Every finding on record at Atrium Place Health and Rehabilitation

Based on interview and record review, the facility failed to have physician orders for the resident's immediate care when staff failed to transcribe one resident's surgical wound treatments from the hospital discharge orders into the facility physician orders and failed to obtain a treatment order for the coccyx (tailbone) wound, which was present on admission, which resulted in the treatment not being provided/documented for four days after admission (Resident #111). The sample size was 24. The census was 102. The administrator was notified on 6/26/25, of past non-compliance. When the facility identified the issue, they immediately assessed the resident's current condition, notified the physician/Nurse Practitioner (NP). Treatment orders were put in place per provider's order. The admitting nurse and wound nurse received corrective actions. Nurses were educated on ensuring all orders were transcribed properly and obtaining wound orders upon notification of admission and/or new skin issues and on documentation. The deficiency was corrected on 5/27/26. Review of the facility's Documentation in Medical Record policy, dated revised 8/1/25, showed:-Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation;-Licensed staff and interdisciplinary team members shall document all assessments, pertinent observations. and services provided in the resident's medical record in accordance with state law and facility policy;-Documentation shall be completed at the time of service. but no later than the shift in which the assessment, observation, or care service occurred. Review of the facility's Documentation of Wound Treatments and Assessments policy, dated revised 8/21/25, showed:-Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Weekly wound assessments are completed on wounds such as pressure, and surgical;-The following elements are documented as part of a weekly wound assessment:--Type of wound (pressure injury, surgical, etc.) and anatomical location;--Stage of the wound, if pressure injury or the degree of skin loss if non-pressure (partial or full thickness);--Measurements: height, width, and depth;--Description of wound characteristics:--Color of the wound bed;--Type of tissue in the wound bed;--Condition of the peri-wound skin;--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 should be documented each shift. Review of Resident #111's After Visit Summary, dated 4/14/26 through 5/1/26 and printed on 5/1/25, showed:-Wound care instructions: post-discharge dressing care, apply moist to wet Vashe (sterile medical gauze moistened with solution) gauze to midline and thigh wound twice a day (BID); change more frequently for drainage as needed;-A check mark was placed in front of the order. Review of the resident's Weekly Wound Assessment, dated 5/1/26, showed:-Date of onset was 5/1/26;-Was admitted with Stage II pressure ulcer (partial-thickness skin loss where the outer layer of skin and part of the underlying layer are damaged) on sacrum (triangular bone that sits at the end of the spine);-Size: three centimeters (cm) length X two cm width, no depth, wound bed was pink and yellow with no drainage;-Electronically signed on 5/4/26. Review of the resident's progress notes, dated 5/1/26 through 5/5/26, showed:-On 5/1/26 at 2:59 P.M., Full body assessment performed by the nurse, resident noted to have open areas to right thigh, abdomen- eight staples noted, open coccyx (tailbone) wound. Resident will continue with current plan of care per discharge (d/c) paperwork. Referral to wound physician completed;--At 8:22 P.M., Areas noted to coccyx, anal/peri area (located between the genitals and the anus), right thigh and midline which included eight staples. Wound team aware of resident's arrival and skin condition. All orders verified by nurse practitioner (NP).-On 5/5/26 at 11:11 A.M., admitted with abdominal surgical wound, tight surgical wound and pressure ulcer on sacrum.-There was no documentation showing the treatment was on hold. Review of the resident's care plan, dated 5/5/26, showed:-Focus: Residents had actual impairment to skin integrity;-Goal: Resident will maintain or develop clean intact skin by next review date;-Intervention: Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate and any other notable changes or observations. Date initiated 5/4/26. Review of the resident's active Order Summary Report, showed:- A physician order to cleanse abdomen with Normal Saline (NS)/wound cleanser (DWC). Pat dry pack with Vashe (medical grade wound cleanser) moisten gauze and dry dressing daily and prn if soiled/dislodged everyday shift for wound healing. Start date 5/4/26;-A physician order to cleanse right thigh with NS/DWC. Pat dry with Vashe moisten gauze and dry dressing daily and prn if soiled/dislodges everyday shift for wound healing; Start date was 5/4/26;-A physician order to cleanse with NS/DWC. Pat dry apply calcium alginate with silver (highly absorbent wound dressing) and dry dressing daily and prn if soiled/dislodged everyday shift for wound healing; Start date was 5/4/26. Review of the resident's Treatment Administration Record (TAR), dated 5/1/26 through 5/ 14/26, showed:-A physician order to cleanse abdomen with Normal Saline/wound cleanser (NS/DWC). Pat dry and pack with Vashe moisten gauze and dry dressing daily and as needed (PRN) if soiled/dislodged everyday shift for wound healing. Start Date: 5/5/26;--Documentation showed treatment started on 5/5/26;-A physician order to cleanse right thigh with NS/DWC. Pat dry pack with Vashe moisten gauze and dry dressing daily and PRN if soiled/dislodged everyday shift for wound healing. Start date 5/5/26;--Documentation showed the treatment started on 5/5/26;-A physician order to cleanse with NS/DWC, Pat dry apply calcium alginate w/silver and dry dressing daily and PRN if soiled/dislodged everyday shift for wound healing. Start date 5/5/26;--Documentation showed the treatment started on 5/5/26. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/5/26, showed:-admitted [DATE];-Moderately impaired cognition;-Functional limitation in range of motion in both lower extremities;-Substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for personal and toilet hygiene, bathing, dressing and rolling in bed.-Dependent for transfers;-Diagnoses include cancer, atrial fibrillation (irregular heart rhythm) heart failure, diabetes and depression;-At risk for developing pressure ulcers/injuries;-No unhealed pressure ulcers;-Had surgical wounds. Review of the Medical Doctor's progress note, dated 5/5/26, showed midline incision to be packed twice daily with wet to dry dressings. Thigh dressing to be changed twice daily with wet to dry dressings. During an interview on 6/23/26 at 12:30 P.M. and at 2:14 P.M., Licensed Practical Nurse (LPN) E said when a resident was admitted to the facility, the nurse on the floor was responsible for completing the admission. The nurse reviewed the paperwork sent from the hospital and entered the orders into the computer. If the Medical Doctor (MD)/NP was at the facility LPN E, would take the orders to her and she would review the paperwork. If the MD/NP was not at the facility, LPN E would call the physician to verify orders. Skin assessments were part of the admission process. If a resident had a wound but did not have a treatment order, LPN E would notify the in-house wound nurse and obtain a treatment order. The wound nurse would assess the resident, obtain treatment orders and enter them into the computer. LPN E said the resident had several wounds on admission, but he/she could not recall the location of the wounds. During an interview on 6/24/26 at 9:20 A.M., LPN A said when a resident was admitted to the facility, he/she used the discharge paperwork from the hospital for the orders. The nurse who was admitting the resident was responsible for entering the orders into the computer. Orders were verified the with MD/NP. If an order was changed, it should be documented in the progress notes. If a resident had a wound, it would be documented in the progress notes and on the skin assessment. The assessment should include the location of the wound, size and description of the wound. If there were no treatment orders for the wound, he/she would notify the MD/NP and obtain an order. During an interview on 6/24/26 at 9:45 A.M., the NP said the facility used the discharge summary for orders. If the NP was in house when a resident was admitted , the nurse would give her the paperwork, and she would review it. The nurses entered the orders into the computer. The nurse should do a skin assessment on admission. Most of the time, the residents would come to the facility with wound care orders. If they did not, the nurse would obtain a treatment order until the resident could be seen by the wound doctor. During an interview 6/24/26 at 11:47 A.M., the Wound Nurse said if the resident had a wound and no treatment order, the nurse should notify the MD/NP and obtain orders. The resident admitted with surgical wounds on his/her abdomen and thigh. The resident also had a wound on his/her sacral area and heel. The resident's orders should have been entered into the computer when he/she was admitted . When the NP came that Monday on 5/4/26, the facility obtained treatment orders, and they were entered into the computer. During an interview on 6/24/26 at 12:22 P.M., The Director of Nursing (DON) said the nurse could only go by the After Visit Summary or Discharge Summary for the orders. If a resident was admitted with a wound and had no treatment orders, the nurse should call and obtain treatment orders and document it in the progress notes. The resident's wound care should have been put in at the time of the admission and the nurse should have obtained a treatment order for the wound on the coccyx. The admitting nurse said he/she completed the resident's treatments over the weekend. During an interview on 6/26/26 at 1:12 P.M., the Administrator said when a resident was admitted to the facility, she would expect staff to print off a copy of the discharge summary/after visit summary and give a copy to the NP if she was in the building and to the Minimum Data Set (MDS) nurse. If the NP was not in the building, she would expect staff to call them to verify orders. The Administrator expected staff to follow the facility's policies and procedures. 30189133018448

Based on observation, interview and record review, the facility failed to ensure staff followed the Nurse Practitioner's (NP) order for intravenous (IV) fluids following critical laboratory results for one of 24 sampled residents (resident #68). The NP order for IV fluids was entered into the electronic physician's order sheet (ePOS). There was no documentation the IV fluids were administered. The resident continued to decline and was transferred to the hospital for treatment. The census was 102. Review of the medical provider order policy, reviewed 5/4/26, showed:-Policy: use uniform guidelines for the ordering and following of medical provider orders;-Explanation and guidelines:--Medications and/or treatments should be administered upon signed order;--Verbal orders should be received only by nurses, pharmacist or verified in writing by the medical provider;-Following of medication/treatment orders:--Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the order contains all required elements;--Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of Resident #68's medical record, showed:-re-admitted : 3/26/26;-Diagnoses included brain hemorrhage, stroke, respiratory failure, Parkinson's (progressive brain disorder when brain nerve cells die or become impaired), epilepsy (seizures), difficulty swallowing, gastrostomy status (GT, hollow tube inserted into the stomach to provide food and fluids);-Unable to make needs or wants clearly known;-Staff provided full care needs. Review of the laboratory results, dated 4/17/26, showed:-Sodium: 154 high (normal 136-145). Review of the progress notes, showed:-On 4/18/26 at 6:30 P.M., a nurse note: the NP called and notified writer that the resident's blood test results had a critical sodium level. NP ordered IV fluids, and if IV could not be administered, send the resident to the hospital for placement;-On 4/18/26 at 8:53 P.M., a nurse note: a critical sodium level reported. New order received to place a hypodermoclysis (a technique used to administer fluids directly into the fat layer below the skin) and administer one liter of 0.45 percent fluids and recheck the sodium level once infusion is completed. Review of the April treatment administration record (TAR), dated 4/1/26-4/30/26, showed:-An order, dated 4/19/26: Sodium Chloride solution 0.9 %. Administer 50 milliliters (ml) IV one time a day for increased sodium level. Noted as blank on the TAR on 4/19/26. Review of the progress notes, showed:-On 4/20/26 at 5:53 A.M., a change in condition note: the resident had a change in vital signs. High pulse rate. New orders to send to the emergency room (ER) for evaluation and treatment;-On 4/20/26 at 6:14 A.M., a nurse note: the resident experienced a change in condition. The resident's symptoms included rapid breathing and lethargy. Vital signs were within normal ranges except for an elevated heart rate. The physician was notified and new orders received to send the resident to the ER. Review of the hospital Discharge summary, dated [DATE], showed:-admitted : 4/20/26;-discharged : 4/28/26;-Hospital problems:--admitted from a different hospital to current hospital for a pulmonary embolism response team ([NAME]) action for a large pulmonary embolism (medical emergency, blood clot within the lungs) with right sided heart strain;--Hypernatremia (high sodium): presented initially with Na (sodium) 156 and Chloride (Cl) 122, indicated severe hypernatremia and elevated osmolality. May have contributed to the reported acute mental status. The patient is bedbound, nonverbal and G-tube dependent.-Patient initially had a 0.6 x 90 kilogram (kg) x (150/140-1) = 6.4 Liters free water deficit;-Plan: may have enteral route (preferred) vs. IV;-Acute kidney injury (AKI): initial creatine was 1.33, improved to 1.15 on the same day after aggressive fluid resuscitation. AKI likely from hypoperfusion and currently improving;-Flush G-tube with 150 ml of water every six hours. Review of the Nurse Practitioner progress note, dated 4/30/26, showed:-Resident readmitted to the facility;-Plan: physical therapy evaluation, staff assist with all care. During an interview on 6/24/26 at 9:41 A.M., the NP reviewed the resident's medical record and said it appeared the resident did not receive the ordered IV fluid medications. She ordered the fluids due to the laboratory results and wanted to ensure hydration. Not receiving the fluids could have contributed to the continued decline in the resident's health status. The resident also developed a pulmonary embolism that was discovered upon admission into the hospital. If the ordered fluids could not be administered, he/she would have sent him/her to the hospital for fluids. She expected staff to document when care or treatments were administered to residents. If it was not documented, the order was considered not completed. The facility was working on education on documentation and ensuring orders were completed. During an interview on 6/24/26 at 12:40 P.M., the Director of Nursing (DON) said when an order was received, she expected the nurses to administer the order. The NP had ordered subcutaneous fluids due to elevated sodium levels. The resident received the ordered fluids. The nurses did not document the administration in the medical record. At the hospital, the resident was diagnosed with a pulmonary embolism that likely contributed to the increased heart rate and rapid breathing. The nurses were newer graduates, and the facility was continuing to provide education regarding administration of ordered fluids. During an interview on 6/25/26 at 8:32 A.M., Licensed Practical Nurse (LPN) A said the resident relied on the G-tube for food and fluids. The resident had an order for free water flushes when re-admitted to the facility. LPN A was a new nurse and had received in-servicing regarding the importance of administering water to resident's who were ordered NPO. The resident did not have a kangaroo water bag in place and relied on nurses to administer the water. During an interview on 6/25/26 at 9:33 A.M., the resident's physician said, the resident had an irregular fast heartbeat for a day or two. Staff notified the NP, and the NP ordered stat labs which showed the hypernatremia. There was concern that resident had not been getting ordered free water flushes through the g-tube. Not getting the fluids would have kept the sodium levels elevated. The resident continued to experience a change in condition, and he/she was sent to the hospital for treatment. Upon admission to the hospital, it was discovered he/she had developed a pulmonary embolism that needed treatment. The resident also received fluid resuscitation which helped lower the sodium level. She discussed thoughts with nursing management and determined since many of the nurses were new, in-servicing began immediately for training to ensure water flushes were administered to residents with g-tubes. The facility had ordered and implemented kangaroo water bags and pumps to ensure accurate administration of fluids. Resident #68 should have a kangaroo bag in place next week; several were on order for facility residents. Since the resident was readmitted , his/her laboratory values have been within range. 2994027

Based on interview and record review, the facility failed to ensure services provided were consistent with professional standards when one resident (Resident #111) was admitted to the facility with a physician's order for a regular diet with Total Parenteral Nutrition (TPN, a nutrient solution, including lipids, that is administered through a central venous access device. This solution usually consists of proteins. carbohydrates, electrolytes, vitamins. trace minerals, and lipids (as indicated)); and staff failed to transcribe the order into the medical record and/or failed to document communication with the hospital showing the physician order was changed. The sample was 24. The census was 102.The Administrator was notified on 06/26/26, of the past non-compliance. When the facility identified the issue, they immediately assessed the resident's current condition for decline or complications related to nutrition or treatment interruption. Staff reviewed the resident's admission records and available hospital transfer documentation was reviewed for TPN orders and discontinuation information. The facility Notified the Nurse Practitioner (NP). Communicated with the hospital case manager regarding their concerns with TPN. The resident's current care plan was discussed with the Interdisciplinary Team (IDT). Treatment orders were put in place per the provider's order. Staff were educated on auditing new admissions for treatments in a timely manner, all orders are transcribed properly and clarification received for any discontinued medication, documentation of order clarifications, notification of change in condition. The care plan was reviewed and updated. The event was referred to Quality Assurance Performance Improvement (QAPI) due to the identified admission order communication gap. The admitting nurse received corrective action. The deficiency was corrected on 5/27/26. Review of the facility's Documentation in Medical Record policy, date revised 08/01/25, showed:- Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation;-Licensed staff and IDT members shall document all assessments, pertinent observations. and services provided in the resident's medical record in accordance with state law and facility policy;-Documentation shall be completed at the time of service. but no later than the shift in which the assessment, observation, or care service occurred. Review of the facility's Medical Provider Orders policy, date revised 04/07/25, showed:-Validate newly prescribed medications and/or treatments in the electronic medication administration record (MAR)/treatment administration record (TAR);-Written Transfer Orders (sent with a resident by a hospital or other health care facility) Implement a transfer order without further validation, if it is signed and dated by the resident's current attending medical provider, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned. or signed by another medical provider, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending medical provider before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. [NAME]/M. [NAME], R.N. Review of the facility's TPN policy, date revised 04/01/25, showed:-The nurse will verify the practitioner's order for the TPN. The order should include, at a minimum, the dextrose (sugar) concentration, the component names and dosages, route, rate, duration of use and any test results that require monitoring;-Consult the dietitian for assessment and monitoring. Review of Resident #111's After Visit Summary from the hospital, dated 04/14/26 through 05/01/26, showed:-Call Provider for any other concerns or questions. Please call the colorectal office and phone number was provided for any questions or concerns;-Diet instructions: Regular diet with TPN. A question mark was handwritten in front of the order. Review of Resident #111's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 05/05/26, showed:-Moderately impaired cognition;-No rejection of care;-Set up or clean up assistance (helper sets up or cleans up, resident completes the activity. Helper assists only prior to the activity): Eating;-Diagnoses include cancer, atrial fibrillation (irregular heart rhythm) heart failure, diabetes and depression;-Intravenous access (IV, (a medical technique that administers fluids, medications and nutrients directly into a person's vein) was blank. Review of the Order Summary Report, dated active orders as of 05/01/26, showed:-Clear liquid diet, date ordered 05/01/26. Start date was 05/04/26;-There was no physician order for TPN. Review of the progress notes dated 05/01/26 through 05/13/26, showed:-On 05/01/26 at 8:22 P.M., resident arrived at facility via ambulance from hospital. Consumed a regular diet, able to feed self. Devices Left Upper Arm (LUA) double lumen (catheter contains two completely separate internal channels, allowing healthcare providers to deliver two different medications or fluids simultaneously without them mixing) Peripherally Inserted Central Catheter (PICC, is a flexible, long medical tube inserted into a vein in the upper arm and advanced toward the heart) PICC with a Clean Dry and Intact (CDI) dressing. All orders verified by NP;-On 05/07/26 at 8:45 A.M., dual lumen IV access removed from Left Upper Extremity (LUE) per physician order;-On 05/11/26 at 7:47 P.M., the nurse looked at resident's vitals and noted blood pressure (B/P, normal 120/80 through 90/60) to be very low at 55/30. NP made aware, new order received for 0.9 % Normal Saline (NS, salt concentration that closely mirrors the natural balance of fluids and salts found in human blood) 1000 milliliters (mL) at 75 mL/hour (hr) through hypodermoclysis (the administration of fluids or medications directly into the subcutaneous tissue). Infusion started without difficulty. New order received for PICC to be placed. LUA double lumen PICC successfully placed. Temperature 98.8 (T, normal 97.9 through 99.1), Pulse 85 (P, normal 60 through 100), Respirations 16 (R, normal 12 through 20), B/P 60/42, NS @ 75 ml/hr to be infused via PICC, started as ordered. B/P 66/42, P84, R18 T 98.1. Resident appears more alert post start of infusion. B/P 70/50 P88 R 18 T 97.8. NP updated on resident's condition;-On 05/12/26 at 5:58 A.M., double lumen PICC to LUE noted. Completed a 1000 mL bag of fluids about 4:00 A.M., resident alert and oriented but slow to respond. Vitals obtained and documented B/P still running low at 86/56;-On 05/12/26 at 7:01 P.M., Resident reviewed via IDT related to TPN orders not being sent from the hospital upon initial admission, and facility staff receiving verbal confirmation from hospital staff that TPN had been discontinued at the time of admission. Resident had a doctor's appointment on 05/06/26 and returned to the facility the same day. On 05/06/26, the facility received a message from the hospital case manager inquiring about the resident. A return call was placed to the case manager on 05/07/26, and a message was left requesting clarification regarding discharge medications and TPN orders; however, no return call was received. On 5/11/26, another call was placed to the case manager requesting a return call. NP also contacted the case manager and received an answer. The nurse spoke with the case manager for clarification of orders but did not receive clarification at that time. The nurse then contacted the surgeon's office and spoke with Office Staff D, who confirmed that the resident was supposed to continue TPN upon admission to the facility. Upon review of the discharge orders, Office Staff D confirmed that the TPN order had not been properly transcribed into the after-visit summary by hospital staff. Upon the resident's arrival to the facility on [DATE], orders indicated a regular diet with TPN; However, there were no specific orders for TPN administration, mixture, laboratory monitoring, or initial formula. The nursing staff contacted the hospital discharging nurse at that time and was informed that TPN had been discontinued;-On 05/12/26 at 7:02 P.M., the nurse contacted the pharmacy which confirmed that no medication or TPN orders had been received from the hospital. On 05/11/26, a new PICC line was inserted Resident was started on IV fluids and remained on IV fluids pending clarification and initiation of TPN orders. Call placed to surgeon, and resident has a follow-up appointment scheduledfor 5/13/26 at 10:00 A.M. Labs were ordered, drawn via PICC line, and sent to the laboratory. Resident condition noted stable at that time. Resident states he/she felt better this shift. Vital signs: BP 99/64, P84, R 18, T 98.2;.-On 5/13/26 at 11:02 A.M., resident went to scheduled appointment this shift, and call received from Office Staff D to inform facility that resident will be direct admitted to the hospital. Review of the Outpatient Parenteral Nutrition Orders, located in the miscellaneous section of the medical record, dated 04/30/26, showed: the form was dated 04/30/26 and faxed to the facility on [DATE]. Written on the top of the form was for discharge possibly on 05/01/26. The form had Lab monitoring weekly: Comprehensive Metabolic Panel (CMP, lab test for electrolytes) Magnesium and phosphorus (electrolytes), Complete Blood Count (CBC, lab test for measurement the cells) and Triglycerides (type of lipid (fat) circulating in the blood) and weekly weight. Infuse the formula over 12 hours seven days a week. Review of the Medical Doctor's (MD) progress note, dated 05/05/26, showed patient was discharged to the facility on a regular diet with bowel regimen and TPN. Patient was stable for discharge on [DATE]. discharged on regular diet. During interviews on 06/23/26 at 12:30 P.M. and 2:14 P.M., Licensed Practical Nurse (LPN) E said when the resident admitted , he/she had a line (PICC line) but the resident did not have an order for TPN. LPN E called the hospital and spoke with the nurse who gave him/her report, and the nurse told LPN E the TPN had been discontinued, and he/she verified the order with the NP. The NP also gave an order to discontinue the PICC line. Someone discontinued the line a few days later. LPN E did not recall if he/she verified the TPN orders with the surgeon or not. The resident was still being followed by the surgeon. When the resident went out for the follow up appointment, the resident took his/her order sheet with him/her. The doctor could look at the orders and see the resident was not on TPN. During an interview on 06/23/26 at 4:55 P.M., the Pharmacy Office Manager said they received a referral for TPN on 05/27/26. The pharmacy did not send the TPN out because the resident was admitted to a skilled nursing facility (SNF). If the pharmacy was unable to provide the service, the pharmacy would notify whoever sent the referral. During an interview on 06/24/26 at 9:45 A.M., the NP said the resident was admitted to the facility on Thursday or Friday. The NP visited the facility on Monday or Tuesday, and she was told staff called the hospital and the TPN was discontinued, and the resident was eating. A few days later, staff reported they had been trying to reach the outside Register Dietician (RD) for a few days, and she was not returning their call. The NP said she placed a call to the RD and left a message, and about 20 minutes later the RD called back. The RD claimed the hospital faxed the orders for TPN to the facility and claimed the information should have come in the hospital discharge paperwork. After speaking to the RD, the NP said she placed an order for a new PICC line to be placed. The plan was to start TPN. The day she clarified the order with the RD, the resident's blood pressure was low. The resident initially refused care, fluids and to go to the hospital. After speaking with the resident and his/her family, the resident agreed to receive fluids by hypodermoclysis until the PICC line was placed. The resident ate for about a week, then his/her blood pressure began trending low. Not receiving TPN could possibly cause the blood pressure to trend low. During an interview on 06/24/26 at 12:22 P.M., The Director of Nursing (DON) said when a resident is admitted to the facility the admitting nurse should verify the orders and transcribe the orders into the computer. If an order is clarified, it should be documented in the progress notes and in the order and communicated. The nurse can only go by what is on the After Visit Summary/Discharge Summary for the orders. The nurse should document any communication they had with the MD/NP. During the last conversation the facility had with the hospital, the hospital was not sure if the resident would be admitted with TPN or not. When a resident is admitted with TPN, the hospital should send a sheet with the TPN information, dated the day the resident is discharged and the TPN order should be included in the medication list. The TPN sheet shows what labs need to be monitored and how often they should be drawn, along with the script for the TPN and how to administer it. When the admitting nurse received the paperwork, TPN was not listed under the medication list and there was no sheet for the TPN. The admitting nurse saw the order for regular diet with TPN; that's why there was a question mark placed in front of the order. The admitting nurse said he/she called the hospital and spoke with the nurse who discharged the resident to obtain clarification for the TPN. The hospital nurse told the admitting nurse the TPN was discontinued. The admitting nurse did not document the conversation. The facility needs TPN orders to be clear. The TPN sheet must be dated when the resident was discharged . On 05/06/26, the resident went out for his/her follow up appointment with the surgeon, but the appointment was rescheduled for 05/08/26. The case manager called around 05/06/26 or 05/07/26 asking about the TPN, and they found out the surgeon was managing the TPN. The surgeon was okay with the resident not receiving TPN. The facility and the NP were monitoring the resident. The facility attempted to call the RD several times regarding the TPN and left several messages over a few days, but the RD did not call back. When the NP came to the facility, staff notified her they were trying to reach the RD but she did not call back. The NP called the RD and spoke with her. When the resident had a change in condition, the facility contacted the surgeon's office and received orders for labs and fluids. When the resident went out for his/her follow up appointment, the resident was admitted to the hospital. During an interview on 06/25/26 at 9:02 A.M., the Medical Director said TPN is ordered by dietary. There was a breakdown between the RD and the pharmacy. The RD said she sent the script to the pharmacy. There was possible communication between the pharmacy, hospital, etc. that was not documented. The Medical Director expected staff to document any communication. During an interview on 06/26/26 at 1:12 P.M., the Administrator said if orders are clarified it should be documented in the progress notes. The Administrator expected staff to follow the facility's policies and procedures. 301993130189133018448

Based on observation, interview and record review, the facility failed ensure one resident (Resident #12) received the correct treatment order for a pressure injury (damage to the skin and underlying tissue caused by prolonged pressure) and failed to update the resident's care plan to include the resident's pressure injury. In addition, two residents received new treatment orders for pressure injuries on 1/2/26, that were not implemented until 1/5/26, and staff failed to ensure one of those two residents with an order for off-loading boots (pressure relieving boots) wore those boots at all times as ordered (Residents #4 and #1). Five residents were sampled for pressure injuries, four current residents and one discharged resident, and problems were found with three. The census was 98.Review of the facility Pressure Injury Prevention and Management policy dated 9/1/21 and revised on 1/23/23, showed:-Policy: This facility is committed to the prevention and avoidable pressure injuries and the promotion of healing of existing pressure injuries;-Definitions:- Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device;-Policy Explanation and Compliance Guidelines: -There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For the purpose of this policy, pressure injury, as the current standard terminology, will be used;-The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate;-Interventions for Prevention and to Promote Healing:-After completing a thorough assessment/evaluation, the interdisciplinary team (IDT) shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions;-Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.). Provide appropriate, pressure-redistributing, support surfaces;-Modifications of Interventions:-Any changes to the facility's pressure injury prevention and management process will be communicated to relevant staff in a timely manner;-Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include changes in resident's degree of risk for developing a pressure injury; new onset or recurrent pressure injury development. Review of the facility and Wound Care Company (Provider) service agreement, dated 1/13/25, showed:-Facility Responsibilities:-Facility agrees to support the Wound Care Company's delivery of wound care services and commits to: -Provide a dedicated nurse to round and communicate with the Provider;-Discuss recommendations/wound care plan with the Provider on the day of rounds;-Grant the Provider rendering services with access privileges to the Facility's internet service and electronic health record;-Respect the physician-patient relationship and allow the Provider, once consulted, to provide services and procedures to such resident as Provider determines to be medically necessary. Review of the facility Medical Provider Orders policy, dated 9/1/21 and revised on 4/7/22, showed:Policy: This facility shall use the uniform guidelines for the ordering and following of medical provider orders;-Policy Explanation and Compliance Guidelines:1. Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe;2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility;3. Elements of the Medication and/or Treatment Order;-Date and time the order is written;4. Documentation of Medication and/or Treatment Orders;-If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy;-Validate newly prescribed medications and/or treatment is in the electronic MAR (medication administration record)/TAR (treatment administration record);5. Following of Medication and/or Treatment Orders: Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements. Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order;6. Specific Procedures for Medication Orders;-Handwritten Order Signed by the Medical Provider: The charge nurse on duty at the time the order is received should note the order and enter it on the medical provider order sheet or electronic order format, if not written by the medical provider. Review of the facility Treatment Nurse - LPN (Licensed Practical Nurse) job description, undated, showed:-Position Description: Responsible for the center's general application of the skin management program. Responsible for delivering safe, efficient and effective treatment to heal various types of wounds, including ulcers, and bed sores;-Principle Responsibilities:-Performs resident skin assessments, obtain treatment orders, administer treatment as ordered, and document appropriately to ensure that resident skin integrity is improved/or maintained;-Administer treatments as prescribed within standard nursing practice guidelines and in full compliance with established infection control protocols;-Coordinate and lead weekly wound rounds and processes, including rounds, measurements, interdisciplinary care plan review, treatment recommendations, physician orders, and required documentation;-Receives, transcribes and implements new treatment orders in a timely manner. 1. Review of Resident #12's admission face sheet, located in the EHR, showed diagnoses of: Quadriplegia (paralysis of the body from the neck down), pressure injury of the sacral (triangular bone area located above the tailbone) region, diabetes, muscle weakness, and cognitive communication deficit. Review of the resident's Braden Scale (an assessment tool used to determine pressure injury risk) located in the EHR and dated 10/26/25, showed a score of 15, or low risk to develop pressure injuries. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 10/30/25, and located in the EHR, showed:-Moderately impaired cognition;-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer;-Always incontinent of bowel;-Is the resident at risk of developing pressure ulcers/injuries: Yes;-Does the resident have one or more unhealed pressure ulcers/injuries: No. Review of the resident's care plan, located in the EHR, showed:-12/25/22: Focus: Impaired cognitive function/dementia or impaired thought processes. Goal: Will maintain current level of cognitive function. Interventions: Ask yes/no questions to determine resident's needs. Cue, reorient and supervise as needed;-12/25/22: Focus: At risk for impairment to skin integrity related to quadriplegia. Goal: Will maintain or develop clean and intact skin. Interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces;-7/5/23: Focus: Current Functional Performance. Goal: Functional status will progress towards personal discharge goal. Interventions: Bed mobility, dressing, personal hygiene, toilet use and transfers - Total assist/one-person physical assist;-7/5/23: Focus: Impaired Physical Mobility. Goal: Resident will be able to perform activity within physical limits. Interventions: Will use call monitor to ask for assistance. Staff will answer call monitor in a timely manner;-The care plan did not identify the resident had a current pressure injury. Review of the resident's weekly skin check assessment (completed by a licensed nurse), located in the EHR, showed:-11/2/25 at 10:15 A.M., and completed by the facility Wound Nurse: No wounds were identified during the skin check;-11/9/25 at 8:54 P.M.: Left buttock, pressure, 7.0 centimeters (cm) (Length) x 5.0 cm (Width). Area cleaned with normal saline (NS, salt/sodium water mixture) and foam dressing applied. Review of the resident's progress note dated 11/10/25 at 5:03 P.M., located in EHR, and documented by the facility Wound Nurse, showed a full body assessment performed. Resident noted to have recurrent wound to coccyx (tail bone). Resident and family educated on repositioning and new treatment plan. Review of the resident's physician's order sheet (POS) located in the EHR, showed:-11/11/25: Cleanse sacrum (bony area between the small of the back and the upper buttocks) with NS, pat dry and apply calcium alginate (highly absorbent dressing for wounds with moderate to heavy exudate (drainage)) every day shift for wound healing. Review of the resident's progress note dated 11/11/25 at 12:26 P.M. and completed by the Director of Nurses (DON), showed: Resident reviewed via IDT for skin area reopening. At this time, resident referred to wound team for follow-up and treatment order in place. Physician, resident and family aware of plan of care and in agreement at this time. Will follow-up as needed. Review of the resident's TAR, dated 11/1/25 through 11/30/25, located in the EHR, showed:-11/11/25: Cleanse sacrum with normal saline, pat dry and apply calcium alginate dry dressing every 24 hours and PRN (as needed/necessary). Review of the resident's wound company Wound Evaluation and Management Summaries, completed by the Wound Care Company Physician and located in the EHR, showed:-11/13/25:-Chief Complaint: Resident has a wound on the right buttock (the POS and TAR identified as the sacrum);-Focused Wound Exam: Unstageable (due to necrosis (dead tissue)) (known but not stageable due to coverage of wound bed by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin)) of the right buttock full thickness;-Etiology: Pressure;-MDS 3.0 Stage: Unstageable necrosis;-Objective: Healing/Maintain Healing;-Healing Potential: Fair;-Care Goal: Decrease Wound Area, Decrease Necrosis;-Wound Size (Length x Width x Depth): 7.0 cm x 7.7 cm x 0.1 cm;-Surface Areas: 53.90 cm;-Exudate: Heavy Sero-sanguinous (contains both serum (the liquid part of blood) and a small amount of blood. It typically appears as a thin, watery discharge that is light pink in color);-Thick adherent devitalized necrotic tissue: 30%;-Slough: 30%;-Granulation tissue (new connective tissue that forms during the healing process): 40%;-Pain Assessment: Described as mild;-Infection Assessment: No sign(s) of infection;-Dressing Treatment Plan: Alginate calcium with silver (combines calcium alginate's absorbent properties with silver's antimicrobial (agents that kill or inhibit the growth of microorganisms, including bacteria, viruses, fungi, and parasites) properties, apply once daily and as needed;-The Wound Care Company Physician surgically debrided (removal of necrotic tissue) the wound on this date.-11/20/25:-Right buttock;-MDS 3.0 Stage: Stage 3 (full thickness tissue loss. Subcutaneous fat may be viable but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.);-Wound Size: 7.0 cm x 10 cm x 0.1 cm;-Surface Area: 70.00 cm;-Exudate: Heavy Sero-sanguinous;-Granulation tissue: 100%;-Wound Progress: Improved evidenced by decreased necrotic tissue;-Pain Assessment: Described as Moderate;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-11/24/25:-The resident's visit has been rescheduled. Resident unable to be seen as he/she is already up and out of bed. Review of the resident's TAR, dated 11/1/25 through 11/30/25, showed:-11/11/25: Cleanse sacrum with normal saline, pat dry and apply calcium alginate dry dressing every 24 hours and PRN; -11/13/25 through 11/30/25: The facility failed to change the resident's treatment order from calcium alginate to calcium alginate with silver as ordered by the Wound Care Company Physician on 11/13/25. Review of the resident's wound company Wound Evaluation and Management Summaries, showed:-12/4/25: -Right buttock;-MDS 3.0 Stage: Stage 3;-Wound Size: 8.0 cm x 8.8 cm x 0.1 cm;-Surface Area: 70.40 cm;-Exudate: Moderate Sero-sanguinous;-Thick adherent devitalized necrotic tissue: 40%;-Slough: 20%-Granulation tissue: 40%;-Wound Progress: Not a goal due to resident non-compliant with wound care;-Pain Assessment: None;-Infection Assessment: None;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-12/11/25:-The resident's visit has been rescheduled. Out at an appointment;-12/18/25:-Right buttock;-MDS 3.0 Stage: Stage 3;-Wound Size: 5.1 cm x 7.0 cm x 0.1 cm;-Surface Area: 35.70 cm;-Exudate: Moderate Sero-sanguinous;-Granulation tissue: 70%;-Other viable tissues: 30%;-Wound Progress: Improved as evidenced by decreased necrotic tissue, decreased surface size;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-12/22/25:-Right buttock;-MDS 3.0 Stage: Stage 3;-Wound Size: 4.5 cm x 6.6 cm x 0.1 cm;-Surface Area: 29.70 cm;-Exudate: Moderate Sero-sanguinous;-Slough: 20%;-Granulation tissue: 50%;-Other viable tissues: 30%;-Wound Progress: Improved as evidenced by decreased surface area;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed. Review of the resident's TARs, dated 12/1/25 through 12/31/25, and 1/1/26 through 1/7/26, showed:-11/11/25: Cleanse sacrum with NS, pat dry and apply calcium alginate dry dressing every 24 hours and PRN;-The facility failed to change the resident's treatment order from calcium alginate to calcium alginate with silver as ordered by the Wound Care Company Physician on 11/13/25. Review of the resident's wound company Wound Evaluation and Management Summary, showed:-1/2/26: -Right buttock;-MDS 3.0 Stage: Stage 3;-Wound Size: 8.0 cm x 6.3 cm x 0.1 cm;-Surface Area: 50.40 cm;-Exudate: Heavy Serous (clear to yellow fluid);-Thick adherent devitalized necrotic tissue: 20%;-Granulation tissue: 50%;-Other viable tissues: 30%;-Wound Progress: Not at goal due to patient non-compliant with wound care;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-Prescription Recommendations: amoxicillin-clavulanate (antibiotic) 875/125 milligram (mg) twice daily for 10 days. Start 1/2/26. End 1/12/26. Review of the resident's POS, showed:-1/3/2026: Bactrim DS (antibiotic) 800-160 mg. Give one tablet by mouth in the morning for wound infection for 10 days and give one tablet by mouth at bedtime for wound infection for 10 days. Review of the resident's MAR, dated 1/1/26 through 1/7/26, showed:-1/3/26: Bactrim DS 800-160 mg, give one tablet at 7:30 A.M. and one tablet at 7:30 A.M. and at 7:30 P.M. Review of the resident's EHR showed no explanation why the facility was administering Bactrim DS 800-160 mg when the Wound Care Physician ordered amoxicillin-clavulanate 875/125 mg. During a telephone interview on 1/13/26 at 3:38 P.M., the DON said she spoke to the Wound Care Company Physician on 1/12/26 and she confirmed she wanted the resident's antibiotic to be Bactrim DS, not amoxicillin-clavulanate. Observation on 1/5/26 at 8:22 A.M., showed the resident lay in bed on a low air loss mattress (a pressure relieving mattress) for a skin assessment. The facility Wound Nurse peeled back the dressing covering the resident's sacrum showing a large open area. The facility Treatment Nurse said the pressure injury was covered by 40-50% dark tissue and 40-50% red beefy tissue. During an interview on 1/7/26 at 8:38 A.M., the facility Treatment Nurse said she works Monday through Friday. On her days off the facility nurses complete the resident treatments. At 11:19 A.M., the facility Treatment Nurse said she rounds with the Wound Care Company Physician every week, usually on Thursdays. The Wound Care Company Physician will verbally tell her as they round any new orders, and she writes them down. Before the Wound Care Company Physician leaves the facility, she will upload her Wound Evaluation and Management Summary notes into the resident's EHR. She (the facility Treatment Nurse) is responsible to accurately transcribe the Wound Care Company Physician's orders on the POS and TAR. She did not change the resident's treatment order from calcium alginate to calcium alginate with silver on the POS and TAR like she should have. She has been using the calcium alginate with silver when she does the resident's treatment, but because the TAR shows calcium alginate only, she cannot be sure the nurses are using the calcium alginate with silver. She did not round with the Wound Care Company Physician on 1/2/26, when she ordered the amoxicillin-clavulanate 875/125 mg. She was off last week and did not return until 1/5/26. During an interview on 1/7/26 at 12:15 P.M., LPN F said he/she works the day shift and every other weekend. The facility Treatment Nurse usually does the treatments Monday - Friday, but he/she does treatments on the weekends he/she works. He/She looks at the TAR in the EHR to know what treatment to administer. If the order on the TAR showed calcium alginate, that is what he/she would use, not calcium alginate with silver. During an interview on 1/7/26 at 12:31 P.M., LPN H said if he/she was doing the treatments, he/she would look at the TAR in the EHR. If the treatment order showed calcium alginate, that is what he/she would use, not calcium alginate with silver. During an interview on 1/7/26 at the DON said what the Wound Care Company Physician orders is what should be on the POS, MAR and TAR. Any orders from the Wound Care Company Physician should begin the same day the facility received the order(s). During an interview on 1/8/26 at 8:21 A.M., the Wound Care Company Physician said calcium alginate with silver has antimicrobial properties while calcium alginate does not. She expected staff to follow her treatment orders as written. Review of the resident's wound company Wound Evaluation and Management Summary, showed:-1/8/26: -Right buttock;-MDS 3.0 Stage: Stage 3;-Wound Size: 8.0 cm x 6.0 cm x 0.1 cm;-Surface Area: 48.00 cm;-Exudate: Moderate Serous;-Thick adherent devitalized necrotic tissue: 30%;-Slough: 10%;-Granulation tissue: 40%;-Other viable tissues: 10%;-Skin: Intact normal color: 10%;-Wound Progress: Improved, evidenced by decreased surface area;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-Prescription Recommendations: Continue amoxicillin-clavulanate (antibiotic) 875/125 milligram (mg) twice daily for 10 days. Start 1/2/26. End 1/12/26. 2. Review of Resident #4's quarterly MDS dated [DATE], and located in the EHR, showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer;-Always incontinent of bowel and bladder;-Diagnoses of cerebral palsy (a group of conditions that affect movement and posture caused by brain damage most often before birth), and seizure disorder;-Is this resident at risk of developing pressure ulcers/injuries: Yes;-Does this resident have one or more unhealed pressure ulcers/injuries: Yes;-Number of Stage 3 pressure ulcers: One. Review of the resident's care plan, located in the EHR, showed:-5/1/24: Focus: Bowel and Bladder Incontinence. Goal: Will remain free from skin breakdown due to incontinence and brief use. Interventions: Check resident every two hours and assist with toileting as needed. Provide perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone) after each incontinent episode;-5/13/24: Focus: Requires assistance with activities of daily living. Goal: Will maintain current activity of daily living status. Interventions: Encourage resident to participate to the fullest extent possible with each interaction;-5/13/24: Focus: Impaired cognitive function/dementia or impaired thought processes related to cerebral palsy. Goal: Will develop skills to cope with cognitive decline and maintain safety. Interventions: Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Engage the resident in simple, structured activities that avoid overly demanding tasks;-6/21/24: Focus: Actual impairment to skin integrity. Goal: Will have no complications related to the alteration of skin integrity. Interventions: Followed by wound company. Treatment of wounds per physician's orders;-1/9/26: Focus: Actual skin impairment. Goal: Area will improve. Interventions: Incontinence care as needed. Skin prevention intervention as ordered. Treatment as ordered. Review of the resident's POS, located in the EHR, showed:-12/18/25: Off-loading boots on at all times;-12/19/25: Skin prep (a liquid forming film that forms a protective barrier on the skin) to the dorsal (top of the foot) left foot and the left heel every day shift for wound healing. Review of the resident's TAR dated 12/1/25 through 12/31/25, and located in the EHR, showed:-12/1/25 through 12/31/25: 12/18/25: Off-loading boots on at all times;-12/19/25: Skin prep (a liquid forming film that forms a protective barrier) to the left dorsal (top of the foot) foot and left heel, every day shift for wound healing. Review of the resident's TAR dated 1/1/26 through 1/31/26, showed:-12/18/25: Off-loading boots on at all times;-12/19/25: Skin prep to the left dorsal foot and left heel every day for wound healing. Staff initialed the skin prep had been applied to the resident's dorsal left foot and left heel on 1/1 and 1/2/26. Review of the resident's wound company Wound Evaluation and Management Summary, showed:-1/2/26:-Left Dorsal Foot;-Etiology: Pressure;-MDS 3.0 Stage: Stage 3;-Wound Size: 1.5 cm x 0.5 cm x 0.1 cm;-Surface Area: 0.75 cm;-Exudate: Moderate Serous;-Granulation Tissue: 60%;-Other viable tissues: 50%;-Wound progress: Not a goal due to need more time;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver once daily and as needed;-Left Heel;-Etiology: Pressure;-MDS 3.0 Stage: Stage 3;-Wound Size: 1.8 cm x 1.2 cm x 0.1 cm;-Surface Area: 2.16 cm;-Exudate: Moderate Serous;-Granulation tissue: 100%;-Wound progress: Exacerbated due to resident scratches, need to make sure pressure boots are in place;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed;-Specific To Visit Recommendations: Pressure Off-Loading boot. Review of the resident's POS, showed:-Discontinue Date 1/5/26: Skin prep to the left dorsal foot and the left heel daily for wound healing;-Start Date 1/5/26: Cleanse left dorsal foot and left heel with normal saline and apply calcium alginate with silver every day shift for wound healing. Review of the resident's TAR, dated 1/1/26 through 1/31/26, showed:-1/3/26 and 1/4/26: Staff initialed skin prep had been applied to the resident's dorsal left foot and left heel;-No order for calcium alginate with silver to the left dorsal foot and left heel on 1/2, 1/3 or 1/4/26. Observation on 1/5/26 at 8:33 A.M., showed the resident lay in bed with contractures to the upper and lower extremities. He/She was not wearing pressure off-loading boots. The facility Treatment Nurse completed the resident's skin assessment. The resident had a dressing on the left dorsal foot and the left heel. Both dressings were dated 1/2/26. The facility Wound Nurse said she was off last week and did not round with the Wound Care Physician on 1/2/26. Prior to being off last week, the resident had an order for skin prep (skin prep does not require dressings) to the left dorsal foot and the left heel. The Wound Care Company Physician may have changed the order on 1/2/26. At 10:58 A.M., the facility Treatment Nurse said the Wound Care Company Physician changed the resident's treatment order on the left dorsal foot and left heel to calcium alginate with silver on 1/2/26. The new treatment orders should have been changed on the POS and TAR on 1/2/26. She was not sure why that did not happen. The left dorsal foot pressure injury was open with red beefy tissue and measured 1.5 cm x 0.5 cm. The left heel pressure injury had 50% brown slough and 50% red beefy tissue and measured 1.7 cm x 2.0 cm x 3.0 cm. Review of the resident's POS, showed:-12/18/25: Off-loading boots on at all times;-1/5/26: Cleanse left dorsal foot and left heel with normal saline. Apply calcium alginate with silver daily and as needed. Review of the resident's TAR dated 1/1/26 through 1/31/26, showed:-1/5/26: Cleanse the left dorsal foot and left heel with NS and apply calcium alginate with silver daily and as needed. Observation and interview on 1/7/26 at 8:16 A.M., showed the resident lay in bed. Certified Nursing Assistant (CNA) C and CNA D were providing personal care to the resident. The resident was not wearing an off-loading boot. CNA C said the resident does have off-loading boots, but they were taken to the laundry yesterday and have not come back yet. During an interview on 1/7/26 at 12:47 P.M., the DON said if the resident had an order for off-loading pressure boots at all times, they should be worn at all times. Review of the resident's wound company Wound Evaluation and Management Summary, showed:-1/8/26:-Left Dorsal Foot;-Etiology: Pressure;-Wound Progress: Resolved, anatomic location of previously existing wound examined today and resolved. Follow up only as needed;-Left Heel;-Etiology: Pressure;-MDS 3.0 Stage: Stage 3;-Wound Size: 1.3 cm x 0.9 cm x 0.1 cm;-Surface Area: 1.17 cm;-Exudate: Moderate Serous;-Granulation tissue: 100%;-Wound progress: Improved as evidenced by decreased surface area;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver apply once daily and as needed;-Specific To Visit Recommendations: Pressure Off-Loading boot. 3. Review of Resident #1's quarterly MDS dated [DATE] and located in the EHR, showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer;-Always incontinent of bowel and bladder;-Diagnoses of wound infection, diabetes and stroke;-Is this resident at risk of developing pressure ulcers/injuries: Yes;-Does this resident have one or more unhealed pressure ulcers/injuries: No. Review of the resident's care plan, located in the EHR, showed:-8/25/25: Focus: Actual impairment to skin integrity. Goal: Will have no complications related to the alteration of skin integrity. Intervention: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, and signs/symptoms of infection;-8/27/25: Focus: The resident has an activity of daily living self-care performance deficit. Goal: Will maintain/improve level of functioning. Interventions: Bedfast all or most of the time. Requires two staff for bathing/showering, dressing, bed mobility and toilet use. Encourage the resident to participate to the fullest extent possible with each interaction. Review of the resident's Braden Scale assessment dated [DATE], showed the resident was a low risk to develop a pressure injury. Review of the resident's POS located in the EHR, showed:-12/19/25: Zinc oxide ointment (used to prevent and treat skin irritations), apply to right buttock topically every shift for wound healing. Review of the resident's Wound Evaluation and Management Summary dated 1/2/26, and located in the EHR, showed:-Right Posterior Thigh;-Etiology: Pressure;-MDS 3.0 Stage: Stage 3;-Objective: Healing/Maintain Healing;-Healing Potential: Good;-Wound Size: 0.8 cm x 5.0 cm x 0.1 cm;-Surface Area: 4.00 cm;-Exudate: Moderate Serous;-Granulation tissue: 100%;-Wound progress: Exacerbated due to likely reinjury;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed. Review of the resident's POS, showed:-1/5/26: Cleanse the right posterior thigh with NS and pat dry. Apply calcium alginate with silver and dry dressing every day for wound healing. Review of the resident's TAR dated 1/1/26 through 1/31/26, showed:-Nurses initialed they applied zinc oxide to the right buttocks on 1/2, 1/3 and 1/4/26;-1/5/26: Cleanse right posterior thigh with normal saline and pat dry. Apply calcium alginate with silver and dry dressing every day shift for wound healing. Observation and interview on 1/5/26 at 8:45 A.M., showed the resident lay in bed. The facility Treatment Nurse stood at the bedside to complete the resident's skin assessment. The facility Wound Nurse said she went on vacation last week and did not make rounds with the Wound Care Company Physician on 1/2/26. When she went on vacation, the resident had an order for zinc oxide ointment. When she returned today, she noted the treatment order had been changed to calcium alginate with silver daily on 1/2/26. That order had not been added to the POS or TAR until today when she added it. Observation of the resident's right posterior thigh showed thin horizontal open areas across the posterior right thigh and no dressing in place. Review of the resident's Wound Evaluation and Management Summary dated 1/8/26, and located in the EHR, showed:-Right Posterior Thigh;-Etiology: Pressure;-MDS 3.0 Stage: Stage 3;-Objective: Healing/Maintain Healing;-Healing Potential: Good;-Wound Size: 6.3 cm x 2.8 cm x 0.1 cm;-Surface Area: 17.64 cm;-Exudate: Moderate Serous;-Granulation tissue: 20%;-Skin: Intact normal color 80%;-Wound progress: Improved as evidenced by decreased surface area;-Pain Assessment: None;-Infection Assessment: No signs of infection;-Primary Dressing: Alginate calcium with silver, apply once daily and as needed. 4. During an interview on 1/8/26 at 8:21 A.M., the Wound Care Physician said she rounds with a facility nurse, usually the facility Wound Nurse, every week when she is in the facility. She will verbally tell the nurse what changes she is making, and she will upload her Wound Evaluation and Management Summary notes into the EHR before she leaves that day, so her written orders are available. She expected staff to begin any new orders the same day she is here. 5. During an interview on 1/8/26 at 2:30 P.M., the Administrator said the policies and procedures are current, and she expected facility staff to follow them. 27064942706772

Based on observation, interview and record review, the facility failed to ensure staff followed their Enhanced Barrier Precautions (EBP) policy while providing care to residents that required EBP precautions during high contact activities. Five residents were observed during skin assessments, treatments and/or personal care, and staff failed to wear gowns during four of those five observations. (Residents #1, #4, #7 and #12). The census was 98.Review of the facility Enhanced [NAME] Precautions policy dated 1/1/23 and revised on 4/23/25, showed:-Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs);-Definitions: - Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and gloves use during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing;-Policy Explanation and Compliance Guidelines:-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions;-All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions;-The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities;-Initiation of Enhanced Barrier Precautions:-An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers (wound due to poor blood flow in the veins) and/or indwelling medical devices (e.g., central lines, urinary catheters (thin, flexible tube), feeding tubes, tracheostomy (surgical procedure that creates an opening in the trachea)/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters) even if the resident is not known to be infected or colonized with MDRO;-Implementation of Enhanced Barrier Precautions:-Make gowns and gloves available immediately near or outside of the resident's room;PPE (personal protection equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room;-The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education;-High-contact resident care activities include: Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting in toileting, device care or use, and wound care to any skin opening requiring a dressing. Review of the facility's Enhanced Barrier Precautions sign (posted on the outside of resident room doors of those residents requiring EBP) showed:-Everyone Must: Clean their hands, including before entering and when leaving the room. Providers And Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: -Dressing; -Bathing/Showering; -Transferring;-Changing Linens;-Providing Hygiene;-Changing briefs or assisting with toileting;-Device care or use: Central line, urinary catheter, feeding tube, tracheostomy;-Wound Care: Any skin opening requiring a dressing. Review of the facility Treatment Nurse - LPN (Licensed Practical Nurse) job description, undated, showed:-Position Description: Responsible for the center's general application of the skin management program. Responsible for delivering safe, efficient and effective treatment to heal various types of wounds, including ulcers, and bed sores;-Principle Responsibilities:-Performs resident skin assessments, obtain treatment orders, administer treatment as ordered, and document appropriately to ensure that resident skin integrity is improved/or maintained;-Administer treatments as prescribed within standard nursing practice guidelines and in full compliance with established infection control protocols;-Safety and Sanitation: Wears and/or uses safety equipment and supplies when indicated and properly trained to use. Review of the facility's Certified Nursing Assistant (CNA) job description, undated, showed:-Position Description: The CNA is responsible for delivering and assisting residents with daily needs, including personal care needs. Provide basic nursing care to residents within the scope of the nursing assistant responsibilities and performs basic nursing procedures under the direction of the licensed nurse supervisor;-Principal Responsibilities: -Responsible for knowledge of proper procedures to provide personal care services to residents; provide requested personal care services to residents;-Serves and protect the center's community by adhering to professional standards, company policies and procedures, federal, state, and local requirements. 1. Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/10/25 and located in the electronic healthcare record (EHR), showed:-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer;-Diagnoses of wound infection, diabetes and stroke;-Feeding tube (gastrostomy tube/a tube inserted through the abdomen into the stomach to provide medication/nutrition/fluids);-Is this resident at risk of developing pressure ulcers/injuries: Yes. Review of the resident's care plan, located in the EHR, showed:-8/25/25: Focus: Actual impairment to skin integrity. Goal: Will have no complications related to the alteration of skin integrity. Intervention: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, and signs/symptoms of infection;-8/27/25: Focus: The resident has an activity of daily living self-care performance deficit. Goal: Will maintain/improve level of functioning. Interventions: Bedfast all or most of the time. Requires two staff for bathing/showering, dressing, bed mobility and toilet use. Encourage the resident to participate to the fullest extent possible with each interaction;-10/6/25: Focus: Requires a tube feeding. Goal: Will be free from aspiration (substance(s) enters the lungs such as food/liquids). Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Review of the resident's physician's orders sheet (POS), located in the EHR, showed:-10/7/25: Tube feeding. Check for placement every shift;-1/5/26: Cleanse right posterior thigh with normal saline (NS), pat dry and apply calcium alginate (an absorbent treatment) and cover with dry dressing daily;-No order for EBP. Observation on 1/5/26 at 8:45 A.M., showed an EBP sign posted on the outside of the resident's door and a supply of gloves and gowns on the inside of the room door. The resident lay in bed as LPN A and the facility Treatment Nurse completed the resident's skin assessment. Both LPN A and the facility Treatment Nurse donned gloves, but not gowns during the skin assessment. The resident had a tube feeding stoma (surgically created opening) on the abdomen covered by a dressing and open areas on the right posterior thigh. 2. Review of Resident #4's quarterly MDS dated [DATE], and located in the EHR, showed:-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer;-Always incontinent of bowel and bladder;-Diagnoses of cerebral palsy (a group of conditions that affect movement and posture caused by brain damage most often before birth), and seizure disorder;-Does this resident have one or more unhealed pressure ulcers/injuries: Yes;-Number of Stage 3 pressure ulcers (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling): One. Review of the resident's care plan, located in the EHR, showed:-5/13/24: Focus: Requires assistance with activities of daily living. Goal: Will maintain current activity of daily living status. Interventions: Encourage resident to participate to the fullest extent possible with each interaction;-6/21/24: Focus: Actual impairment to skin integrity. Goal: Will have no complications related to the alteration of skin integrity. Interventions: Followed by wound company. Treatment of wounds per physician's orders;-11/21/24: Requires Enhanced Barrier Precautions due to chronic wounds. Goal: EBP will reduce the risk of transmission (spread) of known or unknown MDROs. Interventions: Discuss EBP and reason needed with resident and responsible party. EBP includes the use of gowns and gloves during high-contact resident care;-1/9/26: Focus: Actual skin impairment. Goal: Area will improve. Interventions: Incontinence care as needed. Skin prevention intervention as ordered. Treatment as ordered. Review of the resident's POS, located in the EHR, showed:-9/16/25: Enhanced Barrier Precautions for chronic wound. Gown and gloves required for high-contact resident care;1/5/26: Cleanse the dorsal (top) left foot and left heel with NS, pat dry and apply calcium alginate with silver daily. Observation on 1/5/26 at 8:33 A.M., showed an EBP sign posted on the outside of the resident's room door and a supply of gloves and gowns on the inside of the room door. The resident lay in bed as the facility Treatment Nurse completed a skin assessment. The resident had uncovered open areas on his/her left dorsal foot and on his/her left heel. The Treatment Nurse donned a pair of gloves but did not don a gown to complete the skin assessment. Observation on 1/5/26 at 10:58 A.M., showed the resident lay in bed as the facility Treatment Nurse completed the resident's treatment to the left dorsal foot and left heel. The Treatment Nurse donned a pair of gloves but did not don a gown during the treatment. Observation on 1/7/26 At 8:16 A.M., showed the resident lay in bed. CNA D, wearing a pair of gloves but not a gown, prepared to complete personal care. CNA C entered the room to assist CNA D with providing personal care, including a bed bath. CNA C donned a pair of gloves but did not don a gown. During an interview on 1/7/26 at 8:44 A.M., CNA D said he/she was aware the resident had a pressure injury (damage to the skin and underlying tissue caused by prolonged pressure), and he/she should have worn a gown while providing care. During an interview on 1/7/26 at 9:28 A.M., CNA C said he/she was aware the resident had pressure injuries, but he/she was not aware he/she needed to wear a gown while providing personal care. 3. Review of Resident #7's quarterly MDS, located in the EHR and dated 12/8/25, showed:-Dependent for oral hygiene, toileting, shower/bathing, upper/lower dressing, and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfers;-Diagnoses of stroke, seizure disorder and respiratory failure;-Feeding tube;-Tracheostomy care. Review of the resident's care plan, located in the EHR, showed:-9/2/25: Focus: Activity of Daily Living self-care performance deficit. Goal: Will maintain/improve level of functioning. Interventions: Resident is totally dependent on one staff for: Bathing/showering, bed mobility, dressing, and personal hygiene;-9/2/26: Focus: Tracheostomy. Goal: Will have clear and equal breath sounds. Interventions: Administer oxygen as ordered. Provide good oral care daily. Suction as necessary. Review of the resident's POS, located in the EHR, showed:-9/3/25: Enhanced Barrier Precautions for tracheostomy and feeding tube. Gown and gloves required for high contact resident care. Observation on 1/6/26 at 8:33 A.M., showed an EBP sign posted on the outside of the resident's room door and a supply of gloves and gowns on the inside of the door. The resident lay in bed with humidified oxygen infusing through his/her tracheostomy tubing and collar. LPN A and CNA E entered the room to complete the resident's skin assessment. Both the LPN and CNA donned gloves but did not don gowns for the skin assessments. The resident had a dressing covering his/her feeding tube stoma. The resident had a large loose bowel movement, and both staff cleaned the resident and changed the resident's incontinent brief. During an interview on 1/8/26 at 8:17 A.M., LPN A said he/she should have worn a gown to take of the resident on 1/6/26. All the supplies, including gowns are on the back of the room door. 4. Review of Resident #12's admission face sheet, located in the EHR, showed a diagnoses of: quadriplegia (paralysis of the body from the neck down), pressure injury of the sacral (triangular bone area above the tailbone) region, diabetes, muscle weakness, and cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE] and located in the EHR, showed:-Functional Limitation in Range of Motion: Impairment of both upper and lower extremities;-Dependent for toileting, shower/bathe, upper/lower body dressing and personal hygiene;-Dependent for roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer. Review of the resident's care plan, located in the EHR, showed:-12/25/22: Focus: At risk for impairment to skin integrity related to quadriplegia. Goal: Will maintain or develop clean and intact skin. Interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces;-7/5/23: Focus: Current Functional Performance. Goal: Functional status will progress towards personal discharge goal. Interventions: Bed mobility, dressing, personal hygiene, toilet use and transfers - Total assist/one-person physical assistance;-7/5/23: Focus: Impaired Physical Mobility. Goal: Resident will be able to perform activity within physical limits. Interventions: Will use call monitor to ask for assistance. Staff will answer call monitor in a timely manner. Review of the resident's POS, located in the EHR, showed:-11/10/25: Cleanse sacrum (the area between the top of the buttocks and lower back) with NS, pat dry and apply calcium alginate and dry dressing daily;-No order for EBP. Observation on 1/5/26 at 8:22 A.M., showed an EBP sign posted on the outside of the resident's room door. On the inside of the room door was a supply of gowns and gloves. The resident lay in bed. The facility Treatment Nurse donned a pair of gloves but did not don a gown to complete the skin assessment. The resident had a large dressing covering the sacrum. 5. During an interview on 1/7/26 at 10:27 A.M., the facility Infection Preventionist said she expected staff to follow the instructions on the EBP signs on the resident room doors. The purpose of EBP is to protect the resident, other residents' staff are taking care of and the staff, from the spread of infection. 6. During an interview on 1/7/26 at 11:19 A.M., the facility Treatment Nurse said she should have worn a gown when she was doing the skin assessments and treatments. Gowns should be worn for infection control purposes. 7. During an interview on 1/7/26 at 12:47 P.M., the Director of Nursing (DON) said she expected staff to follow the instructions for EBP that are on the signs on the resident room doors. 8. During an interview on 1/8/26 at P.M., the Administrator said the policies and procedures are current, and staff are expected to follow them.

Based on interview and record review, the facility failed to ensure services provided met professional standards by not following physician orders and not obtaining one resident's vital signs (blood pressure, temperature, pulse rate, respirations and oxygen saturation) (Resident #1). The sample was three. The census was 100. Review of the facility's Medical Provider Orders policy, revised, [DATE], showed: -Policy: The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Following of medication and/or treatment orders: -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Dependent on staff for personal and toileting hygiene, lower and upper body dressing, and bathing; -Diagnoses included: Quadriplegia (paralysis of arms and legs), malnutrition (inadequate nutritional intake) and chronic osteomyelitis (infection of the bone); -Three, stage three pressure ulcers (a wound caused by prolonged pressure to an area of the body that has full thickness loss of skin in which underlying fat visible); -Two, stage four pressure ulcers (a wound caused by prolonged pressure to an area of the body that has full thickness skin and tissue loss which underlying muscle and bone is visible); -The resident has a suprapubic catheter (a tube that is surgically inserted in the resident's bladder through the abdomen to drain urine) and an ostomy (an opening that is surgically created through the abdomen to divert stool to the outside of the body). Review of the resident's care plan, in use while the resident was in the facility, did not address obtaining the resident's vital signs. Review of the resident's physician orders, dated [DATE], showed an order, dated [DATE], check a full set of vital signs on [DATE] and continue monthly. Review of the resident's Treatment Administration Record (TAR), dated 5/1 through [DATE], showed: -An order, start date [DATE], obtain vital signs and report abnormalities to the nurse practitioner (NP) or physician, one time on day shift; -On [DATE], blood pressure documented: not applicable (N/A); temperature documented: N/A; respirations documented: X; Oxygen saturations: N/A, day shift: 2 drug refused; -On [DATE], blood pressure: blank; temperature: blank; respirations: blank; oxygen saturation: blank; -No further documentation that vital signs were obtained. Review of the resident's progress notes show: -On [DATE] at 2:40 P.M., the resident continues to be on observation after being catheterized (a tube placed in the bladder to drain urine). Draining yellow urine without difficulty. No further concerns. Blood Pressure: 128/65 (normal is 120/80); Temperature: 98.4 Fahrenheit (normal is 98.6 ); Pulse: 93 beats per minute (normal range is 60-100); Respiratory rate per minute: 18 (normal range is 12-20). -No oxygen saturation was documented. Review of the resident's TAR, dated 6/1 through [DATE] showed: -An order, start date [DATE], obtain vital signs and report abnormalities to NP or physician, every month, starting on the fifth of the month; -On [DATE], blood pressure: blank; temperature: blank; respirations: blank; oxygen saturation: blank; -No further documentation that vital signs were obtained. Review of the resident's electronic medical record (EMR), under the vital signs tab, showed no documentation of vital signs obtained for May and [DATE]. Review of the resident's death in facility tracking MDS, dated [DATE], showed the resident expired on [DATE]. During an interview on [DATE] at 9:15 A.M., Licensed Practical Nurse (LPN) E said that vital signs are obtained every shift and as needed and placed in the resident's medical records under the vital signs section or on the TAR. Any nursing staff can obtain vital signs. During an interview on [DATE] at 9:44 A.M., Certified Nursing Assistant (CNA) B said that he/she only does vital signs when the nurse tells him/her to and was not aware of any routine or monthly orders for vital signs for this resident. During an interview on [DATE] at 11:18 A.M., the Wound Nurse said vital signs are obtained every shift for newly admitted residents for 72 hours and then monthly once the resident becomes established at the facility. The physician may have blood pressure checks with certain medications as well. During an interview on [DATE] at 11:44 A.M., the Director of Nursing (DON) said she would expect staff to follow the physician orders and obtain the resident's vital signs as ordered and document them in the resident's medical record. The facility did not have a policy related to obtaining resident vital signs. During an interview on [DATE] at 9:54 A.M., the facility's Medical Director said she would expect staff to obtain vital signs at the very minimum once a month on the resident. Vital signs include blood pressure, temperature, pulse, respirations and oxygen saturation. She would expect the vital signs to be accurate, timely, and easily accessible in the resident's medical record. MO00256438

Based on interview and record review, the facility failed to accurately document completed wound treatments or treatment refusals by the resident on the treatment administration record (TAR) for one resident (Resident #1). The sample was three. The census was 100. Review of the facility's Medical Provider Orders policy, revised, [DATE], showed: -Policy: The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Following of medication and/or treatment orders: -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Dependent on staff for personal and toileting hygiene, lower and upper body dressing, and bathing; -Diagnoses included: Quadriplegia (paralysis of arms and legs), malnutrition (inadequate nutritional intake) and chronic osteomyelitis (infection of the bone); -Three, stage three pressure ulcers (a wound caused by prolonged pressure to an area of the body that has full thickness loss of skin in which underlying fat visible); -Two, stage four pressure ulcers (a wound caused by prolonged pressure to an area of the body that has full thickness skin and tissue loss with underlying muscle and bone visible). Review of the resident's care plan, used while the resident was at the facility, showed: -Focus: The resident is resistive to care by refusing treatments to be completed by nursing and causing his/her wounds to get worse; -Interventions: Allow the resident to make decisions to treatment regime to provide a sense of control; Provide the resident with opportunities for choice during care provisions. -Focus: Wound management; -Interventions: Provide wound care per treatment order. Review of the resident's Treatment Administration Record (TAR), dated 6/1 through [DATE] showed: -An order, dated [DATE], cleanse right ischium (forms part of the hip) with normal saline and wound cleaner, apply soaked gauze and cover with ABD (a large thick dressing) pad twice daily and as needed (PRN); -For 14 out of 43 opportunities, the treatment entry was blank; -An order, dated [DATE], cleanse left sacrum (tailbone) with Vashe (wound cleaner), apply soaked gauze and cover with ABD pad, twice daily and PRN; -For 14 out of 43 opportunities, the treatment entry blank; -An order, dated [DATE], cleanse right sacrum with Vashe, apply soaked gauze and cover with ABD pad twice daily and PRN; -For 14 out of 43 opportunities, the treatment entry was blank; -An order, dated [DATE], cleanse right hip with Vashe, apply soaked gauze and cover with ABD pad twice daily and PRN; -For 14 out of 43 opportunities, the treatment entry was blank; -An order, dated [DATE], cleanse left ischium with normal saline and wound cleaner, pat dry, apply Santyl (an ointment used to remove dead skin) and cover with ABD pad, twice daily and PRN; -For 14 out of 43 opportunities, the treatment entry was blank; -An order, dated [DATE], cleanse left leg with normal saline and wound cleaner, pat dry, apply Xeroform (a specialized dressing), ABD pad and dry dressing, every day; -For two out of six opportunities, the treatment entry was blank; -An order, dated [DATE], cleanse right leg with normal saline and wound cleaner, pat dry, apply moistened gauze and dry dressing, every day; -For two out of six opportunities, the treatment entry was blank. Review of the resident's death in facility tracking MDS, dated [DATE], showed the resident expired on [DATE]. During an interview on [DATE], at 9:30 A.M., Licensed Practical Nurse (LPN) A said staff should document treatments as completed or document if a resident refused on the TAR. The electronic medical record prompts you to put in a reason as to why the treatment was not completed. A box will pop up and the nurse can place a narrative reason in the documentation box. LPN A did not know what it meant when the administration times were left blank. It could be that someone just forgot to chart. During an interview on [DATE] at 11:18 A.M., the facility Wound Nurse said the resident refused wound treatments frequently. She would expect clear and accurate documentation of the resident's treatments. The staff should not leave the treatments undocumented or blank on the TAR. During an interview on [DATE] at 11:44 A.M., the Director of Nursing said she expected clear and accurate documentation of the resident's treatments on the TAR and not for the dates and times to be left blank. During an interview on [DATE] at 12:13 P.M., Nurse Practitioner (NP) D said he/she had a conversation with the resident on [DATE] and [DATE] about the resident's frequent refusals of wound dressing changes and provided education to the resident. NP D said she would expect the staff to document clear and accurate information about the resident's treatments.

Based on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents. Resident #1 had physician orders for a full code status. On [DATE] shortly before 7:00 A.M., staff removed the resident's oxygen when transferring the resident to bed, placed him/her on the bed in a flat position and as staff turned him/her, the resident was noted not to be breathing. Licensed Practical Nurse (LPN) A got the Nurse Manager (NM), who said the resident died. The NM told LPN A two nurses could verify a resident's death. Staff did not perform CPR. The resident expired. The facility had 89 out of 94 resident who were listed as full code. The census was 94. The administrator was informed on [DATE] of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's CPR policy, revised [DATE], showed: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR; -Policy Explanation and Compliance Guidelines: -1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In the absence of advance directives or a Do Not Resuscitate order; and; -3. CPR certified staff will be available at all times; -4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. Review of the facility's Medical Emergency Response policy, revised [DATE], showed: -Policy: It is the policy of this facility to respond to medical emergencies for residents, staff and visitors. Policy Explanation and Compliance Guidelines: -1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance; -2. CPR will continue unless: -a. There is a Do Not Resuscitate (DNR) order in place; -b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection, or decomposition); -c. Initiating CPR could cause injury or peril to the rescuer; -3. A nurse will: -a. Assess the situation and determine the severity of the emergency; -b. Stay with the resident; -c. Designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed; -4. A Code Blue will be announced over the intercom system, if necessary; -5. All available staff will respond to the emergency accordingly; -6. The Registered Nurse (RN) supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed; -7. This will continue until emergency personnel arrive and resident is transported to the emergency room (ER) by the Emergency Medical Services (EMS); -8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In absence of advance directives or a DNR order, and; -c. If the resident does not show obvious signs of clinical death; -9. The RN supervisor or designee will ensure emergency medications and equipment are inventoried and restocked; -10. The night shift supervisor or nurse will ensure that all emergency carts and equipment are stocked and ready to use; -11. The facility will ensure that CPR certified staff are available at all times; -12. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable; -13. This facility will not implement a No CPR policy. Review of the facility's Residents' Rights Regarding Treatment and Advance Directives Policy, revised [DATE], showed: -Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive; -Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated; -Policy Explanation and Compliance Guidelines: -1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive; -2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive; -3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff; -4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities; -5. The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions; -6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate; -7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives; -8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions; -9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care; -10. The facility will not discharge or transfer a resident should they refuse treatment either through an advance directive or directly unless the criteria for transfer or discharge are otherwise met; -11. Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart: -a. What the resident refused; -b. The reason for the refusal; -c. The advice given to the resident about the consequences of refusing; -d. The offering of alternative treatments; -e. The continuation of providing all other services; -12. Any services that would be otherwise required, but are refused, will be documented in the resident's comprehensive care plan; -13. The facility will not initiate or discontinue any other care based on refusal of care by the resident; -14. The facility will use the process as provided by State law for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, seizures, unsteadiness on feet, communication deficit, and muscle weakness. Review of the resident's physician orders active as of [DATE], showed an order of full code (in the event of no pulse, initiation of CPR and summoning 911) with an order start date of [DATE]. Review of the resident's current care plan, dated [DATE], showed he/she had a full code status. During an interview on [DATE] at 12:42 P.M., the Administrator said the resident did not have an advanced directive. The resident did not have the mental capacity to do an advanced directive. Residents only have advanced directives if they are admitted to the facility with one or if a resident voices they would like to have one. If a resident has an advanced directive it is reviewed in the care plan meetings to verify they have the same wishes as listed on their advanced directive. Review of the nurses notes, dated [DATE] at 7:33 A.M., showed LPN A and Certified Nurse Aide (CNA) D did a two man transfer of the resident, into bed. CNA D rolled the resident to check his/her brief, and when he/she rolled the resident onto his/her back, the resident did not appear to be breathing. LPN A called for the Nurse Manager (NM). The NM used a stethoscope and verified the resident had no heartbeat or pulse. Two nurses confirmed time of death as 6:58 A.M. Call placed to Nurse Practitioner (NP) C. During an interview on [DATE] at 7:08 A.M., CNA D said the resident was in the common area from approximately 5:00 A.M. to just before 7:00 A.M. The resident was transferred from the recliner into his/her wheelchair and taken to his/her room. The resident was transferred into his/her bed and when the resident was turned over, CNA D asked LPN A if the resident passed. LPN A got the NM, who listened with a stethoscope and said the resident passed away at 6:58 A.M. CNA D heard LPN A tell the NM several times the resident was a full code. No compressions were done. During an interview on [DATE] at 11:22 A.M., LPN A said on [DATE], he/she and CNA D transferred the resident from the wheelchair to the bed. The resident was breathing when they transferred him/her. LPN A and CNA D had to remove the oxygen so they could transfer him/her, as they didn't want the resident to get caught up in the tube. CNA D transferred the resident onto the bed. Once in bed, CNA D said he/she didn't think the resident was breathing. LPN A assessed the resident by checking for a pulse in his/her neck and arm. LPN A did not feel a pulse. The bed was flat, there was no rise and lowering of the resident's chest to indicate he/she was breathing. LPN A called the NM to confirm no heartbeat. LPN A told the NM the resident was a full code, and the NM said the resident was gone, there was no reason to do CPR, and both nurses could verify the resident expired. CPR was not done. During an interview on [DATE] at 8:30 A.M., the NM said LPN A told him/her he/she didn't think the resident was breathing. The NM checked one side of his/her neck for a pulse and LPN A checked the other side. There was no pulse. LPN A did not say anything to the NM about being a full code. The NM thought the resident was a DNR. During an interview on [DATE] at 12:51 P.M., NP C said she did not tell the NM two nurses could verify a resident's death. Staff reported to her on [DATE] at 7:04 A.M., the resident passed in his/her sleep. During interviews on [DATE] at 9:00 A.M., and [DATE] at 12:30 P.M., the Administrator said she received a phone call from the NM on [DATE] around 7:00 A.M., reporting there was a death in the facility and the resident had expired. The Administrator arrived at the facility around 7:20 A.M. and said LPN A was upset. The NM was calm and on the phone handling things regarding the resident's death. LPN A did not report any concerns to the Administrator. CNA D told the Administrator he/she and LPN A took the resident to his/her room to change him/her, put the resident in bed and when CNA D rolled the resident over, the resident was not breathing. LPN A left the room and had the NM come and check on the resident. The NM told the Administrator LPN A did not have any sense of urgency when he/she asked him/her to come to the resident's room, so the NM said he/she assumed the resident was a DNR. The Administrator's expectation is if a resident is found unresponsive, for staff to assess the resident and check the resident's code status. If the resident is a full code, CPR should be initiated, 911 called, and CPR should continue until EMS arrives and takes over care. The expectation is for staff to follow physician orders, and this includes code status. She expected staff to be knowledgeable of and to follow the facility policies. During an interview on [DATE] at 10:05 A.M., the resident's physician, who is also the Medical Director (MD), said staff should have followed the resident's wishes to be a full code. The MD said the odds of resuscitating someone is much higher if staff are there at the time the resident stops breathing. The chances of being revived if CPR was started at the time the resident stopped breathing versus finding a resident that has not been breathing for an unknown amount of time is much greater if CPR is started immediately and 911 is called at that time. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. Note: At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00249747

Based on interview and record review, the facility failed to notify the physician of one resident's (Resident #1) low lab results and to ensure the Medical Director (MD) and other physicians had full access to lab results in the system the physicians use. The MD was not aware of lab results for seizure medications for Resident #1, and the resident sustained seizure activity 18 days later. The facility also failed to ensure the physician was notified when Resident #1 had a change of condition of new purple discoloration to the resident's fingertips at 8:30 P.M. and did not notify the on call Nurse Practitioner (NP) until approximately 4:30 A.M. after the resident had a fall. The facility failed to document the initial assessment of the change of condition in the medical record. In addition, the facility failed to check gastrostomy tube (g-tube a thin, flexible tube inserted directly into the stomach through a small incision in the abdomen) residuals (the volume of fluid remaining in the stomach) for one of three residents sampled with a g-tube (Resident #13). The sample was 3. The census was 94. Review of the facility's Notification of Changes Policy, revised [DATE], showed: -Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -Definitions: -Life threatening conditions: Examples - Heart attack or stroke; -Clinical Complications: Examples - Development of Stage Two (partial thickness loss of dermis (inner layer of the two main layers of the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (a layer of dead, non-viable tissue that accumulates on the surface of a wound that is typically yellow, white, or gray in color and may appear moist, stringy, or adherent). May also present as an intact or open/ruptured blister) pressure injury (localized area of skin and underlying tissue damage caused by prolonged pressure, shear, or friction), recurrent episodes of delirium (mental state in which a person is confused and has reduced awareness of their surroundings), recurrent urinary tract infection (UTI) or onset of depression; -Need to alter treatment significantly: means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before; -Right to privacy: The facility is required to inform the resident of his/her rights upon admission and during the resident's stay including the resident's right to privacy; -Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; -Circumstances requiring notification include: -1. Accidents; -a. Resulting in injury; -b. Potential to require physician intervention; -2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: -a. Life-threatening conditions, or; -b. Clinical complications; -3. Circumstances that require a need to alter treatment. This may include: -a. New treatment; -b. Discontinuation of current treatment due to: -i. Adverse consequences; -ii. Acute condition; -iii. Exacerbation of a chronic condition; -4. A transfer or discharge of the resident from the facility; -5. A change of room or roommate assignment; -6. A change in resident rights; -Additional considerations: -1. Competent individuals: -a. The facility must still contact the resident's physician and notify resident's representative, if known; -b. A family that wishes to be informed would designate a member to receive calls; -c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident; -2. Residents incapable of making decisions: -a. The representative would make any decisions that have to be made; -b. The resident should still be told what is happening to him or her; -3. Death of a resident: The resident's physician is to be notified immediately in accordance with State law; -4. Notice of room changes: -5. Contact information of the resident's legal representative or family member must be recorded and periodically updated; -6. Right to privacy: -a. The facility is required to inform the resident of his/her rights upon admission and during the resident's stay including the resident's right to privacy; -b. If a resident specifies that he/she wishes to exercise this right and not notify family members in the event of a significant change as specified at this requirement, the facility should respect this request, which would obviate the need to notify the resident's interested family member or legal representative, if known; -c. If a resident specifies that he/she does not wish to exercise the right to privacy, then the facility is required to comply with the notice of change requirements. Review of the facility's Laboratory Services and Reporting Policy, revised [DATE], showed: -Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law; -Policy Explanation and Compliance Guidelines: -1. The facility must provide or obtain laboratory services to meet the needs of its residents; -2. The facility is responsible for the timeliness of the services; -3. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories; -4. If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of services in accordance with the requirements; -5. Assist the resident in making transportation arrangements to and from the laboratory if necessary; -6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record; -7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, seizures, unsteadiness on feet, communication deficit, and muscle weakness. Review of the resident's undated care plan, showed: -Focus: Resident has a seizure disorder; -Interventions: -Give medications as ordered. Monitor/document for effectiveness and side effects, initiated [DATE]; -Monitor labs and report and sub therapeutic or toxic results to physician, initiated [DATE]. Review of the resident's orders, showed: -Keppra 500 milligrams (mg) give by mouth two times a day for seizures, start date [DATE], discontinue (DC) date [DATE]; -Keppra 500 mg give one tablet by mouth every morning and at bedtime related to seizures, start date [DATE], DC date [DATE]; -Dilantin tablet chewable 50 mg give three tablets by mouth two times a day for seizure, start date [DATE], DC date [DATE]; -Dilantin tablet chewable 50 mg give three tablets by mouth every morning and at bedtime for seizures, start date [DATE], DC date [DATE]; -Keppra and Dilantin levels every six months starting on the fourth, start date [DATE], DC date [DATE]. Review of the resident's lab results, showed: -Collected: [DATE] at 8:19 A.M.; -Reported [DATE] at 1:02 P.M.; -Dilantin (phenytoin, medication used to treat seizures. Measures the amount of Dilantin in the blood for therapeutic levels for treating seizures, normal therapeutic range 10-20 ug micrograms (ug) /mL); -Less than (<) 2.5 ug/mL, Low; -Keppra (levetiracetam, medication used to treat seizures. (levetiracetam, measures the amount of Keppra in the blood for therapeutic levels to treat seizures, normal therapeutic range 6-46 ug/mL); -< 2 ug/mL, Low. Review of the resident's progress notes, showed: -[DATE] at 11:02 A.M., labs reviewed, see order management; -[DATE] at 2:11 P.M., labs reviewed, see order management; -No documentation the physician was notified of the low Dilantin and Keppra levels. Review of the resident's orders, showed: -No new orders entered on [DATE]. Review of the resident's progress notes, showed: -[DATE] at 10:50 P.M., resident started to have a seizure at 10:50 P.M. lasting for five to six minutes. Emergency Medical Services (EMS) called at 11:00 P.M. EMS arrived at 11:15 P.M. and upon assessment resident was stable; -[DATE] at 4:08 A.M., resident was sitting in common area by the nurses station when this nurse noticed the resident having strange behavior. Nurse approached resident and resident was having a seizure at 4:00 A.M. lasting for five to seven minutes. On call NP notified. Review of the resident's physician progress note written by the resident's physician/Medical Director, dated [DATE], showed: -Progress Note Acute Care: -Chief Complaint: Physical acute visit: -Interval History: Resident seen and examined at bedside. Resident is reported to have had two seizures overnight earlier this week. Per resident and nursing, resident has been at baseline since seizures occurred and had no proceeding symptoms or signs of illness. Resident had recent bloodwork, but it did not include levels for his/her antiepileptic (medication used to prevent or treat seizures) medications or follow up on his/her hypothyroidism (thyroid does not produce enough thyroid hormone); -Labs: Labs listed, but did not include TSH 3 UL, Dilantin, Keppra; -Assessment/Plan: Seizures: Continue current medications and will check therapeutic levels. During an interview on [DATE] at 11:17 A.M., the MD said regarding her progress note on [DATE], she was unable to see any labs regarding the resident's Keppra levels, Dilantin levels and TSH levels. The MD said the electronic records system the facility uses, Point Click Care (PCC) and the lab system talk to the system the physicians use and those labs were not in her system. The MD logged onto PCC and went to the resident's medical record, looked under labs and opened the lab results that were collected on [DATE] and reported on [DATE]. When the MD looked at the lab results in PCC, she noticed the lab results for Keppra levels, Dilantin levels and TSH levels. The MD said she could see all the lab results were not pulled over from PCC. The MD said usually the nurse will report any abnormal lab results to the NP or herself. There was no adjustments made on the resident's seizure medication by the acting NP at that time and if the results of the Keppra and Dilantin levels were reviewed on [DATE], there would have been an adjustment made on the resident's seizure medication and an order to recheck the labs. The NPs also use the same system the MD does for reviewing resident charts. The resident ended up having two seizures after the labs were drawn and the labs showed the seizure medication was not at a therapeutic level for the resident. The resident had labs completed on [DATE] and the Keppra and Dilantin levels were in normal range at that time, so the low levels could have been because the resident was not metabolizing the medication well or the resident was not receiving the medication consistently. During an interview on [DATE] at 11:56 A.M., Licensed Practical Nurse (LPN) H said lab results are under the results tab in PCC or the nurse can call the lab to get results. The nurses are responsible for checking the results tab if a resident had labs completed to view the results. The lab will call the facility if there are critical lab results and report those critical lab results to the nurse on duty. The lab does not call if there are abnormal labs. It is the nurse's responsibility to follow up on the lab results and report them to the NP or physician. If a lab has abnormal results, LPN H sends them to the NP through fax or sends them a photo of the labs. LPN H does not look at the specific lab results prior to sending them to the NP or physician. LPN H would document in a progress note if the labs for the resident were sent to the NP or physician. During an interview on [DATE] at 12:04 P.M., LPN I said he/she goes through PCC to get lab results for residents or he/she can log into the lab portal and get the results of a resident's labs. If a resident has abnormal labs, the lab will call the facility and inform the nurse of the abnormal labs that are high or low. It does not have to be critical result. LPN I would then immediately call the physician and report the abnormal labs. With abnormal labs, the physician may want to adjust the resident's medication or send the resident to the ER depending on what labs are abnormal. If all lab results were normal, LPN I would still notify the NP or physician the labs were normal and would leave them for them to review. If there were abnormal labs, LPN I would not wait on the NP to come in and review the labs, he/she would call and notify the physician. The notification would be documented in a progress note, including if the physician had any new orders for the resident. If a resident was being checked for Keppra and Dilantin levels and the labs came back low, he/she would call the physician immediately because the physician would probably want to increase the seizure medication or may want to send the resident to the hospital. If the numbers came back low, that would increase the possibility of the resident having seizures and that is why it would be important for report it to the physician. During an interview on [DATE] at 12:30 P.M., the Administrator said the facility gets lab results electronically in PCC by the lab company. The Administrator said the lab will call the facility if there are critical results that need to be reported. It is the nurse's responsibility to look for lab results for residents who have had labs drawn. The Administrator said management also checks the lab and radiology results daily during the week when they have their clinical meetings. If a resident has abnormal labs, the expectation is the nurse will report the abnormal labs to the NP or physician. It is expected the nurse will document the notification in a progress note along with any new orders the NP or physician gives. The Administrator expected the physicians and NPs to have access to view all lab results in their system. If lab results came back as low for Keppra <2.5 and Dilantin <2, that would be a concern for that resident. The Administrator would be concerned the resident could have seizures due to the Keppra and Dilantin levels not being in a therapeutic range. The Administrator expected staff to be knowledgeable of and to follow the facility policies. During an interview on [DATE] at 1:02 P.M., the Director of Clinical Intervention (DOCI) said labs are dumped into PCC and the NP, physician, or the MD has to sign off on them. The DOCI said it is the nurse's responsibility to check the dashboard in PCC at least three times each shift and that would notify the nurse as an alert if a resident had new lab results. She expected nurses to review the labs results in PCC as they have been taught and to notify the NP or physician if there are abnormal labs. She also expected the nurse to document the notification in PCC. The DOCI said she expected the MD and NPs to be able to see all residents full lab results in their system. She would be concerned about the resident having seizures if the lab results came back low for Keppra and Dilantin, if the resident was using the medication for seizures. The DOCI expected staff to be knowledgeable of and to follow the facility policies. Review of the resident's progress notes, dated [DATE] at 4:51 A.M., showed the resident was found on the floor unable to explain how he/she got there. LPN A did full body assessment, no open areas noted upon getting resident to his/her feet. Resident unable to walk without assistance so nurse placed resident in wheelchair and brought him/her to the nurse's station to check vital signs (VS). Resident blood pressure (BP, normal 120/80) 125/92, pulse rate (P, heart beats per minute (BPM), normal range 60 - 100) 101, oxygen saturation (SpO2), 93% on room air (RA) (normal range, 95% - 100%), respiratory rate (R, breaths per minute, normal range is 12-18) 16, temperature, (T, normal 98.6 degrees Fahrenheit (F)) 98.1. Resident also has some noted blue fingertips when asked if resident was experiencing pain resident denied. Resident was placed on 2 liters (L) of oxygen for comfort resident not showing and signs or symptoms (S/S) of distress. Call placed to on call NP E. NP E stated to continue to monitor resident as normal and he/she will inform in house NP C to round on resident regarding blue fingertips. During an interview on [DATE] at 8:12 A.M., CNA F said the first time he/she worked with the resident was on [DATE] day shift (7:00 A.M. to 3:00 P.M.) and evening shift (3:00 P.M. to 11:00 P.M.). CNA F said while working the evening shift, he/she noticed the resident's fingertips were purple and that was the first time CNA F saw this and it scared her because that means no oxygen. CNA F reported the resident had purple fingertips to LPN G. During an interview on [DATE] at 11:22 A.M., LPN A said he/she worked the night shift (7:00 P.M. to 7:00 A.M.) on [DATE] and was at the facility from approximately 7:30 P.M. to 9:00 A.M. on [DATE]. LPN A said CNA F reported to him/her the resident's fingertips were purple at the start of shift change, approximately 8:30 P.M. LPN A said he/she and LPN G assessed the resident and gave the resident his/her seizure medication. The resident was in bed. LPN A said the resident was fine except his/her fingertips were purple. LPN A said the assessment he/she completed on the resident was a grip test, asked the resident if he/she was in pain, the resident denied pain, and checked the resident's SpO2 levels. It was 96% on RA. The resident was not using oxygen. LPN A said NP C was going to see the resident the next day. LPN A did not notify the on-call NP E at that time. Around 4:45 A.M., CNA D and LPN A went to the resident's room because the call light was on. When CNA D and LPN A entered the resident's room, the resident was crawling around on the floor on his/her roommate's side of the room. LPN A said he/she performed a full body assessment on the resident and found nothing abnormal. LPN A transferred the resident from the floor into a wheelchair and brought the resident up to the nurse's station in the wheelchair a little before 5:00 A.M. to take the resident's vitals. LPN A said the resident's vitals were alright. His/Her pulse was elevated, the SpO2 was kind of low at 93% and LPN A placed the resident on 2 Liters (L) of oxygen with a nasal cannula. LPN A said the resident's fingertips were still purple. LPN A wanted to send the resident to the hospital at that time to get evaluated, because he/she was a full code (in the event of no pulse, initiation of CPR and summoning 911), fell, his/her SpO2 was low, his/her pulse was elevated, and the resident had purple fingertips. LPN A said the Nurse Manager (NM) who was working the night shift said the resident's vital signs were stable, and they just needed to monitor the resident. LPN A said he/she discussed his/her concerns with NM and told the NM the resident was a full code. LPN A called NP E and notified NP E about the fall, resident's vital signs, and the purple fingertips. The NM and CNA D moved the resident to the common area in front of the nurse's station. LPN A was completing vital signs and neurological checks on the resident after the fall, and they were within normal range. The resident continued to wear oxygen during this time. When other residents began coming into the common area, LPN A and CNA D transferred the resident from the recliner into the wheelchair to take the resident back to his/her room to change the resident. The resident was breathing when he/she was transferred into the wheelchair. LPN A removed the oxygen from the resident prior to the transfer because LPN A did not want the resident to get tangled up in the oxygen tubing. The resident was not wearing oxygen when he/she was brought to his/her room. CNA D transferred the resident into his/her bed and when CNA D rolled the resident over, CNA D told LPN A, he/she did not believe the resident was breathing. LPN A assessed the resident by checking for a pulse in the resident's neck and arm, LPN A did not feel a pulse. The resident's bed was in a flat position and LPN A did not see any rising or lowering of the resident's chest. LPN A did not have a stethoscope on him/her so he/she called the NM to the resident's room to assess the resident and confirm there was no heartbeat. NM confirmed there was no heartbeat and told LPN A the resident was gone so there was no reason to perform cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) and two nurses could verify death. NM called NP C to report the resident's time of death. During an interview on [DATE] at 7:08 A.M., CNA D said he/she and LPN A answered the call light on [DATE] early in the morning and the resident was on the floor on his/her roommate's side of the room. The roommate said the resident walked to his/her side of the room and fell. CNA D and LPN A picked the resident up and took the resident by wheelchair to the nurse's station. CNA D said the resident's vital signs were stable, but LPN A did not like how the resident looked. CNA D said the resident's eyes were sunken in and the resident had blue fingertips. LPN A wanted to send the resident to the hospital. That was the first time CNA D noticed the resident having purplish/bluish colored fingertips. The pointer finger was discolored from the second bend to the tip and the middle finger was discolored from the first bend to tip on both hands. The resident was responsive while at the nurse's station when he/she would say the resident's name the resident would look at CNA D. When LPN A took the first set of vitals, he/she wanted to send the resident out. LPN A verbalized to NM that he/she wanted to send the resident out and NM said not to send the resident out, because the resident's vitals were stable, and the hospital complains because the facility sends residents out so frequently. NM and CNA D moved the resident onto the couch in the common area in front of the nurse's station. Then NM and CNA D moved the resident to the recliner because the resident did not look comfortable on the couch. The resident was then moved from the recliner to the wheelchair a little before 7:00 A.M. to bring the resident down to his/her room to change him/her. CNA D said the resident's eyes were closed and he/she thought the resident was just sleeping. After transferring the resident into bed, when the resident was turned over, CNA D asked LPN A if the resident passed away, because it didn't look like the resident was breathing. LPN A got the NM and the NM listened to the resident and said that the resident passed away at 6:58 A.M. CNA D said LPN A told NM the resident was a full code. The NM said the resident was already gone. During an interview on [DATE] at 8:39 A.M., the NM said he/she came into work the night shift on [DATE] around midnight and worked into the morning of [DATE]. The NM was not aware of any change of condition for the resident until around 4:40 A.M. to 4:45 A.M. when a call came to the nurse's station from the resident's roommate that the resident was on the floor. LPN A and CNA F went down to the resident's room and brought the resident up to the nurse's station in a wheelchair. LPN A used a wrist blood pressure cuff and could not get a reading on the resident, so the NM did a manual blood pressure. The blood pressure was 120/80 or 120/90. LPN A used a pulse oximeter (device that measures the oxygen saturation of the blood) on the resident's finger. The SoO2 reading was 93% on RA and his/her pulse was 101. The resident's fingertips were discolored. LPN A told the NM he/she believed the resident had Raynaud's disease (condition that causes blood vessels in the extremities (usually fingers and toes) to narrow excessively in response to cold temperatures or stress and it is often accompanied by changes in the color of the skin). NM said the resident's three fingertips, pointer finger, middle finger and ring finger on his/her right hand, were a purplish/blue color from the tips to the first bend of the finger. The resident's left hand also had the same purplish/blue discolor on the same three fingers, but it was lighter than the right hand. NM had seen the resident on [DATE] during the day with NP C and the resident's fingertips were not like that during the day. NM said the discoloration, which was not normal for the resident and was showing something acute (something that begins suddenly) and new. The NM was concerned why the resident's fingertips would be changing colors. The resident was placed on supplemental oxygen on 2L with a nasal cannula after obtaining vital signs after the resident had the fall, and before the resident was transferred onto the couch in the common area. The NM and CNA D transferred the resident onto the couch and laid him/her down and then transferred the resident into the recliner next to the couch. NM said his/her observation of the resident stopped at that time, around 5:00 A.M., because he/she began passing medications to his/her assigned residents. LPN A did not say anything about wanting to send the resident out to be evaluated at the emergency room (ER) or that the resident was a full code. LPN A was calling his/her name and said come here I think I need your help. The NM did not feel that there was any urgency when LPN A requested help. When the NM got to the resident's room, LPN A said he/she did not think the resident was breathing. The NM checked one side of the resident's neck and LPN A checked the other side. There was no pulse. LPN A did not say the resident was a full code, so the NM thought the resident was a Do Not Resuscitate (DNR, in the event no pulse no life saving measures to be taken, no CPR) because LPN A did not use any urgency when asking for assistance. LPN A told NM he/she thought the resident died in his/her sleep so the NM called NP C right then and informed NP C the resident expired in his/her sleep. The resident was pronounced expired at 6:58 A.M. NP C gave a death diagnosis of cerebrovascular accident (CVA, stroke). During an interview on [DATE] at 7:08 A.M., CNA J said he/she worked the night shift on [DATE] but was not assigned to the resident. CNA J said when the resident was brought up to the nurse's station, he/she was alright for a minute then his/her head went back, and the resident went incoherent while sitting in the wheelchair at the nurse's station. CNA J stood in front of the resident when LPN A took the resident's vital signs, and the resident went incoherent. The resident's head went back and he/she wasn't answering the nurses, LPN A and NM. The NM and CNA D transferred the resident to the couch and LPN A put oxygen on the resident. They tried to lay the resident flat on the couch, but the resident didn't look comfortable. The resident was breathing fast at first, but his/her breathing slowed down after a little while. When CNA J saw the resident next, he/she was in the recliner, the resident was on the couch maybe five to ten minutes. The resident was transferred into the wheelchair and taken to his/her room. The oxygen was removed before the resident was transferred. CNA J said the resident did not look good because the resident's jaw looked sunken in. During an interview on [DATE] at 9:38 A.M., NP E said she was on call for the facility and received a call from the facility at 4:39 A.M. on [DATE]. LPN A reported the resident had an unwitnessed fall, the resident's vital signs were stable. The resident was seen on [DATE] during the day at the facility NP C. LPN A reported the resident had purplish colored fingertips since that morning. NP E recommended to monitor and do neuro checks per facility protocol and have facility NP C round on the resident to check it ou

Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents were involved in physical resident to resident altercation, after an argument escalated with both residents hitting each other (Residents #1 and #2). The residents were separated by staff and other nearby residents. The sample was four. The census was 91. The facility was notified of past non-compliance on 9/25/24. Facility staff notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on the abuse and neglect prevention, intervention and de-escalation of resident arguments and disagreements. This deficiency was corrected on 9/18/24. Review of the facility's Abuse, Neglect and Exploitation, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -The facility will have written procedures to assist staff in identifying the different types of abuse: mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations; -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur; -The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: -Responding immediately to protect the alleged victim and integrity of the investigation; -Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; -Increased supervision of the alleged victim and residents; -Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; -Protection from retaliation; -Providing emotional support and counseling to the resident during and after the investigation, as needed; -Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/24, showed: -Diagnoses included hypertension (high blood pressure), kidney failure, obstructive uropathy (urine is unable to drain through urinary tract), Parkinson's disease (chronic, progressive nervous system disorder), malnutrition, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) and asthma; -No cognitive impairment; -No behaviors. Review of the resident's care plan, in use during survey, showed: -Focus: Resident smokes tobacco. Resident has a history of begging for cigarettes; -Goal: Resident will adhere to the tobacco/smoking policies of the facility; -Intervention: Cigarettes (or other smoking materials) and lighter at nurse's station; -Conduct smoking safety evaluation on admission and as needed (PRN); -Educate resident/ responsible party on the facility's tobacco/ smoking policy; -If a smoking facility, orient resident to smoking times and procedures; -Notify charge nurse immediately if it is suspected resident has violated facility smoking policy; -Focus: The resident has a behavior problem related to struck a resident after resident had ran over his/her foot with his/her wheelchair; -Goal: Resident will have no evidence of behavior problems; -Interventions: Anticipate and meet the resident's needs; -Nurse Practitioner (NP) assess if need for further medical attention, monitor for pain, and swelling; -Urinalysis (UA, a lab test that checks for bacteria in the urine) and culture and sensitivity (C&S) and routine labs. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Diagnoses included hypertension, peripheral vascular disease (circulatory condition), hyperlipidemia (high level of lipids in the blood), depression, -Moderate cognitive impairment; -No behaviors. Review of Resident #2's care plan, in use during survey, showed: -Focus: The resident has a behavior problem. Resident has been noted smoking marijuana while in the facility; -Goal: The resident will have fewer episodes of behavior; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Caregivers provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by; -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention, remove from situation and take to alternate location as needed; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes; -Praise any indication of the resident's progress/improvement in behavior; -Provide a program activities that is interest and accommodates residents status; -Focus: Resident is dependent on tobacco and requires staff supervision during smoke breaks; -Goal: The resident will have minimized risk of injury from unsafe smoking practices; -Interventions: Cigarettes (or other smoking materials) and lighter nurse's station; -Educate resident about smoking risks and hazards. Encourage resident to participate in a smoking cessation program; -Instruct resident about the facility policy on smoking: Locations, smoke times, facility rules, and safe smoking practices; -Notify social worker/administrator immediately if it is suspected resident has violated facility smoking policy; -Observe clothing and skin for signs of cigarette burns; -The resident requires supervision while smoking; -Focus: The resident has a behavior issue related to resident to resident, striking at another resident after running over his/her foot; -Goal: The resident will have no evidence of behavior issues physical aggression; -Intervention: Remove from motorized wheelchair. Therapy to re-evaluate for safe use while in motorized wheelchair for safety; -Supervise safety after separation. Review of Resident #2's progress notes, showed: -On 9/18/24 at 2:07 P.M., during smoke break residents were lined up to go outside. Resident #1 tried to rush past the other residents that were waiting which caused him/her to have his/her foot ran over by this resident's motor chair. Both residents were separated by staff. NP & Director of Nursing (DON) notified. Residents are on one on one observation this shift; -On 9/19/24 at 7:11 A.M., patient remains on observation for resident to resident. Patient has been in his/her room throughout the night resting with eye closed breathing non labored. Patient voiced no complaints of pain and no signs and symptoms of distress. Patient vital signs 128/70 (blood pressure), 68 (pulse), 18 (respirations), 98% (oxygen saturation) room air. Patient in a pleasant mood. Patient up and in chair in dining room waiting to go smoke at this time. Plan of care ongoing; -On 9/20/24 at 6:57 A.M., patient remains on observation for resident to resident. Patient has been in his/her room throughout the night resting with eye closed breathing non labored. Patient voiced no complaints of pain and no signs and symptoms of distress. Patient in a pleasant mood. Patient up and in chair in hallway talking to other resident waiting to go smoke at this time. Plan of care ongoing; -On 9/20/24 at 2:41 P.M., resident remains on observation for resident to resident altercation. No behaviors noted. Resident currently in the dining room playing cards with other residents. Will continue to monitor; -On 9/21/24 at 3:11 P.M., resident remains on follow-up observation day 2/3 due to resident to resident altercation. No behaviors were noted during the evening shift. Vitals signs are stable. Presently resting in bed with both eyes closed, breathing is non-labored; -On 9/22/24 at 1:11 A.M., resident remain on follow-up observation day 3/3 due to a resident/resident verbal altercation. No altercations noted or reported this evening, nor through the night. Presently resting in bed with both eyes closed. Respirations even and non-labored; -On 9/22/24 at 1:39 A.M., resident declined to have vital signs taken. Stated, someone else already checked them. Review of Resident #1's progress notes, showed: -On 9/18/24 at 10:27 A.M., resident reported to be in a resident-to-resident altercation. Resident seen standing near nurses station, agreeable to talk to this writer. Reports other resident ran over toe with wheelchair and he/she was pushed in chest. Agreeable to physical exam. Resident alert and appears in no distress. Slight smell of urine noted. Additionally, appears urine on floor in room. Bilateral feet dry with onychomycosis (fungal infection). Hypertrophic toenails (increase of soft tissue volume at the distal edge of the nail). No redness, cuts, bruises or pain when feet palpated. Labs ordered, UA with CS added. Discussed with resident, resident is agreeable at this time. Foot care provided, toenails trimmed and filed with Dremel (a tool used to remove excess skin and overgrown nails). Resident tolerated well; -On 9/18/24 at 2:23 P.M., resident had an altercation with another resident. At pervious smoke session this resident jumped the line of resident heading outside to smoke causing the other resident to hit his/her foot with his/her power chair. This resident then spilled some of his/her coffee. The resident began to have a verbal altercation thinking each resident did what they did on purpose. Both residents were separated and assessed. NP was present so he/she was informed of event. No new orders (NNO) or injuries received. Will continue to monitor both parties; -On 9/18/24 at 7:25 P.M., resident has UA sample in fridge. Resident tolerated procedure well. Will notify physician of results; -On 9/19/24 at 7:12 A.M., patient remains on observation for resident to resident. Patient has been in his/her room throughout the night resting with eyes closed breathing non labored. Patient voiced no complaints of pain and no signs and symptoms of distress. Patient vital signs 135/72 (blood pressure), 18 (respirations), 98.1 (temperature), 99% (oxygen saturation) room air. Patient up in a pleasant mood. Patient in dining room waiting for breakfast. Patient asked this nurse to warm up coffee, this nurse did as patient asked. Patient has no new concerns. Plan of care ongoing; -On 9/20/24 at 7:03 A.M., Patient remains on observation for resident to resident. Patient has been in his/her room throughout the night resting with eyes closed, breathing non labored. Patient voiced no complaints of pain and no signs and symptoms of distress. Patient vital signs 132/76 (blood pressure), 18 (respirations), 80 (heart rate), 97.8 (temperature), and 99% oxygen saturation room air. Patient up in a pleasant mood. Patient near nursing station watching morning news, waiting to go smoke. Patient has no new concerns, Plan of care ongoing. During an interview on 9/23/24 at 10:05 A.M., Resident #1 said he/she went out of the door to go outside to smoke, and Resident #2 got in the way. He/She ran over his/her left toe. There was a little bit a pain at the time. Resident #1 said, you ran over my toe and Resident #2 said, you were in my way and then you need to watch yourself. Resident #1 replied, I do not have to do it and Resident #2 responded I will do it again. Resident #1 and Resident #2 started to call each other names. Resident #1 repeated what he/she said to Resident #2, you no good (man/woman), you were with all those (men/women). Resident #2 said, I'll do it again and beat your ass. Resident #2 hit Resident #1 in the upper chest and Resident #1 hit Resident #2 on the back on his/her neck. Resident #2 started swinging, but Resident #1 got out of the way. Resident #1 said he/she set his/her coffee down and they started to fight, but staff broke it up. Resident #2 said you cannot whoop my ass. Resident #1 said, bitch, [NAME], you prostitute punk, you were in my way. He/She said Resident #2 was not going to do anything. Resident #1 said he/she never been in a wheelchair, so Resident #2 is not doing nothing. Resident #2 thinks he/she was going to whoop my ass. He/She needs to go back to the other table with his/her friend. Resident #1 was not hurt. The foot stung, but that was it. There was no pain, redness, bruising, or swelling to the foot. He/She had staff cut down his/her toenail. The coffee spilled a little on him/her and did spill on Resident #2. There were no in the past issues with Resident #2. He/She never saw Resident #2 in an altercation. He/She feels safe at the facility. During an interview on 9/23/24 at 9:50 A.M., Resident #2 said it was during the smoke break. He/She was sitting at the door, and Resident #1 crossed him/her and went out the door. He/She started to spill the coffee and Resident #2 said do not spill your coffee on me. Resident #1 said something, but Resident #2 did not remember what he/she said, but Resident #1 hit him/her. Resident #1 only hit him/her on the shoulder, and it did not hurt. Resident #2 did not hit Resident #1 back because after he/she hit him/her, Resident #1 ran to the door and told staff that Resident #2 rolled over his/her foot. That was a lie. Resident #2 said he/she was 200 pounds and this is a big wheelchair and if I rolled over his/her foot, he/she would not be able to walk around at all. Resident #1 always picks on other residents, but Resident #2 never witnessed Resident #1 in a physical altercation. Resident #1 thinks he/she is Sergeant of Arms around here. Resident #2 said he/she felt safe. Review of the facility's abuse investigation report, showed: -Date/time alleged incident reported: 9/18/24 at 10:18 A.M.; -Date/time alleged incident occurred: 9/18/24 at 9:20 A.M.; -Location of incident: smoke area; -Name of person who reported alleged incident: Housekeeper A -Type of abuse: physical; -Summary: Resident #2 states he/she was in the doorway waiting to go out to smoke. When the door opened, Resident #1 rushed past him/her, nearly spilling his/her coffee on Resident #2. Resident #2 states do not run in front of me before I run you over, and you almost spilled coffee on me. Resident #1 took that as a threat and began cursing at him/her and then they both went back and forth with threats of hitting. He/She states Resident #1 hit him/her and a resident jumped in to stop it before he/she could hit back; -Summary of interviews with witnesses: Witnesses state they saw residents hitting each other for a brief period before being separated. No witness was able to clearly state if it was the running over Resident #1's toe or just Resident #2's verbiage that started the verbal aggression. Witnesses agree the situation was handled quickly and appropriately; -Summary of interviews with staff: Staff agrees there was verbal altercation that proceeded physical. It is unclear if he/she rolled over his/her toe or if it was Resident #2's comment that started the verbal. Staff agrees it was handled quickly and appropriately; -Summary of investigation findings: The facility has completed investigation including interviews with residents and staff. It can be concluded that there was an altercation between Resident #2 and Resident #1. Based on interviews and assessments, the facility cannot conclude that Resident #2 ran over Resident #1's foot. Both residents have continued their normal daily routines and have had no further issues or psychosocial decline. Both stated they feel safe in facility; -Outcome of the investigation and any interventions/changes to plan of care: As a result of this incident, police were notified as well as NP and regional supervisors. Residents were separated and closely monitored by staff. They were thoroughly assessed for pain, injury, mental well-being and safety and comfort. Staff and residents have been informed that there must be a single-file line when going out to smoke. Review of Resident #3's written statement, dated 9/18/24, showed: -Did you see a resident to resident altercation: yes; -Who hit who first: Resident #2 did not run over his/her feet. Resident #1 swung on him/her first. Resident #2 was not able to swing back because they jumped in the middle. He/She was trying to go outside and Resident #1 almost run into him/her. He/She said do not run in front of me because I am able to run you over. He/She did not mean it like that, but just letting him/her know to be careful because he/she could get run over; -Was staff present? How was it stopped: The girl smoking us tried to stop it, but Resident #1 over powered him/her and he/she yelled for help. Resident and kitchen guy stopped it; -Do you continue to feel safe: Yeah I feel safe. During an interview on 9/23/24 at 9:10 A.M., Resident #3 said he/she witnessed the altercation between the two residents. He/She was outside next to Resident #2. Both residents were in the wrong on how the situation was handled. Resident #1 almost spilled his/her coffee and Resident #2 moved back in his/her wheelchair and said, you almost spilled coffee on me. Then Resident #2 went off. Resident #3 did not remember what was said, but Resident #1 started moving toward Resident #2. No coffee was spilled on the residents. When Resident #1 started moving toward Resident #2, he/she swung at him/her, and Resident #2 swung back. They both missed. Resident #3 said he/she got in between the two residents and tried to break it up. Staff was there as well. Staff was young and skinny. He/She tried to break it up, verbally and then physically by putting him/herself in between the residents. The wheelchair never rolled over Resident #1's feet. That was a motorized wheelchair and if he/she rolled over his/her foot, everyone would have known about it. That is a heavy wheelchair. You would not be able to do anything after that. Residents #1 and #2 had never been in a altercation prior to this. They do not interact with each other. They usually sit on opposite sides of the smoking area. Maybe they had a bad day, but to Resident #3's knowledge, it was a one time thing that he/she witnessed. They did not have altercations with other residents. Review of Resident #4's written statement, dated 9/18/24, showed: -Did you see a resident to resident altercation: Yeah I was right there; -Who hit who first: Both swung at the same time. I do not know what it was about; -Was staff present? How was it stopped: I tried to stop it. I rolled my chair between them. My whole point was to try to stop. I think Resident #1 almost spilled coffee on Resident #2; -Do you continue to feel safe: Yeah I feel very safe. Review of Housekeeper A's written statement, dated 9/18/24, showed: -When did you last see these residents: When we were outside smoking; -Did you observe an altercation: Yes, I got in between them to stop it; -Who hit who first: Resident #1; -How was it stopped: Me and a resident broke it up. During an interview on 9/23/24 at 10:32 A.M., Housekeeper A said it all happened in a second. He/She was at the door to go to the outside patio. Resident #2 was in line. As soon as he/she handed Resident #2 the cigarette, Resident #1 tried to get by him/her. He/She heard Resident #1 say, you can't just rush, wait a minute. Housekeeper A said Resident #1 tried to go around them. Then Housekeeper A heard, I'll beat your ass. It was basically someone jumping in front of someone over a cigarette. Housekeeper A told Resident #1 to walk around to the other side, but came back to Resident #2. Resident #2 said Resident #1 thinks he/she is special. When they got their cigarettes, they were still arguing. Both residents hit each other at the same time. They went up to each other and started hitting each other. Resident #1 was hit in his/her upper chest. Resident #2 was hit, on his/her arm. It was open handed. Housekeeper A got in between them along with another resident. Housekeeper A had Resident #1 and the other resident was keeping Resident #2 away. As soon as he/she saw the residents swing, they were separated. It happened near the door, so other residents did not get to go out because they started fighting. The residents yelled for staff. Administrator and other staff arrived, but Housekeeper A broke up the altercation and stayed until staff arrived. No one was hit in the face. Coffee had spilled, but Housekeeper A was not sure if it spilled on a person. It could have spilled on Resident #1 because he/she was holding it. Resident #1 always has a cup in his/her hand and always spills coffee. Housekeeper A was not sure if the coffee was hot, but he/she always has his/her cup. Housekeeper A never witnessed Resident #2's wheelchair run over his/her foot. Resident #2 is good and he/she flies in the wheelchair, but he/she was not moving quick in his/her wheelchair at that time. He/She was already there. Resident #1 was in a hurry and tried to get in front of the line. Housekeeper A said he/she felt the other residents pick on Resident #1 sometimes. He/She told Resident #1 to ignore Resident #2, but Resident #1 ended up walking near Resident #2 and Resident #2 moved closer to Resident #1, and that was when it happened. It happened so fast. It was about five minutes from the time they received their cigarettes, argued, started fighting, and were separated. Housekeeper A never witnessed the residents in an altercation with each other or other residents before. Since the incident, they have been to make sure the residents are separated when they are smoking. There have been no arguments. During an interview on 9/23/24 at 12:57 P.M., Certified Nurse Aide (CNA) B said he/she was there on that day. He/She witnessed it, but he/she was in the dining room. It was early in the morning and he/she believed Housekeeping was also with the residents. He/She saw Resident #2 roll over Resident #1's foot. Resident #1 said something to Resident #2. He/She said, you rolled over my foot. Resident #2 said I should have rolled over you. They were all going out the door. Resident #2 was behind Resident #1 and hit his/her foot. When Resident #2 hit Resident #1's foot, CNA B did not remember if anyone intervened. Resident #2 rolled past him/her, and he/she was outside at that point. Both residents were back and forth with the names. Resident #2 hit Resident #1 first on his/her shoulder. Resident #1 hit Resident #2 back and that was the end of it. CNA B took Resident #1 and walked around the nurse's station and then he/she went to their room. CNA B did not see Resident #1 again that morning. Resident #1 said he/she was fine. The other residents think Resident #1 is a snitch because he/she snitches on their illegal activities. CNA B thought the wheelchair incident was an accident, but then Resident #2 said, I should have rolled over you. CNA B believed Resident #2 showed off in front of his/her friend. CNA B said neither resident had a history of aggressive behavior. The other residents believe Resident #1 is a snitch, so they do not interact with him/her like that. During an interview on 9/23/24 at 7:45 A.M., the DON said both residents are still in the facility, but they do not reside on the same hall. There have been no issues since the altercation. They stay out of each other's way. The residents never had any physical altercation or verbal alteration history. During an interview on 9/23/24 at 8:50 A.M., the Administrator said Resident #1 said Resident #2 rolled over his/her foot. Resident #2 said it did not happen. There were no injuries to the resident's foot. At 1:00 P.M., the Administrator said the other residents believe Resident #1 is a snitch. The younger residents try to smoke marijuana and he/she tells staff. He/She keeps to him/herself for the most part. If someone makes fun of him/her, that does set him/her off as well. The resident is often bored, so they find activities for him/her to do. He/She was not able to purchase cigarettes in the past, so staff purchased them for him/her. The resident offered to help out with activities, but the other residents thought he/she was special or received special treatment. Resident #2 stays under the radar because he/she often did things he/she should not do. He/She plays cards and visits with another resident he/she is in a relationship with. There had been no reports of altercations and or further concerns. During an interview on 9/25/24 at 2:20 P.M., the Administrator said the in-service, dated 9/18/24, included intervening when residents are in an argument. Housekeeper A thought the argument was over; however, Resident #1 walked back around to Resident #2 and they started again. The Administrator expected staff to intervene and de-escalate arguments between residents, so it will not become a physical altercation. MO00242261

Based on observation, interview, and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment. One resident's air conditioning unit leaked into the room, causing puddles under the bed and a wet feel and smell in the room (Resident #78). One resident's call light indicator, above his/her room door, did not work resulting in a delay in staff answering the call light (Resident #16). In addition, staff failed to provide a homelike environment on the 300 hall when there were floor tiles chipped, baseboard and transition strips chipped and broken along the floor, and the door frame for room [ROOM NUMBER] pulled away. The census was 85. The sample was 18. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission to the facility, showed: -Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination; -Right to a dignified existence: A homelike environment, and use of personal belongings when possible. 1. Review of Resident #78's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/6/24, showed: -Cognitively intact; -Diagnoses included anxiety disorder, depression, and asthma. During an interview on 7/29/24 at 12:38 P.M., the resident said his/her air-conditioning until is leaking water. Staff are aware. It started a couple weeks ago. Maintenance staff came in, took the cover off, and said they were going to fix it. They left the room and never came back. This was a week ago. Observation showed the air-conditioning/heating unit cover leaned against the wall near the resident's head of bed. The inner workings of the unit visible. The room with a wet smell and feel. A small puddle noted near the wall under the unit. Observation and interview on 7/30/24 at 6:29 A.M., showed the resident lay in bed. The bed located on the far side of the room near the window. An air-conditioning/heating unit installed into the wall under the window. The cover of the unit leaned against the wall near the resident's head of bed. The inner workings of the unit visible. A large puddle of water pooled under the resident's bed. A wet blanket saturated, lay under the bed on the floor. The puddle extended out from under the bed. The resident said staff put the blanket down to soak up the water. Observation on 7/31/24 at 7:37 A.M., showed the resident in bed asleep. A puddle approximately a foot and a half pooled under the bed, extending from the unit. The unit cover remained off an leaned against the wall. Observation and interview on 8/1/24 at 9:28 A.M., showed a small amount of water under the bed. The unit cover remained off and leaned against the wall. A smell of moisture noted in the room. The resident said maintenance had not been by recently. 2. Review of Resident #16's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: heart failure, high blood pressure, diabetes, stroke, and lung disease. Observation and interview on 7/29/24 at 4:22 P.M., showed the resident lay in bed and said when he/she turned the call light on, staff do not always come timely. Staff told the resident they do not always know he/she had his/her call light on. The resident pushed the button on the call light. The red light for the call light lit up on the wall in the resident's room. The light in the hall above the door did not light up. At approximately 4:53 P.M. the residents call light remained lit in the room and no staff had responded to the light. A beeping sound was heard out in the hall by the nurse's station. An staff member at the nurses station said the beeping sound was the call bells and he/she could tell which room was ringing by looking at the call bell panel located at the nurse's station. He/She looked at the panel and named the residents room number as ringing. 3. Observation of the 300 hall, on 7/29/24 at 12:00 P.M., on 7/30/24 at 6:19 A.M., on 7/31/24 at 7:30 A.M., and on 8/1/24 at 9:20 A.M., showed scuffs and stains noted on the floor throughout the hall. An orange stain on the floor at the top end of the hall, on the right-hand side. Areas of chipped and missing tile, one area approximately the size of a softball located near the top left side of the hall. Another area of chipped tiles near the top left-hand side of the hall, approximately 4 inches by 2 inches. The cove base near the bottom of the doors throughout the hall, chipped with a buildup of a dark blackish brown substance along the edges. Paint on the wall near the medication room peeled off near the ground, an area approximately 5 inches by 4 inches and irregular shaped. An area of paint peeled on the wall in long strips near the 300 central bath, approximately 2 feet by 1 inch and 1.5 feet by 1 inch. At 6:25 A.M., room [ROOM NUMBER] room door closed. The door frame edges pulled away from the wall on the right side of the doorframe, with jagged edges. 4. During an interview on 7/31/24 at 11:35 A.M., the Maintenance Director said paper request slips are available on the wall at the nurse's station for staff to fill out if they identify maintenance issues. He picks them up when he gets to work and reviews them. He is aware of the leaking air-conditioning/heating unit. He became aware earlier this week. The drain line just needs to be cleaned out. Chipped paint, broken cove base, chipped floor tiles and broken doorframes are the responsibly of maintenance. Some hall floors were just replaced. The 300 hall was not done and it is not scheduled to be replaced at this time. He was not aware of the broken doorframe. Staff should have reported it. He was not aware of the broken call light. It is probably just a bulb that needs to be replaced. 5. During an interview on 7/30/24 at 11:04 A.M., the Administrator said when owned by the prior corporation, they started the remodel of some of the halls. Then when the current corporation purchased the facility the work was stopped. The 300 hall floor needs stripped because it does appear the stains were waxed over; therefore, housekeeping would not be able to clean it up. MO00238123 42247

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents. One resident was not positioned in an upright position during meals, resulting in a coughing episode (Resident #6). In addition, staff failed to adequately monitor smoke breaks to ensure residents followed facility protocol for safe smoking for two of three smoke breaks observed (Residents #33, #82, and #41). The census was 85. The sample was 18. 1. Review of Resident #6's care plan, in use at the time of the survey, showed: -Diagnoses included dementia and dysphagia (difficulty swallowing); -Focus: Current functional performance Hoyer (mechanical lift) and new recliner wheelchair: -Goal: Will progress towards personal discharge goals; -Interventions included: Eating: independent/set-up help only. Transfer: Total assist/one-person physical assist; -Focus: Activity of daily living self-care performance/limited physical mobility deficit related to cognitive deficit with impaired safety awareness with lower extremity weakness due to spinal stenosis (when there is too little space between the bones of the spin, resulting in decreased mobility): -Goal: Activities of daily living needs will be met; -Interventions included: Requires 1-2 staff for bed mobility and transfers. Monitor for safety/positioning in wheelchair. Is able to feed self with set up assist and supervision. Review of the resident's Speech Therapy Plan, for certification period of 7/23/24 through 9/5/24, showed: -Treatment diagnoses: Dysphagia, oral phase (difficulty swallowing); -Impairments: Decreased oral motor coordination and control; -Continued skill: Reason for skilled services- Patient presents with oral dysphagia which necessitates skilled services for dysphagia to assess/evaluate for safety level of oral intake. Observation of the lunch meal service in the main dining room on 7/29/24 at 11:38 A.M., showed staff already served desert and drinks to the residents who had arrived. The resident was positioned in a tilt-back wheelchair, tilted to an approximate 60 degrees, and slid down with his/her buttocks near the end of the seat of the wheelchair. An empty desert plate sat in front of the resident. At 11:52 A.M., staff served the resident what appeared to be broccoli rice with beef and gravy. The resident remained at an approximate 60-degree angle when staff served the tray and walked away. The resident began to feed him/herself. Staff did not assist the resident to sit up. The resident fed him/herself with his/her left hand. The resident spilled his/her drink. Speech Pathologist A assisted the resident with a drink but did not assist the resident to sit up. He/She then walked away. The resident struggled to get a bite of food to his/her mouth as the food fell off the tilted fork before reaching his/her mouth. After taking a couple bites, the resident started coughing a very wet cough. Three staff rushed over, to include Speech Pathologist A, who gave the resident a drink, despite the resident actively coughing. This resulted in the resident coughing more. Staff attempted to assist the resident to sit up in his/her chair. The position of the resident's buttocks on the seat was readjusted so it was closer to the back of the chair, but the resident's wheelchair remained tilted back. Staff again went to give the resident a drink while he/she was coughing. The resident was breathing heavy and making attempts to clear his/her throat. Staff assisted the resident back up to the table, wiped food from his/her face, then went and refilled the resident's drink. The resident continued to feed him/herself with a tilted back wheelchair. During an interview at this time, Speech Pathologist A said the resident is receiving speech therapy. He/She slides down in his/her chair and will sometimes put too much food in his/her mouth. That is what speech therapy is working with him/her on. During an interview on 7/30/24 at 10:53 A.M., Speech Therapist E said the resident has difficulty swallowing and is being followed by speech therapy to make sure he/she is on the least restrictive diet. He/She should be upright, near 90 degrees, for meals. Staff should sit him/her up for meals. Nursing staff who serve the food tray or who are present in the dining room should ensure proper positioning when eating. He/She can feed him/herself once served. No one reported to him/her that the resident had a coughing episode. Review of the resident's Speech Therapy treatment encounter note, date of service 7/29/24, completed date 7/30/24, showed Speech Therapy was present in the dining room to see a different resident when this resident was noted to be coughing during the meal. Speech Therapy asked for help to reposition the resident to an upright position and was able to change position. Resident was still struggling to clear food from pharyngeal cavity (a hollow, muscular tube inside the neck that starts behind the nose and opens into the esophagus) so Speech Therapy implemented compensatory techniques including hard throat clear and coughing until no more signs and symptoms of aspiration, including wet voice, were present. Resident was instructed then to take small sips of liquids and three bites of mechanical soft food and Speech Therapy observed to ensure no more signs and symptoms of aspiration with current position. During an interview 8/2/24 at 9:06 A.M., the Administrator and Director of Nursing (DON) said residents should be in an upright position when eating. If they are not, staff should assist them to sit upright prior to serving food. 2. Review of the facility's Resident Smoking policy, last reviewed/revised on 6/25/24, showed: -It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; -Safety measures for the designated smoking area will include, but not limited to: Provision of ashtrays made of noncombustible material and safe design. Accessible metal containers with self-closing covers into which ashtrays can be emptied; -Residents who smoke will be further assisted, using the smoking assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all; -All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan; -If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional safety measures; Review of the facility's Resident Smoking List, showed 26 residents identified as smokers to include Residents #33, #82, #41, and #10. Review of the posted smoke break schedule, showed scheduled cigarette times and responsible departments: -7:00 A.M. Activities; -9:00 A.M. Housekeeping; -11:00 A.M. Maintenance; -1:00 P.M. Activities; -3:00 P.M. Dietary; -5:30 P.M. Reception- Certified Nursing Assistant (CNA); -7:00 P.M. Nursing. 3. Review of Resident #33's medical record, showed: -Diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke; -A smoking assessment, dated 6/14/24, resident is a smoker, can light own cigarette, requires supervision; -A care plan in use at the time of the investigation, the resident is a smoker. The resident will follow all facility smoking rules. The resident requires supervision while smoking. Review of Resident #82's medical record, showed: -Diagnoses included high blood pressure and chronic obstructive pulmonary disease (COPD, lung disease); -A smoking assessment, dated 5/22/24, resident is a smoker, can light own cigarette, requires supervision; -A care plan in use at the time of the investigation, resident is dependent on tobacco. The resident will have minimized risk of injury from unsafe smoking practices. The resident requires supervision while smoking. Observation of the 1:00 P.M. smoke break on 7/29/24 at 1:12 P.M., showed an overhead page announcing smoking time. Approximately 16 residents sat in the smoking area. No staff were present. There was one dietary staff member cleaning the dining room, but the staff member was not in view of the smoking area. A resident sat at the door waiting to come in. The resident opened the door and exited the smoking area. He/She was followed by a resident actively smoking. As the resident approached the door, he/she flicked his/her cigarette into the grass. Another resident who smoked a cigarette also flicked the cigarette into the grass as he/she exited the smoking area. Observation of the smoking area, showed a lit cigarette lay on the ground near the facility entrance, and several other cigarette butts scattered around on the ground. A plastic trash can sat on the patio with cigarettes inside, on top of trash. A red ash can was approximately 10 percent full of cigarette butts and a wire mesh over the top and a chip bag and empty cigarette pack sat on top of the mesh. There was a second red ash can with wire mesh on top with a paper plate, napkins, empty cigarette packs, and a kitchen hair net on top of the mesh. Numerous cigarettes lay in the grass and on the patio. The Activity Director arrived to the smoking area and assisted a resident to leave by propelling his/her wheelchair. No staff remained in the smoking area after the Activity Director left. The Activity Director returned to the area as another resident prepared to leave. The resident held a cigarette and flicked the cigarette onto the grass as the Activity Director held the door. The Activity Director did not educate or redirect the resident on safe smoking practices. Resident #33 smoked with a smoking apron on throughout the observation, including during unsupervised times. Resident #82 also smoked throughout the observation, including during times of no supervision. 4. Review of Resident #41's care plan, in use during survey, showed: -Focus: Resident smokes tobacco. Resident has a history of begging for cigarettes; -Goal: Resident will adhere to the tobacco/smoking policies of the facility; -Interventions: Conduct smoking safety evaluation on admission and as needed (PRN). Educate resident/responsible party on the facility's tobacco/smoking policy(s). Review of the resident's admission smoking assessment, dated 5/22/24, showed: -Smoking status: Resident is a smoker; -Safety: Resident need for adaptive equipment: Supervision. Observation and interview on 7/29/24 at 3:19 P.M., showed the resident sat outside smoking a cigarette. There was no staff outside or in view of the smoking area. He/She said they are able to smoke every 1.5 hours. He/She did not have any issues with not being able to smoke. The resident smoked independently. 5. During an interview on 8/2/24 at 9:06 A.M., the Administrator and DON said if a resident requires supervision with smoking, staff should provide continuous supervision. The staff responsible for the smoke break is responsible to pass out cigarettes, help residents light the cigarettes if necessary, help with proper disposal of ashes and cigarettes, and ensure safety. If a resident is observed not practicing safe cigarette handling or disposal, staff should correct them. 6. During an interview on 7/31/24 at 9:51 A.M., the Activity Director said she has one other activity staff that works under her. For the scheduled smoke breaks that the activity department is responsible for, if the staff under her is not available, she will supervise the smoke break. She is responsible to pass out the cigarettes and go out with the resident as they smoke. If a resident requires a smoking apron, they assist the resident to put one on. When residents are done smoking, they let them in. If she sees a resident with unsafe smoking practices, she will inform the DON. If residents are not safely disposing the cigarettes, she will reeducate them and make sure the cigarette is completely out. 35394

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the most recent available quarterly payroll-based journal (PBJ) staffing report. The sample was 18. The census was 85. Review of the facility's PBJ Staffing Data Report, dated for Quarter 2 20204 (January 1- March 31), showed: -This staffing data report identifies areas of concern that will e triggered (e.g., requires follow-up during the survey); -One star staffing rating: Triggered; -No RN hours: Triggered; -Infraction dates: Thursday 3/21, Friday 3/22, Saturday 3/23, Sunday 3/24, Saturday 3/30, Sunday 3/31. During an interview during the entrance conference, on 7/29/24 at 10:27 A.M., the Administrator said Corporate Staff B is responsible for the PBJ reports. During an interview on 7/30/24 at 7:50 A.M., Corporate Staff B said he/she had been helping with the PBJ reports and did a lot of the input. He/She verified the PBJ report is accurate and had confirmed it with the administrator at the time. He/She had suggested the facility borrow RNs from other sister facilities to get those hours covered. These are the hours they could not get coverage for.

Based on observation, interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of two narcotic books reviewed. The census was 85. Review of the Facility's Controlled Substance Administration & Accountability policy, dated 9/1/21, showed: -Policy: it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure; -Policy explanation and compliance guidelines: -Inventory Verification: for areas without automated dispensing systems, two licensed nurses or per state regulations account for all controlled substances and access keys at the end of each shift. Review of the facility's Controlled Substance Shift Change Count -Check Sheet, for the dates of 7/1/24 through 7/29/24, showed: -Station: 300; -Number of packages: -73 out of 87 opportunities were blank; -Nurse's initials on: 29 of 87 opportunities were blank; -Nurses initials off: 32 of 87 opportunities were blank; -Station: 100/700; -Number of packages: 23 out of 87 opportunities were blank; -Nurse's initials on: 19 of 87 opportunities were blank; -Nurses initials off: 25 of 87 opportunities were blank. During an interview on 7/30/24 at 7:30 A.M. and at 9:00 A.M., the Director of Nursing said the oncoming nurse should count controlled substances with the off going nurse. Both nurses should document on the controlled substance count sheet. She would expect the controlled substance change count to be completed without blanks on it. Some of the nurses work eight-hour shifts and some of the nurses work 12-hour sheets. The form is set up for eight-hour shifts and this is confusing for some of the nurses. She would expect for staff to follow the facility's policy and procedures.

42247 Based on observation, interview and record review, the facility failed to ensure a medication rate less than 5%. Out of 27 opportunities for errors, four errors occurred resulting in a 14.81% medication error rate (Residents #18, #72 and #50). The sample was 18. The census was 85. Review of the facility's Medication Administration Policy, dated 9/1/21, showed: -Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Policy explanation and compliance guidelines; -Review Medication Administration Record (MAR) to identify medication to be administered; -Compare medication source (bubble pack, vial, etc.) with MAR to verify name, medication, form, dose, route, and time; -Administer medication as ordered in accordance with manufacturers specifications; -Crush medications as ordered. Do not crush medications with do not crush instructions; -Do not crush medications: enteric coated. Review of the manufacturer's instructions for use for insulin lispro (Humalog, short acting insulin) pen, showed: -Select a new needle. Push the capped needle straight onto the pen and twist the needle until it is tight; -Pull off the outer and inner needle shield; -Prime before each injection: Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin; -To prime your pen, turn the dose knob to select 2 units; -Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding your pen with needle pointing up. Push the does knob until it stops and 0 is seen in the dose window. Hold the does knob in and count to 5 slowly. If you do not see insulin, repeat priming, no more than 4 times. If you still do not see insulin, change the needle and repeat. 1. Review of Resident #18's medical record, showed: -Diagnoses included diabetes; -An order dated 7/2/24, for Humalog (insulin lispro) 4 units subcutaneously (under the skin) three times a day. Scheduled administration time 8:00 A.M., 12:00 P.M., and 5:00 P.M.; -An order dated 7/2/24, for Humalog insulin per sliding scale. Administer 4 units for a blood sugar level between 251 and 300. Observation on 7/30/24 at 11:33 A.M., showed Licensed Practical Nurse (LPN) F checked the resident's blood sugar level with a result of 254. He/She obtained the resident's insulin lispro pen, applied the needle to the end, and set the insulin to administer 8 units of insulin. He/She did not prime the insulin pen. LPN F entered the resident's room and administered the insulin into the resident's right upper arm. During an interview on 7/30/24 at 1:06 P.M., the Director of Nursing (DON) said insulin pens should be primed prior to administration. 2. Review of Resident #72's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/16/24, showed: -Should brief interview for mental status be conducted? No; -Cognitive skills for daily decision making severely impaired never/rarely made decisions; -Diagnoses included heart failure and high blood pressure. Review of the order summary, dated 6/30/24, showed: -An order for ascorbic acid (vitamin C) 500 milligrams (mg) take one by mouth twice daily for wound healing; -An order for aspirin 81 milligrams (mg) (chewable) via gastrostomy tube (g-tube, a tube surgically inserted into the stomach to give direct access for supplemental feeding, hydration, or medicine) one time daily for acute heart attack. Observation on 7/30/24 at 7:30 A.M., showed LPN N poured one tablet of Vitamin C 250 mg into a medication cup and crushed the medication. Then he/she poured one tablet of enteric coated (EC) aspirin 81 mg into another medication cup and crushed it. After the medications were crushed, LPN N administered the medications via the g-tube. 3. Review of Resident #50's annual MDS, dated [DATE], showed: -Cognitive intact; -Diagnoses included diabetes and high blood pressure. Review of the Fluorometholone ophthalmic suspension (used to help reduce swelling in the eye) manufacturer's guidelines, showed: -Tilt head back, look upward, and pull the lower eyelid to make a pouch; -Hold the dropper directly over the eye and place 1 drop into the pouch; -Look downward and gently close eyes for 1 to 2 minutes; -Place one finger at the corner of the eye (near the nose) and apply gentle pressure. Review of the physician order summary sheet, dated 6/30/24, showed: -An order for Fluorometholone ophthalmic suspension, instill 1 drop in both eyes two times a day for eyes. Observation on 7/30/24 at 8:05 A.M., showed Certified Medication Technician (CMT) M administered one Fluorometholone eye drop into each eye and handed the resident a tissue for the resident to pat his/her eye after the eye drop was administered. CMT M did not place one finger at the corner of the eye near the nose and apply gentle pressure. 4. During an interview on 8/2/24 at 7:55 A.M., LPN G said EC medications should not be crushed and when staff administers an eye drop, they should instill one eye drop at a time and the eye drop should sit in the resident's eye for 1 to 2 minutes. Staff should have a Kleenex ready in case there is any drainage. 5. During an interview on 8/2/24 at 9:00 A.M., the DON said she expected staff to follow acceptable nursing practices and follow the manufacturer's recommendations for medication administration.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and facility policy in three of three medication carts reviewed. The census was 85. Review of the facility's Medication Storage Policy, dated [DATE], showed it is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the facility's Medication Administration policy, dated [DATE], showed identify expiration date. If expired, notify nurse manager. 1. Observation and interview on [DATE] at 7:15 A.M., of the ,d+[DATE] nurse medication cart, showed in the top drawer, one out of three Aspart insulin (short acting insulin) pens opened and undated. The Director of Nursing (DON) said insulin should be dated when opened. She did not know when the insulin was opened. 2. Observation and interview on [DATE] at 7:20 A.M., of the ,d+[DATE] Certified Medication Technician (CMT) medication cart, showed: -In the top drawer there were 2 plastic medication cups with pre-popped medications in them. One cup had six pills in it and the other cup had four pills in it. The DON said she did not know who the medications belonged to, and staff should pop the medications when they are given; -Seven out of 16 eye drops opened and undated; -One bottle of geritussin (cough syrup) open and undated and one bottle of Levetiracetam solution (used to treat seizures) open and undated; -One bottle of allergy relief tablets with an expiration date of ,d+[DATE]; -One bottle of sodium bicarb (baking soda) tablets with an expiration date of ,d+[DATE]; -One bottle of multivitamin with an expiration date of ,d+[DATE]. 3. Observation and interview on [DATE] at 7:30 A.M., of the 300-nurse medication cart, showed: -In the top drawer, one out of thirteen insulin pens opened and undated; -One bottle of lactulose (used to treat constipation) open and undated; -One bottle of senna plus (stool softener plus laxative) with an expiration date ,d+[DATE]; -Five out of seven eye drops opened and undated. 4. During an interview on [DATE] at 7:20 A.M., the DON said both CMTs and nurses should check meds for expiration dates and remove from the cart if they are expired. Eye drops should be dated when opened and they are good for 30 to 45 days after opening. Liquid medications should be dated when opened. On [DATE] at 9:00 A.M., the DON said she would expect medications to be stored according to standards of practice and she would expect staff to follow the facility's policy and procedures.

Based on observation and interview, the facility failed to maintain an effective pest control program to control the presence of flies in the kitchen. The facility census was 85. Observation of the kitchen on 7/29/24 at 10:30 A.M., showed the backdoor to the outside left opened. There were several flies throughout the food prep areas of the kitchen, outside of the walk-in cooler, and inside the dry food storage room. There were flies outside of the walk-in cool. Observation of the kitchen on 7/30/24 at 6:27 A.M. and 7:05 A.M., showed multiple flies throughout the food prep areas of the kitchen. There was a swarm of flies outside of the walk-in cooler. The backdoor to the outside stood opened. Observation of the kitchen on 8/1/24 at 7:30 A.M. and 12:25 P.M., showed multiple flies throughout the food prep area of the kitchen. The backdoor to outside remained opened. During an interview on 8/2/24 at 9:07 A.M., the administrator said she would expect for the kitchen to be free of flies and for the back door to be closed.

Based on interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #59). The sample size was 18. The census was 85. The facility was notified of past non-compliance on 8/3/24. Facility staff immediately intervened, separated the resident and staff, reported the incident, and began their investigation. The investigation consisted of written statements, interviews from witness, and other staff and residents on the unit. Staff were in-serviced on abuse and neglect prevention and promoting/maintaining resident dignity. The deficiency was corrected on 7/2/24. Review of the facility's Promoting/Maintaining Resident Dignity policy, dated 7/2/24, showed: -Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality; -Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; -During interactions with residents, staff must report, document and act upon information regarding resident preferences; -Interview results will be documented; the provision of care and care plans will be revised, if appropriate, based on information obtained from resident interviews; -The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences; -When interacting with a resident, pay attention to the resident as an individual; -Respond to requests for assistance in a timely manner; -Explain care or procedures to the resident before initiating the activity; -Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered; -Groom and dress residents according to resident preference; -Speak respectfully to residents; avoid discussions about residents that may be overheard; -Respect the resident's living space and personal possessions; -Maintain resident privacy; -Assist residents to participate in activities of choice; -Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source; -Random observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy. Review of Resident #59's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/27/24, showed: -Cognitively intact; -Diagnoses include neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), wound infection, quadriplegia (paralysis of all four limbs), malnutrition, and depression; -Dependent with eating, oral hygiene, toileting, shower/bath, and personal hygiene; -No behaviors. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has an Activity of Daily Living (ADL) self-care performance deficit; -Goal: Resident will maintain/improve level of functioning; -Interventions: Bathing/Showering: Avoid scrubbing and pat dry sensitive skin; -The resident is totally dependent on one staff for personal hygiene and oral care. Review of the resident's progress notes, showed: -On 6/29/24 at 12:00 P.M., this nurse assisted Certified Nurse Aide (CNA) with cleaning and dressing patient for the day. Upon departure from room, this nurse went into adjacent room to wash hands. When coming out of room this nurse began to hear some yelling and cursing. He/She then approached this patient's room and CNA appeared to have been washing patient's face, but then tossed towel onto patient and proceeded to walk out of the room, stating that he/she was unable to work with patient because he/she is rude. This nurse then asked patient what occurred. Patient stated, all he/she asked him/her to do was to get the towel off of his/her bed. He/She then stated, you can at least say please. Patient states that he/she then replied, You didn't give me a chance to finish my sentence. Patient states that CNA then started saying things like You can't say anything to us, and you are so rude, while using profanity. Patient states that CNA then proceeded to wash his/her face with a washcloth but was very rough when doing so. Patient states that he/she then threw the towel on top of his/her head and walked out of the room. This nurse immediately had patient and CNA separated and informed CNA that he/she is not to return to patient's room or communicate with him/her. This nurse educated CNA on therapeutic communication and providing care with ease while caring for patients. CNA sent home pending investigation. Patient has no distress or injuries noted; -On 6/29/24 at 1:00 P.M., patient phoned his/her parent following verbal altercation informing him/her of incident. Patient's parent then arrived to the facility and came to the nursing station. This nurse spoke with patient's parent and informed that CNA was sent home, and informed him/her that there will be a full investigation conducted. Patient's parent eventually calmed down and visited with patient. Director of Nursing (DON) and administrator informed of verbal altercation. Review of the facility's investigation, showed: -Date/time alleged incident occurred: 6/29/24 at 12:15 P.M.; -Summary of interview with person(s) reporting the alleged incident: Resident reported that CNA L was cursing at him/her and while wiping his/her face with the towel was rough and smashing his/her face. He/she denies cursing at CNA L during the interaction; -Summary of interviews with witnesses: Licensed Practical Nurse (LPN) K had been assisting CNA L with the resident and had left the room to assist someone else. He/She was in the adjacent room when he/she heard cursing coming from the resident's room. LPN K states that he/she heard both CNA L and the resident say the F word but could not hear the interaction. When he/she entered the room, he/she saw CNA L toss the towel on his/her head. It was on his/her forehead/top of his/her head. Upon assessment there were no visible marks; -Summary of interviews with staff: CNA L stated that he/she and the nurse went to assist the resident and everything was fine until the nurse left the room. He/She stated that the resident became disrespectful and stated the staff is to come when he/she calls them. He/She stated that he/she was calling staff names. CNA L stated that he/she told him/her that he/she cannot talk to people like that and he/she said, F you. At which time he/she responded, F me? He/She denies ever cursing at him/her but did say she/he was only repeating what he/she said to him/her. CNA L denies ever being rough while wiping his/her face and that he/she tossed the towel onto his/her forehead/top of his/her head as he/she always has a towel around his/her head. He/She stated that he/she had never had any prior negative interactions with the resident; -Summary of investigators findings: It is the determination of the facility that abuse cannot be substantiated. A thorough investigation was completed including interviews of staff and residents. While a negative interaction occurred between resident and CNA L, it cannot be said that abuse occurred; -Outcome of the investigation and any interventions/changes to plan of care/corrective actions (if appropriate) taken: A post trauma assessment was completed with resident with no negative psychosocial impacts noted. He/She has continued his/her normal daily routine since the incident. His/her care plan has been updated as needed. Education with staff on abuse/neglect as well as resident rights/dignity to be completed. Review of CNA L's written statement, dated 6/29/24, showed: myself and LPN K was in the resident's room to change his/her dressing. As we were finishing up, he/she was being very disrespectful by saying he/she was tired of the place and we CNAs/nurses are supposed to come when he/she calls, and he/she can talk to me the way he/she wants to. He/she asked for his/her towel and I said hold up and that is when he/she responded by saying you are lazy, your job is to do whatever I ask, no matter how he/she says it. CNA L then said who are you talking to like that, you cannot talk to people like that. The resident said F you, then CNA L said, F me, really? F me? CNA L then walked out and asked the nurse to remove him/her from his/her assignment. He/She did not feel comfortable. Review of CNA L's telephone interview, dated 7/3/24, showed: -Was LPN K in there the whole time: He/She was in there until he/she finished his/her dressing and stepped out; -Was there any negative interaction between you and him/her while the nurse was in there? No, he/she was just frustrated that he/she had to wait a little while to get his/her wounds done. We got him/her up and then he/she wanted repositioned in his/her chair, so we did that and the nurse left; -Did you curse directly at him/her: No, I repeated what he/she had said to me; -Did you wash his/her face with the towel: He/she had sweat on his/her forehead, and I wiped it off; -Did he/she make any comments while you were wiping his/her forehead: No, he/she was fine and didn't say anything; -Did you wipe his/her face in a rough manner or did he/she say anything to the affect that you were hurting him/her? No; -When you were done wiping his/her face, what did you do with it: Placed it on his/her forehead because that is where he/she always has it; -Have you ever had any negative interactions with the resident: No. Review of LPN K's written statement, dated 6/29/24, showed this nurse along with CNA L had gotten the resident out of bed for the day. Once patient was in his/her wheelchair, this nurse went into adjacent room to wash hands. Upon leaving the room, I could hear loud cursing coming from this patient's room. He/She then reapproached the room and asked, What happened, what is going on? CNA L tossed the towel that he/she was using onto patient's head and proceeded to walk out the room, stating he/she cannot work with him/her, he/she is too rude. When he/she asked patient what transpired, he/she stated he/she asked him/her to get the towel off the bed and he/she said, you could at least say please. They began to go back and forth with profanities. Patient stated that he/she was wiping his/her face forcibly. I did hear patient stating you can stop now several times as I was approaching the room. When I asked CNA what occurred he/she stated that he/she thinks that he/she can talk to people any kind of way, and he/she admitted to using profanities when speaking with him/her. Review of LPN K's telephone interview, dated 7/2/24, showed: -When you entered the room, did you witness him/her toss the towel on his/her head: Yes; -Where did the towel land: Forehead/top of head; -Was it in any way covering his/her eyes, nose, or mouth: No; -Did you clearly hear what the cursing was: No, just could hear the F word from both of them; -Did you notice any agitation prior to incident while you were in the room: No. Review of the resident's follow up interview, dated 6/29/24, showed they were getting the resident up. CNA entered the room. CNA to wipe resident's face, CNA responded you could say please. Resident say you did not give me a chance and it's your job. CNA said you're rude, he/she then took the towel covered his/her face with the towel, wiped hard like smashing his/her face. The nurse walked up to the resident room in the doorway and saw the CNA had the towel over the resident's face. The nurse then took the resident outside to calm him/her down. Resident denies cursing at CNA. Review of the resident's progress notes, showed on 6/30/24 at 11:22 P.M., resident noted to be in wheelchair and in good spirits. Found to be joking with other residents. States he continues to feel safe and has not had any ill feelings since the incident. No pain or open skin in facial area. Investigation follow up (IFU) continues. During an interview on 7/31/24 at 12:41 P.M., the resident said he/she remembered the incident that occurred with the CNA. He/She did not know the CNA's name. The CNA got mad because he/she did not say please when he/she asked the CNA to clean his/her face. He/She told the CNA that he/she did not give the resident a chance, and even if I did not, it's his/her job. The aide mushed the towel on the resident's face after asking to wipe it. The resident clarified and said the aide pushed the cloth into his/her face. Instead of wiping his/her face, the aide pushed the towel in his/her face. The resident said it felt aggressive and it was an assault. The resident said the CNA continued to mush him/her. The resident said the CNA did not cuss at him/her. The aide covered the resident's face with the towel when the nurse came in. The nurse came in and asked what was going on. The CNA walked out of the room leaving the towel over the resident's face. It was the first time having interaction with the aide and first time seeing her/him. The aide told the resident he/she was demanding. The resident said he/she was not demanding but was just telling him/her what he/she needed. The resident never had problems with anyone here. Everyone gives him/her love and maybe that aide just had a bad day. During an interview on 8/5/24 at 8:28 A.M., CNA L said he/she had worked at the facility for three weeks. He/She never took care of the resident on his/her own. On that day, he/she assisted the resident, and he/she was upset with the nurse. He/She wanted to get his/her wounds done so he/she could go out to smoke. When the nurse was able to go in there it was 11:00 A.M. Nurse asked CNA L to go in and the resident was irritated. Once the resident sat in the chair, the nurse walked out of the room and the resident said these lazy Bs. CNA L could not remember exactly how it went, but the resident said, I'm so tired of these lazy Bs and these MFs. CNA L asked the resident, who he/she was talking to. The resident said I am talking to you. CNA L said you cannot talk to me like that. The resident said he/she can talk to him/her however the F he/she wants and F you. CNA L said F me, really? The resident cursed at CNA L and then asked CNA L to wipe his/her forehead. He/She wiped his/her forehead and around the same time the nurse entered the room and asked what was going on. CNA L said I cannot assist him/her. CNA L also spoke to someone from corporate. He/She reported that he/she only repeated what the resident said. He/She did not curse or hit him/her. He/She wiped the sweat from the resident's face. He/She did not do anything to him/her. CNA L wanted to be removed from the assignment. CNA L also found out they had a meeting about the resident's behavior the week before. When asked to describe how he/she wiped the resident's face, CNA L said he/she patted the resident's face. He/She patted his/her face from side to side, never smooshed his/her face into the towel. CNA L lay the towel on his/her forehead because he/she goes around the building like that since he/she sweats. During an interview on 8/01/24 at 1:18 P.M., LPN K said he/she was across the hall when he/she heard the CNA and the resident cursing. The CNA had not worked at the facility long and LPN K did not know his/her name. When LPN K entered the resident's room, the resident was overheard saying you can stop now to the CNA. The CNA stood in front of the resident and tossed a towel on top of the resident's head and said he/she could not work with the resident. The towel was not on his/her face, just on top of his/her head. After the aide tossed the towel, he/she walked out of the room. LPN K asked the CNA what happened. The resident asked her/him to wipe his/her face and he/she asked for a specific towel on the bed. The resident was rude and aggressive. There was an issue with the resident telling the CNA what to do instead of asking him/her, or it was a rude manner in the way the resident said it. The CNA told the resident, you could at least say please and they started going back and forth from there. LPN K heard the resident say don't f'ing touch me and the CNA said the F word also, but LPN K could not remember what was said. The resident was asked what happened and he/she said the same thing. He/She asked for a specific towel and the CNA started being rude and said he/she needed to talk to him/her different. The resident told the aide, you need to wash my face, but the aide was rude, so the resident started cussing at him/her. LPN K said the resident reported the aide pushed the towel into his/her face, wiping vigorously in a rough manner. The CNA denied being rough. The resident reported the aide cussed at him/her. The aide reported whatever the resident said to him/her, he/she repeated it back to the resident. LPN K said the resident has behaviors at times, but it is because he/she wanted things at a certain time. He/She can be demanding. He/She is a smoker, so he/she does not like to stay in bed. The resident becomes upset related to getting out of bed at a certain time to smoke. The CNA was new and only at the facility for a week. He/She worked with him/her on one or two shifts. There were no issues between the aide and other residents. There were no reports of physical abuse. Review of CNA L's employee file, received on 8/1/24, showed he/she was terminated on 7/1/24 for violation of policy and procedure. During an interview on 8/02/24 at 9:07 A.M., the Administrator said she would expect all residents to be treated with dignity and respect. MO00238305

Based on observation, interview and record review, the facility failed to provide services based on acceptable standards of practice by not obtaining a physician order for one resident who was using a Bi-level positive airway pressure (bi-pap, helps with breathing) machine (Resident #16) and for failing to complete neuro check documentation for one resident who fell (Resident #63). The sample was 18. The census was 85. Review of the facility's Medical Provider Orders Policy, dated 9/1/21, showed: -Policy: this facility shall use uniform guidelines for ordering and following medical providers orders; -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe. Review of the facility's Fall Prevention Program Policy, dated 9/1/21, showed: -Policy: each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; -Definitions: fall: an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere; -When any resident experiences a fall, the facility will: -Assess the resident; -Complete a post fall assessment; -Complete an incident report; -Notify physician and family; -Review the resident's care plan and update as indicated; -Document all assessments and actions; -Obtain witness statements in case of injury. Review of the facility's neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) flowsheet, showed: -Neuro checks should be completed for unwitnessed falls or fall in which head was hit. Complete initial, then every 15 minutes times four, every 30 minutes times two, every hour times two and every shift for 72 hours. 1. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/18/24, showed: -Cognitive intact; -Diagnoses included obstructed sleep apnea (OSA, when something blocks part or all your upper airway while you sleep); -Used Bi-pap on admission. Review of the care plan, in use at the time of survey, showed: -Focus: resident used a continuous positive airway pressure machine (CPAP machine, used for the treatment of sleep apnea) for sleep apnea; -Goal: The resident will use their c-pap/bi-pap nightly with minimal risk for complications; -Intervention: bi-pap/c-pap titrate pressure at settings as ordered. Provide preferred and ordered equipment. Review of the progress notes, dated 7/12/24 through 7/29/24, showed: -On 7/12/24 at 3:15 P.M., the patient arrived back to facility from hospital, accompanied by 2 transporters. The patient had a history of OSA. The nurse set up patient's bi-pap for tonight's use for patient on nightstand; -On 7/20/24 at 4:30 A.M., uses c-pap machine while sleeping. Review of the after-visit summary, dated 7/4/24 through 7/12/24, showed: -Other instructions: bi-pap with all sleep. Observation on 7/29/24 at 1:30 P.M., showed the resident lying in bed with his/her bi-pap on. Review of the physician order summary, dated 7/30/24, showed: -There was no physician order for the bi-pap. During an interview on 7/31/24 at 3:10 P.M., Central Supply Employee D said the resident used a bi-pap machine. During an interview on 8/2/24 at 9:00 A.M., the Director of Nursing (DON) said the resident should have a physician order for the bi-pap. 2. Review of Resident #63's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, stroke with hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face) and seizure disorder. Review of the care plan, in use at the time of survey, showed: -Focus: resident is at risk for falls. 6/17/24, rolled out of bed; -Goal: resident will not sustain serious injury through next review; -Intervention: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance; follow facility fall protocol. Review of the progress notes, dated 6/17/24 through 6/20/24, showed: -On 6/17/24 at 6:21 A.M., the resident was observed lying on the floor at his/her bedside, resident states that he/she rolled out of bed. Resident observed lying on his/her back on the floor. Resident assessed for injuries, none noted. Neuro-checks within normal limits; -On 6/17/24 at 7:26 P.M., the resident observed lying in bed resting quietly at this time with his eyes closed. Neuro-checks within normal limits at this time; -On 6/19/24 at 3:26 A.M., resident observed resting quietly in bed with eyes closed. Neuro checks within normal limits. Review of the neuro check flowsheet dated 6/17/24 through 6/20/24, showed: -Level of Consciousness: six out of 18 opportunities were blank; -Movement/ROM: three out of 18 opportunities were blank; -Hand grasp: three out of 18 opportunities were blank; -PERL (pupil equal and reactive to light): three out of 18 opportunities were blank; -Pupil response right: three out of 18 opportunities were blank; -Pupil size right: three out of 18 opportunities were blank; -Pupil response left: three out of 18 opportunities were blank; -Pupil size left: three out of 18 opportunities were blank; -Speech: three out of 18 opportunities were blank; -Pain: three out of 18 opportunities were blank; -Pulse: six out of 18 opportunities were blank; -Respirations: six out of 18 opportunities were blank; -Blood pressure: six out of 18 opportunities were blank; -Nurse initials: three out 18 opportunities were blank. 3. During an interview on 8/2/24 at 7:55 A.M., Licensed Practical Nurse (LPN) G said if a resident fell , he/she would assess the resident, notify the medical doctor and the family, document the fall in risk management and do neuro checks. Post fall documentation should be done every shift for 3 days. 4. During an interview on 8/2/24 at 9:00 A.M., the Director of Nursing (DON) said if a resident fell , she expected staff to stay with the resident and call for the nurse. The nurse should assess the resident. If the resident is ok to get up, staff would assist the resident up and document the fall, notify the medical doctor and the family or if the resident needed to be sent out, the facility would send them out. For an unwitnessed fall, staff should do neuro checks per the neuro check sheet form and monitor the resident for 72 hours. The DON expected the neuro sheets to be completed. Neuro checks are not part of the facility's policy, but the facility did them because it is best nursing practice.

Based on interview and record review, the facility failed to keep one resident (Resident #92) with a seizure disorder free from a significant medication error, when the facility failed to obtain Vimpat (medication used to prevent seizures) from the pharmacy timely, resulting in the medication not being administered for four and half days. The sample was 18. The census was 85. Review of the facility's Unavailable Medication Policy, dated 9/1/21, showed: -The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications; -Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: -Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medications. -Notify physician of inability to obtain medications upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold; -If a resident misses a scheduled dose of the medication, staff shall notify physician/family and monitor the resident for adverse reactions to omission of the medication. Review of Resident #92's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/26/24, showed: -Cognitively intact; -Diagnoses included: seizure disorder or epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of the resident's care plan in use at time of the survey, showed: -Problem: Resident has a seizure disorder; -Goal: will be free from injury from seizure activity through the review date; -Intervention: give medications as ordered. Review of the resident's order summary sheet dated 7/29/24, showed an order for Vimpat tablet 200 milligrams (mg), give 200 mg two times a day for seizures. Review of the resident's Medication Administration Record (MAR), dated 6/21/24 through 6/25/24, showed an order for Vimpat tablet 200 mg two times a day for seizure: -The medication not documented as administered for the 5:00 P.M. administration on 6/21 through 6/25/24; -The medication not documented as administered for the 9:00 A.M. administration on 6/22 through 6/25/24. Review of the resident's progress notes dated 6/21/24 through 6/25/24, showed: -On 6/23/24 at 11:41 A.M., pharmacy was contacted regarding Vimpat medication. Representative verbalized they were waiting on a new script; it was requested 6/21 and a new request will be sent to the medical doctor (MD); -On 6/23/24 at 11:43 A.M., MD's office was contacted. A representative verbalized I will see if the on-call physician can get it signed. I don't know. I'll let the nurses know also. The representative was also informed of missing doses at this time. Nurse will continue to monitor request today; -On 6/24/24 at 11:32 A.M., received a fax from the pharmacy regarding the residents Vimpat requesting a signed script. The nurse faxed information over to MD office; -There was no other documentation showing the MD was made aware the resident did not receive his/her medication and/or if the MD gave orders for an alternate treatment or monitoring while the pharmacy was waiting for a new script and the facility was waiting for the medication to be delivered. During an interview on 7/31/24 at 7:35 A.M., The Director of Nursing (DON) said if a medication was not available she would expect for staff to call the pharmacy and check to see what is going on with the medication/when the medication would be at the facility and notify the MD and check to see if something else can be given or if the medication should be placed on hold until it was available. The DON would expect staff to notify the MD for each dose of medication that was missed. During an interview on 7/31/24 at 7:45 A.M., Licensed Practical Nurse (LPN) K said Certified Medication Technicians (CMTs) would report to him/her if a medication was not available and he/she would call the pharmacy, to see what was going on with the medication. If a medication needed a script, he/she would follow up with the MD. LPN K said the facility did try to contact the pharmacy and the MD to obtain the residents script for his/her Vimpat. He/She did not recall how long the resident was out of his/her medication. During an interview on 7/31/24 at 7:55 A.M., LPN J said if a medication was not available, he/she would call the pharmacy and notify the MD. The MD should be notified for each dose of medication missed and it should be documented in the progress notes. If a script was needed, staff should call the MD's office and let them know we are waiting on a script. During an interview on 7/31/24 at 8:12 A.M., CMT I said if a medication was not available, he/she would check to see if the medication was available in the overstock and call the pharmacy. Medications are reordered through the computer system. Seizure medications are important because if the resident did not get their medication they are at risk for seizures. During an interview on 7/31/24 at 8:43 A.M., Registered Nurse (RN) H said if a medication was not available, he/she would tell the pharmacy we are out of the medication, and they would rush it out. Plus, he/she would check in the computer system. Seizure medication would be considered a high importance medication. If he/she was not getting a timely response from the pharmacy, he/she would call the pharmacy and call the MD and update the MD of the situation. During an interview on 7/31/24 at 8:50 A.M., the Pharmacist said medications can be reordered by pulling the sticker off the medication label and faxing it to the pharmacy or by electronically ordering it. Medications ordered by noon will be delivered the same day. Medications ordered after noon will be delivered the next day unless staff notified the pharmacy they needed the medication the same day. If a medication needed a script, the pharmacy would reach out to the MD to obtain the script. Nurses are educated to reorder medications five days prior to running out of the medication. Vimpat required a script. The facility contacted the pharmacy on 6/21/24 at 6:21 P.M. that they needed the medication. There were no refills on the script. The MD's office was faxed on 6/21 and 6/23 to try to obtain a new script. The pharmacy obtained the script on 6/24 and the medication was sent out on 6/24/24. During an interview on 8/2/24 at 9:00 A.M., the DON said she would expect staff to refill the medication when it is the blue (color on the medication card to indicate low quantity). Both the CMTs and nurses can reorder the medication. She would expect staff to follow the facility's policy and procedures. MO00239482

Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice, and care plan interventions related to pain for one of six sampled residents (Resident #3). The facility failed to timely administer pain medications in accordance with the physician's orders. Additionally, facility staff failed to follow up with resident pain medication to ensure availability for administration and failed to implement measures, including use of medication available in the facility starter kit/emergency drug kit, when the resident's pain medications were unavailable. The census was 94. Review of the Medication Reordering policy, dated 9/1/21, showed: -It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident; -The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident; -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; -Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting; -In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician; -For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container (may be used if applicable). Review of the facility's Physician's Orders policy, revised 4/7/22, showed: -Policy: This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Policy Explanation and Compliance Guidelines: Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility; -Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order; -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -Call, fax, or electronically transmit the medication and/or treatment order to the provider pharmacy; -Validate newly prescribed medications and/or treatment is in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order is in the electronic MAR/TAR; -Notify resident's sponsor/family of new medication order; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order; -Handwritten Order Signed by the Medical provider: The charge nurse on duty at the time the order is received should note the order and enter it on the medical provider order sheet or electronic order format, if not written by the medical provider. If necessary, the order should be clarified before the medical provider leaves the nursing station, whenever possible; -Verbal Orders: The nurse should document an order by telephone or in person on the medical provider's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical records. Medical provider orders should be signed per state specific guidelines. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/31/24 , showed: -Usually understood and usually understands others; -Set up or clean up assistance for eating; -Diagnoses included anemia (deficiency of red blood cells), atrial fibrillation (abnormal heart rhythm), coronary artery disease (damage in the heart's major blood vessels), heart failure, acid reflux, renal failure, diabetes, arthritis and stroke; -Been on a scheduled pain medication regimen: Yes; -Received as needed (PRN) pain medications: Yes; -Received non-medication intervention for pain: Yes; -Pain presence: Yes; -Pain frequency: Yes; -Pain Effect on Sleep: Frequently; -Pain Interference with Therapy Activities: Frequently; -Pain Interference with Day to Day Activities: Frequently; -Pain Intensity: 8 out of 10; -At risk for pressure ulcers; -Does this resident have one or more unhealed pressure ulcer at Stage 1 or higher: Yes; -Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: Three; -Number of these unstageable pressure ulcers that were present upon admission/reentry; -Enter the total number of venous and arterial ulcers present: one; -Diabetic foot ulcer: yes. Review of the resident's care plan, dated 2/14/24, showed: -Focus: Resident requires assist with activities of daily living related to blindness; -Goal: Resident's Activities of Daily Living (ADL) status will improve through the review date; -Interventions: Encourage resident to participate to the fullest extent possible with each interaction; -Encourage resident to use bell to call for assistance; -Monitor for changes in status, notify interdisciplinary team as needed; -Focus: The resident has diabetes; -Goal: The resident will be free from any signs and symptoms of hyperglycemia (high blood sugar); -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness; -Dietary consult for nutritional regimen and ongoing monitoring; -Monitor/document/report PRN compliance with diet and document any problems; -Focus: The resident has pain related to arthritis, depression, diabetic neuropathy; -Goal: The resident will display a decrease in behaviors of inadequate pain control: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through the review date; -Interventions: Administer analgesia (pain reliever) as per orders; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Identify, record and treat resident's existing conditions which may increase pain and or discomfort. Review of the resident's MAR and progress notes, dated April 2024, showed the following physician orders and administration: -An order, dated 3/5/24, Acetaminophen Oral tablet 325 milligram (mg). Give two tablets by mouth every six hours as needed for pain: was not administered 4/1/24 through 4/7/24; -An order, dated 3/27/24, Oxycodone (opioid, treatment for severe pain) HCL Immediate Release (IR). Give 5 mg by mouth three times a day for pain, showed: -On 4/1/24: -At 6:00 A.M., documented administered; -At 2:00 P.M., medication unavailable. Review of the progress notes, dated 4/1/24 at 2:16 P.M., showed medication unavailable; -At 9:00 P.M., documented administered; -On 4/2/24: -At 6:00 A.M. and 2:00 P.M., documented administered; -At 9:00 P.M. staff documented resident was sleeping; -On 4/3/24: -At 6:00 A.M., blank; -At 2:00 P.M., Absent from home without meds; -At 9:00 P.M., documented administered; -On 4/4/24: -At 6:00 A.M. and 2:00 P.M., documented administered; -At 9:00 P.M., see progress notes. Review of the progress notes, dated 4/4/24 at 9:00 P.M., showed no documentation; -On 4/5/24: -At 6:00 A.M., 2:00 P.M. and 9:00 P.M., see progress notes. Review of the progress notes, 4/5/24 at 4:23 A.M., showed no documentation; -At 5:02 A.M., no documentation; -At 1:39 P.M., medication unavailable, phoned pharmacy; -At 10:12 P.M., reordered; -On 4/6/24: -At 6:00 A.M., 6:00 P.M., see progress notes. On 4/6/24 at 5:28 A.M., not available, awaiting from pharmacy; -At 2:00 P.M., documented administered; -At 9:00 P.M., blank; -On 4/7/24 at 6:00 A.M. and 2:00 P.M., see progress notes. On 4/7/24 at 7:04 A.M., not available, physician made aware. Pharmacy needs a script to refill -At 1:13 P.M., awaiting script. Observation and interview on 4/7/24 at 1:30 P.M., showed the resident in his/her bed. The resident was covered with a blanket with his/her lower extremities outside of the blanket. The resident's legs appeared dry and cracked. He/She had a wrap on his/her left foot. The resident said he/she had an open sore on his/her foot. He/She is a diabetic. He/she had not received Oxycodone. Staff said they did not have any Oxycodone and Tylenol was not offered to him/her. He/She had pain from his/her hip to the foot due to a previous stroke. He/She rated his/her current pain as a 7 out of 10. During an interview on 4/7/24 at 2:15 P.M., Licensed Practical Nurse (LPN) B said they were waiting for the script for Oxycodone. The pharmacy sent a fax to the physician on Friday. That was the last thing he/she heard. The resident may have an order for Tylenol, but he/she would have to ask for it because it is as needed. Tylenol is available in the facility. LPN B was unsure how long the resident has been out of the Oxycodone. He/She checked the narcotic book and it showed 3/28, but he/she wanted to check the electronic medical record. During an interview on 4/27/24 at 2:20 P.M., Regional Nurse C said the last time Oxycodone was administered was on 4/1/24. The resident receives Lyrica (medication for nerve pain) for pain as well. Regional Nurse C will call the pharmacy to see what was going on. It was documented that the pharmacy was notified. At 2:25 P.M., Regional Nurse C said once the physician signs the script, it is sent to the pharmacy, and the medications are delivered on the next run. The pharmacy was awaiting a script from the doctor. At 2:45 P.M., Regional Nurse C said the physician changed the Oxycodone order from as needed to scheduled. The pharmacy sent out what was available to the resident at the time, but there was not a new order for the script. The physician knew the pharmacy would contact him/her. The pharmacy said they tried to contact the physician, but there was no communication. During an interview on 4/7/24 at 3:14 P.M., the Administrator said she expected staff to follow physician's orders. If there are blanks in the MARs and TARs, it was not done. She expected it to take approximately 48 hours from the time the medication was ordered or changed, called out to the pharmacy and receive the medication. Pharmacy said the issue was with the script. The Administrator expected staff to notify the pharmacy and the physician. She expected the medication to be pulled from Pyxis (medication dispensing machine) if it were unavailable. She expected staff to re-order medications approximately five days before they run out of the medication. There should be no lapse in medications. She expected Tylenol to have been offered to the resident as well. The Administrator said the physician did not receive anything from the pharmacy and the pharmacy only had a fax number. Pharmacy has sent the script for the physician to sign.

Based on interview and record review, the facility failed to follow their Home Dialysis Treatment policy and Notification of Changes policy for one resident readmitted to the facility on [DATE], with an order for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) three times a week. Facility staff failed to provide or attempt to provide the resident's transportation to/from dialysis on 11/8/23 and to communicate with the dialysis facility to request a different time for dialysis. Staff also failed to contact the resident's physician of the missed appointment timely and was not notified of the missed dialysis until 11/9/23. In addition, the facility failed to reassess/monitor and notify the physician of the resident's low blood pressure (BP) obtained on the evening of 11/8/23. Approximately two hours after the resident's low BP was obtained, the resident was sent to the hospital where he/she was admitted with a diagnoses of a critically high potassium level, hypotension (low BP), abdominal and chest pain, and shortness of breath. The facility identified three residents who received dialysis, and problems were found with one (Resident #4). The census was 82. Review of the facility's Home Dialysis Treatment policy, last reviewed/revised on 9/1/21, showed: -Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving home dialysis; -Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This includes: -The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -Compliance Guidelines includes: -Residents may receive chronic dialysis treatments which includes transporting the resident to and from an off-site facility for dialysis or treatments; -The facility must assist the resident to assure that arrangements are provided for safe transportation to and from the dialysis facility; -The facility will immediately contact and communicate with the attending practitioner (physician), nephrologist (kidney physician), or dialysis staff and resident/representative any significant changes in the resident's status related to clinical complications or emergent situations regarding dialysis; -The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. The facility will coordinate with the dialysis facility for rescheduling of the resident's dialysis treatment if canceled; -If dialysis is canceled or postponed, the facility and dialysis staff will provide or obtain ongoing monitoring and medical management for changes such as a fluid gain, respirator issues, review of relevant lab results, and any other complications that occur until dialysis can be rescheduled based on resident assessment, stability and need; -In the event circumstances do not allow dialysis to be provided by the designated trained and qualified individual, the facility must immediately notify the dialysis facility in order to make arrangements to assure that no dialysis treatments are missed. Review of the facility's Notification of Changes policy, last reviewed/revised on 9/1/21, showed: -Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification; -Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychological status. This may include life-threatening conditions, or clinical complications; -A transfer or discharge of the resident from the facility, acute (sudden change) condition, or exacerbation of a chronic condition. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/23, showed: -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Cognitively intact; -Always incontinent of bowel; -Colostomy (a surgical opening in the large intestine): Blank; -Diagnoses of anemia (decrease in the number of red blood cells;), renal (kidney) insufficiency/renal failure or end-stage renal disease (ESRD), diabetes mellitus and malnutrition (protein or calorie); -Dialysis: Blank. Review of the resident's care plan showed: -8/7/23: Focus: Current functional performance. Goal: Resident's functional status will progress towards personal discharge goal during stay. Interventions: Functional mobility of ambulation (walking) to sink/bathroom with stand-by assistance. Bed mobility, eating, personal hygiene, transfer, and independent locomotion on/off the unit; -8/7/23: Renal insufficiency related to kidney disease. Goal: The resident will be able to resume normal daily activities of daily living. Interventions: Monitor and report changes in mental status: lethargy, tiredness, fatigue. Monitor for signs and symptoms of hypovolemia (a condition where the body loses fluid like blood or water), increased pulse, respirations, decreased blood pressure, sweating, anxiousness. Monitor/document/report the following: edema (swelling), weight gain of over two pounds a day, neck vein distention, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, lung sounds; -8/7/23: Receives dialysis related to renal failure. Goal: The resident will have no signs/symptoms of complications from dialysis. Interventions: Monitor and treat for side effects. Review of the resident's census report (admissions/discharges) showed the resident was discharged to the hospital on 9/18/23 and returned to the facility on [DATE]. Review of the resident's progress note, dated 11/5/23 at 8:47 P.M., showed the resident complained to writer he/she wanted to be sent back to the hospital after having several explosive episodes of loose stool in his/her colostomy. Writer attempted to put wound vacuum (a machine that applies intermittent suction to drain fluid from a wound) in place to help stool from getting into wound on mid abdomen. Writer called exchange (physician's exchange) spoke to Nurse Practitioner who gave ok to send resident to emergency department (ED). Writer made resident's spouse aware of hospital transport. Review of the resident's census report, located in the resident's medical record, showed the resident was readmitted to the facility on Tuesday, 11/7/23. Review of the resident's medical record/progress notes showed: -11/7/23: No documentation showing the resident was readmitted to the facility; -11/7/23: No documentation the facility attempted to make arrangements for transportation to/from dialysis scheduled on Wednesday 11/8/23 at 7:00 A.M. Review of the resident's November 2023 physician's order sheet (POS) showed: -11/8/23: Re-admit charting every shift for 72 hours; -11/8/23: Dialysis infusion every Monday-Wednesday-Friday from 7:00 A.M. until 11:00 A.M. The order provided the name/number of the dialysis facility. Review of the resident's November 2023 medical record/progress notes showed: -11/8/23: No documentation the facility attempted to make arrangements for the resident's transportation to/from dialysis. No documentation the facility communicated with the dialysis facility to determine if they could accommodate a later dialysis time on 11/8/23; -11/8/23 at 2:00 P.M.: Resident had three complete bed changes due to colostomy bag not adhering to skin due to excoriation. Colostomy bag was changed as well; -11/8/23 at 7:07 P.M., the resident had a BP of 93/56 (normal BP is 120/80); -No further assessment or monitoring of the resident's BP or physician/family notification regarding the low BP; -11/8/23 at 9:31 P.M., a progress note documented by Nurse A: Resident was being sent to hospital related to stoma (a surgical opening on the body) and abdomen excoriation. On-call exchange has been notified; -11/8/23: No documentation the resident missed dialysis, or on-going assessments, monitoring for complications due to missing dialysis (edema, lung sounds, shortness of breath, or complete vital signs (temperature, pulse, respirations, blood pressure). No documentation staff contacted the dialysis facility or the resident's physician/family were notified about the resident missing dialysis. Review of the Ambulance Patient Care Report, dated 11/8/23, showed: -9:25 P.M.: Call received from facility; -9:55 P.M.: At patient's side; -Narrative: Arrived to find patient in nursing home bed. Patient stated he/she was having chest pain, abdominal pain, shortness of breath, and weakness. Nursing home staff reported they are calling Emergency Medical Staff (EMS) due to patient issues with his/her colostomy bag. They reported leakage around the colostomy bag and excessive production of fecal material. Staff reported history of dialysis, kidney failure, chronic hypotension (low BP), colostomy, and diabetes. Patient reports he/she was having chest pain in the middle of his/her chest. Patient reported he/she had been feeling chest pain over the past few hours. He/She reported it stays in the middle of his/her chest and did not radiate anywhere else; -Blood Pressure: -At 10:00 P.M. 70/49; -At 10:01 P.M. 78/48; -At 10:09 P.M. 84/54; -10:10 P.M.: Transport to hospital; -10:33 P.M.: Arrival at hospital; -10:35 P.M.: Care transferred to hospital staff; -Run Completion: Patient condition upon arrival at facility: Critical (RED). Patient condition at the end of EMS care: Emergent (YELLOW). Review of the hospital admission records showed: -admitted /time: 11/8/23 at 10:38 P.M.; -10:38 P.M.: Arrived at ED; -10:40 P.M.: Chief complaint chest pain, shortness of breath, general weakness, and abdominal pain near ostomy (a surgical opening in the abdomen, changing the way waste exits the body); -10:41 P.M.: Immediate life saving interventions needed? Yes; -10:42 P.M.: BP 82/62; -10:46 P.M.: Patient presented with chest pain. Patient complains of midsternal (breast bone) chest pain and intermittent shortness of breath. Patient stated chest pain began a couple of hours ago. Patient stated he/she has been going to dialysis and his/her last dialysis was Monday (11/6/23). Per EMS BPs were 70s/40s. Patient appears fatigued with a soft spoken voice; -History of Present Illness: Today the resident missed dialysis. Last dialysis was on 11/6/23. Throughout the day he/she began having chest pressure and sharp upper abdominal pain with generalized weakness and increased ostomy drainage prompting him/her to call EMS. En route, resident found to have low BPs; -Medical Decision Making: Resident presented with chest pain and generalized abdominal pain centered mostly around his/her incision. Will place in intensive care unit (ICU) for dialysis and further evaluation; -Clinical Impression: Hyperkalemia (excess potassium (K)), ESRD, hypotension (low BP), chronic anemia (low red blood cell count), protein-calorie malnutrition, generalized abdominal pain, chest pain, uremia (blood poisoning resulting from the retention of waste products usually excreted as urine), and metabolic acidosis (the buildup of too much acid in the body due to kidney disease or kidney failure. Symptoms can include an accelerated heartbeat, confusion and fatigue); -Reason for ICU admission: Resident presented to the ED where he/she was noted to have hyperkalemic emergency, an abnormal EKG, and metabolic acidosis; -Hyperkalemia in patient with ESRD: Notified by Registered Nurse of severely elevated K level initially reported to the physician was 7.8 (normal range is 3.4 - 5.0), but after checking with the lab was apparently 7.4. Review of the resident's November 2023 facility progress notes showed: -11/9/23 at 11:09 A.M.: Spoke to physician notification service, notified resident missed dialysis due to no transportation. Resident returned back to our facility on 11/7/23 at 9:37 P.M.; -11/9/23 at 11:25 A.M.: Resident missed dialysis Wednesday on 11/8/23. During an interview on 11/21/23 at 9:40 A.M., Nurse A said the resident was admitted to the hospital a couple of weeks ago for stoma problems and had not returned. During an interview on 11/21/23 at 1:15 P.M., the Administrator said the resident was readmitted from the hospital on 11/7/23, late in the evening. The facility's transportation van was already scheduled to take another resident to an appointment on the morning of 11/8/23, and their van only accommodates one wheelchair resident at a time. She did not know if the admitting nurse attempted to contact the transportation company to see if they could transport the resident the next morning. During an interview on 11/22/23 at 8:19 A.M., a representative from the transportation company said someone was available to take calls 24 hours a day. Dialysis is considered an urgent need and would have been given priority for transportation. Had they been contacted on the night of 11/7/23, when the resident returned, they most likely would have been able to have arranged transportation to the dialysis facility. The representative could not find documentation showing the facility contacted them on the night of 11/7/23, or the morning of 11/8/23. The last time they transported the resident to the dialysis facility was 9/22/23. During an interview on 11/22/23 at 8:35 A.M., the Director of Nursing (DON) said it's very important for residents to receive dialysis as scheduled. She expected the admitting nurse on 11/7/23 to have contacted the transportation company that night to try and arrange transportation to dialysis on 11/8/23. If transportation could not be arranged, she expected staff to contact the dialysis facility to see if the resident could receive dialysis later that same day when the facility van was available. If that couldn't be arranged, she expected staff to have contacted the resident's physician to inform him of the transportation issue and find out if the resident could miss dialysis or if the physician wanted the resident sent to the hospital via ambulance for dialysis. She did not know if any attempts were made to contact the transportation company, the dialysis facility, or physician/family. If attempts were made, staff should have documented it in the progress notes. During an interview on 11/22/23 at 12:00 P.M., Certified Nursing Assistant D said he/she took care of the resident on the day and evening shift on 11/8/23. The only problem he/she was aware of was the resident's colostomy bag was not adhering and filling up quickly, and the resident complaining of pain at the stoma site. The resident did not complain of chest pain or shortness of breath to him/her. During an interview on 1/22/23 at 1:40 P.M., the Administrator said she expected the nurse who admitted the resident to contact the transportation company to see if they could take the resident to dialysis on the morning of 11/8/23. During a telephone interview on 11/29/23 at 12:45 P.M., the Charge Nurse at the dialysis facility listed on the POS, said their facility always has open chairs to accommodate patients. Had the facility notified them on the morning of 11/8/23, they would have been able to accommodate the resident at a later time on 11/8/23. Due to the resident being in and out of more than one hospital during the past few months, the last time the resident had received dialysis at their facility was in September. Their nephrologist has not been following the resident at the hospitals. Potassium is one of the electrolytes that is removed through dialysis. A potassium level of 7.4 is a critical high. After a dialysis session, potassium levels usually decrease by about 2 points. During an interview on 11/30/23 at 2:25 P.M., the DON reviewed the resident's vital sign page in the medical record that showed the resident had a BP of 93/56 on 11/8/23 at 7:07 P.M. She expected staff to re-check the resident's BP, and if it was that low, staff should have contacted the resident's physician. The staff member who recorded the BP is no longer working at the facility. During a telephone interview on 11/30/23 at 2:30 P.M., Nurse A said he/she sent the resident to the hospital on the evening of 11/8/23. The resident did not complain to him/her about chest pain or shortness of breath. The only thing the resident complained of was pain to the colostomy site, which was red, excoriated, and very tender. The staff member who recorded the 93/56 BP did not tell him/her about the BP. Had he/she been informed, he/she would have checked the BP himself/herself and if it was that low, he/she would have called the physician. During an interview on 12/4/23 at 4:00 P.M., the resident's physician and facility Medical Director said the last time he saw the resident at the facility was on 9/6/23. It would have been best for the resident to have gone to dialysis as scheduled on 11/8/23. The faciity should have contacted the transportation company and the dialysis facility to try and arrange dialysis on 11/8/23. If they were unable to make the arrangements for dialysis, they should have notified the nephrologist and/or him. In a perfect scenario, if the resident was doing ok, had no extra fluid or shortness of breath, it may be alright for the resident to have missed dialysis, but he would have expected periodic assessments of the resident until his/her next scheduled dialysis day. On 11/8/23 at 7:07 P.M., he said he expected the staff member who documented the low BP to have informed the nurse, and if the resident's BP remained low, he should have been notified. He expected staff to document their attempts to arrange dialysis, and on-going assessments in the resident's medical record. A potassium level of 7.4 is a critical high and cardiac arrhythmia may develop, which could be due to missing dialysis and why the resident complained of chest pain and shortness of breath. MO00227214

Based on interview and record review, the facility failed to follow their policies regarding skin assessments and wounds when they failed to immediately put interventions in place when a resident (Resident #1) with a history of amputation had a new wound develop on his/her toe. Facility staff failed to obtain physician orders or send the resident to the hospital until 24 hours after becoming aware of the wound. At the hospital, the resident was diagnosed with osteomyelitis (bone infection) and required surgery. In addition, the facility failed to follow their policy by not performing a full body skin assessment weekly by a licensed nurse (Resident #1). The sample size was seven. The census was 86. Review of the facility's Wound Treatment Management Policy dated 9/1/21, showed: Policy: -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; Policy Explanation and Compliance Guidelines: -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; -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 (i.e. skin tear, medical adhesive related skin injury); -Atypical (i.e. dermatological or cancerous lesion, pyoderma (bacterial skin infection), calciphylaxis (calcium accumulation)); -Characteristics of the wound: -Pressure injury stage (or level of tissue destruction if not a pressure injury); -Size - including shape, depth, and presence of tunneling and/or undermining; -Volume and characteristics of exudate (drainage); -Presence of pain; -Presence of infection or need to address bacterial bioburden; -Condition of the tissue in the wound bed; -Condition of peri-wound skin; -Location of the wound; -Goals and preferences of the resident/representative; 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; -Treatments will be documented on the Treatment Administration Record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: -Lack of progression towards healing; -Changes in the characteristics of the wound (see above); -Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Review of the facility's Skin Assessment Policy dated 9/1/21 and revised 3/3/22, showed: Policy: -It is the facility's policy to perform a full body skin assessment as part of their systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment; Policy Explanation and Compliance Guidelines: A full body, or head or toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ readmission and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Review Resident #1's medical record, showed: -admitted to the facility from an acute care hospital on 11/23/22. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/23, showed the following: -Cognitively intact: -Understood/understands; -Adequate hearing and vision; -Clear speech - distinct intelligible words; -One person physical assist for bed mobility, dressing, toilet use, personal hygiene and bathing; -Diagnoses of diabetes, atrial fibrillation (A-Fib, irregular heart rhythm), end stage renal disease (ESRD, chronic irreversible kidney failure), stroke, coronary artery disease (CAD, sclerosis of the arterial walls) and respiratory failure. Review of the resident's undated care plan, and in use during the survey, showed: -Focus: The resident has actual skin impairment to skin integrity; -Goal: The resident will have no complications related to the alteration of the skin integrity through the next review date; -Interventions: Encourage good nutrition and hydration, in order to promote healthier skin. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, and maceration (skin break-down due to moisture), etc to physician. Obtain blood work as ordered by the Physician. Weekly skin assessments done by a licensed nurse. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -No documentation relating to skin/wound issues of the resident's toe, and/or the care of the resident's toe; -No documentation regarding refusals of skin assessments. Review of the resident's electronic physician's orders (POS) dated 3/7/23, showed: -An order dated 11/23/22 with a start date of 11/28/22, for resident shower days Monday and Thursday evening shift; -An order dated 11/23/22 with a start date of 11/30/22, for weekly skin assessment. Perform skin assessment weekly. Specify day and shift in routine every day shift every Wednesday, if there are any new skin issues, identify on skin assessment; -No orders for any skin related treatments prior to 3/3/23. Review of the resident's skin assessments from 2/1/23 to 2/28/23, showed: -An order dated 11/23/22 with a start date of 11/30/22, for weekly skin assessment. Perform skin assessments weekly. Specify day and shift in routine, every day shift every Wednesday, if there are any new skin issues, identify on skin assessment; -Documented as given one out of three opportunities; -2/1/23: Marked as given; -2/8/23: Blank; -2/15/23: Number (2) entered (meaning refused). Review of the progress notes, showed no progress note on the date of the refused treatment. Review of the resident's treatment administration record (TAR) dated 2/1/23, showed: -An order dated 11/23/22 with a start date of 11/28/22, for resident shower days Monday and Thursday evening shift; -Documented as given five out of five opportunities. Review of the resident's record, showed: -No progress notes from 1/28/23 to 2/17/23; -One shower sheet dated for 2/8/23: -No skin issues identified. Review of the resident's progress notes, showed: -On 2/18/23 at 5:43 P.M., the resident asked Licensed Practical Nurse (LPN) D for an antibiotic. When LPN D asked the resident why did he/she needed an antibiotic, the resident showed LPN D his/her left foot. On the resident's left foot, between the big toe and the third toe, LPN D observed slough (dead skin tissue) and skin peeling and the resident missing his/her second toe. The resident reported that his/her toe had been amputated for over five years. LPN D placed two calls out to Physician F and waited for a return call to the facility. LPN D made LPN C aware; -On 2/19/23 at 6:01 P.M., LPN D spoke with Physician F and obtained an order to collect a culture, with no antibiotic until the culture was complete, to apply silver sulfadiazine (wound treatment), dry dressing and triple antibiotic ointment (TAO), and the resident made aware. LPN D spoke with the regional nurse to make aware. LPN D faxed all orders to the pharmacy. Culture was collected. Waited on labs to pick up. LPN D was unable to complete treatment due to treatment cart being locked up; -On 2/19/23 at 7:01 P.M., this nurse was made aware on 2/18/23 at 4:33 P.M. while at home, by charge nurse that the resident approached him/her and asked for an antibiotic. It was also stated to LPN C that the resident showed the nurse his/her left foot, which had a wound on it. LPN C advised the charge nurse to call the Physician and get wound care orders, prophylactic antibiotic orders, as well as treatment supplies from central supply. LPN C told the charge nurse to apply a dry dressing until orders were obtained. This evening, LPN C was called by the regional nurse to come and assess the resident's foot. Upon assessment, LPN C observed an area between the left great toe and amputated second digit. Area measures 6.5 centimeters (cm) by 2.0 cm by 3.7 cm with 100% slough to wound base, moderate yellow drainage, and foul odor. Call placed to Physician to obtain orders to send resident to hospital; -On 2/19/23 at 7:55 P.M., Call was placed to Physician, times three, left message on voice mail. Call placed to the responsible party and left message to call facility. Call placed to local ambulance for transfer. Review of the resident's hospital record, showed: -admitted [DATE]; the resident was admitted for an infection of his/her left toe; -He/She underwent surgery and then treated with antibiotics; -The hospital course showed the resident had a history of a second toe amputation (2012) and presented with infection of the left second toe amputation site. The resident said he/she had pain two days prior to admission and noticed infection one day prior to admission. The resident underwent incision and drainage and first toe amputation; -On 2/28/23, he/she was discharged with a discharge diagnosis of osteomyelitis. During an interview on 3/6/23 at 2:15 P.M., the resident said he/she has diabetes. His/Her toe was infected and he/she didn't know it. He/She has neuropathy (weakness, numbness and pain from nerve damage). He/She already had a toe amputated four or five years ago. His/Her big toe was infected and amputated about three weeks ago. Before his/her toe was amputated, the facility had not been treating it. He/She didn't know until the last minute that it was infected. During an interview on 3/6/23 at approximately 4:45 P.M., Wound Nurse/LPN C said he/she started working at the facility on 2/13/23. He/She works Monday to Friday 6:30 A.M. to 3:30 P.M. or 7:00 A.M. to 3:30 P.M. or until he/she is finished. He/She was familiar with the resident. The resident had his/her toe amputated. LPN C thinks he/she may have been working at the facility for five days at the time the resident was sent to the hospital. LPN D called LPN C and said the resident had something on his/her foot. First, LPN D said the resident asked him/her for an antibiotic. LPN D asked the resident why and the resident said he/she had something on his/her foot. So then he/she showed LPN D his/her foot. LPN C was wondering why LPN D called him/her. LPN C did not know the resident had anything on his/her foot. LPN C was hired as the wound nurse but his/her first week at the facility, he/she worked on the floor due to the facility being short staffed. LPN C told LPN D that he/she did not know anything about a sore on the resident's foot. The next day, the corporate nurse called LPN C and asked him/her if he/she could go in and look at the resident's foot. LPN C went to work on Sunday (2/19/23) to look at the resident's toe. When he/she saw the resident's toe, he/she smelled it; it had a foul odor and was completely covered in yellow slough. LPN C was thinking the resident didn't need a pill; he/she was beyond that. He/she needed intravenous (IV) antibiotics. That particular toe was infected. LPN C called Physician F and the resident's family member. He/she could not get in touch with Physician F after calling him/her three times. He/She left a voice message with the resident's family member to call back to the facility. Per LPN C's nursing judgment, he/she sent the resident out to the hospital because he/she didn't want the resident to be septic. The resident stayed in the hospital for maybe a week or so, and then he/she returned back to the facility with his/her left great toe amputated. The digit next to it was already amputated. It looked like they debrided it when the resident went to the hospital the last time around because it was like one area now. After LPN C's first week, he/she was working at his/her full capacity as a wound nurse. LPN C never completed a wound report here because he/she didn't have a spreadsheet. He/She just got a access to a spreadsheet today (3/6/23). The administration was aware that he/she could not access the spreadsheet since he/she had been at the facility. LPN C does not know if the resident's toe was being treated at all, prior to the recent hospitalization . During an interview on 03/13/23 at 1:24 P.M., LPN D said he/she recently stopped working at the facility about two weeks ago. He/she is familiar with the resident and he/she worked all the shifts. Generally, the resident does his/her own showers with someone to oversee him/her to make sure he/she doesn't fall. In the past, LPN D was the unit manager and then became a weekend staff person. LPN D returned to work on Saturday, 2/18/23, which was his/her first day back at the facility in almost two weeks. He/she worked that weekend but he/she was not the resident's nurse. When the resident came to him/her and told him/her he/she needed antibiotic, LPN D asked the resident what did he/she need the antibiotic for. The resident told him/her, he/she needed it for his/her foot. LPN D told the resident to sit so he/she could see the foot. LPN D instantly saw slough coming out of the resident's toe. There was an odor from the resident's toe. It looked bad, so he/she looked for the wound cart but couldn't find the wound cart. LPN D called the recently hired wound nurse, LPN C. LPN C said the wound cart was locked up in his/her office. LPN C said there should be some type of treatment to clean the resident's toe with to hold him/her over until LPN C arrived. LPN C never did gave a time that he/she was going to go the facility, so LPN D called Physician F, but he didn't answer that day. LPN D called the former wound nurse, LPN M for wound supplies or where to find them so he/she could do a treatment on the resident's toe. LPN D did a treatment and wrapped up the resident's toe. LPN D said he/she worked as the resident's CNA the day the resident went to the hospital (Sunday 2/19/23) because they were short CNAs but had five nurses. They called LPN D in the kitchen and the dietary manager told him/her that the resident's treatment had fallen off so everything was exposed. LPN D went to go get the assigned nurse (not sure of the name), explained to him/her what was going on and called Physician F. Physician F said to give the resident TAO, a dry dressing and do a culture of the wound. The Physician specifically said don't put the resident on any antibiotics until the cultures come back. LPN D entered the lab into the system and charted while the assigned nurse obtained the stat (immediate) culture. Prior to this, there were never any orders for the resident's foot. The resident said he/she had been telling staff he/she needed antibiotics but no one was listening to him/her. The resident did not say who he/she told and/or how long he/she had been telling them this. After LPN D put the note in, he/she called the regional nurse, and told him/her what happened. Thirty minutes after the conversation with the regional nurse, LPN C was in the building and this was about 6:00 P.M. It was the wound nurse's job to make sure residents didn't have any skin issues. When the former administration was there, they kept a log of the showers. The CNAs would document what areas they saw and the wound nurse would sign off and make everyone aware. Now they no longer do that. Somewhere between 2/6/23 to 2/18/23 (while LPN D was not working), the resident's toe became infected. Apparently, no one was doing any skin assessments during that time. LPN C went in and charted in front of LPN D and lied. LPN D spoke to the resident's family member on Saturday (2/18/23) and Sunday (2/19/23), and he/she asked LPN D to send him/her a picture of the resident's toe on that Saturday but LPN D said he/she couldn't because of privacy laws. Everybody gets skin assessments on shower days and there are already orders put in place for that. During an interview on 3/17/23 at 2:51 P.M., LPN O said he/she was is familiar with the resident. LPN O might have worked with the resident sometime before his/her amputation, but the resident didn't mention anything about his/her toe, and neither did any other staff mention anything abnormal about the resident's toe. All the residents should be getting weekly skin assessments, Nursing is usually responsible for doing the skin assessments. He/she did not know if the resident had a treatment order in place before his/her amputation but if there was a skin issue before the amputation, he/she should have had a treatment order in place. During an interview on 3/17/23 at 3:01 P.M., LPN N said he/she had worked at the facility since October of 2022. He/she was familiar with the resident. The resident had a recent toe amputation. LPN N did not remember when he/she last worked with the resident prior to his/her toe being amputated, but the resident never mentioned any issues with his/her toe. LPN N never noticed anything abnormal about the resident's toe either. The residents gets skin assessments, usually weekly depending on the resident. Depending on the aide, they will also alert the nurse if there are any new skin issues. During an interview on 3/17/23 at 3:24 P.M. LPN H said he/she was familiar with the resident, but typically didn't work on the resident's hall. The resident is alert and oriented times four, so he/she typically doesn't need any help. Through word of mouth, LPN H heard about he resident asking for antibiotics and being sent to the hospital. Staff found out through another resident, that Resident #1 had got some shoes from another resident without washing them or anything. There was nothing wrong with the other resident's foot, but LPN H did not think the other resident was too clean. The resident went to the hospital on a Sunday night (2/19/23). The treatment nurse called for the resident to be transported. LPN C came in specifically for the resident's foot. LPN H said he/she and the Assistant Director of Nursing (ADON) were there when the ambulance came to pick up the resident. The resident didn't have any skin issues of which LPN H was aware. There was nothing abnormal about his/her foot. The resident should have been getting weekly skin assessments. Skin assessments typically happen on shower days. During an interview on 3/14/23 at 12:11 P.M. and 12:24 P.M., Physician F said if a resident had a history of amputations, and/or skin issues, he would expect weekly skin assessments to be completed as ordered and reported to him. The facility has his number, as well as the number to the exchange, so they know how to contact him. He would have expected for staff to contact him if the resident was experiencing any skin issues. The facility probably wouldn't contact him if a resident was refusing skin assessments. Physician F couldn't say that if the facility was doing regular skin assessments or calling him and obtaining orders, it would have changed the outcome of the resident's toe. Since staff sent the resident out to the hospital, someone must have assessed the resident. During an interview with Administrator B and the ADON on 3/20/23 at 3:41 P.M., Administrator B initially said they didn't have a wound report log, but they had a wound care nurse. They had a pressure wound log and the wound nurse always had access to it, but at first LPN C did not know how to access it. They have a wound report now. LPN C has a wound report that she prints out daily, and he/she charts the assessments in the electronic medical record. Skin assessments should be done weekly. The ADON said skin assessments pop up on the TAR, so it would be the nurse's responsibility to complete the skin assessments. The ADON said she does plan to complete in-servicing with the nurses on skin assessments, refusals, and how to document refusals in the electronic medical record. The ADON was unsure if Resident #1 was getting skin assessments on a regular basis or not. When this situation transpired with the resident, she was on her third day in the building. During the situation, the ADON and the wound care nurse (LPN C) came into the building about the same time. Once they came to the facility, they assessed the resident and identified any areas of concern. They found that probably no one noticed the resident had an area of concern with his/her toe. Resident #1 is one of the residents who refuses skin assessments. The resident didn't know what happened. Staff found out something was wrong with the resident's toe, and he/she was sent out to the hospital, so any orders would have been put into place after the resident returned from the hospital. The Physician was contacted and the first order was to send him/her to the hospital. She could not verify what happened in the past, but once they found out what was going on with Resident #1, they took the proper steps and proper precautions to get the resident some help. The Administrator said if they were aware that something was going on with the resident, of course an order would have been put in place. Once they found out there was something amidst, staff took care of it immediately. Administrator B said if a resident refuses skin assessments, medications, and/or treatments, or any type of care, she would expect for this to be care planned, and documented in the resident's medical record. MO00214939

Based on interview and record review, the facility failed to ensure a resident who admitted to the facility with intact skin, did not develop wounds. The facility failed to perform and document weekly skin assessments. When an open area was observed nine days after admission, the staff failed to notify the wound care nurse and failed to ensure the physician-ordered ointment was documented on the treatment administration record (TAR). When the resident discharged home, the facility failed to inform the next of kin of the wound care treatments. The resident was discharged home 1/31/22 and readmitted into the hospital on 2/1/22 for wound infection (Resident #9). The sample was 3. The census was 69. Review of the Wound Treatment Management policy, dated 9/1/21, showed: -Policy: To promote wound healing of various types or wounds. It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Policy explanation and compliance guidelines: -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 the 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 (stool) has seeped underneath the dressing, the dressing had dislodged or the dressing is soiled otherwise or is wet; -Dressings will be applied in accordance with manufacturer recommendations; -Treatment decisions will be based on: -Etiology (cause) of the wound: -Pressure injuries (the breakdown of skin due to pressure, most commonly in bony areas) will be differentiated from non-pressure wounds, such as arterial and venous (wounds caused by poor blood circulation) wounds, diabetic (wounds that form due to poor blood sugar control and poor circulation), moisture related skin damage; -Surgical; -Incidental (skin tear, medical adhesive related skin injury); -Atypical (dermatological or cancerous lesion); -Characteristics of the wound: -Stage or level of tissue destruction if not a pressure injury; -Size: including shape, depth, and presence of tunneling or undermining; -Volume (amount) and characteristics of exudate (drainage); -Presence of pain; -Presence of infection or need to address; -Condition of the tissue in the wound bed; -Condition of the peri-wound (tissue to the wound edge) skin; -Location of the wound; -Goals and preferences for the resident or representative; -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 the unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances; -The facility will follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Treatments will be documented on the TAR; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: -Lack of progression towards healing; -Changes in the characteristics of the wound; -Changes in the resident's goals and preferences, such as at the end of life or in accordance with his/her rights. Review of the skin assessment policy, dated 9/1/21, showed: -Policy: It is the policy to perform a full body skin assessment as part of a systemic approach to skin injury prevention and management; -Policy explanation and compliance guidelines: -A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission, re-admission and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified wound or pressure injury; -Documentation of the skin assessment: -Include date and time of the assessment, the nurse name, position and title; -Document observations (skin condition, how the resident tolerated the procedure); -Document wound type; -Describe wound (measurements, color, type of tissue in wound bed, drainage, odor and pain); -Document if the resident refused the assessment and why; -Document other information as indicated or appropriate. Review of Resident #9's hospital physician discharge progress note, dated 1/7/22, showed: -Physical exam: -Musculoskeletal: -Left upper arm: [CONDITION(S)] (swelling) and tenderness; -Left elbow: decreased range of motion; -Skin: -General: warm and dry; -Findings: bruising (open blister to the left elbow); -Assessment and plan: The patient has a history of high blood pressure, stroke with left sided deficits and mild cognitive impairment. He/she was brought to the emergency room (ER) by ambulance from home after he/she was found down. Plan to discharge to skilled nursing facility. -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood); -Left arm pain: no fracture. Keep left elbow blister clean, dry and apply dry dressing. Change as needed; -Stroke with residual left sided deficits: prior deficits related to stroke history in 2013. Continue physical and occupational therapy. Review of the facility admission skin assessment, dated 1/8/22, showed: -Skin integrity: -Color: Normal; -Temperature: Warm; -Turgor (ability of skin to change shape and return to normal): Normal; -Integrity: Are there skin issues: No; -Comments: Right arm 2+ [CONDITION(S)] (pressure leaves an indentation of 3-4 millimeters that rebounds in fewer than 15 seconds). Review of the admission electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, showed no weekly skin assessments documented for the week of 1/10/22 through 1/16/22. Review of the baseline care plan, dated 1/12/22, showed: -Safety/risk: -Does the resident have impaired skin integrity at admission: Yes; -Location: Left elbow; -Bathing preferences: three times a week in the afternoon; -Medical conditions: -Therapy; -Wound any type: blank; -Discharge plan: rehabilitation to home. Review of the skin monitoring: comprehensive certified nurse aide (CNA) shower sheet, dated 1/12/22, showed no areas of skin concern. The form was signed by the aide and unsigned by the nurse. Review of the facility wound report, dated 1/12/22, showed the resident not listed on the report. Review of the physician physical exam, dated 1/12/22, showed: -History of present illness (HPI): resident hospitalized post fall. Severe rhabdomyolysis. He/she stabilized in the hospital and discharged to the facility. Left arm swollen; -Review of systems: -Extremities: left arm [CONDITION(S)] (swelling); -Skin: intact. Left arm [CONDITION(S)] and tenderness all the way to the shoulder; -Impression and Plan: -Post fall, provide therapy -Rhabdomyolysis; -High blood pressure; -Stroke with left sided weakness. Review of the admission Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 1/14/22, showed: -admitted from the hospital on 1/8/22; -Moderate cognitive impairment; -No behaviors or mood concerns; -Required supervision for bed mobility, transfers, dressing, locomotion and toileting; -Required assistance of one staff needed for personal hygiene and bathing; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Skin problem: skin tear; -Received pressure reducing device for the bed, application of nonsurgical dressing and ointments other than to feet; -Received occupational and physical therapy. Review of the skin monitoring: comprehensive CNA shower sheet, dated 1/15/22, showed no areas of skin concern. The form was signed by the aide and unsigned by the nurse. Review of the progress notes, showed: -On 1/17/22 at 7:51 P.M., the resident gave verbal consent to see wound care team; -On 1/17/22 at 8:09 P.M., CNA notified the nurse the resident had two open area found during his/her shower. The left forearm wound measured 3 centimeters (cm) x 3 cm, the area noted partially scabbed and scant drainage noted to the other half. Second wound noted to the left armpit. The wound measured 6 cm x 4 cm. The area is red, pink and a small area is yellow. Small amount of drainage noted. Area is painful to touch. The resident unable to lift his/her arm. Pain medication administered and dressing applied. Further review of the January ePOS, showed orders, dated 1/17/22: -Apply triple antibiotic ointment (TAO, topical antibiotic cream) and dry dressing to the upper forearm and the left armpit until wound care company can evaluate and treat; -Wound care team to evaluate and treat. Review of the January TAR, showed no wound treatment orders for the left upper forearm or the left armpit from 1/17/22 through 1/31/22. Further review of the medical record, showed no detailed skin assessment completed as a result of the wound discovery on 1/17/22. Review of the facility wound report, dated 1/18/22, showed: -Date of wound discovery: 1/8/22; -Location: Left underarm; -Stage: previous and current week: Stage III (wound extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone); -Most severe tissue type: Granulation (pink, healing tissue); -Measurements: length 8.5 cm x width 13 cm x depth 0.1 cm; -Worse; -Present on admission: yes; -Stage on admission: II (the skin usually breaks open, wears away, or forms a shallow ulcer, which is usually tender and painful); -Home acquired: Present on admission but worsened in house; -Current treatment: blank; -Frequency of treatment: daily or more often. Review of the skin monitoring: comprehensive CNA shower sheet, dated 1/19/22, showed a circled area on the body image to the left armpit as open and the left inner forearm scabbed. The form was unsigned by the aide and the nurse. Review of the physician visit note, dated 1/19/22, showed: -HPI: receiving skilled services. Had open area to left arm, continue until healed; -Skin: treatment in place to left arm pit; -Assessment and plan: -Continue with therapy; -Left arm open area, wound physician initiated. Further review of the progress notes, dated 1/20/22 at 2:58 P.M., showed an MDS note: The resident admitted from the hospital. He/she was found down by family, with his/her left arm caught between the mattress and box spring. He/she had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Receiving physical therapy. Required staff stand by assistance to limited assistance for dressing, hygiene, bathing and grooming. Skin tear to eft elbow is healed. All other skin is intact, without rashes, redness or open areas. Review of the admission comprehensive care plan, initiated 1/20/22, showed: -Focus: The resident has a potential/actual impairment of the skin to the left elbow, a skin tear healing related to post fall; -Goal: The resident will maintain or develop clean and intact skin and the skin tear to the left elbow will be healed; -Interventions: Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin monitoring: comprehensive CNA shower sheet, dated 1/22/22, showed a handwritten note, with a line drawn to the body image of the left underarm. The note, showed Director of Nursing (DON) aware. The form was unsigned. Further review of the medical record, showed no weekly skin assessment completed 1/24/22 through 1/31/22. Further review of the progress notes, showed: -On 1/24/22 at 12:45 P.M., the resident tested positive for Covid-19 on 1/21/22. He/she moved to the Covid-19 unit for further evaluation. His/her physician was notified, the resident is his/her own responsible party; -On 1/25/22 at 1:42 A.M., the resident's respirations are even and unlabored. Skin warm and dry, no signs or symptoms of pain or discomfort. Continue with skilled services Further review of the ePOS, showed: -An order, dated 1/26/22, for weekly skin assessments on the evening shift every Wednesday. Further review of the facility wound report, dated 1/26/22, showed the resident was not listed on the report. Further review of the medical record, showed no weekly skin assessments documented from 1/17/22 through 1/31/22. Review of the skin monitoring: comprehensive CNA shower sheet, dated 1/26/22, showed a circle to the left armpit noted an open area and treatment in place. The form was unsigned. Review of the physician visit note, dated 1/26/22, showed: -HPI: the resident had Covid-19 and is in isolation; -Exam: no skin irregularities documented; -Assessment and Plan: -Covid-19 positive, continue isolation and monitor symptoms; -No documentation of the left armpit wound. Review of the skin monitoring: comprehensive CNA shower sheet, dated 1/29/22, showed a circle to the left armpit noted an open area and a scabbed area to the left forearm. The form was signed by the aide and unsigned by the nurse. Further review of the progress notes, showed: -On 1/31/22 at 2:56 P.M., a nurse note: the resident discharged home with his/her family. The resident ambulated independently to the car with use of a cane. Medications and discharge instructions given to the family; -On 1/31/22 at 4:19 P.M., a social service note: the resident discharged home with his/her family and home health. The family stated he/she would arrange physical therapy services. Review of the emergency department (ED) provider note, dated 2/1/22, showed: -Physical exam: notable wound to the posterior (back) medial (middle) axilla (armpit) as well as the anterior (front) medial axilla which appears to go down to the fascia/muscle layer. There is some purulent (thick), serous (yellow) drainage as well as induration (abnormal hardening of the tissue caused by consolidation of [CONDITION(S)]); -Patient is a poor historian, and stated the wound to the left axilla was present since his/her fall on 1/2/22. No prior records to confirm; -Admit for intravenous (IV, thin hollow tubing used to administer fluids and medications) antibiotics for wound infection and surgical consult for axillary wound. Review of the inpatient hospital history and physical, dated 2/2/22, showed: -Surgery was consulted and recommended IV antibiotics and Dakins (diluted bleach solution to clean wounds) to dry dressing twice a day to the axilla wound. The patient was started on intravenous (IV) [MEDICATION(S)] (antibiotic); -Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . No abscess noted on imaging During an interview on 2/7/22 at 1:22 P.M., the facility wound nurse said all residents should receive a full head to toe skin assessment weekly by the nurse. She confirmed the resident did not receive any weekly skin assessment after admission on 1/8/22. A wound was discovered under the left armpit and the nurse received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the ordered wound treatment to the left armpit wound. She said she observed the wound on 1/18/22 before the resident went onto the positive Covid-19 unit. After the resident moved onto the Covid-19 unit, she did not provide wound treatments. The Covid-19 unit charge nurse would have done the ordered treatments. She did not have wound measurements for the week of 1/26/22. The resident was not listed on the wound report. The wound measurements had worsened from the measurements dated 1/17/22. The wound appeared to be a cyst and not pressure related. She was unaware the ordered treatment had not appeared on the resident's TAR. The wound nurse said if the treatment was not added to the TAR, the nurses would not know to complete a treatment. The wound would have worsened. During an interview on 2/7/22 at 1:42 P.M., the Director of Nursing said all the nurses including agency should be completing and documenting weekly skin assessments. If a physician gave a treatment order, the order should be placed in the TAR for the nurses to complete. If an order does not get carried onto the TAR, the nurse may not realize the resident had a treatment order in place. Missed wound treatments could place the resident at risk for wound infection and worsening wound status. Shower sheets should be signed by the aide and the nurse. The Covid unit charge nurse should conduct and document treatments and report any wound changes to the wound nurse and the physician. During an interview on 2/7/22 at 2:01 P.M., the Administrator said the facility use some agency floor and nurse staff. Some of the agency staff do not understand how to use the electronic medical record to place orders and ensure the orders are placed in the correct area for the resident. All nurses regardless if they are agency or hired staff should complete and document weekly skin assessments, and administer physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If staff are unsure of policy or procedures, they should contact the DON or himself for assistance. During an interview on 2/8/22 at 7:22 A.M., the resident's next of kin (NOK), said he/she picked the resident up from the facility on 1/31/22 to discharge home with a home health aide. The facility nurse handed the NOK the resident's medication pills. The nurse did not inform him/her of any skin issues. The NOK took the resident home, and the morning of 2/1/22 the home health aide called the NOK and said the resident had a wound under his/her left armpit. The NOK went to the resident's home, observed the wound and took the resident to the local urgent care. The urgent care staff observed the wound and advised the NOK to take the resident to the hospital emergency room (ER). The NOK said when the resident arrived at the ER, the ER staff assessed the wound and informed the NOK the resident would be admitted to the hospital for antibiotics. The hospital planned to discharge the resident on 2/8/22 to a different nursing facility. During an interview on 2/8/22 at 8:05 A.M., the hospital Registered Nurse (RN) Manager said the resident is scheduled to discharge from the hospital on 2/8/22. He/she reviewed the inpatient hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . When the resident was admitted , the ER noted the wound had yellow purulent drainage,was painful and the wound was not well taken care of. The resident received IV antibiotics and would be discharged with oral antibiotics. Review of the hospital inpatient discharge summary, dated 2/8/22 at 11:19 A.M., showed: -admitted : 2/1/22; -Discharge: 2/8/22; -Hospital Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Hospital course: presented with a left axilla [CONDITION(S)] secondary to a wound. The computerized tomography (CT, series of images of body to obtain detailed images) scan of the left extremity and showed a left posterior axillary superficial ulcer with extensive surrounding [CONDITION(S)] in the posterior axilla and arm, but no abscess or myositis (rare group of diseases characterized by inflamed muscles). The patient was given IV [MEDICATION(S)] for 24 hours and then transitioned to oral antibiotics to complete a 14-day course. Surgery consulted and recommended aggressive wound care with frequent dressing changes. During an interview on 2/10/22 at 2:40 P.M., the resident's physician said that it is a standard of practice to conduct a full head to toe weekly skin assessment on every resident. Weekly skin assessments should be documented in the medical record. If no weekly skin assessment are documented, it would mean the assessment was not completed. Treatments should be completed as ordered. A wound treatment not completed could cause the wound to get worse and risk infection. The resident received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the treatment order was not on the TAR, the treatment would not have been completed. The wound likely would have gotten worse with no treatment. Wounds should be assessed weekly by the wound care nurse, documented and the treatment plan revised if needed. If wound measurements worsen, the physician should be contacted. The resident's family should be notified and given supplies at the time of discharge of any wound care needs. MO 783

JW Based on observation, interview and record review, the facility failed to ensure a resident admitted from the hospital with multiple pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) received weekly skin assessments, ordered wound treatments, ordered intravenous (IV, thin, hollow tubing inserted into a vein) antibiotics and dietary supplements. The resident was not added to the facility wound report until almost a month after his/her admission to the facility. The wounds increased in size from the admission measurements. This affected one of two sampled residents (Resident #1). The census was 66. Review of the undated wound management program, showed: -Mission and Policy: To facilitate resident independence, promote resident comfort and preserve resident dignity. All caregivers are responsible for preventing, caring for, and providing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -Introduction: -Wounds are prevented and treated to minimize morbidity and mortality when possible, and to provide cost effective methods or management, while managing any accompanying problems, such as pain or decreased mobility, when desired or possible; -Purpose: -To identify risk factors for potential skin breakdown and wounds; -To prevent skin breakdown and wounds as much as possible; -To provide treatment that promotes the prevention of wounds and skin breakdown and the healing of existing wounds, when desired or possible; -To improve resident outcomes and quality of life by providing prevention and treatment or management of skin breakdown and wounds; -Process: In order to ensure residents have access to the appropriate assessments and management to prevent, treat, maintain, or oversee wounds, the facility will have an ongoing organized approach to wound care. The facility will use the following aspects of wound care to achieve the mission of the program: -Assessment of the resident including the risk factors for wound development including pressure injury; -Skin assessment and wound assessment; -Determination of wound etiology (cause) and management of contributing factors for all wounds when possible or desired; -Management of tissue loads as allowed; -Appropriate local wound care including management of bacterial colonization and infection; -Management of comorbid (diseases or medical conditions that are simultaneously present) conditions, when possible that may contribute to the development of wounds or inhibit wound healing; -Preventative measures for pressure injury and other wounds as possible; -Support for the healing of pressure injuries and other wounds that are present as possible; -Providing education to residents, families and caregivers; -Improving the quality of care and clinical outcomes through the quality improvement process. Review of the undated Risk and Skin Assessment policy, showed: -Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure injuries or other breaks in the skin. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. The assessments will begin upon admission with a head to toe assessment as close to the actual time of admission as possible but no more than two hours from the time of actual arrival and continue throughout the resident's stay; -Purpose: The purpose is to establish a consistent and objective method of assessing the resident's risk for wound and pressure injury development and to implement a standardized plan to prevent wounds and pressure injury as much as possible; -Procedure: The assessment will include: -A licensed nurse will complete a standardized risk assessment using the Braden Scale (an assessment tool used to predict the risk to develop pressure ulcers, based on the total of scores given in the category of sensory perception, moisture, activity, mobility, nutrition and friction and shear). The assessment is completed upon admission/readmission, weekly for the first four weeks, quarterly and with a significant change in condition or ability; -All factors included in the risk assessment will be addressed even if the assessment does not indicate risk for pressure injury development; -Risk factors that may contribute to the development of wounds including pressure injuries will be identified using the comprehensive alternative risk factor form: -Impaired or decreased mobility and decreased functional ability; -Co-morbid conditions such as diabetes, cardiovascular, pulmonary or renal disease; -Cognitive impairment; -Exposure of the skin to urinary and/or fecal incontinence, perspiration, drainage or weeping; -Poor or reduced meal and fluid intake; -Previous healed ulcer and/or open area; -At risk for friction or shearing from repositioning or repetitive movements by the resident; -Preadmission factors like prolonged bed rest, surgery, signs of skin impairment on admission; -Inpatient or outpatient hospitalization in the last 90 days; -Current open ulcers; -Braden score; -All residents will have a visual inspection of their skin: -A complete head-to-toe skin check is completed by the licensed nurse upon admission/readmission (as soon as possible but no longer than 2 hours) and document in the medical record; -Skin checks are completed weekly and as needed by the licensed nurse and are documented in the medical record; -Skin/body check is completed on each shower day by nursing assistant staff: -Shower sheet or electronic medical record (EMR) may be used to document the skin check; -If an area is identified, the nurse is notified via the stop and watch tool or through the EMR; -The licensed nurse completes an assessment if there is a skin condition; -The nursing assistant visually inspects the skin daily and with care; -If an area is identified, the nurse is notified via the stop and watch tool or through the EMR; -Appropriate measures will be initiated; -Nutritional and hydration assessment: -Upon admission; -Quarterly and annually; -With a change in condition. Review of the undated wound and pressure injury prevention policy, showed: -Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible; -Purpose: To establish and provide consistent measures for the prevention of wounds and pressure injuries based upon the assessment of the resident and resident choice; -Procedure: Implement interventions based upon the results of the risk assessment to develop an individualized plan of care: -Sensory deficits, mobility impairment, and activity limitations: -Residents with sensory deficits will be reminded to turn and reposition as appropriate based on the plan of care and on the resident's choice and needs; -Residents who are unable to turn or reposition independently will be assisted to turn and reposition as appropriate based on the plan of care and on the resident's choice and needs: -Residents have a choice to refuse turning and repositioning; -When residents refuse to be turned and repositioned, an attempt to identify the reason it is made; -Additional interventions may be indicated to assist the resident to turn and reposition as recommended; -The plan of care should reflect the resident's choice; -Residents should not be positioned directly on the side or trochanter (upper hip) as much as possible as this may contribute to breakdown on the hip; -Residents who are inactive will be encouraged to change position frequently and ambulate and will be assisted per resident choice as appropriate; -Support surfaces including pressure reduction and pressure relief devices will be used as appropriate, devices may include gel, static air, foam or alternating air; -Positioning devices will be used to keep bony prominences from direct contact with each other, pillows, foam wedges, or other devices may be used for this purpose and prevent trauma injury as much as possible; -Float heels to relieve pressure, devices such as boots or pillows as appropriate; -Elbow protectors and heel protectors may be used as appropriate; -Time spent up in a chair may need to be limited based on resident choice and condition; -Any clothing, shoes, braces and splints that may not be fitting properly should be reported to the licensed nurse, the nurse completes and assessment and implements interventions and indicated; -Incontinence management/promotion of clean, dry and moisturized skin: -Residents who are incontinent of urine and/or stool will be assisted to use the toilet or bedpan; -Residents who are unable to communicate the need to void or defecate will be placed on an appropriate program for incontinent management; -Cleaning will be completed after each episode of incontinence; -Protectant products may be used and applied per manufacturer recommendations and products containing active ingredients are applied by a nurse; -Skin moisturizers may be used as needed, avoid the use of powders; -Avoid massaging over areas of concern as this may cause further tissue damage and breakdown; -Avoidable pressure injury occurs when the resident developed a pressure ulcer and the facility did not do one or more of the following: -Evaluate the resident's clinical condition and pressure ulcer risk factors; -Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; -Monitor and evaluate the impact of the interventions or revise the interventions as appropriate; -An assessment of the resident is completed to determine whether all appropriate interventions were in place: -Comorbid conditions that may contribute to wound and pressure injury development; -Interventions in place for prevention of wounds and pressure injuries are documented in the medical record; -Compliance with the implemented interventions per resident choice. Review of the undated wound assessment policy, showed: -Policy: To complete a systematic, ongoing assessment of all wounds that will provide a consistent means of wound evaluation to determine the response to treatment modalities and to facilitate continuity of care and communication among staff and health care providers, staff, and the resident and family on an ongoing basis; -Procedure: The presence of any wounds, injuries, and/or other skin abnormalities will be identified upon admission/readmission and with ongoing assessments; -A licensed nurse will complete a skin and wound assessment upon admission/readmission, identify any wounds or other skin abnormality and document/describe the wound/skin abnormality in the medical record as soon as possible after admission; -Note: Nurses do not diagnose and therefore should describe the wound in terms of tissue depth (partial thickness, full thickness) until a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The wound should be described and measured when identified; -It is acceptable to use common terms (dime sized, quarter sized, etc.) to describe the wound until actual measurements can be obtained; -For any reddened area identified, assess for blanching (whitish appearance as blood flow to the region is prevented); if the area does not blanch, reassess blanching again in 30 minutes; -The wound team will complete a skin and wound assessment and documents the presence of any wounds, injuries, or other skin abnormalities including measurements and the wound assessment in the medical record; -Any wound, pressure injury or the skin abnormality identified during the resident's stay will be documented in the same manners when identified upon admission/readmission; -Type of wound/etiology will be identified by the provider: -Per provider notes; -Based upon the location, clinical features, and appearance of the wound; -Diagnostic testing; -Consider co-morbidities; -Wounds are measured weekly by the wound care team of designee: -Wounds are measured preferably by the same clinician when possible to decrease variability; -The status of the wound is documented in the medical record; -Wound status is also monitored with each dressing change; -Any changes in the wound are documented at the time identified and the provider and the family are notified. Review of the hospital records dated 12/5/21, showed Resident #1: -admitted to the hospital on 11/23/21 from his/her home where he/she lived with his/her grandson; -Exam: admitted for multiple wounds from home to the left lateral (outer) buttock, left knee, left and right trochanters (back of the upper hip bone), the sacrum (tailbone) and to the left buttock with drainage; -Assessment and Plan: [CONDITION(S)]-like secondary to ulcers, post surgical debridement (surgical removal of dead tissue, to promote healthy tissue growth), wound culture completed on 11/27/21 supported administration of cefriaxone (antibiotic) and [MEDICATION(S)] (antibiotic). Orders to continue both antibiotics with an end date of 12/9/21 per infectious disease physician; Hospital admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital discharge summary wound measurements, dated 12/6/21, showed: -Pressure ulcer: Left knee; -Wound bed: pearly pink; -Wound margin (edge): defined; -Measurements: Length 2.0 centimeters (cm) x Width 2.5 cm x Depth 0.0 cm; -Staging: Stage II (skin is broken open, or is a fluid filled blister); -Peri-wound (tissue surrounding the wound) skin assessment: Intact; -Dressing/treatment: open to air; -Pressure Ulcer: Sacrum: -Wound bed: pearly pink, brown; -Exudate (drainage): none; -Wound margins: defined edges; -Measurements: 2.5 cm x 2.5 cm x 0.0 cm; -Staging: Stage III (full-thickness skin loss potentially extending into the subcutaneous (fat) tissue layer); -Peri-wound: intact; -Dressing: open to air; -Pressure ulcer: Left trochanter (hip): -Wound bed: black; -Exudate: small, purulent (thick), odorous; -Measurements: 3.0 cm x 4.0 cm x unable to assess due to eschar (thick black scab covering a wound); -Staging: unstageable (an ulcer that has full thickness tissue loss but is covered by extensive necrotic (dead) tissue or by an eschar); -Peri-wound: intact; -Dressing: dry dressing; -Pressure ulcer: Left buttock; -Wound bed: Deep pink and slough (yellow, stringy dead tissue); -Exudate: moderate, odorous; -Measurements: 5.0 cm x 6.0 cm x 2.0 cm; -Staging: Stage III; -Peri-wound: intact; -Dressing: Dry dressing; -Pressure ulcer: Right trochanter; -Wound bed: deep purple; -Exudate: none; -Measurements: 1.5 cm x 1.5 cm x 0.0 cm; -Staging: suspected deep tissue injury (an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body that restricts blood flow in the tissue causing the tissue to die); -Peri-wound: intact; -Dressing: open to air; -Pressure ulcer: Right ankle; -Wound bed: deep pink; -Exudate: none; -Measurements: 1.5 cm x 1.0 cm x 0.0 cm; -Staging: Stage II; -Peri-wound: intact; -Dressing: open to air. Review of the hospital discharge summary, dated 12/7/21 at 11:58 A.M., showed: -Admission: 11/23/21; -Discharge: 12/7/21; -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .g., fascia, tendon, or joint capsule), making [CONDITION(S)] (infection in the bone) likely to occur. Exposed bone/tendon is visible or can be felt); -Condition at discharge: Stable; -Start taking these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Start taking on 12/8/21 once every 24 hours for infection; -Registered dietician recommends to continue an oral nutrition supplement two to three times daily for 30 days after discharge; -Why hospitalized : -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Specialized diet instructions: -Current diet order: easy to chew/mechanical soft (processed to allow food to be easier to chew and swallow); -Current supplement order: Ensure [MEDICATION(S)] (liquid supplement specially formulated to help maintain and rebuild lean body mass and strength) three times a day (TID) and magic cup (special diet frozen dessert cups for adding calories and protein for those experiencing involuntary weight loss). Review of the facility admission electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Order to begin on 12/12/21; -An order to cleanse the left buttocks with saline, pat dry and apply skin prep (used to protect skin from tears) to the surrounding area. Apply calcium alginate (used to absorb wound drainage and interact with wound bed to encourage healing) to wound bed and cover with a foam dressing. Change daily and as needed (PRN), if soiled, until healed; -An order to cleanse left buttocks with saline, pat dry. Apply skin prep to the surrounding area. Apply calcium alginate to the wound base and cover with a foam dressing. Change daily and PRN if soiled until healed; -An order to cleanse the left inner knee with saline, pat dry. Apply skin prep to the surrounding area. Apply calcium alginate to the wound base and cover with a bordered gauze dressing. Change daily and PRN if soiled until healed; -An order, to cleanse the left trochanter daily. Apply skin prep to area and cover with foam dressing. Change daily and PRN until healed; -An order to cleanse the right ankle, apply skin prep to area. Cover with foam dressing daily and PRN until healed; -An order to cleanse the right trochanter daily, apply skin prep to the area and cover with a foam dressing. Change daily and PRN until healed; -An order to cleanse the sacrum with saline, pat dry and apply skin prep to surrounding area. Apply calcium alginate to the wound base and cover with a foam dressing. Change daily and PRN if soiled until healed; -Weekly skin assessment, perform skin assessment weekly, start on 12/13/21; -No admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Braden scale, dated 12/7/21 at 4:42 P.M., showed: -Sensory perception: Ability to respond meaningfully to pressure related discomfort: Very limited, responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment that limits the ability to feel pain or discomfort over half of the body; -Moisture: The degree to which the skin is exposed to moisture: Occasionally moist, the skin is occasionally moist, requiring an extra linen change approximately once daily; -Activity: Bedfast, confined to the bed; -Mobility: The ability to change and control body position: Completely immobile, does not make even slight changes in body or extremity position without assistance; -Nutrition: Usual food intake pattern: Very poor, never eats a complete meal. Eats two or less servings of protein per day and takes fluids poorly. Does not take a liquid dietary supplement for more than five days; -Friction and shear: Problem, requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contracture or agitation leads to almost constant friction; -Scoring: 9, very high risk. Review of the resident's progress notes, showed an admission note, dated 12/7/21 at 5:30 P.M., the resident arrived to the facility by ambulance. The resident admitted for multiple wounds and therapy. The family's goal is to discharge home. The resident denied pain, but grimaced and tensed when touched. He/she is alert to person, place and time (x 3) but confused. Open ulcer on left lateral (outer) buttock, green slough and a black area with tunneling (wound that's progressed to form passageways underneath the surface of the skin) present. An ulcer on the left buttocks with clear drainage noted and on the sacral region no discharge but tunneling present. The right trochanter pressure ulcer skin is intact. Right ankle pressure ulcer skin intact and an ulcer on the back of the left knee. Vital signs taken and stable. Bed placed in lowest position, used pillow and wedges for positioning and comfort. Dressings changed. Orders verified by the physician. Review of the December 2021 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 12/8/21, for normal saline flush 10 ml IV every 24 hours for IV maintenance and after every dose of antibiotic until 12/23/21. Six out of 15 opportunities missed and undocumented; -The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2021 electronic treatment administration record (eTAR), showed the following orders: -An order, dated 12/9/21, to cleanse left inner knee with saline, pat dry. Apply skin prep to the surrounding area. Apply calcium alginate to wound base, cover with border gauze dressing. Change every day shift and PRN if soiled until healed or reevaluated. 13 out of 23 wound treatments missed and undocumented; -An order, dated 12/9/21, to cleanse the left trochanter daily. Apply skin prep to area and cover with foam dressing. Change every day shift and PRN until healed or reevaluated. 13 out of 23 wound treatments missed and undocumented; -An order, dated 12/9/21, to cleanse right trochanter daily. Apply skin prep to area and cover with foam dressing. Change every day shift and PRN until healed or reevaluated. 13 out of 23 wound treatments missed and undocumented; -An order, dated 12/9/21, to cleanse the sacrum with saline, pat dry. Apply skin prep to surrounding area. Apply calcium alginate to wound base, cover with border gauze dressing. Change every day shift and PRN if soiled until healed or reevaluated. 13 out of 23 wound treatments missed and undocumented. 13 out of 23 wound treatments missed and undocumented; -An order, dated 12/8/21 and ended 12/12/21, for [MEDICATION(S)] solution 2 gm IV once every 24 hours for infection, [CONDITION(S)] to left buttocks, stop 12/22/21. Documented as unavailable to administer from 12/8/21 through 12/12/21. Administration started on 12/13/21 and stopped on 12/22/21 per physician orders. The resident did not received the ordered IV antibiotic for 5 days; -No treatment orders documented for the right ankle or left buttock as noted from the hospital discharge wound summary measurements. Further review of the resident's progress notes, showed: -On 12/8/21 at 7:48 P.M., showed the resident's skin assessed. All of the wounds measured and proper treatment order placed in the orders. No documentation located of wound measurements. Review of the skin monitoring: Comprehensive certified nurse aide (CNA) shower review sheet, dated 12/9/21, showed: -Bed bath given; -No hand written circled areas on the body image indicating wounds or skin concerns; -Signed by a CNA; -No charge nurse signature. Further review of the progress notes, showed: -On 12/9/21 at 9:59 A.M., writer spoke with pharmacy technician. Pharmacy stated the IV antibiotics, IV supplies and pump scheduled delivered this morning; -On 12/9/21 at 2:06 P.M., antibiotic [MEDICATION(S)] solution 2 gm for [CONDITION(S)], infection to the left buttock. Not administered and documented unavailable. No physician or pharmacy contact documented; -On 12/9/21 at 2:07 P.M. and 2:08 P.M., normal saline flush 10 ml and [MEDICATION(S)] 50 mg tablet, both not administered and documented as unavailable. No physician or pharmacy contact documented; -On 12/9/21 at 9:09 P.M., writer called pharmacy regarding separate medications, no documented follow up with the physician regarding the delay in IV antibiotic prescription; -On 12/10/21 at 9:17 A.M., call placed to pharmacy regarding IV antibiotic medication. The pharmacy technician stated the medication delivered today; -On 12/10/21 at 9:23 A.M., spoke with the physician and notified of the antibiotic status. The physician stated to begin the antibiotic once it arrived from the pharmacy and extend the date; -On 12/10/21 at 12:48 P.M., antibiotic [MEDICATION(S)] 2 mg IV solution for infection to the left buttock, medication not in yet; -On 12/11/21 at 2:51 A.M., resident experienced a fall, bruising noted to the right hip. The peripherally inserted central catheter (PICC, a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV antibiotics, nutrition, medications, and blood draws and ends near the heart) line noted on the floor. The Assistant Director of Nursing (ADON) notified. The electronic medical records not accessible, and are down for maintenance. The ADON instructed call 911 and send to the emergency room (ER) for treatment; -On 12/11/21 at 10:01 A.M., the resident sent out for post fall evaluation and PICC line placement. The ER sent the resident back without PICC line replacement, and stated they were unaware it needed to be placed. The writer spoke with the resident's physician. The physician stated the PICC line needed replaced. The resident sent back to the ER for PICC line replacement; -On 12/11/21 at 11:08 A.M., antibiotic [MEDICATION(S)] 2 gm IV solution for infection to left buttocks and the normal saline 10 ml flush. Not administered, no PICC line in place; -On 12/12/21 at 7:10 A.M., the resident returned from the hospital with a new PICC line in place. Monitor for swelling and bruising at the insertion site. The resident noted resting in bed; -On 12/12/21 at 2:27 P.M., resident started on IV antibiotics. No s/sx of antibiotic side effects. No swelling or redness at IV site. IV line flush without difficulty. Review of the admission Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 12/14/21, showed: -Memory problem; -Severe cognitive impairment, inattention and disorganized thinking; -No behaviors; -Required total staff assistance with bed mobility, transfers, mobility, dressing, eating, toileting hygiene and bathing; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Did not receive PRN medications in the last five days; -Has one or more stage I or higher wounds; -At risk to develop pressure ulcer; -Stage II wounds: none; -Stage III wounds: none; -Stage IV wounds: none; -Unstageable wound, with eschar and slough: three; -Received: pressure reducing device on bed and chair and pressure ulcer care. Review of the skin monitoring: Comprehensive CNA shower review, dated 12/14/21, showed: -No documentation if shower or bed bath was given; -No hand written circled areas on the body image indicating wounds or skin concerns; -Signed by a CNA; -No charge nurse signature. Review of the weekly skin assessment schedule, showed no skin assessment completed on 12/14/21. Review of the skin monitoring: Comprehensive CNA shower review, dated 12/16/21, showed: -No documentation if shower or bed bath was given; -No hand written circled areas on the body image indicating wounds or skin concerns; -Signed by a CNA; -No charge nurse signature. Further review of the progress notes, dated 12/19/21, showed: -At 4:09 P.M., cleanse the left inner knee with saline, pat dry, apply skin prep and cover with border gauze. Not completed, not enough time to complete; -At 4:10 P.M., cleanse the left trochanter with saline, pat dry, apply skin prep and cover dry dressing. Not completed, not enough time to complete; -At 4:36 P.M., cleanse left buttocks with saline, pat dry, apply skin prep, apply calcium alginate to wound base and cover with a foam dressing. No completed, not enough time; -At 4:37 P.M.: -Cleanse right trochanter daily, apply skin prep and cover with foam dressing. Not completed, not enough time; -Cleanse sacrum with saline, pat dry and apply skin prep to surrounding tissue. Apply calcium alginate to wound base and cover with foam dressing. Not completed, not enough time. Review of the weekly skin assessment schedule, showed no skin assessment completed on 12/21/21. Further review of the progress notes, showed the initial nutritional assessment progress notes, dated 12/21/21 at 9:13 A.M., showed: -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Diet: regular, mechanical soft; -Skin: multiple areas of skin breakdown, buttocks, sacral region, trochanter, ankle, knee- wound assessment reviewed. Treatments in place. Dietician to follow; -medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident newly admitted , monitor appetite. Resident with increased nutritional needs to aid with healing; -Goal: assess weight goal next visit, adequate oral intake and skin improvement and healing; -Plan: add multivitamin and 30 milliliters (ml) of liquid protein supplement to aid with healing. Continue current diet regimen, monitor weight, skin and oral intake. Review of the skin monitoring: Comprehensive CNA shower review, dated 12/23/21, showed: -No documentation if a shower or bath was given; -A hand written circled area on the body image to the right shoulder, right inner ankle, right buttock and tailbone; -Signed by a CNA; -A charge nurse signature. Review of the weekly skin assessment schedule, showed no skin assessment completed on 12/28/21. Review of the care plan, dated 12/30/21, showed: -Focus: The resident has pressure ulcer development related to immobility; -Goal: The pressure ulcer will show signs of healing and remain free from infection; -Interventions: Staff administer medications as ordered, monitor and document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident, family and caregivers to causes of skin breakdown, including transfer, positioning requirements, importance of taking care during movement, good nutrition and frequent repositioning. Review of the January 2022 ePOS, showed: -An order, dated 12/8/21: Cleanse left buttock with saline, pat dry, apply skin prep to surrounding area. Apply calcium alginate to wound base, cover with foam dressing change every day shift and PRN; -An order, dated 12/8/21: Cleanse left inner knee with saline, pat dry, apply skin prep to surrounding area. Apply calcium alginate to wound base. Cover with border gauze dressing. Change every day shift and PRN; -An order, dated 12/8/21: Cleanse left trochanter daily, apply skin prep to area. Cover with foam dressing every day shift and PRN; -An order, dated 12/8/21: Cleanse right ankle, and apply skin prep to the area. Cover with foam dressing every day shift and PRN; -An order, dated 12/8/21: Cleanse right trochanter and apply skin prep to the area. Cover with foam dressing every day shift and PRN; -An order, dated 12/8/21: C

JW Based on observation, interview and record review, the facility failed to ensure the resident was free from significant mediation errors. The resident admitted with infected wounds and pain. The facility failed to administer all doses of the ordered antibiotic and pain medication. This resulted in the resident experiencing worsening of the infection that resulted in the resident's death. This affected one of two sampled residents (Resident #1). The census was 66. Review of Resident #1's hospital discharge summary, dated [DATE] at 11:58 A.M., showed: -Admission: [DATE]; -Discharge: [DATE]; -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .g., fascia, tendon, or joint capsule), making [CONDITION(S)] (infection in the bone) likely to occur. Exposed bone/tendon is visible or can be felt); -Condition at discharge: Stable; -Start taking these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Start taking on [DATE] once every 24 hours for infection; -Acetaminophen (used to treat fever or mild pain) 325 milligram (mg). Take two tablets every four hours as needed (PRN) for fever or pain; -Why hospitalized : -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes, showed an admission note, dated [DATE] at 5:30 P.M., the resident arrived to the facility by ambulance. The resident denied pain, but grimaced and tensed when touched. He/she is alert to person, place and time (x 3) but confused. Open ulcer on left lateral (outer) buttock, green slough and a black area with tunneling (wound that has progressed to form passageways underneath the surface of the skin) present. An ulcer on the left buttocks with clear drainage noted and on the sacral region no discharge but tunneling present. The right trochanter (located where the back of the upper thigh and buttock meet) pressure ulcer skin is intact. Right ankle pressure ulcer skin intact and an ulcer on the back of the left knee. Vital signs taken and stable. Bed placed in lowest position, used pillow and wedges for positioning and comfort. Dressings changed. Orders verified by the physician and new order received for [MEDICATION(S)] (pain medication) 50 mg take one tablet four times a day for pain. Review of the facility admission electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Order to begin on [DATE]; -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the [DATE] electronic treatment administration record (eTAR) and electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], for [MEDICATION(S)] 15 mg four times a day. Scheduled administration times of 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.: -Documented as not administered, other 12 of 94 opportunities in [DATE]; -Scheduled administration time left blank 8 of 94 opportunities in [DATE]; -An order, dated [DATE] and ended [DATE], for [MEDICATION(S)] solution 2 gm IV once every 24 hours for infection, [CONDITION(S)] to left buttocks, stop [DATE]. Documented as unavailable to administer from [DATE] through [DATE]. Administration started on [DATE] and stopped on [DATE]. The resident did not received the ordered IV antibiotic for 5 days. Further review of the progress notes, showed: -On [DATE] at 9:59 A.M., writer spoke with pharmacy technician. Pharmacy stated the IV antibiotics, IV supplies and pump scheduled delivered this morning; -On [DATE] at 2:06 P.M., antibiotic [MEDICATION(S)] solution 2 gm for [CONDITION(S)], infection to the left buttock. Not administered and documented unavailable. No physician or pharmacy contact documented; -On [DATE] at 2:07 P.M. and 2:08 P.M., normal saline flush 10 ml and [MEDICATION(S)] 50 mg tablet, both not administered and documented as unavailable. No physician or pharmacy contact documented; -On [DATE] at 9:09 P.M., writer called pharmacy regarding separate medications, no documented follow up with the physician regarding the delay in IV antibiotic prescription; -On [DATE] at 9:17 A.M., call placed to pharmacy regarding IV antibiotic medication. The pharmacy technician stated the medication delivered today; -On [DATE] at 9:23 A.M., spoke with the physician and notified of the antibiotic status. The physician stated to begin the antibiotic once it arrived from the pharmacy and extend the date; -On [DATE] at 12:48 P.M., antibiotic [MEDICATION(S)] 2 mg IV solution for infection to the left buttock, medication not in yet; -On [DATE] at 2:51 A.M., resident experienced a fall, bruising noted to the right hip. The peripherally inserted central catheter (PICC, a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV antibiotics, nutrition, medications, and blood draws and ends near the heart) line noted on the floor. The Assistant Director of Nursing (ADON) notified. The electronic medical records not accessible, and are down for maintenance. The ADON instructed call 911 and send to the emergency room (ER) for treatment; -On [DATE] at 10:01 A.M., the resident sent out for post fall evaluation and PICC line placement. The ER sent the resident back without PICC line replacement, and stated they were unaware it needed to be placed. The writer spoke with the resident's physician. The physician stated the PICC line needed replaced. The resident sent back to the ER for PICC line replacement; -On [DATE] at 11:08 A.M., antibiotic [MEDICATION(S)] 2 gm IV solution for infection to left buttocks and the normal saline 10 ml flush. Not administered, no PICC line in place; -On [DATE] at 7:10 A.M., the resident returned from the hospital with a new PICC line in place. Monitor for swelling and bruising at the insertion site. The resident noted resting in bed; -On [DATE] at 2:27 P.M., resident started on IV antibiotics. No s/sx of antibiotic side effects. No swelling or redness at IV site. IV line flush without difficulty. Review of the facility emergency medication kit (E-Kit), showed [MEDICATION(S)] 50 mg tablets available. Review of the admission Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated [DATE], showed: -Memory problem; -Severe cognitive impairment, inattention and disorganized thinking; -No behaviors; -Required total staff assistance with bed mobility, transfers, mobility, dressing, eating, toileting hygiene and bathing; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Did not receive PRN medications in the last five days; -Has one or more stage I or higher wounds; -At risk to develop pressure ulcer; -Unstageable wound, with eschar and slough: three; -Received: pressure reducing device on bed and chair and pressure ulcer care. Review of the care plan, dated [DATE], showed: -Focus: The resident has acute and chronic pain related to wounds; -Goal: The resident will not have an interruption in normal activities due to pain and will not have discomfort; -Interventions: The resident will receive analgesia as ordered. Staff will anticipate the need for pain relief and staff will respond immediately to a complaint of pain. Staff will identify and record pain history, pain management and impact on function; -Focus: The resident has pressure ulcer development related to immobility; -Goal: The pressure ulcer will show signs of healing and remain free from infection; -Interventions: Staff administer medications as ordered, monitor and document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident, family and caregivers to causes of skin breakdown, including transfer, positioning requirements, importance of taking care during movement, good nutrition and frequent repositioning. Further review of the resident's progress notes, showed: -On [DATE] at 9:15 A.M., resident observed on his/her right side with mouth open and eyes half open. Writer attempted to stimulate the resident and called his/her name, but the resident did not respond. Vital signs were attempted but unable to obtain an oxygen saturation (PSO2, level of oxygen in red blood cells) or blood pressure. Temperature 97.8 (normal 97.,d+[DATE].6 degrees F) degrees, heart rate 143 (normal ,d+[DATE] beats per minute) and decreased respirations; -On [DATE] at 9:23 A.M., call placed to the resident's physician to notify of the change in condition. The physician stated the resident was not receiving hospice services and was a full code, send the resident to the hospital; -On [DATE] at 9:30 A.M., called placed to next of kin and notified of the change in condition. Family stated they will be up to the facility; -On [DATE] at 9:34 A.M., family notified writer to send the resident to local hospital; -On [DATE] at 9:40 A.M., emergency medical services (EMS), reported resident condition and ambulance to be dispatched; -On [DATE] at 9:45 A.M., writer and CNA cleaned the resident, provided oral care and completed wound treatments. The resident continued to be unresponsive but was breathing, he/she appeared comfortable and was repositioned; -On [DATE] at 9:52 A.M., the resident's family arrived at the facility and EMS arrived at the same time. Report given to EMS staff. EMS unable to obtain a blood pressure or PSO2 level and stated once the resident was in the ambulance, they would reattempt. Resident's family was in the hallway. Two facility nurses assisted EMS to transfer the resident onto EMS stretcher. During an interview on [DATE] at 11:32 A.M., the corporate interim wound nurse said she was contacted by the interim ADON that Resident #1 had admitted into the facility with wounds the week of [DATE]. She instructed the ADON to obtain measurements and entered the resident onto the wound report. The interim wound nurse's first assessment of the resident's wounds occurred on [DATE]. On [DATE], the resident's wounds had worsened and some had an odor. During an interview on [DATE] at 11:27 A.M., the facility wound care nurse said she had assessed the resident on [DATE] approximately 9:15 A.M., for wound care. She had first cared for the resident's wounds on [DATE]. Some odor from the wounds. The wounds did not look good and she wanted the resident to be seen by the wound care physician. The family had not returned the signed wound physician consult forms. The resident was lethargic, unresponsive to verbal stimuli and had irregular breathing. He/she was a full code and the physician issued orders to send to the hospital for evaluation and treatment. She did not obtain a wound assessment, measurements or change the dressings due to the sudden decline in the resident's condition. Treatments, dietary supplements and antibiotics should be completed as ordered. A delay in treatment, supplements and lack of bathing/showers could allow infection to develop or worsen and slow wound healing. During an interview on [DATE] at 12:09 P.M., the interim Director of Nursing (DON) said all treatments should be completed as ordered. If a treatment is missed, the nurse should document in the progress notes if the resident refused or was unavailable for the treatment. The facility hired a new wound nurse who began earlier in the week. Review of the hospital records, dated [DATE] through [DATE], showed: -admitted emergently from the facility on [DATE] at 10:56 A.M.; -Chief complaint: unresponsive. Presented to the ER from nursing facility after he/she was found unresponsive. Per EMS, the patient was hypoxic (low oxygen level), hypotensive (low blood pressure) and [CONDITION(S)] (irregular, fast heart rate). He/she was unable to provide any history related to mental status; -Physical exam: -Blood pressure: ,d+[DATE]; -Pulse: 48 beats per minute; -Temperature: 97.3 F; -Respiration: 28 (normal ,d+[DATE] breaths per minute); -Constitutional: In acute distress, appears ill and toxic; -Pulmonary: Respiratory distress present; -Laboratory values: -Blood culture: Peripheral (blood taken from an IV line in the arm): critical growth of gram-positive cocci in clusters (indicative of [CONDITION(S)]); -COVID-19: positive; -The ER provider note, dated [DATE] at 1:55 P.M., showed the patient minimally responsive and does not withdraw from pain. He/she is [CONDITION(S)], hypotensive and very frail appearing and appears to be critically ill. He/she is a full code. Numerous wounds noted to his/her buttocks. High concern for deterioration. Provider had an extensive discussion with the family for plan of care. Family notified provider the last time they saw him/her was two weeks ago and normal baseline. Due to his/her positive COVID-19 result at the facility, family was unable to visit him/her. The facility had informed the family the patient had been doing well. The family was unaware of his/her current condition, which appears to have been progressively getting worse. Based on laboratory results and cardiac function tests, concern for severe [CONDITION(S)]. The hospital chaplain consulted and had an extensive conversation with the family. The family is aware the patient's condition will likely worsen and be un-survivable; -The hospital history and physical, dated [DATE] at 12:42 P.M., showed: -General appearance: unresponsive; -Assessment: septic shock (life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention, may result in body organ failure and death); -Plan: discussed goals of care with family. Code status change to do not resuscitate (DNR), no medications for blood pressure. Continue to provide IV antibiotics and fluids. Hospice consulted. COVID-19 positive, chest x-ray is unremarkable; -A multidisciplinary progress note, dated [DATE], showed the resident expired at 3:15 A.M., the family, physician and nurse practitioner notified; -The physician discharge summary, dated [DATE] signed at 11:45 A.M., showed: -Summary: presented to the ER from the nursing home for unresponsiveness and also found to be hypoxemic, hypotensive and [CONDITION(S)]. Unable to obtain further history due to altered mental status; Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:35 P.M., the resident's next of kin said the resident expired at the hospital. The family obtained an autopsy to verify the cause of death, but the doctor at the hospital felt it was likely due to a massive infection from several wounds. During an interview on [DATE] at 12:35 P.M., the corporate wound nurse said when a medication is not available, the nurse should contact the pharmacy to rush the medication to the facility. If the medication is not delivered in the next pharmacy delivery, the pharmacy and physician should be contacted.

Based on interview and record review, the facility failed to follow a physician's order and the facility policies for a resident, under strict aspiration precautions, with a tube feeding and to receive tube feeding formula via bolus (using a syringe or gravity to deliver the feeding) infused over the course of an hour. The nurse administered the formula in 30 minutes. Approximately one hour later, staff found the resident, who had a full code order, unresponsive with tube feeding formula coming out of his/her mouth and nose. The nurse failed to assess the resident, immediately check his/her code status, perform cardiopulmonary resuscitation (CPR, life sustaining measures in the event the heart stops beating) and call 911 in accordance with the facility's policy. This affected one of three sampled residents (Resident #1). The census was 60. Review of the facility's policy titled Aspiration Precautions Guidelines dated [DATE], showed aspiration (choking) precautions are interventions to reduce the risk of aspirating on food, liquids, and/or secretions during the swallowing process into the trachea and lungs. Inhaling foreign materials into the lungs and [MEDICATION NAME] tubes may cause aspiration pneumonia. Residents receiving enteral feedings are at risk for aspiration (see enteral feeding section). Review of the facility's policy titled Enteral and [MEDICATION NAME] Feedings (General Guidelines) revised [DATE], showed direction for staff, under standard orders for all tube feedings, to document the amount of formula and water provided every eight hours. Total intake every 24 hours. They are to check tube placement before initiation of formula, medication administration, and flushing the tube or at least every eight hours. Nursing staff is to observe condition of tube site when checking placement. They must also check and record residuals every shift. The head of the resident's bed is to be elevated 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding was stopped. Review of the facility's policy titled Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED), revised [DATE], showed direction for staff to follow practice guidelines for CPR by initiating resuscitation with and without an AED, as appropriate and in accordance with patient/resident advance directives. Appropriate staff members in the immediate area are to respond and call and designate a person to call 911 or locally appropriate emergency number. Staff is to assist with basic life support, direct visitors out of the room, relocate any roommates to another room, verify clearance of the hallway and room. A staff person is to verify transportation of the emergency cart to the patient/resident location. Review of the facility's policy titled Emergency, 'Code Blue'-Initiation of revised [DATE], showed direction for staff to announce code blue to notify the appropriate team members to participate in a systematic, organized procedure during a potential life-threatening situation for a full code resident. Staff is to follow practice guidelines for CPR, page overhead code blue (room and unit) and repeat it two times. Those expected to respond, include but are not limited to, the following: physician (if in-house), respiratory therapist (if available), charge nurse, and DON. Staff is to call 911 for emergency transfer to an acute care center, unless the resident is coding, and staff has determined that he/she is a DNR. Staff is to contact the resident's physician for further orders and notify the resident's responsible party of the resident's change in condition. Staff is to continue CPR efforts as appropriate, in accordance with the resident's advance directives, until an advanced rescue team arrives or until spontaneous respirations, pulse and blood pressure return. Staff is also expected to provide transport to an acute care center if appropriate, send the appropriate documentation with the resident for transport if appropriate and document in the appropriate area of the medical record. Review of the facility's policy titled Emergency Cart revised ,[DATE], showed direction for the licensed nursing staff or designee to maintain the emergency cart and store it in an easily accessible location. Nursing staff or a designee is to verify that the cart contains all supplies and equipment needed for emergencies and resuscitation. The facility is to delegate the specific times the cart will be checked for supplies and restocking. Review of Resident #1's hospital [MEDICAL CONDITION] consultation, dated [DATE], showed the resident was hospitalized on [DATE], after he/she was involved in a motor vehicle accident as a pedestrian. He/she sustained lumbar [MEDICATION NAME] process (bony protrusion from the back of a vertebrae bone in the spine) fracture, closed [MEDICAL CONDITION] bone (bones that form part of the sides of the skull), subdural hematoma (bleeding into the space between the brain cover and the brain itself), traumatic subarachnoid hemorrhage (bleeding in the space between the brain and its surrounding membrane), closed fracture of multiple pubic rami (thin, flat part of the pelvis which extends to the side and rear of a midline joint), tibial plateau fracture (break in the very top of the shin bone, within the knee joint) on the right, traumatic pneumocephalus (presence of air or gas within the cranial cavity associated with disruption of the skull), orbital wall fracture (traumatic injury to the eye socket), [MEDICAL CONDITION], and closed [MEDICAL CONDITION] zygomatic arch (bony arch at the outer border of the eye socket). The resident underwent [REDACTED]. On [DATE], the resident underwent [REDACTED]. He/she also underwent a right craniectomy (a neurosurgical procedure in which part of the skull is removed to allow for swelling and the brain room to expand) for subdural hematoma evacuation (a surgical procedure to remove pooling of blood on the brain) and decompression. Review of the resident's hospital neurology progress note, dated [DATE], showed the resident was awake and making eye contact, but not tracking. He/she did not follow any of the physician's commands. The resident did not attempt to mouth any words or communicate in any other way. His/her vital signs were stable. The resident's flexion knee contractures (inability to fully straighten the knee) were improving with increased range of motion exercise. Review of the resident's undated face sheet, showed an admitted to the facility on [DATE] and full code status. The resident was documented as being responsible for self. Review of the nurses notes, dated [DATE] at 3:30 P.M., showed the resident was admitted to the facility. He/she arrived via ambulance, in semi-fowler's position (lying in bed with the head of the bed at approximately 30 to 45 degrees), eyes open, not following. Lower extremities contracted, right side of head sunken due to craniotomy. Gastrostomy tube feeding ([DEVICE], a tube inserted through the abdomen to deliver nutrition directly to the stomach), patent and intact, aphasic (partial or total loss of ability to speak), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on sacrum. Dry dressing applied, no distress noted. Review of the resident's social services progress notes, dated [DATE] (no time documented), showed the resident's code status was full code, he/she had no known advance directives or funeral home preferences. The resident was non-responsive beyond opening his/her eyes when his/her name was loudly called. Review of the resident's admission paperwork, dated [DATE], showed an advance directive acknowledgement initialed by his/her family member to indicate that he/she elected not to execute any advance directive measures. Review of the resident's undated interim plan of care, showed the following: -Monitor tube feeding intake; -Tube feeding protocol; -Intake and output. Review of the resident's physician's orders, dated [DATE] through [DATE], showed the following: -[DATE], [MEDICATION NAME] high nitrogen (HN) (high calorie formula used for increased protein and calorie requirements) every four hours, infuse over one hour by pump-strict aspiration precaution; -[DATE], Flush [DEVICE] with 50 cubic centimeters (cc) of water before and after each feeding; -No documentation of the resident's code status. Review of the POS [REDACTED] -[MEDICAL CONDITIONS] ([MEDICAL CONDITION], progressive lung disease), multiple fractures; -Full code; -Review of systems: unable because of dementia/language; -[DEVICE]; -Vegetative state. Review of the resident's physician's orders, dated [DATE], showed the following: -Clarify tube feeding order as bolus, one can [MEDICATION NAME] HN every four hours. Change flush to 100 milliliters every four hours. Review of the resident's Medication Administration Record [REDACTED].M., 6:00 A.M., 10:00 P.M., 2:00 P.M., 6:00 P.M. and 10:00 P.M.), infuse over one hour. Strict aspiration precaution. Review of the resident's nurse's notes, showed no documentation on the resident after [DATE] until the nurse's notes, dated [DATE] at 6:10 A.M., which showed Nurse A was called to the resident's room by a certified nurse aide (CNA), who said that his/her co-worker's patient passed away. The resident was unresponsive with no blood pressure, no apical pulse and no respirations. He/she was lying supine (lying face up), slightly reverse Trendelenburg (the body lying flat with the head ,[DATE] degrees higher than the feet) and the CNA was providing post-mortem care. Nurse A went from the resident's room to the resident's chart where he/she noted the resident was a full code, but notification delays and discovery delays and knowledge of the brain's activity after eight minutes of no oxygen prevented the nurse from providing CPR. Family, Director of Nurses (DON), coroner, funeral home and physician notified. During an interview on [DATE] at 8:28 A.M., Charge Nurse A said he/she became a registered nurse in [DATE] and at previous places of employment, had served as charge nurse for up to 50 to 60 residents during a single shift. Nurse A taught first aid and community CPR since 1999. Nurse A's first day off of orientation at the facility was during the night shift on [DATE]. During the early morning hours of [DATE], he/she was the only nurse on duty. At 4:00 A.M., he/she administered the resident's bolus tube feeding and watched 240 cc of [MEDICATION NAME] HN flow into the resident's [DEVICE] port. The tube feeding was completed at 4:30 A.M. After flushing the tube, Nurse A disconnected it from the [DEVICE] port and left the room. During interviews on [DATE] at 8:20 A.M. and [DATE] at 6:30 A.M., CNA B said he/she had only been employed at the facility for a month. Because the resident was non-verbal, bedridden, contracted and receiving tube feedings, CNA B entered the resident's room during rounds in order to make sure his/her head was up (due to the tube feedings), ensure he/she was still breathing and dry. On [DATE], CNA B checked on the resident at 11:00 P.M. and found him/her asleep. CNA B checked on the resident again at 2:00 A.M. and 4:00 A.M. He/she was fine at those times. CNA B returned to the resident's room between 5:30 A.M. and 5:45 A.M. and called out the resident's name. Normally, the resident looked at CNA B and tracked CNA B a little with his/her eyes. That time, the resident's eyes were already open, but they just stared blankly into space, as though he/she were daydreaming. The head of the bed was at approximately a 45 degree angle. His/her skin was really cold, because the air conditioner was on. The resident's skin and nail bed colors were unchanged. Tube feeding formula was coming out of the resident's nose and mouth. CNA B felt for a pulse and could not find one. He/she did not know what the resident's code status was and did not know where to find that information. CNA B believed it was the charge nurse's responsibility to initiate and perform CPR. CNA B assumed the resident died and went to inform Nurse A, who was not at the nurse's station. CNA B asked CNA C to find Nurse A and inform him/her the resident passed away. CNA B returned to the resident's room and began cleaning him/her from head to toe. CNA B moved the resident up onto his/her right side, in order to drain as much of the tube feeding formula as possible, because it continued to run out of the resident's nose and mouth. His/her back was very wet, because the formula had pooled in the bed underneath him/her. During an interview on [DATE] at 9:00 A.M., CNA C recalled that towards the end of his/her shift on the morning of [DATE] (exact time unknown), when it was time to start getting residents up, CNA B saw CNA C standing at the nurses' station and said if CNA C saw Nurse A, to let Nurse A know the resident needed suctioning. CNA B did not at any point tell CNA C the resident was dead. Consequently, CNA C waited until he/she saw Nurse A come out of the medication room to convey CNA B's message. CNA C worked on the 100 and 700 halls and consequently, did not find out the resident passed away until his/her next shift at the facility. During an interview on [DATE] at 1:20 P.M., Certified Medication Technician (CMT) D said from where he/she stood passing medications on the 200 hall on [DATE], sometime between 5:45 A.M. and 6:00 A.M., CMT D heard CNA B tell Nurse A, that a resident was dead. Nurse A said, What? CNA B said a specific resident was dead. Nurse A left his/her medication cart on the 700 hall, ran past the nurses' station and into the resident's room. CMT D remained on the 200 hall and continued to pass medications. He/she did not respond to the room or check the resident's medical chart. Nurse A never made a code blue announcement or asked CMT D for assistance. During interviews on [DATE] at 10:06 A.M. and [DATE] at 8:28 A.M., Nurse A said he/she was on another hall passing 6:00 A.M. medications when CNA C reported the other CNA said that one of his/her people passed away. Nurse A asked where the CNA was and CNA C led him/her to CNA B, who was providing post mortem care to the resident. That threw Nurse A, who had just been in the room at 4:30 A.M. and watched the tube feeding drain into the resident's [DEVICE] port without any problems. At that time, the resident's vital signs were normal and he/she did not exhibit any signs of dying. Nurse A was shocked to find CNA B had the head of the bed flat and tilted backwards approximately 10 degrees. The resident's skin was cool and dusky in coloration. The resident did not have good color when he/she was alive. CNA B pushed him/her up so far onto his/her right side that it looked as though the resident was going to drop off the bed, as CNA B stood behind him/her washing his/her back and trying to change his/her bed sheet. Nurse A told CNA B to hold on, went to the medication cart at the end of the hall, (he/she said there was one at the end of each hall) and returned with a stethoscope as well as a blood pressure monitor. The resident's arm was so stiff, CNA B had to help apply the blood pressure monitor. Nurse A checked and found no pulse or blood pressure. Nurse A did not know if the blood pressure monitor display screen kept showing E because it needed batteries or if it was an indication the resident had no pulse. Nurse A then held the resident up, so that CNA B could clean him/her. Nurse A noticed that approximately ,[DATE] to ,[DATE] of the tube feeding formula had pooled in the bed underneath the resident's back. It was running out of his/her nose and mouth. Nurse A had previously disconnected the feeding tube from the resident's [DEVICE] port. However, Nurse A checked the tubing to see if that was where all the formula was coming from. The clamp on the tube was still closed. Nurse A was in the room with them for 20 to 25 minutes. He/she then went to the nurses' station and pulled the resident's medical chart, in order to notify the resident's family and physician of his/her passing. Nurse A looked at the resident's records and realized that his/her code status was full code. At that point, the resident had gone without respirations and oxygen for a little over ,[DATE] minutes. In Nurse A's mind, the resident could not be resuscitated. Nurse A did not initiate CPR or call 911. Nurse A realized he/she should have done those things. However, during that shift, Nurse A was very overwhelmed with trying to learn the facility procedures and there were no other nurses on duty to answer his/her questions. Nurse A believed the policy binder was probably out where he/she could have found it. Normally, when a resident became unresponsive, Nurse A would check the resident's code status, call a code, start CPR and send the CNA to call 911. Nurse A knew what was expected of him/her and there was no excuse for failing to follow proper procedure. Nurse A believed CNA B was employed at the facility for a while and would have known to come and get Nurse A at the first sign of trouble for all full code residents. Consequently, Nurse A assumed the resident's code status was do not resuscitate (DNR). The CNAs were both behaving as though the resident's status was DNR. When the Assistant Director of Nursing (ADON) asked if Nurse A had done CPR on the resident, Nurse A said, yes because of all of the chaos. The next day, when he/she returned to the facility, in order to provide a written statement and nurse's note regarding the incident, the ADON read his/her statement and realized that staff had not performed CPR on the resident. Nurse A did not know why he/she initially told the ADON that staff performed CPR on the resident. During interviews on [DATE] at 8:20 A.M. and [DATE] at 6:30 A.M., CNA B said Nurse A entered the room approximately ten minutes after CNA B asked CNA C to inform Nurse A the resident had passed away. CNA B told Nurse A the resident was dead. Nurse A walked over to the bed, looked into the resident's eyes and said, Yeah he/she was dead, checked the tube feeding device and briefly assisted CNA B by holding up the resident, before leaving the room. Nurse A never checked the resident's pulse or blood pressure. CNA B never put a blood pressure monitor on the resident or assisted Nurse A to put one on him/her. Review of facility records, showed Nurse A and CMT D were certified in CPR. CNA B and CNA C were not certified in CPR. During interviews on [DATE] at 12:12 P.M. and [DATE] at 8:42 A.M., the Director of Nursing (DON) said the resident did not have a signed advanced directive or code status sheet. The facility was using a gravity bag with a slow drip clamp, not a tube feeding machine, to deliver the resident's bolus tube feedings. Per his/her physician's order, [MEDICATION NAME] HN was to be infused over the course of an hour. In order to ensure that it infused for at least an hour, the nurse administering the feeding was to open the clamp on the tubing far enough to permit a slow drip and then remain in the room for the duration of the feeding or periodically check the progress of the infusion. The resident arrived at the facility from the hospital with those orders. Hospital staff said because the resident was at high risk for aspiration, it was necessary for the tube feeding to infuse for an hour. If the resident was to receive the formula in under an hour, then it would increase his/her risk for aspiration. The resident's tube feeding residuals (volume of tube feeding remaining in the stomach) should have been documented on his/her Medication Administration Record [REDACTED]. Upon discovery of an unresponsive resident, staff were to check his/her code status. If the resident's status was full code, then staff were expected to start CPR, call 911 and notify the resident's physician of the resident's change in condition. If a CNA was the first to discover an unresponsive full code resident, then the CNA could start CPR. The charge nurse was expected to bring the emergency cart to the resident's room. The facility's policy regarding CPR was not discussed during nurse or CNA training. However, the facility conducted monthly mock codes with the staff on duty during each shift. The facility did not have an automatic external defibrillator (AED). During orientation, the trainer notified staff that there was a binder containing the facility's policies located in the 700 hall medication room and one was in the administrator's office. Nurses and CMTs had keys to the 700 hall medication room. The administrator, admissions coordinator, and social worker had keys to the administrator's office. During interviews on [DATE] at 8:48 A.M. and [DATE] at 10:32 A.M., the administrator said nurses were expected to check residuals prior to administering tube feedings. However, they did not document the resident's residuals, because there were no physician's order in place for them to be documented. Normally, a resident's advance directive and code status forms were filled out and signed upon admission. The resident was admitted to the facility without an advance directive. Consequently, his/her code status automatically became full code. The resident was his/her own responsible party. During an interview on [DATE] at 12:23 P.M., Physician E said if the resident's nurse saw the tube feeding formula flow into the resident's [DEVICE] port and then the formula flowed out of the resident's nose and mouth, then the resident most likely aspirated or vomited the formula. A large amount of formula coming up through the resident's nose and mouth at the same time would prevent the resident from being able to breathe. As soon as staff discovered that a full code resident was unresponsive to stimuli, they should immediately start CPR. A delay in initiating CPR could result in the resident expiring. Staff should call 911 for a full code resident whether or not they believed the resident was dead. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan of correction which included re-educating nursing staff on the CPR policy and process, emergency procedures for residents found unresponsive, the procedure for administering and documentation of tube feedings and proper physician's orders. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO 0819

Based on interview and record review, the facility failed to appropriately assess, monitor, follow physicians orders and delayed calling for an ambulance. The facility also failed to recognize a change in condition and communicate all the facts to the physician for one of three sampled residents who had a fall and change of condition. (Resident #71). The census was 63. 1. Review of Resident #71's readmission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 9/21/10, showed the following: -Moderately impaired in cognitive skill for daily decision making; -Long and short term memory problems; -Vision severely impaired; -Totally dependent on staff for ambulation; -Extensive assistance required from staff for dressing and hygiene; -fell in past 31 - 180 days. Review of the residents care plan dated 7/5/10 and updated 10/3/10, showed staff identified the resident as a potential for falls due to cognitive deficit, little safety awareness, history of falls and a unsteady gait and showed the following interventions: -Check the resident frequently, especially while in bed; -Explain call light; -Monitor for and document perceptual changes; -Provide safe well monitored area for resident to wander; -Wheelchair alarm. Review of the residents physician order [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 11/12/10, for staff to send the resident to the hospital. Review of the residents nurses notes dated 11/12/10, showed the following: -At 7:45 P.M., the resident sat in his/her wheelchair on the carpeted area by the nurses station. Staff documented the wheelchair was locked and the wheelchair alarm was attached. -At approximately 8:15 P.M., Nurse K called Nurse H from room [ROOM NUMBER] who stated the resident had fallen. Nurse H found the resident on the carpeted area laying on his/her right side with his/her hands folded under his/her head with the wheelchair alarm sounding. The resident began mumbling/garbled speech which was normal for the resident. Nurse H documented no visible bruises or lacerations. The resident was able to move all extremities independently and able to stand with the assistance of two staff members. Nurse H instructed the CNA to assist the resident back to his/her room and obtain a set of vital signs. Vital signs were temperature 97.5 degrees Fahrenheit (normal 98.6 degrees Fahrenheit), pulse 76 (normal 80), respiration 18 (normal 18), and blood pressure 131/97 (normal 120/80). -At 8:20 P.M., Nurse H documented the CNA called him/her to the residents room. Neurological checks were continued with the resident mumbling while doing the assessment. The resident had a loose stool with emesis (vomiting). Nurse H documented the emesis to be brown in color with no signs or symptoms of a fecal impaction. -At 8:25 P.M., Nurse H documented the CNA had cleaned the resident up with no signs of distress. The resident was still mumbling undetermined words and staff had placed the resident on his/her right side. -At 8:35 P.M., Nurse H contacted the physician and informed him that the resident had fallen with no visible signs of injury or change in level of consciousness with emesis times one and diarrhea. The physician ordered the resident be sent to the hospital for evaluation. Vital signs were temperature 97.6 degrees Fahrenheit, pulse 96, respiration 20, and blood pressure 153/94. -At 8:45 P.M., Nurse H continued neurological checks with no change in level of consciousness. The residents could squeeze the nurses hand and moved freely in bed. The resident had a small amount of emesis noted. The resident was mumbling and moving in bed. -At 9:00 P.M., at 9:15 P.M., at 9:30 P.M., and at 9:45 P.M., staff only documented no change in level of consciousness. -At 10:00 P.M., Nurse H documented the resident had a moderate amount of emesis and diarrhea and no distress noted. -At 10:12 P.M., Nurse H called the ambulance service to transport the resident to the hospital. Nurse H made the ambulance service aware that the resident was stable but needed to be transported at the next available opportunity. -At 10:45 P.M., Nurse H documented the resident had no emesis, no change in level of consciousness, bruising, or lacerations. -At 11:15 P.M., Nurse H called the ambulance service for a second time. The ambulance service informed him/her the ambulance estimated time of arrival would be in about 25 minutes. -At 11:30 P.M., Nurse H documented the resident responding to stimuli by opening and closing his/her eyes after calling his/her name several times. -On 11/13/10 at 12:30 A.M., Nurse H documented the ambulance crew arrived. Nurse H gave a report to the ambulance crew along with a transfer sheet, medication list, and a medical history of [REDACTED]. -On 11/13/10 at 12:45 A.M., Nurse H documented the ambulance crew informed Nurse H the resident was not responding and they would be diverting to the closest hospital. During an interview on 12/1/10 at 4:15 P.M., Nurse K said he/she and Nurse H sat at the nurses station. He/she heard a loud thud looked up and saw Resident #71 on the floor holding his/her head. Nurse H ran to the resident and began assessing the resident. Nurse K said Nurse H told him/her that the resident hit his/her head. Nurse H did not ask for assistance. When Nurse H and a CNA took Resident #71 back to his/her room, he/she thought they were going to send the resident out. Since Nurse A had the situation under control Nurse K went back to his/her assignment and provided care to other the residents. Nurse K said the resident hit the floor very hard. He/she does not know if Resident #71 had emesis prior to the fall. During an interview on 12/3/10 at 9:00 A.M., Nurse H said he/she was providing care to a resident in room [ROOM NUMBER]. Nurse K came into the room and told him/her that Resident #71 had fallen. He/she does not know why Nurse K would say that he/she had been sitting at the nurses station when Resident #71 fell . He/she did not know if Resident #71 had hit his/her head or not. Nurse H performed neurological checks because that is part of the procedures after a fall. He/she did the neurological checks according to the facility policy. He/she only documented no change in levels of consciousness. When the CNA left the residents room he/she remained to assess and care for the resident. The only time he/she left the residents room was to obtain clean linen. Nurse H said it is not normal procedure to wait for one to two hours to call the ambulance. He/she just lost track of time making sure the residents needs were being met. No reason he/she did not call 911 after the lengthy delay of the ambulance arrival. Nurse H said he/she kept notes on a clip board while caring for the resident then transcribed the notes to the nurses note after the resident left the facility. During an interview on 11/29/10 at 12:40 P.M., Nurse H said the resident had emesis after supper prior to the fall. The emesis was brown in color, the color of the turkey and gravy the resident had for supper. The resident had a history of [REDACTED]. After the resident fell , he/she did not have any change in the level of consciousness until right before the ambulance arrived. Review of the residents medical record, showed no documentation the resident had an episode of emesis prior to the fall on 11/12/10 at 8:15 P.M., During an interview on 11/29/10 at 1:15 P.M., Nurse H said he/she performed neurological checks every 15 minutes. The neurological checks included the following: -Pupil reaction; -Observations of facial drooping; -Range of motion; -Respiration; -Weakness; -Vital signs; -Bruising/injuries. All neurological checks were within normal limits. The only thing Nurse H observed out of the ordinary was the emesis and a large bowel movement. He/she thought the resident had bowel obstruction causing the emesis. Review of the residents medical record, showed no documentation of the neurological assessments other than the nurse charting no change in level of consciousness. During an interview on 12/1/10 at 1:30 P.M., CNA I said he/she was assigned to care for Resident #71. At about 8:00 P.M., he/she entered the residents room. He/she could not leave the residents room because the resident kept throwing up. He/she stayed in the room for about an hour. He/she asked Nurse H for assistance about two or three times in the hour he/she remained in the room. After he/she cleaned the resident he/she returned to the unit to give resident showers and care for the other residents. He/she looked in on the resident about three times during the remainder of the evening. During an interview on 11/30/10 at 10:30 A.M., CNA J said he/she was assigned to the 700 hall. While walking towards the nurses station he/she heard a wheelchair alarm sounding. He/she ran towards the nurses station and observed Resident #71 standing and starting to fall. He/she ran towards the resident but he/she fell before he/she could get to him/her. Nurse H came up and began assessing the resident. The resident had no bruising, lacerations, bumps or marks on his/her face. Nurse H and he/she transferred the resident back to his/her wheelchair. The resident began mumbling something he/she could not understand. Mumbling is a normal behavior for the resident. He/she took the resident back to his/her room and transferred the resident to bed. He/she did not see the resident for the remainder of the night. He/she did inform the Nurse H the resident hit his/her head on the floor. Review of the ambulance trip report dated 11/13/10 at 12:45 A.M., showed the facility contacted the ambulance dispatcher at 10:15 P.M., and the ambulance crew arrived at the facility at 12:15 P.M. The ambulance crew documented Nurse H stated the resident started vomiting at 7:00 P.M., following supper. Nurse H stated the resident had been alert and oriented at 10:30 P.M., when staff last checked on him/her. When they entered the room, they found the resident unresponsive to sternal rubs or any stimuli. The ambulance would be diverted to the nearest hospital. During an interview on 12/3/10 at 11:30 A.M., the Director of Operations for the Ambulance Service said the dispatcher made the run as a non-emergency/routine run. Emergency triage is driven by what the facility staff tell the dispatcher. During an interview on 12/6/10 at 9:00 A.M., the Director of Operations for the Ambulance Service said Nurse H called the dispatcher at 10:15 P.M. Nurse H told the dispatcher that the resident had a possible bowel obstruction. The dispatcher asked if it was life threatening or an emergency and Nurse A responded no. Nurse A did not mention the resident had a fall or had emesis. During an interview on 11/30/10 at 2:55 P.M., Nurse H said he/she did not tell the ambulance crew that he/she last checked on the resident at 10:30 P.M. He/she and CNA I checked on the resident every 15 minutes. The reason for the delay in calling the ambulance stems from the resident having numerous bouts of diarrhea and the CNA kept calling him/her to the residents room to help clean him/her up. When he/she called the physician he/she told the physician that the resident fell . He/she did not tell the physician that the resident hit his/her head because he/she did not witness the fall and staff had not informed him/her that the resident hit his/her head. During an interview on 11/30/10 at 1:50 P.M., Physician L said the facility staff did inform him the resident had fallen. They did not inform him the resident had hit his/her head. He would expect staff to call the ambulance immediately after he gave the order to send the resident to the hospital and not wait for one to two hours to call. He gave the order to send to the closest hospital because staff told him the resident sustained [REDACTED]. If staff had informed him the resident hit his/her head he would have ordered staff to call 911. During an interview on 11/29/10 at 2:00 P.M., the Director of Nursing said the resident had no visible bruising or injuries. She called the hospital the next morning and the nurse informed her that the only bruise documented in the emergency room notes was a bruise to the right shoulder. She spoke with Nurse H the next morning and Nurse H told her the resident had emesis prior to the fall which continued after the fall. Nurse H told her that he/she was busy assessing the resident and did not have time to call the ambulance. The resident had no visible signs of an injury and no evidence of a subdural hematoma. During an interview on 12/3/10 at 10:30 A.M., Physician L said the facility did not inform him/her the resident had emesis after the fall. If he/she would have known of the emesis he/she would have told the nurse to call 911. Emesis after a fall is critical. During an interview on 12/3/10 at 10:15 A.M., the Director of Nursing said the time frames for transferring a resident from the facility to the hospital depends on noticeable injuries. Normally residents should be transferred between one hour to an hour and a half after the physician orders [REDACTED]. She said the facility does not have a neurological flow sheet. The staff should document all of the data collected during the neurological checks in the residents nurses notes. Review of the hospital history and physical dated 11/24/10, showed the resident to be in a stable state of health until 7:00 P.M., until he/she sustained a fall. A few hours later he/she was said to be in an altered mental status and having coffee ground emesis (dark brown vomit) after eating his/her dinner. The EMT found him/her unresponsive and also with fecal incontinence. In the emergency room he/she was orally intubated (insertion of a tube into the trachea for airway ventilation) because of [MEDICAL CONDITION]. A scan of the head showed a massive right acute subdural hematoma (bleeding inside the head) with marked shift of the midline structures to the left. Review of the WebMD web site showed the following signs and symptoms of a subdural hematoma are: -Confusion; -Change in behavior; -Headache; -Dizziness; -Nausea and vomiting; -Drowsiness; -[MEDICAL CONDITION]; -Weakness. Review of the facility's undated policy and procedure for Neurological assessments showed the following: Neurological assessments are indicated when: -Upon a physician order; -Following an unwitnessed fall; -Following a fall or other accident/injury involving head trauma; -When indicated by resident's condition. When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be an indication of increased intracranial pressure. Any changes in vital signs or neurological status in a previous stable resident should be reported to the physician immediately. Steps in the Neurological assessment: -Take temperature, pulse, respirations, and blood pressure; -Check pupil reaction; -Determine motor mobility; -Determine sensation in extremities; -Check gag reflexes with a tongue depressor; -Have the resident smile to determine if there is facial drooping. The following information should be recorded in the medical record: -The date and time of the procedure; -All assessment date obtained. Review of the facility's undated Emergency Transfer policy and procedure showed the following: Facility staff will be available for any non-emergency transport of a resident. If the situation is considered to be out of the realm of routine transfer, the Ambulance Company shall be notified of the need for transport to an acute care setting. The professional staff member on duty shall make the decision. If the transfer is extreme emergency, such as a [MEDICAL CONDITIONS], or a situation where danger of life or limb is possible, a member of the professional staff shall call 911 emergency services. MO