Every finding on record at Bentwood Nursing & Rehab

Based on interview and record review, the facility failed to ensure services were provided to treat pressure ulcers (skin and tissue damage caused by prolonged, unrelieved pressure on the skin) and/or wounds for one resident (Resident #2). On 06/05/26, a nurse identified a Stage II (a partial-thickness skin loss that damages the outer epidermis and dermis) pressure ulcer on the resident's right buttock but failed to obtain treatment orders until 06/18/26, after the resident had a fall and a full skin assessment was completed. The sample was 5. The census was 105. Review of the facility's Wound Management Policy, revised 11/15/22, showed:-Policy: To promote wound healing of various types of wounds. The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: -Wound Management: --Wound treatment will be provided in accordance with physician's order; --Charge Nurse will notify physician in the absence of treatment orders;--Treatment selection will be based on the etiology of the wound;--Pressure injuries will be differentiated from non-pressure wounds. -Wound Characteristics/Documentation: --Location of the wound; --Pressure injury & stage; --Non-Pressure level of tissue destruction; --Size (shape, depth, tunneling and/or undermining); --Volume & exudate (drainage) characteristics; --Pain evaluation; --Presence of infection/bioburden; --Condition of the wound bed & wound edges; --Condition of the peri-wound (skin surrounding the wound);-Guidelines for Dressing Selection: Obtain physician's order. Treatments will be documented on the Treatment Administration Record (TAR).-The effectiveness of treatments will be monitored through ongoing evaluation of the wound(s). Review of Resident #2's medical record, showed:-admission date 05/09/26;-Diagnoses included altered mental status, end stage renal disease (ESRD, kidney disease), diabetes, depression, and muscle weakness. Review of the resident's care plan, revised 05/27/26, showed:-Focus: Resident has a potential/actual impairment to skin integrity related to fragile skin;-Goal: The resident will maintain or develop clean and intact skin by the review date;-Interventions: Pressure reducing mattress while in bed. Review of the resident's skin assessment, dated 06/05/26 at 6:27 P.M., showed:-Site: Right buttock;-Type: Pressure;-Length: 3.0 centimeter (cm);-Width: 2.0 cm;-Depth: Blank;-Stage: II. Review of the resident's electronic physician order sheet (ePOS) and TAR for June 2026, showed:-An order, start date 06/05/26 and end date 06/05/26, for STAT (immediately) due to pain: Wound consult as needed to evaluate and treat right buttocks open wound, appears to be a Stage II;--Marked as completed on the TAR on 06/08/26 at 9:41 A.M. Review of the resident's skin assessment, dated 06/18/26 at 10:34 A.M., showed no new skin issues noted. Review of the resident's wound assessment, dated 06/18/26 at 10:58 A.M., showed:-Date wound identified: 06/18/26;-Where was wound acquired: Acquired after admission to the facility;-Type of Wound (pressure or non-pressure): Blank;-Wound description: Right gluteal fold. Type: Skin tear. Length 2.7 cm, width 2.8 cm, depth 0.1 cm. Stage N/A;-Drainage: Serosanguinous (thin, watery, pale pink or light red fluid);-Resident exhibits two or more conditions that increase likelihood of the development of an unavoidable wound: No;-Resident demonstrates signs/symptoms that increase the likelihood of the development of an unavoidable: No;-Are treatment/equipment in place: Yes;-Treatments: Turning and repositioning, wound treatment/application of dressing;-Is pain associated with the wound: No;-Physician Notified: Yes. Review of the resident's progress note, dated 06/18/26 at 11:12 A.M., showed new skin tear/open wound noted to right gluteal region. Skin flap present with drainage noted. Wound cleansed with wound cleanser. Skin flap gently approximated. Calcium alginate (absorbent dressing) applied to wound bed and covered with foam dressing per treatment protocol. Resident tolerated treatment without difficulty. No acute signs and symptoms of infection noted at this time. Physician/Nurse Practitioner (NP) notified of new wound and treatment recommendations. Review of the resident's ePOS, showed:-An order, start date 06/19/26 and discontinued 06/24/26, for right gluteal (buttocks): Cleanse with wound cleanser, apply calcium, cover with bordered gauze. Daily and as needed as may be dislodged or saturated;-No treatment ordered for the right buttocks/gluteal area prior to 06/19/26. During an interview on 06/26/26 at 12:39 P.M., Licensed Practical Nurse (LPN) A said the resident was only here about a month and had a left or right foot wound. LPN A did not remember any other open areas. If a new open area was noted during skin assessments, nurses were to put in a consult and let the wound nurse and physician know. If the wound nurse was not there, then the nurse would assess the area and obtain measurements. The wound nurse normally gets to residents the next day, after a consult was entered. If the consult was entered on a Friday or Saturday, then the wound nurse would get to them on Monday. During an interview on 06/26/26 at 12:45 P.M., Certified Nursing Assistant (CNA) G said if staff found an open skin area on a resident, then staff were supposed to let the nurse know. During an interview on 06/26/26 at 12:50 P.M., the Director of Nursing (DON) said she found out about the resident's open area on his/her bottom on 06/18/26 when they were assessing his/her skin after his/her fall. The wound nurse told her about the open area. She never looked at it personally, so she did not know what it looked like. The resident's family insisted he/she be up in a chair and never wanted the resident to lay down so she would not be surprised if it was pressure ulcer. The DON expected for when a new wound was found, the wound nurse should assess and measure the wound and put in treatment orders. If it seemed like a bad wound, then the wound nurse would put in a wound consult and the wound NP that did rounds would assess and make determination if the resident needed to be put on wound rounds. The DON did not know if the resident's open area was a Stage II as documented on 06/05/26 or a skin tear as documented on 06/18/26. The nurses were doing weekly skin assessments, so she was confused about the one completed on the06/05/26 that showed Stage II pressure. Typically, the nurses were not supposed to stage wounds. During an interview on 06/26/26 at 1:40 P.M., the Administrator and DON said if a new area was found on a resident, they expected the wound nurse to assess the area and enter orders. If the resident had an area identified on 06/05/26, then they expected the assessment to have been completed and entered in the record before 06/18/26. If the wound was discovered on a Friday, then they expected the assessment to be completed first thing Monday morning. On the weekend, the floor nurse was expected to assess and put in orders and then the wound nurse would reassess Monday morning. If the wound nurse was out, then the DON or Assistant Director of Nursing (ADON) was expected to complete the assessment. If the area was truly a Stage II, then there should have been more documentation in the resident's record. The wound nurse found an open area on 06/18/26 when he/she did the skin assessment after the resident fell. The DON said the nurse that documented the skin assessment was a regular nurse. The DON was not sure why the nurse staged the wound. The nurses were not supposed to do that. The corporate staff provided a wound note dated 06/08/26 that was the assessment on the sacral area. She was trying to check to get confirmation and the note that would match this assessment. When asked about the assessment completed on 06/16/26, the DON and Administrator said that was only done because the family requested it to be done. 3034448

Based on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist for the facility's infection prevention control program. The census was 100.Review of the facility's Surveillance for Healthcare Associated Infection, dated 10/2021, showed:-Surveillance for Healthcare Associated Infections (HAI) will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infections.- Complete the Monthly Infection Control Surveillance Log utilizing a new form each month or complete electronic version on medical record software. Complete the data as indicated;--Identifying the information i.e. resident's name;--admission date;--Infection onset date (may be onset of symptoms, if known, or date of positive diagnostic test);--Infection site (be as specific as possible, i.e. cutaneous infection should indicate pressure ulcer right foot, or respiratory infection as pneumonia RUL (right upper lobe));--Symptoms or related diagnosis;--Date of pre-treatment culture if known or indicated;--Identify the pathogen;--Record antibiotics or other treatment used;--Record any invasive, or high-risk procedures the resident may have had completed;--Identify if the infection was acquired outside the facility, i.e. community acquired;--Record other interventions;--Date infection resolved; -Perform the surveillance using any or all the following data gathering tools as possible indicators of nosocomial (health care associated) infections. (Note: Once an effective mechanism is identified, use the same methods to ensure meaningful trend data):Forward the Infection Control Surveillance Log to the Director of Nursing or Infection Control Designee, and RNC (Regional Nurse Consultant) at the end of each month;--Laboratory records;--Would evaluation ;--Infection control rounds or interviews; Pharmacy Records; --Hospital Transfer Logs; --Discharge Summaries;-The Monthly Infection Report will be provided to the facility Quality Assurance and Performance Improvement (QAPI) Team Members in the Quality Process Improvement Meeting;-The policy did not include having an Infection Preventionist. During interviews on 2/18/26 at 9:45 A.M. and on 2/24/26 at 11:15 A.M., the Director of Nursing (DON) said the Assistant Director of Nursing (ADON) would start courses to obtain certifications in wound care and infection perfection. The DON is working on getting her Infection Preventionist (IP) certification. The facility does not currently have an Infection Preventionist onsite.

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs. The facility failed to ensure one resident received showers, was dressed in clothing, and was assisted out of bed (Resident #40) and failed to ensure one resident received nail care and facial hair was removed (Resident #98). The sample was 22. The census was 100. Review of the facility's nail care policy, dated 7/21/22, showed:-Policy: the purpose of nail care is to clean the nail bed, trim nails, and prevent infection;-Key Points: nails may be cleaned during bathing. Nail care includes daily cleaning and regular trimming. Stop and report to the Charge Nurse ingrown nails, infection, pain, or nails that are thick and difficult to trim. Review of the facility's ADL care bathing policy, dated 7/21/22, showed:-Policy: nursing staff will assist in bathing residents to promote cleanliness and dignity. The Charge Nurse will be made aware of residents who refuse bathing;-Procedure: observe the residents skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point. blisters, or skin breakdown. Soap has a drying effect on the skin. Be sure to rinse the skin well. Be gentle and do not rush the procedure; allow for breaks if needed. 1. Review of Resident #40's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated, 11/30/25, showed:-No rejections in care;-Dependent on staff for bed to chair transfers, toilet hygiene, bathing, and upper and lower body dressing;-Requires moderate assistance with personal hygiene;-Diagnosis include hemiplegia (weakness to one side of the body), aphasia (inability to speak) and stroke. Review of the resident's care plan, in use at the time of survey showed:-Focus: The resident has ADL self-care deficit related to stroke and limited mobility;-Interventions: Offer bathing or showering twice a week; Requires staff to assist with dressing; Transfer resident using a Hoyer (a mechanical lift).The resident's care plan did not show the resident refuses ADL care from facility staff. Review of the resident's Certified Nursing Assistant (CNA) skin monitoring and bathing review sheets dated 2/1 through 2/23/26 showed the resident received a bed bath on 2/2, 2/5, 2/12, and 2/23/26. During observation on 2/18/26 at 11:19 A.M., 2/19/26 at 12:05 P.M., and 2/20/26 at 10:00 A.M., and 2/24/26 at 6:20 A.M., the resident lay in bed with the room dark. The resident wore a green hospital gown with food stains. Observation and interview on 2/23/26 at 5:10 P.M., the resident lay in bed with the room dark. The resident wore a green hospital gown with food stains. The resident's right eye was crusted with white matter. The resident raised his/her left arm during the interview, and a strong body odor was present. The resident nodded yes when asked if he/she would like to get out of bed. During an interview on 2/23/26 at approximately 12:30 P.M., CNA J said the resident requires assistance from staff getting dressed, bathing and getting out of bed. CNA J said the resident usually refuses to get out of bed or get dressed. The resident receives a bed bath twice a week. CNA J said he/she changes the resident's gown every day he/she works. During an interview on 2/24/25 at approximately 9:00 A.M., CNA H said the resident is provided a bed bath twice a week and will only get out of bed occasionally. The resident has clothing in his/her closet. The resident should be offered to change out of the hospital gown and get out of bed daily. If the resident refuses the nurse is notified. During an interview on 2/24/26 at 10:50 A.M., the Director of Nursing (DON) said she would expect staff to provide the residents a bed bath or shower twice a week. She would expect residents to be clean, dry and odor free every day. The DON would expect staff to offer the resident to change into their personal clothing and get out of bed every day. If the resident refuses ADL care, it is expected to be included in the resident's care plan. 2. Review of Resident #98's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Dependent on staff for personal hygiene care;-Diagnoses included Alzheimer's disease, heart failure, depression, and muscle weakness; Review of the resident's care plan, in use at the time of the survey, showed:-Focus: resident has an ADL self-care performance deficit;-Goal: resident will maintain current level of function with ADLS through the review date;-Interventions: offer bathing/showering twice weekly and as necessary.Check nail length and trim and clean on bath day and as necessary. Report anychanges to the nurse. Observation on 2/18/26 at 10:49 A.M., showed the resident in bed asleep. The resident's fingernails were long and jagged with chipped nail polish. The resident had facial hair around his/her lips and on his/her chin. Observation on 2/20/26 at 11:20 A.M., showed the resident sat in his/her wheelchair at the nurse's station. The resident's fingernails were long and jagged with chipped nail polish. The resident had facial hair around his/her lips and on his/her chin. During an interview on 2/23/26 at 8:02 A.M., Licensed Practical Nurse A said resident fingernails should be kept clean and trimmed to the resident's liking. He/She would expect resident's facial hair to be trimmed/ shaved. During an interview on 2/23/26 at 8:13 A.M., the DON said she would expect residents to have clean fingernails. She would expect nursing staff to trim or file resident's nails if they are jagged. She would expect staff to shave the resident's facial hair upon request or use nursing judgement if the resident was unable to communicate.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for one of one sampled resident who expired (Resident #110). The sample was 22. The census was 100. Review of the facility's admission agreement, showed:-You have the right to manage your personal financial affairs or have someone you trust do so, including the facility. With your written approval, the facility will open a personal account for you through Resident Fund Management Services (RFMS). The personal resident trust account is controlled by you or your Resident Representative only. We will provide you with an accounting of these funds upon your request, and at least once every three months. Review of Resident #110's resident trust fund account, showed:-A balance of $4,708.23 as of [DATE];-Resident expired on [DATE];-A debit, in the amount of $4,698.95 on [DATE] for personal needs.-Closing interest in the amount of $1.36 on [DATE];-A debit, in the amount of $10.64 on [DATE], to close account. During an interview on [DATE] at 2:00 P.M., the Business Office Manager (BOM) said the resident's check was given to the family after they provided receipts for expenses for the resident's funeral. Review of the resident's trust record, received [DATE], showed:-A check, dated [DATE], in the amount of $4,698.95 to the pay to the resident's family member;-A receipt, dated [DATE], in the amount of $2,591.39 for repast (post funeral reception) at a Banquet Center;-A receipt, dated [DATE], in the amount of $210.50 for a Fossil watch at Macy's department store;-A receipt, dated [DATE], in the amount at $1,663.14 for a jacket ($698.00), blouse ($276.00), and pants ($648.00) at [NAME] Fifth Avenue;-A receipt, dated [DATE], in the amount of $93.92 for a full slip ($69.00) and unidentified item ($18.00) at JC [NAME];-A receipt, dated [DATE], in the amount of $140.00 from a funeral home for obituaries. During an interview on [DATE] at 8:36 A.M., the Business Office Manager said when a resident expires, the family will request funds for funeral expenses. Anything that was left they will send to TPL. If a resident has a credit balance, he/she will send it to TPL. When the resident expired, he/she asked if it was okay to give the resident's money to the family. The Regional manager said it was fine as long as they provide receipts, and the family submitted the receipts. They had expenses for the funeral and wanted to purchase clothes to [NAME] to the resident in. He/She said the family wanted the resident to dress fancy; however, he/she did not know why the family purchased a full slip from JC [NAME] if a jacket and pants were also purchased at [NAME] Fifth Avenue. The BOM checked the receipts when they were submitted but did not have a conversation with corporate BOM about it. The check was printed at the facility level and given to the resident's family. The BOM said corporate was not involved at that point. During an interview on [DATE] at 12:58 P.M, the Administrator said he would expect the BOM to send the resident's funds to TPL if it was not used for funeral expenses. He would expect the money to be sent back to the state. They were told that the resident was fancy and they wanted the resident to look nice. Intake number: 1550386

Based on observation, interview and record review, the facility failed to ensure physician's order(s) were followed for treatments related to a post-surgical site for a resident's left hand. For one of three residents sampled (Resident #81). The sample was 22. The census was 100. Review of the facility's Physician Order Policy, dated 10/2022, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, State & Federal guidelines;-Responsibility: Licensed Nurses- Registered Nurse (RN) and License Practical Nurse (LPN), Nursing Administration, & Director of Nursing (DON);-Orders must be Recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders must be documented clearly in the medical record. The required components of a complete Order: Date and time of order, name of practitioner providing order, name and strength of medication/treatment, quantity/duration, dosage/frequency, route of administration, indication/diagnosis;-Physician Order Sheet will be maintained with current physician orders as new orders are received. Discontinued orders will be marked as discontinued with the date, and all new orders will be written in the appropriate area on the physician order sheet with the date the order was received;---Physician orders will be transcribed to the appropriate electronic medication administration record (MAR) or electronic treatment administration record (TAR). Review of the facility's Wound Management Policy, dated November 2025, showed:-To promote Wound healing of various types of Wounds, the Facility will provide evidence-based treatments in accordance with current standards of practice and physicians orders.-Procedure: Wound Treatment will be provided in accordance with physician's order: Cleaning method, type of dressing, frequency of dressing change. Review of Resident's #81's medical record, showed diagnoses included absence of left finger, stroke, cognitive communication deficit (impaired communication), need for assistance, atrial fibrillation (irregular heartbeat), kidney disease and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/25, showed:-Cognitively intact;-Number of ulcers, wounds and other skin conditions: none present;-Skin and ulcer/injury treatment(s): application of nonsurgical dressing. Review of the resident's care plan, in use during survey, showed:-Focus: He/She has an arterial wound on the left hand fingers 2-5;-Goal: The resident will be free from infection or complications related to arterial ulcer through review date;-Interventions: Monitor/document/ report as needed any signs and symptoms for infection. Weekly treatment(s) documentation to include measurements of each area of skin breakdown width, length, depth, type of tissue and exudate (drainage that is infected) and any other notable changes or observations. Review of the resident's hospital discharge paperwork, dated 9/11/25, showed the resident had left ring finger dry gangrene (tissue death) related to chronic (long term) digital (finger) ischemia (lack of blood flow). Special instructions: Hand hygiene is a must especially pre and post bandage change. Review of the resident's TAR, dated October 2025, showed an order dated 10/21/25, for Xeroform Petrolate (sterile, non-adherent, fine-mesh gauze infused with medication), apply to left hand between fingers topically one time a day, fold 1 pad externally: Wound care not documented as completed 11 out of 11 opportunities. Review of the resident's wound physician initial evaluation and management summary, dated 11/5/25, showed:-Post surgical wound of the left, fourth (ring finger) amputation 3.5 centimeters (cm) by 1cm by 3 cm; heavy serosanguinous (clear bloody drainage);-Treatment order: cleanse with wound cleaner apply once daily: if saturated (visibly dirty with bodily fluids), soiled, or dislodged use collagen powered daily and as needed (PRN), alginate calcium (highly absorbent, seaweed-derived fibers used for moderate-to-heavy exuding wounds);-Second dressing use gauze (sterile dressing), apply once daily, and PRN: if saturated, soiled, dislodged; Review of the resident's MAR, dated November 2025, showed:-An order date 10/21/25 and discontinued 11/13/26, for Xeroform Petrolate patch apply to left hand between fingers topically one time a day: Wound care not documented as completed 13 out of 13 opportunities;-An order date 11/13/25 and discontinued 11/15/26, for left 4th amputation of finger: Clean area with wound cleaner and pat dry, stack 4X4, cover with Alginate Calcium, top with collagen powder cover powder with 1 gauze 4X4, apply to amputation site. Wrap with kerlix (gauze wrap) secure with tape. Change daily and if dislodged or soiled PRN for wound care: Wound care not documented as completed 3 out of 3 opportunities;-The resident on hospital leave from 11/14 through 11/18/26;-An order dated 11/20/25 and discontinued 12/1/25, for Xeroform Petrolate patch. Apply to left ring finger topically, one time a day. Cleanse left ring finger with normal saline. Apply xeroform and Kling (gauze wrap) daily: Wound care not documented as completed four out of 11 opportunities. Review of the resident's wound physician management summary, dated 11/26/25, showed:-Post surgical wound of the left, fourth ring finger amputation 3.5 cm by 0.6 cm by 0.5 cm; light serosanguinous; improved evidenced by decreased depth;-Treatment Plan:--Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Xeroform gauze apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: Single layer. Avoid trauma or bleeding during dressing changes;--Gauze sponge sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 9 days; Gauze roll (kerlix) 4.5 apply once daily and as needed: if saturated, soiled, or dislodged. For 9 days; Tape (retention) apply once daily and as needed: if saturated, soiled, or dislodged. For 9 days. Review of the resident's wound physician management summary, dated 12/3/25, showed:-The progress of this wound and the context surrounding the progress were considered in greater detail today. The patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications and poor prognosis. Patient presents deterioration of necrotic tissue. Please refer him/her to a surgical consult.-Post surgical wound of the left, fourth ring finger amputation 6.5 cm by 0.9 cm by 0.5 cm; moderate serosanguinous; exacerbation due to arterial. Review of the resident's wound physician management summary, dated 12/31/25, showed:-Left hand surgery scheduled for 1/8/26;-Wound sized 13 cm by 7 cm by 0.6 cm; Review of the resident's MAR, dated January 2026, showed:-An order dated 1/1/26 and discontinued 1/21/26, for left 2nd through 5th finger. Clean area with wound cleanser and pat dry, paint with betadine, cover with gauze, secure with tape, then apply ace wrap. Change daily or if soiled or dislodged: Not documented as completed on 1/19 or 1/21/26;-An order dated 1/22/26 showed, for left 2nd through 5th finger: Clean with wound cleaner and pat dry, paint with betadine, apply collagen powder to open area (amputation site), cover with gauze, secure with tape, then apply ace wrap change every day or if soiled or dislodge: Wound care not documented as completed four out of 10 opportunities. Review of the resident's wound physician management summary, dated 1/21/25, showed:-Wound is improving 10.4 cm by 6.5 cm by 0.6 cm;-Treatments Plan;--Primary Dressing(s): Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: In the gangrene fingers; Gauze sponge sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: Non-woven gauze; Collagen powder applied once daily and as needed: if saturated, soiled, or dislodged. For 30 days: Only on the granulation tissue.--Secondary Dressing(s): Gauze roll (kerlix) 4.5 apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Tape (retention) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Review of the resident's medical record, showed the resident on hospital leave from 1/28 through 2/6/26. Review of the resident's MAR, dated February 2026, reviewed on 2/20/26, showed:-No wound care ordered or documented as completed from 2/6/26 through 2/9/26;-An order date 2/10/26 showed: Cleans Left index, middle and ring finger with wound cleanser. Pat dry. Apply betadine-soaked gauze, dry dressing and wrap with kerlix daily and PRN one time a day for wound care: Wound care not documented as completed eight out of 10 opportunities. Review of the resident's wound physician management summary, dated 2/10/25, showed arterial wound of the left, 2nd through 5th fingers, gangrene finger. The vascular procedure was discussed, possible fingers amputation and surgical follow up. Observation 2/19/26 at 10:09 A.M., showed the Wound Nurse entered the resident's room to provide wound care. The current dressing on the resident's left hand had no date, time or initial from the previous dressing change to show when it was last changed. The Wound Nurse completed the treatment as ordered. The resident's fingernails were long and curled up inside the palm of his/her hand. The Wound Nurse documented the date on the new dressing. During an interview on 2/19/26 at 10:09 A.M., the Wound Nurse said the podiatrist does not want the fingernails clipped. Also, the resident is re-scheduled for surgery for amputation. Staff are required the date of the dressing when changed. During an interview on 2/23/26 at 7:38 A.M., The Wound Specialist said the resident's uncontrolled diabetes and diagnosis of necrotic fingers on the left had complicated things. He/she was under the direct care of the surgeon. She was removed from the case while the resident was under the care of the surgeon. She was not consulted again on the case until January 28, 2026. The resident had a complication and went back to the hospital and that was the last time she saw the resident. Treatments not being done as ordered post-surgical could cause harm to the wound. During an interview on 2/24/26 at 8:44 A.M., the Assistant Director of Nursing (ADON) said every shift wound treatments should be completed. If the resident refused, staff should notify the medical director, inform the oncoming staff nurse, and place a progress note into the electronical medal record. Nurses are expected to put in a progress note about the wound dressing when completed. 2721422

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed for treatments, pressure reducing boots in place, and the air mattress set no higher than the resident's weight, for one of three sampled residents for wounds (Resident #25). The sample was 22. The census was 100.Review of the facility's Wound Management Policy, dated November 2025, showed:-To promote wound healing of various types of wounds, the facility will provide evidence-base treatments in accordance with current Standards of Practice and physicians orders.-Procedure:--Wound Management:---Wound treatment will be provided in accordance with physician's order;---Cleaning method;---Type of dressing;---Frequency of dressing change;--Charge Nurse will notify Physician in the absence of treatment orders;--Dressing changes may be provided outside the frequency parameter in certain situations;---Urine, feces, or other bodily fluids have saturated through the dressing;---Dressing is dislodged;---Dressing is soiled;--Wound characteristics/documentation;---Location of the wound;---Pressure injury & stage;--- Non-Pressure-Level of tissue destruction;---Size (shape, depth, tunneling and/or undermining (tissue destruction beneath the skin surface at the wound edge). Volume and exudate (drainage) Characteristics;---Pain evaluation;---Presence of infection/bioburden (amount of microorganisms);---Condition of the wound bed and wound edges;---Condition of the peri-wound (area around the wound);---Resident/Resident Representative preferences/goals. Review of Resident's #25's medical record, showed diagnoses included abnormal posture, cognitive communication deficit (impaired communication), need for personal assistance, pain in joints, paraplegia (impaired motor and sensory in lower extremities), and diabetes. Review of the resident's annual minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/26, showed:-admission date 8/10/24;-Severely cognitively impaired;-Weight charted as 167 pounds (lbs.);-Dependent assistance required for activities of daily living (ADLs);-Resident has pressure injuries over bony prominence, or non-removable dressing/devices;-No other ulcers, wounds and skin problems noted;-Skin and ulcer/injury treatments are pressure reducing device for wheelchair (w/c) and pressure reducing for bed;--Number of stage 3 pressure ulcer (severe, full-thickness skin injury appearing as a deep, open, crater-like wound where subcutaneous fat is visible, but muscle, tendon, or bone are not), three are present, but not present upon admission;--Number of stage 4 pressure ulcer (severe, full-thickness wound extending to exposed bone, tendon, or muscle, often featuring deep tissue damage, tunneling, and high infection risk), one is present, but not present upon admission. Review for the resident's care plan, in use during survey, showed:-Focus: Resident has a stage 4 pressure wound to his/her left buttocks, stage 3 pressure wound of the left medial (middle) buttocks, stage 3 sacrum/ coccyx (above buttocks) unstageable deep tissue injury (DTIs) left lateral (side) ankle, and foot; delayed healing due to diabetes, immobility and incontinence;-Goal: Wound(s) will remain free from infection;-Interventions: Administer treatments as ordered and monitor for effectiveness, low air loss mattress bed, and position pillows in place, off-load wound (reduce the pressure) as tolerated, side-to-side turning, treatments as ordered. Review of the resident's physician order sheets (POS), dated February 2026, showed:-An order dated, 9/18/24, for wound consult;-An order dated 9/18/24, low air loss (LAL) mattress to bed and check settings every shift;-An order dated 7/1/25, air mattress for preventative measures;-An order dated 9/19/25, complete a skin assessment every Thursday on day shift;-An order dated 1/5/26, wound consult as needed to evaluate and treat;-An order dated 1/10/26, Prevalon protection boots bilateral foot at all times;-An order dated 1/14/26, lateral left foot: Clean with cleanser and pat dry, apply alginate honey (sterile wound care products that combine the high absorbency of seaweed-derived calcium alginate with the antimicrobial/healing properties of honey) cover with gauze and wrap with kerlix (cotton gauze roll featuring a unique crinkle-weave pattern), change every day (QD);-An order dated 1/21/26, left medial buttocks: Clean with soap and water, apply barrier every shift;-An order dated 2/8/26, left lateral ankle clean with wound cleaner and pat dry apply collagen powder (topical treatment that speeds healing) cover with alginate calcium (highly absorbent, seaweed-derived fibers used for moderate-to-heavy exuding wounds, such as ulcers and burns) then gauze and wrap with kerlix, change every two days (q2d);-An order dated 2/8/26, left buttocks: Clean with Vashe (solution to cleanse, irrigate, and debride acute/chronic wounds) pat dry, apply collagen with calcium (Ca+) alginate silver (highly absorbent, antimicrobial, conformable wound dressing made from seaweed fibers and ionic silver. It manages moderate to heavy exudate by turning into a gel);-An order dated 2/8/26, sacrum: Clean area with Vashe pat dry, apply collagen power with Ca+ silver then superabsorbent fiber with silicone border, change twice daily (BID). Review of the resident's medication administration record (MAR), dated February 2026, showed:-Left lateral ankle, clean with wound cleaner and pat dry, apply collagen powder cover with alginate calcium then gauze and wrap with kerlix, change Q2D, missed two out of three opportunities;-Left lateral foot, clean with wound cleanser and pat dry, apply alginate honey cover with gauze and wrap with kerlix, change every day and every day shift every other day (how it is written in the MAR) for wound care, missed five out of 11 opportunities;-Left medial buttock: Clean with soap and water, apply barrier every shift for wound care, missed 18 out of 45 opportunities;-Left buttock: Clean with Vashe, pat dry, apply collagen powder with Ca+ alginate silver then superabsorbent fibers with silicone border BID, missed 14 out of 30 opportunities;-Sacrum: Clean area with Vashe and pat dry apply collagen powder and cover with Ca+ alginate then gauze and superabsorbent fiber with silicone border, change BID, missed 43 out of 44 opportunities;-Prevalon protective boots on bilateral feet at all times, every shift for skin integrity, protects bony prominences to bilateral legs, missed 17 out of 46 opportunities. Review of the wound doctor's progress note, dated 2/18/26 at 8:23 A.M., showed:-General recommendations of reposition per facility's protocol;--Off-load wound(s): pillows underneath left knee;--Turn side-to-side in bed;--Float heels in bed;-Specific to visit recommendations;--Other: 12/24/25, please keep mattress settings per patient's weight;--Other: 12/31/25, please have Certified Nurse's Assistant (CNA) to clean with wipes saturated with soap and water, for personal hygiene and incontinence. Observation on 2/18/26 at 12:00 P.M., showed the resident wore a brief (incontinent absorbent garment) and the catheter tubing was visible. The resident had no protective boots on. Observation on 2/19/26 at 9:38 A.M., showed the following:-The resident's air mattress was set to 350 pounds;-The resident's left hip bandage had no date, or time and drainage soaked through the bandage;-The resident's left ankle had brown and bloody drainage and the bandage was dated 2/18 without a time;-Staff turned the resident. During an interview on 2/19/26 at 9:38 A.M., the Wound Nurse said the left ankle had serosanguinous (serum and small amounts of blood) drainage. The dressing was brown and dried at the left ankle and dated 2/18. If staff see a soiled dressing, they should change it. The wound was debrided (remove damaged tissue or foreign objects from) yesterday which would increase the drainage of the wound. Observation on 2/19/26 at 1:41 P.M., showed the resident lay on his/her left side without protective boots on, and air mattress settings were set at 350 lbs. Observations on 2/20/26 at 5:37 A.M. and at 6:34 A.M., showed the resident's air mattress was set at 350 pounds (lbs.) At 6:34 A.M., the resident did not have protective boots on. Observation on 2/20/26 at 6:34 A.M., showed the Wound Nurse rolled the resident over, and the Wound Nurse and Assistant Director of Nurses (ADON) changed the resident's dressings. The resident had a residue of barrier cream around his/her rectum. The wound nurse cleaned the wounds on the resident's coccyx/sacrum area, but did not clean the surface around the wounds by the barrier cream residue left on the resident. Observation on 2/20/26 at 9:06 A.M., showed the resident had no protective boots on, and the air mattress blinked red and showed power failure. The bed was still inflated. At 9:29 A.M., the resident did not have his/her protective boots on. Observation on 2/20/26 at 1:34 P.M., showed the resident's mattress was off, no lights were on the control monitor, but the bed was still inflated During an interview on 2/22/26 at 9:29 A.M., CNA D said, he/she was unaware if the resident had an order for protective boots, but they were in stock. CNA D said, the resident has never laid on his/her right since he/she has been employed. Observation on 2/23/26 at 6:45 A.M., showed the resident's air mattress was beeping, and the monitor said failure. The mattress felt deflated. The resident did not have his/her protective boots on while he/she lay in bed. During observation and interview on 2/23/26 at 8:58 A.M., the resident's air mattress was completely deflated, and the resident complained about his/her left arm pain. Maintenance Employee E said he/she just got the ticket to fix the bed. Observation on 2/23/26 at 9:31 A.M., showed the resident's bed settings were set at 490 lbs. with rotation every 15 minutes, while he/she lay in bed. Observation on 2/23/26 at 10:30 A.M., showed the resident had no protective boots on, and his/her wound dressings were dated Friday 2/20/26 at 6:55 A.M. The Director of Nursing (DON) reviewed the bed control panel and confirmed the settings at 490 lbs were out of range for the resident's weight. During an interview on 2/23/26 at 10:30 A.M., the DON said, she would 100% expect the air mattress to be within range of the resident's weight. She would expect no brief on a resident who had a suprapubic catheter and wound to his/her buttocks. A brief is a contraindication because the resident has wounds and a catheter. The dressing to the resident's left hip was heavy serosanguinous drainage, and there was heavy drainage coming from his/her left ankle dressing. The Wound Nurse would now change the dressings and notify the wound doctor of the dressing not changed over the weekend. The DON expected staff to use protective boots for the resident, since a physician's order was in place. During an interview on 2/23/2026 at 7:38 A.M., the Wound Physician said the resident's pressure wounds have been present for a while. He/She favored the left side. His/Her challenge was repositioning. The Wound Physician said, offloading was very important, and she recommended protective boots as the best practice. She would expect the air mattress be set at the patient's weight and no higher. There are new CNAs who are not aware why the beds needed to be at the recommended weight levels. She wished there was a system for staff to check off loading residents. The Wound Physician said staff believe placing the air mattress at a higher level or all the way up was good; that is the perception, but that is not accurate. During an interview on 2/24/26 at 8:44 A.M., the ADON said every shift wound treatments should be completed. If a resident refuses, staff were expected to notify the medical director, oncoming nurse and place a progress note in the record. Interventions should be followed. If the mattress is too firm, the mattress can cause more pressure to the resident's skin. 2721422

Based on observation, interview and record review, the facility failed to provide one resident (Resident #40), who had limited mobility, the appropriate services, equipment and assistance to maintain or improve their mobility. The sample was 22. The census was 100.During an interview on 2/24/26 at approximately 9:00 A.M., the Director of Nursing (DON) said the facility did not have a restorative therapy (RT) policy that focuses on regaining or maintaining physical function. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/30/25, showed:-No rejection of care;-Functional limitation of range of motion: No impairment to the upper extremities. Impairment on both sides of the lower extremity;-Dependent on staff for bed to chair transfers, toilet hygiene, bathing, and upper and lower body dressing;-Requires moderate assistance with personal hygiene;-Diagnosis include hemiplegia (weakness to one side of the body), aphasia (inability to speak) and stroke. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an activity of daily living (ADL) self-care deficit related to stroke and limited mobility;--Interventions: Offer bathing or showering twice a week; Requires staff to assist with dressing; Transfer resident using a Hoyer (a mechanical lift).-Focus: The resident is at risk for falls related to gait and balance problems;--Interventions: Physical therapy to treat as ordered and as needed. -The care plan did not show the resident refusing ADL care from facility staff. Review of the facility's list of RT case load, dated 2/9/26, did not show the resident listed. Observation on 2/18/26 at 11:19 A.M., and 2/23/26 at 5:10 P.M., showed the resident lay in bed. The resident's right arm was bent and positioned close to his/her body. The resident's right hand was tightly clenched. The resident was unable to open his/her right hand or move his/her right arm when requested. During an interview on 2/23/26 at approximately 12:30 P.M., Certified Nursing Assistant (CNA) J said the resident requires assistance from staff getting dressed, bathing and getting out of bed. The resident is unable to move his/her right arm. The resident will usually not let anyone touch his/her right arm due to pain when he/she moves it. CNA J said he/she has never seen splints or therapy work with the resident. During an interview on 2/23/26 at 5:00 P.M., Licensed Practical Nurse (LPN) M said he/she has provided care to the resident and thinks that a splint or RT would be appropriate and helpful to the resident. The resident guards his/her right arm at times due to pain when the resident moves it. Nursing staff should let the therapy department and the physician know if the resident needs to be screened for any type of therapy. During an interview on 2/24/26 at 9:50 A.M., Restorative Aide (RA) N said the resident was not on his/her current workload. The therapy department gives them a list of residents that require RT. The resident requires a Hoyer lift for transfers and RA N will occasionally assist with the resident's transfer. The resident has a history of refusing care. The resident's arm and hand are contracted and would benefit from RT. During an interview on 2/23/26 at approximately 1:00 P.M., the Therapy Director said she was not familiar with resident. The last time the resident was seen by the therapy department was 6/12/24 through 9/19/24. She would have expected the staff to notify the therapy department that the resident was having difficulty moving his/her right arm and hand so that therapy could screen the resident and make the appropriate recommendations and interventions. During an interview on 2/25/26 at 10:50 A.M., the DON said she would expect the resident to receive some type of therapy, device or intervention to help with the mobility of the resident's right arm and hand. The resident may require a type of topical pain medication to assist with movement of his/her arm and hand. Any refusal of ADL care is expected to be in the resident's care plan.

Based on observation, interview and record review, the facility failed to provide a safe transfer technique for two residents who required assistance with transfers. Staff failed to ensure a gait belt was use for one resident (Resident #19). In addition, staff failed to ensure two staff transported a resident by mechanical lift (Resident #14) after a family member was observed assisting staff. The sample was 22. The census was 100. Review of the facility's Gait Belt Transfer policy last reviewed,10/25/22, showed:-Policy: the facility will utilize a gait belt for residents who require one assist with transfer to promote safety during resident transfers;-Procedure: -Ensure the resident is wearing non-skid footwear; -Place the gait belt around the resident's waist over their clothing with the buckle facing the front; -Buckle and fasten the gait belt; -Position your body close to the resident; -Transfer the resident by grasping the gait belt using an underhand grip; -While firmly gripping the gait belt, staff should keep their back straight and bend knees slightly with feet in a wide stance to maintain proper body mechanics; -Begin to rock back and forth and instruct the resident ton the count of three to push off the surface; -Allow the resident to pivot and to bear weight; -Guide the resident to the destination surface; -Keeping a firm grip on the gait belt, gently lower the resident onto the surface; -Assist the resident to a comfortable position. 1. Review of Resident #19's care plan, in use at the time of survey, showed:-Focus: The resident has a self-care performance deficit related to activities of daily living (ADL);-Interventions: The resident requires one person assistance with transfers and toileting. Review of the resident's medical record, showed diagnoses that included fracture of right arm, unsteadiness on feet, muscle weakness, and hemiplegia (weakness) of the right arm and Alzheimer's disease. During observation on 2/20/26 at 6:30 A.M., the resident lay in bed. The resident's right arm showed a soft cast. Certified Nursing Assistant (CNA) F assisted the resident to the side of the bed. CNA F placed slippers on the resident and positioned his/her hands under the resident's arms and lifted the resident up off the bed. The resident was unable to stand upright, and the resident's feet were sliding on the floor. CNA F instructed the resident to stand up. The resident was unable to straighten his/her knees. CNA F pivoted the resident to the resident's wheelchair by holding the resident under his/her arms. CNA F propelled the resident into the bathroom and lifted the resident out of his/her wheelchair by holding the resident under his/her arms and placed the resident on the toilet. Once the resident was done using the toilet, CNA F asked for help from CNA G to assist the resident off of the toilet. CNA F and CNA G stood on each side of the resident and lifted the resident off the toilet by holding the resident under his/her arms. CNA F and CNA G pivoted the resident into his/her wheelchair. CNA F and CNA G did not use a gait belt while transferring the resident. During an interview on 2/24/26 at approximately 9:00A.M., CNA H said gait belts are to be used anytime the resident requires assistance transferring. The gait belt provides stability for the resident and allows the staff member to safely lower the resident to the floor or chair if the resident's knees buckled. Resident #19 requires a gait belt for all transfers. During an interview on 2/24/26 at 10:25 A.M., Certified Medicine Technician (CMT) I said a gait belt is to be used anytime the resident requires assistance from staff to transfer. The gait belt is used so that staff is not pulling on the resident. Transferring the resident by holding them under their arms is not a good or proper transfer technique. The gait belt is also a safety device so that in case the resident starts to fall the staff member can use the gait belt to safely lower the resident to the floor. It also gives the resident a sense of security. During an interview with on 2/24/26 at 10:50 A.M., the Director of Nursing (DON) said there are gait belts located on the supply carts on each of the halls. She would expect the staff to use a gait belt on all residents requiring assistance with transfers. She would have expected staff to use a gait belt while transferring Resident #19. 2. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/21/26, showed:-Cognitively intact;-Has indwelling catheter;-Diagnoses included cancer, high blood pressure, obstructive uropathy (a blockage in the urinary tract that hinders urine flow), viral hepatitis, diabetes, hyperlipidemia (high cholesterol in the blood), hemiplegia (paralysis affecting one side of the body), anxiety, depression;-Impairment on one side to the lower extremity;-Uses wheelchair;-Total dependent with personal hygiene and toileting hygiene;-Total dependent with transfers. Review of the resident's care plan, in use during survey, showed:-Focus: Safety: Resident requires a Hoyer (mechanical) lift for transfers. Requires two person assist at all times during transfers. Use a large lift sling;-Goal: Resident will remain safe;-Interventions: Requires two person assist at all times during transfers. Observation on 2/23/26 at 8:34 A.M., showed the resident's family member exited from the room, wearing gloves. CNA R exited the room and returned to the resident's room with a mechanical lift. There was no other staff seen inside the resident's room. CNA R donned PPE outside of the resident's room and closed the door; however, the door did not latch and opened up. CNA R was observed operating the mechanical lift while assisted by the resident's family member. The resident's wheelchair was moved in front the open door while CNA R operated the lift to lower the resident as the family member assisted the resident into the electric wheelchair. At 8:42 A.M., CNA R doffed the PPE and placed it into the bin. There was no other staff seen inside the resident's room. The resident's family member was seen in front of the door assisting the resident and re-positioning him/her into the wheelchair. CNA R returned to the room and removed the mechanical lift out of the resident's room and placed it in the hallway. During an interview on 2/23/26 at 8:51 A.M., CNA R confirmed the resident's family member assists with the resident's care. He/She was unsure if the family member was able to assist with transfers or trained. He/She confirmed the resident's family member helped with the mechanical lift transfer. He/She asked staff for help, but no one was available. The job had to get done. During an interview on 2/24/26 at 8:00 A.M., the DON said they became aware the resident's family assisted with mechanical lift transfers. The aides did not know what to do. They did not know they could say stop to the family. The family member used to have the resident at home and had a mechanical lift there, so it was done at home. Staff think they cannot say no to family. A nurse mentioned that they would not know what to tell a family member. She would expect staff to follow policy and only staff to transfer residents. The resident's family member is very involved and will often grab gloves and start doing care. They will need to have a care plan meeting with the family member.

Based on observation, interview and record review, the facility failed to ensure supra pubic catheter (medical device used to collect bodily waste) care was provided by staff and physician orders were obtained for a gauze to cover the site for one resident (Resident #25). The facility also failed to ensure one resident with a Foley catheter (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a bag, held in place by a small, water-filled balloon) had appropriate physician's orders for the catheter, catheter tube change, and urine output (Resident #14). The facility identified three residents with a catheter, two were sampled and issues were identified with both residents. The sample was 22. The census was 100. Review of the facility's Catheter Care Policy, dated July 2022, showed:Policy: The Facility will maintain consistent and adequate hygiene standards for residents with Indwelling Catheter to maintain function and prevention of infection or complications;-Responsibility: Nursing Staff, Licensed Nurses Registered Nurse (RN) and Licensed Nurse Practical (LPN), Administration and Director of Nursing (DON);-Procedure: Gather Supplies: Towel, incontinent Wipes, Incontinent Pad;--Identify Resident & Explain Procedure;--Provide Privacy;--Perform Hand Hygiene & Apply Gloves;--If able, Position Female Resident in the Dorsal Recumbent (on their side) Position; Males in the Supine (on their backs); Position. Place Incontinent Pad under Resident's Hips;--Place sheet over Resident; Only exposing Perineal Area;--Perform Incontinence Care per facility protocol prior to providing Catheter Care;-Female: With non-dominant hand, retract labia to fully expose urethral meatus and Catheter insertion site. Maintain hand position throughout the procedure;-- Cleanse the labia major (he larger outer folds of the vulva) using soap and water and a clean washcloth, cleanse downward motion. Change the position of the washcloth with each downward stroke;--Repeat for the labia minor using a clean washcloth cleansing down the length of the Catheter at least 4;--Do not allow the washcloth to drag on resident's skin or bed linen;-Men: Retract the foreskin of the uncircumcised penis to expose urethral meatus and Catheter insertion site. Maintain hand position throughout the procedure;--Cleanse the urethral meatus using soap and water and a clean washcloth down the length of the catheter at least 4. Cleanse glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke;--With a clean washcloth, rinse with warm water using the above technique;--Return foreskin to normal position. 1. Review of Resident's #25's medical record, showed diagnoses included neuromuscular dysfunction of bladder (loss of normal bladder function, nerve damage between brain and bladder), retention of urine (inability to empty bladder), cognitive communication deficit (impaired communication), need for personal assistance, pain in joints, paraplegia (impaired motor and sensory in lower extremities), and diabetes. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/16/26, showed:-Severely cognitively impaired;-Dependent assistance required for activities of daily living (ADLs);-Indwelling catheter. Review for the resident's care plan, in use during survey, showed:-Focus: Requires catheterization suprapubic catheter due to neurogenic bladder;-Goal: Resident will show no signs/symptoms of urinary tract infection (UTI);-Interventions: Position catheter bag away from door entrance. Monitor/document for pain and discomfort due to catheter. Supra-pubic catheter changes as directed with 10 cubic centimeters (cc) balloon and as needed (PRN), Bedside drainage bag. Review of the resident's physician order sheet (POS), dated February 2026, showed:-An order, dated 6/17/25, for catheter care every shift;-An order, dated 1/5/26, for wound consult as needed to evaluate and treat. Review of the resident's medication administration record (MAR), dated February 2026, showed catheter care charted as provided 45 times out of 45 opportunities. Observation on 2/18/26 at 12:00 P.M., showed the resident wore an incontinence brief. A catheter bag was positioned below the bladder, hooked onto the resident's bed frame, and facing the door. The resident's catheter bag was not in a privacy covering. Sediment (buildup of minerals) and a brown discoloration were inside the tubing attached to the catheter. Observation on 2/19/26 at 6:48 A.M., showed the resident's catheter bag positioned below the bladder, hooked onto the resident's bed frame, and facing the door. During an interview, the Wound Nurse said there was no gauze surrounding the resident's suprapubic tube, in between the abdominal fold. The abdominal fold was infected. During an interview on 2/23/26 at 7:38 A.M., the Wound Physician said she was unaware there was an infection at the site of the suprapubic catheter, between the abdominal fold. She had prior knowledge of the resident's past issues about the suprapubic catheter leaking; however, the resident would need to be followed up by a urologist (a specialist function for the treatment and disorders of the urinary system). Observation on 2/23/26 at 7:38 A.M., showed the Director of Nursing (DON) assessed the resident's suprapubic catheter site. During an interview, the DON said the resident had a suprapubic catheter and wound to his/her coccyx (tailbone) and left hip, so there should not be an adult brief on the resident. The brief was a contraindication because the resident had wounds and a catheter. The suprapubic site looked infected and should have a dressing between the abnormal fold. During the assessment, the resident said, That hurts, when the DON lifted his/her abdominal fold to look at the site of the catheter. The DON told the wound nurse to contact the physician and get an order if the wound needed a dressing. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed:-Diagnoses included cancer, high blood pressure, obstructive uropathy (blockage of urine flow), viral hepatitis, diabetes, hemiplegia (paralysis on one side), anxiety, depression;-Cognitively intact;-Cognitively intact;-Has indwelling catheter;-Impairment on one side to the lower extremity;-Uses wheelchair;-Totally dependent with personal hygiene and toileting hygiene;-Totally dependent with transfers. Review of the resident's care plan, in use during survey, showed:-Focus: Resident has an indwelling 18 French (size) catheter related to obstructive uropathy;-Goal: No signs or symptoms of urinary infection;-Intervention: The resident has 18 French (fr) indwelling Foley (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a bag, held in place by a small, water-filled balloon). Position catheter bag and tubing below the level of the bladder and away from entrance room door;--Check tubing for kinks each shift;--Complete catheter care per orders;--Enhanced Barrier Precautions (EBP) foley in place as directed;--Indwelling catheter;--Monitor/document for pain/discomfort due to catheter. Review of the resident's POS, dated February 2026, showed:-An order, dated 1/28/26, for catheter care every shift;-An order, dated 1/28/26, to change catheter bag every month and PRN in the morning every 30 days;-No physician's order for the indwelling catheter, including the size, and no orders to change catheter tubing, or to document urine output. Review of the resident's Treatment Administration Record (TAR), dated 2/18/26 through 2/24/26, showed staff documented the completion of catheter care at 7:00 A.M. and 7:00 P.M. Observation on 2/18/26 at 11:50 A.M., showed the resident lay in bed, with the catheter hung on the left side of the bed. The catheter tube and drainage bag were below the bladder; however, there was approximately 18 inches of yellow urine that did not flow to the covered drainage bag. During an interview, the resident said he/she currently had a urinary tract infection and had issues with staff keeping him/her clean. Staff did not complete catheter care on him/her. Observation on 2/19/26 at 8:46 A.M. and 2/20/26 at 9:08 A.M., showed the resident in bed, with the catheter hung on the left side of the bed. The catheter tubing and drainage bag were below the bladder. There was no urine in the catheter tubing. During an interview on 2/25/26 at 8:00 A.M., the DON said she expected the resident to have orders for catheter use that included the size and bulb for the catheter, and orders to change the catheter and bag, and to document catheter output. The nurses are responsible for ensuring all orders are in the medical record. They would be able to see the type of catheter the resident had by visually checking the resident's catheter or the hospital record.

Based on observation, interview and record review, the facility failed to provide respiratory services consistent with professional standards of practice by failing to ensure oxygen tubing was stored properly, oxygen tubing was changed, and the oxygen rate was set properly for one of one sampled resident investigated for respiratory services and who was on oxygen (Resident #100). The census was 100.Review of the facility's undated oxygen administration policy showed implementation: Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Review of the facility's oral inhalation administration policy, dated 9/2014, showed:-Policy: to allow for safe, accurate, and effective administration of medication using an oral inhaler or nebulizer (delivers medication directly to the lungs);-Procedure: when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days. Review of Resident #100's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/25, showed:-Diagnoses included chronic respiratory failure, depression, and diabetes;-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident is at risk for impaired gas exchange, shortness of breath;-Goal: Resident will demonstrate no decrease in activity tolerance or shortness of breath. Will experience ease of respiratory efforts;-Interventions: Adjust head of the bed for shortness of breath when lying flat, as needed. Assist with body positioning as needed to assist in easing respiratory effort. Administer oxygen therapy per order and monitor for response to therapy. Change oxygen equipment per policy. Administer respiratory medications as ordered. Monitor response to medications and monitor for effectiveness/side effects. Review of the resident's physician orders summary, dated 2/2026, showed:-An order dated 12/6/25, for ipratropium-albuterol solution (medication used to treat asthma and lung disease) 0.5-2.5 milligram (mg)/3 milliliter (ml) inhale every 2 hours as needed for shortness of breath or wheezing related to chronic obstructive pulmonary disease (CPD, lung disease) via nebulizer;-An order dated 12/7/25, for oxygen at 5 liters via nasal canula (NC) continuous;-An order 12/21/25, change the humidifier bottle (used to add moisture to the administered oxygen) and oxygen tubing weekly on Sunday night. Observation on 2/18/26 at 10:55 A.M., showed the resident in bed, awake. The oxygen concentrator (medical device that is used to deliver oxygen) on and set to 4 liters. The resident's NC was positioned in his/her nose. The oxygen tubing for the concentrator and nebulizer was dated 1/2/26. Observation on 2/19/26 at 7:53 A.M., showed the resident in his/her wheelchair in his/her room. The oxygen concentrator on and set to 4 liters. The nebulizer and oxygen concentrator tubing dated 1/2/26. Observation on 2/20/26 at 11:17 A.M., showed the resident awake in bed and wore an oxygen nasal cannula. The resident's nebulizer mask lay on the floor by the resident's bed. The resident's oxygen concentrator was on and set to 4 liters. During an interview on 2/23/26 at 7:56 A.M., Licensed Practical Nurse (LPN) A said night shift normally changes oxygen tubing. The nebulizer masks should be stored in a plastic bag when not in use. He/She would expect oxygen to be administered per the physician's order. During an interview on 2/23/26 at 8:08 A.M., the Director of Nursing (DON) said oxygen should be administered to residents at the rate ordered by the physician. She would expect the resident's nebulizer mask and nasal canula to be stored properly when not in use. She would expect the nebulizer mask to be in a plastic bag labeled with the resident's name. She would expect oxygen tubing and masks to be changed once a week on the night shift.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. Out of 27 opportunities observed, five errors occurred, resulting in a 18.52% error rate (Residents #17 and #70). The census was 100.Review of the facility's Medication Administration policy, dated December 2017, showed:-Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-Procedures:-Medications are prepared only by licensed nursing, medical, pharmacy, or other personnel, authorized by state laws and regulations to prepare and administer medications;--Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these five rights is recommended at in three steps in the process of preparation of a medication for administration;---When the medication is selected;---When the dose is removed from the container;---Just after the dose is prepared and the medication is put away;--The medication administration record (MAR) is always employed during medication administration. Prior to the administration of any medications, the medication and dosage schedule on the resident's MAR are compared with the medication label. Review of the facility's Eye Drop Administration policy, dated December 2017, showed:-Purpose: To administer ophthalmic solution or suspensions into the eye is a safe accurate, and effective manner;-Procedures:-Put on gloves;-If the eye drop is a suspension, shake well;-Remove the cap, taking care to avoid touching the dropper tip;-Tilt the resident's head slightly back;-With a gloved finger, gently pull down lower eyelid to form pouch while instructing the resident to look up. Place the other hand against the resident's forehead to steady. Hold the inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of the eye. If the resident blinks or a drop lands on the resident's cheek, repeat administration;-Instruct the resident to close eyes slowly to allow for even distribution over the surface of the eye; The resident should also refrain from blinking or squeezing eyes shut. Review of dorzolamide-timolol ophthalmic solution (medication to lower pressure in the eyes) leaflet instruction for use, revised January 2023, showed:-Apply eye drops in the following way:--Remove protective cap;--Tilt head back and look at the ceiling;--Gently pull the lower eyelid down until there is a small pocket;--Squeeze the upturned dropper bottle to release a drop into your eye;--While keeping the affected eye closed, press fingers against the inner corner of the closed eye (inner canthus), the side where the eye meets the nose and hold for about two minutes. This helps to stop the medicine from getting into the rest of the body;-- Avoid touching the dropper tip against your eye or anything else;--Replace and tighten the cap straight after use. 1. Review of Resident #17's MAR, dated February 2026, showed:-An order, dated 2/7/26, for dorzolamide-timolol ophthalmic solution 2-0.5%, instill one drop in both eyes, three times daily. Hours: 8:00 A.M., 12: 00 P.M., and 5:00 P.M.;-An order, dated 2/7/26, for Symbicort (budesonide/formoterol, an inhaler used to treat lung disease) inhalation aerosol, two puffs, twice daily. Hours: 7:00 to 10:00 A.M. and 4:00 P.M. to 7:00 P.M.;-An order, dated 2/10/25, for Yupelri oral inhaler solution (a breathing treatment used to treat lung disease) 175 micrograms (mcg)/3 milliliters (ml), give one time daily. Hours: 7:00 to 10:00 A.M. Observation on 2/20/26 at 7:47 A.M., showed Certified Medicine Technician (CMT) K and CMT I prepared the resident's medications at the medication cart. During an interview, CMT I said he/she had been a CMT for a few years but was new to the facility and CMT K was orienting him/her. CMT I gave the resident his/her oral medications and explained to the resident that he/she was going to give the resident his/her eye drops. The resident tilted his/her head back slightly. CMT I held the resident's eyes open and applied the eye drops. The resident immediately started to blink his/her eyes and CMT I gave the resident a tissue to wipe his/her eyes. CMT I did not hold or press the resident's inner canthus for two minutes after the instillation of the eye drops. CMT K and CMT I did not administer the resident's Symbicort inhaler or Yupelri oral inhaler solution breathing treatment. 2. Review of Resident #70's MAR, dated February 2026, showed:-An order, dated 10/23/25, for magnesium oxide (a supplement used to treat low magnesium blood levels) 400 milligrams (mg) orally, give one time a day. Hours: 7:00 A.M. to 10:00 A.M;-An order, dated 3/23/24, for polyethylene glycol (medication used to treat constipation) 17 grams (g), give 34 g once daily. Hours: 7:00 to 10:00 A.M. Observation on 2/20/26 at 8:20 A.M., showed CMT K prepared the resident's medications. CMT K removed magnesium oxide 500 mg. out of a bottle located on the medicine cart. CMT K crushed all the resident's medication and mixed the crushed pills with pudding. CMT K mixed the polyethylene glycol with water. CMT I entered the resident's room and administered the resident his/her crushed medications and the resident started to drink the polyethene glycol mixed in water. After one sip, the resident said the water was too cold. CMT I went into the resident's bathroom and gave the resident some warm water in a cup that the resident had at his/her bedside. CMT I left the room with the cup of polyethylene glycol and water and placed it in the trash can on the medication cart. CMT K did not administer the correct ordered dose of magnesium oxide 400 mg. CMT I did not prepare the resident's polyethylene glycol with warm water as the resident requested. 3. During an interview on 2/24/26 at 9:20 A.M., CMT L said the five rights of medication administration should be followed when giving medications to the residents. The medication should be given in its entirely. CMTs are allowed to give breathing treatments and inhalers. With certain eye drops, the staff administering the eye drops should hold the resident's inner canthus for three to five seconds. He/She wasn't sure why it needed to be done that way, or which eye drops required that step. 4. During an interview on 2/24/26 at 9:30 A.M., Licensed Practical Nurse (LPN) A said the five rights of medication administration should be followed during medication administration. CMTs can give breathing treatments and inhalers. Medication should be given as ordered in its entirety. The amount of time that the resident's inner canthus needs to be held after giving eye drops is three to five minutes. LPN A wasn't sure which eye drops required that step or why it needed to be done. 5. During an interview on 2/24/26 at 10:50 A.M., the Director of Nursing (DON) said she expected staff to follow the five rights of medication administration. The resident's polyethene glycol should have been prepared with warm water and administered to the resident after the resident complained that the water was cold. She expected staff to know which eye drops required the inner canthus to be held for the recommended amount of time. CMTs can administer breathing treatments and inhalers. 2721422

Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions during care and failed to follow acceptable infection control practices during wound care for two of two residents observed for wound care (Residents #25 and #67). In addition, staff failed to ensure one out of five residents sampled for vaccinations and health screenings had a two-step Tuberculosis (TB, infectious lung disease) Screening within the 48-72 hours post admission per facility policy (Resident #67). The sample was 22. The census was 100. Review of the Facility's Enhanced Barrier Precautions policy, dated May 2024, showed:-The Facility may expand the use of Protective Personal Equipment (PPE) & refer to the use of gowns & gloves during high-contact resident care activities that provides opportunities for transfer of Multidrug Resistant Organisms (MDROs) to hands/clothing. The use of gown & gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection/colonization;-Procedure: Dressing, transfers, providing hygiene, changing linens, changing brief or toileting, device care; central line, urinary catheter, enteral tube, tracheostomy/ventilator, and wound care: skin opening requiring a dressing. 1. Review of Resident's 25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/26, showed:-Diagnoses included need for personal assistance, paraplegia (impaired motor and sensory in lower extremities), and diabetes;-Number of stage 3 pressure ulcers (full-thickness skin injury appearing as a deep, open, crater-like wound where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed): three are present, but not present upon admission;-Number of stage 4 pressure ulcers (full-thickness wound extending to exposed bone, tendon, or muscle): one is present, but not present upon admission. Observation on 2/19/26 at 9:38 A.M., showed Certified Nursing Assistant (CNA) O entered the resident's room to provide care. He/She did not perform hand hygiene upon entering the resident's room and before providing care. CNA O placed gloves on, but no gown. Staff repositioned the resident. The resident had a left hip bandage with drainage soaked through the bandage. The resident's left ankle had brown and bloody drainage, and the bandage dated 2/18. During an interview on 2/19/26 at 9:38 A.M., the Wound Nurse said the left ankle dressing had serosanguinous (clear bloody) drainage. The exterior dressing was brown and dried at the left ankle. The wound was debrided (removal of dead tissue) yesterday which would increase the drainage of the wound. Observation on 2/20/26 at 6:34 A.M., showed the Assistant Director of Nurse (ADON) and Wound Nurse entered the resident's room to provide care. The ADON draped a towel over her left shoulder as she entered the resident's room. Both staff wore gloves and gowns. The ADON removed the towel from her shoulder and placed it directly under the resident's left foot. The Wound Nurse removed the soiled dressings and the foot rested directly on the towel. The Wound Nurse stepped outside and the ADON covered the resident with a blanket that had noticeable dried blood on it. The Wound Nurse returned and changed her gloves and resumed the treatment. During an interview 2/24/26 at 8:44 A.M., the ADON said she expected enhanced barrier precautions to be used for residents with wounds. The facility does not offer drapes for wound care due to the cost. She expected staff to have something clean under the resident's wound. A towel that was carried on the staff's shoulder is contaminated and should not have been used, due to the staff's hair touching the towel. 2. Review of the Facility's Tuberculosis Screening policy, dated January 2026, showed: -The community shall screen all residents for tuberculosis infection and disease. Individuals identified with active TB shall be isolated from other residents and ancillary staff until transported to an appropriate care setting that can accommodate air-borne precautions as soon as possible.-All new admissions shall have a Mantoux skin test (the test used to check for TB infection) administered within 48-72 hours of admission unless the resident has a known history of receiving the TB Vaccine (Bacille Calrnette-Guerin or BCG) or know history of TB infection. The test shall be read within 48-72 hours after administration;--If the Mantoux skin test is negative, a second test shall be repeated 1-3 weeks after the first test is read, typically within 7-21 days;--If second test is negative, no repeat Mantoux testing is required, unless there is a possible known exposure to TB;-All residents shall be screened for TB symptoms annually. Review of Resident's 67's admission MDS, dated [DATE], showed:-Diagnoses included: unstageable left heel ulcer (full-thickness pressure injury where the wound base is completely covered by dead tissue (slough or eschar), making its true depth and stage impossible to determine) and Alzheimer's disease;-admitted [DATE];-Moderately impaired cognition. Review of the resident's Immunizations Report dated 2/23/2026 printed at 2:23 P.M., showed:-Step one: TB vaccine administered on 2/2/26; negative result;-Step two: Not recorded. Observation on 2/20/26 at 7:12 A.M., showed the Wound Nurse and Licensed Practical Nurse (LPN) C entered the resident's wound to provide wound care. The Wound Nurse sterilized the bedside table with a Sani wipe (medical grade anti-bacterial wipe), then lay Kleenex down on the surface as a barrier. The Wound Nurse touched the bed frame with his/her gloved hand, unfastened the resident's brief, then removed the dressing dated 2/19 from the resident's buttocks. The dressing was saturated with drainage. The Wound Nurse cleansed the wound, changed her gloves and used skin prep (barrier wipe) on the skin surrounding the wound, then waved her hand back in forth to help it air dry faster. LPN C touched the resident then reached over and handed the Wound Nurse Sterile gauze from the bedside table using his/her gloved hand. The Wound Nurse used the gauze to provide wound care. During an interview 2/20/26 at 7:12 A.M., the Wound Nurse said she waved her hand to help the air dry the skin prep. During an interview 2/20/26 at 7:12 A.M., LPN C said he/she broke the clean barrier when he/she touched the resident then handed a supply from the clean field to the Wound Nurse to use on the wound. During an interview 2/24/26 at 8:44 A.M., the ADON said she expects staff to complete glove changes after they touch something dirty and before they handle a sterile gauze to be used in a dressing change.

Based on observation, interview and record review, the facility failed to ensure nutritional needs were met for two of two sampled residents receiving tube feedings. The facility failed to ensure the tube feeding pump was working properly, resulting in weight loss for one resident (Resident #13), and failed to ensure one resident received his/her scheduled bolus (method of delivering formula into the stomach through a feeding tube using a syringe) feeding (Resident #8). The sample was 22. The census was 100. Review of the facility's tube feeding policy, dated 7/31/25, showed:-Policy: Residents with an order for tube feeding will be assessed and monitored by a registered dietitian to ensure nutritional needs are being met;-Procedure: Nursing will receive tube feeding order written by physician. Resident may be weighed weekly or more often as ordered by physician. Weight monitoring recommendations may be modified by registered dietitian. Review of the facility's weight variance policy, dated 1/27/26, showed:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by registered dietitian. Recommendations from registered dietitian to include but not limited to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes. Residents receiving supplements shall be monitored for acceptance by the Dietary Manager and nursing staff.-Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be reviewed by the registered dietitian for review and assessment. 1. Review of Resident's #13's medical record, showed:-Diagnoses included stroke, chronic obstructive pulmonary disease (COPD, ineffective breathing), dysphagia (impaired swallowing), alter mental statues, cognitive communication deficit (impaired communication), and diabetes. Review of the resident's weights on the facility's weight report, showed the resident weighed 188 pounds (lbs) on 1/8/26. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/26, showed:-Severe cognitive impairment;-Dependent on staff for activities of daily living (ADLs, eating, bathing, dressing and mobility);-Weight: 191 pounds (lbs.);-Weight loss: No or unknown. Review of the resident's electronic physician's order sheet (POS), showed:-An order, dated 1/31/26 for monthly weights;-An order, dated, 1/31/26, for Jevity (tube feeding formula) 1.5 (calorie amount per milliliters (mL)) at 55 mL per hour via Gastrostomy Tube (G-tube), a medical device inserted directly into the stomach to deliver nutrition and medication;-An order, dated 1/31/26 for Water flush 300 mL every 4 hours (Q4H). Review of the resident's weights on the facility's weight report, showed a weight of 186 pounds on 2/8/26. Review of the Medical Director's progress note, dated 2/12/26, showed the resident had a warning for a -7.5% weight loss. His/Her weight was charted as 186 lbs. on 2/7/26 at 12:03 P.M. Review of the resident's care plan, in use during the time of survey, showed:-Focus: Resident has a percutaneous endoscopic gastronomy tube (PEG-tube, a soft flexible feeding tube inserted through the abdomen directly into the stomach to provide long-term nutrition, hydration and medication) related to failing swallowing;-Goal: Resident will maintain adequate nutritional and hydration with stable weight;-Interventions: Monitor for tube dislodged, tube dysfunction or malfunction. Registered dietitian will evaluate quarterly and as needed (PRN), monitor calorie intake, estimate needs, and make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See Medical Directors (MD) orders for current feeding orders. Observation on 2/18/26 at 8:47 A.M. and 12:16 P.M., showed the resident's Jevity 1.5 feeding pump programmed to infuse at 55 mL/hour and water flush programed to infuse at 150 mL every four hours. The sealed Jevity 1.5 formula bottled contained 1,000 mL if formula. The bottle was labeled as hung on 2/18/26 at 7:00 A.M. At 3:54 P.M., the tube feeding infused and the container with 900 mL of formula that remained. During the timeframe of 7 hours and 8 minutes, only approximately 100 ml of formula infused. Observation on 2/19/26 at 8:14 A.M., showed the resident's 1,000 mL bottle of Jevity 1.5 formula set to infuse at 55 mL/hour. At 10:25 A.M., the Jevity remained with 1,000 mL of formula that remained. At 1:37 P.M., the bottle had 850 mL of formula that remained. During the timeframe of 5 hours and 23 minutes, only approximately 150 ml of formula infused. Observation on 2/20/26 at 5:39 A.M., showed the Jevity 1.5 hung at 4:30 A.M. The self-contained prefilled tube feeding formula bottle, showed the bottle contained 1,000 ml. The tube feeding pump was programmed at 55 mL/hr. At 10:58 A.M., the resident's tube feeding was disconnected. The bottle had 900 mL of formula that remained. At 11:03 A.M., LPN C said he/she needed to change the resident due to the tube feeding leaking. Staff weighted the resident with a mechanical lift scale. LPN C said the resident's weight measured 179.4 lbs. The resident was fully dressed in pants, shirt, socks, and a brief. After the resident was back in bed, LPN C took the clothing items and weighed them which totaled 3 lbs. LPN C took mechanical weight of 179.4 lbs. minus 3 lbs., for a weight of 176 lbs. At 1:32 P.M., the tube feeding container with 800 mL of formula that remained. By 2:00 P.M., the container with 750 mL of formula remained. During the timeframe of 8 hours and 21 minutes, only approximately 250 mL of formula infused. During an interview on 02/20/2026 at 2:02 P.M., the Director of Nursing (DON) said expectations were for the nurses to check the pump to ensure the resident was receiving the nutrition. The DON said she would exchange the pump immediately. On 02/23/2026 12:13 P.M., the DON said the resident was sent to the emergency room (ER) Friday night due to a hole in his/her tube. Review of the nurse's progress note on 2/20/26 at 2:22 P.M., showed the resident had tube feeding on his/her brief. Upon an assessment, the nurse located a small hole within the tube. LPN C notified the nurse practitioner (NP) and DON about the results. NP put orders in to send the resident to a local hospital for replacement. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic kidney disease, type two diabetes, and muscle weakness;-Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident receives alternative nutritional intake via tube feeding;-Goal: The resident will be free of aspiration through the review date;-Interventions: Listen to lung sounds as indicated. Review of the resident's POS, dated 2/2026, showed:-An order, dated 2/9/26, enteral feed, after meals and at bedtime, Jevity 1.2 300ml per G-tube. Review of the resident's weights summary, showed:- On 01/13/2026, the resident weighed 101.9 lbs. On 02/07/2026, the resident weighed 95.2 lbs , which was a -6.58 percent weight loss. Observation on 2/18/26 at 9:33 A.M., showed the resident in bed awake. A bottle of Jevity 1.2 was on the resident's nightstand. There was 1000 mLs of formula still in the bottle. The bottle was dated 2/18/26. Observations on 2/19/26 at 6:19 A.M., showed the resident in bed awake. A bottle of Jevity 1.2 was on the resident's nightstand. The bottle was dated 2/18/26. There was 1000 mL of formula in the bottle. At 10:11 A.M., the resident was in bed asleep. The bottle of Jevity 1.2 was on the nightstand. There was 1000 mL of formula in the bottle. The bottle was dated 2/18/26. Observation on 2/20/26 at 6:36 A.M., showed the resident in bed asleep. A bottle of Jevity 1.2 was on the resident's nightstand. The bottle was dated 2/20/26. The bottle was unopen with the seal still on. Observations on 2/20/26 at 7:55 A.M., 8:25 A.M., and 9:00 A.M., showed the resident in the dining room during the breakfast meal. During an interview on 2/20/26 at 9:32 A.M., LPN A said the resident received bolus feedings of the Jevity 1.2 and eats food. He/She believed the resident only received a bolus if the resident ate under a certain amount. He/She did not know the amount. He/She said he/she had already administered the resident's morning bolus at approximately 8:20 A.M. and used a different bottle of Jevity 1.2 to administer the bolus than the bottle that was on the resident's nightstand. Review on 2/20/26 at 9:43 A.M., of the resident's February MAR, showed no documentation of the bolus being administered. During an interview on 2/20/26 at 10:28 A.M., Certified Nursing Assistant(CNA) B said LPN A did not administer a bolus feeding while the resident was in the dining room. He/She had been at the table where the resident was seated, assisting residents during breakfast. During an interview on 2/23/26 at 7:56 A.M., LPN A said bolus feedings should be administered per the physician's orders. He/She said meal intake should be documented for the resident if weight loss was a concern. During an interview on 2/23/26 at 8:08 A.M., the DON said bolus feeding should be administered per the physician's orders. She would expect the resident to receive his/her four scheduled bolus's. She would expect documentation of bolus feedings to be accurate. She would expect meal intake to be documented if weight loss was a concern. 271394

Based on observation, interview and record review, the facility failed to ensure one resident, identified as high risk for falls, received adequate supervision to prevent accidents (Resident #1). Staff placed the resident near the nurses' station for close observation in a locked wheelchair. Staff left the area, during which time Resident #1 attempted to get up and fell from the wheelchair, resulting in a fractured wrist. In addition, the facility failed to ensure fall prevention interventions for three residents who were identified as high risk for falls, were consistently and accurately documented across the care plan, physician orders, and progress notes, as required by the facility's Fall Management Policy and Incident Documentation and Investigation Policy (Residents #1, #3 and #4). The sample size was three. The census was 91.Review of the facility's policy entitled, Fall Management, dated 2/28/23, showed:-Policy: is to provide an environment that remains as free of accident hazards as possible. The facility will complete a Morse Fall Scale Evaluation on residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries.-Procedure (Risk Identification/Evaluation): Residents shall be evaluated for fall risk upon admission/re-admission, post-fall, quarterly, annually and significant change using Morse Fall Scale Evaluation. Identify risks factors should be address in the resident's care plan to ensure individualized interventions to reduce the risk are implemented.-Steps: Charge nurse will evaluate for injury; complete neurological evaluation post-fall on residents with potential head injury or unwitnessed fall; notify Primary Care Physician (PCP), resident representative; implement interventions to reduce further occurrences; document in resident's medical record Electronic Medical Records (EMR)/ Point Click Care (PCC); complete incident report; implement post-fall evaluation and documentation; the care plan should be reviewed after every fall and updated with a new intervention. Review of the facility's policy entitled, Accident & Incident Documentation & Investigation, dated 4/26/23, showed:-Policy: Accidents and/or Incidents involving residents will be investigated and documented on an Incident Report entry in the EMR.-Procedure: The licensed nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth in the Incident Report; The license nurse may complete a Nurses' note and update the resident care plan as needed; The nurse's notes may contain the following documentation - clear objective facts of what occurred; Incident Report will be completed in the EMR. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/16/25, showed: -Diagnoses included hemiplegia following cerebral infarction affecting right dominant side (paralysis on one side of body caused by stroke), unsteadiness on feet, dysphagia-oropharyngeal phase (trouble swallowing during the mouth and throat stage of swallowing); -Severe cognitive impairment;-No behaviors; -Functional abilities showed walker, wheelchair; supervision or touching assistance with toileting and sit to stand; partial to moderate assistance with the ability to wheel at least 150 feet in corridor. Review of the resident's care plan, in use during the survey, showed:-Focus: limited physical mobility;-Goal: will remain free of complications relate to immobility, fall related injury through the next review date;-Interventions: Provide supportive care, assistance with mobility as needed Document as needed. -Focus: Resident has a history of falls and is at risk for further falls with confusion, impaired mobility, incontinence;-Goal: Resident will be free of falls through the review date; -Interventions: Resident to be sitting at nurse's station for direct observation until safety deemed established per nursing discretion; on 10/2/25 fall mat at beside; on 10/6/25 provide activity apron; resident needs activities that minimize the potential for falls while providing diversion and distraction. Bed positioning is not addressed. Review of the Physician Order Sheet (POS), showed an order, dated 10/2/25, for floor mats; no order for low bed. -Progress notes showed:-10/6/25 at 7:20 A.M., Resident up throughout the night, resident at nurse station for observation, resident self-propels in wheelchair, as desires, nurse later observed resident on floor in sitting position, no pain voiced, resident has history of dementia and could not recall event. Noticed swelling to left wrist and hand. X-ray ordered.-10/6/25 at 3:13 P.M., Small hematoma (raised area with skin discoloration and swelling) noted to left forehead and bruising noted around left eye. X-ray results came back, impression stated acute distal radius and ulna fracture (the two forearm bones: the radius and ulna, close to the wrist). Spoke with Nurse Practitioner, received order to send resident to emergency room (ER) for further evaluation;-10/9/25, Interdisciplinary Team (IDT) risk meeting held today, care plan reviewed and interventions in place, resident alert and not acute changes noted. Interventions applied: low bed with floor mats, chair dump and activity apron. -10/11/25, at 3:30 P.M., resident was readmitted to facility from hospital with brace to left wrist.-Review of Facility's Incident Report on 10/9/25 showed resident had interventions applied: low bed with floor mats, chair dump and activity apron. Review of Neurological evaluation was not kept in the resident's EMR, the neurological evaluations were only available upon request that were kept in a filing cabinet behind the nurse's station. Observation and interview on 10/21/25 at 11:20 A.M., showed the resident sat in his/her wheelchair, with both wheel breaks on, in his/her room visiting with a family member. The resident wore a brace on his/her left forearm that was propped up on a pillow. The resident said he/she was asleep when the fall happened, so the resident does not know how it happened. The resident's family member said the facility still has not explained how the resident fell, and he/she is very concerned because the most recent fall on 10/6/25 makes the fourth fall since June at this facility. Observation on 10/22/25, showed:-At 6:55 A.M., resident sat in wheelchair with both wheels locked on the 600-hall television room with no staff members in view. Resident was observed fiddling with left wrist brace; the brace was up twisted with the thumb hole positioned at the back of the hand. The resident was fully dressed and not wearing his/her activity apron. -11:41 A.M., resident sat in wheelchair with right wheel locked and left wheel unlocked on the 600-hall television room with no staff members in view. The resident wore a brace on his/her left wrist and was calmly fiddling with the pillow that laid on his/her lap; activity apron was not present. During interviews on 10/22/25 at 9:30 A.M. and at 10:35 A.M., Registered Nurse (RN) I said the resident never sleeps and is normally up all night and unruly. RN I said the staff know to make sure when resident is in bed, the bed is in low position with the floor mats on both sides of the bed. RN I said on the night of 10/6/25, the resident was very restless and continued to try to get out of his/her wheelchair, so he/she placed the resident at the nurses' station with the wheelchair wheels locked so staff could watch the resident. RN I had to start passing out other residents' medications and the Certified Nurse Aide (CNA) had to start with morning care. They walked away from the desk, leaving the resident at the nurse's station. It was a short time later he/she saw the resident on the floor. RN I said neither he/she nor the CNA witnessed the resident fall out of the wheelchair. During an interview on 10/22/25 at 7:00 A.M., CNA E said the resident stays up all night. CNA E said the resident continues to attempt to get out of his/her wheelchair and his/her bed, so the resident has to be watched. CNA E said he/she makes sure the resident's floor mat is on the floor and the bed is in low position. During an interview on 10/22/25 at 7:10 A.M., Graduate Practical Nurse (GPN) F said the resident does not sleep much throughout the night. GPN F said the resident is very confused but does not demonstrate combative behavior. The resident is on fall precautions and has a floor mat and the bed must be in low position. During an interview on 10/22/25 at 11:05 A.M., CNA H said he/she tries to always keep the resident in an open area because the resident is a fall risk. CNA H said when the resident is in bed, he/she has to make sure the bed is low position, and the floor mats are down on both sides. CNA H said he/she also checks on the resident every 10 minutes because the resident continues to try to get out of the bed. CNA H said the resident has an activity apron to help keep him/her calm and occupied. CNA H said the resident should use the activity apron, but he/she just forgot to give it to the resident. 2. Review of Resident #3's annual MDS, dated [DATE], showed:-Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke with right side paralysis), anxiety disorder and dysphagia;-Severe cognitive impairment;-Moderate severe depression. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident has history of falls, poor balance, unsteady gait and at risk for falls;-Goal: will resume usual activities without further incident and free of falls through the review date;-Interventions: On 10/7/25 fall mat placed. On 10/13/25 frequent rounding and follow fall protocol. The bed positioning is not addressed. Review of the resident's POS, showed no order for floor mat or low bed. Review of the resident's progress notes, showed:-On 10/9 and 10/16/25 Interdisciplinary Team (IDT) fall meeting and care plan and intervention in place; fall mats. -On 10/13/25 resident in bed in low position with interventions in place. Review of Facility's Incident Report, showed:-10/9/25, IDT fall risk meeting held, care plan reviewed and intervention(s) in place: fall mats, frequent rounding and have resident up for meals and activities; low bed not addressed.-10/12/25, incident description of resident was witnessed on the floor on mat. The incident was not reflected in the resident's progress notes. -Review of Neurological evaluation was not kept in the resident's EMR, the neurological evaluations were only available upon request that were kept in a filing cabinet behind the nurse's station. 2. Review of Resident #4's annual MDS, dated [DATE], showed:-Diagnoses included metabolic encephalopathy (brain function is disturbed due to a chemical imbalance or metabolic problem in the body), acute kidney failure and unsteadiness on feet;-Intact cognition;-Hoyer lift (mechanical full body lift); two persons assist. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident is at risk for falls due to reduced physical mobility, weakness, history of seizures;-Goal: Resident will be free of falls through the review date;-Interventions; Resident's call light is within reach.-The care plan did not reflect the resident's fall on 10/7/25 or interventions. Review of the facility's Incident Report, dated 10/7/25, showed resident was assisted, neuro checks done and vital signs obtained. No interventions noted at this time. Review of the progress notes, showed:-10/10/25, showed the resident alert oriented, uses Hoyer lift with transfers, self-propels in wheelchair, feeds self, encourage to use call light, resident observation falls interventions in place.-10/16/25 IDT fall risk meeting held, care plan reviewed and intervention(s) in place: will apply roll bars to back of wheelchair and educated the resident on the importance of using the call light for assistance. Review of Neurological evaluation was not kept in the resident's EMR, the neurological evaluations were only available upon request that were kept in a filing cabinet behind the nurse's station. Observation and interview on 10/21/25 at 11:50 A.M., showed the resident laid in bed on top of a Hoyer sling with the bed approximately 4 feet from the ground. The resident was not wearing a fall bracelet. The resident's call light laid on the floor between the bed and the wall. The resident said he/she was unable to reach the call light and would yell out if he/she needed anything. Observation on 10/22/25 at 7:15 A.M., showed the resident sat in his/her room in a wheelchair. The wheelchair had no roll bars on the back of wheelchair. The resident's call light laid on the floor between the bed and the wall. During an interview on 10/21/25 at 10:15 A.M., CNA D said the residents who are a fall risk are identified by a fall risk bracelet. CNA D said those residents with the bracelet should have their beds in low position and have a floor mat. During an interview on 10/21/25 at 3:45 P.M., the Director of Nursing (DON) said she expected staff to follow the facility's Fall Management Policy and Accident and Incident Documentation and Investigation policy. The DON expected the medical records to accurately reflect the residents' plan of care consistently and accurately documented across the care plan, physician orders and progress notes. During an interview on 10/22/25 at 11:40 P.M., Licensed Practical Nurse (LPN) J said residents who are high risk will have fall mats, low beds and pillow wedges. The residents who are high fall risk will have their wheelchairs locked and are kept at the nurses' station or in a common area to keep them safe. Staff know who is high risk because the resident wears a high risk bracelet and is noted in the resident's care plan. During an interview on 10/22/25 at 1:40 P.M., the MDS Coordinator said after every resident fall, the resident's intervention(s) are placed on the individuals care plan. The MDS Coordinator expected interventions such as floor mats, low bed, anti-roll backets be reflected on a resident's care plan. During an interview on 10/22/25 at 2:45 P.M., the Administrator said she expected staff to follow the facility's Fall Management Policy and Accident and Incident Documentation and Investigation policy. 2636245

Based on observation, interview and record review, the facility failed to ensure staff followed the facility's policy regarding gastronomy tube (g-tube, a small rubber tube surgically inserted through the abdomen in to the stomach to administer nutrition, fluids and medications) feedings by not recording on the bag the name of the formula, the date and time hung and the resident's name, failed to accurately determine the amount of food and fluid consumed per meal and also failed to follow physician orders for two residents (Residents #3 and #40) out of three sampled residents. The facility also failed to ensure staff correctly positioned a resident who received tube feedings (Resident #3). The census was 96.Review of the facility's Tube Feeding policy, undated, showed:-Gastric enteral tube feeding involves delivery of a liquid feeding formula directly to the stomach via an enteral tube (providing nutrition directly into the digestive system through a tube);-Verify the practitioner's order;-Position the patient with the head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration (accidental inhalation of foreign material, such as food, liquid, or saliva, into the lungs);-Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route; rate of administration; administration duration (if cycled or intermittent); initials of who prepared, hung, and checked the enteral formula against the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY.1. Review of Resident #3's care plan, undated, showed:-Problem: Activities of daily living (ADL) self-care performance deficit. Interventions included: Totally dependent on staff for repositioning and turning, dependent on staff for personal hygiene/oral care. ADL-Eating;-Problem: History of dehydration or potential fluid deficit related to tube feeding. Interventions included: Monitor and document intake and output as per facility policy and as needed for assistance with fluid intake in order to meet daily requirements;-Problem: Nutritional problem or potential nutritional problem. Interventions included: Provide and serve diet as ordered and Nutrition - Amount Eaten.Review of the resident's electronic health medical record (EHMR), showed:-The resident's medical diagnoses included: hemiplegia (paralysis on one side of the body) affecting right dominant side, moderate protein-calorie malnutrition, diabetes mellitus, dysphagia (difficulty swallowing) and gastrostomy (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications). Review of the resident's Brief Interview for Mental Status (BIMs) evaluation, dated 10/6/25, showed the resident had severe cognitive impairment, with a score of 5 out of 15. Review of the resident's Physician Order Sheet (POS), showed:-An order, dated 10/6/25, for mechanical soft diet, mechanical soft texture, thin consistency, mechanical soft diet for pleasure. Feeding assistance for diet;-An order, dated 10/9/25, for head of bed (HOB) elevated every shift for tube feeding (TF);-An order, dated 10/9/25, for Jevity 1.2 (calorically, dense fiber fortified therapeutic nutrition for long or short term tube feeding) 65 milliliters (ml) an hour (hr), 150 water flushes (water flushes for resident hydration and to prevent g-tube from clogging) every 4 hours. Give TF in the evening;-An order, dated 10/9/25, for Jevity 1.2, give a bolus (single large dose of a substance) of 240 ml if less than 50% of meal consumed, three times a day. Review of the resident's nutritional report, dated 10/10/25, showed:-Assessment: The resident was on a mechanical soft diet, oral intake was 25% with an order for Jevity 1.2, 65 ml/hr, at night from 6:00 P.M. to 6:00 A.M., with an order for 240 ml bolus of Jevity 1.2 if consumed less than 50% of meal;-Goals: Adequate tube feeding and tolerance and greater than 75% intake at meals. Review of the resident's nutrition history, dated 10/14/25, showed:-Diet order: Nothing by mouth (NPO)/pleasure diet mechanical soft;-Assistance was not required.Review of the resident's progress notes, dated 10/16/25, at 2:17 P.M., showed the resident required full assistance with ADLs and the resident received continuous feeding via g-tube site. Review of the resident's ADL documentation for amount eaten, dated 10/5/25 through 10/21/25, showed:-No documentation after 10/16/25 showing the percentage of the meal the resident consumed. Review of the resident's ADL documentation for fluid, dated 10/5/25 through 10/21/25, showed:-No documentation after 10/16/25 showing the amount of fluid the resident consumed. Review of the resident's discharge evaluation progress note, dated 10/17/25 at 2:54 P.M., showed:-Reason for evaluation was discharge;-Self Care evaluation dates for 3-day window: 10/15/25 through 10/17/25 with collaboration from Licensed Nurse and MDS Nurse;-Eating: Discharge performance: Dependent. Observation on 10/21/25 at 8:44 A.M., showed the resident lay in his/her bed, asleep, with a feeding pump at bedside, not connected to the resident and not running. The resident's bedside table was pushed against the wall, on the right side of the resident's bed, with several absorbent pads stacked in a pile and a pink cup placed on top of the table. Review of the resident's Medication Administration Record (MAR), dated 10/21/25 at 11:28 A.M., showed:-An order, dated 10/9/25, for Jevity 1.2 65 ml/hr and 150 water flush every four hours, give in evening from 4:00 P.M. through 7:00 P.M. Documentation showed the staff administered per the order on 10/20/25;-An order, dated 10/9/25, to elevate HOB every shift for TF was documented as completed on 10/21/25 at 7:00 A.M.;-An order, dated 10/9/25, to give a bolus of 240 ml of Jevity 1.2, if less than 50% of meal consumption, three times a day. Documentation showed the staff administered 240 ml of Jevity 1.2 on 10/21/25 at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Observation on 10/21/25 at 11:45 A.M. showed:-The resident's bedside table was pushed against the wall, on the right side of the resident's bed, with several absorbent pads stacked in a pile and a pink cup placed on top of the table.-The resident lay in his/her bed, not connected to the feeding pump;-The resident's HOB was elevated to approximately 30 degrees. Observation on 10/21/25 at 12:39 P.M., showed:-The resident's bedside table was pushed against the wall, on the right side of the resident's bed, with several absorbent pads stacked in a pile and a pink cup placed on top of the table.-The resident lay in his/her bed, with a feeding tube connected to his/her g-tube;-The feeding pump was turned on and running;-A bottle of Jevity 1.2 was hung on the feeding pump, labeled hung on 10/21/25 at 12:18 P.M., run at 65 ml/hr;-The resident's head of his/her bed was elevated approximately 15 degrees;-During the observation, the feeding pump began beeping. During an interview on 10/21/25 at 12:40 P.M., the resident said:-He/She did eat breakfast in his/her room;-The nurse did not administer any water flushes through his/her g-tube yet that day;-He/She did not receive his/her lunch yet. Observation on 10/21/25 at 12:45 P.M., showed:-Licensed Practical Nurse (LPN) A entered the resident's room;-LPN A silenced the feeding pump, assessed the feeding pump TF tube (tube that is connected to the Jevity 1.2 TF bottle, ran through the feeding pump and connected to the resident's g-tube), corrected the problem and turned the feeding pump back to on to resume the TF to the resident;-The resident's HOB was elevated to approximately 15 degrees. Observation on 10/21/25 at 1:10 P.M., showed staff passing lunch trays out to residents in their rooms on the resident's hall. Observations on 10/21/25 at 1:11 P.M, 1:16 P.M., 1:23 P.M, 1:40 P.M. and 2:00 P.M., showed:-The resident lay in his/her bed, asleep, with the feeding pump on, administering Jevity 1.2 at 65 ml/hr;-The resident's HOB was elevated to approximately 15 degrees;-The resident's bedside table was pushed against the wall, on the right side of the resident's bed, with several absorbent pads stacked in a pile and a pink cup placed on top of the table. During an interview on 10/21/25 at 2:33 P.M., LPN A said:-He/She was the nurse assigned to the resident from 7:00 A.M. through 7:00 P.M.;-The resident required a bolus TF if he/she did not consume 50% or more of his/her meals;-The resident was on a continuous TF of Jevity 1.2;-LPN A started the resident's TF of Jevity 1.2 at 10:33 A.M. that day;-When residents received TF, their HOB was expected to be raised to 45 degrees or higher to prevent aspiration (accidental intake of food/liquid into the lungs);-He/She was not sure how to find if a resident needed assistance with feeding in residents' EHMR;-LPN A would ask a CNA if a resident required feeding assistance;-Nurses were responsible for informing CNAs when a resident required feeding assistance, to ensure residents were getting their meals with feeding assistance, and ensuring residents' HOB was raised to at least 45 degrees while receiving TF;-LPN A gave the resident a bolus TF after breakfast because the resident only consumed 30% of his/her meal;-LPN A was not sure if the resident was eating food for pleasure or if the resident was served a lunch tray;-CNA B told LPN A the resident consumed less than 20% of his/her lunch, at an unknown time. During an interview on 10/21/25 at 3:05 P.M., CNA B, said:-He/She was responsible for the resident's care that day;-He/She did not give a meal tray to the resident during lunch;-He/She was asked by an unknown staff member how much the resident consumed during lunch and CNA B could not answer as he/she did not know if the resident had eaten lunch;-LPN A did not ask CNA B how much the resident consumed during lunch and CNA B did not report to LPN A how much the resident consumed during lunch;-CNA B was not told which residents on his/her assignment required feeding assistance;-CNA B expected the nurse to inform him/her of any residents who needed feeding assistance;-Residents who received TF needed their HOB elevated high to prevent any complications such as aspiration or choking. During an interview on 10/21/25 at 3:19 P.M., Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator said:-He/She was a LPN;-He/She did not assist feeding any residents during lunch;-He/She helped pass lunch trays out to residents on the resident's hall;-He/She picked up the resident's lunch tray, went to the resident's room and gave the lunch tray to LPN A, who was already in the resident's room;-LPN A took the resident's lunch tray from the MDS Coordinator and the MDS Coordinator left the room;-The MDS Coordinator did not know if LPN A stayed to provide feeding assistance to the resident;-The MDS Coordinator did not know if the resident required feeding assistance and he/she did not pick up the resident's lunch tray at the end of meal time.Review of the resident's progress notes, dated 10/22/25 at 12:57 P.M., showed no documentation as to whether the resident received TF on 10/21/25 during the day. 2. Review of Resident's #4's EHMR, showed his/her diagnoses included dysphagia, diabetes mellitus, lack of coordination, cognitive communication deficient, hemiplegia affecting left non-dominant side, and a percutaneous endoscopic (PEG) gastrostomy (PEG tube is a thin, flexible tube inserted directly into the stomach through a small incision in the abdominal wall). Review of the resident's care plan, undated, showed:-Problem: ADL self-care performance deficit. Interventions included: Totally dependent on staff for repositioning and turning, dependent on staff for personal hygiene/oral care. ADL-Eating;-Problem: Has a PEG tube placed due to a failed swallow study and diet is mechanical soft and nectar consistency. Interventions included: Registered Dietician to evaluate quarterly and as needed to monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed. Review of the resident's POS, showed:-An order, dated 8/22/25, to record meal intake three times a day for meal consumption;-An order, dated 10/5/25, for TF, give Jevity 102, at 50 ml/hr every night shift on at 7:00 P.M. and off at 7:00 A.M.;-An order, dated 10/7/25, for regular diet, regular texture with nectar thick consistency for fluids. Review of the resident's BIMs score, dated 10/10/25, showed the resident was cognitively intact with a score of 15. Review of the resident's Registered Dietician monthly review, dated 10/16/25 at 12:32 P.M., showed:-Regular diet with nectar thick liquid and Jevity 1.2, give 50ml/hr from 7:00 P.M. to 7:00 A.M., and 150 ml of water flush every four hours;-Recommend to discontinue TF and monitor oral intake. Review of the resident's ADL documentation for amount eaten, dated 10/5/25 through 10/21/25, showed:-No documentation after 10/19/25 with the percentage of the meal the resident consumed. Review of the resident's ADL documentation for fluid, dated 10/5/25 through 10/21/25, showed:-No documentation after 10/19/25 with the amount of fluid the resident consumed. Review of the resident's progress notes, showed no documentation documenting food or fluid intake daily. Review of the resident's MAR, dated 10/25, showed:-An order for TF, Jevity 1.2, give 50 ml/hr via g-tube every night shift from 7:00 P.M., through 7:00 A.M. Documentation showed the facility administered the TF as ordered on 10/20/25 and 10/21/25. Observation on 10/21/25 at 11:51 A.M., showed:-The resident lay in his/her bed, fully clothed with tennis shoes on his/her feet, with his/her upper body slumped over to the left side of the bed and his/her pillow half covering his/her right side his/her face;-The HOB was elevated to approximately 45 degrees;-There was a feeding pump present at the foot of the bed, not running, with a bottle of Jevity 1.2 with no documentation showing the date and time when it was hung or the rate the Jevity 1.2 was ordered to run per hour;-A pink mug filled with regular, thin consistency water on the resident's bedside table, within reach. During an interview on 10/21/25 at 11:52 A.M., the resident said:-He/She received TF at night;-He/She was told by staff he/she did not swallow properly;-He/She did not get any breakfast that morning;-The resident demonstrated how he/she could reach the pink mug filled with regular, thin consistency water. Observation on 10/21/25 at 12:38 P.M., showed:-The resident lay in his/her bed, fully clothed with tennis shoes on his/her feet, with his/her upper body slumped over to the left side of the bed;-The HOB was elevated to approximately 45 degrees;-There was a feeding pump present at the foot of the bed, not running, with a bottle of Jevity 1.2 with no documentation showing the date and time when it was hung or the rate the Jevity 1.2 was ordered to run per hour;-A pink mug filled with regular, thin consistency water was on the resident's bedside table, within reach. Observation on 10/21/25 at 1:12 P.M., showed:-The resident lay in bed with a lunch tray in front of him/her, placed on a bedside table;-The resident's meal tray ticket said regular diet and nectar thick liquids;-The resident had two cups of unidentified liquids covered in plastic wrap, both contained thickened liquids-The resident's HOB was elevated approximately 45 degrees. During an interview on 10/21/25 at 1:38 P.M., the resident said:-A staff member just picked up his/her meal tray;-He/She ate most of his/her lunch;-The liquids were thick. 3. During an interview on 10/21/25 at 2:33 P.M., LPN A said:-He/She was assigned to care for both Residents #3 and #4 during his/her shift from 7:00 A.M. through 7:00 P.M.;-He/She followed dietary orders found on the resident's POS;-CNAs and nurses were responsible to ensure residents' dietary orders matched the food served to the residents;-CNAs were ultimately responsible for ensuring residents received the correct dietary orders;-He/She expected CNAs to report to the nurse and document the amount of food and/or fluid residents consumed after meals;-LPN A expected CNAs to inform him/her of how much residents consumed during their lunch by 1:00 P.M. to 1:30 P.M.;-Nurses were ultimately responsible for ensuring residents food and/or fluid was documented in the EHMR in the MAR;-Nurses were expected to follow physician orders. During an interview on 10/22/25 at 11:27 A.M., the Director of Nursing (DON) said:-She expected nursing staff to have knowledge of and follow facility policies;-She expected nursing staff to know resident's diet order;-She expected nursing staff to know if residents needed feeding assistance;-She expected nurses to look at residents' POS to find dietary orders, if feeding assistance was required;-She expected CNAs to find dietary orders on residents' meal tray tickets found on residents' meal trays;-She also expected CNAs or other nursing staff to ask the nurses if they were unsure of residents' dietary orders or feeding status; -She expected nursing staff to follow dietary orders when passing water to residents;-She expected CNAs to thicken the water if that was a requirement on a residents' diet order;-Nurses were ultimately responsible to ensure diet orders are followed and feeding assistance was given to residents if required;-She expected nursing staff to follow physician orders;-Residents were at risk of an adverse reaction if physician orders were not followed, such as choking if a diet order was not followed;-She expected nurses to verify orders at admission, after any change of condition, and before administering the medication;-The DON was responsible for reading any nutritional reports/assessments, to report the Registered Dietician's recommendations to the Primary Care Provider (PCP), put in any new orders into residents' EHMR, notify the Dietary Manager and MDS Coordinator and document all that was done in a progress note in residents' EHMR;-The Dietary Manager was responsible for updating the dietary orders on the meal tray tickets;-She expected the nursing staff to follow the care plan, and utilize the interventions because they may help the residents;-The MDS Coordinator was responsible to ensure care plans and interventions are utilized;-She expected residents' HOB to be elevated to 30 or 45 degrees while they received TF to lower the risk of aspiration. It was ultimately the nurses' responsibility to ensure residents' HOB was elevated to the correct position;-She expected nurses and the CNAs to round on residents every two hours who were actively receiving TF, to look for signs and symptoms of aspiration, vomiting, labored breathing, flushes, or any other abnormalities. -She expected nurses to accurately document what they did/administered in the resident's medical record as it affects the plan of care. Physicians, Registered Dieticians, and other medical providers use the information found in the resident's medical record to determine the next action in the plan of care. During an interview on 10/22/25 at 12:00 P.M., the Administrator said:-She expected staff to have knowledge of and to follow facility policies;-She expected nursing staff to know a resident's diet order;-She expected nursing staff to know if residents needed feeding assistance;-She expected nurses to find dietary orders and if feeding assistance was required in residents' care plans and POS;-She expected nurses to inform the CNAs of their assigned residents' dietary orders, feeding assistance requirements and any care plan interventions;-She expected nursing staff to follow physician orders;-Residents were at risk of any number of adverse affects, even death, if their plan of care and/or physician orders were not followed;-Residents were at risk of aspiration, allergic reactions and/or choking if their diet orders were not followed;-The DON was responsible for reading the nutritional assessments from Registered Dieticians, notifying the PCP of the recommendations and putting in the orders and informing the rest of the Interdisciplinary Team (IDT) during daily morning meetings;-The MDS Coordinator was responsible for updating the care plans;-The purpose of a care plan was to ensure we translated what was needed to take care of the residents;-She expected staff to used care plan interventions which were specific and personalized to the resident. Interventions were determined if they were appropriate by observing whether or not they worked;-She expected nurses to document in progress notes intervention failure so IDT would know to change it. Interventions were put in care plans and expected to be used, they were not recommendations;-She expected nursing staff to follow care plan interventions, such as monitor and document intake and output as per facility policy; -All nursing staff was responsible for following physician orders and residents' plan of care;-Management was responsible to oversee nursing staff and to follow up to ensure physician orders and residents' plan of care was followed; -Residents receiving TF were expected to have their HOB elevated to 45 degrees to lower the risk of aspiration;-She expected nurses to round frequently on when a resident is actively getting TF to monitor for signs and symptoms of aspiration and to ensure the residents' HOB was in the correct position;-She expected any staff who passed ice water to residents to know their diet orders and to provide thickened water if that was the requirement of their diet order;-She expected nursing staff to accurately document what they did/administered in the resident's medical record as it affected the plan of care. Physicians, Registered Dieticians and other medical providers use the information found in the resident's medical record to determine the next action in the plan of care. 2604120

Based on observation, interview and record review, the facility failed to follow their policy by failing to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and perform wound treatments for two of three residents sampled (Residents #9 and #12). The census was 106. Review of the facility's Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: Wound treatment will be provided in accordance with physician's orders; -Cleansing method; -Type of dressing; -Frequency of dressing change; -Charge Nurse will notify physician in the absence of treatment orders; -Wound dressings will be applied in accordance with manufacturer's recommendations; -Wound Characteristics/Documentation: -Location of the wound; -Size (shape, depth, tunneling and/or undermining),volume and drainage characteristics; -Pain evaluation; -Condition of the wound bed; -Condition of the peri-wound (skin surrounding the wound); -Guidelines for Dressing Selection: -Obtain physician's order; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of the treatments will be monitored through ongoing evaluation of the wounds. Review of the facility's Physician Orders policy, last reviewed on 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state, and federal guidelines; -Responsibility: Licensed nursing, administration, and Director of Nursing (DON); -Procedure: Physician orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders. Physician orders must be documented clearly in the medical record. Physician orders must be documented clearly in the medical recorded. Physician orders will be transcribed to the appropriate administration record electronic Medication Administration Record (MAR/eMAR) or electronic Treatment Administration Record (TAR/eTAR). 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/20/24, showed: -Diagnoses included cancer, high blood pressure, peripheral vascular disease (lack of blood flow to the legs), diabetes, high cholesterol and end stage renal disease; -Cognitively intact; -No documented wounds. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's treatment to his/her right, first toe. Review of the resident's physician orders (POs), dated September 2024, showed an order dated 9/20/24, at 7:00 A.M., right first toe, cleanse with wound cleanser, apply betadine (a topical antiseptic that treats minor wounds and prevents infections), cover with gauze and wrap with kerlix (gauze) every day shift (7:00 A.M.-3:00 P.M.). Review of the resident's eTAR, dated September 2024, showed: -On 9/20/24, the treatment was documented as completed; -On 9/21/24, the treatment record was blank; -On 9/22/24, the treatment was documented as completed; -On 9/23/24, the treatment was documented as completed; -On 9/24/24, the treatment was documented as resident out of facility. Observation and interview on 9/24/24 at 10:46 A.M., showed the resident lay in bed. The resident said the dressing on his/her right big toe were not completed every day. The resident had a dressing on his/her right first toe, dated 9/20/24. Observation and interview on 9/25/24 at 8:58 A.M., showed the resident sat in his/her wheelchair, at the nurse's station. The resident had a dressing on his/her right, first toe, dated 9/24/24. The resident said a nurse changed the dressing last night. During an interview on 9/25/24 at 10:57 A.M., Licensed Practical Nurse (LPN) G said the resident's wound is supposed to be cleansed daily, between 7:00 A.M. and 3:00 P.M. If the treatment gets missed, staff will do it later. If the treatment is done late, it will appear as yellow or red on the eTAR. If the TAR is blank, it means the treatment was not completed. He/She made a mistake on 9/23/24. He/She usually predates the tape and must have put the wrong date on the dressing. On 9/24/24, the resident was not in the facility at the end of his/her shift. He/She left instructions for the evening shift nurse to change the resident's dressing. The nurse did not document the treatment. He/She was assigned multiple duties and could not complete the treatment before the resident left the facility for dialysis. During an interview on 9/25/24 at 11:13 A.M., LPN H said when he/she completes the resident's treatment, he/she puts betadine and gauze on the resident's toe. He/She dates and initials the dressing. He/She was not sure why the resident's dressing said 9/20/24. He/She changed the dressing on 9/22/24. He/She must have grabbed the tape with the wrong date on it. He/She was probably moving too fast. If the TAR is blank, the treatment was not completed. The resident usually leaves for dialysis at 9:00 A.M. on the weekend. He/She is assigned multiple duties and cannot complete the resident's treatment before he/she leaves. 2. Review of Resident #11's significant change MDS dated [DATE], showed: -admitted [DATE]; -Severe cognitive impairment; -Diagnoses included diabetes, adult failure to thrive, dementia, and pressure ulcer of sacral region; -Stage four 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 or tunneling) present upon admission. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident had potential/actual impairment to skin integrity of the sacrum, moisture associated skin damage (MASD), related to fragile skin, and infection to right buttock; -Goal: The resident will have no complications related to MASD infection of the sacrum/right buttock through the review date; -Interventions: Perform treatment to wound per current treatment order. Assess wound for signs and symptoms of infection with each dressing change/treatment. Report positive findings of redness, warmth, swelling, increased drainage, and increased pain. Review of the resident's POs, dated September 2024, showed an order dated 9/19/24 for sacrum, cleanse area with wound cleaner, apply Dakin's (a liquid antiseptic that is used to treat wounds) moistened gauze, followed by dry gauze and cover with border gauze every day shift (7:00 A.M.-3:00 P.M.). Review of the resident's TAR, dated September 2024, showed on 9/19/24 through 9/23/24, the treatment was documented as completed. Observation and interview on 9/24/24 at 11:00 A.M. and 11:32 A.M. , showed LPN G entered the resident's room with the hospice nurse. The bedside table was set up with wound care supplies and the resident was lying on his/her left side with assistance from the hospice nurse. LPN G said the resident had a wound to the sacral area. Observation showed no old dressing on the wound. LPN G said it was removed during peri care by a Certified Nurse Assistant (CNA) earlier. LPN G sanitized and applied gloves, cleansed the wound with wound cleaner, removed his/her gloves, hand sanitized, applied new gloves, applied prepared Dakin's-soaked gauze to wound, covered with 4 x 4 gauze, covered with abdominal dressing, covered with Medi-port tape, an applied date on the dressing. This surveyor noticed a trash can next to the resident bed, with only an old dressing lying in the bottom. Surveyor requested LPN G remove the dressing from the trash can. LPN G removed the dressing and observation showed the dressing was still warm, smelled foul, was saturated, and dated 9/20/24. LPN G said he/she assumed this was the dressing removed today since it was still warm, it was the only thing in the trash can, and verified the date on the dressing is the date he/she applied it, on 9/20/24. LPN G said staff must have put it in the trash when it fell off during peri-care. The hospice nurse said the old wound dressing was not removed while she was in the room. LPN G said if there is a blank on the TAR, that means the treatment was not completed. A check mark and initials mean treatment was completed and the initials are the initials of the nurse completing the treatment. He/She has never marked and initialed a treatment completed if she has not completed it. He/She waits until completion of treatment before marking completed. He/She only marks a date on a new dressing, no time, or initials. During an interview on 9/25/24, at 11:50 A.M., the Assistant DON said he/she dates dressing changes after they are completed. He/She must have marked the wrong date on the dressing or used precut and dated tape kept in treatment cart to secure the dressing by mistake. He/She only marks the date on new dressings, no time, or initials. 3. During an interview on 9/25/24, at 11:30 A.M. the Administrator and Regional Nurse said they do not expect staff to mark a treatment as completed if it has not been completed. Staff should follow facility policy and procedure and use best practice method. MO00242127

Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #1) received proper treatment and care to maintain mobility and good foot health. The sample was four. The census was 106. Review of the facility's Activities of Daily Living (ADL) policy, reviewed 7/21/22, showed: -Policy: Nursing staff will assist in bathing resident to promote cleanliness and dignity; The charge nurse will be made aware of residents who refuse bathing. -Bed Bath: Wash feet and in between toes. Review of the facility's Podiatry (foot) Services policy, reviewed 10/7/21, showed; -To provide podiatry services to the residents as needed; -Responsibility: Licensed Nurse; -Procedure: -Determine when the podiatrist will be in the facility; -The charge nurse will prepare a list of residents who require podiatry services; -Communication to the attending physician will be done by the licensed nursing staff of any recommended treatment made by the podiatrist (foot physician); -Approval must be obtained from the resident's attending physician for any treatment change before implementation by nursing staff; -The Administrator will engage the services of a podiatrist. Review of Resident #1's face sheet, undated, showed diagnoses that included peripheral vascular disease (PVD, a narrowing of blood vessels that constricts blood flow to the legs), difficulty walking, kidney failure, hepatitis (inflammation of the liver), muscle wasting, abnormalities of gait and mobility, polyarthritis (arthritis that affects five or more joints at a time). Review of the resident's 5-day scheduled Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/24, showed: -Dependent on staff for showering and bathing, lower body dressing, and to put on and take off footwear. Review of the resident's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -No rejection in care; -Lower extremity impairment on both sides. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has PVD; -Interventions and tasks: -Educate the resident on the importance of proper foot care including proper fitting shoes, wash and dry feet thoroughly, keep toenails cut, inspect feet daily, daily change of hosiery and sock; -If resident has thick nails, corns, calluses, refer to podiatrist; -Keep skin on extremities well lubricated with lotion in order to prevent dry skin and cracks of the skin; -Monitor, document, and report to physician as needed any signs or symptoms of skin problems related to PVD: Redness, edema (swelling), blistering, itching, burning, bruises, cuts and other skin lesions. -The care plan did not note any refusal of care. Review of the resident's physician order sheets, dated September, 2024, showed: -An order, dated 6/3/24, triamcinolone acetonide external cream (a specialized cream used for dry skin), 0.025%, apply to legs topically two times a day for dry skin; -No orders for skin treatments, creams or ointments to the feet; -No order for daily inspection of the resident's feet; -No order for a podiatry consult. Review of the resident's nursing skin observation tool documentation showed: -On 9/2/24; no new areas; -On 9/9/24; no new areas; -On 9/13/24: skin intact. Review of the Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower review showed: -On 9/3/24, the resident had dryness, a circle was on the diagram of a body on the lower extremities and feet labeled dry; Lotion applied to both legs and feet; -On 9/6, 9/10, and 9/13/24 the resident refused bathing. Review of the resident's progress notes, dated 9/13/24 at 10:34 A.M., showed the resident was sent to the hospital for an evaluation. Review of the resident's hospital photographs, dated 9/13/24 at 12:48 P.M., labeled right top foot, showed the resident's foot was extremely dry. The resident's right top foot had large white flakes and deep crevices in the skin. His/Her toenails were extremely thick and jagged in appearance. Review of the resident's hospital photographs, dated 9/13/24 at 12:47 P.M., labeled right foot, bottom, showed extremely dry skin, the bottom of the resident's entire big toe was covered with thick white, crusted, callus-like skin. The bottom of his/her right foot from the heel to the ball of the foot had scale-like dry skin and crevices in the skin and was leather- like appearance. Review of the resident's hospital photographs, dated 9/13/24 at 12:49 P.M., labeled left foot, upper, showed the entire top of his/her foot had extremely dry skin and scale-like appearance with large white flakes of dry skin peeling off. His/Her toenails were extremely thick and jagged in appearance. Review of the resident's hospital photographs, dated 9/13/24 at 12:47 P.M., labeled left foot, bottom, showed large crevices of dry skin from the resident's heel to the ball of his/her foot. The resident's entire left large toe had layers of thick white, crusted, callus-like skin with large flakes of skin peeling off. During an interview on 9/13/24 at 5:40 P.M., Hospital Nurse A said the resident was wearing fall precautions socks when he/she arrived to the emergency room (ER). The socks were growing into his/her skin. He/She had to soak the resident's feet because the socks were imbedded. Nurse A said it took a half an hour to remove the socks because there was significant thick skin underneath. During an interview on 9/14/24 at 7:20 A.M., Hospital Registered Nurse (RN) B said the resident's feet were crusted with thick white dry skin when he/she arrived to the ER. The socks the resident were wearing were moulded to his/her feet. During an interview on 9/14/24 at 9:35 A.M., Hospital RN D said the resident arrived to the ER, and he/she wore socks which had imbedded skin and were crusted with dry thick flakes of skin. During an interview on 9/14/24 at 9:50 A.M., Hospital RN C said the resident came into the ER with socks on that looked like they had not been changed in a very long time. Both feet were extremely dry, and it was a challenge removing the socks off the resident's feet. Observation and interview on 9/14/24 at approximately 9:50 A.M., showed the resident lay in bed at the hospital. The resident's toenails to both feet were extremely thick and jagged. There was minimal dryness to both feet with no open areas. Hospital RN C said the resident's feet looked better since they have been cleaned and moisturized after admission to the hospital. During an interview on 9/14/24 at approximately 12:00 P.M., Licensed Practical Nurse (LPN) E said the resident always had an unusually large amount of thick dry skin to his/her feet that was always peeling off. The bed sheet would be covered with dry skin that had peeled off. The resident's feet and legs were always extremely dry and his/her toe nails were thick. LPN E did not know if the resident was currently being seen by the podiatrist or if the resident had seen one in the past at the facility. The resident did not refuse care for LPN E. LPN E did not see the resident's feet prior to being sent to the hospital. During an interview on 9/14/24 at 2:15 P.M., Certified Nursing Assistant (CNA) F said he/she had a good rapport with the resident, and the resident would normally allow him/her to bathe him/her. The resident was a bed bath and did not like showers because he/she would get cold. The resident required more assistance with bathing and hygiene needs since the resident returned from the hospital about a month ago. The resident normally always had extremely dry skin to his/her feet and legs. When CNA F would remove the resident's socks and shake them out, there would be an extremely large amount of dry skin in his/her socks. The resident also had thick toenails. CNA F would use Vaseline or A & D ointment (an ointment used to protect skin form irritation and inflammation by creating a protective barrier) to moisturize the resident's feet and legs. CNA F would retrieve the Vaseline or A & D ointment from the Certified Medication Technician (CMT) who had the ointments in his/her cart. CNA F said he/she changed the resident's socks daily. During an interview on 9/16/24 at 9:53 A.M., the Interim Director of Nursing (DON) said she expected staff to reach out to the physician if the resident's dry skin was not getting better, to obtain other treatment orders and a podiatry consult. She expected the nurse to call the doctor and have the triamcinolone cream to include the resident's feet, since he/she had dry skin to his/her feet. The resident was private pay so she wasn't sure if the resident had approved podiatry services, but expected some type of documentation from the Social Worker that podiatry was offered for his/her feet issues. She expected staff to notify the DON or the charge nurse if the treatments were not working for the resident's dry skin issues. The nurses were expected to remove the resident's socks during their weekly skin assessments. During an interview on 9/17/24 at 8:55 A.M., the Administrator said the nursing staff were expected to reach out to the physician if treatment orders need adjustments and follow whatever the doctor recommended. Every resident in the facility was offered podiatry, and it is in their admission packet. She was not able to provide documentation that the resident was approached about podiatry services and that it would require an out-of-pocket expense. MO00242033

Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of two residents (Resident (R)73 and R84) reviewed for abuse. The census was 106. Review of the facility's policy titled, Abuse Prevention revised 10/21/22, revealed the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogated, sponsors, friends, visitors, or any other individual. Review of R73's Admission Record, located in the Profile' tab of the EMR, showed R73 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, anxiety disorder, attention deficit hyperactivity disorder and major depressive disorder. Review of R73's Quarterly MDS with an ARD of 03/15/24 showed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Review of R73's care plan, located under the Care Plan tab of the EMR and dated 01/23/24, showed ''The resident has substance abuse/addition issues related to inadequate coping skills.'' Review of a Nurses Notes, dated 05/02/24 at 12:59 P.M., in the EMR, under the Resident Services tab written by Social Services Supervisor (SSS), showed R84 was in a verbal altercation in which R73. R73 stated that R84 physically hit her. R84 was educated that he can't physically put his hands on other residents. He stated that he did understand but he was upset because the other resident keeps lying on him and having visitors coming up here. R84 said it was making him mad because they know he has feelings. It was repeated to the resident that it still did not give him the right to physically hit anyone in the facility. Social Services will continue to monitor this situation. During an interview on 05/07/24 at 2:00 P.M., R73 said on 05/02/24 R84 was drunk when he was coming back from the smoking area and passed her and her roommate on their way to the smoking area. R73 said R84 got into her face and was talking bad and told her On his momma he was going to kill her and took his fingers and made a gun symbol and put his fingers up against her forehead and pushed her head. She said it was in the hallway and the cameras saw it and so did the activities person. The next day R84 came up to her again and put his open hand on the side of her face and pushed it and took her wheelchair and pushed her into the door. She said she called the police after both incidents but Licensed Practical Nurse (LPN) 1 spoke with the police first and they never interviewed her or allowed her to file a police report. She said she and R84 used to be good friends, but he got jealous anytime she had a male visitor come to see her. She said anytime she or her roommate had a visitor R84 got upset and the visitor was kicked out and they were not allowed to come back. R84 hit her roommate's family member who came to visit in March, and he was no longer allowed back. She was afraid of R84 when he drank because he would get irate and violent. All the staff were aware of R84's aggression when he was drinking, and they also were aware he would leave to get alcohol all the time. She said the facility has not put any restrictions between her and R84 having contact with each other. She said in March R84 started punching the walls because he saw her with a male visitor when they walked to the smoking area. She said last week she was sent out to the emergency room because she was so upset that LPN1 was trying to convince her that R84 did not do anything to her and that she was lying. She said she had been in an abusive relationship in the past and she was not going to allow that to happen to her. During an interview on 05/09/24 at 10:48 A.M., R84 said it has been rocky for him lately and that he has been having nightmares, but he is not really interested in talking with anyone about it. He does attend AA classes and he has not been drinking that much lately. He did drink but he does not feel his drinking was an issue and felt he had it under control. R73 was a friend, and they were playing, talking, and touching each other. He said R73's roommate got involved and said some stuff, but there was nothing physical that occurred. He said he would not put his hands on anyone especially R73. He said everyone knew they played a lot, but he never put his hands on her or told her he was going to kill her. He said he never hit her on the side of the face with an open hand and never took her wheelchair and pushed her. R84 then stated he may have been pushing her and accidentally ran her into the wall. He remembered that R409 spit on him three times and came over and got in his face and he might have pushed her. During an interview on 05/07/24 at 5:02 P.M., Registered Nurse (RN)1 said R84 and R73 go together meaning they are in a relationship. RN1 said R73 was a manipulator and had male visitors come to visit her which made R84 very mad. R84 would sign out of the facility for leave of absence (LOA) and go to the store to get and consume alcohol. R84 drank alcohol during the day and by the evening shift he was intoxicated. She said one time R84 got hold of R73's wheelchair and pushed her into the wall and that R84 was hard to control. Staff started 15-minute checks. RN1 said that on Friday (05/03/24) she had to send R73 out to the emergency room (ER). She said R73 went to the smoking area and saw R84 out there and left and then said R84 came up to her and hit her on the face, but RN1 said that R84 said she did not do that. RN1 said she did not witness the incident, but she believed R84. She said that R73 ended up calling the cops and then became hysterical when police did not listen to her. R84 was not allowed to smoke in the same area as R73 but that R73 would come down to the 600 hall that R84 was on. But she said there was nothing else in place to supervise either resident. She said that R84 was hard to keep in his room to complete 15-minute checks and that staff can't keep him there, but they try to be aware of his whereabouts, but that staff do not put eyes on him every 15 minutes when he is in other parts of the facility. During an interview on 05/08/24 at 9:52 A.M., LPN5 said on 05/02/24 she was made aware by staff there was an issue with R84 and R73, so she went to the front to see what was going on. She spoke with R73 who told her R84 took his fingers and pushed the middle of her forehead, but she said R73 said she pushed R84 first. She said she was not able to understand most of what R73 was saying due to her screaming. She spoke with R84 who denied touching R73. She separated them and they were not allowed to be around each other. Staff started 15-minute checks which are still ongoing with R84. During an interview on 05/08/24 at 10:31 A.M., SSS said R84 got along with staff and other residents, but did have an alcohol problem and became upset when he was unable to get alcohol. SSS has never personally seen R84 under the influence, but staff have reported that he has been. SSS stated, there was one time when R84 became belligerent, and staff believed he was under the influence, but the SSS was unsure when that occurred. Last week R73 had another male visitor come visit and R84 got mad and upset. The SSS said after R84 found out that another man visited R73, she witnessed R84 punching the walls, saying I can't believe you did this. She spoke with R73 who denied hitting R73. R84 has now started attending Alcoholics Anonymous (AA) meetings. All staff were aware they should be monitoring both residents and keeping them apart. She was unsure how that was communicated to staff, but she assumed they were aware. SSS was unsure what the plan was to monitor R84 if he became aware that R73 had a male visitor. She does meet with both residents separately three times a week. During an interview on 05/08/24 at 1:02 P.M., the ADON said she has never personally seen R84 become aggressive, but staff have reported he has. Staff have also reported that R84 becomes more aggressive when he is under the influence of alcohol. She said R73 and R84 have a relationship and they have had arguments and there have been some physical incidents between them that staff have reported. Staff have reported that R84 becomes upset when male visitors come to the facility to visit R73. Both residents have been reeducated by the social worker and the Administrator. They have done 15-minute checks for 72 hours after an altercation. But she was unsure what had been done to address R84's inability to handle his emotions and his aggression. He recently started attending AA, but she was unsure what else was done after R84 refused a Psychiatric evaluation or why there were no Psychiatric services in place to address the underlying issues that cause R84 to self-medicate with substance issues. And she was aware that R84 became irate and was punching walls after R73 had a male visitor. During an interview on 05/08/24 at 2:43 P.M., the Director of Nursing (DON) stated she was aware there was an incident between R84 and R73 last week. She said R84 got jealous after R73 had an outside boyfriend come to visit her in the facility last week.

Based on observation and staff interview, the facility failed to utilize Enhanced Barrier Precautions for three of 33 residents sampled (Resident (R)19, R60, and R77). The failure had the potential to increase the risk of adverse events of spreading infections to other residents in the facility. Findings include: During the initial tour of the facility on 05/06/24 beginning at 11:00 AM, R19, R60 and R77 did not have signage on their door to reflect the residents were in Enhanced Barrier Precautions. 1.Review of R19's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R19 was readmitted the facility on 02/04/21with the diagnosis of Alzheimer's disease and during R19's stay developed dysphagia which required a feeding tube for nourishment. Review of R19's annual Minimum Data Set (MDS) under the MDS Tab, with an Assessment Reference Date (ARD) of 04/09/24 documented that R19 acquired a feeding tube while a resident in the facility. 2.Review of R60's undated Face Sheet located under the Profile tab in the EMR revealed R60 was admitted the facility on 01/06/22 with the diagnosis of obstructive and reflux uropathy (urinary tract disorder that occurs when urine flow is blocked, causing urine to back up and damage the kidneys). Review R60's quarterly MDS with an ARD of 04/09/24 documented that R60 had an indwelling catheter. 3. Review of R77's undated Face Sheet located under the Profile tab in the EMR revealed R77 was admitted to the facility on [DATE] with the diagnosis of urinary tract infection. Review R77's significant change MDS with an ARD of 04/10/24 documented that R77 had an indwelling catheter with a diagnosis of neurogenic bladder. During an interview on 05/08/24 at 2:30 PM, when asked about Enhanced Barrier Precautions (EBP), Certified Medication Technician (CMT)2 denied knowing what EBP was and stated she had not received any training on this. During an interview on 05/08/24 at 2:35 PM, the Certified Nursing Assistant (CNA)3 stated, You would wear gloves, mask and maybe PPE (personal protection equipment). During an interview on 05/08/24 at 2:45 PM, when asked about EBP, Licensed Practical Nurse (LPN)4 stated, For C Diff, COVID, MRSA and sometimes HIV you would wear gowns and gloves. We haven't had any training on this at all. During an interview on 05'08/24 at 2:50 PM, when asked about EBP, LPN3 stated, Yes I have heard about it in the hospital where I worked before. During an interview on 05/08/24 at 4:23 PM, when asked about EBP, CNA1 stated, We have had a lot of training, and I just can't remember exactly what it is. During an interview on 05/09/24 at 9:58 AM, LPN2 stated, We have our standard universal precautions and if a resident has a medical device, you would use gloves if needed, if there is an infection. During an interview on 05/09/24 at 10:34 AM, the Director of Nursing (DON) confirmed R19, R60, and R77 were not in EBP. When asked if these residents should have been in EBP, the DON stated, I would have to read up on that to tell you specifically. During an interview on 05/09/24 at 12:57 PM, the Regional Nurse Consultant (RNC) was asked about EBP. The RNC stated, This is for anyone that has open ports, wounds, g-tubes or Foleys (indwelling catheters). The policy is currently being developed .we have a call next week concerning this [EBP] and will get this rolled out next week also. The RNC also confirmed staff had not been trained in EBP.

Based on interview, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics for one of 33 residents sampled (Resident (R)77). This had the potential to affect residents being prescribed antibiotics that were potentially unnecessary. Findings include: Review of R77's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R77 was readmitted to the facility on [DATE] with the diagnoses of urinary tract infection and paraplegia. Review of R77's progress notes, found under the Notes tab of the EMR, dated 05/06/24 at 11:12 AM, revealed, Resident c/o [complains of] burning sensation. Resident stated that his catheter is not flowing. This nurse flushed resident catheter with 10 ml [milliliters] flow down without issue .Call placed to physician n.o (sic) [new order] for Cipro 250 mg BID [twice a day] x [times] 7 days with a UA [urinalysis] . Review of R77's Medication Administration Record located under the Orders tab in the EMR revealed Cipro 250 milligrams (mg) BID by mouth was started on 05/08/24 and ended on 05/15/24. Review of R77's urinalysis , provided by the facility, obtained on 05/06/24 revealed positive for protein, bilirubin, leukocytes, and bacteria. The review of the urine culture and sensitivity report, dated 05/06/24 and reported to the facility on [DATE], revealed the culture had a growth of greater than 100,000 colony forming units. This report stated, .ID [identification] and sensitivity to follow. The facility did not provide any further report showing the sensitivity of the organism to a specific antibiotic. Review of the Antibiotic Stewardship Monthly Tracking logs, dated September 2023 through May 2024, consisted of name, type of infection, signs, and symptoms present, lab present, antibiotic used, and start and stop date of the antibiotic. There was no documentation on the logs which stated the criteria for antibiotic use was met or not met. Review of the May 2024 Antibiotic Stewardship Monthly Tracking log revealed R77 was listed on the document but did not indicate criteria for antibiotic use was met or not met. During an interview on 05/09/24 at 12:05 PM, Licensed Practical Nurse (LPN)2 stated, We utilize the McGeer's Criteria but wedon't have them [McGeer's Criteria Form] filled out for any of the other antibiotics on the logs. When asked what was the basis for which the antibiotic was warranted for this resident LPN2 stated, Based on the signs and symptoms of burning sensation and then the results of the lab work. During an interview on 05/09/24 at 12:57 PM, the Regional Nuse Consultant (RNC) stated, We should follow the McGeer's criteria. We don't have it in the policy per say but that is what we are using. During an interview on 05/09/24 at 1:13 PM, the Administrator stated, The IP [Infection Preventionist] is the sole person responsible for infection control. During the QAPI [Quality Assurance and Performance Improvement] meetings we discuss who are on antibiotics, reinfections, stop and start dates, and IV therapy. When asked if McGeer's criteria for antibiotic use had been discussed, the administrator stated, McGeer's name has come up. Review of the undated facility policy Antibiotic Stewardship Plan revealed, . 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee. 2. The IP, or designee, will review antibiotic utilization as part of the Antibiotic Stewardship Program and identity/ specific situations that are not consistent with the appropriate use of antibiotics. a. The organism is not susceptible to antibiotic chosen; b. The organism is susceptible to narrower spectrum antibiotic; c. Therapy was ordered for prolonged surgical prophylaxis; or d. Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. 3. After the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name b. Room number c. Date symptoms appeared; d. Name of antibiotic e. Start date of antibiotic f. Pathogen identified g. Site of the infection h. Date of culture i. Stop date j. Total days of Therapy k. Outcome, and l. Adverse Events . Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority .

Based on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) in a timely manner for one of seven sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). Additionally, not all direct care staff were aware of the location of the code status documentation in residents' records (Residents #2 and #3). Also, the facility policy did not address the location of the code status documentation and how the information would be communicated throughout the facility so that staff would know immediately what action to take or not take when an emergency arises. The census was 114. The Administrator was notified on [DATE] at 3:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Cardiopulmonary Resuscitation policy, dated [DATE], showed: -Policy: The facility will provide basic life support prior to the arrival of Emergency Medical Services (EMS), including initiation of CPR to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident Advance Directives or a signed Do Not Resuscitate (DNR) order; -Charge nurse will initiate CPR unless: -Valid DNR is in place; -Clinical evaluation reveals obvious signs of clinical death (rigor mortis (stiffness of the muscles and joints of the body after the death of an individual), dependent lividity (bluish-purple discoloration of skin after death), decapitation (total separation of the head from the body), transection (to cut across something; to divide something by cutting it) or decomposition (the state or process of rotting or decay); -Initiating CPR could cause serious injury/immediate danger to the rescuer; -Responsibility: Licensed nurses, nursing administration and Director of Nursing (DON); -Procedure: -Full Code/CPR Upon resident assessment with absent vital signs; *Charge nurse will initiate a code blue; *Resident who is full code will have CPR initiated immediately; *CPR will continue until EMS arrives to take over CPR. -The policy did not address the location of the code status in the resident's medical record. 1. Review of Resident #1's medical record,showed: -admitted [DATE]; -Full code; -Diagnoses included: Heart failure, Alzheimer's Disease, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), bradycardia (slow heart rate) and presence of a cardiac pacemaker (small electronic device, implanted in the chest to help regulate heart function). Review of the resident's electronic Physician's Order Sheet (ePOS), showed an order dated [DATE], for a full code. Review of the resident's care plan dated [DATE], showed: -Focus: Responsible party requests full code. Full code - initiate CPR; -Interventions/Tasks: Call for an ambulance. In event of cardiac arrest, do initiate cardiopulmonary resuscitation measures. Provide emergency measures as appropriate. Review code status routinely. Review of the resident's progress notes on [DATE], showed: -On [DATE] at 11:30 P.M., Licensed Practical Nurse (LPN) S saw the resident at approximately 11:30 P.M., lying on his/her back while in bed; -On [DATE] at 1:37 A.M., Certified Nurse's Aide (CNA) H called LPN D to the resident's room. LPN D observed the resident in bed unresponsive. CPR was immediately started and 911 was called. CPR was unsuccessful. Unknown staff called the resident's physician and he gave a death diagnosis of heart failure and coronary artery disease (CAD, a narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart). Review of a typed investigation report dated [DATE], showed: -On [DATE] between 12:15 A.M. and 12:30 A.M., during rounds, CNA H found the resident in a kneeling position on the mat beside his/her bed and called out for assistance; -LPN D and CNA J entered the room. The nurse assessed the resident and found his/her skin cool to the touch and no pulse present; -Code status was verified, a board was placed under the resident and CPR was initiated; -CNA R dispatched EMS requesting emergent transport; -EMS arrived and applied leads. Staff continued CPR until directive was given to discontinue at or around 12:30 A.M. Review of a written statement by CNA H dated [DATE], showed: -While doing rounds at 12:15 A.M., he/she noticed a patient on the floor in a praying position. His/Her face was face down on the mattress; -The CNA yelled for help to get the resident off the floor and LPN D and CNA J came in the room to help assist the resident off the floor; -LPN D along with LPN I started CPR. During an interview on [DATE] at 6:00 A.M., CNA H said he/she started work at 11:00 P.M., on [DATE]. The first time he/she saw the resident was at 12:15 A.M. on [DATE]. He/She had to pull the curtain back to see the resident. He/She observed the resident on the floor, beside his/her bed, on his/her knees in a praying position. His/Her hands were beside him/her, on the fall mat with his/her face pressed into the bed. The CNA immediately went to the door and yelled for help. LPN D and CNA J came into the room. The nurse told them to get the resident off the floor and into the bed, so he/she and the other CNA picked the resident up and placed him/her onto the bed. The resident did not look good, but he/she was warm to the touch. CNA H knew the resident was a full code, so he/she immediately ran to the nurse's station, to get the crash cart so they could perform CPR. When he/she got back to the room with the crash cart, LPN D told him/her to take it back because the resident was a DNR. The CNA explained he/she was sure the resident was a full code, but the nurse continued to say the resident was on hospice and was a DNR. The CNA pushed the crash cart out into the hall and ran to check the chart to verify the resident was a full code. He/She found the full code in the paper chart, but the nurse wanted to check it in the electronic record. It took them a little while to figure out the resident was actually a full code. Once they realized the resident was a full code, then staff called 911 and started CPR. Review of an undated written statement by CNA J, showed: -He/She was at the nurse's station around 12:15 A.M.-12:30 A.M., when CNA H came out of the resident's room and said he/she was on the floor; -LPN D and he/she entered the room and found the resident on the floor; -The nurse checked the resident's pulse and there was no pulse; -CPR was started. During an interview on [DATE] at 6:25 A.M., CNA J said CNA H was doing rounds and came and got him/her and LPN D when he/she found the resident on the floor. LPN D told him/her and CNA H to get the resident off the floor and into the bed. They were frantically trying to understand what would be the best course of action, as he/she did not know if the resident needed a lift to get into bed. He/She and CNA H decided to lift the resident under his/her arms and legs and put him/her into the bed. The resident was warm to the touch when he/she lifted him/her up into the bed. CNA H ran to get the crash cart. CNA J left the room after this. Review of a written statement by LPN D dated [DATE], showed: -At 12:15 A.M., he/she was called to the resident's room; -When he/she got to the room, he/she observed the resident on his/her knees, on his/her fall mat, in a praying position with his/her head on his/her bed; -LPN D called out the resident's name with no response; -CNA J and CNA H assisted the resident back into his/her bed so the nurse could assess him/her; -The resident's color was in normal limits, his/her skin was cool to the touch and he/she had no pulse; -Code status was verified, they placed a backboard under the resident and CPR was initially started; -LPN I arrived to assist with CPR; -CNA R called 911 and EMS arrived at approximately 12:33 P.M.; -LPN D and LPN I continued CPR until directive given to discontinue. During an interview on [DATE] at 6:15 A.M., LPN D said he/she heard CNA H call out and he/she and CNA J went into the resident's room. The resident was on his/her knees on the floor with his/her face in the bed. He/She looked dead. The resident's chest was not rising. LPN D felt for a pulse and could not find one. The two aides got the resident up into the bed so he/she could assess the resident better. The nurse believed the resident was on hospice and was a DNR. CNA H thought he/she was a full code and went to look in the resident's chart to verify. Usually the code could be found right in a resident's paper chart. It was confusing to find the code, and everything happened really fast. LPN D found it on the computer. Once they realized the resident was a full code, they called 911 and immediately started CPR. During interviews on [DATE] at 6:40 A.M. and on [DATE] at 5:51 P.M., LPN I said he/she was working on the other hall during the morning of the incident. CNA R came and got him/her and said a resident was nonresponsive and needed CPR. When he/she got to the resident's room, LPN D and CNA H were standing by the bed, there was a board under the resident and an oxygen mask on his/her face, but they had not started compressions. LPN D asked if they needed to do CPR since the resident had no pulse and looked deceased . LPN I said since the resident was warm to the touch and a full code they had to perform CPR. They started CPR. LPN D and CNA H continued CPR until the EMS arrived and told them to stop. Review of the EMS records, showed the facility called 911 at 12:26 A.M. During an interview on [DATE] at 11:50 A.M., the resident's physician said staff should have been able to verify code status immediately because the chances for survival increase if CPR is started within five minutes of a cardiac event. The longer the resident goes without CPR decreases the likelihood of survival. 2. Review of Resident #3's medical record, showed: -admitted on [DATE]; -Full code. During an observation and interview on [DATE] at 11:00 A.M., Registered Nurse (RN) E said code status should be found in the resident's electronic medical record and paper chart. He/She was unable to locate the code status for Resident #3 in either place. He/She thought it might be because the resident had just been admitted over the weekend. An unidentified staff member came over and showed RN E where the code status could be found in the resident's electronic medical record in the physician's orders. 3. During an interview on [DATE] at 9:00 A.M., CNA K said if a resident was found unresponsive, code status could be found in a resident's paper chart. He/She was unable to locate a code status in Resident #2's paper chart. He/She said the nurses would know where to find the code status in an emergency. During an interview on [DATE] at 10:55 A.M., CNA N said if he/she found a resident unresponsive, he/she would let the nurse know. The nurse would have to check the code status because he/she did not have access to the resident's electronic medical records. If the nurse was not at the desk, it might take a little time to find the code status. During an interview on [DATE] at 3:00 P.M., the Director of Nursing said she would expect the staff to immediately verify the resident's code status and start CPR. Code status could be found in the resident's electronic medical records. Nurses and Certified Medication Technicians were the only staff who could access to the electronic medical records. The staff should know where to locate the code status. She was not told there was a delay in starting CPR on Resident #1 while staff tried to find his/her code status. She would have expected the nurse to have immediately verified the code status and started CPR. During an interview on at [DATE] at 3:05 P.M., the Administrator said she would expect staff to immediately verify the resident's code status and start CPR if the resident is a full code. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00231034

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one resident (Resident #3) when staff failed to evacuate a bed ridden resident from a room that was on fire. On [DATE] at approximately 12:30 A.M., a fire occurred in the resident's room. Staff responded to the room, but were unable to remove the resident from the room. Staff interviewed said the bed did not fit through the doorway and there was insufficient number of staff who responded to the room with the fire to remove the resident from the bed. In addition, staff in the facility failed to follow their fire plan by not responding appropriately to the fire alarm. One staff finished providing care before responding to the fire and at that time, the smoke was too thick to enter the affected area. Another staff left the facility upon identifying there was a fire and did not assist with evacuation. Because Resident #3 remained in the room, staff did not close the door, so the containment of the smoke from the room of fire origin was delayed. This delay placed all other residents in danger. The resident was not evacuated until first responders evacuated him/her through the first-story window. The resident sustained burns and smoke inhalation, which required intubation and admission to the intensive care unit. The resident expired 22 days later. Seven residents were sent to the emergency room as a result of the fire. Of those seven, one had burns (Resident #3) and three had clinical indication of smoke inhalation (Residents #3, #1, #6). The census was 90. The administrator was notified on [DATE] at 4:35 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of the facility's Fire Plan Initial Actions, undated, included: -If fire is suspected to be within closed spaces, check the door to the room suspected of being involved in the fire: -If heat is detected, sound the alarm and clear the immediate area around the affected room; -Only if victims are suspected to be in affected rooms, rescue anyone in immediate danger while protecting the safety of the rescuing staff member(s). Follow the facility's procedure for [NAME] (Alert, Rescue, Alarm, Contain/Confine, Extinguish/Evacuate); -Alert residents and staff members by announcing Code Red and the location three times loud and clear on the overhead paging system. Pull the nearest fire alarm; -Call 911 immediately; -Contain the fire if possible without undue risk to personal safety; -In a large-scale fire, the local fire department may order evacuation of the facility. In which case, evacuate residents from the building as quickly and as safely as time permits; -If time permits, a good rule of thumb is to evacuate ambulatory residents first; -Facility should evacuate the triangle of rooms (examples provided). It should always be the room next to and across the hall for the triangular zone; -Residents and staff should be moved out according to each smoke zone (examples provided); -No mention of how to evacuate bed-ridden residents or residents who have beds which do not fit through the doorframes; -Emergency contact information for administrator, director of nursing and maintenance director not consistent through the emergency plan. 2. Review of Fire Department O's run report, dated [DATE], showed: -Department was dispatched to a fire at the facility; -Call received at 12:34 A.M.; -On scene at 12:39 A.M.; -Upon arrival, nursing home staff was waving us through the front door stating the fire was through the doors and pointed in several different directions. They informed us the fire was in a resident's room and that room had two residents. No fire was seen, but heavy smoke conditions were met upon entry to the facility. Nursing home staff pointed towards the [NAME] side. (Generally speaking, [NAME] is the back of the structure of the building so that is where the search began.) Fire department O was married with Fire Department P who informed us they were at the fire room and beginning to extinguish. Fire Department O told Fire Department P they would split off and cover the other wings, either beginning evacuation or deeming if it was acceptable for the residents to shelter in place. Residents being evacuated from their rooms were sent to the day room on the [NAME] side where Lieutenant Q made transportation decision. Once all residents were accounted for and deemed to be in a safe space Fire Department O was instructed to retrieve the fans off a the fire truck and bring one to the [NAME] and Alpha side to begin ventilation. Review of the fire marshal investigation report, dated [DATE], showed: -Upon arrival, fire suppression activities were completed and crews were in the process of removing residents from affected areas of the building; -No major fire damage to the structure, just contents in room [ROOM NUMBER], smoke deposits noted throughout portions of the building; -The exterior showed smoke and heat venting from the room of origin (room [ROOM NUMBER]) with the window completely gone; -Fire patterns indicated this fire originated and was contained in room [ROOM NUMBER] on the south wall. This is the location of the Packaged Terminal Air Conditioner (PTAC) unit and its electrical connection to the building electrical system; -The final hypothesis of the cause of the fire is the right lower side of the PTAC unit located on the south wall of room [ROOM NUMBER]. The first material ignited was the wood board supporting the PTAC unit. During an interview on [DATE] at 10:00 A.M., the local fire marshal said they received a call at approximately 1:00 A.M. on [DATE] of a fire in the building. Upon arrival, facility staff waved the emergency services toward the new area of the building. The fire was extinguished from the exterior. The crew could not immediately evacuate one resident out of the room because his/her bed would not fit through the doorframe. They wanted to evacuate all residents on the 200 hall to other areas of the building due to the amount of smoke. The fire marshal's main concern was the size of the bed in the room of the fire's origin. If staff were able to remove the resident in the bed more quickly, they could have immediately closed the room door and contained the fire and smoke. 3. Review of the facility's investigation summary, dated [DATE], included: -On [DATE] at approximately 12:30 A.M., the fire alarm sounded; -The fire was located in room [ROOM NUMBER], flames noted on the PTAC unit and bed near window; -Upon completion of the investigation the facility determined the PTAC unit was the cause of the fire in room [ROOM NUMBER]. During an interview on [DATE] at 12:35 P.M., Registered Nurse (RN) G said the residents who initially went to the hospital at the time of the fire were Resident's #1, #2, #3, #4, #5, and #6. Resident #3 is in the intensive care unit (ICU). This was the resident who resided in the bed near the window in the room of the fire and the resident who was not evacuated from the room. Observation of the affected areas of facility, on [DATE] at 12:55 P.M., with the administrator and maintenance director, showed when walking from the front lobby into the nursing station area, there are 4 halls in a wagon wheel formation. Soot and debris was visible on the ceiling and on the floor in the nurse's station areas. Approximately 8 feet down each hall is a fire door. Some soot was visible on the ceiling that lead to the fire doors on each hall. No soot noted past the fire doors. The affected hall was to the immediate right when entering the unit. The ceiling, walls and equipment on this hall observed to have a layer of debris and soot. The room [ROOM NUMBER] was taped off with caution tape. When opening the room door, the ceilings and walls were covered with black debris and soot. The window unit lay on the floor, charred, and broken into pieces. The window had a board over it and the hole in the wall where the PTAC unit had been was open to the outside. The administrator said they are allowing that to air out for a while. The bed that would have been by the window was pulled to the middle of the room. The room, hall, and nurse's station smelled very smoky. Mid-way down the 200 hall was a fire door. There was no visible soot past the fire door. The administrator said the dampers all shut and fire doors all shut. The sprinklers only in the affected area went off. Staff immediately removed the residents from that room and called 911. During an interview on [DATE] at 1:00 P.M., the maintenance director said he just started at the facility in September. The PTAC unit is what caused the fire. He was aware of no issues with this unit before the fire. He got a call from the alarm company when the fire alarm went off. It was about 12:40 A.M., that he got the call. When they called they said the fire alarm was going off and staff were evacuating. By the time he arrived to the facility, the fire department was already at the facility and had blocked off the street. There is no routine maintenance required for the PTAC units. They are not made to be worked on, if they stop working, a new one is installed. During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said when emergency medical services (EMS) was taking residents out during the fire, they were just taking them and bringing them to local hospitals in the area. The facility did not even know who all was taken until they were allowed back in the building to do a head count. A total of seven residents went to the hospital as a result of the fire. 4. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated [DATE], showed: -Resident is rarely/never understood; -Extensive assistance of two persons required for bed mobility and transfer; -Total dependence of one staff required for locomotion on and off the unit; -Surface to surface transfer: Not steady, only able to stabilize with human assistance; -Used a wheelchair; -Primary medical condition category: Other neurological conditions; -Diagnoses included: High blood pressure, diabetes, stroke, aphasia (loss of ability to understand or express speech), and hemiplegia or hemiparesis (one sided weakness or paralysis); -Weight: 177 pounds; -Had a feeding tube. Review of the resident's care plan, showed: -Focus: Activity of daily living (ADL) function: Requires assistance with ADL care needs, mobility. Here for a long-term stay and is at risk for functional decline: -Goal: Have needs met daily; -Interventions included: Staff of one or two for safe positioning in bed and wheelchair. Use a Hoyer lift (mechanical lift) for transfers. Staff of one or two to assist with ADL needs; -Focus: Limited physical mobility related to stroke: -Goals: Demonstrate the appropriate use of adaptive devise(s) to increase mobility. Remain free of complications related to mobility, including contractures (loss of range of motion caused by muscle and tendon rigidity), skin breakdown, and fall related injury; -Interventions included: Total dependence on staff for locomotion with the use of the wheelchair. Provide supportive care, assistance with mobility as needed. Review of Fire Department O's run report, dated [DATE], showed the following for the resident: -Primary impression Burn; -Secondary complaint: Smoke inhalation; -Injury: Burns- burn of unspecified degree, nursing home [DATE]; -Mechanism of injury: Burn; -Medical/trauma: Trauma; -Barriers of care: Physical barrier (unable to access patient); -At 12:51 A.M.: -Mental status: Patients eyes are open and follows verbal commands with his/her eyes. No verbal response; -Skin: Patient's skin is wet and cold form fire suppression efforts; -Head, eyes, ears, nose, and throat (HEENT): Black soot note around nose and mouth. No swelling to areas noted. Jaw is noted to be clinched shut; -Chest: Course lung sounds noted upon initial assessment. Does not appear to have labored breathing. Lunch sounds rhonchi (rattling or whistling respiratory sound resembling snoring, caused by secretions in the airway) to all lobes; -Extremities: Two separate third degree burns (extended into the fat layer that lies beneath the skin) noted to right arm. First wound is on lateral (to the side) forearm, approximately 3 inches long and 1 inch wide. Second is on lateral upper arm, approximate 2 inches in diameter. Patient does not move his/her extremities or follow commands with extremities. Unknown patient's normal baseline condition; -At 1:16 A.M.: -Mental Status: Patients eye responses are beginning to become sluggish and patient is more difficult to arouse; -Chest: Pink frothy sputum noted coming from mouth just prior to arrival at receiving facility. Oxygen saturation beginning to drop along with heart rate; -Chief complaints of this patient is burns and smoke inhalation. First alarm units are on scene performing fire attack operations and search and rescue. This patient was found in a fire room and was extracted through a window. This patient was placed on a stretcher and brought to transport upon arrival on scene. Patient was extracted through window of facility and secured to stretcher in supine position with safety straps. Patient is transported to the hospital without compilations. Patient is moved to the emergency room (ER) room via stretcher. Patient care is transferred to ER nursing staff with a decline in patient's condition. Review of the resident's hospital record, showed: -Arrived [DATE] at 1:21 A.M.: -Unknown resident presented with burns and inhalation injury after fire in nursing home. Per EMS the patient was in the room the fire started in and was pulled out of the fire through the window. They think they fire may have started from his/her furnace. Patient presented with soot around his/her mouth and to the face, superficial burns to face, partial thickness burns to right arm and left knee with approximately 1% total body surface area. He/she was given Cyanokit (can be used to treat multiple sources of cyanide poisoning, including smoke inhalation and ingestion) by EMS in-route. He/she arrived to theER on a non-rebreather (a device used in medicine to assist in the delivery of oxygen therapy. Allows for delivery for higher concentration of oxygen) and unresponsive and per EMS they were unable to intubate due to the resident's jaw being clenched. Heart rate was in the 40's (normal 60 through 100) and oxygen saturation (percent of oxygen in the blood) in the 60s (normal 95% through 100%), so the patient was emergently intubated. Patient became hypotensive (low blood pressure) with systolic blood pressure (SBP, top number, normal is 90 through 120) in the 30s and was given a total of 3 liters of crystalloid (water-soluble electrolytes including sodium and chloride) which stabilized his/her pressure. He/she was briefly on levophed (used to treat low blood pressure and heart failure) but was then able to be stopped. He/she was also given 1 amp of bicarb (used to lower acidosis, high acidity level in the blood); -Patient unable to provide history but nursing staff from the nursing home later called and provided the resident's name; -Primary survey: Airway absence of airway protection, airway not patent, frothy sputum present, soot in airway; -Partial thickness burn to right inner elbow; -Partial thickness burn to left knee -Head/face: Soot to head. Superficial burns to face; -Oral cavity: Oropharynx (the part of the throat behind the mouth) with soot. Superficial burns to lips; -admitted to the medical surgical intensive care unit (ICU) form the ER; -Physical examination on [DATE] at 11:30 A.M., blood pressure high at ,d+[DATE] (normal ,d+[DATE] through ,d+[DATE]), temperature low at 96.1 degrees Fahrenheit (F, normal 97.8 through 99.1). Sedated on vent. Some redness to face/burns; -A chest x-ray obtained on [DATE], showed central consolidation in glass density with interior lobular septal thickening. Findings are likely related to pulmonary edema (swelling). Bilateral (both sides) dependent consolidation may represent a combination of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) and/or aspiration. Review of the resident's progress notes, showed: -On [DATE] at 1:54 A.M., called hospital for an update on the resident's condition. Spoke to the nurse who said the resident is still intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway. The tube keeps the airway open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and sedated. Burns noted to his/her right forearm and blisters to the left knee. Observation of the resident's room on [DATE] at 12:55 P.M., showed black soot coated the ceiling, walls and furniture. The window missing and a board covering the hole in the wall. Burns visible around the hole. A hole below the window where the PTAC unit formerly sat, open to the outside. The PTAC unit was in pieces and burnt up on the floor of the room. Two beds were in the room. The roommate's bed positioned was up against the wall on the side of the room closest to the door. The resident's bed was positioned in the middle of the room with side rails up on both sides of the bed. Both beds had dark soot that coated them. Observation in the hallway outside the residents room, showed dark soot on the ceilings, walls and doors on the hall and at the nurse's station. Observation of the exterior of the building on [DATE] at 2:21 P.M., showed a feeding pump pole lay on the ground and appeared charred. Other debris, to include what appeared to be the window frame lay on the ground. Plywood was positioned into the window and there was a hole in the wall below the window where the PTAC unit had been. Observation on [DATE] at 11:38 A.M., showed the resident's bed frame measured 42 inches wide. The bed measured 43 inches wide to the edges of the side rails, from side to side. The inner part of the door frame measured 42 inches. During an interview on [DATE] at 9:25 A.M., the resident's family member said the resident is now out of the intensive care unit (ICU), but remains in critical condition. It was not so much the burns that is causing the problems, but the smoke inhalation. Due to the burns, smoke inhalation and long term ventilator use, the resident's kidneys are failing. The emergency room staff said the resident was taken out the window of the room and was concerned as to why they took the resident out the window and not out the door. Review of the resident's Certificate of Death, showed: -Actual or presumed date of death : [DATE]; -Immediate cause of death: End stage renal (kidney) disease. 5. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Rarely/never understood; -Extensive assistance required for bed mobility, transfer, and locomotion on and off the unit; -Diagnoses included schizophrenia and muscle weakness. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Impaired mobility related to impaired range of motion; -Goals: Participate in mobility needs to the limit of ability; -Interventions included: Maintain upper body alignment, perform actions to maintain optimal joint mobility and muscle function during periods of immobility, provide for therapy consult if indicated. Review of the resident's progress notes, showed on [DATE] at 1:20 A.M., charge nurse noted to send resident to hospital via EMS related to smoke inhalation. Resident was exposed to smoke inhalation. Resident sent out for prophylactic (prevention). Family and physician aware. Resident at the hospital under observation. Review of the fire department emergency transport run sheet for an unidentified resident, later identified as Resident #1, dated [DATE], showed: -Chief complaint: Possible smoke inhalation; -Duration: 15 minutes; -Signs and symptoms: Generalized symptoms- other general symptoms; -Barriers of care: psychologically impaired, uncooperative; -Vital signs at 1:02 A.M.: Blood pressure ,d+[DATE], pulse 120, respirations 16, oxygen saturation 96%; -Vital signs at 1:15 A.M.: Blood pressure ,d+[DATE], pulse 118, respirations 20, oxygen saturation 98%; -Narrative: 911 was called for a possible fire in a local nursing home. We responded to ambulance staging and were immediately given a patient for transport. The patient had no demographic or medical history upon transfer. The patient was in the room next to the fire. The patient did not have any visible smoke or burn injuries. Patient answered some question but was combative and would not answer most. Lungs clear bilaterally (both sides). We attempted oxygen and the patient fought us and would not allow the mask on his/her face. The emergency room made aware. Review of the resident's hospital records, dated [DATE], showed: -The resident originally admitted as an unknown patient until later identified as Resident #1; -Resident here for smoke exposure. Per EMS, patient from a nurse home that caught fire. Patient was in the room next to the one that caught fire. Patient exposed to black smoke. Upon evaluation, patient agitated, yelling; -In the emergency department, patient was yelling and agitated. He/she was found to have elevated carboxyhemoglobin (a stable complex of carbon monoxide that form sin red blood cells when carbon monoxide is inhaled. Elevated levels can indicate carbon dioxide poisoning. Can be caused by smoke inhalation) and placed on a nonrebreather (mask that delivers high levels of oxygen and prevents the rebreathing of exhaled carbon dioxide). Patient is admitted for further management. During an interview on [DATE] at 8:30 A.M., the DON said Resident #1 is still at the hospital, but is due to come back. 6. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Resident rarely/never understood; -Independent with bed mobility and transfer; -Supervision required with locomotion on and off the unit; -Diagnoses included high blood pressure and Alzheimer's disease. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Activity of daily living self-care performance deficit; -Goal: Maintain current level of function; -Interventions included: Able to reposition self in the bed, requires one staff participation to dress. Review of the resident's progress notes, showed: -On [DATE] at 3:11 A.M., confirmed the resident is at the hospital, is stable and will be returning; -On [DATE] at 2:16 P.M., patient sent to the emergency room for further evaluation. Patient crying noted hand was burned, nose and lip was burned. Review of the resident's hospital records, dated [DATE] at 9:42 A.M., showed: -Chief complaint: Smoke inhalation: From a nursing home fire 8 hours prior. Staff noticed soot around his/her nose. Wanted him/her to be checked out. Patient was across the hall from the fire; -Clinical impression: Smoke inhalation; -Carboxyhemoglobin 4.7 (normal is typically lower than 2, can but up to 5 in individuals who smoke), will plan discharge. 7. Review of the facility census report at the time of the fire, dated [DATE], showed Resident #10 resided in the room the fire began in the bed closest to the door. Review of Resident #10's annual MDS, dated [DATE], showed: -Can make self-understood and understands; -Moderately impaired cognition; -Independent with bed transfers and locomotion; -Used a walker and a wheelchair; -Diagnoses included dementia, anxiety, depression, and asthma, chronic obstructive pulmonary disease (COPD, lung disease), or chronic lung disease. During an observation and interview on [DATE] at 12:43 P.M., showed the resident sat in a wheelchair in his/her new room at the facility. The resident said he/she remembers the fire. He/she saw the light, like a candle flickering. Someone came in and got him/her and took him/her out of the room. 8. Review of the list of staff on duty at the time of the fire, provided by the facility, showed: -Two nurses: Licensed Practical Nurses (LPN) A and LPN B; -Six certified nursing assistants (CNA): CNA C, CNA D, CNA E, CNA F, CNA H, and CNA I; -No ancillary staff at the facility at the time of the fire. During an interview on [DATE] at 2:40 P.M., the Director of Nursing (DON) said the schedule showed 7 staff on duty, but there was also someone there on light duty not listed on the schedule, CNA I. Also, CNA H was in orientation. 9. Review of LPN A's hand written statement, dated [DATE], showed around 12:30 A.M., he/she sat at the nurse's station charting when he/she heard someone call out for help. Upon entering the resident's room, he/she saw flames by the window at the bottom of the air conditioning unit. He/she grabbed Resident #10 out of the room. The fire alarm started to alarm and he/she ran to call 911. By now, the other staff was available, he/she grabbed the 200 hall fire extinguisher, pulled the pin and sprayed the base of the fire, backed up and sprayed again. He/she did this three times before he/she was unable to keep doing it due to inhaling the smoke. He/she and a second nurse tried to pull the resident (Resident #3) out in his/her bed, but was unsuccessful. The smoke grew and became black and the staff were unable to see and breathe. The staff then started moving other residents behind fire doors. He/She noticed emergency lights and ran outside to meet the fire department and showed them the area of the fire and was told to stay behind the 100 hall fire doors. During an interview on [DATE] at 11:10 A.M., LPN A said he/she worked at the facility through an agency. Upon arrival, about 10:45 P.M. on [DATE], the nurse manager showed him/her the emergency call list. LPN A found other needed lists and supplies on his/her own. They figured out staffing for the shift, and he/she began making rounds and charting. At 12:22 A.M. on [DATE], he/she heard yelling for help. He/she followed the sound and smelled smoke. When he/she arrived to the room (room [ROOM NUMBER]), he/she removed one resident (Resident #10) from the room, but could not remove the other resident (Resident #3) who was in the bed in the room. Resident #3's bed was too big to fit through the door. He/she does not know if the bed had parts that could be removed to fit through the door. He/she wondered about a sheet lift, but did not think there were enough people. Also, for staff to enter the room, they would have had to push Resident #3's bed back toward the fire. He/she called 911 and then heard the fire alarm sound. Other staff did not respond right away. CNA C asked if this was a drill. LPN A said No, I'm on the phone with 911. LPN A grabbed a fire extinguisher and pulled the pin, but it didn't work. He/she used another extinguisher and swept the fire three time, but it bounced back in his/her face. The nurse from the 600 hall arrived, and LPN A tried sweeping the fire with the extinguisher again, but the fire remained. He/she attempted three times to put out the fire with the extinguisher, but the fire kept going. Staff started evacuating other residents around the room and closing the resident room doors as they were evacuated. LPN A could see the emergency lights and directed EMS to the side door. They said they would take over from there. LPN A did not think there was enough staff. One CNA left the building while he/she was on the phone with the 911 operator. Review of the staff statements provided by the facility as part of their investigation, showed no statement provided for LPN B. During an interview on [DATE] at 9:13 A.M., LPN B said he/she has been a nurse at the facility for about one month, and works night shift on the 600 hall. On the night of the fire, he/she arrived a little before 11:00 P.M. and received report. He/she gathered supplies and helped with a dressing change of a resident. He/she heard the fire alarm sound and the fire doors closed. He/she went to the fire panel on 600 and saw it said the fire was on the 200 hall. LPN B and a CNA went over to the 200 hall. It looked like a vent was on fire. The one resident's bed was caught on the other resident's bed. The bed was blocking the door. Smoke was billowing. They could have done a sheet transfer, but the bed was blocked and they couldn't enter the room. CNA F went outside to see if he/she could extinguish the fire from there. LPN B tried to find other staff, but it was smoky and hard to see. The light-duty aide gave him/her an extinguisher, but it was not firing correctly, when he/she pulled the pin, it did not seem pressurized. The area was getting so black from the smoke so fast, she had to back up. The police arrived before the fire department. They helped move residents out of the way of the fire, in case a total evacuation was needed. There was another CNA on 600 at the back of the hall, CNA E. LPN B did not see CNA E anymore that night after the fire alarm sounded. CNA E did not say anything to him/her before leaving, LPN B said they had enough staff that night but not everyone was knowledgeable, they had a lot of agency and new people and one person was on light duty. The facility has a code alert for fire, to alert everyone overhead, but no one did the overhead page. LPN B thinks the other nurse called 911. Review of the staff statements provided by the facility as part of their investigation, showed no statement provided for CNA F. During an interview on [DATE] at 11:05 P.M., CNA F said he/she has worked at the facility for about 3 months and was working on the 600 hall side. He/she clocked in and started doing rounds. He/she was finishing up in room [ROOM NUMBER] when he/she heard the fire alarm. He/she and LPN B went to the 200 hall. There was a resident still in the room with the fire. They tried to get him/her out, but the first bed was blocking the way. LPN B came with a fire extinguisher. The bed was too big. There were smoke and flames and he/she thinks it was from the PTAC unit. The window was already busted, he/she went outside to see if he/she could extinguish the fire from there. He/she did not have any problems with his/her extinguisher, but was not able to put out the fire. When the fire department arrived, they helped get the residents on that side of the building out of the way. One staff member named CNA E left the facility, he/she did not tell anyone. They could have used more staff. He/she does not remember fire safety from orientation, but knew how to use a fire extinguisher from past jobs. Review of CNA C's handwritten statement, dated [DATE], showed on [DATE] night shift, the fire alarm went off when he/she was orientating, doing round. He/She instantly stared checking rooms, closing doors and then went through double doors. There was a lot of smoke to where he/she could not see, so he/she reacted and started getting people out of their rooms, behind the fire doors. Then EMS and police showed up. During an interview on [DATE] at 6:07 P.M., CNA C said he/she did not find the fire. At the time he/she found out there was a fire, he/she was doing rounds and heard the alarm going off. He/she started checking rooms on his/her assigned hall, hall 400. He/she was on the opposite side of the fire doors as the fire. Once done with those rooms, he/she went out past the double doors and could see smoke on a different hall. He/she started getting people out of that area. He/she did not evacuate the residents on the hall with the fire. Then police and fire department came. They started to come in the front door, so she showed them the side door, the door closest to the affected area but behind the smoke doors. It was too smoky in the hall with the fire to go to that area, it was black smoke. The fire department got the bed bound residents out. No one on 200 hall was evacuated by him/ [TRUNCATED]

Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition. On 11/18/22 at approximately 11:00 A.M., two staff noticed they could not turn down the packaged terminal air conditioner (PTAC) unit in a resident room (Resident #3 and Resident #10). The staff did not report the problem to maintenance staff. On 11/19/22 at approximately 12:30 A.M., a fire occurred in the residents' room. Review of the facility's investigation summary showed they determined the cause of the fire was the PTAC unit. Review of the fire marshal investigation showed the final hypothesis on the origin of the fire was the lower right side of the PTAC unit in the residents' room. Resident #3 sustained burns and smoke inhalation, which required intubation and admission to the intensive care unit. Seven residents were sent to the emergency room as a result of the fire. Of those seven, one had burns (Resident #3) and three had clinical indication of smoke inhalation (Residents #3, #1, #6). The census was 90. The administrator was notified on 12/16/22 at 12:41 P.M. of an Immediate Jeopardy (IJ) which began on 11/19/22. The IJ was removed on 12/16/22, as confirmed by surveyor onsite verification. 1. Review of the facility's building maintenance software (TELS), showed clean air filters, inspect condenser coils and clean as required for PTAC units documented as done on the following dates: 11/30/21, 2/28/22, 5/31/22, and 8/31/22. During an interview on 12/7/22 at 12:53 A.M., certified nurse's aide (CNA) R said he/she worked on the day shift 11/18/22 (prior to the fire). The heater (PTAC unit) was on in room [ROOM NUMBER] (Room where Resident #3 and Resident #10 resided). The room continued to become hotter. CNA R and the nurse were both in the room. The nurse turned off the heater, but it kept turning back on. The PTAC unit kept winding back up to heat. The nurse said he/she would report the problem to the maintenance director. The nurse did not ask CNA R to report it to maintenance. CNA R does not know if the unit was fixed that day. This was the first day CNA R noticed the problem with the heater in room [ROOM NUMBER]. During an interview on 12/2/22 at 4:35 P.M., Nurse S said he/she worked the day shift (11/18/22) prior to the fire. He/she is an agency employee. On the morning before the fire (11/18/22) between 11:00 A.M.-noon, staff could not get the PTAC unit in room [ROOM NUMBER] to turn down/off. Nurse S told the CNA to go tell the maintenance director about the problem. Nurse S saw the CNA head in the direction of the maintenance director, so he/she assumed it was done. Nurse S does not know if anyone in maintenance returned to work on the PTAC unit or not. During interviews on 12/2/22 at 11:50 A.M. and on 12/8/22 at 1:00 P.M., the maintenance director said maintenance staff conduct routine maintenance on the PTAC units on a quarterly basis, check the filters, look at the wiring and check for leaks. No one reported any problems to him about the PTAC unit in room [ROOM NUMBER]. He was not aware of any concerns. If the PTAC unit was not powering down, it could have been a thermostat issue. If he had been aware there was a problem with the PTAC unit, he would have had someone in maintenance check on it immediately. During an interview on 12/14/22 at 12:20 P.M., the administrator said he makes rounds in resident rooms daily, as does the maintenance director. They are in and out of the rooms all of the time, and they were not aware of any prior problems with the PTAC unit in room [ROOM NUMBER]. The PTAC units have generally been functioning well, and they do have extra units if one has a problem. The fire safety training they completed after the fire did not include education about reporting maintenance issues. Review of the facility's investigation summary, dated 11/23/22, included: -On 11/19/22 at approximately 12:30 A.M., the fire alarm sounded; -The fire was located in room [ROOM NUMBER], flames noted on the PTAC unit and bed near window; -Upon completion of the investigation the facility determined the PTAC unit was the cause of the fire in room [ROOM NUMBER]. During an interview on 11/19/22 at 12:35 P.M., Registered Nurse (RN) G said the residents who initially went to the hospital at the time of the fire were Residents #1, #2, #3, #4, #5, and #6. Resident #3 is in the intensive care unit (ICU). This was the resident who resided in the bed near the window in the room of the fire. During an interview on 11/21/22 at 8:30 A.M., the Director of Nursing (DON) said another resident (Resident #7) not initially reported, went to the hospital later in the day on 11/19/22, because he/she said he/she had smoke inhalation. Review of the fire marshal investigation report, dated 11/19/22, showed: -Upon arrival, fire suppression activities were completed and crews were in the process of removing residents from affected areas of the building; -No major fire damage to the structure, just contents in room [ROOM NUMBER], smoke deposits noted throughout portions of the building; -The exterior showed smoke and heat venting from the room of origin (room [ROOM NUMBER]) with the window completely gone; -Fire patterns indicated this fire originated and was contained in room [ROOM NUMBER] on the south wall. This is the location of the PTAC unit and its electrical connection to the building electrical system; -The final hypothesis of the cause of the fire is the right lower side of the PTAC unit located on the south wall of room [ROOM NUMBER]. The first material ignited was the wood board supporting the PTAC unit. 2. Observation of room [ROOM NUMBER] on 11/19/22 at 12:55 P.M., showed black soot coated the ceiling, walls and furniture. The window was knocked out and a board covered the hole in the wall. Burns were visible around the hole. A hole below the window where the PTAC unit formerly sat was open to the outside. The PTAC unit lay in pieces and scorched on the floor of the room. Two beds were in the room. Both beds were coated with dark soot. Observation in the hallway outside of the room, showed dark soot on the ceilings, walls and doors on the hall and at the nurse's station. 3. Review of Resident #3's hospital record, showed: -Arrived 11/19/22 at 1:21 A.M.: -Unknown resident presented with burns and inhalation injury after fire in nursing home. Per emergency medical services (EMS) the patient was in the room the fire started in and was pulled out of the fire through the window. They think they fire may have started from his/her furnace. Patient presented with soot around his/her mouth and to the face, superficial burns to face, partial thickness burns to right arm and left knee with approximately 1% total body surface area. He/she was given Cyanokit (can be used to treat multiple sources of cyanide poisoning, including smoke inhalation and ingestion) by EMS in-route. He/she arrived to the emergency room (ER) on a non-rebreather (a device used in medicine to assist in the delivery of oxygen therapy. Allows for delivery for higher concentration of oxygen) and unresponsive and per EMS they were unable to intubate due to the resident's jaw being clenched. Heart rate was in the 40's (normal 60 through 100) and oxygen saturation (percent of oxygen in the blood) in the 60s (normal 95% through 100%), so the patient was emergently intubated. Patient became hypotensive (low blood pressure) with systolic blood pressure (SBP, top number, normal is 90 through 120) in the 30s and was given a total of 3 liters of crystalloid (water-soluble electrolytes including sodium and chloride) which stabilized his/her pressure. He/she was briefly on levophed (used to treat low blood pressure and heart failure) but was then able to be stopped. He/she was also given 1 ampule of bicarb (used to lower acidosis, high acidity level in the blood); -Patient unable to provide history, but nursing staff from the nursing home later called and provided the resident's name; -Primary survey: Airway absence of airway protection, airway not patent, frothy sputum present, soot in airway; -Partial thickness burn to right inner elbow; -Partial thickness burn to left knee -Head/face: Soot to head. Superficial burns to face; -Oral cavity: Oropharynx (the part of the throat behind the mouth) with soot. Superficial burns to lips; -admitted to the medical surgical intensive care unit (ICU) form the ER; -Physical examination on 11/19/22 at 11:30 A.M., blood pressure high at 194/74 (normal 90/60 through 120/80), temperature low at 96.1 degrees Fahrenheit (F, normal 97.8 through 99.1). Sedated on vent. Some redness to face/burns; -A chest x-ray obtained on 11/19/22, showed central consolidation in glass density with interior lobular septal thickening. Findings are likely related to pulmonary edema (swelling). Bilateral (both sides) dependent consolidation may represent a combination of atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung) and/or aspiration. Review of the resident's progress notes, showed: -On 11/21/22 at 1:54 A.M., called hospital for an update on the resident's condition. Spoke to the nurse who said the resident is still intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway. The tube keeps the airway open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and sedated. Burns noted to his/her right forearm and blisters to the left knee. During an interview on 12/1/22 at 9:25 A.M., the resident's family member said the resident is now out of the ICU, but remains in critical condition. It was not so much the burns that is causing the problems, but the smoke inhalation. Due to the burns, smoke inhalation and long term ventilator use, the resident's kidneys are failing. Review of the resident's Certificate of Death, showed: -Actual or presumed date of death : December 11, 2022; -Immediate cause of death: End stage renal (kidney) disease. 4. Review of Resident #1's progress notes, showed on 11/19/22 at 1:20 A.M., charge nurse noted to send resident to hospital via EMS related to smoke inhalation. Resident was exposed to smoke inhalation. Resident sent out for prophylactic (prevention). Family and physician aware. Resident at the hospital under observation. Review of the resident's hospital records, dated 11/19/22, showed: -The resident originally admitted as an unknown patient until later identified as Resident #1; -Resident here for smoke exposure. Per EMS, patient from a nurse home that caught fire. Patient was in the room next to the one that caught fire. Patient exposed to black smoke. -In the emergency department, patient was yelling and agitated. He/she was found to have elevated carboxyhemoglobin (a stable complex of carbon monoxide that form in red blood cells when carbon monoxide is inhaled. Elevated levels can indicate carbon dioxide poisoning. Can be caused by smoke inhalation) and placed on a nonrebreather (mask that delivers high levels of oxygen and prevents the rebreathing of exhaled carbon dioxide). Patient is admitted for further management. 5. Review of Resident #6's progress notes, showed: -On 11/19/22 at 3:11 A.M., confirmed the resident is at the hospital, is stable and will be returning; -On 11/19/22 at 2:16 P.M., patient sent to the emergency room for further evaluation. Patient crying noted hand was burned, nose and lip was burned. Review of the resident's hospital records, dated 11/19/22 at 9:42 A.M., showed: -Chief complaint: Smoke inhalation: From a nursing home fire eight hours prior. Staff noticed soot around his/her nose. Wanted him/her to be checked out. Patient was across the hall from the fire; -Clinical impression: Smoke inhalation; -Carboxyhemoglobin 4.7 (normal is typically lower than 2, can but up to 5 in individuals who smoke), will plan discharge. Nursing home states understanding the patient should return for any other concerns about his/her health. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure all residents were free from mental and verbal abuse when one staff member, Certified Nursing Assistant (CNA) KK, cursed at and threatened physical violence against one resident (Resident #605). The staff member used profanity, made verbal threats, and used threatening gestures toward the resident. When the charge nurse was made aware, he/she failed to promptly notify administration per facility policy. Additionally, the facility failed to follow it's policy for protection of residents by failing to immediately suspend the employee after the allegation of abuse was made. CNA KK continued working the remainder of his/her shift, providing direct care to residents for approximately five and a half hours and worked again two days later, entering Resident #605's bedroom- causing the resident to contact the Concierge with his/her concerns. The sample size was 11. The census was 83. The administrator was notified on 6/30/22 of the immediate jeopardy (IJ) past non-compliance, which occurred on 5/28/22. On 5/30/22, the former administrator became aware of the allegation of abuse and suspended the involved staff pending an investigation. The facility identified the staff failure and terminated the involved staff. The facility provided training and in-services for all staff regarding the facility's abuse policy. The IJ was removed and corrected on 5/30/22. Review of the facility's Abuse Prevention policy, last reviewed on 4/28/21, showed: -Policy: The facility is committed to protecting the residents from abuse by anyone, including but not limited to, facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Definitions: -Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident or visitor to resident; -Verbal Abuse: An employee making a threat of physical violence to a consumer, when such threats are made directly to a consumer or about a consumer in the presence of a consumer; -Procedure: Steps to prevent, detect and report; -Prevention; -Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse. When an incident of abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred; -Identification; -The administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident; -Investigation; -The facility will initiate at the time of any findings of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation; -Protection; -Any allegation of abuse, or neglect, misappropriation or exploitation against any employees must result in his/her immediate suspension to protect the resident. Review of the facility's Provider Assignment Record (Time Sheet), for CNA KK, showed: -On 5/28/22, CNA KK worked from 7:00 A.M. to 3:00 P.M.; -On 5/30/22, CNA KK worked from 7:00 A.M. to 11:00 A.M. Review of Resident #605's medical record showed: -Diagnoses included heart failure, major depressive disorder, high blood pressure, difficulty in walking, muscle weakness and aphasia (a language disorder that affects a person's ability to communicate). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/22, showed: -Cognitively intact; -Exhibited no behaviors. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/8/22, showed: -Cognitively intact; -Exhibited no behaviors. Review of the facility's investigation, dated 6/3/22, showed: -On 5/30/22 at approximately 10:00 A.M., the resident reported that on 5/28/22 CNA KK was using profane language towards him/her while he/she was attempting to enter his/her room. The resident stated CNA KK was providing care to his/her roommate and told him/her not to come into the room. The resident continued to enter the room and CNA KK threatened him/her and said, bust your head. CNA KK was interviewed and suspended pending an investigation. -Upon completion of the investigation, the facility determined the alleged employee's conduct with the resident was inappropriate. During interview with the alleged employee, CNA KK stated he/she did use profane language when interacting with the resident and stated the resident was using profane language towards him/her first. He/she denied threatening the resident. It was confirmed during staff/roommate interviews that CNA KK's conduct was inappropriate. The social services director conducted interviews with other residents with no findings. CNA KK was terminated and placed on the Do Not Return list from the staffing agency. The resident remains at the facility and staff will continue his/her plan of care. During interviews on 6/28/22 at 9:30 A.M. and 6/29/22 at 1:10 P.M., the resident said on the morning of 5/28/22, at approximately 9:00 A.M., both he/she and his/her roommate (Resident #604) pulled their call lights for assistance, because Resident #604 was about to fall out of bed. When CNA KK arrived to assist the roommate, the resident left the room. CNA KK provided care to Resident #604 as the resident waited outside the door. Before leaving, CNA KK turned both call lights off. When CNA KK opened the door, he/she told the resident he/she gave the roommate his/her call light because the roommate's was not working. The resident was sitting in his/her wheelchair outside of the door and told CNA KK not to give the roommate his/her call light, or turn the call light off. CNA KK got upset and told the resident to move out of the way. The resident said he/she again told CNA KK to leave the call light where it was, and not give it to the roommate. CNA KK began cussing. The resident said CNA KK Ran up on me, but did not hit him/her. CNA KK said, I will knock you upside the head and called the resident a motherfucker. When CNA KK ran towards the resident, his/her fist was balled like he/she was going to hit the resident. The resident felt disrespected. Other staff and the roommate overheard the incident and staff arrived to assist. CNA KK was removed from the room and reassigned to give other residents showers. Two days later, on 5/30/22, CNA KK returned to the facility and entered the resident's room to speak with his/her roommate. The resident contacted the Concierge and questioned why CNA KK was back at the facility after the incident on 5/28/22. During interviews on 6/29/22 at 9:19 A.M. and 6/30/22 at 8:40 A.M., CNA KK said he/she worked through a staffing agency and 5/28/22 was his/her first time at the facility. He/she was assigned to Resident #605's hallway. After breakfast, between the hours of 8:00 A.M. and 9:00 A.M., the call light came on for bed one, the resident's roommate (Resident #604). He/she entered the room and provided care to Resident #604. Resident #604's call light was not working, so CNA KK told the resident he/she would give him/her Resident #605's call light until he/she could bring another one to the room. At this point, Resident #605 knocked on the door to re-enter the room. CNA KK told Resident #605 he/she was going to give Resident #604 his/her call light until he/she could find another. Resident # 605 said, You are not taking my fucking call light and blocked his/her exit from the room. CNA KK said to the resident, I need to leave out. The resident would not move and locked his/her wheelchair. CNA KK reached down to unlock the resident's wheelchair and the resident raised his/her foot in a motion to kick the CNA. CNA KK said, Please don't fucking kick me and denied hitting or saying anything else to the resident. A staff member showed up because they overheard the commotion. CNA KK contacted the nurse manager/MDS coordinator, who was the on-call manager, to explain what happened. The nurse manager instructed CNA KK to speak with Nurse HH, who was the nurse on duty. After the nurse manager spoke with Nurse HH, Nurse HH reassigned CNA KK the task of completing resident showers. CNA KK worked until his/her shift was complete. Review of Resident #604's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 6/29/22 at 10:00 A.M., Resident #604 said on the morning of 5/28/22, Resident #605 and CNA KK were cussing each other out. He/she could not recall what was said but CNA KK got in (Resident #605's) face. He/she said CNA KK was as wrong as two left feet and This was the wild, wild west. CNA KK was in the resident's face and cursing, but he/she did not see CNA KK hit Resident #605. During an interview on 6/29/22 at 11:26 A.M., CNA A said he/she was at the nurse's station after breakfast between the hours of 8:00 A.M. and 9:00 A.M., and overheard cursing and yelling coming from Resident #605's room. He/she ran to the room and saw Resident #605 trying to enter the room and CNA KK trying to leave. CNA KK said, I don't fucking play like that. I'm not working with a motherfucker like that. CNA KK's fist were balled and he/she said, Back up before I punch you in the face. He/she was close to the resident's face with his/her fist balled. CNA A was the only staff member around who witnessed the incident. CNA A separated the two and said Resident #605 was shocked by the incident and tried to communicate, but was having a difficult time. CNA KK said he/she was leaving the facility. CNA KK left the area and walked in the direction towards the exit of the facility. After ensuring the resident was okay, CNA A reported the incident to Nurse HH. Later during the day, CNA A saw CNA KK speaking to Nurse HH. CNA KK was reassigned to provide residents with showers. During an interview on 6/29/22 at 9:50 A.M. and 1:30 P.M., the nurse manager said she was the on-call nurse on 5/28/22. CNA KK called her and said he/she had never worked in a place like this. She asked CNA KK what happened. CNA KK told her a resident tried to stand up on him/her. CNA KK admitted to cursing at the resident. She told CNA KK they did not have any aggressive residents on that unit. She then turned the situation over to Nurse HH, who was the supervisor on duty. She did not suspend CNA KK, because of the way the information was presented. She did not think it was abuse because it did not get physical and Resident #605 was alert and oriented and could say if he/she felt uncomfortable. The facility policy was to remove the alleged perpetrator from the situation and suspend pending an investigation. There was no reason, when asked why she did not suspend CNA KK. The nurse manager did not contact the resident following the incident. She allowed the on-call nurse to handle the situation. During an interview on 6/29/22 at 2:03 P.M., Nurse HH said he/she was on another unit on the morning of 5/28/22, when the nurse manager called and said CNA KK was cursing at Resident #605. Nurse HH pulled CNA KK into the medication room and asked what happened. CNA KK admitted to cursing at the resident. Nurse HH pulled CNA KK from the assignment and switched him/her to showers. At first, Nurse HH said he/she sent CNA KK home, then said she reassigned him/her to give showers. He/she could not recall why he/she did not suspend CNA KK immediately after he/she was made aware of the allegations. He/she no longer worked at the facility and said he/she could not recall all of the details. He/she did not contact the administrator. The on-call nurse manager was aware of the situation. During an interview on 6/30/22 at approximately 1:00 P.M., the concierge said on 5/30/22, he/she received a call from Resident #605. The resident told him/her what happened on 5/28/22 and said CNA KK just entered his/her room to speak with his/her roommate. The concierge immediately notified the administrator, and CNA KK was suspended pending an investigation. During an interview on 6/30/22 at 7:12 A.M., the administrator said if an allegation of abuse is suspected or alleged, the alleged perpetrator should be suspended immediately pending an investigation. He was not the administrator at the time, but when the previous administrator found out about the allegations, he suspended CNA KK and began an investigation. Nurse HH and the nurse manager should have suspended the employee and contacted the administrator immediately following the incident. CNA KK should not have provided care to other residents following an allegation of abuse. MO00201859

Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardio-pulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to restore spontaneous blood circulation and breathing in a person in [CONDITION(S)]), to any resident requiring such care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to have a system to ensure residents' code statuses are obtained timely upon admission, updated when changed and documented congruently through the medical record. Staff identified the hard chart (the paper medical record/chart) as the first place they would look for a resident's code status. For one resident with an incongruent code status, staff would have been directed not to do CPR when the resident desired CPR based on the documentation in the hard chart (Resident #435). Three residents had no ordered code status or signed code status sheets available to staff (Residents #535, #190 and #235). Two residents had incongruently documented code statuses (Residents #535 and #19). Three residents had no ordered code status and no signed code status sheet in the medical record until [DATE] (Residents #186, #187 and #77). Two residents had a signed code status sheet but no ordered code status (Residents #188 and #189). These failures put residents who wished not to receive CPR at risk for receiving CPR against their wishes and residents who wished to receive CPR at risk for not receiving CPR per their wishes. The census was 90. Of those 90 residents, 69 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The administrator was notified on [DATE] at 12:54 P.M., of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. 1. Review of the nursing policy and procedure binder, located at the long-term care nurse's station, reviewed on [DATE], that contained a policy titled Cardio-Pulmonary Resuscitation, revised [DATE], showed: -Upon determination that a resident is in cardio-pulmonary or respiratory arrest, CPR will be initiated by a CPR certified staff member and 911 called for advanced cardiac life support, unless one of the exceptions applies: -When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has issued a written DNR order that is maintained in the facility's clinical record; -When attempts to perform CPR would place the rescuer at risk of personal injury; -Each resident code status will be maintained in the clinical record; -The policy did not identify the process to obtain and document a resident's code status upon admission or when the code status is changed. During an interview on [DATE] at 9:24 A.M., the administrator said he was not sure where staff would look if they needed to know a resident's code status. He will provide the policy. [DATE] was his first day at the facility. The Regional Director of Operations was the administrator prior to that. Review of the facility's Advanced Directives policy, dated as last reviewed on [DATE] and provided by the administrator, showed: -It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so; -Upon admission, the facility will provide each resident medically deemed competent or resident's representative, who does not have an existing advance directive, with written information and instruction regarding the right to make advance directives prior to the initiation of care or at any requested time: -The resident may revise or revoke an advance directive at any time; -If the resident cannot communicate whether an advance directive exists and no advance directive is produced, the resident will be treated as if an advance directive does not exist; -The resident's instructions, the resident's receipt of written information, and the existence or non-existence of the resident's advance directive must be documented in the resident's record; -If the facility makes a determination that no advance directives exist, the facility will explore options for financial and health care decision-making on behalf of the resident, i.e. appointment of a guardian if necessary; -The facility employees will be educated regarding the resident's right to self- determination; -The facility shall make a determination if resident's advance directive is valid. If so, the facility shall honor such directive; -The policy did not identify the process to obtain and document a resident's code status upon admission or when the code status is changed. During an interview on [DATE] at 9:59 A.M., with the administrator and Regional Nurse Consultant, they said staff would check the physician orders, order profile and paper chart when determining a resident's code status. The first place they would look in the event of an emergency would be the hard chart. Staff would respond according to the documentation found in the hard chart. They would expect code statuses to be congruent throughout the medical record. There should be conversations with the resident or resident representative about the decision to be a full code (CPR to be initiated) or DNR. Social Services is responsible through audits to ensure all residents have a code status. 2. Review of Resident #435's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -The resident admitted to the facility from an acute care hospital on [DATE]; -Moderately impaired cognition; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary medical condition category: Medically complex conditions. Review of the resident's electronic medical record, showed: -An order dated [DATE], for full code; -A face sheet, showed full code; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -An unsigned and undated purple DNR sheet. During an interview on [DATE] at 11:12 A.M., the resident said he/she believed he/she was a full code but wanted no extreme measures. 3. Review of Resident #535's entry MDS, dated [DATE], showed the resident admitted from another nursing home on [DATE]. Review of the resident's electronic medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A baseline care plan, dated [DATE], showed the advanced directives/code status section, blank; -No ordered code status; -A face sheet did not identify the resident's code status; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -No green, red, or purple color-coded paper in the front of the chart; -No code status sheet. 4. Review of Resident #190's entry MDS, dated [DATE], showed the resident admitted from the community on [DATE]. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -No color-coded paper in the front of the chart; -No code status sheet. 5. Review of Resident #235's entry MDS, dated [DATE], showed the resident admitted from another nursing home on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE] at 12:15 P.M., showed: -No ordered code status; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the hard charts at the nurse's station on [DATE], showed no hard chart available for the resident. During an interview on [DATE] at 9:59 A.M., with the administrator and Regional Nurse Consultant, they said if there was no code status to refer to, staff should default to full code. During an interview on [DATE] at 11:30 A.M., Licensed Practical Nurse (LPN) C provided the resident's hard chart and said the facility had been looking for the hard chart for the resident for days. The hard chart contained the hospital record, but there is no other documentation. He/she would expect the chart to contain more information, such as the code status sheet. Review of the resident's hard chart, showed: -No color-coded paper in the front of the chart; -No code status sheet. During an interview on [DATE] at 12:02 P.M., the Regional Nurse Consultant provided the hospice folder for the resident and said the folder was located in the MDS office. Review of the information located in the folder, showed an outside of the hospital DNR sheet, dated [DATE]. The Regional Nurse Consultant said she would have expected the hospice folder to be at the nurse's station, where it could be accessed by all staff. 6. Review of Resident #534's admission MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]; -Moderately impaired cognition; Review of the resident's electronic medical record, reviewed on [DATE], showed: -A face sheet, code status: Full code; -An order dated [DATE], for full code; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -A signed code status sheet in the hard chart, dated [DATE] for DNR. During an interview on [DATE] at 9:20 A.M., it was explained to the resident what it meant to be a full code and to receive CPR or a DNR and not to receive CPR, and he/she was asked which code status would he/she prefer to be. The resident said he/she wanted to be a full code. During an interview on [DATE] at 9:59 A.M., the administrator and Regional Nurse Consultant, said if staff followed the directions in the paper chart for the resident's DNR, staff would not be following the resident's wishes. Regarding the resident, the most recent order, which would be the full code physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's electronic medical record, showed: -The resident's order dated [DATE] for full code discontinued on [DATE] and a new ordered for DNR dated [DATE]. The order entered by the Nurse Manager/MDS Coordinator; -No documentation to show staff discussed with the resident or resident representative the resident's desired code status. Further review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A red sheet of paper, showed DNR; -A signed code status sheet in the hard chart, dated [DATE] for DNR. During an interview on [DATE] at 10:22 A.M., the Nurse Manager/MDS Coordinator said if a resident had an incongruent code status, she would expect staff to talk with the resident before changing the order. She talked to the resident about his/her wishes as it related to code status, not long ago today ([DATE]) and the resident said he/she wanted to be a DNR. At 10:23 A.M., the Nurse Manager/MDS Coordinator and the surveyor entered the resident's room. The Nurse Manager/MDS Coordinator told the resident that she was just in to talk to the resident a little bit ago. She then explained to the resident what it was to be a full code and to receive CPR or a DNR and not to receive CPR, and the resident was asked which code status he/she would prefer. The resident said he/she wanted to be a full code. The resident added that he/she talked to the social worker the other day and said that is what he/she wanted. The Nurse Manager/MDS coordinator then left the room and the resident said that person never came in to talk to him/her today about his/her code status, only the surveyor did. Further review of the resident's electronic and paper chart, on [DATE], showed the resident still listed as a DNR in both locations. The code status not changed to full code per the resident's wishes. During an interview on [DATE] at 10:43 A.M., the administrator said he would follow up regarding the resident's code status. During an observation an interview on [DATE] at approximately 11:00 A.M., the social worker, administrator, Nurse Manager/MDS Coordinator and Regional Nurse Consultant were at the nurses station. The social worker held up the resident's signed DNR, dated [DATE] as they discussed the resident's code status. The social worker and Regional Nurse Consultant then walked down the hall and entered the resident's room. The social worker held up the signed code status sheet to the resident and said look you signed this don't you want to be a DNR? The resident replied, oh yes, DNR. It was not explained to the resident the difference between a full code and DNR at this time. 7. Review of Resident #19's quarterly MDS, dated [DATE], showed: -admitted from an acute care hospital on [DATE]; -Severe cognitive impairment. Review of the resident's electronic medical record, showed: -A progress note dated [DATE], the resident arrived to the facility family is very involved in the care. The resident is a full code status; -No further documentation of discussion of the resident's code status; -An order dated [DATE], for DNR; -A face sheet, showed DNR. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green paper in from of chart, showed full code; -A code status for full code, signed [DATE]. During an interview on [DATE] at 9:59 A.M., the administrator and Regional Nurse Consultant, said regarding the resident, the most recent order would supersede the older order. The resident would be a DNR. They would expect there to be documentation with the family regarding the change in code status. During an interview on [DATE] at 8:46 A.M., LPN P said he/she was not sure how to know a resident's code status, possibly on the back of the room door. If not there, he/she was not sure. Observation on [DATE] at 8:57 A.M., of the resident's room, showed no code status listed on the back of the door to the room, closet or bathroom. 8. Review of Resident #186's entry MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full coded status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 9. Review of Resident #187's entry MDS, dated [DATE], showed the resident admitted from an acute care hospital on [DATE]. Review of the resident's electronic medical record, reviewed on [DATE], showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full coded status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 10. Review of Resident #77's admission MDS, dated [DATE], showed: -The resident admitted from the community on [DATE]; -Moderately impaired cognition. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE]; -No documentation a code status was obtained prior to [DATE]. 11. Review of Resident #188's entry MDS, dated [DATE], showed the resident admitted from the community on [DATE]. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE] 12. Review of Resident #189's admission MDS, dated [DATE], showed: -The resident admitted from an acute care hospital on [DATE]; -Resident is rarely/never understood. Review of the resident's electronic medical record, showed: -No ordered code status. Review of the resident's hard chart, located at the nurse's station and reviewed on [DATE], showed: -A green piece of paper, with full code; -Full code status sheet, dated [DATE]. 13. During an interview on [DATE] at 8:43 A.M., the staffing coordinator said in the event of an emergency, staff should look in the front of the hard chart to determine a resident's code status. 14. During an interview on [DATE] at 8:50 A.M., Social Services said the process to obtain a resident's codes status on admission is, the admission coordinator and concierge get the initial code status signed. If a code status changes during a resident's stay, she will take the old signed code status sheet from the chart and add the new code status sheet. Nurses are then notified so they can change the order in the electronic medical record. Signed code status sheets are also kept in the business chart. 15. During an interview on [DATE] at 8:57 A.M., Certified Nursing Assistant (CNA) O said he/she works for a nursing agency and does not know where to look for a resident's code status, he/she would find facility staff in the event he/she needed to know a resident's code status in an emergency. 16. During an interview on [DATE] at 9:06 A.M., CNA A said he/she would look in the hard chart, located at the nurse's station, for a resident's code status. If it was not there, he/she would ask the nurse. 17. During an interview on [DATE] at 9:07 A.M., CNA N said if he/she found someone expired and needed to know their code status, he/she would look in the hard chart at the nurse's station. If nothing was there, he/she would ask the charge nurse. 18. During an interview on [DATE] at 9:09 A.M., Certified Medication Technician (CMT) M said if he/she entered a resident's room and saw that the resident had expired and he/she needed to know their code status, he/she would look in the hard chart at the nurse's station. If nothing was there, then he/she would get the nurse. 19. During an interview on [DATE] at 9:44 A.M., LPN L said the first place he/she would look for code status is in the electronic medical record. Hard copies are also kept in the hard chart. 20. During an interview on [DATE] at 10:28 A.M., the admission coordinator said the facility has an admission packet that is provided to the residents upon admission, but to her understanding, it is the responsibility of the concierge to get the signed code status orders. The facility identified that it was not being done in a timely manner, so now she will go down the room and make sure it gets signed. When she does this, she will talk to the resident and have them sign. If they are not able to talk, she will call the family. She is not a nurse and cannot enter orders into the computer, she works the front desk. After getting the paperwork signed, she will put the paperwork in the hard chart with the corresponding red or green paper. She does not tell the resident's nurse anything after getting the code status signed, because all she has to do is put the information in the chart. She was not sure what the nurses do from there. She started employment at the facility on [DATE], went on leave [DATE] and just got back yesterday. 21. During an interview on [DATE] at 10:32 A.M., LPN H said he/she had never done an admission at the facility, but would put the ordered code status in the system if he/she did have to admit a resident. If he/she found a resident unresponsive, he/she would start CPR and have another staff check the orders. If they say the resident was a DNR, he/she would stop CPR. 22. During an interview on [DATE] at 10:36 A.M., the Assistant Director of Nursing (ADON) said the admitting nurse transcribes the orders, including code status. The ADON or Director of Nursing (DON) then audits the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A red paper/sheet with big/bold letters DNR will be placed in the chart's first page, then a purple sheet signed consent will be placed in back of the red sheet. If full code, a green sheet will be used. If a code sheet is not found in the resident chart, she would look in the electronic medical record. If orders are not found during her audit, she will refer to the hospital medical records. 23. During an interview on [DATE] at 10:43 A.M., LPN K said he/she thinks the admission coordinator gets the resident's code status orders. In the event he/she needed to know a resident's code status urgently, he/she would look in the hard chart. 24. During an interview on [DATE] at 11:01 A.M., LPN J said the nurses are responsible to obtain resident code statuses. In the event a resident were to stop breathing, staff would follow the resident's code status in the hard chart. 25. During an interview on [DATE] at 11:05 A.M., the Concierge/CNA said she had been employed by the facility since 2008. When a new admission arrives, she is responsible to do the admission paperwork. She will greet the resident then get them to the bed and situated. The code status sheet is completed with the family and resident at the same time because it is very important. The signed code status sheets are then brought to the admission coordinator, she does not give them to the nurse. CNAs are not able to enter orders, but she can add a colored sheet into the front of the chart. Green for full code and red for DNR. She does not give the signed code status to the nurses. The code status sheet is given to the admission coordinator. 26. During an interview on [DATE] at 10:44 A.M., LPN C said the charge nurse is responsible for transcribing orders, including the resident's code status. Orders are then entered into the electronic medical record and hard chart. The ADON or DON audit the orders within 24 hours. If there is no code status in the admission records, she will ask or clarify with the resident, and if resident is non-verbal, she will talk or call the family or responsible person. If code sheets are missing in the electronic medical record or hard chart, she would immediately notify the DON or ADON. 28. During an interview on [DATE] at 1:34 P.M., the Regional Director of Operations said the facility had a mock survey around the week of [DATE]. Issues were identified with resident code statuses at that time. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure pain management was provided to Resident #40 when the facility failed to medicate the resident prior to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) resulting in pain to the resident. The facility failed to ensure routine orders of pain medication were filled for Resident #37 who had pain in the lower extremities, which resulted in several days of missed doses, causing the resident to experience high levels of pain. The sample size was 18. The census was 90. Review of the facility's Pain Management Guidelines policy, revised 9/2017 and located at the nurses station, showed: -To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: -Recognize when a resident is experiencing pain; -Identify circumstances when pain can be anticipated; -Evaluate existing pain causes; -Practice guidelines: -Upon admission, residents will be assessed for pain by using the nursing admission assessment form; -Residents will be screened for pain by using the assessment form quarterly, annually and with a significant change and/or new onset of pain; -Pain intensity and pain relief will be assessed prior to administration of medications and post pain medication administration to assess for effectiveness of pain medications; -Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion, restlessness, etc. To distinguish between pain and other signs or symptom of distress ([CONDITION(S)], depression, etc.) it is imperative to assess residents to confirm signs and symptoms are indeed related to pain; -If any resident reports inadequate pain control, the resident will have an assessment performed: -Following the pain evaluation, notify the physician of the findings; -Each resident identified for pain will have a pain management care plan. The care plan will have individualized interventions related to that resident's individual control of pain management. The care plan may include both pharmacological and non-pharmacological pain management interventions; -Licensed nurse will implement a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The interdisciplinary team (IDT) will discuss the new onset of pain or change in resident pain at the daily stand up meeting and IDT team conference; -The licensed nurse when administering PRN pain medications, will record the drug administration and the following on the MAR: -Pain level prior to pain medication administration; -Pharmacological interventions attempted; -Non-pharmacological interventions attempted; -Follow up observations, post interventions to determine the effectiveness of PRN pain interventions. If the resident is asleep or resting, document as an observation. 1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/21, showed: -admitted [DATE]; -Severely cognitively impaired; -No speech; -Rarely/never understood and understands; -Required two+ persons assistance in bed mobility and transfers; -Required one person physical assistance in locomotion on and off unit, dressing, toilet use and personal hygiene; -Unhealed pressure ulcers; -Pain management - Any time in the last 5 days: -On scheduled pain regimen medications; -Received non-medication intervention for pain; -Indicators of pain: non-verbal, facial expressions, protective body movements or postures. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Wounds: right elbow, right lateral fifth toe, right medial foot, right lateral shin; -Goal: Will promote healing and reduce the risk of complications and further skin breakdown; -Interventions: Assist with repositioning, low air loss mattress, monitor for verbal and nonverbal symptoms of pain, treat pain as ordered by the physician, off load pressure to wound and heels, position, with a pillow between legs, right elbow protector, sponge boot to right foot, treatments as needed. Review of the resident's electronic medical record (EMR), showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -On 2/8/22, an order received for [MEDICATION(S)] tablet (opioid pain reliever used to treat moderate to severe pain) 5-325 milligrams (mg), via gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach), every 8 hours as needed for pain. Review of the wound physician's documentation, dated 5/2/22, showed the following: -Stage IV pressure wound of the right lateral (side or away from midline of body) shin, measured 9.7 x 3.3 x 2.5 centimeters (cm); -Stage I pressure wound (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching)) of the right, medial (middle) foot, measured 1 x 1.2 cm; -Stage II pressure wound (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) of the right lateral fifth toe, measured 0.2 x 0.2 x 0.1 cm; -Stage I pressure wound of the right elbow, measured 2 x 2 cm. Observation on 5/2/22 at 7:26 A.M., showed the resident in bed, calm and quiet, head of bed slightly elevated, tube feeding not infusing. The Assistant Director of Nursing (ADON) prepared the resident for wound treatment as requested by the wound physician. The resident's right leg was contracted, his/her knee was bent, pressing and rubbing against his/her left knee/leg. The resident's right elbow was also contracted, pressing against his/her side. The resident moaned, grimaced and was resistive when the ADON turned the resident to the left side, and when the current dressing was removed. The ADON continued and did not acknowledge the resident's signs of pain. The wound physician gently applied the medication to the wound and verbally attempted to ensure the resident of a quick procedure. The resident continued to show signs of pain every time he/she was moved or repositioned by the ADON. The resident slightly screamed with facial grimacing when his/her right leg was lifted to apply the wound dressing. The ADON told the resident he/she will give him/her pain medication after finishing the treatment. Observation and interview on 5/4/22 at 11:11 A.M., showed the resident with signs of pain during a wound treatment procedure, including facial grimacing, resistance and moaning. Registered Nurse (RN) HH said he/she provided wound care to the residents in the facility two days a week including some weekends. RN HH said he/she provided wound care to the resident and is very familiar with the resident. He/she said the resident did not receive pain medication prior to starting the wound treatment procedure. He/she said the resident reacts to anything, even slight stimulation. He/she gave [MEDICATION(S)] to the resident in the past, but it showed no relief. He/she said positioning the resident on his/her back, rather than on his/her side, seemed to help. Signs of pain continued to be observed during the process. Review of the resident's MAR, showed no documentation of pain medication administered for 5/2/22 or 5/4/22. Review of the nurse's narcotics sheets, showed documentation the last time resident received [MEDICATION(S)] was on 1/3/22 at 6:00 A.M. During an interview on 5/5/22 at 8:15 A.M., the Nurse Manager said non-verbal residents are assessed for pain by observing facial grimacing, guarding, and/or resistance to physical stimulation. The Nurse Manager said the resident showed all those signs with repositioning. The resident usually reacted to verbal and physical stimulation, but when given stronger pain medication, such as [MEDICATION(S)], the resident showed less signs of pain. Providing wound treatment can cause severe discomfort to a resident. He/she expected staff to medicate the resident prior to wound care. 2. Review of Resident #37's medical record, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission MDS, revised on 2/16/22, showed: -Pain presence: yes; -Frequency of pain: occasionally; -Intensity of pain: 6 out of 10. Review of the resident's admission care plan, revised 2/18/22, showed no focused goals related to the resident's pain control. Review of the resident's physician orders, showed an order, dated 2/9/22, for [MEDICATION(S)] (used to treat muscle pain and nerve damage) 75 mg three times a day for nerve pain. Review of the resident's MAR, dated April 2022, showed: -No [MEDICATION(S)] administered to the resident between 4/6/22 and 4/12/22; -No [MEDICATION(S)] administered to the resident 4/14/22 and 4/16/22; -No [MEDICATION(S)] administered to the resident on 4/18/22 or 4/19/22; -No [MEDICATION(S)] administered to the resident between 4/21/22 and 4/25/22; -No [MEDICATION(S)] administered to the resident between 4/27/22 and 4/30/22; -No reasons documented for [MEDICATION(S)] not administered. Observation on 5/3/22 at 12:50 P.M. showed the resident resting in bed with a pained expression on his/her face. The resident said he/she went about a month without receiving the prescribed medication [MEDICATION(S)] and complained of pain at a level of six out of ten. The resident also complained of intense tingling in the lower extremities. The resident said he/she had told staff about his/her pain and received Tylenol, but not the prescribed [MEDICATION(S)]. Observation on 5/4/22 at 12:17 P.M. showed the resident resting in bed with a pained expression on his/her face. He/she complained of pain in the lower extremities, as well as numbness in both legs. The pain was at a level of seven out of ten. During an interview on 5/4/22 at 12:22 P.M., Licensed Practical Nurse (LPN) J called the pharmacy (at this time) because the resident had been out of his/her [MEDICATION(S)] medication. The reason the resident had not received the medication is because no staff member had re-ordered it after it ran out. LPN J said with the pharmacy, an active order existed for the resident, and the medication was express refilled. During an interview on 5/5/22 at 11:44 A.M., the Director of Nursing said she expected residents to receive all medications as ordered, including pain medications. During an interview on 5/6/22 at 12:35 P.M. the Corporate Nurse Consultant said she expected all residents to receive all medications as ordered, including pain medications. She expected staff to order refills for resident medications with an active order, and expected staff to contact the pharmacy for a refill a week before the medication runs out. 3. During an interview on 5/12/22 at 9:03 A.M., the Medical Director said he/she expected staff to assess residents for pain, and use their clinical judgment especially for non-verbal residents. He/she said staff should administer pain medication an hour to two hours prior to evaluation and treatment procedure of a Stage IV pressure ulcer. Pain medications are to be administered as needed or as ordered. MO 490 MO 395 MO 419 MO 525

Based on interview and record review, the facility failed to ensure one resident (Resident #1), who was admitted with intact skin did not develop pressure injury/ulcers (any lesion caused by unrelieved pressure resulting in the damage of underlying tissue, usually over a bony prominence). Staff failed to assess and document the resident's compromised skin, failed to address the recommendation of the registered dietitian (RD) for a nutritional supplement, failed to notify the RD of the development of pressure ulcers and failed to promptly notify the physician and follow orders timely. The sample was 3. The census was 83. Review of the facility's Skin Management Guideline Overview, revised 7/2017, showed: -Overview: Residents who are at risk or with wounds and/or pressure and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or injury. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes; Staging: -Stage I Pressure Injury: Non-blanchable [CONDITION(S)] (discoloration of the skin that does not turn white when pressed) of intact (non-open) skin: Intact skin with localized area of non-blanchable [CONDITION(S)]; -Stage IV Pressure Injury: Full thickness (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous (fat) tissue or beyond (into muscle, bone and tendons) skin and tissue loss: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough (yellow, stringy dead tissue) and/or eschar (dry, black, hard necrotic (dead) tissue) may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury; -Unstageable pressure injury: Obscured full thickness skin and tissue loss: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, at Stage III or Stage IV pressure injury will be revealed. Stable eschar on an ischemic (poorly profused blood flow area) limb or the heel should not be removed; -Deep tissue pressure injury (DTI): persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed of blood filled blister. Pain and temperature change often precede skin color changes. The injury results from intense and/or prolonged pressure and shear forces at the bone-muscle surface. The wound may evolve rapidly to reveal the actual extent of the injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury. Review of the facility's Skin Management Practice Guidelines, revised 7/2017, showed: -Purpose: To identify at risk residents for potential breakdown or ulceration, to prevent breakdown of tissue or ulceration, to provide treatment that promotes the prevention of ulcerations and healing of existing ulcerations; -Risk factors: -Impaired mobility; -Co-morbid conditions such as, end stage kidney disease, [CONDITION(S)] disease or diabetes; -Drugs such as steroids may prevent wound healing; -Impaired or diffuse blood flow, such as arterial or venous insufficiency; -Resident right of choice in some aspect of care and treatment; -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -Under nutrition, malnutrition and hydration deficits; -Newly admitted residents: -Upon admission, residents are assessed for skin integrity by completing an assessment and documenting in the electronic health record (EHR); -Following admission, the Braden scale (measures the risks that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure), quarterly, annually and with a change of condition of their risk for development of pressure injury; -Nurse aides will complete body audits. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition; -Appropriate preventative measures will be implemented on all residents identified at risk and interventions documented on the care plan. These may include: -Turn and reposition; -Pressure reduction surfaces for the bed and wheelchair; -Floating areas of concern such as the heels when appropriate; -Separation of bony prominences with a pillow or device when lying on the side; -Use of elbow or heel protectors when appropriate; -Promotion of clean, dry and well moisture skin; -Avoiding powders; -Following the dietician recommendations to promote optimal nutrition; -Reduction of shearing force by appropriate body mechanics when moving, turning or repositioning the resident; -The care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to hydration, nutrition, preventive devices, physical activities, pain, positioning devices and proper body alignment; -Ongoing monitoring and continuous quality improvement will be achieved by the interdisciplinary team; -At risk review meetings will be conducted to review/discuss: -New admissions; -Residents identified at risk or with compromise; -Treatment modalities and interventions; -Recommendations based on interdisciplinary evaluation; -Weights will be monitored and dietary consumption reviewed. Review of Resident #1's hospital discharge summary, dated 6/10/21, showed: -Physician exam: skin intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the progress notes, dated 6/10/21 at 9:09 P.M., showed the resident arrived by emergency services at 6:00 P.M., from the hospital. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the undated care plan, showed: -Focus: The resident had a potential for pressure ulcer development related to disease process and immobility; -Goal: The resident will have intact skin, free of redness, blisters or discoloration; -Interventions: The resident requires a pressure reducing device for the bed and wheelchair, a low air loss mattress. Staff administer treatments as ordered. Assess/monitor/record wound healing. Staff measure length, width and depth when possible, assess and document status of the wound perimeter, wound bed and healing process. Staff report improvements and declines to the physician. Avoid placing the resident on his/her back for long periods and turn side to side, use pillows for positioning; -Focus: Impaired skin integrity as evidenced by pressure injury, arterial ulcer (wound as a result of poor blood flow in the artery of lower legs), friction and shearing (wound caused by skin rubbing against another surface) to the buttock, heels and ears; -Goal: The resident will exhibit signs of progressive healing without infection; -Interventions: Staff provide assistance to lift the resident's head as he/she likes to rub against the pillow, the family educated on asking for staff assistance for all dressing and personal care and to make sure shoes fit properly, staff apply neck pillow, turn and reposition often, apply soft boots and elevate feet, place pillows between legs, assess areas and initiate skin sheet and treatment order. Apply alternating pressure air mattress and ensure inflation setting is correct. Apply pressure reducing cushion to the wheelchair; -Focus: Potential nutritional problem related to anorexia (loss of appetite), diet restrictions; -Goal: Maintain adequate nutritional status as evidenced by maintaining weight within baseline, no signs/symptoms of malnutrition and consuming at least 50% of at least 3 meals daily through review date; -Interventions: Provide and serve diet as ordered: low concentrated sweets and no added salt diet, regular texture, thin consistency, provide and serve supplements as ordered, offer health shake when resident has a poor oral intake/appetite. Staff to assist and encourage intake. RD to evaluate and make diet change recommendations as needed (PRN). Weigh at same time of day and record. Resident weighed weekly with the use of his/her wheelchair; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission pressure injury risk assessment, dated 6/10/21 at 11:54 P.M., showed: -Sensory perception: The ability to respond meaningfully to pressure related discomfort: No impairment, responds to verbal commands. Has no sensory deficit, which would limit the ability to feel or voice pain or discomfort; -Moisture: The degree to which skin is exposed to moisture: Occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day; -Activity: Degree of physical activity: Chair fast-ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into the chair or wheelchair; -Mobility: Ability to change and control body position: Slightly limited-makes frequent though slight changes in body or extremity position independently; -Nutrition: Usual food intake pattern: Adequate-eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day). Occasionally will refuse a meal, but will usually take a supplement when offered; -Friction and shear: Potential problem: Moves feebly or requires minimum assistance. During movement, the skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down; -Total score: 17, or moderate risk to develop a pressure ulcer/injury. Review of the skin monitoring: comprehensive certified nurse aide (CNA) shower review, dated 6/11/21, showed: -A handwritten circled area to the coccyx (small triangular bone at the base of the spinal column) noted as pink and barrier cream applied; -The shower sheet signed by a CNA; -The charge nurse signature, dated 6/12/21; -Charge nurse assessment: blank; -Intervention: blank; -Forwarded to Director of Nursing (DON): (yes/no): blank; -DON signature: blank. Review of the daily skilled summary, dated 6/11/21 at 12:47 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edem (swelling caused by excess fluid trapped in the body's tissues): No; -Skin integrity/positioning devices: None present. Review of the resident's [MEDICATION(S)] level (protein level), dated 6/11/21, showed a level of 3.4 (normal range, 3.5-5.5). Further review of the medical record, showed no daily skilled assessment on 6/12/21 or 6/13/21. Review of the admission nutritional assessment, dated 6/13/21, showed: -Diet order: low concentrated sweets and no added salt, regular texture; -Intake: monitor; -Most recent weight: 126.0 pounds (lbs); -Recommended weight range: 160 lbs (plus/minus 10%); -Status: within recommended weight range (WRWR); -Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Skin breakdown: No; -Assessment: per the nursing staff, the resident has poor appetite and poor oral consumption. Based on reported intake, not appropriate to meet nutritional needs. Per nursing, the resident had received intravenous (IV) fluids. Unable to see the resident, he/she was asleep. Weight maintenance to gain desired for the resident; -Goals: adequate oral intake to maintain/improve admission weight status, maintain skin integrity and honor food preferences as appropriate; -Plan/Recommendations: Ensure Plus three times a day (TID, provides up to 1050 calories), will continue to monitor as needed. Review of the skin monitoring: comprehensive CNA shower review, dated 6/14/21, showed: -A handwritten circled area to the coccyx, and barrier cream applied; -The shower sheet signed by a CNA; -The charge nurse signature, dated: 6/14/21; -Charge nurse assessment: blank; -Intervention: blank; -Forwarded to DON: (yes/no): blank; -DON signature: blank. Review of the daily skilled summary, dated 6/14/21 at 7:53 A.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: None present; -Detailed summary note: Total assist of one staff for all care. Received therapy as ordered. Staff provide perineal care (cleansing from the front of the hips, between the legs and buttocks to the back of the hips). Review of the pressure wound log, dated 6/14/21, showed the resident not listed on the log. Review of the daily skilled summary, dated 6/15/21 at 7:54 A.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: None present; -Detailed summary note: Assist of one staff and up to his/her high backed wheelchair daily. He/she received therapy as scheduled. The resident is incontinent of bowel and bladder and staff provide perineal care PRN; Review of the daily skilled summary, dated 6/16/21 at 4:07 A.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: None present; -Detailed summary note: Assist of one staff and up to his/her high backed wheelchair daily. He/she received therapy as scheduled. The resident is incontinent of bowel and bladder and staff provide perineal care as needed (PRN). Review of the admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/17/21, showed: -admitted on [DATE]; -Severe cognitive impairment; -No mood concerns; -No behavior concerns; -Required extensive staff assistance for bed mobility, transfers, locomotion, dressing, toileting and hygiene; -Required limited staff assistance for eating; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk to develop pressure injury/ulcer: Yes; -Any unhealed pressure ulcer: No; -Any current pressure ulcer: No; -Any other wounds: No; -Skin and ulcer treatments include a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems and applications of ointments or medications other than to feet. Review of the skin monitoring comprehensive CNA shower review, dated 6/17/21, showed: -A handwritten circled area to the coccyx and the groin. A handwritten note, showed incontinent of bowel and bladder. Barrier cream applied; -The shower sheet signed by the CNA; -The charge nurse signature, dated: 6/18/21; -Charge nurse assessment: blank; -Intervention: blank; -Forwarded to DON: (yes/no): blank; -DON signature: blank. Review of the daily skilled summary, dated 6/17/21 at 3:08 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: chair and seat cushion; -Detailed summary note: The resident observed in bed with his/her eyes closed and the call light in reach. The resident needs assistance with all care, transfers and meals. The resident is working with therapy services. Review of the daily skilled summary, dated 6/18/21 at 1:49 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: none used; -Detailed summary note: Staff provide total care. Received therapy as ordered. Incontinent of bowel and bladder. Perineal care given PRN. Staff provide encouragement with meals. Review of the daily skilled summary, dated 6/19/21 at 2:03 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: chair and seat cushion and an alternating pressure mattress in bed; -Detailed summary note: The resident lay in bed, rest with his/her eyes closed. The resident needs assistance with transfers, care and meals. He/she continued to work with therapy and voiced no complaints. Review of the daily skilled summary, dated 6/20/21 at 11:16 A.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: No; -Edema: No; -Skin integrity/positioning devices: chair and seat cushion and an alternating pressure mattress in bed; -Detailed summary note: The resident lay in bed, resting with his/her eyes closed. The resident needs assistance with transfers, care and meals. He/she continued to work with therapy and voiced no complaints and feeling ok. Review of the skin monitoring comprehensive CNA shower review, dated 6/21/21, showed: -A handwritten circled area: -To the right ear, showed bruising; -To the right toe, showed red; -To the left toe and ankle, showed red; -The coccyx, showed dark purple; -The shower sheet signed by a CNA: -The charge nurse signature, dated: 6/21/21; -Charge nurse assessment: blank; -Intervention: blank; -Forwarded to DON: (yes/no): blank; -DON signature: blank. Review of the daily skilled summary, dated 6/21/21 at 12:32 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: Yes to the buttocks and right ear; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers; -Edema: No; -Skin integrity/positioning devices: chair and seat cushion; -Detailed summary note: The resident repositioned frequently. He/she is up to his/her wheelchair frequently for short periods. Received therapy as ordered. Open noted to the right ear, new treatment ordered. Darkened areas noted to the bilateral (both sides) buttocks and coccyx. New treatment ordered. Review of the wound care physician initial wound evaluation and management summary, dated 6/21/21, showed: -Chief complaint: the patient has multiple wounds; -History of present illness: at the request of the resident's physician, a thorough wound care assessment and evaluation was performed. The resident has an unstageable DTI to the sacrum (coccyx). There is no exudate (thin, pink, and watery drainage) and no pain; -Focused wound exam (site 1): Unstageable DTI on the sacrum; -Etiology (cause): pressure; -Duration: greater than 1 day; -Objective (goal): healing; -Wound size: 10 centimeters (cm) x 10.6 cm x no depth; -Exudate: none; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary: skin prep (topical liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) once daily for 30 days; -Secondary: foam dressing apply once daily for 30 days; -Recommendations: off load the wound, reposition per facility protocol-turn side to side and front to back in bed every 1-2 hours if able. Apply low air loss mattress; -Focused wound exam (site 2): Stage I of the right lateral (outside edge) ankle; -Etiology: pressure; -Duration: greater than 1 day; -Objective: healing; -Wound size: 2 cm x 1.5 cm x no depth; -Exudate: none; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary: skin prep apply once daily for 30 days; -Recommendations: EZ boots (eliminates pressure on the heel for treatment and prevention of heel pressure injuries) to be worn in bed and chair to off load wound; -Focused wound exam (site 3): Stage I of the left medial (middle) toe; -Etiology: pressure; -Duration: more than 1 day; -Objective: healing; -Wound size: 0.7 cm x 1.6 cm x no depth; -Exudate: none; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary: skin prep once daily for 30 days; -Recommendations: EZ boot worn in bed and chair to off load the wound; -Focused wound exam (site 4): Wound to the face; -Etiology: infection; -Duration: greater than 1 day; -Objective: ear; -Wound size: 3.0 cm x 1.0 cm x 0.1 cm; -Periwound (tissue surrounding the wound): [CONDITION(S)]; -Exudate: light serous (lightly blood tinged, thin drainage); -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary: triple antibiotic ointment apply twice daily for 30 days; -Secondary: gauze sponges apply twice daily for 30 days, tape in place, change twice daily; -Site 4: surgical excisional debridement (removal of dead or infected tissue) procedure; -Indication: removal of infected tissue; -Procedure: The wound cleaned with normal saline and anesthesia achieved with topical benxocaine (numbing agent). Tissue removed including slough (yellow, stringy infected tissue) and subcutaneous fat. Healthy bleeding tissue observed and clean dressing applied. Review of the pressure wound log, dated 6/21/21, showed: -Wound 1: -Facility acquired: blank; -Site: Sacrum; -Stage: unstageable; -Measurements: length: 10 cm x width: 10.6 cm x depth: 9 cm; -Date of acquirement: blank; -Treatment: skin prep; -Intervention: therapeutic bed and positioning pillows; -Wound 2: -Facility acquired: blank; -Site: right lower ankle; -Stage: I; -Measurement: 2 cm x 1.5 cm x 0.0 cm; -Date of acquirement: blank; -Treatment: skin prep; -Intervention: blank; -Wound 3: -Facility acquired: blank; -Site: Left medial toe; -Stage I; -Measurements: 0.7 cm x 1.6 cm x 0.0 cm; -Date of acquirement: blank; -Treatment: skin prep; -Intervention: therapeutic bed and positioning pillows; -Wound 4: -Facility acquired: blank; -Site: right face; -Stage: blank; -Measurements: 3.0 cm x 1.0 cm x 0.1 cm; -Date of acquirement: blank; -Treatment: triple antibiotic; -Intervention: blank Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 6/21/21 and a start date of 6/23/21, to cleanse the sacrum with wound cleanser, pat dry and apply skin prep every day shift; -No orders for the Ensure Plus supplement documented; -No further physician wound care orders were documented to begin on 6/21/21. Review of the daily skilled summary, dated 6/22/21 at 1:41 P.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions No; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers; -Edema: No; -Skin integrity/positioning devices: chair and seat cushion and alternating pressure mattress; -Detailed summary note: The resident lie in bed with eyes closed and call light in reach. The resident had a change in condition, lung sounds diminished and physician notified. New orders received. Review of the resident's [MEDICATION(S)] level, dated 6/22/21, showed 3.0 (normal range, 3.5-5.5). Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 6/22/21 and a start date of 6/22/21, to wash both ears with soap and water once daily for drainage; -An order, dated 6/22/21 and a start date of 6/23/21, to cleanse the wound to the right ear with wound cleanser, pat dry, apply triple antibiotic, cover with non-stick gauze every day shift; -An order, dated 6/22/21 and a start date of 6/23/21, to clean the right lateral ankle with wound cleanser, pat dry and apply skin prep every day shift; -An order, dated 6/22/21 and a start date of 6/23/21, to clean the left medial toe with wound cleanser, pat dry, apply skin prep every day shift; -No orders documented for the Ensure Plus supplement. Review of the June 2021 treatment administration record (TAR), showed: -An order dated 6/22/21 and started on 6/23/21, to cleanse the right ear with wound cleanser, pat dry, apply triple antibiotic and cover with a non-stick gauze. Change every day shift. Documented as completed daily 6/23/21 through 6/30/21; -An order dated 6/22/21 and documented as started on 6/23/21, to cleanse the right lateral ankle with wound cleanser, pat dry and apply skin prep every day shift. Documented as completed daily 6/23/21 through 6/30/21; -An order dated 6/22/21 and documented as started on 6/23/21, to cleanse the sacrum with wound cleanser, pat dry and apply skin prep every day shift. Documented as completed daily 6/23/21 through 6/30/21; -An order dated 6/22/21 and documented as started on 6/23/21, to cleanse the left medial toe with wound cleanser, pat dry and apply skin prep every day shift. Documented as completed daily 6/23/21 through 6/30/21. -No documentation of the order to wash both ears with soap and water daily. Further review of the daily skilled summary, dated 6/23/21 at 10:49 A.M. showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: Yes to the buttocks; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers; -Edema: No; -Skin integrity/positioning devices: alternating pressure mattress; -Detailed summary note: total assist of one staff, repositioned frequently while in bed. He/she placed in wheelchair daily. Received therapy services as ordered. Incontinent of bowel and bladder, perineal care provided PRN. Treatment to the buttocks as ordered. He/she feeds him/herself at meals and staff provided encouragement. Review of the resident's [MEDICATION(S)] level, dated 6/11/21, showed 2.9 (normal range, 3.5-5.5). Review of the daily skilled summary, dated 6/24/21 at 11:23 A.M., showed: -Skin turgor: Fair; -Open areas, cuts, skin tears, lacerations and abrasions: Yes to the bilateral ears; -Bruises, rashes, abnormal skin color: No; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers. -Edema: No; -Skin integrity/positioning devices: chair and seat cushion, and alternating pressure mattress; -Detailed summary note: total care with all care. He/she sat in the Broda chair (reclining, padded chair) in the morning and was well tolerated. Incontinent of bowel and bladder, perineal care provided PRN. Review of the skin monitoring: comprehensive CNA shower review sheet, dated 6/24/21, showed: -A handwritten X'd area: -To the right ear; -To the right mid abdomen; -To the right toe; -To the buttock; -To the right heel; -The shower sheet signed by a CNA; -The charge nurse signature, dated: 6/24/21; -Charge nurse assessment: blank; -Intervention: float heels, low air loss mattress, barrier cream, dressing changes with perineal care; -Forwarded to DON: (yes/no): blank; -DON signature: blank. Review of the daily skilled summary, dated 6/25/21 at 2:37 P.M., showed: -Skin turgor: Fragile, thin tissue; -Open areas, cuts, skin tears, lacerations and abrasions: Yes, buttocks; -Bruises, rashes, abnormal skin color: Yes, arms; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers; -Edema: No; -Skin integrity/positioning devices: alternating pressure mattress in bed; -Detailed summary note: The resident repositioned frequently. Perineal care given PRN. No distress noted. Further review of the medical record, showed no daily skilled summary on 6/26/21 and 6/27/21. Review of the daily skilled summary dated 6/28/21 at 12:07 P.M., showed: -Skin turgor: Fragile, thin tissue; -Open areas, cuts, skin tears, lacerations and abrasions: No; -Bruises, rashes, abnormal skin color: Yes, arms; -Any pressure, vascular, arterial or diabetic ulcers, gangrene or necrotic areas, surgical wounds or other: Yes, pressure ulcers; -Edema: No; -Skin integrity/positioning devices: none are present; -Detailed summary note: Total care for all care needs. Repositioned frequently. Dressing changes to wounds completed daily and PRN. Review of the skin monitoring comprehensive CNA shower review sheet, dated 6/28/21, showed: -Handwritten circled areas: -To the right ear; -To the left ear; -To the left inner elbow; -To the right mid abdomen; -To the right shin; -To the buttock with a hand written note, which showed the dressing changed; -To the right and left heels, showed to float with pillows; -The shower sheet signed by a CNA; -The charge nurse signature, dated 6/28/21; -Charge nurse assessment: low air loss mattress, pillow to float the heels; -Intervention: blank; -Forwarded to DON: (yes/no): blank; -DON signature: blank. Review of the wound care physician wound evaluation and management summary, dated 6/28/21, showed: -Chief complaint: the patient has multiple wounds; -History of present illness: at the request of the resident's physician, a thorough wound care assessment and evaluation was performed. He/she had a shear wound of the right posterior face for more than one day, no exudate noted; -Focused wound exam (site 1): unstageable sacrum; -Etiology: pressure; -Duration: greater than 7 days; -Objective: healing; -Wound size: 9.8 cm x 7.5 cm x no depth; -Exudate: moderate serous; -Thick necrotic tissue: 100% -Wound progress: improved; -Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Primary: Santyl (used to treat wound infection and remove dead tissue) ointment, apply once daily for 30 days. Apply calcium alginate (used to absorb excess fluid in the wound) once a day for 30 days; -Secondary: Abdominal pad, apply once daily for 30 days, use tape to secure in place; -Recommendations: Off load the wound, reposition frequently and turn side to side/ front to back i

Based on interview and record review, the facility failed to ensure staff safely and appropriately operated a mechanical lift to transfer one dependent resident. During the transfer, not all six loops of the sling were attached to the hooks on the lift and the resident slipped out of the sling, fell to the floor and hit his/her head. Staff called 911, the resident was sent to the hospital and returned with six staples to close a laceration the back of his/her head (Resident #200). The census was 64. Review of Resident #200's care plan, dated 12/29/16 and revised on 1/11/18, showed the following: -Problem: Impaired functional mobility; -Focus: Transfers using a Hoyer lift (mechanical device used to transfer a totally dependent resident from one area to another) with two staff; -Goal: The resident's activities of daily living (ADLs) needs are met with the assistance of staff; -Interventions: Nursing will provide assistance as needed for transfers and ambulation, wheelchair, two staff for transfer using Hoyer lift. Review of Resident's readmission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/31/18, showed the following: -Diagnoses: [REDACTED]. -Severe cognitive impairment; -No behaviors; -Did not resist care; -Required total assist of one staff for bed mobility, locomotion on and off the unit, eating, dressing, bathing, personal hygiene and toileting; -Required total assistance of 2+ staff for transfers; -One side impairment to upper extremity (shoulder, elbow, wrist,hand); -Non-ambulatory; -Used a wheelchair; -Incontinent of bowel and bladder; -No falls. Review of the resident's nurse's notes, dated 12/5/18, showed the following: -At 11:45 [NAME]M., Nurse K documented a Certified Nurse Aide (CNA) reported the resident fell in the shower room while being transferred from the shower chair to his/her wheelchair. The resident had an open area to the left side of his/her head. A gross amount of blood was noted. Pressure was applied by nurses. Staff notified the resident's physician and he/she was transferred to the emergency room ; -At 12:59 P.M., the Assistant Director of Nurses (ADON) documented a late entry nurse's note: Nurse H reported the resident fell in the shower room during a transfer. She entered the shower room and assessed the resident was lying on his/her back. The resident was bleeding from the left side of his/her head; -At 2:52 P.M., Nurse K documented the hospital called and reported the resident received staples for the gash on the left side of his/her head; -At 10:30 P.M., staff documented the resident returned to the facility at 3:45 P.M., with a [DIAGNOSES REDACTED]. The resident received six staples to the left side of his/her head. During an interview on 12/6/18 at 9:20 [NAME]M., CNA F said he/she helped shower the resident on 12/5/18. He/she put the Hoyer sling under the resident while the resident lay on the shower bed. CNA G and CNA [NAME] were in the shower room when he/she left the room. During an interview on 12/11/18 at 2:00 P.M., CNA G said he/she helped with the resident's shower on 12/5/18. He/she and CNA F put the Hoyer lift sling under the resident then CNA F left the shower room. He/she connected the loops of the Hoyer lift sling to the hooks on the Hoyer lift. While he/she and CNA [NAME] transferred the resident from the shower bed to his/her wheelchair he/she fell out the right side of the Hoyer lift sling. When the resident fell , CNA [NAME] left the shower room to get a nurse. Nurses and other staff came to the shower room immediately to assess and treat the resident's head injury. During an interview on 12/6/18 at 8:45 [NAME]M., CNA [NAME] said CNA G connected the resident to the Hoyer sling, while CNA G transferred the resident from the shower bed, he/she stood behind the resident. During the transfer the resident fell out the right side of the Hoyer sling. CNA [NAME] left the shower room and reported the fall to a Nurse J immediately. Nurse J followed him/her to the shower room and assessed the resident. During an interview on 12/11/18 at 11:40 [NAME]M., Nurse J said he/she worked day shift on 12/5/18. He/she was eating lunch in the employee lounge when CNA [NAME] reported the resident fell from the Hoyer lift in the shower room. He/she immediately went to assess the resident. When he/she entered the shower room, the resident was laying on the floor, bleeding from his/her head. Nurse J stepped out of the shower room and called for additional staff. He/she applied pressure to the back of the resident's head. Staff notified the resident's physician of the fall, 911 was called and the resident was transferred to the hospital. During an interview on 12/6/18 at 10:00 [NAME]M., Nurse K said he/she worked day shift on 12/5/18 and was assigned to the resident. Staff reported the resident fell from the Hoyer lift in the shower room. He/she entered the shower room and saw the resident was on the floor. Nurse H and Nurse J were in the shower room at that time. Nurse K left the shower room and called the resident's physician and 911. He/she recalled the Hoyer lift was on the opposite side of the shower room but did not assess the Hoyer lift or the placement of the Hoyer sling loops at that time. Nurse K said staff are trained on proper Hoyer lift technique including to connect all loops of the Hoyer sling to the Hoyer lift hooks. During an interview on 12/6/18 at 10:05 [NAME]M., Nurse H said he/she was at the facility when staff reported the resident fell from the Hoyer on 12/5/18. He/she entered the shower room and saw the resident lay on the floor with blood under his/her head. Nurse J applied pressure to the back of the resident's head, staff notified the resident's physician and called 911. Nurse H did not assess the Hoyer lift or the placement of the Hoyer sling loops at that time. During an interview on 12/6/18 at 9:20 [NAME]M., CNA F said after he/she left the shower room staff told him/her the resident fell from the Hoyer lift. He/she entered the shower room and saw the resident lay on the floor with blood pooling behind his/her head. CNA G told him/her the resident fell out of the side of the Hoyer lift. CNA F looked at the Hoyer lift sling, which was still hanging from the Hoyer lift and noted the two middle loops were not connected to the two middle Hoyer lift hooks. CNA F said the resident leans to the right in his/her wheelchair and that was why it was important to connect all six loops of the Hoyer lift sling to the Hoyer lift hooks. During an interview on 12/11/18 at 2:00 P.M., CNA G said the Hoyer sling had six loops to connect to the six Hoyer lift hooks, two at the head, two at the foot and two on the sides. He/she connected the two loops of the sling to the hooks at the head and the two loops of the sling to the hooks at the foot of the Hoyer lift. CNA G did not connect the two middle loops of the sling to the hooks on the Hoyer lift during the transfer. He/she never connected the middle loops of the sling to the middle hooks on the Hoyer lift. CNA G said he/she was not trained to connect the middle loops to the Hoyer lift, that was why he/she did not connect them. CNA G clarified the two middle Hoyer sling loops were not used during the transfer and he/she did not connect middle loops of the Hoyer sling to the hooks on the Hoyer lift after the resident fell . During an interview on 12/5/18 at 8:45 [NAME]M., CNA [NAME] said the Hoyer sling middle hooks were not connected to the Hoyer lift during the transfer. When the resident leaned to the right, he/she fell out of the Hoyer sling. CNA [NAME] did not connected the Hoyer sling to the Hoyer lift, CNA G did. CNA [NAME] said he/she should have checked the Hoyer sling hooks were connected properly but did not because he/she trusted that CNA G connected the sling properly. During an interview on 12/11/18 at 11:40 [NAME]M., Nurse J said when he/she entered the shower room, the Hoyer lift was on the other side of the shower room. He/she applied pressure to the back of the resident's head until emergency medical services (EMS) got to the facility. He/she did not assess the Hoyer lift or the placement of the Hoyer sling loops at that time because he/she was providing first aid for the resident. During an interview on 12/6/18 at 7:30 [NAME]M., the ADON said staff reported the resident fell from the Hoyer lift when staff transferred him/her from the shower bed to his/her wheelchair. CNA G told her the resident squirmed during the transfer and fell out the side of the Hoyer lift sling. The resident was transferred to the emergency room and received six staples to the back of his/her head. The Hoyer lift was on opposite side of the shower room when she entered the room and the Hoyer sling was connected to the six hooks properly. During an interview on 12/6/18 at 10:15 [NAME]M., the interim Director of Nurses (DON) and ADON said when they entered the shower room the resident was on the floor with blood under his/her head. The interim DON and ADON confirmed the Hoyer lift sling was connected to the Hoyer lift and all six loops of the Hoyer sling were connected to the Hoyer lift. They did not know how the resident fell from the Hoyer lift at that time. During an interview on 12/13/18 at 10:00 [NAME]M., CNA L said he/she was an experienced CNA at the facility. He/she orientated new CNAs and trained them how to transfer residents using a Hoyer lift. During the training, he/she showed new CNAs how to connect the Hoyer sling to the Hoyer lift properly ensuring all six loops were connected to the Hoyer lift. He/she orientated CNA G one day and they transferred at least two residents in Hoyer lifts that day. CNA G was trained on proper Hoyer lift transfers and to connect all six loops of the Hoyer sling to the Hoyer lift. During an interview on 12/12/18 at 8:30 [NAME]M., the interim DON said the facility Hoyer lift had six hooks and all of the slings had six loops. During an interview on 12/12/18 at 9:58 [NAME]M., Physical Therapist I said she assessed the resident for positioning and safe transfers. The resident was a Hoyer lift transfer for over a year and a half. The resident leans in his/her wheelchair to the left but sometimes to the right. All Hoyer slings at the facility have six loops, two at the head, two in the middle and two at the feet. Staff are trained to connected all six loops of the Hoyer sling to the six hooks on the Hoyer lift. If the Hoyer sling was not connected to the Hoyer lift with all six loops, the resident could fall out of the Hoyer sling. During an interview on 12/10/18 at 9:45 [NAME]M., the interim DON said initially staff lied to her regarding how the resident fell from the Hoyer lift. After the surveyor left on 12/6/18, CNA [NAME] and CNA F told her the Hoyer sling loops were not connected to the Hoyer lift properly, the side loops were not connected to the Hoyer lift, the resident leaned to the right during the transfer from the shower bed to the wheelchair and that was how he/she fell out of the Hoyer lift sling. The interim DON said upon hire CNAs receive four days of 1:1 orientation training with an experienced CN[NAME] They are trained how to transfer residents using a Hoyer lift. During the training they are instructed to connect all loops on the Hoyer sling to the Hoyer lift hooks. Review of the facility's Hoyer lift policy, dated 5/2017, showed the following: -Secure the assistance of two staff; -Attach the sling to the Hoyer lift with the hooks in place. Review of the facility's Hoyer lift policy, revised 12/6/18, showed ALL Hoyer lift sling hooks (loops) are to ALWAYS be hooked to the Hoyer lift to ensure the resident is properly secured in the Hoyer sling prior to engaging the Hoyer lift. MO 319

Based on interview and record review, the facility failed to adequately monitor, assess and ensure the guidance and direction of the physician/Medical Director was obtained, regarding a resident experiencing a change in condition. Over a four day period, staff observed the resident with an elevated temperature, an increased heart rate and labored breathing. On the fourth day the physician was made aware of the resident's change, and gave orders to send the resident to the hospital where he/she was admitted to the intensive care unit (ICU). In addition, the facility failed to ensure adequate follow up and physician notification regarding a resident with ongoing vaginal discharge (Residents #202 and #201). The census was 62 residents. Review of the facility's policy and procedure on Change in Condition, updated 3/2017, showed: -Purpose: The facility will make every effort to inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is following: #2. A significant change in the condition, health, mental or psychosocial status, that is a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications; -Procedure: 1. If the physician cannot be reached, the Medical Director will be notified; 2. During medical emergencies, notifications will be made as soon as possible; 3. The facility will promptly notify the physician of laboratory results that fall outside of the clinical reference ranges in accordance with Doctor parameters or laboratory normal reference ranges; 4. Changes in condition will be evaluated for the need to complete a Significant Change in condition MDS 3.0/RAI Assessment, in accordance to the RAI/MDS 3.0 Instruction Manual; 5. The care plan will be updated as necessary; -The policy did not instruct staff on what steps they should take when a resident had a change in condition such as assessing, monitoring, taking vital signs, documenting or what to do if the physician/Medical Director could not be reached. 1. Review of Resident #202's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/18, showed: -[DIAGNOSES REDACTED]. -Severely impaired cognition; -Clear speech; -Usually able to make self understood and to understand others; -Required total staff assistance for all activities of daily living (ADLs); -Wheelchair used for mobility; -Incontinent of bowel and bladder; -Mechanically altered diet; -Life expectancy of six months or less: No. Review of the resident's progress note, completed by the physician, dated 12/8/18, showed: -History of multiple problems; -Respirations (R) 16 (normal 12-16), pulse (P) 72 (normal 60-100); -Respiratory: Lungs clear to auscultation, no respiratory distress, no oxygen use, no wheezing; -Medical management: Stable, dementia, depression, stroke, diabetes and increased blood pressure. Review of the resident's nurse's notes, showed: -On 12/25/18 at 5:48 A.M.: admitted to hospital with [DIAGNOSES REDACTED]. -On 1/4/19 at 6:46 P.M.: readmitted to the facility at 3:38 P.M. Alert but does not speak. Grunts when name is called and makes eye contact. Vital signs (VS): Blood pressure (B/P) 123/76 (normal 120/80), P 79, R 16, temperature (T) 99.7 (normal 98.6). Oxygen saturation (O2 Sats) 96% (normal 95-100%). Tylenol given. Review of the resident's physician's orders [REDACTED]. -Full code; -No order documented for oxygen; -Nothing by mouth (NPO); -[MEDICATION NAME] (generic for Tylenol) 500 milligrams (mg) by mouth every six hours as needed for elevated temperature or pain. Review of the resident's interim care plan, dated 1/4/19 at 3:38 P.M., showed: -Risk for skin breakdown; -Cognitively impaired; -Total assistance with ADLs; -Medications/Treatments: Oxygen; -Medical Conditions: SOB (shortness of breath), [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Review of the resident's nurse's notes, showed: -On 1/5/19 at 5:20 A.M.: VS: T 100.0, P 100, R 18, BP 111/56, O2 Sats 94%, alert, readmit, Tylenol given for temperature, head of bed elevated, lungs sounds clear to auscultation, oxygen applied at 2 liters (L) per minutes for shortness of breath and comfort; -On 1/5/19 at 3:00 P.M.: Alert but non verbal. NPO and remains on continual tube feeding without problems. Will continue to monitor for any changes. No vital signs documented. No further nurses note documented until 1/6/19 at 5:20 A.M.; -On 1/6/19 at 5:20 A.M.: In bed, eyes closed, resting. Total care with ADLs, toileting and transfers. VS: T 99.7, P 110, R 16, B/P 118/75. O2 Sats 94% with oxygen at 2 L. No documentation staff notified the physician of the resident's increased pulse rate or increased temperature; -On 1/6/19 at 12:58 P.M.: While on break, another charge nurse reported the resident was not looking good. VS: B/P 118/75, P 110, O2 Sats 93% on 2 L of oxygen, T 99.5, R 24 and blood glucose of 132. Resident was SOB with slight wheezing. Call placed to the resident's physician, awaiting call back. Resident is a full code. [MEDICATION NAME] (medication used to treat anxiety) administered. Will continue to monitor; -On 1/6/19 at 3:20 P.M.: VS: B/P 122/77, O2 Sats 94%, R 18, resident still has elevated temperature. Awaiting call back from the physician. Called times two. No pulse or temperature documented; -On 1/6/19 at 9:00 P.M.: No documentation regarding the resident's vital signs or condition nor whether the physician returned a call to the facility. The next note documented, on 1/7/19 at 10:39 P.M. Review of the resident's Speech Therapy Plan of Care, dated 1/7/19, showed: -Reason for Referral: Dysphagia (difficulty swallowing) referred for dysphasia evaluation and treatment for [REDACTED]. Resident is NPO; -Exam given: NPO status. Left facial droop noted, poor lip seal and labored breathing. Recent [DIAGNOSES REDACTED]. Patient did not trigger a swallow during exam despite tactile and verbal cues. Patient consumed a mechanical soft diet with thin liquids prior to hospitalization . Review of the resident's nurse's notes, showed: -On 1/7/19: No day shift note for 7:00 A.M. through 3:00 P.M.; -On 1/7/19 at 10:39 P.M.: Resident has had an active decline. Temperature unstable at 103.1, was given Tylenol and ice packs were placed to lower temperature. When nurse returned to reassess, resident was noted to be short of breath, remained on oxygen at 2 L per nasal cannula. Unable to obtain O2 Sats, temperature remains unstable at 101.4. Will continue to monitor. No documentation whether the staff contacted the physician or whether the physician returned the call from 1/6/19; -On 1/8/19 at 1:11 A.M.: VS: T 102.0, P 107, R 22, B/P 90/54, O2 Sats not documented. Resident short of breath, with pursed lip breathing (a breathing technique that consists of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the mouth closed), using facial and abdominal muscles to breath, head of bed elevated. Tylenol given for temperature. Physician called. The physician asked staff if the resident was a hospice patient, staff replied no. Order received to send to the hospital for evaluation. Ambulance called and gave instructions to call 911 due to resident being in respiratory distress. Resident on O2 at 3 L, while having increased shortness of breath, color pale. Assistant Director of Nurses (ADON) made aware. Resident transported to hospital; -On 1/8/19 at 5:59 A.M.: admitted to the ICU with a [DIAGNOSES REDACTED]. Review of the resident's care plan, updated 1/8/19, showed: -Problem: Oxygen therapy related to ineffective gas exchange, at times observed with SOB and required oxygen; -Interventions: Monitor for signs and symptoms of respiratory distress and report to the physician as needed: Respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (excessive sweating), headaches, lethargy, confusion, cough, bloody sputum, accessory muscle usage and skin color. During an interview on 1/8/19 at 11:16 A.M., Certified Nurse Aide (CNA) Q said he/she works the day shift. When the resident returned from the hospital on [DATE], he/she didn't look well. He/she took care of the resident on 1/6/19. After breakfast, while providing care, he/she noted the resident was short of breath and told CNA U to get the charge nurse. Nurse D and Nurse M came to the room. Nurse D said the resident was short of breath. Nurse D told him/her to raise the head of the bed. CNA Q believes the nurse gave him/her a nebulizer treatment, but was not sure. When he/she made his/her last rounds, the resident continued to have labored breathing. He/she doesn't know if the nurse checked him/her again. He/she didn't get the resident up on 1/7/19, and his/her condition was about the same. During an interview on 1/8/19 at 11:42 A.M., Nurse M said he/she worked the day shift on Sunday 1/6/19. While the resident's nurse was on break, CNA Q and CNA U reported the resident wasn't looking good. When he/she entered the room, the resident was pursed lip breathing and using his/her abdominal muscles to breath. The resident's respirations were 22 to 24 and O2 Sats were 95% on 2 L of oxygen. He/she took the resident's B/P and pulse, but doesn't recall what they were and didn't document them at the time. He/she instructed CNA Q and CNA U to stay with the resident while he/she got the resident's nurse. He/she was very concerned about the resident's condition and wanted to call 911, because the resident's respirations were labored and his/her skin was sweaty and clammy, but he/she wasn't the resident's nurse. He/she and Nurse D returned to the room to assess the resident. He/she asked Nurse D if he/she needed any help, but he/she declined. He/she left the room at that time, but knows Nurse D administered a [MEDICATION NAME] (antianxiety medication) to help calm the resident down and placed a call to the physician. Nurse D also called the ADON to make her aware. The resident's physician didn't call back on their shift. He/she didn't work on 1/7/19. During an interview on 1/8/19 at 3:55 P.M., CNA R said he/she took care of the resident on 1/5 and 1/6/19 on the evening shift. He/she was very drowsy and responded only when he/she provided care. The resident normally awakens easily and resists care. His/her lips were very dry and he/she applied Vaseline to them. No one reported any changes in report. During an interview on 1/8/19 at 4:00 P.M., Nurse T said he/she took care of the resident on the evening shift of 1/6/19. Nurse D reported he/she had given the resident [MEDICATION NAME] on the day shift. He/she saw the resident during rounds, and noted a decline. He/she had pursed lip breathing which lasted 5 to 7 minutes at various times. He/she didn't notice the use of accessory muscles to breath. He/she saw the the resident about three times on his/her shift. Staff didn't report any changes and the physician didn't return call on his/her shift. During an interview on 1/8/19 at 10:55 A.M., the speech therapist said she evaluated the resident on 1/7/19, in the morning. The resident was very lethargic, had very little oral movement and was unable to close his/her lips. He/she was short of breath with audible breathing and sounded very congested. She was surprised to see the resident was receiving tube feeding, because prior to hospitalization he/she received a mechanical soft diet with thin liquids. She did not report the resident's condition to the nursing staff. During an interview on 1/8/19 at 1:59 P.M., Nurse D said he/she took care of the resident on 1/5, 1/6 and 1/7/19 on the day shift. He/she doesn't recall any problems with the resident on 1/5/19 and no one reported any concerns. On 1/6/19, while on break, Nurse M reported the resident was breathing hard, his/her pulse was elevated and O2 Sats and B/P were normal. He/she assessed the resident and noted slight wheezing and an elevated temperature of 99.5. He/she raised the HOB higher and placed a call to the physician at about 11:00 A.M. or 12:00 P.M. He/she checked on the resident during his/her shift, but did not document his/her condition. He/she notified the ADON and was told to call the physician. The ADON also asked if the resident had anything for anxiety and instructed him/her to administer it. The physician did not return the call prior to the end of his/her shift on 1/6/19. He/she saw the resident on the morning of 1/7/19, when he/she administered his/her medications and didn't notice any shortness of breath at that time. Speech therapy did not report any concerns regarding the resident. He/she was unaware the speech therapist documented pursed lip breathing, audible wheezing, lethargy or sounds of congestion. He/she would have expected the therapist to report any changes in his/her condition to the nurse. During an interview on 1/8/19 at 3:50 P.M., CNA S said he/she took care of the resident on 1/7/19, on the evening shift. He/she could see the change in the resident since his/her return from the hospital. The resident was drooling from his/her mouth which was unusual for him/her. He/she was drowsy and slept most of the evening. The resident normally would be more alert. During an interview on 1/8/19 at 2:27 P.M., the ADON said she would consider an elevated pulse a change in condition. The nurses administered Tylenol for the temperature and did what they were supposed to do, but the ADON was unable to state how long staff should administer Tylenol for a elevated temperature before notifying the physician. She expected the nurses to document in the nurse's notes when there is a change in condition and to document every shift until the resident is stable. She would have expected the therapist to notify nursing immediately of any changes in the resident's condition. The resident had a history of [REDACTED]. During an interview on 1/8/19 at 3:10 P.M., the Administrator said he expected staff to notify the physician anytime there is a change in the resident's condition. During an interview on 1/10/19 at 12:30 P.M., the resident's physician, who was also the facility's Medical Director, said he expected staff to document in the medical record any change in the resident's condition. He would have expected the therapist to notify nursing of any changes in the resident's condition. Anytime a nurse had concerns and felt the resident needed to be sent to the hospital and 911 needed to be called, he expected them to use nursing judgement, send the resident and notify him afterward. 2. Review of Resident #201's readmission MDS, dated [DATE], showed: -A readmission date of [DATE]; -[DIAGNOSES REDACTED]. -Moderately impaired cognition; -Extensive to total staff assistance for ADLs; -Wheelchair for mobility; -Incontinent of bowel and bladder. Review of the resident's progress notes, showed: -On 1/3/19 at 2:27 P.M., CNA informed the charge nurse, while perineal care (peri-care, cleaning of the genital and anal areas) was provided, the resident had a greenish and tan colored vaginal discharge. The resident denied burning during urination and/or vaginal itching at this time. Message left for the resident's physician to contact the facility. Awaiting return telephone call from the physician. The resident's responsible party was contacted and made aware of the resident's change in condition; -On 1/4/19 at 10:25 P.M., nursing staff administered [MEDICATION NAME] (antifungal medication) 150 mg, one tablet, for vaginal discharge as ordered by the resident's physician; -On 1/5/19 at 4:50 A.M., monitored for vaginal discharge; -On 1/6/19 at 1:26 P.M., continues to have heavy green discharge from vaginal area. Telephone call placed to the resident's physician; -On 1/8/19 at 12:10 P.M., no vaginal discharge reported today. Call placed to the resident's physician regarding past history of heavy vaginal drainage. New order received for [MEDICATION NAME] 150 mg, one tablet, for one time dose; -On 1/8/19 at 2:15 P.M., call placed to pharmacy for order of [MEDICATION NAME] to be sent on stat (immediately) run from the pharmacy; -No progress note found indicating the physician contacted the facility on 1/6 and/or 1/7/19 related to the resident's vaginal drainage; -No progress note found indicating nursing staff attempted to contact the resident's physician again regarding the resident's vaginal drainage until 1/8/19. Review of the resident's POS, dated 1/1 through 1/31/19, showed: -A telephone order dated 1/3/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times one dose; -A telephone order dated 1/8/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times one dose. Review of the resident's Medication Administration Record [REDACTED] -On 1/4/19, no staff initials to indicate the administration of [MEDICATION NAME] 150 mg, one tablet; -On 1/8/19, staff initialed to indicate the administration of [MEDICATION NAME] 150 mg, one tablet. Review of the facility's 24 hour nursing report sheet dated 1/6/19, showed staff documented regarding the resident: -7:00 A.M. to 3:00 P.M. shift, having green vaginal drainage, call placed to the resident's physician, resident leave of absence from the facility and returned; -3:00 P.M. to 11:00 P.M. shift, no vaginal drainage this shift; -11:00 P.M. to 7:00 A.M. shift, continues to have vaginal drainage; -No documentation to indicate the resident's physician called the facility back related to the resident's vaginal drainage; -No documentation to indicate nursing staff attempted to contact the physician again after contacting the physician on the 7:00 A.M. to 3:00 P.M., shift. Review of the facility's 24 hour nursing report sheet dated 1/7/19, showed staff documented regarding the resident: -7:00 A.M. to 3:00 P.M. shift, out to [MEDICAL TREATMENT] (process of filtering toxins from the blood in individuals with kidney failure); -3:00 P.M. to 11:00 P.M. shift, returned from [MEDICAL TREATMENT]; -11:00 P.M. to 7:00 A.M. shift, is alright; -No documentation to indicate the resident's physician called the facility regarding the resident's vaginal drainage; -No documentation to indicate nursing staff attempted to contact the physician regarding the resident's vaginal drainage. During an interview on 1/8/19 at 11:55 A.M., Nurse M verified he/she worked the day shift on 1/6/19. He/she telephoned the resident's physician regarding the resident's vaginal drainage, but had not received a telephone call back from the physician prior to him/her leaving on 1/6/19. To his/her knowledge, the physician had not contacted the facility back regarding the resident's vaginal drainage. The nurse verified he/she did not receive any information in report from the nursing staff, to indicate the physician had contacted the facility regarding the resident's vaginal drainage and/or staff contacted the physician since Nurse M called the physician on 1/6/19. During an interview on 1/8/19 at 12:00 P.M., the resident said he/she had a small amount of vaginal drainage that day. She could not recall if nursing staff had assessed him/her that day regarding the vaginal discharge or not. The resident denied having any pain or discomfort. During an interview on 1/8/19 at 12:05 P.M., Nurse M said he/she had contacted the resident's physician and received an order to administer [MEDICATION NAME] 150 mg one tablet that day. During an interview on 1/8/19 at 3:30 P.M., Nurse N verified the resident's physician contacted the facility during the evening shift on 1/3/19, and gave an order to administer [MEDICATION NAME] 150 mg one tablet dose. He/she placed the order for the [MEDICATION NAME] in the computer to the pharmacy at approximately 10:30 P.M. on 1/3/19. Nurse N verified he/she administered the resident's [MEDICATION NAME] on 1/4/19 at approximately 7:00 P.M., but forgot to document the administration of the [MEDICATION NAME] on the resident's MAR. During an interview on 1/8/19 at 2:45 P.M., the ADON said she expected nursing staff to continue to have attempted to contact the resident's physician regarding the vaginal drainage when staff first contacted the physician on 1/6/19. She expected the nursing staff to document each time they attempted to contact the resident's physician in the progress notes.

Based on interview and record review, the facility failed to adequately monitor, assess and ensure the guidance and direction of the physician/Medical Director was obtained, regarding a resident experiencing a change in condition. Over a four day period, staff observed the resident with an elevated temperature, an increased heart rate and labored breathing. On the fourth day the physician was made aware of the resident's change, and gave orders to send the resident to the hospital where he/she was admitted to the intensive care unit (ICU). In addition, the facility failed to ensure adequate follow up and physician notification regarding a resident with ongoing vaginal discharge (Residents #202 and #201). The census was 62 residents. Review of the facility's policy and procedure on Change in Condition, updated 3/2017, showed: -Purpose: The facility will make every effort to inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is following: #2. A significant change in the condition, health, mental or psychosocial status, that is a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications; -Procedure: 1. If the physician cannot be reached, the Medical Director will be notified; 2. During medical emergencies, notifications will be made as soon as possible; 3. The facility will promptly notify the physician of laboratory results that fall outside of the clinical reference ranges in accordance with Doctor parameters or laboratory normal reference ranges; 4. Changes in condition will be evaluated for the need to complete a Significant Change in condition MDS 3.0/RAI Assessment, in accordance to the RAI/MDS 3.0 Instruction Manual; 5. The care plan will be updated as necessary; -The policy did not instruct staff on what steps they should take when a resident had a change in condition such as assessing, monitoring, taking vital signs, documenting or what to do if the physician/Medical Director could not be reached. 1. Review of Resident #202's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/18, showed: -[DIAGNOSES REDACTED]. -Severely impaired cognition; -Clear speech; -Usually able to make self understood and to understand others; -Required total staff assistance for all activities of daily living (ADLs); -Wheelchair used for mobility; -Incontinent of bowel and bladder; -Mechanically altered diet; -Life expectancy of six months or less: No. Review of the resident's progress note, completed by the physician, dated 12/8/18, showed: -History of multiple problems; -Respirations (R) 16 (normal 12-16), pulse (P) 72 (normal 60-100); -Respiratory: Lungs clear to auscultation, no respiratory distress, no oxygen use, no wheezing; -Medical management: Stable, dementia, depression, stroke, diabetes and increased blood pressure. Review of the resident's nurse's notes, showed: -On 12/25/18 at 5:48 [NAME]M.: admitted to hospital with [DIAGNOSES REDACTED]. -On 1/4/19 at 6:46 P.M.: readmitted to the facility at 3:38 P.M. Alert but does not speak. Grunts when name is called and makes eye contact. Vital signs (VS): Blood pressure (B/P) 123/76 (normal 120/80), P 79, R 16, temperature (T) 99.7 (normal 98.6). Oxygen saturation (O2 Sats) 96% (normal 95-100%). Tylenol given. Review of the resident's physician's orders [REDACTED]. -Full code; -No order documented for oxygen; -Nothing by mouth (NPO); -[MEDICATION NAME] (generic for Tylenol) 500 milligrams (mg) by mouth every six hours as needed for elevated temperature or pain. Review of the resident's interim care plan, dated 1/4/19 at 3:38 P.M., showed: -Risk for skin breakdown; -Cognitively impaired; -Total assistance with ADLs; -Medications/Treatments: Oxygen; -Medical Conditions: SOB (shortness of breath), [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Review of the resident's nurse's notes, showed: -On 1/5/19 at 5:20 [NAME]M.: VS: T 100.0, P 100, R 18, BP 111/56, O2 Sats 94%, alert, readmit, Tylenol given for temperature, head of bed elevated, lungs sounds clear to auscultation, oxygen applied at 2 liters (L) per minutes for shortness of breath and comfort; -On 1/5/19 at 3:00 P.M.: Alert but non verbal. NPO and remains on continual tube feeding without problems. Will continue to monitor for any changes. No vital signs documented. No further nurses note documented until 1/6/19 at 5:20 [NAME]M.; -On 1/6/19 at 5:20 [NAME]M.: In bed, eyes closed, resting. Total care with ADLs, toileting and transfers. VS: T 99.7, P 110, R 16, B/P 118/75. O2 Sats 94% with oxygen at 2 [MI] No documentation staff notified the physician of the resident's increased pulse rate or increased temperature; -On 1/6/19 at 12:58 P.M.: While on break, another charge nurse reported the resident was not looking good. VS: B/P 118/75, P 110, O2 Sats 93% on 2 L of oxygen, T 99.5, R 24 and blood glucose of 132. Resident was SOB with slight wheezing. Call placed to the resident's physician, awaiting call back. Resident is a full code. [MEDICATION NAME] (medication used to treat anxiety) administered. Will continue to monitor; -On 1/6/19 at 3:20 P.M.: VS: B/P 122/77, O2 Sats 94%, R 18, resident still has elevated temperature. Awaiting call back from the physician. Called times two. No pulse or temperature documented; -On 1/6/19 at 9:00 P.M.: No documentation regarding the resident's vital signs or condition nor whether the physician returned a call to the facility. The next note documented, on 1/7/19 at 10:39 P.M. Review of the resident's Speech Therapy Plan of Care, dated 1/7/19, showed: -Reason for Referral: Dysphagia (difficulty swallowing) referred for dysphasia evaluation and treatment for [REDACTED]. Resident is NPO; -Exam given: NPO status. Left facial droop noted, poor lip seal and labored breathing. Recent [DIAGNOSES REDACTED]. Patient did not trigger a swallow during exam despite tactile and verbal cues. Patient consumed a mechanical soft diet with thin liquids prior to hospitalization . Review of the resident's nurse's notes, showed: -On 1/7/19: No day shift note for 7:00 [NAME]M. through 3:00 P.M.; -On 1/7/19 at 10:39 P.M.: Resident has had an active decline. Temperature unstable at 103.1, was given Tylenol and ice packs were placed to lower temperature. When nurse returned to reassess, resident was noted to be short of breath, remained on oxygen at 2 L per nasal cannula. Unable to obtain O2 Sats, temperature remains unstable at 101.4. Will continue to monitor. No documentation whether the staff contacted the physician or whether the physician returned the call from 1/6/19; -On 1/8/19 at 1:11 [NAME]M.: VS: T 102.0, P 107, R 22, B/P 90/54, O2 Sats not documented. Resident short of breath, with pursed lip breathing (a breathing technique that consists of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the mouth closed), using facial and abdominal muscles to breath, head of bed elevated. Tylenol given for temperature. Physician called. The physician asked staff if the resident was a hospice patient, staff replied no. Order received to send to the hospital for evaluation. Ambulance called and gave instructions to call 911 due to resident being in respiratory distress. Resident on O2 at 3 L, while having increased shortness of breath, color pale. Assistant Director of Nurses (ADON) made aware. Resident transported to hospital; -On 1/8/19 at 5:59 [NAME]M.: admitted to the ICU with a [DIAGNOSES REDACTED]. Review of the resident's care plan, updated 1/8/19, showed: -Problem: Oxygen therapy related to ineffective gas exchange, at times observed with SOB and required oxygen; -Interventions: Monitor for signs and symptoms of respiratory distress and report to the physician as needed: Respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (excessive sweating), headaches, lethargy, confusion, cough, bloody sputum, accessory muscle usage and skin color. During an interview on 1/8/19 at 11:16 [NAME]M., Certified Nurse Aide (CNA) Q said he/she works the day shift. When the resident returned from the hospital on [DATE], he/she didn't look well. He/she took care of the resident on 1/6/19. After breakfast, while providing care, he/she noted the resident was short of breath and told CNA U to get the charge nurse. Nurse D and Nurse M came to the room. Nurse D said the resident was short of breath. Nurse D told him/her to raise the head of the bed. CNA Q believes the nurse gave him/her a nebulizer treatment, but was not sure. When he/she made his/her last rounds, the resident continued to have labored breathing. He/she doesn't know if the nurse checked him/her again. He/she didn't get the resident up on 1/7/19, and his/her condition was about the same. During an interview on 1/8/19 at 11:42 [NAME]M., Nurse M said he/she worked the day shift on Sunday 1/6/19. While the resident's nurse was on break, CNA Q and CNA U reported the resident wasn't looking good. When he/she entered the room, the resident was pursed lip breathing and using his/her abdominal muscles to breath. The resident's respirations were 22 to 24 and O2 Sats were 95% on 2 L of oxygen. He/she took the resident's B/P and pulse, but doesn't recall what they were and didn't document them at the time. He/she instructed CNA Q and CNA U to stay with the resident while he/she got the resident's nurse. He/she was very concerned about the resident's condition and wanted to call 911, because the resident's respirations were labored and his/her skin was sweaty and clammy, but he/she wasn't the resident's nurse. He/she and Nurse D returned to the room to assess the resident. He/she asked Nurse D if he/she needed any help, but he/she declined. He/she left the room at that time, but knows Nurse D administered a [MEDICATION NAME] (antianxiety medication) to help calm the resident down and placed a call to the physician. Nurse D also called the ADON to make her aware. The resident's physician didn't call back on their shift. He/she didn't work on 1/7/19. During an interview on 1/8/19 at 3:55 P.M., CNA R said he/she took care of the resident on 1/5 and 1/6/19 on the evening shift. He/she was very drowsy and responded only when he/she provided care. The resident normally awakens easily and resists care. His/her lips were very dry and he/she applied Vaseline to them. No one reported any changes in report. During an interview on 1/8/19 at 4:00 P.M., Nurse T said he/she took care of the resident on the evening shift of 1/6/19. Nurse D reported he/she had given the resident [MEDICATION NAME] on the day shift. He/she saw the resident during rounds, and noted a decline. He/she had pursed lip breathing which lasted 5 to 7 minutes at various times. He/she didn't notice the use of accessory muscles to breath. He/she saw the the resident about three times on his/her shift. Staff didn't report any changes and the physician didn't return call on his/her shift. During an interview on 1/8/19 at 10:55 [NAME]M., the speech therapist said she evaluated the resident on 1/7/19, in the morning. The resident was very lethargic, had very little oral movement and was unable to close his/her lips. He/she was short of breath with audible breathing and sounded very congested. She was surprised to see the resident was receiving tube feeding, because prior to hospitalization he/she received a mechanical soft diet with thin liquids. She did not report the resident's condition to the nursing staff. During an interview on 1/8/19 at 1:59 P.M., Nurse D said he/she took care of the resident on 1/5, 1/6 and 1/7/19 on the day shift. He/she doesn't recall any problems with the resident on 1/5/19 and no one reported any concerns. On 1/6/19, while on break, Nurse M reported the resident was breathing hard, his/her pulse was elevated and O2 Sats and B/P were normal. He/she assessed the resident and noted slight wheezing and an elevated temperature of 99.5. He/she raised the HOB higher and placed a call to the physician at about 11:00 [NAME]M. or 12:00 P.M. He/she checked on the resident during his/her shift, but did not document his/her condition. He/she notified the ADON and was told to call the physician. The ADON also asked if the resident had anything for anxiety and instructed him/her to administer it. The physician did not return the call prior to the end of his/her shift on 1/6/19. He/she saw the resident on the morning of 1/7/19, when he/she administered his/her medications and didn't notice any shortness of breath at that time. Speech therapy did not report any concerns regarding the resident. He/she was unaware the speech therapist documented pursed lip breathing, audible wheezing, lethargy or sounds of congestion. He/she would have expected the therapist to report any changes in his/her condition to the nurse. During an interview on 1/8/19 at 3:50 P.M., CNA S said he/she took care of the resident on 1/7/19, on the evening shift. He/she could see the change in the resident since his/her return from the hospital. The resident was drooling from his/her mouth which was unusual for him/her. He/she was drowsy and slept most of the evening. The resident normally would be more alert. During an interview on 1/8/19 at 2:27 P.M., the ADON said she would consider an elevated pulse a change in condition. The nurses administered Tylenol for the temperature and did what they were supposed to do, but the ADON was unable to state how long staff should administer Tylenol for a elevated temperature before notifying the physician. She expected the nurses to document in the nurse's notes when there is a change in condition and to document every shift until the resident is stable. She would have expected the therapist to notify nursing immediately of any changes in the resident's condition. The resident had a history of [REDACTED]. During an interview on 1/8/19 at 3:10 P.M., the Administrator said he expected staff to notify the physician anytime there is a change in the resident's condition. During an interview on 1/10/19 at 12:30 P.M., the resident's physician, who was also the facility's Medical Director, said he expected staff to document in the medical record any change in the resident's condition. He would have expected the therapist to notify nursing of any changes in the resident's condition. Anytime a nurse had concerns and felt the resident needed to be sent to the hospital and 911 needed to be called, he expected them to use nursing judgement, send the resident and notify him afterward. 2. Review of Resident #201's readmission MDS, dated [DATE], showed: -A readmission date of [DATE]; -[DIAGNOSES REDACTED]. -Moderately impaired cognition; -Extensive to total staff assistance for ADLs; -Wheelchair for mobility; -Incontinent of bowel and bladder. Review of the resident's progress notes, showed: -On 1/3/19 at 2:27 P.M., CNA informed the charge nurse, while perineal care (peri-care, cleaning of the genital and anal areas) was provided, the resident had a greenish and tan colored vaginal discharge. The resident denied burning during urination and/or vaginal itching at this time. Message left for the resident's physician to contact the facility. Awaiting return telephone call from the physician. The resident's responsible party was contacted and made aware of the resident's change in condition; -On 1/4/19 at 10:25 P.M., nursing staff administered [MEDICATION NAME] (antifungal medication) 150 mg, one tablet, for vaginal discharge as ordered by the resident's physician; -On 1/5/19 at 4:50 [NAME]M., monitored for vaginal discharge; -On 1/6/19 at 1:26 P.M., continues to have heavy green discharge from vaginal area. Telephone call placed to the resident's physician; -On 1/8/19 at 12:10 P.M., no vaginal discharge reported today. Call placed to the resident's physician regarding past history of heavy vaginal drainage. New order received for [MEDICATION NAME] 150 mg, one tablet, for one time dose; -On 1/8/19 at 2:15 P.M., call placed to pharmacy for order of [MEDICATION NAME] to be sent on stat (immediately) run from the pharmacy; -No progress note found indicating the physician contacted the facility on 1/6 and/or 1/7/19 related to the resident's vaginal drainage; -No progress note found indicating nursing staff attempted to contact the resident's physician again regarding the resident's vaginal drainage until 1/8/19. Review of the resident's POS, dated 1/1 through 1/31/19, showed: -A telephone order dated 1/3/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times one dose; -A telephone order dated 1/8/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times one dose. Review of the resident's Medication Administration Record [REDACTED] -On 1/4/19, no staff initials to indicate the administration of [MEDICATION NAME] 150 mg, one tablet; -On 1/8/19, staff initialed to indicate the administration of [MEDICATION NAME] 150 mg, one tablet. Review of the facility's 24 hour nursing report sheet dated 1/6/19, showed staff documented regarding the resident: -7:00 [NAME]M. to 3:00 P.M. shift, having green vaginal drainage, call placed to the resident's physician, resident leave of absence from the facility and returned; -3:00 P.M. to 11:00 P.M. shift, no vaginal drainage this shift; -11:00 P.M. to 7:00 [NAME]M. shift, continues to have vaginal drainage; -No documentation to indicate the resident's physician called the facility back related to the resident's vaginal drainage; -No documentation to indicate nursing staff attempted to contact the physician again after contacting the physician on the 7:00 [NAME]M. to 3:00 P.M., shift. Review of the facility's 24 hour nursing report sheet dated 1/7/19, showed staff documented regarding the resident: -7:00 [NAME]M. to 3:00 P.M. shift, out to [MEDICAL TREATMENT] (process of filtering toxins from the blood in individuals with kidney failure); -3:00 P.M. to 11:00 P.M. shift, returned from [MEDICAL TREATMENT]; -11:00 P.M. to 7:00 [NAME]M. shift, is alright; -No documentation to indicate the resident's physician called the facility regarding the resident's vaginal drainage; -No documentation to indicate nursing staff attempted to contact the physician regarding the resident's vaginal drainage. During an interview on 1/8/19 at 11:55 [NAME]M., Nurse M verified he/she worked the day shift on 1/6/19. He/she telephoned the resident's physician regarding the resident's vaginal drainage, but had not received a telephone call back from the physician prior to him/her leaving on 1/6/19. To his/her knowledge, the physician had not contacted the facility back regarding the resident's vaginal drainage. The nurse verified he/she did not receive any information in report from the nursing staff, to indicate the physician had contacted the facility regarding the resident's vaginal drainage and/or staff contacted the physician since Nurse M called the physician on 1/6/19. During an interview on 1/8/19 at 12:00 P.M., the resident said he/she had a small amount of vaginal drainage that day. She could not recall if nursing staff had assessed him/her that day regarding the vaginal discharge or not. The resident denied having any pain or discomfort. During an interview on 1/8/19 at 12:05 P.M., Nurse M said he/she had contacted the resident's physician and received an order to administer [MEDICATION NAME] 150 mg one tablet that day. During an interview on 1/8/19 at 3:30 P.M., Nurse N verified the resident's physician contacted the facility during the evening shift on 1/3/19, and gave an order to administer [MEDICATION NAME] 150 mg one tablet dose. He/she placed the order for the [MEDICATION NAME] in the computer to the pharmacy at approximately 10:30 P.M. on 1/3/19. Nurse N verified he/she administered the resident's [MEDICATION NAME] on 1/4/19 at approximately 7:00 P.M., but forgot to document the administration of the [MEDICATION NAME] on the resident's MAR. During an interview on 1/8/19 at 2:45 P.M., the ADON said she expected nursing staff to continue to have attempted to contact the resident's physician regarding the vaginal drainage when staff first contacted the physician on 1/6/19. She expected the nursing staff to document each time they attempted to contact the resident's physician in the progress notes.

Based on observation, interview and record review, the facility failed to adequately monitor, assess, document and address a change in condition for one of three expanded sampled residents. Staff found the confused resident, who was to have nothing by mouth and a history of taking food and drinks and rapidly consuming them, with a soda can in his/her hand and blue lips and fingernail beds, gasping for breath. Staff made two entires into the resident's medical record at 4:15 P.M., regarding the incident and the next note and only other note, at 5:35 P.M., showed the resident died . The sample was 13. (Resident #18) The census was 75. Review of Resident #18's hospital Transfer/Discharge sheet, dated [DATE] at 3:08 P.M., showed the following: -Diagnosis: [REDACTED].>-Vital signs: Blood pressure (BP): ,[DATE] (normal ,[DATE]), pulse (P): 84 (normal 60 to 100), respirations (R): 22 (normal 12 to 20); -Mental status: Alert and oriented times two, confused; -Diet: Tube fed; -Respiratory needs: Tracheotomy (a surgical procedure to create a [MEDICAL CONDITION] (an opening in the trachea (windpipe) where a tube is usually placed to provide an airway and to remove secretions from the lungs)) [MEDICAL CONDITION] (a soft plastic mask that fits over and around [MEDICAL CONDITION] to allow the administration of humidified oxygen); -Skin condition: Surgical wound. Review of the resident's admission nurse's note, dated [DATE] at 2:30 P.M., showed the following: -Admitting [DIAGNOSES REDACTED]. -Trach collar; -Abdomen wound. Review of the resident's post acute history and physical, completed [DATE], showed the following: -Chief complaint/History of present illness: [AGE] year old with [MEDICAL CONDITION], mental [MEDICAL CONDITION], multiple failed attempts [MEDICAL CONDITION]. History of pneumonia; -Resident is non verbal; -Physical exam: Tracheotomy, resident [MEDICAL CONDITION] off. [DEVICE] (gastrostomy tube, a tube surgically inserted through the abdomen into the stomach for nutrition, fluid and medications), abdominal wound; -Assessment and Plan: [MEDICAL CONDITION], tracheotomy and as needed oxygen. Dysphagia (difficulty swallowing): Tube feeding with [MEDICATION NAME] 1.2 (a high protein, fiber fortified formula for long or short term tube feeding) at 55 cubic centimeters (cc) per hour. Review of the resident's admission physician's orders [REDACTED]. -Do not resuscitate (DNR): -Diet: Nothing by mouth (NPO); -[DEVICE]; -Trach care every shift; -[MEDICATION NAME] 1.2 infuse at 55 cc per hour. Review of the resident's nurse's notes, dated [DATE], showed the following: -11:00 P.M. to 7:00 A.M.: Resident disconnecting tube feeding, feeding running in bed; -3:00 P.M. to 11:00 P.M.: Resident on the move, trying to stand up, in and out of other residents' rooms. Review of the resident's POS, showed the following: -[DATE]: Change [DEVICE] feeding to a bolus (all at once) four times per day; -[DATE]: Speech therapy to evaluate. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -No speech: Absence of spoken words; -Severe cognitive impairment; -Unable to conduct Brief Interview for Mental Status; -Short/long term memory problems; -No behaviors; -Extensive staff assistance for bed mobility; -Total dependence on staff for transfers, dressing, eating, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder; -Nutritional approach: Feeding tube, 51% or more of nutrition through tube; -Shortness of breath: None; -Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: No; -Special treatments: Tracheotomy. Review of the resident's initial speech assessment, dated [DATE], showed the following: -Reason for referral: Due to reports from nursing staff of resident attempting to eat other residents' food; -Therapy: Skilled speech is required for dysphagia treatment to determine the safest and least restrictive diet consistency, decrease aspiration (inhalation of material from the mouth or stomach into the lungs) risk; -Medical history related to diagnoses/condition: Acute [MEDICAL CONDITION], pneumonia, [DEVICE] placement, tracheotomy, abdominal surgery with small bowel resection (removal of all or part of the small bowel), [MEDICAL CONDITION] and developmental delay. Review of the resident's care plan, dated [DATE], showed the following: -Problem: NPO. At risk for aspiration related to constantly eating other residents' food and/or eating out of the trash can. Easily redirected but will steal food. At times fed snacks by therapy. Have been observed eating from other residents' trays in the dining room and is easily redirected; -Interventions: Monitor frequently as needed to ensure he/she does not eat foods due to being NPO. Review of the resident's physician's progress note, dated [DATE], showed the following: -Chief complaint: [MEDICAL CONDITION], status [REDACTED]. -Review of symptoms: The word non verbal written in; -Assessment/Plan: status [REDACTED]. Review of the resident's nurse's notes, dated [DATE] at 10:45 A.M., showed the following: -NPO: [MEDICATION NAME] 1.2 bolus given at scheduled times; -Resident made several attempts, at breakfast, to take food from tables in the dining room. Staff redirected the resident out of the dining room to prevent him/her from eating food off of the tables. Continues physical and speech therapy. Review of the resident's POS, showed the following: -Late entry: [DATE]: Effective [DATE]: Skilled speech therapy five times per week for two weeks to treat dysphagia and determine least restrictive diet; -[DATE]: Upgrade diet to pureed with thin liquids. Review of the resident's nurse's notes, showed the following: -[DATE], 7:00 A.M. to 3:00 P.M.: Pureed lunch fed to resident, consumed 20% of meal, pushed food away, appeared not to like the consistency of the food; -[DATE], 7:00 A.M. to 3:00 P.M.: Ate only a few bites of pureed breakfast. [MEDICATION NAME] 1.2 bolus given. Notable wheezing, attempted breathing treatment, resident refused to keep mask on. Oxygen saturation (O2 Sats, the concentration of oxygen in the blood) (normal ,[DATE]%): 97% on room air. Small amount of emesis noted after breakfast, resident refused pureed lunch, bolus given as scheduled; -[DATE] at 10:45 A.M.: Call placed to the physician. Resident has audible wheezing, attempt to give nebulizer treatment, resident refuses. Physician returned call, informed of above. New orders received. 3:00 P.M. to 11:00 P.M.: Tolerated tube feeding well, lung sounds wheezing on inspiration with clear nasal drainage. Review of the resident's POS, showed the following: -[DATE]: Recommend diet downgrade to NPO; -[DATE]: Late entry: [MEDICATION NAME] Pack (a steroid medication used to treat allergies/breathing disorders). Review of the resident's physician's progress note, dated [DATE], showed the following: -Chief complaint: Wheezing; -History of present illness: Resident was receiving speech therapy and began wheezing after eating some food. Resists breathing treatment and still has audible wheezing; -Review of symptoms: Positive for nasal congestion. Has audible upper airway. No wheezing heard in lungs; -Assessment/Plan: Upper respiratory infection: On [MEDICATION NAME] Pack, [MEDICATION NAME] D (medication used to treat allergies and containing a decongestant), one by mouth every 12 hours times four weeks. Obtain a chest X-ray. Dysphagia: Will order modified [MEDICATION NAME] swallow (MBS, test to determine swallowing ability), (if resident will cooperate). Wheezing: Get chest X-ray. Review of the resident's POS, showed an order dated [DATE], for [MEDICATION NAME] D, a MBS and a chest X-ray to evaluate wheezing. Review of the resident's chest X-ray results, dated [DATE], showed the following: -Results: Clear lungs; -Conclusion: No acute cardiopulmonary findings. Review of the resident's POS, showed the following: -[DATE]: Start [MEDICATION NAME] 10 milligrams (mg) per [DEVICE] daily for 14 days, [MEDICATION NAME] (a nasal decongestant) 10 mg per [DEVICE] daily for 14 days; -[DATE]: Continue skilled speech therapy five times per week for four weeks for dysphagia and to determine least restrictive diet. Review of the resident's physician's progress note, dated [DATE], showed the following: -History of present illness: Seen for wheezing and strider (harsh vibrating sound when breathing). status [REDACTED]. Resident's breathing is much less audible, no reported respiratory distress; -Assessment/Plan: Upper respiratory infection, dyspnea: speech to determine least restrictive diet. Review of the resident's MBS report, dated [DATE], showed the following: -Chief complaint: Dysphagia, resident had recent abdominal surgery, history of tracheotomy. Currently NPO, [DEVICE]. Recently placed on by mouth foods, staff noted wheezing and change in [MEDICAL CONDITION] status; -Physician interpretation: Resident is orally defensive and multiple attempts were made to get him/her to take [MEDICATION NAME] pudding. The [MEDICATION NAME] pudding was replaced with [MEDICATION NAME] ice cream and the resident became agitated and would not cooperate with the study. The overall [DIAGNOSES REDACTED]. Review of the resident's POS, showed an order dated [DATE], to upgrade diet to pureed with thin liquids. Review of the resident's Therapy Progress and Discharge Summary, dated [DATE], showed the following: -Start of care: [DATE]; -End of care [DATE]; -Goal: The resident will safely swallow mechanical soft diet utilizing cuing or compensatory strategies from trained staff or caregivers. Goal not met: discharged on [DATE]; -Analysis of Functional outcome: Functional progress has been limited secondary to cognitive deficits. Staff educated on resident's attempts to steal food from table, rooms and out of trash; -Impact on burden of care/daily life: Diet upgrade attempted to pureed and thin liquids secondary to no overt signs or symptoms of aspiration noted during therapy sessions. Once diet was upgraded resident started to aspirate. Resident refused to participate in modified [MEDICATION NAME] swallow. Review of the resident's POS, showed the following: -[DATE]: Discontinue skilled speech therapy due to maximum potential achieved; -Diet: NPO, [MEDICATION NAME] 1.2, 240 milliliters five times per day bolus per [DEVICE]; -[DATE]: Change nebulizer treatments to as needed. Review of the resident's nurse's notes, showed the following: -[DATE]: 3:00 P.M. to 11:00 P.M.: Resident wheezing and gasping for air, almost impossible to give him/her breathing treatment; -Very strong and moving all over the nurse's station; -Resident must be in view to keep him/her from eating; -Up in wheelchair and constantly on the move and combative; -No documentation whether the physician was notified -[DATE] at 2:10 P.M.: Up in wheelchair, propels self. Went into main dining room multiple times and redirected two of the multiple times. Resident grabbed some pie, bread and ate it. No acute distress observed, no shortness of breath. Review of the resident's physician's progress note, dated [DATE], showed the following: -History of present illness: No cough or shortness of breath or upper respiratory infection symptoms today. MBS not completed due to resident's oral defensiveness; -Assessment/Plan: Dysphagia: continue bolus feeding. Review of the resident's POS, dated [DATE], showed an order for [REDACTED]. Review of the resident's speech therapy plan of care, showed the following: -Start of care: [DATE]; -Treatment Diagnosis: [REDACTED].>-Reason for referral: Referred to therapy due to reports from nursing of swallowing difficulties. History of dysphagia. Skilled speech for treatment of [REDACTED].>-Updated plan of care: [DATE]; -The resident demonstrates tolerance of by mouth trials with mechanical textures given by speech therapy. Requires one on one supervision and attention due to behaviors. He/she grabs for food and often puts large amounts in his/her mouth which increases choking and aspiration risk. The patient seeks out food and demonstrates difficulty maintaining nothing by mouth status. He/she often takes food from other residents, was not able to complete MBS when it was scheduled due to behaviors and objective measure was not obtained of swallow function. Demonstrates open mouthed chew and swallow; -Skilled services provided since last report: The resident participates in by mouth trials with speech only to increase tolerance of by mouth intake. If the resident's guardian give permission to allow him/her to eat, speech recommends that the resident be supervised one on one and be fed one bite at a time; -Prognosis for further progress: Good due to stable medical condition. Observation on [DATE] at 12:50 P.M., showed the resident self propelled into the dining room and grabbed food off another resident's plate. The other resident knocked the food from the resident's hands, screamed, telling him/her to stop and get out. Other residents at other tables also yelled at the resident to get out. Several minutes went by before staff removed the resident from the dining room. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to conduct Brief Interview for Mental Status; -Short/long term memory problems; -Nutritional approach: Feeding tube, 51% or more of nutrition through tube; -Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: No. Review of the resident's nurse's notes, showed the following: -Late entry: [DATE] at 4:15 P.M.: Resident sitting near nurse's station and propelling self. Staff informed nurse resident grabbed another resident's soda and drank it; -[DATE] at 4:15 P.M.: In front of room [ROOM NUMBER] when aide informed Nurse J he/she was needed now in room [ROOM NUMBER] B. Entered resident's room, the resident was hunched over in the wheelchair gasping for air. Certified Nurse Aide (CNA) instructed to get oxygen and Nurse K, in the room, asking the resident's code status. Nurse J said the resident is a no code. Oxygen applied at 2 liters per nasal cannula. Resident transferred to bed at a 50 degree angle. O2 Sats at 95% with a pulse of 56. Resident resting with eyes closed, no gasping noted, lung sound clear through out bilaterally. Doctor called, new order received, chest X-ray and send to the hospital if O2 Sats drop below 90%; -No further documentation regarding the resident's condition, O2 Sats or vital signs. Review of the resident's POS, showed the following: -An untimed order dated [DATE]; -Chest X-ray and send to hospital if O2 Sats drop below 90%; -No documentation to show which physician gave order. Review of the resident's chest X-ray requisition, dated [DATE] at 4:56 P.M., showed the following: -Service date: [DATE]; -Priority: Routine; -Entered by: Nurse J; -Procedure: Chest, single view, frontal; -Reason: Other signs and symptoms involving the circulatory and respiratory symptoms; -Ordering physician: Resident's physician. During an interview on [DATE] at 3:06 P.M., a representative from the X-ray company said the facility called on [DATE] at 4:55 P.M. and ordered a routine chest X-ray for [DATE]. During an interview on [DATE] at 12:11 P.M., Housekeeper L said around 4:00 P.M., he/she saw a soda on the table next to the couch in front of the nurse's station. A little later he/she saw the resident with the soda in his/her hand, he/she said no to the resident and grabbed the soda from him/her. The resident was gasping. Nurse J and Nurse K took the resident to his/her room and he/she heard one of the nurses say the resident was turning purple. Later he/she asked Nurse J how the resident was doing. Nurse J told him/her the resident was ok, he/she was in his/her room and Housekeeper L could see him/her after he/she got off work. After clocking out at 5:00 P.M., he/she went to the resident's room. The resident lay in bed with his/her eyes closed. The resident didn't open his/her eyes when he/she talked to him/her. He/she usually respondsed by smiling or nodding his/her head. Housekeeper L told the resident he/she shouldn't take other residents' food or drink. He/she usually responds but didn't this time. He/she told the resident he/she would see him/her tomorrow. No one was in the room with the resident but his/her roommate, who was also fed by [DEVICE]. Review of the resident's nurse's notes, showed the following: -[DATE] at 5:35 P.M.: Resident checked periodically in 15 minute intervals; -No documentation of resident's vital signs or O2 Sats; -Nurse J outside the resident's room on medication pass, glanced at the resident, noticed the resident wasn't breathing. Asked unknown CNA passing the resident's room to get Nurse K. Unable to detect pulse, O2 removed to hear better, no heartbeat detected, verified with Nurse K. Physician, guardian and Assistant Director of Nurses (ADON) made aware of the resident passing away. During an interview on [DATE] at 11:30 A.M., the MDS Coordinator said the resident was NPO, non compliant with a history of rummaging in other residents' rooms and the dining room for food, drinks and snacks. He/she was non verbal, used a wheelchair and was able to stand, pivot and at times would crawl on the floor. During an interview on [DATE] at 11:50 A.M., the Physical Therapy Director said, the resident lived in a group home prior to coming to the facility and was there to rehab and return to the group home. He/she was receiving speech therapy for swallowing. The resident started stealing food approximately four weeks ago and that's when speech therapy was started again to confirm where he/she was with swallowing. During an interview on [DATE] at 11:55 A.M. the Speech Therapist said, the resident was NPO, but was being trialed with food and liquids with speech therapy for the last three to four weeks. The resident had behaviors of shoving food in his/her mouth. Her recommendation to nursing would have been to talk to the guardians, inform them of the resident's risk of choking and his/her strong desire to eat and allow the guardians to make the decision to allow the resident to eat versus the risk of aspiration. She had not notified nursing of the recommendation. Resident remained NPO, with trials of food and liquids with speech therapy only. During an interview on [DATE] at 1:32 P.M., Nurse J said the resident was NPO, non verbal and received bolus tube feedings. He/she came into work at 3:00 P.M. on [DATE]. The resident sat in his/her wheelchair at the nurse's station. At approximately 4:00 P.M., he/she was at room [ROOM NUMBER] preparing to pass medication. Nurse K and two CNAs (unknown) rushed passed him/her with the resident and said they needed him/her in the resident's room. The resident was gasping when they passed him/her. He/she grabbed a stethoscope and pulse oximeter (a machine used to check oxygen level in the blood) and went to the resident's room. When he/she arrived the resident was slumped over in his/her wheelchair. He/she straightened the resident and did a sternal rub (a painful test to determine level of consciousness, by using the knuckles to rub on the sternum (breast bone)) to possibly dislodge anything he/she might have swallowed. At the same time one of the CNAs said a housekeeper pulled a soda can from the resident. Nurse K asked the resident's code status and Nurse J said the resident was a no code. He/she listened to the resident's lungs and was unable to hear any gurgling or signs of aspiration. With the assistance of another (unknown) staff member, he/she transferred the resident to the bed. The resident was bent over in his/her wheelchair prior to transferring him/her to the bed. After they straightened the resident, he/she started breathing better. He/she continued to hear occasional gasping every 15 to 20 breaths. He/she stayed in the room for maybe five minutes because he/she had to give the resident's roommate some medication. During that time, the resident was ok. He/she checked the resident every 15 minutes, at approximately 4:45 P.M., 5:00 P.M. and 5:15 P.M., but didn't document it in the nurse's notes. He/she got the order from the physician at 4:30 P.M., for a chest X-ray. When he/she checked on the resident at 5:30 P.M., his/her eyes were closed and he/she was breathing normally. His/her O2 sats were above 90% but he/she failed to document it. At 5:35 P.M., something told him/her to go back in the room, to check on the resident. He/she noted the resident's chest was not rising or falling, checked for a heart beat and none was detected. He/she asked a CNA to get Nurse K. Nurse K checked the resident for a heartbeat and none was detected. He/she turned off the oxygen, covered the resident and called the physician. He/she doesn't know why he/she didn't document any vital signs or O2 sats in the nurse's notes. During an interview on [DATE] at 3:15 P.M., Certified Medication Technician (CMT) M said he/she saw the resident by the couch in front of the nurse's station, at around 3:35 P.M. At approximately 3:40 P.M. to 3:50 P.M., one of the housekeeping staff said the resident drank someone's soda. The housekeeper came to the desk and said he/she didn't know who's soda it was. The resident was trying to catch his/her breath. Nurse J and Nurse K took the resident to his/her room, and he/she went to the resident's room too. The nurse instructed him/her to get O2 and O2 tubing. When he/she returned to the room, the resident was breathing and CMT M heard the nurse say the resident's O2 sats were 95%. The resident's eyes were open at that time. He/she left the room to pass medications, the nurses remained in the room. He/she did not return to the room nor was he/she instructed to do so. The next time he/she saw the resident, he/she had passed away, which was after 5:00 P.M. During an interview on [DATE] at 3:40 P.M., CNA N said he/she was the CNA assigned to the resident that evening. He/she saw the resident when he/she came in to work, around 3:00 P.M., at the nurse's desk. The next time he/she saw the resident he/she lay in bed at about 5:00 P.M. When he/she walked past the resident's room after 5:00 P.M., the resident lay in bed. He/she thought the resident was sleeping. A little later a CNA told him/her the resident had passed away. The nurse did not instruct him/her to check on the resident more frequently or to stay in the room with him/her. He/she asked Nurse J why he/she didn't send the resident to the hospital. Nurse J said the ADON told him/her to get a chest X-ray. Nurse J said he/she felt bad and felt he/she should have sent the resident to the hospital. During an interview on [DATE] at 3:45 P.M., CNA O said he/she saw the resident at the nurse's station at the beginning of his/her shift. At approximately 4:30 P.M., Nurse K called him/her to the desk. The resident sat with a soda in his/her hand. He/she told Nurse J and Nurse K and both nurses went over to the resident, but the housekeeper took the soda can from the resident. The resident was having trouble breathing. While taking the resident to his/her room he/she continued to try and catch his/her breath, making a snoring like sound. Nurse J put oxygen on the resident, and he/she was breathing. No one instructed him/her to stay with the resident. Around dinner time, after 5:00 P.M., Nurse J asked him/her to get Nurse K. The resident had no heartbeat or pulse. During an interview on [DATE] at 4:15 P.M., Nurse K said he/she was in another resident's room when he/she heard the housekeeper scream the resident drank a soda. The resident was gasping for air and his/her lips were turning blue. He/she continued to gasp while they took him/her to his/her room. Nurse J applied O2 and some of the resident's color returned. They placed him/her in bed and raised the head of the bed. His/her O2 sats were 95% at that time. He/she left the room and returned to his/her hall. Later Nurse J asked him/her to check for a heartbeat but the resident had passed. During an interview on [DATE] at 12:04 P.M. and 4:30 P.M., the ADON said Nurse J called her at 4:32 P.M. and said he/she thought the resident aspirated on another resident's soda. Nurse J said he/she put the resident in bed, raised the head of bed and put oxygen on him/her. He/she instructed the nurse to call the resident's physician for a chest X-ray. Nurse J said the resident was wheezing really bad and thought the resident had aspirated. Nurse J didn't tell her the resident was gasping for air. She would have expected the nurse to check on the resident as often as he/she could, because of the condition he/she was in. She would have expected the nurse to get vital signs and document them in the nurse's notes. Nurse J called her at 5:45 P.M., she missed the call and called him/her back at 5:46 P.M., that's when Nurse J informed her the resident had passed away. She would have expected the chest X-ray to be gotten stat (at once). She believed the nurse thought the chest X-ray was gotten stat. The ADON reviewed the resident's POS order dated [DATE], for a chest X-ray and to send to the hospital if the O2 stats dropped below 90%. She didn't know why the nurse didn't order the chest X-ray stat because that's what she would have expected. The DON said the resident was a DNR, the resident stabilized and his/her color came back. If the O2 sats dropped at that moment, the resident was a DNR, if gasping for air, staff should put O2 on the resident. They can't do anymore than that. The ADON said there wasn't a sense of urgency, but she would have expected the nurse to check on the resident. She knew the resident was a DNR. She would have come to the facility if the resident had been a full code. She doesn't come to the facility every time a resident dies. She came in the next day around 5:30 A.M., to check the documentation. During an interview on [DATE] at 1:33 P.M., Nurse J said he/she didn't see the resident drink the soda, one of the staff said the resident drank the soda. The resident was gasping with blue lips and nail beds when they took him/her to his/her room. He/she did a sternal rub and put oxygen on the resident. Nurse J said he/she believes he/she spoke to the resident's primary care physician regarding the resident. During an interview on [DATE] at 9:30 A.M., the Director of Nurses said he would have expected the nurse to check on the resident more than once and check the O2 Sats and document them in the nurse's notes. He's not sure what else the nurse could have done. During interviews on [DATE] at 2:41 P.M. and 2:49 P.M., the resident's primary physician said he/she wasn't the physician on call the evening of [DATE] and didn't talk to the staff. He/she learned of the resident's death when he/she arrived at the facility that day, [DATE]. If the nurse had informed him/her the resident was gasping, he/she would have sent the resident to the hospital because of the resident's history of [MEDICAL CONDITION] and tracheotomy. The resident was a Do Not Resuscitate (DNR). If he/she was alive and became unresponsive he/she would not have sent him/her out. If he/she was gasping and still alive he/she would have sent the resident to the hospital. During an interview on [DATE] at 11:18 A.M., the on call physician said he started the on call rotation at 5:00 P.M. on [DATE]. He received one call from the facility, at around 5:40 P.M., notifying him that the resident passed away. He did not give any orders for a chest X-ray. If the nurse had called and informed him the resident was gasping he would have given orders to call 911. This is a very unique incident, any time a resident is gasping for air they should be sent out 911 to the hospital. During an interview on [DATE] at 8:15 A.M., the resident's primary care physician said he never spoke to the facility staff, or gave orders for a chest X-ray. He was in the facility earlier in the day on [DATE], saw the resident and he/she was in no distress. He found out he/she passed away when he visited the facility on Monday, [DATE]. During an interview on [DATE] at 10:50 A.M., the medical director said he was in the facility at the nurse's station but did not witness the incident. He heard Nurse J speaking to someone and thought it was the resident's physician. After hanging up the phone, Nurse J got up from the desk and went to the resident's room. When he/she returned the nurse said the resident had passed away. He was surprised when Nurse J said the resident had passed away. Nurse J was upset and said he/she wished he/she had called 911. He asked the resident's code status and Nurse J said the resident was a DNR. During an interview on [DATE] at 2:00 P.M., the resident's guardian said the resident was a DNR but they would have allowed the resident to go to the hospital. The facility didn't call to notify them until after the resident had passed away. Usually in an emergency situation the facility would send the resident to the hospital. They were unaware the resident was gasping for air after possibly drinking a soda. They would have expected the facility to call and notify them of any change of condition. Review of the facility's Policy and Procedure on Change in Condition, dated [DATE], showed the following: -Purpose: To ensure prompt notification of the resident, the attending physician and Durable Power of Attorney/Responsible Party of the changes in the resident's physical, psychosocial and or mental condition and or status; -Procedure: The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in the usual sign/symptoms and or the signs/symptoms are unrelieved by measures already prescribed; -Specific information that requires prompt notification include but not limited to: change in level of consciousness, any unusual occurrence, accident or incident involving the resident, a significant change in the resident's physical, psychosocial, mental condition, Instructions to notify the physician of changes in the resident's condition; -Orders will be obtained for an acute care transfer for situations in which cannot be safely managed within the facility. MO 186

Based on interview and record review, the facility failed to ensure staff accurately transcribed MEDICATION ORDERS FOR [REDACTED]. Three medications were transcribed in error and he/she received them. Of the three nonprescribed medications, he/she received seven doses of an oral diabetic medication used to treat high blood sugar levels. On [DATE], the resident was found unresponsive, with a blood sugar level of 33 (normal is ,[DATE]) and was revived with [MEDICATION NAME] (a liquid sugar solution) and orange juice with sugar. On [DATE], the resident was again found unresponsive with a blood sugar level of 33. [MEDICATION NAME] was given but ineffective, 911 was called and the resident went to the hospital. The resident expired, at the hospital on [DATE], with the principle cause of death being profound [DIAGNOSES REDACTED] (low blood sugar). (Resident #1) The census was 70. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Original admission date of [DATE]; -[DIAGNOSES REDACTED]. -Short term memory loss; -Mood: Feeling down or depressed, poor appetite; -Behavior: Verbal behavioral symptoms directed at others; -Required extensive staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel; -Gastrostomy tube ([DEVICE], a tube surgically inserted through the abdomen into the stomach, used to administer fluids, nourishment and medications). Review of the resident's care plan, updated [DATE], showed the following: -Problem: Diabetes mellitus; -Goal: Will be free of signs and symptoms of [DIAGNOSES REDACTED]; -Interventions: Diabetes medication as ordered by the physician. Monitor and report to the physician any signs of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech and staggering gait. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes, dated [DATE] at 6:20 A.M., showed the following: -Resident called 911 to report staff for not giving him/her medication; -Staff noted the resident had tied the call light around his/her neck several times. Staff removed the cord from the resident's neck and informed him/her, he/she was going to the hospital; -Sent to the hospital for evaluation. Review of the resident's hospital history and physical, dated [DATE], showed the following: -Past medical history of [REDACTED]. -admitted on [DATE] with suicidal idealations. Review of the resident's hospital discharge orders, dated [DATE], showed the following: -admitted : [DATE]; -discharge date : [DATE]; -Diagnosis: [REDACTED].>-A list of medications that did not include: [MEDICATION NAME] (medication used to treat high blood sugar related to diabetes mellitus) 5 milligrams (mg) by mouth twice a day with morning and afternoon meals, [MEDICATION NAME] (medication used to treat high blood pressure) 1 mg at bedtime, [MEDICATION NAME] (antibiotic) 250 mg by mouth twice a day for seven days. Review of the resident's readmission POS, dated [DATE], showed the following: -[MEDICATION NAME] 5 mg by mouth twice a day with morning and afternoon meals; -[MEDICATION NAME] 1 mg at bedtime; -[MEDICATION NAME] 250 mg by mouth twice a day for seven days. Review of the resident's Medication Administration Record, [REDACTED] -[MEDICATION NAME] 250 mg by mouth twice a day: Staff documented as given on [DATE] at 8:00 A.M.; -[MEDICATION NAME] 1 mg by mouth at bedtime: Staff documented as given on ,[DATE] through ,[DATE]; -[MEDICATION NAME] 5 mg one tablet twice a day with morning and afternoon meals: Staff documented as given on [DATE] at 1:00 P.M. and on ,[DATE] through ,[DATE] at 9:00 A.M. and 1:00 P.M. Review of the resident's nurse's notes, showed the following: -[DATE]: 11:00 P.M. to 7:00 A.M.: One episode of deep moaning coming from room. Found resident lying on back, continuously moaning, unaware of behavior. Shook resident awake, he/she not aware he/she was moaning and closed his/her eyes. Vital signs (VS): temperature (T) 93.6 (normal 98.6), blood pressure (BP) ,[DATE] (normal ,[DATE]), pulse (P) 87 (normal 60 to 100 beats per minute), respirations (R) 20 (normal 14 to 18); -[DATE] 11:00 P.M. to 7:00 A.M.: Reassessed resident, blood sugar 33, Insta-glucose (medication used to treat low blood sugar) administered two times with minimal response. Orange juice 240 milliliters (ml) with two tablespoons of sugar administered with good response, blood sugar 70. On coming nurse in assistance, aware of the resident's condition and will contact family and physician; -7:00 A.M. to 3:00 P.M.: Physician notified of the resident's blood sugar dropping. Physician said the resident needed to be fed correctly and gave no new orders. Responsible party also made aware. -2:15 P.M.: Resident's physician in to see resident. New order to decrease [MEDICATION NAME] from twice a day to daily and blood sugar checks twice a day for four days. -3:00 P.M. to 11:00 P.M.: 9:00 P.M. VS: T 98.6, P 62, R 18, BP ,[DATE]. In wheelchair propelling self, no inappropriate behavior; -[DATE] at 2:30 A.M.: Resting in bed with eyes closed. No acute distress noted. VS: T 98.0, P 105, R 24, BP ,[DATE], oxygen saturations (O2 SATs, oxygen level in the blood) 96% (normal 95 to 100%); -[DATE], 11:00 P.M. to 7:00 A.M., 7:00 A.M.: Resident non responsive, arms and legs flaccid (hanging loosely/limply), heavy breathing, appears to be in a deep sleep. Blood sugar 33, administered [MEDICATION NAME] 1.5 (calorie dense liquid nutrition), blood sugar went up to 60. Administered [MEDICATION NAME] 1.5, after 10 minutes blood sugar dropped to 59. Continued to try to revive resident by calling his/her name loudly and tapping his/her shoulders. No response. Administered [MEDICATION NAME] 1.5 and elevated resident's legs due to low BP ,[DATE]. Resident's blood sugar rose to 160 but resident remains unresponsive. Call placed to the resident's physician, unable to reach through the exchange. Called 911 and resident sent to the hospital. Family and Assistant Director of Nurses (ADON) made aware. VS: BP ,[DATE], P 114, R 20, T 98.0, O2 SATs 95% on room air. Review of the resident's hospital Emergency Department notes, showed the following: -[DATE] at 7:40 A.M.: Chief complaint: Patient presents with LOW BLOOD SUGAR: Blood sugar 33 per nursing home (NH). Altered mental status, patient having decreased alertness. Normally alert and oriented times four per NH, now is alert and oriented times zero. NH reported patient with blood sugar of 33, fed through [DEVICE], followed by a blood sugar of 160, but no change in mental status. Assessment and Plan: Acute [MEDICAL CONDITION]/Respiratory Acidosis/Metabolic Acidosis/[MEDICAL CONDITION] (disease or damage of the brain) probably due to profound acute [DIAGNOSES REDACTED] present on arrival. Patient was unresponsive at NH with blood sugar 33, [MEDICATION NAME] given without relief of symptoms. He/she is not diabetic per family and was started on [MEDICATION NAME] at the NH on [DATE] for unclear reasons. This patient is not diabetic, he/she was not discharged to the NH on [MEDICATION NAME], on [DATE], per review of hospital pharmacy records. Blood toxicology (blood test) screen negative, CT (specialized x-ray) scan of the brain negative for acute findings, no active urinary tract infection [MEDICAL CONDITION]. 7:44 A.M.: D 50 (a 50% [MEDICATION NAME] in water solution administered intravenously in emergency care to treat [DIAGNOSES REDACTED]) administered. No change in mental status. [MEDICATION NAME] (medication used to reverse the effects of certain types of medication) 1 mg administered. No change in mental status. 8:25 A.M.: Patient intubated (a procedure in which a tube is inserted through the mouth down into the trachea, to assist with breathing). 8:35 A.M. NH staff reports the patient waking up hypoglycemic and confused yesterday ([DATE]) as well. They report giving the patient glucose (sugar) yesterday ([DATE]) with him/her returning to baseline: Alert and oriented times three. Today ([DATE]) NH gave patient glucose with no change in mental status; -Admit to Intensive Care Unit (ICU). Review of the resident's facility nurse's notes, dated [DATE] at 1:00 P.M., showed the following: -Resident's family member asked who prescribed the medication [MEDICATION NAME] and how long had he/she received it; -Explained the resident was not supposed to receive the [MEDICATION NAME], the facility made a mistake; -He/she received the [MEDICATION NAME] twice a day, from [DATE], until he/she went to the hospital, for a total of seven doses. During an interview on [DATE] at 12:47 P.M., the Clinical Nurse Manager said her job is to compare the old POS with the new POS and make sure they are correct. She is also supposed to check all new and readmit orders. She thought she checked the resident's chart, but wasn't sure. She recently realized she was not checking the new admission orders [REDACTED]. He/she had been checking the computer printout of the orders, the facility nurse put into the computer, against the printed computer copy of the same printed orders, the facility nurse put in the resident's chart. This was the way he/she had always checked the orders, but now knows it was the incorrect way to verify orders. During an interview on [DATE] at 1:00 P.M., the ADON said there were two admissions, to the facility, on the evening shift on [DATE]. Both admissions were going to the same hall. Nurse A was assisting Nurse B with the admissions. Nurse A input the orders for both residents into the computer and somehow input the wrong orders for the wrong resident. The night shift was supposed to check the discharge orders with the orders that were in the computer. The next day the Clinical Nurse Manager should have verified the orders, but failed to do so. The Clinical Nurse Manager did determine the resident was not supposed to receive [MEDICATION NAME] and discontinued it, but failed to check the remaining orders to determine whether they were correct or not. The resident received one dose of the [MEDICATION NAME], four doses of the [MEDICATION NAME] and seven doses of the [MEDICATION NAME]. She also determined the Clinical Nurse Manager was verifying orders by comparing the computer POS with the computerized copy of the POS in the chart. (This meant the Clinical Nurse Manager was comparing the same orders with each other). The facility was unaware the resident received the wrong medications until a family member called and asked when the resident started taking [MEDICATION NAME]. During an interview on [DATE] at 3:15 P.M., Nurse A said he/she was helping Nurse B with the two admissions. Both of the residents' discharge orders were on the desk and he/she thinks he/she just picked up the wrong order for the wrong resident. He/she didn't know at the time he/she had input the wrong orders. During an interview on [DATE] at 8:14 A.M., Certified Nurse Aide (CNA) C said he/she took care of the resident in the early morning of [DATE]. He/she first saw the resident during rounds at around 11:15 P.M. The next time he/she saw the resident was at around 2:00 A.M., when he/she emptied the resident's catheter bag. The resident was asleep, but breathing hard. He/she didn't tell the nurse about the resident's breathing. The resident was quiet that night. He/she usually puts on his/her light a lot at night to be cleaned. The CNA saw the resident again at around 6:00 A.M., when he/she helped the resident get dressed and into his/her wheelchair. He/she also gave the resident some water. Later Nurse D asked him/her to put the resident to bed, because he/she was sleepy. The resident's body was heavy and he/she was drooling red medicine. CNA C changed the resident's clothes and put him/her to bed. That was the last time he/she saw the resident. After 7:00 A.M., the emergency medical technicians came and took him/her to the hospital. During an interview on [DATE] at 4:15 P.M., Nurse A said he/she verified the orders with the physician before transcribing them into the computer. He/she doesn't recall whether he/she called both residents' physicians to verify orders, but he/she was the one who transcribed the orders to the computer. He/she believes while transcribing the orders, he/she got up to do something and when he/she returned, picked up the wrong orders and transcribed them into the computer. During an interview on [DATE] at 2:17 P.M., Nurse D said he/she took care of the resident on ,[DATE] and ,[DATE]. The resident's blood sugar was 33, on [DATE], and he/she responded to the instant glucose. On [DATE], he/she monitored the resident, and he/she appeared to be sleeping and snoring throughout the night. On the morning of [DATE], staff had gotten the resident up, but he/she appeared different and not responding. The resident's blood sugar was 33, and the nurse tried to give him/her instant glucose, but the resident was unable to swallow. The nurse gave him/her three doses of [MEDICATION NAME] 1.5 per his/her [DEVICE]. When the resident did not respond, 911 was called and he/she was transported to the hospital. He/she was not aware the resident received medications that weren't ordered for him/her nor was he/she aware of the [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:50 A.M., the Director of Nurses (DON) said staff transcribed the wrong medication for the wrong resident. He didn't determine the resident received the wrong medication until he/she went to the hospital and a family called to inquire about the medications. The night nurses are to do chart checks on new orders, but failed to check the resident's chart because he/she was a readmission. They should have checked the chart the night after the resident's admission. In addition, the Clinical Nurse Manager failed to check the resident's chart the next day. The transcription error should have been caught by staff. The DON said the facility does not have a written policy regarding verifying and transcribing orders. Review of the resident's hospital multidisciplinary progress notes, showed the following: -[DATE] at 8:13 A.M.: Prognosis is grave, continue comfort measures. Patient is actively dying now. Doubts if he/she will survive much longer. 12:59 P.M.: Death of patient confirmed; -[DATE] at 9:55 A.M.: Principle cause of death: Profound [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:43 A.M., the resident's primary physician said the facility called and verified the medication orders. He wasn't aware until later that the resident received diabetic medication that wasn't on the hospital discharge orders. In addition, he was not aware the resident received seven doses of the diabetic medication. He believes the resident had other contributing factors and couldn't say whether it would have made a difference in the outcome without first reviewing the hospital records. During an interview on [DATE] at 1:25 P.M., the resident's hospital physician said the resident was not on [MEDICATION NAME] when he/she was discharged from the hospital on [DATE]. The resident was admitted to the hospital on [DATE] after he/she was found at the nursing home with a blood sugar of 33. All of the tests conducted were negative for acute changes. The resident's cause of death was profound [DIAGNOSES REDACTED]. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, all nursing staff, registered nurses (RNs), licensed practical nurses (LPNs) and certified medication technicians (CMTs), were in serviced on what to do when the facility admits or readmits a resident. When an admission or readmission occurs at the facility, discharge orders will be verified with the resident's physician. Once verified, the orders will be transcribed into the facility's computer system. The orders will then be printed and placed in the resident's chart along with the discharge orders. The charge nurse on the next shift will verify the orders for accuracy and report any discrepancy immediately to the physician of the resident as well as the DON and ADON. In addition, the facility inserviced all evening and night licensed nurses and CMTs prior to working. The DON and ADON will continue to monitor all new and readmissions to ensure staff have followed the policy. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 193

Based on observation, interview and record review, the facility failed to provide appropriate care and services to prevent the development of pressure ulcers for one sampled resident who had a Stage III pressure ulcer and an unstageable pressure ulcer. The facility identified five residents with pressure ulcers. All five were sampled and problems were found with one (Resident #7). The census was 68. Review of Resident #7's face sheet, showed an admission date of [DATE]. Review of the resident's Admission Evaluation and Interim Care Plan, dated 8/20/13, no time noted, showed the following: -Admitting diagnoses, urinary tract infection, [MEDICAL CONDITION] weakness, high blood pressure, obesity and knee replacement; -Body diagram with "X" marks on both breasts, abdomen, left shin, coccyx and a circle on both heels; -No documention or description of any of the areas marked with an "X" or the circles on the heels; -Review of the Braden scale, attached to the Admission Evaluation and Interim Care Plan: blank. Review of the resident's nurse's notes, dated 8/20/13 at 4:30 P.M., showed the following: -Alert and oriented to person, place and time; -Skin assessment: Red circle on shin, redness under right breast, groin slightly red and moist, bilateral heels very dry; -No further documentation regarding the resident's skin until 9/28/13. Review of the resident's electronic physician's orders [REDACTED]. Review of the resident's physician progress notes [REDACTED]. -Patient doing well; -Wheelchair bound; -Skin: Negative for ulcers and rash. Review of the resident's Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review Sheet, showed the following: -Direction: Perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to the Director of Nursing (DON) for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number: -Visual assessment: 1. Bruising. 2. Skin tears. 3. Rashes. 4. Swelling. 5. Dryness. 6. Soft heels. 7. [MEDICAL CONDITION]. 8. Decubitus. 9. Blisters. 10. Scratches. 11. Abnormal color. 12. Abnormal skin. 13. Abnormal skin temperature (h-hot/c-cold). 14. Hardened skin (orange peel texture); -8/26/13: Refused shower; -9/2/13: Body Chart: blank; -Signed by CNA and charge nurse. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/2/13, showed the following: -Short term memory loss; -Required extensive assistance of staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of urine; -Pressure ulcer: Risk of developing pressure ulcers: yes. Does the resident have one or more unhealed pressure ulcers at Stage I (An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: -- Skin temperature (warmth or coolness); -- Tissue consistency (firm or boggy); -- Sensation (pain, itching); and/or -- A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) or higher: yes. Current number of unhealed pressure ulcers at each stage: Unstageable (unstageable: slough (dead tissue, that is lighter in color, thin and stringy) and/or eschar (dead tissue that is dark in color, thick and hard): Known but not stageable due to coverage of wound bed by slough and or/eschar) Number of these unstageable pressure ulcer that were present on admission: 1: Dimensions of unhealed pressure ulcer: 4 centimeters (cm) by 3.2 cm by 0. Most severe tissue type for any pressure ulcer: 4: Necrotic tissue: eschar. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -9/5/13: Front of the body chart: The word red with an arrow pointing to the left side of the upper abdomen. Back of the body chart: blank. Signed by the CNA and charge nurse. Review of the resident's care plan initiated on 9/9/13, showed the following: -Impairment to skin integrity, suspected deep tissue injury, unstageable area to his/her coccyx (tailbone); -Staff were to encourage good nutrition, follow protocols for treatment of [REDACTED]. -Staff were to report abnormalities, failure to heal, signs and symptoms of infection, maceration (the softening and whitening of skin that is kept constantly wet), etc to the physician. Further review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -9/12/13: Front of the Body chart: Blank. Back of the body chart: Blank. Signed by the CNA and the charge nurse; -9/16/13: Front of the body chart: Blank. Back of the body chart: blank. Signed by the CNA and the charge nurse. Review of the resident's physician progress notes [REDACTED]. -Patient doing well; -Wheelchair bound; -Skin: Negative for ulcers or rash. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -9/20/13: Front of the body chart: Blank. Back of the body chart: blank. Signed by the CNA and the charge nurse; -9/23/13: Front of the body chart: Blank. Back of the body chart: blank. Signed by the CNA and the charge nurse. Review of the resident's nurse's note, dated 9/28/13 at 12:30 A.M., showed the following: -CNA changing the resident, noted a pressure ulcer to the coccyx; -Measured: 1.7 cm by 0.8 cm by 0.1 cm with dark edges, wound bed pink with scant amount of drainage; -Pressure ulcer cleaned with wound cleaner, Duoderm (wound dressing) applied. Review of the resident's current electronic POS, showed an order dated 9/28/13, for staff to cleanse coccyx pressure ulcer with wound cleanser, apply Duoderm every three days and as needed. Check every shift until healed. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -9/30/13: Front of the body chart: Blank. Back of the body chart: blank.; -Signed by the CNA and charge nurse. Review of the resident's nurse's note, dated 10/2/13 at 9:51 P.M., showed the following: -Pressure ulcer on the coccyx; -Yellow in color, 3.5 inches by 4 inches in diameter. No drainage, awaiting treatment orders from the physician. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, dated 10/3/13, showed the following: -Front of body chart: The word "red" written in with lines pointing to both breast: -Back of body chart: The words "blister" and red written in with lines pointing to the left buttock. Review of the resident's nurse's notes dated 10/5/13, showed the following: -1:00 A.M.: Resting in bed, turned every two hours, pressure ulcer to coccyx, area cleaned with wound cleanser. Day charge nurse will call the physician in the A.M. for treatment; -7:00 A.M.: Nursing informed day charge nurse regarding pressure ulcer. Day charge nurse said the resident's physician would be at the facility that day, 10/5/13, for rounds; -11:00 A.M.: Resident's physician visited. New orders received for Santyl (an active enzymatic therapy ointment that continuously removes necrotic tissue from wounds) to the coccyx pressure ulcer once a day. Review of the resident's current electronic POS, showed the following: -10/5/13: Santyl ointment once a day to pressure ulcer with daily dressing; -Wound management evaluation. Review of the resident's electronic treatment administration record (TAR), showed the following: -Duoderm: cleanse coccyx wound with wound cleanser, apply Duoderm, change every three days and as needed. Start date 9/28/13, End date 10/5/13; -Santyl ointment: Apply to coccyx once a day and as needed, cover with dry dressing. Start 10/5/13. Review of the resident's physician progress notes [REDACTED]. 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 or tunneling.) or 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.), 3 cm in size. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -10/7/13: Front of the body chart: blank. Back of the body chart: Red with arrows pointing to the right buttock; -Signed by the CNA; -Signed by the nurse; -Charge nurse assessment: written in: Redness noted, has a coccyx pressure ulcer that has treatment orders; -10/13/13: Front of the body chart: blank. Back of the body chart: blank; -Signed by the CNA; -Signed by the nurse; -Nothing written in the charge nurse assessment. Review of the resident's nurse's note, dated 10/15/13 at 2:30 P.M., showed the following; -2:30 P.M.: Coccyx pressure ulcer: unstageable (slough and/or eschar (dead tissue): Known but not stageable due to coverage of wound bed by slough and or/eschar) pressure ulcer; -Measured: 4 cm by 3.2 cm by unable to determine (utd) depth; -Pressure ulcer wound bed: necrotic tissue with brown slough; -New order received for Santyl and [MEDICATION NAME] (topical antibiotic ointment) to wound bed and pack with calcium alginate (a specialized antimicrobial dressing used to wounds with drainage) daily. Review of the resident's dietitian's nutritional progress notes, dated 10/17/13, showed the following: -Wound and treatment noted; -Add multivitamin with minerals to help with wound healing. Review of the facility's Weekly Wound Report for pressure sores, dated 10/18/13, showed the following: -admitted with or acquired: blank; -Stage: blank; -Site: coccyx; -Size: 4 cm by 3.2 cm; -Depth: utd; -Odor: slight; -Drainage: moderate; -Treatment: Santyl and [MEDICATION NAME]; -Start date: 10/15/13; -This was the first time the resident's name appeared on the facility wound report. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, dated 10/21/13, showed the following: -Refused; -10/21/13: Front of the body chart: blank; -Back of body chart: blank; -Signed by CNA, unsigned by nurse. Review of the resident's nurse's note, showed the following: -10/23/13 at 2:30 P.M.: A new order received for specialized wound consult and treatment order. Review of the resident's care plan updated on 10/25/13, showed: -Stage III to his/her coccyx; -Staff were to follow turn schedule, complete treatments as ordered and resident was followed by specialized wound management (SWM). Review of the facility's Weekly Wound Report for pressure sores, dated 10/25/13, showed the following: -admitted with or acquired: Acquired; -Stage: III; -Site: coccyx; -Size: 3.5 cm by 3.0 cm; -Depth: .3 cm; -Undermining: .2 -Odor: no; -Drainage: moderate; -Treatment: Santyl and Calcium alginate; -Start date: 10/5/13; -Nutritional therapy: Vitamin therapy. Review of the resident's POS through 10/25/13, showed no vitamin therapy for wounds. Further review of the resident's nurses notes, showed the following: -10/30/13 at 8:00 A.M.: new pressure ulcer treatment received; -10/30/13 at 9:00 A.M.: healing unstageable pressure, appears as a Stage III. 3.5 cm by 3.0 cm by 0.3 cm with undermining (tissue destruction underlying intact skin along wound margins) from six o'clock to nine o'clock, moderate drainage. Treatment order of Santyl and calcium alginate. Review of the resident's POS, showed a new order dated 10/30/13, for multivitamin with minerals, zinc (vitamin used to promote wound healing) 220 mg by mouth for 14 days and Vitamin C 500 mg by mouth daily. All ordered for wound treatment (order obtained 13 days after recommended by the dietician). Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -10/31/13: Visual assessment: Dryness and blisters. Front of body chart: The word dry written in with arrows pointing to the face. Back of the body chart: The word blister pointing to the coccyx. Signed by the CNA. Unsigned by the nurse; -11/4/13: Front of the body chart: blank. Back of the body chart: blank. Signed by the CNA. Unsigned by the nurse. Review of the resident's initial Specialized Wound Management, evaluation, dated 11/5/13 (originally ordered on [DATE]), showed the following: -Stage III pressure ulcer to the coccyx; -Clean wound with wound cleanser, apply Santyl, [MEDICATION NAME], calcium alginate and cover with dry dressing; -Follow up in one week. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheet, showed the following: -11/6/13: Front of the body chart: blank. Back of the body chart: blank. Signed by the CNA. Signed by the nurse; -11/11/13: Visual assessment: bruising circled, open area written in. Front of the body chart: The word red written three times on the abdomen area, the word bruise written in on the knee, inner thigh and on both lower legs. The back of the body chart: open area written in with a line pointing to the buttocks. Bruise written in with lines pointing to the left hands, back of both legs and the word dark with a line pointing to the right heel. Signed by the CNA, unsigned by the nurse. Review of the resident's nurse's notes, dated 11/12/13 at 1:00 A.M., showed the following: -The resident complained to the nurse that his/her right heel hurt and asked the nurse to rub some cream on it; - Right heel: black in the center with thick white sloughing skin, placed a dry dressing and floated the resident's heels. Will call in the morning for a treatment. Review of the resident's POS, showed the following: -11/12/13: New order for low air loss mattress, heel lift boot to the right foot while in bed; -Clean the right foot with normal saline, apply Santyl and dry dressing daily and as needed. Review of the resident's Specialized Wound Management, evaluation, dated 11/12/13, showed the following: -Wound #1: Coccyx pressure ulcer: Stage III; -Wound #2: Right heel pressure ulcer: unstageable. Acquired 11/11/13. Status: new, 3 cm by 3 cm by utd. Review of the resident's care plan updated 11/14/13, showed the resident had an area to his/her right heel. The resident was to wear a protective boot when in bed and have a low air loss mattress. Observation on 11/14/13 at 6:37 A.M., showed the resident lay in bed sleeping without a heel lift boot on the right foot. A dressing on the right foot was dated 11/14/13. During an interview on 11/14/13 at 1:55 P.M., the resident said he/she had a sore on his/her bottom and right foot. He/She said he/she hadn't been doing well and complained of being tired. During an interview on 11/14/13 at 3:30 P.M., a family member of the resident said he/she knew about the pressure ulcer on the resident's coccyx but not the one on the foot. The resident had been complaining that the foot hurt for awhile. Observation on 11/15/13 at 8:02 A.M., showed the resident lay in bed. Nurse H pulled back the resident's covers exposing the right foot without the heel lift boot. The sheet under the right foot showed smears of dried light red drainage. The resident said his/her right foot hurt and burned earlier in the night. The nurse removed the right foot dressing, cleaned and measured the pressure ulcer. He/She said the right heel pressure ulcer measured 2 cm by 3 cm with 1 cm maceration around the wound bed. In addition the pressure ulcer had 90% slough and 10% granulation (healthy healing tissue). He/she staged the sore as unsteagable. The coccyx pressure ulcer measured 3.5 cm by 2.5 cm by 0.4 cm depth. Nurse H said it was a Stage III. During an interview at that time, Nurse H said the facility's policy was when a wound was found staff were to notify the charge nurse, he/she should assess and call the resident's physician for a treatment order and notify the assistant director of nurses (ADON), who does the measurements and wound report. Review of the facility's policy on Wound and Skin Care Policy and Protocol, updated 9/20/13, showed the following: -Purpose: To prevent pressure ulcer formation by identifying those residents at risk for pressure ulcers and to develop appropriate interventions. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of pressure ulcers in a cost efficient and timely manner; -Procedure: 1. The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure ulcer, and identify related causes and complications. 2. A Braden Scale should be completed for all residents upon admission, readmission, when a significant change of condition occurs and with each MDS assessment. 3. Identified risk factors should be discussed in RAP documentation and addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. 4. Residents with a Braden score of 12 or less should be considered to be at high risk for pressure ulcer development. 5. Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. Finding from the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form. 6. CNAs should complete a Comprehensive CNA Shower Review Sheet on all residents when they are bathed or showed and give to the charge nurse. In addition the CNAs should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate follow up. The charge nurse should review, sign and address any conditions noted. After reviewed by the the charge nurse, the Comprehensive CNA Review Sheet should be given to to the Wound Nurse or designee, for appropriate follow up. The Comprehensive CNA Shower Review Sheet should be reviewed by the DON at least weekly. 7. Any skin impairments, including pressure ulcers, non pressure ulcers wounds, surgical wounds, skin tears, abrasions, should be assessed and documented weekly by the Wound Nurse and or designee on the Wound Evaluation Flow Sheet. During an interview on 11/18/13 at 8:30 A.M., the DON said the facility didn't start doing the wound reports until October 2013. She said it should not have taken three days before the staff notified the resident's physician regarding the pressure ulcer to the resident's coccyx. She also said the pressure ulcer to the resident's right heel should have been found sooner. The ADON said the treatment obtained on 9/28/13 should have been something to help debride the pressure ulcer to the coccyx since it had dark areas. In addition, she said she didn't begin completing a wound report until 10/18/13 and had no wound reports prior to that date. Since that time she has been measuring all wounds. CNAs are to notify the nurse when a open area is found. The nurses are to leave a note notifying her of all new wounds. They are responsible for calling the resident's physician when a new wound is found and obtain a treatment order. She will then measure and determine whether the treatment is appropriate for the wound. During an interview on 11/25/13 at 12:45 P.M., the resident's physician said he would expect the facility staff to assess, monitor and notify him timely of any changes that occur with the resident's skin.