Every finding on record at Aurora Health and Rehabilitation

Based on observation, interview, and record review, facility staff failed to label eye drops in accordance with professional standards and failed destroy expired medications. The facility census was 66.1. Review of the facility's Medication Storage policy, dated 05/01/25, showed it is the policy of the facility to ensure all medications housed on the premises will be stored according to the manufacturer's recommendations. The consultant pharmacist routinely inspects for discontinued, outdated defective or deteriorated medications with worn illegible, or missing labels. These medications are destroyed. 2. Observation on 12/09/25 at 8:02 A.M., showed the 400-hall medication cart contained: -One bottle of artificial tear eye drops open, undated,and unlabeled;-One bottle of Fluorometholone (used to treat inflammation, swelling and/or redness) 0.1% eye drop open and dated 09/01/25;-One bottle of Dorzolamide (used to decrease eye pressure related to glaucoma) eye drop open and dated 09/07/25;-Two bottles of artificial tears open and undated;-One bottle of Lumigan 2.5 eye drops open and undated;-One container of Cyclosporin (antibiotic) 0.05% eye drops single use vials opened and dated 08/23/25;-One loose vial of an unknown eye drop. During an interview on 12/09/25 at 8:02 A.M., Certified Medication Technician (CMT) C said eye drops are only good for 30 days once opened. He/She said he/she does not check the eye drops unless he/she is responsible to give them. The person who administers the medication is responsible to ensure the medication is not expired. The CMT said if the bottle is not labeled, it could be unstable and should not be used. He/She said he/she thinks the nurses check the carts weekly, but he/she was not sure. During an interview on 12/09/25 at 8:15 A.M., Registered Nurse (RN) B said eye drops can be used for 30 days once opened. He/She said it is the responsibility of the nursing team to ensure the medication carts are checked for expired, outdated and discontinued medications. He/She said the pharmacy helps with this process monthly. He/She was not aware there were outdated and discontinued medications in the medication cart.During an interview on 12/11/25 at 9:44 A.M., the Director of Nursing (DON) said between the nurse managers, CMT's, and the pharmacist, the medication carts should be checked routinely, and at a minimum monthly by the consultant pharmacist. Staff should date the bottle when opened. He/she did not know there were expired and outdated medications in the medication cart. During an interview on 12/11/25 at 10:25 A.M., the administrator said the night shift nurses are responsible to ensure outdated and expired medications are removed from the medication cart on a weekly basis. If tge eye drops are outdated or expired, staff are expected to remove them from the cart. Staff are to follow manufacturers' recommendations on when the drugs expire.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two residents (Resident #6 and #73) out of 3 residents sampled who were hospitalized . The facility census was 66.1. Review of the facility's Bed Hold policy, dated 08/01/25, showed at the time of transfer for hospitalization, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. In the event of emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policy. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 2. Review of Resident #6's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 11/26/25. Review showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 12/11/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party.3. Review of Resident #73's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 11/19/25. Review showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 12/05/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party.4. During an interview on 12/10/25 at 8:02 A.M., Registered Nurse (RN) B said he/she does not complete bed holds and thinks the social services department does. During an interview on 12/11/25 at 8:41 A.M., the Social Service Designee (SSD) said he/she was not aware it was his/her responsibility until this week. He/She believed the nurses were completing them. During an interview on 12/11/25 at 9:44 A.M., the Director of Nursing (DON) said he/she is working on a process for bed hold completion. He/She is new to the facility and was not aware until this week, the bed holds were not being completed. His/her expectation is the nurse will try to obtain the bed hold prior to the resident leaving the facility with the SSD helping with follow up as needed. During an interview on 12/11/25 at 10:25 A.M., the administrator said nurses are expected to initiate the bed holds and the SSD should follow up with the resident or responsible party within 24 hours. He/she has only been with the facility a very short time and is not sure if the bed holds are being completed.

Based on observation, interview and record review, facility staff failed to complete a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility. Facility census was 75.1. Review of the facility's Facility Assessment policy, Review of the facility assessment, dated 10/09/25, showed: -Average daily census of 77 residents;-Dayshift to include: one-two Registered Nurse (RN)'s, zero-three Licensed Practical Nurse (LPN)'s, three-five Certified Nurse Aide (CNA)'s, and zero-two Certified Medication Technician (CMT)'s;-Nightshift to include: zero-one RN, zero-two LPN's, two-five CNA's.-Evening shift to include zero-two CMT's;-The assessment did not contain direction or guidance of shift times;-The assessment did not contain direction or guidance to include staffing needs for each resident unit. Observation on 10/21/25 at 10:30 A.M., showed the facility with 100, 200, 300, and 400 hall. During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said he/she staffs the building based on census and the facility assessment. He/She said he/she has input into the assessment. The DON said he/she was not aware the assessment needed to include specific staffing needs for each unit. During an interview on 10/22/25 at 2:15 P.M., the administrator said the facility assessment is completed with the interdisciplinary team to include the floor staff but the final say comes from the regional team. He/She was not aware the facility assessment needed to contain guidance for specific staffing needs for each resident unit. #2644893

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to wear appropriate Personal Protective Equipment (PPE) during provisions of care for two resident's (Resident #12 and #13) out of two sampled residents who required Enhanced Barrier Precautions (EBP), and failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for two residents (Resident #14 and #16) out of two sampled residents. The facility census was 75.1. Review of the facility's Infection Prevention and Control policy, dated 05/10/25, showed:-Residents with an infection or communicable disease shall be placed on Transmission-Based Precautions (TBP) as recommended by the current CDC (Centers for Disease Control) guidelines;-All staff receive training regarding the infection prevention and control program;-All staff shall demonstrate competence in relevant infection control practices;-Direct care staff shall demonstrate competence in resident care protocols established by the facility.2. Review of the facility's EBP policy, revised 02/05/25, showed:-It is the policy of the facility to implement EBP for the prevention of transmission of multi-drug resistant organisms;-All staff will receive training on EBP upon hire and annually;-An order for EBP will be obtained for residents with any wounds, indwelling medical devices such as catheters, feeding tubes, tracheostomies, hemodialysis access, intravenous lines, etc.;-The facility will have the discretion on how to communicate to staff which resident's require the use of EBP as long as the staff are aware which resident's require the use of EBP prior to providing high-contact care activities. -Gowns and gloves will be available immediately near or outside the resident's room;-Provide education to staff, resident, and visitors;-The Infection Preventionist will incorporate periodic monitoring and assessment of adherence.3. Review of Resident #12's Annual MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and having wounds. Review of the resident's care plan, revised 07/22/25, showed the resident required EBP precautions due to wounds. Observation on 10/21/25 at 11:00 A.M., showed the residents door did not contain a sign for EBP. Observation showed Registered Nurse (RN) K and Licensed Practical Nurse (LPN) completed wound care on the resident. Observation on 10/22/25: at 8:45 A.M., showed the residents door did not contain a sign for EBP. Observation on 10/22/25: at 11:50 A.M., showed the residents door did not contain a sign for EBP. 4. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and having wounds. Review of the resident's care plan, revised 10/20/25, showed staff assessed the resident with a room. Review showed the care plan did not contain direction for EBP. Observation on 10/21/25 at 10:48 A.M., showed the residents door did not contain a sign for EBP. Observation showed LPN Y and the housekeeping supervisor completed wound care on the resident without a gown. Observation on 10/21/25 at 2:00 P.M., showed the residents door did not contain a sign for EBP. Observation on 10/22/25 at 9:00 A.M., showed the residents door did not contain a sign for EBP. Observation on 10/22/25 at 11:53 A.M., showed the residents door did not contain a sign for EBP. During an interview on 10/22/25 at 1:00 P.M., LPN Y said a resident with a wound requires EBP and should have a sign on their door indicating that. LPN Y said he/she did not think to wear a gown when he/she did wound care on the resident because there was not a sign on the resident's door to remind him/her. LPN Y said he/she should have worn a gown and gloves while completing wound care on the resident. LPN Y said staff are to wear PPE and use EBP to prevent spreading staff germs to the resident. LPN Y said he/she does not know who is responsible to ensure the EBP signs are placed on the correct doors. During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said EBP should be used with any resident who has a wound, catheter, feeding tube, or indwelling medical lines. The DON said when a resident is on EBP staff must wear a gown and gloves to provide care to the resident. The DON said the resident's door should have an EBP sign on it to indicate staff need to use EBP. The DON said the previous IP was responsible to ensure the correct signs were on the correct doors, but that person resigned two weeks ago. The DON said the central supply person has been responsible since the IP left. The DON said they discuss who needs EBP in the morning meeting and the central supply person is made aware then who needs a sign on the door and PPE outside the door. The DON said he/she was not aware residents didn't have EBP signs when they were need.During an interview on 10/22/25 at 2:42 P.M., the Administrator said he/she expects staff to follow EBP policy when providing care to residents with wounds, feeding tubes, catheter, and any other indwelling medical device to prevent their germs from infecting the resident. The Administrator said a resident's door should have an EBP sign on it to indicate to staff the need for the PPE. The Administrator said the previous IP was responsible to ensure the correct signs were on the correct doors, but that person resigned two weeks ago. The Administrator said the central supply person has been responsible since the IP left. The Administrator said they discuss who needs EBP in the morning meeting and the central supply person is made aware then who needs a sign on the door and PPE outside the door. The Administrator said he/she was not aware residents didn't have EBP signs when they were need. The Administrator said staff received education regarding PPE, and EBP upon hire and as needed. 5. Review of the facility's mechanical lifts policy, undated, showed staff are to disinfect per the manufacture guidelines. Review of the Food and Drug Administrations (FDA's) guide titled Patient Lifts Safety Guide, undated, showed manufacture instructions to clean and disinfect mechanical lifts before and after each patient use. 6. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as having moderate cognitive impairment and dependent on staff for transfers. Review of the resident's care plan, revised 10/07/25, showed the resident required a mechanical lift for transfers.Observation 10/21/25 at 4:30 P.M., showed Certified Nursing Assistant (CNA) P and CNA B completed a mechanical lift transfer on the resident. Observation showed staff did not sanitize the mechanical lift before or after the resident transfer was completed. During an interview on 10/21/25 at 4:47 P.M., CNA B said staff sanitize the mechanical lift after completing a transfer with a Covid positive residents, but don't otherwise. CNA B said it makes sense to sanitize the mechanical lift before and after use to prevent cross contamination from one resident to another though. CNA B said he/she learned something and will implement this from now on. 7. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as having severe cognitive impairment and dependent on staff for transfers.Review of the resident's care plan, revised 10/01/25, showed the resident required a mechanical lift for transfers.Observation on 10/21/25 at 9:45 A.M., showed CNA C and CNA B completed a mechanical lift transfer on the resident. Observation showed staff did not sanitize the mechanical lift before or after the resident transfer was completed. During an interview on 10/22/25 at 12:05 P.M., CNA C said he/she did not know he/she should have. CNA C said it makes sense to sanitize it before and after resident use to prevent the spread of germs and reduce contamination.During an interview on 10/21/25 at 1:48 P.M., CMT N said staff should sanitize the mechanical lifts before and after resident use to ensure germs aren't spread from one resident to another.During an interview on 10/22/25 at 1:33 P.M., the DON said he/she expects staff to sanitize the mechanical lifts before and after resident care to prevent contamination. The DON said the lifts sit in the hallway and anyone could touch them putting germs on them. During an interview on 10/22/25 at 2:42 P.M., the Administrator said he/she does not know the exact policy regarding sanitizing the mechanical lifts. He/She said he/she thinks staff should sanitize them before and after resident care to reduce germs being transmitted from one resident to another. 2647073

Based on interview and record review, facility staff failed to complete pre-employment screenings Criminal Background Checks (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nurse Aide (CNA) Registry for six sampled employees Registered Nurse (RN) G, CNA F, Certified Medication Technician (CMT) V, housekeeper W, CNA S, and housekeeper U out of ten sampled employees sampled. The facility census was 75. 1. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 05/01/25, showed:-Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property and the facility will maintain documented proof of the screening. Review of the facility's policy titled Background Checks, undated, showed:-The employee pre-employment background check policy applies to any candidate who go through the company's hiring process;-The below pre-employment checks are required to complete prior to hire: -FCSR; -EDL; -OIG; -SAM; -CNA verification; -Nurse license verification; -Administrator licenses verification -Therapy licenses verification;-All required background investigations should be directed toward the Human Resources (HR) Director or Administrator.2. Review of RN G's personnel file showed:-Date of hire 09/05/24;-EDL verification dated 05/03/25;-FCSR dated 10/21/25;-CBC dated 10/21/25;-Did not contain documentation of a CNA Registry verification. 3. Review of CNA F's personnel file showed:-Date of hire 02/06/25;-EDL verification dated 10/06/25;-FCSR dated 10/06/25;-CNA Registry verification dated 10/06/25.Review of the CNA F's timecard showed his/her first day worked was 02/06/25.4. Review of CMT V's personnel file showed:-Date of hire 02/20/25;-FCSR dated 05/07/25;Review of the CMT V's timecard showed his/her first day worked was 02/21/25.5. Review of housekeeper W's personnel file showed:-Date of hire 04/17/25;-FCSR dated 05/06/25.Review of the housekeeper W's timecard showed his/her first day worked was 04/17/25.6. Review of CNA S's personnel file showed:-Date of hire 05/08/25;-EDL verification dated 10/21/25;-Did not contain documentation of FCSR, CBC, or CNA Registry verification.Review of the CNA S's timecard showed his/her first day worked was 05/08/25.7. Review of housekeeper U's personnel file showed:-Date of hire 08/27/25;-FCSR dated 10/22/25;-CBC dated 10/22/25.Review of the housekeeper U's timecard showed his/her first day worked as 08/27/25.8. During an interview on 10/22/25 at 1:33 P.M. the Director of Nursing (DON) said the HR director is responsible to complete the pre-employment screenings for all new hires. The DON said once he/she completes the interview with a potential new hire he/she takes the new hires paperwork to HR director. The DON said the HR director runs the pre-employment screenings and they are supposed to be completed before the staff member is hired or works in the facility. During an interview on 10/22/25 at 2:25 P.M., the HR director said he/she started the end of May and only got two days with the former HR director to train for this role. The HR director said he/she has asked for more training but has not received it and has been winging it. The HR director said if the facility decides to hire someone, he/she is responsible to complete the pre-employment background screenings, and they are to be completed prior to the new hire beginning work at the facility. The HR director said he/she is to complete the FCSR, EDL, CNA verification, and any license verifications. The HR director said if potential new hires are not screened correctly then the facility could potentially hire someone who would harm a resident, and the facility must protect the residents. The HR director said any pre-employment screenings completed prior to 6/1/25 the former HR director would have completed, and he/she would not know why they weren't completed correctly. During an interview on 10/22/25 at 2:42 P.M. the administrator said all new hires are to have their pre-employment screenings completed prior to the date of hire. The administrator said it is HR director is responsible to complete all new hire screenings. The administrator said the current HR director is the third one the facility has had this year. The administrator said he/she was not aware the screenings weren't getting done correct and timely. The administrator said if a pre-employment screening is not completed correctly the facility runs the risk of having someone working here who could harm a resident and the facility must protect them. The administrator said it is critical to do these before the date of hire for everyone. Complaint #2659561; 2663004

Based on interviews and record review, facility staff failed to report allegations of abuse and neglect for two residents (Resident #17, and #15) to the Department of Health and Senior [NAME] (DHSS) within the required time frame of two hours for allegations of abuse and neglect. The facility census was 75. 1. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 05/01/25, showed it is the policy of the facility to provide protections for health, welfare, and rights of each resident. The facility will develop policies that prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property. Review showed:-The facility will investigate any such allegations;-The facility will train any new and existing staff members on abuse, neglect, exploitation, misappropriation, and reporting procedures;-An immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or misappropriation occur;-The facility will report all alleged violations to the Administrator, state agency adult protective services, and all other required agencies within in 2-hours after the allegation is made if the evens that cause the allegations involve abuse or result in serious bodily injury;-The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and report the results of the investigation when final within five working days of the incident. 2. Review of Resident #17's admission Minimum Data Set (MDS), a federally mandated tool, dated 07/07/25, showed staff assessed the resident as having severe cognitive impairment.Review of the facility investigation report, dated 09/19/25, showed the resident reported being slapped in the face by an employee. The investigation did not contain documentation staff reported the incident to DHSS until 09/29/25. During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said he/she was leaving for the day when the incident with Resident #17 was reported. The DON said he/she completed a skin assessment on the resident and the Regional Nurse Consultant was responsible to complete the rest of the investigation and ensure it was report to DHSS. The DON said he/she had to work night shift and left the facility to go home until the night shift began.3. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the facility investigation report, dated 09/23/25, showed Certified Nurse Assistant (CNA) A reported CNA S refused to toilet the resident and stated to just shit in your brief. The investigation did not contain documentation staff reported the incident to the State survey and certification agency until 09/29/25. During an interview on 10/22/25 at 1:33 P.M., the DON said the incident regarding Resident #15 he/she assisted with the investigation. The DON said he/she suspended CNA S until he/she completed his/her investigation. The DON said he/she reported the incident by phone the day of the incident to DHSS, but he/she did not have proof of that. 4. During an interview on 10/02/25 at 1:54 P.M., the Regional Nurse Consultant said he/she oversaw the facility while the Administrator was on vacation 09/13/25 through 09/28/25. The Regional Nurse Consultant said he/she has an administrator's license and can fill in as an interim administrator when needed. The Regional Nurse Consultant said he/she was responsible to complete the facility investigations and ensure they were reported to DHSS while the administrator was on vacation. The Regional Nurse Consultant said he/she thought he/she had reported the incidents to DHSS timely, but his/her email did not go through. During an interview on 10/22/25 at 2:42 P.M., the administrator said he/she was out of the country on vacation from 09/13/25 through 09/28/25 and the Regional Nurse Consultant was the interim administrator while he/she was gone. The Administrator said she did not know the reports were filed late to DHSS and said she would have expected any employee to resident abuse allegation to investigated per facility policy and to be reported to DHSS within the two-hour time frame. Complaint #2659561; 2663004

Based on observation, interview and record review, facility staff failed to ensure ten residents (Residents #1, #3, #5, #6, #9, #12, #13, #14, #15, and #16) out of 18 sampled residents, who were dependent on staff for activities of daily living (ADLs) received necessary care and services to maintain good personal hygiene. The facility census was 75.1. Review of the facility's Bathing a Resident policy, dated 08/01/25, showed it is the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/25/25, showed staff assessed the resident as:-Cognitively impaired;-Dependent on staff for bathing, dressing and personal hygiene;-No behaviors or rejection of care;-Diagnosis of stroke and anxiety.Review of the resident's care plan, undated, showed staff assessed the resident required maximum assistance of one staff for bathing/showering twice a week and as needed.Review of the resident's shower sheets, dated August 2025, showed staff documented the resident received two baths/showers for the month. Review of the resident's shower sheets, dated September 2025, did not contain documentation the resident received a bath/shower. Review of the resident's shower sheets, dated October 2025, showed staff documented the resident received one bath/shower for the month. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Impaired vision;-No behaviors or rejection of care;-Required partial to moderate staff assistance for bathing, dressing and transfers;-Diagnosis of unsteadiness on feet, dementia, lung disease and tremors.Review of the resident's care plan, dated 10/03/25, showed staff assessed the resident required moderate assistance of one staff with bathing/showering twice weekly and as necessary. Review of the resident's shower sheets, dated July 2025, showed staff documented the resident received two baths/showers for the month.Review of the resident's shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month. Review of the resident's shower sheets, dated September 2025, staff documented the resident received one bath/shower for the month. Review of the resident's shower sheets, dated October 2025, showed staff documented the resident received two bath/showers for the month.During an interview on 10/21/25 at 4:08 P.M., the resident said he/she likes to get his/her showers at least twice a week. He/She said his/her family discussed this with the staff during the care meeting. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-No behaviors or rejection of care;-Required partial to moderate staff assist for upper body dressing;-Required substantial to maximal staff assist for bathing and lower body dressing;-Diagnosis of stroke and paralysis on one side.Review of the resident's care plan, dated 08/13/25, showed staff assessed the resident required maximum assistance of one to two staff with bathing/shower twice weekly and as needed.Review of the resident's shower sheets, dated July 2025, showed staff documented the resident received two baths/showers for the month.Review of the resident's shower sheets, dated October 2025, showed staff documented the resident received two baths/showers for the month.Review of the resident's shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month. 6. Review of Resident #12's Annual MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment; -No behaviors or rejection of care;-Dependent for transfers, dressing, hygiene, and bathing;-Diagnosis of Parkinson's disease, dementia, heart failure, atrial fibrillation, and muscle weakness.Review of the resident's care plan, revised 07/22/25, showed staff assessed the resident is dependent on one to two staff to provide bath/shower twice weekly and as necessary.Review of the resident's shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month.Review of the resident's shower sheets, dated September 2025, showed staff documented the resident received one bath/shower for the month.Review of the resident's shower sheets, dated October 2025, showed staff documented the resident received one bath/shower for the month. 7. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment; -No behaviors or rejection of care;-Required moderate assistance for dressing;-Required maximum assistance for transfers, hygiene, and bathing;-Diagnosis of dementia, coronary artery disease, heart failure, muscle weakness, and need for assistance with personal care. Review of the resident's care plan, revised 06/08/25, showed staff assessed the resident required maximum assistance of one to two staff with bathing/showering twice weekly and as necessary.Review of the shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month.Review of the shower sheets, dated September 2025, showed staff documented the resident received one bath/shower for the month.Review of the shower sheets, dated October 2025, showed staff documented the resident received one bath/shower for the month.8. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-No behaviors or rejection of care;-Dependent on staff for transfers, dressing, hygiene, and bathing;-Diagnosis of traumatic brain injury, diabetes, neurogenic bladder, seizure disorder, muscle weakness, and need for assistance with personal care. Review of the resident's care plan, revised 10/07/25, showed staff assessed the resident is dependent with bathing/showering twice weekly and as necessary, and with dressing. Review of the shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month.Review of the shower sheets, dated September 2025, showed staff documented the resident received one bath/shower for the month.Review of the shower sheets, dated October 2025, showed staff documented the resident received one bath/shower for the month. During an interview on 10/21/25 at 4:30 P.M., the resident said he/she got a shower for the first time today in a long time and the staff member put his/her dirty shirt back on him/her afterwards. The resident said he/she doesn't know why they did that as he/she has plenty of clean clothes. 9. Review of Resident #15's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-No behaviors or rejection of care;-Required maximum assistance for transfers, dressing, hygiene, and bathing;-Diagnosis of Parkinson's disease, muscle weakness, and need for assistance with personal care. Review of the resident's care plan, revised 09/30/25, showed staff assessed the resident required maximum assistance with bathing/showering twice weekly and as necessary.Review of the resident's shower sheets, dated August 2025, showed staff documented the resident received one bath/shower for the month. Review of the shower sheets, dated August 2025, showed staff documented the resident received the resident did not receive a shower the weeks of August 11, 25.Review of the shower sheets, dated September 2025, showed the resident did not receive a shower the weeks of September 1, 8, 15, 22, and 29.Review of the shower sheets, dated October 2025, showed the resident did not receive a shower the weeks of October 6, 13, and 20. 10. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment;-No behaviors or rejection of care;-Dependent on staff for for transfers, dressing, hygiene, and bathing;-Diagnosis of dementia, coronary artery disease, renal insufficiency, and sleep apnea.Review of the resident's care plan, revised 10/01/25, showed staff assessed the resident as dependent with bathing/showering twice weekly and as necessary.Review of the resident's shower sheets, dated August 2025, showed the resident received one bath/shower the week of August 18.Review of the resident's shower sheets, dated September 2025, showed staff documented the resident received one bath/shower for the month.Review of the resident's shower sheets, dated October 2025, showed staff documented the resident received only one bath/shower for the month. 11. During an interview on 10/21/25 at 1:48 P.M., Certified Medication Technician (CMT) N said there are not enough staff to ensure showers are done, assist with meals, toilet residents, and answer call lights timely. During an interview on 10/21/25 at 3:25 P.M., Certified Nurse Assistant (CNA) B said he/she is concerned for the residents of the facility due to staffing concerns. CNA B said there is usually one aide assigned to each hall and staff are not able to ensure residents get oral care, good hygiene, or showers completed. The CNA said he/she has not had time for showers in over a month because there is just not enough time. During an interview on 10/21/25 at 5:22 P.M., CNA C said he/she is lucky to check on the residents every two hours for toileting, so showers are just not getting done. He/She said he/she focuses on toileting to keep skin from breakdown, he/she doesn't have time for showers.During an interview on 10/21/25 at 6:33 P.M., CNA F said the shift is hectic, especially at the beginning of the shift, and there is not enough time to get showers done. Residents don't like to be woken up in the middle of the night for showers. Giving a shower would leave the hall unattended. He/She said he/she would feel gross if not able to get a shower.During an interview on 10/21/25 at 6:42 P.M., CNA D said he/she does not do showers because him/her on the floor. He/She said he/she wouldn't want to be woke in the middle of the night to get a shower, so he/she doesn't do it to the residents. During an interview on 10/22/25 at 1:00 P.M., Licensed Practical Nurse (LPN) Y said the facility has a high acuity of residents and he/she knows showers do not get completed like they should. LPN Y said the aides are responsible to complete showers, but the charge nurse is responsible to oversee the aides and ensure the showers get completed. Showers are the things that gets pushed back and not done.During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said he/she is aware showers do not get completed twice a week. The DON said he/she started writing out the shower sheets daily himself/herself to ensure residents get showers, and if they do not get completed on that date they are moved to the following day. 2647073

Based on observation, interview and record review, facility staff failed to provide sufficient staff according to facility assessment provide nursing care to meet the care needs of five residents (Resident #1, #3, #5, #9, and #14) out of 18 sampled residents to ensure adequate care and comfort. This had the potential to affect all residents. The facility census was 75.1. Review of the facility's Facility Assessment, dated 10/09/25, showed: -The Facility Assessment includes an evaluation of staff needed to ensure enough staff to meet resident needs as identified through resident assessment and care plans;-Resident daily schedules (waking, bathing, activities, rest periods, meals, bedtime, etc.) are considered;-Staff needed to care for resident population include: Director of Nursing (DON), Assistant Director of Nursing (ADON), Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA), Certified Medication Technician (CMT), Minimum Data Set (MDS) Nurse, Infection Preventionist (IP) and hospitality aides;-The facility considers the resident population, care and support needs for staffing decisions; We make a good faith effort to ensure we have sufficient staff to meet the needs of our residents;-The facility will make a good faith effort to evaluate the overall number of facility staff needed to ensure qualified staff are available to meet each resident's needs;-Staffing needs for each shift are determined and adjusted as necessary based on changes to the resident population (census increase or decrease) during normal operations and emergencies;-Additional items that are considered when determining staff are acuity levels, which may include, medications and treatments, Acok thanks have a great eveningtivities of Daily living and care levels, admissions, and readmissions;-Average daily census of 77;-Dayshift to include: One-two RN's, zero-three LPN's, three-five CNA's, and zero-two CMT's;-Nightshift to include: zero-one RN, zero-twoPN's, two-five CNA's.-Evening shift to include zero-two CMT's. Review of facility mechanical lift list, undated, showed facility has 21 residents who require mechanical lifts. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/25/25, showed staff assessed the resident as:-Cognitively impaired;-Dependent on staff for bathing, dressing and personal hygiene;-No behaviors or rejection of care;-Diagnosis of stroke and anxiety.Observation on 10/21/25 at 10:28 A.M., showed resident in a group activity. He/she had long facial hair and his/her hair was disheveled. Observation on 10/21/25 at 12:00 P.M., showed resident at lunch table with long facial hair and long nails. His/her hair was disheveled. Observation on 10/22/25 at 11:51 A.M., showed resident in the dining room with long facial hair and disheveled hair. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Impaired vision;-No behaviors or rejection of care;-Required partial to moderate staff assistance for bathing, dressing and transfers;-Diagnosis of unsteadiness on feet, dementia, lung disease and tremors.During an interview on 10/21/25 at 4:08 P.M., Resident #3 said it seems like there isn't enough staff to help with showers. He/She said he/she is lucky to get a bath once a week, and that isn't enough. He/She hates to feel dirty, and he/she has had to go several weeks between baths.4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-No behaviors or rejection of care;-Required partial to moderate staff assist for upper body dressing;-Required substantial to maximal staff assist for bathing and lower body dressing;-Diagnosis of stroke and paralysis on one side.Observation on 10/21/25 at 10:19 A.M., showed resident in bed with long facial hair and long nails. His/Her hair appeared greasy.Observation on 10/22/25 at 9:28 A.M., showed the resident in bed with long facial hair and long fingernails. His/her hair appeared greasy. 5. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-No behaviors or rejection of care;-Required moderate assistance for transfers, dressing, hygiene, and bathing;-Diagnosis of stroke, seizure disorder, muscle weakness, and need for assistance with personal care. During an interview on 10/21/25 at 2:05 P.M., Resident #9 said staff treat him/her good, but there is not enough of them. The resident said he/she hasn't had a shower in 2 weeks and I can smell myself. 6. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-No behaviors or rejection of care;-Dependent on staff for transfers, dressing, hygiene, and bathing;-Diagnosis of traumatic brain injury, diabetes, neurogenic bladder, seizure disorder, muscle weakness, and need for assistance with personal care. During an interview on 10/21/25 at 4:30 P.M., Resident #14 said he/she got a shower for the first time today in a long time.7. Observation on 10/21/25 at 12:22 P.M., showed the assist dining table with nine residents and two staff members, CMT N and CNA C, to assist those residents. Observation showed the housekeeping supervisor arrived at 12:27 P.M. to assist the two staff members at the assist dining table. Observation on 10/21/25 at 5:10 P.M., showed the assist dining table with eight residents and one staff member to assist, CNA A. Observation showed CNA A walked around the assist dining table feeding multiple residents by himself/herself. Observation on 10/22/25 at 9:05 A.M., showed the assist dining table with nine residents and three staff members, CNA C, CNA B, and the Social Service Director (SSD). Observation on 10/22/25 at 9:28 A.M., showed the SSD left the assist dining table to deliver the hall trays. Observation on 10/22/25 at 12:25 P.M., showed the assist dining table with ten residents and one staff member, CNA C, to assist the residents. 8. During an interview on 10/21/25 at 1:48 P.M., CMT N said the facility recently started having the CMT assist with feeding at mealtime due to not having enough aides. CMT N said the assist dining table normally has between ten to 11 residents with one or two staff assisting them to eat. CMT N said there is not enough staff to ensure showers are done, assist with meals, toilet residents, or answer call lights timely. CMT N said the facility has a high acuity of resident population and there are over 20 residents that require mechanical lifts for transfers. CMT N said it is common to have one aide assigned per hall and the residents don't get adequate care with only one aide on each hall. During an interview on 10/21/25 at 3:25 P.M., CNA B said he/she is concerned for the residents of the facility due to staffing concerns. CNA B said there is usually one aide assigned to each hall who are responsible for 25 to 28 residents, and they have multiple residents who mechanical lifts for transfers. CNA B said the aides have to leave the hall to go find another staff member to assist with each mechanical lift transfer which in turn cuts into the time they have for resident care. CNA B said staff are not able to ensure residents get oral care, good hygiene, or showers completed. CNA B said recently a resident got another resident dressed due to not having enough staff. CNA B said there are multiple residents to assist at mealtime and there is usually one or two aides to assist three to four residents each. CNA B said management does not assist the floor staff with meals, cares, or showers. During an interview on 10/21/25 at 5:22 P.M., CNA C said he/she is usually responsible for one hallway by themselves, and the hall is usually full. He/She said they don't always get to check on the resident every two hours due to the number of residents they are responsible for. He/She said the staff don't have time to complete showers. If he/she stopped to give a shower, then he/she would have to let a resident stay wet or visa versa. He/She would rather toilet a resident to keep the skin from breakdown than give a full shower. He/She said there is two residents who require a lift for transfers and when they want to go to bed or get up from bed, he/she has to leave the hall unattended to get help from a second person and that takes time away from giving care. He/She said he/she would feel horrible if he/she could not get oral care or showers.During an interview on 10/21/25 at 6:33 P.M., CNA F said the facility is really short staffed and sometimes he/she is responsible for up to 28 residents. He/She usually works the night shift and its always very hectic early in the shift with finishing supper, laying the residents down and toileting. By the time that is finished its going on ten o'clock and most of the residents don't want to take a shower then or would have to be woken back up for bathing. The CNA said that if a resident is a mechanical lift, then he/she would have to leave the hall unattended to go and get help which often takes time because the other aides are busy too. During an interview on 10/21/25 at 6:37 P.M., CNA Q said he/she wished the state surveyors were at the facility all the time because the aides get more help. CNA Q said the transporter and administration team normally leaves at 4:00 P.M. and he/she is only here this evening to assist with meals due to the state surveyors being at the facility. During an interview on 10/21/25 at 6:42 P.M., CNA D said he/she usually works the evening shift and works a hall that should have two staff on it due to the amount of assist the residents need but is often by themselves. If he/she needs help he/she has to leave the hall unattended to get it. He/She said the nurses have their own jobs to do and the CMT's are busy until they leave after their medication pass. He/She said he/she does the best they can but goes home feeling like its just not good enough often neglecting to give oral care and good personal hygiene. During an interview on 10/22/25 at 9:08 A.M., CMT H said with the number of residents staff are responsible for and have to give medications to, he/she is not always timely in giving out medications but does the best he/she can with the time he/she has. CMT H said he/she is too busy to help the CNA's on the floor with direct care. During an interview on 10/22/25 at 9:30 A.M., CNA C said the SSD does not assist with meals like he/she did today. CNA C said the SSD was only assisting due to the state surveyors being at the facility. During an interview on 10/22/25 at 9:32 A.M., CNA B said the SSD does not assist with meals like he/she did today. CNA B said the SSD was only assisting due to the state surveyors being at the facility and that is all for show. During an interview on 10/22/25 at 12:05 P.M., CNA C requested the state surveyors observe the lunch meal. CNA C we get help that way, and it's a nice break. During an interview on 10/22/25 at 1:00 P.M., LPN Y said when the facility is short staff, they utilize the other staff to assist, such as the housekeeping supervisor, SSD, and activity director. LPN Y said the facility has a high acuity of residents and he/she knows showers do not get completed like they should. LPN Y said the aides are responsible to complete showers, but the charge nurse is responsible to oversee the aides and ensure the showers get completed. During an interview on 10/22/25 at 1:33 P.M., the DON said the facility staffing need is based on census, and facility assessment. The DON he/she works the floor as a charge nurse sometimes. The DON said he/she feels like the facility could always use more staff. The DON said he/she feels like some staff have poor time management which causes them to feel shorter staffed. The DON said he/she is aware showers do not get completed twice a week. The DON said he/she started writing out the shower sheets daily himself/herself to ensure residents get showers, and if they do not get completed on that date they are moved to the following day. During an interview on 10/22/25 at 2:42 P.M., the Administrator said he/she feels like the facility has enough staff to meet the resident needs, but he/she would be happy to have more staff. The Administrator said extra staff would make a difference between minimum care verses great care. The Administrator said he/she would not want the facility to have any less staff than they currently do. The Administrator said staffing needs are determined by the facility assessment, acuity of care, and the census. The Administrator said he/she does get complaints from residents and families regarding staffing. #2644893 and #2600355

Based on interview and record review, facility staff failed to ensure the Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The census was 75.1.Review of the Facility Assessment, dated 10/09/25, showed: -Average daily census of 77;-The DON is identified as needed to care for the resident population;-The assessment does not indicate if the DON is a full-time staff member or how many hours are dedicated to the role of DON;-The assessment does not indicate if the DON is allocated to direct care. 2.Review of the facility's nursing schedule dated 09/01/25 through 9/30/25 showed the DON as charge nurse: - On 09/06/25, nightshift with census of 77;- On 09/07/25, nightshift with census of 77;- On 09/08/25, nightshift with census of 78;- On 09/10/25, nightshift with census of 78;- On 09/12/25, nightshift with census of 76;- On 09/15/25, nightshift with census of 78;- On 09/16/25, nightshift with census of 78;- On 09/19/25, nightshift with census of 77;- On 09/20/25, nightshift with census of 77;- On 09/25/25, nightshift with census of 78;- On 09/30/25, nightshift with census of 78. Review of the facility's nursing schedule, dated 10/01/25 through 10/21/25, showed the following: - On 10/05/25, nightshift with census of 79;-On 10/13/25, nightshift with census of 81. During an interview on 10/22/25 at 1:33 P.M., the DON said he/she works the floor to help provide resident care. He/She has a nurse who is out with a medical issue and have been covering for them where needed. He/She said there is regional support to help with the DON tasks while he/she is working as a floor nurse. He/She said the ADON was assisting as well, but they resigned a couple of weeks ago. The DON said he/she is aware of the regulation. During an interview on 10/22/25 at 2:00 P.M., the Administrator said he/she is aware the nursing director is working the floor. #2644893

Based on interview and record review, facility staff failed to provide discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the hospital discharged the resident. The facility census was 80.1. Review of the facility's Transfer and Discharge policy, revised 04/23/25, showed staff were directed to:-Once admitted , the resident has the right to remain in the facility unless their transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;-The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: -The specific reason and basis for transfer or discharge;-The effective date of transfer or discharge;-The specific location (such as the name of the new provider or description and/or address if the new location is a residence) to which the resident is to be transferred or discharged ;-An explanation of the right to appeal the transfer or discharge to the State;-The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests;-Information on how to obtain an appeal form;-Information on obtaining assistance in completing and submitting the appeal hearing request;-The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman;-For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness(or related disabilities), the notice will include name, mailing and e-mail address and phone number of the state agency responsible for the protection and advocacy of these populations;-The notice must be provided at least 30 days prior to transfer or discharge of the resident;-If the facility determines it cannot meet the resident's needs, the resident's physician will document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the specific services available at the receiving facility to meet the needs of the resident which cannot be met at the current facility;-The facility will provide transfer/discharge notice to the resident/representative and ombudsman as indicated;-For a transfer to another provider, ensure necessary information (All other information necessary to meet the resident's needs) is provided along with, or as part of, the facility's transfer form.2. Review of Resident #1's Discharge Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 06/25/25, showed an admission date of 06/04/25 and discharge date of 06/25/25.Review of the resident's nurse's note, dated 06/25/25, showed staff sent the resident to the emergency department by ambulance for suicidal ideation (often referred to as suicidal thoughts, is the experience of thinking about, considering, or contemplating suicide). Review of the resident's electronic medical record, dated 6/25/25, showed the medical record did not contain a 30 day discharge or an emergency discharge notice.During an interview on 07/02/25 at 2:05 P.M., the Social Service Director (SSD) said he/she is responsible for discharge planning and being the liaison between the facility, the family and any resources the residents may need. He/She said he/she has been sending out referrals for the resident to be transferred to another facility and they have been denied. He/She was not aware the resident was denied reentry to the facility. He/She said he/she is not aware of the rules for discharging a resident and not allowing them to reenter. He/She said when a resident is going to be discharged to another facility, he/she usually provides a 30-day notice and helps the resident to find a new placement.During an interview on 07/02/25 at 2:19 P.M., the administrator said the resident has had suicidal ideations since admission on [DATE]. He/She said the last transfer out to the hospital was on 06/25/25. He/She said in order for the resident to return to the facility, the resident would need to be placed on one-on-one care in order to ensure his/her safety. He/She said the facility does not offer one-on-one care and cannot provide the level of care the resident needs to ensure his/her safety. He/She said he/she spoke with corporate, after the hospital called the facility to discharge the resident. He/She talked to them about the resident returning to the facility and they decided as a team, since his/her care level has shifted they are denying him/her reentry. He/She said he/she was not aware of the requirement to allow the resident to return to the facility nor the proper process for discharging the resident. MO00256824

Based on interviews and record review, facility staff failed to notify the physician and family/resident representative in a timely manner of a change in condition for one resident (Resident #1) who had a medical emergency, and failed to notify the family/resident representative for one resident (Resident #1) who sustained a fall. The facility census was 71. 1. Review of the facility's Notification of Changes policy, revised 9/1/21, shows the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his/her authority, resident representative when there is a change requiring notification. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/16/25, showed staff assessed the resident as follows: -Cognitive impairment; -Diagnosis of a Stroke, (when blood flow to the brain is interrupted, causing brain cells to die), high blood pressure, and Dementia. Review of the resident's nurses notes, dates 2/22/25, showed staff documented the resident found on his/her floor in his/her room. Resident noted to be laying on the floor on his/her back in the doorway to the bathroom. Review of the resident nurses notes did not contain documentation staff notified the residents family of the fall. Review of the resident's nurses notes, dated 2/24/25, showed staff documented, the resident had episodes of nausea and projectile vomiting at noon meal. Resident unresponsive for approximately two minutes. Review of the residents nurses notes did not contain documentation staff notified the physician of the change in condition. During an interview on 3/11/25 at 8:20 A.M., the Director of Nursing (DON) said the resident had an episode in the dining room where he/she vomited, but when he/she assessed the resident back in his/her room the resident was already alert and speaking. The DON said he/she believed the Nurse Practitioner was notified because he/she was in the building but did not know who notified him/her. The DON said he/she does not know if the residents guardian was notified for the change in condition or the residents fall. During an interview on 3/11/25 at 8:20 A.M., the administrator said he/she is unaware if the residents family was notified of the change in condition or the fall but they are supposed to be. During an interview on 3/11/25 at 10:19 A.M., the residents guardian said he/she was not aware the resident had a medical episode. The guardian said he/she would have requested the resident be sent to the hospital because he/she has a history of strokes. The guardian said he/she did not know the resident had a fall on 2/22/25 and would like to be notified of his/her falls because the resident has dementia and can not relay this information. During an interview on 3/11/25 at 10:44 A.M., Licensed Practical Nurse (LPN) A said he/she was the charge nurse on duty and would have been responsible to notify the physician and the family but he/she can not remember if it was done. During an interview on 3/11/25 at 11:15 A.M., the Nurse Practitioner said he/she was notified of the residents fall on 2/22/25 but was not notified of the residents medical episode on 2/24/25, The Nurse Practitioner said he/she was in the building that day and there was no reason for staff not to have informed him/her. MO00249720

Based on observation and interview, facility staff failed to maintain wheelchairs for three residents (Resident #5, #7 and #8) of nine sampled residents. The facility census was 76. 1. Review of the facility's policy, Physical Environment: Space and Equipment, dated 02/03/25, showed staff were directed inspection of resident care equipment will be completed routinely and as needed to maintain and ensure safe operating conditions according to manufacturer's recommendations. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Uses a wheelchair. Observation on 03/20/25 at 12:11 P.M., showed Resident #5 in his/her wheelchair with both arm rest torn. 3. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 12/30/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Uses a wheelchair. Observation on 03/20/25 at 12:46 P.M., showed Resident #7's wheelchair armrest were worn with sections of missing vinyl. 4. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Uses a wheelchair. Observation on 03/20/25 at 1:48 P.M., showed Resident #8 in his/her wheelchair and the wheelchair had a bent metal piece connecting the chair to the leg rest. Observation showed medical bandage wrapped around the metal connecting piece. During an interview on 03/20/25 at 1:51 P.M., the maintenance director said he/she did not know the resident had a maintenance issue with his/her wheelchair. He/She said the resident owned his/her wheelchair, so staff did not provide repairs to personal wheelchairs. He/She said it was possibly a safety issue and believed the bandage placed on the chair to hold the leg rest to the chair. During an interview on 03/20/25 at 1:56 P.M., the administrator said he/she did not know about the condition of the resident's wheelchair. He/She said staff should have ordered him/her a new wheelchair. He/She said staff should have immediately reported the concern with the wheelchair, due to the potential to harm the resident. 5. During an interview on 03/20/25 at 1:38 P.M., the maintenance director said staff were directed to document wheelchair concerns in the maintenance book, which he/she checked daily. He/She said he/she did not know any of the resident chairs were in need of repair. He/She said there was a concern with skin abrasions if the resident had a worn arm rest. During an interview on 03/20/25 at 2:23 P.M., Registered Nurse (RN) C said staff are directed to report issues with wheelchairs to the maintenance department or document in the maintenance log book. During an interview on 03/20/25 at 1:56 P.M., the administrator said staff should check the condition of resident's wheelchairs daily and report to his/her supervisor to document any issues in the maintenance book or report to the appropriate person. He/She said if the wheelchair arm rest are torn, there was a potential for skin tears. During an interview on 03/20/25 at 2:41 P.M., the Director of Nursing (DON) said staff are directed to check the wheelchair every time in use or weekly when being cleaned by staff. He/She said staff should document concerns in the maintenance book. He/She said if it's the resident's personal wheelchair, staff should notify family and/or guardian for a replacement. He/She said if the wheelchair arm rest are torn, there was a potential for skin tears. MO00250878

Based on observation, interview, and record review, facility staff failed to provide care to meet the hygiene needs for four residents (Resident #3, #5 and #6) out of seven sampled residents when staff did not provide nail care and assist with facial hair. The facility census was 76. 1. Review of the facilities policy, Activities of Daily Living, dated 01/01/25, showed staff are directed to assist a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The policy did not provide direction for staff in regard to when and how to provide personal hygiene. 2. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not exhibit behavior of rejecting care; -Required partial to moderate assistance from staff for personal hygiene. Review of the resident's care plan, dated 01/27/25, showed staff assesed the resident required moderate to maximum assistance with the majority of his/her ADL's due to impaired mobility related to right side hemiparesis. The care plan showed resident required moderate assistance from one staff member with personal hygiene and oral care. The plan did not contain documentation the resident had behaviors of rejecting care. Observation on 03/20/25 at 12:05 P.M., showed the resident nails long, a hole in his/her shirt, white debris on his/her shirt and pants, and unbrushed hair. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Did not exhibit behavior of rejecting care; -Required partial to moderate assistance from staff for personal hygiene. Review of the resident's care plan, dated 01/07/25, showed staff assessed the resident required moderate assistance for personal hygiene and oral care. The care plan showed the resident had limited physical mobility due to hemiparesis. The plan did not contain documentation the resident had behaviors of rejecting care. Observation on 03/20/25 at 12:11 P.M., showed the resident nails long and with debris, unbrushed hair and unkempt facial hair. 4. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not exhibit behavior of rejecting care; -Required substantial to maximum assistance from staff for personal hygiene. Review of the resident's care plan, dated 06/17/24, showed staff assessed the resident required maximum assistance with personal hygiene and oral hygiene. The plan did not contain documentation the resident had behaviors of rejecting care. Observation on 03/20/25 at 12:15 P.M, showed the resident with facial hair, a hole in his/her shirt and his/her hair matted. 5. During an interview on 03/20/25 at 2:10 P.M., Certified Nurse Aide (CNA) B said the aides were responsible to dress resident's and brush the resident's hair daily and as needed. The CNA said CNA's are to provide nail care and facial hair shaves on shower days and as needed. He/She said he/she did know resident's needed their nails trimmed and facial hair shaved. During an interview on 03/20/25 at 2:23 P.M., Registered Nurse (RN) C said nursing staff are to provide facial hair shaves and nail care on shower days or as needed. He/She said staff are directed to change resident's clothing and brush hair daily and as needed. During an interview on 03/20/25 at 2:41 P.M., the administrator said staff were directed to shower resident's twice a week, but they did not have enough shower aides until recently, so resident's were showered once a week. He/She said staff are educated to provide nail care and facial hair on shower days and as needed. He/She said staff changed clothing daily and brushed hair when gotten up and as needed. During an interview on 03/20/25 at 2:42 P.M., the Director of Nursing (DON) said they recently hired two shower aides to assist with personal hygiene needs. He/She said staff are directed to provide nail care and facial hair shaving on shower days and as needed. He/She said staff are directed to brush hair and change clothing when assisted out of bed or as needed. He/She said the nursing staff was responsible to provide care and should be checking the resident's grooming needs daily. MO00250878

Based on interview and record review, facility staff failed to prevent the misappropriation of seven resident's (Resident #2, #3, #4, #5, #6, #7, and #8) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/22/22, showed misappropriation defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's permission. 2. Review of the facility's investigation, dated 9/12/24, showed staff had suspicions the narcotics count were off when they identified LPN A had subtracted various pills inaccurately for multiple residents. Upon their investigation it was identified five residents had counts off or were given a narcotic outside of their normal scheduled timeframe. When LPN A was notified he/she did not cooperate and did not return to the facility. The Assistant Director of Nursing (ADON) was made aware on 9/20/24 LPN A had been arrested at another local facility and officers found empty narcotic cards in LPN A's car for Aurora Health and Rehabilitation. The Director of Nursing (DON) tried reaching out to police on 9/17/24 and 9/23/24 for more information. 3. Review of the police reported, dated 9/20/24, showed officers arrested LPN A at another local facility for misappropriation of narcotics. The police report showed the officer documented seven different empty narcotic pill cards from the facility labeled with resident's names were found in LPN A'sa car. 4. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/10/24, showed staff assessed the resident as: -Cognitively intact; -Experienced occasional pain; -Received scheduled and as needed pain medications. Review of the resident's Physician Order Sheets (POS), dated 10/2024, showed an order for Hydrocodone/APAP 5-325 mg (narcotic pain medication) administer one tablet by mouth every 4 hours. Review of the police report, dated 9/20/24, showed the officer documented he/she found one empty Hydrocodone/APAP 5-325 mg medication card with the resident's name in LPN A's car. 5. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Experienced occasional pain; -Received scheduled and as needed pain medications. Review of the resident's POS, dated 10/2024, showed an order for Oxycodone (narcotic pain medication) five mg administer one talbet by mouth every six hours for severe pain and Oxycotin (narcotic pain medication) 20 mg administer one tablet by mouth two times a day for pain. Review of the residents narcotic log sheet, dated 9/5/24, for Oxycodone 5 mg, showed LPN A signed out that he/she administered one pill on 9/6/24 but he/she subtracted two pills from the narcotic count. Review showed LPN A administered one pill on 9/8/24 but he/she subtracted two pills from the narcotic count. Review showed LPN A wasted one pill on 9/9/24 without a witness. Review of the police report, dated 9/20/24, showed the officer documented he/she found one empty Oxycodone 5 mg and one empty Oxycotin 20 mg medication card with the resident's name in LPN A's car. 6. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Received scheduled pain medications. Review of the resident's POS, dated 10/2024, showed an order for Oxycodone/APAP 10-325 mg take one tablet by mouth every 12 hours, and Oxycodone/APAP 10-325 mg take one tablet by mouth every 24 hours as needed for pain. Review of the residents narcotic log sheet, dated 8/28/24, for Oxycodone 10-325 mg, showed LPN A signed out that he/she administered one Oxycodone 10-325 mg pill on 8/28/24 but he/she subtracted two pills from the narcotic count. Review of the police report, dated 9/20/24, showed the officer documented he/she found one empty Oxycodone 10-325 mg medication card with the resident's name in LPN A's car. 7. Review of Resident #5's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact;-Experienced occasional pain; -Received scheduled pain medication. Review of the resident's POS, dated 10/2024, showed an order for Oxycodone 5 mg capsules five mg by mouth four times a day for pain. Review of the police report, dated 9/20/24, showed the officer documented he/she found one empty Oxycodone 5 mg medication card with the resident's name in LPN A's car. 8. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Experienced occasional pain; -Received as needed pain medications. Review of the resident's POS, dated 10/2024, showed an order for Hydrocodone/APAP 7.5-325 mg administer one tablet by mouth every 6 hours. Review of the police report, dated 9/20/24, showed the officer documented he/she found one one narcotic count sheet and two empty Hydrocodone/APAP 7.5-325 mg medication cards with the resident's name in LPN A's car. 9. Review of Resident #7's Discharge MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Experienced occasional pain; -Received scheduled and as needed pain medication. Review of the residents POS, dated 10/2024, showed an order for Hydrocodone/APAP 10-325 mg take one tablet by mouth every six hours, at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6 P.M. for moderate to severe pain. Review of the resident's narcotic log sheet, dated 9/9/24, showed LPN A signed out that he/she administered Hydrocodone/APAP 10-325 mg one pill on 9/10/24 but he/she subtracted two pills from the narcotic count. Review of the police report, dated 9/20/24, showed the officer documented he/she found one empty Hydrocodone/APAP 10-325 mg medication card with the resident's name in LPN A's car. 10. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Experienced occasional pain; -Received scheduled and as needed pain medications. Review of the resident's POS, dated 10/2024, showed an order for Hydrocodone/APAP 10-325 mg take one tablet by mouth every six hours as needed for chronic pain. Review of the narcotic log sheet, dated 9/1/24, showed LPN A signed out that he/she administered one pill on 9/10/24 but he/she subtracted two pills from the narcotic count. 11. During an interview on 10/8/24 at 9:50 A.M., the administrator said he/she was made aware of the allegation of misappropriation and they started an investigation. He/She said the investigation showed no one missed their medications but the subtraction was off in the narcotic book. He/She said corporate was contacted about the allegation for assistance. Their investigation showed no pills were misappropriated. LPN A was asked to come into the office to talk about the miscalculations but never showed back up to work. Even after being notified of the empty narcotic cards the count was not off so they concluded the investigation as unsubstantiated. During an interview on 10/8/24 at 10:00 A.M., the DON said upon starting the investigation and going through the carts the narcotic counts were correct. The investigation showed discrepancies with the subtraction and administration of some of the narcotics so they contacted LPN A who was responsible for the medications at that time. LPN A would not come back to the facility and did not show back up to work an interview. During an interview on 10/10/24 at 12:32 P.M., LPN A said he/she worked a lot of hours and picked up a lot of shifts at the facility. He/She does not know what happened to the additional pills and said he/she must have subtracted incorrectly. He/She said he/she never wasted a medication while working at the facility. He/She said she was arrested at another facility and knows there were some narcotic log sheets in her car from the facility that he/she had accidentally taken and never took back. LPN A said he/she did not take any medications from the facility. LPN A said he/she was not aware medications were given outside of prescribed timeframe's and gave medications as ordered. LPN A said there was nothing else besides the narcotic sheets found in his/her car from the police. MO00242392

Based on interview and record review, facility staff failed to report an allegation of misappropriation of narcotics to the State Survey Agency within the 24 hour time frame, in accordance with their policy, and state law for seven residents (Resident #2, #3, #4, #5, #6, #7, and #8) out of 10 sampled residents. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/2022, showed reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframe's. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Review of the facility's investigation, dated 9/12/24, showed the Assistant Director of Nursing (ADON) documented their narcotic count had discrepancies and/or medications being given outside of scheduled timeframe by Licensed Practical Nurse (LPN) A. The ADON attempted to speak with LPN A but he/she never returned to the facility. Review showed the Director of Nursing (DON) contacted the police on 9/23/24 and left a message to call him/her back regarding the empty narcotic cards found in LPN A's car. Review showed the facility did not report the alleged misappropriation to the Department of Health and Senior Services within the required 24 hour timeframe. During an interview on 10/8/24 at 9:50 A.M., the administrator said they started an investigation because the narcotic count was off. He/She said their investigation showed no residents missed their medications and there was just an issue of the narcotic counts being subtracted incorrectly by LPN A. He/She said the DON and ADON tried to interview LPN A but he/she did not cooperate with them and never came back to the facility. He/She was made aware by the ADON and DON on 9/20/24 empty narcotic cared were found by an officer in LPN A's car at another local facility. He/She said the corporate office was called and said it was not reportable because the investigation did not show any pills had been misappropriated even though cards were found by an officer in LPN A's car at another local facility. During an interview on 10/8/24 at 10:00 A.M., DON said the counts in the narcotic book were correct but they still had speculation and concern of LPN A not counting the narcotics right. He/She said they were unable to interview LPN A about their concerns with the count not being subtracted correctly. The DON said he/she talked with corporate after being made aware on 9/20/24, by the ADON, empty narcotic cards were found at another local facility by police. He/She was told this was not a reportable incident since they were unable to substantiate their investigation even though narcotic cards were found in LPN A's car at another local facility. He/She said with allegations of misappropriation the state should be notified. During an interview on 10/8/24 at 12:35 P.M., the Assistant Director of Nursing (ADON) said he/she received a call from an administrator at another local facility on 9/20/24, stating they had found narcotic cards from their facility in LPN A's car. The ADON said he/she told corporate about the incident, but was told it was not a reportable incident because their counts were not off. The ADON said he/she followed what corporate said to do. During an interview on 10/8/24 at 1:06 P.M., the Regional Nurse Consultant said he/she was made aware of the allegation and of the missing narcotic cards and sheets found at the other local facility by the police by the ADON and DON. He/She said staff are trying to get into contact with the police for more information and who was affected. He/She said they did not have any names for the residents whose narcotic cards were supposedly taken. He/She said the nurse involved never came back to be interviewed and did not take a drug test. He/She said they report when they have a proven allegation of misappropriation and without reasonable cause it was not reportable to the state. MO00242392

Based on interview and record review, facility staff failed to protect one resident (Resident #1) from neglect when staff failed to properly secure a resident while they transported the resident in the facility vehicle. Facility staff failed to secure the shoulder strap across the resident and when the vehicle came to an abrupt stop, the resident fell over his/her lap belt and from his/her wheelchair which resulted in fractures of both femurs, thoracic spine fractures, and an upper arm fracture. The facility census was 78. The administrator was notified on 8/13/24 of past non-compliance, which occurred on 8/07/24. Staff assessed the resident, notified the resident's physician, sent the resident to the hospital, and in-serviced all transportation staff on the proper way to secure a resident in the van during transport. The IJ was corrected on 8/8/2024. Review of the Facility's Transportation Driving Safety Policy, reviewed 05/04/23, showed: -Drivers of company vans, buses or vehicles carrying residents should have at least three years of driving experience and will be required to complete initial and annual training per manufactures guidelines to include how to properly restrain a wheelchair and use of safety mechanisms for residents in wheelchairs per manufactures guidelines. The driver shall ensure each passenger is properly restrained to include wheelchair(s) properly fastened and shoulder strap in place and/or passenger seat belts are properly latched. Review of the facility's Q-Straint Series Securement-Device User Instructions Manual, undated, showed staff are directed as follows: -Place wheelchair face forward in securement area; apply wheel locks or turn power off; -Attach lap belts-use integrated stiffeners to feed belt through openings between seat backs and bottoms and/or armrests to ensure proper belt fit around occupant; -Attach shoulder belt-extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt; -Ensure belts are adjusted as firmly as possible, but consistent with user comfort. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE]. showed staff assessed the resident as follows: -Cognitively intact; -Impairments to both sides of lower extremities; -Dependent to roll left and right; -Dependent to move from lying to sitting on bedside; -Used wheelchair. Review of the facility's investigation summary, dated 08/07/24, showed staff documented at approximately 10:33 A.M., the facility's van driver reported to the administrator he/she called 911 after having an accident with the resident while returning from the dialysis clinic. The driver told the administrator the car in front of him/her slammed on the brakes and he/she hit the brakes to avoid hitting the other car. The driver told the administrator the resident fell out of his/her wheelchair and may have bit his/her lip as there was some blood on the resident's mouth. Review showed the driver told the administrator Emergency Medical Services (EMS) arrived and encouraged the resident to be transported to the hospital. Review of Driver A's Incident Statement, dated 08/07/24, showed Driver A documented a vehicle abruptly applied its brakes in front of the transport van at an intersection, he/she applied the brakes so he/she would not hit the vehicle. He/She documented the resident gasped behind him/her. When he/she looked in the rearview mirror he/she saw the resident's mouth agape before the resident fell over his/her seatbelt. He/She pulled the van over to assess the resident. He/She documented the resident was silent and non-responsive so he/she called EMS, at which time the resident began to moan softly before responding to questions. Driver A documented the resident initially refused to go to the hospital, but after talking with EMS the resident agreed to go to the hospital for further assessment. Review of the hospital emergency department records, dated 08/07/2024 at 10:58 A.M., showed the patient was being transported from dialysis and was sitting in his/her wheelchair which was secured, however the patient was not strapped into the wheelchair. The transport vehicle slammed on the brakes causing the patient to fall forward onto his/her forehead. The patient reports that he/she is having pain between his/her shoulder blades, left shoulder, and in his/her right hip. He/She denies that he/she lost consciousness. He/She denies feeling dizzy and denies any nausea, vomiting, or headache. He/She states it hurts in his/her back whenever he/she takes a deep breath or moves any type of way. Review showed the patient had multiple fractures including T spine compression fractures (happens when one or more bones in the spine weaken and crumble), bilateral femur fractures (a broken bone in the long bone of the leg), and humerus fracture (a broken bone in the upper arm). During an interview on 08/12/2024 at 9:28 A.M., Driver A said he/she went to the dialysis clinic to pick up the resident. Driver A said he/she fastened the chair restraints and fastened the waist buckle. He/She said a shoulder strap was not fastened because the resident did not like it on. Driver A said he/she approached an intersection and the car in front of them hit the brakes. Driver said he/she was going 20 miles per hour and hit the brakes to keep from hitting the vehicle in front them. Driver A said the resident went over the waist belt to the floorboard. Driver A said he/she pulled the van over and called EMS and the facility. Driver A said a police officer did stop, but did not speak with him/her. Driver A said when he/she was trained he/she did not use the manufacturer's Device User Instructions Manual. Driver A said a former employee provided a demonstration in the van, but did not tell him/her about using the shoulder strap. During an interview on 08/12/24 at 8:10 P.M., the administrator said facility staff had a driver's license review, van training, and a van loading competency before transporting residents. The administrator said he/she could not locate the original training documentation for Driver A. The administrator said staff were not monitoring to ensure the transport drivers were securing residents properly in the van prior to transport. MO00240339

Based on observation and interview, the facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 83. 1. Review of the facility's Dishwasher Temperature policy, reviewed January 2024, showed manufacturer's instructions shall be followed for machine washing and sanitizing. For low temperature dishwashers with chemical sanitation the washer temperature shall be 120 degrees Fahrenheit (F). Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes. Review showed facility records did not contain a dishwasher temperature log for the month of June 2024. Observation showed a poster labeled General Operating Instructions, hung on the clean side of the dishwasher. The poster instructed users to report to supervisor if water temperature was less than 120 degrees F. Observation on 06/25/24 at 10:04 A.M., showed Dietary Aide (DA) F washed two racks of soiled kitchen wares in the mechanical dishwasher. Observation showed the DA did not check the temperature of the dishwasher during the cycles. Observation showed the gauge of the dishwasher indicated the water temperature during the wash and rinse cycles as 102 degrees F. Observation showed when the dishwasher cycle finished, the DA removed the rack of wares to the clean side of the dishwasher to dry and then loaded another rack of soiled dishes into the machine to wash. Observation of the manufacturer's instruction label on the dishwasher showed direction for the minimum water temperature to be 120 degrees F. Observation on 06/25/24 at 10:22 A.M., showed DA F ran one rack of soiled wares through the dishwasher and removed a rack of clean dishes which were placed on drying racks. Observation showed the dishwasher indicated a temperature of 110 degrees F during the wash and rinse cycles. Observation on 06/25/24 at 10:41 A.M., showed DA F washed two racks of soiled kitchen wares in the dishwasher and removed both racks to the clean side of the dishwasher to dry. Observation showed the gauge of the dishwasher indicated the water temperature during the wash and rinse cycles was 106 degrees F. Observation on 06/26/24 at 12:27 P.M., showed the DS ran the dishwasher through three consecutive wash/rinse cycles. Observation showed the gauge of the dishwasher indicated the water temperature after the third wash/rinse cycle was 108 dF. During an interview on 06/25/24 at 10:25 A.M., DA F said sometimes he/she checked the dishwasher temperature. DA F said he/she did not check the dishwasher temperature on this day and he/she did not know if anyone else had. During an interview on 06/25/24 at 12:29 P.M., DA G said the dish machine temperature should be between 100 and 200 degrees, but any temperature over 100 is okay. DA G said he/she did not look at the dishwasher temperatures but the water should be hot enough after two cycles. During an interview on 06/25/24 at 12:26 P.M., the Dietary Supervisor (DS) said he/she was responsible for making sure the dishwasher worked properly and the dishwasher usually took three cycles to get to the correct temperature. The DS said the dishwasher temperature should be at least 120 degrees F. The DS said he/she did not know what happened to the June 2024 temperature log or the last time the machine temperature was checked. During an interview on 06/27/24 at 1:10 P.M., the administrator said he/she and the DS were responsible for making sure kitchen equipment worked properly. The administrator said he/she could not remember the correct temperature for the dishwasher and was not aware of any issues before this survey.

Based on observation, interview, and record review, facility staff failed to ensure resident's personal medical information was protected for two residents (Resident #9 and #281) of 11 sampled residents when staff left the Electronic Medical Information (EMR) open and unattended in a public area, posted care instructions for residents in a public hallway and failed to provide personal privacy for . The facility census was 83. 1. Review of the facility's Resident Rights policy, dated 09/01/22, showed the resident has a right to personal privacy and confidentiality of his or her personal and medical records. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. 2. Observation on 06/27/24 at 9:36 A.M., showed a tablet opened and unattended on the nurses' desk with resident personal information visible to visitors, residents and staff. During an interview on 06/28/24 at 9:33 A.M., Certified Nursing Assistant (CNA) D said if staff steps away from a screen, the screen should be cleared in order to ensure privacy. If any staff passes an open an unattended screen, they should close it. During an interview at 9:36 A.M., the Director of Nursing (DON) said the tablet should be closed down when unattended to provide privacy. He/She did not know why it was left open. During an interview on 06/28/24 at 9:46 A.M., Licensed Practical Nurse (LPN) C said the screen with the EMR should be cleared before staff steps away because the resident's private medical information would be visible. If staff passed by the open screen, staff should close it. During an interview on 06/28/24 at 10:59 A.M., the Corporate Quality Assurance representative said if staff works on the medical record, the record must be closed with staff leaves the screen. If staff passed an open screen, they should close the screen. Closing the screen is necessary to protect a resident's medical confidentiality. 3. Observation on 06/25/24 at 11:27 A.M ., 6/26/24 at 2:15 P.M., and 06/27/24 at 11:46 A.M., showed the 300 hallway CNA station contained a posted sign visible to visitors, residents and staff contained the following resident information: -Nine resident names requested certain care givers only; -11 resident names used adaptive equipment and the type of equipment used; a sign indicating -A resident get up list with residents names listed for 100 hallway, 200 hallway, 300 hallway and 400 hallway; -Five resident names to sit at the assist table; -Five resident names to sit at the cue table; -Fiveresident names on thickened liquids and the consistency of the liquids; -The shower schedule for all hallways to include resident names and room numbers. 4. Observation on 06/25/24 at 3:02 P.M., showed the ice chest on the 300 hallway with a laminated list of resident names and their current diet orders. 5. During an interview on 06/28/24 at 8:55 A.M., Registered Nurse (RN) I said he/she is not aware of any resident specific information posted in the facility but would expect it to be hidden from visitors and residents to protect their privacy and dignity. He/She said all staff are responsible to ensure resident data is protected. During an interview on 06/28/24 at 10:58 A.M., the Corporate Quality Control staff said any data posted should not include resident names to protect the residents privacy. During an interview on 06/28/24 at 11:32 A.M., the administrator said resident information should be posted in their rooms and not visible to others to protect the residents privacy. He/She said he/she should have paid attention to those areas but did not. 6. Observation on 06/26/24 at 10:29 A.M., showed Resident #9 in bed without pants on and a shirt pulled up to his/her chest. The door to the room open and the resident could be seen from the hallway. Observation on 06/27/24 at 2:59 P.M., showed the resident in bed without pants on and was exposed from the chest down. The door to the room open and the resident could be seen from the hallway. Observation showed staff walked by the resident room and did not assist the residents. 7. Observation on 06/25/24 at 10:33 A.M., showed Resident #281 in bed with legs and bare chest exposed. The door to the room open and the resident could be seen from the hallway. The privacy curtain laid on the floor next to the bed. Observation showed staff walked by the resident room and did not assist the resident. Observation on 06/26/24 at 8:20 A.M., showed the resident in bed and did not have a privacy curtain available to provide privacy to the hallway. Observation showed staff walked by the resident room and did not assist the resident. During an interview on 06/28/24 at 11:35 A.M., the administrator said he/she was not aware the curtain was down for the resident, but would expect all residents to have a privacy curtain around their bed. The administrator said when curtains are taken down to clean them, an alternate curtain should be hung in its place. 8. During an interview on 06/28/24 at 8:05 A.M., CNA A said residents shouldn't be exposed to the hall. The door should be closed, or the resident covered back up. It would also be possible to pull the privacy curtain for the resident. During an interview on 06/28/24 at 8:16 A.M., CNA B said residents should not be exposed to the hallway if they are undressed. Staff could and should cover them with a bed sheet. During an interview on 06/28/24 at 8:23 A.M., LPN C said residents exposed to the hallway should not be left nude and instead should have the privacy curtain pulled or be covered with a blanket. During an interview on 06/28/24 at 11:05 A.M., the Director of Nursing said staff should provide privacy if a resident is exposed to the public. If a door can't be shut, staff can pull the privacy curtain, dress the resident, or cover them with a blanket. During an interview on 06/28/24 at 11:35 A.M., the administrator said staff should enter the room to pull the privacy curtain if a resident is exposed to the hall or open windows. 42484 43327

42484 Based on interview and record review, staff failed to maintain professional standards of care when staff failed to document follow-up neurological assessments after a fall for four (Resident #47, #60, #73, and #258) of four sampled residents. Facility staff failed to follow physician orders for two (Resident #21and #73) out of nine residents who required tube feedings and/or skin assessments, failed to complete weekly weights for one (Resident #21) of four newly admitted residents. Staff failed to clarify a medication order and obtain lab values for one (Resident #5) of one resident who received Lithium (mood stablizer). The facility census was 83. 1. Review of the facility's Incidents and Accidents Policy, reviewed/revised 09/01/22, showed it is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or alleged involve a resident: -Falls required an incident/accident report; -In the event of an unwitnessed fall or blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner; -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 2. Review of Resident #47's Admission Minimum Data Set (MDS), federally mandated assessment, dated 04/01/24, showed staff assessed the resident as follows: -Cognitively intact; -Did not have falls since prior assessment and/or admission; -Required partial to moderate assistance transfers and to walk 10 feet; -Diagnoses of a stroke. Review of the resident's medical record, dated 04/20/24, and 05/28/24, showed staff documented the resident had an unwitnessed fall on 04/20/24, and 05/28/24. Review showed the medical record did not contain documentation staff completed neurological checks. 3. Review of Resident #60's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Had one non-injury fall since prior assessment and/or admission; -Required substantial to maximal assistance for personal assistance, bed mobility transfers, upper and lower body dressing; -Unable to walk; -Diagnosis of a stroke. Review of the resident's medical record showed staff documented the resident with an unwitnessed fall on 06/07/24. Review showed the medical record did not contain documentation staff completed neurological checks. 4. Review of Resident #73's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Had one non-injury fall since prior assessment and/or admission; -Required partial to moderate assistance for transfers and walking 10 feet or more. Review of the resident's medical record showed staff documented on 05/21/24 an unwitnessed fall and the resident reported a fall on 05/24/24. Review showed the medical record did not contain documentation staff completed neurological checks. 5. Review of Resident #258's Admission MDS, dated [DATE], showed staff assessed the resident as follows: - Cognitively impaired; - Did not contain assessment of functional ability documented; - Diagnosis of heart failure. Review of the resident's medical record showed staff documented on 06/13/24 the resident with an unwitnessed fall on 06/13/24. Review showed the medical record did not contain documentation staff completed neurological checks. 6. During an interview on 06/28/24 at 9:45 A.M., Licensed Practical Nurse (LPN) C said neurological checks should be done if a resident hits their head or has an unwitnessed fall. If the neuro checks are not done, nursing could miss a brain bleed. After a fall the charge nurse should check the resident from head to toe. If the fall is unwitnessed, and if the resident has impaired cognition, neurological checks should be done according to a fall protocol and scanned into the electronic medical record. During an interview on 06/28/24 at 10:59 A.M., the Director of Nursing (DON) said if a resident has an unwitnessed fall, the resident needs neurological checks every 15 minutes for a certain amount of time, and then hourly after that. If the checks are not done, the resident could suffer a serious brain injury. The charge nurse is responsible for the assessments and follow up. During an interview on 06/28/24 at 11:29 A.M., the administrator said if a resident has an unwitnessed fall or hits their head, the charge nurse should immediately do a full assessment to note if there is an injury, and after that do neurological checks for the next 72 hours. 7. Review of the facility's Medication Administration policy, reviewed/revised 09/01/22, showed medications are administered as ordered by the physician and in accordance with professional standards of practice. Review of the facility's Medical Provider Order policy, reviewed/revised 04/07/22, showed staff are instructed to: -Follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -Orders should be reviewed prior to administration of medication to validate the order contains all required elements. -Orders should be reviewed prior to administration of medication to validate the order contains all required elements. -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. -The policy did not address direction of standard facility orders. Review of the facility's Weight Monitoring Policy, reviewed/revised 01/09/22, showed staff are instructed to: -Develop a weight monitoring schedule upon admission; -Newly admitted residents - monitor weight weekly for four weeks. 8. Review of Resident #21's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent for eating; -Received 51% of more of his/her nutrition from a feeding tube; -Received 510 cubic centimeters ((cc) a measure of volume in the metric system) average fluid intake from the tube feeding. Review of Resident #21's medical record showed: -admitted [DATE]; -Diagnosis of Malignant neoplasm (cancer) of the lower third of the esophagus; -Severe protein-calorie malnutrition; -Did not contain an order for weights: -Did not conatin doucumentation of weekly weights for four weeks. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed staff are instructed to administer: -Gastric tube 20 milliliter (mL) flush four times a day; -Glucema (gastric tube feeding) 1.2 give 250 mL six times a day; -Nutren 1.5. Give two cartons at breakfast, lunch and dinner via g-tube with meals for esophageal cancer. Review of the resident's Medication Administration Record (MAR), dated may 2024 and May 2024, showed staff did not document the resident recieved: -Two cartons of Nutren for one meal on 06/20/24; -A dose of Glucema on 05/24/24 and 05/29/24; -A 200 mL flush on 05/04/24, 06/04/24, 06/05/24, 06/06/24, 06/07/24, 06/11/24, 06/14/24 and 06/25/24. During an interview on 06/28/24 at 9:45 A.M., LPN C said weights should be done on new residents weekly for four weeks unless the physician orders them more frequently. If the charge nurse notices the physician orders do not have an order for weights, the physician should be called to get an order for weights. The orders would be a part of the TAR and if there are blanks in the TAR, it means the resident did not receive the treatment. LPN C said all tube feedings are important to maintain the resident's weight. The missing feedings were not done, but may have been omitted because the resident was out of the building and it was not documented properly. During an interview on 06/28/24 at 9:55 A.M., the dietician said the resident should be weighed weekly for four weeks and then monthly. The dietician said tube feedings were important for the resident to maintain weight. During an interview on 06/28/24 at 10:59 A.M., the DON said residents should be weighed once a week for four weeks and then monthly. The DON said the orders should be placed in the POS, and if they were missing, the charge nurse should assure the orders for weights are obtained. During an interview on 06/28/24 at 11:29 A.M., the administrator said it was policy to weigh a newly admitted resident once a week for four weeks. He/She said the resident should have been weighed four times in the first month the resident was at the facility. The administrator said the weights should be documented, and if not documented, it did not happen. 9. Review of Resident #73's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -High risk of pressure ulcers; -One Stage II pressure ulcer (the sore has broken through the top layer of the skin and part of the layer below). Review of the resident's POS, dated June 2024, showed an order, dated 05/15/24, to complete a weekly skin assessment every Wednesday on the evening shift. Review of the resident's medical record showed staff did not document a weekly skin assessment for the week of 06/02/24 and 06/17/24. 10. Review of Resident #5's Admission, MDS dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for eating; -Complained of pain and difficulty swallowing; -Used a feeding tube and received greater than 51 percent calories and average fluid intake through the tube; -Diagnosis of stroke and aphagia (difficulty with communication). Review of the resident's POS, dated June 2024, showed the physician directed staff to administer -Bisacodyl Delayed-release (for constipation) 5 mg by mouth daily; -Docusate Sodium (for constipation) liquid, 50 mg per 5 milliliters (ml), give 5 ml by mouth daily at bedtime; -Ondansetron (for nausea) 4 mg by mouth every eight hours as needed for nausea and/or vomiting; -Nothing by mouth; -Carbidopa-levodopa 25/100 (for symptoms of shaking and tremors) two tablets by mouth four times a day; -Lorazepam (an antianxiety medication) 50 mg by mouth every twelve hours. Review of the resident's care plan, dated 06/25/24, showed staff assessed the resident required a feeding tube, to have nothing by mouth and to administer medication as ordered. During an interview on 06/25/24 at 03:10 P.M., the resident said he/she does not receive any medications by mouth. He/She said all medication and food go through his/her feeding tube. During an interview on 06/28/24 at 08:55 A.M., Registered Nurse (RN) I said if a resident is to have nothing by mouth, then they are not to receive anything by mouth or risk aspiration (inhaling of substance into the lungs). He/She said he/she was not aware of the conflict with the resident but would expect staff to clarify the order before administering it. He/She said the nurse accepting the order should clarify the medication with the physician to include the route. During an interview on 06/28/24 at 10:58 A.M., the DON said chart audits should be done monthly by the Interdisciplinary team (IDT) and the pharmacist. He/She said if a resident is to have nothing by mouth, then they should not receive medication by mouth and did not know why the resident had orders stating by mouth. 11. Review of Resident #45's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of anxiety, depression, and bipolar disease. Review of the resident's POS, dated June 2024 showed an order directed staff to administer Lithium Carbonate 00 mg daily at bedtime. Review showed the POS did not contain an order for lithium level. During an interview on 06/28/24 at 08:53 A.M., RN I said residents should have blood work periodically when they take certain medications like lithium. He/She said lithium can be toxic to some people if not monitored. He/She did not know if the resident has blood work for his/her lithium use but should have and would check into it. He/She said the person accepting the order should double check for blood work to correlate with the drug use. During an interview on 06/28/24 at 11:32 A.M., the administrator said he/she is not a nurse but would expect that if the drug required blood work that an order is obtained by nursing. He/She said there are monthly audits completed during the IDT meeting and charts are reviewed and updated at that time. He/She was not sure why there was no blood work. 43327

Based on observation, interview, and record review, facility staff failed to provide bathing and personal hygiene for six (Resident #9, #17, #21, #32, #46, and #47) out of twelve sampled dependent residents . The facility census was 83. 1. Review of the facility's Resident Showers policy, dated 2021, showed it is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. The Certified Nurse Aid (CNA) will assess the skin for any changes while performing bathing and inform the nurse of any changes. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/15/24, showed staff assessed the resident as: -Moderate cognitive impairment; -Total dependence of staff with bathing; -Moderate assistance of staff with personal hygiene -Diagnoses Alzheimer's disease. Review of the resident's care plan, dated 05/22/24, showed staff documented the resident required extensive assist with bathing/showering twice weekly and as needed. Review showed the resident required extensive assist with one staff for personal hygiene and oral care. Review of the resident's care summary, dated 04/01/24 through 06/27/24, showed staff documented the resident received a shower on 04/09/24, 04/13/24, 04/21/24, 04/28/24, 05/09/24, 05/18/24, 05/30/24, 06/05/24, and 06/08/24. Observation on 06/26/24 at 9:03 A.M., showed the resident hair greasy and disheveled. Observation on 06/27/24 at 2:57 P.M., showed the resident in bed with greasy, disheveled hair and with a strong odor of urine. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Showering moderate assist; -Personal hygiene supervision; -Diagnosis of Alzheimer's, asthma, and hypertension. Review of the resident's care plan, dated 06/24/24, showed staff were directed as follows: -Requires supervision with ADL's; -Showering requires one staff assistance two times weekly and as necessary; -Personal hygiene supervision. Review of the resident's care summary, dated 04/01/24 through 06/27/24, showed staff documented the resident received a shower on 04/09/24, 05/23/24, and 06/12/24. Observation on 06/26/24 at 9:07 A.M., showed the resident with disheveled hair and strong body odor dressed in stained jeans. Observation on 06/27/24 at 2:53 P.M., showed the resident with a strong body odor and dressed in stained jeans. During an interview on 06/27/24 at 2:55 P.M., the resident said he/she had not received a shower in over two weeks and did not like to go that long without showering. 4. Review of Resident #21's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Showering maximal assistance; -Personal hygiene moderate assistance; -Diagnoses of cancer and arthritis, Review of the resident's care plan, dated 06/10/24, showed staff were directed as follows: -Requires moderate assistance with ADL's; -Showering extensive assist of one to two staff; -Personal hygiene requires moderate assist. Review of the resident's care summary, dated 05/16/24 through 06/27/24, showed staff documented the resident received one shower on 06/27/24. Observation on 06/25/24 at 10:58 A.M., showed the resident with greasy hair and a greasy sheen to the skin with body odor present. Observation on 06/26/24 at 08:38 A.M., showed the resident with greasy hair and a greasy sheen to the skin with body odor present. During an interview on 06/25/24 at 10:58 A.M., the resident said he/she had not had a shower for several weeks and did not like feeling unclean. 5. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Showering dependent; -Personal hygiene moderate assistance; -Diagnosis of renal failure, diabetes mellitus, stroke, hemiplegia, seizure disorder, and depression. Review of the resident's care plan, dated 06/04/24, showed staff were directed as follows; -Requires extensive assistance with ADL's; -Showering requires assist of one to two staff; -Personal hygiene requires extensive assist. Review of the resident's care summary, dated 04/01/24 through 06/27/24, showed staff documented the resident received a shower on 04/10/24, 04/12/24, 04/28/24, 05/28/24, and 06/11/24. Observation on 06/25/24 at 3:00 P.M., showed the resident had greasy disheveled appearing hair and skin. Observation on 06/27/24 at 3:02 P.M., showed the resident in the dining room with greasy disheveled hair pulled back in a ponytail. The resident's skin had a greasy sheen on it. During an interview on 06/25/24 at 3:15 P.M., the resident said his/her hair gets greasy and he/she does not feel clean which is important. 6. Review of Resident #46's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Showering dependent; -Personal hygiene moderate assistance; -Diagnosis of heart failure, arthritis, urinary tract infection, Alzheimer's Disease, and a stroke. Review of the residents care plan, dated 03/13/24, showed staff were directed as follows: -Requires extensive assistance with ADL's; -Showering requires assist of one to two staff; -Personal hygiene requires extensive assist. Review of the resident's care summary, dated 04/01/24 through 06/27/24, showed staff documented the resident received a shower on 04/20/24, 05/09/24, 05/30/24, and 06/14/24. Observation on 06/25/24 at 03:09 P.M., showed the resident with greasy hair wearing blue shorts and a blue and white Hawaiian shirt. Observation on 06/27/24 at 03:20 P.M., showed the resident with greasy hair wearing blue shorts and a blue and white Hawaiian shirt. During an interview on 06/26/24 at 10:29 A.M., the resident said he/she was not getting showers as often as he/she would like to have them. The resident said showers should be every other day, but that doesn't happen. 7. Review of Resident #47's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Showering maximal assistance; -Personal hygiene moderate assistance; -Diagnosis of heart failure, respiratory failure, pneumonia, urinary tract infection, arthritis, urinary tract infection, stroke, anxiety and depression. Review of the resident's care plan, dated 05/22/24, showed staff were directed as follows; -Requires moderate assistance with ADL's; -Showering requires moderate to maximal assist; -Personal hygiene requires supervision to moderate assist. Review of the resident's care summary, dated 04/01/24 through 06/27/24, showed staff documented the resident received a shower on 06/13/24. Observation on 06/25/24 at 11:23 A.M., showed the resident with a dull greasy sheen on the skin, and disheveled greasy hair, appearing almost wet. Observation on 06/26/24 at 09:39 A.M., showed the resident with a dull greasy sheen on the skin, and disheveled greasy hair, appearing wet. Observation on 06/28/24 at 9:33 A.M., showed the resident with a dull greasy sheen on the skin, and disheveled greasy hair, appearing almost wet. During an interview on 06/25/24 at 11:23 A.M., the resident said showers were rare and residents had to request them. The resident said he/she was reluctant to request a shower because staff was too busy. 8. During an interview on 06/28/24 at 8:01 A.M., CNA A said there is a schedule for showers that we look at to see if any showers are missed. The showers are not getting done because we don't have enough staff. Personal hygiene should be done before a resident leaves their room. During an interview on 06/28/24 at 8:15 A.M., CNA B said showers should be done two or three times a week. Personal hygiene should be done before a resident leaves the room. During an interview on 06/28/24 at 8:25 A.M., Licensed Practical Nurse (LPN) C said showers should be done twice a week or more or more if requested. He/She said staff are not doing a good job at this right now. All personal hygiene should be done for dependent residents before they leave their room. During an interview on 06/28/24 at 10:58 A.M., the Director of Nursing said showers should be done twice a week per policy unless otherwise requested. Personal hygiene and showers should be documented in the residents electronic health record and on paper skin assessments. He/She thinks the showers are being done but not documented. During an interview on 06/28/24 at 11:29 A.M., the Administrator said we have one shower aide and need two. Showers should be documented in the residents' electronic health record and on skin assessment sheet. He/She said some residents show as not receiving showers and they should be clean and odor free. MO00237780 42484 43327

Based on interview and record review, the facility staff failed to follow infection control guidelines by allowing two staff members, Licensed Practical Nurse (LPN) F and Social Services Director (SSD), to work in the facility with COVID negative residents after testing positive for Covid-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The facility census was 82. The administrator was notified on 8/12/22 at 12:36 P.M., of an Immediate Jeopardy (IJ) which began on 7/25/22. The IJ was removed on 8/12/22 as confirmed by surveyor onsite verification. 1. Review of the facility's Return to Work Criteria for Healthcare Personnel (HCP) with confirmed or suspected COVID-19 Infection policy, revised 2/4/22, showed work restrictions for HCP with SARS-COV-2, vaccination status up to date and not up to date showed: -Conventional staffing: 10 days or 7 days with negative test, if symptomatic or mild to moderate symptoms (with improving symptoms); -Contingency staffing: 5 days with/without negative test, if symptomatic or mild to moderate symptoms (with improving symptoms); -Crisis staffing: No work restriction, with prioritization considerations (e.g. types of patients they care for). Review of the CDC's Contingency Capacity Strategies to Mitigate Staffing Shortages, updated 01/21/2022, showed the following: Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: -At least 5 days have passed since symptoms first appeared (day 0), and - At least 24 hours have passed since last fever without the use of fever-reducing medications, and -Symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative antigen test or nucleic acid amplification test (NAAT). HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: -At least 5 days have passed since the date of their first positive viral test (day 0). Healthcare facilities may choose to confirm resolution of infection with a negative antigen test or NAAT. Considerations for determining which HCP should be prioritized for this option include: -The type of HCP shortages that need to be addressed. -Where individual HCP are in the course of their illness (e.g., viral shedding is likely higher earlier in the course of illness). -The types of symptoms they are experiencing (e.g., persistent fever, cough). -Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment? -The type of patients they care for (e.g., consider patient care only with patients known or suspected to have SARS-CoV-2 infection rather than patients who are immunocompromised). If HCP are requested to return to work before meeting all conventional Return to Work Criteria, they should still adhere to the recommendations described below. -They should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen. Until they meet the conventional return to work criteria: -They should wear a respirator or well-fitting facemask at all times, even when they are in non-patient care areas such as breakrooms. -If they must remove their respirator or well-fitting facemask, for example, in order to eat or drink, they should separate themselves from others. -To the extent possible, they should practice physical distancing from others. -Patients (if tolerated) should wear well-fitting source control while interacting with these HCP. Review of the facility's staffing sheet dated, 7/25/22 and 7/26/22, showed LPN F as the only charge nurse on the main unit. 2. During an interview on 7/27/22 at 9:09 A M., the Administrator said two staff members had tested positive at the facility for COVID-19 on Monday, 7/25/22. The social services director (SSD) who is in his/her office with the door closed and wearing an N95 respirator and the nightshift charge nurse, LPN F who is asymptomatic and wearing an N95 respirator. The administrator said no residents have tested positive for COVID-19. During an interview on 7/27/22 at 9:09 A.M., the Director of Nursing (DON) said he/she was aware of the new CDC guidelines and stated staff can work with a positive COVID-19 test result, wearing an N-95. He/She said LPN F worked the last two night shifts. The DON said the facility is only testing staff who are unvaccinated twice weekly for routine testing. The DON said he/she considered the facility in contingency capacity, possible crisis, but they only had one nursing staff test positive for COVID. During an interview on 7/27/22 at 9:30 A.M., the infection preventionist said the SSD is COVID-19 positive and is in the building but is sticking to his/her office. He/She said the DON and Assistant Director of Nursing (ADON) keep track of the staff positives. He/She saw LPN F in the building on Monday (7/25/22) and was not aware LPN F was COVID-19 positive. He/She said his/her understanding whether vaccinated or not, the positive employee could not come back to work for five days. During an interview on 7/27/22 at 9:37 A.M., the ADON said if there are staffing issues, staff with COVID-19 can work with a N95 respirator. He/She said the facility does not have a system in place to track staff that are COVID-19 positive. During an interview on 7/27/22 at 10:54 P.M., the administrator and ADON said the facility was previously utilizing agency staffing and were fully staffed, but corporate will no longer allow the facility to use agency staffing. During an interview on 7/27/22 at 2:25 P.M., the administrator and training administrator said only one LPN has COVID-19. They do not consider themselves in crisis staffing but in contingency staffing, because the facility is short on staff in general, but this is not due to COVID-19. There is no policy on staffing with COVID-19, there is just an impromptu Quality Assurance and Performance Improvement (QAPI) on infection control when the problem arises. During an interview on 7/27/22 at 2:58 P.M., the administrator said if the COVID-19 positive LPN would have been symptomatic, he/she would have pulled the DON, ADON or infection preventionist to the floor for nurse coverage. There are no floor nurses from days to pull to nights. During an interview on 7/27/22 at 2:25 P.M., the training administrator said on Monday, 7/25/22, when LPN F tested positive, the nurse management team had all worked previously and could not do an overnight shift. He/She felt it was a higher risk situation to pull nurse management from their positions. He/She said the way the CDC guidance reads is in a contingency staffing scenario there are no restrictions (contingency staffing allows for positive staff to return to work five days after testing positive with improving symptoms). During a telephone interview on 7/28/22 at 9:39 A.M., the SSD said he/she tested positive for COVID-19 on Monday 7/25/22 after he/she started having symptoms that morning. He/She said after the first day, he/she was asymptomatic. He/She was in the office on Wednesday 7/27/22 with a N95 respirator on and he/she said there was minimal contact with the ADON. During an interview on 7/29/22 at 2:42 P.M., LPN F said he/she tested positive twice on Monday 7/25/22 and the facility had him/her work on Monday 7/25/22 and Tuesday 7/26/22. He/She said other positive staff members have been sent home and not allowed to work, but he/she did not know their vaccination status or if they were asymptomatic. He/She said he/she wanted to continue to work. He/She said agency was kicked out and the facility is now short staffed. During an interview on 7/28/22 at 11:18 A.M., Certified Nursing Assistant (CNA) C said he/she worked with LPN F on Monday night, 7/25/22. During an interview on 8/10/22 at 1:43 P.M., the DON said nightshift charge nurses are in charge of treatments, creams, assessments and tube feeds, he/she said the facility has five residents that require tube feeds. He/She said the nightshift charge nurse would also be responsible for some A.M. medications, and believes that there are around ten residents that received medications from the nightshift charge nurse. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, 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. 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 E 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). MO00204549

Based on observation, interview and record review, facility staff failed to maintain the proper function of individual and centralized heating equipment in the facility and provide prompt repair to the equipment to provide a safe and comfortable environment for residents. The facility census was 73. The administrator was notified on 11/17/21 at 5:58 P.M. of an Immediate Jeopardy which began on 11/17/21. The IJ was removed on 11/24/21, as confirmed by surveyor onsite verification. 1. Review of the facility's Maintenance Service policy dated December 2009, showed: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. -Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards. d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. Review of the facility's Inspection of Heat/Air-Conditioning Systems dated May 2008, showed: -Our facility's heating and air-condition system shall be inspected at least semi-annually. -Prior to the beginning of each heating/cooling season our facility's heating and air conditioning systems shall be inspected for possible gas leaks, lines that have burst, etc. -The Maintenance Department shall be responsible for such inspections, and shall have the authority to use local gas companies and/or approved repairmen to assist in making such inspection when assistance is necessary. Review of the facility's physical emergency preparedness manual, dated 10/24/18, showed the manual did not contain documentation of the facility's policy and procedures in the event of extreme temperatures or loss of heat. Review of the weather underground official local weather for the facility's location, showed the projected daily low temperatures for the dates of 11/17/21 through 11/24/21 as: -11/17/21 34 degrees Fahrenheit; -11/18/21 26 degrees Fahrenheit; -11/19/21 38 degrees Fahrenheit; -11/20/21 44 degrees Fahrenheit; -11/21/21 29 degrees Fahrenheit; -11/22/21 28 degrees Fahrenheit; -11/23/21 41 degrees Fahrenheit; -11/24/21 38 degrees Fahrenheit. Observations on 11/17/21 during the Life Safety Code inspection, showed the following rooms did not contain functional packaged terminal air conditioner (PTAC) units (a type of self-contained heating and air conditioning system installed into the wall of a room) to supply heat to the room: -unoccupied resident room 105; -resident room 108 occupied by one resident; -the common lounge area on the 100 hall; -the common shower room on the 100 hall; -unoccupied resident room 208; -unoccupied resident room 210; -resident room 410 occupied by two residents. During an interview on 11/17/21 at 8:45 A.M., the Maintenance Director said resident room 105 had been used for storage since the PTAC unit broke down in July 2021. The facility currently needed eight new PTAC units to replace broken ones, but he/she could not get any more units as the appliance company they order the units from stopped letting them order due to non-payment of past due balance and the company would not provide the funds to buy new ones. He/she had tried to fix the units with the supplies he/she had in-house as he/she had not been able to purchase maintenance supplies in four months and he/she could not repair them. The previous administrator tried to order more units from the facility's medical supply company that they are still able to order from, but the company did not have the units. Review of the stack of check requests forms and invoices provided by the Business Office Manager on 11/17/21 and identified as the records sent to the CEO on 11/02/21, showed the records included invoices from the appliance company dated 10/23/19 which billed the facility $1404.35 for PTAC units, 11/18/19 which billed the facility $1404.35 for PTAC units and 12/27/19 which billed the facility $774.38 for a PTAC unit. During an interview on 11/17/21 at 3:30 P.M., Resident #28 said a fuse was blown and the heater in his/her room did not work. The room did not get cold as long as he/she kept the room door open. During an interview on 11/17/21 at 3:30 P.M., Resident #39 said the heater in his/her room is broken and he/she believed staff were working on it, but they are just not very quick about it. He/she is cold in the room at night. During an interview on 11/17/21 at 3:35 P.M., the Maintenance Director said he/she did not know any residents were in the rooms with the non-functional PTAC units. He/she tells the staff responsible to assign residents rooms which rooms do not have functional PTAC units so they do not put residents in those rooms. During an interview on 11/17/21 at 5:58 P.M., the administrator said he/she knew some rooms did not have functional PTAC units, but he/she had been told those rooms were not occupied by residents. Observation on 11/18/21 from 7:45 A.M. to 8:15 A.M., showed the temperatures of rooms without functional PTAC units measured that below 71 degrees Fahrenheit when tested from the center of the room with a calibrated metal stem-type thermometer as follows: -resident room 105 measured 67.1 degrees Fahrenheit; -resident room 108 measured 69.1 degrees Fahrenheit; -the 100 hall common shower room measured 67.1 degrees Fahrenheit; -resident room 410 measured 70.3 degrees Fahrenheit. During an interview on 11/17/21 at 12:50 P.M., the Maintenance Director said they were having problems with the air conditioning in 2019 and he/she had the technician from their heating, air condition, and ventilation (HVAC) company come look at the units around September 2019. The technician worked on one of the units and gave a bid to replace all five of the HVAC units. He/she gave the bid to the administrator at that time, who submitted the bid to corporate staff and corporate staff delayed starting the repairs. The administrator left around December 2019 or January 2020 at which time he/she spoke to Administrator KK about the repairs. Administrator KK told him/her that the corporation had changed their mind about their regular HVAC company doing the work and hired a different company. The new company came in to replace the HVAC units around the spring of 2020. It took the company about three weeks to install the new units and after they left, the 100, 300 and 400 halls would not stay cool and the 200 hall would stay cool, but the unit leaked so they would have to turn it off and on. They had the new company come back a couple of times to fix the units, but they eventually were not allowed back into the building. He/she then hired their regular HVAC company around July or August of 2020 to work on the units because the air conditioning would not work. When that technician inspected the units, he/she said they had not been installed properly and the duct work had not been reconnected so there was air blowing, but it was not going anywhere. The technician began work to repair the issues around August 2020 and when he/she started to hook up the heat, he/she said something was not right with the unit and it needed to be redone. Administrator KK gave the okay for the technician to do the work and he/she started on the 400 hall, but then had to work on the kitchen unit. The technician would return to the facility for emergency repairs, but then he/she stopped working at the facility and stopped returning his/her calls. The last time the technician was in the facility was May 2021. Then sometime around June 2021, the company came and told Administrator KK that they would not do any more work because they had not been paid their past due balance. He/she also made corporate maintenance staff aware of the situation at that time. Administrator KK left around the end of August to beginning of September 2021 and then he/she talked to the new administrator about it, but they were only at the facility for about a month. The Maintenance Director said he/she wrote out everything that needed to be fixed and why it had not been fixed and he/she gave it to Administrator MM who said he/she would work on it. He/she did not know exactly what Administrator MM did about the situation, but he/she said he/she spoke to corporate staff about it. Administrator MM left the faciity on [DATE] and he/she spoke to the current administrator about it and he/she said he/she would work on it. The Maintenance Director said to date, the heat for the central heat that supplied heat to the hallways and common areas on 100, 300 and 400 halls still did not work. During an interview on 11/17/21 at 1:45 P.M., the Business Office Manager said the company the corporation hired to install the new HVAC units, did not install the new units properly and they had tried multiple times to get them fixed. Their regular HVAC company, who they had come in to try and fix the units, stopped services because they had not been paid their past due balance. They have had problems with the corporate office paying the bills for services provided by the vendors. He/she sends emails every month regarding the outstanding bills and he/she most recently sent a stack of unpaid invoices to the corporation's chief executive office (CEO) on 11/02/21, which included the bill the HVAC company. Even though he/she sends the check request, the corporation does not pay the bills or does not pay them in full and he/she did not know why. The payment checks are sent by the corporate office. Review of facility operational financial records, which included emails, check requests forms and invoices provided by the Business Office Manager on 11/17/21, showed the records included: -an email from the business office manager to the corporation's chief executive officer (CEO) dated 04/28/20, in which the business office manager documented I sent this on 3/4/20 and was needing a check due to he/she had done the work 10/22/19 and was not paid and we needed him/her to come back. We now have large trash cans under leaks from the ceiling and he will not come out until paid and back in October when he was here he/she had given [former administrator] an estimate what it would cost to repair the air conditioner on each hall. The last 3 pages are the estimate he would like partial payment on this prior to doing the work. Review showed the CEO responded Approved to the business office manager. Further review showed an invoice from the HVAC company dated 10/22/19 which billed the facility for $764.45 for services provided and a late fee, as well as check request form dated 03/04/20 for $764.45 attached to the email. Further review of the email, showed a hand-written note which read a check was sent on 04/22/21 for $664.74 which was $99.71 less than the amount due; -an email from Administrator KK to the CEO dated 05/14/21 with the subject title FW: approve and no text written in the body of the email. Review showed the CEO responded back approved. Further review showed an estimate from a secondary company dated 05/02/20 for $22,000 to remove and replace four HVAC units; check request forms dated 05/06/20 for $22,000, 05/14/20 for $14,000 and 05/20/20 for $620; and a copy of a check for $620 attached the email; -an email from the business office manager to the CEO dated 06/08/20, in which the business office manager requested two checks which included one to the HVAC company for $1350 to replace a blower motor and belts on the 10 ton rooftop HVAC unit. Review showed the CEO responded approved. to the business office manager. Further review showed an estimate from the HVAC company dated 06/05/20 for $1350 for repair of the rooftop unit and a check request form dated 06/08/20 for $1350 attached to the email -an email from the business office manager to the CEO dated 08/17/20, in which the business office manager documented This is for the service performed and they need paid please. [Corporate maintenance staff] are here and they said they had spoken to you about all this. Review showed the CEO responded approved to the business office manager. Further review showed invoices from the HVAC company for services provided dated 07/07/20 for $903, 07/30/20 for $160, and 08/14/20 for $3861.72 as well as a check request form dated 08/17/20 for $4924.72 (the sum total of the three attached invoices). During a telephone interview on 11/17/21 at 2:25 P.M., the technician from the HVAC service provider said the facility contacted him/her in 2019 regarding issues with the air conditioning not cooling the facility. He/she went to the facility and conducted an assessment and provided the facility with an estimate for the needed repairs. He/she did not find reason for the HVAC units to be replaced at the time, but had mentioned that they were aging and would need to be replaced at some point. After he/she provided the estimate, he/she did not hear anything back from the facility about doing the repairs. The facility called him/her back to the facility in 2020 to make an assessment for needed repairs of the new HVAC units installed by another company that did not function properly and were leaking. He/she came to the facility and found that the new HVAC units were not installed properly which included the units not being installed level and gaps in the duct work. The gaps in the duct would have affected the heating of the building as the heated air would have been released through the gaps and not distributed throughout the facility in the duct work. The facility hired him/her to make the necessary repairs, but he/she did not complete the repairs and stopped providing services to the facility around August 2021 due to non-payment of services. He/she sent a member of the company to the facility with the outstanding bills which totaled over $5000 and told facility staff that they would no longer provide services until paid. The facility still had not paid the past due balance to date. During an interview on 11/18/21 at 2:00 P.M., the administrator said maintenance staff is responsible to monitor the heating units in the facility. If a PTAC unit is not functional in a resident's room, nursing staff should be made aware so that the resident can be moved to a room with a functional unit. If there is a problem with the heat, maintenance should notify the administrator and take immediate action. He/she did know there was a flow situation with the HVAC units, but no concerns with the facility temperature were ever expressed to him/her in the last five days that he/she had been administrator. He/she had heard when he/she started that some vendors had stopped services due to non-payment and he/she had reached out to the vendors and spoke to his/her boss to make him/her aware of the situation. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on record review and interview, the facility staff failed to ensure one of five sampled residents (Resident #1) was free from a significant medication error when the facility staff failed to transcribe a blood thinning medication to the resident's medication administration record (MAR) and administer the resident's medication for 14 days. The facility census was 63. The administrator was notified on 05/17/19 at 6:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 05/01/19. On 05/15/19, the administrator became aware the facility staff failed to administer a blood thinning medication to one resident for 14 days due to a transcription error. Upon discovery, the facility conducted an audit of all residents' physician order [REDACTED]. The facility amended the medication administration policies and in-serviced nursing staff regarding the policies. The IJ was removed and corrected on 05/15/19. 1. Review of the facility's Medication and Treatment Orders policy, dated (MONTH) (YEAR), showed the following: -Drug and biological orders must be recorded on the physician's orders [REDACTED]. Such orders are reviewed by the consultant pharmacist on a monthly basis; -Orders for Medications, treatments, medical equipment will be added to the MAR and/or (Treatment Administration Record) TAR as applicable. Review of the facility's Adverse Consequences and Medication Errors policy, dated (MONTH) 2014, showed the following: -The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate; -A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. -Examples of medication errors include: a. Omission - a drug is ordered but not administered. Review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Physician order [REDACTED]. Further review of the POS, showed the resident's physician directed the facility to provide the resident with 20 milligrams (mg) of Xarelto (a blood thinner) by mouth daily at bedtime. Review of the resident's MARs, dated 05/01/19 through 05/31/19, showed staff did not document they administered 20 mg of Xarelto daily at bedtime for the dates of 05/01/19 through 05/14/19 (14 days). Review of the resident's nurse's notes, dated 05/15/19, showed Licensed Practical Nurse (LPN) A documented the facility sent the resident out to the hospital for a possible blood clot in the right lower extremity per physician's orders [REDACTED]. Review of the resident's hospital records, dated 05/15/19, showed the following: -The resident's medication regimen included 20 mg of Xarelto by mouth daily at bedtime; -Limited range of motion to the right lower extremity, limited by pain, with [MEDICAL CONDITION] (swelling) noted to the right calf and ankle and tenderness to palpitation (method of feeling with fingers or hand during a physical examination); -While in the emergency room , the resident was noted to be in an [MEDICAL CONDITION]-fibrillation rhythm associated with rapid ventricular response and a computerized tomography (CT) scan ordered due to an elevated heart rate; -The resident's computerized CT scan results showed evidence of bilateral [MEDICAL CONDITION] emboli and poor cardiac output; -The resident's elevated heart rate contributed to his/her bilateral [MEDICAL CONDITION] emboli; -Elevated [MEDICATION NAME] time/international normalized ratio (PT/INR) (tests used to monitor blood clotting and the effectiveness blood thinning medications) results of 16.4 seconds /1.3. Review showed the normal range for a PT listed as 12-14.8 seconds and the normal range for an INR listed as 0.9 to 1.1; -The resident was ordered Xarelto over two weeks ago, and due to a pharmacy mishap, had not been receiving the medication; -The emergency department started the resident on anticoagulant (blood thinning) therapy; -The resident was at risk for death if he/she were to be sent back to the nursing home; -The resident admitted to the hospital for treatment of [REDACTED]. During an interview on 05/17/19 at 1:30 P.M., the Administrator said the facility changed pharmacies the beginning of (MONTH) 2019 and the previous pharmacy was responsible to provide the POS, MARs and treatment administration records for the month of (MONTH) 2019. The Administrator said the pharmacy did not provide MARs for Resident #1, so the Assistant Director of Nursing (ADON) created a hand written MAR for the resident. The Administrator said during the transcription process, the ADON did not include the resident's Xarelto on the MAR and the resident missed the prescribed doses from 05/01/19 through 05/14/19. The Administrator said on 05/15/19, the resident went to the hospital due to a new swelling of the resident's right leg that day and the facility discovered the resident had not received the medication while the resident was at the hospital. The Administrator said he/she did not know the condition of the resident other than the hospital reported the resident did not have any blood clots and they were testing for [MEDICAL CONDITION] embolism. During an interview on 05/17/19 at 2:00 P.M., the ADON said on 05/15/19, therapy called LPN A into the therapy room to look at the resident's legs due to complaints of pain and limited range of motion in his/her lower extremities. The ADON said, the resident complained of right leg pain to the LPN and upon assessment, the LPN found the resident's right lower leg with greater than grade four [MEDICAL CONDITION] (swelling of body tissues that when pressure is applied to the area leaves a deep indention that does not return to normal for more than 20 seconds). The ADON said the LPN notified the resident's physician of the [MEDICAL CONDITION] and the physician ordered for the resident to be sent to the emergency room . The ADON said around 3:15 P.M., LPN B came to him/her and said the hospital called to go over the resident's medication list and he/she needed to know when the last time the resident received the Xarelto. The ADON said when he/she looked at the resident's medication records, he/she found the resident had not received the medication since 04/30/19. The ADON said the facility changed pharmacies at the beginning of (MONTH) 2019 and the previous pharmacy was responsible to provide the POS and MARs for the month of (MONTH) 2019. The ADON said the pharmacy did not provide MARs for the resident, so he/she hand wrote the resident's (MONTH) 2019 MARs. The ADON said when he/she made the resident's MARs, he/she failed to transcribe the resident's order for the Xarelto on to the MARs and the resident missed the prescribed doses from 05/01/19 through 05/14/19. The ADON said later in the day on 05/15/19, LPN B spoke to the hospital and the hospital reported the resident did not have any blood clots, but they continued to run tests to check for [MEDICAL CONDITION] embolisms. Additionally, the ADON said the the facility had the resident's Xarelto available until 05/13/19, when it was returned to the previous pharmacy. Review of the pharmacy medication return signature receipt, dated 05/13/19, showed the resident's Xarelto was sent back to the previous pharmacy. During an interview on 05/17/19 at 2:30 P.M., LPN A said on 05/15/19 around 1:30 P.M., therapy called him/her in to the therapy rooms due to complaints of pain by the resident and reduced range of motion in the resident's lower extremities. The LPN said when he/she assessed the resident, he/she found greater than grade four [MEDICAL CONDITION] to the resident's right lower leg. The LPN said he/she also had LPN B assess the resident at which time LPN B agreed with his/her assessment. The LPN said he/she called the resident's physician to notify of the pain and swelling and the physician ordered for the resident to be sent to the emergency room . The LPN said he/she left the facility after the resident went to the hospital and the next day he/she found out staff did not administer the resident's Xarelto in (MONTH) 2019. The LPN said the medication was on the (MONTH) 2019 MARs and staff administered as prescribed until 05/01/19. During an interview on 05/17/19 at 3:00 P.M., the Director of Nursing (DON) said on 05/15/19 the ADON reported to him/her therapy had called LPN A to look at the resident's leg because it looked funny, the LPN called the resident's physician due to pain and swelling in the right leg, and the resident's physician ordered for the resident to be sent to the emergency room . The DON said the ADON also reported when the hospital called to go over the resident's medications, he/she found staff did not administer the resident's Xarelto in (MONTH) 2019. The DON said the facility changed pharmacies the beginning of (MONTH) 2019 and the previous pharmacy was responsible to provide the POS and MARs for the month of (MONTH) 2019. The DON said the pharmacy did not provide MARs for the resident, so the ADON hand wrote the resident's (MONTH) 2019 MARs. The DON said said when the ADON hand wrote the MARs, he/she did not transcribe the resident's Xarelto on to the MARs which resulted in staff not administering the medication from 05/01/19 through 05/14/19. The DON said he/she did not know the condition of the resident except the hospital reported later that day that the resident did not have any blood clots, but they were going to do a CT scan to check for [MEDICAL CONDITION] embolisms. During a telephone interview on 05/17/19 at 3:53 P.M., the Hospital Registered Nurse (RN) said the emergency room admitted the resident to the hospital with a [DIAGNOSES REDACTED]. During a telephone interview on 05/17/19 at 4:03 P.M., the resident's attending hospital physician said the hospital admitted the resident on 05/15/19 with [DIAGNOSES REDACTED]. The attending hospital physician said a nurse from the facility called to report they did not administer the resident's Xarelto for two weeks. During a telephone interview on 05/17/19 at 4:30 P.M., the resident's Primary Care Physician (PCP) said the facility contacted him/her on 05/15/19 and reported swelling of the resident's right leg. The PCP said he/she ordered for the resident to be sent to the hospital due to a concern of [MEDICAL CONDITIONS]. The PCP said he/she spoke to the emergency room physician who said the resident did not have a [MEDICAL CONDITION], but had multiple [MEDICAL CONDITION] embolisms. The PCP said the facility notified him/her that due to a pharmacy change the resident's Xarelto had not been transferred from one record to the next and staff did not administer the resident's Xarelto medication in (MONTH) 2019. The PCP said he/she would expect staff to transcribe all the medications into the resident's record as ordered. MO 116

Based on record review and interview, facility staff failed to obtain a PT/INR lab ([MEDICATION NAME] time and International normalized ratio which are laboratory tests that help to show the ability of a person's blood to clot.) as ordered by the physician for one resident (Resident #1). The facility census was 39. 1. Review of the facility's Laboratory Testing Policy and Procedure, dated 04/25/13, showed the policy directed staff to complete the following: -Orders will be promptly carried out as directed in the physician's orders [REDACTED].>-The appropriately licensed individual will complete a telephone order for a blood test at the direction of the ordering practitioner; -Staff will note the blood test on the 24-hour report; -The charge nurse receiving test results shall be responsible for notifying the physician of abnormal test results; -Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record; -Laboratory, radiological and diagnostic test shall be reviewed in the Quality of Care meeting. Review of the Drug Information Handbook for Nursing, 2007, 8th edition, showed the following information regarding [MEDICATION NAME]: - [MEDICATION NAME] is a high alert medication and has a heightened risk of causing significant patient harm when used in error. - Hemorrhage is the most significant risk, and bleeding, accidents, or falls must be reported by patients. - The elderly may be more sensitive to anticoagulant therapy. - Laboratory testing (PT/INR) must be monitored closely. - Monitor patient frequently for adverse reactions (including bleeding from any site). - A risk of bleeding complications has been associated with increased age. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/27/16, showed staff assessed the resident as follows: -Mild cognitive impairment for daily decision making; -Dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Received anticoagulation therapy six times per week. Review of the resident's face sheet, dated 02/05/16, showed the resident as diagnosed with [REDACTED]. Review of the resident's comprehensive care plan, dated 02/10/16, showed staff did not include a plan of care for the use of an anticoagulation therapy. Review of the resident's Physician order [REDACTED]. Review of the resident's Laboratory Service Report dated 1/28/16, showed the resident's PT level at 28.8 seconds and INR level at 2.6 seconds. Review showed an order documented on the lab report for staff to check the resident's PT/INR in one month. Review of the resident's telephone order sheet, dated 01/28/16, showed an order for [REDACTED]. Review of the resident's nurses notes, dated 01/28/16, showed staff documented telephone order for recheck PT/INR level in one month due to increased level. Review of the resident's lab result reports did not show PT/INR lab result reports for 02/2016 or 03/2016 to show staff checked the resident's PT/INR levels as ordered. During an interview on 04/06/16 at 2:30 P.M., Licensed Practical Nurse (LPN) G said he/she wrote the telephone order for the resident's PT/INR lab draw due on 2/29/16. LPN G said he/she thought he/she put the order on the resident's POS, in the Medication Administration Record [REDACTED]. He/She said they could not seem to find it in the lab book after they realized they missed the order. He/She said the lab would not get drawn unless it was in the lab book. Review of the resident telephone order sheet, dated 03/21/16 at 08:00 A.M., showed an order for [REDACTED]. Review of the resident's POS, dated 03/01/16-03/31/16, showed the physician ordered [MEDICATION NAME] 4 mg, take two tablets (8 mg) once daily, order date 01/02/16. Review of the resident's Medication Regimen Review sheet for January, February, and March of 2016 showed the pharmacist did not find any irregularities and did not make any recommendations after reviewing the resident's medications. Review of the facility's lab tracking log, dated 01/13/16-03/21/16, showed staff documented on 1/13/16 the resident had a PT/INR drawn by lab and an order dated 3/21/16 for PT/INR to be drawn that morning. Review showed lab did not draw the PT/INR on 3/21/16 at 8:00 A.M. Further review showed staff had not documented lab draws for the resident since 1/13/16. Review of the resident's Certified Nursing Assistant (CNA) daily skin inspection record, dated 03/15/16, 03/16/16, and 03/17/16, showed staff documented the resident had bruising to his/her right chest/upper abdomen, left chest/upper abdomen, right upper leg/lower abdomen, and right knee. Review of the resident's nurse's notes showed staff did not document further assessment of the bruising, assess a possible cause, or notify the physician of the resident's bruising. During an interview on 03/23/16 at 11:00 A.M., LPN A said on 03/21/16 he/she attempted to give the resident his/her blood pressure medication but he/she held the medication due to the resident's low blood pressure. Around 08:45 A.M., staff reported the resident threw up and needed his/her [MEDICATION NAME]. The LPN said the vomit did not have blood in it. Review of the resident's nurse's notes, dated 03/21/16 at 9:50 A.M., showed staff documented the resident as short of breath, vomiting one hour prior, an oxygen level of 59% (normal is > 90%) on room air, and the resident sent to the emergency room . Review of the resident's transfer communication form, dated 03/21/16, showed staff documented the resident had audible gurgling, bleeding from the mouth, oxygen saturation of 59% on room air (normal is >90%) and was placed on four liter per minute of oxygen. Additionally, staff documented the resident's last INR as 2.6 seconds and drawn on 01/28/16. Review of the resident's emergency room history and physical, dated 03/21/16, showed the resident presented to the emergency department with dried blood in the nasal and oral cavities and with [DIAGNOSES REDACTED]. Review of the physician's documentation showed the following: -Resident in critical condition; -Admission to the Intensive Care Unit (ICU); -The resident intubated; -PT greater than 80 and the INR greater than 10 (normal range PT 12.0-14.8 seconds and INR 0.9-1.1 seconds for [MEDICATION NAME] therapy INR normal range for conventional anticoagulation as 2.0-3.0 and for intensive anticoagulation 2.5-3.5 seconds); -PTT (partial [MEDICAL CONDITION] time a test that looks at how long it takes for blood to clot) of 219 seconds (normal range 22-35 seconds); -Hemoglobin (HGB) 8.3 (normal range 13.7 to 17.5 grams (g)/deciliter (dl)); -Potassium (K+) 8.4 (normal range 3.6-5.0); -Bruising to the right extremity probably from injections, bruise under right breast, and right flank (side). Review of the resident's hospital patient notes, dated 03/21/16, showed hospital staff documented they administered two units of packed red blood cells to the resident. Review of the resident's hospital history and physical, dated 03/21/16, showed the physician documented the resident has a history of [MEDICAL CONDITION] infarction (MI- [MEDICAL CONDITION]), [MEDICAL CONDITION] (CAD), [MEDICAL CONDITION]-fibrillation (A-Fib), and [MEDICAL CONDITION]. The physician documented the resident was on [MEDICATION NAME] (anticoagulant/blood thinner) for A-Fib and received vitamin K (helps to prevent excessive bleeding) in the emergency room . The resident's CT scan showed multifocal liver laceration (caused by liver trauma) and possible healthcare associated pneumonia. Additionally the physician documented the resident is unable to provide further medical history in regards to the resident being intubated with sedation. During an interview on 3/22/15 at 04:00 P.M., the resident's physician said staff did not notify him/her of the missed PT/INR lab draw or the bruising on the resident's right flank and under his/her right breast. He would expect staff to check the PT/INR if missed and notify him. The physician said the lacerated liver, elevated potassium, and other acute issues that led to the hospitalization were not related to the elevated PT/INR. During an interview on 03/23/16 at 1:00 P.M., LPN B said if staff find bruising on a resident they are to report it to the charge nurse and the charge nurse is to go and assess the bruising. When the nurse finishes the assessment, they are to report the findings to the Director of Nursing (DON). When orders for labs are received the nurse is to put the order on the lab requisition, lab tracking book, and POS. Chart checks should be done nightly by the charge nurse. LPN B said the resident had been complaining of itching three to four days before he/she went to the hospital but he/she did not know of any bruising to the resident's right breast or right flank area. During an interview on 04/06/16 at 2:30 P.M., LPN G said when completing a chart check, nursing staff looked at new telephone orders and recent lab results to make sure staff transcribed the orders to the POS. During an interview on 03/23/16 at 02:05 P.M., the DON said she is not aware of any bruising on the resident's right flank or under the right breast. When staff notice bruising on a resident they are to report to the nurse, the nurse is to assess the bruising and do an investigation, report to the DON, and notify the physician. The DON said the physician orders [REDACTED]. The nurses are responsible for ensuring that all labs including PT/INRs are completed upon ordering. They are to transfer the order over to the POS and Lab requisition book. Labs are faxed to the doctor unless they are are critical and then nursing is to call the physician. The orders for the PT/INR are to go on the lab requisition book. The facility just recently started putting the orders on the lab reports. The physician had ordered for the PT/INR to be rechecked in one month on 1/28/16. The nurse placed the order everywhere but in the lab book and the PT/INR was missed. The DON said she does chart checks. The DON randomly picks five charts three times a week and goes through the entire chart. MO 982

Based on observation, interview, and record review, facility staff failed to prevent five facility acquired unstageable pressure ulcers and one Stage I pressure ulcer for one resident (Resident #9). Staff failed to assess and identify unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (adherent yellow, tan, gray, green or brown dead tissue) pressure ulcers and/or eschar (adherent black or brown dead tissue in the wound bed) on the resident's right great toe, second toe, and third toe. Staff also failed to assess and identify a Stage I (Intact skin with non blanchable redness of a localized area usually over a bony prominence) pressure ulcer on the resident's left outer foot. The facility census was 41. 1. Review of the facility's Wound Care Policies and Procedures, revised 06/01/15, showed: -Areas identified during the initial wound evaluation require the following documentation: type of wound, location, measurements, general appearance/presence of healing, wound bed characteristics, description of wound edges and surrounding skin, and presence or absence of signs of infection. -Residents at risk for pressure ulcer development should be monitored daily for changes in their skin condition. -Any abnormal findings/changes should be documented on appropriate facility forms and reported to the licensed nurse for evaluation and follow up. Abnormal findings/changes should be reported to the resident's primary care provider and family/responsible party by the licensed nurse per facility protocol. -Documentation of the primary care provider notification, orders received, family notification and resident response to any treatment should follow facility protocol as well. -Weekly documentation should include the date observed and location with staging/depth description for pressure wounds, measurements, wound bed characteristics, description of wound edges and surrounding skin, any exudate including characteristics, and any pain. 2. Review of Resident #9's Minimum Data Set (MDS), a resident assessment instrument, dated 01/13/16, showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not have behaviors; -Did not refuse care; -Dependent on two or more staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Dependent on one staff for eating; -Frequently incontinent of bowel and bladder; -At risk for pressure ulcers; -No current pressure ulcers. Review of the resident's plan of care, last updated 01/24/16, showed staff assessed the resident with scabbed areas to right anterior toes and side of right great toe. Additional review showed the following interventions: -Complete skin inspections with daily cares; -Do measurements weekly and document; -Float heels while in bed; -Will be followed by wound care consultant. Review of the certified nursing assistant (CNA) Daily Skin Inspection Record forms dated 11/01/15 through 11/30/15, showed staff noted the resident had sores on the resident's right foot on 11/09/15 through 11/13/15, on 11/16/15, and 11/21/15 through 11/30/15. Review of the CNA Daily Skin Inspection Record forms, dated 12/01/15 through 12/15/15, showed staff noted redness on the resident's left foot 12/01/15 through 12/13/15, redness on the resident's left and right foot 12/14/15 through 12/17/15, and redness on the resident's left foot 12/18/15 through 01/01/16. Review of the CNA Daily Skin Inspection Record forms, dated 01/01/16 through 01/31/16, showed staff noted open area on the resident's toes 01/02/16 through 01/05/16, and open area on the resident's right toes 01/06/16 through 01/28/16. Review of the resident's Weekly Skin Integrity Review forms, dated 11/07/15 through 12/26/15, showed licensed nursing staff assessed the resident's skin as intact. Review showed the forms dated 11/16/15 and 11/23/15 noted redness of the resident's left and right toes. Review of the resident's medical record showed the record did not contain any Weekly Skin Integrity Review forms for January 2016. Review of the nurses' notes, dated 01/27/16, showed staff documented Dressings changed to toe scabs. Tolerated well. Review showed the nurses' notes did not contain any other documentation related to the resident's pressure ulcers. Review of the facility's Weekly Wound Tracking Worksheets, used to track all resident wounds in the facility, dated 11/02/15 through 01/25/16, showed the resident was not listed on the worksheets and did not contain any documentation of wounds on the resident's feet. Observation on 01/28/16 at 7:55 A.M., showed both of the resident's heels rested directly on the mattress. Observation showed two brown areas to the resident's right great toe, two black areas to the resident's right second toe, and one black area to the resident's right third toe. Observation also showed the skin surrounding the brown and black areas bright red. Observation showed bandaids partially covered the brown and black areas. Observation on 01/28/16 at 1:50 P.M., showed the Assistant Director of Nursing (ADON) assessed the resident's feet. Observation showed a pillow under the resident's legs and the resident's heels rested directly on the mattress. Observation showed the ADON measured the brown area on top of the resident's right great toe at 0.6 centimeters (cm) by 0.6 cm. Observation showed the brown area on the medial aspect of the resident's right great toe measured 1.0 cm by 1.0 cm. Observation showed the black area on top of the distal area of the right second toe measured 1.0 cm by 1.0 cm and the black area on the proximal area of the right second toe measured 0.6 cm by 0.4 cm. Observation showed the black area on top of the right third toe measured 0.4 cm by 0.4 cm. Observation showed the skin surrounding the brown and black areas bright red and swollen. Observation showed a dark red area on the outer aspect of the resident's left heel. Additional observation showed the dark red area did not blanch. During an interview on 01/28/16 at 11:50 A.M., Certified Nursing Assistant (CNA) C and D said the resident has had some spots on his/her feet that they have recorded on their CNA documentation sheets. The CNAs said they have notified the charge nurses and have discussed the toes among themselves also. CNA C said that is why the resident is not wearing shoes, we are only putting socks on him/her because his/her toes are tender. The CNAs said they record resident activities of daily living (ADL) information, including skin condition, on every resident every shift and submit the CNA Daily Skin Inspection Records to the charge nurses. During an interview on 01/28/16 at 12:05 P.M., Licensed Practical Nurse (LPN) A said he/she did not know about the areas on the resident's right toes before 01/24/16. The LPN said charge nurses are expected to review the CNA Daily Skin Inspection Records, but said he/she had only recently switched to day shift from night shift and was not completely familiar with the system. The LPN said he/she expects the CNAs to report any change or concern in skin condition immediately. The LPN said he/she did not know if the wound care company had been contacted. During an interview on 01/28/16 at 1:20 P.M., LPN B said he/she did not know about the areas on the resident's right toes before 01/24/16. The LPN said the areas should have been identified and reported. The LPN said he/she does not sign off on the CNA Daily Skin Inspection Records and only reviews them when there is an issue. The LPN said he/she did not know if the wound care company had been notified. During an interview on 01/28/16 at 1:50 P.M., the ADON said it is possible the brown and black areas on the resident's right foot are pressure ulcers, but he/she does not believe they are. The ADON said staff will wait for Mobile Wound Solutions (MWS) to evaluate the wounds and give staff a better determination. During an interview on 01/28/16 at 2:35 P.M., the ADON said he/she was not aware of the wounds on the resident's feet before 01/24/16. The ADON said charge nurses are responsible for weekly skin assessments and are responsible to review the CNA skin assessment sheets at the end of each shift. The ADON said he/she expects staff to review all skin assessments and address any problems. The ADON said he/she is responsible to ensure those assessments are completed and accurate. The ADON said he/she is not currently monitoring the weekly skin assessments. The ADON also said the wound care company was at the facility 01/25/16, but did not see the resident to evaluate his/her wounds. The ADON said he/she did not know why MWS did not see the resident on 01/25/16. During an interview on 01/28/16 at 4:00 P.M., the Director of Nursing (DON) said he/she was not aware of the resident's wounds prior to 01/24/16. The DON said he/she expects CNAs to notify the charge nurses of any skin issues they find. The DON said he/she expects the charge nurses to review the CNA skin assessment sheets every day, and that the nurses have been educated to do so. The DON said staff do not stage wounds and that MWS stages wounds for the staff. The DON said he/she did not know why staff do not stage wounds although the policy directs staff to do so. The DON said he/she expects staff to document a new wound with documentation of measurements, characteristics of the wound, and a description of the wound. The DON also said he/she did not know why staff did not document the initial wound assessment because we educate staff all the time on wound care. The DON said he/she would expect MWS to have seen the resident on 01/25/16 because that's the whole point of having MWS and did not know why the resident was not seen that day. The DON said he/she did not know why the resident developed wounds on his/her feet and said the staff dropped the ball. Review of the resident's medical record showed it did not contain an order for [REDACTED].

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) did not develop avoidable pressure ulcers when the facility failed to monitor and assess multiple unstageable necrotic pressure ulcers on the resident's right foot, which resulted in a [MEDICAL CONDITION] to the resident's right leg. Additionally, facility staff failed to assess, prevent, and promote the healing of pressure ulcers for three residents (Resident #2, #3, and #4). The facility census was 42. 1. Review of the facility's Licensed Nurse Skin Checks policy and procedure, dated 12/2011, showed: -Weekly the Licensed Nurse is to perform a head to toe check of the patient's/resident's skin, paying particular attention to the surfaces of the skin that come in contact with the bed and chair, bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.), the surfaces of the skin that come in contact with any orthotic device, tube, brace or positioning device, and skin folds. -The nurse is to observe for redness, rashes, bruising, and open areas. -Any significant abnormal findings are reported to the patient's/resident's physician and patient/resident contact person. -Documentation that the check was performed is denoted on the Medication Administration Record [REDACTED]. -Abnormal findings to be documented in the Nurse's Note or on the back of the TAR if space allows. -Document the actions taken in the Nurses Note along with a summary of all persons who were notified and their responses. 2. Review of the facility's Pressure Ulcer policy and procedure, dated 12/2011, showed: -Evaluate the pressure ulcer initially for location, stage, size (in centimeters (cm), sinus tracts, undermining, tunneling, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and [MEDICATION NAME]. -Re-evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (two weeks), the treatment plan should be re-evaluated. -If the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. 3. Review of Resident #1's right ankle x-ray report, dated 2/21/15, showed an acute [MEDICAL CONDITION] malleolus (fractured ankle joint). Review of the resident's Physician order [REDACTED]. Review of the resident's comprehensive care plan, dated 02/27/15, showed: -Keep the resident's boot on at all times; -The resident will be sent to follow up appointment for re-evaluation of ankle; -Encourage the resident to turn and reposition every two hours and as needed, utilizing extra pillows for support; -Monitor the residents skin on bath/shower days and while providing care; -Notify the charge nurse of any nonblanchable redness or any noted open areas. Review of the resident's shower sheet, dated 3/2/15, showed staff documented the resident's right heel contained a bruise. Review showed licensed staff did not sign they reviewed the form. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 03/05/15, showed staff assessed the resident as follows: -Fall with major injury; -At risk for skin breakdown; -No pressure ulcers; -Requires extensive assistance with bed mobility, personal hygiene, and dressing; -Dependent on staff for toileting; -The resident did not transfer or ambulate during the assessment. Review of the resident's shower sheet, dated 3/9/15, showed staff documented a sore on top of the resident's right foot. Review showed licensed staff did not sign they reviewed the form. Review of the resident's weekly skin documentation, dated 3/1/15, 3/10/15, and 3/17/15, showed staff documented the resident had a boot to the right lower extremity. Review showed staff did not document an assessment of the right foot or ankle. Review of the resident's nurses' note, dated 3/21/15, showed staff first documented an assessment of pressure ulcers on the resident's right ankle and foot. Staff documented the residents right heel appeared black in color, very mushy to touch around the necrotic area, and maceration (the softening or breaking down of skin resulting from prolonged exposure to moisture) to the surrounding area. The wound measured 5 centimeters (cm) length by 4 cm width and 0.4 cm depth. Redness to the right inner ankle bone measuring 2.4 cm length by 3.0 cm width by 0 cm depth. Redness to the top of the right foot measuring 7 cm length by 4 cm width and 0 cm depth with a dark area in the center measuring 0.5 cm length by 0.4 cm width and 0 cm depth. Redness to the lower shin measuring 3.2 cm length by 2.0 cm width and 0 cm depth. The right inner aspect of the resident's right heel appears to have a fluid-filled area measuring 3.0 cm length by 1.0 cm width and the second area to the heel on the outer aspect appears fluid filled, measuring 2.0 cm length by 0.5 cm depth. Redness to the outer aspect of the resident's right ankle, measuring 3.0 cm length by 4.0 cm width, with a 0.6 cm length by 0.6 cm width dark area in the center of the redness. Further review showed no prior documentation of the wounds in the nurses' notes. Review of the telephone order sheet, dated 3/21/15 showed an order for [REDACTED]. Mobile wound clinic to evaluate. Review of the Treatment Administration Record (TAR) showed staff did not document they applied treatment to the resident's right foot from 3/21/15 through 3/23/15. Review of the resident's mobile wound physician assessment, dated 3/23/15, showed the wound physician assessed the resident with pressure wounds caused by the orthotic splint to immobilize the ankle fracture. The wound physician documented assessment of six wounds on the resident's right inner and outer ankle, heel, toe, and Achilles tendon area as a result of pressure from the orthotic splint. The physician documented four of the wounds as unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), and two of the wounds with suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to the adjacent tissue.) Review showed the mobile wound solutions physician ordered for staff to cleanse the wounds to the right lateral ankle and the right anterior ankle with wound cleanser, apply Santyl for enzymatic debridement, Vaseline gauze to the wounds, cover with gaze and secure with gauze wrap and tape. Change the dressing daily. The physician ordered staff to cleanse the right heel, Achilles tendon area, the lateral right 5th metatarsal (toe), and the medial right ankle with wound cleanser, apply skin prep, and secure with gauze wrap. Change daily Review of the resident's POS, dated 3/30/15, showed it did not contain a change in treatment as ordered by the mobile wound physician. Review of the resident's comprehensive care plan, dated 04/3/15, showed: -Provide all treatments as ordered; -Monitor the resident's wounds for color, consistency, amount of drainage, and odor; -Keep the resident's heels elevated; -Apply extra padding to the right heel when wearing orthopedic boot; -Notify the resident's physician of any changes to wound; -Mobile wound solution to evaluate and treat. Review of the resident's mobile wound physician assessment, dated 04/06/15, showed the wound physician documented the resident with a new unstageable, necrotic (dead tissue) pressure ulcer on the resident's plantar heel that required debridement (surgical removal of dead tissue), the physician also debrided the toe ulcer, but the ulcer on the Achilles tendon area resurfaced and the physician did not document measurements. The physician documented the other five ulcers assessed on 03/23/15 remained with deteriorated status. Review showed the mobile wound physician ordered for staff to communicate with the orthopedic surgeon to find another alternative splint to avoid further damage to the skin on 3/30/15 and for staff to not use [MEDICATION NAME] dressing and 4x4 gauze. Review showed on the right heel assessment and treatment plan for staff not to use Vaseline gauze and [MEDICATION NAME] dressing dated 3/30/15. Review of the resident's TAR, dated 3/30/15 through 4/24/15, showed a treatment order for staff to apply skin prep to the right heel area along the Achilles, outer aspect of the foot, inner aspect of the foot, and inner ankle on day shift daily. Review showed an order for [REDACTED]. Pad with extra 4x4 gauze or gauze wrap when using brace. Review showed staff did not discontinue the previous order as directed and did not apply the new treatment as directed. Review of the resident's mobile wound physician assessment, dated 04/13/15, showed the wound physician documented the resident with six pressure ulcers, with five showing improvement and one showing decline in condition. Review of the resident's ultrasound report, dated 04/15/15, showed the resident with no evidence of significant stenosis (a narrowing within the arterial wall) within either lower extremity arteries. Review of the resident's nurses' note, dated 04/18/15, showed the resident with necrotic tissue on the right heel with some drainage, three other open areas cleaned, santyl ([MEDICATION NAME] ointment used to break down dead tissue) applied, Vaseline gauze applied, and kerlix gauze wrap. Review of the resident's orthopedic physician note, dated 4/24/15, showed the physician directed staff to remove the walking boot and referred the resident to the hospital wound clinic. Review of the resident's hospital wound clinic notes, dated 4/24/15, showed the wound clinic staff documented the resident with five wounds with no staging of the wounds. The clinic staff documented the wounds contained slough. Review of the resident's hospital wound clinic notes, dated 4/29/15, showed the wound clinic staff documented they performed debridement of the five pressure ulcers down to tendon and bone. Review of the resident's hospital wound clinic notes, dated 5/4/15, showed the resident was seen with five Stage IV pressure ulcers. Staff documented they debrided all five pressure ulcers with resulting increase in size and depth. Review of the resident's hospital wound clinic notes, dated 5/11/15, showed they assessed the resident with noticeable odor and extensive worsening of two of the pressure ulcers with new areas extending significantly past the original dressing with increased redness. They admitted the resident to the hospital. Review of the resident's hospital record, dated 5/11/15, showed [DIAGNOSES REDACTED]. Staff documented duskiness to the resident's foot and toes and appears to be grossly necrotic. The physician recommended a right foot [MEDICAL CONDITION]. During an interview on 5/12/15, at 4:00 P.M., the resident's hospital Registered Nurse (RN) said the resident had surgery on 5/12/15 to remove his/her right foot below the knee. During an interview on 05/12/15 at 3:55 P.M., the resident's physician said he/she would not typically order staff to keep the walking boot on while the resident was in bed. During an interview on 05/12/15 at 04:09 P.M., the MDS coordinator said the resident's physician ordered the boot to be on at all times except during showers. After the nurse found the wounds, staff received an order for [REDACTED]. He/she said the resident's wounds had a foul odor coming from them but he/she was unsure if they cultured the wound. The MDS coordinator said the resident's physician should be notified if wounds show signs of deterioration. During an interview on 05/13/15 at 12:40 P.M., License Practical Nurse (LPN) A said the Assistant Director of Nursing (ADON) was in charge of measuring resident wounds. After the ADON was terminated, they began to notice a lot of skin issues on the residents. When he/she removed the resident's boot he/she observed multiple wounds on the foot, ankle, and heel. He/she notified the Director of Nursing (DON) and the physician. The LPN said the resident had the boot on at all times. The LPN said he/she would expect the Certified Nurse Aides (CNAs) to notify the charge nurse of any new skin issues or any new changes. During an interview on 05/13/15 at 01:15 P.M., CNA E said the resident had a red spot/sore on the top of his/her foot during the shower on 03/09/15 and he/she reported it to the charge nurse at the time. The resident had an elastic bandage on his/her foot and ankle under the boot. The CNAs were instructed to keep the boot on at all times except during showers. He/she did not notice a smell from the resident's wounds until last week, but he/she does not usually work on the hall that the resident is on. During an interview on 05/18/15 at 03:10 P.M., the resident's orthopedic physician said he/she ordered the CAM boot (an orthopedic walking boot used for sprains and fractures) to be worn at all times except during showers. The physician said he/she decided to place the resident in the CAM boot versus a cast so staff could assess the resident's foot/ankle. The physician said he/she did not see and was not aware the resident ended up with multiple open wounds in areas that had contact with the CAM boot until 04/03/15. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, 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, staff conducted a head-to-toe skin assessment on every resident and documented any new concerns. The administrator began to re-educate licensed staff regarding the facility wound protocol including but not limited to weekly skin assessments and completing and documenting treatments. The administrator began to re-educate CNAs prior to their shift regarding the completion of daily skin checks and reporting any changes in skin condition to the charge nurse. The facility staff will continue to conduct corrective action by assigning a mobile Director of Nursing until compliance is achieved. The facility will continue the notification of physicians and families of new skin concerns and obtain treatments. The facility will continue to utilize the services of a contractual wound service to evaluate, measure, suggest treatments and provide education as necessary to staff on wound prevention. The Director of Nursing and/or designee will round with the wound service weekly. 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 G 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). 4. Review of Resident #2's Admission MDS, dated [DATE], showed: -Cognition severely impaired; -Total dependence of two person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Uses a wheelchair for mobility; -Dementia; -admitted with one unstageable pressure ulcer with slough and/or eschar; -admitted with one unstageable pressure ulcer with suspected deep tissue injury; -No wound infections; -At risk of developing pressure ulcers. Review of the resident's care plan dated 02/26/15, showed staff documented the resident as at risk for skin breakdown related to dementia, decreased mobility and occasional incontinence. Review of the care plan showed staff documented the resident was admitted with a suspected deep tissue injury on the left heel and an unstageable pressure area on the midback. Further review of the care plan showed: -CNA to monitor skin every day during Activities of Daily Living (ADL) care and bathing; -Float heels while in bed; -Nurse to conduct a systematic skin assessment weekly and measure, monitor and document on the wounds; -Treatments and medications as ordered. Review of the resident's care plan dated 05/02/15, showed staff documented the resident is on an antibiotic treatment (ABT) for wound drainage to back. Further review of the care plan showed: -Provide all ABT as ordered; -Monitor for signs and symptoms of adverse effects; -Notify the primary care physician of any adverse effects. Review of the resident's wound culture laboratory document dated 04/27/15, showed Escherichia Coli in the resident's back wound resulting in a wound infection. Review of the resident's POS, dated 05/2015, showed: -[MEDICATION NAME] 500 milligrams (mg's) four times daily for ten days; -Acidophillus two times daily for twelve days; -[MEDICATION NAME] 500 mg one time daily for seven days; -Use polymem small strip for packing back wound twice daily; -Apply skin prep and gauze wrap daily and as needed to left heel. Review of the resident's TAR dated 04/2015, showed: -Lumbar back: apply santyl ointment to affected area, then apply Vaseline gauze to wound and cover with 4x4's and secure daily. Review showed staff did not document treatment on 04/01, 04/03, 04/09, 04/10, 04/13, 04/15, 04/17, 04/28, or 04/29. -Float heels while in bed; -Left heel: Apply santyl ointment to wound, then apply Vaseline gauze to wound bed and cover with 4x4's and wrap with kling daily. Review showed staff did not document treatment on 04/01, 04/03, 04/06 - 04/13, 04/15, 04/17, 04/28, or 04/29. Review of the resident's TAR dated 05/15, showed: -Lumbar back: polymem small strip for packing back wound twice daily. Apply santyl to affected area, then apply Vaseline gauze cover with 4x4's and secure with tape daily. Review showed staff did not document treatment on 05/10/15 or 05/11/15. -Float heels while in bed; -Left heel: apply santyl ointment to wound, then apply Vaseline gauze to wound bed cover with 4x4's and wrap with kling daily. Review showed staff did not document treatment on 05/10/15 or 05/11/15. Review of the resident's mobile wound physician assessment, dated 04/13/15, showed the wound physician documented an unstageable pressure ulcer to the resident's lumbar spineous and an unstageable pressure ulcer to the left heel. Review showed staff was directed to keep weight off the resident's left heel at all times. Review of the resident's mobile wound physician assessment, dated 04/27/15, showed the wound physician documented the resident's left heel as deteriorated. The wound physician documented the wound contained a moderate amount of slough and had a small amount of drainage. Further review showed the wound physician documented an order for [REDACTED]. Review of the resident's mobile wound physician assessment, dated 05/04/15, showed the wound physician documented tissue culture done on 04/27/15 showed growth of E. Coli. Tissue culture showed susceptibility to [MEDICATION NAME] and [MEDICATION NAME]. The resident's primary care physician ordered [MEDICATION NAME]. Review showed the physician documented the wound to the resident's lumbar spineous as unchanged. The physician documented a third wound to the resident's right lateral ankle as an unstageable pressure ulcer. Review of the resident's weekly skin documentation form dated 04/2015 and 05/2015, showed staff did not complete any weekly skin assessments as directed in the policy. Review of the resident's wound treatment and progress record form dated 03/2015, showed the resident's back wound and left heel wound was assessed and measured on 03/02/15 and 03/09/15. Further review showed staff did not document any additional wound assessments or measurements for the month of 03/2015. Review of the resident's wound treatment and progress record form dated 04/2015, showed staff did not document any weekly wound assessments or measurements for the month of 04/2015. Review of the resident's wound treatment and progress record form dated 05/2015, showed staff did not document any weekly wound assessments or measurements for the month of 05/2015. Observation on 05/12/15 at 03:45 P.M., showed both the resident's feet and heels lay directly on the bed with the wound dressings half off. Observation showed the resident with two open areas on his/her left heel, one open area on his/her right ankle, and a large open area on his/her back on the right side of his/her lumbar spine. The wounds on the left heel and right ankle contained 25% adherent yellow slough with redness around the wound bed. The wound to the resident's back showed 100% yellow adherent slough, tunneling at 6 o'clock, and the surrounding skin with redness. LPN C cleansed the wounds, applied santyl (aides in the breaking up and removal of dead tissue in wounds) to the wound bed of all the wounds, covered with Vaseline gauze and 4x4 gauze. LPN C applied kerlix gauze wrap to both feet/ankles and cotton adhesive tape to the back wound. Observation on 05/13/15 at 10:59 A.M., showed the resident lay in bed with heel protector boots on both feet. Observation showed staff did not float the resident's heels as directed. Observation on 05/13/15 at 1:35 P.M., showed the resident lay in bed with heel protector boots on both feet. Observation showed staff did not float the resident's heels as directed. Observation on 05/13/15 at 03:58 P.M., showed staff did not place heel protectors on the resident and did not float heels as directed. Observation showed the resident's heels lay directly on the bed. Observation on 05/15/15 at 10:47 A.M., showed the resident lay in bed with a bandage off his/her left foot. Further observation showed the resident's heels lay directly on the mattress. Staff did not float the resident's heels as directed. During an interview on 05/12/15 at 03:45 P.M., the MDS coordinator said the resident came into the facility with an unstageable wound on his/her back. He/she said the wound deteriorated and mobile wound staff assessed and evaluated the resident's wounds. The resident acquired the heel/foot wounds on the left foot and the wound on the right ankle at the facility. The wound nurse sees the resident every week on Monday. The wound on the resident's back is tunneling about 0.8 centimeters. After the wound nurse debrided the wound, the resident had a cyst in the base of the tunneling. Staff cultured the wound and the resident was placed on antibiotics. During an interview on 05/13/15 at 12:40 P.M., LPN/Charge Nurse A said the resident wears heel protector boots while in bed, but will often take them off. He/she said it is difficult to float the resident's heels while in bed because the resident moves so much. During an interview on 05/14/15 at 3:00 P.M., the DON said staff understands the importance of floating the heels of a resident with a pressure ulcer and said staff should be floating the resident's heels. 5. Review of Resident #3's Significant Change MDS, dated [DATE], showed: -Moderate cognitive impairment; -[MEDICAL CONDITION]; -Dementia; -[MEDICAL CONDITION]; -[MEDICAL CONDITION]; -Total dependence of two person physical assist for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; -Uses a wheelchair for mobility; -At risk of developing pressure ulcers; -Pressure reducing device for chair. Review of the resident's care plan dated 01/27/15, showed staff documented the resident is at risk for skin breakdown. Review of the care plan showed: -Check the resident's skin on bath/shower days and while providing care; -Encourage the resident to turn and reposition every two hours and as needed, utilizing extra pillows for support; -Notify the charge nurse of any nonblanchable redness or open areas. Review of the resident's care plan dated 03/02/15, showed staff documented the resident with a popped blister to his/her right heel. Review of the care plan showed: -Do treatment as ordered; -Provide pressure relief to resident; -Notify the physician of any changes. Review of the resident's care plan dated 05/14/15, showed staff documented the resident's wound to right heel is now eschar. Review of the care plan showed: -Get order for Mobile Wound Solutions to evaluate and treat; -Provide pressure relief; -Provide treatment as ordered by physician; -Notify family and physician of any changes. Review of the resident's POS dated 03/2015 and 04/2015, showed it did not contain a physician order [REDACTED]. Review of the resident's POS dated 05/2015, showed a physician's orders [REDACTED]. Review of the TAR dated 0320/15 and 04/2015, showed it did not contain a wound treatment for [REDACTED]. Review of the resident's TAR dated 05/2015, showed to apply skin prep to right heel, cover with 4x4's and wrap with kling daily and as needed until healed. Further review of the TAR showed staff did not document they completed a treatment on 05/10, 05/11, 05/13, or 05/14. Review of the resident's Wound Treatment and Progress Record form dated 05/2015, showed an order to cleanse the right heel with wound cleanser and 4x4's, pat dry, and apply santyl to wound bed then apply a foam dressing. During an interview on 05/21/15 at 8:46 A.M., a mobile wound nurse said he/she could not find any Wound Treatment and Progress Records for 03/2015 and 04/2015. Review of the resident's CNA Shower Review sheets dated 03/04/15, 03/06/15, 03/09/15, 03/13/15, 04/02/15, 04/14/15, 04/21/15, 04/28/15, showed CNA's did not identify any skin problems to the resident's right heel. Further review of the Shower Review sheets showed the charge nurse did not sign the sheets on 03/04/15, 03/09/15, 04/02/15, 04/14/15, and 04/21/15. Review of the resident's Weekly Skin Documentation form dated 03/02/15, 03/14/15, and 03/24/15, showed staff did not identify the resident with skin breakdown to his/her right heel. Review of the resident's Weekly Skin Documentation form dated 04/2015, showed staff completed only one skin assessment on 04/26/15 and did not identify any skin breakdown to the resident's right heel. Review of the resident's Weekly Skin Documentation form dated 05/2015, showed staff did not complete any skin assessments. The facility did not complete weekly skin assessments as directed in the policy. Review of the resident's nursing notes dated 05/01/15, showed staff documented resident noted to have dressing to right heel, dressing removed and area cleansed. Appears to be a popped blister, skin prep applied, covered with 4x4's and kling applied. Observation on 05/13/15 at 04:30 P.M., showed the MDS coordinator removed the resident's dressing to his/her right heel. The dressing showed a date of 05/05/15. Observation showed a black intact necrotic area on the right heel the size of a quarter. Observation on 05/14/15 at 11:15 A.M., showed the resident with a quarter sized unstageable wound to his/her right heel. During an interview on 05/13/15 at 12:40 P.M., LPN A/Charge Nurse said the ADON was the wound nurse and was responsible for assessing, staging, and measuring wounds, but was recently terminated. He/she said after the ADON left they completed skin assessments on all of the residents and found some skin issues that had not been previously identified. LPN A/Charge Nurse said the day shift charge nurses are now responsible for completing the weekly wound reports. He/she said the LPN/MDS Coordinator has been helping with wound documentation and treatments. During an interview on 05/13/15 at 3:45 P.M., LPN B said wound documentation can be found on weekly skin assessment forms. He/she said each shift has specific residents to complete skin assessments on. During an interview on 05/14/15 at 11:15 A.M., the MDS coordinator said the resident's right heel wound started out as a facility acquired stage II blister. He/she said he/she thinks the wound has eschar and is now unstageable. The LPN/MDS Coordinator said he/she either relies on the nurse assessment of wounds or looks at the wounds himself/herself to determine resident's wound status. 6. Review of Resident #4's admission nurse's notes, dated 02/23/15, showed the resident with small scabbed areas to both feet. Review of the resident's Admission MDS, dated [DATE], showed: -Total dependence of two person physical assist for bed mobility and personal hygiene; -Extensive assistance of two person physical assist for toilet use and transfers; -Extensive assistance of one person physical assist for dressing; -Uses a wheelchair for mobility; -At risk of pressure ulcers; -admitted with one stage one pressure ulcer. Review of the resident's care plan dated 03/01/15, showed the resident was admitted with a stage one pressure ulcer from hospital. Review of the care plan showed: -Encourage the resident to turn and reposition every two hours and as needed; -Measure stage one pressure ulcer weekly until healed; -Monitor the resident's skin on bath/shower days and while providing care; -Notify the charge nurse of any new redness or open areas; -Notify physician if stage one pressure ulcer becomes open or if a new pressure ulcer develops; -Provide all treatments as ordered. Review of the resident's nurses' notes, dated 03/08/15, showed staff notified the nurse of skin breakdown to the resident's right heel. Further review showed the right heel contained a pressure ulcer that measured 0.9 cm. X 3.9 cm. X 0.1 cm. with 95% of the wound base intact. The wound also had clear drainage. Staff did not document an assessment of the resident's left foot. Review of the resident's care plan dated 04/03/15, showed the resident with a pressure ulcer to the right heel and top of left foot. Review of the care plan showed -Provide treatment as ordered; -Monitor wound for color, drainage, odor, etc.; -Provide the resident with pressure relief to bilateral heel; -Have mobile wound solutions to evaluate as needed; -Notify mobile wound solutions and physician of any changes to wound. Review of the resident's POS, dated 03/08/15, showed it contained an order to ensure pressure relief boot to right heel while in bed every shift. Review of the resident's POS dated 05/2015, showed the following: -Alevyn dressing to buttocks daily (foam dressing); -Off load pressure to buttocks; -Santyl ointment 30 grams (gm), apply topically as directed once daily; -Right heel: Ensure pressure relief/boot on while in bed every shift; -Right heel: Cleanse with wound cleanser, apply xeroform optiform (non-adhesive), gauze wrap daily and as needed. Review of the resident's TAR dated 05/2015, showed:

Based on interview and record review the facility staff failed to accurately assess pressure ulcers for one resident (Resident #1) ; failed to document a full description of the resident's facility-acquired Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. May also present as an intact or open/ruptured blister) pressure ulcer on the resident's coccyx (tailbone); failed to document weekly wound tracking assessments; failed to document they followed the physician's wound treatment orders for the resident's coccyx and bilateral heel pressure ulcers, and failed to notify the resident's physician when the resident's coccyx wound declined in condition. The facility census was 44. 1. Review of Resident #1's readmission nurses notes dated 05/30/14 at 8:25 P.M., showed licensed staff documented the resident did not have pressure ulcers. Review of the resident's Braden Scale (for predicting pressure sore risk) dated 05/30/14 showed licensed staff assessed the resident as a 17 (at risk for pressure ulcer development). Review of the resident's interim plan of care dated 05/30/14 showed the care plan directed staff to provide the following interventions for the resident: - Provide pressure relief; - Turn and reposition; - Inspect skin according to facility protocol; - Provide incontinent care as needed. Review of the resident's nurses notes dated 06/07/14 at 11:35 A.M., showed licensed staff first documented the resident developed a "new open area" on his/her coccyx which measured 1.45 centimeters (cm) x 0.75 cm x 0.5 cm. Staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. Review of the resident's physician's orders [REDACTED]. - Open area to coccyx: Cleanse area and apply Duoderm (padded dressing for wounds) dressing. Change every third day and as needed for [DIAGNOSES REDACTED]. Review of the resident's nurses weekly skin documentation dated 06/07/14 showed staff documented the resident had a Stage II pressure ulcer on his/her coccyx. Further review showed staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. Staff documented the resident's right and left heels were "soft and red". Review of the resident's weekly wound tracking worksheet dated 06/10/14 showed staff documented the area on the resident's coccyx resulted from "moisture" and measured 1.0 cm x 0.5 cm x 0.1 cm. Staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. Review of the resident's plan of care updated 06/11/14 showed staff documented the resident had a Stage II pressure ulcer on his/her coccyx. Further review showed the care plan directed staff to provide the following interventions for the resident: -Provide the treatment to his/her coccyx as ordered; -Apply heel protectors while in bed; -Assist the resident to turn and reposition every two hours and as needed; -Notify the physician of any skin breakdown; -Complete weekly skin assessments. During an interview on 08/01/14 at 2:30 P.M., the Director of Nursing (DON) said the area on the resident's coccyx looked like something that had been wet too long. He said the wound bed was red with white edges (maceration due to prolonged exposure to moisture) and there was no odor or drainage. Review of the resident's weekly wound tracking worksheet dated 06/18/14 showed staff documented the resident's coccyx pressure ulcer was due to "moisture" and measured 1.0 cm x 0.3 cm x 0.1 cm. Staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. Review of the resident's weekly wound tracking worksheet dated 06/25/14 showed staff documented the resident's coccyx pressure ulcer was "other" and measured 1.2 cm x 0.5 cm x 0.1 cm. Staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. Review of the resident's weekly wound tracking worksheet dated 07/02/14 showed staff documented the resident's coccyx pressure ulcer measured 1.8 cm x 1.0 cm x 0.1 cm. Staff did not document a stage for the wound, wound description to include drainage, odor, color of the wound bed or surrounding skin. During an interview on 08/01/14 at 2:15 P.M., the Assistant Director of Nursing (ADON) said she assumed the role of maintaining the weekly wound tracking worksheets around the time of the 07/02/14 wound report. The ADON said she should have described the coccyx wound better than what she had done. She said she would have staged it as a Stage II pressure sore with a beefy red wound bed, macerated (prolonged exposure to moisture causing the skin to soften and turn white) edges and no drainage or odor. Review of the resident's nurses notes dated 07/07/14 at 3:00 P.M., showed staff documented the resident's coccyx ulcer was "beginning to deepen." Further review showed staff documented the resident's bilateral heels were soft and red with the right heel non-blanching (no blood flow to the area). Staff did not document measurements of the areas to his/her coccyx or bilateral heels. Staff did not document they notified the physician of the resident's coccyx wound becoming deeper. During an interview on 08/01/14 at 2:15 P.M., the ADON said no one reported to her that the resident's coccyx wound was worse. She said the nurse on duty at the time should have notified the physician. Review of the resident's physician's orders [REDACTED]. Review of the resident's treatment record dated 07/07/14 through 07/25/14 showed staff documented a physician's orders [REDACTED]. Further review showed staff did not document they provided the treatment 34 out of a possible 56 times. Review of the resident's weekly wound tracking worksheet dated 07/10/14 showed staff documented the pressure ulcer on the resident's coccyx measured 2.3 cm x 2.8 cm x 0.1 cm. Staff did not document a stage of the resident's coccyx wound, or a wound description to include drainage, odor, color of the wound bed or surrounding skin. Further review of the 7/10/14 wound worksheet showed staff documented an area to the resident's left heel as an "abrasion" which measured 2.5 cm x 2.5 cm x 0.1 cm. Staff did not document a wound description to include drainage, odor, color of the wound bed or surrounding skin. During an interview on 08/01/14 at 2:15 P.M., the ADON said the area on the resident's inner left heel was approximately 2.0 cm round with a tannish/brown center and no odor or drainage. The ADON said the surrounding skin was tough. She said to the best of her knowledge, eschar (dead skin tissue) was black in color. She said if eschar can be tan or brown in color, then she would have to say it was eschar. Review of the resident's physician's orders [REDACTED]. Review of the resident's treatment record dated 07/10/14 through 07/22/14 showed staff documented a physician's orders [REDACTED]. Further review showed staff did not document they applied the treatment eight out of a possible 13 times. During an interview on 08/22/14 at 10:00 A.M., the ADON said the nurse who obtained the resident's [MEDICATION NAME] order just wrote the wrong date down. She said the correct date was 07/10/14. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument dated 07/30/14 showed staff assessed the resident as follows: - Dependent on staff for bed mobility; - Dependent on staff for transfers; - Did not ambulate; - Dependent on staff for locomotion; - Required extensive assistance of staff for dressing; - Required set up assistance of staff for eating; - Dependent on staff for toilet use; - Dependent on staff for grooming; - Frequently incontinent of feces and bladder - (1) Acquired Unstageable pressure ulcer (not stageable due to coverage of wound bed by slough (dead skin tissue separating from living skin tissue) and/or eschar (dead skin tissue). During an interview on 08/06/14 at 1:30 P.M., Licensed Practical Nurse (LPN) A said he/she circled his/her initials 07/21/14 and 07/22/14 on the resident's treatment record for the [MEDICATION NAME] treatment to the resident's coccyx because they did not have the [MEDICATION NAME]. LPN A said he/she was not sure if staff notified the physician. Review of the resident's nurses notes dated 07/16/14 (no time documented) showed staff documented the resident had "a large open area" on his/her coccyx with "two small areas starting to open". Staff did not document wound measurements or a wound description to include drainage, odor, color of the wound bed or surrounding skin. Review of the facility's weekly wound tracking worksheet manual showed staff did not document they completed a weekly wound worksheet for 07/16/14. During an interview on 08/01/14 at 2:15 P.M., the Assistant Director of Nursing (ADON) said she was responsible for the weekly wound tracking worksheets. She said she could not find the 07/16/14 weekly wound tracking worksheet. The ADON said she just "did not get it done that week." During an interview on 08/01/14 at 2:30 P.M., the Director of Nursing said he could not find the weekly wound tracking worksheet to cover the 07/16/14 period of time. He said the Assistant Director of Nursing was responsible for keeping the weekly tracking worksheets current. Review of the resident's nurses notes dated 07/17/14 at 11:45 A.M., showed staff documented they completed the treatment as ordered. Staff recorded increased tunneling (channels extending from the central injury into the surrounding tissue) noted. (Staff did not previously document they assessed tunneling of the wound). During an interview on 08/01/14 at 12:45 P.M., the Director of Nursing said he was not informed of the increased tunneling of the resident's coccyx wound. He said the nurse should have notified the physician to see if a new treatment was in order. Review of the resident's nurses notes dated 07/22/14 at 5:00 P.M., showed staff documented the nurse on duty notified the Assistant Director of Nursing to assess the resident's coccyx wound because he/she stated, "I think it is worse." Staff documented upon inspection it was noted an approximately 10.0 cm x 6.0 cm leathery skin on coccyx noted with several small open areas surrounding area. Staff documented the wound had a foul odor. Staff documented an approximate 1.0 cm x 1.0 cm open "hole" in the center of the coccyx wound. Staff documented they notified the physician who ordered antibiotics. Review of the resident's physician's progress notes dated 07/22/14 showed the physician documented the resident was non-compliant with staying off buttocks or getting out of bed. Review of the resident's nurses notes dated 07/25/14 at 11:00 P.M., showed staff documented the resident was resting in bed. Staff documented the resident was incontinent of feces which soiled his/her coccyx wound and needed his/her treatment to his/her coccyx reapplied. Staff documented the resident's coccyx site was "very greenish" in color. Staff documented the resident had very dark loose stools. Staff recorded the resident appeared weak. Staff documented the resident complained of pain and was administered a [MEDICATION NAME]. Review of the resident's nurses notes dated 07/26/14 at 2:30 A.M., showed staff documented the resident was resting in bed with an axillary (underneath the armpit) temperature of 100.1 and oxygen saturation (amount of oxygen in the blood) of 88-89% (normal is 90-100%). Staff documented the resident was still in pain. Staff documented the resident requested to be sent to the hospital. Staff documented the resident's responsible party and physician were notified and they sent the resident to the hospital. During an interview on 08/06/14 at 5:30 P.M., LPN B said he/she was the nurse on duty the night of 07/25/14 when the resident was sent to the hospital. He/she said he/she only worked on two nights per week, but the resident's coccyx wound had gotten so much worse in the week's time since he/she had last seen the resident. LPN B said when he/she reapplied the resident's treatment to his/her coccyx, and the resident was in "so much pain" he/she had to give the resident [MEDICATION NAME] (narcotic pain medication) before he/she could finish the treatment. LPN B said the resident's bilateral heels were red, mushy and purplish. LPN B said the resident's hips both were starting to show signs of skin breakdown with some reddish and blotchy coloring. LPN B said the resident could not hold a conversation, was lethargic, "looked bad" and he/she knew he/she needed to send the resident to the hospital. Review of the resident's hospital admission record dated 07/26/14 showed hospital staff documented the resident was admitted with a Stage II-Stage III (full thickness tissue loss. Subcutaneous (tissue underneath the top layer of skin) fat may be visible but bone, tendon or muscle is not exposed) sacral (area above the coccyx) decubitus ulcer and bilateral heel [DIAGNOSES REDACTED] (redness). Review of the resident's hospital record dated 07/28/14 showed staff documented the following wounds: - Wound #1: Sacral 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) pressure ulceration post debridement (to remove dead, damaged or infected tissue) which measured 10.0 cm x 9.0 cm x 6.0 cm post debridement. Undermining (wound bed open under the lip of the wound) at 12 o'clock was 7.0 cm. Undermining at 3 o'clock was 5.0 cm. Undermining at 6 o'clock was 1.0 cm. Undermining at 9 o'clock was 4.0 cm. Staff recorded the would was 95% remaining slough. Staff documented there was minimal pink tissue visible, 5% with serosanguinous (watery bloody) drainage and a musty odor. Staff documented the physician was unable to remove all of it due to the patient being in pain; - Wound #2: Right hip deep tissue injury (pressure related injury to the skin with no open areas). Staff documented the wound measured 9 cm x 0.1 cm. Staff documented the wound was purple in color with nonblanchable [DIAGNOSES REDACTED], 100% of the wound base; - Wound #3: Right medial plantar foot (bottom of inner heel) wound was 2.0 cm x 2.0 cm blister, Stage II pressure ulcer. No open areas noted; - Wound #4: Right medial heel (inner heel) wound was 2.0 cm x 2.0 cm blister, Stage II pressure ulcer. No open areas noted; - Wound #5: Lateral heel wound was 4.0 cm x 4.0 cm, healing deep tissue injury. No open areas noted; - Wound #6: Left medial heel wound was 4.0 cm x 4.0 cm, healing deep tissue injury. No open areas noted; - Wound #7: Left lateral heel wound was 3.0 cm x 2.0 cm blister, Stage II pressure ulcer. During an interview on 08/01/14 at 2:45 P.M., the ADON said the resident was non-compliant with getting up out of bed for meals. The ADON said the aides would turn and reposition him/her but then he/she would roll onto his/her back because it was his/her preference. The ADON said the resident would refuse to allow the aides to clean him/her up. The ADON said the resident would refuse to keep his/her heel protectors on. During an interview on 08/06/14 at 1:30 P.M., the administrator said if the staff ran out of supplies they should have notified the pharmacy or the doctor to see if other orders might be obtained. The administrator said she expected staff to document full descriptions of wounds. She said she expected staff to document treatments were done as per the physician's orders [REDACTED]. MO 080 MO 145

Based on observation, interview and record review, facility staff failed to follow physician's orders to treat an existing Stage II pressure ulcer (a partial thickness loss of the dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy at times); may also present as an intact or open/ruptured blister) for one resident (Resident # 4) which developed into a Stage III pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible 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) and developed a wound infection. In addition, facility staff failed to place heel protectors as ordered on two of five residents (Residents #1 and #5) who were identified by the facility as at risk for skin breakdown. The facility census was 41. 1. Review of Resident #4's Braden Scale (assessment used to predict a person's risk of developing a pressure ulcer), dated 8/28/13, showed staff assessed the resident scored a 15 (at mild risk of developing pressure ulcers). Review of the resident's admission nurses' notes, dated 8/28/13, showed staff documented the resident admitted to the facility at 3:30 P.M.. Review showed the resident had a Stage II right heel pressure ulcer that measured 3.5 centimeter (cm) by 5.5 cm, a pink wound bed, and did not have drainage. Review of the resident's Physician's Order Sheet (POS), undated, showed the following: - On 8/28/13, the physician directed staff to apply waffle boots ( helps relieve heel pressure) if the resident will tolerate, if not float heels and low air loss mattress; - On 8/28/13, the nurse practitioner (NP) directed staff to cleanse the resident's right heel wound with wound cleanser, apply [MEDICATION NAME] (helps hydrate dry wounds and maintain an optimal moist wound healing environment), apply [MEDICATION NAME] (an absorbent foam dressing) and wrap with Kerlix (gauze roll wrap) and change daily; - On 8/29/13 the physician directed staff to apply air boots (helps relieve heel pressure) to the resident's bilateral feet; - On 9/3/13 the physician directed staff to change the right heel dressing to [MEDICATION NAME] (a bandage that absorbs fluids from a wound, but is coated with a substance that prevents the bandage from adhering to the wound that could result in a disrupted healing process) and Kerlix and change daily. Review of the resident's Treatment Administration Record (TAR), undated, showed the following: - Staff documented an order from 8/28 to cleanse the resident's right heel wound with wound cleanser, apply [MEDICATION NAME], cover with [MEDICATION NAME] and wrap with Kerlix and change daily. Review showed staff did not document a dressing change on 8/29/13 or 8/30/13; - Staff documented an order, undated, to change the resident's right heel treatment to [MEDICATION NAME] and gauze wrap and change daily. Staff documented they completed this treatment on 8/29/13, 8/30/13, and 9/1/13 (before the physician gave this order). Staff failed to document they performed the treatment on 9/4/13, 9/5/13, 9/6/13, 9/7/13, 9/8/13, 9/11/13, 9/18/13 and 9/20/13 (a total of eight times). Review of the resident's History and Physical, dated 8/29/13, showed the resident's physician documented the resident had a Stage II pressure ulcer to the right heel, [MEDICAL CONDITION] of the lower extremities, and [MEDICAL CONDITION]. Review of the resident's progress note, dated 9/3/13, showed the resident's physician documented the resident had a Stage II pressure ulcer to the right heel. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/4/13, showed staff assessed the resident as follows: - Cognitively intact; - Required extensive assistance from two staff for bed mobility, transfers, toilet use and personal hygiene; - Impaired range of motion to one side of the lower extremities; - Occasionally incontinent of bladder; - diagnosed with [REDACTED]. - Stage II pressure ulcer. Review of a wound assessment, dated 9/4/13, showed staff documented the resident had a pressure ulcer on the right heel that measured 2.5 cm by 3.0 cm with a depth less than 0.1 cm, was pink, and did not have drainage. Review of a weekly skin assessment, dated 9/9/13, showed staff documented the resident's "skin is intact". Review showed staff did not document the resident had any wounds. Review of a wound assessment, dated 9/11/13, showed staff documented the resident had a pressure ulcer on the right heel that measured 2.0 cm by 3.0 cm with a depth less than 0.1 cm, was pink, and did not have drainage. Review of the resident's progress note, dated 9/12/13, showed the resident's physician documented the resident had a Stage III pressure ulcer to the right heel. Review of the resident's POS, undated, showed the resident's physician wrote orders dated 9/12/13 that directed staff to "please keep dressings on right heel" and "please follow wound care instructions". Review of the resident's care plan, dated 9/17/13, showed staff assessed the resident had an open areas to his/her right heel. Review showed the resident had a low air loss mattress. Review showed the care plan directed staff to do the following: - Assist with repositioning every two hours and as needed; - Apply waffle boots; - Apply treatment to right heel as ordered; - Complete a weekly skin assessment; - Obtain and monitor lab work as ordered by physician and notify physician of lab results; - Provide limited assistance with bed mobility and personal hygiene; - Provide extensive assistance with transfers, toileting, bathing and locomotion. Review of the resident's progress note, dated 9/20/13, showed the resident's nurse practitioner (NP) documented the resident's right heel had an open area with slough mixed with pink granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal) and had serous (clear yellowish fluid) drainage through the [MEDICATION NAME] into the gauze wrap. Review of the resident's POS, undated, showed the resident's physician wrote an order dated 9/20/13 that directed staff to obtain a culture and sensitivity (a test to detect and identify bacteria or fungi that may be infecting the skin or a wound and the medication the bacteria or fungi is susceptible or resistant to) of drainage from the resident's right heel. Review of a right heel wound culture, collected on 9/20/13 with results reported on 9/23/13 at 8:09 A.M., showed the wound had a "large number" of [MEDICAL CONDITION] (MRSA) (a bacterium responsible for difficult-to-treat infections in humans). Review showed at the bottom of the lab report, staff wrote they did not notify the resident's physician of the lab results until 9/30/13 at 4:15 P.M.. Review of the resident's TAR, dated 9/21/13 through 10/21/13, showed the following: - an order for [REDACTED]. Review of a wound assessment, dated 9/25/13, showed staff documented the resident had a pressure ulcer on the right heel that measured 2.0 cm by 2.0 cm with a depth less than 0.1 cm, was pink, and did not have drainage. Observation on 09/27/13 at 8:00 A.M., showed the resident lay in bed. Further observation showed he/she did not have his/her air boots (heel protectors) on as ordered. Observation on 09/27/13 at 9:45 A.M., showed the resident lay in bed. Further observation continued to show he/she did not have his/her air boots on as ordered. Observation on 09/27/13 at 11:15 A.M., showed the resident lay in bed. Further observation continued to show he/she did not have air boots on as ordered. Licensed Practical Nurse (LPN) B removed the Kerlix and [MEDICATION NAME] from the resident's right foot. Observation of his/her right heel showed a Stage III pressure ulcer which was approximately the size of one-half dollar. The wound bed was red with granulation mixed with strings of yellow colored slough. During a phone interview on 10/16/13 at 1:40 P.M., Certified Nurse Aid (CNA) D said staff were directed to put air boots on the resident when he/she is in bed. During a phone interview on 10/16/13 at 1:45 P.M., LPN E said staff were directed to put air boots on the resident when he/she is in bed. During a phone interview on 10/16/13 at 3:30 P.M., the DON said staff were directed to put air boots on the resident when he/she is in bed. Review of the resident's progress note, dated 9/30/13, showed the resident's NP documented the resident's right heel had an open area with cream colored slough on the wound base and an increase in serous drainage. Review of the resident's POS, dated 9/21/13 through 10/20/13, showed the resident's physician wrote the following orders dated 9/30/13: - Staff to "call wound culture and sensitivity results" of the resident's right heel to him/her "today, test ordered 9/20"; - Bactrim DS (double strength) (an antibiotic) by mouth twice daily for 10 days. Review of a wound assessment, dated 10/2/13, showed staff documented the resident had a pressure ulcer on the right heel that measured 1.5 cm by 2.2 cm with a depth less than 0.1 cm, was pink, and did not have drainage. Review of the resident's progress note, dated 10/2/13, showed the resident's physician documented the resident had a Stage III pressure ulcer to the right heel that was infected [MEDICAL CONDITION]. Review of the resident's POS, dated 9/21/13 through 10/20/13, showed the resident's physician wrote the following orders: - An order dated 10/2/13 that directed staff to change the right heel dressing to [MEDICATION NAME] (a medicated dressing which absorbs drainage to clean the wound bed and reduces the amount of bacteria on the wound surface), [MEDICATION NAME], and Kerlix and change daily; - An order dated 10/5/13 that directed staff to continue to give the resident Bactrim DS twice daily through 10/15/13 and culture the right heel pressure ulcer on 10/18/13. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review showed staff did not document they gave the resident two doses of Bactrim on 10/8/13 (the evening dose) and 10/11/13 (the morning dose). Review on 10/9/13 of the resident's TAR, dated 9/21/13 through 10/21/13, showed the following: - Staff continued to document the treatment of [REDACTED]. - Staff documented an order, undated, to change the resident's right heel treatment to [MEDICATION NAME] and Kerlix and change daily. Staff documented they did not administer this treatment on 10/5/13, 10/6/13, 10/7/13, 10/8/13, and 10/9/13. Staff did not document they did any dressing change on these dates or on 10/3/13. On the back of the TAR, staff documented on 10/5/13 and 10/6/13 the [MEDICATION NAME] was not available. Review of a weekly skin assessment, dated 10/8/13, showed staff documented the resident's right heel was open and [MEDICATION NAME] was unavailable. Staff documented they cleansed the wound with soap and water and covered it with [MEDICATION NAME] and Kerlix. Observation on 10/9/13 at 1:45 P.M., showed LPN B removed the resident's right house shoe. The right house shoe had brownish drainage absorbed into the shoe. LPN B removed Kerlix from the resident's right foot and [MEDICATION NAME] from the resident's right heel. The [MEDICATION NAME] had yellow drainage on it. The pressure ulcer on the resident's right heel measured 1.2 cm long by 2.0 cm wide and was pink with yellow drainage in it. LPN B said the wound was a Stage II pressure ulcer. LPN B put [MEDICATION NAME] on the resident's right heel wound and wrapped Kerlix around the resident's right foot. LPN B put the resident's right house shoe that had drainage in it back on the resident's foot. During an interview on 10/9/13 at 2:15 P.M., LPN B said the following: - He/she monitored resident's wounds. He/she measured the residents' wounds and performed treatments every Wednesday; - The facility did not have the [MEDICATION NAME] dressing the resident's physician ordered on [DATE] for the resident's right heel wound; - He/she was unsure why staff did not transcribe the 10/2/13 treatment change from [MEDICATION NAME] to [MEDICATION NAME] to the TAR until 10/5/13. This resulted in staff performing a discontinued treatment on 10/4/13 and 10/5/13; - He/she was unsure what treatment other staff performed on the resident's right heel wound after 10/5/13 since staff did not document any treatment, but he/she put just [MEDICATION NAME] and Kerlix on the wound on the days he/she did the treatment (10/8/13 and 10/9/13); - He/she was unsure if staff notified the resident's physician the facility did not have [MEDICATION NAME] and was not completing the resident's ordered treatment. He/she did not notify the resident's physician of this. If staff did notify the resident's physician of this, it should be documented in a nurse's note; - The resident had an infection to the right heel pressure ulcer and was on antibiotics for the infection; - The resident's TAR did not include the physician's order for air boots, but staff should have put it on the TAR. During an interview on 10/9/13 at 3:00 P.M., the Director of Nurses (DON) said the following: - The nurses are directed to monitor lab results, but there was no specific system in place to do so; - Staff did not notify her they did not have [MEDICATION NAME] the resident's physician ordered on [DATE], and if staff had let her know she would have gotten the [MEDICATION NAME] from a different pharmacy; - She was unsure why staff did not transcribe the 10/2/13 treatment change from [MEDICATION NAME] to [MEDICATION NAME] to the TAR until 10/5/13, but thought it may be because staff did not have the [MEDICATION NAME]; - She was unsure if staff notified the resident's physician the ordered treatment of [REDACTED]. If staff did notify the resident's physician, it should be documented in a nurse's note; - If staff failed to document a treatment, it meant they did not perform the treatment. Review of the resident's progress note, dated 10/10/13, showed the resident's NP documented the resident's right heel wound had an open, pink and moist wound base. Review showed the NP documented "discussed with nursing to put dressing on immediately after bathing as NO dressing was in place at time of exam and sock and slipper with drainage noted". Review of the resident's progress note, dated 10/14/13, showed the resident's NP documented the resident's right heel wound had an open, pink and moist wound base. Review showed the NP documented "discussed with nursing need to change dressing daily, date on dressing 10/12". Review on 10/15/13 of the resident's TAR, dated 9/21/13 through 10/21/13, showed staff failed to document they completed the [MEDICATION NAME] and Kerlix dressing change to the resident's right heel wound on 10/13/13. During a phone interview on 10/15/13 at 2:25 P.M., the resident's physician said the following: - The resident's right heel pressure ulcer was a Stage II pressure ulcer when the resident came to the facility but developed into a Stage III pressure ulcer at the facility; - Staff were supposed to ensure the resident wore air boots when the resident was in bed and in the wheelchair; - Staff should have notified him/her of [MEDICAL CONDITION] positive wound culture of the resident's right heel wound on 9/23; - He/she went to the facility on [DATE] and the wound culture results were not in the resident's chart so he/she wrote an order for [REDACTED]. - The reason he/she changed the right heel pressure ulcer treatment from [MEDICATION NAME] to [MEDICATION NAME] on 10/2/13 was because the wound had drainage and was "wet" and [MEDICATION NAME] helps moisten wounds and [MEDICATION NAME] helps to dry wounds; - Staff did not notify him/her they were not doing the resident's ordered treatment of [REDACTED]. - The staff not doing the ordered treatments contributed to the resident's right heel pressure ulcer infection; - He/she observed "multiple times" the resident did not have a dressing on his/her right foot pressure ulcer and the wound was directly touching the house shoe. The resident's house shoe had drainage in it and the resident's heel wound was macerated (when skin is consistently wet, the skin softens, turns white, and can easily get infected with bacteria or fungi); - He/she did not think the antibiotics would resolve [MEDICAL CONDITION] infection in the resident's right heel wound as long as staff continued to put the resident's right foot in the house shoe that contained wound drainage. During a phone interview on 10/15/13 at 3:15 P.M., the resident's NP said the following: - Staff did not notify him/her they were not doing the resident's ordered treatment of [REDACTED]. - He/she made "several" observations where the resident did not have a dressing on his/her right foot pressure ulcer; - He/she saw the resident on 10/14/13 and the dressing on the resident's right heel was dated 10/12/13 (ordered to change daily). During an interview on 10/15/13 at 1:00 P.M., the Director of Nursing (DON) said she expected staff to follow physician's orders. 2. Review of Resident #1's plan of care dated 04/18/13 showed staff recorded the resident was at risk for skin breakdown due to decreased mobility, incontinence, diabetes mellitus, obesity and [MEDICAL CONDITION]. Further review showed the care plan directed staff to provide the following interventions for the resident: - Float his/her heels while in bed (prevent pressure to the heels). Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 07/17/13 showed staff assessed the resident as follows: - Confused; - Dependent on staff for personal hygiene, transfers, locomotion and toilet use; - Required extensive assistance of staff for dressing; - Required limited assistance of staff for bed mobility; - [DIAGNOSES REDACTED]. - Continent of bowel and bladder. Review of the resident's physician's orders dated 09/20/13 showed his/her physician ordered staff to place heel protectors on the resident while in bed. Review of the resident's Braden Scale assessment (scale used by the staff to show residents at risk for pressure sore development) dated 09/20/13 showed staff scored his/her as a 13 (total score of 13-14 showed moderate risk for pressure sores). Observation on 09/27/13 at 5:15 A.M., showed the resident lay in bed. Further observation showed he/she did not have heel protectors on his/her feet or heels floated to prevent pressure sores. Observation on 09/27/13 at 7:00 A.M., continued to show the resident lay in bed without heel protectors on his/her feet or heels floated. Observation on 09/27/13 at 10:25 A.M., continued to show the resident lay in bed without heel protectors on his/her feet or heels floated. During an interview on 09/27/13 at 10:25 A.M., Licensed Practical Nurse (LPN) B said staff should apply heel protectors while the resident was in bed. Observations on 10/9/13 at 9:55 A.M. and 10:25 A.M., showed the resident lay in bed on his/her back and did not have heel protectors on. Observations on 10/9/13 at 11:20 A.M. and 11:45 A.M., showed the resident lay in bed tilted to his/her left side and did not have heel protectors on. Observation on 10/9/13 at 1:45 P.M., showed the resident lay in bed on his/her back and did not have heel protectors on. Observation on 10/09/13 at 2:20 P.M., showed the resident lay in bed. Further observation showed he/she did not have heel protectors on his/her feet or heels floated. Certified Nurse Aide (CNA) C said sometimes the resident refused to wear his/her heel protectors. CNA C said he/she was not aware they should float the resident's heels. 3. Review of Resident # 5's Braden Scale skin assessment, dated 09/13/13, showed staff assessed the resident at moderate risk for pressure ulcers. Review of the resident's Physician Order Sheet (POS), dated 09/13/13, showed direction for staff to apply Waffle Boots (soft boots to protect heels) on both feet when in bed and check every shift. Review of the resident's interim care plan, dated 09/13/13, showed direction for staff to apply Waffle Boots on both feet when in bed. Review of the resident's Minimum Data Set (MDS), a federally mandated resident assessment instrument, dated 09/24/13, showed facility staff assessed the resident as follows: - Severe cognitive impairment; - Did not refuse care; - Dependent on one or more staff for dressing, toilet use, personal hygiene, and bathing; - Required extensive assistance of two or more staff for bed mobility and transfers. Observation on 10/9/13 at 10:30 P.M., showed staff entered the resident's room and transferred him/her into bed. Staff positioned the resident on his/her back with his/her heels resting directly on the mattress. Observation also showed the resident's heel protectors lay in a chair across the room. Staff did not apply the waffle boots on the resident's feet before they left the room as directed by the physician and plan of care. Observation on 10/9/13 at 11:25 P.M., showed the resident lay in bed on his/her back and his/her heels rested directly on the mattress. Observation also showed the resident's heel protectors remained in a chair across the room. Observation on 10/9/13 at 12:30 P.M., showed the resident lay in bed on his/her back and his/her heels rested directly on the mattress. Observation showed the resident did not have heel protectors on. During an interview on 10/16/13 at 1:40 P.M., Certified Nurse Aide (CNA) D said staff were directed to put the resident's heel protectors on when the resident was in bed. During an interview on 10/16/13 at 1:45 P.M., Licensed Practical Nurse (LPN) E said staff were directed to put the resident's heel protectors on when the resident was in bed. During an interview on 10/16/13 at 3:30 P.M., the DON said staff were directed to put the resident's heel protectors on when the resident was in bed. MO 255

Based on observation, interviews, and record review facility staff failed to initiate Cardiopulmonary Resuscitation (CPR), for one resident (Resident #3) with a full code status, when they found him/her without vital signs. The facility's census was 42. 1. Review of the facility's "Policy & Procedure Emergency Response," most recently updated on [DATE], showed the following: -Upon discovery of a resident with a medical emergency, the employee responding will initiate the emergency response protocol by assisting the resident into a supine position to determine: a. Responsiveness will be determined by attempting to arouse using verbal (shouting) and/or tactile (sternal rub, shaking) stimuli. b. The code status will be verified. -The first licensed nurse to respond to the scene is responsible for evaluation of the medical emergency and will direct the activities of the emergency response protocol. This licensed nurse will remain with the resident until stable or care is transferred to EMS. -Code status will be identified: if a full code status is identified, CPR will be immediately initiated by an individual with current CPR certification if the resident is evaluated to be in cardiopulmonary arrest. Review of the resident's transfer information from the acute care hospital to the facility on [DATE] showed acute care hospital staff communicated to the facility staff by phone that the resident's code status was "Full Code". Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment instrument used to plan care, dated [DATE], showed staff assessed the resident as follows: -able to understand others and make self understood; -independent with cognitive skills for daily decision making; -required assistance with walking. Review of the resident's most recent physician's orders [REDACTED]. Further Review of the POS [REDACTED]. Review of the resident's medical record for code status, showed a document signed by the resident's Durable Power of Attorney (DPOA) as well as two witnesses on [DATE] indicating: "Yes I do wish CPR efforts in the event of [MEDICAL CONDITION] I agree to full [DATE] protocol and transportation to nearest hospital." Review on [DATE] at 10:30 A.M. of the resident's medical record showed staff placed a green dot sticker on the outside of the resident's medical record next to the resident's name. Observation on [DATE] at 10:30 A.M., showed a green dot sticker on the outside of the resident's room next to the resident's name at the door to the resident's room. During an interview on [DATE] at 11:30 A.M. Registered Nurse (RN) E said, the facility used color coding for Code Status on the chart and on the resident's door. A red dot meant Do Not Resuscitate (DNR), a green dot meant Full Code. RN E said the expectation of Full Code or if the Code Status was not established, was to start CPR and call [DATE]. Emergency Medical Technicians (EMTs) are usually at the facility within six minutes. He/she said he/she was CPR certified. During an interview on [DATE] at 11:40 A.M. Certified Nurse Aide (CNA) H said a green dot means Full Code and a red dot means DNR. He/she said in a Full Code he/she would start CPR, get a nurse and then the nurse takes over and directs everything. He/she said he/she was CPR certified. During an interview on [DATE] at 11:50 A.M. Licensed practical Nurse (LPN) A said, a green dot means Full Code and a red dot means DNR. These dots are on the chart as well as on the room doors. For a Full Code, staff should start CPR and call [DATE] as well as the physician and the family. He/she said he/she was CPR certified. During an interview on [DATE] at 2:00 P.M. the Administrator said, the facility did not require staff to be CPR certified and per policy did not require a CPR certified staff person on duty during all shifts. Review of the resident's nurses' notes, dated [DATE] showed staff did not document any assessment of the resident's mental status other than "alert". Review of the resident's nurses' notes dated [DATE] showed: - 2320 (11:20 P.M.) The director of nursing (DON) recorded staff called him/her to the resident's room - resident found without blood pressure, pulse, respirations. Listened to the resident's chest- no heart rate or respirations. Verified two times, RN and CNA. - 2322 (11:22 P.M.) The DON called (next-of-kin) and left a voicemail on home phone and cell phone. - 2323 (11:23 P.M.) The DON called the resident's other next-of kin, "informed of resident expiring. Informed I am attempting to contact resident's (Power of Attorney). States he/she will continue to try to contact him/her." - 2325 (11:25 P.M.) The DON called resident's physician - left voicemail to call facility. Immediately returned call, informed resident without vital signs, family aware. Order to release body to funeral home of family's choice. The review of the resident's nurses' notes showed staff did not document they reported to the physician or the next-of-kin that staff did not perform CPR and did not call [DATE]. During an interview on [DATE] at 1:40 P.M., the resident's next-of-kin said the resident was typically coherent, so for him/her to be confused was different. The next-of-kin said the resident called him/her on [DATE] (unknown time) and said he/she had "a hard time getting his/her head together". The next-of-kin said he/she talked to a nurse and asked her to watch the resident. The next-of -kin said about an hour later he/she went to see the resident and the nurse said the resident was running a little fever. The next-of-kin said his/her sibling talked with the resident on [DATE] at about 9:30 P.M. and the resident seemed more confused. The next-of-kin said the resident was a "Full Code". He/she was admitted to the facility during the first part of [DATE] and it was only these last few weeks staff finally finalized the code status paperwork. The next-of-kin said they had initially filled out the code status paperwork upon the resident's admission, but then something happened to the paperwork and they had to fill it out again. During an interview on [DATE] the DON said he/she worked the night shift of [DATE] because of a "call-in" along with two CNAs. One of the CNAs found the resident unresponsive, about 30 minutes after the CNA had spoken with the resident. The CNA called him/her and he/she responded to the resident's room at about 11:20 P.M. and the resident "was gone". The resident did not have vital signs and was "cool to the touch". The DON said he/she called the resident's physician, but did not recall exactly what he/she said to the physician. The DON said he/she looked for the resident's code status and did not realize the meaning of the colored dots. He/she said he/she did not know why he/she did not start CPR or call [DATE]. The DON repeated the resident "was cool to the touch" and he/she was unable to clarify the code status. He/she was not CPR certified at this time. During an interview on [DATE] at 11:00 A.M. the facility's Maintenance Director said a green dot meant full code and a red dot meant DNR. He/she said he/she was CPR certified and if he/she should find an unresponsive resident he/she would "yell for the nurse". During a telephone interview on [DATE] at 10:10 P.M. CNA I said he/she came on duty at 10:00 P.M. and spoke with Resident #3 shortly after that while making rounds. The resident told him/her he/she was not feeling good, but did not give anything specific. At about 11:15 P.M. CNA I went back into the resident's room to get the water pitcher and found the resident on the bed and he/she "was dead". There was no pulse, no breathing and he/she was pale. CNA I said he/she called for help and got the charge nurse, RN D. He/she said they did not discuss the resident's code status or wether to do CPR or not. The charge nurse looked through the chart and made phone calls. The CNA said, the facility's code status system was "green dot means Full Code and red dot means DNR". He/she did not remember the color of the dot on the resident's door. He/she said, he/she did not know why they did not do CPR on the resident. The charge nurse tells the CNAs what to do, to start CPR or not. He/she said he/she was CPR certified. During a telephone interview on [DATE] at 10:25 P.M. CNA J said, he/she used to be CPR certified, but let the certification lapse. He/she said he/she did not have much to do with the situation because he/she worked on the other hall. He/she went to help CNA I when he/she found the resident. CNA J said a green dot meant Full Code and red dot meant DNR. He/she did not recall any discussion about starting CPR or not. During an interview on [DATE] at 1:15 P.M. the facility's Medical Director said, his/her expectation was, if a resident wished to be a Full Code, he/she expected staff to start CPR and call [DATE]. He/she said, the decision not to do CPR should be made by a physician not by the nurse on duty. If staff was unable to determine a Code Status or if none was on record, he/she would expect staff to start CPR, call [DATE] and transfer the resident to the emergency room . During a telephone interview on [DATE] at 1:30 P.M. Resident #3's physician said, he/she recalled the nurse calling him/her during the night ([DATE]) telling him/her staff interacted with the resident and the resident had been talking, but when they went back the resident was "dead". The physician said, staff did not call him/her regarding this resident on this date or on preceding days regarding changes in the resident's condition. He/she said, he/she expected staff to have Advance Directives readily available on the chart and the resident's Code Status clear. If a resident wanted CPR, then staff needed to do CPR and call [DATE]. During a telephone interview on [DATE] at 11:30 A.M. the Administrator said the facility's policy regarding CPR and Do Not Resuscitate (DNR) are discussed during the admission process by the admission nurse. Per facility policy, the facility did not require nursing staff to be CPR certified but was required to have at least one person who is CPR trained on duty. Review of an autopsy report, dated [DATE], showed under the heading 'Preliminary Autopsy Diagnosis', "There is no preliminary autopsy [DIAGNOSES REDACTED]. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. A monitoring visit was completed on [DATE]. Based on observation, 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 this time. Staff conducted audits of all medical records for code status documentation on [DATE]. Staff addressed medical records found without code status documentation with phone calls to the resident's next-of-kin beginning [DATE] and planned to continue until all residents' code status had been determined. Staff inserviced nursing staff regarding code status determination and documentation. The charge/admitting nurse will complete the code status documentation upon admission. The ADON or designee will audit all new admissions' medical records within 24 hours for code status documentation completions. Staff planned to inservice all staff prior to their shift and continue until all staff are addressed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D grid 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 the Class I violation. MO 972