Every finding on record at Beauvais Rehab and Healthcare Center

Based on interview and record review, the facility failed to protect one resident from misappropriation of property when Certified Nurse Aide (CNA) A took the resident's debit card to obtain vending machine snacks for the resident and then started to Cash App themself money over a period of two months. The resident (Resident #4) had only given the CNA permission to get him/her snacks. CNA A removed a total of $483.40 from the resident's bank account and then credited the resident $29.40 for a total withdrawal amount of $454.00. The sample was 8. The census was 137.The facility was notified of past non-compliance on 9/10/25. The resident's bank notified the Administrator on 9/8/25 of the suspicious charges. The Administrator, contacted the police and suspended the employee. The facility reimbursed the resident for the full amount on 9/10/25. The employee was terminated. Staff were in-serviced on 9/8/25. This deficiency was corrected on 9/10/25. Review of the facility's Abuse Prevention and Prohibition Program Policy, revised 10/24/22, showed:-Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.-Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. -Screening: The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.-Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation.-Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring.-Investigation: The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.-If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team (the Investigator) to investigate the alleged incident.-Integration with the Quality Assurance and Performance Improvement Program (QAPI). The Administrator will report data concerning abuse, neglect, misappropriation of resident funds, and exploitation to the Quality Assessment and Assurance (QAA) Committee. Review of the facility's Resident Rights Policy, revised 5/1/23, showed:-Purpose: to promote and protect the rights of all residents at the facility.-Policy: All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility including those specified in this policy.-Procedure: State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a residents' right to: Have the Facility manage their funds, upon request; Retain and use personal possessions to the maximum extent that space and safety permit;-Each employee has a duty to read and be familiar with the residents' rights.-Inquiries concerning residents' rights are referred to the Administrator and/or the Director ofNursing Services. Review of Resident #4's medical record, showed:-A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff, dated 4/11/25, showed the resident cognitively intact; -A Brief Interview of Mental Status assessment, dated 8/26/25, showed the resident cognitively intact;-Diagnoses included sleep disorder, muscle weakness, need for assistance with personal care, mood disorder due to known psychological condition with depressive features, difficulty walking, and hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following a stroke;-A progress note dated 9/10/25 at 3:32 P.M., facility administration was notified by bank in regard to alleged misappropriation of funds. Immediate interventions and investigation was initiated. Police notified. DHSS aware. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: The resident has limited physical mobility:--Goal: Remain free from complications related to immobility;--Interventions: The resident is non-weight bearing. Set up assist in motorized wheelchair. Provide supportive care, assistance with mobility as needed;-Focus: The resident has a psychosocial well-being problem related to major depressive disorder (MDD). On 9/10/25, the resident noted to be involved in alleged misappropriation of funds:--Goal: Resident will effectively cope with his/her feelings;--Interventions: DHSS notified, investigation initiated, policy notified. Psychosocial follow-up completed. Review of the Financial Institution's report, dated 9/24/25, showed the eligible adult, Resident #4. The customer reported unauthorized Cash App charges to an employee of the facility, where he/she resides, CNA A. The customer stated he/she uses a wheelchair and has received assistance from this employee when purchasing vending machine items using his/her debit card. Reported this to facility administrator, who came to the branch with a check made payable to our customer for the total amount of Cash App payments ($483.40). This check was then charged back to the account with a stop payment placed on it. Bank did not receive any notice from facility that there might be an issue with this check, and the bank has encouraged our customer to file a police report. During an interview on 9/26/25, the bank representative said the facility put a stop check on the resident's reimbursement of $483.40. They provided a new check on the same day. The first check was dated 9/16/25 and the second check was dated 9/10/25. They were not sure why the first check was stopped or why they provided a second one with an earlier date and later check number. During an interview on 9/26/25 at 3:20 P.M., the Administrator said the reason for the two checks was a mix-up. It was a misunderstanding. He said that corporate sent a check the same day he brought one up to the bank himself. So that is why one had to be stopped because it was a duplicate payment. Review of the resident's Bank Card Dispute Form, dated 7/29/25 through 9/8/25, showed the following withdrawals:-On 7/29/25 Cash App to CNA A $20;-On 7/29/25 Cash App to CNA A $50;-On 9/1/25 Cash App to CNA A $25;-On 9/1/25 Cash App to CNA A $25;-On 9/1/25 Cash App to CNA A $40;-On 9/1/25 Cash App to CNA A $50;-On 9/2/25 Cash App to CNA A $15;-On 9/2/25 Cash App to CNA A $15;-On 9/2/25 Cash App to CNA A $20;-On 9/2/25 Cash App to CNA A $20;-On 9/2/25 Cash App to CNA A $20;-On 9/3/25 Cash App to CNA A $10;-On 9/3/25 Cash App to CNA A $10;-On 9/3/25 Cash App to CNA A $10;-On 9/3/25 Cash App to CNA A $10;-On 9/4/25 Cash App to CNA A $10;-On 9/4/25 Cash App to CNA A $10;-On 9/4/25 Cash App to CNA A $10;-On 9/4/25 Cash App to CNA A $10;-On 9/4/25 Cash App to CNA A $10;-On 9/5/25 Cash App to CNA A $10;-On 9/5/25 Cash App to CNA A $10;-On 9/5/25 Cash App to CNA A $10;-On 9/5/25 Cash App to CNA A $10;-On 9/7/25 Cash App to CNA A $7;-On 9/8/25 Cash App to CNA A $7;-On 9/8/25 Cash App to CNA A $10. Review of the resident's Bank Card Dispute Form, dated 7/29/25 through 9/8/25, showed the following credits:-On 9/5/25 Cash App from CNA A $19.65;-On 9/5/25 Cash App from CNA A $9.75. Review of the facility investigation, showed: -A statement from the Resident, dated 9/10/25, he/she would let CNA A use his/her card to get him/her snacks. He/She does not always get up and needs stuff.-Resident admitted on [DATE]. He/She was alert and oriented with a mild cognitive impairment. He/She diagnoses include diabetes, high blood pressure, hemiplegia (weakness on one side), and mood disorder. -Summary of Findings: On 9/10/25, Resident #4's bank notified the Administration at the facility of potential suspicious activity on the resident's bank account. The bank sent his/her bank ledger that revealed several transactions to CNA A in the amount of $483.00 via Cash App dating back to July 2025 to current. The resident stated he/she did give CNA A permission to utilize his/her debit card to go get him snacks and items from the store and vending machines. CNA A stated he/she did use the resident's card to send money to himself/herself hat was utilized to buy the resident items. CNA A was suspended pending investigation and employment was terminated. Resident #4 will be reimbursed the funds that were utilized in the amount of $483 dollars. The resident educated on the importance of not giving out his/her banking information and/or debit card. Staff in-serviced on misappropriation of funds, resident rights, and not taking money from residents to buy them items. No other items or funds were taken per the resident. Police and Department of Health and Senior Services (DHSS) notified. The resident is alert and oriented. The resident does require assistance to get out of bed. Encouragement and education given to the resident to ask for assistance to get into wheelchair as he/she is able to wheel himself to get the items he/she needs. The resident voiced understanding. Resident #4 consulted with the bank and was advised to shred his/her debit card. The resident did not want another debit card stated he/she would rather utilize cash. Other residents with outside bank accounts were interviewed and family members notified and no other residents were affected. The resident was offered a lock box for his/her personal items and declined as he/she has a drawer with a lock and key.-Interventions: Abuse and Neglect In-Servicing; Misappropriation of Funds In-servicing; Resident Rights In-servicing; CNA A Termination; Resident #4 reimbursed funds; Resident #4 no longer utilizes a debit card; Resident interviews; Psych-social follow up; Resident Audit of Funds. During an interview on 9/23/25 at 1:55 P.M., Resident #4 said the actions by CNA A surprised him/her. He/She gave the CNA permission to get snacks or a soda. Then he/she found out CNA A got money out. CNA A never asked him/her for money. The facility reimbursed him/her for the amount that was taken. Resident #4 said he/she does not have any concerns since the facility reimbursed him/her. During an interview on 9/23/25 at 2:15 P.M., the Director of Nursing (DON) said prior to this incident they had no incidents with CNA A; however, he/she was on settlement agreement with the Employee Disqualification List (EDL). He/She had to do so many hours of training. The facility and the CNA had to sign an agreement. The facility had to do monthly in-service check in's and had to notify the EDL department if CNA A was terminated. The facility emailed them the day he/she was terminated. The settlement agreement did not say why the CNA was on a settlement agreement. During an interview on 9/26/25 at 4:30 P.M., the Administrator said he had zero problems with CNA A prior to this incident. The only thing that came across was the probation with DHSS. The settlement agreement did not say why CNA A was on the settlement agreement, just that he/she could work with the listed provisions. He in-services all his staff frequently about not taking gifts or personal cards or even cash from residents. The facility has activity staff or a designated person handle all the funds to protect the residents. He talked to the resident directly after the incident and reimbursed the resident for the amount that was taken. He talked to CNA A and the CNA just kept saying, I know, I know, I know, I messed up. The CNA would not answer to many questions and would not say he/she was sorry, just kept saying that he/she messed up and should not have done that. 2614335

Based on interview and record review, the facility failed to protect one resident's right (Resident #2) to be free from physical abuse when his/her roommate (Resident #3), who had a history of aggressive behaviors, punched him/her in the face, then displayed a sharp knife and threatened to kill him/her. The sample was 7. The census was 140. The facility was notified of past non-compliance on 6/6/25. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 5/23/25. Review of the facility's abuse prevention and prohibition program revised 10/24/22, showed: -Each resident has the right to be free from mistreatment, neglect and abuse. The facility has zero-tolerance for abuse and neglect. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility screens for potentially abusive residents during the pre-admission process; -The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts; -The facility ensures protection of residents during abuse investigations; -The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental behavior. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/15/25, showed: -Cognitively intact; -Diagnoses included bipolar disorder (a mood disorder characterized by extreme mood swings, ranging from periods of intense elation or irritability (mania) to periods of deep sadness or hopelessness (depression)), anxiety disorder and schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania). Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation. Review of the resident's skin observation, dated 5/22/25 at 10:40 P.M., showed moderate swelling to his/her right eye. He/She refused an x-ray. Review of the resident's progress notes, showed: -On 5/23/25 at 9:55 A.M., a psychosocial assessment was completed on the resident. No signs or symptoms of distress; -On 5/24/25 at 10:08 A.M., the interdisciplinary team met on 5/23/25 to discuss altercation between residents. New interventions put in place. During an interview on 6/3/25 at 10:00 A.M., Resident #2 said he/she was on a one to one observation. The staff member was sitting in the hallway with the door closed. Resident #3 pulled his/her bed next to Resident #2's bed. Resident #3 accused Resident #2 of moving his/her pillow. Resident #2 said he/she did not move the pillow. Resident #3 said Fuck you! I'm a gangster. Don't disrespect me. I'll kill you. Resident #3 punched Resident #2 in the face. Resident #3 pulled out a pocket knife with a black handle and sharp, silver blade. The aide entered the room and yelled He/She has a knife. He/She left the room to get help, then came back. Staff separated the residents. The facility called the police. Review of Resident #3's quarterly MDS dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder, and major depressive disorder. Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation. Review of the facility's investigation, dated 5/22/25, showed: -Summary: Staff responded to an altercation at 10:30 P.M. Resident #3 said he/she moved his/her bed next to Resident #2's bed. Resident #3 was upset about Resident # 2's pillow overlapping on his/her bed. Resident #3 got out of bed, walked around to Resident # 2's bed and was verbally and physically aggressive towards him/her. An altercation occurred. Staff separated the residents. A room search was completed, and contraband was removed from room. Police were called and both residents remained on one to one to ensure protective oversight. Head to toe skin assessments and pain assessments completed on both residents; -Interventions: Immediate separation of residents, de-escalation of situation, psych visit from facility physician requested, police contacted, continuation of enhanced observation, psychosocial follow-up completed, staff in-servicing: abuse/neglect, residents' rights, de-escalation, one to one monitoring and nurse practitioner assessment. Review of the resident's hospital discharge paperwork dated 5/23/25, time unknown, showed the resident was transported to the hospital by the police. The resident said he/she resided in a transitional home and had an altercation with his/her roommate. The resident fell on his/her back during the altercation. The police told him/her, he/she should go somewhere else until the boss arrived at the facility. X-rays completed with no notable findings. The resident was discharged back to the facility. Review of the resident's progress notes, showed: -On 5/23/25 at 9:58 A.M., a psychosocial assessment was completed on the resident. No signs or symptoms of distress; -On 5/24/25 at 10:17 A.M., the interdisciplinary team met on 5/23/25 to discuss altercation between residents. New interventions put in place. Review of the resident's care plan, in use during the survey and revised on 5/25/25, showed: -Focus: The resident had potential to be verbally aggressive toward staff and residents (initiated 4/11/15). On 5/20/25 the resident was verbally aggressive with facility administrator. On 5/22/25 altercation with another resident; -Goal: The resident will verbalize understanding of need to control verbally abusive behavior; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Certified Nursing Assistant (CNA) C's written statement, dated 5/22/25 (time unknown), showed he/she sat outside the residents' room on the 200 hall. He/She heard Resident #2 and Resident #3 fussing at each other. He/She went in the room, and they were fighting. He/She ran down the hall to get help. During an interview on 6/4/25 at 7:54 A.M., CNA B said he/she has worked as needed (PRN) at the facility for two years. On 5/21/25, he/she was assigned to one to one with Resident #3. Another CNA was on one to one with Resident #2. Both CNAs were sitting in the hallway with the door closed. Resident #2 was in bed. Resident #3 went out to smoke and returned to his/her room. Around 10:00 P.M., he/she heard the residents arguing. The CNA on one to one with Resident #2 opened the door and Resident #3 was standing over Resident #2 with a hunting knife in his/her hand. He/She opened the door and yelled down the hall for assistance. Resident #2 fell on top of Resident #3 when staff tried to separate them. The Certified Medical Technician (CMT) took Resident #3 to the dining room. Staff did not find the knife. The police were called and took Resident #3 to the hospital. He/She was only in-serviced on abuse/neglect. During an interview on 6/4/25 at 11:44 A.M., the Administrator said Resident #3 was verbally and physically aggressive prior to the altercation. After the incident, Resident #3 went to the hospital. When staff cleaned out the resident's room they found the knife. It was a pocket knife. The tip was broken, and it did not appear to be new. Resident #3 came back to the facility the next day. He/She was placed on a one to one observation. He/She started yelling and beating on the glass. The police were called, and he/she was arrested for assault. MO00254863

Based on observation, interview and record review, the facility failed to follow up with the facility's primary care physician and/or the resident's Veteran's Affairs (VA) physician to get medication orders after finding filled prescription bottles in the resident's room after he/she returned from an appointment for one out of three sampled residents (Resident #6). Additionally, the facility failed to provide care consistent with professional standards of practice when staff sat in the hallway, outside the residents' room, with the door closed during one-to-one observation. The residents (Resident #2 and Resident #3) had a physical altercation inside their room and Resident #3 displayed a knife and threatened to kill Resident #2. The sample was 7. The census was 140. Review of the facility's Physician Order policy, dated 10/24/22, showed: -Purpose: To ensure that all physician orders are complete and accurate; -The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary; -Whenever possible the Licensed Nurse receiving the order will be responsible for documenting and implementing the order; -Documentation pertaining to physician orders will be maintained in the resident's medical record. Review of the facility's Enhanced Supervision policy, undated, showed: -To initiate enhanced supervision when there is a reasonable assumption that the resident has tried to harm themselves, harm others, expresses suicidal thoughts or intent, or resident has had increased behaviors; -The facility considers enhanced supervision as a means to enhance the oversight of the resident; -Facility staff are educated on the types of enhanced supervision which may include but not limited to the following: -One to one Observation: Staff member will be scheduled to keep resident within line of sight. 1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/25, showed: -Cognitively intact; -Preadmission Screening and Resident Review (PASRR, used to identify individuals who may have serious mental illness (SMI), intellectual disability (ID), developmental disability (DD) or related condition (RC)) showed mental retardation; -No behaviors noted; -Diagnoses included stroke, hemiplegia (complete or sever loss of strength on one side of the body) or hemiparesis (mild weakness on one side of the body) affecting right side of body, traumatic brain injury (TBI, brain injury affecting cognitive physical or psychosocial functions) and needed assistance for personal care. Review of the resident's care plan, undated, showed: -Problem: At risk for impaired cognitive function related to history of cerebral infarction and history of TBI; -Interventions included: Administer medications as ordered; Ask simple yes/no question in order to determine the resident's needs; Use task segmentation to support short term memory deficits. Break tasks into one step at a time. Review of the resident's progress notes, dated 3/2/25 through 6/3/25, showed: -On 5/27/25, at 5:11 P.M., the resident had a physician appointment scheduled for 5/28/25 at 10:40 A.M.; -There was no documentation found showing the resident went to the appointment, when he/she returned from the appointment and if there were any new orders. During an interview on 6/3/25 at 9:25 A.M., the resident said: -He/She had medication from his/her last appointment at the VA and a facility staff person took the filled medication bottles from his/her room; -He/She had not received the medications from the nurses and could not understand why; -He/She kept asking the nursing staff for the medications that his/her VA physician prescribed but they would not administer the medications to the resident; -He/She did not know why; -He/She was constantly itchy, uncomfortable and believed it was due to missing medications; -He/She showed the prescription documents which corresponded to the medications the facility staff removed from his/her room. Review of the prescription documents, showed: -An order dated 5/28/25, for Diphenhydramine (Benadryl, antihistamine) 25 milligram (mg) capsule (cap), take one at night as needed; -An order dated 5/28/25, for Prednisone (decreases inflammation) 10 mg tablets. Take four tablets for seven days; Take two tablets for two days; Take one tablet one day. Start on 5/28/25. Review of the resident's physician order sheet, dated 6/3/25, showed: -An order dated 5/14/25, for acetaminophen extra strength (Tylenol, pain and fever reducer) 500 mg, give two tablets every six hours as needed for pain/discomfort/elevated temperature; -No orders for Diphenhydramine 25 mg or Prednisone 10 mg. Review of the resident's progress notes, dated 3/2/25 through 6/3/25, showed: -No documentation the facility staff found filled prescription bottles in the resident's room and removed them; -No documentation the facility tried to notify the primary care physician (PCP) or VA physician to obtain new orders for the Prednisone 10 mg or Diphenhydramine 25 mg capsules. Observation on 6/4/25 at 8:19 A.M., showed: -The resident was getting help with dressing from Certified Nursing Assistant (CNA) D; -The resident had several small areas of reddened skin on his/her back and shoulders. During an interview on 6/4/25 at 8:36 A.M., Licensed Practical Nurse (LPN) G said: -If residents come in to the facility with medications from home, the hospital or the VA, nursing staff were instructed to remove the medications from the resident's room because the facility can not verify what is actually in the medication bottles, medications are only administered by the facility so they could verify what the resident actually took which reduced the risk of overdose; -The medications were then stored in the medication room and were destroyed by the Assistant Director of Nursing (ADON). Observation on 6/4/25 at 8:40 A.M., of the medication room for the hall in which the resident resided, showed: -There were no medications bottles from other pharmacies found for the resident; -LPN G was not aware of any stored medications from other pharmacies for the resident. During an interview on 6/4/25 at 8:48 A.M., Certified Medication Technician (CMT) E said: -He/She was responsible for passing medications to the resident today and had not passed any medications to the resident yet; -The resident complained of feeling uncomfortable and asks for acetaminophen extra strength every morning and the CMT administers the medication as ordered; -CMT E pulled up the medications scheduled for administration to the resident during the A.M. medication pass and showed there were no orders for Prednisone; -He/She was not aware the resident had an order for Prednisone. During an interview on 6/4/25 at 9:05 A.M. and at 9:15 A.M., ADON F said: -When residents admit with filled prescriptions from the hospital, home, or VA, nursing staff are instructed to remove the medications from the residents room for their safety; -All outside medications are taken to the medication room to get destroyed if they are not able to send the medications home with the residents' family or return unopened bubble packs to the pharmacy for credit to the residents' account. The medications are then reordered from the facility pharmacy and administered to residents by staff; -She tells residents their outside medications will get destroyed by the facility and hopes her nursing staff explains the same to the residents; -She was aware the resident came back with two bottles of medications from the VA and they were removed from the resident's room; -She explained to the resident they had to remove them from his/her possession for his/her safety but would use the medications and administer them to the resident as prescribed; -She gave the two medication bottles to LPN G and asked the LPN to put in the appropriate orders for the Diphenhydramine and Prednisone; -She expected LPN G to get the orders and put them in the resident's electronic medical health record (EMHR); -She tried to call the resident's physician at the VA twice on the day she received the two medication bottles and could not get through; -She asked the resident for the corresponding paperwork from the VA physician and the resident never got back to her. During an interview on 6/4/25 at 9:15 A.M. and at 9:27 A.M., LPN G said: -A CNA gave him/her two medication bottles (Diphenhydramine and Prednisone) after the CNA had found them in the resident's room; -LPN G did not put an order for the medications because he/she did not have the corresponding paperwork from the resident's VA appointment; -He/She asked the resident for the corresponding paperwork to the medications and the resident said he/she would get them from the VA to clarify the orders; -LPN G did not call the resident's physician from the VA; -The resident never got back to LPN G with the appropriate paperwork; -LPN G could not tell when the prescription bottles were filled by the pharmacy, saying they could be a year old; -LPN G pulled the two medication bottles filled by the VA for the resident, one for Diphenhydramine 25 mg and the other for Prednisone 10 mg, and could not located the fill date on the prescription bottles; -The Surveyor showed LPN G the fill date on both medication bottles and the LPN confirmed they were both filled by the VA pharmacy on 5/28/25; -He/She should have documented in the resident's progress notes when the medication bottles were found in the resident's room, what the prescription was on the bottles, contacted either the facility PCP or VA physician to get the appropriate orders, and if there was no response from either physician, he/she should have included that in the progress note and reported it to on-coming nursing staff so they could follow up; -The resident was at risk of suffering complications related to delayed treatment of Prednisone, including but not limited to increased inflammatory response and respiratory depression and was at risk of feeling uncomfortable and itchy with delayed administration of the Diphenhydramine. During an interview on 6/4/25 at 9:22 A.M., ADON F said: -She asked the resident if she could look at the corresponding paperwork to the two medications (Diphenhydramine and Prednisone); -The resident showed ADON F the corresponding paperwork that was in the resident's room which had the orders for both medications; -The resident shrugged his/her shoulders when ADON F asked if the resident remembered her asking for the paperwork sometime last week; -ADON F did not think to call the facility PCP to verify the orders once she had possession of the two medication bottles; -She should have documented in the resident's progress notes when the medication bottles were found in the resident's room, what the prescription was on the bottles, noted the time and results of her calling the resident's VA physician, contacted the facility PCP and if there was no response from either physician, he/she should have included that in the progress note and reported it to on-coming nursing staff so they could follow up. During an interview on 6/4/25 at 1:31 P.M., the Director of Nursing (DON) said: -She expected nursing staff to have knowledge of and to follow facility policies; -If residents came to the facility with filled prescriptions from the VA, she expected nursing to remove the medications from the residents' possession for safety; -She expected nursing staff to follow up with the residents' VA physician to clarify orders and if they were not available, to notify the facility PCP of the situation, noting the prescription and the order on the prescription bottle, get new orders, including to use the medication from the VA until it was empty and then order more from the facility pharmacy if needed; -She expected nursing staff to continue to try to follow up with the VA physician for continuity of care and to ensure the plan of care was followed; -She expected nursing staff to document everything in a progress note in the resident's EMHR, including what medications were found and removed from the resident's room, who they tried to contact and the results of the conversation, including any new orders; -She expected nursing staff to document in progress notes if they were not able to clarify order with the VA physician or facility PCP, including that they reported the same to the oncoming nurse so they could follow up on the situation; -She also expected nursing staff to inform management of the situation immediately so they could ensure it was followed up on and the resident received their medications as per plan of care; -It was not appropriate to depend on or ask a resident to get the corresponding paperwork to medications as residents were not always cognitively able to perform the task and it was the nurses responsibility to do so, not the residents; -It was not appropriate to wait several days to clarify an order from a physician. It was actual non-compliance as nursing staff were not following plan of care or attempting to follow physician orders; -Delaying treatment could put the resident at risk for several different health complications depending on what why the medication was prescribed; -It was not appropriate to destroy any outside medications residents brought in from home, the hospital, or other facility's as medications were very expensive and pharmacies may not fill the prescription again as it was too soon since it was last filled. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included bipolar disorder, anxiety disorder and schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania). Review of Resident #3's quarterly MDS dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder, and major depressive disorder. During an interview on 6/4/25 at 11:44 A.M., the Administrator said on 5/21/25, Resident #2 was on one to one for smoking in his/her room. Resident #3 was on one to one for aggressive/erratic behaviors. Review of the facility's investigation dated 5/22/25, showed: -Staff responded to an altercation at 10:30 P.M. Resident #3 said he/she moved his/her bed next to Resident #2's bed. Resident #3 was upset about Resident # 2's pillow overlapping on his/her bed. Resident # 3 got out of bed, walked around to Resident # 2's bed and was verbally and physically aggressive towards him/her. An altercation occurred. Staff separated the residents; -Staff in-serviced on one-to-one observations. During an interview on 6/3/25 at 10:00 A.M., Resident #2 said he/she was on a one to one. The staff member was sitting in the hallway with the door closed. Resident #3 pulled his/her bed next to Resident #2's bed. Resident #3 accused Resident #2 of moving his/her pillow. Resident #2 said he/she did not move the pillow. Resident #3 said Fuck you! I'm a gangster. Don't disrespect me. I'll kill you. Resident #3 punched Resident #2 in the eye. Resident #3 pulled out a pocket knife. The knife had a black handle and sharp, silver blade. Resident #3 said he would stab Resident #2. The aide entered the room and yelled (He/She) has a knife. He/She left the room to get help, then came back. Staff separated the residents. Review of CNA C's written statement dated, 5/22/25 (time unknown), showed he/she sat outside the residents' room on the 200 hall. He/She heard Resident #2 and Resident #3 fussing at each other. He/She went in the room, and they were fighting. During an interview on 6/4/25 at 7:54 A.M., CNA B said on 5/21/25, he/she was assigned to one to one with Resident #3. Another CNA was on one to one with Resident #2. Both CNAs were sitting in the hallway with the door closed. The residents were on one to one for smoking, therefore, staff did not have to be inside the resident's room. The residents have the right to close their doors. He/She does not like to sit in the resident's room because they have mice. He/She was only in-serviced on abuse/neglect. During an interview on 6/6/24 at 10:10 A.M., ADON A said staff should be within arm's length of the resident during a one to one. It is not appropriate for staff to sit in the hallway, with the resident's door closed. During an interview on 6/4/25 at 1:59 P.M., the DON said staff should always be with the resident during a one to one. They should document what the resident is doing. It is never appropriate for staff to sit in the hallway, with the door closed during a one to one. Staff are supposed to be within arm's length of the resident. During an interview on 6/4/25 at 11:44 A.M., the Administrator said during the one to one, staff are supposed to be within eye sight or arm's length of the resident. It is not appropriate to sit in the hallway with the door closed. MO00254863

Based on interview and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened residents and staff members, and used illicit substances. The resident's behaviors escalated, and he/she punched his/her roommate in the face, displayed a knife and threatened to kill him/her. Additionally, staff did not complete a Pre-admission admission Screening and Resident Review (PASRR) (a federally mandated screening process for individuals with serious mental illness (SMI), intellectual disability/developmental disability (IDD/DD), and/or related condition who apply for or reside in a Medicaid Certified bed in a nursing facility regardless of payment source) when it was determined the resident would be admitted to the facility for long-term care. The sample was 7. The census was 140. Review of the facility's Behavior Management policy, undated, showed: -Purpose: To ensure facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well being meet each resident's needs and include individualized approaches to care; - The concept of behavior management is an interdisciplinary process. The key components of this process are: -Identifying residents whose behaviors may pose a risk to self or others; -Developing individual and practical care strategies based on assessed needs; -Implementing the behavior management program; -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs. -When a resident exhibits adverse behavioral symptoms (crying, yelling, hitting, biting, etc.), licensed nursing staff will document the behaviors in the medical record, noting the time the behavior(s) occur, prior events, possible causal factors and interventions attempted; -Upon observing the adverse behavioral symptom, staff will do the following as indicated: -Ensure the safety of the resident as well as all other residents; -Document notification of the Attending Physician; -Document notification of the resident's family and/or responsible party about the change in behaviors and the Attending Physician's response; -Document the incident on the 24 hour report. -The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed; -Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility; -Nursing staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated: -Date and time of behavior; -Location of resident when the behavior occurred; -Description of the behavior (what the resident said or did and if the behavior intensified); -Non-verbal cues (darting eyes may indicate anxiety or fear, crossed arms may signal withdrawal or fear, and tears may indicate sadness, frustration or fear); -What seemed to cause the behavior; -Any interventions used and their effect; -In assessing the resident for potential causal factors, licensed nursing staff will consider the following factors and document their findings in the medical record: -Physical conditions (pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence); -Environmental conditions (inappropriate room temperature, noise, overcrowding); -Psychosocial or emotional stressors (change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition, financial concerns); -Medical conditions that require treatment (diabetes mellitus, heart disease, chronic obstructive pulmonary disease (COPD), infection, constipation, recent stroke, arthritis); -Mental health conditions, which may contribute to resident's behavior (consider if the resident could be cheeking medications. If a dose adjustment is necessary due to a change in a medical condition, or there has been an increase in the resident's hallucinations and/or delusions). Review of Resident #3's history and physical assessment, dated 1/23/25, showed: -admitted to the hospital on [DATE] for shortness of breath; -He/She smoked 8-9 cigarettes per day; -admitted to using cocaine prior to arrival at hospital; -Urinalysis was positive for cocaine. Review of the resident's social history and initial assessment, dated 2/5/25 at 9:06 A.M., showed: -Reason for admission: Long term care/rehab; -History of drug abuse, blank; -History of smoking, blank; -Anticipated length of stay: Long-term. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident was a smoker; -Goal: The resident will not suffer injury from unsafe smoking practices; -Intervention: Instruct resident about smoking risks and hazards and about available smoking cessation aids. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident can smoke unsupervised. The resident's smoking supplies are stored by staff; -Focus: The resident used oxygen therapy as needed due to congestive heart failure (CHF) and COPD; -Goal: The resident will have no signs and symptoms of poor oxygen absorption; -Intervention: Change resident's position every two hours to facilitate lung secretion movement and drainage; -No documented discharge planning. Review of the resident's progress notes, showed: -On 2/16/25 at 12:08 P.M., the nurse practitioner noted the resident was seen for an initial evaluation following an acute admission [DATE] - 02/03/2025) for acute CHF/COPD exacerbation. He/She presented to the emergency room with shortness of breath, non-productive cough, and substernal chest pain. He/She reported cocaine use the day before. He/She had multiple admissions 7/24/24, 8/24/24, 9/24/24, 12/24/24 for similar concerns; -On 2/19/25 at 2:42 P.M., the Administrator counseled the resident on smoking in his/her room. The resident was informed he/she would be terminated immediately if it happened again. The resident verbalized an understanding. At 2:50 P.M., the social worker talked to resident about smoking in the facility and in his/her room. Social Services informed the resident he/she would be immediately discharged from the facility if he/she did it again. The resident verbalized understanding. Review of the resident's psychiatric notes, dated 2/19/25, showed: -Chief complaint: They don't want to help. I asked them to get me in rehab; -Review of symptoms: Depressed, anxious and irritable; -Feelings: Expressed feelings of helplessness/hopelessness; -Judgement: Poor insight/judgement; -Dangerousness assessment: Danger to self; -Recommendation: Not a good fit for the facility; -Resident made aware if he/she continued to smoke in his/her room, he/she would be discharged ; -The social worker said the resident refused to complete the rehab program. Review of the medical record, showed no documented psychiatric visits for March or April, 2025. Review of the Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/25, showed: -admitted [DATE]; -Moderate cognitive impairment; -Little to no interest in doing things; -Felt down, depressed, or hopeless; -Trouble falling asleep; -Tired and little energy; -Poor appetite; -Trouble concentrating on things; -No behaviors exhibited; -Diagnoses included CHF, COPD, adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania), and major depressive disorder; -No antipsychotic medications. Review of the resident's progress notes, showed: -On 3/20/25 at 2:30 P.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas; -On 3/24/25 (late entry) 8:30 A.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas; -On 4/10/25 at 12:40 P.M., the resident used foul language towards dietary staff, in the dining room. Social services informed the resident if the behavior continued, he/she could not eat in the dining room. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident had potential to be verbally aggressive toward staff and residents (initiated 4/11/15); -Goal: The resident will verbalize understanding of need to control verbally abusive behavior; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the resident's progress notes, showed: -On 4/16/25 at 4:06 P.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas; -On 5/20/25 at 3:16 P.M., the Administrator noted, the resident voiced disapproval regarding an incident with another resident. The resident was caught taking inappropriate pictures of a female staff member and resident. The resident was aggressive. He/She walked around the Administrator's desk, pointed his/her finger in the Administrator's face and said, I will kick your ass. The Administrator tried to redirect the resident. The resident became irate and approached the Administrator briskly with clenched fists. Review of the resident's psychiatric note, dated 5/21/25 (time unknown), showed: -Chief complaint: They moved me down the hall and I don't like that. I want to get out of here; -Review of symptoms: The resident was anxious and notably pissed off; -Interview behaviors: Uncooperative, irritable, negative, hostile and aggressive; -Mood: He/She was angry and tried to control it; -Feelings: Negative feelings evident with hopelessness/helpless; -Insight/judgement: The psychiatrist was notified this date of the resident threatening violence and sexual actions towards residents and staff; -Dangerousness assessment: The resident was a danger to others; -Recommendation: Discharge the resident and request police intervention for threats of dangerousness. Review of the resident's record, showed no laboratory work was completed. Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation. During an interview on 5/23/25 at 2:35 P.M., the Administrator reported the resident had a history of homelessness and incarceration. He/She had been displaying pen behaviors (slang for behaviors often displayed by people who have served time in prison). The resident had an altercation with his/her roommate. He/She was discharged from the hospital back to the facility at 9:00 A.M. The resident was throwing stuff and cornered the Administrator. The police returned to the facility. The police found a crack pipe (used to smoke crack cocaine) with residue, alcohol bottles and cans with holes in them (used to smoke illegal substances). The resident was arrested. Review of the facility's discharge letter, dated 5/23/25, showed: -The facility could not meet the resident's needs; -The resident's presence was a danger to the health and safety of others in the facility; -The resident became irate with a staff member and threw a full urinal- filled with urine into the charge nurse's face. The resident was alert and oriented and showed no regard for what transpired. During an interview on 6/6/24 at 10:10 A.M., the Assistant Director of Nursing (ADON) A said he/she has worked at the facility for three years. He/She assisted with the 200 hall. He/She did not approve referrals. He/She greeted the residents upon arrival to the facility. The resident was admitted for rehab/long-term care. The ADONs read the history and physical prior to admission. He/She was not aware of the resident's substance use. The resident's behaviors were in and out. At baseline the resident was pleasant. His/Her behaviors started two to three weeks after admission. The resident had to be redirected about smoking in his/her room. Staff would give the resident space to calm down. Sometimes he/she would apologize for the behavior. The psychiatrist was in the building often. He/She is not sure if the resident had regularly scheduled visits with the psychiatrist. The resident was placed on one to one observation after the incident with the Administrator. ADON A thinks the interventions the facility put in place worked. During an interview on 6/4/25 at 11:37 A.M., the social worker said the resident was alert and oriented. He/She signed in and out of the building. He/She was admitted due to homelessness. He/She had a substance abuse issue. The nursing department was responsible for addressing his/her substance use issues. The social worker thinks the resident was placed on a one to one after he/she tried to attack the Administrator. The resident was verbally aggressive towards staff prior to the incident. He/She was not present for the resident-to-resident altercation. The police were called, and the resident was escorted to the hospital. The resident returned to the facility and the police were called again. The resident was arrested. He/She thinks the resident was seeing a psychiatrist. She did not know if a PASRR was completed for the resident. Someone from corporate does the referrals. During an interview on 6/4/25 at 1:59 P.M., the Director of Nursing said she has been at the facility for five days. When Resident #3 displayed verbal and physical aggression, the resident's physician and family should have been notified. They should have looked at the resident's meds and adjusted if needed. She would have put the resident on one to one observation and obtained labs. If a resident is using illicit drugs something should have been put in place. The social worker and the nursing department should have worked together to find resources. The substance use issue should have been addressed during the admission assessment. It should have been on the resident's care plan. During an interview on 6/4/25 at 11:44 A.M., the Administrator said he did not know why the resident was admitted to the facility. He did not see the referral. He was not aware the resident was actively using cocaine. The police found drug paraphernalia. He assumed a PASRR was completed for the resident. The facility was trying to find placement for the resident and then everything kicked off. After the resident tried to attack him, he just avoided the resident. It was hard to put interventions in place for the resident, because he/she was non-compliant. The resident was placed on a one to one. He tried to get a psych evaluation, but the resident was very aggressive towards the psychiatrist. The psychiatrist wanted the resident discharged from the facility. The Administrator did not want to discharge the resident to a homeless shelter. MO00254863

Based on staff interview and record review, the facility failed to ensure competencies were completed for Certified Medication Technician (CMT) staff to safely administer medications to residents for 10 (CMT2, CMT3, CMT4, CMT6, CMT8, CMT9, CMT10, CMT11, CMT12, and CMT14) of 10 CMT personnel reviewed. The facility census was 136. Findings include: During an observation on 03/19/25 at 7:34 AM, CMT6 was observed at his medication cart. Multiple medication cups were sitting on top of the cart. Each cup contained medications for different residents. CMT13 looked at the surveyor and then stacked the medication cups, placed them in the medication cart, and locked the cart. During an interview on 03/19/25 at 7:39 AM, CMT6 stated he/she knew it was not policy to prepare the residents' medications in advance. He/She stated he/she had signed the medications as being administered when he/she placed the medications into the medication cups. Review of ten CMT personnel files revealed the file for CMT2, CMT3, CMT4, CMT6, CMT8, CMT9, CMT10, CMT11, CMT12, and CMT14 revealed no documented evidence of medication administration competency checks for the CMTs. During an interview on 03/20/25 at 8:46 PM, the Director of Nursing (DON) stated the onboarding of CMTs included new employee orientation, validated certifications, and background screening. The DON stated CMTs were not required to have medication administration competency completed upon hire. She stated, It is assumed that the CMT has the training when they complete their certification. They are given 3 days of orientation with another CMT or nurse for medication pass. As the DON, it is my job to oversee clinical services here at [NAME].

Based on record review, and interview, the facility failed to ensure binding arbitration agreements were explained in a form and manner that residents understood and that the resident or their representative acknowledged that they understood the agreement for three of three residents (Resident (R) 92, R95, and R189) reviewed for binding arbitration agreements out of a total sample of 48. The facility census was 136. Findings: 1. Review of R92's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/25 and located under the MDS tab of the electronic medical record (EMR), revealed R92 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension, chronic kidney disease, stage 3 type 2 diabetes mellitus and anemia. It was recorded R92 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R92 was cognitively intact. Review of R92's Admission Agreement, located under the MISC (Miscellaneous) tab of the EMR, revealed R92 signed a binding arbitration agreement electronically on 11/21/23. R92's signature was appended to the binding arbitration agreement under the following verbiage: By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement. During an interview on 03/20/25 at 5:58 PM, R92 stated she did not know what a binding arbitration agreement was and did not recall signing one. 2. Review of R95's quarterly MDS, with an ARD of 03/04/25 and located under the MDS tab of the EMR, revealed R95 was admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension, alcohol dependence with alcohol-induced mood disorder, and mild cognitive impairment. It was recorded R 95 had a BIMS score of 15 out of 15, which indicated R95 was cognitively intact. Review of R95's Admission Agreement, located under the MISC tab of the EMR, revealed R95 signed a binding arbitration agreement electronically on 08/11/23. R95's signature was appended to the binding arbitration agreement under the following verbiage: By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement. R95 was unavailable for interview. 3. Review of R189's entrance tracking MDS, located in the EMR under the MDS tab and with an ARD of 02/28/25, revealed R189 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic (congestive) heart failure, unspecified severe protein-calorie malnutrition, and anxiety disorder due to known physiological condition. Review of R189's Admission Agreement, located under the MISC tab of the EMR, revealed R92 signed a binding arbitration agreement electronically on 02/20/25. R189's signature in the binding arbitration agreement was appended to the following verbiage: By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement. During an interview with R189 on 03/20/25 at 6:00 PM R189 stated, No, I did not sign it. I don't know what that is. During an interview on 03/19/25 at 4:41 PM, the Administrator stated he had been in the position for two years and was not the person responsible for presenting and explaining binding arbitration agreements to residents and their representatives, but the people responsible were not available. When asked what an arbitration agreement was, the Administrator stated it had something to do with legal or financial and he knew nothing about them. During a telephone interview with 03/19/25 at 4:57 PM, the regional director of business development (RDBD) stated arbitration was, if there were to be a lawsuit, the attorneys would meet behind closed doors and reach an agreement agreeable to those involved. The RDBD was unaware the facility had any current arbitration agreements. The RDBD was asked if she had ever been responsible for explaining the contents of an arbitration agreement to a prospective resident before they signed. She stated she had. The RDBD was asked if she explained to the residents that they were giving up the constitutional right to a trial, and that they had a right to a neutral venue and neutral arbitrator. She stated she did not know that. The RDBD was asked if she explained that residents have a right to rescind the agreement, she stated they had 30 days to rescind. The RDBD was asked if she was aware the residents have to sign that they understand as well as agree with the agreement. She stated she did not know that and that the current arbitration the facility had to be updated.

Based on observation, interview, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible to 27 of 27 residents and/or visitors who resided on the secure unit. This failure had the potential to allow inappropriate access to resident records. The facility census was 136. Findings include: Review of the facility's policy titled, General Provisions- Medical Records Manual-General, revised 10/24/22, revealed, Active records are to be located in an area not accessible to unauthorized persons. Review of the facility's policy titled, Resident Rights, revised 05/01/23, indicated, . State and federal laws guarantee certain basic rights to all residents in this Facility. These rights include, but are not limited to, a resident's right to . Privacy and confidentiality. Review of the facility's policy titled, Confidentiality of Information and Personal Privacy, revised 10/01/17, indicated, . The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . Access to resident personal and medical records will be limited to authorized staff and business associates . 52126 During an observation on 03/19/25 at 7:39 AM, Certified Medication Technician (CMT) 6 administered medications to R38 in R38's room. The medication cart was located in the dining room. CMT6 left R38's electronic medical records (EMR) open which contained confidential and private medical information visible to any resident or visitor in the dining room. Multiple residents were in the dining room waiting for breakfast. During an observation on 03/19/25 at 7:42 AM, CMT6 administered medications to R123 in R123's room. The medication cart was located in the hallway outside of R123's room. CMT6 left R123's EMR open which contained confidential and private medical information visible to any resident or visitor in the hallway outside of R123's room. Residents were observed walking down the hallway. During an observation on 03/19/25 at 7:53 AM, CMT6 left the medication cart that was located in the dining room. CMT6 left the EMR for all residents on the hall open which contained confidential and private medical information visible to any resident or visitor in the dining room. There were 27 residents located on this hall. During an interview on 03/19/25 at 08:16 AM, CMT6 stated, I didn't realize I was leaving the screen open. During an interview on 03/20/25 at 5:33 PM, the Director of Nursing (DON) stated, The [EMR] screen should be locked when the nurse walks away from the medication cart. There would be privacy concerns if the screen was left open.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure adequate staffing on the fifth floor for four of 18 residents (Resident (R) 138, R97, R75, and R89) reviewed for staffing concerns out of a total sample of 48. This failure had the potential to affect quality resident care. The facility census was 136. Findings include: Review of the facility's policy titled, Nursing Department- Staffing, Scheduling & Postings, revised 10/24/22, revealed, . The facility will employ sufficient nursing staff as determined by resident assessments and individual plans of care . 1. Review of R138's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. Diagnosis included acute respiratory failure. Review of R138's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/25 and located under the MDS tab of the EMR, revealed R138 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 11:39 AM, R138 stated the call light response times were long and could be 40 minutes. She stated they did not come, and she could not breathe. She stated it was taking a long time for a call light response this day and she was blind. During an observation on 03/17/25 at 11:59 AM, R138's call light was on and a staff member (Certified Medication Technician (CMT) 1) on the floor was noted to be talking on the phone through earbuds. During an interview on 03/17/25 at 12:05 PM, CMT1 was seated in the corner and stated she worked at the facility about once a week. She stated she was on break but was going to pass trays once they arrived. During an observation on 03/17/25 at 12:08 PM, the trays arrived on the floor. CMT1 remained talking on the phone and started to pass trays. R138's call remained on. At 12:16 PM, the call light was answered by a different unidentified staff member. The call light was observed to be on from 11:59 AM through 12:16 PM. 2. Review of R97's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included cognitive communication deficit, schizoaffective disorder, mood disorder, neurocognitive disorder with Lewy bodies, Parkinson's disease, dementia, depression, and other seizures. Review of R97's quarterly MDS, with an ARD of 01/09/25 and located under the MDS tab of EMR, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 10:19 AM, R97 stated there were not enough staff on the fifth floor, and there were no staff available on the weekends. Review of R75's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included bipolar disorder, paranoid schizophrenia, anxiety, and the history of falling. Review of R75's quarterly MDS, with an ARD of 02/24/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 10:48 AM, R75 stated they did not have staff at night and the call lights were not answered. Review of R89's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included anxiety, schizophrenia, difficulty in walking, and repeated falls. Review of R89's quarterly MDS, with an ARD of 02/19/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 03/17/25 at 12:11 PM, R89 stated there were not enough staff on the fifth floor. During an interview on 03/19/25 at 5:15 AM, CMT15 stated there were not enough staff on the fifth floor at night. She stated she was usually the only staff on the floor from 11:00 PM- 7:00 AM She stated there was one resident on the floor who had seizures. Review of the February 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had only one staff member, either a CMT or a Licensed Practical Nurse (LPN) on the floor for the 11:00 PM- 7:00 AM shift on the following nights: 02/14/25; 02/15/25; 02/16/25; 02/17/25; 02/18/25; 02/19/25; 02/20/25; 02/23/25; 02/24/25; 02/26/25; 02/27/25. There was no Certified Nurse Aide (CNA) on those shifts. (Eleven nights with one staff member (CMT or an LPN) on the floor) Review of the March 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had only one staff member, either a CMT or LPN, for the 11:00 PM- 7:00 AM shift on the following nights: 03/01/25; 03/02/25; 03/03/25; 03/05/25; 03/10/25; 03/11/25; 03/16/25. There was no CNA on those shifts. (Seven nights with one staff member (CMT or LPN) on the floor) Review of the March 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had no CMT or Licensed Practical Nurse (LPN) coverage for the 11:00 PM- 7:00 AM shift on the following nights: 03/09/25; 03/14/25. The floor was staff with only one CNA. During an interview on 03/20/25 at 10:46 AM, the Scheduler stated she had been in this position for two years. She stated her expectation was to have at least one CMT and one CNA on nights for the fifth floor. She stated the CMT preferred to work by herself. The Scheduler stated the staff were supposed to call off at least two hours before their shift, but they had been calling off less than one hour, at times. She stated they did not tolerate staff talking on their phones during their shifts. She confirmed the missing coverage displayed on the staffing sheets and stated it was due to call-offs. During an interview on 03/20/25 at 12:21 PM, the interim Director of Nursing (DON) stated that for nights, staffing was tricky. She stated that ideally, they should have a nurse and a CNA. She stated if that pattern was not available, then a CMT and the nurse from 400-hall would cover the nursing duties. She confirmed she was aware of a staffing concern. She stated phone usage had been a struggle on the floor and that earbuds were not allowed. M00247452 MO00248617 MO00250713 MO00251444

Based on interview, facility documentation, and facility policy review, the facility failed to ensure eight hours of Registered Nurse (RN) coverage every day of the week for 136 of 136 census residents. This failure had the potential to affect the safety of resident care. The facility census was 136. Findings include: Review of the facility's policy titled, Nursing Department-Staffing, Scheduling & Postings, revised 10/24/22, revealed, . The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days per week, unless a waiver applies . Review of the January 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 01/02/25, 01/09/25, 01/18/25, 01/23/25, 01/27/25, and 01/30/25. Review of the February 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 02/01/25, 02/06/25, 02/10/25, 02/13/25, 02/15/25, 02/20/25, 02/24/25, and 02/27/25. Review of the March 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 03/01/25, 03/02/25, 03/10/25, 03/15/25, and 03/16/25. During an interview on 03/20/25 at 10:46 AM, the Scheduler stated they had some staff currently transitioning to be an RN. She confirmed the lack of RN coverage in the building and stated it was difficult to get RNs. She stated the only RN working in a management role was the Director of Nursing (DON). She also confirmed there was no RN coverage due to call-offs. During an interview on 03/20/25 at 12:21 PM, the interim DON confirmed the lack of RN coverage in the facility. She stated if anything in the facility required an RN then she would handle it. M00247452 MO00248617

Based on observation, interview, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, and expired medications were disposed of and not made available on the medication cart for 4 of 4 medication carts reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications. The facility census was 136. Findings: Review of the facility's policy titled, Storage of Medication, dated 01/2024 revealed, . Medications and biologicals are stored properly, following the manufacturer or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy . if a current order exists . The following observations were made during reviews of medication carts throughout the facility: 1. During a medication administration observation on 03/18/25 at 12:53 PM on the 4th floor with Registered Nurse (RN)1, RN1 administered insulin with HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) insulin pen for R71. The insulin pen was not labeled with open or discard dates. During an interview on 03/18/25 at 12:55 PM, RN1 acknowledged the pen did not have an open date or discard date. When asked how many days after opening before the pen must be discarded, she stated she thought it was 30 days, but was unsure and would ask her supervisor. During a follow-up interview on 03/18/25 at 1:07 PM, RN1 stated her supervisor had confirmed the insulin pen must be discarded 28 days after first use. 2. During a review of the medication cart on the 5th floor on 03/20/25 at 11:07 AM with Licensed Practical Nurse (LPN) 6, the following were observed: a. Novolin N NPH (insulin isophane human) Suspension 100 units/ml vial, received date 12/28/24, with no open or discard dates for R40. b. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) vial received date 11/01/24 with no open or discard dates for R111. c. Basaglar Kwikpen received date 02/27/25 labeled with R138's name, with no open or discard dates. d. Insulin Aspart 100 units per ml pen NovoLOG Pen received date 01/3/25. No open or discard dates for R110. e. Lantus Solostar subcutaneous solution (insulin glargine) received date 03/10/25 with no open or discard dates for R106. f. Lantus Pen with no patient label, no open or discard date. g. Lyumjev KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro-aabc) with an open date of 2/19/25 was on its 29th day, for R75. h. Basaglar Kwik pen insulin glargine subcutaneous solution pen-injector 100 unit/ml (insulin glargine) no open or discard received date 3/15/25 for R97. i. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) received date 12/24/24 for R106. The insulin pen cap had a sticker with a handwritten date 03/15/25 and the first name of R138. j. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) for R138 received date 02/27/25 with no open or discard date. This item was stored in the same bin and was identical in appearance to R106's insulin pen. k. Vial of insulin lispro 100 units/ml received date 8/13/24. Open date 12/09/24 for R106. The discard date would have been 01/06/25, 28 days after the open date of 12/09/24. During an interview on 03/20/25 at 11:33 AM, LPN6 stated, They put the top on the wrong pen, but it is the same medication. The Assistant Director of Nursing/Infection Preventionist (ADON) 4 and the Assistant Director of Nursing/Unit Manager (ADON) 1 joined the conversation on 03/20/25 at 11:35. ADON4 acknowledged the handwritten name of R138 on the cap of R106's single person use insulin syringe could potentially cause a medication error and stated that as a nurse, she would be looking at the pharmacy's printed label, not the handwritten name on the cap. She stated, You read labels, not caps. ADON4 further stated R138 was in the hospital and was unsure of when the two medications were open and when they should be discarded. When asked when the insulin pen for R106 was opened, ADON1 stated it looked like 03/15/25, but was not sure since the open date sticker on R106's medication had R138's handwritten name on it. ADON4 stated the insulin syringes and vials should be labeled with open and discard dates once opened and the seal is broken and that she would discard the medications immediately. 3. The following observations were made in the 4th floor cart with Certified Medication Aide (CMT)2 on 03/20/25 at 12:37 PM: a. Ketorolac eye drops for R24 labeled as open on 01/15/25. No discard date. b. For R87 prednisolone eye drops, no open or discard date. c. Dorzolamide eye drops for R84. Marked opened on 01/16/25. d. Ciprofloxacin Dexamethasone Eye Drops for R107 open 02/08/25, no open or discard date. During an interview on 03/20/25 at 12:42 PM, CMT2 stated she did not know how long it was before the medications must be discarded after opening and did not know why they were not labeled with open and discard dates. 4. Observations during review of the medication cart on the 2nd floor with CMT3 on 03/20/25 at 12:52 PM revealed: a. Latanoprost eyedrops for R5 with no open or discard dates. b. Atropine 1% eyedrops for R13 with no open or discard dates. c. Latanoprost 0.005% for R339, no open and discard dates. d. Insulin pen Lispro opened on 10/30/24 labeled with the name of a resident deceased on [DATE]. The pen cap was handwritten with the name of a resident that had been discharged from the facility on 02/12/25. e. Atropine 1% eye drops for R8. No open or discard dates. During an interview on 03/20/25 at 12:43 PM, CMT3 stated she had been gone for 12 days and all the eyedrops were in the medication cart when she returned to work. She stated she had no idea where some of the residents were and that some were no longer on the second floor, including R339 and R8. 5. The following observations were made of the 1st floor medication cart on 03/20/25 at 1:04 PM with CMT7: a. For R4, prednisolone 1%, no open or discard date. b. For R25 Polymyxin eye drops labeled for use for 7 days. Receive date 02/21/25. no open or discard date. c. For R18 Brimonidine 0.2 eye drops no open or discard date. d. For R65 latanoprost eyedrops expired 11/2/24. e. For R53 Tobramycin eye drops labeled for use for 5 days, received date 2/4/24. No open or discard dates. f. For R65 Dorzolamide eye drops opened 10/1/24 no discard date. g. For R51 sublingual Nitroglycerin expired on 10/01/24. h. For R18 Brimonidine 0.2 eye drops expired 09/12/24. i. For R25 Olopatadine eye drops expired 07/11/24. j. For R65 Brimonidine 0.2 eye drops expired 10/12/24. k. For R51 sublingual Nitroglycerin 0.4 mg expired 11/20/22. l. For R4 Prednisolone expired 08/01/24. During an interview on 03/20/25 at 1:15 PM, CMT7 stated she did not know she had to label eyedrops with date opened and did not know how long it was before they were discarded. During an interview on 03/20/25 at 2:08 PM, ADON4 stated the time limits for eyedrops vary, but they should be labeled with the date opened. ADON4 stated it was her expectation that staff should call pharmacy if they are unsure of duration after opening. She stated some eyedrops are different, and if they are antibiotics, staff should follow the order. ADON4 stated some insulins are good for 30 days, and some are good for 28 days. ADON4 stated staff should follow directions and consult the pharmacy. ADON4 stated it was her expectation that expired and outdated medications should be discarded. During an interview on 03/20/25 at 6:04 PM, the Director of Nursing (DON) stated the standard of care is that insulin pens are good for 28 days, and insulins should be dated the day they are open. The DON stated that expired medications should be discarded, and medications of residents who have been discharged should be removed from the cart and discarded.

Based on observation, interview, and sampling of a meal test tray, the facility failed to ensure food prepared by the facility was palatable for seven of seven residents (Resident (R) 42, R129, R77, R99, R109, R96, and R132) reviewed for palatability out of a total sample of 48. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. The facility census was 136. Findings include: 1. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/25 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated no cognitive impairment During an interview on 03/17/25 at 11:48 AM, R42 stated the food did not taste good, and trying to get an alternative was almost impossible. 2. Review of R129's admission MDS, with an ARD of 02/14/25 and located under the MDS tab of the EMR, revealed R129 had a BIMS score of 14 out of 15 which indicated no cognitive impairment. During an interview on 03/17/25 at 11:48 AM, R129 stated the food was awful, and she did not like it. She stated she did not eat what they served a lot because of it. 3. Review of R77's modification admission MDS, with an ARD of 01/18/25 and located under the MDS tab of the EMR, revealed R77 had a BIMS score of 14 out of 15, which indicated no cognitive impairment. During an interview on 03/20/25 at 12:30 PM, R77 stated the French dip sandwich was bland and had no flavor. He stated the food's flavor was usually not good. 4. Review of R99's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included moderate protein-calorie malnutrition. Review of R99's quarterly MDS, with an ARD of 01/03/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 2:06 PM, R99 stated he did not like the meat and vegetables provided. 5. Review of R109's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included obstruction pulmonary disease. Review of R109's quarterly MDS, with an ARD of 01/02/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 2:09 PM, R109 stated breakfast was cold, and the food was inedible. He stated they had to eat what they gave them, and it was so greasy. He stated he was weak because he could not eat the food and had to buy his own. He stated he was running out of money and felt like he was going to die because the food was so bad. 6. Review of R96's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included moderate protein-calorie malnutrition. Review of R96's annual MDS, with an ARD of 02/20/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. During an interview on 03/17/25 at 2:22 PM, R96 stated the food needed improvement. 7. Review of R132's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included chronic obstructive pulmonary disease. Review of R132's quarterly MDS, with an ARD of 02/28/25 and located under the MDS of the EMR, revealed the resident had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 03/17/25 at 10:10 AM, R132 stated he could not tell if there was a menu, because they served the same food all the time. On 03/20/25, a test tray left the kitchen at 12:00 PM on a cart carrying 49 trays. The last tray was passed at 12:50 PM. The temperatures were taken of the foods on the test tray. The beef dip meat was 110 degrees Fahrenheit (F) and the tater tots measured 110 degrees F. During an interview on 3/20/25 at 4:42 PM, the Dietary Manger (DM) stated she had heard there were resident complaints about the food. She stated some residents asked for more seasoning in the food, but salt and pepper were available on request. She stated the younger residents seemed to be the ones who had more concerns. The DM stated they asked for specific seasonings that the facility did not offer. During an interview on 03/20/25 at 5:33 PM, the Director of Nursing stated she expected that residents would be served food they enjoyed.

Based on observation, interview, record review, and review of facility policies, the facility failed to deliver meal trays in a manner to prevent cross-contamination for seven of 48 sampled residents (Resident (R) 5, R8, R80, R117, R76, R93, and R91) reviewed for infection control, and administer medications in a manner to prevent cross-contamination for four of four residents (R41, R24, R92, and R106) observed during the medication pass observation. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. The facility census was 136. Findings include: Review of the facility's policy titled, Hand Hygiene, dated 10/24/22, revealed . Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy . Facility Staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances . In between glove changes . Hand hygiene is always the final step after removing and disposing of personal protective equipment. VII. The use of gloves does not replace hand hygiene procedures . Review of the facility's policy titled, Personal Protective Equipment - Using Gloves, revised September 2010 revealed, . When to Use Gloves 1. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; 2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.; 3.When cleaning up spills or splashes of blood or body fluids;3.When cleaning potentially contaminated items; and 5. Whenever in doubt . 1. During an observation of the noon meal tray delivery on 03/17/25 beginning at 12:06 PM, Certified Nurse Aide (CNA) 5 pushed the lunch tray cart containing Styrofoam cups and a pitcher of lemonade down hallway 200 and stopped near R5's room. CNA5 poured a cup of lemonade and delivered it to R5's bedside table. CNA5 pushed the bedside table in front of R5. CNA5 exited the room and did not perform hand hygiene. CNA12 followed CNA5 down the hallway pushing the lunch tray cart containing plates of food covered with plastic wrap labeled with each resident's name. CNA12 sorted through plates of food until finding R5's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R5's bedside table. CNA12 moved R5's personal items and cup of lemonade on bedside table to make more room for her meal set up. CNA12 exited the room and did not perform hand hygiene. At 12:09 PM, CNA5 poured a cup of lemonade and delivered it to R8's bedside table. CNA5 pushed the bedside table in front of R8. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R8's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R8's bedside table. CNA12 moved R8's personal items and cup of lemonade on bedside table to make more room for her meal set up. CNA12 exited the room and did not perform hand hygiene. At 12:11 PM, CNA5 poured a cup of lemonade and delivered it to R80's bedside table. CNA5 moved the bedside table in front of R80. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R80's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R80's bedside table. CNA12 moved R80's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene. At 12:14 PM, CNA5 poured a cup of lemonade and delivered it to R117's bedside table. CNA5 pushed the bedside table in front of R117. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R117's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R117's bedside table. CNA12 moved R117's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene. At 12:16 PM, CNA5 poured a cup of lemonade and delivered it to R76's bedside table. CNA5 pushed the bedside table in front of R76. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R76's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R76's bedside table. CNA12 moved R76's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene. At 12:18 PM, CNA5 picked up R93's and R91's plates and two forks from the pile of forks on top of cart. CNA5 stacked the plates with both still covered in plastic wrap on top of another. CNA5 pushed R93's bedside table in front of R93 and moved his personal items on bedside table to make more room for his meal set up. CNA5 removed the plate stacked on top of the other plate and delivered it to R91, setting the plate on R91's bedside table. CNA5 pushed the bedside table in front of R91 and moved his personal items on his bedside table to make more room for his meal set up. CNA5 exited the room and did not perform hand hygiene. CNA12 poured two cups of lemonade and delivered them to R93 and R91's bedside tables. CNA12 exited the room and did not perform hand hygiene. During the continuous observation of the noon meal tray delivery on 03/17/25 from 12:06 PM through 12:18 PM, CNA5 and CNA12 were observed delivering meal trays and drinks to eight residents. The CNAs touched overbed tables and personal belongings with each delivery. The CNAs did not perform hand hygiene during this continuous observation During an interview on 03/17/25 at 12:30 PM, CNA5 stated, Yes, I sanitized my hands, I have it right here in my pocket and use it in between each resident. CNA5 was not able to show the hand sanitizer from her pocket. CNA5 stated, It's missing now, but I only passed two trays down on that hall. When I go into their rooms I wash my hands every single time. I washed my hands when I went back to my hall. During an interview on 03/17/25 at 12:32 PM, CNA12 stated, I'm sorry. I didn't know you were supposed to hand sanitize in between each resident. I was just trying to hurry and get them passed. No, I didn't use hand sanitizer in between passing trays. I'm sorry, but I will do it next time. During an interview on 03/17/25 at 1:12 PM, Assistant Director of Nursing and Infection Preventionist (ADON 4) stated, All the staff know they are required to do hand hygiene before resident care, in between residents, and after residents. We do in-services annually and have the upcoming annual skills fair check-off coming up next month. We do in-services quarterly and monthly as well and always cover infection control in them. We're always going around and doing reminders weekly and daily sometimes so that it's just always in their mind that they need to do it. During an interview on 3/19/25 at 8:41 AM, the Director of Nursing (DON) stated, We are continually doing ongoing education and training on infection control. Staff know to use hand hygiene before, during, and after resident care or whenever they touch any of the resident's personal items. We have a skills fair check-off scheduled for the first week of April for all staff. But we constantly give reminders weekly if not daily sometimes. During an interview on 3/19/25 at 8:42 AM, the Administrator stated, Staff know they should perform hand hygiene, and I will be making sure they all get reeducated again. 30260 2. During medication administration observation on 03/18/25 at 1:07 PM with Certified Medical Technician (CMT)5, CMT5 entered R41's room, gave R41 oral medications in a cup, and exited R41's room without performing hand hygiene. CMT5 returned to her medication cart, touched her computer, dipped her hands in her pocket to retrieve medication cart keys, and opened the medication cart, touching the contents without performing hand hygiene. On 03/18/25 at 1:24 PM CMT5 administered eye drops to R24. On 03/18/25 at 1:31 PM, CMT5 accidentally dropped the eyedrops lid on floor. CMT5 picked up the lid and screwed it back on. When asked, CMT5 confirmed she should have cleaned the lid before putting it back on. During medication administration observation on 03/19/25 at 7:33 AM with Licensed Practical Nurse (LPN)5, LPN5 applied a pair of gloves and administered an insulin injection on R92. LPN5 removed the gloves and failed to perform hand hygiene before touching her computer, pocket, keys, and medication cart. LPN returned R92's insulin vial to the medication cart. At 7:36 AM, without performing hand hygiene, LPN5 applied another pair of gloves and wiped off the glucometer. LPN5 removed her gloves and did not perform hand hygiene. During an interview on 03/19/25 7:38 AM, LPN5 acknowledged she had changed gloves several times without performing hand hygiene between glove changes. During an observation with CMT2 on 03/19/25 at 8:26 AM, CMT administered a Spiriva inhaler to R106 without applying gloves. CMT2 had a cup of water which she stated was for R106 to rinse and spit after using the inhaler. At 8:26 AM, R106 rinsed his mouth with water and spat it out in a cup and gave the cup back to CMT2 who received it with her bare hand. CMT2 discarded the cup and returned to her medication cart without performing hand hygiene and touched her computer and medication cart. During an interview with CMT2 on 03/19/25 at 8:33 AM, CMT2 confirmed that she could have been exposed to R106's fluids and should have worn gloves and performed hand hygiene. During an interview on 03/19/25 at 11:07 AM, the Assistant Director of Nursing (ADON)1 stated staff should perform hand hygiene before entering residents' rooms, should wash their hands before and after applying gloves, and that CMT2 should have been wearing gloves during administration of the inhaler for R106.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the fifth-floor shower room was cleaned as required for one of one resident (Resident (R) 109) reviewed for the environment out of a total sample of 48. This failure had the potential to affect the resident's health and ability to utilize the shower area. The facility census was 136. Findings include: Review of the facility's policy titled, Housekeeping- Restroom and Showers, revised 10/24/22, revealed . Showers . Scrub bathtubs and showers . Review of R109's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. Diagnoses included displaced fracture, chronic obstructive pulmonary disease, chronic respiratory failure, and emphysema. Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/25 and located under the MDS tab of the EMR, revealed R109 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. During an interview on 03/17/25 at 2:09 PM, R109 stated he wished there were better places to take showers because the shower was not clean. During an observation and interview on 03/17/25 at 2:25 PM with the Certified Nurse Aide (CNA) 1, the shower area had orange-colored stains on the lower sides of the standing shower tiles and within the shower grout. CNA1 stated the Housekeepers should have been cleaning the area. During an observation and interview on 03/17/25 at 2:31 PM, the Maintenance Director (MD) stated the orange area was probably soap scum. He stated he did not see why the orange areas could not be removed. During an observation and interview on 03/17/25 at 2:37 PM, Housekeeper (HSK) 1 observed the orange area and stated she did not usually work on the fifth floor. She stated they normally cleaned the shower rooms. During an observation and interview on 03/17/25 at 2:40 PM, Housekeeping Manager (HSKM) stated the shower was supposed to be cleaned every day. She sprayed the orange area and while wiping, it was coming off. She confirmed the area was improving as she sprayed with a chemical and wiped. She stated there was no documentation of the shower rooms being cleaned. She stated it was supposed to be cleaned every day. She confirmed it had been a while since it had been deep cleaned. MO00248617 MO00251444

Based on record review, staff interview, and facility policy, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of change for one of 10 residents (Resident (R) 23) reviewed for significant change assessments out of a total sample of 48. R10 showed a severe weight loss of 11.28% in six months and declined in mobility status that impacted more than one area of the resident's health status. This failure had the potential to cause further decline in the resident's status without further intervention by staff, interdisciplinary review, or revision of the care plan. The facility census was 136. Findings include: Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified . Policy: I. The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment for each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual . Review of R23's undated Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, insomnia, mood disorders, dysphagia, dementia, and depression. Review of R23's annual MDS, with an assessment reference date (ARD) of 12/02/24 and located under the MDS tab of the EMR revealed R23 had not normally used a wheelchair in the last 7 days. Review of R23's quarterly MDS, with an ARD of 02/27/25 and located under the MDS tab of the EMR, revealed R23 had a change and had normally used a wheelchair in the last 7 days. Review of R23's Weights, located in the EMR under the --- tab, revealed R23 weighed 133.0 pounds (lbs) on 08/07/24 and 118.0 lbs on 02/20/25. This constituted an 11.28% severe weight loss in six months. Review of R23's Progress Notes, dated 2/28/2025 at 11:32 AM and located under the Progress Notes tab of the EMR, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 118# 2/20/25, BMI 22.3; +2.3% in 1 month, -11.3% in 6 months. Diet: mechanical soft, super cereal with breakfast, milk/chocolate milk with meals, Magic Cup with lunch. Eats meals in SCU dining room. Ambulates ad lib. Staff reported intake varies and refuses to be fed. Order for weekly weights to follow trend. Receiving supercereal with breakfast, milk/chocolate milk with meals, and Magic Cup with lunch to help increase nutritional intake. Current weight indicates some weight gain x 1 month. Will continue to follow and intervene further prn [as needed]. Review of R23's MDS tab of the EMR revealed no documented evidence a significant change assessment was completed when it was noted the resident had a major decline in nutritional status and a decline in mobility. It was recorded a quarterly MDS, with an ARD of 02/27/25 was completed. During an interview on 03/19/25 at 5:30 PM, the MDS Coordinator (MDSC) stated We have IDT meetings to discuss residents. I would do the significant change assessment within 8 days. Significant change would include significant permanent changes in ADLs [activities of daily living], insurance status changes for hospice, significant weight, mood, and behavior changes. The MDSC stated she was unsure if changes in two care areas were required to qualify for a significant change MDS. During an interview on 03/20/25 at 10:34 AM, the MDSC stated, The weight on 02/20/25 was not within 180 days of the August weight taken on 08/07/25 and was not in compliance per CMS guidelines and therefore does not count. Since the weight taken in August was greater than 180 days, we cannot use it for a significant weight loss.

Based on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two of 48 residents (Resident (R) R23 and R136) whose records were reviewed. This had the potential to cause unmet care needs for the residents. The facility census was 136. Findings include: Review of the facility's policy titled, Assessment and Management of Resident Weights, revised 10/24/22, indicated, . V. Significant Weight Change Management: A. Significant weight changes will be reviewed by the Director of Nursing Services or designated licensed nurse. Significant weight changes are: i. 5% in one (1) month, ii. 7.5% in three (3) months, iii. 10% in six (6) months . Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified . Policy: I. The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment for each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual . 52126 1. Review of R23's Admission Record,, located under the Profile tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, insomnia, mood disorders, dysphagia, dementia, and depression. Review of R23's Weights, located under the Wts/Vitals tab of the EMR, revealed: On 08/07/24, the weight was 133.0 pounds (Lbs). On 01/09/25, the weight was 115.4 Lbs. On 02/02/25, the weight was 118.0 Lbs. Review of R23's Progress Notes, dated 01/20/2025 at 9:24 AM, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 115.4# 1/9/25, BMI 21.8; essentially stable x 1 month, -6.2% in 3 months, -14.3% in 6 months . Review of R23's Progress Notes, dated 02/28/2025 at 11:32 AM, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 118# 2/20/25, BMI 22.3; +2.3% in 1 month, -11.3% in 6 months . Review of R23's quarterly MDS, with an ARD of 02/27/25 and located under the MDS tab of the EMR, revealed the resident was coded to have no weight loss of 5% or more in the last month or 10% or more in the last six months. During an interview on 03/19/25 at 10:34 AM, the MDSC stated, the weight on 02/20/25 for R23 was not within 180 days of the August weight taken on 08/07/25 and was not in compliance per CMS guidelines and therefore did not count. She stated, Since the weight taken in August was greater than 180 days [old], we cannot use it for a significant weight loss. 2. Review of R136's Admission Record, located under the Profile tab of the EMR,, revealed R136 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and chronic kidney disease stage 3. The resident was discharged on [DATE] to home. Review of R136's Order Summary, located under the Orders tab of the EMR, revealed an order dated 12/27/24 to Discharge home 12/28/24 with all belongings including meds. Review of R136's Progress Notes, located under the Prog Notes tab of the EMR, revealed no documentation regarding R136's discharge. Review of R136's Discharge MDS, with an ARD of 12/30/24, located under the MDS tab of the EMR, revealed the resident was coded to have discharged to short-term general hospital. During an interview on 03/19/25 at 5:30 PM, the MDSC stated she was unable to provide an explanation for the discrepancy regarding the discharge status of R136 and stated, The discharge assessment information would have been taken from the [EMR]. During a subsequent interview on 03/20/25 at 10:40 AM, the MDSC stated, [R136] was discharged home and the discharge MDS has been modified.

Based on record review, interviews, and facility policy review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASARR) level one was updated with a new diagnosis after admission for one of two residents (Resident (R) 91) reviewed for PASARR out of a total sample of 48. This failure had the potential to affect the resident's need for any potential additional services. The facility census was 136. Findings include: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), revised 07/27/23, revealed, . The facility also conducts Level 1 screen for current residents who have a mental illness or intellectual disability and experience a significant change in their condition based on MDS [Minimum Data Set] 3.0 guidelines . A negative PASRR Level 1 screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual ability arises later . Review of R91's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. It was recorded that a diagnosis of mood disorder was added on 12/06/23. Review of R91'sLevel One PASARR, located under the Misc section of the EMR and dated 08/02/23, revealed under the section Does the individual have a current, suspected, or history of a Major Mental Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition? There was no documented evidence that R91's PASARR had been updated to include the diagnosis of mood disorder when it was added on 12/06/23. During an interview on 03/19/25 at 9:56 AM, the Social Services Director (SSD) stated she did not do anything regarding PASARRs. During an interview on 03/19/25 at 10:06 AM, the Business Office Manager (BOM) stated she did not do anything regarding the PASARR. She stated the Regional BOM (RBOM) oversaw the PASARR. The BOM called the RBOM, and the RBOM stated the facility usually sent her any changes. The RBOM stated that for a new diagnosis, they would do a duplicate PASARR to add the new diagnosis. She stated it would have been the MDS Coordinator (MDSC) who would have updated her. During an interview on 03/19/25 at 10:41 AM with the Administrator, Interim Director of Nursing (DON), and MDSC, the MDSC stated she did not update the BOM when R91 received the diagnosis of mood disorder. She stated she only updated the diagnosis in the EMR. She stated no one had ever asked her to do anything different. The Interim Director of Nursing (DON) stated she was unsure of who oversaw sending updates to the RBOM. The Administrator stated he thought it would be between Social Services or the BOM.

Based on record review and interview, the facility failed to develop and implement a care plan for a resident's hospice services for one of one resident (Resident (R) 57) reviewed for hospice out of a total sample of 48. This had the potential to cause unmet care needs. The facility census was 136. Findings include: Review of R57's Face Sheet, located in the Profile tab of the EMR, revealed R57 was admitted to the facility on [DATE]. Review of R57's Physician Orders, located under the Orders tab in the EMR and dated 02/07/25, revealed an order for hospice services. Review of R57's Care Plan, located under the Care Plan tab of the EMR and dated 02/07/25, revealed there was no evidence R57 had a care plan developed for hospice services. During an interview on 03/19/25 at 5:29 PM, the MDS Coordinator (MDSC) stated the facility missed developing a care plan for hospice services for R57. She stated updating the care plan to include hospice was missed since the payor type was not updated. During an interview on 03/20/25 at 5:42 PM, the Director of Nursing (DON) stated that a care plan should have been implemented for hospice services.

Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for the use of a helmet related to fall safety for one of one resident (Resident (R) 2) reviewed for Helmet use out of a total sample of 48. This had the potential to increase R2's risk of injury with any fall. The facility census was 136. Findings include: Review of R2's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's with dyskinesia, functional quadriplegia, mood disorder, schizoaffective, paranoid schizophrenia, vascular dementia, intellectual disabilities, and other seizures. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/25 and located under the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. Review of R2's Care Plan, revised 11/29/24 and located under the Care Plan tab of the EMR, revealed R2 wore a helmet for fall safety. It was documented the resident often refused to wear the helmet. Review of R2's Physician Orders, dated 03/20/25 and located under the Orders tab of the EMR, revealed an order dated 11/21/24 for R2 to have a helmet on to prevent major injuries due to continuous falls and to document all refusals in the progress notes. Review of R2's Nurses Notes, dated March 2025 and located under the Prog (Progress) Notes tab of the EMR, revealed no documentation staff offered the helmet to R2 or that he refused to wear the helmet. During observations of R2 on 03/18/25 at 2:35 PM, 03/18/25 at 3:30 PM, 03/19/25 at 5:45 AM, and 03/19/25 at 8:20 AM, R2 did not have a helmet on. During an observation and interview on 03/19/25 at 6:04 AM, Licensed Practical Nurse (LPN)8 stated she just documented No on the treatment record (TAR) when R2 was not wearing the helmet. She stated he had not been wearing the helmet. LPN8 stated she did not know she was supposed to document any refusals in the electronic medical record, LPN8 stated R2 did not have a helmet in his room. She stated she was not sure what happened to it. During an observation and interview on 03/19/25 at 7:28 AM, Certified Nurse Aide (CNA)2 stated he was unsure if R2 was supposed to wear a helmet. He stated he had heard the resident's family talking about it. He stated he had not seen the helmet. CNA2 went into R2's room and checked the room and the closet, but was unable to find a helmet. He stated he thought the family took it home and never brought it back, but he did not notify a nurse. During an interview on 03/20/25 at 5:44 PM, the Director of Nursing (DON) stated she expected staff to follow physician orders. She stated if there was an issue or concern, staff should have contacted the physician and staff should have attempted to locate the helmet.

Based on record review, staff interview, and facility policy review, the facility failed to ensure vision services related to cataract surgery provided for one of two residents (Resident (R) R16) reviewed for vision and hearing services out of a total sample of 48. R16 had a failed appointment for cataract surgery in May of 2024 and the facility failed to reschedule the appointment. This failure had the potential to prevent R16 from living in the highest practicable physical well-being. The facility census was 136. Findings include: Review of the facility's undated policy titled, Care and Services, revealed, Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of R16's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included other specified cataract. Review of R16's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/24 and located under the MDS tab of the EMR, indicated R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R16 was cognitively intact. The assessment indicated R16's vision was adequate without the use of corrective lenses. Review of R16's Care Plan, dated 02/27/23 and located under the Care Plan tab of the EMR, revealed R16 had cataracts, and interventions included, Arrange consultation with eye doctor PRN [as needed]. Review of eye surgery appointment letter located under the Misc (miscellaneous) tab of the EMR revealed R16 was to have laser eye surgery on the right eye on 03/05/24, with post-operative follow-up visits scheduled for 03/07/24 and 03/12/24 respectively. Review of R16's Progress Notes, dated 03/05/24 and found under the Progress Notes tab of the EMR, revealed in part, the resident returned from her eye appointment, did not have cataract surgery done, needs to reschedule because the resident stated the facility needed to send a Hoyer lift machine with her. During an interview on 03/18/25 at 9:39 AM, R16 stated she should have had cataract surgery a year ago, but the facility did not send her again after it did not work out the first time. During an interview on 03/19/25 at 1:25 PM, the 4th floor Unit stated she was not employed at the facility in March of 2024, but was able to find out that R16 needed a Hoyer lift in order to be placed in the chair for surgery at the surgery center in order to undergo the cataract surgery. She stated the surgery center did not have a Hoyer (a mechanical device that allows a person to be lifted and transferred with minimum physical effort) lift or the capacity to lift her into the chair, and the surgery was canceled. When asked why the issue was never revisited and the surgery attempted since last year, she stated she did not know. During an interview on 03/20/25 at 7:30 PM, the Director of Nursing (DON) stated she did not know why the facility did not attempt to reschedule R16's cataract surgery since it was canceled the previous year on 03/05/24.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) R2) reviewed for smoking out of a total sample of 48 did not smoke inside the facility. R2, who was assessed to need supervision while smoking locked himself in his bathroom and smoked. The facility census was 136. Findings include: Review of a facility policy titled, Smoking by Residents, revised April 2024, indicated, . Smoking is not allowed anywhere inside the facility . Residents will be allowed to smoke in designated smoking area(s) only . It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that can occur. For this reason, any violations will result in the following actions: 1. First Offense - Written warning and counseling session with the understanding that continued violation will result in further action. 2. Second Offense - The Facility will notify your attending physician and a care conference will occur to discuss further consequences, which may include discharge to a more appropriate setting. 3. Third Offense - Due to the safety risks posed to Facility Staff and other residents including harboring flammable materials and paraphernalia around medical equipment, the Facility may initiate discharge based on resident safety concerns consistent with state and federal law . Review of R2's Face Sheet located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's with dyskinesia, functional quadriplegia, mood disorder, schizoaffective, paranoid schizophrenia, vascular dementia, intellectual disabilities, and other seizures. Review of R2's quarterly MDS, with an ARD of 01/08/25 and located under the MDS tab of the EMR,, revealed R2 had a BIMS score of six out of 15, which indicated severe cognitive impairment. Review of R2's Care Plan, revised 02/06/24 and located under the Care Plan tab of the EMR, revealed, . Potential for safety hazard, injury related to smoking . Interventions in place were to wear a smoking apron during supervised smoking, smoking only in designated areas, smoking supplies to be stored by staff, to notify charge nurse of violation of facility protocol, and direct supervision by staff when smoking. Review of Progress Note, dated 03/11/25 at 9:02 AM, located under the Prog Notes tab of the EMR, and written by LPN2 revealed, . Resident was observed smoking in his room with his bathroom door locked resident was educated on how important it is to not smoke in his room for safety reason will notify SW [Social Worker] about resident behavior . During an observation on 03/18/24 at 3:30 PM, R2 was observed in the outside smoking area. Staff placed a smoking apron on the resident and provided him with a cigarette. Staff lit the cigarette for R2. Staff then provided R2 with another cigarette. R2 smoked the first cigarette and attempted to light the second cigarette with the lit butt of the first cigarette. Staff took the lit butt from the resident and lit the second cigarette. During an interview on 03/19/25 at 7:28 AM, CNA2 stated that on 03/11/25 he noticed R2's call light was on, and he went into the resident's room, and he observed the resident's bathroom door was closed and locked. He stated he knocked on the bathroom door, and he could smell smoke, but the resident would not open the door. CNA2 stated he had to leave the room and get maintenance to get the master key to unlock the door, but by the time maintenance got back, R2 had unlocked the door. CNA2 stated he could smell the smoke, but he was unable to find the lighter or cigarette. He stated R2 would get cigarettes from other residents. He stated they were supposed to be changing R2's bathroom doorknob to one that did not lock, but it had not been done yet. CNA2 stated he was unsure why the doorknob had not been changed. During an interview on 03/19/25 at 9:52 AM, LPN2 stated that on 03/11/25, CNA2 told her he was knocking on R2's bathroom door because it was locked and CNA2 had reported he believed R2 had been smoking in the bathroom. LPN2 stated CNA2 went to get the Maintenance Director (MD) and they both went to the resident's room. LPN2 stated she was not aware prior to that day that the bathroom door locked from the inside. She stated CNA2 told them they took the lock off the door. LPN2 stated she did not report to management because it was reported to maintenance, and she believed they would fix it. She stated that no residents should have smoking paraphernalia on them or in their rooms. During an interview on 03/19/25 at 10:07 AM, the MD stated he was not aware of an issue with the bathroom door in R2's room and was not asked to do anything with the doorknob until this morning. The MD stated he was still waiting to get clarification on what needs to be done with doorknob. During an interview on 03/20/25 at 5:44 PM, the Director of Nursing (DON) stated the lock on the resident's door was a safety lock. She stated it could be opened with any key, but they could have done a better job educating staff to ensure they knew how to unlock the door. She stated she was unsure what other changes were made to R2's plan of care after he was caught in the bathroom smoking. She stated she was not aware that R2 did not have a smoking assessment completed prior to 03/11/25, but she would have expected that one was completed prior to allowing the resident to smoke.

Based on interview and record review, the facility failed to provide protective oversight for one resident who resided on a secured unit and whose diagnoses included dementia, from elopement (Resident #1). The resident left the facility, without staff knowledge on 7/8/23 or 7/9/23. Emergency Medical Services (EMS) took the resident to an emergency roiagnom on [DATE], and he/she was released to his/her family member, who took the resident back to the facility. On 7/9/23, the facility assessed the resident as at high risk to wander. Insufficient measures were implemented to prevent another elopement. On 7/10/23, the resident again left the facility without staff knowledge. Staff and physician interviews showed the resident was at risk due to his/her physical and mental health status, combined with the current weather conditions. The census on the secured care unit (SCU) was 26. The sample was 6. The census was 134. The administrator was informed on 7/14/23 of an Immediate Jeopardy (IJ), which began on 7/8/23. The IJ was removed on 7/18/23 as confirmed by surveyor on-site verification. Review of the facility's wandering and elopement policy, revised 8/2020, showed: -Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement; -Procedure: -1. The licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition; -2. The resident's risk for elopement and preventative interventions will be documented in the resident's medial record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon identification of significant change in condition; -3. IDT may consider interventions listed in elopement risk reduction approaches for residents identified to be at risk for elopement; -4. Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record and the elopement/wandering risk binder; -5. Facility staff will reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement; -6. If facility staff observes a resident leaving the premises without having followed proper procedures, he/she may: -a. Try to prevent the departure in a courteous manner; -b. Get help from other facility staff in the immediate vicinity, if necessary; and; -c. Direct another facility staff member to inform the charge nurse or Director of Nursing (DON) that a resident is trying to leave the premises; -7. Response to resident elopement: -a. The facility staff member who finds that a resident is missing will alert facility staff; -b. The charge nurse will call code pink and organize a search. Facility staff will search areas of the facility, including common areas, bathrooms, showers, outside areas, etcetera; -c. If the resident cannot be located, the charge nurse will notify: -1. Administrator/designee; -2. DON/designee; -3. Attending physician; -4. Responsible party; -5. Regional leadership of clinical and operations; -6. Senior [NAME] President (VP) of operations; -7. Senior VP of clinical; -d. The Administrator/designee will contact law enforcement and provide them with the following information: -1. The resident name, description (hair and eye color, complexion, weight, height, clothing, distinguishing marks, etcetera), addresses and telephone number of residents previous residence and family members; -2. The resident's mental status and pertinent medical conditions; -e. The Administrator/designee will continue to work with law enforcement and the responsible party until the resident is located; -f. The licensed nurse most familiar with the incident will document in the resident's medical record how the elopement occurred; -g. The facility will make necessary reports to state agencies; -8. Return of the resident: -a. When an individual who departed without following proper procedures returns to the facility, the DON or licensed nurse should: -1. Examine the resident for any possible injuries; -2. Notify the attending physician; and; -3. Notify the resident's responsible party; -b. The licensed nurse will initiate or update the resident's care plan and implement immediate interventions(s) to prevent further wandering/elopement by the resident; -c. The IDT, with input from the licensed nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the care plan to prevent a recurrence; -d. The quality assessment and assurance committee will review all instances of elopement. During an interview on 7/18/23 at 10:29 P.M., the Administrator said the facility did not have policies on the following: -Continuity of care; -Staff responding to door alarms in the facility; -Increased monitoring for 1:1, 15 minute checks, or hourly checks. Review of the Resident #1's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -No moods or behaviors; -Wandering behavior not exhibited; -Resident stated it was very important to go outside to get fresh air when the weather is good; -Required limited assistance with one person physical assist for bed mobility, dressing, toilet use, and personal hygiene; -Required supervision with one person physical assist for transfer, locomotion on and off the unit; -Not steady, but able to stabilize without human assistance with moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer; -No mobility devices used; -No wandering or elopement alarm; -Diagnoses of bradycardia (heart beats very slow), high blood pressure, diabetes mellitus, difficulty in walking, muscle weakness, other lack of coordination, need for assistance with personal care, hypokalemia (low levels of potassium in the blood), alcohol abuse, dementia, anxiety disorder, unspecified mood disorder and depression. Review of the resident's care plan, in use during the survey, viewed on 7/12/23 at 9:13 A.M., showed: -Focus: Resident is an elopement risk/wanderer related to dementia. Resident resides on memory unit, date initiated 4/28/22, revision on 4/28/22; -Goal: Resident's safety will be maintained through the review date, date initiated 4/28/22, revision on 6/26/23, target date 10/8/23; -Interventions: -Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, date initiated 10/4/22, revision on 11/1/22; -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, date initiated 10/4/22, revision on 11/1/22; -Monitor for fatigue and weight loss, date initiated 4/28/22; -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, date initiated 10/4/22; -Focus: Resident has a behavior problem. Resident has been noted to be exit-seeking, verbally aggressive and resistant to care. Resident has dementia and resides on the memory unit. Resident will refuse skin assessments at times, date initiated 4/28/22, revision on 12/14/22; -Goal: Resident will have fewer episodes of 3 times a week by date, date initiated 4/28/22, revision on 6/26/23, target date 10/8/23; -Interventions: -Administer medications as ordered. Monitor and document for side effects and effectiveness, date initiated 4/28/22; -Anticipate and meet resident's needs, date initiated 4/28/22, revision on 11/1/22; -Explain all procedures to resident before starting and allow the resident to adjust to changes, date initiated 6/13/22, revision on 11/1/22; -Focus: Resident has impaired cognitive function/communication related to dementia, date initiated 4/28/22, revision on 4/17/23; -Goal: The resident will maintain current level of cognitive function through the review date, date initiated 10/4/22, revision date on 6/26/23, target date 10/8/23; -Interventions: -Administer medications as ordered. Monitor and document for side effects and effectiveness, date initiated 5/2/22; -Communicate with resident/family/caregivers regarding the resident's capabilities and needs, date initiated 10/4/22, revision on 11/1/22; -Discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers, date initiated 10/4/22, revision on 11/1/22; -Keep resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, date initiated 10/4/22, revision on 11/1/22; -Monitor/document/report as needed (PRN) any changes in cognitive function, date initiated 10/4/22. During an interview on 7/17/23 at 1:21 P.M., Certified Nurse Aide (CNA) E said he/she worked on Saturday 7/8/23 and the resident was upset when he/she left that day because he/she could not get out of the SCU. CNA E said he/she was sitting next to the front door on the SCU to make sure the resident couldn't get out. CNA E had to tell the resident the door was locked. On Saturday, the resident was saying that he/she needed to get to work. CNA E left the facility around 2:50 P.M. and he/she made sure to check the front door to the SCU locked all the way. CNA E said it was like the magnets on the door were not sticking. At different times, CNA E noticed the door would not lock and it appeared the magnet was not sticking so it would take a while for the door to latch. The problem with the door was reported to the Maintenance Assistant on Friday, 7/7/23. CNA E reported the door was not latching properly and informed the Maintenance Assistant the door was not locking at times. The Maintenance Assistant told CNA E that someone was coming to look at the door. He did not say when or who was coming to look at the door. Review of Fire Department EMS patient care record, dated 7/9/23 at 8:36 A.M., showed the following: -EMS was alerted by the Police Department (PD) at 8:10 A.M. EMS arrived on the scene at 8:28 AM.; -The resident was found inside of a store looking for his/her wallet; -The resident was confused; -The resident was transported to the hospital; -The family member was called and alerted to the resident's location; -The family member stated the resident should have been at the facility. Review of hospital records, dated 7/9/23, showed the following: -At 8:50 A.M., the resident was admitted to the hospital emergency department (ED); -At 9:03 A.M., mental status was altered and he/she had a guardian. An elopement band (used to activate an alarm at exit doors and elevators) was placed on the resident due to the risk of elopement; -At 10:30 A.M., the attending physician assessed the resident. EMS stated the resident had escaped from the facility. The resident's guardian was on the way to pick the resident up from the ED and return the resident to the facility. The resident knew he/she was in the hospital and stated the year was 2018; -At 10:30 A.M., the resident was discharged from the ED in to the care of his/her guardian. The resident was transported via private car back to the facility; -The discharge diagnosis included dementia and delirium. The clinical impression was wandering associated with a mental disorder. During an interview on 7/12/23 at 9:57 A.M., Durable Power or Attorney (DPOA) A said the resident was found at a grocery store located 3.2 miles away from the facility on Sunday morning 7/9/23, by the fire department and was brought to the hospital. The hospital called DPOA B and informed DPOA B the resident was at the hospital. DPOA B went to the hospital and picked up the resident and brought the resident back to the facility on [DATE]. DPOA A said the facility was not aware the resident was not at the facility and was unsure if the resident got out of the facility on Saturday 7/8/23 or Sunday 7/9/23. DPOA A said the facility did not notify either DPOA A or B the resident was missing on Saturday or Sunday. During an interview on 7/14/23 at 7:47 A.M., DPOA B said he/she received a phone call from the fire department the morning of 7/9/23, informing DPOA B the resident was found at a grocery store. DPOA B asked the fire department what the resident was doing at the grocery store that is located 3.2 miles away from the facility the resident resides in. The facility did not call and notify him/her that the resident was missing from the facility. The fire department said they were going to have the resident taken to a hospital to be checked out and gave DPOA B the name of the hospital. DPOA B arrived at the hospital and the resident told DPOA B that he/she got out of the door and it was tricky. DPOA B said the hospital examined the resident and said he/she looked fine and the DPOA B drove the resident back to the facility. After arriving to the facility around 11:30 A.M. to 12:00 P.M. the DPOA B told the receptionist that he/she was there bringing back the resident because he/she had got out of the facility and told the receptionist he/she needed to speak with someone. Three staff members came to speak to DPOA B and the resident. DPOA B does not remember the staff member's name but one of them was a nurse. The staff said they did not know when or how the resident got out of the facility. They did not know if the resident got out of the facility in the middle of the night on 7/8/23, Saturday night or if the resident got out this morning. They asked the resident what time he/she left the facility and asked if the resident went out the front door of the facility. At the time they were asking the resident if he/she went out the front door of the facility, the resident was in the lobby reception area and could visualize the front door the staff were referring to. The resident told the staff that he/she went out a different door, not the front door but would not tell them which door he/she exited out of. The staff told the resident not to leave the facility again and told the resident if he/she wanted to go for a walk, just to let them know. The staff assured DPOA B the resident would not elope from the facility again. The three staff members brought DPOA B and the resident back to the SCU and the resident began to cry because he/she was upset that he/she worried DPOA B. DPOA B asked the resident to stop crying and told the resident that DPOA B was alright. The resident told DPOA B he/she was tired after his/her long walk. The staff assured DPOA B the resident would not elope again and DPOA B left the facility. Review of the resident's EMR, showed: - Wandering risk assessment, dated 7/9/23, showed, the resident score of 13 (high risk to wander). - No documentation of the resident's elopement from the building on 7/9/23; - No documentation of the resident returning to the facility on [DATE] or any interventions put into place after the elopement on 7/9/23. Review of the resident's care plan in use during the survey, viewed on 7/12/23 at 9:13 A.M., showed no updates to the care plan after the resident eloped and was returned on 7/9/23. Review of the facility's investigation of the elopement on 7/9/23, undated, showed the following: -In a written statement, signed on 7/9/23, no time noted, CNA G said he/she worked on the resident's assigned hall on 7/8/23 during the 3:00 P.M. to 11:00 P.M. shift. The resident was acting a bit upset when CNA G arrived on his/her shift. Staff reported the resident was looking for his/her keys, saying he/she needed them to go to work. Dinner was served around 4:30 P.M. and the resident ate his/her dinner in his/her room. CNA G also worked the 11:00 P.M. to 7:00 A.M. shift, stating he/she was very busy and did not notice if the resident was gone when he/she went to help other residents to bed. CNA G also did not hear any alarms during his/her shifts; -In a written statement, undated, CNA E said he/she arrived for his/her shift at 7:00 A.M. (no date was noted). CNA E made rounds of all the rooms and brought residents to the dining room. When he/she went to get the resident from his/her room, CNA E found the resident was not there. CNA E began checking every room for the resident and could not locate the resident; -An undated interview with Receptionist H, showed the receptionist worked on 7/8/23 from 11:00 P.M. until 7:00 A.M. He/She said he/she only left the receptionist desk one time at approximately 12:00 or 12:15 A.M. Receptionist H said while he/she was away from the desk there was a CNA sitting on the couch. Receptionist H did not say he/she asked the CNA to watch the desk while he/she was away or if the CNA knew the receptionist left the desk unattended. Receptionist H said around 1:00 A.M., he/she called a fell ow employee, told them the employee door was open by the time clock and asked the employee to shut the door. There was no information found in the interview of how long the receptionist was away from his/her desk, or how the receptionist knew the employee door by the time clock was open or if the door was ever closed by the other employee. During an interview on 7/17/23 at 1:21 P.M., CNA E said he/she worked on 7/9/23, Sunday morning. CNA E brought residents to the dining room for breakfast and when he/she went to get the resident, the resident was not in his/her room. CNA E thought maybe the resident was in a different resident's bathroom. CNA E went to the dining room and asked the resident's roommate if he/she had seen the resident and the resident's roommate said he/she had not seen the resident all night. CNA I then called the Assistant Director of Nurses (ADON) to inform her the resident was missing. CNA E went through the whole building and there were no alarms going off in the facility. CNA E said he/she did not receive any report from the night shift, CNA G. CNA E said CNA G was headed out of the facility when CNA E was walking into the SCU. CNA E said CNA G was the only staff member working on the SCU on 7/8/23, Saturday night. When DPOA B brought the resident back to the facility on Sunday 7/9/23, CNA E asked the resident what happened and the resident said all he/she could remember was a person told him/her that he/she couldn't leave and before he/she knew it, he/she was gone. The resident said he/she was confused and the resident said he/she didn't know where he/she was at. CNA E said the resident was not placed on any special checks after the resident was returned from the elopement on 7/9/23. During an interview on 7/14/23 at 6:31 A.M., CNA I said on Sunday morning 7/9/23, while passing breakfast trays, CNA E said he/she could not find the resident. CNA I said at that time, both CNAs searched the SCU and were unable to locate the resident. CNA I said no alarms were sounding at any time prior to CNA E noticing the resident was missing. CNA I said he/she contacted the ADON and the Staffing Coordinator to inform them they could not find the resident. CNA I said the resident disappeared sometime during the night shift on Saturday 7/8/23. CNA I said he/she did not get report from the previous shift on Sunday morning. CNA I said CNA G was the only staff member working on the SCU on Saturday night 7/8/23. CNA I said the resident's roommate said the resident was gone last night. CNA I said the resident was always making comments that he/she needs to get his/her keys and he/she has to go to the post office and get some stamps. The resident would also make comments about needing to go to work and that he/she is going to be late. The resident was always going to the front door and staff would tell the resident the door is closed. CNA I said there have been issues with the front door going onto the SCU unit. CNA I said sometimes it worked and sometimes it didn't. CNA I said they would say they fixed it but the door would sometimes not latch. CNA I said after entering the code, the light on the keypad turns green and then the red light comes on after about 10 seconds. CNA I said sometimes you could push on the door and it would open. CNA I said the door has been like that for a long time and everyone is aware of the door not latching, anyone can go and just push on it without entering the code and exit the SCU. CNA I said the ADON, DON, Administrator, Charge Nurses, Maintenance, Housekeeping, and Dietary all know about the door. You would think the door was locked and it wouldn't be locked. CNA I said Maintenance has worked on the door but it still was not latching. During an interview on 7/13/23 at 8:23 A.M., the Maintenance Assistant said a while back there was a problem with the door going into the SCU, as it was not locking. They called the company that worked on the doors to come out and repair it. He/She was unsure when that occurred. The Maintenance Assistant said he/she was at the facility on Sunday 7/9/23 when the staff noticed the resident was missing. The Maintenance Assistant said he/she had to show the DON and other staff the door alarms were set and the alarms were working correctly in the facility. He/She also said the door to the SCU was working correctly, latching when shut and only able to open when entering the correct code. During an interview on 7/13/23 at 9:13 A.M., the Maintenance Director said he/she was called to the facility on Sunday 7/9/23 because a resident had eloped. He/She was called in around 10:30 A.M., to make sure the doors were working properly. He/She clocked in at the facility at 11:00 A.M. on Sunday. During an interview on 7/14/23 at 8:53 A.M., Certified Medication Technician (CMT) L said he/she gave the resident his/her medication on 7/9/23, Sunday afternoon around 1:30 P.M. after the resident returned from the elopement. CMT L said he/she left the SCU after passing medication on the SCU and went to a different hall to pass medication. CMT L said the resident was not on 1:1 monitoring on Sunday 7/9/23 or Monday 7/10/23. CMT L said the resident was moving around like normal on his/her own. CMT L said he/she has heard other staff talk about the door going onto the SCU and it would sometimes open without having to enter the code. CMT L said the light on the keypad will sometimes be green like someone has entered the code when nobody has entered the code and the door will open if you push on it. During an interview on 7/13/23 at 11:04 A.M., the ADON said any resident with a score on the wandering risk assessment that shows a high risk to wander, has a history of exit seeking or wandering, has a BIMS of 8 or below, and has a medical diagnosis of dementia or Alzheimer's should be on the SCU. The ADON said all residents on the SCU are at risk for elopement. The ADON said he/she was very familiar with the resident. The resident has dementia and some days the resident will get up and say he/she is going to work. The resident knows his/her name and birthday. The resident would frequently pack his/her bag and wander in other residents' rooms. The ADON said interventions staff would use for the resident included if the resident was up and wandering, staff would redirect the resident and ask him/her if he/she needed to use the restroom or if he/she was looking for his/her room. The ADON said the minimum amount of time he/she expected staff to make rounds on the residents on the SCU should be every 30 to 45 minutes. The normal standard rounding time is every two hours but he/she expected the staff to round on the residents on the SCU every 30 to 45 minutes. The ADON expected more frequent rounding to be completed on the SCU because a lot of the residents wander and the staff need to ensure the residents have not wandered into another resident's room. Normal staffing for the SCU is two CNAs every shift, a Certified Medication Technician (CMT) or nurse who is dedicated only to the SCU every shift. There are three staff members assigned to the SCU at all times. The nurse or CMT who is scheduled on the SCU is not shared with any other halls. The ADON said the resident has not been able to get off the SCU unattended in the past at this facility. The ADON said if a resident gets off the SCU unattended in the building, staff should call a code pink, and a CNA or staff member should stand at the door of the SCU to make sure no other residents are getting out at that time. The other CNA will be checking the census against the residents on the SCU and the CMT/nurse calls the DON or Administrator to inform them of the code pink. A picture is brought to the nurse on the other floors to show the other staff what the resident looks like. The other staff on the other floors are checking the census on the halls and searching for the missing resident. The receptionist look to see what residents are currently out of the building, and the receptionist will be monitoring the front door to ensure nobody enters or exits during that time. If resident is not located, management that has reported to the building will begin to search outside the building and other management will start doing the investigation. The management inside the building working on investigation will be calling the resident family and the doctor to notify them of the missing resident. The other management will be searching outside the facility building. If the resident is not located outside the facility building part of the management team will expand the search past the facility grounds. The ADON expected documentation in a progress note if a resident is exit seeking and expected to be notified immediately. If a resident succeeded in exiting the SCU the ADON expected the nurse to make a progress note on what happened and that the responsible party and physician was notified. The ADON said the resident had eloped from a sister facility and had also eloped on 7/9/23. The ADON said she received a phone call from CNA I on Sunday 7/9/23 around 8:30 A.M. to 8:40 A.M. CNA I told the ADON that he/she could not locate the resident. The ADON instructed CNA I to call a code pink. The ADON arrive at the facility around 9:00 A.M. on 7/9/23 and the DON and the on call nurse were at the facility. When the ADON came upstairs from searching the basement around 11:00 A.M., DPOA B was at the facility with the resident in the front lobby. DPOA B said the resident was found at a grocery store located 3.2 miles away from the facility. The resident was attempting to purchase food and did not have any money. A firefighter was at the grocery store and notified EMS. When EMS arrived they took the resident to a hospital and the hospital notified DPOA B the resident was at the hospital. The physician was notified the resident was returned to the facility and the ADON requested to give the resident his/her morning medication that was missed because the resident was missing and the physician agreed to give the resident his/her morning medications at that time. The ADON said it was determined that the last time the resident was seen was on Saturday at 11:00 P.M. by CNA I. The ADON expected there to be a nursing progress note when a resident is returned after an elopement. The nursing progress note should include when the physician was notified, if the physician has any new orders, such as labs that would need to be drawn, what the resident is doing at that time and the condition of the resident. The nursing progress note should paint a picture of what happened from the charge nurse from the time the resident was noted missing, when the code pink was called, everything that took place including notifications, and when and how the resident returned to the facility. The ADON said she did not know why there were no nursing progress notes for the resident's elopement on 7/9/23. The ADON said after the resident returned on Sunday 7/9/23, the resident was placed on 1:1 monitoring. The ADON said CNA I provided the 1:1 monitoring on 7/9/23 from 11:00 A.M. until 3:00 P.M. Then CNA G came in and took over the 1:1 monitoring from 3:15 P.M. until 9:45 P.M. CNA J provided 1:1 monitoring from 11:30 P.M. until 6:15 A.M. Review of the facility's Enhanced Supervision Monitoring Tool, dated 7/9/23, showed the following: -The form had time slots in 15 minute intervals, starting at 6:30 A.M. and ending at 6:15 A.M., with two corresponding columns for documentation; one marked location/activity/behavior and the other for staff initials; -The resident's name was listed on the form; -Reason for monitoring was filled out as Exit-Seeking (ES) with a hand-drawn line connecting to the sentence this document is used for one to one; -At 11:00 A.M. through 11:30 A.M., the location was documented as room and initialed by CNA I; -At 11:45 A.M. through 12:15 P.M., the activity was documented as came out to eat without any initials of staff; -At 12:30 P.M. though 12:45 P.M., the location was documented as hallway and initialed by CNA I; -At 1:00 P.M. through 3:00 P.M., the location was documented as room and initialed by CNA I; -At 3:15 P.M. through 9:45 P.M., the location was documented as dining room and initialed by CNA G; -At 10:00 P.M., the location was documented as room and initialed by CNA I; -At 10:15 P.M., through 11:15 P.M., no documentation for location, no staff initials; -At 11:30 P.M. through 1:30 A.M., the location was documented as room and initialed by CNA J; -At 1:45 A.M. through 2:30 A.M., the location was documented as hall and initialed by CNA J; -At 2:45 A.M. through 6:00 A.M., the location was documented as room and initialed by CNA J; -At 6:15 A.M., the location was documented as hall and initialed by CNA J. During an interview on 7/14/23 at 6:31 A.M., CNA I said he/she never provided 1:1 monitoring with the resident on 7/9/23. CNA I said he/she has never done any 1:1 monitoring at this facility. CNA I said he/she only provided 15 minute monitoring/checks for the resident after the resident returned from the elopement on Sunday. The 15 minute monitoring/checks CNA I provided was approximately from around 11:00 A.M. to 3:00 P.M. CNA I said the DON and ADON gave him/her the sheet for the 15 minute monitoring/checks. CNA I said the sheet has the time listed in 15 minute intervals and the line next to the time is blank to put the location of the resident and can also put what the resident was doing in that location, next to the location was a place to put the initials of the person providing the monitoring. CNA I said when providing 15 minute monitoring/checks for a resident every 15 minutes the staff member needs to find the location of the resident and put the location of the resident on the 15 minute check sheet. CNA I said he/she gave the 15 minute monitoring/checks to CNA G at 3:00 P.M. and CNA G monitored the resident from 3:00 P.M. until CNA I was getting ready to leave for the night and CNA I went and checked on the resident at 10:00 P.M., and the resident was in his/her bedroom. CNA I said he/she signed the 10:00 P.M. spot for the 15 minute monitoring/checks and then left for the night. CNA I said CNA G was supposed to continue the 15 minute checks after he/she left. During an interview on 7/14/23 at 4:38 P.M., the DON said staff were providing 1:1 monitoring on Sunday 7/9/23 after the resident returned from the elopement. The DON said she arrived to the facility very early on 7/10/23 and she walked the entire building and it was reported the resident was settled and back to normal. The DON does not remember the time she arrived at the facility on Monday morning and does not remember who she spoke to that reported the resident was back to his/her normal. Because of what was reported to her, she decided to take the resident off 1:1 monitoring and had the staff transition to hourly checks. The DON said the resident told her on Sunday after returning to the facility, that he/she wanted to feel the sun and the DON told the resident to tell her and she would take him/her outside when he/she wanted to go outside and feel the sun. Review of the facility's Enhanced Supervision Monitoring Tool, dated 7/10/23, showed the following: -The form had time slots in 15 minute interv

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards and followed their Wound Management-Nursing Care policy to identify, document, monitor, notify physicians and promptly initiate physician's orders to treat pressure injuries/ulcers (injury to the skin and underlying tissue caused by pressure or friction) for two of six residents sampled with actual pressure injuries and/or at risk of developing pressure injuries (Residents #21 and #22). The census was 133. Review of the facility Wound Management-Nursing Care policy, last revised 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Pressure Injury: Any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed; -Assessment: A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a new wound the licensed nurse will: -Measure the wound (length, width, depth); -Initiate a wound monitoring record sheet; -Implement a wound treatment per physician's order; -An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to: -Identifying risk factors; -Treatment; -Mechanical offloading and pressure reducing devices; -Reducing skin friction, sheer, and moisture; -Nutritional status; -Evaluating and modifying interventions for a resident with an existing pressure ulcer/pressure injury; -Wound Management: -The attending physician will be notified to advice on appropriate treatment promptly; -The licensed nurse will notify the responsible party of the presence of a pressure injury -A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician; -Per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -The attending physician and interdisciplinary team will be notified of: -New pressure injuries or wounds; -Pressure injuries or wounds that do not respond to treatment; -Pressure injuries or wounds that worsen or increase in size; -Complaints of increased pain; -Signs of ulcer sepsis (infection in the bloodstream), presence of exudates (drainage), odor or necrosis (dead tissue) if not already noted by the attending physician; -Documentation: New pressure injuries or wounds will be documented on the 24 hour log; Wound documentation will occur at a minimum of weekly until the wound is healed; -Documentation Will Include: -Location of wound; -Length, width, and depth measurements recorded in centimeters (cm); -Direction and length of tunneling and undermining (if applicable); -Appearance of the wound base; -Drainage amount and characteristics including color, consistency, and odor; -Appearance of wound edges; -Description of the peri-wound (skin surrounding the wound) or evaluation of the skin adjacent to the wound; -Presence of pain; -Interdisciplinary team will document discussion and recommendations for: -Pressure injuries and wounds that do not respond to treatment; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence of exudates, odor or necrosis; -Residents refusing treatment; -Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Document notifications following a change in the resident's skin condition; -Update the resident's care plan as necessary. 1. Review of Resident #21's facility Admission Record, showed an admitted [DATE]. Review of the resident's physician order sheet (POS), dated 7/2023, showed the following: -Diagnoses of weakness, arthritis and difficulty walking; -Weekly skin assessment every Monday on night shift; -Apply zinc oxide ointment 10% (topical ointment used to treat or prevent minor skin irritations such as diaper rash) cleanse coccyx (tailbone) with soap and water, apply thin layer to coccyx every day and evening shift. Review of the resident's treatment administration records (TAR), dated 7/2023, showed the following: -Weekly skin assessment every Monday night; -No skin assessment documentation for 7/10 and 7/31/23; -Cleanse coccyx with soap and water, apply zinc oxide ointment twice a day; -No documentation of administered treatment on 7/6/23. Review of the facility's Pressure Injury report, dated 7/16/23 through 7/23/23, showed no documentation regarding the resident. Review of the resident's Shower Sheet/Skin Condition report (a form completed by CNAs), showed the following: -Directions: The sheet is to be completed by the Nurse's Assistant for each resident scheduled for a shower or whenever an abnormal area is observed. The sheets must be signed by the nursing assistant, the nurse and returned to the Director of Nursing (DON) or designee; -Shower Sheet/Skin Condition report dated 7/18/23, showed no abnormal skin issues; -All reports were signed by the certified nurse aides (CNA) and nurse. Review of the resident's nurse's notes, showed the following: -7/18/23 at 6:12 A.M.: Weekly skin observations, completed by the Charge Nurse, showed: skin color was normal, skin temperature was dry and warm, skin turgor normal. No skin issues present, no new skin concerns noted; -7/18/23 at 9:35 P.M.: Called to room by CNA, noted two pressure ulcers to the coccyx. Measured: 3 cm by 3 cm and 1 cm by 1.5 cm. Areas were tan in color with some blackened area. Areas cleaned with wound cleaner and applied calcium alginate (a fibrous absorbent dressing) and dry dressing. The physician was notified, verified treatment order and gave order for Wound Nurse to follow up. Assistant Director of Nurses (ADON) was notified. He/she was to notify resident's family and the Wound Nurse in the morning. Review of the resident's POS, dated 07/2023, showed an order dated 7/18/23, to clean pressure ulcer to coccyx with wound care solution (wound cleaner), cover with calcium alginate and dry dressing. Review of the resident's TAR, dated 7/2023, showed the following: -Weekly skin assessment every Monday night; -No order to cleanse the coccyx with wound care solution, cover with calcium alginate and dry dressing. Review of the resident's nurse's notes, dated 7/19/23 and 7/20/23, showed no documentation the staff notified the family of the pressure ulcers or notified the Wound Nurse of the physician's order for follow up. Review of the resident's Shower Sheet/Skin Condition report dated 7/21/23, completed by the CNA, showed the following: -7/21/23: Blank, no documentation regarding the pressure ulcer on the coccyx; -Signed by CNA and Charge Nurse. Review of the facility's Pressure Ulcer report, dated 7/23/23-7/29/23, showed the following: -Facility acquired: Yes; -Site: Right Buttock/Coccyx; -Stage: Unstageable (full-thickness pressure injuries in which the base is obscured by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) and/or eschar (hard, black dead skin); -Size: 4.6 cm by 4.8 cm; -Depth: 2 cm; -Odor: No; -Drainage: Yes; -Treatment: Santyl (ointment is used to remove damaged tissue from chronic skin ulcers)/Bactroban (topical antibiotic) apply calcium alginate and cover with foam dressing; -Notes: Refer to wound company. Review of the resident's nurses' notes, showed the following: -7/23/23 at 9:13 P.M.: Consent from resident for outside wound care company and hospice. Family notified; -7/24/23 at 10:44 A.M.: Skin/Wound Note completed by the wound nurse showed the following: Notified by CNA of pressure ulcer to the resident's coccyx. Assessment showed an unstageable pressure ulcer to the coccyx which measured 4.6 cm by 4.8 cm by 2 cm depth. Moderate amount of purulent drainage with malodor (strong odor). Wound bed has 51-75% of slough and 1 to 25% eschar with no granulation (new healing tissue) present. Periwound (skin surrounding the wound) was friable (bleeds with very gentle touch). Treatment orders in place. Resident referred to Wound Care Company. Call placed to the resident's physician, awaiting call back; 7/24/23 at 11:46 A.M.: Weekly Skin Observation: Skin issues present. Unstageable pressure ulcer to the coccyx; -No documentation the resident's physician returned call on 7/24 or 7/25/23. Review of the resident's Shower Sheet/Skin Condition report dated 7/25/23 at 11:46 A.M., completed by the CNA, showed the following: -Marked with a check mark: Change in color (red, bluish, pale, gray) and open area; -Anatomical drawing: A circle drawn on buttocks; -Signed by the CNA and Charge Nurse. Review of the resident's nurses' notes, showed the following: -7/25/23 at 7:00 P.M.: Weekly Skin Observation: Skin issues present; -7/26/23 at 1:10 P.M.: Wound nurse spoke with resident's physician regarding possible soft tissue infection to coccyx pressure ulcer. New order received for Doxycycline (antibiotic used to treat infections) 100 milligrams (mg) twice a day for 10 days. First dose pulled from the emergency kit and administered. DON notified; -No further documentation regarding the coccyx pressure ulcer until 7/31/23. Review of the resident's 7/2023 POS, provided by the facility during the onsite on 9/21/23, showed no documentation regarding the order for Doxycycline 100 mg twice a day. Review of the resident's 7/2023 Medication Administration Record (MAR), showed the following: -Doxycycline 100 mg by mouth two times per day for ten days; -Staff documented as administered twice a day on 7/26/23 through 7/31/23. Review of the resident's 7/2023 TAR, showed the following: -7/26/23: Mupirocin (Bactroban) ointment 2% mix with Santyl, and apply nickel thick to the wound bed up to the periwound edges; -Staff documented as complete on 7/26 through 7/31/23. Review of the resident's 7/2023 POS, showed no order for Mupirocin Ointment 2% mix with Santyl, apply nickel thick to the wound bed up to the periwound edges. Review of the resident's Shower Sheet/Skin Condition report dated 7/28/23 at 10:15 A.M., completed by the CNA, showed the following: -Marked with a check mark: Shower and skin check; -Anatomical drawing: a circle drawn on the buttocks; -Signed by the CNA and Charge Nurse. Review of the resident's Wound Care Company progress notes, dated 7/31/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Note: Doxycycline 100 mg by mouth twice a day for ten days started on 7/26/23 through 8/5/23; -Sacrum and coccyx x-ray's negative for osteomyelitis (inflammation of the bone caused by infection); -Discussed the importance of repositioning, off loading and keeping wounds clean and dry; -Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some or parts of the wound bed. Often includes undermining and tunneling) pressure ulcer positive for bacteria; -Coccyx debrided (removal of dead, damaged, or infected tissue); -Recommend medicating resident with pain medication prior to visit to make resident more comfortable; -Wound assessment: Coccyx was an acute Stage IV unhealed pressure injury pressure ulcer. Pressure ulcer measurements post debridement: 9.5 cm by 7 cm by 2 cm depth, bone exposed. Moderate amount of sero-sanguinous drainage which has a strong odor. Undermining (erosion under the wound edge margins which results in more extensive damage under the skin). Pain level of a five out of 10. Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar; -Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant (Skin Prep: solution used before applying wound dressing. provides a protective barrier) and apply Santyl and Bactroban nickel thick to entire wound bed daily. Review of the resident's nurse's notes, showed the following: -7/31/23 at 12:58 P.M.: Skin/Wound Note completed by the Wound Nurse; -Rounds with Wound Company; -Stage IV pressure ulcer to coccyx, measured 9.5 cm by 7 cm by 2 cm depth; -Moderate amount of serous sanguineous drainage (bright red blood and clear yellow liquid) with strong malodor noted; -Wound bed had 26-50% granulation, 26-50% slough and 1-25% epithelialization (a process of covering wound), no eschar; -Periwound was friable, scarred and moist with red skin tone and signs and symptoms of infection; -Treatment orders in place; -Resident advised of progress and expressed understanding. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff , dated 8/1/23, showed the following: -Diagnoses of malnutrition, arthritis and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues); -Short/Long term memory loss; -Extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene; -Total staff assistance for toilet use and bathing; -Risk for pressure ulcers: Yes; -Unhealed pressure ulcers: No; -Current number of unhealed pressure ulcers: None. Review of the resident's nurses' notes, showed the following: -8/1/23 at 1:13 P.M.: Weekly skin observation. No skin issues present. No new skin issues. Refer to full assessment for more information; -8/1/23 at 5:29 P.M.: Nutrition/Dietary note: Very poor oral intake. Significant weight loss in last 30 days. New Unstageable pressure ulcer to coccyx with drainage and odor. Multiple nutrition interventions in place to support weight and skin integrity; -8/1/23 at 7:00 P.M.: New order for Morphine Sulfate (an opioid indicated for the management of pain not responsive to non-narcotic pain medication) oral solution: 20 mg/5 ml as needed for pain; -8/2/23 at 5:48 P.M.: New order for Levofloxacin (antibiotic) 750 mg by mouth once a day for soft tissue infection for seven days; -8/6/23 at 9:26 A.M.: Resident remained on hospice care. Nonverbal indicators of pain when turned and positioned and during wound care, as needed pain medication administered. Review of the facility's Pressure Ulcer Report, dated 8/6/23-8/12/23, showed the following: -Facility acquired: Yes; -Site: Right Buttock/Coccyx; -Stage: Unstageable; -Size: 4.6 cm by 4.8 cm; -Depth: 2 cm; -Odor: No; -Drainage: Yes; -Treatment: Santyl/Bactroban apply calcium alginate and cover with foam dressing; -Notes: Refer to wound company. Review of the resident's Wound Care Company progress notes, dated 8/07/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Notes: Wounds debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry. DON updated on plan of care; -Wound assessment: Measurements: 9.5 cm by 7 cm by 2 cm depth, bone and adipose tissue (connective tissue that extends throughout the body) exposed; -Moderate amount of sero-sanguinous drainage which had a strong odor; -Undermining noted at 12:00; -Pain level of a five out of 10; -Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar; -Quality of tissue deteriorated compared to the conclusion of previous visit; -Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant and apply Santyl and Bactroban nickel thick to entire wound bed daily. Review of the resident's care plan, dated 8/10/23, showed the following: -Problem: Resident had ADL (activities of daily living) self-care performance deficit due to weakness, decreased cognition and disease process; -Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse; -Problem: Resident had the potential/actual impairment to skin integrity; -Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface. Review of the resident's Wound Care Company progress notes, dated 8/14/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Notes: Coccyx negative for bacteria. Wound debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry.; -Wound assessment: Measurements: 7.5 cm by 8 cm by 3 cm depth, bone and adipose tissue exposed. Moderate amount of sero-sanguineous drainage which has a strong odor. Undermining noted at 12:00. Pain level of a five out of 10; -Wound bed: 51% bright red granulation (new connective tissue), 1-25% slough and 1-25% epithelialization, no eschar; -Quality of tissue improved in comparison to previous visit; -Wound orders: Cleanse pressure ulcer with saline, pat dry, protect peri-wound (area surrounding wound) with skin protectant, and apply Santyl nickel thick to entire wound bed, apply calcium alginate and cover with sacral silicone dressing (specialized wound dressing) daily. Discontinue Bactroban ointment. Observation of a skin assessment on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. CNA W removed the resident's covers and soiled incontinence brief. CNA W and ADON E turned the resident to the right side, revealing a dressing to the coccyx dated 9/12/23. After personal care was provided, ADON E removed the dressing which revealed a large pressure ulcer. The wound bed was red in color with no odor. The pressure ulcer measured 8.5 cm by 8.9 cm. ADON E cleaned the pressure ulcer with wound cleaner, applied Skin Prep to periwound area, Santyl and calcium alginate to the wound bed and covered with a dry dressing. During an interview on 9/18/23 at 4:23 P.M., CNA S said he/she worked the evening shift and had taken care of the resident. He/She said CNA X found the pressure ulcer a few months ago when it began as a reddened spot. He/She reported it to the charge nurse and was instructed to apply a thick white cream. The reddened area began to get worse and changed to a sore. He/She continued to apply the cream to the sore because he/she hoped the sore would get better. During an interview on 9/15/23 at 9:30 A.M., CNA F said he/she worked on the day shift and had taken care of the resident. The first time he/she saw the resident's pressure ulcer was approximately a week ago. He/she helped to position the resident while the nurse changed the dressing. The pressure ulcer was like a large circle at the time. He/She doesn't remember when the pressure ulcer started or what it looked like. When he/she found an open area to a resident's skin he/she reported it to the nurse. During an interview on 9/18/23 at 4:14 P.M., Nurse R said he/she worked the night shift and had taken care of the resident. The resident required total care from the staff. He/She didn't recall whether he/she worked the night the pressure ulcer was found. He/She completed skin assessments as scheduled on the night shift. Staff for the most part would report changes in the residents' skin. Some of the staff wouldn't report changes and they had to be reminded to do so. He/She had staff who he/she trusted to report changes. Occasionally he/she would ask staff whom he/she trusts, about the resident's skin after they had completed their rounds and documented this on the resident's skin assessment. He/She didn't do that all the time, only when certain staff members worked. He/She didn't recall staff reporting any problems with the resident's skin and didn't recall when the pressure ulcer developed on the resident's coccyx. During an interview on 9/19/23 at 1:10 P.M., Nurse T said he/she worked on the evening shift and had taken care of the resident. Staff reported the pressure ulcer to the resident's coccyx. He/She recalled the pressure ulcer had slough and blacked areas. After he/she assessed the wound he/she called the physician for a treatment order. He/She reported the information to the ADON, who said he/she would notify the Wound Nurse and family the next day. The facility had assigned shifts for skin assessments to be completed. When staff found an open area they were to report it to the nurse. The nurse was to assess the area, notify the physician for a treatment order and notify the ADON and Wound Nurse. He/she didn't know why the 7/18/23 treatment order wasn't on the TAR. During an interview on 9/14/23 at 10:24 A.M., Nurse Q said he/she worked the day shift and had taken care of the resident. He/She didn't remember when the resident developed the pressure ulcer. The facility had a Wound Nurse who did the treatments daily. The prior Wound Nurse wanted the nurse to call the physician for an order for the resident to be seen by the Wound Nurse. Once the order was obtained the Wound nurse would assess the wound and call the physician for a treatment order. The current policy was when a wound was found, the nurse assessed the wound, called the physician for treatment orders and notified the Wound Nurse of the new order. They were to also notify the ADON. The Wound Nurse did the treatments daily. The nurse would do the treatment on the days when the Wound Nurse wasn't working or if the dressing became soiled. During an interview on 9/14/23 at 12:38 P.M., ADON E said he/she was unaware the treatment order for calcium alginate and dry dressing, dated 7/18/23, was not on the TAR. He/She expected staff to report any changes in the resident's skin. The nurse should assess the area, call the physician for an order and notify the ADON and the Wound Nurse. During an interview on 9/14/23 at 12:38 P.M., the DON said she was not aware the resident's treatment for calcium alginate and dry dressing ordered 7/18/23, was not on the TAR. She would have expected the nurse to make sure the order was on the TAR. She said a treatment order was obtained on 7/24/23 for a change in the resident's pressure ulcer but wasn't started until 7/26/23. Mistakes were made by the former Wound Nurse who no longer worked at the facility. During an interview on 9/14/23 at 1:19 P.M., the Regional Nurse Consultant said, the nurse failed to push the correct tab in the computer when transcribing the 7/18/23 order for the calcium alginate and dry dressing. That error caused the treatment order not to be on the TAR. The resident received a treatment of zinc oxide to his/her buttocks during the time of the order. She was unable to show the resident received the treatment that was ordered by the physician. In addition she said staff called the physician on 7/24/23 and obtained a new treatment order. No response was received as to why the treatment was not started until 7/26/23. 2. Review of Resident #22's annual MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands, clear comprehension; -Extensive assistance of one person required for bed mobility, transfers, walking in room/corridor, dressing, toilet use, personal hygiene and bathing; -Always incontinent of bowel and bladder; -Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression; -At risk of developing pressure ulcers?: Yes; -Unhealed pressure ulcers?: No. Review of the resident's care plan, showed: Focus: -11/11/22: Focus: Resident had an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves). Intervention: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers; -1/2/23: Focus: Resident was incontinent of bowel and bladder. Intervention: Keep skin clean and dry. Use lotion on dry skin; -1/2/23: Focus: Resident had a nutritional problem or potential nutritional problem and had a diagnosis of malnutrition with interventions in place. Intervention: Provide, serve diet as ordered; -8/30/23: Focus: Resident had actual skin impairment to skin integrity. Stage III pressure injury (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 (passageways underneath the surface of the skin)) to right hip. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities. Failure to heal, signs and symptoms of infection to physician. Clean perineal area (buttocks/genitalia) with each incontinence episode. Review of the POS, showed: -An order dated 12/16/22: Weekly skin assessment every evening shift every Monday; -An order dated 8/25/23: Wound Care Company to evaluation and treat; -No dressing order to the right hip from 8/15/23 through 8/22/23, per Nurse P's progress note dated 8/15/23 at 6:11 P.M.; -An order dated 9/8/23: Right Posterior Hip: Apply collagen powder (a protein used to heal wounds) to wound bed. Apply Hydrogel (promotes a moist healing environment in wounds) on top of powder on wound bed. Cover with silicone bordered foam (provides gentle adhesion, highly breathable absorbent film) daily and as necessary; -An order dated 9/18/23: Right Posterior Hip: Apply collagen powder to wound bed. Apply Hydrogen on top of powder on wound bed. Apply calcium alginate to wound base. Cover with silicone bordered foam daily and as necessary; -An order dated: 9/14/23, Coccyx: Apply collagen powder to wound bed. Apply hydrogel on top of powder on wound bed. Cover with silicone bordered foam daily and as necessary. Every day shift. Review of the resident's assessment tab on 9/13/23, and located in the electronic heath care record, showed no Braden Scale (an assessment used to determine a resident's probability of developing a pressure injury) on file. Review of the facility's weekly Pressure Injury Report, dated 8/6/23 through 8/12/23, showed no documentation regarding the resident. Review of the resident's Weekly Skin Observation form, dated 8/7/23 at 10:34 P.M., showed: -Observations: -Skin Color: Normal; -Skin Temperatures: Dry; -Skin Turgor (refers to the elasticity or firmness of the skin): Normal; -Skin Issues: No. Review of the resident's Shower Sheet/Skin Condition report, dated 8/9/23, showed: -Shower and skin check, normal, dry skin (scalp); -No documentation about a pressure injury to the right hip/trochanter. Review of the resident's progress notes, showed: -8/14/23 at 7:51 A.M., completed by Nurse P: Upon skin assessment, noticed a quarter size open area to the resident's right hip area. Unit manager made aware of new open area. This nurse cleaned area and applied a dry dressing; -8/14/23 at 8:03 P.M., completed by Nurse P: Call out to physician to make aware of new open area found on the right hip. Message left awaiting call back for orders. Review of the residents Weekly Skin Observation form, dated 8/14/23 at 7:49 P.M., and completed by Nurse P, showed: Observations: -Skin Color: Normal; -Skin Temperatures: Dry; -Skin Turgor: Normal; -Skin Issues: Yes; -Site: Right trochanter/hip, quarter sized open area; -Notes: Area cleaned and placed dry dressing. Review of the facility's weekly Pressure Injury Report, dated 8/13/23 through 8/19/23, showed: -Facility Acquired: Yes; -Right posterior hip/trochanter; -Stage II pressure injury (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.); -Measurement: 3.0 cm by 2.0 cm by 0.2 cm; -Drainage: No; -Treatment: Calcium alginate with silicone border foam; -No other pressure injuries noted. Review of the resident's progress notes, showed: -8/15/23 at 6:11 P.M., completed by Nurse P: Representative from physician's office returned call (from 8/14/23 at 8:03 P.M.) and said the physician said to put a dressing on the wound (right hip/trochanter). No specific order given. Wound Nurse made aware of wound on resident as well; -There was no clarification documented about what type of dressing/treatment or when and/or how often it should be applied/changed; -8/16/23 at 4:21 P.M. Late Entry, completed by the facility Wound Nurse: Skin color was normal. Skin temperature was dry, warm. Skin turgor showed tenting due to delay in return skin. Skin issues present. Refer to assessment for more information. Seen (facility) Wound Care Registered Nurse (RN) after report of skin change by DON. Refer to assessment for more information; -8/21/23 at 8:48 P.M., completed by Nurse Q: Skin color was normal. Skin temperature was dry, warm. Skin turgor was normal as skin returns promptly. No skin issues present. Refer to full assessment for more information; -8/23/23 at 9:44 A.M., Nutrition/Dietary, RD Note: August weight 103.8 pounds (lbs), another 2.8 lbs weight loss in one month. New open area, unclassified, noted to right hip. Recommend 90 milliliters (ml) of 2-Cal supplement (a nutritional supplement) three time a day with medication pass for additional nutritional support. Review of the resident's POS and MAR on 9/14/23, showed no order for 2-Cal 90 ml three times a day per the Registered Dietician's (RD) recommendation on 8/23/23 at 9:44 A.M. Review of the facility's weekly Pressure Injury report, dated 8/20/23 through 8/26/23, showed: -Facility Acquired: Yes; -Right posterior (back) hip/trochanter; -Stage II pressure injury; -Measurement: 2.0 cm by 3.0 cm by 0.2 cm; -Drainage: No; -Treatment: Calcium alginate with silicone border foam; -No other pressure injuries noted. Review of the resident's Weekly Skin Observation form, dated 8/21/23 at 8:48 P.M., showed: -Skin Color: Normal; -Skin Temperature: Dry and warm; -Skin Turgor: Normal; -Skin Issues?: No. Review of the facility pressure injury report, dated 8/27/23 through 9/2/23, showed: -Facility Acquired?: Yes; -Right posterior hip; -Stage II pressure injury; -Measurements: 2.0 cm by 3.0 cm by 0.2 cm; -Drainage: Yes; -Treatment: Collagen powder with silicone border foam; -No other pressure injuries noted. Review of the resident's progress notes, showed: -8/25/23 at 4:47 P.M., completed by the facility Wound Nurse: Consent obtained for wound company to evaluate and treat; -8/29/23 at 2:06 P.M., completed by the facility Wound Nurse: Resident lying partially on right side. Stated wound now hurt. Yellow purulent drainage noted on the dressing with some shadowing. No odor from drainage. Previously did not have drainage. Periwound edges raised and erythematous (red/swollen). Added bac

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards and followed their Wound Management-Nursing Care policy to identify, document, monitor, notify physicians and promptly initiate physician's orders to treat pressure injuries/ulcers (injury to the skin and underlying tissue caused by pressure or friction) for two of six residents sampled with actual pressure injuries and/or at risk of developing pressure injuries (Residents #21 and #22). The census was 133. Review of the facility Wound Management-Nursing Care policy, last revised 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Pressure Injury: Any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed; -Assessment: A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a new wound the licensed nurse will: -Measure the wound (length, width, depth); -Initiate a wound monitoring record sheet; -Implement a wound treatment per physician's order; -An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to: -Identifying risk factors; -Treatment; -Mechanical offloading and pressure reducing devices; -Reducing skin friction, sheer, and moisture; -Nutritional status; -Evaluating and modifying interventions for a resident with an existing pressure ulcer/pressure injury; -Wound Management: -The attending physician will be notified to advice on appropriate treatment promptly; -The licensed nurse will notify the responsible party of the presence of a pressure injury -A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician; -Per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -The attending physician and interdisciplinary team will be notified of: -New pressure injuries or wounds; -Pressure injuries or wounds that do not respond to treatment; -Pressure injuries or wounds that worsen or increase in size; -Complaints of increased pain; -Signs of ulcer sepsis (infection in the bloodstream), presence of exudates (drainage), odor or necrosis (dead tissue) if not already noted by the attending physician; -Documentation: New pressure injuries or wounds will be documented on the 24 hour log; Wound documentation will occur at a minimum of weekly until the wound is healed; -Documentation Will Include: -Location of wound; -Length, width, and depth measurements recorded in centimeters (cm); -Direction and length of tunneling and undermining (if applicable); -Appearance of the wound base; -Drainage amount and characteristics including color, consistency, and odor; -Appearance of wound edges; -Description of the peri-wound (skin surrounding the wound) or evaluation of the skin adjacent to the wound; -Presence of pain; -Interdisciplinary team will document discussion and recommendations for: -Pressure injuries and wounds that do not respond to treatment; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence of exudates, odor or necrosis; -Residents refusing treatment; -Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Document notifications following a change in the resident's skin condition; -Update the resident's care plan as necessary. 1. Review of Resident #21's facility admission Record, showed an admission date of 3/4/22. Review of the resident's physician order sheet (POS), dated 7/2023, showed the following: -Diagnoses of weakness, arthritis and difficulty walking; -Weekly skin assessment every Monday on night shift; -Apply zinc oxide ointment 10% (topical ointment used to treat or prevent minor skin irritations such as diaper rash) cleanse coccyx (tailbone) with soap and water, apply thin layer to coccyx every day and evening shift. Review of the resident's treatment administration records (TAR), dated 7/2023, showed the following: -Weekly skin assessment every Monday night; -No skin assessment documentation for 7/10 and 7/31/23; -Cleanse coccyx with soap and water, apply zinc oxide ointment twice a day; -No documentation of administered treatment on 7/6/23. Review of the facility's Pressure Injury report, dated 7/16/23 through 7/23/23, showed no documentation regarding the resident. Review of the resident's Shower Sheet/Skin Condition report (a form completed by CNAs), showed the following: -Directions: The sheet is to be completed by the Nurse's Assistant for each resident scheduled for a shower or whenever an abnormal area is observed. The sheets must be signed by the nursing assistant, the nurse and returned to the Director of Nursing (DON) or designee; -Shower Sheet/Skin Condition report dated 7/18/23, showed no abnormal skin issues; -All reports were signed by the certified nurse aides (CNA) and nurse. Review of the resident's nurse's notes, showed the following: -7/18/23 at 6:12 A.M.: Weekly skin observations, completed by the Charge Nurse, showed: skin color was normal, skin temperature was dry and warm, skin turgor normal. No skin issues present, no new skin concerns noted; -7/18/23 at 9:35 P.M.: Called to room by CNA, noted two pressure ulcers to the coccyx. Measured: 3 cm by 3 cm and 1 cm by 1.5 cm. Areas were tan in color with some blackened area. Areas cleaned with wound cleaner and applied calcium alginate (a fibrous absorbent dressing) and dry dressing. The physician was notified, verified treatment order and gave order for Wound Nurse to follow up. Assistant Director of Nurses (ADON) was notified. He/she was to notify resident's family and the Wound Nurse in the morning. Review of the resident's POS, dated 07/2023, showed an order dated 7/18/23, to clean pressure ulcer to coccyx with wound care solution (wound cleaner), cover with calcium alginate and dry dressing. Review of the resident's TAR, dated 7/2023, showed the following: -Weekly skin assessment every Monday night; -No order to cleanse the coccyx with wound care solution, cover with calcium alginate and dry dressing. Review of the resident's nurse's notes, dated 7/19/23 and 7/20/23, showed no documentation the staff notified the family of the pressure ulcers or notified the Wound Nurse of the physician's order for follow up. Review of the resident's Shower Sheet/Skin Condition report dated 7/21/23, completed by the CNA, showed the following: -7/21/23: Blank, no documentation regarding the pressure ulcer on the coccyx; -Signed by CNA and Charge Nurse. Review of the facility's Pressure Ulcer report, dated 7/23/23-7/29/23, showed the following: -Facility acquired: Yes; -Site: Right Buttock/Coccyx; -Stage: Unstageable (full-thickness pressure injuries in which the base is obscured by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) and/or eschar (hard, black dead skin); -Size: 4.6 cm by 4.8 cm; -Depth: 2 cm; -Odor: No; -Drainage: Yes; -Treatment: Santyl (ointment is used to remove damaged tissue from chronic skin ulcers)/Bactroban (topical antibiotic) apply calcium alginate and cover with foam dressing; -Notes: Refer to wound company. Review of the resident's nurses' notes, showed the following: -7/23/23 at 9:13 P.M.: Consent from resident for outside wound care company and hospice. Family notified; -7/24/23 at 10:44 A.M.: Skin/Wound Note completed by the wound nurse showed the following: Notified by CNA of pressure ulcer to the resident's coccyx. Assessment showed an unstageable pressure ulcer to the coccyx which measured 4.6 cm by 4.8 cm by 2 cm depth. Moderate amount of purulent drainage with malodor (strong odor). Wound bed has 51-75% of slough and 1 to 25% eschar with no granulation (new healing tissue) present. Periwound (skin surrounding the wound) was friable (bleeds with very gentle touch). Treatment orders in place. Resident referred to Wound Care Company. Call placed to the resident's physician, awaiting call back; 7/24/23 at 11:46 A.M.: Weekly Skin Observation: Skin issues present. Unstageable pressure ulcer to the coccyx; -No documentation the resident's physician returned call on 7/24 or 7/25/23. Review of the resident's Shower Sheet/Skin Condition report dated 7/25/23 at 11:46 A.M., completed by the CNA, showed the following: -Marked with a check mark: Change in color (red, bluish, pale, gray) and open area; -Anatomical drawing: A circle drawn on buttocks; -Signed by the CNA and Charge Nurse. Review of the resident's nurses' notes, showed the following: -7/25/23 at 7:00 P.M.: Weekly Skin Observation: Skin issues present; -7/26/23 at 1:10 P.M.: Wound nurse spoke with resident's physician regarding possible soft tissue infection to coccyx pressure ulcer. New order received for Doxycycline (antibiotic used to treat infections) 100 milligrams (mg) twice a day for 10 days. First dose pulled from the emergency kit and administered. DON notified; -No further documentation regarding the coccyx pressure ulcer until 7/31/23. Review of the resident's 7/2023 POS, provided by the facility during the onsite on 9/21/23, showed no documentation regarding the order for Doxycycline 100 mg twice a day. Review of the resident's 7/2023 Medication Administration Record (MAR), showed the following: -Doxycycline 100 mg by mouth two times per day for ten days; -Staff documented as administered twice a day on 7/26/23 through 7/31/23. Review of the resident's 7/2023 TAR, showed the following: -7/26/23: Mupirocin (Bactroban) ointment 2% mix with Santyl, and apply nickel thick to the wound bed up to the periwound edges; -Staff documented as complete on 7/26 through 7/31/23. Review of the resident's 7/2023 POS, showed no order for Mupirocin Ointment 2% mix with Santyl, apply nickel thick to the wound bed up to the periwound edges. Review of the resident's Shower Sheet/Skin Condition report dated 7/28/23 at 10:15 A.M., completed by the CNA, showed the following: -Marked with a check mark: Shower and skin check; -Anatomical drawing: a circle drawn on the buttocks; -Signed by the CNA and Charge Nurse. Review of the resident's Wound Care Company progress notes, dated 7/31/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Note: Doxycycline 100 mg by mouth twice a day for ten days started on 7/26/23 through 8/5/23; -Sacrum and coccyx x-ray's negative for osteomyelitis (inflammation of the bone caused by infection); -Discussed the importance of repositioning, off loading and keeping wounds clean and dry; -Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some or parts of the wound bed. Often includes undermining and tunneling) pressure ulcer positive for bacteria; -Coccyx debrided (removal of dead, damaged, or infected tissue); -Recommend medicating resident with pain medication prior to visit to make resident more comfortable; -Wound assessment: Coccyx was an acute Stage IV unhealed pressure injury pressure ulcer. Pressure ulcer measurements post debridement: 9.5 cm by 7 cm by 2 cm depth, bone exposed. Moderate amount of sero-sanguinous drainage which has a strong odor. Undermining (erosion under the wound edge margins which results in more extensive damage under the skin). Pain level of a five out of 10. Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar; -Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant (Skin Prep: solution used before applying wound dressing. provides a protective barrier) and apply Santyl and Bactroban nickel thick to entire wound bed daily. Review of the resident's nurse's notes, showed the following: -7/31/23 at 12:58 P.M.: Skin/Wound Note completed by the Wound Nurse; -Rounds with Wound Company; -Stage IV pressure ulcer to coccyx, measured 9.5 cm by 7 cm by 2 cm depth; -Moderate amount of serous sanguineous drainage (bright red blood and clear yellow liquid) with strong malodor noted; -Wound bed had 26-50% granulation, 26-50% slough and 1-25% epithelialization (a process of covering wound), no eschar; -Periwound was friable, scarred and moist with red skin tone and signs and symptoms of infection; -Treatment orders in place; -Resident advised of progress and expressed understanding. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff , dated 8/1/23, showed the following: -Diagnoses of malnutrition, arthritis and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues); -Short/Long term memory loss; -Extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene; -Total staff assistance for toilet use and bathing; -Risk for pressure ulcers: Yes; -Unhealed pressure ulcers: No; -Current number of unhealed pressure ulcers: None. Review of the resident's nurses' notes, showed the following: -8/1/23 at 1:13 P.M.: Weekly skin observation. No skin issues present. No new skin issues. Refer to full assessment for more information; -8/1/23 at 5:29 P.M.: Nutrition/Dietary note: Very poor oral intake. Significant weight loss in last 30 days. New Unstageable pressure ulcer to coccyx with drainage and odor. Multiple nutrition interventions in place to support weight and skin integrity; -8/1/23 at 7:00 P.M.: New order for Morphine Sulfate (an opioid indicated for the management of pain not responsive to non-narcotic pain medication) oral solution: 20 mg/5 ml as needed for pain; -8/2/23 at 5:48 P.M.: New order for Levofloxacin (antibiotic) 750 mg by mouth once a day for soft tissue infection for seven days; -8/6/23 at 9:26 A.M.: Resident remained on hospice care. Nonverbal indicators of pain when turned and positioned and during wound care, as needed pain medication administered. Review of the facility's Pressure Ulcer Report, dated 8/6/23-8/12/23, showed the following: -Facility acquired: Yes; -Site: Right Buttock/Coccyx; -Stage: Unstageable; -Size: 4.6 cm by 4.8 cm; -Depth: 2 cm; -Odor: No; -Drainage: Yes; -Treatment: Santyl/Bactroban apply calcium alginate and cover with foam dressing; -Notes: Refer to wound company. Review of the resident's Wound Care Company progress notes, dated 8/07/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Notes: Wounds debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry. DON updated on plan of care; -Wound assessment: Measurements: 9.5 cm by 7 cm by 2 cm depth, bone and adipose tissue (connective tissue that extends throughout the body) exposed; -Moderate amount of sero-sanguinous drainage which had a strong odor; -Undermining noted at 12:00; -Pain level of a five out of 10; -Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar; -Quality of tissue deteriorated compared to the conclusion of previous visit; -Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant and apply Santyl and Bactroban nickel thick to entire wound bed daily. Review of the resident's care plan, dated 8/10/23, showed the following: -Problem: Resident had ADL (activities of daily living) self-care performance deficit due to weakness, decreased cognition and disease process; -Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse; -Problem: Resident had the potential/actual impairment to skin integrity; -Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface. Review of the resident's Wound Care Company progress notes, dated 8/14/23, showed the following: -Chief Complaint: Seen for evaluation and management of wounds; -Notes: Coccyx negative for bacteria. Wound debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry.; -Wound assessment: Measurements: 7.5 cm by 8 cm by 3 cm depth, bone and adipose tissue exposed. Moderate amount of sero-sanguineous drainage which has a strong odor. Undermining noted at 12:00. Pain level of a five out of 10; -Wound bed: 51% bright red granulation (new connective tissue), 1-25% slough and 1-25% epithelialization, no eschar; -Quality of tissue improved in comparison to previous visit; -Wound orders: Cleanse pressure ulcer with saline, pat dry, protect peri-wound (area surrounding wound) with skin protectant, and apply Santyl nickel thick to entire wound bed, apply calcium alginate and cover with sacral silicone dressing (specialized wound dressing) daily. Discontinue Bactroban ointment. Observation of a skin assessment on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. CNA W removed the resident's covers and soiled incontinence brief. CNA W and ADON E turned the resident to the right side, revealing a dressing to the coccyx dated 9/12/23. After personal care was provided, ADON E removed the dressing which revealed a large pressure ulcer. The wound bed was red in color with no odor. The pressure ulcer measured 8.5 cm by 8.9 cm. ADON E cleaned the pressure ulcer with wound cleaner, applied Skin Prep to periwound area, Santyl and calcium alginate to the wound bed and covered with a dry dressing. During an interview on 9/18/23 at 4:23 P.M., CNA S said he/she worked the evening shift and had taken care of the resident. He/She said CNA X found the pressure ulcer a few months ago when it began as a reddened spot. He/She reported it to the charge nurse and was instructed to apply a thick white cream. The reddened area began to get worse and changed to a sore. He/She continued to apply the cream to the sore because he/she hoped the sore would get better. During an interview on 9/15/23 at 9:30 A.M., CNA F said he/she worked on the day shift and had taken care of the resident. The first time he/she saw the resident's pressure ulcer was approximately a week ago. He/she helped to position the resident while the nurse changed the dressing. The pressure ulcer was like a large circle at the time. He/She doesn't remember when the pressure ulcer started or what it looked like. When he/she found an open area to a resident's skin he/she reported it to the nurse. During an interview on 9/18/23 at 4:14 P.M., Nurse R said he/she worked the night shift and had taken care of the resident. The resident required total care from the staff. He/She didn't recall whether he/she worked the night the pressure ulcer was found. He/She completed skin assessments as scheduled on the night shift. Staff for the most part would report changes in the residents' skin. Some of the staff wouldn't report changes and they had to be reminded to do so. He/She had staff who he/she trusted to report changes. Occasionally he/she would ask staff whom he/she trusts, about the resident's skin after they had completed their rounds and documented this on the resident's skin assessment. He/She didn't do that all the time, only when certain staff members worked. He/She didn't recall staff reporting any problems with the resident's skin and didn't recall when the pressure ulcer developed on the resident's coccyx. During an interview on 9/19/23 at 1:10 P.M., Nurse T said he/she worked on the evening shift and had taken care of the resident. Staff reported the pressure ulcer to the resident's coccyx. He/She recalled the pressure ulcer had slough and blacked areas. After he/she assessed the wound he/she called the physician for a treatment order. He/She reported the information to the ADON, who said he/she would notify the Wound Nurse and family the next day. The facility had assigned shifts for skin assessments to be completed. When staff found an open area they were to report it to the nurse. The nurse was to assess the area, notify the physician for a treatment order and notify the ADON and Wound Nurse. He/she didn't know why the 7/18/23 treatment order wasn't on the TAR. During an interview on 9/14/23 at 10:24 A.M., Nurse Q said he/she worked the day shift and had taken care of the resident. He/She didn't remember when the resident developed the pressure ulcer. The facility had a Wound Nurse who did the treatments daily. The prior Wound Nurse wanted the nurse to call the physician for an order for the resident to be seen by the Wound Nurse. Once the order was obtained the Wound nurse would assess the wound and call the physician for a treatment order. The current policy was when a wound was found, the nurse assessed the wound, called the physician for treatment orders and notified the Wound Nurse of the new order. They were to also notify the ADON. The Wound Nurse did the treatments daily. The nurse would do the treatment on the days when the Wound Nurse wasn't working or if the dressing became soiled. During an interview on 9/14/23 at 12:38 P.M., ADON E said he/she was unaware the treatment order for calcium alginate and dry dressing, dated 7/18/23, was not on the TAR. He/She expected staff to report any changes in the resident's skin. The nurse should assess the area, call the physician for an order and notify the ADON and the Wound Nurse. During an interview on 9/14/23 at 12:38 P.M., the DON said she was not aware the resident's treatment for calcium alginate and dry dressing ordered 7/18/23, was not on the TAR. She would have expected the nurse to make sure the order was on the TAR. She said a treatment order was obtained on 7/24/23 for a change in the resident's pressure ulcer but wasn't started until 7/26/23. Mistakes were made by the former Wound Nurse who no longer worked at the facility. During an interview on 9/14/23 at 1:19 P.M., the Regional Nurse Consultant said, the nurse failed to push the correct tab in the computer when transcribing the 7/18/23 order for the calcium alginate and dry dressing. That error caused the treatment order not to be on the TAR. The resident received a treatment of zinc oxide to his/her buttocks during the time of the order. She was unable to show the resident received the treatment that was ordered by the physician. In addition she said staff called the physician on 7/24/23 and obtained a new treatment order. No response was received as to why the treatment was not started until 7/26/23. 2. Review of Resident #22's annual MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands, clear comprehension; -Extensive assistance of one person required for bed mobility, transfers, walking in room/corridor, dressing, toilet use, personal hygiene and bathing; -Always incontinent of bowel and bladder; -Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression; -At risk of developing pressure ulcers?: Yes; -Unhealed pressure ulcers?: No. Review of the resident's care plan, showed: Focus: -11/11/22: Focus: Resident had an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves). Intervention: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers; -1/2/23: Focus: Resident was incontinent of bowel and bladder. Intervention: Keep skin clean and dry. Use lotion on dry skin; -1/2/23: Focus: Resident had a nutritional problem or potential nutritional problem and had a diagnosis of malnutrition with interventions in place. Intervention: Provide, serve diet as ordered; -8/30/23: Focus: Resident had actual skin impairment to skin integrity. Stage III pressure injury (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 (passageways underneath the surface of the skin)) to right hip. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities. Failure to heal, signs and symptoms of infection to physician. Clean perineal area (buttocks/genitalia) with each incontinence episode. Review of the POS, showed: -An order dated 12/16/22: Weekly skin assessment every evening shift every Monday; -An order dated 8/25/23: Wound Care Company to evaluation and treat; -No dressing order to the right hip from 8/15/23 through 8/22/23, per Nurse P's progress note dated 8/15/23 at 6:11 P.M.; -An order dated 9/8/23: Right Posterior Hip: Apply collagen powder (a protein used to heal wounds) to wound bed. Apply Hydrogel (promotes a moist healing environment in wounds) on top of powder on wound bed. Cover with silicone bordered foam (provides gentle adhesion, highly breathable absorbent film) daily and as necessary; -An order dated 9/18/23: Right Posterior Hip: Apply collagen powder to wound bed. Apply Hydrogen on top of powder on wound bed. Apply calcium alginate to wound base. Cover with silicone bordered foam daily and as necessary; -An order dated: 9/14/23, Coccyx: Apply collagen powder to wound bed. Apply hydrogel on top of powder on wound bed. Cover with silicone bordered foam daily and as necessary. Every day shift. Review of the resident's assessment tab on 9/13/23, and located in the electronic heath care record, showed no Braden Scale (an assessment used to determine a resident's probability of developing a pressure injury) on file. Review of the facility's weekly Pressure Injury Report, dated 8/6/23 through 8/12/23, showed no documentation regarding the resident. Review of the resident's Weekly Skin Observation form, dated 8/7/23 at 10:34 P.M., showed: -Observations: -Skin Color: Normal; -Skin Temperatures: Dry; -Skin Turgor (refers to the elasticity or firmness of the skin): Normal; -Skin Issues: No. Review of the resident's Shower Sheet/Skin Condition report, dated 8/9/23, showed: -Shower and skin check, normal, dry skin (scalp); -No documentation about a pressure injury to the right hip/trochanter. Review of the resident's progress notes, showed: -8/14/23 at 7:51 A.M., completed by Nurse P: Upon skin assessment, noticed a quarter size open area to the resident's right hip area. Unit manager made aware of new open area. This nurse cleaned area and applied a dry dressing; -8/14/23 at 8:03 P.M., completed by Nurse P: Call out to physician to make aware of new open area found on the right hip. Message left awaiting call back for orders. Review of the residents Weekly Skin Observation form, dated 8/14/23 at 7:49 P.M., and completed by Nurse P, showed: Observations: -Skin Color: Normal; -Skin Temperatures: Dry; -Skin Turgor: Normal; -Skin Issues: Yes; -Site: Right trochanter/hip, quarter sized open area; -Notes: Area cleaned and placed dry dressing. Review of the facility's weekly Pressure Injury Report, dated 8/13/23 through 8/19/23, showed: -Facility Acquired: Yes; -Right posterior hip/trochanter; -Stage II pressure injury (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.); -Measurement: 3.0 cm by 2.0 cm by 0.2 cm; -Drainage: No; -Treatment: Calcium alginate with silicone border foam; -No other pressure injuries noted. Review of the resident's progress notes, showed: -8/15/23 at 6:11 P.M., completed by Nurse P: Representative from physician's office returned call (from 8/14/23 at 8:03 P.M.) and said the physician said to put a dressing on the wound (right hip/trochanter). No specific order given. Wound Nurse made aware of wound on resident as well; -There was no clarification documented about what type of dressing/treatment or when and/or how often it should be applied/changed;<b[TRUNCA

Based on observation, interview, and record review, the facility failed to adequately support the nutritional status of one resident who experienced a weight loss of 25.70% in four months by not notifying the physician to obtain orders for the Registered Dietician (RD) recommendations and the facility failed to follow their policy by not having the resident re-weighed (Resident #2). The facility also failed to follow physician orders in providing a therapeutic diet and liquids for one resident who experienced a weight loss of 6.5% in two months (Resident #10) and for one resident who experienced a weight loss of 5.6% in two months (Resident #4). The sample size was 14. The census was 138. Review of the facility's Nutritional (Impaired)/Unplanned Weight Loss, policy, revised September 2017, showed: -Assessment and Recognition: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change in baseline appetite or food intake. -Cause and identification: -The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions; -For individuals with recent or rapid weight gain or loss (for example, more than a pound a day), the staff and will review for possible fluid and electrolyte imbalance as a cause; -Treatments: -The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. -The physician will authorize appropriate interventions, as indicated; -Treatment and management: -The physician will document if cause-specific interventions could not be identified or are not feasible; -The staff and physician will review and consider existing dietary restrictions and modified consistency diets; -A pertinent assessment and meaningful review of possible medical and non-medical causes of altered nutritional status should precede the use of such medications. -Monitoring: -The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting); -When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident responses, goals, wishes, prognosis, and complications. Review of the facility's Assessment and Management of Residents Weights policy, revised June 2020, showed: -Purpose: To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem; -Policy: Weights are obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT); -Procedure: -A licensed nurse or designee will weigh residents; -Admissions and re-admissions will be weighed on the shift they arrive; -Hospital weight will not serve as admission or re-admission weight; -Adaptive or assistive equipment used during measurement will be documented; -If the weight is less than or greater than 5 pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight; -Weights will be entered into the clinical record on that shift; -Significant Weight Change Management: -Significant weight changes will be reviewed by the designated licensed nurse; -Significant weight changes are: 5% in one month, 7.5 % in three months, and 10% in six months; -The licensed nurse will: Report weight change in the medical record and on the 24-Hour Report; Notify the physician and dietitian of significant weight changes; and document notification in the nurses notes; -The RD will: Complete a nutritional assessment on all residents with a significant weight change; Document the nutritional assessment and weight management recommendations in the medical record; The licensed nurse will notify the physician of the dietitian's recommendations and notify the family/health care decision maker of the weight change, as indicated; If the physician does not implement the dietitian's recommendations they will document the rationale for non-implementation in the medical record; The licensed nurse will document physician's refusal and communicate this information to the Director of Nursing Services (DNS) for follow-up on the 24 Hour Report; Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care; The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change. 1. Review of the Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/24/23, showed: -Severe cognitive impairment; -Rejected care daily; -Dependent on facility staff for transfers, dressing, and personal hygiene; -Required extensive assist from facility staff for bed mobility, eating, and toilet use; -Diagnoses included: cancer, coronary artery disease (CAD, damage or disease in the heart's major blood vessels), heart failure (inability of the heart to pump blood through the body), hypertension (high blood pressure), high cholesterol, aphasia (inability to speak), hemiplegia (weakness to one side of the body) or hemiparesis (numbness to one side of the body), malnutrition (protein or calorie) or at risk for malnutrition, anxiety, depression and chronic obstructive pulmonary disease (COPD, constriction of the airways in the lungs making it difficult to breathe); -No or unknown weight loss or weight gain. Review of the resident's weights showed: -On 10/5/22: 143.5 lbs; -No weights recorded for November, 2022, December, 2022 and January, 2023. Review of the resident's lab results, dated 12/6/22, showed a blood urea nitrogen (BUN, a blood test that reflects kidney function and hydration) of 7 mg/deciliter (dl) (normal range is 7-26) and a Creatinine level (a blood test that reflects how well your kidneys are filtering waste products) of 0.9 mg/dl (normal range is 0.71 - 1.16). Review of the resident's care plan, initiated 1/31/23, showed: -Focus: The resident has a nutritional problem or potential nutritional problem and is at risk for malnutrition with interventions in place; He/She is on an altered diet and in non-compliant with diet; -Plan: RD to evaluate and make dietary recommendations as needed (PRN); Weight per facility protocol; -Focus: The resident is frequently resistant to care and vital signs (VS, blood pressure, pulse, respiratory rate and temperature) being obtained; The resident will strike staff, yell out and kick at staff; The resident will refuse medications and treatments at times; -Plan: If the resident resists activities of daily living (ADL), reassure the resident and leave and return 5-10 minutes later and try again; Review of the resident's RD note, dated 2/28/23 at 1:34 P.M., showed the resident continues on a regular mechanical soft diet, intake fair. Available weight is from October, 2022, 143.5 lbs. and body mass index (BMI, a calculation to determine a healthy weight) low at 17.7 (a normal BMI is 18.5 to 24.9). Resident appears very thin, observed bony prominences (area in which the bone is close to the skin) in shoulder and temporal (temples of the head) regions. Recommend Ensure Plus (a nutritional supplement) three times daily (TID) with meals. Obtain weight. Provide two glasses water at each meal. Review of the resident's weights showed: -No weights recorded for February 2023; -On 3/8/23: 105.9 lbs. The residnet was not reweighed as directed by the policy; -No further weights were documented. Review of the resident's physician order sheets (POS), dated March 2023 and April 2023, did not show an order for the Ensure Plus three times daily or for staff to provide two glasses of water at each meal. Review of the resident's progress notes showed: -No documentation the resident refused for his/her weight to be obtained or the resident's physician was notified of his/her weight loss, dietary recommendations, or any refusals of weights; -On 4/3/23 at 9:44 A.M., the resident was sent to the hospital due to a noticeable change in condition, alert and oriented to self, vital signs blood pressure 84/48 (BP, normal 120/80), respirations 21 (normal 12-18) pulse 66 (normal 60-100), oxygen saturation 77% (normal 95-100 %). This writer was unable to arouse the resident at bedside, oxygen therapy initiated, 911 activated, physician and responsible party (RP) notified. The resident has been transferred to the hospital. Review of the resident's hospital progress notes, dated 4/3/23, showed the resident presented to the emergency room and appeared severely cachectic (loss of body weight and muscle mass). Diagnosis included pneumonia and kidney failure. Review of the resident's hospital lab results, dated 4/3/23, showed a BUN of 86 mg/dl (indicator of dehydration) and a Creatinine level of 3.16 mg/dl. During an interview on 4/27/23 at approximately 11:00 A.M., Certified Nursing Assistant (CNA) E, said the resident did not like the food at the facility and he/she would only eat snacks and soda. He/She never saw the resident drink water. CNA E noticed a decline in the resident's weight over the last month or two. During an interview on 4/28/23 at 8:45 A.M., Certified Medication Technician (CMT) C said the resident never received nutritional supplements. The resident was a picky eater and had to be fed because he/she had contracted hands. The resident only liked certain staff members and would usually be more receptive with care when those staff members took care of him/her. CMT C had noticed the resident was getting really thin over the last month before he/she passed away. If staff noticed the resident was having issues with weight loss, the nurse should be notified. If a resident refuses care, the staff member should try again later or get another staff member to try. During interviews on 4/28/23 at 8:35 A.M. and 8:50 A.M., Nurse B said the CMTs give the nutritional supplements. The dietician progress notes are reviewed by the nurse and if there are recommendations for the resident, the physician is called and orders are placed in the computer. The dietician recommendations should be addressed immediately with the physician. Nurse B said he/she had taken care of the resident frequently. He/She noticed the resident was losing weight, because his/her face looked sunken in and he/she wasn't eating as much. He/She did not like the facility food and would frequently eat snacks. The resident was non-compliant with the mechanical soft diet. Nurse B had notified the physician of the resident's recent decline. He/She thought he/she had documented the notification. The physician is to be notified anytime the resident refuses any weights, care or medications. During an interview on 4/28/23 at 12:05 P.M., RD K said the resident was severely underweight. The resident's BMI was 14.9 based off of the 3/8/23 weight of 105.9 lbs. The resident should have been reweighed. The resident should have received the Ensure supplements as recommended. During an interview on 4/28/23 at 1:18 P.M., the facility's Medical Director's Nurse Practitioner (NP) G said he/she saw the resident on 2/3/23 and 3/2/23 and did not recall if the resident appeared malnourished. He/She does not recall if he/she was notified of the resident's weight loss or refusal of weights. NP G expected staff to follow their policy regarding weights and could not make any assumptions on when the dietary recommendations should be implemented. During an interview on 4/28/23 at 2:07 P.M., the Administrator and the Regional Nurse Consultant said the resident would refuse to be weighed and would fight with staff. When the resident refuses weights, the physician or their representative is expected to be notified with documentation in the progress notes that the physician was notified. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Required extensive assist from staff with bed mobility, transfers, dressing, eating, toilet use and personal hygiene; -Diagnosis included: anemia (a lack of red blood cells in the blood), diabetes, dementia, malnutrition (protein or calorie) or at risk for malnutrition, and COPD; -No or unknown weight loss or weight gain. -No rejection of care. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has a potential nutritional problem and has a diagnosis of malnutrition with interventions in place; The resident eats and gets nutrition and fluids through his/her feeding tube; -Interventions: Monitor/record/report to the physician PRN signs and symptoms of malnutrition; emaciation (the state of being abnormally thin), cachexia, muscle wasting, significant weight loss: 3 lbs in one week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months; Provide, serve diet as ordered; Monitor intake and record every meal. RD to evaluate and make diet change recommendations PRN; Weigh per facility protocol. Review of the resident's weights, showed: -On 3/8/23: 113.4 lbs; -On 4/6/23: 108.0 lbs; -On 4/10/23: 101.2 lbs. Review of the resident's lab results, dated 3/16/23, showed the resdient's BUN level was 38mg/dl (indicates Dehydration). Review of the resident's POS, dated 4/1/23 through 4/27/23, showed: -An order dated, 2/28/23, for enteral feed (tube feeding) order, Glucerna 1.2 (a type of diabetic tube feeding) at 45 milliliters (mls) and a water flush 150 mls every four hours. -An order dated, 3/1/23, for pureed diet (a diet that all foods have a soft pudding like consistency) with honey consistency liquids; Review of the resident's progress notes, dated 4/17/23 at 12:08 P.M., showed the RD documented in the resident's tube feeding and wound review: 4/6/23, weight: 108 lbs; 4/10/23, weight: 101.2 lbs; significant loss of 6.8 lbs (6.3%) in less than a week. However question accuracy of weights. Appears usual weight is 106 - 110 lbs in past 6 months. BMI is 17.4, underweight. The resident is at high nutritional risk. History of severe protein-calorie malnutrition. Ideal body weight (IBW) is 120 lbs. The resident has six to seven wounds (coccyx (tailbone area), left buttock, left and right heels, right outer ankle) requiring increased calories and protein to promote healing. Current tube feeding: Glucerna 1.2 at 45 mls per hour. Observation on 4/28/23 at 8:53 A.M., showed the resident was weighed by two facility staff members with the use of a Hoyer lift (a mechanical lift used to transfer or reposition the resident) and the resident's weight showed: 105.6 lbs. Observation on 4/26/23 at 12:10 P.M., 4/27/23 at 8:05 A.M. and 8:35 A.M. and on 4/28/23 at 8:53 A.M., showed the resident lay in bed with a tube feeding pump located next to his/her bed with Glucerna 1.2 at 45 mls with a water flush bag infusing into the resident's feeding tube. No meal tray or liquids to drink were brought into the resident's room to assist him/her with eating. The resident was able to make eye contact, but could not speak. The resident appeared thin and had dry skin on his/her arms and legs. Dressings to the resident's feet were observed. During an interview on 4/28/23 at 8:22 A.M., Nurse P said the resident could eat a pureed diet and required assistance with feeding. They usually fed the resident during breakfast and lunch on his/her shift. Observation on 4/28/23 at 8:24 A.M., showed no breakfast plate on the cart for the resident. CNA E said the resident did not have a breakfast tray. During an interview on 4/27/23 at approximately 8:35 A.M., CNA E said when he/she initially starts working with a resident and notices the resident is on tube feeding and gets a tray, he/she would clarify with the nurse if the resident is to be eating in addition to the tube feeding. CNA E had never given the resident a tray to eat since he/she had been working with the resident. During an interview on 4/27/23 at 9:38 A.M., Licensed Practical Nurse (LPN) F said he/she was surprised the resident was still on tube feeding, because he/she eats a lot when staff sit down and assist the resident with eating and drinking. The resident will comment on how good the food is. During an interview on 4/28/23 at 12:00 P.M., CNA E said he/she passed lunch trays on the unit and there was not a tray for the resident. The resident can eat a pureed diet, but he/she had not fed the resident. He/She worked on the unit the previous day and today and did not provide a tray or feed the resident. The resident did not receive breakfast or lunch on 4/27/23 or 4/28/23. 3. Review of Resident #4's quarterly MDS, dated ,d+[DATE] 23, showed: -Cognitively intact; -Total dependence of staff for bed mobility, transfers, dressing, toilets use and personal hygiene; -Diagnoses included spinal cord dysfunction, quadriplegia (paralysis of all four limbs), malnutrition (protein or calorie) or at risk for malnutrition, anxiety and depression; -Weight loss or weight gain: No or unknown. -No rejection of care. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has a potential nutritional problem and has a diagnosis of malnutrition with interventions in place; -Interventions: Provide, serve diet as ordered; Monitor intake and record every meal; RD to evaluate and make diet change recommendations PRN; Weigh per facility protocol. Review of the resident's POS, dated 4/1/23 through 4/27/23, showed: -An order, dated 7/28/22, for regular diet, ice cream with lunch daily, whole milk only with breakfast. -An order, dated 10/21/22, for Ensure plus, TID, for nutritional support. Review of the resident's weights, showed: -On 3/2/23: 142 lb.; -On 4/7/23: 138.5 lbs. Review of the resident's RD progress note, dated 4/28/23 at 12:24 P.M., weight today 134 lbs, a decrease in 8 lbs and 5.6 % in two months, BMI 19.3. Diet order regular diet. The resident required full assistance with all meals and fluids. Intake varies 25-100%. Order noted for Ensure TID. Observation on 4/28/23 at 9:40 A.M., showed the resident was weighed by two facility staff members with the use of a Hoyer lift and the resident's weight showed: 134.0 lbs. During an interview on 4/28/23 at approximately 1:40 P.M., the resident said he/she can feed him/herself finger foods, but the staff will step in if he/she required help eating. He/She said he/she only receives 2% milk, not whole milk and never receives ice cream. The resident gets supplements but didn't really like them. 4. During an interview on 4/28/23 at 8:35 A.M, Nurse B said the nursing staff can review the RD notes in the computer that will have the recommendations. Sometimes they are told by the ADON and DON about the RD recommendations but not all the time. Nursing should then call the physician once the recommendations are received. He/She was not sure of the timeline on when the recommendations need to be followed through. 5. During an interview on 4/28/23 at 9:27 A.M., Restorative Aide J said he/she obtains weights monthly along with other nursing staff and places all weights in the computer. Staff are to reweigh the resident if a discrepancy in the weight has occurred and would inform the nurse, Assistant Director of Nursing (ADON) or the Director of Nursing (DON). 6. During an interview on 4/28/23 at approximately 11:00 A.M., the Dietary Manager said he/she receives the report from the RD that has the dietary recommendations on it. He/She then passes the report onto the DON or ADON. 7. During an interview on 4/28/23 at 12:05 P.M., RD K said his/her recommendations are in a report format and sent to the dietary manager and then they are distributed to the ADON and DON for review. The recommendations are expected to be implemented immediately. RD K expected staff to provide a meal tray with liquids and assist with feeding the residents. RD K expected weights to be completed monthly. Nursing staff should also review the dietician notes in the computer. A monthly weight meeting would be beneficial to keep track of the weights of the residents, because he/she is not always notified when a weight issue has occurred with the residents. 8. During an interview on 4/28/23 at approximately 12:45 P.M., the Medical Director's NP H said staff are expected to follow physician orders and follow the facility weight policy. The RD recommendations are expected to be implemented within 14 days of receiving them. Dietary recommendations are usually not considered emergent. The facility will usually send the dietary recommendations by e-mail or place them in the provider's incoming mailbox. The ADON and DON will review the weights and the dietary recommendations and sometimes will call him/her if a notable concern is determined. 9. During an interview on 4/28/23 at 2:07 P.M., the Administrator and the Regional Nurse Consultant said staff are expected to follow physician orders, provide a meal tray and to assist the resident with the meal. Dietary recommendations are to be implemented within 14 days of receiving them. The facility is working on a better process of communication between dietary services and nursing staff. The RD, ADON and DON are responsible to review the recommendations and the resident weights. Staff are expected to follow the weight policy. The residents are to be weighed monthly or as needed and the physician is to be notified if a weight loss or weight gain has been determined. A weight loss can be determined by reviewing the resident's medical record and making sure the resident is not on dialysis and has not had a recent hospitalization that may affect the resident's weight. MO00216659

41151 Based on observation, interview, and record review, the facility failed to conduct a thorough pre-admission assessment to ensure a resident's needs could be met by the facility (Resident #32). Prior to the resident's admission, the facility was aware the resident needed to reside on a secured unit as a condition to receive outpatient dialysis. At admission, the resident was not placed on a secured unit and missed a dialysis appointment as a result. The resident was then placed on the secured unit, which resulted in self-injurious behavior. The resident was sent to the hospital and issued an immediate discharge notice due to the facility's interdisciplinary team (IDT) determining the facility was not an appropriate placement for the resident. The census was 115. Review of the Secured Care Neighborhood policy, revised on 8/2022, showed: -Purpose: The goal of the Secure Care Neighborhood is to meet the individual needs of residents with dementia related illnesses. The Secure Care Neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere; -Policy: The secure care neighborhood may be used to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed with a physician order completed; -Residents eligible for admission to the Secure Care Neighborhood will have a diagnosis of dementia or dementia related illness; -The need for admission to the Secure Care Neighborhood must have a physician order. Review of Resident #32's hospital discharge summary, dated 9/27/22, showed: -Patient has a complicated history of cognitive decline over the past 5 years that appears to have accelerated over the past several months that has been associated with violent, aggressive, sometimes hypersexual behavior. He/she has had multiple hospital admissions since 1/2022. Over the course he/she has had multiple admissions for ongoing hemodialysis (HD, treatment that removes the waste products and excess fluid from the blood due to kidney failure) needs and re-initiation of antibiotics due to noncompliance. On prior two admissions he/she has been deemed to have capacity and has left against medical advice (AMA) after violent encounters with staff (2/17-2/22; 2/25-2/26). Of note, he/she underwent Brain Magnetic Resonance Imaging (MRI, a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body) on 2/19/22 that was consistent with likely vascular component of presumed dementia; -He/she has been fired from outpatient dialysis centers; most recently for bringing a gun and urinating in a trash can. He/she has had worsening paranoia, often confabulating per prior reports; -He/she most recently left AMA on 2/26/22, and reportedly on day of discharge pulled a gun on family of a fell ow resident at his/her apartment facility. He/she was presented to the hospital Emergency Department (ED) by the police for a psychiatric evaluation. The patient became agitated and was attempting to break the windows and required chemical sedation. User Defined Assessment (UDA, a simple checklist of care plan completed at the time of admission) was positive for cocaine/oxycodone. Psychiatric evaluation deemed patient not to have capacity and patient admitted . On the floor he/she is alert and oriented to person, place and time (A&Ox3). He/she is unable to describe why he/she was brought to the hospital. When asked about pulling a gun on individuals recently, he/she states he/she does not have a gun. When asked about his/her last use of cocaine given positive (+) blood level?, he/she stated he/she has not used cocaine in years; -Started HD in early 2021. Difficulty with HD placement. Previously had accepting skilled nursing facility, but await accepting HD center. Renal continuing inpatient HD Please clarify. Nephrology (the branch of medicine that deals with the physiology and diseases of the kidneys) agrees that given improvement in behavior, that he/she is a candidate for outpatient HD; -Goals of care, counseling/discussion: Aggressive behavior attributed to vascular dementia has resulted in removal from prior HD unit. Behavioral episodes early in hospitalization which have now improved. Family member did not feel comfortable being guardian. Patient has expressed interest and adherence with ongoing HD therapy. Family meeting 7/12/22 desire to continue dialysis. Will need to re-address as there are no accepting outpatient HD centers. Review of the resident's facility medical record, showed: -An admitted [DATE]; -Diagnoses included kidney failure, heart failure, and vascular dementia with behavioral disturbances. Review of the resident's physician's orders, showed: -An order, dated 9/27/22, for Chlorpromazine (used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and other psychotic disorders), HCI Tablet 10 milligrams (MG). Give 1 tablet by mouth three times a day for antipsychotic behaviors; -Haloperidol (used to treat certain mental/mood disorders) Tablet 1 MG Give 1 tablet by mouth every 6 hours as needed for agitation; -An order, dated 9/2722, to check bruit and thrill to dialysis fistula LFA (left forearm) every shift; -An order, dated 9/27/22, for right chest dialysis catheter (no directions); -No order for dialysis to included dates, time, dialysis location cite, etc.; -An order, dated 9/27/22, may have leave of absence with medications and responsible party; -No order to admit the resident to the secured unit. During an interview on 10/4/22 at 2:32 p.m., the clinical coordinator for the outpatient dialysis center said the terms of the resident's acceptance to the outpatient dialysis center had been made between the nephrologist at the hospital and the dialysis center. The terms upon discharge from the hospital to come back to the dialysis center were for the resident to be housed on a secured unit and be accompanied by a staff person. The clinical coordinator said she spoke with the administrator and explained the terms. He said he would try to comply with the terms. During a telephone interview on 10/26/22 at 2:38 P.M., the administrator said the facility had been tracking the resident in the hospital for a while and knew that he/she needed to be on a secured unit when admitted . There was a mistake during the admission process and the resident was not placed on the secured unit. When going through paperwork for dialysis, the facility realized the resident should be on a secured unit and moved him/her to the unit at that time. During an interview on 10/5/22 at 2:30 P.M., the resident's physician said she was unaware of the resident's placement on the secured unit or the dialysis center's recommendations. Review of the resident's care plan, dated 9/29/22, showed: -Focus: Resident needs dialysis; -Intervention: Check and change dressing daily at access site. Document. Do not draw blood or take blood pressure in left arm with graft (dialysis access site). -The care plan did not address the need for a secured unit due to the dialysis center request. Review of the resident's nurse's progress notes, showed: -On 9/29/22 at 3:14 P.M., Dialysis missed due to transportation. Resident shows no signs of distress at this time, vitals within normal range; -On 9/30/22 at 9:06 A.M., (date created on 10/3/22 at 12:39 P.M.), social worker documented he spoke with the hospital social worker, the conversation over resident's placement at this facility reviewed/discussed. The hospital social worker reported the resident deemed incapacitated by medical team with recommendation for locked unit placement per dialysis center request due to safety concern with resident's community access, IDT notified. -On 9/30/22 at 12:29 P.M., Physician was notified resident missed dialysis and there has been no change in condition. Appointment was re-scheduled; -On 9/30/22 at 2:16 P.M., Patient moved to locked unit, left message with contact on file no answer; -On 9/30/22 at 12:36 P.M., Late Entry: At 12:00 A.M., resident is sitting in wheelchair beside the doors in the locked unit. Resident refused blood pressure medication, state the importance of medication, resident states he/she understands and still refuses. Resident stated he/she is not taking any medication until he/she is out of the locked unit. Resident is alert and oriented to self, today's date and on the locked unit. Resident did not know the name of the facility and kept stating he/she is not supposed to be in the locked unit, will continue to monitor during shift; -On 10/1/22 at 8:51 A.M., Resident hospitalized ; During an interview on 10/4/22 at 11:42 A.M., licensed practical nurse (LPN) H, said this was the first time he/she had worked with the resident. He/she didn't know the resident's baseline. LPN H said when he/she came on duty on 9/30/22, he/she asked the previous nurse why the resident was on the secured (locked) unit, and the previous nurse was not able to provide any information why the resident was on the unit. The resident was at the door, and LPN H had seen him/her at the door when he/she came duty at 11:00 P.M. Later, around 2:00 A.M., the resident was banging his/her hand on the wall, and had blood on his/her face. LPN H said he/she had seen the blood on the resident's face, and called the physician, and they didn't know why he/she was on the secured unit. The resident told LPN H he/she had bumped his/her nose. LPN H called the physician's exchange and got an order to send him/her to the hospital. During an interview on 10/4/22 at 1:30 P.M., the facility social worker said he visited with the resident on Friday, September 30, 2022. During the visit on Friday, the resident didn't seem incapacitated, he/she had no cognitive impairment. The social worker said his visit on 9/30/22 was part of the resident's admission assessment to determine his/her baseline. During his visit, the resident was told he/she was going to the secured unit so he/she could receive dialysis. The resident said he/she understood, but after going onto the unit, the social worker said he didn't think the resident liked it. The dialysis center wanted to be safe and that was the request they made. The resident could only come from a locked unit and had to be accompanied by a staff person. It was unusual for a resident be required to be on the unit in order to receive dialysis. The transportation company did not send transportation on Thursday, 9/29/22. The social worker reached out to the dialysis center and they told him the reason, because the resident had not resided on a secured unit. Placement on the memory care/secured unit is typically for behaviors which include wandering, elopement risk, severe dementia, Alzheimer's. Those are the typical residents on the unit. The Medical Director questioned the resident's admission to the facility. The admission team along with Director of Nursing (DON) accepts residents. The IDT team had planned to meet on Monday, 10/3/22, regarding his/her placement because the dementia unit was not a behavior unit. The resident was higher functioning, and placement was not appropriate. This was mainly because of the people who wander which puts those residents at risk of harm. The DON and the social worker talked about the concerns about the resident's placement on the unit. It was not a good idea, but they had concerns he/she had to have dialysis. They were trying to comply with the dialysis center's wishes because he/she needed dialysis. He/she missed Thursday's, 9/29/22, appointment and was supposed to have dialysis on Saturday, 10/1/22. The social worker saw the note he/she was banging on the door at midnight, and was not surprised because he/she was higher functioning and probably felt trapped. During an interview on 10/3/22, at 3:50 P.M., the administrator said he believed the social worker and DON assessed the residents before placing the resident in the secured unit and determined he/she was not appropriate for the secured unit. He said the resident was placed on the secured unit following the recommendation of the hospital, but more so from the dialysis center. Staff moved the resident to the secured unit, and then found he/she was not appropriate for the secured unit. The resident was banging his/her head against a wall, he believed inside the secured unit, and was sent to the hospital. Review of the resident's nurse's progress notes, showed: -On 10/3/22 at 12:26 P.M., IDT met to discuss resident's care/discharge plan including resident's placement to unit/facility. Due to safety concerns for self and others, IDT in agreement for current placement to be inappropriate due no evidence for resident to reside on memory care unit. Assessment conducted with resident does not indicate the resident's incapacity for decision-making. IDT in agreement for current placement to locked unit facilities. The resident is at great risk for aggressive behavior placing him/her and others at risk for harm. IDT in agreement for the resident's placement to facility to be inappropriate with immediate discharge letter. During an interview on 10/6/22 at 10:30 A.M., the facility's medical director said the resident was placed in a secured unit, was banging his/her head on the wall and needed stitches. She told staff to send him/her out. She said she did not write an order to move the resident to the secured unit. Everyone on dialysis has a diagnoses of vascular dementia. A&O x 4 (alert and oriented to person, place, time and event) does not mean a decisional capacity. She did not believe the resident should have been admitted to the facility. The facility was not given adequate information from the hospital, and she thought the resident would put the other residents at risk. The resident was given an emergency discharge because the facility cannot protect him/her and the other residents. The resident needs to be in a place that is designed for the safety of individuals who are unsafe to others.

Based on observation, interview and record review, the facility failed to ensure staff followed the facility skin ulcer and wound policy by failing to assess/monitor, document and treat pressure ulcers timely. In addition, staff failed to ensure treatment orders were documented on residents' treatment administration records, failed to show treatments had been completed as ordered by failing to initial treatments as completed and failed to follow or promptly follow the recommendations of the Registered Dietician for nutritional supplements recommended to assist with the healing of pressure ulcers. The facility identified nine residents with known pressure ulcers. Three of those nine were sampled along with one additional resident at risk to develop pressure ulcers. Of those four, problems were identified with two of the three residents, with a facility identified pressure ulcer, as well as an observation of one of those residents having no dressing covering a pressure ulcer for several hours. In addition, seven discharged residents with pressure ulcers were sampled and problems were identified with five (Residents #36, #1, #35, #12, #16, #18 and #24). The sample was 45. The census was 106. Review of the facility Skin Ulcer-Wound Policy, dated 8/15/18, showed: Policy: -All caregivers are responsible for preventing, caring for and providing treatment for [REDACTED].>Purpose: -To identify at risk residents for potential breakdown or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; Definition: For the purpose of this policy, a skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open. If the nurse: -Identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner) for diagnosis; -Examples of this discoloration may include a Stage I pressure ulcer (intact skin with non-blanchable redness (when the area is pressed with a fingertip, blood is not forced out of the capillaries, so the area remains red. If the tissue was blanchable the area would turn white when pressed with a finger tip and then turn red again when the pressure is removed) of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching), suspected deep tissue injury, a Wagner Grade 0 (a [MEDICAL CONDITION] classification system, a Grade 0 refers to intact skin), or other varieties of conditions that meet this criteria; Risk Factors: -Impaired/decreased mobility and decreased ability; -Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus; -Cognitive impairment; -Exposure of skin to urinary and fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; Assessment: Licensed staff will, upon admission, perform a head to toe body audit within two hours of admission. The findings will be documented in the resident's clinical record. Any items not documented on the admission assessment form will be charted in the nurse's notes; -Licensed staff members will, upon admission complete a risk scale once the head to toe body assessment is complete. The risk scale will be completed weekly for the first four weeks after admission for each resident at risk, then quarterly, or whenever there is a change in condition or functional ability requiring a significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; -Licensed staff will complete a head to toe skin assessment weekly and as needed. The skin assessment will be documented on a skin assessment form and become part of the resident's clinical record. Any unusual findings will be documented on the form with a follow-up note in the nurse's notes further describing the area of concern; Skin Ulcer Prevention; -Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating. This may include: Turn and reposition every two hours as appropriate. Pressure reduction surfaces for beds, wheelchairs when appropriate. Floating areas of concern such as heels. Separation of bony prominence's with a pillow or other pressure reducing device. Promotion of clean, dry, and well moisturized skin. Use of elbow or heel protectors when appropriate. Avoiding powders. Following Registered Dietician (RD) recommendations to promote optimum nutrition when possible. Reduction of shearing force by appropriate body mechanics when moving, turning, or repositioning a resident; -Certified Nursing Assistants (CNAs) will complete body audits at least weekly, but preferably with every bathing opportunity. The body audits are turned into the charge nurse for review. Nurses will review the results. If the nurse assesses and determines there is a skin condition present, facility protocol will be followed; -Incontinent residents will be checked and changed as needed; Treatment Protocols: -Consult wound care providers when appropriate; -Until wound care providers can assess and order treatment, the following techniques may be employed: Following standard precautions and good hand hygiene techniques. For non-open areas of concern or areas with stable eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) apply skin prep (a spray or wipe that is applied wet and dries to in a film adding protection to the skin) daily and use preventative measures. On areas where skin prep is not appropriate, moisture barrier is adequate. Skin prep may also be used for unruptured blood filled blisters. For all other open areas, the treatment is determined based on tissue type and drainage. All orders must be approved by a physician within 24 hours of discovering the open area or change in treatment; Assessment Protocols: -Nurse may not diagnose, just describe; -Measurements must be completed weekly by the same licensed person when at all possible; -At the time a skin issue is discovered it must be measured. Wounds are three dimensional, therefore the length, width, and depth must be documented if using measuring instrument; -If a reddened area is identified, the nurse should assess if the area is blanching. If it is not blanching, the nurse should leave for approximately 30 minutes, then return to assess if the area is blanchable. If it is blanchable, it is not a skin concern. If it is not blanching then it should be captured on the licensed body audit report. 1. Review of Resident #36's MDS entry tracking record, dated 12/11/20, showed an admission date of [DATE]. Review of the resident's medical record, showed [DIAGNOSES REDACTED]. Review of the Resident's Weekly Skin Observation (Licensed Nurses), dated 11/9/20, showed: -Coccyx (tailbone, at the very tip of the sacrum (lower mid back area just above the buttocks)), 10.3 x 6.0 x 3.4 undermining (a wound that extends in all directions into the subcutaneous tissue under the skin) 5-8 depth 3.8; -Right thigh (rear), 4 x 4 x 2.3; -No other description noted. Review of the resident's progress notes, showed: -11/9/20 at 7:15 P.M., Resident is alert and oriented to person, place, time and situation. Intravenous line (IV) present. Bowel, incontinent. Bladder, catheter (inserted into the bladder to drain urine). Skin issues present, refer to skin assessment for more information; -11/11/20 at 2:33 A.M., IV medication to treat wound infection. Review of the resident's care plan, undated, showed: -Potential/actual impairment to skin integrity: Encourage good nutrition and hydration in order to promote healing. Treatments per physician's orders [REDACTED].>-Bowel incontinence. Review of the resident's physician's orders [REDACTED]. -11/9/20 Right Hip: Cleanse wound with normal saline (salt water mixture). Apply hydrogel (a clear water based gel that helps to inhibit infections) into gauze and fill in the wound. Cover with dry dressing daily and PRN (as needed); -11/9/20 Sacrum: Cleanse with normal saline. Apply hydrogel into gauze and fill wound bed. Cover with dry dressing daily and PRN. Review of the facility weekly wound reports, dated 11/19/20 and 11/25/20, showed no documentation regarding the resident. Review of the resident's treatment administration record (TAR, a record where treatment orders are documented and where nurses initials serve as verification a treatment has been administered as ordered), dated 11/1/20 through 11/30/20, showed: -Right Hip, start date 11/10 through end date 11/16: Cleanse with normal saline, apply hydrogel with gauze, fill in wound bed and apply dry dressing daily and PRN; -The TAR showed no staff initials on 11/16; -Right Hip, start date 11/17 through end date 12/9: Cleanse with wound cleanser, calcium alginate (a highly absorbent dressing that provides a moist environment to promote healing) to wound base, cover with dry dressing daily and PRN; -The TAR showed no staff initials on 11/17 and 11/28; -Sacral Region: No treatment order documented on the TAR from 11/9 through 11/16; -Sacral Region, start date 11/17 through end date 12/9: Cleanse with wound cleanser. Apply calcium alginate to wound base and cover with dry dressing daily and PRN; -The TAR showed no staff initials on 11/17 and 11/28. Review of the facility weekly pressure ulcer/wound tracking reports, dated 12/3/20, showed for the resident: -Sacral: Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling (channels or tunnels that extend into the subcutaneous tissue under the skin). admitted with 11/17/20. Measurements: 14 centimeters (cm) (length) by 14 cm (width) by 1.2 cm (depth) Undermining, 2 cm from 12 to 3 O'clock. Treatment calcium alginate every day; -Right Hip: 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) admitted with on 11/17/20. Measurements: 4 cm by 3.5 cm by 1 cm, 2.5 cm undermining from 12 O'clock. Treatment calcium alginate every day. Review of the resident's progress notes, showed: -12/7/20 at 12:21 A.M., sent to the hospital for complaints of pain; -12/11/20 at 9:04 P.M., readmitted . Review of the resident's RD assessment, dated 12/18/20, showed: -Resident admitted with multiple wounds in various stages, some noted to be deteriorating. Gangrene noted; -Recommendations: Health shakes (nutritional supplement) at each meal, Pro Stat (a protein supplement for pressure ulcer/wound healing) 30 milliliters (ml) three times a day, Med Pass (nutritional supplement) 90 ml three times a day and multi-vitamin with minerals daily; -Goal: Stable weight and improved skin integrity. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's POS, showed: -12/11/20: Sacrum, cleanse wound with normal saline, apply hydrogel into gauze and fill wound bed, cover with dressing daily and PRN. Review of the resident's progress note, showed a Skin/Wound Note, dated 12/24/20 at 11:32 A.M.,: Sacral is a Stage IV pressure injury pressure ulcer. Right hip is a chronic Stage III pressure injury pressure ulcer. Review of the resident's TAR, dated 12/1/20 through 12/30/20, showed: -Right Hip, start date 11/17 through end date 12/9: Cleanse with wound cleanser, apply calcium alginate to wound base and cover with dry dressing daily and PRN; -The TAR showed staff documented the resident's treatment administered as ordered; -Right Hip, start date 12/12 through end date 1/20: Cleanse wound with normal saline. Apply hydrogel into gauze and fill wound bed. Cover with dressing daily and PRN; -The TAR showed no staff initials on 12/15, 12/18, 12/19, 12/23, 12/25, 12/26, 12/28, and 12/29; -Sacral Region, start date 11/17 through end date 12/9: Cleanse with wound cleanser, apply calcium alginate to wound base and cover with dry dressing daily and PRN; -The TAR showed staff documented the resident's treatments administered as ordered; -Sacral Region: Review of the TAR, showed no treatment order for the sacral region after the resident returned from the hospital on 12/11 through 12/31. Review of the resident's MAR, dated 1/1/21 through 1/31/21, showed: -1/11: an order for [REDACTED].>-1/12: an order for [REDACTED].>-1/19: an order for [REDACTED].>-No documentation regarding health shakes at each meal. Review of the resident's TAR, dated 1/1/21 through 1/31/21, showed: -Right Hip, start date 12/12 through end date 1/20: Cleanse wound with normal saline. Apply hydrogel into gauze and fill wound bed. Cover with dressing daily and PRN; -The TAR showed no staff initials on 1/1, 1/3, 1/5, 1/11, 1/12, 1/15, 1/16 and 1/18; -Sacral Region: No treatment order documented on the TAR from 1/1 through 1/21; -Sacral Region, start date 1/21 through (no end date): Cleanse wound with hypochlorous acid (a weak acid solution used to disinfect), apply calcium alginate to wound base, cover with super absorbent pad daily and PRN; -The TAR showed no staff initials on 1/22. Review of the facility weekly pressure ulcer/wound tracking report, dated 1/21/21, showed for the resident: -Sacral: Chronic Stage IV pressure ulcer. Measurements: 17 cm by 11.5 cm by 0.5 cm; -Right Hip: Chronic Stage III pressure ulcer. Measurements: 2 cm by 2.3 cm by 0.6 cm. Undermining has been noted at 11 O'clock and ends at 2 O'clock with a maximum distance of 1 cm. Observations on 1/25/21 and 1/26/21, showed: -1/25/21 at 6:50 A.M.: The resident lay on his/her back in bed; -1/25/21 at 7:35 A.M.: During a skin assessment with CNA D, showed the resident lay in bed with no dressing covering his/her right hip; -1/25/21 at 7:50 A.M.: The resident said a nurse came in yesterday evening and competed his/her treatments. The nurse cleaned the pressure ulcer on the right hip, but never placed a dressing on it. There has not been a dressing covering it since that time. Staff usually change his/her dressings daily, sometimes every other day; -1/25/21 at 2:00 P.M.: The resident lay in bed without a dressing covering the pressure ulcer on his/her right hip. The resident said staff had been in his/her room a couple of times to reposition him/her, but no one had placed a dressing on his/her right hip pressure ulcer; -1/26/21 at 8:05 A.M., Nurse F said he/she worked yesterday. He/she saw the surveyor go into the resident's room yesterday around 2:00 P.M. After the surveyor left, he/she asked the resident what was going on and found out there was no dressing on his/her right hip. He/she completed the treatment and placed a dressing on it after the surveyor had left. No one told him/her yesterday the resident did not have a dressing on his/her right hip. He/she would have expected staff to inform him/her and he/she would have administered the treatment including placing a dressing on the right hip. During a telephone interview on 2/11/21 at 2:00 P.M., the administrator reviewed the resident's 11/2020, 12/2020 and 1/2021 TARs. She could not explain why the resident was admitted on ,[DATE] with a pressure ulcer on his/her sacral region, but had no order on the TAR until 11/17. She did not know why there was no order for the sacral region on the 12/2020 TAR after the resident returned from the hospital on [DATE], and the order did not reappear until 1/21/21 on the 1/2021 TAR. She would hope the nurses were completing the treatment on the sacral region, but without the order in place she could not be sure. If they were completing the treatment, she had no idea why they would not have restarted the order and and placed it on the TAR sooner than 1/21/21. The RD recommendations should have been followed up on within 48 to 72 hours after the recommendation was received. The RD usually has her recommendations given to the facility within 48 hours. She did not know why it took so long to process the recommendations or why the health shakes were never obtained. 2. Review of Resident #1's entry tracking MDS, dated [DATE], entry tracking record showed an admission date of [DATE]. Review of the resident's [DIAGNOSES REDACTED]. Review of the nurse's progress note, dated 12/24/20 at 2:13 P.M., showed the resident arrived per driver and in a wheelchair. The resident was alert, pleasant and able to make some needs known. Skin warm and dry. No acute distress noted. Resident came from another facility. Resident states he/she had a broken arm. Review of the facility Shower/Shave Schedule, showed the resident should receive a shower every week on Wednesday and Saturday. Review of the resident's Skilled Charting assessment, dated 12/24/20 at 2:22 P.M., showed: -Orientation/Cognition: Alert and oriented to person, place, time and situation; -Bed mobility: Extensive - performed part of activity, weight bearing support provided, full staff performance; -Bed mobility support provided: Two (+) persons physical assistance; -Transfer: Extensive - performed part of activity, weight bearing support provided, full staff performance; -Transfer: Two (+) persons physical assistance; -Check all that apply: Weakness; -Devices: Wheelchair; -Urinary incontinence: Frequently incontinent, incontinent daily but some control present; -Bowel continence: Occasionally incontinent, has some control but has incontinent episodes; -Skin integrity: Not completed, blank. Review of the resident's Weekly Skin Observation assessment, dated 12/24/20 at 2:38 P.M., showed: -Skin color: Normal; -Skin temperature: Dry, warm; -Skin turgor (pinching the skin to determine how long it takes to snap back into place, skin with normal turgor snaps back rapidly): Normal (skin returns promptly); -Skin issues: No (no open areas); -Review of the resident's medical record, showed no other Weekly Skin Observation assessments. Review of the resident's admission assessment, dated 12/24/20 at 9:43 P.M., showed: -Skin color: Normal; -Skin temperature: Dry; -Skin turgor: Normal, skin returns promptly; -Skin issues: Bruises to right hand, scar on left hand and scab on the shin. No other skin abnormalities noted. Review of the resident's Braden Scale (an assessment used in determining pressure ulcer risk), dated 12/24/20 at 9:54 P.M., showed a score of 13. The scoring on the Braden scale is as follows: 9 or below - very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 at risk, no indication of a score 19 and above. Review of the resident's Skilled Charting assessment, dated 12/25/20 at 10:04 P.M., showed: -Orientation/Cognition: Alert and oriented to person; -Bed mobility: One person physical assistance; -Check all that apply: Impaired balance, weakness; -Urinary incontinence: Always incontinent; -Bowel continence: Always incontinent; -Skin integrity: No new changes to skin integrity noted; -Review of the resident's medical record showed no other Skilled Charting assessments. Review of the resident's care plan, initiated on 12/24/20, showed: -Communication problem; -Bowel incontinence; -Potential/actual impairment to skin integrity. Goal: Will maintain intact skin. Approaches: Monitor/document location, size and treatment of [REDACTED]. Review of the facility Shower/Shave Schedule, showed: -The resident should have received a body audit with his/her shower every Wednesday and Saturday (12/26/20, 12/30/20, 1/2/21, 1/6/21 and 1/9/21); -Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review forms, showed one shower documented as given and it was on 12/29/20. The body audit showed no skin abnormalities. Review of the resident's medical record, showed: -POS: An order dated 1/6/21, for the wound care company to evaluate and treat. The order did not show why the evaluation was requested; -The resident had no TARs for 12/2020 or 1/2021. Review of the resident's nurse's progress notes, showed: -No documentation on 1/6/21 regarding the resident's skin; -A note documented 1/7/21 at 11:10 A.M., showed he/she had redness to the buttocks, barrier cream applied. The documentation did not show the size of the redness or if the resident's physician and responsible party had been notified; -A note dated 1/7/21 at 2:27 P.M., that the results of a chest x-ray showed he/she had pneumonia, the physician was notified and the resident was started on antibiotics. The note did not show if staff updated the physician regarding the resident's red buttocks during the notification regarding the pneumonia. Review of the resident's medical record, from 1/6/21 through 1/12/21, showed no other documentation in the nurses' progress notes regarding the redness to the buttocks. Further review of the resident's medical records showed no Skilled Charting assessments, Weekly Skin Observation assessments, or Skin Monitoring: Comprehensive CNA Shower Reviews from 1/1/21 through 1/12/21. Review of the nurse's progress note, dated 1/12/21 at 2:27 P.M., showed he/she was sent to the hospital for respiratory complications. Review of the resident's hospital records, showed: -1/12/21: Admission to the hospital with [DIAGNOSES REDACTED]. -1/13/21 at 9:55 A.M.: The record showed the resident was admitted with wounds. Sacral with a large burgundy discoloration, with multiple open areas, measuring 10 cm by 10 cm by 0 cm. Consistent with an evolving deep tissue injury (DTI, a pressure related injury to the subcutaneous tissues). A large left heel area with an unroofed bullae (blister) and dark burgundy to brown tissue under, measuring 6 cm by 5 cm by 0 cm. This is also consistent with an evolving DTI. Treatment orders: Sacral wound: Cleanse with normal saline, apply Silverstat gel (an antimicrobial gel used to treat burns, wounds and pressure ulcers), cover with dressing and change every Monday-Wednesday-Friday. Continue heel offloading (reducing pressure) with heel boots at all times; -1/25/21 at 3:13 P.M.: Follow up on this resident admitted with multiple wounds. The large area of burgundy discoloration, with multiple open area, continues to measure 10 cm by 10 cm by 0 cm, an evolving DTI. A large left heel, measuring 6 cm by 5 cm by 0 cm. Area is now dry brown, unstageable (unable to determine the stage of the pressure ulcer as the depth of the pressure ulcer is not known due to either an un-removable dressing, slough/eschar or DTI) wound that presented upon admission as a DTI. Treatment orders: Sacral wound and left heel wound: Cleanse with normal saline, apply Silverstat gel, cover with dressing and change every Monday-Wednesday-Friday. Wedges and pillows for turning. Continue heel off loading with heel boots at all times. During an interview on 2/4/21 at 11:19 A.M., the administrator said the resident did not have a TAR for 12/2020 or 1/2021. On 1/7/21, she would have expected staff to follow the facility Skin Ulcer-Wound Policy. She would have expected staff to have began a TAR to monitor the redness on the resident's buttocks daily. She would have expected staff to have notified the physician and resident's representative. There should have been weekly Skin Observations completed by the licensed staff and there should have been more than one Skin Monitoring: Comprehensive CNA Shower Reviews form completed. The resident was discharged prior to the wound care company being able to assess the resident. During a telephone interview on 2/9/21 at 3:00 P.M., the facility Medical Director said he would have expected staff to monitor the resident's red buttocks daily once it was identified. Because it is a change in condition, they should have notified the resident's physician and the resident's representative as well. He expects the facility to follow their policy by completing weekly skin assessments and completing the body audits on shower/bath days. 3. Review of Resident #35's medical record, showed: -admitted : 9/4/12; -[DIAGNOSES REDACTED]. Review of the resident's annual MDS, dated [DATE], showed: -Resident is rarely/never understood; -Needed extensive assistance of one staff member for bed mobility, dressing, eating, and personal hygiene; -Needed total assistance for transfers, toileting and bathing; -Unhealed pressure ulcer, marked yes; was receiving pressure ulcer care; -Resident had pressure relieving devices for bed and chair. Review of the resident's care plan, in use at time of survey, showed: -Problem: at risk for alteration in skin integrity related to incontinence, limited mobility, and appetite; -Goal: will continue to be free from breakdown by next review; -Interventions: CNA to monitor skin during routine care and report any changes to nurse; -Weekly skin checks; -Provide assist with pressure redistribution, provide pressure relieving mattress on bed and in wheel chair; -Care plan did not address wounds on the heel. Review of the resident's progress notes, dated 10/9/2020 through 11/4/2020, showed: -On 10/9/20, seen by wound care. New acquired right medial heel, acute deep tissue pressure injury 1.5 cm x 2.5 cm x 0.1 cm, no drainage; -On 10/23/20, seen by wound care team, right medial heel, 1.2 cm x 2.5 cm x 0.1 cm, no drainage; -On 11/4/20, wound note. Right medial heel, is an acute Stage III pressure injury pressure ulcer, the wound deteriorating. Review of the resident's physician orders [REDACTED]. -an order for [REDACTED]. Secure with a dressing roll gauze and tape in the morning for wound care. Start date 11/6/20, discontinue date 11/30/20; -Documentation showed: On 11/6, 11/16, 11/19, 11/23, and 11/27/20, blank; -an order for [REDACTED].> -Documentation showed: On 11/16, 11/19, 11/23, and 11/27/20, blank; -an order for [REDACTED]. Cover with gauze pad. Secure with gauze dressing every day shift; start date, 11/30/20; -Documentation showed: on 11/30/20, blank; -an order for [REDACTED]. Review of the wound care company progress notes, for 11/2020; for the right medial heel acute Stage III pressure ulcer, showed: -On 11/12/20, there was no change noted in the wound progression. Wound measured 1.2 cm length by 1.7 cm width by 0.2 cm depth. There is a moderate amount of sero-sanguineous (clear blood tinged) noted. Wound bed has 76-100% slough; -On 11/19/20, no change in wound progression. Wound measured 1.3 cm by 1.3 cm by 0.1 cm. No drainage. 76-100% eschar (dry dead tissue); -On 11/25/20, wound was improving. Wound measured 1.2 cm by 1 cm by 0.2 cm. Scant (small amount) of sero-sanguineous drainage. Wound bed has 76-100% granulation (new tissue growth). Review of the resident's physician orders [REDACTED]. -an order for [REDACTED]. Cover with gauze pad. Secure with gauze dressing every day shift and as needed. Start date: 11/30/20; -Documentation showed: the entire month, all days left blank; -an order for [REDACTED].>Review of the wound care company progress notes, for 12/2020; for the right medial heel acute Stage III pressure ulcer, showed: -On 12/3/20, wound was deteriorating. Wound measured 1 cm by 1.2 cm by 0.2 cm. Moderate amount of sero-sanguineous drainage noted. Wound bed has 76-100% slough, no granulation; -On 12/10/20, wound was improving. Wound measured 0.7 cm by 0.7 cm by 0.2 cm. Moderate amount of sero-sanguineous drainage noted. Wound bed has 26-50% slough, 26-50% granulation tissue; -On 12/17/20, there was no change noted in the wound progression. Wound measured 2 cm by 2 cm by 0.1 cm. No drainage noted. Wound bed has 76-100% eschar; -On 12/24/20: no change noted in the wound progression. Wound measured 1.5 cm by 1.5 cm by 0.1 cm. Small amount of sero-sanguineous drainage noted. Wound bed has 76-100% eschar. Review of the resident's physician orders [REDACTED]. -an order for [REDACTED]. Cover with gauze pad. Secure with gauze dressing every day shift and as needed. Start date: 11/30/20; -Documentation showed: The treatment documented as completed on 1/24/21 only. All other days left blank. Review of the wound care company progress notes for January 2021, reviewed on 1/24/21, for the right medial heel acute Stage III pressure ulcer, showed: -On 1/7/21, the wound is improving. Wound measured 0.5 cm by 0.5 cm by 0.2 cm. Moderate amount of sero-sanguineous drainage noted. Wound bed has 26-50% slough, 26-50% granulation; -No further wound care company notes provided by the facility. Review of the resident's facility progress notes for 1/2021, showed no documentation of right heel wound assessment or measurements. Observation on 1/22/21 at 9:10 A.M., showed the resident sat in his/her wheelchair and did not respond when spoken to. Heel protectors on both lower extremities. During an interview on 2/3/21 at 12:45 P.M., the administrator said a blank on the TAR meant the item was not done. She was not aware the treatment was not documented as completed on 11/30/20 through 1/23/21. If a treatment is missed on three occasions the physician should be notified. She would expect staff to follow physician orders. 4. Review of Resident #12's medical record, showed: -admitted : 5/30/18; -[DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -No rejection of care; -Bed mobility, personal hygiene, dressing, and eating; activity only occurred once or twice with assistance of one staff; -Transfers; activity only occurred once or twice with two staff; -Bathing: supervision of one staff; -Unhealed pressure ulcers, marked: yes, number of wounds: one; the wound was classified as unstageable; -Resident had pressure relieving devices for bed and chair and was receiving pressure ulcer care. Review of the resident's care plan, review date 6/24/20, showed wounds

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for four residents (#138, #141, #135, and #143), of six residents investigated for non-pressure wounds and wound care when the facility failed to assess and treat wounds per facility policy and standards of practice. Resident #138 had a delay in treatment orders after admission. The facility failed to routinely apply the ordered treatments and assess the wounds. The resident had a change in level of swelling and wound drainage and the facility failed to timely notify the physician after identifying the change. The resident had a change in mental status after several days of increased swelling, drainage and pain; and was sent to the hospital. The resident required surgical debridement (removal of dead tissue) of a right heel wound and a [MEDICAL CONDITION] (BKA) of the left lower extremity due to the condition of the wounds. The sample was 29. The census was 143. Review of the facility's Facility Assessment Tool, updated 2/25/20, showed: -Purpose: To determine what recourses are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being; -Services and care offered based on resident needs: Pressure injury prevention and care, skin care, wound care. Review of the facility's Skin Ulcer-Wound Policy, dated 8/15/18, showed: -All caregivers are responsible for preventing, caring for and providing treatment for [REDACTED].>-Purpose: To identify at risk residents for potential breakdown or ulcerations, to prevent breakdown of tissue or ulcerations and to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Definition: For the purpose of this policy, a skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open if the nurse identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner/physician assistant/midlevel) for diagnosis; -Assessment: -Licensed staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record. Any items not documented in the admission assessment form will be charted in the nurse's notes; -Licensed staff will complete a head to toe skin assessment weekly and as needed. The skin assessment will be documented on a skin assessment form and become part of the resident's clinical record. Any unusual findings will be documented on the form with a follow-up note in the nurse's notes further describing the area of concern; -Treatment protocols: -Consult wound care providers when appropriate; -Until wound care providers can assess and order treatment, the following techniques may be employed: -Follow standard precautions and good hand hygiene techniques; -For non-open areas of concern or areas covered with stable eschar (dry dead tissue), apply skin prep (protective barrier wipe) daily and use preventative measures. On areas where skin prep is not appropriate (i.e. buttocks, etc.) moisture barrier cream is adequate. Skin prep may also be used for un-ruptured serous fluid (clear drainage) or blood-filled blisters; -For all other open areas, the treatment is determined based on tissue type and drainage; -All orders must be approved by a physician within 24 hours of discovering the open area or change in treatment; -Assessment protocols: -Nurses may not diagnose, just describe; -Measurements must be completed weekly; -At the time a skin issue is discovered, it must be measured. Wounds are three dimensional; therefore length, width and depth must be documented if using measuring instrument. It is acceptable to measure using common household objects (i.e. dime size, quarter size, half dollar) until actual measurements can be obtained per facility protocol; -Length of wound should always be measured in head to toe alignment. Width should always be measured in hip to hip or side to side alignment. Depth should always be the deepest part of the wound in perpendicular alignment; -If a reddened area is identified, the nurse should assess if the area is blanching (when skin color fades when pressure is applied and returns when pressure is released). If it is no blanching, then it should be captured on the licensed body audit report. 1. Review of the facility's Notification Changes in Condition policy, revised 1/28/20, showed: -It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status; -Acute change in condition: A sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional status that, without intervention, may result in complications or death; -Upon identification of any change in condition, licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition; -All notification should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions; -All notifications should be documented and should include: -The date and time of the notification; -The name of the individual contacted; -The specific reason for the notification; -And any specific responses that were given by the person contacted; -All changes in condition require follow-up assessment and documentation of resident condition which should include, at a minimum: Vital signs, pain, orientation, any change from baseline status, and status of any pending labs/diagnostics. Review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: -admitted [DATE] from an acute hospital; -Clear speech, understood and understands; -Moderately impaired cognition; -Rejection of care: Behavior not exhibited; -Limited assistance required for dressing; -Supervision required for personal hygiene; -[DIAGNOSES REDACTED]. -Infection of the foot; -Application of nonsurgical dressings other than to feet -Applications of dressings to feet. Review of the resident's care plan, in use while a resident at the facility, showed: -Focus: The resident has [MEDICAL CONDITION]: -Goal: Remain free of complications; -Interventions: Elevate legs when sitting or sleeping. Monitor extremities for signs and symptoms of injury, infection or ulcers. Monitor/document/report as needed any signs and symptoms of skin problems related to [MEDICAL CONDITION]: Redness, swelling, blistering, itching, burning, bruises, cuts or other [MEDICAL CONDITION]; -Focus: The resident has diabetes: -Goal: Have no complications related to diabetes; -Interventions: Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails; -Focus: The resident has infection of the (specify): -Goal: Be free from complications related to infection; -Interventions: (blank); -Focus: The resident has potential/actual impairment to skin integrity: -Goal: The resident will maintain intact skin. Skin breakdown will show to be improved; -Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Educate of causative factors and measures to prevent skin injury. Monitor/document location, size and treatment of [REDACTED]. to the physician. Treatment per physician orders. Weekly treatment documentation. Review of the resident's [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (infection of the skin), acute infection, [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] of the right lower limb, acute infection, [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (inflammation of the bone caused by infection), [DIAGNOSES REDACTED].>-Non-pressure chronic ulcer of right heel and mid foot with necrosis (dead tissue) of bone, history diagnosis; -Sepsis, history diagnosis; -Local infection of the skin and subcutaneous tissue (lower layer of the skin), history diagnosis; -[MEDICAL CONDITION], [DIAGNOSES REDACTED].>-Diabetes, [DIAGNOSES REDACTED]. Review of the resident's progress notes, showed: -On 2/6/20 at 10:58 P.M., the resident admitted for observation/assessment of condition. The resident is alert and oriented to person, place, time and situation. The resident has no changes in mood or behavior noted. The resident has no notable changes in skin integrity. The following wounds are currently being treated: Coccyx (tailbone area), left buttocks. (No documentation of a treatment to the left or right lower extremities). [MEDICAL CONDITION] (swelling) both lower extremities 1+ (based on the [MEDICAL CONDITION] scale, used to determine the severity of the [MEDICAL CONDITION]. 1+ has 2 millimeter (mm) depression or barely visible that disappears rapidly and is the lowest severity grade. The [MEDICAL CONDITION] scale goes up to 4+); -On 2/7/20 at 5:30 A.M., admission assessment: Skin issues present, refer to assessment for more information. Review of the resident's Nursing Admission Assessment, dated 2/7/20 at 5:30 A.M., showed: -Date and approximate time of arrival: 2/6/20 at 5:20 P.M.; -Skin condition: -Top of left foot, red circle area, weeping (draining fluid) noted; -Right toes, missing some great toe. Review of the resident's progress notes, dated 2/7/20 at 10:05 P.M. through 2/11/20 at 6:52 A.M., showed: -On 2/7/20 at 10:05 P.M., there are no wounds currently noted. [MEDICAL CONDITION] 1+ both lower extremities. Infection details: (blank); -On 2/8/20 at 7:50 P.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: left buttocks. [MEDICAL CONDITION] 1+ both lower extremities. Infection details: [MEDICAL CONDITION]; -On 2/9/20 at 1:54 A.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: left buttocks. [MEDICAL CONDITION] 1+ both lower extremities. Infection details: [MEDICAL CONDITION]; -On 2/9/20 at 1:30 P.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: Both lower extremity dressing changed per treatment order. [MEDICAL CONDITION] 3+ (5-6 mm depression) both lower extremities and arms. Infection details: [MEDICAL CONDITION]; -On 2/9/20 at 10:00 P.M., the resident has notable changes in skin integrity. The following wounds are being treated: Left buttocks. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [DIAGNOSES REDACTED]; -On 2/10/20 at 2:12 A.M., the resident has notable changes in skin integrity. The following wounds are being treated: Left buttocks. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [MEDICAL CONDITION]; -On 2/10/20 at 2:49 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. Both lower extremity feet dressings changed per treatment order. [MEDICAL CONDITION] present, both feet. Infection details: [DIAGNOSES REDACTED]; -On 2/11/20 at 6:52 A.M., resident alert, pleasant, skin with dressing; -No further documentation of the wounds to the lower extremities, documentation the physician was notified of the wounds, increased [MEDICAL CONDITION], or descriptions/measurements of the wounds. Review of the resident's electronic physician order [REDACTED]. -An order dated 2/6/20, for [MEDICATION NAME] (Tylenol) 325 milligram (mg) every 4 hours as needed for pain; -An order dated 2/11/20 at 7:00 A.M., cleanse area to left anterior (front side) foot with wound cleanser, pat dry, apply triple antibiotic ointment (TAO) and ABD pad (absorbing dressing), wrap with Kerlix (gauze wrap) and secure with tape daily; -An order dated 2/11/20 at 7:00 A.M., cleanse area to right lower extremity with wound cleanser, pat dry, apply ABD pads, wrap with Kerlix and secure with tape daily, every day shift for third spacing drainage (occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or third space-the nonfunctional area between cells. This can cause potentially serious problems such as [MEDICAL CONDITION]); -An order dated 2/12/20, for weekly skin assessments; -No treatment order for the lower extremities prior to 2/11/20. Review of the resident's treatment administration record (TAR), for February 2020, showed: -An order dated 2/11/20 at 7:00 A.M., cleanse area to left anterior foot with wound cleanser, pat dry, apply TAO and ABD pad, wrap with Kerlix and secure with tape daily: -Documented as not administered, see progress note, on 2/11/20 and 2/18/20; -Not documented as refused or administered on 2/12, 2/13, 2/15, 2/20 and 2/21/20; -An order dated 2/11/20 at 7:00 A.M., cleanse area to right lower extremity with wound cleanser, pat dry, apply ABD pads, wrap with Kerlix and secure with tape daily, every day shift for third spacing (occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or third space-the nonfunctional area between cells. This can cause potentially serious problems such as [MEDICAL CONDITION], reduced cardiac output, and low blood pressure); -Documented as refused on 2/11/20; -Not documented as refused or administered on 2/12, 2/13, 2/15, 2/20 and 2/21/20; -Documented as not administered, see progress note, on 2/18/20; -No documentation of any treatment orders for the left lower or right lower extremity prior to 2/11/20. Review of the facility's wound reports, dated 2/12/20, 2/28/20 and undated and identified by the director of nursing (DON) as dated 2/21/20, showed the resident not listed on the wound report for any wounds. No tracking of wound progress, measurements or treatments. Review of the resident's progress notes, dated 2/11/20 at 5:32 P.M. through 2/12/20 at 11:07 P.M., showed: -On 2/11/20 at 5:32 P.M., orders administration note: Cleanse area to left anterior foot with wound cleanser, pat dry, apply TAO and ABD pads, wrapped with Kerlix and secure with tape daily. Refused, resident stated every time I get ready to do something, someone comes in; -On 2/11/20 at 10:58 P.M., the resident has no notable changes in skin integrity. The following wounds are currently being treated: left buttocks. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [MEDICAL CONDITION]; -On 2/12/20 at 10:25 A.M., weeping [MEDICAL CONDITION] to both lower extremities; -On 2/12/20 at 10:45 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [MEDICAL CONDITION]; -On 2/12/20 at 11:07 P.M., weekly skin observation. Skin color is normal. Skin temperature is dry and warm. Skin issues present. Refer to assessment for more information. Review of the resident's weekly skin observation, dated 2/12/20 at 11:07 P.M., showed: -Skin condition: Reddened area top of left foot. On antibiotic therapy. Review of the resident's progress notes, dated 2/13/20 at 2:43 A.M. through 2/19/20 at 3:35 P.M., showed: -On 2/13/20 at 2:43 A.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [MEDICAL CONDITION]. Additional comments: Resident is on antibiotics related to [MEDICAL CONDITION] to both lower extremities and feet; -On 2/13/20 at 10:07 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. [MEDICAL CONDITION] 3+ both lower extremities and feet. Infection details: [MEDICAL CONDITION]. Additional comments: Resident completed antibiotics; -On 2/17/20 at 11:30 A.M., infection note: On antibiotic for [MEDICAL CONDITION], noted weeping [MEDICAL CONDITION] to both lower extremities; -On 2/17/20 at 5:15 P.M., [MEDICATION NAME] administration for pain; -On 2/17/20 at 7:20 P.M., infection note: On antibiotic for [MEDICAL CONDITION], noted significant weeping and [MEDICAL CONDITION] to both lower extremities; -On 2/17/20 at 9:15 P.M., [MEDICATION NAME] administration for pain; -On 2/18/20 at 5:07 A.M., weeping [MEDICAL CONDITION] to both lower extremities; -On 2/18/20 at 3:04 P.M., cleanse are to left anterior foot. Resident declined wound care today; -On 2/18/20 at 3:05 P.M., cleanse area to right lower extremity. Resident declined wound care today; -On 2/18/20 at 4:03 P.M., [MEDICATION NAME] administration for pain. Resident complained of throbbing pain in feet; -On 2/18/20 at 5:50 P.M., [MEDICATION NAME] administration for pain; -On 2/19/20 at 3:35 P.M., weekly skin observation: Skin issues present. Refer to assessment for more information. Review of the resident's Weekly Skin Observation, dated 2/19/20 at 3:35 P.M., showed: -Reddened area great toe/antibiotic therapy. Review of the resident's progress notes, dated 2/19/20 at 7:47 P.M. through 2/23/20 at 4:00 P.M., showed: -On 2/19/20 at 7:47 P.M., roommate called nursing staff to room stating the resident is on the floor. Upon arrival to room, the resident was lying on the floor stating he/she tried to stand up and fell on the floor. DON, physician and facility supervisor informed; -On 2/19/20 at 11:02 P.M., weekly skin observation: No skin issues present; -On 2/22/20 at 1:37 P.M., [MEDICAL CONDITION] 4+ (8 mm depression, or a very deep indentation, the most severe type of [MEDICAL CONDITION]) weeping to both lower extremities. Dressings changed; -On 2/22/20 at 9:38 P.M., [MEDICAL CONDITION] 4+ weeping to both lower extremities. Dressing changed; -On 2/23/20 at 3:00 P.M., resident has signs and symptoms of altered mental status and weakness noted. Very poor appetite this shift. Resident asking for juice and water with juice and water sitting on table within reach of resident. Resident appears very weak. Unable to sit on side of bed without falling to side. [MEDICAL CONDITION] and drainage to both lower extremities seems to be getting worse, legs wrapped x2 this shift and draining continues to come though wraps, on bed and floor. Drainage is yellow and very foul smelling. Toes to right leg have dark discoloration noted. Verbal, but not making sense (less sense than normal). Family at bedside stating that the resident is not responding to them the way that the resident normally does. Call placed to physician, notified of assessment and change in condition noted. New orders noted to send to hospital. Call placed to ambulance for non-emergency transfer; -On 2/23/20 at 4:00 P.M., ambulance arrived. Further review of the resident's ePOS, showed an order dated 2/23/20, send resident to hospital. Review of the resident's hospital surgical report, dated 2/23/20, showed: -Date of surgery 2/23/20; -Preoperative Diagnosis: [REDACTED]. -Surgery/procedure performed: Left lower extremity below-knee guillotine amputation (open or guillotine amputation is often required when infection is present and there is a need for free drainage from the operative site. A second surgical procedure involving stump (or residual limb) revision or closure is needed after the guillotine procedure. This is done only after the infection has been eliminated); -Findings: Grossly ischemic left lower leg that appeared unsalvageable, left great toe completely dusky/black, desquamation (sheading of skin) and dependent blood pooling the into soft tissues of the left foot and lower leg up to mid-calf. Left lower leg cool to the touch and pale with moderate soft tissue [MEDICAL CONDITION]. Sluggish bleeding from amputation site, muscle dusky but appeared viable; -Indications for surgery/procedure: The resident arrived to the hospital emergency department with altered mental status from a nursing facility. He/she was brought to the hospital by a family member who was concerned about the care that the resident was receiving at the nursing facility and noted acute changes to the left lower extremity. On arrival, the resident was found to have significant ischemic changes to the left foot and lower leg up to the mid-calf including a completely black left great toe, pallor (paleness) of the lower leg and desquamation. The patient was unable to provide medical history due to altered mental status and was admitted to the intensive care unit with an urgent surgical consult. Due to the appearance of the left lower extremity and concerns for critical limb ischemia, urgent surgical intervention was discussed with family, involving a left lower extremity below-knee guillotine amputation. Review of the resident's hospital surgical report, dated 2/26/20, showed: -Date of surgery: 2/26/20; -Preoperative Diagnosis: [REDACTED]. -Surgery/procedure performed: Right foot wound debridement (removal of dead tissue). Revision of left lower extremity amputation, left knee disarticulation (amputation of a limb through a joint, without cutting of bone); -Findings: Ischemic changes of left lower extremity below the knee stump that appears unsalvageable; -Indication for surgery/procedure: Left lower extremity ischemia,[MEDICAL CONDITION]/shock; -Condition at discharge: Critical. During an interview on 3/16/20 at 12:09 P.M., with the DON, Administrator, and nurse practitioner, the DON said care plans should be complete. The DON and nurse practitioner said if a resident is admitted with a wound, treatment orders should be obtained on admission. Staff should follow the wound policy and document assessments of wounds. Changes in wounds should be reported to the physician. Treatments should be applied as ordered. 2. Review of Resident #141's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, toilet use and personal hygiene; -[DIAGNOSES REDACTED]. -Other ulcer, wounds and skin problems: No. Review of the resident's care plan, dated 11/1/18, showed: -Focus: Open area noted to left buttock non-pressure related. Updated 2/26/20: The wound seems to be deteriorating as he/she continues to spend long periods of time in his/her wheelchair. Skin is also staying moist due to constant sweating on bottom, fold and creases; -Goal: Wound will exhibit signs of healing and/or be healed without any signs/symptoms of infection; -Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the resident's medical record, showed: -An order dated 11/10/19, for skin prep wipes to left gluteal (buttocks) two times day; -The order not documented as completed as ordered or refused, 11 of 62 opportunities in December 2019; -An order dated 12/5/19, for skin prep to left buttocks daily; -The order not documented as completed as ordered or refused, six of 27 opportunities in December 2019; -A weekly skin observation, dated 12/9/19: left buttocks, treatment in place; -A weekly wound observation tool, dated 12/10/19: Left buttocks moisture associated skin damage (MASD) measured 1.8 x 2 x 0.1; -A weekly skin observation, dated 12/16/19: Left gluteal fold, skin prep and cream applied; -A weekly wound observation tool, dated 12/17/19: Left buttocks MASD measured 1.8 x 2 x 0.1; -A weekly skin observation, dated 12/23/19: Left gluteal fold open area; -A weekly wound observation tool, dated 12/24/19: Left buttocks MASD measured 2 x 1.8 x 0.1; -A weekly skin observation, dated 12/30/19: Left gluteal fold with current treatment in place; -The order for skin prep wipes to left gluteal two times a day not documented as completed as ordered or refused, seven of 43 opportunities in January 2020; -The order for skin prep to left buttocks daily not documented as completed as ordered or refused, seven of 22 opportunities in January 2020; -A weekly skin observation, dated 1/6/20: Left buttocks treatment in place; -A weekly wound observation tool, dated 1/8/20: Left medial thigh MASD 5 x 4 x 0.2; -A weekly skin observation, dated 1/13/20: Left gluteal fold open area with treatment in place; -A weekly skin observation, dated 1/20/20: Left gluteal fold open area with treatment in place; -An order dated 1/22/20, to discontinue both orders for skin prep; -No treatment for [REDACTED]. -No skin assessments or wound assessment completed from 1/23/20 through 2/10/20; -A weekly skin observation, dated 2/11/20: Left buttocks open area; -An order dated 2/12/20 and discontinued 2/17/20, for Venelex ointment (combination medicine used to treat skin wounds) apply to left buttocks topically two times a day for left buttocks abrasion; -Not documented as applied as ordered or refused, three of 12 opportunities in February 2020; -A weekly skin observation, dated 2/17/20: Left buttocks treatment in place; -An order dated 2/18/20, for Venelex ointment, apply to right buttocks topically every day and evening shift for right buttocks abrasion; -Not documented as applied as ordered or refused, 13 of 24 opportunities in February 2020; -A weekly skin observation, dated 2/24/20: Left buttocks dressing intact; -A weekly skin observation, dated 3/2/20: Right gluteal fold buttocks, treatment nurse aware; -A weekly skin observation, dated 3/9/20: Right gluteal fold wound to area beefy red; -An order dated 3/9/20, for the wound care clinic to evaluate and treat; -No further wound measurements since 1/8/20. No further descriptions of wound appearance or drainage. No clarification if the wound was on the left or right buttock. Further review of the resident's medical record, showed an order, dated 3/11/20 at 7:00 A.M., to clean wound with wound cleaner, pat dry, apply calcium alginate (used to absorb moisture) to wound bed, cover with ABD and secure with tape daily; Observation on 3/11/20 at 7:43 A.M., showed Wound Nurse O provided wound care for the resident with the nurse from the wound clinic. The wound was located on the resident's left posterior thigh/buttocks area. A dressing dated 3/10/20 was in place. The wound was large and beefy red. An area with loose grey tissue visible. The wound care nurse measured the wound. Review of the wound care clinic note, dated 3/11/20, showed the following for the resident: -Wound assessment: Left thigh acute full thickness (extend past the two layers of skin (dermis and epidermis) and extend into the subcutaneous (fat) tissue). Measurements 7.5 centimeter (cm) length (L) by 8.3 cm width (W) by 0.2 cm depth (D), there is a moderate amount of serosanguineous (thin, watery, pale red to pink drainage) drainage noted. Wound bed has 51-75% slough (moist dead tissue), 26-50% granulation (new tissue growth). The wound is deteroriating. Review of the facility's wound report, dated 2/28/20 and the most recent wound report provided by the facility, showed the resident listed with a new wound onset date of 3/2/20. During an interview on 3/12/20 at 6:35 P.M., with the DON, Administrator and Wound Nurse O, they said the documentation in the wound report and documentation in the medical record should be accurate. The wound on the resident is MASD and not pressure. Nurses are not trained to stage wounds and should not be staging wounds. The nurse practitioner or wound company are the only ones who can stage a wound. If staff observe a wound, they should describe the wound and measure the wound. Staff should be knowledgeable with anatomical locations of wounds. The resident has had the wound healed out and then comes back, as well as having other wounds that have healed. Documentation should clearly identify wounds and show the progression of the wounds. Wound assessment and measurements should be obtained immediately upon admission and the wound nurse will assess any reported wounds to determine if the wound company needs to be consulted. The wound policy should be followed and measurements obtained weekly. The resident's wound was just added to the February 28th wound report, which is why the onset date shows March 2nd. The facility is currently transitioning from one wound nurse to another. Treatments should be administered as ordered and current wounds should have orders for treatments. 3. Review of Resident #135's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Total dependence for bed mobility, transfer, dressing and personal hygiene; -[DIAGNOSES REDACTED]. -Total number of venous and arterial ulcers, one; -Surgical wound care not indicated. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Chronic pressure ulcers present on admission due to limited mobility. Open areas to Coccyx/sacral, medial back, both gluteal fold, right lateral leg distal and open areas to left and right hip, left lateral foot: -Goal: Pressure ulcers/other wounds will show signs of healing and remain free from infection; -Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the resident's medical record, showed: -A skin/wound note, dated 10/25/29: Resident seen by wound care: -Area to right distal lateral lower leg presents as a chronic full thickness arterial ulcer measuring at 37.8x2.5x0.4, with moderate serosanguineous drainage. Tendon and bone are exposed. Wound bed has 51-75% bright red granulation; -Area to medial abdomen presents as an acute full thickness surgical wound measuring at 01.3x0.8x0.2, with moderate serosanguineous drainage. Wound bed has 76-100% granulation; -Area to left anterior ankle presents as an acute full thickness arterial ulcer measuring at 1.4x2.4x0.2, with moderate serosanguineous drainage. Wound bed has 76-100% bright red granulation; -A weekly skin observation, dated 10/26/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdomen wound); -A weekly skin observation, dated 11/2/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdominal wound); -A weekly skin observation, dated 11/9/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdominal wound); -A weekly skin observation, dated 11/16/19: No skin issues present; -A weekly skin observation, dated 12/17/19: No skin issues present; -A weekly skin observation, dated 12/24/19: No skin issue

Based on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulcers and ensure residents with pressure ulcers receive the necessary treatment and services to promote healing, for five of seven residents investigated for pressure ulcers (Residents #56, #135, #60, and #143). The facility failed to assess wounds per facility policy and standards of practice and provide treatments as ordered. Resident #56 had a delay in identification of a pressure ulcer. When first identified by the facility, the pressure ulcers was a stage III. This resulted in a delay of treatment. After identified, the facility failed to assess and monitor the wound and failed to provide treatments as ordered consistently, which resulted in the wound developing into a stage IV pressure ulcer. The wound became infected and the resident required hospitalization [MEDICAL CONDITION] and surgical wound debridement. The sample was 29. The census was 143. Review of the facility's Centers for Medicare and Medicaid (CMS) form 802, showed: -The facility identified five resident's as having pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue); -Residents #56 and #143 were not identified as having pressure ulcers. Review of the facility's Facility Assessment Tool, updated 2/25/20, showed: -Purpose: To determine what recourses are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being; -Services and care offered based on resident needs: Pressure injury prevention and care, skin care, wound care. Review of the facility's Skin Ulcer-Wound Policy, dated 8/15/18, showed: -All caregivers are responsible for preventing, caring for and providing treatment for [REDACTED].>-Purpose: To identify at risk residents for potential breakdown or ulcerations, to prevent breakdown of tissue or ulcerations and to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Definition: For the purpose of this policy, a skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open if the nurse identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner/physician assistant/midlevel) for diagnosis; -Assessment: -Licensed staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record. Any items not documented in the admission assessment form will be charted in the nurse's notes; -Licensed staff will complete a head to toe skin assessment weekly and as needed. The skin assessment will be documented on a skin assessment form and become part of the resident's clinical record. Any unusual findings will be documented on the form with a follow-up note in the nurse's notes further describing the area of concern; -Treatment protocols: -Consult wound care providers when appropriate; -Until wound care providers can assess and order treatment, the following techniques may be employed: -Follow standard precautions and good hand hygiene techniques; -For non-open areas of concern or areas covered with stable eschar (dry dead tissue), apply skin prep (protective barrier wipe) daily and use preventative measures. On areas where skin prep is not appropriate (i.e. buttocks, etc.) moisture barrier cream is adequate. Skin prep may also be used for un-ruptured serous fluid (clear drainage) or blood-filled blisters; -For all other open areas, the treatment is determined based on tissue type and drainage; -All orders must be approved by a physician within 24 hours of discovering the open area or change in treatment; -Assessment protocols: -Nurses may not diagnose, just describe; -Measurements must be completed weekly; -At the time a skin issue is discovered, it must be measured. Wounds are three dimensional; therefore length, width and depth must be documented if using measuring instrument. It is acceptable to measure using common household objects (i.e. dime size, quarter size, half dollar) until actual measurements can be obtained per facility protocol; -Length of wound should always be measured in head to toe alignment. Width should always be measured in hip to hip or side to side alignment. Depth should always be the deepest part of the wound in perpendicular alignment; -If a reddened area is identified, the nurse should assess if the area is blanching (when skin color fades when pressure is applied and returns when pressure is released). If it is no blanching, then it should be captured on the licensed body audit report. 1. Review of Resident #56's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/19, showed: -Moderate cognitive impairment; -Extensive assistance required for bed mobility, toilet use and personal hygiene; -[DIAGNOSES REDACTED].>-At risk for pressure ulcers; -Does the resident have one or more unhealed pressure ulcers: Yes; -Number of stage I pressure ulcers (intact skin with non-blanchable redness): 0; -Number of stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer, may also present as an intact or open blister): 0; -Number of stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed): 0; -Number of stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle): 0; -Number of unstageable pressure ulcers (depth unable to be determined due to coverage of wound bed by slough (moist dead tissue) or eschar). Review of the resident's care plan, updated 2/29/20, showed: -Focus: Incontinent of bowel and bladder which increases risk for pressure related injuries: -Goal: Will remain free from skin breakdown; -Interventions: Check resident every two hours and assist with toileting as needed; -Focus: Impaired skin integrity, pressure injuries to left lower leg, coccyx (tailbone area) and left heel; -Goal: Be free of complications related to skin breakdown; -Interventions: Treatments per physician orders, low air loss mattress, weekly treatment documentation, wound clinic to treat. Review of the resident's medical record, showed: -No ordered treatment to the buttocks area from 11/1/19 through 11/26/19; -A weekly skin observation, dated 11/11/19: Skin issues present. Right buttocks open areas moisture associated skin damage. Moisture barrier cream applied to areas on buttocks, referred to wound nurse; -A weekly skin observation, dated 11/18/19: Skin issues present (the buttocks area not documented as an area of concern); -A weekly skin observation, dated 11/25/19: Skin issues present (the buttocks area not documented as an area of concern); -A weekly wound observation tool, dated 11/26/19: Left buttocks pressure ulcer, acquired stage III. First observation, no reference. Granulation tissue (new tissue growth) present, slough tissue present. Percent of necrosis and/or slough in wound bed, 26-50%. Moderate amount of serosanguineous (thin, watery, pale red to pink) drainage. Measurement: Length (L) 3.8 centimeter (cm) by width (W) 5.5 cm by depth (D) 0.2 cm; -An order dated 11/27/19, to cleanse area to left buttocks with wound cleanser, pat dry, apply hydrogel (gel used to keep the wound bed moist and aid in healing) and calcium alginate (absorbent product) daily. Order discontinued on 11/27/19, after the first application of the treatment; -An order dated 11/28/19, to cleanse area to left buttocks with wound cleanser, pat dry and apply Santyl (ointment used to remove dead tissue) and calcium alginate daily; -A weekly skin observation, dated 12/2/19: Skin issues present. Left buttocks dressing intact to area. Treatment done per wound nurse; -A weekly skin observation, dated 12/9/19: Skin issues present. Left buttocks open area with granulation and slough tissue present; -A weekly wound observation, dated 12/12/19: Left buttocks pressure ulcer, acquired stage III, improving. Granulation tissue present, slough tissue present. Percent of necrosis and/or slough in wound bed, 26-50%. Moderate amount of serosanguineous drainage. Measurement (LxWxD): 2.8 by 0.5 by 0.2; -A weekly wound observation, dated 12/12/19: Right buttocks partial thickness wound acquired 12/12/19. First observation, no reference. Granulation tissue present. Scan serosanguineous drainage. Measurements (LxWxD): 3.0 cm by 1 cm by 0.1 cm; -The prior treatment order to the left buttocks discontinued on 12/13/19; -An order dated 12/14/19, skin prep to right buttocks daily: -The treatment not documented as completed five of 18 opportunities in December 2019; -No treatment for [REDACTED]. -A weekly skin observation, dated 12/16/19: Skin issues present. Area to buttocks with current treatment in place; -A weekly wound observation, dated 12/18/19: Left buttocks pressure ulcer, acquired stage III, unchanged. [MEDICATION NAME] (new tissue growth) and granulation tissue present. Measurement (LxWxD): 6.0 cm by 4.0 cm by 0.2 cm: -Further review of prior wound measurements for the left buttocks, showed the wound grew in size and was not unchanged as indicated on the assessment; -A weekly wound observation, dated 12/18/19: Right buttocks acute full thickness wound, unchanged. [MEDICATION NAME] and granulation tissue present. Moderate amount of serosanguineous drainage. Measurement (LxWxD): 6 cm by 4 cm by 0.2 cm; -Further review of prior wound measurements for the right buttocks, showed the wound grew in size and was not unchanged as indicated on the assessment; -An order dated 12/23/19, to cleanse area to coccyx with wound cleanser, pat dry, apply Santyl and cover with dry dressing daily: -The treatment not documented as completed as ordered three of nine opportunities in December 2019 and four of 16 opportunities in January 2020; -A weekly skin observation, dated 12/23/19: Skin issues present. Area to coccyx with current treatment order in place; -A weekly skin observation, dated 12/31/19: No skin issues; -A weekly skin observation, dated 1/6/20: Right buttocks with current treatment in place; -A weekly skin observation, dated 1/13/20: Area to coccyx with current treatment in place; -The prior treatment order to the coccyx discontinued on 1/16/20; -An order dated 1/17/20, to cleanse area to coccyx with wound cleanser, pat dry, mix [MEDICATION NAME] (antibiotic) ointment with Santyl and cover with dry dressing daily: -The treatment not documented as completed as ordered two of 15 opportunities in January 2020 and three of nine opportunities in February 2020; -A weekly skin observation, dated 1/20/20: No skin issues present; -A weekly skin observation, dated 2/3/20: Sacrum (buttocks area) stage IV pressure ulcer, treatment in place; -No measurements documented from 12/18/19 through the resident being sent to the hospital on [DATE]; -A transfer to hospital summary, dated 2/9/20: Resident stated to writer he/she did not feel good and wanted to go to hospital. Vital signs taken at that time were blood pressure 132/77 (normal 90/60 through 120/80), heart rate 88 (normal 60 through 100), respirations 20 (normal 12 through 22), temp 101.0 temporal (taken on the skin over the temple, normal 97.8 through 99.1). Call placed to resident's doctor to inform doctor of resident's condition. New order given to send resident out to hospital for evaluation and treatment. Resident left building via ambulance transport at 5:55 P.M. Review of the resident's hospital records, showed resident admitted to the hospital on [DATE] with [MEDICAL CONDITION] (systemic infection) related to infected sacral decubitus ulcer (pressure ulcer). General surgery consulted for wound debridement (surgical removal of dead tissue) at bedside on 2/10/20 and operating room on 2/11/20 for further debridement. Further review of the resident's medical record, showed: -The resident readmitted to the facility on [DATE]; -A readmission assessment, dated 2/20/20: admitted from hospital on [DATE] at approximately 5:45 P.M. Skin issues present (skin assessment blank); -An order dated, 2/21/20 for [MEDICATION NAME] ointment (an enzyme that helps promote healthy tissue growth), apply to affected area topically daily; -The treatment not documented as completed as ordered six of nine opportunities; -A weekly skin observation, dated 2/24/20: Area to coccyx with treatment in place; -A skilled charting note, dated 2/29/20: Total care, no resident participation for bed mobility. Skin integrity: No new changes to skin integrity noted. Resident has treatable wounds, pressure to coccyx. Dressing change not required; -The ordered treatment for [REDACTED]. -No new treatment ordered for the buttocks pressure ulcer until 3/2/20; -An order dated 3/2/20: Change wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to buttocks on Mondays, Wednesdays and Fridays: -Not documented as applied until 3/4/20. Observation of the resident on 3/11/20 at 6:32 A.M., showed the resident lay in his/her bed, asleep. Wound vac attached. During an interview on 3/12/20 at 6:35 P.M., with the Director of Nursing (DON), Administrator and Wound Nurse O, they said the resident came back to the facility today after leaving to have a second scheduled surgical debridement of the wound. He/she had originally gone to the hospital to have surgical debridement of the wound to the coccyx in February. Wound Nurse O said when the resident returned from the hospital in February, he/she had an order for [REDACTED]. Once the site was ready, the order for the wound vac was entered in the system and the wound vac was applied. He/she did not document any of this. The administrator said any treatment changes, treatments applied and communication with the physician should be documented. Wounds should be identified, assessed and documented with treatment orders obtained. People do not just wake up one day with a stage III wound. The wound should have been identified and treated prior to becoming a stage III. They would expect the documentation regarding the location of the wound be accurate. The wound was on the buttocks. Staff will use different locations interchangeable and this is not the correct way to do it. Staff would benefit from training on locations of wounds. Documentation should be accurate. Treatments should be applied as ordered. Staff should follow the wound policy and obtain measurements weekly. 2. Review of Resident #135's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Total dependence for bed mobility, transfer, dressing and personal hygiene; -[DIAGNOSES REDACTED]. -At risk for pressure ulcers; -Two stage II pressure ulcers; -Two stage III pressure ulcers; -One stave IV pressure ulcer; -One unstageable pressure ulcer. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Chronic pressure ulcers present on admission due to limited mobility. Open areas to coccyx/sacral, medial back, both gluteal fold, right lateral leg distal and open areas to left and right hip, left lateral foot: -Goal: Pressure ulcers/other wounds will show signs of healing and remain free from infection; -Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the resident's medical record, showed: -A skin/wound note, dated 10/25/29: Resident seen by wound care: -Area to left ischium presents as a chronic stage III pressure injury measuring at 2.0x2.5x0.6 with moderate serosanguineous drainage. Wound bed is 1-25% slough 76-100% granulation; -Area to medial coccyx presents as a chronic stage IV pressure injury measuring at 6.0x11.0x1.0 with moderate serosanguineous drainage. Wound bed has 76-100% bright red granulation; -A weekly skin observation, dated 10/26/19: Skin issues present. Vertebrae (upper middle) treatment in place (no mention of the left ischium or medial coccyx wound); -A weekly skin observation, dated 11/2/19: Skin issues present. Left gluteal fold treatment in place, coccyx treatment in place, vertebrae (upper middle) treatment in place; -A weekly skin observation, dated 11/9/19: Skin issues present. Left gluteal fold treatment in place, coccyx treatment in place, vertebrae (upper middle) treatment in place; -A weekly skin observation, dated 11/16/19: No skin issues present; -A weekly skin observation, dated 12/17/19: No skin issues present; -A weekly skin observation, dated 12/24/19: No skin issues present; -A weekly skin observation, dated 12/31/19: No skin issues present; -A weekly skin observation, dated 1/7/20: No skin issues present; -A weekly skin observation, dated 1/14/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound); -A weekly skin observation, dated 1/21/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound); -A weekly skin observation, dated 1/28/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound); -A weekly skin observation, dated 2/5/20: Skin issues present. Treatment in progress abdomen, buttocks, right lower extremity dressings dry and intact; -A weekly skin observation, dated 2/11/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound); -A weekly skin observation, dated 2/18/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound); -A weekly skin observation, dated 2/25/20: Skin issues present. Treatment in progress coccyx, left ischium (no mention of the back wound); -A weekly skin observation, dated 2/25/20: Treatment in progress coccyx, left ischium (no mention of the back wound); -A weekly skin observation, dated 3/3/20: Treatment in progress coccyx, back (no mention of the ischium wound); -No further weekly wound observations from September 2019 through March 2020; -No further pressure ulcer measurements or descriptions from September 2019 through March 2020. Review of the resident's wound clinic notes, dated 3/11/20, showed: -Medial back acute stage III pressure ulcer. Measurement (LxWxD): 2 cm by 4.1 cm by 0.2 cm. Scant amount of drainage. Wound is improving; -Left ischial chronic stage III pressure ulcer. Measurement (LxWxD): 2 cm by 2.5 cm by 0.7 cm, moderate amount of serosanguineous drainage. The wound is deteriorating; -Coccyx chronic stage IV pressure ulcer. Measurement (LxWxD): 6 cm by 11 cm by 1.4 cm, moderate amount of serosanguineous drainage. Wound is deteriorating. Further review of the resident's medical record, showed: -An order dated 1/9/20: Cleanse area to right mid back with wound cleanser, pat dry, apply calcium alginate and dry dressing daily; -An order dated 2/7/20: Cleanse area to left ischium with wound cleanser, pat dry, apply [MEDICATION NAME] (antibacterial foam dressing), ABD and secure with tape, every day shift Mondays, Wednesdays, and Fridays; -An order dated 2/7/20: Cleanse area to coccyx with wound cleanser, pat dry, apply [MEDICATION NAME], ABD and secure with tape, every day shift Mondays, Wednesdays, and Fridays; -No order for a right medial back wound treatment. Observation of the resident's pressure ulcer treatments, on 3/13/20 at 9:18 A.M., showed Nurse A entered the resident's room with the treatment cart. Nurse A washed his/her hands and applied gloves. A Certified Nurse Aide (CNA) M assisted the nurse in turning the resident on his/her left side by using the turning sheet. The resident did not have anything covering his/her back, ischium, or coccyx wounds. Bloody wound discharge was visible on the bed. Nurse A returned to his/her cart removed a spray bottle of wound cleanser, returned to the resident's bed side, sprayed all open wound areas on the resident's back, coccyx and ischium. He/she did not pat the wounds dry. Two wounds located on the resident's back. One to the right medial side of the back and one to the medial back: -Nurse A applied a piece of calcium alginate to the right medial back wound. The wound bed beefy red. He/she placed a piece of gauze 4 by 4 on top (there was no treatment order for this wound); -Nurse A took two precut pieces of [MEDICATION NAME] from clean area on cart and placed it on the medial back wound. The wound bed appeared beefy red (calcium alginate not applied as ordered and [MEDICATION NAME] applied and was not ordered for this wound); -Nurse A applied an ABD pad over both back wounds and secured with tape; -Nurse A placed a large piece of [MEDICATION NAME], shaped like a half moon, on the resident's coccyx wound, covered with an ABD pad and secured with tape; -Nurse A used an applicator and applied collagen powder to the left ischium wound, placed gauze over the area and secured with tape ([MEDICATION NAME] not applied as ordered and collagen powder applied and was not ordered for this wound). During an interview on 3/13/20 at 10:13 A.M., CNA M said the pad was visibly soiled with wound drainage and dirt from the resident. During an interview on 3/13/20 at 10:13 A.M., Nurse A said all dressings were removed earlier when the resident was cleaned up from a large bowel movement. He/she has no way to measure the wounds and does not know the size. The wound nurse normally does the treatments and measurements. The resident's wounds are very time consuming. 3. Review of Resident #60's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care: Behavior not exhibited; -Total dependence for bed mobility, dressing and personal hygiene; -[DIAGNOSES REDACTED]. -At risk for pressure ulcers; -One stage III pressure ulcer; -Two stage IV pressure ulcers; -One unstageable pressure ulcer. Review of the resident's care plan, dated 7/9/18, showed: -Focus: Will often refuse care: -Goal: Fewer episodes of refusal of care behaviors; -Interventions: Monitor behavior episodes; -Focus: Has open areas throughout his/her body. Remains at risk for further decline and/or new open areas as he/she remains dependent on staff for bed mobility, transfers and incontinent care: -Goal: Will show signs and symptoms of healing without infection; -Interventions: Pressure relieving mattress, pressure relieving cushion to protect the skin while up in chair. Monitor/document location, size and treatment of [REDACTED]. Review of the resident's medical record, showed he/she frequently refused wound care and skin assessments. Review of the resident's medical record, reviewed on 3/11/20, showed: -An order dated 2/29/20, cleanse area to coccyx with wound cleanser, pat dry, apply Santyl nickel thick, apply calcium alginate over Santyl, cover with ADB pads (absorbent dressing), secure with tape daily: -Not documented as completed as ordered or refused three of 10 opportunities; -An order dated 2/29/20, cleanse area to left ischium (lower buttocks) with wound cleanser, pat dry, and apply Santyl nickel thick. Apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily: -Not documented as completed as ordered or refused three of 10 opportunities; -An order dated 2/29/20, cleanse area to right ischium with wound cleanser, pat dry, apply Santyl nickel thick, apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily: -Not documented as completed or refused three of 10 opportunities; -An order dated 2/29/20, cleanser area to right medial foot with wound cleanser, pat dry, protect peri-wound (skin surrounding wound bed) with skin protectant, apply Santyl nickel thick, apply dry dressing and secure with tape: -Not documented as completed or refused three of 10 opportunities; -An order dated 2/29/20, use skin prep to left back, and do not wash skin around wound. Apply dry dressing and secure with tape every day shift: -Not documented as completed or refused three of 10 opportunities; -An order dated 3/2/20, cleanse area to left lower lateral leg with cleanser, pat dry, apply Santyl nickel thick, cover with ABD pads and secure with tape daily: -Not documented as completed or refused two of nine opportunities; -No order for treatment to a left outer thigh wound. Review of Drugs.com, showed Santyl: Apply this medication only to the affected skin wound. Try not to get any ointment on the healthy skin around the wound. Observation on 3/10/20 at 10:09 A.M., showed Wound Nurse Q said he/she used to be the wound nurse and is currently filling in until the facility can find a different full time wound nurse. He/she prepped the treatment cart, obtained supplies. He/she had two whole ABD pads and several pieces of ABD pad cut into various sizes. He/she obtained Santyl ointment from cart, and the tube of Santyl not labeled with a resident's name. The tube appeared new and unused. He/she squirt a large amount of Santyl in a swirling motion on three of the small and one of the whole ABD pads. He/she entered the resident's room with the treatment cart and supplies. As the wound nurse repositioned the resident, a fowl wound odor permeated the room. The resident complained about the smell. The wound nurse cut more ABD pads and applied the remainder of the tube of Santyl onto the dressings. Each dressing had a large amount of Santyl piled up on the dressing: -The buttocks/coccyx dressing saturated and the date unable to be read. The wound nurse removed the dressing and exposed an approximate basketball sized wound. When removing this dressing, the dressing to the left and right ischium also came off. The wound nurse cleansed the buttocks/coccyx area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered); -An elongated wound to the left ischium, extended vertical in relation to the resident's body. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered); -An elongated wound to the right ischium, extended vertical in relation to the resident's body. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered); -The left back/shoulder area dressing had peeled off, the date could not be read and the area surrounding the wound red and inflamed. The wound nurse cleansed the wound with wound cleanser spray (the order indicated not to cleanser the skin around the wound), patted dry, and applied an ABD dressing with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and expanded outside the wound edges and onto healthy tissue when the dressing was applied; -The left lateral lower leg/knee dressing, dated 3/9. The dressing removed and exposed an approximate quarter sized wound. The wound nurse removed a second tube of Santyl from the treatment cart. He/she applied the Santyl to an ABD pad and placed the Santyl on the treatment cart. He/she cleansed the wound to the leg/knee, patted dry, applied the ABD pad with Santyl. The Santyl on the ABD pad more than a nickel thick and expanded outside the wound edges and onto healthy tissue. The dressing secured with tape. Observation of the tube of Santyl used on the leg/knee wound, showed a different resident's name labeled on the tube; -The left outer thigh dressing removed and exposed an approximate dime size wound. No dressing or treatment applied to thigh wound. The wound remained open to air; -The right inner foot dressing removed and exposed a wound approximately larger than quarter size. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied and applied over the wound. The Santyl on the ABD pads more than a nickel thick and expanded outside the wound and onto healthy tissue when the dressing was applied (no skin protectant applied to the wound edges as ordered). During an interview on 3/16/20 at 12:09 P.M., with the DON, Administrator and nurse practitioner, they said physician orders [REDACTED]. 4. Review of Resident #143's admission MDS, dated [DATE], showed: -admitted [DATE] from an acute care hospital; -Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene; -[DIAGNOSES REDACTED]. -At risk for pressure ulcers; -One stage II pressure ulcer on admission. Review of the resident's medical record, reviewed on 3/11/20, showed no comprehensive care plan completed. Review of the resident's baseline care plan, dated 2/13/20, showed for his/her skin assessment: Normal color, skin temperature dry and warm, no skin issues. Review of the resident's medical record, showed: -An Admission Assessment Nursing, dated 2/13/20, showed no skin conditions; -A weekly skin observations progress note, dated 2/13/20, showed: -Resident admitted on [DATE]; -Refer to assessment for more information; -An Admission Weekly Skin Observation assessment, dated 2/13/20, showed: -Skin issues: yes; -Sacrum (buttocks) wound to bottom, treatment nurse did assessment; -No measurement or description of the sacrum wound documented; -A progress note, showed a skin/wound note, dated 2/13/20 at 4:30 P.M., showed an area to right and left buttocks observed as unstageable and measured 5.0 by 7.5 by 0.1, moderate drainage with [MEDICATION NAME] tissue to periwound (skin around wound edges); -The ePOS, showed an order dated 2/14/20, to cleanse area to buttocks with wound clenser, pat dry, apply calcium alginate and dry dressing daily: -Treatment not documented as applied or refused five of 16 opportunities in February 2020; -Treatment not documented as applied or refused three of 10 opportunities in March 2020; -A weekly skin observation assessment, dated 2/18/20, showed no skin issues; -Further review of progress notes, showed a skin/wound note, dated 2/25/20 and 3/3/20, showed skin color normal, skin temperature dry and warm. Skin issues present. Refer to asses

Based on observation, interview and record review, the facility failed to provide care to one of four sampled residents according to professional standards, when Resident #4 was sent to the hospital and admitted to the intensive care unit (ICU) for urosepsis (a condition in which a urinary tract infection spreads from the urinary tract to the bloodstream). In addition, the facility failed to intervene and monitor when a resident's family member placed one of three sampled residents (Resident #5), who had a physician's orders [REDACTED]. The census was 150. 1. Review of Resident #4's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/19/19, showed the following: -admitted to the facility on [DATE]; -No behaviors of rejecting care; -Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment), score of 7 out of 15 (moderate cognitive impairment); -Required substantial/maximum assistance from staff for all mobility and activities of daily living (ADL); -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 4/19/19 and in use at the time of the abbreviated survey, showed the following: -Focus: The resident is at risk for dehydration; -Goal: The resident will be adequately hydrated; -Interventions: Give intravenous (IV) fluids for dehydration. Monitor for signs and symptoms of dehydration such as poor skin turgor, confusion, dark urine and dry mucus membranes. Monitor labs and report to physician. -Focus: The resident has an indwelling Foley catheter (sterile tube inserted into the bladder to drain urine) due to [MEDICAL CONDITION]; -Goal: The resident will remain free from catheter related trauma; -Interventions: Empty catheter bag every shift. Catheter change per physician orders. Monitor for pain, discomfort, signs and symptoms of discomfort on urination and frequency. Monitor, record and report to physician signs and symptoms of urinary tract pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increase temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status change, change in behavior and change in eating patterns. Review of the resident's physician order [REDACTED]. -Catheter (cath) care every shift with peri care, dated 4/17/19; -Change Foley catheter as needed if occluded, dated 4/17/19. Review of the resident's nurse notes, showed the following: -6/21/19 at 1:48 P.M., the resident is alert and oriented to person. The resident has no changes in mood or behavior noted. Urinary continence is not rated because the resident has a Foley catheter which is patent, draining and intact. Urine color is yellow, clear with no odor. The resident is always incontinent of bowel, has no diarrhea or constipation and uses briefs. Bowel sounds are present. No changes to skin integrity with no wounds. Respiratory within normal limits, pulse has normal rate and rhythm, adequate hearing and vision clear with appropriate speech. No pain; -6/22/19 at 2:45 P.M., butterfly needle inserted and secured to right abdomen subcutaneous tissue for hypodermoclysis (the subcutaneous infusion of fluids, a hydration technique suitable for mildly to moderately dehydrated adult patients) infusing at 60 ml per hour without difficulty. Procedure tolerated well; -6/22/19 at 3:09 P.M., The resident is not responding. Could not obtain a blood pressure, had multiple nurses try, got a systolic at 100. Abdomen distended could not hear bowel sounds but resident had a large bowel movement, informed assistant director of nursing (ADON) and obtained new orders from nurse practitioner (NP); -6/22/19 at 3:16 P.M., Called lab company to obtain STAT blood work basic metabolic panel (BMP, a blood test that measures your sugar level, electrolyte, fluid balance, and kidney function) and complete blood count (CBC, a blood test used to evaluate overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]), will be out today. Further review of the resident's POS, showed the following: -6/22/19, STAT (immediately) labs, draw CBC and BMP; -6/22/19, Hypodermoclysis D51 with ½ normal saline infusion at 60 milliliters (ml) per hour for 3 liters. Review of the resident's blood work collected on 6/22/19, showed the following: -Processed on 6/22/19; -White blood cell count (WBC can indicate an infection, inflammation, trauma, allergy, or certain diseases) 32.3 (normal reference range, 4.8-10.8); -Glucose (sugar level) 173 (normal reference range, 65-110); -Blood urea nitrogen (BUN measures the amount of urea nitrogen in blood) 57 (normal reference range, 7-21); -Creatinine (sign of kidney damage) 2.6 (normal reference range, 0.7-1.5). Further review of the resident's nurse notes, showed the following: -6/23/19 1:19 P.M., Lab results came back, nurse practitioner reviewed results, no new orders given; -6/23/19 1:22 P.M., The resident is in bed with head of bed elevated and call light within reach. Hypodermoclysis is still infusing, no swelling or redness noted. The resident is more alert today, talking and asking questions. Alert and oriented to self, no distress noted at this time; -6/23/17 at 5:01 P.M., a nurse note by NP, lab results noted increased BUN and WBC. If fluids per hypodermoclysis in use, continue until 3 liters are completed. Discussed results with ADON. WBC elevated in past, being seen by hematology (the study of blood). Faxed results to hematology; -6/25/19 10:43 P.M., Hypodermoclysis discontinued. Further review of the resident's POS, showed the following: -Flush Foley cath with 100 cubic centimeters (cc) of warm water for abdominal distention, dated 6/26/19; -Collect urine for analysis, culture and sensitivity (UA C&S), dated 6/26/19. Further review of the resident's nurse notes, showed the following: -6/26/19 at 6:34 A.M., The resident's Foley had 200 ml of urine for an eight hour shift. Lower abdominal distention noted; -6/26/19 at 10:15 A.M., The resident is lying in bed, reported resident had blood in urine on 11:00 P.M. to 7:00 A.M. shift. Foley catheter patent and draining yellow urine with sediment noted, no blood noted at this time. Will continue to monitor and obtain UA C&S if indicated, approximately 200 ml urine noted in drain bag; -6/26/19 at 3:15 P.M., Collected urine specimen for testing, requisition filled out and specimen placed in refrigerator, Physician was in facility, gave new order for [MEDICATION NAME] 17 grams by mouth daily; -6/27/19 at 2:42 A.M., late entry for 6/26/19; -At 6:35 A.M., nurse entered patient's room to empty Foley cath bag. 200 ml amber colored urine noted. Lower abdominal distention noted, resident reports feeling the need to urinate; -At 6:40 A.M., Entered room to change Foley cath, when old Foley cath was removed, approximately 10 ml of blood noted, no urine flow noted through urethra; -At 6:45 A.M., Call placed to physician to inform him/her of blood from urethra. Ordered to place new Foley with 100 cc warm water flush. UA C&S ordered. -6/27/19 at 7:08 A.M., at 6:45 A.M., 450 ml noted in Foley cath bag heavily saturated with blood, urine noted to have thick mucus consistency. At 7:20 A.M., call placed to physician, received order to encourage fluid intake, Pending results from UA C&S; -6/27/19 at 4:31 P.M., The resident has dark brown liquid stool, reported to physician and received new order for stool guaiac test and [MEDICAL CONDITION] testing. Further review of the resident's record, showed no guaiac and no [MEDICAL CONDITION] specimen collected. Further review of the resident's lab work, showed urine collected on 6/26/19 at 3:15 P.M. No lab results found. The lab made a note that read, due to specimen received with missing, incorrect or incomplete identification, the test could not be completed. No name or date of birth was on specimen, reported on 6/27/19 at 5:16 P.M. Further review of the resident's nurse notes, showed the following: -No documentation on 6/28/19; -6/29/19 at 5:43 P.M., the resident is alert and oriented to person. The resident has no changes in mood or behavior noted. Urinary continence in not rated because the resident has a Foley catheter which is patent, draining and intact. Urine color is yellow, clear with no odor. The resident is always incontinent of bowel, has no diarrhea or constipation and uses briefs. Bowel sounds are present. No changes to skin integrity with no wounds. Respiratory with in normal limits, pulse has normal rate and rhythm, peripheral pulses palpable. Adequate hearing and vision. Resident denies pain. Total care provided. Foley cath patent and intact. Vital signs stable. The resident refused to get up on day shift today. Infusion IV patent and intact, no signs nor symptoms of infiltration noted; -6/29/19 at 5:49 P.M., resident has pulled his/her IV infusion out of left upper arm. Resident has increased confusion more than usual. He/she appears to be more weak than usual. Notified physician, received order to send resident to the emergency room ; at 6:00 P.M., supervisor on duty was notified. Resident states he/she was in pain. When asked the resident to rate his/her pain on a scale of 1-10, he/she stated he/she has not been having pain; -6/29/19 at 6:43 P.M., ambulance arrived to transport the resident to the hospital; -6/30/19 at 1:10 A.M., Call placed to hospital inquiring on the residents status. The resident was admitted to ICU (intensive care unit) with a massive UTI (urinary tract infection) with 4+ bacteria. Blood results of WBC 60.5, BUN 190, and Creatinine 8.1. The resident has a [MEDICAL CONDITION] ([MEDICAL CONDITION] a blood clot that forms in a vein deep in the body) in the left leg and a nephrology (kidney specialist) consult. Further review of the resident's POS, showed the following: -Normal saline 0.9% infusion (for fluid and electrolyte [MEDICATION NAME]) at 70 ml per hour, give four liters, dated 6/28/19; -Send resident to hospital emergency room for further evaluation, dated 6/29/19. During an interview on 8/9/19 at 4:10 P.M., the DON said the guaiac test was not done. The stool was not collected for [MEDICAL CONDITION] testing. The order was put in on 6/28/19, and on 6/29/19, the nurse charted no diarrhea, thus there was no stool to send. By default, formed stool cannot be run for [MEDICAL CONDITION] testing. During an interview on 8/9/19 at 1:15 P.M., the Administrator said she expected staff to follow physician orders. Staff should contact the physician and the DON immediately if a lab specimen was not obtained or rejected from the lab. She expected staff to follow the facility policy. During an interview on 7/5/19 at 10:20 A.M., a hospital representative said the resident was admitted urosepsis. During an interview on 8/12/19 at 3:30 P.M., the resident's primary care doctor said she expected staff to follow all orders given. If a lab sample was rejected from the lab, she expected staff to notify her and to recollect the specimen immediately. The physician was unaware the specimen was rejected. When a resident had a change of condition, she expected staff to document each shift regarding the resident's health status. Regarding the resident, he/she has a baseline of an elevated WBC, and was being seen by a hematologist. The resident was on a chronic catheter (urinary drainage managed with chronic indwelling catheter). Review of the facility physician order [REDACTED]. -Physician orders [REDACTED]. -Once obtained and, if necessary, clarified the order must be carried out as soon as possible. The nurse carrying out the order must then bracket and sign the order by writing noted and then date and sign with name and title. Carrying out the order consists of but is not limited to transcribing the order, placing the order on the appropriate flow-sheets, requisition, or administration records, notifying other applicable departments/vendors, and/or making any necessary appointments; -The receipt and implementation of all physician orders [REDACTED]. - In the event an order cannot be implemented the nursing staff must notify the physician who wrote or provided the order to discuss care alternatives. The inability to carry out orders must also be documented in the nurses/interdisciplinary notes and the nurse's communication log; -Laboratory testing, all general guidelines for obtaining orders apply. A requisition for each one-time laboratory test must be completed and filed in the lab box under the date in which it is to be drawn by the individual taking the order. Specimen requisitions should only be filed once the specimen has been obtained and is ready for pick-up; -The lab must be notified by phone to schedule any ordered STAT laboratory test or to pick up specimens obtained outside of routine draw days; -A standing order sheet must be completed for each new, changed, or discontinued routine, the form must be placed in the lab draw box or faxed to the lab; -Routine laboratory testing should commence within the time frame specified by the order and from the date of the last test of the same type. If no test of the same type has been drawn within the last 30 days then a baseline test can be ordered to establish the schedule. Diagnostic laboratory testing from a hospitalization can be used when establishing a routine schedule. 2. Review of Resident #5's care plan, updated 5/9/19, showed the following: -Alert and oriented times one; -Mechanically altered diet; -Activities of daily living self-care deficit related to [MEDICAL CONDITION]; -Total dependence on staff for eating; -Diet to be followed as prescribed; -Swallowing problem related to difficulty with thin liquids; -All staff to be informed of the resident's dietary and safety needs; -Instruct the resident to eat in an upright position, to eat slowly and chew each bite. Review of a communication with family note, dated 5/10/19 at 5:00 P.M., the Director of Nursing (DON) documented the resident's family member was at the facility with a barbeque meal and regular drink for the resident. The family member received education on the proper texture of drinks and food to avoid aspiration. The family member said the resident drank regular drinks when he/she drove the resident from out of town and the family member would continue to give the resident whatever he/she wanted to give the resident. Review of the resident's nursing notes, showed the following: -5/26/19 at 2:41 P.M., resident refused medications this shift; he/she was saying they are hard to swallow; -5/29/19 at 1:34 P.M., the resident's family member reported to nurse that the resident was having a coughing spell. The nurse noted the family member was giving the resident red soda in a glass. The resident was on thin liquids. His/her family member continued to give him/her thin liquids, after being educated on the risks of the resident drinking thin liquids; -5/30/19 3:30 P.M., the DON documented the resident's family member was upset about the resident's diet. Staff attempted to educate the family member on the safety of adherence to physician/dietitian prescribed diet. The family member brought in regular textured food multiple times a week and gave the resident regular liquids, despite the safety risk. Staff made multiple attempts to schedule a care plan meeting. The family member would not respond to messages or provide a date and time, in which he/she would be available. Review of the resident's medication review report, dated 7/1/19 through 7/31/19, showed the following: -7/15/19, admit to palliative care (specialized medical care that focuses on relief from the symptoms and stress of living with a serious illness); -7/15/19, nectar thick liquids (slightly thick, so it coats the inside of the glass and beads up on the end of a fork) every shift; -7/15/19, may crush appropriate meds; -7/29/19, regular diet: pureed texture, nectar consistency. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Weight 125 pounds, 65 inches tall; -Wheelchair mobility; -[DIAGNOSES REDACTED]. -Sign and symptom of [MEDICAL CONDITION]: fluctuating inattention; -Required limited assistance of one with eating, bed mobility, transfers, locomotion, toilet use, and personal hygiene. Further review of the resident's care plan, showed his/her diet order was not updated to reflect the resident's current dietary needs: pureed texture food and nectar consistency for liquids. The care plan also did not explain or describe the resident's safety needs relating to consumption. No documentation of the tendency for the resident's family member to feed the resident thin liquids and foods which are not pureed. The care plan did not include any guidelines for reporting, intervening, documenting, monitoring the resident, or assessing his/her condition after he/she ingested thin liquids or food which is not pureed. Review of a written statement from the DON, dated 8/9/19, showed the resident's family never provided documentation of power of attorney status. Observation and interview on 7/30/19 at 3:00 P.M., showed the resident and his/her family member had returned from an outing. The resident had a plate of regular consistency food and an eight ounce open plastic bottle of juice (thin liquid) on an over the bed table in front of him/her, 1/3 full. According to the family member, the resident had eaten two pancakes, sausage, bacon, scrambled eggs and potatoes. The resident was consuming the last of the eggs, pancake, and sausage. The family member said he/she regularly fed the resident thin liquids and food was not pureed, because the facility tended to serve the same pureed meals for lunch and dinner without seasoning and the resident refused to eat it. The resident paused and put down the plastic fork. His/her family member verbally urged the resident to finish the meal. When he/she did not comply, the family member stood and fed the resident the remainder of the meal, quickly placing forkfuls of food in the resident's mouth. A few minutes later, the resident began coughing intermittently. The family member informed the resident he/she had some grapes out in the car, asked the resident if he/she wanted them, and went out to the car to get them, when he/she nodded to indicate yes. During the family member's absence, the resident began coughing again. His/her roommate picked up the plastic juice bottle, handed it to the resident, and urged him/her to drink. The resident drank the remaining juice. The roommate placed the empty bottle on the over the bed table and the resident began looking around and said where's the juice? What happened to the juice? The roommate said, you just drank it. Review of the resident's speech therapy progress and discharge summary, dated 8/9/19, showed the following: -Medical Diagnosis: [REDACTED]. -Treatment Diagnosis: [REDACTED]. -Resident swallowed 100% of pureed solids and nectar thickened liquid with no overt signs/symptoms of aspiration; -Caregiver educated in precautions and able to recount information with 80% accuracy; -Goal not met: Resident will tolerate a regular diet with the use of compensatory strategies 80% of the time without signs/symptoms of aspiration to optimize nutrition and hydration. Explanation: progress ceased. During interviews on 7/30/19 at 1:35 P.M. and 8/9/19 at 11:48 A.M., the DON said the resident had a poor appetite related to difficulty swallowing. He/she coughed related to particles in his/her lungs, from the family member giving him/her food and drink which were not allowed. No matter what staff said, the family member's attitude did not change. The family member would not sign a waiver acknowledging having been educated on the risk for harm in feeding the resident regular consistency foods and thin liquids. A lot of the time, staff was unaware when the family member fed the resident something other than puree or thickened liquids. They tended just to see remnants of meals: wrappers and empty drink containers. The family member had recently gotten better at not leaving evidence; throwing away empty containers or wrappers someplace other than the resident's room, knowing that staff was looking for the evidence for purposes of documentation and re-education. When the DON saw evidence that the family member had fed the resident, she did not conduct a documented formal assessment of the resident's condition. She would observe the resident, talk to him/her and asked the resident how he/she was feeling. During an interview on 7/30/19 at 3:25 P.M., the Administrator said the resident tended to tuck solid food in his/her cheeks and under his/her tongue. The resident's family member persisted in feeding the resident, even though aspiration led to hospitalization . During an interview on 8/9/19 at 7:21 P.M., the therapy director said the resident failed a modified [MEDICATION NAME] swallow (a special x-ray that is taken to determine whether or not food or liquid is entering a person's lung, also known as aspiration). His/her speech therapist conducted mechanical soft food trials with the resident and he/she coughed. A puree diet with double portions was appropriate, because they did not want the resident to develop aspiration pneumonia. The resident was a silent aspirator; he/she would not show signs or symptoms of aspiration. The resident's family member continued feeding the resident foods which were not pureed, against recommendations from the therapy department. There was a good chance that the resident would develop aspiration pneumonia, if he/she ate non-pureed food. Grapes could get lodged in his/her throat. MO 955 MO 893

For examples, see the survey dated January 15, 2014, at Event ID X1FX13.

For examples, see the survey dated November 27, 2013, at Event ID X1FX12.

Based on observation, interview and record review, the facility failed to assess and notify the physician in a timely manner of one of 24 sampled residents who complained of severe pain (Resident #7). The census was 177. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/10/13, showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory problems; -Able to make own decisions; -Required total assistance for staff for all activities of daily living; -Pain: On a pain regimen. Review of the resident's care plan, updated 7/23/13, showed the following: -Problem: Pain and limited movement secondary to [MEDICAL CONDITION] joint disease, chronic pain, [MEDICAL CONDITION] and [MEDICAL CONDITION]; -Goal: Encourage participation in daily care, rest periods, controlled activities and exercise. Provide medications as ordered and monitor for effectiveness in relieving pain. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (medication used to treat pain and fever) 500 milligrams, (mg) two tablets by mouth every morning and afternoon; -[MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication) 5/500 mg at bedtime; -[MEDICATION NAME] 325 mg, one or two tablets by mouth every four to six hours as needed (PRN) for pain or elevated temperature. Observation on 9/23/13 at 8:20 A.M., showed the resident lay in bed. Certified Nurse Aide (CNA) N and CNA O turned the resident to the right side, the resident began to moan out, "OW, OW, OW", while staff placed the Hoyer lift pad under him/her. The resident said his/her side really hurt. CNA N said he/she complained of pain yesterday, 9/22/13, and he/she told the nurse. CNA N and CNA O lifted the resident with the Hoyer lift and transferred the resident to the wheelchair and the resident moaned and complained of pain throughout the transfer. CNA O told the resident he/she would report the resident's pain to the charge nurse. Observation on 9/23/13 at 1:38 P.M., showed the resident lay in bed. CNA N and Nurse F transferred the resident from bed to his/her wheelchair. The resident complained of pain in his/her right side throughout the transfer. Nurse F asked the resident at this time if he/she would like to stay in bed. The resident refused, stating "I'm already up". Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] 500 mg, two tablets every morning and afternoon; all doses initialed by staff as done; -[MEDICATION NAME] 325 mg, one or two tablets PRN for pain or elevated temperature; no initials documenting the resident received any doses. Observation on 9/24/13 at 7:32 A.M., showed the resident lay in bed. Certified Medication Technician (CMT) Q entered the room to administer the resident's morning medication and as he/she began to roll up the head of the bed, the resident began to complain of pain in his/her right side. The CMT had to roll the bed down and lift the resident's head in order to give him/her water. CMT Q said he/she would notify the nurse of the resident's pain. Review of the resident's nurse's notes, showed no documentation regarding the resident's complaints of pain on 9/22/13 and 9/23/12. The last nurse's note documented was 9/6/13. During an interview on 9/24/13 at 10:55 A.M., the resident's physician said the nurse informed her of the resident's pain when she arrived at the facility that morning. She said the resident doesn't usually complain of pain, so that was significant. She said she would order an X-ray of the resident's hip and order a KUB (an X-ray used to determine if he/she had a bowel obstruction). During an interview on 9/25/13 at 12:20 P.M., Nurse Manager R said the resident complained of pain while receiving care. The physician gave orders for the resident to be sent the hospital for evaluation. The right hip X-ray and the KUB were negative. No one notified him/her prior to 9/24/13, of the resident's complaints of pain. He/She would expect staff to notify the charge nurse who would assess the resident's pain and document in the medical record. During an interview on 9/25/13 at 12:30 P.M., Nurse F said CNA Q notified him/her of the resident's pain on 9/24/13, and that was the first time he/she heard of the resident's pain. He/She would expect staff to notify him/her of any change in the resident's condition. During an interview on 9/25/13 at 1:00 P.M., CNA Q said he/she informed Nurse F of the resident's pain on Monday 9/23/13. Review of the resident's hospital discharge orders, dated 9/25/13 at 8:00 P.M., showed the resident returned from the hospital with a [DIAGNOSES REDACTED]. During an interview on 9/27/13 at 8:10 A.M., the Director of Nurses said she expected staff to inform the charge nurse when a resident complained of pain and she expected the charge nurse to assess the resident, notify the physician and document it in the nurse's notes.

This deficiency is uncorrected. For previous examples refer to the statement of deficiencies dated [DATE]. Based on interview and record review, the facility failed to assess a resident who complained of shortness of breath during the latter part of the evening shift. On two different occasions, the resident complained of difficulty breathing and requested a breathing treatment. The staff failed to assess, notify the physician or provide a breathing treatment. The resident became pulseless, paramedics arrived and transported the resident to the hospital. (Resident #14). The census was 170. Review of Resident #14's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated [DATE], for Ipratr-Albuteral (Combination of [MEDICATION NAME] and [MEDICATION NAME] used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with [MEDICAL CONDITION]) 0.5 milligram (mg)-3 mg per 3 milliliter (ml). One vial per nebulizer (converts liquid medication into a mist so it can be easily and more effectively inhaled through a mask or mouthpiece) twice daily as needed for shortness of breath Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -No short/long term memory problems; -Mood: Feeling tired/little energy; -Required supervision of staff for bed mobility, transfers, walking in room and corridor, toilet use and personal hygiene; -Always continent of bowel and bladder. Review of the physician's progress note, dated [DATE], showed the following: -Mood: Happy. Behavior: calm. Dyspnea (shortness of breath): no. Chest pain: no. Incontinence: stool: no, urine: no. -Vital signs: blood pressure: ,[DATE], Pulse: 70, respirations: 22; -Attending note: Participating in activities, nursing reports elevated blood sugar. [MEDICAL CONDITION] (high blood sugar) secondary to poor diabetes control, resident has poor diet compliance. Review of the resident's nurse's notes, dated [DATE], showed the following: -10:55 P.M.: Staff found the resident in the hallway gasping for air, nebulizer treatment initiated. Blood sugar: 109. Night supervisor arrived and began to assess the resident; -11:00 P.M.: Certified Nurse Assistant (CNA) notified the night supervisor of the resident in distress. Upon arrival, the resident was non responsive, pulseless and without visual or audible respirations. Lowered to the floor from the wheelchair, Cardiopulmonary Resuscitation (CPR) initiated, charge nurse sent to call 911, CPR continued; -11:10 P.M.: Paramedics arrived and continued CPR, the resident remained unresponsive; -11:30 P.M.: Paramedics transported the resident, CPR continued. Review of the nurse's notes, dated [DATE] at 10:00 A.M., showed the following: -Resident in intensive care unit; -[DIAGNOSES REDACTED]. During an interview on [DATE] at 12:57 P.M., CNA B said he/she worked the evening shift on [DATE]. At about 9:30 P.M., he/she saw Resident #14 at the top of the hall by the double doors asking for a breathing treatment. He/She didn't hear what the nurse said to the resident at that time. Both evening shift nurses, Nurse G and Nurse J, were at the nurse's desk. During an interview on [DATE] at 12:47 P.M., CNA A said he/she worked the evening shift on [DATE]. He/She saw the resident around 9:00 P.M. to 9:30 P.M., at the top of the hall asking Nurse J for a breathing treatment. He/She didn't hear the nurse respond. Both evening nurses, Nurse G and Nurse J, remained at the desk. During an interview on [DATE] at 1:15 P.M., CNA D said he/she saw the resident close to the end of the shift. The resident came out of his/her room into the hall asking the evening shift nurse, Nurse J, for a breathing treatment. The resident sounded panicky and was wheezing. The nurse asked the resident if he/she had a breathing machine in his/her room. The resident responded, "No". The nurse checked the resident's chart at that time and said the breathing treatment was discontinued. Neither evening shift nurse checked the resident's vital signs and "didn't seem to take the resident seriously." During an interview on [DATE] at 1:13 P.M., CNA C said he/she worked the evening shift on [DATE]. At approximately 10:55 P.M., the resident sat in the hall outside his/her room asking for a breathing treatment. The resident yelled up the hall to the nurse several times, asking the evening nurse for a breathing treatment. Nurse J, yelled down the hall saying, "You don't have an order" about three times. The resident sounded out of breath and he/she could hear him/her yelling for the breathing treatment as he/she left the floor. During an interview on [DATE] at 8:47 P.M., Nurse G said he/she worked the evening shift on [DATE]. He/She saw the resident walking in the hall at approximately 10:40 P.M. to 10:45 P.M., asking Nurse J for a breathing treatment. One of the evening CNAs, name unknown, also told Nurse J, the resident was asking for a breathing treatment. Nurse J checked the resident's chart at that time and yelled down the hall to the resident, that he/she didn't have a order for a breathing treatment. Nurse G saw the resident walk down the hall to his/her wheelchair and sit in the hall in front of his/her room. Nurse H, the night shift nurse, arrived on the floor and Nurse J gave him/her report stating, "You might have to call the physician to get an order for [REDACTED]. After giving report to Nurse H, Nurse G began straightening the nurses's desk and could see the resident in his/her wheelchair looking toward the ceiling. Nurse G told Nurse H, CNA E and CNA F at that time, the resident didn't look good and might be dead. Nurse G told the CNAs, they needed to make rounds and check their residents, because anything could be wrong, Resident #14 might be dead pointing to the resident. He/She thought at the time there might be a problem with the resident's blood sugar because he/she has had a history of [REDACTED]. He/She made the statement again, because none of the night staff were making rounds. Nurse G said he/she didn't check the resident's vital signs, O2 Sats or blood sugar. The CNAs and Nurse H went to check the resident at that time and said he/she was not responding. Nurse G left the floor at that time and clocked out at 11:03 P.M., because the staff aren't supposed to do overtime unless it's approved. He/She crossed the hall to the supervisor's office and told the evening supervisor (Nurse K), the resident wasn't looking good. He/She returned to the floor, walked to the resident's room, his/her respirations were shallow. Nurse G said he/she did not check the resident's O2 Sats, vital signs or blood sugar at that time, because he/she didn't have anything to check him/her with. He/She had already packed them in his/her bag. Nurse G walked to the nourishment room to get some sugar packets. The evening supervisor, Nurse K, passed him/her on the way to the nourishment room. The evening supervisor directed Nurse H to get the blood sugar machine to check the resident's blood sugar. The night supervisor reached the resident's room and said he/she was not breathing, to call 911 and started CPR. At that time he/she went to the resident's room and spoke to a unknown CNA standing at the crash cart asked if they had a nasal cannula (long tubing used to administer oxygen). The CNA said he/she didn't know what a nasal cannula was. Nurse G walked to medication room, obtained a face mask and returned to the resident's room. The night supervisor, (Nurse I) had begun CPR. During an interview on [DATE] at 2:30 P.M., CNA F said he/she worked the night shift on [DATE]. He/She did rounds at approximately 10:45 P.M. The resident walked out of his/her room and said," I can't breathe, I need a breathing treatment". The resident was incontinent of bowel at that time. The two evening nurses, Nurse J and Nurse G, sat at the nurse's desk. Nurse J checked the medication book and said the resident didn't have an order for [REDACTED]. Nurse J left the floor shortly afterwards. Nurse G remained at the nurse's desk giving report to the night nurse. At that time, CNA F asked Nurse G his/her name because he/she wanted to report him/her to the supervisor, because the evening CNAs left the residents on the floor soiled and wet. Nurse G told CNA F he/she needed to stop complaining and make rounds, pointing towards Resident #14, stating, "He/She might be dead". CNA F said Nurse G repeated he/she might be dead, pointing toward the resident. CNA F and CNA E checked on the resident at that time, who sat in a wheelchair in the doorway of his/her room with his/her head hanging backward gasping for air and his/her feet stretched out in front. CNA F told CNA E to go and get the night supervisor. CNA F called Nurse H who administered a nebulizer treatment and checked the resident's blood sugar. When the night supervisor arrived he/she said the resident wasn't breathing and had no pulse. They lowered the resident to the floor and began CPR. During an interview on [DATE] at 11:55 A.M., CNA E said he/she worked the night shift on [DATE]. He/She arrived on the floor at about 10:52 P.M.. CNA F stood at the nurses's desk complaining that the evening shift left the residents wet and soiled. CNA F told him/her he/she was going to report Nurse G. Nurse G said at that time, "While you all are complaining, you need to check on your resident", pointing to Resident #14, "He/She's in the hall dead". Nurse G repeated the statement again, pointing to the resident in the hall. Nurse H looked down the hall at that time and said, "Oh my God". The resident sat in his/her wheelchair with his/her head laying backwards, gasping for air. CNA F said at that time, "I heard him/her asking the evening nurse for a breathing treatment". Nurse H administered a breathing treatment at that time, while CNA E went to the nursing office to get the night supervisor. CNA E asked the night supervisor, Nurse I, to please come and check on the resident. The evening supervisor said, "Don't worry about it, I'll go up there, the resident's probably complaining about his/her blood sugar". CNA E and the night supervisor walked up the steps to the floor, went to the resident's room. The nurse supervisor checked the resident and said he/she had no pulse and had stopped breathing and to call 911. The night supervisor and CNA F placed the resident on the floor and began CPR. During an interview on [DATE] at 9:08 A.M., Nurse H said he/she worked the night shift on [DATE]. He/She arrived on the floor at approximately 10:51 P.M.. During report, Nurse J said nothing went on during the shift and they counted the narcotics. Nurse J left at that time. While receiving report from Nurse G, CNA F asked, "What is Nurse G's name?" Nurse G said, "Don't tell him/her my name". Nurse H realized at that time, something else was going on. He/She overheard Nurse G say, "That resident is dead", to CNA F. Nurse G repeated it, "That resident is dead" to CNA E and CNA F. Nurse H looked down the hall and saw the resident with his/her head hanging backwards. He/She asked Nurse G at that time, if the resident was dead. Nurse G said, "Probably". Nurse H and the two CNAs went to the resident and found his/her respirations were labored. He/She and CNA F repositioned the resident and he/she administered a breathing treatment. The evening supervisor, Nurse K, arrived and said, "Nothing's wrong with her, it's just his/her blood sugar". Nurse H checked the resident's blood sugar, it was 109 (per the American Diabetes Association the normal range is 70 to 130 mg/dl). The night supervisor arrived, checked the resident's vital signs and said there weren't any. The nursing supervisor and CNA F started CPR and Nurse H called 911. Paramedics arrived shortly afterwards, continued CPR and transported the resident to the hospital. Afterwards CNA F said the resident was asking Nurse J for a breathing treatment when he/she arrived on the floor and Nurse J told the resident he/she didn't have an order for [REDACTED]. During an interview on [DATE] at 9:00 A.M., the night supervisor, Nurse I, said he/she worked the night of [DATE]. He/she arrived at approximately 10:48 P.M.. While in the supervisor's office, Nurse G entered and told the evening supervisor that Resident #14 was throwing another one of his/her "fits". The evening supervisor said, "Ok, I'll be up there". At this time, CNA E came in and said, to the night supervisor, "Please come and check on this resident because he/she's screaming. The resident can't breath, he/she needs some help". The evening supervisor said," Don't worry, I'm going up the there". The evening supervisor left the office at that time and took the elevator upstairs. He/She and CNA E went up the stairs and asked where the resident was. The staff said the resident's room. When he/she arrived the resident was in his/her wheelchair with his/her head extended backward, not moving and with no rise and fall of his/her chest. Nurse I did a sternal rub (a firm rub done in the middle of the chest) and called the resident's name with no response. He/She checked the resident's carotid (neck) pulse, none felt, he/she listened to the resident's heart and heard nothing. He/She instructed Nurse H to call 911. He/She and CNA F lowered the resident to the floor and started CPR. The evening supervisor kept saying, "It's his/her blood sugar". Nurse H said the blood sugar was 109 and he/she and CNA F continued CPR until the paramedics arrived. During an interview on [DATE] at 3:30 P.M., the Director of Nurses said the night supervisor told her when he/she reached the floor the resident had no pulse or blood pressure, started CPR and continued until the paramedics arrived. She said she was unaware of the resident asking for a breathing treatment. She would expect the staff to assess the resident, provide any care that's needed and notify the physician. During an interview on [DATE] at 2:53 P.M., the emergency room physician said the paramedics brought the resident to the emergency room in [MEDICAL CONDITION]. The paramedics had given one dose of [MEDICATION NAME] (medication used to stimulate the heart) which reestablished his/her heart beat and intubated (endotracheal tube (ET), placed into the trachea to help with breathing) the resident. He/She didn't know whether the outcome would be different if the resident had received the breathing treatment when requested or not. If a resident complained of difficulty breathing and requested a breathing treatment, then staff should assess and administer it if he/she has an order. Review of the resident's hospital emergency department (ED) progress note, dated [DATE] at 2:41 A.M., showed the following: -History: Patient presents with loss of consciousness. Found down and unresponsive at nursing home, paramedics were called, CPR started, intubated by paramedics and received one round of [MEDICATION NAME]. On arrival to emergency department, patient was intubated, had return of spontaneous circulation. Accucheck in the 200's; -Physical exam: Appears distressed, ET tube in place. Eyes: pupils fixed and dilated. Cardiovascular: regular rhythm and normal heart sounds. Initially with faint radial and pedal pulses. Neurological: Initially unresponsive to painful stimuli, no gag reflex, no spontaneous movement of extremities; -Assessment: Presented to the emergency department with [MEDICAL CONDITION]; -Active problems: [MEDICAL CONDITION]: Had return of spontaneous circulation in the field, unclear how long he/she was down. The cause of his/her [MEDICAL CONDITION] is unclear. Currently has a Glasgow score (is an objective way of measuring the level of consciousness after a trauma, range from 3 to 15, 3 being the lowest) of 3. His/Her CT scan (computerized tomography, a series of x-rays taken by a computer to [DIAGNOSES REDACTED]. Review of the resident's Intensive Care Unit History and Physical, showed the following: -[DATE] at 6:19 A.M.: History: Presented to the hospital emergency room , status [REDACTED]. Per ED report, patient was found down by nursing home staff, who called 911. Paramedics arrived, intubated and performed CPR. Patient had return of spontaneous circulation after one round of advanced cardiac life support (ACLS). Arrived in emergency department with no purposeful movement observed. CT of head: Diffuse loss of gray white differentiation consistent with diffuse cerebral [MEDICAL CONDITION] in setting of [MEDICAL CONDITIONS]. Patient intubated and admitted to medical intensive care unit (MICU). Overnight noted to have myoclonic (a disorder in which the electrical activity in the brain becomes disordered leading to [MEDICAL CONDITION]) jerks/[MEDICAL CONDITION].; -[DATE]: started on Propofol (short acting intravenous anesthesia), [MEDICAL CONDITION]/myoclonic jerks decreased, started on hypothermia (lowered body temperature); -[DATE]: Continued on hypothermia protocol, continue on Propofol; -[DATE]: No significant change in mental status, has spontaneous breathing; -[DATE]: Continued to have elevated blood pressures, tolerating tube feedings. Review of the facility's policy on Notification, Changes in Condition, dated [DATE], showed the following: -Policy statement: It is the responsibility of the staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental and or psychosocial status; -Definition: Change of Condition: If any assessment finding, observance or event that deviates or has the potential to cause a deviation in the resident's usual or expected physical, mental or psychosocial status; -Policy guidelines and interpretation: 1. Upon identification of a change in condition licence nursing personal will contact the resident's attending physician/on call physician to notify him/her of the change. 2. All notifications should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and or transfer decisions. 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, the facility identified all residents who received nebulizer treatments and placed a list at each nurses station. All nursing staff (RNs, LPNs, CMTs and CNAs) were inserviced on what to when a resident has a change in condition. This surveyor interviewed random staff to determine whether they knew what to do if they observe a change in condition and who to report it to. The facility's administrative and nursing supervisory staff will review all 24 hour reports on a daily basis to determine whether staff identified potential changes in condition. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

This deficiency is uncorrected. For previous examples refer to the statement of deficiencies dated [DATE]. Based on observation, interview and record review, the facility failed to provide appropriate/timely emergency care for Resident #50 who was found by a nurse without signs of life; no pulse and no respirations at 4:55 A.M., and did not perform CPR, call a code blue or call 911, but left the room and called the night shift supervisor. In addition, the facility failed to notify the physician of the inability to obtain pain medication ([MEDICATION NAME]:a potent opiate [MEDICATION NAME] drug that is used to relieve severe pain) for Resident #51 who moaned in pain, and failed to cut Resient #52's toenails, one of which curled around the resident's toe. The census was 170. 1. Review of Resident #50's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. characterized by either partial or total loss of the ability to communicate) and [MEDICAL CONDITION] disorder; -Short/Long term memory loss; -Cognitive impairment; -No behavior symptoms; -Required extensive assistance of staff for bed mobility, dressing and personal hygiene; -Required total assistance of staff for transfers, toilet use and bathing; -Incontinent of bowel and bladder; -Swallowing disorder: none. Review of the resident's physician's order sheet (POS), dated [DATE] through [DATE], showed the following: -[DIAGNOSES REDACTED]. -Emergency orders: Full code. Review of the resident's nurse's notes, showed the following: -[DATE] at 4:15 P.M. At 3:30 P.M., the resident complained of chest pain. Vital signs (VS): temperature (T): 97.6 Fahrenheit (F) (normal 98.6), pulse (P): 71 (normal 60 - 80 beats per minute, respirations (R): 20 (normal 16 - 20 breaths per minute), blood pressure (BP): ,[DATE] (normal ,[DATE]), oxygen saturation (O2 SATS): 98% (normal 96% - 100%) on room air. When asked where the pain was, he/she pointed to his/her chest and said it really hurt. The resident's physician was called at 3:40 P.M., and gave orders to send the resident to the hospital. At 3:41 P.M., staff placed a call to a family member, no answer, message left. At 3:43 P.M., called a private ambulance service and was instructed to call 911 due to estimated time of arrival of one hour. At 3:45 P.M., called 911 then checked on the resident again, who still complained of chest pain but had no signs of labored breathing and respirations remained even. At 3:52 P.M. emergency medical service (EMS) arrived and at 4:02 P.M., transferred the resident to the hospital; -[DATE]: no time noted, admitted to hospital; -[DATE] at 7:15 A.M.: admitted to the hospital with [REDACTED]. -[DATE] at 5:45 P.M.: readmitted to facility with a [DIAGNOSES REDACTED]. New orders for [MEDICATION NAME] (antibiotic) 750 milligram (mg) by mouth for seven days and to increase [MEDICATION NAME] (treats high blood pressure) to 10 mg daily (had been on 5 mg daily since [DATE]), VS: T: 97.4 F, P: 61, R: 18, BP: ,[DATE], O2 SATS: 96% on room air. Alert and oriented times one, able to respond to commands. Incontinent of bowel and bladder, bilateral [MEDICAL CONDITION], right arm [MEDICAL CONDITION], no evidence of pain, will continue to monitor. Review of the resident's Resident Status Sheet, used by certified nurse aide (CNA) staff, dated [DATE], showed the following: -Mental Attitude:Oriented to person; -Resident spits medicines out, including liquids. (written in on the bottom of page) Review of the resident's nurse's notes, showed the following: -[DATE] at 5:00 A.M.: Quiet night. No complaints of pain or distress. Continued antibiotic therapy, VS: BP: ,[DATE], P: 76, R: 20, T: 98.9, O2 SATS: 95%; -[DATE] at 1:00 P.M.: Resident lay in bed with head of bed elevated 30 degrees, no complaint of pain, no signs or symptoms of distress. VS: BP: ,[DATE], P: 64, R: 20, O 2 SATS: 96% on room air; -[DATE] at 8:00 P.M.: Resident non compliant with care, resisting and pushing back when the CNA, attempts to roll resident over. Refused to swallow medicines, including [MEDICATION NAME] (a medication used to thin the blood and prevent blood clots) letting medication and water run out of his/her mouth. Resident observed trying to push [MEDICAL CONDITION] (Continuous positive airway pressure, a machine that helps a person who has obstructive sleep apnea breathe more easily during sleep) mask off his/her face. He/She refused to eat dinner. When asked if his/her throat hurt when trying to swallow, the resident shook his/her head, yes. When asked whether he/she had a sore throat, the resident gave no response. Remains on antibiotic therapy [MEDICAL CONDITION], no adverse reaction noted. T: 97.8 F. No further nurse's note until [DATE] at 5:10 A.M. -[DATE] at 5:10 A.M.: (Note written by the night supervisor, Nurse M) Called to the resident's room by charge nurse. Upon entering the room, found the resident in bed non-responsive without any obtainable vital signs, eyes fixed, body cold to touch with no signs of life noted. Paramedics called at 5:15 A.M.; -[DATE] at 7:18 A.M., late entry: (Note written by the night nurse, Nurse N) Went to the room to do rounds at 4:55 A.M., the resident lay in bed with [MEDICAL CONDITION] intact. Attempted to arouse to check if ok, no breath sounds noted, unable to obtain vital signs, pupils were fixed. Called night supervisor to make aware of the situation, that resident wasn't responsive. At 5:08 A.M., contacted fell ow nurse to the floor through extension (called on the phone). Upon arrival of supervisor and fell ow shift nurse, complete assessment was started on the resident. Checked lung sounds, pulse, with zero response. A blood glucose level test was performed with no reading given due to machine unable to read. A sternal rub (a painful test to determine if a person is conscious, done by making a fist and then rubbing up and down on the breast bone) was done to check for further arousal and the resident was still unresponsive. Chest compressions started by supervisor. [MEDICAL CONDITION] machine still fully intact. No results. Called 911 at 5:16 A.M. The resident's physician was called at 5:20 A.M., and a message was left with the medical exchange. Called the resident's responsible party/family member at 5:21 A.M., and notified of situation change and advised to come to facility to view the body as the resident had expired per supervisor. At 5:24 A.M. EMS arrived at facility, applied leads to attempt vital signs, dead on arrival (DOA) called at 5:27 A.M. At 5:33 A.M., the resident's physician returned call, was informed of the resident's death and a [DIAGNOSES REDACTED]. During an interview on [DATE] at 8:06 A.M., Nurse L said he/she worked the evening shift on [DATE]. He/She saw the resident in bed at approximately 2:45 P.M. through 3:00 P.M. The resident smiled when Nurse L said he/she was glad he/she was back. The nurse saw the resident at 4:00 P.M., while doing his/her blood glucose level check. At dinner time the resident refused to eat or drink, but this was nothing new for him/her. Nurse L said he/she didn't know why the resident wouldn't eat. Later that evening, he/she placed the [MEDICAL CONDITION] machine on, medicine and water ran out his/her mouth. He/She removed the [MEDICAL CONDITION] mask, cleaned it and encouraged the resident to allow him/her to put it back on. He/She asked the resident if his/her throat was sore and the resident nodded his/her head, yes. That was the last time he/she saw the resident. He/She documented the above in the nurse's notes because he/she felt these things needed to be documented, but the behaviors weren't new behaviors. Nurse L told the night nurse about the resident's resisting care and letting the medicine and water run out of his/her mouth. During an interview on [DATE] at 7:08 A.M., Nurse N said he/she worked the night shift on [DATE]. He/She had two CNAs working that night and no Certified Medication Technician (CMT). During report, the evening shift nurse said the resident had been non-compliant with taking his/her medicines. Nurse N saw the resident during rounds on the floor at approximately 11:00 P.M. through 12:00 A.M. He/She checked the resident's O2 SATS which were 92%. The resident was sleeping at the time with his/her [MEDICAL CONDITION] machine on. He/She didn't check the resident's vital signs at that time. The nurse saw the resident again at 4:55 A.M., while doing blood glucose level checks. He/She looked at the resident, who had the [MEDICAL CONDITION] machine on but couldn't tell if he/she was breathing. He/She checked for a pulse, none felt, and tried to arouse him/her by shaking with no response. He/She did a sternal rub, checked for vital signs and checked his/her pulse again, but was unable to obtain any vital signs, no pulse and no response to the sternal rub. The nurse listened for breath sounds and none heard. He/She called the night supervisor, Nurse M, to double check. It took the night supervisor five minutes to arrive to the floor, during that time the resident lay in bed and he/she continued to try to see if the resident was alive. He/She checked his/her blood glucose level and it registered zero on the machine. The supervisor arrived and tried to arouse the resident by calling his/her name, did a sternal rub and couldn't arouse him/her. Nurse N said he/she stepped out and called 911. After returning to the room he/she removed the [MEDICAL CONDITION] mask, the supervisor had started chest compressions while Nurse N called 911. The resident remained in bed while chest compressions were being done. EMS arrived, placed the EKG (electrocardiogram, a test to determine heart function) leads on the resident's chest and pronounced the resident DOA. During an interview on [DATE] at 10:46 A.M., Nurse M said he/she worked the night of [DATE], as the night supervisor. He/She received a call from Nurse N at 5:10 A.M., asking him/her to come to the floor to check on a resident. Nurse N didn't tell him/her why he/she wanted him/her to check the resident, but his/her voice sounded urgent. It took Nurse M approximately five minutes to reach the floor because he/she was on the other side of the building. When he/she arrived he/she and Nurse N went to the room, the resident lay in bed, unresponsive. Nurse M checked the resident's vital signs: unable to obtain, did a sternal rub: no response, O2 SATS: registered zero, called the resident's name, no response and said the resident wasn't breathing. He/She initiated cardiopulmonary resuscitation (CPR) at that time and sent Nurse N to call 911. The resident remained in bed while he/she performed CPR, with the [MEDICAL CONDITION] mask on his/her face to provide air. Nurse M didn't remember if the crash cart was brought to the room. No Ambu bag (a resuscitator bag used to assist ventilation) was used and a back board (a piece of rigid plastic used to provide a flat and hard surface, during cardiopulmonary resuscitation) was placed under the resident, but he/she did not know who put it there. EMS arrived five to fifteen minutes later, asked what went on with the resident and his/her condition when found. EMS applied EKG leads to the resident's chest and pronounced the time of death as 5:27 P.M. Nurse M said staff had a recent inservice regarding change of condition and CPR. During an interview on [DATE] at 8:49 A.M., CNA E said he/she worked the night shift on [DATE]. He/She saw the resident during the first rounds of the night at approximately 11:00 P.M. and he/she was asleep with the [MEDICAL CONDITION] machine on. The resident usually didn't talk but was able to follow directions, make expressions, smile and help staff turn himself/herself from side to side or lift when instructed to do so. The CNA dried the resident at approximately 2:30 A.M. and noticed he/she didn't help like he/she normally did. He/She had to physically push the resident over to provide care. The staff had mentioned during report the resident needed more help since returning from the hospital. At approximately 4:30 A.M., during rounds, he/she heard the nurse say loudly, "You got to be kidding me". CNA E thought at that time he/she had done something wrong. He/She passed the nurse in the hallway, as the nurse came out of the resident's room. When CNA E reached the room, he/she could see the resident's eyes were wide open and he/she wasn't breathing. He/She left the room and went to the nurse's station. The nurse stood at nurse's station and a few minutes later, the night supervisor (Nurse M) came to the floor. Nurse N told the night supervisor Nurse N found the resident unresponsive. Both nurses went to the resident's room shortly afterwards. Neither nurse called a "Code Blue" or took the crash cart to the room. Neither nurse instructed him/her to do anything for the resident. No one performed CPR. After a few minutes the ambulance came. At the end of the shift, the nursing supervisor asked him/her to write a statement. Since that time no one had asked him/her about what went on that night or about the resident. During an interview on [DATE] at 6:57 A.M., Nurse P said he/she worked as one of the night charge nurses in the facility on [DATE]. He/She did not see the resident nor did he/she respond to a "Code Blue" because no one called a "Code Blue" that night. When he/she clocked out that morning, the night supervisor (Nurse M) called him/her into the office and said someone died on 200 hall and the nurse didn't call a "Code Blue". Nurse P asked the night supervisor why they didn't call a Code Blue. The night supervisor said the resident was cold and blue. Nurse P informed the night supervisor that staff were supposed to perform CPR until the ambulance arrives. The night supervisor made no further comment. Nurse P said staff has had inservices in November regarding when to start CPR. During an interview on [DATE] at 7:18 A.M., Nurse Q said he/she worked the night of [DATE], as a charge nurse in the facility. Nurse N called the floor and asked if he/she could come to his/her floor for a moment but didn't say what he/she wanted or why. Nurse N didn't say it was a emergency so Nurse Q finished passing medications and went to the floor five to ten minutes later. When he/she arrived he/she saw Nurse N standing in the hallway and asked him/her what he/she needed. Nurse N said someone passed away. Nurse Q walked toward the room, passing the night supervisor in the hallway. When he/she reached the room, the privacy curtain was pulled. He/She didn't go into the room and figured everything was over. He/She didn't remember the ambulance being there. He/she assumed the resident was a No Code. Neither Nurse N or the night supervisor said what the resident's code status was. Nurse Q assumed the resident was a No Code because a "Code Blue" wasn't called and he/she left the floor at that time. Review of the resident's EMS Patient Care Report, dated [DATE], showed the following: -Type of Service: 911 response; -Dispatch time: 5:21 A.M.; -Arrived at scene: 5:25 A.M.; -At Patient: 5:26 A.M.; -Vital signs at 5:27 A.M.: BP: none, P: none, R: none; -Treatment: Cardiac monitoring; -Outcome: Dead on arrival; -Chief complaint: [MEDICAL CONDITION]; -Impression: Obvious death; -[MEDICAL CONDITION]: Prior to EMS arrival; -Resuscitation attempted: Obvious signs of death; -First monitored rhythm: asystole: (flatline, is a state of no cardiac electrical activity); -Narrative: Bystanders on scene state patient was last seen at 2:00 A.M. Nurse at nursing home states he/she walked in and found patient not breathing and unresponsive. States he/she did not initiate CPR. CPR not initiated by anyone in nursing home. Arrived to find patient lying supine on bed, pulseless and apneic (without breathing), rigor mortis (stiffing) in jaw, lividity (pooling of blood, bluish color) in hands, pale, cool, dry skin, pupils normal, no obvious signs of trauma noted, no signs of foul play noted, asystole in all EKG leads, time of death 5:27 A.M. Review of the facility's policy on Cardiopulmonary Resuscitation, dated [DATE], showed the following: -Policy statement: CPR is a set of actions that support delivery of oxygen to the brain and heart until other advanced care is available. CPR modalities including but not limited to rescue ventilation and chest compressions will be provided to resident's or staff who present with an assessed cardiac or respiratory arrest and are without a valid advanced directive. -Policy guidelines: The will be at least one staff person on duty at all times who has been properly trained to handle [MEDICAL CONDITION] and cardiac emergencies. Any facility employee who is on duty in the facility and has current training in the provision of basic life support (CPR) may be utilized to meet this requirement. It is expected that staff perform CPR to the best of their ability. Residents may elect to execute an advanced directive to have CPR withheld in the event of cardiac or respiratory arrest. CPR may be withheld or stopped once it has been determined the resident has such a directive/order. Residents without an executed advanced directive will receive CPR until ordered to stop by higher trained EMS first responders or licensed practitioners (physicians); -Procedure Outline: 1. When an unresponsive patient is found a nurse should be immediately called and an assessment of the individual's respiratory and cardiac status should be initiated. 2. When the resident is assessed and has been found to be in respiratory and or [MEDICAL CONDITION], a "Code Blue" should be announced. In included in the announcement should be the location of the emergency. 3. All available staff should respond to the location. 4. Any CPR trained staff member may initiate and/or assist in the provision of CPR. 5. CPR trained licensed staff (nurses) will be responsible for delegating and managing the emergency situation. In the event a licensed member is not available the most senior CPR trained staff member may initiate management of the emergency and/or the performance of CPR. 6. One person should be delegated to call 911 and get the emergency cart while another or other trained rescuers begin CPR. 7. CPR should continue until EMS arrives or a valid directive/order for no CPR is presented to the rescuers. 8. Authority for management of the emergency situation will be deferred to EMS upon their arrival. 9. Staff should remain available to assist EMS responders in the management and transfer of the individual. During an interview on [DATE] at 8:07 A.M., the resident's physician said the resident had a history of [REDACTED]. He/She had a past medical history of [REDACTED]. The resident would smile when spoken to. She recently sent the resident to the hospital for complaints of chest pain. On [DATE] she saw the resident as he/she sat in a wheelchair watching TV. Staff called to notify her of the resident's death and said they found him/her dead. Staff didn't notify her that medication and water had run out of his/her mouth earlier. She knew the resident spit out medications and resisted care, but letting water and medications run out of his/her mouth was different from spitting medications out. During an interview on [DATE] at 2:50 P.M., the Director of Nurses (DON) said she would expect staff to check the resident's code status, call 911 and do CPR. During an interview on [DATE] at 3:03 P.M., the administrator said she interviewed the nurses that took care of the resident but had not interviewed the CNA staff. Nurse P told her a "Code Blue" wasn't called when staff found the resident unresponsive. She would have expected the nurse to call a "Code Blue" and begin CPR. During an interview on [DATE] at 12:47 P.M., the facility's medical director said she attends the facility's monthly Quality Assurance meetings. In addition, she participates in policy development and had a role in developing the revised CPR policy for the facility. She also participated in the development of the plan of correction for the recent immediate jeopardy citation. She said she would expect the facility staff to follow the CPR policy. If staff find a resident unresponsive they should call 911 and start CPR. 2. Review of Resident #51's quarterly MDS, dated [DATE], showed the following: -Rarely or never understands; -Memory problems; -Severely impaired decision making; -No behaviors; -Poor appetite; -No refusal of care; -Total dependence for all activities of daily living; -Incontinent of bowel and bladder; -Contractures in the arms and legs. Review of the resident's undated care plan, currently in use by the facility, showed the following: -Short-term memory recall and difficulty making decisions; -Poor safety awareness; -Difficulty hearing; -Total assistance with all activities of daily living; -Incontinent of bowel and bladder; -At risk for falls; -Required a hoyer lift with two person assist for transfers; -Required a geri-chair; -Pureed diet with feeding assistance; -Underweight and at risk for weight loss; -Risk for skin breakdown related to decreased mobility and incontinence; -Pain during movement or activities that required movement; -Hospice services for a [DIAGNOSES REDACTED]. Review of the resident's physician's progress note, dated [DATE], showed the following medical Diagnoses: [REDACTED]. -High blood pressure; -[MEDICAL CONDITION] (swelling and pain in the joints); -Contractures (permanent tightening of the non-bony tissues near the joints resulting in loss of movement); -Anorexia and weight loss Review of the resident's nurse's notes, showed the following: -On [DATE] at 7:15 P.M., CNA A reported to Nurse B that the resident was experiencing pain in his/her right hip when touched or moved. Nurse B notified Physician C who was on call for the resident's primary physician. A physician's order was received to obtain a right hip x-ray and to administer [MEDICATION NAME] (a pain medication used for moderate to severe pain) 5 milligrams (mg) every four hours as needed for pain (PRN). There was no documentation the family was notified; -On [DATE] at 1:24 A.M., Nurse E documented the resident was experiencing severe pain to the right hip and [MEDICATION NAME] was not available. Nurse E had called the pharmacy, on [DATE] at 11:45 P.M., to order the medication and notified the x-ray company of the order for the right hip x-ray. There was no documentation the physician was notified that the pain medication was not available. -On [DATE] at 7:30 A.M., Nurse F documented the x-ray technician was unable to obtain the x-ray related to the resident's contractures. There was no documentation the physician or family was notified; -There were no nurse's notes for [DATE]; -On [DATE] at 10:00 A.M., Nurse G documented the resident displayed signs of pain and [MEDICATION NAME] was administered; -There were no nurse's notes for [DATE], [DATE], [DATE] or [DATE]. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -An order dated [DATE], for [MEDICATION NAME] 10 mg every six hours PRN; -An order dated [DATE], for Tylenol 325 - 650 mg every 4 to 6 hours PRN; -An order dated [DATE], for Tylenol 650 mg three times per day; -An order dated [DATE], for Tylenol 650 mg four times per day, discontinue Tylenol order for three times per day; -An order dated [DATE], for [MEDICATION NAME] 5 mg every four hours PRN, discontinue previous [MEDICATION NAME] order. Review of the resident's undated [DATE] PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -An undated entry on the top line for [MEDICATION NAME] 100 mg/5 milliliter (ml), 0.25 ml by mouth every four hours as needed. -The front page had no dated blocks for initials and no times for administration. Review of the pharmacy delivery record, for [DATE], showed the [MEDICATION NAME] was delivered to the facility at 5:38 A.M. on [DATE]. Review of the back side of the [DATE] PRN MAR, showed the following: -On [DATE] at 11:45 (not documented if A.M. or P.M.), [MEDICATION NAME] 0.5 ml for right hip pain-effective; -On [DATE] at 10:00 A.M., [MEDICATION NAME] 0.5 ml for all over pain-effective; -On [DATE] at 2:30 P.M., [MEDICATION NAME] 0.25 ml for generalized pain-effective; -On [DATE] at 7:00 (not documented if A.M. or P.M.), [MEDICATION NAME] 0.25 mg for all over pain-effective; -On [DATE] at 1:00 P.M., [MEDICATION NAME] 0.25 mg for generalized pain-effective; -No administration of [MEDICATION NAME] on [DATE]; -On [DATE] at 1:00 A.M., [MEDICATION NAME] 0.25 mg for generalized pain-some relief; -On [DATE] at 5:30 A.M., [MEDICATION NAME] 0.25 mg for generalized pain-no documentation of result. Review of the resident's Narcotic administration sign-out sheet, for [MEDICATION NAME] 100 mg/5 ml, 0.25 ml = 5 mg every 4 hours PRN, dated [DATE], showed the following: -On [DATE] at 9:00 P.M., [MEDICATION NAME] 0.25 ml; This was the first dose of [MEDICATION NAME] administered. -On [DATE] at 11:45 (not documented if A.M. or P.M.), [MEDICATION NAME] 0.25 ml; Comment: Right hip signs and symptoms of pain-facial grimacing; -On [DATE] at 6:30 P.M., [MEDICATION NAME] 0.25 ml; -On [DATE] at 12:00 A.M., [MEDICATION NAME] 0.25(no documentation if ml or mg); -On [DATE] at 6:00 A.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 10:00 A.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 2:30 P.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 6:20 P.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 10:30 P.M., [MEDICATION NAME] 0.25 ml; -On [DATE] at 7:00 A.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 1:00 P.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -No [MEDICATION NAME] signed out for [DATE]; -On [DATE] at 1:00 A.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 5:30 A.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -On [DATE] at 10:30 P.M., [MEDICATION NAME] 0.25 (no documentation if ml or mg); -No [MEDICATION NAME] signed out for [DATE]. Further review of the resident's nurse's notes, showed the following: -There were no nurse's notes for [DATE]; -On [DATE] at 12:12 A.M., Nurse E documented the resident was still having pain in the right hip with movement. The right leg was flaccid and he/she grimaced when the leg was touched or moved. Nurse E called the hospice company who told the nurse to obtain a right hip x-ray. There was no documentation the physician or family was notified. There was no physician's order for a right hip x-ray on [DATE]; -On [DATE] at 10:05 A.M., the x-ray report showed: marked displaced acute subtrochanteric fracture with overriding of the fracture fragments (a right [MEDICAL CONDITION]). In comparison to prior study, the findings are new; -On [DATE] at 12:30 P.M., the hospice nurse documented Physician C was notified of the right [MEDICAL CONDITION] and a message was left for the resident's family. There was no documentation the facility notified the physician or contacted the family. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -An order dated [DATE], for [MEDICATION NAME] 5 mg by mouth every eight hours routinely; -An order dated [DATE], for [MEDICATION NAME] 5 mg by mouth every six hours routinely. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -No [MEDICATION NAME] was administered on [DATE]; -On [DATE], staff documented the administration of [MEDICATION NAME] 5 mg every 8 hours, at 2:00 P.M. and 10:00 P.M., but not at 6:00 A.M. No documentation to show the administration of any PRN [MEDICATION NAME]; -On [DATE], staff documented the administration of [MEDICATION NAME] at 10:00 P.M., but not at 6:00 A.M. and 2:00 P.M.. No documentation to show the administration of any PRN [MEDICATION NAME]; -On [DATE], staff documented the administration of the [MEDICATION NAME] at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Staff documented the administration of a PRN dose of [MEDICATION NAME] at 6:00 P.M., and noted it was effective; -On [DATE], staff documented the administration of the [MEDICATION NAME] at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Staff documented the administration of a PRN dose of [MEDICATION NAME] at 6:30 P.M. for pain and noted it was effective; -On [DATE], staff documented the administration of the [MEDICATION NAME] at 6:00 A.M., 2:00 P.M. and 10:00 P.M. No documentation to show the administration of any PRN [MEDICATION NAME]; -On [DATE], staff documented the administration of the [MEDICATION NAME] at 6:00 A.M., and 10:00 P.M., but not 2:00 P.M. Staff documented the administration of a PRN dose of [MEDICATION NAME] at 6:00 P.M., but did not document a comment; -On [DATE], staff documented the administration of [MEDICATION NAME] at 6:00 A.M. The order was then changed to every 6 hours (6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 A.M.) Staff did not document the administration of the 12:00 P.M. dose. Staff documented the administration of the 6:00 P.M. and 12:00 A.M. doses. Further review of the resident's Narcotic administration sign-out sheet, for [MEDICATION NAME] 100 mg/5 ml, 0.25 ml = 5 mg every 4 hours PRN, dated [DATE], showed the following: -On [DATE], no [MEDICATION NAME] was signed out; -On [DATE] at 2:00 P.M., [MEDICATION NAME] 025 (no decimal point and no documentation if ml or mg); -On [DATE] at 6:30 P.M., [MEDICATION NAME] 0.25 ml; -On [DATE] at 10:00 P.M., [MEDICATION NAME] 0.25 ml; -On [DATE] at 10:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 A.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 2:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 10:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 2:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); - On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 A.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 2:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 10:00 (not documented if A.M. or P.M.), [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 A.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 2:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 10:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); On [DATE], the order changed from every 8 hours routinely to every 6 hours routinely. -On [DATE] at 12:00 A.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 A.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); -On [DATE] at 6:00 P.M., [MEDICATION NAME] 0.25 (not documented if ml or mg); During an interview on [DATE] at 9:50 A.M., CNA A said she worked evening shift on [DATE]. At approximately 7:00 P.M., he/she reported to Nurse B, the resident was having pain in the right hip and leg. This was unusual for the resident. The resident's right leg was flimsy and moved too easily. The resident moaned and made a funny face when the leg was touched or moved. He/She also slapped at the sheets and the CNA's hands. He/She filled out a "stop and watch" form (a facility communication tool used to communicate changes in resident's condition) and gave it to Nurse B. During an interview on [DATE] at 8:41 A.M., Nurse B said he/she worked the evening shift, from 3:00 P.M. through 11:00 P.M., on [DATE]. He/She was on duty when CNA A reported the resident's pain in the right hip at approximately 7:00 P.M. A "stop and watch" form was given to him/her by CNA A. Nurse B put it in the unit manager's box as he/she was instructed to do by the manager. Nurse B assessed the resident. The right leg and hip were painful if touched or moved. The resident winced, moaned and made a facial grimace. There was no swelling or bruising to the right leg. The physician was called and orders were received, but the family was not c

Based on observation, interview and record review, the facility failed to accurately and consistently identify, assess, monitor and document on residents' pressure ulcers and also failed to provide the necessary care and services to promote healing, prevent infection and prevent the development of new pressure ulcers. The facility identified 12 residents with pressure ulcers, four were chosen for the sample and problems were found with three and one other sampled resident that had not been identified as having pressure ulcers. The total sample was 24. (Resident #11, #2, #8 and #9) The census was 178. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/11, showed the following: -Short/Long term memory loss; -Severe cognitive impairment; -Total assistance of staff for bed mobility, transfers, personal hygiene, bathing and dressing; -Incontinent of bowel and bladder; -No pressure ulcers. Review of the resident's treatment administration record (TAR), dated 9/1/11 through 9/30/11, showed the following: -An order on the front of the TAR, dated 8/10/11, for weekly skin assessments, check and record on Tuesdays; -9/6/11: Front of TAR initialed by staff to show completion of skin assessment. Back of TAR showed no open area; -9/13/11: Front of TAR initialed by staff to show completion of skin assessment. Back of TAR showed no open areas noted. Review of the resident's physician's orders [REDACTED]. -- Skin temperature (warmth or coolness); -- Tissue consistency (firm or boggy); -- Sensation (pain, itching); and/or -- A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues) on the coccyx, change every three days. Review of the resident's nurse's notes, dated 9/14/11, showed the following: -No time indicated: Red coccyx, barrier cream applied, monitor area; -At 9:00 P.M.: [MEDICATION NAME] to Stage I; No documentation of the size of the Stage I pressure ulcer. Review of the resident's TAR, dated 9/1/11 through 9/30/11, showed the following: -Front of TAR: [MEDICATION NAME] to sacrum, change every three days; -Back of TAR: 9/14/11: [MEDICATION NAME] to sacrum, doctor aware. No documentation of the appearance or measurements of the pressure ulcer. Review of the resident's Body Check at Bath Time Sheet, completed by a Certified Nurse Aide (CNA), dated 9/15/11 at 6:00 P.M., showed the following: -Instructions: Circle area on figure and mark with a letter listed below; -A diagram of a body with nothing marked; -Nothing to report, circled and signed by CNA and nurse. Review of the facility's Weekly Pressure Ulcer Log, dated 9/16/11, showed no entry for the resident's Stage I pressure ulcer. Review of the resident's Body Check at Bath Time Sheet, dated 9/19/11 at 6:40 P.M., showed the following: -Diagram of a body with nothing marked; -Nothing to report, circled. Review of the resident's nurse's notes, from 9/15/11 through 9/19/11, showed no further documentation regarding the resident's pressure ulcer. Review of the resident's nurse's notes, dated 9/20/11, showed the following: -At 9:30 P.M.: Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) [MEDICATION NAME] applied, message left for wound care nurse to see, on 9/21/11. -At 10:30 P.M.: Resident has an order, from 9/14/11, for [MEDICATION NAME] to sacrum. Further review of the resident's TAR, dated 9/1/11 through 9/30/11, showed the following: -9/20/11: Skin assessment: initialed as completed by a nurse; -9/20/11: Back of the TAR, changed [MEDICATION NAME], treatment nurse to see. No documentation of the size or appearance of the pressure ulcer; -9/20/11: Second entry: pressure ulcer on sacrum, treatment nurse will see; -9/21/11: Apply calcium alginate (specialized dressing used for moderate to heavily draining wounds), then [MEDICATION NAME] every three days; Review of the back of the TAR, showed no documentation of the size or appearance of the pressure ulcer. Review of the resident's physician's progress note, dated 9/21/11, showed the following: -Skin: Wound: yes; -Type: Pressure; -Location: written in: sacral Stage II, with secretions. Review of the resident's POS, dated 9/1/11 through 9/30/11, showed the following order, dated 9/21/11: -Apply calcium alginate then apply [MEDICATION NAME] every three days to the sacrum; -Change the resident's position every two hours. Review of the resident's Body Check at Bath Time Sheet, dated 9/22/11, at 9:20 P.M., showed the following: -Diagram: No circle/mark to identify a pressure ulcer; -Note written in by CNA: No open, torn, swollen or reddened areas; -Signed by the CNA and Nurse. Review of the facility's Weekly Pressure Ulcer Log, dated 9/23/11, showed the following for the resident: -Date of onset: 9/15/11; -Stage: NS (non-stageable - slough and or eschar: known but not stageable due to coverage of wound bed by slough and or eschar); -Previous measurement: none; -Current measurement: 7 centimeters (cm) by 5.5 cm, yellow; -Site: sacrum; -Status: N (new); -Acquired legend: in house; -Treatment: Santyl/calcium alginate. Review of the resident's TAR, dated 9/1/11 through 9/30/11, showed the following: -Front of the TAR: no initial for the 9/27/11, skin assessment to indicate it was completed; -Back of the TAR: No documentation of the appearance or size of the pressure ulcer. Review of the resident's TAR, no date, showed the following: -A handwritten order on the front of the TAR, dated 9/27/11: Sacral wound, cleanse with wound cleaner, apply Santyl, cover with calcium alginate then gauze daily and as needed. The back of the TAR contained no documentation. Review of the resident's nurse's notes, from 9/20/11 through 9/27/11, showed no further documentation regarding the resident's pressure ulcer. Review of the resident's nurse's notes, dated 9/28/11, showed the following lone entries by the treatment nurse, on a separate sheet of paper with no other entries: -At 8:00 A.M.: Sacral pressure ulcer, measured 7.5 cm by 5.5 cm with 100% thick yellow slough; -At 11:45 A.M.: Sent to the hospital for scheduled gastrostomy tube replacement. Review of the resident's POS, dated 9/20/11, showed an order, dated 9/28/11, to discontinue previous treatment orders, cleanse sacral pressure ulcer with wound cleaner, apply santyl (an medicated ointment used to removed dead tissue) ointment then calcium alginate and cover with a dry dressing twice a day. Review of a hospital wound care nurse consult note, dated 9/29/11 at 1:00 P.M., showed the resident had an unstageable sacral pressure ulcer with necrotic tissue. Review of the resident's nurse's note, dated 9/29/11 at 3:00 P.M., showed the resident was readmitted to the facility. Review of the resident's Body Check at Bath Time Sheet, dated 9/29/11 at 8:30 P.M., showed the following for the resident: -Diagram: circle on the sacral area; -Nothing marked to show what type of area; -Signed by the nurse and CNA. Review of the facility's Weekly Pressure Ulcer Log, dated 9/30/11, showed the following for the resident: -Date of onset: 9/15/11; -Stage: NS - nonstageable; -Previous measurement: 7 cm by 5.5 cm yellow; -Current measurement: 7 cm by 5.5 cm yellow; -Site: sacrum; -Status: New; -Acquired Legend: in house; -Treatment: Santyl/calcium alginate. Review of the facility's Weekly Pressure Ulcer Log, dated 10/7/11, showed the following for the resident: -Date of onset: 9/15/11; -Stage: NS- nonstageable; -Previous measurement: 7 cm by 5.5 cm yellow; -Current measurement: 6 cm by 4 cm yellow; -Site: sacrum; -Status: improved; -Acquired Legend: in house; -Treatment: Santyl/calcium alginate. Review of the resident's physician's progress note, dated 10/11/11 at 11:00 A.M., showed the following: -Procedure note: Wound debridement; -Under sterile condition, removed 2 cm to 5 cm of dead tissue and scraped area until minimal blood obtained. Observation on 10/13/11 at 9:00 A.M., during the initial tour of the facility, showed the resident lay in bed on a wet and soiled incontinence pad. CNA I and CNA J provided perineal care and turned the resident to his/her left side revealing a large, approximately 6 cm, uncovered pressure ulcer to the sacrum, with gray slough. The soiled incontinence pad did not have an old dressing. CNA I wiped bowel movement toward the open pressure ulcer several times, placed a clean incontinence pad under the resident and positioned the resident. Observation on 10/14/11 at 5:58 A.M., showed CNA H provided incontinence care. CNA I turned resident to his/her left side revealing an uncovered pressure ulcer to the sacrum and no old dressing noted in the incontinence pad. During an interview on 10/14/11 at 10:20 A.M., the treatment nurse said she just finished the treatment to the resident's sacrum. She said staff failed to tell her or tell the charge nurse the dressing had come off or had been soiled. Staff had been told several times to report to the nurse when a dressing became soiled or came off so it could be replaced. Observation on 10/18/11 at 7:55 A.M., showed the resident lay in bed on his/her left side. The treatment nurse said staff just finished providing care so she could do the treatment. During an interview at this time she said the wound began as a Stage I. She did not see the resident's sacral pressure ulcer, on 9/13/11 or 9/14/11, nor did staff make her aware of the Stage I pressure area on 9/15/11. She went on vacation, on 9/16/11, returned on 9/26/11, and saw the nonstageable pressure ulcer, on 9/28/11, when she returned to work. During an interview on 10/18/11 at 10:12 A.M., the treatment nurse said it was the facility's policy, when a pressure ulcer developed, for staff to assess, call the physician, obtain a treatment order and document it in the nurse's notes. When Nurse Q observed the pressure ulcer to the resident's sacrum he/she should have assessed, documented and obtained a treatment order, this should also have been done with the weekly skin assessments. Staff should not wait for her to obtain the treatment orders. During an interview on 10/24/11 at 10:06 A.M., the resident's physician said she expected facility staff to assess the development of a pressure ulcer and document the findings in the resident's medical record. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive assistance required from staff for transfers, ambulation, dressing and hygiene; -Incontinent of bowel and bladder; -At risk of developing pressure ulcers. Review of the resident's TAR, dated 10/1/11 through 10/31/11, showed the following: 10/3/11: Front of TAR initialed by staff to show completion of a skin assessment. Back of TAR showed intact skin. Review of the resident's Body Check at Bath Time Sheet, completed and signed by a CNA, dated 10/3/11, showed no areas circled on the body diagram. Review of the resident's admission nursing assessment, dated 10/7/11, following readmission from a hospital stay, showed skin intact and no open areas noted. Review of the resident's care plan, dated 10/7/11, showed the section "At risk for skin breakdown" not completed and marked "N/A". Review of the resident's TAR, dated 10/1/11 through 10/31/11, showed the following: 10/10/11: Front of TAR initialed by staff to show completion of skin assessment. Back of TAR showed intact skin. Review of the resident's Body Check at Bath Time Sheet, completed and signed by CNA, dated 10/10/11, showed no areas circled on the body diagram. Observation on 10/17/11 at 3:00 P.M., showed the resident sat in the shower room. CNA T removed the resident's shoes and socks revealing darkened areas to the left outer heel and right inner heel. The CNA said the resident had the areas for a while and he/she thought they developed from the resident's shoes being too tight. Boots had been ordered for the resident, but they hadn't arrived. CNA T asked the resident if he/she wanted his/her shoes on and reapplied the shoes and socks. Review of the resident's nurse's note, dated 10/17/11, no time, showed the following: -Darkened areas to the right and left outer heels; -Left heel measured 2.8 cm by 2 cm, right heel measured 4 cm by 3 cm; -Both sites smooth, dry and non blanchable (When a finger is gently pressed against healthy tissue, the skin blanches or turns white. If, on applied press, a questionable spot maintains its red, blue, or purple hue and does not blanch, it is classified as an early stage pressure ulcer). This was the first documentation regarding the condition of the resident's heels, in the medical record. Review of the resident's undated POS, showed an order, dated 10/17/11, for darkened sites to right and left heels; apply skin prep (used to toughen skin) to heels, wrap with gauze wrap, pressure relief boots on at all times. Review of the resident's TAR, dated 10/1/11 through 10/31/11, showed the following: -10/17/11: weekly skin assessment 3:00 P.M. through 11:00 P.M., initialed as completed; -Order to apply skin prep and cover with gauze and wrap with gauze wrap for right and left lateral heel darkened sites; -Back of TAR: 10/17/11: discoloration bilateral heels, dressing intact. A second entry: 10/17/11: Left lateral heel 2.8 cm by 2 cm darkened, dry firm, surrounding tissue clear, right lateral heel, 4 cm by 3 cm darkened, slightly boggy (soft), surrounding tissue clear. During an observation on 10/18/11 at 10:55 A.M., of a skin assessment, the treatment nurse said the darkened areas to the resident's heels were noticed during a shower, on 10/17/11, and were probably caused by the resident's diabetic shoes. The brown pressure ulcer to the left outer heel measured 2.8 centimeters (cm) by 2 cm with some slight separation at the top. The black right heel pressure ulcer measured 4 cm by 3 cm. Both were unstageable. She received an order for [REDACTED]. During an interview on 10/19/11 at 10:58 A.M., the treatment nurse said the pressure areas on the resident's right and left heels did not develop over night. She would have expected the CNA who first discovered them to immediately report the development of the new areas to the nurse. The nurse would then assess the area, call the physician, obtain an order, document in the nurse's notes and notify her of the new treatment order. 3. Review of Resident #8's significant change in status MDS, dated [DATE], showed the following: -Understood/Understands; -Two (+) persons required for bed mobility, transfers and toilet use; -Walking in room/corridor did not occur; -One person physical assistance required for locomotion on/off the unit; -Extensive assistance of one person required for personal hygiene and bathing; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -At risk for developing pressure ulcers; -Stage II pressure ulcers. Review of the facility's Weekly Pressure Ulcer Log, dated 9/30/11, showed the resident's multiple Stage II pressure ulcers had healed. Review of the resident's TAR, dated 10/1/11 through 10/4/11, showed the resident had no pressure ulcer treatment. A handwritten note on the back of the TAR, dated 10/4/11, showed the resident had no open areas. Review of the resident's TAR, dated 10/5/11 through 10/11/11, showed the resident had no pressure ulcer treatment. A handwritten note on the back of the TAR, dated 10/11/11, showed the resident had no new open areas. Observation on 10/13/11 at 9:15 A.M., showed the resident sat in a wheel chair in his/her room waiting for staff to transfer him/her to bed. The resident said he/she had wet himself/herself and needed to lay down and his/her buttocks hurt. Nurse H, Nurse K and CNA L transferred the resident to bed using a hoyer lift (machine used to transfer residents that are unable to bear weight). They positioned the resident onto his/her left side to wash his/her buttocks and observation showed the resident had two, open areas, Stage II pressure ulcers on the coccyx. Nurse H said the resident's coccyx had excoriation and applied barrier cream over the pressure ulcers. Review of the resident's TAR, dated 10/13/11 through 10/16/11, showed the resident had no pressure ulcer treatment and no documentation about the resident's pressure ulcers. Review of the resident's POS, showed a handwritten note, dated 10/16/11, with the following:-Open area to the gluteal crease (groove between the buttocks/coccyx area); -Apply barrier cream every shift. Review of the resident's TAR, dated 10/16/11 through 10/18/11, showed the resident had no pressure ulcer treatment and no documentation about the resident's pressure ulcer. A handwritten note on the back of the TAR, dated 10/18/11, showed skin intact. Observation on 10/18/11 at 11:12 A.M., showed the resident lay in bed. The facility treatment nurse said the resident had two Stage II pressure ulcers on the gluteal crease measuring 1.2 cm by 0.3 cm by 0.1 cm and 0.4 cm by 0.5 cm by 0.1 cm. During an interview on 10/19/11 at 9:55 A.M., Nurse H said he/she thought the resident's coccyx/gluteal crease had excoriation. He/She did not see the two Stage II pressure ulcers. If he/she had seen the pressure ulcers he/she would have notified the resident's physician to obtain a treatment order and notified the facility treatment nurse. During an interview on 10/19/11 at 10:15 A.M., the treatment nurse said Nurse H did not tell her the resident had Stage II pressure ulcers on 10/13/11. The treatment nurse said she assessed the resident's pressure ulcers on 10/16/11, but did not follow the facility protocol by documenting measurements or descriptions of the pressure ulcers on the TAR or in the nurse's notes, but should have. She wrote the order for the barrier cream on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was the first time she had put a treatment order on the MAR; she wanted to try something different. She did not know who documented "skin intact" on the back of the TAR on 10/18/11, but they should not have. Review of the resident's MAR, dated 10/16/11, showed an order for [REDACTED]. Review of the resident's nurse's notes showed no documentation about the resident's skin. During an interview on 10/24/11 at 10:10 A.M., the resident's physician said he expects a nurse to know the difference between excoriation and a pressure ulcer. If Nurse H had identified the pressure ulcers on 10/13/11, he/she could have called him to start a treatment. 4. Review of Resident #9's significant change in status MDS, dated [DATE], showed the following: -Understood, usually understands; -One person extensive assistance required for bed mobility and transfers; -[DIAGNOSES REDACTED]. -One unstageable pressure ulcer. Review of the resident's care plan, dated 9/26/11, showed staff should not lay the resident on his/her right side. Review of the facility's Weekly Pressure Ulcer Log, dated 10/14/11, showed the following for the resident: -Right lower buttock: 0.1 cm by 0.1 cm by 0.4 cm unstageable pressure ulcer; -Apply [MEDICATION NAME]/Wound gel (treatment) daily. Observation on 10/14/11, from 5:45 A.M. until 7:30 A.M., showed the resident lay in bed on his/her right side. A sign, positioned on the wall above the head of the bed showed: "Never turn on right side". Observation on 10/14/11 at 9:15 A.M., showed the resident sat in a chair. CNA S transferred the resident from the chair to bed. The CNA positioned the resident onto his/her right side and said the resident needed to be positioned from his/her back to his/her right side. The resident remained on his/her right side until 11:30 A.M. During an interview on 10/19/11, at 10:15 A.M., the treatment nurse said she placed the sign above the resident's bed to remind staff not to position the resident on his/her right side. She did not know why staff did not follow those instructions. 5. Review of the facility's undated Skin Assessment policy, showed the following: -Standard: Routine skin assessments are completed in an effort to detect changes in skin integrity and to ensure prompt treatment of [REDACTED]. -Policy: It is the policy of the facility to monitor the residents skin for signs of injury and/or breakdown; -Upon admission the facility will conduct an assessment of the resident's skin; -Residents who are determined to be at risk for the development of pressure ulcers will have a daily skin assessments conducted by either a licensed nurse or a CNA which will be documented on either the daily skin assessment record or the TAR; -All residents regardless of risk will have a documented weekly assessment of their skin condition during their shower, completed by the CNA and documented on the Skin Attention Form. 6. Review of the facility's undated "Wound Assessment" policy, showed the following: -Systematic, consistent and accurate wound assessment is completed to determine the response to nursing care and treatment; -The facility will note the presence of wounds, ulcers, and/or skin abnormalities upon the admission of a resident to the facility; -A complete wound assessment will be completed at least weekly by a licensed nurse for all wounds, ulcers and impairments in the skin integrity; -Wound/wound dressing status will be monitored daily and recorded on the Wound Dressing Status Sheet or the Treatment Administration Record; -Additional documentation using criteria below is required whenever there is an observed deterioration in the wound status; -The wound assessment will be documented using the following tools: -At the time of admission the presence and status of wounds will be documented in conjunction with the completion of the initial admission nursing assessment. Assessment data will be recorded either in the nursing notes and/or on the admission nursing assessment tool; -Follow-up documentation will occur at least weekly on the wound documentation tool; -The wound assessment will contain at a minimum: Wound classification (wound type), wound location, staging (for pressure ulcers) or extent of tissue damage, description of: Wound bed, drainage, margins surrounding the skin, color, wound measurements and wound related pain; -Each wound assessed will be documented separately and will be recorded on either the weekly wound form or pressure ulcer surveillance report. 7. During an interview on 10/18/11 at 12:00 P.M., the Director of Nurses said she expected staff to assess, notify the physician, obtain treatment orders and document the discovery of a pressure ulcer. Staff should notify the nurse when a dressing was soiled or came off. She said facility staff had recently been inserviced, on 8/11/11, on pressure ulcer prevention. MO 312 .