remeron. LPN M failed to document any interventions to reduce the risk of future falls. Record review of nurse's notes dated 7/06/10 at 6:50 A.M. showed LPN M documented the resident was up early to eat breakfast before a physician's appointment when the resident tried to get up and fell . LPN M documented the resident received a small laceration to the right side of the eye. LPN M documented he/she covered the wound with steri-strips and there were no other apparent injuries. LPN M documented he/she notified the physician by fax at 7:30 A.M. LPN M documented at 9:00 A.M., the resident had a small new bruise on the right shoulder plus yellowed bruises from last fall and a puffy area on the right wrist. Record review of nurse's notes dated 7/07/10 showed Nurse U documented an order to x-ray the right hand/right wrist and right (orbit) eye to rule out fractures. The nurse documented the x-rays were completed. The staff moved the resident off the special care unit. The nurse documented the resident's right eye was bruised with a three centimeter raised bruise at the site on the lower temple area. The nurse also documented the right wrist had a large raised area on the outer wrist, red from wrist to mid-forearm on back of arm, but some areas on inner forearm very bruised and the arm was tender to touch. Record review of nurse's notes dated 7/07/10 at 9:00 P.M. showed LPN R documented the results of the x-rays were negative for fractures. LPN R faxed the results to the physician's office. Record review of nurse's notes dated 7/10/10 at 8:00 P.M. showed Nurse U documented the resident fell and the staff found him/her on the floor, in a seated position. The nurse documented no apparent injuries. The nurse documented he/she recommended a bed and chair alarm but failed to indicate if the devices were put into place. Record review of nurse's notes dated 7/11/10 at 6:35 P.M., showed the resident used a wheel chair with a lap buddy (a device put across a resident's wheel chair to prevent rising). The nurse documented the resident took the lap buddy off and the staff monitored. Record review of nurse's notes dated 8/02/10 at 12:40 P.M. showed LPN A wrote the resident had a right wrist fracture. Record review of the physician's visit dated 8/06/10, showed the following information: -The resident fell approximately one month prior and fractured his/her right wrist; -The resident had a recent right hip arthroplasty (repair of a fracture) on 6/05/10; -The resident saw the orthopedist on 7/15/10 after the fall and the right wrist fracture was not noted at that time and was not evaluated; -The resident had another appointment with the orthopedist the middle of August and the right wrist would be immobilized until then; -The x-rays of the right wrist, hand and orbits were reviewed; - The orbits were negative for fractures; -The right hand was negative for fractures but positive for significant arthritic changes; -The right wrist was positive for fracture to the distal radius and ulnar styloid (where the lower arm attaches to the hand) -The visit did not show the physician discussed interventions with the nursing staff to decrease the resident's risks for falls. Record review of the nurse's notes dated 8/31/10: -at 11:30 P.M. showed LPN M documented the resident called out and LPN M saw the resident lying in the floor in the hall. LPN M documented the resident complained of pain in the right shoulder and right elbow with a small abrasion at the elbow. LPN M faxed the physician. LPN M failed to document what information he/she faxed to the physician; -at 1:30 A.M. showed LPN M documented the resident had some swelling at the right shoulder with no bruises at present. LPN M applied an ice pack to the shoulder; -at 3:30 A.M. showed LPN M documented shoulder swollen and bruised with complaint of discomfort when moved; -at 5:00 A.M. showed LPN M documented the resident was awake with complaint of shoulder pain but refused to open mouth to take the "as needed" pain pill. -LPN M failed to document if he/she called the physician after assessing the resident had swelling and bruising of the right shoulder and continued complaint of pain with refusal to take an oral pain medication. Record review of the nurse's notes dated 9/1/10: -at 6:40 A.M. showed LPN A documented the resident was awake and moaning a little with swelling of the right shoulder and bruising at humerus (the bone in the upper arm). LPN A documented staff received an order for [REDACTED]. LPN A documented the resident was left in bed because the resident cried out in pain when turned to be changed; -at 10:10 A.M. x-ray of the right shoulder was obtained; -at 11:15 A.M. LPN A called the physician's office and obtained an order to send the resident to the hospital for evaluation and treatment due to [DIAGNOSES REDACTED]. -at 12:10 the resident left the facility by ambulance; -at 8:00 P.M. showed LPN R documented the resident returned to the facility with a splint (immobilizer to hold the shoulder in one position) to his/her right shoulder with no signs of pain. LPN R documented staff received a new order to change the hydrocodone/APAP 5/325 mg to one tablet every four hours as needed for pain from one tablet every six hours. Record review of the resident's care plan dated 4/13/10 to 8/31/10 did not show any interventions or goals to reduce the fall risk for the resident. Handwritten entries were dated 8/31/10 to show the following: -The problem was the resident fell per self on 8/31/10 and had removed the personal alarm; -The goal was not indicated; -The intervention was a low bed with a floor mat and change the personal alarm to a pressure alarm. Record review of the resident's care plan updated on 9/02/10 in handwritten entries showed the following information: -The problem was the resident was a high risk for falls; -Interventions of a pressure pad in bed and wheel chair dated 9/02/10; -Interventions of a lap buddy when up in wheel chair to prevent falls dated 9/7/10; -Interventions of a low bed with pads on the floor and a body (personal) alarm with a lap buddy when in wheel chair and a pressure alarm when in bed dated 9/17/10. During an interview on 10/13/10 at 9:15 A.M., LPN M said he/she had faxed the physician two times during the night of 8/31/10 that Resident #15 fell . He/she stated that if the resident has no pain medication he/she would have called the physician but did not know if there were any pain medications in the emergency kit. LPN M thought the resident had a fentanyl (pain medication) patch before his/her shoulder was injured. He/she said the medical director had a standing order to send residents to the emergency room if the nurse thought it was needed during hours the office was not opened. He/she said all the other physicians could be called at night. LPN M said the resident had a half siderail on his/her bed so the resident would not roll out of bed. LPN M said the resident walked out in the hall and fell . During an interview on 10/13/10 at 2:20 A.M., LPN A said Resident #15 was very confused and needed assistance of one staff member. LPN A said the resident would forget, get up and fall. LPN A said the falls occurred on other shifts and he/she was just doing the follow up. LPN A said the resident's physician was hard to reach and the nurses could call the medical director.