Every finding on record at Belleview Care Center

Based on observation, interview and record review the facility failed to notify the physician, and state survey agency (SA) when one resident (Resident #1) had a bruise of unknow origin to his/her left eye. Registered Nurse (RN) A assessed the bruise on 08/22/26 and did not notify the physician, assistant director of nursing (ADON) or the SA. The resident's family member discovered the bruise on 08/24/26 and notified the ADON. The ADON did not notify the resident's physician or SA of the bruise of unknown origin. The facility census was 83. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 09/01/21 showed the facility staff are to report allegations of abuse to the Administrator and the SA, immediately but not more than two hours after the allegation is made. Review of the facility investigation dated 08/24/26 showed:-RN A observed a small area of bruising/ red discoloration to the resident's left outer corner of the eye on 08/22/26;-Family Member A notified the ADON on 08/24/26 of bruising to the resident's left eye;-The ADON initiated an investigation on 08/24/26 but did not notify the resident's physician or the SA of the bruising of unknown origin. Review of the Resident #1's quarterly Minimum Data Set (MDS, an assessment completed by the facility staff), dated 07/20/26 showed:-The resident diagnoses included dementia (a disease that affects memory and reasoning), high blood pressure, and stroke;-The resident had a brief interview mental status score of three, indicating severe cognitive impairment;-The resident was dependent on staff for toileting, showering, and getting dressed. Review of the resident's Physician Order Sheet (POS) dated August 2026 showed:-An order dated 11/26/25 for Aspirin 81 milligram (mg), give one by mouth one time daily to prevent blood clots;-An order dated 11/26/26 for Plavix (a medication used to keep blood platelets from sticking to each other) 75 mg, give one by mouth one time daily. Review of the resident's Medication Administration Record (MAR) dated August 2026 showed: -The resident received his/her scheduled dose of Plavix and Aspirin on August 21, 22, 23, 24, and 25. Review of the resident skin assessment dated [DATE] showed:-RN B assessed the resident's skin;-RN B documented the resident had bruising around his/her left eye;-No trauma to the eyeball seen;-The resident denied pain and the ADON and family were notified. Review of the resident's anticoagulant (prevent blood clots) therapy care plan dated 09/17/25 showed:-The resident received PLavix;-The staff were supposed to document and report to the physician any instances of bruising. During an interview and observation on 08/25/26 at 8:09 A.M. the resident said:-He/She did not know what happened to his/her eye;-He/She did not have any pain or itching;-The residents left eye had a raised area the size of a small pea, that was dark purple in color at the outer corner of his/her left eye;-The resident's left eye was dark purple in color over his/her eye lid, to his/her left temple area, and down to his/her upper cheek area. During an interview on 08/25/26 at 8:52 A.M., Certified Nurse's Aide (CNA) A said: -He/She took care of the resident during the daytime on 08/22/26;-He/She saw the resident had a black eye on the left side;-He/She did not know where the injury came from;-He/She reported the black eye to RN A who assessed the resident. During an interview on 08/25/26 at 10:29 A.M., RN A said: -He/She saw the resident's left eye on 08/22/26 during his/her shift;-At that time the resident had a dark purple raised area to the outer corner of the left eye;-The resident was rubbing the area, but denied pain;-He/She did not report the area to the resident's physician, but assumed it was a broken blood vessel because the resident took Plavix (a medication that prevents blood platelets from sticking together);-He/She saw the residents left eye on 08/23/26 and saw the resident had dark purple bruising to the left eye;-He/She did not report the bruising to the resident's physician, ADON, or the SA and should have. During an interview on 08/25/26 at 8:28 A.M. CNA B said:-He/She took care of the resident on 08/24/26 and saw the resident had a black eye;-He/She reported the resident's black eye to RN B. During an interview on 08/25/26 at 8:45 A.M. RN A said:-He/She took care of the resident on 08/20/26, completed a weekly skin assessment and had no concerns;-He/She took care of the resident next on 08/24/26 and found the resident had dark purple bruising to his/her left eye;-He/She reported the injury of unknown origin got the ADON and completed a skin assessment. During an interview on 08/25/26 Physician's Office Representative A said:-RN A called the resident's physician on 08/25/26 at 9:00 A.M. to report the resident had bruising to his/her left eye and the facility staff do not know how it happened;-The resident's physician expected the facility to call immediately when a bruise of unknown origin occurred. Intake 3175343

Based on record review and interview, the facility failed to maintain a system to assure an accurate accounting of resident trust fund accounts was sent to the resident or resident's representative, on a quarterly basis. This deficient paractice affected four of four sampled residents, (Resident #1, #2, #3, and #4). The facility census was 84. Review of the facility's Transactions Involving Resident Funds or Property policy, dated 6/1/2023, showed:-It is the practice of this facility that any time there is a transaction involving residents, the resident must be provided with a receipt of such transaction;-Copies of each transaction are filed in the business office;-The facility will establish and maintain a system that assures a complete and separate accounting of each resident's personal funds and is according to generally accepted accounting principles;-The Business Office Manager (BOM) is responsible for ensuring that resident funds are reconciled on a monthly basis;-Discrepancies are promptly reported to the Administrator for investigation;-Quarterly statements will be provided in writing to the resident, or the resident's representative, within 30 days after the end of the quarter and upon request. 1. Review of Resident #1's Resident Trust Fund (RTF) account showed:-A quarterly reporting of the account was sent to the resident's representative on 11/10/2025;-A quarterly report had not been sent to the resident's representative in the previous six months. 2. Review of Resident #2's RTF account showed a quarterly accounting of the report had not been sent to the resident's representative in the previous six months. 3. Review of Resident #3's RTF account showed a quarterly accounting of the report had not been sent to the resident's representative in the previous six months. 4. Review of Resident #4's RTF account showed a quarterly accounting of the report had not been sent to the resident's representative in the previous six months. During an interview on 12/4/25 at 1:34 P.M., the BOM said:-He/She had not been sending the quarterly reports of RTF to the resident or resident's representatives;-An accounting of the resident's RTF account should be sent to the resident or their representative quarterly and upon request. During an interview on 12/4/25 at 3:15 P.M., the Facility Regional Consultant said:-The BOM was responsible for sending the RTF accounting reports to residents or resident representatives;-These reports are to be sent quarterly and upon request; -These can be provided in writing or in electronic form. Intake 2634140

Based on interviews and record review, the facility failed to protect one sampled resident, Resident #2, right to be free from physical abuse when Resident #1 used two hands and shoved Resident #2 to the floor. The facility census was 80. The Administrator was notified on 11/12/25 at 4:00 P.M. of the past noncompliance which began on 11/9/25. The facility staff immediately assessed and seperated Resident #2 and Resident #1, conducted an investigation, interviewed residents to ensure no others had been abused. All staff were re-trained on the facility abuse prevention policy and on monitoring residents with physical behaviors towards others. In-servicing was completed by 11/11/25. Resident #1 and #2's care plans were updated to reflect increased monitoring of both resident's whereabouts in proximity to one another. The noncompliance was corrected on 11/11/25. Review of the facility's Abuse, Neglect and Exploitation policy, revised 5/1/25, showed:- It is the policy of this facility to provide protections for the health, welfare and rights of each resident;- Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;- Residents will have an assessment of their functional and mood/behavior status, medical acuity, and special needs;- The facility will implement policies and procedures to prevent and prohibit all types of abuse and neglect;- Identifying, correcting and intervening in situations in which abuse or neglect is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents;- Possible indicators of abuse include, but are not limited to hitting, slapping, punching, biting and kicking and is the willful intent to inflict harm or injury.Review of staff training for Resident Abuse and Neglect Prevention, dated 11/10 and 11/11/25, showed 39 staff members attended the training.1.Review of Resident #1's Face Sheet, dated 11/12/25, showed the resident had impaired cognition, COPD (pulmonary disease), diabetes, chronic kidney disease, neurocognitive disorder, dementia and depression. Review of Resident's Care Plan, undated, showed:- Resident had potential to be physically aggressive related to anger and dementia and has a history of harm to others. Had poor impulse control;- Resident could be physically aggressive with staff members and attempting to break windows;- When resident becomes agitated staff are to intervene before escalation, guide resident away from source of distress;- Resident had impaired cognitive function and impaired thought processes;During an interview on 11/12/25 at 1:37 P.M., Resident #1 said he/she pushed Resident #2 once because he/she was blocking his/her way in the corridor. He/she pushed him/her to the ground. He/she didn't plan on doing it again and didn't mean to hurt Resident #2 when he/she pushed him/her, but it just happened. 2. Review of Resident #2's Face Sheet, dated 11/12/25, showed:- Diagnosis: Alzheimer's disease, dementia, anxiety disorder, GERD (acid reflux), rheumatoid arthritis, osteoarthritis of the knee, cognitive communication deficit, and depression;Review of Resident's Care Plan, undated, shows:- Resident had the right to be free from physical abuse;- Resident resides on the secured memory care unit and safety will be maintained through the next review;- Resident enjoys walking around with the other residents;- Resident had potential to be physically aggressive related to dementia and hits staff when upset or agitated;- Resident had impaired cognitive function or impaired thought processes;- Resident was at risk for falls;During an interview on 11/12/25 at 2:05 P.M., Resident #2 said he/she was pushed down by someone and fell to the ground. He/she does not remember who pushed him/her but remembered that it hurt when fell to the floor and h/she still felt minor pain near the thigh and pelvic area. He/she felt safe and said the staff take good care of him/her. He/she was not able to remember the fall well enough to provide any details. During an interview on 11/12/25 at 1:55 P.M., CNA (A) said:- He/she had been talking with Resident #1 while walking down the hall and Resident #2 was coming towards them. Resident #2 stepped in front of Resident #1 and Resident #1 pushed Resident #2 with both hands in the chest. Resident #2 fell backwards stiffly onto the floor. Staff took Resident #2's vitals and checked to check for injury. Both residents were separated. Resident #2 had no injuries and did not complain of pain. CNA A then reported the incident to the Charge Nurse, Director of Nursing (DON) and the Administrator.During an interview on 11/12/25 at 3:40 P.M., the DON and Administrator said:- The investigation findings show that Resident #1 pushed Resident #2 to the ground. - Resident #1 used both hands and pushed Resident #2 in the chest. Resident #1's actions are that of abuse. Neurological checks and a complete assessment were completed for Resident #2 after the fall to make sure he/she was not hurt. All residents have the right to be free from abuse and not to be pushed to the ground by another resident or staff. - Resident #2 does not have a history of aggression towards residents. - Resident #1 has a history of aggression towards others and at the time of the incident, was experiencing a urinary tract infection which he/she believes caused Resident #1 to act out. - Resident #1 is considerably larger than Resident #2 and it would not take much effort for him/her to push the resident to the ground. - Interventions that the facility had completed since the incident include staff training on abuse and neglect prevention, both residents were sent out for a psychological evaluation with the findings still pending to the facility, both residents were separated from each other right after the incident, Resident #2 had trauma informed care performed with no negative findings from the incident, and Resident #1 was screened for a urinary tract infection to make sure that was not the cause of the aggression.Intake 2664086

Based on interview and record review, the facility failed to protect three residents right to be free from abuse when Resident #1 punched Resident #4 with a closed fist in the right shoulder and Resident #1 hit Resident #2 and Resident #3 with an open hand across the cheek. The facility's census was 82. On 03/27/25, the Administrator was notified of the past noncompliance which began on 03/25/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 03/18/25. Review of the employee In-service sign in sheet showed staff received education on monitoring of individuals on the secure care unit, completed on 03/18/25. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Abuse means the willful infliction of injury and/or intimidation resulting in physical harm, pain or mental anguish; -Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.-Mistreatment means inappropriate treatment of a resident; -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of the facility's policy titled, Resident Rights, dated 09/01/22, showed the resident has the right to .live a dignified existence; exercise his/her rights as a resident of the facility; be treated with respect and dignity; and make choices about aspects of his/her life in the facility. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/19/24 showed: - Cognition not intact; - Physical behaviors directed towards others; - Verbal behaviors directed towards others; - Behaviors that put others at risk; - Current behaviors are worse; - Diagnoses included, Alzheimer's disease, depression, diabetes mellitus. Review of Resident # 1's care plan dated 12/19/24 showed: - Activities of Daily Living (ADLs) self care performance deficit related to aggressive behavior; - Potential to be physically and verbally aggressive to staff related to poor impulse control. 1. Review of Resident #4's quarterly MDS, dated [DATE] showed: -Moderate cognitive impairment; -Partial assistance of staff for ADLs; -Incontinent of bowel and bladder; -Diagnoses included, dementia, depression, anxiety, high blood pressure and respiratory failure. Review the Resident's care plan dated, 02/09/25 showed: -ADL self care performance deficit related activity intolerance; -Potential to be physically and verbally aggressive related to poor impulse control. Review of the facility investigation dated 03/12/25 at 05:40 P.M. showed: -Resident #1 and Resident #4 were in the dining room; -Resident #4 setting at a table taking a breathing treatment; -Resident #1 stepped on the cord of Resident #4's breathing treatment machine and the machine fell on to the floor; -Resident #4 yelled at Resident #1; -Resident #1 turned around and struck Resident #4's right shoulder. During an interview on 03/27/25 at 10:10 A.M., the Activity Director said: -She has received education from the facility about caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse; -She saw Resident #1 step on the nebulizer tubing of resident #4; -Resident #4 called Resident #1 a dumb ass; -Resident #1 turned, made a fist and hit resident #4 on the shoulder; During an interview on 03/27/25 at 10:18 A.M., Activities Aide A said: -Resident #1 punched resident #4 in the arm on 03/13/25 with a closed fist. -He/She wrote in his/her statement of the incident that resident #1 punched resident #4. -She recently received education from the facility about caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse; 2 .Review of Resident' #3's care plan dated, 01/14/25 showed: -ADL self care performance deficit related to dementia; -Dependent on staff for meeting emotional, intellectual and physical needs; -Verbally aggressive. Review of the Resident's Significant change MDS, dated [DATE] showed: -Severe cognitive impairment; -Dependent on staff for ADL's; -Incontinent of bowel and bladder; -Diagnoses included, Alzheimer's disease, depression and high blood pressure. Review of the facility's investigation, dated 03/13/25 at 06:40 P.M., showed: -Certified Nurses Aide (CNA) A stated resident #1 was trying to push Resident #3 in a wheel chair; -Before staff could intervene Resident #1 made contact with resident #3 with an open hand to the cheek. Review of the facility's Abuse Investigation Staff Questionnaire, dated 03/13/25, completed by CNA A showed: -Resident #1 and Resident #3 in the dining room; -Resident #3 setting in a wheel chair; -Resident #1 was touching Resident #3's wheel chair before staff could redirect Resident #1; -Resident #3 said something that was not understandable and then Resident #1 struck Resident #3 across the cheek; During an interview on 3/27/25 at 11:15 A.M., CNA A said: -Resident #1 was on 1:1; -He/She was watching resident #1, -Resident #1 hit resident #3 before he/she could stop it. -He/She recently received education from the facility about caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse. During an interview on 03/27/25 at 12:12 P.M., the Director of Nursing (DON) said: -Resident #1 was on 1:1 monitoring; -Staff did not immediately intervene to prevent Resident #1 from smacking Resident #3 across the cheek. -Resident #1 is non verbal and communicates through physical touch; -She was not sure if a reasonable person would communicate with a gentle smack across the cheek. 3. Review Resident #2's care plan dated 02/27/25, showed: -Behavior issues related to dementia; -ADL self care performance deficit related to activity intolerance; -Mood and behavior changes. Review of the Resident's Significant change MDS, dated [DATE] showed: -Severe cognitive impairment; -Dependent on staff for ADLs; -Incontinent of bowel and bladder; -Diagnoses included, Dementia, arthritis and high blood pressure. Review of the facility's investigation dated 03/18/25 showed: -CNA B stated on 3/17/25 at 6:40 P.M., Resident #1 was attempting to push Resident #2 in his/her wheel chair; -As staff redirected Resident #1 he/she smacked Resident #2 across the cheek with an open hand; -Resident #1 was sent to the emergency room for evaluation. During an interview on 03/27/25 at 12:45 P.M., CNA B said: -Resident #1 hit resident #2 on the cheek with an open hand; -Resident #1 has a history of behaviors. -He/She recently received education from the facility about caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse. During an interview on 03/27/25 at 01:33 P.M., the DON said: -Resident #1 was on 1:1 monitoring; -Resident #1 still has the right to move about the unit even on 1:1; -Staff did not immediately intervene to prevent Resident #1 and from hitting Resident #2. -Resident #1 is non verbal and communicates through physical touch; -She was not sure if a reasonable person would communicate with a gentle smack across the cheek; -She received orders from the physician to send Resident #1 to the emergency room for a psychiatric evaluation after the last incident on 03/17/25; -Resident #1 was transferred to a psychiatric hospital from the emergency room and admitted for an inpatient psychiatric stay; -The hospital reported Resident #1's behavior was becoming more aggressive; -Resident #1 was discharged from this facility and never returned; -She immediately began educating all staff on caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse; -This education was completed with all staff on 03/18/25; -Abuse is a willful and deliberate; -Any resident to resident altercation should be reviewed as a potential situation of abuse; -Resident #1's action was deliberate even though it is not known if he/she meant to hurt other residents; -He/She expected all residents to be free from abuse. During an interview on 3/27/25 at 01:42 P.M., the Administrator said: -The physician was notified of all incidents between Residents #1, #4, #2 and #3; -The DON received orders from the physician to send Resident #1 to the emergency room for a psychiatric evaluation after the last incident on 03/17/25; -Resident #1 was transferred to a psychiatric hospital and admitted for an inpatient psychiatric stay; -The hospital reported Resident #1's behavior was becoming more aggressive; -Resident #1's responsible party was notified and said Resident #1 needed a higher level of care; -The facility sent a referral to another facility while Resident #1 was at the hospital; -Resident #1 was accepted to another facilty; -The resident never returned to the after he/she was sent out after the last behavior; -The DON immediately began educating all staff on caring for residents with dementia, de-escalating aggressive residents, how to identify abuse, how to prevent abuse and how to report abuse; -The education was completed by all staff on 03/18/25; -Abuse is a willful and deliberate; -Any resident to resident altercation should be reviewed as a potential situation of abuse; -Resident #1's action was deliberate even though it is not known if he/she meant to hurt another resident; -He/She expected residents to be free from abuse. MO 251029 MO 251036 MO 251230

Based on observation, interviews, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to label and date all foods, discard expired food, keep daily logs for freezer temperature, test and record dishwasher chemical sanitizer levels, seal all foods after opening, use proper hand washing, and properly store food storage containers and dishes. The facility census was 82. Review of the facility's Food Storage Policy, dated [DATE]., showed: -All areas of food storage will be clean, dry, and maintained at temperatures as required to meet food safety requirements. -All open products will be sealed, wrapped and closed to ensure quality and prevent contamination against pests or rodents. -All outdated goods will be discarded the day after expiration date. -All temperatures log will be maintained and kept up to date. -All refrigerator and freezer logs will be maintained and kept up to date. Review of the facility's Sanitation Policy. dated [DATE]., showed: -All kitchen areas, dining areas, shall be kept clean. -All utensils , kitchen equipment, and shelves, and counters will be clean and in good repair. Continuous observation of the kitchen on [DATE] at 9:34 A.M. to 10:15 A.M. showed: -The floor in front of stove was greasy and slippery; -The refrigerator in the serving area outside kitchen was missing temperature recordings on the log for ,d+[DATE] through ,d+[DATE]; -Unbranded hamburger buns and white bread were on cart outside kitchen without a label indicating the date the product was opened; -Plates near steam table outside kitchen were face up and had no cover on the cart; -The metal rack next to the freezer had pitcher lids and the food processor container stored face up; -The walk-in freezer temperature log was missing entries for ,d+[DATE] through ,d+[DATE]; -Pans on the bottom of the prep table across from the oven were stored upright; -Unbranded loaf of white bread on the prep table shelf had no open date; -Staff did not know where dishwasher test log was located; -Empty boxes were scattered on the kitchen floor in front of handwashing sink; -Mixing bowls and punch bowl on pantry shelf were stored upright; -Large bag of Cortona pasta open with no open date; -Banquet three-pound tub of shortening had no open date and the best by date on the container was [DATE]; -Great Value 8-ounce Organic Rubbed Sage, received date was labeled ,d+[DATE] and the best by date on the package was [DATE]; -Spice Islands 7-ounce Cinnamon Sticks labeled as received on ,d+[DATE] and the best by date on the package was [DATE]; -[NAME]-[NAME] 18-ounce Pure Almond Extract had a best by date of ,d+[DATE]; -Sysco 10-ounce Imperial Parsley Flakes had a best by date of [DATE] with an open date labeled as ,d+[DATE]; -Sysco 4.5 pounds Classic Paprika had a best by date of [DATE] and an open date labeled ,d+[DATE]; -Sysco 27.5-ounce Imperial Thyme Leaves opened date was [DATE]; -Items toward the front of the walk-in freezer, chicken nuggets, ice cream cups, and -Totino's pizza rolls, were soft and not as cold to the touch as the frozen items in the back of the walk-in freezer; -Box of 1000 count Ghirardelli chocolate chips stored uncovered in walk-in freezer; -Dirty and rusted ceiling vent next to walk-in freezer; -Two large water stains (12 inches x 12 inches and 10 inches by 24 inches) through patched, cracked, unpainted putty on ceiling next to the walk-in freezer; -Peeling paint and drywall on wall outside the walk-in freezer near the ceiling; -Dietary Manager washed hands, then dried hands with a paper towel and used the paper towel to turn off the faucet, then continued to dry hands and arms with the same paper towel, re-contaminating his/her hands. Observation on [DATE] at 9:50 A.M. showed the Dietary Manager washed his/her hands, dried his/her hands with paper towels then wiped the sink and turned off faucet, then used the same paper towels to continue drying hands, re-contaminating his/her hands. Observation on [DATE] at 10:55 A.M. showed the Dietary Manager washed hands, dried with paper towel, then used same paper towel to turn off the faucet, wipe sink, and transferred the paper towel to the other hand before throwing away, re-contaminating his/her hands. Observation on [DATE] at 9:50 A.M. showed: -Dark spatters on ceiling near smoke alarms and in between fluorescent lights; -Dirty ceiling vent outside of kitchen office; Observation on [DATE] at 2:40 P.M. showed Dietary Aide A with a beard cover below his/her chin, long chin hairs visible. Observation on [DATE] at 2:41 P.M. showed drywall cracked and chunks of paint missing where the handwashing sink meets the wall. Observation on [DATE] at 4:22 P.M. Dietary Aid A with a beard cover pulled down, exposing his/her chin hair. During an interview on [DATE] at 9:43 A.M, Dietary Aid B said: -He/She worked weekends and had never tested the dishwasher chemical solution; -He/She did not know how to test the dishwasher chemical solution or know where the log book was kept. During an interview on [DATE] at 3:57 P.M., Dietary Aid A said: -Expired foods, including spices should be thrown out; -Opened food items should be labeled with date the item was opened; -After washing hands, they should dry their hands with a paper towel, then turn off the faucet with the paper towel; -They should not continue drying hands with same paper towel that was used to turn off the faucet; -The kitchen ceiling and vents should be clean and in good repair; -Opened food items should be covered and dated for storage; -Plates, bowls, mixing bowls, and containers should be stored upside down or covered; -The kitchen floor should not be greasy and slippery; -Hairnets and beard covers should cover hair completely. During an interview on [DATE] at 4:26 P.M., the Dietary Manager said: -He/She expects expired foods and spices to be thrown out; -Opened food items should be labeled with opened date; -He/She expects staff to not use same paper towel to dry off hands after using the paper towel to turn off the faucet; -Kitchen ceiling and vents should be clean and in good repair; -He/She expects opened food items to be covered for storage; -Plates, bowls, mixing bowls, and containers should be stored facing down; -The kitchen floor should not be greasy and slippery; -Hair nets and beard covers should be always worn in the kitchen. During an interview on [DATE] at 4:33 P.M., the Dietician said: -Expired foods and spices should be thrown out; -Opened food items should be labeled with the received and opened dates; -He/She expects the same paper towel that was used to turn off faucet would not be used to dry hands; -The kitchen ceiling and vents should be clean and in good repair; -Opened food items should be covered for storage; -Plates, bowls, mixing bowls, and containers be stored inverted; -The kitchen floor should not be greasy and slippery; -Hairnets and beard covers should be always worn in the kitchen; During an interview on [DATE] at 2:15 P.M., the Administrator said: -Expired foods and spices should be disposed of; -Opened food items should be labeled with the dates received and opened; -He/She expects the paper towel used to turn off faucet would not be used to dry hands; -Kitchen ceiling and vents should be clean and in good repair; -He/She expects opened food items be covered for storage; -He/She expects plates, bowls, mixing bowls, and containers be stored inverted; -Kitchen floor should not be greasy and slippery.

Based on observations, interviews, and record review, the facility failed to ensure that it maintained essential equipment in a safe and operable working condition. Specifically, when the large walk-in freezer had been left with a build-up of ice on the freezer floor and on the ceiling of the walk-in freezer, which left the the walk in freezer with elevated temperatures for several days, while it was defrosting. This had the potential to affect all residents due to the health risks associated with serving foods that had been thawed for an unknown period of time. The facility census was 82. The facility did not provide a policy on maintaining kitchen equipment. Observation on 2/09/25 at 10:12 A.M. showed: -Missing freezer temperature logs from 2/7 to 2/9; -A measurement of 20 inch by 30 inch and 1/4-inch-thick area of ice buildup on the freezer floor in front of the back wall of the walk in freezer; -Icicles and frost build up on ceiling under freezer fans; -Thermometer inside the freezer read 28 degrees Fahrenheit, rather than the 0 degrees Fahrenheit recommended by the FDA (Food and Drug Administration); -Freezer external thermometer read 12 degrees Fahrenheit, rather than the 0 degrees Fahrenheit recommended by the FDA (Food and Drug Administration); -Food toward the front of the freezer, a bag of chicken nuggets, single serve ice cream cups and a bag of pizza rolls, were softer and warmer to the touch than the items in the back of the freezer. An observation on 2/10/25 at 10:47 A.M., the freezer temperature logs showed: -2/5 read -2 degrees Fahrenheit in the morning and 22 degrees Fahrenheit in the evening; -2/6 read-2 degrees Fahrenheit in the morning and 20 degrees Fahrenheit the evening; -2/7 read -8 degrees Fahrenheit in the morning and 22 degrees Fahrenheit in the evening; -2/8 read -9 degrees Fahrenheit in the morning and 30 degrees Fahrenheit in the evening; -2/9 read -8 degrees Fahrenheit in the morning and -6 degrees Fahrenheit in the evening. During an interview on 2/10/25 at 3:57 P.M., Dietary Aid A said: - Items in freezer should be frozen; -Freezer temperature should read 0 degrees Fahrenheit or below; -Freezer temperature logs should match the temperature on the freezer thermometer; -If they saw ice on the floor of the freezer, they would fill out work order sheet. During an interview on 2/10/25 at 4:26 P.M., the Dietary Manager said: - Freezer temperature should read ten degrees Fahrenheit or below; -There should not be ice build up on the freezer floor or on the ceiling near the fans; - Items like ice cream, chicken nuggets, and pizza rolls should be frozen when stored in the freezer; - Freezer temperature logs should match the temperature on the freezer thermometer; - If the freezer was not working, they would fill out a maintenance sheet to request repairs. During an interview on 2/10/25 at 4:33 P.M., the Dietician said: -Freezer temperature should be kept at 10 degrees or below; - There should not be ice on the floor of the freezer and ice buildup on the freezer ceiling near the fans. - Frozen items should be frozen solid when stored in the freezer; -Freezer temperature logs should match the temperature on the thermometer in the unit. -If the freezer was not working properly, dietary aids should let the kitchen manager know, who should inform the maintenance director; -If the maintenance director cannot make the freezer repair, they should request service call. During an interview on 2/11/25 at 10:21 A.M., the Maintenance Director said: -If the freezer was not working, they would try to repair it and if they could not perform the repair, then they would request the freezer to be serviced the repair company. -If the freezer was going into a defrost, there would be icicles and ice buildup on the ceiling and the floor. -There should not be ice buildup inside the freezer; -They were notified on 2/9/25 about the freezer not working properly; -Repair company was at the facility on 2/9/25 and 2/10/25 working to repair the freezer. During an interview on 2/11/25 at 2:15 P.M., the Senior Regional Administrator said: -The freezer temperature should be between 32 to 34 degrees Fahrenheit; -Frozen items should be frozen when stored in the freezer; -There should not be ice on the floor of the freezer and on the ceiling near the fans; -Freezer temperature logs should match the temperature on the thermometer in the unit. -Staff should notify maintenance when the freezer temperature is too low; -Maintenance Director should look at the freezer to see if it is a defrost issue; -If Maintenance Director could not fix the freezer, then they should call for servicing; -If the freezer temperature continued to be too low, they should move all the food to a working freezer.

Based on observation and interview, the facility failed to ensure staff served food to the residents that was palatable and attractive for two of 18 sampled residents (Resident #8 and #16). The facility had a census of 82. The facility did not provide a policy on food palatability and appearance. Observation on 2/11/25 at 12:46 P.M. showed: -Alfredo noodles tasted dry and bland; -The cream pie dessert had gritty texture and was tasteless. 1. Review of Resident #16's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/22/24, showed: -Resident was cognitively intact; -Diagnoses included: Debility (physical weakness), heart disease, diabetes (chronic high blood sugar), depression, and lung disease. During an interview on 2/10/25 at 8:26 A.M., Resident #16 said: -Sometimes food was served cold and raw; -They did not get the drinks that they ordered with their meals; During an interview on 2/10/25 at 3:19 P.M., Resident #16 said: -The way the way the food was presented made Him/Her not want to eat it; -He/She was not happy when the food was served cold and looked bad. 2. Review of Resident #8's Quarterly MDS, dated [DATE], showed: -Resident was cognitively intact; -Diagnoses included: Diabetes (high blood sugar), anxiety, depression, lung disease, During an interview on 2/9/25 at 11:31 A.M., Resident #8 said: -The food was not good and was cold when the tray was delivered to their room; -The food was not appetizing to look at so they would not eat it and would eat the snacks He/She had in His/Her room; -He/She was tired of eating hamburgers as an alternate menu item; -The waffles that were served on 2/8/25 were so hard that He/She could not eat them because it was like a brick; During an interview on 2/10/25 at 04:26 P.M., the Dietary Manager said: -They expect hot foods to be served hot and cold foods to be served cold; -The food should have an appealing appearance, seasoning and an appropriate texture. During an interview on 2/10/25 at 4:33 P.M., the Dietician said: -Hot foods should be served hot and cold foods should be served cold; -They expect the food to have an appealing appearance and appropriate texture, and be seasoned. During an interview on 2/11/25 at 2:15 P.M., the Senior Administrator said: -They expect hot foods to be served hot and cold foods to be served cold; -The food should have an appealing appearance, seasoning and appropriate texture.

Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent when facility staff made two medication errors out of 26 opportunities for error resulting in a medication error rate of seven percent which affected two of the 18 sampled residents (Resident #14 and #18). The facility census was 82 Review of the facility's undated policy for medication administration showed, all medications will be administered to every resident by a licensed nurse or a Certified Medication Technician (CMT) and as ordered by a physician in a safe and sanitary manner. The facility did not provide a policy for administration of eye drops. Review of the website, https://webmd.com, for artificial tears eye drops showed: - To avoid contamination, do not touch the dropper tip to the eye or or any other surface; - Tilt your head back, look up, and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; 1. Review of Resident #14's Physician's Order Sheet (POS) dated January 2025 showed Artificial Tears instill one drop in left eye three times a day for dry eyes. Review of the resident's medication administration record (MAR) dated January 2025 showed instill one drop in Artificial Tears instill one drop in left eye three times a day for dry eyes. Observation on 02/10/25 12:26 P.M., showed: - CMT A washed his/her hands, applied gloves and cleaned the resident's eye lids, removed gloves and washed his/her hands and applied new gloves; - CMT A placed one drop in the resident's left and the tip of the eye dropper touched the resident's eye lid and eye lashes. CMT A applied lacrimal pressure (gentle pressure applied to the inner eye by the nose) for 20 seconds; In an interview on 02/10/25 12:36 P.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lid or eye lash; - Lacrimal pressure should be applied for one to two minutes. 2. Review of Resident #14's Physician's Order Sheet (POS) dated January 2025 showed Artificial Tears instill one drop in left eye three times a day for dry eyes. Review of the resident's medication administration record (MAR) dated January 2025 showed instill one drop in Artificial Tears instill one drop in left eye three times a day for dry eyes. Observation on 02/10/25 12:26 P.M., showed: - CMT A washed his/her hands, applied gloves and cleaned the resident's eye lids, removed gloves and washed his/her hands and applied new gloves; - CMT A placed one drop in the resident's left and the tip of the eye dropper touched the resident's eye lid and eye lashes. CMT A applied lacrimal pressure (gentle pressure applied to the inner eye by the nose) for 20 seconds; In an interview on 02/10/25 12:36 P.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lid or eye lash; - Lacrimal pressure should be applied for one to two minutes. In an interview on 12/10/24 at 1:20 P.M., the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the resident's eye lashes or eye lids; - Staff should apply lacrimal pressure for one minute.

Based on observation, interview, and record review, the facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete peri care. This affected three of 18 sampled residents (Resident #10, #39 and #25). The facility census was 82. Review of the facility's policy, Activities of Daily Living, dated, 09/01/21, showed: -The facility will ensure that residents who are unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. Review of the facility's policy, Perineal Care, dated 09/01/21, showed: -It is the practice of this facility to provide perineal care to all incontinent residents as needed to promote cleanliness, comfort, prevent infection and prevent skin breakdown; -Female: Separate the resident's skin folds with one hand and cleanse perineum, wiping front to back; -Repeat on opposite side using a new disposable wipe; -Clean the urethral opening with a new wipe with each stroke; -Turn the resident on their side, using a new wipe with each cleansing motion, cleaning all areas urine or feces have touched; -Males: Cleanse urethral opening, in a circular motion, working outward, -Cleaning all areas urine or feces have touched. 1. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/17/25, showed: -No cognitive impairment; -Dependent for all ADL's and transfers; -The resident has a urinary catheter; -The resident is frequently incontinent of bowel; -Diagnoses included, asthma and obstructive uropathy (a condition where urine flow is blocked or hindered, leading to backup of urine in the urinary tract). Review of the resident's care plan, dated 01/20/25, showed: -The resident has an ADL self-care performance deficit related to limited mobility; -The resident has potential impairment to skin integrity related to limited mobility. -Resident is dependent on nursing staff to maintain personal and peri care hygiene needs. Observation on 02/09/25, at 10:55 A.M., showed: -Certified Nurses Aide (CNA) D and Nurses Aide (NA) B entered the resident's room; - CNA D removed the resident's brief; - CNA D wiped down each side of the groin with a new wipe each time; - CNA D wiped across the abdominal fold with a new wipe; - CNA D did not separate and clean all the perineal folds. - CNA D and NA B turned the resident onto his/her side; - CNA D used a new wipe and cleaned the rectal area; - CNA D did not separate and clean all the skin folds. In an interview on 02/09/25, at 11:22 A.M., CNA D said: -He/She did not separate and clean all the perineal folds when he/she provided peri care to the resident; -When doing perineal care all areas that urine or feces have touched should be separated and cleaned. In an interview on 02/09/25, at 11:25 A.M., NA B said when providing perineal care all areas that urine or feces have touched should be separated and cleaned. 2. Review of Resident #39's Annual MDS, dated [DATE], showed: -No cognitive impairment; -Dependent for all ADL's and transfers; -Diagnoses included, multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system), arthritis and high blood pressure. Review of the resident's care plan, dated 12/08/24, showed: -The resident has an ADL self-care performance deficit related to multiple sclerosis and arthritis; -The resident is incontinent of bowel and bladder; -The resident has potential impairment to skin integrity related to limited mobility; -Dependent on staff for toileting and personal/peri care hygiene needs. Observation on 02/11/25, at 09:35 A.M., showed: -CNA B and CNA C entered the resident's room; - CNA B removed the sheet from the resident; - CNA C wiped down each side of the groin with a new wipe each time; - CNA C wiped across the abdominal fold with a new wipe; - CNA C did not wipe down the center and did not separate and clean all the perineal folds; - CNA C and CNA B turned the resident onto his/her side; - CNA C used a new wipe and cleaned the rectal area; - CNA C did not separate and clean all the perineal folds. In an interview on 02/11/25, at 09:46 A.M., CNA C said: -He/She did not separate and clean all the perineal folds when he/she provided peri care to the resident; -When doing perineal care all areas that urine or feces have touched should be separated and cleaned. In an interview on 02/11/25, at 09:49 A.M., CNA B said staff should separate and clean all the perineal folds when providing perineal care to an incontinent resident. 3. Review of Resident #25's Quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent for all ADL's and transfers; -Always incontinent of bowel and bladder; -Diagnoses included, stoke, hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body), and diabetes mellitus (a chronic condition where the body does not use insulin effectively). Review of the resident's care plan, dated 01/21/25, showed: -The resident has an ADL self-care performance deficit; -The resident in incontinent of bowel and bladder; -Dependent on staff for toileting and personal/peri care hygiene needs. Observation on 02/11/25, at 10:04 A.M., showed: -CNA B and CNA C entered the resident's room; - CNA B wiped down each side of the groin with a new wipe each time; - CNA B wiped across the abdominal fold with a new wipe; - CNA B did not wipe down the center and did not separate and clean all the perineal folds; - CNA B and CNA C turned the resident onto his/her side; - CNA B used a new wipe and cleaned the rectal area; - CNA B did not separate and clean all areas that urine or feces had touched. In an interview on 02/11/25, at 10:18 A.M., CNA B said: -He/She did not separate and clean all the perineal folds when he/she provided peri care to the resident; -When doing perineal care all areas that urine or feces have touched should be separated and cleaned. In an interview on 02/11/25, at 10:04 A.M., Licensed Practical Nurse (LPN) C said: -Staff should separate and clean all the perineal folds when providing peri care to an incontinent resident; -When cleaning a male resident, the area of the urethral opening should be cleansed in a circular motion, working outward; -When doing perineal care all areas that urine or feces have touched should be separated and cleaned. In an interview on 02/11/25, at 11:55 A.M., Registered Nurse (RN) B said when providing perineal care, all areas that urine or feces have touched should be separated and cleaned. In an interview on 02/11/25, at 02:15 P.M., the Director of Nursing (DON) said: -She expects staff to separate and clean all the perineal folds when providing peri care to an incontinent resident; -She expects staff to clean the area of the urethral opening in a circular motion, working outward when cleaning a male resident; -When doing perineal care all areas that urine or feces have touched should be separated and cleaned. -During the interview, the Administrator concurred with the DON.

Based on observation and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment when the facility failed to maintain and replace pealing wallpaper, repair water stained ceilings, clean and replace broken furniture, repair scraped and missing paint from walls, replace broken window blinds, fix and repair loose headboards and foot boards on resident beds. and assure medical equipment is clean and stored away from residents in a common area. The facility census was 40. Review of the facility's Physical Environment Space and Equipment policy, dated 9/1/21, showed an inspection of resident care equipment will be completed routinely and as needed to maintain safe operation condition. Review of the facility's Resident Right Policy, date 9/1/22., showed the resident has the right to a safe, clean, comfortable, and homelike environment, that supports daily living. 1. Observation of the memory care unit on 2/9/25 at 10:35 A.M., showed: - Two uncovered suction machines, with visible debris on both machines in the common area where resident's gather, machines sitting on a dirty cart by the medication refrigerator. - A blue/gray chair with ripped up cushion exposing foam insert sitting in a common area by the nurses station. - Main hallway and dining area floors with dull finish, and sticky. In an interview on 2/9/25 at 11:35 A.M., NA A., said -He/She was not sure who was responsible for medical equipment, or where suction machines are to be stored, but thought the nurse would know. - He/She had been there a short time and just started. - He/She usually sees a housekeeper most days. - He/She was not sure if torn furniture should be in resident areas. Observation on 2/10/25 at 1:15 P.M., showed the suction machine remained uncovered, and in the common area. In an interview on 2/10/25 at 1:30 P.M., LPN A, said: - The torn chair and suction machines had been there for a few days. - The suction machines should be cleaned, covered, and stored for next use. - Torn and broken equipment should be removed from resident sitting areas. 51166 2. Observation on 2/9/25 at 11:48 A.M. in room [ROOM NUMBER] showed: -Unpainted patches on wall above TV and above the bed; -Missing light bulb and bulb cover in fixture above mirror in the bathroom; -Holes patched but not painted in the bathroom. Observation on 2/09/25 at 12:19 P.M. in room [ROOM NUMBER] showed unpainted patches on the wall next to the bed. Observation on 2/09/25 at 12:26 P.M. showed: -Water stains and chips in paint on ceiling in three inches by two-inch area across from room [ROOM NUMBER]; -Water stain 12 inches by 36 inches on ceiling next to room [ROOM NUMBER]. Observation on 2/10/25 at 8:02 A.M., showed a nightstand in room [ROOM NUMBER] had edges worn off on front and sides, exposing pressed wood. Observation on 2/10/25 at 2:57 P.M. showed: -An unpainted two inch by three-inch unpainted patch where garbage can was stored across from shower room on 100 hall; -Water stains and ceiling puttied over cracks but not painted across from shower room on 100 hall. Observation on 2/10/25 at 2:58 P.M. showed wallpaper peeling on 150 hall near the exit sign. 3. Observation of the memory unit on 2/9/24 and 2/10/24 showed: - 02/09/25 10:00 A.M. room [ROOM NUMBER] Right side door frame broken and headboard very loose. - 02/09/25 11:21 A.M. room [ROOM NUMBER] Window blinds broken in room with pieces in window sill. Bathroom has old metal riser on toilet. - 02/10/25 8:52 A.M. Chair in memory care sitting area has no cover on cushion/exposed foam. - 02/10/25 8:54 A.M. room [ROOM NUMBER] Broken window blinds. room [ROOM NUMBER] Headboards and footboards loose both beds. Sink faucet fixture loose. - 02/10/25 8:58 A.M. room [ROOM NUMBER] Phone jack broken off wall hanging by wires. Wall scratched and gouged. Curtain rod broken. Air vent crooked/partially off by TV. - 02/10/25 9:01 A.M. room [ROOM NUMBER] Window blinds broken. room [ROOM NUMBER] Window blinds broken. - 02/10/25 9:09 A.M. room [ROOM NUMBER]. Gouge in wall by TV. In an interview on 02/11/25 at 08:38 A.M. the Maintenance Director said: -They have a computer based preventative maintenance program that directs their efforts. -Nursing writes out a work order if they run across any issues in rooms or in facility, submit it to maintenance. -Maintenance then fix it and sign off after completed. -Maintenance is responsible for checking the O2 (Oxygen) storeroom weekly. In an interview on 02/11/25 at 08:44 A.M. the DON said: -Nursing knows how to report issues like loose headboards, broken blinds, and wall gouges. -They report it to maintenance via maintenance orders. -Housekeeping only does the cleaning and can also fill out the work orders too. -Nursing equipment should be cleaned and stored appropriately away from other residents when not in use. In an interview on 02/11/25 at 09:02 A.M. the Regional Housekeeping Manager said: -If housekeeping runs across anything needing repaired they write it in the maintenance log if not an emergency. -If an emergency they would notify maintenance directly and log it. - He said there is a log at each nurses station.

Based on observation, interviews, and record review the facility failed to ensure staff maintained residents rights, when providing ADL (activities of daily living) cares for cognitively impaired residents in a dignified manner when the facility staff failed to ensure facial hair was removed from three of the 18 sampled residents (Resident #11, Resident #64, and Resident #21) and additionally failed to honor the bathing preferences of one cognitively intact Resident, (Resident#16). The facility census was 82. Review of the facility's Resident Rights Policy, dated 09/01/22, showed: -The resident has a right to a safe, clean, and homelike environment, including but not limited to receiving treatment and supports for daily living. Review of the facility's Grooming Residents Facial Hair Policy, dated 09/01/21, showed: -It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. - All resident's dignity will be maintained and needs honored to promote individualized care. 1. Review of Resident 11's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/19/24, showed: - admitted on [DATE] to memory care unit. - Mild cognitive impairment. - Requires assistance with all Activities of Daily Living (ADL's) and supervision with transfers. - Occasionally incontinent of bladder - Diagnosis of: Dementia, breast cancer, high blood pressure, and stroke. Review of Resident #11's care plan dated 01/30/20 showed: -Resident has an activities of daily living (ADL) self-care performance deficit related to dementia and requires supervision with personal hygiene and substantial assistance with shower and bath. -Resident has a terminal prognosis related to breast cancer and staff will work with hospice team to ensure physical and social needs are met. Observation on 02/09/25 at 10:00 A.M., showed Resident #11, in his/her room, with 1/2 inch hair growth on his/her chin. Observation on 02/10/25 at 12:30 P.M., showed Resident #11, in hallway, with 1/2 inch hair growth on his/her chin. Observation on 02/11/25 at 08:45 A.M., showed Resident #11, by nurse's station with 1/2 inch hair growth on his/her chin. 2. Review of Resident 64's quarterly MDS), dated [DATE], showed: - admitted on [DATE] to memory care unit. - Moderate cognitive impairment. - Required assistance with all Activities of Daily Living (ADL's) and supervision with transfers. - Frequently incontinent of bowl and bladder. - Takes scheduled pain medications. - Diagnosis of: Diabetes (A group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a group of lung diseases that cause airflow obstruction and breathing problems), high blood pressure, Alzheimer's disease (a brain disorder that causes memory loss, confusion, and changes in thinking and behavior), and depression. Review of Resident #64's care plan, dated 03/19/23., showed the resident has an activities of daily living (ADL) self-care performance deficit related to aggressive behavior and Alzheimer's and requires moderate assistance with personal hygiene and substantial assistance with showers and bathing. Observation showed on 02/09/25 at 10:15 A.M., Resident #64, standing by table in dining room, with 1/2 inch hair growth on his/her chin. Observation showed on 02/10/25 at 09:50 A.M., Resident #64, in quiet area, with 1/2 inch hair growth on his/ her chin. Observation showed on 02/11/25 at 09:00 A.M., Resident #64, sat in the dining room, with 1/2 inch hair growth on his/her chin. During an interview on 2/8/25 at 10:55 A.M., NA said resident's should be offered a shave on bath days. During an interview on 2/9/25 at 1:25 P.M., RN B said all resident's who don't want facial hair should be shaved. Not all resident's will allow shaving, but staff should attempt again. 3. Review of Resident #21's Significant Change MDS, dated [DATE]., showed: - Significant Impairment to Cognition. - Total assist of nursing staff for all activities of daily living. - Diagnoses included: Parkinsons ( A progressive neurological condition that affects fine motor skills), Pneumonia (Infection of the lungs, with fluid build up), Dementia, Diabetes (Excessive sugar in the blood)> Observation on 02/09/25 at 11:49 A.M., showed: -Resident sitting up in a specialized reclining chair with dirty dried food on the cushions of the chair. -Resident had dried food on his/her face from the prior meal and his/her facial chin hair was 1-2 inches in length. Observation on 2/10/25 1:50 P.M. showed the resident in a wheelchair with dried dirt and crusty food debris on the chair cushion and arm rest. The resident had visible chin hairs on his/her face and food from the noon meal dried on his/her face. During an interview on 2/9/25 at 12:02 P.M., NA A said: - He/She was unsure who routinely cleaned resident equipment. - He/she believed that resident's should not have dried food on his/her face and chin hairs should be shaved. During an interview on 2/10/25 at 1:30 P.M. LPN A said: - Female residents should be offered a shave with showers. - Residents #21 should have been assisted by staff to ensure he/she had a clean face and hands after the meal service. 52043 4. Review of Resident #16's Annual MDS, dated [DATE], showed: -Resident is cognitively intact; -Resident requires moderate assistance of nursing staff for all ADL'S (Activities of Daily Living); -Resident is dependent on a wheelchair; -Diagnoses included: Debility (physical weakness), heart disease, diabetes (chronic high blood sugar), depression, and lung disease. During an interview on 2/10/25 at 8:16 A.M and 3:19 P.M., Resident #16 said: -I had one shower last week but would prefer showers twice a week. -The facility doesn't always have a shower aid on duty; - It upsets me off that I can only shower once every ten days. I wish I could do my own showers; -It is bad enough that I can't shower every day, dammit it, but why can't I have 2-3 showers each week?; - He/she was thinking about getting on hospice so they can get showers because hospice comes twice a week; -He/she had not started hospice services yet because that is your last hope. -They don't always have a shower aid here. During an interview on 2/10/25 at 5:14 P.M., CNA A said residents be provided with at least two showers weekly, and more showers if they ask. During an interview on 2/10/25 at 3:37 P.M., LPN C said residents should be provided with a shower as often as they want. During an interview on 02/11/25 at 2:15 P.M., DON states he/she expects residents with facial hair to be shaved and well groomed. During an interview on 2/11/25 at 2:15 P.M., the Administrator said: -Residents should get showers twice a week, unless they ask for more then staff should provide it. - Resident's should be offered a shave on shower days and as often needed. - Resident equipment should be cleaned when it becomes dirty. 51166

Based on observation, interview, and record review, the facility failed to assure Resident #36 and Resident #79 had access to a call light while lying in bed to prevent potential accidents by allowing these residents to summon staff as needed. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Call Light Policy- Accessibility and Timely Response, dated 09/1/21, showed: -Assurance that the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Cal lights will directly relay to a staff member or centralized location to ensure appropriate response. -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. -Special accommodations will be identified on the plan of care and provided accordingly touchpads, larger buttons, bright colors. -With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 1. Review of Resident #36's Quarterly Minimum Data Set (MDS), a Federally mandated assessment instrument completed by facility staff dated 02/12/25., showed: -Severe cognitive impairment. -Resident requires nursing assistance with all activities of daily living (ADL's) and transfers. -He/She is incontinent of bowel and/or bladder and requires nursing assistance with personal hygiene needs. -Diagnoses included: Alzheimer's Disease (a brain disorder that causes memory loss, confusion, and changes in thinking and behavior), chronic obstructive pulmonary disease (a long-term lung disease that causes airflow obstruction and breathing problems), an anxiety disorder, and depression. Review of Resident #36's care plan, dated 11/25/4, showed: -At risk for skin breakdown due to incontinence and decreased mobility. -Resident is a DNR(Do not resuscitate- No life saving or heroic measures) -Requires total staff assist for all ADLS. -Communication problem related to Alzheimer's-Staff to anticipate and meet all needs. -Impaired cognitive thought processes-Staff to anticipate and meet all needs. -He/She was at risk for falls -On routine psychotropic (mood altering medications) medications for verbal and physical behaviors. -Resident has history of breathing issues and requires oxygen. Observation on 02/09/25 at 09:45 A.M. showed Resident #36's call light was not visible to him/her. -Resident was lying in bed, and the call light was behind curtain and underneath the bed on the floor, out of the resident's reach. During an Observation and Interview on 02/09/25 at 09:45 Resident #36 said: - He/She did not know if they had a call light - Denies knowing how to contact a nurse if needed assistance. - Observation showed the resident was unaware of surroundings and or how to use call light assistance. In an interview on 02/09/25 at 11:00 A.M. CNA-B he/she said call lights should be within reach for all residents. In an interview on 02/10/25 at 10:15 A.M LPN-B said that call lights should be within reach for the resident. In an interview on 02/11/25 at 08:30 A.M the Maintenance Director said call lights should be within reach of the resident. 2. Review of Resident #79's Quarterly Minimum Data Set (MDS) dated [DATE], showed: -Moderate cognitive impairment. -Unable to communicate needs effectively. -Total assist of nursing staff for all ADLS. -Incontinent of bowel and/or bladder -Diagnoses included: of Coronary Artery Disease (CAD)( a condition where the arteries that supply blood to the heart become narrowed or blocked). This reduces blood flow to the heart muscle, which can lead to symptoms such as chest pain, shortness of breath, and heart attack., high blood pressure, Diabetes Mellitus (a chronic disease that affects how the body uses glucose (sugar) for energy), and Dementia, (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities). Review of Resident #79's care plan dated 10/30/24, showed: -Goal is to maintain safety with call light in reach; -Staff to anticipate and monitor resident's needs: -Dignity should be honored: -Requires nursing assistance with performing activities of daily living: -Impaired cognition. Observation on 02/09/25 at 10:30 A.M. showed Resident #79 laid on bed and the call light was not within his/her reach. The call light was clipped to the light on wall at head of bed at and out of the resident's reach. In an interview with Resident #79 on 02/09/25 at 10:30 AM the reisdent said he/she did not know how to call the nurse. In an interview on 02/09/25 11:00 A.M. CNA B said the residents call light should be placed within reach. In an interview on 02/10/25 at 10:15 A.M. LPN B said that call lights should be within the resident's reach. In an interview on 02/11/25 at 12:30 P.M. the Director of Nursing said call lights should be within reach so the residents can call staff for assistance when needed.

Based on observations, interviews, and record review, the facility failed to provide the care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for three of the 18 sampled residents (#16, #47, and #48) when the facility failed to complete proper assessments, obtain a physician's order for medication to be administered to resident #47 by resident #48 and additionally failed to respect resident choice regarding showers for resident #16. The facility census was 82. The facility's Resident Rights policy, dated 9/1/22, showed: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is clinically appropriate; -The resident has the right to, and the facility must promote and facilitate resident self-determination through support of a resident's choice including the right to choose schedules and health care; -The resident has a right to make choices about aspects of their life in the facility that are significant to the resident. 1. Review of Resident #47's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/1/25, showed: -Resident is cognitively impaired; -Diagnoses included: Dementia (decline in mental abilities that affect memory), Alzheimer's disease (progressive brain disease that destroys memory and thinking ability). Observation on 2/9/25 at 10:14 A.M. showed: -Resident #47's medications were in a small plastic cup sitting on the resident's desk in front of the bed. In an interview on 2/9/25 at 10:14 A.M., Resident's room mate and spouse (Resident #48) said: -Staff gives resident #47's medications to him/her to administer to Resident #47; - He/She administered medications to his/her spouse (Resident #47); -He/She had previously worked as a Registered Nurse. Review of Resident #47's electronic medical records showed: -No physician's orders for Resident #48 to administer medication to resident #47; -No competency assessment for Resident #48 to administer medications to Resident #47. In an interview on 2/10/25 at 3:50 P.M., RN B said: -They must get a physician's order for a resident to self-administer medications or administer medications to other residents; -After physician's orders are received, they educate the resident on administering medication and the resident must demonstrate competency, which should be documented in the resident's progress notes; -Medications should be given directly to the resident they are prescribed to unless there are proper assessments, care planning and orders. -It is a complicated situation with Resident #47 & Resident 48. 2. Review of Resident #48's Annual MDS, dated [DATE], showed: -Resident had moderate cognitive impairment; -Diagnoses included: Debility (physical weakness), heart disease, cirrhosis of the liver (severe scarring of the liver), and lung disease. In an interview on 2/9/25 at 10:14 A.M., Resident #48 said: -He/She was an RN; -Staff gives His/Her spouse's medications to Him/Her if their spouse is sleeping so He/She can administer the medications when his spouse awakens; -He/she picked up the plastic medication cup with medications in it from the desk to show the surveyor. 3. Review of Resident #16's Annual MDS, dated [DATE], showed: -Resident is cognitively intact; -Resident requires moderate assistance of nursing staff for all ADLS (Activities of Daily Living); -Resident is dependent on a wheelchair; -Diagnoses included: Debility (physical weakness), heart disease, diabetes (chronic high blood sugar), depression, and lung disease. In an interview on 2/10/25 at 8:16 A.M., Resident #16 said: -I had one shower last week but would prefer showers twice a week. -The facility doesn't always have a shower aid on duty; In an interview on 2/10/25 at 3:19 PM, Resident #16 said: - It upsets me off that I can only shower once every ten days. I wish I could do my own showers; -It is bad enough that I can't shower every day, dammit, but why can't I have 2-3 showers each week?; - He/she was thinking about getting on hospice so they can get showers because hospice comes twice a week; -He/she had not started hospice services yet because that is your last hope. -They don't always have a shower aid here. In an interview on 2/10/25 at 5:14 P.M., CNA A said staff should provide residents two showers weekly, but residents can receive more if they ask. In an interview on 2/10/25 at 3:37 P.M., LPN C said staff should provide residents showers as often as they want. In an interview on 2/11/25 at 2:15 P.M., the Administrator said: -Residents should not have medications sitting in a cup in their room. -Residents should not administer medications to another resident. -There should be competency assessments, orders, and it should be care planned for a resident to administer meds for another resident. -Residents should get showers twice a week, unless they ask for more.

Based on interview and record review, the facility failed to clarify the status of Resident #10's Do Not Resuscitate Order (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) when the resident signed the DNR authorizing no life saving measures be taken and also signed the revocation provision of the DNR, stating the resident wanted life saving measure to be taken. This affected one (Resident #10) of 18 sampled residents. The facilty census was 83. Review of the facilty's policy titled, Resident Rights Regarding Treatment and Advance Directives, dated, [DATE], showed: -This facilty supports the resident's right to request, discontinue or refuse treatment; -The facilty supports the resident's right to formulate an advance directive; -On admission it will be determined if the resident has executed an advance directive or would like to formulate one; -Periodically the facilty will identify and clarify if the resident would like to make any changes. 1. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -No cognitive impairment; -Dependent for all Activities of Daily Living (ADLs) and transfers; -Diagnoses included, asthma and obstructive uropathy (a condition where urine flow is blocked or hindered, leading to backup of urine in the urinary tract). Review of the resident's care plan, dated, [DATE]; showed: -The resident is a full code status (all life saving measures to be initiated if heart or breathing stops); -Cardiopulmonary Resuscitation (CPR), a life-saving procedure that involves chest compressions and rescue breaths, will be performed as ordered; -The resident will have his/her wishes followed according to his/her signed directive; -Review code status quarterly; -The resident's care plan contained conflicting information regarding the resident's code status. The resident's DNR showed he/she was a full code status and a DNR status. Review of the resident's Medical Record and DNR documents showed: -[DATE], the resident signed the authorization to withhold life saving measures; -[DATE], the resident signed the revocation provision, revoking the resident's DNR code status; -The resident's DNR contained conflicting information regarding the resident's code status. The resident's DNR showed he/she was a full code status and a DNR status. Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed an order for DNR/ No CPR, dated [DATE]. In an interview on [DATE], at 08:05 A.M., the resident said he/she did not want CPR if his/her heart stopped beating. In an interview on [DATE], at 08:20 A.M., the MDS coordinator said: -Resident code status is on the resident's electronic medical record and in a book at the nurses station; -The Social Services Designee (SSD) keeps the code status book updated. In an interview on [DATE] 08:30 A.M., the SSD (social service director) said: -He/She is responsible for ensuring the DNRs, are updated and accurate; -He/She updates the code status book monthly; -Resident #10's DNR should be clear with no conflicting information; -Resident #10 should not have a signature requesting CPR and a signature declining CPR. In an interview on [DATE], at 09:18 A.M., Certified Nurses Aide (CNA) D said: -The staff look at the care plan or at the code status book at the nurses desk to determine the code status of the residents; -He/She was not sure of resident #10's code status with out looking it up; -He/she expects the care plan and code status book to be correct; -He/she could not identify the resident's code status by looking at the medical record or the code status book. In an interview on [DATE], at 10:04 A.M., Licensed Practical Nurse (LPN) C said: -The order for code status on resident #10's POS should match the DNR and the care plan; -He/She looks at the care plan, the code status book and the electronic medical record to determine the code status of all residents; -The resident's DNR should not have a signature in the the authorization to withhold life saving measures and a signature in the revocation provision of the DNR; -Based on this information he/she could not determine the resident's code status. In an interview on [DATE], at 11:55 A.M., Registered Nurse (RN) B said: -The order on resident #10's POS should match the DNR and the care plan; -He/She looks at the care plan and the code status book to determine the code status of the resident; -The resident's DNR should not contain conflicting information; -Based on this information he/she could not determine the resident's code status; -The SSD was responsible to ensuring resident DNRs are completed. In an interview on [DATE] 02:15 P.M., the Director of Nursing (DON) and Administrator said: -The staff can find a resident's code status in the electronic medical record, the care plan and in the code book at the nurses station; -Resident #10's code status should match the physician's order on the POS; -Resident #10's care plan should match the physicians order on the POS; -Resident #10 should not have signatures in both the DNR section and the full code section; -She expects the SSD to keep resident DNRs up to date and clarify any conflicting information. - The Administrator concurred with the DON.

Based on interview, and record review, the facility failed to provide services that met professional standards of practice when staff failed to record the administration of medications on the Medication Administration Record (MAR) for one (Resident #13) of 18 sampled residents. The facility census was 83. Review of the facilty's policy titled, Medication Administration, dated, 09/01/22, showed: -Medications are administered by legally authorized staff as ordered by the physician in accordance with professional standards of practice; -Sign the MAR after the medication has been administered; -Document any adverse effects or refusals. Review of the facilty's policy titled, Medical Provider Orders, dated, 04/07/22, showed staff should follow all medical provider orders. 1. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/02/25, showed: -No cognitive impairment; -Dependent with all Activities of Daily Living (ADLs) and transfers; -Always incontinent of bowel and bladder; -Takes scheduled and as needed pain medications; -Pain is present constantly; -Receives oxygen therapy; -Diagnoses included, heart failure, high blood pressure, anxiety and respiratory failure. Review of the resident's care plan dated 07/10/24 showed: - The resident has an ADL self care performance deficit related to activity intolerance; - The resident has pain; - Administer pain medicine as ordered; - Document any side effects. Observation and interview on 02/09/25, at 03:54 P.M., showed: -The resident in bed in his/her room; -The resident facial grimaced and moaned; -The resident said his/her back hurt; -The resident said he/she takes scheduled pain medications; -The resident said the facilty often runs out of his/her pain medications and the resident has to go without them for several days; -The resident said his/her pain level is severe. Review of the resident's Physician's Order Sheet (POS) dated, December 2024, showed: -Diagnoses included chronic pain. -Order start date: 05/06/24, Gabapentin (used to treat nerve pain) 100 milligrams (mg), give 100 mg every 8 hours for chronic pain; -Order start date: 10/18/24, Oxycodone (used to treat mild to moderate pain) 10/325 mg, give one tablet every 6 hours for pain. Review of the resident's MAR dated 12/01/24 through 12/31/24 showed: -On 12/11/24 at 06:00 P.M., there was no documentation to indicate that his/her Gabapentin 100 mg was administered; -On 12/11/24 at 06:00 P.M., there was no documentation to indicate that his/her Oxycodone 10/325 mg was administered; -On 12/19/24 at 06:00 P.M., there was no documentation to indicate that his/her Gabapentin 100 mg was administered; -On 12/19/24 at 06:00 P.M., there was no documentation to indicate that his/her Oxycodone 10/325 mg was administered. Review of the resident's POS dated, January 2025, showed: -Diagnoses included chronic pain. -Order start date: 10/18/24/24, Oxycodone 10/325 mg, give one tablet every 6 hours for pain. Review of the resident's MAR dated 01/01/25 through 01/31/25 showed on 01/23/25 at 06:00 P.M., there was no documentation to indicate that his/her Oxycodone 10/325 mg was administered. In an interview on 02/11/25, at 09:07 A.M., Certified Medication Technician (CMT) B said: -There should be some sort of documentation on resident #13's MAR to show that the resident took the medications or refused them; -There should be no blank spaces on resident #13's MAR; -It is important to document pain medications to see if they are effective; -He/she did not know why there were blank spaces on the resident 13's MAR. In an interview on 02/11/25, at 10:04 A.M., Licensed Practical Nurse (LPN) C said: -There should be no holes on resident 13's MAR; -There should be an entry in the box to show if the resident took the medication, refused it or it was not available; -There should be documentation to indicate that resident #13's Oxycodone 10/325 mg was administered; -There should be documentation to indicate that resident #13's Gabapentin 100 mg, was administered. In an interview on 02/11/25, at 11:55 A.M., Registered Nurse (RN) B said: -When there is a blank space on resident #13's MAR, we do not know if the medications were given or not; -There should be documentation to indicate that resident #13's Oxycodone 10/325 mg was administered or refused; -There should be documentation to indicate that resident #13's Gabapentin 100 mg, was administered or refused; -There should not be any blank spaces on resident #13's MAR. In an interview on 02/11/25 02:15 P.M., the Director of Nursing (DON) said: -If there is no entry on the resident's MAR we do not know if the medication was given or not; -There should be some kind of entry on the resident's MAR indicating if the medication was given, refused or held; -There should be documentation to indicate that resident #13's Oxycodone 10/325 mg was administered; -There should be documentation to indicate that resident #13's Gabapentin 100 mg, was administered. - During the interview, Administrator concurred with the DON.

Based on observation, interview, and record review, the facility failed to assure that two residents (Resident's #36 & #13) who needed respiratory care, was provided respiratory care consistent with professional standards of practice, when the facility staff failed to follow Physician orders for continuous oxygen therapy for Resident #36, and additionally, failed to assure that staff delivered a clean oxygen oxygen concentrator with oxygen tubing supplies for Resident #13. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Medical Provider Orders Policy, dated 04/07/2022, showed: -It is the responsibility of all staff to follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. If the order is not followed the physician should be notified for clarification of the order. Review of the facility's Oxygen Policy, dated 9/1/21., showed staff are to be educated on oxygen safety precautions in accordance with their roles and responsibilities related to the use of and storage of oxygen. 1. Review of Resident #36's Quarterly Minimum Data Set (MDS), a Federally mandated assessment instrument completed by facility staff dated 02/12/25., showed: -Severe cognitive impairment. -Resident requires nursing assistance with all activities of daily living (ADL's) and transfers. -Diagnoses included: Alzheimer's Disease (a brain disorder that causes memory loss, confusion, and changes in thinking and behavior), COPD (chronic obstructive pulmonary disease a long-term lung disease that causes airflow obstruction and breathing problems), an anxiety disorder, and depression. Review of Resident #36's Care Plan, dated 11/25/24, showed: -Unable to communicate needs related to Alzheimer's-Staff to anticipate and meet all needs. -Impaired cognitive thought processes-Staff to anticipate and meet all needs. -He/She was at risk for falls. -Administer Oxygen as ordered by physician. -Change tubing, humidifier bottle, and plastic holding bag for oxygen tubing every Thursday night shift. -Resident has history of breathing issues and requires oxygen. Observation on 02/09/25 at 12:17 P.M. showed Resident #36 had no oxygen tank or concentrator in his/her room and no nasal cannula or tubing was provided. He/she was on room air. Review of Physician's Order, dated November 2025., showed a written order dated 11/13/2024 for Oxygen at 2 Liters per minute per nasal tubing continuously. Review of nursing progress notes on 02/09/25, showed: An order related to Oxygen administration dated 01/31/25 to change oxygen tubing, humidifier bottle, and plastic holding bag for oxygen tubing every Thursday night. In an interview on 02/10/25 at 09:45 A.M. CMT-B, said he/she was not aware of an active oxygen order for Resident #36. Observation on 02/10/25 at 11:00 A.M. showed Resident #36 had no oxygen tank or concentrator in his/her room. Additionally, no nasal cannula with tubing was in room. He/she is on room air. In an interview on 02/10/25 at 11:15 A.M. LPN-B, said: - He/She was not aware of a continuous oxygen order for Resident #36 and that oxygen saturations were checked once a day and documented on the treatment record. - If oxygen was needed could obtain the oxygen tank from the crash cart in an emergency. Observation on 02/11/25 09:23 A.M. showed an unclean oxygen concentrator in Resident #36's room, sitting on the floor and behind the curtain. The oxygen concentrator was turned off and dirty with dried white liquid streaks running down the front and side of device. Additionally, the nasal cannula was not dated and remained inside a bag hanging on the concentrator. Oxygen was not on the resident. In an interview on 02/11/25 at 09:45 A.M. with CMT-B, said he/she placed concentrator in the room of Resident #36 behind the curtain and did not plug it in. Record review of progress notes and medication administration record on 02/11/25 at 10:00 AM, did not show oxygen administration documentation was completed for the month of January/February. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), dated [DATE]., showed: -Resident is a Full Code (All life saving measures are to be done). -Diagnoses included: Dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities), Congestive heart failure (CHF, also known as heart failure, a condition where the heart muscle is weakened and cannot pump blood effectively and can lead to a buildup of fluid in the lungs and other tissue), Respiratory Failure (a condition where the lungs cannot adequately exchange gases, resulting in insufficient oxygen in the blood and/or excessive carbon dioxide in the blood). Review of Resident #13's care plan, dated 10/17/24, showed: -Risk of poor oxygen absorption and shortness of breath. -Dependent on nursing staff for assistance with all ADLS and transfers. -Impaired cognitive function. -High risk for falls and fall risk monitoring. -Provide extension tubing when portable with oxygen -Keep oxygen levels greater than 91% and monitor as needed. Oxygen flow at 2 Liters Per Minute, continuously while in bed. Observation on 02/09/25 at 12:25 P.M. showed: A dirty oxygen concentrator in room with brown liquids dried and running over filter covering. Additionally, the oxygen tubing was out-dated 01/31/25 by one week. Observation on 02/10/25 at 09:09 A.M. showed resident had a dirty oxygen concentrator in room with brown liquids dried and running over filter covering, additionally the oxygen tubing was still dated 01/31/25. In an interview on 02/11/25 at 09:02 AM Housekeeping Director., said oxygen concentrators are cleaned by housekeeping on the outside, but they do not clean filters, they dust and wipe down the concentrators on the outside, only. In an interview on 02/11/25 at 12:25 P.M the DON, said Housekeeping cleans the oxygen concentrators, but does not do maintenance on oxygen devices. Oxygen equipment is cleaned by housekeeping but if broken the rental company swaps out equipment. Nursing is not involved in cleaning the oxygen filters. Nursing is responsible for replacing and updating dates on tubing. During the exit interview on 02/11/25 at 12:25 P.M. the Administrator said: - Physician orders should be followed as ordered. -Oxygen equipment should be cleaned when provided to a resident for use.

Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when a staff member forcibly fed the resident his/her meal when the resident expressed he/she did not want to eat. The resident was visibly emotionally upset and tearful when describing the actions to staff. This affected one of six sampled residents (Resident #2). The facility census was 82. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Mistreatment means inappropriate treatment of a resident. Review of the facility provided Policy Resident Rights, dated 9/1/22, showed: The resident has the right to: -Request, refuse, and/or discontinue treatment; -A dignified existence; -Exercise his/her rights as a resident of the facility; -Be treated with respect and dignity; -Make choices about aspects of his/her life in the facility. 1. Review of Resident #2's Admission Minimum Data Set (MDS:a federally mandated assessment tool completed by facility staff), dated 10/18/24, showed: -Brief Interview of Mental Status (BIMS) 15, indicating no cognitive deficits; -Set up assistance by staff for eating; -No swallowing/chewing difficulty; -Diagnoses of Congestive Heart Failure (where the heart can't pump enough blood to meet the body's needs), Hypertension (high blood pressure), Muscle Weakness, Type 2 Diabetes Mellitus (where the body does not use or does not produce enough insulin to meet needs), and Gastroesophageal Reflux (when stomach contents leak into the esophagus, causing irritation). Review of the resident's admission care plan showed the resident did not need assistance with eating. Review of the facility Grievance Reporting form, dated 10/28/24 and untimed, showed: -Physical Therapy Assistant (PTA) A attempted to work with Resident #2; -The resident was crying and frustrated; -The resident reported that he/she had been force fed by a staff member on the evening of 10/27/24; -The form was completed by the Director of Therapy (DOT) and signed by the Administrator. Review of the Investigation Summary, dated 10/31/24, completed by the Administrator, showed: -Resident #2 had complained a staff member pushed him/her to eat a meal, when he/she was able to feed himself/herself and refuse food if he/she did not want to eat; -The resident reported he/she kept telling the staff member that he/she did not want to eat, the staff kept trying to feed him/her manually and eventually stopped; -The Administrator assured the resident he/she would not have to work with the staff member again as the administrator felt the staff member acted inappropriately; -During an interview with Certified Nurse Aide (CNA) A, he/she said he/she was assisting the resident, because the resident seemed weak and was not eating. The resident told him/her to stop, but kept eating when helped; -The facility felt this did not elevate to the level of abuse, but the staff member acted inappropriately. During an interview on 11/12/24 at 2:50 P.M., Resident #2 said: -He/She feeds himself/herself; -CNA A entered his/her room at supper time on 10/27/24; -CNA A broke his/her sandwich into pieces and began sticking it into his/her mouth; -CNA A told Resident #2 he/she had to eat, because he/she was going to get sick; -He/She tried to turn his/her head away, CNA A followed and kept pushing the sandwich between his/her lips; -He/She told CNA A to stop, but CNA A kept pushing it between his/her lips; -When he/she would open his/her mouth to say no or stop, CNA A would shove a piece of the sandwich in his/her mouth; -Once he/she had eaten about half the sandwich, CNA A took the tray and left the resident's room; -He/She did not report anything that day, but reported to the night nurse; -The Administrator told him/her, he/she would not have to work with CNA A again; -CNA A made him/her eat and he/she did not want to. CNA A wouldn't take no as an answer; -CNA A force fed him/her and he/she kept opening his/her mouth, because he/she was afraid he/she would choke. During an interview on 11/14/24 at 2:09 P.M., CNA A said: -He/She had been a CNA for [AGE] years; -He/She had education on Resident Rights multiple times; -He/She knows that residents can refuse care; -He/She worked with Resident #2 on 10/27/24; -Resident #2 was very weak; -He/She did not know the resident could feed himself/herself; -He/She fed the resident a couple of bites; -Resident #2 may have said no, but he/she did not remember for sure; -He/She did not remember the resident turning away from him/her; -He/She liked Resident #2 very much and wanted the resident to get well, so he/she assisted them to eat; -He/She did not see helping the resident as abuse; -He/She was taught to help people get well, and people cannot get well if they do not eat. During an interview on 11/14/24 at 5:02 P.M., Licensed Practical Nurse (LPN) B said: -He/She worked the night shift on 10/27/24; -He/She worked with Resident #2; -Resident #2 reported to him/her that CNA A brought the evening meal tray to his/her room, broke the grilled cheese sandwich into pieces, pushed it into his/her mouth, and when the resident tried to say no, pushed the piece of sandwich between his/her lips. The resident was concerned he/she would choke, so he/she chewed and swallowed the pieces. After a few pieces the CNA took the tray and left the room; -He/She felt this was abuse, so he/she notified the Administrator immediately; -The Administrator said he/she would deal with it later; -The Administrator did not tell him/her to send CNA A home. During an interview on 11/12/24 at 1:42 P.M., PTA A said: -On 10/28/24, he/she arrived to Resident #2's room for therapy. The resident was visibly emotionally upset and tearful; -The resident said he/she did not like how he/she was treated by nursing staff; -The resident said he/she was force fed by nursing staff during the evening meal on 10/27/24; -He/She notified LPN A on 10/28/24 what the resident reported to him/her, who said that was impossible as the resident feeds himself/herself; -He/She then immediately went to his/her supervisor and reported what Resident #2 said; -The resident did not have any physical injuries on his/her face that he/she noticed. During an interview on 11/14/24 at 4:47 P.M., LPN A said he/she did not remember being notified by staff that Resident #2 complained of being force fed. During an interview on 11/12/24 at 1:25 P.M., the DOT said: -PTA A completed the Grievance Report for Resident #2 on 10/28/24; -When PTA A reported Resident #2 said force fed, he/she knew it needed to be addressed immediately; -He/She did not work with Resident #2, but had seen him/her working in the gym, and the resident had no problems with his/her hand/arm movement. During an interview on 11/12/24 at 1:10 P.M., the Administrator said: -Once he spoke with the resident, he felt the issue was customer service, not abuse; -The comment of force fed was staff taking liberties with words; -The report that came to him said force fed; -He explained to the resident force fed was holding the resident's head and pushing food into his/her mouth, and he/she said that did not happen; -The staff member thought he/she was helping the resident; -The staff member should have stopped feeding the resident when the resident told him/her to stop; -The resident had the right to refuse the meal. MO245023

Based on observation, interview, and record review, the facility failed to maintain a safe/functional/homelike environment, when the facility failed to recognize and repair a leak in one resident room and one adjacent utility room, causing water to run into the room, puddle on the floor and a mold like substance to form on the ceiling and bedroom walls and in the ceiling of the utility room on the Special Care Unit. Additionally, the facility failed to adequately maintain resident safety by preventing access to the affected area. The facility census was 82. The facility did not provide a policy on wall maintenance or safety. Observation on 11/4/24 at 11:10 A.M., of room [ROOM NUMBER] showed: -The door was closed. There was no stop sign, wet floor sign, or do not enter sign; -The door knob turned easily, and the door swung open with little force; -The room had water running down the left side wall forming a large puddle approximately 6 feet across on the floor; -The left side wall had multiple dark, black/gray/brown, spotty mold like substance areas along the top of the wall and the ceiling tiles; -The left side wall had a patch of peeling sheet rock at the ceiling juncture, approximately a foot in length; -The left side wall was bubbled and misshaped from the ceiling juncture to mid-wall, where it was saturated; -The front wall window frame showed gaps with daylight shining through between the sheet rock and the window frame at the top of the window; -Rain water was running into the room from the gap above the window; -Above the window at the ceiling juncture, was approximately a foot long area of peeling, bulging sheet rock; -The wall above the windows showed multiple dark, black/gray/brown, spotty mold like substance areas along the top of the wall at the juncture of the ceiling tiles; -An electric bed was plugged into an outlet on the left side wall; -Multiple folded towels were lying, saturated, in the window sill; -A large saturated gray blanket was on the floor, near the large puddle. Observation on 11/4/24 at 11:15 A.M., of the un-numbered Utility Room (adjacent to room [ROOM NUMBER]) showed: -An approximately one foot circumference area of dark gray/black/spotty mold like substance next to the ceiling light fixture; -The one foot area of the ceiling was bulging and peeling; -An approximately 18 inch circumference area of yellow/dark gray/black/spotty mold like substance on the ceiling near the sprinkler head. During an interview on 11/4/24 at 1:00 P.M., the Certified Medication Technician A said: -He/She had started working on the memory care unit the last week of October; -room [ROOM NUMBER] had been leaking water since the day he/she started work on the memory care unit. During an interview on 11/4/24 at 1:08 P.M., Nurse Aide A said: -room [ROOM NUMBER] had been leaking for at least two weeks or more; -The door was kept shut to keep resident's out; -Residents have to be reminded at times not to open room [ROOM NUMBER]'s door. During an interview on 11/4/24 at 12:30 P.M., the Administrator said: -The facility would be getting a new roof by the end of the month; -There was a leak in room [ROOM NUMBER] and the area was cordoned off and not being used by residents; -He was not aware of any mold in the building. During an interview on 11/4/24 at 12:34 P.M., the Corporate Nurse said: -He was not aware of any current leaks; -There had been a small leak in the roof of the memory care unit, about two weeks ago that had been repaired, to his knowledge. During an interview on 11/4/24 at 1:12 P.M. the Administrator said: -He had checked the utility room next to room [ROOM NUMBER] (on 11/4/24). -He was not aware of any mold like substance in the utility room before then; -The ceiling was scraped and a mold killing spray was used; -The contract for the roof did not include fixing room [ROOM NUMBER] and the utility room. During an interview on 11/4/24 at 2:17 P.M. the Contractor said: -He/She had the bid to replace the roof; -The bid did not include any dry wall maintenance; -He/She had been working with the facility for a couple to three months on the roof project; -He/She was not aware the roof was leaking into the building; -He/She was waiting on payment to start the project. MO243710

Based on interview and record review, the facility failed to ensure an alleged violation of potential physical abuse was reported immediately, but not later than two hours after the allegation was made, to officials in accordance with State law, including the Survey Agency for one sampled resident (Resident #2) out of six sampled residents. The facility census was 82 residents. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Mistreatment means inappropriate treatment of a resident; -Reporting of all alleged violations to the state agency, adult protective services and all other required agencies within the specified timeframe's: Immediately, but no later than two hours after the allegation is made if the event that cause the allegation involve abuse or result in serious bodily injury; -The Administrator will follow up with government agencies during business hours to confirm the initial report was received and to report the results of the investigation when final within five working days of the incident. 1. Review of Resident #2's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 10/18/24, showed: -Brief Interview of Mental Status (BIMS) 15, indicating no cognitive deficits; -Set up assistance by staff for eating; -No swallowing/chewing difficulty; -Diagnoses of Congestive Heart Failure (where the heart can't pump enough blood to meet the body's needs), Hypertension (high blood pressure), Muscle Weakness, Type 2 Diabetes Mellitus (where the body does not use or does not produce enough insulin to meet needs), and Gastroesophageal Reflux (when stomach contents leak into the esophagus, causing irritation). Review of the resident's admission care plan showed the resident did not need assistance with eating. Review of the facility Grievance Reporting form, dated 10/28/24 untimed, showed: -Physical Therapy Assistant (PTA) A attempted to work with Resident #2. -The resident was crying and frustrated. -The resident reported that he/she had been force fed by a staff member on the evening of 10/27/24. -The form was completed by the Director of Therapy (DOT) and signed by the Administrator. Review of the Investigation Summary, dated 10/31/24 completed by the Administrator, showed: -Resident #2 had complained a staff member pushed him/her to eat a meal, when he/she was able to feed himself/herself and refuse food if he/she did not want to eat it; -The resident reported he/she kept telling the staff member that he/she did not want to eat, the staff kept trying to feed him/her manually and eventually stopped; -The Administrator assured the resident he/she would not have to work with the staff member again as he felt the staff member acted inappropriately; -During an interview with Certified Nurse Aide (CNA) A, he/she said he/she was assisting the resident, because the resident seemed weak and was not eating. The resident had told him/her to stop, but kept eating when helped; -The facility felt this did not elevate to the level of abuse, but the staff member acted inappropriately. During an interview on 11/12/24 at 2:50 P.M. Resident #2 said: -He/She feeds himself/herself; -CNA A entered his/her room at supper time on 10/27/24; -CNA A broke his/her sandwich into pieces and began sticking it into his/her mouth; -CNA A told the resident, he/she had to eat, because he/she was going to get sick; -He/She tried to turn his/her head away, CNA A followed and kept pushing the sandwich between his/her lips; -He/She told CNA A to stop, but CNA A kept pushing it between his/her lips; -When he/she would open his/her mouth to say no or stop, CNA A would shove a piece of the sandwich in his/her mouth; -Once he/she had eaten about half the sandwich, CNA A took the tray and left the resident's room; -He/She did not report anything that day, but reported to the night nurse; -The Administrator told him/her, he/she would not have to work with CNA A again; -CNA A forced him/her to eat and he/she did not want to. CNA A would not take no as an answer. During an interview on 11/14/24 at 5:02 P.M., Licensed Practical Nurse (LPN) B said: -He/She worked the night shift on 10/27/24; -He/She worked with Resident #2; -Resident #2 reported to him/her that CNA A brought the evening meal tray to his/her room, broke the grilled cheese sandwich into pieces, pushed it into his/her mouth, and when the resident tried to say no, pushed the piece of sandwich between his/her lips. The resident was concerned he/she would choke, so he/she chewed and swallowed the pieces. After a few pieces the CNA took the tray and left the room; -Resident #2 reported this event to LPN B the evening of 10/27/24; -He/She felt this was abuse so he/she notified the Administrator immediately; -The Administrator said he/she would deal with it later; During an interview on 11/12/24 at 1:42 P.M., PTA A said: -He/She arrived to Resident #2's room for therapy on 10/28/24 . The resident was visibly emotionally upset and tearful; -The resident said he/she did not like how he/she was treated by nursing staff; -The resident said he/she was force fed by nursing staff during the evening meal on 10/27/24; -He/She notified LPN A on 10/28/24 what the resident reported to him/her, who said that was impossible as the resident feeds himself/herself; -He/She then immediately went to his/her supervisor (DOT) and reported what Resident #2 had said; -The resident did not have any physical injuries on his/her face that he/she noticed. During an interview on 11/12/24 at 1:10 P.M. the Administrator said: - Once he spoke with the resident he felt the issue was customer service, not abuse. And did not feel it needed to be reported to the State Agency; -He could not recall the date when he spoke with the resident; -The comment of force fed was staff taking liberties with words; -The report that was made indicated the resident said force fed; -The resident said he/she was force fed by the CNA, but the Administrator explained to the resident force fed was holding the resident's head and pushing food into his/her mouth, and he/she said that did not happen; -The staff member should have stopped feeding the resident when he/she said to stop; -The resident had the right to refuse the meal; -He should report allegations of abuse to the State Agency, then investigate the incident.

Based on interview and record review, the facility failed to follow their policy to maintain documentation and complete a thorough investigation of an alleged violation of resident abuse after informed by a staff member that one resident (Resident #2) reported a certified nurse aide (CNA) force fed him/her. This affected one of six sampled residents. The facility census was 82. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Mistreatment means inappropriate treatment of a resident; -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur; -Procedures for investigations include: identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and cause and; - Providing complete and thorough documentation of the investigation. 1. Review of Resident #2's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 10/18/24, showed: -Brief Interview of Mental Status (BIMS) 15, indicating no cognitive deficits; -Set up assistance by staff for eating; -No swallowing/chewing difficulty; -Diagnoses of Congestive Heart Failure (where the heart can't pump enough blood to meet the body's needs), Hypertension (high blood pressure), Muscle Weakness, Type 2 Diabetes Mellitus (where the body does not use or does not produce enough insulin to meet needs), Gastroesophageal Reflux (when stomach contents leak into the esophagus, causing irritation). Review of the resident's admission care plan showed the resident did not need assistance with eating. Review of the facility Grievance Reporting form, dated 10/28/24, untimed, showed: -Physical Therapy Assistant (PTA) A attempted to work with Resident #2; -The resident was crying and frustrated; -The resident reported that he/she had been force fed by a staff member on the evening of 10/27/24; -The form was completed by the Director of Therapy (DOT) and signed by the Administrator. Review of seven Resident Questionnaire forms, dated 10/30/24, completed by the Social Service Director showed: other residents were not made to feel uncomfortable, been threatened by anyone, witnessed anyone being mistreated and felt safe in the facility. Review of the Investigation Summary, dated 10/31/24, completed by the Administrator, showed: -Resident #2 had complained a staff member pushed him/her to eat a meal, when he/she was more than able to feed himself/herself and refuse food if he/she did not want to eat it; -The resident reported he/she kept telling the staff member that he/she did not want to eat, the staff kept trying to feed him/her manually and eventually stopped; -The Administrator assured the resident he/she would not have to work with the staff member again as he felt the staff member acted inappropriately; -During an interview with CNA A, he/she said he/she was assisting the resident, because the resident seemed weak and was not eating. The resident had told him/her to stop, but kept eating when helped; -The facility felt this did not elevate to the level of abuse but the staff member acted inappropriately. -Further review showed the facility did not complete staff statements or statements from the Alleged Perpetrator (AP). During an interview on 11/12/24 at 2:50 P.M., Resident #2 said: -He/She feeds him/herself; -CNA A entered his/her room at supper time on 10/27/24; -CNA A broke his/her sandwich into pieces and began sticking it into his/her mouth; -CNA A told the resident he/she had to eat, because he/she was going to get sick; -He/She tried to turn his/her head away, CNA A followed and kept pushing the sandwich between his/her lips; -He/She told CNA A to stop, but CNA A kept pushing it between his/her lips; -When he/she would open his/her mouth to say no or stop, CNA A would shove a piece of the sandwich in his/her mouth; -Once he/she had eaten about half the sandwich, CNA A took the tray and left the resident's room; -He/She did not report anything that day, but reported to the night nurse; -The Administrator told him/her, he/she would not have to work with CNA A again; -CNA A forced him/her to eat and he/she did not want to. CNA A would not take no as an answer. During an interview on 11/14/24 at 2:09 P.M., CNA A said: -The Administrator called him/her several days later and informed him/her the facility was severing his/her work environment. -He/She was unaware of any problems with Resident #2 until he/she was called by the Administrator 4 or 5 days after the incident. During an interview on 11/14/24 at 5:02 P.M. Licensed Practical Nurse (LPN) B said: -He/She worked the night shift on 10/27/24; -He/She worked with Resident #2; -Resident #2 reported to him/her that CNA A brought the evening meal tray to his/her room, broke the grilled cheese sandwich into pieces, pushed it into his/her mouth, and when the resident tried to say no, pushed the piece of sandwich between his/her lips. The resident was concerned he/she would choke, so he/she chewed and swallowed the pieces. After a few pieces the CNA took the tray and left the room; -He/She felt this was abuse so he/she notified the Administrator immediately; -The Administrator said he/she would deal with it later; -The Administrator did not come in during his/her shift on 10/27/24. -The Administrator did not question him/her about the incident. During an interview on 11/12/24 at 1:42 P.M., PTA A said: -He/She had gone to Resident #2's room for therapy. The resident was visibly emotionally upset and tearful; -The resident said he/she did not like how he/she was treated by nursing staff; -The resident said he/she was force fed by nursing staff; -He/She notified the Charge Nurse who said that was impossible as the resident feeds himself/herself; -He/She was not sure of the Charge Nurse's name, he/she just knew to report any complaint of abuse to the Charge Nurse; -He/She then immediately went to his/her supervisor (DOT) and reported what Resident #2 had said; -The Administrator, Social Service Director, or Director of Nursing did not interview or discuss the incident with him/her. During an interview on 11/12/24 at 1:52 P.M. the Social Service Director said: -She had met the resident on admission, only saw him/her in the hall, until 10/30/24 when she talked with the resident about the incident on 10/27/24; -She interviewed the resident by phone, as the resident went to the hospital on Monday 10/28/24 and the incident had occurred over a weekend; -She did interviews with other residents later in the week just to follow up for the filed grievance; -The resident reported to her that he/she was force fed by CNA A; -The resident reported the CNA kept holding the food up to his/her mouth and telling him/her to take it. During an interview on 11/12/24 at 1:10 P.M. the Administrator said: -Once he spoke with the resident he felt the issue was customer service, not abuse. -The comment of force fed was staff taking liberties with words. -The report that came to him did read force fed. -He explained to the resident force fed was holding the resident's head and pushing food into his/her mouth, and he/she said that did not happen. -Residents were interviewed on 10/30/24 by the Social Service Director. -The summary of the incident was written on 10/31/24, but the investigation began immediately. -The staff member should have stopped feeding the resident when the resident said to stop; -The resident had the right to refuse the meal. -He should investigate the incident immediately. -He did not obtain staff statements and statements from the AP as he did not feel this was abuse and did not need a full investigation. During an interview on 11/12/24 at 1:52 P.M. the Social Service Director said: -She had met the resident on admission, only saw him/her in the hall, until 10/30/24 when she talked with the resident about the incident on 10/27/24; -She interviewed the resident by phone as the resident went to the hospital on Monday 10/28/24 and the incident had occurred over a weekend; -She did interviews with other residents later in the week just to follow up for the filed grievance; -The resident reported to her that he/she was force fed by CNA A; -The resident reported the CNA kept holding the food up to his/her mouth and telling him/her to take it.

Based on interviews and record reviews, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of four sampled residents (Resident #3). Staff failed to monitor and assess the resident's blood glucose readings and administer insulin according to the physician's orders when Levemir insulin was ordered on 11/28/23 to be given subcutaneos daily at 8:00 P.M., The facility staff failed to give the resident the medication on 11/28/23 and 11/29/23, resulting in the resident being sent to the hospital with a critically elevated blood glucose level. The facility census was 82. Review of the facility provided policy Notification of Changes dated 9/1/21 showed: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician when there is a change requiring notification; -Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status that may include life threatening conditions or clinical complications; -Circumstances that require a need to alter treatment. The facility did not provide a medication administration policy. Review of the facility provided policy Medication Reordering dated 9/1/21 showed: -It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medication in a timely manner to meet the needs of the resident; -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; -In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the physician; -Stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a sealed emergency box and may be used if applicable. 1. Review of Resident #3's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 11/23/23 showed: -Brief Interview of Mental Status: 15, indicated no cognitive loss; -No behaviors; -Set up to partial assist of staff for Activities of Daily Living (ADL's: fundamental skills required to independently care for oneself, such as eating, bathing, dressing, and mobility); -Occasional incontinence of bladder; -Insulin was not indicated; -Diagnoses of :Diabetes Mellitus (a condition when your body cannot produce enough insulin, or the insulin it produces is not effective, and causes unstable levels of glucose(sugar) in the blood). Chronic Kidney Disease (long term disease where the kidneys don't filter waste effectively). Hypertension (high blood pressure) and Urinary Tract Infection. Review of the resident's Comprehensive Care Plan dated 11/24/23 showed: -The resident will have no complications related to diabetes; - Administer Diabetes medication as ordered by the doctor; -Monitor and document for side effects and effectiveness of medications; - Monitor, document and report, as needed, any signs and symptoms of hyperglycemia such as: Increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, fruity smelling breath or stupor (a state of near-unconsciousness or insensibility) and coma. Review of the resident's lab report dated 11/29/23 showed: -Glucose level of 755 milligrams/deciliter (mg/dl). Normal range of 65 mg/dl to 125 mg/dl; -Indicated on report as critically high. Review of the Physician orders for November 2023 showed: -NovoLOG (Rapid-Acting Insulin is a mealtime insulin made to help control blood sugar spikes ) Pen 100 UNIT/ML, Inject as per sliding scale: if blood glucose 150 - 200 milimoles per liter (mmol/l : the measurement for molecular blood sugar) = 2 units; 201 mmol/l - 250 mmol/l = 4 units; 251 mmol/l - 300 mmol/l = 6 units; 301 mmol/l - 350 mmol/l = 8 units; 351 mmol/l - 400 mmol/l = 10 units over 400 call the physician ., subcutaneous (under the skin) as needed for hyperglycemia (high blood sugar) order date of 11/17/23; -Accucheck (blood glucose check) once a day every Monday. Order date 11/20/23; -Levemir (long-acting insulin that can be taken once or twice daily to control high blood sugar) 100u/ml; 10 units subcutaneous at bedtime for diabetes. Order date 11/28/23 at 9:50 A.M. Review of the Medication Administration Record (MAR) dated November 2023 showed 11/28/23 and 11/29/23 at 8:00 P.M. Levemir 100 U/ml, give 10 units subcutaneous at bedtime, was not given due to awaiting delivery, signed by LPN D. Review of the Resident's Nurse Progress notes showed: -11/29/23 at 6:40 A.M. Licensed Practical Nurse (LPN) D documented: Levemir 100 UNIT/ML Inject 10 unit subcutaneous at bedtime for diabetes not administered due to waiting on pharmacy delivery; -11/29/23 at 12:44 P.M. LPN C documented His/Her skin color appeared pale, denied any pain, complained of not feeling well and his/her whole body felt bad. His/Her covid test was negative. Blood Pressure (BP) 113/72, Pulse 104, Respirations 18, Oxygen saturation 93-94% on room air. He/she stayed in bed all morning. Will call the house physician for orders; -11/30/23 7:14 A.M. LPN D documented Levemir 100 UNIT/ML Inject 10 unit subcutaneous at bedtime for diabetes not administered due to waiting on pharmacy delivery. Review of the hospital record dated 11/30/23 showed: - The resident arrived to the Emergency Department (ED) on 11/30/23; - The facility staff reported the resident had increased confusion and decreased alertness for the past two days; - The resident's blood sugar was 700 on 11/29/23, the facilty staff said the resident had not received insulin because he/she had a new insulin order they were waiting for delivery of; - His/Her blood glucose was 1000 in the ED; - His/Her blood urea nitrogen, (BUN, a lab test that measures how well the kidneys are working) was 107, (normal range 9-23), critically high; - His/Her creatinine (another blood test that measures kidney function) was 3.45 (normal range 0.50 to 1.30) was high.; - He/She received insulin intravenously (IV); - He/She was admitted to the hospital with the following diagnoses: UTI with sepsis (a serious infection that can be life threatening), diabetic ketoacidosis (DKA, a condition when there is not enough insulin in the body causing the blood sugar to rise to dangerous levels and can decrease kidney function), and kidney failure. During an interview on 12/1/23 at 1:52 P.M. LPN C said the resident told the staff he/she was not feeling well. Observation of the facility's locked emergency medication kit (E-kit) on 12/1/23 at 1:30 P.M. showed Levemir Flextouch 100 units/ml pen was in the locked E-Kit. During an interview on 12/6/23 at 10:30 A.M. LPN D said: - He/She did not administer the resident's ordered Levemir on 11/28/23 and 11/29/23 because he/she did not have time to look for the medication and give it to the resident; - He/She was busy providing residents on two halls with treatments and blood sugar checks and insulin's. By the time he/she had time to give the resident his/her insulin, it was 3:00 A.M. and he/she had charting to do; - He/She documented the medication was not available and did not call the physician when he/she thought the medication had not arrived to the facility from the pharmacy; - He/She did not look in the medication cart for the medication; - He/She did not look in the E-Kit for the medication. During an interview on 12/6/23 at 12:45 P.M. pharmacy representative A said: - The pharmacy delivered Levemir 100u/ml; 10 units subcutaneous at bedtime for diabetes for the resident on 11/28/23 at 4:26 P.M; - LPN B signed for the medication delivery. During an interview on 12/6/23 at 1:30 P.M. LPN B said: - He/She signed and accepted the pharmacy delivery for the facility on 11/28/23; - The normal procedure is one nurse accepts and signs the pharmacy delivery and then he/she takes the medications to the appropriate nurses station; - He/She delivered the facilities medications to the appropriate nurses stations on 11/28/23. During an interview on 12/1/23 at 3:00 P.M. The Director of Nursing (DON) said: - She was not aware that the resident had an insulin order that was not given by LPN D; - She expected LPN D to give the medication as the physician ordered it; - Insulin administration is a nurses duty; - She expected all of the nurses to complete their duties. During an interview on 12/1/23 at 3:10 P.M. The Administrator said: - He expected the nurses to give residents medications as the physician has ordered them; - Levemir was available in the E-Kit for use if it was not delivered by the pharmacy; - He expected LPN D to give the resident the ordered Levemir and if it was not available for use to call the pharmacy and the facility would have picked up the medication. During an interview on 12/6/23 at 3:00 P.M. Primary Care Physician (PCP) said: - The facility staff did not notify him the ordered Levemir was not administered to the resident; - He expected the facility staff to contact him if the Levemir was not given to the resident; - If the facility staff had called him, he would have ordered another medication; - It is not ok for the facility nurse to not give the medication due to time constraints. MO228107

Based on observation, record review, and interviews, the facility failed to ensure two of four sampled residents' (Resident #1 and #2) environments remained free of accident hazards which resulted in Resident #1 falling out of bed and suffering multiple rib fractures, a fractured humerous, facial bruising, and cuts that required stitches to the face, chin and elbow and had the potential for Resident #2 to fall out of bed. Staff failed to ensure Resident #2's low-air loss mattress (an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) fit the bed properly, failed to ensure staff knew what settings the low air loss mattresses should be on for Resident #1 and #2, and failed to ensure Resident #1, who had been assessed as needing bed rails for bed mobility, had bed rails in place to assist him/her with turning in bed during personal care, and failed to ensure the bed rails on Resident #2's bed rails were in good repair. Staff also failed to ensure two staff assisted Resident #1, who had been assessed as requiring two staff for bed mbility, assisted the resident in turning to his/her side during personal care. The facility's census was 81. Review of the facility's undated Mattress Selection Algorithm, provided by the facility as their policy for the use of low air loss mattresses, showed the algorithm asked the question Does the resident have a pressure ulcer? then directed staff to follow the following pathways: - Yes: Is the pressure ulcer a Stage 3 (a full-thickness loss of skin, in which 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); if yes, implement a low air loss mattress; - No, not a Stage 3: Stage 1 (intact skin with non-blancable redness of the localized area usually over a bony prominence; darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues) or Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister): * Panacea Immerse Mattress (brand of mattress): o Three distinct zones create varying levels of pressure redistribution; o Enhanced pressure redistribution zones are engineered specifically for high-risk open areas including head, shoulders, hip, legs and heels; o Open-cell Visco Elastic top-layer foam core removes body heat at a greater rate than conventional foams o Built-in firm foam perimeters make for easier transfers and help prevent falls. OR *Panacea Support (a brand of support): o May be appropriate through Stage 2 wounds; o Mattress wound stage rates are general usage guidelines o Resident specific assessment could alter your particular use of these mattresses. - The algorithm did not give parameters for the settings for the bed or talk about setting for other types of mattresses used in the facility and did not direct who would be responsible to ensure the beds were on the correct settings. Review of the facility's falls guidelines, provided as their policy, dated February 2017, showed the purpose was to establish as process that identifies risk and establishes interventions to mitigate the occurrence of falls. The process included on admission: - Newly admitted or readmitted residents are assessed for fall risk; - When a risk factor for falls is identified, a corresponding intervention addressing that risk factor is developed; - When the risk is identified, the intervention is documented on the care plan and on the caregiver guide; - The identified intervention is initiated. Review of the facility's skin care guidelines, provided as their policy for pressure ulcer treatment and prevention, dated July 2018, showed a purpose to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. The process included: - Anyone utilizing a wheelchair as a primary mode of transportation will have a pressure redistribution cushion; - Pressure redistribution mattresses are in place; - The guidelines included a pressure ulcer flow diagram for staff to follow which included implementing specialty mattresses/pressure reduction mattresses on the resident's bed; - Nothing in the skin care guidelines discussed or gave staff direction on ensuring the settings on the specialty mattresses/pressure reduction mattresses such as ensuring the proper settings and who was responsible for tracking the settings. The facility did not have a policy to address the use of bed rails or side rails. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/6/22, showed: - A Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment; - Did not exhibit any behaviors; - Extensive assistance by two staff for bed mobility (how the resident moves to and from lying position, turns side to side and positions while in bed or alternate sleep furniture); did not transfer from bed or chair; extensive assistance of one staff for personal hygiene and toilet use; - Always incontinent of bladder and bowel; - Diagnoses included: Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, heart failure, diabetes, arthritis, other fracture; - Had experienced pain in the last five days and take scheduled pain medications; - No history of falls; - Did not indicate the resident had had other orthopedic surgeries; - At risk for development of pressure ulcers; no open areas at the time of the assessment; used pressure reducing device for chair and for bed; - Did not use any type of restraints or bed rails. Review of the resident's undated, current care plan, provided by the facility on 8/17/22, showed: - At risk for pressure ulcer/skin breakdown due to assistance required in bed mobility, bed fast, bowel incontinence, and diagnosis of diabetes with a goal that his/her skin will remain intact through next care review. Staff listed the following interventions: o Pressure relieving cushion to chair; o Provide low air loss mattress; the plan did not include what the pressure setting of the mattress should be; o Provide thorough skin care after incontinent episodes and apply barrier cream - Had an Activities of Daily Living (ADL) self-care performance deficit related to external fixation device on leg with a goal to improve current level of function in all ADLs through the review date (no date listed). Staff listed the following interventions: o Bed mobility: required extensive assistance of two staff to turn and reposition in bed as necessary; o Bedfast: Is bedfast all or most of the time by choice; o Dressing: Required extensive assistance by one staff to dress; o Personal hygiene: required extensive assistance of one staff with personal hygiene and oral care; o Toilet use: required extensive assistance of one staff for toilet use; - At risk for falls related to gait/balance problems, incontinence, anti-depressant use with a goal of him/her not sustaining any serious injury through the review date (no date listed). Staff listed the following interventions: o Anticipate and meet the resident's needs; o Be sure the resident's call light is within reach and encourage to use it for assistance; o Follow facility fall protocol; o The resident needs a safe environment with: (SPECIFY: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; the bed in lowest position at night; side rails as ordered; handrails on walls; personal items within reach). Staff did not specify if any of these were pertinent to the resident. Review of the resident's clinical health status evaluation, completed on 6/8/21 by the Assistance Director of Nursing (ADON), showed: - admitted [DATE]; - Physical functioning ADL: physical assistance required with all ADL functions including bed mobility, toileting and bathing; - Used assistive devices including side rails, splint/brace, and wheelchair; - Fall risk factors: impairment in gait or balance; not ambulatory and incontinent; had a history of falls with a fracture on 3/6/21; impairment of lower extremity strength; diminished awareness of safety; did not indicate they needed to develop a care plan for being a fall risk; - Skin condition: had a history of pressure ulcers (admitted with a pre-existing Stage 2 to gluteal cleft and perineum); - Side rail assessment screen: o Resident was capable of using call light to request assistance; currently uses the side rail for positioning or support; o Side rail did not restrict freedom of movement or normal access to his/her body; o Side rail had been measured and the gaps between the rails themselves and the gaps between the side rail and mattress are conducive to resident safety based on this individual resident; o The head of the bed was elevated to conduct a visual review to assess that the mattress and the side rail did not shift/slide allowing for an increased gap between the bed and the side rail; no safety concerns; o Side rail was not a restraint and will be utilized to enable the resident to attain or maintain his/her highest practicable level. Review of the resident's physician's order sheet (POS), printed on 8/16/22, showed: - Nursing communication: no range of motion of left knee, dated 3/19/22; - Weight bearing as tolerated to bilateral upper extremities, dated 3/19/22; - Pressure redistribution mattress; dated 5/15/21; did not indicate the setting staff should keep the mattress on. Review of the resident's progress notes showed: - 6/24/22 at 6:51 A.M.: resident in bed resting comfortably at this time; transfers with a mechanical lift to wheelchair; staff to push resident in chair; no complaints of pain; cooperative with all care; - 7/8/22 at 6:14 A.M.: resident is alert and oriented to person, place, situation and time; speech clear, able to make needs known verbally; pleasant and cooperative with nursing; staff assists with all ADLs; skin is clean, dry and odor free; remains in bed daily with repositioning every two hours; no new concerns; - 8/14/22 at 12:15 P.M.: this nurse was doing treatments and at the cart when Certified Nurse Aide (CNA) A ran to me and told me the resident fell . When this nurse entered the room, the resident was face down on the floor. This nurse then redirected CNA A to get some more staff to help assist the resident back to bed. This nurse was asking the resident questions to make sure he/she was still conscious. Other staff entered the room and staff assessed the resident and got him/her up in the mechanical lift to the bed. Continued assessing and cleaning up skin tears to right elbow and chin. Resident requested to go to the emergency room (ER). This nurse came to nurse's desk while the other staff stayed with the resident. Called primary care physician (PCP) to request order to send the resident to the ER, then followed by calling registered nurse supervisor (RN) A, who agreed to go ahead and send resident and wait for call from PCP. Called emergency management service (EMS) and gave them report, requested a pick up and then called the resident's family to inform of situation. Pupils were reacting and the resident was alert and able to answer questions correctly throughout whole time frame before EMS arrived. CNA A was educated by this nurse on patient care and positioning of resident while cleaning him/her and safety. - 8/14/22 at 5:05 P.M.: The resident fell from bed to floor approximately 12:15 P.M., resident was receiving peri-care due to incontinent bowel movement; resident stated his/her stool was hard and his/her rectum hurt while being wiped. Resident stated he/she scooted away from the CNA to make the pain stop, thus sliding off the bed. CNA stated he/she had positioned resident lying on his/her left side, with his/her left leg straightened and behind the top right leg. Right leg was bent at the knee and hip, in front of the bottom left leg. Right arm was extended forward and resting on the bed. Bed was at hip level for CNA. CNA stated he/she positioned the resident's side, then performed peri-care, after multiple wipes, the resident jumped forward, clenching his/her buttocks and thrusting his/her pelvis forward, which caused the resident to slide out of bed. The resident fell in supine position off the left side of the bed. This nurse was alerted to the fall. This nurse observed bruising and swelling to the resident's nose, including the bridge of the nose, bleeding noted from both nares, swelling and bruising noted to chin, bleeding noted from chin. Large hematoma noted to area below chin on the soft side of the jaw line. Skin tear and bleeding noted to right elbow. Approximately 6 centimeters (cm) in length, not approximated, irregular in shape. Resident was lying prone when this nurse performed assessment. Passive range of motion to all joints, resident complained of 10/10 pain to right elbow and left lower extremity upon movement. Resident alert and oriented, neurological checks at baseline to resident, vitals stable. Resident stated he/she wanted to go to the ER, PCP notified. This nurse received order to send resident to ER to treat and evaluate; family notified. DON and administrator notified, maintenance notified of need for hand rails, resident was sent to ER at approximately 12:25 P.M. - 8/14/22 at 5:50 P.M.: This nurse spoke with the ER nurse and confirmed resident is being admitted for rib fractures to the right side, small fracture to the right humerus in upper arm. Observation and interview on 8/17/22 at 10:00 A.M., showed and the resident said he/she was lying on his/her side in bed while CNA A cleaned him/her up after a bowel movement. He/she did not feel safe laying on the edge of the bed. He/she told the CNA multiple times he/she did not feel safe, but CNA A said he/she was almost finished and would make it quick. As CNA A wiped his/her buttocks, it began to hurt as he/she had a raw place on his/her bottom and the fecal material was hard. He/she clinched and when he/she did this, he/she rolled face first out of the bed. He/she had been holding on to the air mattress but it gave way underneath him/her and down he/she went. He/she used to have side rails on the bed to help him/her move around but they were removed or something so he/she did not have them anymore. He/she said he/she had fractured ribs from the fall. The resident appeared in obvious pain during the interview. He/she had dark purple bruising to both eyes, his/her nose and around his/her mouth and down his/her neck. The resident had stitches in the middle of his/her face under his/her nose and under his/her chin. The resident had stitches on his/her elbow and his/her right arm was in a sling. During an interview on 8/17/22 at 11:55 A.M. and 1:05 P.M., CNA A said the resident required total and extensive assistance with all care staff provided. The resident can roll in bed on his/her own. It was usual for him/her to change the resident with only one staff member, but she felt it was better to provide care using two staff. He/she did not know where the other CNAs who were scheduled with him/her that day were. He/she just knew the resident needed to be changed so he/she thought he/she could do it without any problems. They use two staff always to pull the resident up in bed. The resident can role side to side and staff barely help him/her anymore. The day the resident fell , he/she went to change him/her like every other day. The resident had a bowel movement while he/she had him/her rolled to the side and it was definitely in his/her butt crack. The resident told him/her he/she was working with a limited amount of room on the side of the bed. He/she did not remember the resident saying he/she did not feel safe or that he/she felt like he/she was going to fall, just that he/she was working with a limited amount of room. He/she was almost finished with peri-care and he/she thought he/she had more time, then the resident fell . The resident used to have side rails to help him/her move in bed, but does not now. He/she did not know when the rails were removed. The resident was on an air mattress which does not have a sheet on it, only a bath blanket. The resident would have only had the mattress to hang on to when lying on his/her side. Observation and interview on 8/17/22 at 1:05 P.M., showed the resident's room contained an air mattress which was owned by the facility. The bed was set at Soft X1 alternating. CNA A said he/she did not pay attention to the settings on the mattress, he/she thought the charge nurses took care of that. The CNA said the resident's roommate always kept the television volume up loud so he/she could hear it. It could have made it difficult for him/her to hear if the resident had expressed he/she felt afraid on the side of the bed before he/she fell . During a telephone interview on 8/31/22 at 11:20 A.M., RN A said he/she was working as the weekend supervisor on 8/14/22 when the resident fell out of bed. According to the interview with CNA A after the fall, the CNA had the resident positioned correctly to provide peri-care. CNA A was wiping the resident's bottom and he/she was a little sore. He/she wiped the resident's bottom once lightly which caused the resident some pain, and with the second wipe, the resident flinched forward and rolled out of bed. He/she interviewed the resident at the time of the incident before he/she went to the hospital and he/she moved and rolled out of bed. He/she would not have expected CNA A to reposition the resident before proceeding as, according to CNA A, it all happened so fast. He/she did not know what the setting should be for the low air loss mattresses. He/she thought that would be between the charge nurse, DON, physician, and wound care provider to determine what the mattresses should be set on. The facility did not provide any manufacturer's guidelines for the facility owned A.E.D.A Healthcare mattress. Review of the hospital records, dated 8/14/22, showed: - The ER documents: history of congestive heart failure (CHF), high blood pressure, diabetes, anxiety, depression, asthma, post-traumatic stress disorder (PTSD) who presents to the ER with facial pain slip fall around 12:00 P.M. today. Patient states that he/she was getting rolled over in the bed by the nursing home staff and he/she was near the edge of the bed on his/her side when he/she fell and hit the ground. He/she stated he/she hit his/her face, chin, right arm on the ground. He/she denied loss of consciousness. He/she does not ambulate at baseline and is wheelchair-bound. He/she now reports weakness of the right upper extremity as well as paresthesias (an abnormal sensation, typically tingling or pricking pins and needles, caused chiefly by pressure on or damage to peripheral nerves) of the right hand. Additionally complains of neck pain, chest pain, short of breath, left knee pain, right elbow pain. He/she denied back pain, abdominal pain, lower extremity numbness or weakness or any other symptoms this time. - 8/14/22 at 2:29 P.M., CT scan of the abdomen/pelvis with contrast: Multiple right anterior rib fractures are noted. - 8/14/22 at 2:29 P.M., CT scan of the chest with contrast: Multiple right anterior rib fractures are noted. - 8/14/22 at 3:12 P.M. diagnostic x-ray of chest showed questionable right humeral non-displaced fracture. - 8/14/22 at 6:13 P.M. Chief Complaint: I was rolled over in bed while they were changing me and I was too close to the edge and I fell . Presents to the ER today with complaints of I was rolled over in bed while they were changing me and I was too close to the edge and I fell . He/she reports that he/she was rolled over on his/her left side to be cleaned up and changed and reports that he/she felt that he/she was too close to the edge of the bed and told the staff who had him/her rolled over and told them that I only have the mattress to hold onto and states the next thing I knew I was flat on my face on the floor. He/she states that he/she had instant pain to his/her right arm, shoulder, and side as well as his/her face and head. He/she states that since then he/she has had pain in his/her chest more on the right with cough or breathe deep. He/she states that he/she is worried because I landed on both my knees as well and my left leg is still healing from my last surgery where I fell and it was fractured. He/she states that he/she has been waiting for it to heal to do more rehab and that he/she had not recently been feeling ill. He/she states that his/her pain in his/her arm, shoulder, and chest wall that he/she has now was helped when he/she received pain medication here in the ER as well as if I just don't move it doesn't hurt as bad. o Impression and Plan: Admit to observation. It is my reasonable expectation that this patient's stay in the hospital will span less than two midnights. o Fall; acute, from bed at nursing home, while being rolled by staff to change, cardiac monitor continuous, monitor intake and output, daily weight, bedrest until seen by Ortho and Neurosurgery, further activity and physical therapy orders per Ortho and Neurosurgery, further plan as below o T4 Compression Fracture; acute, likely secondary to fall, will consult neurosurgery, in C-Collar at this time, removal per neurosurgery recommendations, further activity and physical therapy orders per ortho and neurosurgery, further plan as below o Proximal Humerus Fracture; acute, Right, secondary to fall, ortho already consulted in ED, sling being placed to right arm in ED, further activity and physical therapy orders per ortho and neurosurgery, further plan as below o Rib Fractures; acute, Right, ribs 3-7, secondary to fall, will have nursing clarify allergic reaction to lidocaine, if only to viscous lidocaine would consider starting Lidoderm patch to Right ribs for pain relief, will start Oxycodone (a narcotic pain medication) 5 milligrams (mg) by mouth every 6 hour for as needed (PRN) pain, hold if lethargy or sedation, fentanyl patch 12 micrograms per hour (mcg/hr) topically every 72 hours for steady state pain relief, due to multiple pain medication intolerances/allergies, hold if lethargy or sedation, turn, cough, deep breathe every hour while awake, Mucinex for PRN cough/congestion, encourage mobility once seen by ortho and neurosurgery and further activity and physical therapy orders obtained from them o Rib pain; acute, right, secondary to rib fractures, plan as above o Arm Pain; acute, right secondary to proximal humerus fracture plan as above o Lacerations; acute, to chin, lower lip, and right elbow, being repaired in ER at this time, will consult wound care for wound treatment recommendations During an interview on 8/17/22 at 1:30 P.M., the resident's PCP said: - He knew the resident had fallen out of bed while staff provided peri-care. - He did not believe the staff member did anything wrong that caused the resident to fall out of the bed. - He was told the resident jumped forward which caused him/her to roll out of the bed. - If the resident required two for bed mobility, they should have two staff present. - The facility should have a policy directing them on how to ensure the low air loss mattresses were at the proper settings. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: - A BIMS score of 15, which indicated no cognitive impairment; - Extensive assistance from two staff with bed mobility, transfers, dressing, toileting and personal hygiene; - Diagnoses included Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling), high blood pressure, renal insufficiency, diabetes, other fracture, cerebral palsy, depression, morbid obesity; - At risk for pressure ulcers; had more than one unhealed Stage 1 or higher pressure ulcer; one Stage 3 pressure ulcer and no Stage 4 pressure ulcers; - Has pressure reducing device in chair and for bed; turning and repositioning program; - Did not use bed rails as a restraint. Review of the resident's care plan showed: - Date initiated 9/2/21 and last revised on 6/15/22: altered skin integrity related to potential for breakdown due to decreased mobility and incontinence, Stage 3 pressure ulcer to coccyx with a goal of having the area healed without complications by next care review. Staff implemented the following interventions: o Provide pressure reducing wheelchair cushion o Provide pressure reduction/relieving mattress; the care plan did not specify the setting for the resident's mattress - Date initiated 2/10/22 and revised on 6/15/22: Stage 3 pressure ulcer to coccyx since admission with a goal for the pressure ulcer to heal without complications. Staff implemented the following interventions: o Provide pressure reducing wheelchair cushion; o Provide pressure reducing/relieving mattress; this care plan did not specify the settings for the resident's mattress; - Date initiated 4/21/22: had restorative (RA) active range of motion and bed mobility program; will participate in RA program three times a week by next review. Staff implemented the following interventions: o All rest breaks as needed o Encourage to attend out of bed activities of choice o Encourage to participate in RA program and document refusals o If refuses, try again at a different time or day o The plan did not discuss the resident's use of bed rails for bed mobility Review of the resident's POS, printed on 8/18/22, showed an order dated 8/4/21, for pressure redistribution mattress. The order did not address the settings the mattress should be on for the resident. Observation and interview on 8/17/22 at 1:10 P.M., showed and the resident said he/she had pressure ulcers so the facility had him/her on an air mattress. He/she said the mattress was too big for his/her bed frame and he/she did not feel safe in the bed. Sometimes only one staff provided care for him/her and he/she feels unsafe when he/she rolls to the right. Observation showed the resident's mattress hung over the right side of the bed frame approximately 6 inches and approximately 2 inches past the foot of the bed. The resident had two small cane rails located by his/her head attached to the bed. The cane rail on the right side of the bed was almost perpendicular to the bed. The resident said he/she could not use the rail to roll to the right side because it was broken. During an interview on 8/17/22 at 1:30 P.M., the resident's PCP said he was familiar with the resident. He knew he/she was on a low air loss mattress. He did not know what the settings should be for the mattresses. The facility should be monitoring those settings and he expected the charge nurse to know what the settings were. He would not necessarily expect the CNAs to know what the settings are. He expected the facility to ensure that side rails are in place for residents who need assistance for bed mobility and that they were installed corrected and not broken. The facility did not provide any manufacturer's guidelines on the use of the Medilogix mattress used by the resident. 3. During an interview on 8/17/22 at 2:02 P.M., LPN B said he/she worked for an agency. No one has told him/her who was supposed to monitor the settings on the low air loss mattresses. He/she did not know if there was any place to document that the settings where correct. He/she had not noticed the broken side rail on Resident #2's bed. During an interview on 8/17/22 at 2:07 P.M., CNAs D and E said they do not do anything with the low air loss mattresses. If they thought there was an issue, they would tell maintenance or the charge nurse. They thought the bed company determined the settings. It varied with Resident #1 on if he/she could roll from side to side without assistance. During an interview on 8/17/22 at 2:10 P.M., LPN A said he/she believed that someone, but did not know who, came in and made recommendations for the settings of the bed. As far as he/she knew, it was not documented anywhere what the settings should be. In other facilities he/she has worked in, the physician would make recommendations and set the settings for the beds. Their electronic medical record (EMR) asks them to check to make sure the bed is on, but does not say what the settings should be. If there was an issue with the bed, he/she would call the number listed on the bed or talk to the ADON or DON about the bed. He/she had not noticed that Resident #2's bed did not fit the frame. He/she is a bariatric resident and needed a larger mattress and frame to accommodate his/her size. He/she had provided care for both Resident #1 and #2 but neither have said they felt unsafe when moving in the bed. He/she always made sure the resident was positioned in the center of the bed to provide care when doing it alone. If the care plan says a resident needed two staff for bed mobility, there should have been two staff to have the resident roll to his/her side for peri-care. They may only need one to provide the actual care, but the second person would be needed to assist in moving the resident. Side rails would have aided Resident #2 in rolling to the side. During an interview on 8/17/22 at 2:20 P.M., CNA C said aides do not know what the settings for the low air loss mattresses should be. If it was not working, he/she would check to be sure it was plugged in, but that was all he/she could do besides telling his/her charge nurse. Resident #1 could hold him/herself on his/her side at times but other times could not. It just depended on the day. During an interview on 8/17/22 at 3:30 P.M., the Administrator, ADON, and MDS Coordinator said they did not know Resident #1's bed did not fit the frame. The Administrator said she thought the frame was one that adjusted to fit the mattress. She did not realize it hung that far off the frame. They did not have any manuals or a policy for any of the facility-owned low air loss mattresses. They relied on the company who brought in the beds to ensure the setting were correct. They did not have a policy for the use of side rails in the facility and only used the algorithm they provided for the use of low air loss mattresses. They did not know that what the resident reported was what happened as the resident sometimes manipulated things due to mental health issues. It is possible the resident said he/she did not feel safe if his/her roommate's television was turned up loud. They did not feel the CNA did anything wrong. The ADON said she had provided care to Resident #1 alone in the past and felt it was safe. She believed that the two-person assist was for pulling the resident up in bed. She did not see it as rolling side to side. Resident #1 had a side rail assessment on admission and had side rails for bed mobility at one time. They did not know when they were removed but thought it was probably around the time of their COVID-19 outbreak when residents were moved from room to room for isolation and beds were changed. If he/she was assessed as needing the rails for bed mobility, he/she should have had them on the bed. Side rails should be installed safely and if the rail did not fit the bed with a bariatric mattress, it should be replaced. They felt what happened to Resident #1 was a horrible accident. During an interview on 8/17/22 at 4:10 P.M., Nurse Aide (NA) A said he/she did not feel comfortable rolling either resident to their side when doing peri-care alone, but he/she had done it. He/she did not know anything about the low air loss mattresses. During an interview on 8/17/22 at 4:15 P.M., CNA B said he/she di [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure staff provided proper emergency care for two residents (Residents #1 and #3). The facility failed to ensure staff performed post fall vital signs and neurological checks for two resident (Residents #1 and #3). The facility failed to ensure staff notified one resident's physician (Resident #3) of an abnormal blood pressure. Facility staff also failed to order one resident's (Resident #2) narcotic medication in a timely manner to ensure the resident had adequate pain relief. The facility census was 67. 1. Review of the undated facility neurological flow sheet showed: - Staff should perform checks every 15 minutes for one hour; - Every 30 minutes for two hours; - Every hour for two hours; - Every shift for 72 hours. The facility did not provide a policy on post fall care. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/19, showed the resident: - Cognitively impaired; - Required extensive staff assistance for dressing, hygiene, and toileting; - Frequently incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - Medications included antipsychotic medications, blood thinners, diuretics, and pain relievers. - Had two non-injury falls since the last assessment; - One minor injury fall since the last assessment. Review of the resident's laboratory results drawn on 9/17/19 showed: - Hemoglobin A1C (a test for blood sugar) 7.4% (normal 4.0% - 5.6%); - Blood urea nitrogen (a test of kidney function) 46 milligram per deciliter (mg/dl) (normal 7 mg/dl - 20 mg/dl); - Creatinine 1.6 mg/dl (normal 0.6 mg/dl - 1.2 mg/dl). Review of the resident's nurses' notes dated 9/20/19 at 11:45 [NAME]M. by Licensed Practical Nurse (LPN) A showed: - He/She called the resident's labs to his/her physician; - He/She told the physician that the resident was lethargic and not eating; - The resident's physician did not provide any new orders. Review of the resident's medical records showed: - The resident fell out of his/her wheelchair in his/her room on 9/20/19 at 12:00 P.M.; - Staff assessment of the resident showed the resident had pinpoint pupils and were non-reactive; - There were drops of blood around the resident's head. Review of the resident's hospital transfer form, dated 9/19/19 (should say 9/20/19) at 3:14 P.M., showed: - Blood pressure 90/48 (120/80 is a normal blood pressure); - Pulse 52 (normal pulse is 60 to 100 beats per minute). Review of the resident's emergency room report, dated 9/20/19 at 3:38 P.M., by the emergency room physician showed: - The resident presented with altered mental status due to falling face first from his/her wheelchair. - Pupils did not react to light. - Temperature 87.6 degrees Fahrenheit; - Impression pneumonia, altered mental status, fall, closed head injury; - Received two liters of intravenous fluid due to [MEDICAL CONDITION] (low blood pressure); -[MEDICAL CONDITION] (the body's life-threatening response to an infection that can lead to tissue damage, organ failure, and death) due to low body temperature, low blood pressure, and altered mental status. During an interview on 9/24/19 at 9:50 [NAME]M., the Assistant Director of Nursing (ADON) said: - LPN A sent for him/her because the resident had fallen; - Certified Nurse Assistant (CNA) A and CNA B were in the room with the resident; - He/She found the resident on the floor with a goose egg on his/her head; - The resident was actively bleeding from several skin tears on both arms; - The resident was not talking; - The resident's eyes were open with pinpoint pupils; - He/She did not do a full set of vital signs (temperature, pulse, respirations, and oxygen saturation); - He/She had staff assist her to put the resident back in bed using a mechanical lift; - He/She did not want him to lie on the ground and be uncomfortable. - Staff did not assess the resident for any other injuries. During an interview on 9/24/19 at 9:10 [NAME]M., the Director of Nursing (DON) said: - On 9/20/19 he/she was walking down the hall and saw a Hoyer (mechanical lift) outside of the resident's room; - The resident was on the floor with spots of blood on the floor. During an interview on 9/24/19 at 10:05 [NAME]M., CNA A said: - The resident normally did not need assistance with eating or drinking and was usually very alert; - On 9/20/19 at breakfast the resident was lethargic and needed to be fed; - He/She told the charge nurse that the resident was lethargic and needed to be fed; - The resident was sitting in his/her wheelchair about 10 minutes prior to the fall; - Another resident's family came and got him/her and said the resident was on the floor; - He/She found the resident on the floor, unresponsive, in a puddle of blood approximately eight centimeters (cm) in diameter; - The charge nurse did not apply pressure to stop bleeding; - He/She went to get the ADON; - He/She suggested to the ADON that the resident be left on the floor; - The ADON said to get the Hoyer and assist with moving the resident to bed; - No staff checked the resident's neck, hips, or legs prior to moving him/her; - He/She did a set of vitals with blood pressure (BP) 90/40, pulse 45, and pupils were pinpoint and did not react to light; - Staff put the resident in bed with his/her head flat; - The Emergency Medical Staff (EMS) asked why the facility did not call sooner. During an interview on 9/24/19 at 10:40 [NAME]M., CNA B said: - He/She told the charge nurse that the resident did not act like him/herself that morning; - Normally the resident did not need assistance with meals; - That morning the resident just looked at the food and did not know what to do; - He/She told the charge nurse that the resident had a change in condition; - He/She was providing care for another resident when a resident's family asked him/her to come check a resident that was on the floor; - He/She found the resident on the floor; - The resident was not responsive and lying in a puddle of blood; - No staff applied pressure to the bleeding wounds; - The charge nurse and the ADON said to help them get the resident back in bed using the Hoyer; - He/She suggested that since the resident had fallen, the resident should stay on the floor until EMS arrived. During an interview on 9/24/19 at 1:40 P.M., the DON said: - After a fall staff should assess a resident's neck, hips, shoulders, and legs for pain before moving the resident; - After a fall staff must perform assessments and vital signs according to the neurological flow sheet. - After a fall staff must immediately notify the resident's physician. During an interview on 9/24/19 at 1:41 P.M., the ADON said: - The resident was moving his/her neck; - He/She did not assess the resident prior to moving the resident onto the bed. During an interview on 9/24/19 at 2:00 P.M. LPN A said: - Staff came and told him/her the resident was on the floor; - He/She found the resident on the floor in the fetal position (curled up); - He/She saw blood splatters on the floor; - The resident was moving on the floor; - He/she asked staff to get the ADON or the DON; - The resident's pupils were very small; - The resident's initial set of vital signs were done on the floor; - The resident's physician saw him/her in the facility the day before; - He/She did not see a change in the resident's condition; - He/She should have assessed the resident prior to moving the resident. During an interview on 9/24/19 at 2:15 P.M. Certified Medication Technician (CMT) A said: - CNA A and CNA B told him/her that morning that the resident was not acting normal. - He/She told the charge nurse; - He/She went to the resident's room after the fall and called the ADON; - The resident was on blood thinners; - The resident had a baseball sized goose egg on his/her head and a splattering of blood on the floor; - The ADON told him/her to get the Hoyer; - He/She thought the resident should not be moved. During an interview on 9/30/19 at 9:30 [NAME]M., the EMS Supervisor said: - Initial treatment after a fall should include controlling the bleeding with pressure; - Then staff should call 911; - Staff should then do an assessment to see if the resident had tenderness with palpation to the neck, hips, shoulders, and legs; - Staff should not move a resident but instead wait for EMS to assess the resident. 3. Review of Resident #3's initial side rail assessment , dated 8/27/19, showed: - The resident used the rails for positioning; - The rails were assessed to be safe; - The resident could use his/her call light. Review of the resident's admission MDS, dated [DATE], showed: - Memory problems; - Total dependence upon staff for transfers; - Required extensive staff assistance for dressing, toileting, and hygiene; - Had a catheter (a sterile tube inserted into the bladder to drain urine) and frequently incontinent of bowel; - [DIAGNOSES REDACTED]. - Received antipsychotic medications. Review of the resident's care plan dated 9/6/19 showed: - Risk of falls; - Required a Hoyer with assist of two for transfers; - [DIAGNOSES REDACTED]. Review of the resident's post fall assessment, dated 9/27/19 at 11:10 [NAME]M., by LPN B showed: - The resident fell in the floor rolling over in bed and caught his/her right arm between the side rail and the bed; - The resident's blood pressure (BP) 74/33. The last blood pressure check was on 9/26/19 at 5:02 P.M. and was 116/68; - LPN B notified the resident's physician and responsible party that the resident fell but did not mention the resident's low B/P on 9/27/19 at 12:45 P.M. Review of the resident's medical records showed no post fall neurological checks and vital signs. Review of the resident's progress note, dated 9/27/19 at 7:20 P.M. by LPN B, showed: - The resident's family stated the resident had a brief loss of consciousness; - The resident's family requested that staff send the resident to the local hospital; - The resident's X-ray came back showing a broken arm; - The resident was sent to the local emergency room . Review of the resident's emergency room records ,dated 9/27/19 at 8:13 P.M., showed: - The resident presented with a right arm injury due to a fall; - The pain was increased with movement; - The resident appeared pale and lethargic; - The resident had a right humeral neck (upper arm) fracture; - The resident's hemoglobin (a protein in red blood cells responsible for transporting oxygen in the blood) was 4.4 (normal hemoglobin is 12 to 14); - [DIAGNOSES REDACTED]. Review of the resident's history and physical, dated 9/28/19 at 2:43 [NAME]M., showed: - Right arm pain due to fracture; - Altered mental status; - Stool positive for blood; - Received blood [MEDICAL CONDITION]. Review of the endoscopy report, dated 9/28/19 at 12:13 P.M., showed the presence and treatment of [REDACTED]. During an interview on 10/1/19 at 11:15 [NAME]M., the facility's Nurse Practitioner (NP) said: - He/She gave the order for the resident's arm X-ray; - Staff did not report the resident's blood pressure to him/her; - He/She would have insisted that staff send the resident to the emergency room immediately. During an interview on 10/1/19 at 11:30 [NAME]M., the DON said after the resident's fall, staff should perform neurological checks and vital signs according to the neurological check sheet. During an interview on 10/1/19 at 11:30 [NAME]M. CNA C said: - He/She put the resident on a bedpan and told the resident to use his/her call light when he/she was finished; - He/She went into the resident's room and found the resident on the floor with his/her arm caught in the side rail; - He/She yelled for LPN B to come to the resident's room immediately; - LPN B told CNA C to get the Hoyer and put the resident back to bed; - He/She asked LPN B if they should leave the resident on the floor until the resident was assessed; - The resident's family came to the facility at 12:30 P.M.; - The charge nurse did not assess the resident or do vital signs at the time of the fall. During an interview on 10/1/19 at 12:10 P.M., LPN B said: - He/She assessed the resident and pulled his/he arm out of the side rail; - The resident's mattress and bed were functioning well; - The resident's B/P normally ran low; - He/She did not remember if he/she reported the resident's blood pressure to the NP; - He/She did not perform further vital signs or assessments because the resident did not hit his/her head; - He/She did not do any vital signs prior to EMS transport because he/she had paperwork to do. During an interview on 10/1/19 at 12:35 P.M. CNA D said: - He/She came to work on 9/27/19 at 3:00 P.M.; - The resident complained of arm soreness; - Staff did not put ice or immobilize the resident's arm; - Around 6:00 P.M. he/she went to pick up the resident's tray and the resident got a blank look in his/her eye; - He/She got the charge nurse who did a chest rub and the resident was alert again. During an interview on 10/1/19 at 2:55 P.M. the DON said: - Staff must do neurological checks after a fall; - Staff must notify resident's physician with abnormal vital signs. 4. Review of the facility policy, dated (YEAR), on medication reordering showed: - Staff should fax any order needing a refill to the pharmacy; - Facility staff should review any faxed orders for potential issues; - Facility staff should check the status of pending refill orders. Review of Resident #2's care plan, dated 4/22/19, showed: - [DIAGNOSES REDACTED]. - The resident experiences chronic pain; - Staff must administer scheduled pan medications and as needed pain medications when requested. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Required supervision for transfers; - Required extensive staff assistance for dressing toileting, and hygiene; - Pain was constant and interrupted sleep. Review of the resident's medication administration (MAR), dated (MONTH) 2019, showed: - an order for [REDACTED]. and 9:00 P.M.; -Staff did not administer the medication, due to medication not available on 9/22 at 9:00 [NAME]M., 9/23 at 9:00 P.M., 9/24 at 9:00 [NAME]M., 9/24 at 9:00 P.M. and 9/25/19 at 9:00 [NAME]M. Review of the facility order audit for the resident's Xtampza ER 13.5 mg showed staff reordered the medication on 9/25/19 because the resident's supply was exhausted. During an interview on 10/1/19 at 2:53 P.M. the resident said the pain was quite intense. During an interview on 9/25/19 at 10:00 [NAME]M. the DON said: - Staff were supposed to reorder a resident's medications when the resident had two day supply; - Staff did not reorder the resident's Xtampza ER 13.5 mg until the resident was out of medication for several days; - Staff were supposed to contact the pharmacy regarding missing medications; - Staff were supposed to contact a resident's physician when medications were missing for a possible substitute; - The facility did not keep Xtampza ER 13.5 mg in the e-kit (a supply of emergency medications). MO 7, MO 9, MO 0, MO 4, MO 7

Based on interview and record review the facility failed to respond timely to assure one resident (Resident #14) of 16 sampled residents received needed medical attention and services to address his/her change in condition. The facility census was 70. 1. Review of Resident #14's care plan showed a plan starting 7/16/18, for activities of daily living (ADL). Staff to provide the resident with assistance of one for morning care and showers. The resident walked with a walker in his/her room and in the halls. At times, the resident forgot his/her walker. Staff to remind the resident to use his/her walker for stability. There were times when the resident had dribbling of urine. Review of Resident #14 Quarterly Review Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/19, showed: - [AGE] years old. - Adequate hearing. - Clear speech. - Made self-understood. - Had ability to understand others. - Had short and long-term memory problems. - Had moderately impaired skills for daily decision making. - Rejected care one to three days weekly. - Only required set-up help with walking in corridor and with locomotion on and off the unit. - Required one-person physical assistance with toileting and personal hygiene. - Had no upper or lower limitations with range of motion. - Did not use mobility devices. - Had occasional urinary incontinence. - Always continent of bowel. - [DIAGNOSES REDACTED]. - Had no pain. Review of nurse's notes showed on 3/10/19, staff prevented the resident from getting into cupboards in the common area, stomped off to his/her room and slammed the door. In an interview on 4/2/19 at 3:20 P.M., Certified Nurse Aide (CNA) E said sometime around 3/11/19, the resident walked to supper in the dining room and walked back to his/her room with no problems. The resident then came back out of his/her room limping and a staff person caught him/her to prevent him/her from falling. From that point on, the resident stayed in his/her room and became incontinent of bladder and bowel. Prior to this, the resident took him/herself to toilet. The resident slowly stopped eating, drinking and stopped normal ADL's. The resident stayed in bed. The resident had a limp that was on and off. He/she complained of pain but was confused. This went on for two weeks. He/she notified every nurse who worked on the special care dementia unit where the resident resided. He/she reported the residents' condition change to the Assistant Director of Nursing (ADON) and all the charge nurses who worked with the resident those two weeks. He/she thought if he/she told them about the residents decline, something would be done. During interviews on 4/15/19 at 4:23 P.M., and 4/16/19 at 11:10 A.M., Registered Nurse (RN) A said: - The resident stopped walking a week prior to 3/17/19. The resident went from walking independently to refusing to walk and staff assisting him/her in a wheelchair. Staff communicated the change during shift change reporting. He/she monitored the resident and the only change he/she noted was in the resident's mobility. The CNA's reported the resident had stopped walking. Staff initiated assisting the resident with mobility by using a wheelchair. Staff wondered what caused the residents change. They wondered if the resident fell or hurt him/herself. No one knew why the resident stopped walking. He/she did a head to toe assessment and everything was fine. He/she should have completed the rest of his/her job by notifying the physician of the residents condition change. The staff all talked to each other about the residents change but nobody thought to call the physician. - He/she assured all notes he/she documented in the facility electronic records system were saved in the system. Review of departmental notes, showed on 3/17/19 at 11:12 A.M., RN A documented that the resident had a change in mobility, will not walk and needs to use a wheelchair to come to the dining room to eat. Staff have to check the resident every two hours for incontinence of bladder and bowel. In an interview on 4/5/19 at 4:04 P.M., the ADON said: - On 3/18/19, he/she became aware of a small change in the residents condition when he/she reviewed RN A's 3/17/19 departmental notes. RN A should have assured the change in the condition was reported to the physician. - On 3/19/19, he/she discussed the residents' condition with Licensed Practical Nurse (LPN) D and instructed him/her to assess the resident and call the physician for follow-up on the resident's condition change. In passing, he/she observed the resident sitting at a dining room table and talking normally. - On 3/20/19, he/she worked overnight and checked the resident's departmental notes and found LPN D had not followed-up with assessing the resident's condition and reporting to the physician. - On 3/21/19 at 7:15 A.M., he/she asked LPN D if he/she followed-up as instructed. LPN D had not. LPN D said he/she thought the resident was better. He/she educated LPN D that he/she should have followed-up by assessing the resident on 3/19/19 and calling the physician regarding the 3/17/19, documented change in the resident from walking to now using a wheelchair. He/she again told LPN D to assess the resident and call the physician and took it that LPN D would follow his/her instruction. During an interview on 4/15/19 at 5:22 P.M., LPN D said: - The morning of 3/21/19, was the only time the ADON asked that he/she look at the resident and see what was going on. Between 1:00 P.M. to 2:00 P.M., he/she assessed the resident who winced when he/she touched the resident's right upper thigh and acted like it was bothering him/her. He/she contacted the physician's office, notified the receptionist that the resident was not walking and asked for an x-ray to see if the resident's hip was broken. The physician's receptionist told him/her to fax the notification. He/she told the receptionist that this was not a fax situation and he/she needed a nurse to call him/her back. He/she got busy with other task and never heard back from the physicians' nurse. He/she documented the contact with the physician's office in the facility electronic system records under nurse's notes. He/she was unaware there were no records to show he/she notified the physician's office. He/she had a problem getting his/her notes to save in the electronic system. - Sometime near 3/21/19, Certified Nurse Aide (CNA) E told him/her that on 3/14/19, the resident was walking, stumbled, almost fell and staff intervened to keep the resident from falling. CNA E said no one did anything. He/she noticed the resident had started using a wheelchair. He/she thought the physician should have been notified of the 3/14/19 incident that CNA E reported to him/her. In an interview on 4/16/19 at 9:48 A.M., Provider Nurse (PN) A said their office did not receive notification from LPN D regarding the resident not walking and a need for an x-ray. Their staff would have taken a message from LPN D if he/she had contacted them. Review of a facility Stop and Watch Early Warning Tool completed by CNA E showed on 3/22/19 at 6:33 P.M., CNA E reported to staff including LPN D and the Director of Nursing (DON) that Resident #14 seemed: - Different than usual; - Overall needs more help; - Pain new or worsening, Participated less in activities; - Ate less. In an interview on 4/2/19 at 3:20 P.M., CNA E said despite his/her reports to the nurses, nothing was done until he/she completed the 3/22/19 Stop and Watch Warning Tool. On 3/23/19, the ADON sent the resident out to the hospital. Review of departmental notes, showed: - On 3/23/19 at 2:04 P.M., the ADON documented that the resident declined over the past few days. On 3/23/19, the resident was lethargic, warm and clammy to the touch. The resident was normally resistive and combative with care but today was not. The resident had been up independent and walking up until a few days ago and had begun using a wheelchair for mobility. Over the past few days, the resident had not gotten or wanted out of bed. He/she was very fatigued and slept most of the day and night. The resident only ate 25% of his/her breakfast and was slow to respond. Assessment of the resident included labored respirations at 26, lung sounds diminished throughout and an elevated pulse at 132. The resident opened his/her eyes and shook his/her head but would not respond verbally. The ADON obtained physician orders [REDACTED]. - On 3/23/19 at 6:45 P.M., the resident was admitted to the hospital [MEDICAL CONDITION] urinary tract infection [MEDICAL CONDITION]. In an interview on 4/5/19 at 4:04 P.M., the ADON said: - On 3/23/19 at 4:30 A.M., he/she checked to see if there was a note showing LPN D followed-up as instructed and found LPN D had not. By 5:00 A.M. on 3/23/19, he/she instructed RN B to check on the resident, assess and notify the physician that the resident went from walking to needing a wheelchair. RN B told him/her said he/she would. - On 3/23/19 at 11:00 A.M., he/she found out that RN B did not follow-up either. He/she then completed the assessment on the resident and notified the physician his/herself. In an interview on 4/15/19 at 5:14 P.M. and 4/16/19 at 4:45 P.M., RN B said: - The resident use to be up walking. The last time he/she saw the resident the resident was in bed. Staff were trying to figure out what was wrong with him/her. He/she was not involved in the resident's care although it shocked him/her that the resident declined so quickly. - The ADON did not instruct him/her to assess the resident and notify the physician. - He/she had no problems with his/her nurse's notes being saved in the facility electronic records system. During an interview on 4/16/19 at 10:05 A.M., Family Member (FM) A said: - On 3/23/19, staff informed him/her of the resident's change of condition. Staff said the resident had not been doing well and his/her health was declining. Staff informed him/her that the resident needed to be sent to the hospital. - The hospital staff found the resident had a UTI. Review of the hospital History Physical documents showed: - On 3/23/19, the emergency room (ER) found the resident to be septic with clots and blood in the urine, diffuse abdominal pain and was admitted to the hospital. Review of systems showed the resident is so demented that he/she does not follow commands. He/she does not answer questions. Per facility, the resident had mental status changes, is weak and had abdominal discomfort. Abdominal x-ray showed a mild to moderate [MEDICATION NAME] distention of the colon and small bowel, most likely representing an adynamic ileus (Paralysis of intestinal ability to move independently). - The resident admitted to the hospital with [REDACTED]. The most common cause of acute [MEDICAL CONDITION].) Review of departmental notes, showed on 3/24/19 at 4:12 A.M., the resident admitted to the hospital [MEDICAL CONDITION] UTI. In an interview on 4/10/19 at 11:38 A.M., Physician A said: - On 3/23/19, the facility called the on-call physician and said the resident was very sick. The resident was normally ambulatory. The resident had dementia and was unable to report what happened. The facility did not provide information to show the duration of the resident's change in condition. Once the resident went to the hospital, he/she was found to [MEDICAL CONDITION] UTI and was really sick. He/she seemed to get better for 48 hours during his/her hospital stay. - It was possible the residents' health decline would have happened regardless if he/she was notified sooner. Since the resident was able to be up in a wheelchair, it was likely harder for the staff to catch the cause of his/her condition. - He/she expected staff to monitor the residents' condition change of going from walking to not walking, by assessing the resident daily at every shift and documenting the assessment. Without assessments and documenting assessment results, staff did not have the information needed to determine the cause of the condition. Documentation was key to protecting the resident. - The resident was placed on hospice with a [DIAGNOSES REDACTED]. 2. In an interview on 4/5/19 at 3:23 P.M., the DON said: - On 3/17/19, RN A should have and did not call the nurse manager to report the resident's change of condition. Administrative staff monitored nursing notes to catch where staff may have missed something and to figure out what to do. She did not discover the 3/17/19 note until 3/20/19. There was a discussion about the resident during daily connect team meeting. The resident went from walking to not walking. They had discussed that something might be going on with the resident. It ended up being worse than what they thought. As soon as the resident's condition worsened, they sent him/her to the ER. Staff should have requested orders for labs and x-rays for the resident once his/her condition changed in order to identify the conditions that were not found until the resident was sent to the ER. The physician was not notified until 3/23/19. If staff had acted sooner they could have prevented the resident's need for hospitalization . - On 4/4/19, the resident returned to the facility from the hospital on hospice. - When staff discover a resident to have a change of condition they should notify nursing management on call and that did not happen for the resident. If staff had called nurse management, then a plan of action to find a root cause for the resident's condition could have occurred. - She thought staff education was needed on communication to administration on change of condition. They needed to assure nurse's reports to administration was accurate. MO 0

Based on interview and record review, the facility failed to assure staff provided adequate care to prevent the development of a pressure ulcer for one resident (Resident #1) of seven sampled residents. Staff failed to provide the necessary care to promote healing after the resident developed a pressure ulcer. The resident required hospitalization for treatment of [REDACTED]. 1. Review of the facility's skin policy and procedure revised 7/27/10 showed the following: - All nurses will use the following procedures for assessing, managing tissue loads (the distribution of pressure, friction, and shear on tissue), decubitus ulcer (pressure ulcer) care, and managing bacterial colonization (presence of bacteria on the surface or in the tissue of a wound without signs of infection) and infection. - The purpose of the policy was to ensure accurate and ongoing assessment for resident's skin and to provide guidelines, based on the best available scientific evidence and clinical exposure, for wound care.- If you find a resident has developed a pressure ulcer, obtain a treatment order from the physician no matter what time of day or night. If physician orders [REDACTED]. bed, without slough; may also present as an intact or open/ruptured blister) and Stage III - may ask for Wound Gel (gel that is used to create a moist wound environment to promote wound healing), cover with CombiDERM (highly absorbent dressing for use over moderately to heavily exuding acute or chronic wounds), change daily and as needed until healed (treatment varies depending on amount of slough on the wound bed and the amount of drainage from the wound); Stage IV, call the physician for orders. Assess the pressure ulcer initially for location, stage, size (length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. After the initial assessment, each pressure ulcer is to be assessed, at least weekly, but deterioration either in the resident's overall condition or in the pressure ulcer itself, mandates more immediate reassessment as well as a reevaluation of the treatment plan. 2. Review of the Resident #1's admission nurses' note dated 9/9/10 at 11:00 A.M., showed staff admitted the resident to the special care unit from the residential care area of the facility. The resident ambulated on his/her own and was unsteady at times. The resident's skin was pink, warm, dry and appeared to be fragile. Review of the resident's Braden Scale (an assessment used for predicting a residents risk for developing a pressure ulcer) showed on 9/9/10, staff assessed the resident with a score of 20. The scale directs a total score of twelve or less represented the resident as a high risk. Review of the resident's nurses' notes dated 9/11/10 at 1:30 P.M., showed staff found the resident on the floor. The resident complained of discomfort in his/her bottom. Staff notified the resident's physician of the fall whom directed staff to place "hipsters" (undergarments with pads on the outer hip area to provide protection to the hips in case of falls) on the resident at all times while up and ambulating. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/22/10, showed the following: - Short- and long-term memory problems. - Moderately impaired cognitive skills for daily-decision making. - Required extensive assistance from staff with dressing, toilet use, and personal hygiene. - Required limited assistance from staff with walking and bed mobility. - Frequently incontinent of bladder. - Occasionally incontinent of bowel. - No pressure ulcers. - No history of resolved ulcers. - Pressure relieving device for his/her bed. - Application of ointments/medications. Review of the resident's current care plan dated 9/22/10, showed staff identified the resident had a potential for skin breakdown related to decreased mobility and incontinence. Staff determined a goal; The resident would not have skin breakdown over the next 90 days. Approaches included: - Encourage and assist the resident to reposition, a minimum of every two hours and as needed. - Keep skin and bed linens clean, dry, and wrinkle free. - Avoid exposure to hot water. Use gentle cleansing agent and pat skin dry. - Apply lotion to the skin following shower or bath, to keep skin moisturized. - Skin check daily by staff with care and twice weekly, by the shower aide. - Report to charge nurse any redness, irritated areas and/or open area. - Braden Scale upon admission and quarterly. Review of the resident's skin report completed on 10/13/10, by the bath aide, Certified Nurse Aide (CNA) A, showed the resident had a red spot on his/her hip. The report did not indicate which hip had a red spot. Licensed Practical Nurse (LPN) A signed to indicate he/she had reviewed the bath sheet. During an interview on 12/1/10 at 2:45 P.M., LPN A said he/she had worked as the wound care nurse while the regular wound care nurse was on maternity leave. LPN A said when he/she first found the area on the resident's left hip. it presented as a red raised area, that stuck up about an inch. The area was not open or scabbed, just red. LPN A said he/she thought it was scar tissue from an old hip surgery. Normally the facility did not use [MEDICATION NAME] (a skin dressing for the treatment of [REDACTED].) LPN A had the MDS coordinator look at the area and she agreed, [MEDICATION NAME] would provide protection to that area of skin. LPN A said he/she felt bad that he/she suggested the [MEDICATION NAME]. Review of a fax sent by the facility to Resident #1's physician on 10/??/10, showed LPN A reported the resident had a sore on his/her left hip related to scar tissue from a hip replacement. LPN A asked the physician for an order for [REDACTED]. Review of the resident's nurses' notes dated 10/18/10 at 12:30 P.M. showed LPN A documented staff received a fax from Resident #1's physician with an order to apply [MEDICATION NAME] to the left hip for protection and change the dressing every three days. LPN A documented the resident's family was aware of the order. LPN A did not document a description of the resident's left hip area. Review of the resident's skin report dated 10/20/10, showed CNA A circled the resident's left hip on the body diagram. Under a section for comments, CNA A documented the resident had an open sore, already notified and bandaged. LPN A signed to indicate he/she reviewed the bath sheet. During an interview on 12/1/10 at 3:40 P.M., CNA A said he/she knew the resident had a sore on his/her hip and it was covered with a dressing. He/she gave the resident his/her showers and documented any new skin issues on the resident's shower sheets. During an interview on 12/1/10 at 2:15 P.M. CNA B said he/she thought the patch on Resident #1's hip was a pain patch. No one ever told him/her to try and keep the resident off his/her left hip. The resident preferred to and always sleep on his/her left side. During an interview on 12/1/10 at 3:15 P.M., CNA D said he/she knew the resident had a dressing on his/her hip. Staff used the task sheets (a form used to indicate the resident's care needs) to know to do for residents. Staff also got report from the charge nurse about each resident. During an interview on 12/1/10 at 3:20 P.M., CNA E said he/she did not see Resident #1's hip before he/she went to the hospital. CNA E knew the resident had a "red dot" and a dressing on his/her hip. One of the other aides told him/her the nurses told them to keep an eye on the resident's hip. CNA's received report from the charge nurses and used the task sheet to direct them in the resident's care needs. Review of the resident's November 2010 physician order [REDACTED]. On 10/18/10, the physician ordered [MEDICATION NAME] dressing. Staff were directed to place hipster pads on the resident every morning to prevent injury, if the resident fell and were to remove the hipsters at bedtime. Review of the resident's November 2010 treatment administration record showed the 11:00 P.M. to 7:00 A.M. shift were to apply [MEDICATION NAME] to the sore area on the resident's left hip for protection, change every third day. Licensed staff documented they changed the [MEDICATION NAME] every three days. Licensed staff did not document an assessment of the resident's left hip wound. Review of the CNA daily task sheets updated on 11/5/10, showed the following care needs: - The resident was continent. - Staff were to encourage the resident to turn and reposition every two hours. - Transferred and ambulated independently. - Toilet every two hours. - Wore hipsters. - Required a Wanderguard. - Required a body alarm at all times. The task sheet did not identify the resident had a dressing or wound on the left hip. Review of the resident's skin report dated 11/10/10, showed CNA A documented a red area on the resident's left hip. Review of the resident's 72 hour assessment/evaluation dated 11/13/10, showed LPN B documented the resident had a wound to on the left hip. LPN B did not document a description of the left hip wound. During an interview on 12/1/10 at 2:05 P.M., Registered Nurse (RN) C said he/she worked as the charge nurse on the night shift, 10:30 P.M. to 7:00 A.M., and was the only nurse in the building during the night shift. RN C said he/she did most of the wound treatments during his/her shift. He/she changed Resident #1's [MEDICATION NAME] every three days. On 11/13/10, he/she changed the [MEDICATION NAME] dressing early in the morning, around 4:30 A.M. RN C said he/she did not turn on the overhead light in the room. He/she turned the light on, located over the sink, across from the resident's bed. He/she turned the resident over and pulled his/her pants down. The old [MEDICATION NAME] was not on the resident, which was not unusual. The [MEDICATION NAME] came off when the resident pulled his/her hipsters and pants up and down while going to the bathroom. RN C said he/she did not turn on the overhead light because he/she did not want to disturb the resident's roommate. RN C said it was light enough for him/her to be able to see what he/she was doing. RN C said he/she thought at the time, the resident's skin looked good. He/she did not see any drainage on the resident's pajama bottoms or bed sheets. RN C thought he/she would have been able to see if the resident's skin was red, even though the lighting was not bright. RN C said he/she did not examine the resident's hip wound closely. He/she did not turn the bright light on and get his/her nose right done to the wound and assess it, but he/she sure thought it looked better. He/she did not feel the skin except to put his/her hand over the [MEDICATION NAME] to get it to stick. The resident did not complain of pain during the dressing change. The resident always liked to sleep on his/her left side. RN C tried to encourage the resident to stay off his/her left side. RN C said he/she was shocked when he/she returned to work, after four days off, and learned the resident's wound was that bad. Review of the nursing daily report sheet dated 11/14/10, showed the following regarding Resident #1: - Night shift (10:30 P.M. until 7:00 A.M.) nurse LPN A, documented the resident vomited three times, had a temperature of 101.5? Fahrenheit (F). LPN A gave the resident Tylenol at 4:25 A.M. - The day shift did not make any notes regarding the resident during their shift. - The evening shift (2:30 P.M. until 11:00 P.M.) nurse documented Resident #1's family member voiced concerned about the resident. He/she did not act like him/herself. The family member asked to be called with any deterioration in the resident's condition. The nurse noted the resident had an elevated temperature, did not eat supper and went to be early. The nurse did not document the resident's temperature or that he/she assessed the resident. During an interview on 12/1/10 at 2:45 P.M. LPN A said he/she worked the night shift on 11/14/10. Resident #1 woke up about 4:00 A.M. and vomited. LPN A said the aide told him/her the resident had a temperature of 101.5? F, so he/she gave the resident Tylenol. The resident threw up the Tylenol, but had a scheduled [MEDICATION NAME] (narcotic pain medication containing Tylenol) later that morning, so LPN A did not give the resident anymore Tylenol. No one reported any drainage from the hip to him/her that night. During an interview on 12/1/10 at 2:15 P.M., CNA B said during the night shift on 11/14/10, the resident vomited and ran a temperature. CNA B thought the resident's temperature was 101.5? F. CNA B told the charge nurse, he/she thought it was LPN A. The nurse gave the resident Tylenol, but the resident threw it up. Staff put cool cloths on the resident. He/she did not see any drainage on the resident's linens. CNA B said the aides used the task sheet to find out what care resident's needed. The aides also get report from the charge nurse and the off-going shift staff. During an interview on 12/1/10 at 1:35 P.M., RN B said he/she worked the evening shift, every Saturday and Sunday as the charge nurse. He/she was the charge nurse for the whole building, except the residential care portion of the facility. The facility had certified medication technicians to pass medications to residents. The night shift nurse routinely did the wound treatments. RN B said he/she thought he/she had put Resident #1's [MEDICATION NAME] on one time, at the beginning of the order, but after that time the night shift nurses' changed it. When he/she first saw the area, it was not open or red. Staff applied [MEDICATION NAME] as a [MEDICATION NAME] measure. RN B said on Saturday night 11/13/10, he/she did not see Resident #1. None of the aides reported anything to him/her about the resident not feeling good or any concerns about drainage from the resident's wound. During an interview on 12/1/10 at 2:55 P.M., CNA C said he/she worked the evening shift on 11/14/10. Resident #1 did not go to the dining for the evening meal, because he/she did not feel well. He/she took a supper tray to the resident's room, which was unusual for the resident. Resident #1 was normally very antsy, up and about a lot. CNA C said the resident had a temperature but did not remember what his/her temperature was. CNA C told the charge nurse about the resident's fever. The resident refused to eat supper and all drinks. CNA C said a family member came to see the resident and asked CNA C to help them get the resident ready for bed. CNA C sat the resident on the side of the bed and got out some pajamas. CNA C did not notice any drainage until he/she laid the resident down on the bed. When the resident laid down, CNA C noted drainage on the resident's bed sheet and pajama bottoms. CNA C said he/she did not know the resident had a wound on his/her left hip. The family member also saw the drainage. CNA C asked the family member to stay with the resident while he/she got the charge nurse. The family member was very upset and said they would tell the charge nurse. CNA C saw the family member go to the nurses station. CNA C said he/she did not report the wound drainage to the charge nurse because the family member reported it. RN B was the charge nurse on duty. RN B did not ask CNA C about the drainage or to notify him/her when the resident got up so he/she could look at the resident's hip. The resident had always like to sleep on his/her left side. During an interview on 12/1/10 at 1:35 P.M., RN B said on Sunday evening 11/14/10, Resident #1's family member came to talk to him/her while he/she was eating supper. The family member said the resident did not look good and something about the resident's dressing, something to the effect, he/she did not know if the dressing should look like it did. RN B told the family member they were using the dressing as a [MEDICATION NAME] measure and the resident did not have a wound, but he/she would check it after his/her supper break. When RN B went to Resident #1's room, the resident was already in bed, asleep. RN B asked the aides and they confirmed the resident was not feeling good and did not eat well at supper. RN B said he/she asked the aides if they saw the resident's dressing. They told him/her it was fine. RN B said he/she did not remember the aides he/she asked. RN B said he/she did not pull back the resident's bed covers to look at the dressing. RN B said he/she did not tell the aides to let him/her know if the resident got up so he/she could check the dressing. The resident's family member asked RN B to let him/her know if the resident had a change in his/her condition. RN B wrote that on the 24 hour report. RN B said he/she gave report to staff on the next shift, but did not tell them about the dressing and the reported drainage. RN B told the next shift the resident did not feel good and the daughter wanted to be called with any change. Review of the resident's nurses' notes dated 11/15/10 at 12:00 midnight showed RN A documented the resident had a temperature of 100.6? F. Staff gave the resident Tylenol and rechecked the resident's temperature at 1:30 A.M., which was 99.6? F. At 6:00 A.M., the certified medication technician (CMT) reporter to RN A, the resident's temperature was 100.4? F. The CMT gave the resident his/her medications. The resident denied pain and stated he/she felt the same as usual. During an interview on 12/1/10 at 2:15 P.M., CNA B said 11/14/10, was the first night he/she saw drainage from the resident's hip wound. He/she went to take the resident to the bathroom and found the resident had a "pretty big area" of something brownish in color, on his/her incontinent pad. At first, CNA B thought it was urine, but the resident was never incontinent of urine. CNA B pulled the resident's pajama bottoms down and noted a spot on the resident's pajama bottoms. The spot was about the size of an orange. CNA B said he/she told RN A about the spots. RN A came to the resident's room to check on it, but CNA B had to leave the room and did not know what RN A did after he/she checked the resident's hip. During an interview on 12/1/10 at 1:50 P.M., RN A said said he/she worked different shifts as a charge nurse. He/she saw Resident #1's hip before they got the [MEDICATION NAME] order. The resident had a raised area on his/her left hip, about the size of a penny. It was a lump under the skin and it was not red when he/she saw it. RN A said he/she never saw the area on the resident's hip again. Every time he/she saw the resident's hip, the [MEDICATION NAME] was in place. The night shift staff changed the [MEDICATION NAME]. RN A said the resident ran a temperature for about a week before he/she went to the doctor on 11/16/10. RN A said they had assessed the resident's lungs and looked at his/her urine as a possible cause of the fever, but he/she never thought about the "nodule" on his/her hip. RN B gave report to RN A on Saturday evening 11/13/10. RN B said the resident was not feeling well and did not go to supper. RN B also said the resident's family member wanted to be called with any changes in the resident's condition. RN B did not say anything in report about the residents hip or any drainage. RN A said he/she felt stupid when he/she found out the resident went to the hospital with an infected hip wound. On 11/15/10 at about 3:00 A.M., CNA A reported he/she found something on the resident's pajama bottoms and incontinent pad. RN A went to the resident's room and helped assist the resident to the bathroom. The [MEDICATION NAME] dressing was still on the resident's hip, dated the day before, so he/she did not remove the dressing to assess the resident's skin. The drainage appeared to be on the front of the resident's hip, so he/she thought it was hot chocolate spilled from the evening before. RN A said he/she told the CNA's to change the resident's clothes and incontinent pad and to come get him/her if they noticed anymore drainage. The next morning, during report to the oncoming shift, RN A reported the possible drainage to LPN B, and that he/she could not figure out where it was coming from, RN A reported to LPN B there were no signs of infection. Review of the nursing daily report sheet dated 11/16/10, showed LPN B documented the resident had a temperature of 99.4? F. and had received Tylenol at 2:30 A.M. The nurse documented the resident's hip looked worse and LPN A needed to have the doctor assess the resident's hip. During an interview on 12/1/10 at 2:15 P.M., CNA B said on 11/16/10 between 2:00 A.M. and 4:00 A.M., he/she got the resident up to go to the bathroom. The resident did not have a dressing on his/her left hip and it was stuck to the bed linens. There was drainage on the incontinent pad and the resident's pajama bottoms. There were several small brown spots of drainage. The resident's hip and upper thigh were wet. The area on the resident's hip was about the size of a golf ball and red. CNA B said you could tell it was raw. There was a small, whitish-yellow area in the center of the red area. CNA B was in shock because he/she did not know the resident had a wound on his/her left hip. The CNA went and told the charge nurse, LPN B who directed him/her to put a warm wash cloth on the area and that he/she was not going to put a [MEDICATION NAME] back on the wound. LPN B said he/she would put a dressing on it and call the doctor for a treatment order. Review of the resident's nurses' notes dated 11/16/10 at 4:45 A.M., showed LPN B documented, night shift staff reported the resident's incontinent pad was wet with wound drainage. LPN B documented approximately 70 cubic centimeters (cc's) of clear, yellow drainage noted on the incontinent pad. The center of the wound presented yellow, measured 0.5 centimeters (cm) by 0.5 cm. The surrounding skin presented pink and warm and did blanch (a temporary whitening of the skin when pressure applied to the area, healthy skin returns to pink once the pressure is relieved). The resident showed no sign of pain while the LPN B cleansed the area. LPN B documented he/she had not seen the area for multiple weeks and was did not know how the site had looked. The day nurse was to contact the family about the resident seeing the physician. Before LPN B left the room, he/she cleaned the area with wound cleanser, applied Safe-gel (transparent, water-based gel used to assist debridement and healing of wounds) and 4 X 4 dressing. LPN B documented he/she did not apply [MEDICATION NAME]. LPN B notified the director of nursing (DON) and MDS coordinator of the wound. LPN B had the CNA's take vital signs, which showed the resident's temperature as 99.0? F. Staff gave the resident Tylenol and applied cool washcloths under the resident's neck and his/her forehead. During an interview on 12/1/10 at 1:15 P.M., LPN B said he/she usually worked the day shift. When he/she worked, he/she was the charge nurse for the special care unit (SCU) until 11:00 A.M. Another nurse came on duty at 11:00 A.M. for the SCU. The facility wound care nurse was off on maternity leave and LPN A was doing wound documentation. The night shift nurses' did most of the wound treatments. LPN B said he/she worked the night shift on 11/15/10 (until the morning of 11/16/10.) LPN B said he/she first discovered the resident's wound was draining that night. LPN B said he/she may have seen the area on the resident's hip one time since the [MEDICATION NAME] order. At that time, it was a bump and red but not open. CNA B told LPN B he/she reported the drainage the night before to RN A. When LPN B saw the resident's wound, he/she said he/she knew [MEDICATION NAME] was not the right treatment for [REDACTED].M. There was no dressing on the wound and there was yellow drainage from the wound. The wound bed had yellow slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucous). It measured 0.5 cm. by 0.5 cm. The skin around the wound was pink about 0.3 cm around it. LPN B said there was approximately 70 cc's of drainage on the resident's incontinent pad. CNA B told LPN B the drainage looked the same as the previous night. LPN B said anytime staff find a wound, they need to report it to the charge nurse. Review of Resident #1's nurses' notes dated 11/16/10 at 7:30 A.M., showed LPN A documented the resident had yellow drainage coming from open area on his/her left hip. The skin was warm to touch and the resident complained of pain when the nurse touched the area around the wound. There was no odor noted. LPN A notified the resident's family member and worked on getting the resident seen by the physician that day. The resident's family member told LPN A he/she noticed the drainage coming from the hip over the weekend. At 10:00 A.M., the family member arrived at the facility and took the resident to see the physician. During an interview on 12/1/10 at 2:45 P.M., LPN A said he/she came to work about 6:30 A.M. on 11/16/10. LPN B asked him/her to look at the resident's left hip wound. The resident's left hip had an open area, with drainage. There was drainage on the incontinent pad and on the 4x4 dressing LPN B had placed on the wound. There was a hole in the center of the wound bed. The hole was not superficial, but he/she could not tell how deep the wound was. The area around the wound was red and warm to touch. LPN A said he/she notified the resident's family member, the resident needed to see the physician. The family made an appointment for that morning and took the resident to see the physician about 10:30 A.M. Review of documentation from the resident's physician office visit on 11/16/10, showed Physician B documented the resident developed a sore on his/her left hip a few months ago that had continued to worsen and had drainage. The resident developed a fever and vomiting over the weekend. The resident woke that morning with the infection worse. Modifying factors showed [MEDICATION NAME] with no relief. Physician B documented a left hip wound that was draining, there was pus and it was very red surrounding the wound. The [DIAGNOSES REDACTED]. The physician documented the resident had [MEDICAL CONDITION] (the systemic response to infection), non-healing. During an interview on 12/2/10 at 10:00 A.M., Physician A's office nurse said he/she was on call on weekends. He/she did not receive a call from the facility from 11/13/10 through 11/15/10, regarding the resident's fever or that the wound had drainage. The facility staff usually called him/her for everything else, but had not called on this resident. The facility staff should have notified the physician when the wound started draining. They should have removed the dressing and assessed the wound at the time the drainage was first reported to the nurses. The staff should monitor any skin area that required a dressing, whether it is an actual wound or a potential area of skin breakdown. Review of the hospital history and physical dated 11/16/10 showed the resident admitted was admitted to the hospital, directly from the physician's office. The resident was admitted due to a draining wound, just posterior to his/her left hip incision from an old total hip repair, which was approximately 0.3 cm. by 0.4 cm. and approximately 0.2 cm. in depth. The resident had a [DIAGNOSES REDACTED]tous (abnormal redness of the skin) ring around it, which was about 0.7 cm. by 0.8 cm. There was an exudative (any fluid that filters from the circulatory system into [MEDICAL CONDITION] or areas of inflammation) bottom in the ulcerative (development of an ulcer) wound. The resident's family member related the resident had a reddened area on the left hip and the facility requested [MEDICATION NAME] to put on it. The family member said they had been using the [MEDICATION NAME] for about the last four weeks. On Saturday (11/13/10), the family member said when they helped the resident to bed, an exudate material ejected from underneath the [MEDICATION NAME]. The physician documented the resident had an infected pressure ulcer or wound, left hip, slightly posterior and inferior to his/her previous scar from a total hip replacement. The physician admitted the resident to the hospital for intravenous antibiotics after obtaining a wound culture. Review of the consulting wound specialist documentation regarding Resident #1's wound showed the reason for the consult was a deep penetrating ulceration over the left greater trochanteric region (hip). The physician documented the resident was unable to give a history but the family member was able to relate what occurred. The family member told the physician about a month ago, the family member noticed a small area of skin breakdown along the left greater trochanteric region. The nursing home personnel told him/her at that time, the area would be taken care of and they applied [MEDICATION NAME] to the area. During the course of the next several weeks, it was noticed the resident had excessive drainage from this area and the resident went to the physician's office for evaluation. The resident was admitted to the hospital for further evaluation and treatment with recent symptoms of fever, chills, and [MEDICAL CONDITION]. The physical examination showed a deep penetrating ulceration with slough to the left hip region. The physician documented it was difficult to ascertain whether or not this does probe to bone. There was some necrotic (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) material within the tract (passageway) of the ulceration. The physician did not see any hardware at this time, but there was a large amount of serous (thin, clean) fluid and slight odor, but no evidence of frank [MEDICAL CONDITION]. The assessment showed a left greater trochanteric ulceration, Stage III (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), possible Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) pressure ulcer, secondary to pressure. During an interview on 12/2/10 at 12:30 P.M., the DON said the facility did not have any wound tracking or monitoring sheets for Resident #1 from October 2010 to present. They did not have to monitor the resident's skin, because the resident did not have a wound. Staff had used the [MEDICATION NAME] as a preventative measure. When shown by the surveyor, facility staff had identified an area on the resident's left hip as a sore and that staff received orders for treatment of [REDACTED]. The DON said the night shift nurses looked at the resident's wound every three days when they changed the [MEDICATION NAME]. However, agreed, none of the staff documented the condition of the wound. The DON said staff should have tried to keep Resident #1 off the left hip as much as possible. She never saw the resident's hip. When the resident developed drainage from the hip wound, the nurses should have peeled back the dressing and assessed the wound. They should have notified the physician when they first noticed the drainage. The DON said the facility staff charted by exception, meaning staff only documented when there was something out of the norm for the resident. The DON said she could not find any documentation of the resident's vital signs or wound drainage in the nurses notes from 11/13/10 through 11/15/10. There were some vital signs documented on the 24 hour report sheet, but those were not part of the resident's medical record. MO , MO