Every finding on record at Big Bend Woods Healthcare Center

Based on observation, interview and record review, the facility failed to ensure the call system on the 100 hall adequately functioned with lights outside of resident rooms and sounded at the call system panel at the nurse's station. The sample was 20. The census was 90.Review of the facility's Call Light policy, revised 8/1/18, showed:-Purpose: To respond to resident's request and needs;-Procedure included answer call lights promptly;-The policy did not provide guidance for ensuring functionality of the facility's call system. 1. During a group interview on 9/10/25 at 2:26 P.M., three out of six residents, whom the facility identified as alert and oriented, said their rooms are on the 100 hall. They said they wait for long periods of time for staff to respond to their call lights. Two of the three residents on the 100 hall said they do not hear sounds coming from the call light panel at the nurse's station. 2. Observation on 9/9/25 at 5:16 P.M., room [ROOM NUMBER]'s and room [ROOM NUMBER]'s call lights illuminated above the door. At 5:22 P.M., room [ROOM NUMBER]'s and room [ROOM NUMBER]'s call lights illuminated above the doors. The call light panel at the 100 hall nurses desk showed Rooms 113's, 114's, 115's and 119's call lights were on. There was no audible alarm coming from the call light panel at the nurse's desk. There were two staff members sitting at the nurse's desk. 3. Observation of room [ROOM NUMBER] on 9/11/25 at 2:27 P.M., showed the call light indicator lit outside of the room. The call light panel at the nurse's station lit for room [ROOM NUMBER] and did not make a sound. Certified Nurse Aide (CNA) C entered the room and the light outside of the room turned off. CNA C stood outside of room [ROOM NUMBER] with his/her back to the door. The call light indicator outside of the room turned back on. During an interview, CNA C said he/she did not see the call light go back on. The call light panel does not make a sound when a call light is pressed in a resident's room. The 100 hall is U-shaped, so staff cannot see all halls at once. Staff have to go up and down the halls often to visually check if lights are on outside of rooms or on the call light panel at the nurse's station. If the call light panel at the nurse's station made noise, staff would be able to hear it on another hall and they would know someone else needed assistance. 4. Observation on 9/10/25 at 2:37 P.M., room [ROOM NUMBER]'s and room [ROOM NUMBER]'s call lights illuminated above the doors. The call light panel at the 100 hall nurse's station showed Rooms 112's and 113's call light were on with no audible sound. 5. Observation of room [ROOM NUMBER] on 9/8/25 at 7:09 A.M., showed the call light panel lit inside the room. The light outside of the room not on. The call light panel at the nurse's station lit for room [ROOM NUMBER] and did not make a sound. 6. Observation of room [ROOM NUMBER] on 9/9/25 at 11:06 A.M., showed the call light indicator lit outside of the room. The call light panel at the nurse's station lit for room [ROOM NUMBER] and did not make a sound. Observation of room [ROOM NUMBER] on 9/11/25 at 1:44 P.M., showed the call light indicator lit outside of the room. The call light panel at the nurse's station lit for room [ROOM NUMBER] and did not make a sound. 7. Observation of room [ROOM NUMBER] on 9/11/25 at 2:47 P.M., showed the call light indicator lit outside of the room. The call light panel at the nurse's station lit for room [ROOM NUMBER] and did not make a sound. 8. Observation on 9/10/25 at 8:16 A.M., room [ROOM NUMBER] had a flashing red light illuminated above the door. The call light panel at the 100 hall nurses' station showed room [ROOM NUMBER]'s light was on with no audible sound. 9. During an interview on 9/11/25 at 2:47 P.M., CNA O said the call light panel at the nurse's station on the 100 hall does not make any sound. The call light system should only make sounds if there is an emergency. 10. During an interview on 9/9/25 at 5:28 P.M., CNA E said the call light panel on the 100 hall has not been audible for several weeks. He/She just looks at the panel board to see what call lights are on. 11. During an interview on 9/11/25 at 2:50 P.M., CNA B said when a resident's call light is pressed, the indicator outside of their room should light up. The panel should light up at the nurse's station, and the panel should make a sound. The call light panel on the 100 hall does not many any sound at this time. It used to make sound but stopped maybe a week or so ago. 12. During an interview on 9/12/25 at 8:58 A.M., the Nurse Manager said she was not aware the call light system on the 100 hall was not functioning properly. The call light panel at the nurse's station should make a sound when a call light has been pressed. She expected staff to report issues with call light functionality to maintenance or nurse management. She wants staff to be able to hear the noise from the call light panel in case they are on another hall. 13. During an interview on 9/12/25 at 8:20 A.M., the Maintenance Director said he was not aware that the call light panel was not audible on the 100 hall and room [ROOM NUMBER]'s call light was not working. When resident call lights are turned on, there should be a light above the door and a light on the panel with an audible sound. He expected staff to notify him immediately that the call light panel or an individual resident's call light was not working either verbally or by filling out a maintenance work request form. 14. During an interview on 9/12/25 at 10:49 A.M., the Administrator said she just found out today the call light panel is not making sound at the 100 hall nurse's station. If staff noticed this wasn't working, they should have notified Maintenance, Administration, or nurse management. Notification can be verbal or in writing. She expected the call light system to have functioning lights and sound.

Based on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment by failing to clean one resident's bathroom after a plumbing issue (Resident #77), failing to clean one resident's wheelchair (Resident #16), failing to clean one resident's room (Resident #37) and failing to keep temperature logs on five residents with personal refrigerators (Resident #11, Resident #48, Resident #17, Resident #4 and Resident #6) The sample was 20. The census is 90. Review of the facility's 100 hall housekeeping checklist, undated, showed;-Sweep/mop soiled closets wipe walls and reduce odors;-Empty trash cans;-Dust top of rooms, light fixtures, nightstands, counter tops, dresser, dispensers, and window sills;-Clean and disinfect sinks, beds. And high touch areas and items;-Sweep rooms;-Mop floor;-Clean and disinfect inside and outside of toilets, top to bottom;-Clean and disinfect shower areas and tubs; -Dust vents;-Sweep floor;-Mop floor including inside of showers. 1.Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 6/12/25, showed:-Cognitively intact;-Independent with bed to chair and chair to bed transfers and toilet transfers;-Uses a manual wheelchair;-The resident has an indwelling urinary catheter (a tube inserted into the bladder that drains urine);-Diagnoses included neurogenic bladder (inability to urinate), depression, muscle weakness, and spinal stenosis (narrowing of the spinal canal causing pain). Observation and interview on 9/10/25 at 2:37 P.M., showed the resident was self-propelling in his/her wheelchair to the shower room on 100 hall. The resident said his/her bathroom toilet was backed up bad and there was a large amount of bowel moment on the bathroom floor, and he/she was instructed by nursing staff to empty his/her urinary catheter bag in the shower room. The resident's bathroom had brown water overflowing out of the toilet and large pieces of bowel movement on the floor. Bowel movement oozed on the side of the toilet. Towels and a thin blanket lay on the floor of the bathroom, and was saturated with brown water. At 2:40 P.M., the Assistant Director of Nursing (ADON) entered the resident's bathroom and said he would call housekeeping and maintenance to get the bathroom clean, and get the toilet fixed. Observation and interview on 9/11/25 at 9:45 A.M., showed the resident's bathroom door was open and the toilet had brown water to the top, dried bowel movement on the side of the toilet, large chunks of dried bowel movement on the floor. A pink wash basin was sitting on top of the trash can in the resident's bathroom. A plunger was located next to the toilet. A soiled towel and thin blanket were on the bathroom floor. The resident said no one came to fix his/her toilet or clean his/her bathroom. The resident said the nursing staff instructed the resident to empty his/her urine from his/her catheter bag into the wash basin, dump it in the toilet but do not flush. The resident said he/she was not going to roll his/ her wheelchair over bowel movement to empty his/her catheter. The resident said he/she used the 100-hall shower room to empty his/her catheter during the night. During an interview on 9/11/25 at 9:45 A.M., Certified Nursing Assistant (CNA) B said he/she was not aware the resident's bathroom was soiled. CNA B said he/she thought someone from maintenance locked the bathroom door so the resident and staff did not use it. The bathroom should not have been left soiled overnight. CNA B thought the bathroom was disgusting. The nursing staff can clean most of it, but the housekeeper would have to come in and disinfect the toilet and floors. CNA B would not expect the resident to use the bathroom, and it was not homelike. During an interview on 9/11/25 at 1:20 P.M., the Housekeeping Supervisor said housekeeping staff are expected to clean and disinfect bathrooms daily and as needed. During an interview on 9/12/25 at 8:20 A.M., the Maintenance Director said he was aware the building was having some plumbing issues but was not aware the resident's toilet had backed up. He expected staff to inform him verbally or fill out a work order to have it fixed. It was not homelike for the resident to have a backed-up toilet and soiled bathroom. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager expected staff to clean the bathroom and have the housekeepers disinfect it. The bathroom should have been cleaned as soon as it happened and not have the resident have a soiled bathroom all night. 2. Review of Resident #16's quarterly MDS, dated [DATE], showed;-Cognitively intact;-Uses manual wheelchair;-Diagnoses included non-Alzheimer's dementia and anxiety. Observation and interview on 9/8/25 at 7:30 A.M., showed the resident sat in his/her wheelchair. The wheels on the wheelchair had food crumbs and dust on them. The area where the wheel connects to the wheelchair had large clumps of gray hair and dust on both sides. The resident said his/her wheelchair was disgusting and he/she would like it cleaned. The resident has never seen the facility staff clean wheelchairs. Observation on 9/9/25 at 11:19 A.M., 9/10/25 at 12:47 P.M., and 9/11/25 at 9:45 A.M., showed the resident sat in his/her wheelchair. The wheel on the resident's wheelchair had food crumbs and dust on them. The area where the wheel connects to the wheelchair had large clumps of gray hair and dust on both sides. During an interview on 9/11/25 at 9:45 A.M., CNA B said it is night shift aides who are responsible for cleaning the resident's wheelchair. There is no wheelchair cleaning schedule. CNA B said the resident's wheelchair needed to be cleaned. During an interview on 9/12/25 at 9:15 A.M., the ADON and Nurse Manager said there was no wheelchair cleaning schedule, and a schedule was just recently put in place. It is the responsibility of the CNAs to clean the residents' wheelchairs. They expected staff to clean wheelchairs if they are visibly soiled. 3. Review of Resident #37's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included non-Alzheimer's dementia, diabetes, hemiplegia (paralysis to one side of the body), stroke and seizures Observation on 9/8/25 at 7:44 A.M., 9/9/25 at 11:34 A.M. and 3:04 P.M., 9/11/25 at 1:20 P.M., showed the resident lay in bed. In the corner of the resident's room behind the resident's bed, lay a crumpled cup and face mask and a large black crumblike substance around the baseboards. The resident's nightstand had a large smear of brown matter. During an interview on 9/12/25 8:20 A.M., Housekeeper D said resident daily room cleaning includes cleaning sinks, floors, furniture, moving furniture out and sweeping behind the furniture. The bathrooms are also cleaned every day. During an interview on 9/11/25 at 1:20 P.M., the Housekeeping Supervisor said resident rooms are cleaned daily and the staff are expected to follow the housekeeping checklist. She expected the housekeeping staff to clean around the baseboards and pick up any trash, move the furniture and mop and sweep behind the furniture. 4. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expected staff to keep the bathrooms clean, report issues to the appropriate persons when a toilet backs up and she expected the bathroom to be cleaned as soon as it happens. She expected the residents' rooms to be cleaned every day, and floors swept. She expected staff to provide the residents a homelike environment. 5. Review of Resident #11's significant change MDS, dated [DATE], showed:-Cognitively intact;-Upper and lower extremity impairment on one side;-Diagnoses included chronic kidney disease and depression. Observation on 9/9/25 at 11:09 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator, and no temperature gauge inside the refrigerator. The refrigerator contained yogurt and various beverages. During an interview, the resident said he/she wasn't sure if staff checked the temperature inside the refrigerator. Observation on 9/11/25 at 8:52 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. 6. Review of Resident #48's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Lower extremity impairment on both sides;-Diagnoses included dementia and generalized muscle weakness. Observation on 9/9/25 at 11:04 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. Observation on 9/10/25 at 7:53 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. The refrigerator contained V8 juices and other beverages. During an interview on 9/10/25 at 9:38 A.M., the resident did not understand questions regarding the temperature of his/her personal refrigerator. 7. Review of Resident #17's MDS, dated [DATE], showed:-Cognitive impairment;-No behaviors;-Utilizes a manual wheelchair;-Diagnoses included diabetes, dementia, anxiety and traumatic brain injury. Observation and interview on 9/8/25 at 9:07 A.M., showed the resident sat in his/her wheelchair in his/her room. A mini refrigerator sat on a stand in the resident's room. No temperature log was on or near the refrigerator. The resident said he/she used the refrigerator regularly and keeps milk in there. Observations on 9/9/25 at 10:59 A.M., 9/10/25 at 7:45 A.M. and 9/11/25 at 8:56 A.M., showed a mini refrigerator in the resident's room. No temperature log was observed on or near the refrigerator. 8. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included high cholesterol, dementia, and psychotic disorder. Observation on 9/9/25 at 4:20 P.M., showed the resident had a personal mini refrigerator in the room. No temperature log sheet observed. Observation and interview on 9/11/25 at 8:53 A.M., showed the resident's refrigerator did not have a temperature log sheet. The resident said he/she had never seen any staff check the refrigerator. The refrigerator contained some milk and juices. The resident's roommate said staff were supposed to check the refrigerator's temperature daily, but nobody was doing it since the time he/she was moved to the room, which was approximately a year ago. 9. Review of Resident #6's annual MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included diabetes, high cholesterol, high blood pressure, anxiety, depression and schizophrenia (a serious mental health condition that affects how people think, feel and behave). Observation and interview on 9/11/25 at 8:58 A.M., showed the resident had a personal mini refrigerator in the room, by the sink. A blank temperature log sheet was taped on the side of the refrigerator. The resident said he/she did not see any staff checking the refrigerator's temperature. He/She did not know what the piece of paper was for that was attached to the refrigerator. The refrigerator contained milk, chocolate milk and bags of salads. During an interview on 9/11/25 at 8:59 A.M., Housekeeping Aide H said they were not responsible for checking and logging temperature of the residents' personal refrigerators. He/She said the CNAs were responsible for that task. During an interview on 9/11/25 at 9:04 A.M., CNA P said the Certified Medication Technicians (CMT) used to check the temperature of the residents' personal refrigerators. He/She did not remember the last time they were being checked. He/She had not seen anyone check them lately. During an interview on 9/11/25 at 2:23 P.M., Housekeeping Aide D said housekeeping staff does not touch or monitor the temperatures of personal refrigerators in resident rooms. During an interview on 9/11/25 at 2:50 P.M., CNA B said dietary is the only department that checks the refrigerators in their kitchen. 10. During an interview on 9/12/25 at 10:49 A.M., the Administrator said housekeeping is responsible for monitoring temperatures inside resident personal refrigerators. She is unsure how often the refrigerator temperatures are checked. They should be checked routinely, and housekeeping should have some system that should be in place.1454154

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, five errors occurred, resulting in a 16.13 % error rate. (Resident #84 and Resident #86). The census was 90. Review of the facility's Medication Administration policy, dated November 2021, showed:-To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; and Right time;-Read the Medication Administration Record (MAR), for the ordered medication dose, dosage form, route, and time;-Verify the pharmacy prescription label on the drug and the manufacturer's identification matches the MAR;-If there is a discrepancy, check the original physician's orders and notify the pharmacy; Do no give the medication until clarified;-Verify that any further medication identifiers match the label and the medication; Identifiers may include drug size, shape and color;-Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to the MAR before administering;-Administer oral medications with a full glass of water. Review of the Novolog (an immediate release insulin) FlexPen manufacturer's insert instructions, undated, showed: Key steps in using the FlexPen include priming the pen, dialing the dose, injecting by pressing the button for at least six seconds, removing the needle, and storing the pen without a needle. 1.Review of Resident #84's medical record showed diagnosis that included atrial fibrillation (irregular heartbeat), major depressive disorder, long term use of aspirin, long term use of anticoagulant (blood thinner), heart failure, and neuropathy (pain and numbness to the lower extremities). Review of the resident's physician order sheets (POS), dated, September 2025, showed:-An order dated, 2/5/25, escitalopram oxalate 20 milligrams (mg), give one time a day for depression;-An order dated, 9/3/24, celecoxib (pain medication) capsule 200 mg, give one capsule one time a day for inflammation;-An order dated, 6/25/22, aspirin 81 mg give one tablet, one time a day for atrial fibrillation;-An order dated, 6/25/22, Eliquis (blood thinner) 5 mg, give one tablet, every 12 hours for atrial fibrillation. Observation on 9/10/25 at 8:04 A.M. showed, Certified Medication Technician (CMT) I prepared the resident's medications at the medication cart on the 100 hall. CMT I entered the resident's room and administered the resident's medications. CMT I did not administer the resident's escitalopram oxalate 20 mg, celecoxib 200 mg, aspirin 81 mg, and Eliquis 5 mg.Review of the resident's MAR, dated 9/1 to 9/30/25, showed:-An order dated, 2/5/25, escitalopram oxalate 20 mgs, give one time a day for depression; A.M. med; documented as administered;-An order dated, 9/3/24, celecoxib capsule 200mgs, give one capsule one time a day for inflammation; A.M. med: documented as administered;-An order dated, 6/25/22, aspirin 81 mg give one tablet, one time a day for atrial fibrillation; A.M. med; documented as administered;-An order dated, 6/25/22, Eliquis 5 mgs, give one tablet, every 12 hours for atrial fibrillation; A.M. med; documented as administered. During an interview on 9/10/25 at 10:49 A.M., CMT I said he/she thought he/she gave the resident all of his/her medications. CMT I thought he/she gave the medications to the resident when the surveyor was not observing but wasn't sure. CMT I said he/she double checks the medication orders on the MAR prior to administering medications. During an interview on 9/11/25 at 10:40 Licensed Practical Nurse (LPN) K said when staff are administering medications, physician orders should be followed and medications should be given at the time the MAR shows in its entirety. If a medication was not given for any reason, it should be charted as not given. Medications should be checked twice against the MAR prior to giving the medicine to ensure accuracy. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said all medications are expected to be given per the physician orders in its entirety. Staff are expected to utilize the five rights when administering medications to ensure accuracy. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expects staff to follow physician orders and accurately give residents their medications in their entirety. 2. Review of Resident #86's medical record showed diagnoses that included cognitive communication deficit and diabetes.Review of the resident's physician order sheets (POS), dated, September 2025, showed:-An order dated, 5/22/25, Novolog FlexPen subcutaneous (fatty layer of the skin) solution pen injector 100 units per milliliter (ml), inject 14 units subcutaneously with meals;-An order dated, 5/22/25, Novolog FlexPen subcutaneous solution pen injector 100 units per ml, inject per sliding scale (a measurement of blood sugar), if blood sugar is: 151-200 inject 2 units; 201-250 inject 4 units; 251-300 inject 6 units; 301-350 inject 8 units; 351-400 inject 10 units.Observation on 9/9/25 at 11:34 A.M., showed Licensed Practical Nurse (LPN) J took the resident's blood sugar and the resident's blood sugar showed 173. LPN dialed the resident's Novolog FlexPen to 16 units, entered the resident's room and administered the Novolog insulin to the back of the resident's left arm. LPN J did not prime the Novolog FlexPen prior to administering the insulin. During an interview on 9/11/25 at 8:56 A.M., Registered Nurse (RN) A said the insulin pens are to be primed with two units of insulin before administering the insulin to the resident every time. Priming the pen removes any air bubbles and ensures the insulin dose more accurate. During an interview on 9/11/25 at 10:40 A.M., LPN K said insulin FlexPens should only be primed when the pen is being used for the first time. LPN K was not aware if the insulin FlexPens should be primed with each use. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said the insulin FlexPens are expected to be primed by the nursing staff administering the medication with 2 units of insulin each time the FlexPen is being used. It ensures a more accurate dose by removing any air bubbles. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she would expect staff to prime insulin FlexPens prior to each use. 1454154

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when laundry staff failed to keep dirty and clean areas separate. Trash was transported through the folding area and clean linen carts. The staff moved back and forth, handling items from washer to dryer and sorting table without hand hygiene. In addition, the facility failed to keep one resident's indwelling catheter bag off the floor (Resident #80). The sample was 20. The census was 90. Review of the facility's Handling of Soiled Laundry and Beddings policy, reviewed 3/2025, showed:-Clean linens are protected from dust and soiling during transport and storage to ensure cleanliness;-Clean linens are sored separately, away from soiled linens, at all times;-Wash hands before handling clean linen (such as when moving from washer to dryer, moving from dryer to sorting table, and through the sorting process). Review of the facility's Catheter Care policy, revised 1/8/23, showed to check catheter to make sure positioning promotes proper flow of urine, no pulling is present, and catheter bag is below level of bladder. 1. Observation and interview on 9/9/25 at 12:24 P.M., showed two doorways to the laundry area. Laundry Aide G said the doorway towards the back was for transporting clean items, while the other was for the dirty laundry that were coming from the chute. He/She said they can use both doorways when transporting clean items depending on which was closer. At the entrance to the laundry area, a sign was on the wall that stated showed to follow orange arrows for trash. Arrow-shaped orange tape was placed on the floor, creating a path towards the back door, passing through the maintenance area and to the clean and sorting tables area. An unknown staff wheeled a trash bin following the orange arrows while the laundry staff folded linens on the sorting table. There were four clean linen carts parked against the wall, close to several cluttered and dirty items outside of the maintenance room, such as wheelchairs, and other broken equipment. The floor was sticky and dirty. Observation and interview on 9/12/25 at 8:48 A.M., the sign for orange arrows was removed. The four clean linen carts were moved to a room. The Maintenance Director said the housekeeping supervisor worked the day prior and may have taken down the sign. He/She said staff has not been taken trash down in the laundry area and towards the back door for about a year now. The staff were supposed to take their trash upstairs. He/She said no trash should be taken downstairs. Housekeeping carts trash containers should be emptied before storing them downstairs. Observed a housekeeping cart parked against the wall with unemptied trash. During an interview on 9/12/25 at 9:11 A.M., the Administrator said dirty and clean items in the laundry should be separated. She expected the staff to use one doorway for clean laundry and the other for dirty or soiled items. There should not be trash in the laundry area. The staff should not transport trash in the laundry and along the clean folding area. 2. Review of Resident #80's care plan, revised 5/19/25, in use during the time of the investigation, showed:-Focus: The resident was admitted with a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen to drain urine from the bladder);-Goal: The resident will be/remain free from catheter-related trauma through the review date;-Interventions: The resident has a suprapubic catheter. Position catheter bag and tubing below the level of the bladder for proper drainage. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/17/25, showed:-Cognitively impaired;-No behaviors;-Utilizes a wheelchair;-Dependent on staff for toileting hygiene;-Indwelling catheter;-Diagnoses included end stage renal disease (kidney disease), anxiety and schizophrenia (a chronic mental health condition characterized by persistent loss of touch with reality). Observation on 9/8/25 at approximately 6:15 A.M., showed the resident lay in a low bed on his/her back asleep. The catheter bag lay directly on the floor, next to the resident's fall mat. Observation on 9/9/25 at 4:19 P.M., showed the resident sat in his/her wheelchair at the nurse's station. The resident's catheter bag was under his/her wheelchair. When the resident propelled him/herself in the wheelchair, the catheter bag dragged on the floor. Observation on 9/10/25 at 8:07 A.M., showed Licensed Practical Nurse (LPN) Q pushed the resident from the dining room down the hallway. The resident's catheter bag dragged onto the floor as he/she was propelled in the wheelchair. During an interview on 9/10/25 at 8:08 A.M., LPN Q said the resident's catheter bag dragged on the floor, but he/she had not noticed it. The catheter bag dragging on the floor could cause it to break and pose a risk for infections. He/She lifted the catheter bag and placed it on a hook on the wheelchair. Observation on 9/12/25 at 9:50 A.M., showed the resident sat at the nurse's station in his/her wheelchair. The catheter bag hung under the resident's wheelchair and touched the floor. During an interview on 9/12/25 at 9:51 A.M., LPN S observed the resident's catheter bag on the floor and agreed it touched the floor. He/She said it should not touch the floor. LPN S did not attempt to reposition it. During an interview on 9/12/25 at approximately 8:28 A.M., the Administrator said catheter bags should not drag on the floor. Catheter bags on the floor increase the risk for infections.

Based on interview and record review, the facility failed to protect a resident's right to be treated with dignity and respect when staff entered the resident's room without the resident's or resident's representative's consent and removed personal belongings (Resident #9). The sample size was 20. The census was 90. Review of the facility's Resident Rights and Dignity Protocol, reviewed January 2024, showed:-Protocol: The facility recognizes the resident right to a quality of life that supports privacy, confidentiality, dignity, independent expression, choice and decision making consistent with State law and Federal regulation. Review of the facility's New Resident Information, required for signature within 24 hours of admission, showed:-Room Search Protocol. Revised November 2023; -Purpose: To assure the safety of resident, staff and visitors without violating Resident Rights, the Room Search Policy and Procedure has been established; -Policy: A resident's room may be searched if, after investigation, evidence suggests that the resident has violated facility policy regarding the possession of contraband, prohibited items or stolen property. If recreational marijuana is legalized, you still may not have it in the facility or smoke it; -Procedure: The facility staff should not conduct searches of a resident or their personal belongings unless the resident or resident representative agrees to a voluntary search and understands the reason for the search, if they refuse then legal authorities should be notified to assist as allowed by law. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/25, showed:-discharged to the hospital on 4/18/25;-Exhibited no behaviors;-Diagnoses included diabetes, anxiety and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's progress note, showed:-4/21/25 at 3:58 P.M., showed a note by the Administrator. Informed by the Director of Nursing (DON) that resident was observed with a vaporizer in room last week. The DON accompanied this writer to resident's room. Search of resident's room resulted in finding two vape pens, two boxes of wooden matches, one lighter, one vape/electric cigarette battery and six bags of edibles. All items removed from room and locked in administrator's office. Storing any smoking supplies in residents' rooms is a violation of facility policy. Having marijuana on facility property is in violation of facility policy;-4/21/25 at 4:19 P.M., showed a note by the administrator. Will discuss smoking supplies found in room with resident and family/responsible party upon return from the hospital. Review of the resident's census report, showed he/she returned from the hospital on 5/6/25. During an interview on 9/10/25 at 1:04 P.M., the resident said he/she was in the hospital for an extended amount of time. Three days after he/she was admitted to the hospital, the Administrator searched his/her room closet without his/her consent and took six bags of marijuana infused edibles and two vape pens. The resident knew he/she could not smoke marijuana at the facility but did not realize he/she could not eat it. He/She did not have an issue with the facility saying he/she could not have the items. The resident was concerned because they searched his/her room without his/her knowledge or consent. The resident found out his/her room was searched by the Administrator and DON from staff at the facility. During an interview on 9/10/25 at 1:20 P.M., the Administrator said she was informed by staff the resident had marijuana in his/her room. She and the DON searched the resident's room and found six bags of marijuana infused edibles and two vaporizer pens. She confiscated the items and called the resident's family member to pick them up. The resident was in the hospital when the room was searched. The Administrator could not recall if she obtained permission from the resident's representative prior to searching the room but did document the occurrence. During an interview on 9/12/25 at approximately 9:30 A.M., the Administrator said she did not obtain permission from the resident or representative prior to searching his/her room. The items were returned to the family, and it was explained that the items were not permitted in the facility. She expected the policies to be followed and resident consent prior to searching a resident's room. 14541571454156

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure the call light was in reach for one resident (Resident #37). The sample was 20. The census was 90. Review of the facility's Call Light policy, dated, 8/1/18, showed:-Purpose: To respond to resident's requests and needs;-Procedure: Answer call lights promptly; Determine resident's request; Listen to resident for further requests and needs; Respond to request; Assist resident as needed to a comfortable position and with call light within reach. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/25, showed:-Moderate cognitive impairment;-Always incontinent of bowel and bladder;-Dependent on staff for toilet hygiene, personal hygiene, bathing, upper and lower body dressing and chair to bed and bed to chair transfers;-Diagnoses included non-Alzheimer's dementia, diabetes, hemiplegia (paralysis to one side of the body), stroke and seizures. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident experiences bowel and bladder incontinence related to dementia, cognitive impairment, impaired mobility, impaired sensation related to stroke;-Interventions: The resident uses adult incontinent briefs; Monitor for soiling on routine rounds and as needed; Assist to cleanse perineum (genitals and rectal area) and change brief as needed;-Focus: The resident has an activities of daily living (ADL) and mobility deficit related to cognitive impairment and dementia, shortness of breath, compromised respiratory status, lasting effects of stroke, weakness and limited endurance;-Interventions: The resident is dependent on staff to complete personal hygiene tasks; The resident is dependent on staff for toileting needs;-The resident's care plan did not address ensuring the resident's call light was in reach. Observation on 9/8/25 at 7:44 A.M. and 9/9/25 at 10:27 A.M., showed the resident lay in bed. The resident's call light was positioned on the floor under the resident's bed out of the resident's reach. Observation on 9/9/25 at 3:04 P.M., showed the resident lay in bed. The resident's call light was positioned under the resident's sheets at the foot of the bed, out of the resident's reach. During an interview on 9/11/25 at 8:56 A.M., Registered Nurse (RN) A said the call light is expected to be within reach for all residents. Every time a staff member leaves the room, the call light should be near the resident. During an interview on 9/11/25 at 9:45 A.M., Certified Nursing Assistant (CNA) B said call lights should always be within the resident's reach no matter the cognition status of the resident. Before leaving the room, staff should make sure the resident has their call light in reach. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and Nurse Manager said they expected staff to ensure all residents always have their call light within reach. During an interview on 9/12/25 at 10:45 A.M., the Administrator said she expected staff to ensure all residents always have their call light within reach. No matter what the resident cognition status is, the call light is expected to always be within reach of the resident.

Based on interview and record review, the facility failed to ensure services provided met professional standards by failing to include blood pressure parameters for two residents (Resident # 69 and Resident # 84), failing to ensure a nutritional supplement order had the specific type of nutritional supplement and the amount to be given included in the physician order for one resident (Resident # 87) and failing to apply tubi grips (elasticated bandage that provides continuous support) for one resident (Resident #20). The sample size was 20. The census was 90. Review of the facility's Medication Administration policy, dated, November 2021, showed:-To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; and Right time;-Perform necessary assessments prior to administering specific medications; For example, vital signs (pulse, blood pressure, and blood sugar). -Read the Medication Administration Record (MAR), for the ordered medication dose, dosage form, route, and time;-Verify the pharmacy prescription label on the drug and the manufacturer's identification matches the MAR;-If there is a discrepancy, check the original physician's orders and notify the pharmacy; Do no give the medication until clarified;-Verify that any further medication identifiers match the label and the medication; Identifiers may include drug size, shape and color;-Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to the MAR before administering. 1.Review of the Resident #69's medical record showed stroke, hypertension (high blood pressure) and hypertensive retinopathy (damage to part of the eye due to high blood pressure). Review of the resident's physician order sheets (POS) showed:-An order, dated, 2/20/24, carvedilol (medication use to treat high blood pressure) 6.25 milligrams (mg), give one tablet twice a day for hypertension;-An order, dated, 2/20/25, lisinopril (mediation used to treat high blood pressure)10 mg, give one tablet in the morning for hypertension;-No blood pressure parameters to hold the medication were noted in the physician orders. Review of the resident's MAR, dated 9/1 through 9/30/25, showed:-An order, dated, 2/20/24, carvedilol 6.25 milligrams (mg), give one tablet twice a day for hypertension; -An order, dated, 2/20/24, lisinopril 10 mg, give one tablet in the morning for hypertension; - On 9/10/25, A.M. med; lisinopril and carvedilol documented as not administered. Review of the resident's progress notes showed no documentation related to the resident's low blood pressure. Observation and interview on 9/10/25 at 8:04 A.M., showed Certified Medication Technician (CMT) I obtained the resident's blood pressure and pulse. The resident's blood pressure was 95/70 (normal is 120/80) and pulse was 75 (normal is 60-100). CMT I said he/she would notify the nurse of the low blood pressure and hold the resident's carvedilol and lisinopril. CMT I said there were no blood pressure parameters listed for the carvedilol and lisinopril. 2. Review of Resident #84's medical record showed diagnoses that included atrial fibrillation (irregular heartbeat), major depressive disorder, long term use of aspirin, long term use of anticoagulant (blood thinner), heart failure, and neuropathy (pain and numbness to the lower extremities). Review of the resident's POS, dated, September 2025, showed;-An order, dated, 6/25/22, metoprolol succinate extended release (a medication used to treat hypertension), give one tablet once a day for hypertension. Review of the resident's MAR, dated 9/1 through 9/30/25, showed:-An order, dated, 6/25/22, metoprolol succinate extended release, give one tablet once a day for hypertension; A.M. medication documented as not given; vital signs outside of parameters. Review of the resident's progress notes showed no documentation related to the resident's low blood pressure. Observation and interview on 9/10/25 at approximately 8:10 A.M , showed CMT I obtained the resident's blood pressure and pulse. The resident's blood pressure was 114/42 and pulse was 61. CMT I said that he/she was going to notify the nurse and CMT I was going to hold the blood pressure medications because the resident's blood pressure was too low. CMT I said there were no blood pressure parameters listed for the metoprolol succinate. During an interview on 9/11/25 at 8:56 A.M., Register Nurse (RN) A said the resident orders should contain parameters about holding medication. With any abnormal blood pressure or pulse, the CMT is expected to tell the nurse so that the nurse can re-evaluate and call the physician. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said blood pressure medications are expected to have parameters. The physician gives the orders for the parameters. The CMT is expected to let the nurse know when the vital signs are abnormal and medication was held so that the nurse can retake the blood pressure and call the physician. 3. Review of Resident #87's medical record showed diagnoses that included protein malnutrition (inadequate nutrition), anorexia (an eating disorder characterized by restricting food intake), and muscle weakness. Review of the resident's POS, dated, September 2025, showed:-An order dated, 3/27/25, nutritional shake, twice a day as a supplement;-The type of nutritional shake or amount of the nutritional shake was not included in the order. Observation and interview on 9/10/25 at 7:44 A.M., showed CMT I prepared the resident's medication and supplement. CMT I said there was no type or amount of supplement in the orders, therefore he/she just gave the resident a little bit of house supplement because the resident normally will not drink it. CMT I poured approximately 60 milliliters (ml) of ReadyCare (a type of nutritional supplement) house supplement and offered it to the resident and left the supplement on the bedside table for him/her to consume later. During an interview on 9/11/25 at 8:56 A.M., RN A said when the order reads nutritional shake that means to give the resident a Boost (type of nutritional supplement) or Ensure (a type of nutritional supplement) and the order should have the volume amount that the resident should receive. During an interview on 9/11/25 at 10:40 A.M., Licensed Practical Nurse (LPN) K said when the physician order reads nutritional shake, LPN K normally gives the ReadyCare house supplement. It depends on the resident, on how much is given. Some residents are unable to consume a lot of the liquid supplement so those residents wound only get a small amount of the ReadyCare. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager said the nutritional shake order is expected to include the type of supplement and the amount of supplement to be given. If a substitute for the nutritional shake is approved by the dietician or physician, then the order should also include the substitution permitted. 4. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/25, showed:-Cognitively intact; -Rejection of care behavior not exhibited;-Substantial/maximal assistance required for lower body dressing and putting on/taking off footwear.Review of the resident's medical record, showed:-Diagnoses included edema (swelling), cellulitis (skin infection) of right lower limb, and heart failure;-An order, dated 7/3/25, for tubi-grips to bilateral lower extremities, on in morning and take off at night, twice a day for bilateral lower extremity swelling. Review of the resident's care plan, in use at the time of survey, showed;-Focus: The resident has potential/actual skin impairment related to decreased mobility, edema, incontinence, history of cellulitis, persistent picking/pulling/scratching skin and/or wounds. 8/20/25: Area(s) to bilateral lower extremities recurring due to resident consistently scratching/picking at skin and/or wounds which delays healing and increases risk for complications;-Interventions included follow physician's orders for treatment of injury/wound/skin condition. Encourage resident to comply with ordered treatments.Observation on 9/8/25 at 8:06 A.M., showed the resident's right lower leg red and swollen with three scabbed areas to the right shin. No tubi-grips were on the resident's lower legs. During an interview on 9/8/25 at 8:06 A.M., the resident said he/she is supposed to get compression socks every day. He/She needs staff to put them on him/her because he/she can't reach his/her feet. Observation on 9/8/25 at 9:52 A.M., showed the resident without tubi-grips on his/her lower legs. RN A entered the resident's room and asked to look at the resident's feet.During an interview on 9/8/25 at 11:02 A.M., the resident said the nurse put cream on his/her legs, but did not apply his/her tubi-grips.Observations on 9/9/25 at 9:50 A.M., 11:23 A.M., and 12:40 P.M., showed the resident without tubi-grips on his/her lower legs. The resident's right leg was swollen and red, with multiple scabbed areas to the shin. During an interview on 9/9/25 at 12:40 P.M., the resident said his/her lower legs hurt. He/She is supposed to wear tubi-grips daily. Observations on 9/9/25 at 1:47 P.M., 4:19 P.M., and 5:50 P.M., showed the resident without tubi-grips on his/her lower legs. Observation on 9/10/25 at 9:39 A.M., showed the resident without tubi-grips on his/her lower legs. Observation on 9/10/25 at 1:06 P.M., showed the resident without tubi-grips on his/her lower legs. The Wound Nurse observed the resident's legs and asked the resident about his/her tubi-grips. The resident said he/she did not get his/her tubi-grips today. During an interview, on 9/10/25 at 1:06 P.M., the Wound Nurse said the resident's tubi-grips are usually applied by the nurse. During an interview on 9/10/25 at 1:20 P.M., RN A said the resident has orders for tubi-grips to be worn daily, but he/she did not get them today. The resident scratches his/her legs. The tubi-grips help reduce swelling in the resident's legs and prevent him/her from scratching them. Review of the resident's progress notes and Treatment Administration Record (TAR) for September 2025, showed staff documented the resident's tubi-grips administered on 9/8/25, 9/9/25, and 9/10/25. There was no documentation of the resident's refusal to wear tubi-grips on these days. During an interview on 9/11/25 at 2:30 P.M., Certified Nurse Aide (CNA) C said the resident has orders for tubi-grips. CNAs, nurses, and therapy staff can apply the resident's tubi-grips. If the CNA applies the tubi-grips, they tell the nurse and the nurse marks the treatment as completed in the TAR.During an interview on 9/11/25 at 8:44 A.M., the ADON said nurses are responsible for applying a resident's tubi-grips. The resident can refuse his/her tubi-grips at times. If the resident refuses, staff should wait until he/she is calm and reapproach later. If the resident continues to refuse, staff should notify the physician and mark the treatment as not completed on the TAR, as well as a progress notes regarding the refusal. During an interview on 9/12/25 at 10:49 A.M., the Administrator said she expects staff to apply tubi-grips as ordered by the physician. Tubi-grips can be applied by the CNA or the nurse. If the resident refuses his/her tubi-grips, staff should notify the physician, document the treatment as not administered on the TAR, and document a progress note regarding the resident's refusal.

Based on observation, interview, and record review, the facility failed to ensure residents requiring assistance with ADLs (activities of daily living) received the necessary services to maintain adequate personal hygiene in accordance with their needs and preferences (Residents #37, #48, and #71). The sample was 20. The census was 90.Review of the facility's Personal Care Needs policy, reviewed 1/2024, showed:-Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. Personal care and support include but is not limited to the following: -Assistance with meals; -Bath/shower; -Grooming/dressing; -Nail care; -Peri-care; -Shave;-Procedure includes: -Develop and implement individualized interventions; -Document on individual resident care plan; -Document in the progress notes if an exception to the established plan of care occurs, i.e., refusals. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 6/12/25, showed:-Moderate cognitive impairment;-Always incontinent of bowel and bladder;-Dependent on staff for toilet hygiene, personal hygiene, bathing and putting on and taking off footwear;-Non-Alzheimer's dementia, diabetes, hemiplegia (paralysis to one side of the body), stroke and seizures. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident experiences bowel and bladder incontinence related to dementia, cognitive impairment, impaired mobility, impaired sensation related to stroke;-Interventions: The resident uses adult incontinent briefs; Monitor for soiling on routine rounds and as needed; Assist to cleanse perineum (genitals and rectal area) and change brief as needed;-Focus: The resident has an ADL and mobility deficit related to cognitive impairment and dementia, shortness of breath, compromised respiratory status, lasting effects of stroke, weakness and limited endurance;-Interventions: Bathing and showering, check nail length and trim and clean on the resident's bathing day; The resident is dependent on staff to complete personal hygiene tasks; The resident is dependent on staff for toileting needs. Observation on 9/8/25 at 7:44 A.M., showed the resident lay in bed. On both hands, the resident's fingernails were approximately one half an inch long with dark matter underneath. The resident's feet were extremely dry with large flakes of skin on the resident's navy-blue mattress. Observation and interview on 9/9/25 at 3:12 P.M., showed Certified Nurse Aide (CNA) E entered the resident's room and explained to the resident that he/she was going to turn and clean the resident. The resident lay in bed, and CNA E checked the resident's brief and said the resident was wet. CNA E positioned the resident on his/her right side and removed the resident's brief. The resident's brief and bed pad were saturated with urine, and the resident also had a large bowel movement. CNA E finished cleaning the resident and said the resident was not on his/her assignment but was helping out another CNA. The resident had extremely dry feet with large flakes of skin on the resident's navy-blue mattress. On both hands, the resident had fingernails that were approximately one-half inch long with dark matter underneath. During an interview on 9/9/25 at 3:35 P.M., CNA F said the assignment switched about 10:30 A.M., and he/she did not know the resident was on his/her assignment. The last time the resident was checked was 10:30 A.M. CNA F said any nursing staff can change residents, but is one of the CNA's primary responsibilities to check incontinent residents every two hours. Observation on 9/10/25 at 10:24 A.M., showed the resident lay in bed. On both hands the resident had long fingernails approximately one half an inch long with dark matter underneath. The resident's feet were extremely dry with large flakes of skin on the resident's navy-blue mattress. 2. Review of Resident #48's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Rejection of care behavior not exhibited;-Lower extremity impairment on both sides;-Substantial/maximal assistance required for showering/bathing self and lower body dressing;-Partial/moderate assistance required for personal hygiene;-Diagnoses included dementia and generalized muscle weakness. Review of the resident's care plan, in use at the time of survey, showed:-Focus: ADL/mobility deficits - Interventions listed are reflective of resident's usual performance and may fluctuate. The resident has an ADL and/or mobility deficit related to activity intolerance, chronic health conditions, cognitive impairment/dementia, weakness/limited endurance; -Interventions included: Check nail length and trim and clean on bath day and as necessary. The resident requires help from staff with bathing/showering. Resident prefers to have facial hair such as a beard. The resident needs assistance from staff with personal hygiene tasks;-The care plan did not identify the resident as having a history of refusing care. Review of the resident's medical record, showed no documentation in August or September 2025 regarding the resident refusing assistance with hygiene care. Observation and interview on 9/8/25 at 7:02 A.M., showed the resident in bed with his/her feet pressed against the footboard. The resident's toenails were long, thick, and jagged with the big toenail on the right foot protruding approximately 0.5 inches from the top of the resident's toe. The middle toenail on the left foot was purple. During an interview, the resident said he/she gets assistance from staff with showers. He/She was unable to answer other specific questions regarding his/her hygiene and grooming needs and preferences. Observations on 9/9/25 at 12:41 P.M and 4:19 P.M., showed the resident's toenails remained long, thick, and jagged and the middle toenail on the left foot was purple. The resident's beard was scruffy. During an interview on 9/11/25 at 11:15 A.M., the resident said he/she wants his/her beard trimmed but needs staff to help him/her. His/Her toenails have not been trimmed. He/She cannot trim them. During an interview on 9/11/25 at 2:30 P.M., CNA C said the resident requires assistance of one staff with hygiene. He/She can make his/her needs known. Observation and interview on 9/12/25 at 9:06 A.M., showed the Nurse Manager removed the socks from the resident's feet and chunks of flakes fell onto the resident's bed. The bottoms of the resident's feet were dry and flaky. During an interview, the Nurse Manager said the resident's middle toenail was purple. Staff would have seen this when putting on the resident's socks. She would have expected staff to notify the nurse of the discolored toenail. She would have expected staff to put lotion on the resident's feet as part of daily care when getting the resident dressed, and on his/her shower days. CNAs can trim toenails, but Resident #48 will be referred to podiatry. 3. Review of Resident #71's quarterly MDS, dated [DATE], showed:-Short and long-term memory problem;-Severely impaired cognition/rarely made decisions regarding tasks of daily life;-Rejection of care behaviors not exhibited;-Upper and lower extremity impairment on one side;-Dependent for showering/bathing self and personal hygiene;-Substantial/maximal assistance required for upper body dressing;-Setup or clean-up assistance required for eating;-Diagnoses included aphasia (language disorder affecting communication), dementia, and hemiplegia or hemiparesis (weakness on one side of the body). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Restorative - The resident is at risk for decline in eating/self-feeding and requires/benefits from restorative nursing intervention; -Interventions included resident prefers to eat with his/her hands;-Focus: ADL/mobility deficits - ADL self-care performance deficit related to impaired balance, limited mobility and weakness related to comorbidities. He/She will refuse showers at times. Will become aggressive with staff. Refuses nail trimming and shaving or trimming beard; -Interventions included: Be aware due to medical conditions/resident's status, ADL self-care performance and mobility are likely to fluctuate. The resident requires set-up help when eating. Supervise/assistance as needed. Check nail length and trim and clean on bath day and as necessary to nurse. The resident is usually/always dependent on staff for bathing/showering and to complete personal hygiene tasks. Encourage compliance with hygiene related tasks;-The care plan did not identify interventions for staff to follow if the resident refused care. Observations on 9/10/25 at 8:00 A.M., showed CNA A seated next to the resident in the dining room. The resident used his/her hand to pick up food while eating. His/Her fingernails were long with brown matter underneath, and the front of his/her shirt was soiled with brown streaks of liquid. CNA A poured hand sanitizer on a paper towel and used the towel to wipe the resident's hands. CNA A did not wipe underneath the resident's fingernails. The resident cooperated with the CNA and did not object or refuse assistance. CNA A brought the resident out of the dining room and to the resident's room. At 8:40 A.M., the resident was seated in his/her Broda chair (reclining chair) in his/her room. The front of the resident's shirt remained soiled and the brown matter remained underneath his/her fingernails. During an interview on 9/10/25 at 8:40 A.M., the resident looked at his/her fingernails and said they were not clean. He/She wants clean hands and fingernails. He/She does not like wearing dirty clothes. Observation and interview on 9/10/25 at 12:14 P.M., showed the resident wearing the soiled shirt, and the brown matter remained underneath his/her fingernails. During an interview, the resident said staff have not cleaned him/her up. Observation on 9/11/25 at 7:45 A.M., 8:46 A.M., and 11:13 A.M., showed the resident with long fingernails with brown matter underneath his/her fingernails. During an interview on 9/11/25 at 2:30 P.M., CNA C said the resident requires maximum assistance from staff with his/her ADLs. He/She is not oriented, but can make his/her needs known and can respond appropriately to the questions asked of him/her. He/She can be combative at times, but it's all about how staff approach him/her. Staff need to explain everything they are doing with him/her, step by step, working with him/her on his/her own time and in his/her own way. During an interview on 9/12/25 at 8:58 A.M., the Nurse Manager said the resident often refuses care. He/She may smile and seem agreeable, but then may attempt to hit staff. Staff should gauge the resident's mood when attempting to provide care. The resident has fingernails and he/she does not like people getting underneath them. When the resident is agreeable, staff should seize the opportunity to provide care as tolerated. During an interview on 9/12/25 at 8:44 A.M., the Assistant Director of Nurses (ADON) said the resident requires total assistance from staff with his/her ADLs. The resident has some behaviors of refusing care. Staff should take a calm approach when working with the resident. He/She does better with male caregivers. If the resident refuses care, staff should try again later and with a different approach. 4. During an interview on 9/11/25 at 9:45 A.M. CNA B said all incontinent residents should be checked at minimum every two hours and as needed. The resident's nails can be trimmed on their bathing day, and the resident's feet can be moisturized anytime. 5. During an interview on 9/11/25 at 2:30 P.M., CNA C said nail care should be provided by CNAs during daily care. CNAs can do toenail trimming if a resident is not diabetic or on blood thinners. Staff should check resident's feet when providing daily care. If they observe something new, like a discolored toenail, they should report it to the nurse and encourage the resident to keep their feet elevated. If a resident refuses care, staff should try again later and maybe try to find another staff to offer the assistance. When resident's clothing becomes soiled, staff should clean up the resident and change their clothes. If a resident's hands are dirty after a meal, staff should help the resident wash their hands and get underneath their fingernails. Staff should offer to help shave or trim a resident's beard as part of daily care. 6. During an interview on 9/12/25 at 8:44 A.M., the ADON said nail trims and shaving are done on a resident's shower days. CNAs can provide nail care and toenail care, unless the resident is diabetic or on a blood thinner, in which case nail care must be done by the nurse. The ADON expected staff to check resident's feet and fingernails when providing daily care. If they observe a resident's toenail is purple or dark in color, they should notify the nurse and the nurse would notify the physician. If a resident uses their hands while eating, staff should help the resident wipe their hands when they are finished eating, and get underneath the resident's fingernails. If a resident's clothing becomes soiled, staff should clean up the resident and change their clothing. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager said they expected staff to check incontinent residents at least every two hours and as needed. Nail care and trimming can be provided by nursing staff during the resident's bath. The resident's feet can also be moisturized at any time but usually with bathing. They would expect staff to know which residents were on their assignments. 7. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expects staff to check on incontinent residents every two hours to ensure their needs are met. Nursing staff are expected to provide fingernail care and foot care when needed. Staff should apply lotion to a resident's feet if they are noted to be dry and flaking. If staff observe a resident's toenail is discolored, they should report it to the nurse. CNAs can trim a resident's toenails unless they are diabetic. Nurses trim toenails for diabetic residents. If a resident's toenails are too thick and cannot be trimmed by the nurse, the resident should be referred to podiatry. If a resident eats with their hands, staff are expected to wash the resident's hands and get underneath their fingernails, if tolerated. If a resident's clothing becomes soiled, staff are expected to provide care to the resident and change their clothes. Resident #71 has a behavior of refusing care and can become combative with staff. When this occurs, she expected staff to redirect and reapproach later. CNAs can shave and trim a resident's beard. Offering to shave or trim a resident's beard is part of a resident's daily care. 2567916

Based on observation, interview and record review, the facility failed to ensure adequate nutritive value, taste and texture for pureed foods (a very smooth blended food like pudding or mashed potatoes) for three out of five observations. This deficient practice affected the three residents who ate pureed meals at the facility. The census was 90.Review of the Spring/Summer Menu Cycle, showed on 9/11/25, lunch consisted of roasted ham slices, baked sweet potatoes, mixed vegetables and pineapple delight dessert. Observation and interview on 9/11/25 at 11:50 A.M., showed the Dietary Manager (DM) prepared pureed ham for three residents. She added three, four-ounce slices of ham to the blender, eight ounces of juice from the ham and one slice of bread. She blended the mixture for approximately one minute and added it to the serving pan. She said she always tasted pureed foods before serving. When tasting the food, the texture was noted to be lumpy and gritty. After tasting the pureed ham, the DM said it was grainy and lumpy, but so are mashed potatoes. She said pureed items should have the consistency of pudding and/or mashed potatoes. She covered the ham with foil to serve. Observation and interview on 9/11/25 at 11:55 A.M., showed the DM prepared three servings of mixed vegetables for three residents. She scooped four, four-ounce servings of vegetables in the blender. She added two and a half slices of bread to the blender. She asked [NAME] M to bring her a coffee pot of hot water. [NAME] M told the DM to use the juice from the vegetable mixture. The DM scooped four ounces of juice from the vegetables and added to the blender and blended for approximately one minute. She poured the pureed vegetables into a serving pan. The mixture appeared lumpy and gritty. The vegetables were sampled. The appearance was lumpy and runny. The taste was bland and pieces of carrot were not blended to a mashed potato or pudding-like substance. During an interview, the DM agreed it was gritty and lumpy and placed foil over the mixture to serve. Review of the Spring/Summer Menu Cycle, showed on 9/11/25, dinner consisted of barbequed hamburger on a bun, baked beans, tomato slices and chilled pears. Observation and interview on 9/11/25 at 3:58 P.M., showed [NAME] N prepared pureed hamburgers for three residents. He/She added two cups of ground beef and one slice of bread and a total of 12 ounces of beef broth to the blender. The DM said she was going to get hot water to add to the mixture. [NAME] N said he/she would only use beef broth. The mixture was blended for approximately one and a half minutes. [NAME] N stirred the mixture and said it needed to be blended again. He/She added more bread and blended for approximately 45 seconds. The mixture appeared grainy and choppy. [NAME] N poured the mixture into a serving pan. When asked to taste, he/she said, I don't taste the pureed food. The DM returned with three adaptive spoons. The texture was lumpy. The Dietary Manager tasted the mixture and agreed it was grainy and said, It could not be helped. Review of the facility's Pureed Food Guidelines, showed:-Entree: Three ounces cooked or a half cup of ground meat. Half slice of bread. Use beef broth for beef, pork for pork. Place bread, then food to be pureed in blender or food processor. Begin with a half a cup of liquid. Puree, then continue to alternate adding half a cup of liquid until product is correct consistency;-Vegetables-cooked: One half cup of cooked vegetables. Half slice of bread and melted margarine. Place bread, then food to be pureed in blender or food processor. Begin with a half a cup of margarine or liquid. Puree. Then continue to alternate half cup of liquid and puree until product is correct consistency. During an interview on 9/12/25 at 8:28 A.M., the Administrator said she expected pureed food items to have the consistency of pudding or mashed potatoes. Pureed foods should not be grainy or lumpy.

Based on interview and record review, the facility failed to ensure two residents, one with cognitive impairment, did not engage in sexual activity (Resident #1 and Resident #2). The sample was four. The census was 88. The Director of Nursing (DON) was notified on 3/19/25 at 12:40 P.M., of the past non-compliance, which occurred on 3/6/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on sexual abuse. The facility also updated Resident #1's care plan. The deficiency was corrected on 3/11/25. Review of the facility's Abuse, Neglect, Misappropriation of Resident Property Policy, dated 8/24, showed the following: -The Administrator has primary responsibility in the facility for implementation of the abuse and neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse, or involuntary seclusion; -Sexual Abuse: -Non-consensual sexual contact of any type with a resident. Includes, but is not limited to: -Unwanted intimate touching of any kind especially of breasts or perineal area; -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -Forced observation of masturbation and/or pornography; and; -Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Review of the facility Sexual Expression Policy, undated, showed the following: -Policy: The facility recognizes and respects the importance of emotional and physical intimacy without regard to sexual orientation or gender. For the purpose of this policy, sexual expression is defined as words, gestures, movements or activities; including touching, flirting, and/or physical contact which appear motivated by the desire for affection, relationship, intimacy, and/or sexual gratification; -In this regard, residents have the right to seek and engage in consensual sexual expression with other residents. Residents also have the right to access and/or obtain for private use, materials with sexually explicit content; books, magazines, film, video, pictures, or drawings. To the extent possible, residents also have the right to access a private space in support of sexual expression; It is the function and responsibility of the staff to uphold and facilitate resident sexual expression. It is also the responsibility of the facility to provide comprehensive and culturally sensitive staff training to ensure resident rights to privacy and to protect residents from abuse. The facility will also develop a care plan and updates on a quarterly basis or when there is a significant change in circumstances. -Purpose: -To ensure that residents' right to safe and healthy sexual expression is recognized, respected, supported, and maintained. -To ensure staff uphold and support resident sexual expression as defined and described in policy. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/24, showed the following: -Severe cognitive impairment; -No behaviors; -Diagnoses of congestive heart failure and high blood pressure. Review of the residents's care plan, showed no documentation regarding sexual behavior or expression. Review of the resident's nurse's note, dated 3/6/25 at 6:02 P.M., showed at 5:30 P.M., this nurse found an opposite sex resident in his/her room at his/her bedside, receiving oral sex. The opposite sex resident was escorted out of room, and moved to another division. There was no injury noted to resident and his/her mood is pleasant. The reporter was unable to reach his/her family member to report situation. During an interview on 3/19/25 at 9:09 A.M., the resident said the person he/she was being intimate with was his/her partner. The resident said they had been dating and were sexually active. The resident he/she cares for his/her partner and wanted to be sexually active. The resident said they had been dating for a while and he/she was very comfortable. Review of Resident #2's admission MDS, dated [DATE], showed the following: -No cognitive impairment; -No behaviors; -Diagnoses of anemia (a condition where your blood doesn't have enough healthy red blood cells or hemoglobin, leading to reduced oxygen delivery to tissues and organs, causing symptoms like fatigue, weakness, and shortness of breath), high blood pressure, and end stage renal disease (ESRD, also known as kidney failure, is a condition where the kidneys have permanently lost most of their ability to function). Review of the resident's care plan, showed no documentation regarding sexual behavior or expression. Review of the resident's nurse's note, dated 3/6/25 at 5:40 P.M., showed the resident was observed in another resident's room, receiving oral sex. The resident was asked to leave this resident's room. The resident did leave the room while chanting boo hoo. The Director of Nursing (DON) and Administrator made aware. The resident was placed on 15 minute checks monitoring. Review of the resident's medical record, showed the resident was discharged home on 3/7/25. During an interview on 3/14/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said he/she was working the day when LPN B came to him/her and said Resident #2 was in Resident #1's room. LPN A said he/she went to Resident #1's room, knocked on the door, entered the room and Resident #2 was receiving oral sex from Resident #1. LPN A said he/she could see Resident #1 laying on the bed covered up with a blanket. LPN A said he/she asked Resident #2 to leave the room and was escorted to his/her room. LPN A said Resident #1 is cognitively impaired and could not consent to sexual activity. LPN A said he/she had recently been in-serviced on the facility's Abuse and Neglect Policy. During an interview on 3/14/25 at 12:47 P.M., LPN B said on 3/6/25 at approximately 5:30 P.M., he/she was coming into work and was walking the halls glancing in resident rooms, as he/she usually does when coming on shift. He/She looked in Resident #1's room and saw Resident #2 standing over Resident #1 with his/her pants down. LPN B went to get LPN A and they went into Resident #1's room. When they entered, Resident #2's mouth was near Resident #1's genitals. LPN B had Resident #1 leave the room immediately. LPN B was recently inserviced on the facility's Abuse and Neglect Policy. During an interview on 3/19/25 at 11:35 A.M., the Social Service Director (SSD) said the two residents were friendly with each other. The SSD said the two would often sit together and talk and never thought the two would become sexually involved. The SSD said due to the low cognitive score of Resident #1, he/she would not recommend the two residents be sexually involved. He/She was recently inserviced on the facility's Abuse and Neglect Policy. During an interview on 3/19/25 at 12:40 P.M., the DON said due to Resident #1's low cognitive score, he/she would not be able to consent to sexual behavior. The DON said he/she did not know the two would be sexually involved. MO00250654

Based on observation, interview and record review, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three residents (Resident #77, Resident #48, and Resident #17). Resident #77 and Resident #48 had a decline in ability to ambulate. Resident # 48 also had a hand contracture, with an order for a splint that was not applied in accordance with the Physician Order Sheet (POS) and care plan. Resident #17 had a hand contracture and no splint use was addressed on the POS and care plan. Additionally, the facility failed to develop resident care policies for restorative services, based on professional standards of practice, including designating who may provide specific treatments. The sample was 18. The census was 86. Review of the facility's Personal Care Needs policy, reviewed 1/2024, showed: -Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of residents. The facility also provides the needed support when the resident performs their activity of daily living (ADLs- bathing, toileting, dressing, etc.). The interdisciplinary plan of care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. Personal care and support include but is not limited to the following: -Ambulation; -Splints; -Procedure: -1. Complete interdisciplinary admission evaluations/observations in the electronic health record (EHR) and identify the individual needs and/or preferences of the resident; -2. Include the resident and/or family, responsible party in the development of the plan of care; -3. Present resident at the next scheduled IPOC; -4. Develop and implement individualized interventions. Document on individual resident care plan; -5. Communicate interventions to the staff and provide training as needed; -6. Educate resident and family as needed; -7. Observe compliance with individualized interventions during daily rounds and monitor resident outcomes; -8. Document in the progress notes if an exception to the established plan of care occurs; -9. Review and revise the plan of care as needed. Review of the facility's Physician Orders policy, reviewed 1/2023, showed: -Protocol: At the time each resident/patient is admitted , the facility will have physician orders for their immediate care. Physician's orders will be verified by the attending physician at the facility. All physician orders will be dated and signed according to State and Federal regulations. All clinicians may take verbal and/or telephone orders as permitted by their state licensure board; -Procedure: -1. Obtain one of the following types of physician orders: verbal, telephone order, transmitted by facsimile machine, written by the physician; -2. Assure physician's orders include the drug or treatment and a correlating medical diagnosis or reason; -3. Assure medication orders include route, dosage, frequency, strength, reason for administration, stop date (i.e., antibiotics); -5. Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician's Telephone Order form as an Orders Clarification.; -6. Confirm verbal and telephone orders by repeating back to the physician; -7. Obtain physician's countersignature within the required time frame as defined by State law. In the absence of State law, the countersignature will be obtained within seven days; -8. Receive and utilize a physician's faxed orders under the following conditions: -Physician signs and retains the original copy of the faxed order; -Physician provides the original copy if requested; -It is not necessary for the physician to re-sign the facsimile order unless required by State law; -Alternatively, the original may be sent to the facility at a later time and substituted for the facsimile copy; -9. Assure appropriate departments are aware of applicable orders; -10. Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change; -11. Fax all orders immediately to the pharmacy; -12. Note physician's orders (recaps/renewals, telephone/verbal, or fax orders, etc.) by writing noted, dating, and signing with name and title; -13. Confirm accuracy of orders when the new monthly orders arrive from pharmacy, transcription errors, errors of omission; -14. Assure physician signs the monthly recap/renewals orders. Do not make changes or updates on the document once it is signed by the physician; -15. Review orders from a physician other than the attending (specialist, consulting physician, etc.) with the attending physician prior to implementation unless the attending physician has given previous written direction to accept the specialist/consultant order(s). 1. During an interview on 2/7/24 at 9:57 A.M., the Director of Nurses (DON) said the facility does not have a restorative policy because the facility does not have a restorative program. When she began working at the facility, they did not have a restorative program. The facility will get a restorative program when they have enough staff available to have one. 2. Review of Resident #77's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/19/23, showed: -Cognitively intact; -Section G (functional status): the resident requires extensive assistance from staff with a one person physical assist for walking. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of anxiety disorder and major depressive disorder; -Section GG (functional ability): the resident uses a wheelchair for mobility. Review of the resident's care plan, dated 6/9/23, showed: -Problem: the resident has a self-care performance deficit; -Goal: the resident will improve current level of function through the review date. He/She will be able to: Transfer with stand by assist (SBA); -Interventions: the resident requires maximum assistance with transferring, physical therapy, occupational therapy, and speech therapy evaluation and treatment as per physician orders. Review of the resident's initial therapy discharge summary, dated 8/27/23, showed: -Long term goals: patient will ambulate with hemi cane (one hand usage cane) least restrictive device with caregiver to improve ambulation in home environment, patient will demonstrate fair standing balance and transfer with caregiver to improve transfers and decrease risk for falls; -Prognosis to maintain current level of function: good with consistent staff follow-through. Review of the resident's Occupational Therapy evaluation and plan of treatment, dated 11/16/23, showed: -Current referral: patient has hemiparesis in left side, referred to occupational therapy due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced sensation, reduced ability to safely ambulate, and reduced activities of daily living participation indicating the need for occupational therapy. Review of the resident's occupational therapy encounter note, dated 12/5/23, showed: -Summary of Skill: neurological re-education and techniques to facilitate motor control and postural control and static standing balance training, dynamic standing balance training, and training in balance recovery during mobility. Patient has been discharged from skilled occupational therapy. During an interview on 2/8/24 at 7:45 A.M., the resident said he/she used to be able to use a cane when he/she arrived to the facility but now is wheelchair bound. He/She believes this is due to the facility not having a restorative therapy program. During an interview on 2/8/24 at 9:38 A.M., the Director of Rehab (DOR) said the resident's initial therapy dates were from 5/12/23 to 8/25/23. The resident reached maximum potential for rehab on 8/25/23. At that time, he/she was able to walk using a quad cane with maximum assistance from staff. The resident was able to walk to the bathroom in his/her room from his/her bed. The resident came to the therapy department and requested further therapy which lasted from 11/16/23 to 12/5/23. The resident was no longer able to walk with his/her quad walker and was dependent on his/her wheelchair. The resident would greatly benefit from restorative therapy and might not have had his/her decline in movement if the facility had a restorative therapy program. During an interview on 2/8/24 at 10:43 A.M., Occupational Therapist (OT) E said therapy is not allowed to pick the resident up on therapy due to the resident's payor source. When therapy gets to work with the resident, therapy is only allowed between two and six visits. Therapy cannot get what needs to be done with the resident with that few number of visits. That is why a restorative program would benefit the resident. During an interview on 2/8/24 at 10:46 A.M., the DON said the resident has been seen by the therapy department and has good and bad days. The resident ambulates using his/her wheelchair. She said the resident can be resistive to assistance from nursing staff. The resident wants the therapy process to go faster and see results right away. The DON has never heard the resident request to walk with nursing staff. She believes the resident would benefit from restorative therapy and would like to see the facility implement a restorative therapy program. 3. Review of Resident #48's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Upper extremity impairment on one side; -Restorative nursing programs: Splint or brace assistance 0 minutes in last 7 days; -Diagnosis included stroke, high blood pressure, seizure disorder, and traumatic brain injury (TBI). Review of the resident's current care plan, showed: -Focus: Resident has an ADL self-care performance deficit related to fall at home and sustained a TBI, confusion and hemiplegia; -Goal: Resident will maintain current level of function in ADLs through the review date; -Interventions: -11/18/20, resident will wear a resting hand splint for left hand A.M. off in P.M. to maintain range of motion (ROM); -12/9/20, start restorative therapy three times weekly for three months for walking as ordered; -Focus: Resident is at risk for falls related to gait/balance problems, right side paralysis; -Goal: Resident will not sustain serious injury through the review date; -Interventions: Restorative therapy per order, discontinued. Date initiated 7/12/22, revision 6/12/23. Review of the resident's Physical Therapy discharge notes, dated 7/20/23, showed: -Long term goal: -1. Patient will demonstrate good/fair standing balance with functional mobility to improve transfers and gait and decreased risk for falls; -Prior level of function (PLOF), (prior to onset) good/fair; -Baseline (6/22/23) poor; -Previous (6/22/23) poor; -Discharge (7/20/23) poor; -2. Patient will safely perform functional transfers with supervised assist with reduced risk for fall in order to perform transfers with out physical assist or assistive device (AD), perform gait and transfers with increased safety and perform functional mobility with less risk for falls; -PLOF, (prior to onset) modified independence (MI, requires an assistive device or aid); -Baseline (6/22/23) contact guard assist (CGA, the caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task); -Previous (6/22/23) CGA; -Discharge (7/20/23) CGA; -3. Patient will ambulate without device or with least restrictive device for 200 feet and standby assist (SBA, the caregiver does not touch the patient or provide assistance but remains close to the patient for safety in case they lose their balance or need help to maintain safety during the task being performed); -PLOF, (prior to onset) MI; -Baseline (6/22/23) minimal assist (MA, Minimal assist is when the assisting person(s) or device(s) are required to perform approximately 25 percent of the work of a mobility task) X (times) two (two person assist) with encouragement; -Previous (6/22/23) MA X 2 with encouragement; -Discharge (7/20/23) 75 feet CGA with hand hold; -Discharge status and recommendations: -Prognosis: Prognosis to maintain current level of function (CLOF), good with consistent staff follow through; -Discharge recommendations: 24 hour care, CGA for ambulation, encourage ambulation daily; -Restorative nursing program (RNP): Not applicable (NA). Review of the resident's electronic Physician Order Sheet (ePOS), dated 2/7/24, showed: -Order dated 8/28/23, order type other orders (no documentation required), resident will have a resting hand splint for left hand don (put on) A.M. and doff (take off) P.M. in order to maintain ROM and avoid further contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) as tolerated. During an interview on 2/8/24 at 10:43 A.M., OT E said the order the resident has for the resting hand splint should be for the right hand not the left hand, in the order it says to prevent further contracture. The resident's right hand is the hand that is contracted. OT E said he/she has not seen the resident's hand splint for a long time. OT E said the resident was on restorative when the facility had the restorative program. The resident was walking with restorative and loved it, restorative also worked with the resident to move the right hand that is contracted, place the splint onto the right hand and do exercises with him/her. 4. Review of Resident #17's annual MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care not exhibited; -Upper extremity, lower extremity limitation in ROM, blank; -Restorative nursing programs: Splint or brace assistance 0 minutes in last 7 days; -Diagnosis included stroke, high blood pressure, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild loss of strength to one side of the body) following stroke. Review of the resident's current care plan, showed: -Focus: Resident has an ADL self-care performance deficit related to stroke with left hemiplegia, decreased active range of motion (AROM, movement of a joint provided entirely by the individual performing the exercise, there is no outside force aiding in the movement) to right hand with full passive range of motion (PROM, movement applied to a joint solely by another person or persons or a passive motion machine); -Goal: Resident will maintain current level of function or improve through the review date; -Interventions: Resident requires moderate assist with dressing related to stroke. During observation and interview on 2/8/24 at 9:03 A.M., the resident said he/she does not have a splint for his/her left hand anymore. The resident said he/she used to have a splint but he/she does not know what happened to it. The resident wore the splint when he/she had it, however, it has been a while since he/she has had the splint or worn it. The resident stopped wearing the splint because he/she could not get staff to assist him/her with putting it on. The resident tried to put the splint on himself/herself and he/she could not get the splint on correctly. The resident said his/her left hand has become a little more contracted since he/she has not been wearing the splint. The resident sat in an electric wheelchair and the resident's left hand rested on top of his/her left thigh with 4 fingers (index finger, middle finger, ring finger and pinkie) touching the palm of his/her hand. The thumb was resting and touching the index finger. During an interview on 2/8/24 at 10:27 A.M., the DOR said the resident had a hand splint years ago but she thought the resident did not like it. The resident was on the restorative program when the facility had one. The restorative program stopped around 2020 or 2021. The resident was previously on restorative for the hand splint and walking. The resident loved to walk, and the restorative aide would walk him/her. The resident would benefit from having restorative and the transfer goals from therapy to restorative would be for the resident to not have a decline in function. During an interview on 2/8/24 at 10:28 A.M., Certified Occupational Therapist Assistant (COTA) L said the resident used to have a splint for his/her contracted left hand and he/she would try and put the splint on himself/herself. The resident would try a lot to put the splint on and then he/she would get frustrated because he/she could not put it on. COTA L offered to order the resident a new splint and the resident said he/she is fine. 5. During an interview on 2/6/24 at 7:18 A.M., the Staffing Coordinator said the facility does not have a restorative program. This week, she was told she would be doing restorative, but she has not started doing it, yet. 6. During an interview on 2/7/24 at 7:47 A.M., the Staffing Coordinator said did not identify Resident #17 or Resident #48 as having a splint. The Staffing Coordinator said staff would know if a resident needed help with items like hearing aids or splints by the Certified Nurse Assistant (CNA) report sheet. The Staffing Coordinator could not locate the CNA report sheet. The Staffing Coordinator said if she could not locate a CNA report sheet, she would make one for the CNAs. The CNA report sheet would have information on it like how residents transfer, if the resident needs assistance with eating, and if they have hearing aids or splints and need assistance with putting them on. The Staffing Coordinator made a CNA report sheet, and it did not identify Resident #17 or Resident #48 as having a splint. 7. During an interview on 2/7/24 at 10:52 A.M., six Resident Council members, whom the facility identified as alert and oriented, said the facility does not have a restorative therapy program. The residents said the program was dropped approximately a year ago. The residents would like the facility to bring back a restorative therapy program. 8. During an interview on 2/7/24 at 12:52 P.M., Registered Nurse (RN) D said Resident #17 has a splint but he/she doesn't think Resident #17 wears it. RN D did not identify Resident # 48 as having a splint. RN D said if a resident had a stroke a splint would help the resident keep the limb from becoming contracted. RN D would know a resident has a splint by looking at the resident's orders and care plan. If a resident does not get the splint applied as ordered, if a limb is contracted from a stroke, the resident would have increased pain and the limb would contract more. 9. During an interview on 2/7/24 at 1:02 P.M., CNA J did not identify Resident #17 or Resident #48 as having a splint. CNA J said he/she would identify a resident had a splint by going into the resident's room and seeing the splint in the resident's room. If CNA J saw a splint sitting on a residents nightstand, he/she would ask the nurse which arm it goes on if therapy has not put the splint on yet. CNA J said therapy puts splints on the residents. He/She has never seen a nurse or CNA put on or take off splints. 10. During an interview on 2/7/24 at 1:10 P.M., Certified Medication Technician (CMT) H did not identify Resident #17 or Resident #48 as having a splint. CMT H would know a resident has a splint by looking at the resident's orders. CMT H would share that information with the CNAs on the floor if he/she noticed a resident had an order for a splint. There is not a system to know how long a splint has been on a resident or when it was put on and when it was taken off. CMT H said there is no documentation for splints. If a resident is supposed to have a splint and does not get it put on and taken off, the hand or arm would contract more, and it would become harder to move. 11. During an interview on 2/7/24 at 1:22 P.M., the DOR said there is not a process for referring residents who discharge off skilled therapy to a restorative program because the facility does not have a restorative program. When a resident is discharged off skilled services, the area on the discharge for the restorative nursing program is marked NA because the facility does not have a restorative nursing program. If a resident discharged is able to understand and follow directions, therapy will set up an individualized plan so the resident can come down to the therapy room themselves and be supervised while working through the individualized plan that was made for them. The DOR said it was two years ago when the company decided not to do restorative in this facility. The DOR would love to have the restorative program back because it bridges care between therapy and the floor and maintains the level of function between the quarterly reviews/screenings that are completed on the residents. 12. During an interview on 2/7/24 at 1:34 P.M., OT E said when residents discharge off therapy, he/she puts an order when the resident discharges. The order is for nursing to put the splint on in the morning and take off in the evening.The splints hold the good position, instead of the hand just hanging there. The splints help with joint alignment, skin integrity, and provides the limb with more stability. Without the splint, the hand contracture would worsen. There is no documentation nursing does to show when the splint is placed on the resident and removed from the resident. All residents would benefit from a restorative program. When residents only have movement from transfers like bed to wheelchair, they decline. If splints are not used, the contracture gets worse. 13. During an interview on 2/8/24 at 10:27 A.M., the DOR said all residents would benefit from a restorative program. Residents have a decline and then they must wait until therapy can pick them back up again. It is unfortunate for some residents who cannot have therapy due to payor sources like Medicaid. Residents have definitely declined without the facility having a restorative program. 14. During an interview on 2/8/24 at 11:20 A.M., the DON said the facility does not have a restorative program. The purpose of a restorative program is to maintain a person's optimum level of function. The DON is unsure how long the facility has been without a restorative program. The reason the facility does not have a restorative program is 100% due to staffing. The DON said if she would try to put a restorative program in place, as soon as someone calls out the restorative person would be the first person who would be pulled to cover the call in and then the facility would not be following physician orders. Nursing does what they can to keep the residents active. Nursing management has a patient at risk meeting every Thursday and they talk about residents who may need to be back on therapy. If there is a resident who is in need of therapy and only has Medicaid, they ask for permission for six visits if they have a decline. Therapy does braces and splints and the DON believes when therapy discharges the residents off therapy, they show the CNAs how to apply the braces and splints and educate the CNAs. The residents would benefit from having a restorative program because it would help to maintain the residents' optimal level of function. If a resident has a splint, it should be in the care plan and Kardex (gives a brief overview of each patient) and on the report sheet the Assistant Director of Nursing (ADON) and Clinical Supervisor C make. Nursing as a whole would be responsible for assisting a resident with putting on a splint and taking the splint off a resident. She is not sure if it is documented anywhere when splints are put on and taken off. If it was documented, it would be located on the resident's electronic Treatment Administration Record (eTAR). She expected if a resident has a splint, for it to be correctly care planned and have a correct physician order. The DON expected if a resident has a contracture and needs a splint, to have one. If a resident does not get a splint applied as ordered, the contracture would worsen. The DON expected staff to follow physician orders and to be knowledgeable of and follow the facility's policy and procedures. 15. During an interview on 2/8/24 at 12:09 P.M., the Administrator said she is aware the facility does not have a restorative program. She said they have discussed implementing a restorative program and would like to start a restorative program, but they have not hired anyone or started setting one up. The Administrator expected staff to follow physician orders. The Administrator expected staff to be knowledgeable of and follow the facility's policy and procedures. 46104 46888

Based on interview and record review, the facility failed to designate a person to serve as the Director of Dietary with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. This had the potential to affect all residents who consume meals at the facility. The census was 86. Review of the facility's director of dietary job requirements showed: -Qualifications: Certified Dietary Manager(CDM), Certified Food Protection Professional (CFPP) certification or registration as dietetic technician. During an interview on 2/8/24 at 11:21 A.M., the Administrator said the RD is not employed full time and is contracted. The Director of Dietary does not have the required qualifications. She would expect for the Director of Dietary to be certified for food handling.

Based on observation and interview, the facility failed to ensure staff were following proper hand hygiene procedures when serving food and assisting residents with meals. Further, the facility failed to ensure oversight when a resident used a drink cup to scoop ice from a community ice bucket in the dining room. The sample was 18. The census was 86. 1. Observation of the main dining room during the lunch meal on 2/5/24 at 12:24 P.M., showed Clinical Supervisor C and the Wound Nurse helping to make up and pass meal trays to residents in the dining room. Clinical Supervisor C and the Wound Nurse repeatedly served multiple resident trays with no hand hygiene in between serving the residents. Neither the Clinical Supervisor nor the Wound Nurse wore gloves as they touched the residents' plates to put them on the table. 2. Observation of the main dining room during the dinner meal on 2/5/24 at 5:56 P.M., showed the Dietary Director and Cook T making up and serving trays for staff to pass to residents. Neither the Dietary Director nor Cook T wore gloves while serving trays, touching resident plates and silverware, and placing food items on resident trays. Cook T repeatedly wiped his/her hands on a towel slung across the shoulder, wiped his/her nose, and adjusted his/her pants, with no hand hygiene performed between these actions and touching resident food items. 3. Observation of the main dining room during the breakfast meal on 2/6/24 at 8:19 A.M., showed the Dietary Director and Cook T making up and serving trays for staff to pass to residents in the dining room. Neither the Dietary Director nor Cook T wore gloves while serving trays, touching resident plates and silverware, and placing food items on trays. 4. Observation of the main dining room during the breakfast meal on 2/7/24 at 7:33 A.M., showed Cook T helping to serve trays to residents in the dining room with ungloved hands. Cook T cut up a resident's food with the resident's fork, wiped his/her hands on a rag at his/her shoulder, adjusted his/her pants, wiped his/her face, and then grabbed a meal ticket and served the next tray. Cook T did not perform hand hygiene between resident trays or before and after touching resident food items. 5. Observation on 2/6/24 at 12:01 P.M., showed an ice bin in the main dining room located on top of a table, with the lid of the ice bucket opened. A resident propelled up in a wheelchair and used a coffee cup to dip into the ice bucket and fill the cup with ice. Staff present in the dining room and did not redirect the resident. At 12:08 P.M., a staff person used the ice scoop, located in an ice scoop cup, to get ice for a resident. He/She left the ice bucket opened. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said the ice bin should only be accessed by staff. The lid should be down when not in use. A drink cup cannot be used to get ice from the ice bin. 6. During an interview on 2/8/24 at 8:29 A.M., Dietary Aide U said he/she was expected to wash his/her hands every time they touch a surface or change their gloves. He/She said proper hand washing should be done to prevent residents from getting sick. 7. During an interview on 2/8/24 at 8:35 A.M., the Dietary Director said she would expect for staff to be following hand washing procedures when handling food and assisting residents during meal times. The Dietary Director would expect for staff to be washing their hands every time they enter and exit the kitchen, when preparing and serving food, and whenever staff touch something.

Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to accommodate resident preferences and accommodate the residents' physical needs, to include hearing and vision difficulties. When concerns were brought to administration regarding the noise level in the dining room, no interventions were put in place and activities were continued in the dining room. The resident council representatives reported when activities are held in the dining room, it is too loud and it is hard to hear, and some residents have stopped going to activities when they are held in the dining room due to the noise level. In addition, two residents (Residents #17 and #16) reported concerns with the activities being held in the dining room. The sample was 18. The census was 86. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/21/23, showed: -Cognitively intact; -Hearing: adequate, no difficulty in normal conversation, social interaction; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included stroke, high blood pressure, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild loss of strength to one side of the body) flowing stroke. Review of the resident's current care plan, showed: -Focus: Resident participates in activity program; -Goal: Resident will attend/participate in activities of choice three to five times weekly by next review date, resident will help lead some activities by next review date; -Interventions: -Resident is a big bingo player and plays bingo every Tuesday, Thursday and Saturday; -Resident participates in morning chat, arts and crafts, bingo and entertainment parties of choice. During an interview on 2/5/24 at 12:39 P.M., the resident said he/she spoke to the Administrator last week regarding playing bingo in the dining room. The resident said he/she told the Administrator he/she and other residents could not hear the numbers being called because of all the other noise in the dining room such as people talking, dietary staff pushing carts through the dining room to set up for lunch, and other noise. The resident said the Administrator told him/her that she wanted the activity room full and if there are not enough residents participating in activities that she will close the activity room and move all activities to the dining room. The resident said he/she normally helps Resident #16 with bingo because Resident #16 cannot hear or see well. Resident #17 said he/she cannot help Resident #16 while playing bingo in the dining room because Resident #17 cannot hear well in the dining room himself/herself. Resident #16 told Resident #17 he/she will not go to the dining room to play bingo anymore because of how loud it is in the dining room. The resident also said there are three or four residents who will not go to the dining room to play bingo anymore. The resident said when playing bingo in the activity room, it gets loud in the hallway outside the activity room, and they can close the door to limit distractions and noise. The resident said in the dining room, there is not a door to close to limit distractions and noise. During an interview on 2/6/24 at 6:55 A.M., the resident said he/she might go play bingo today but he/she does not want to go because it is in the dining room. During an interview on 2/7/24 at 9:50 A.M., the resident said the experience of playing bingo in the dining room yesterday was quieter than it normally is. The resident said he/she still had problems hearing during bingo because of the carts going back and forth and people talking all the time. The resident said he/she did not hear all the numbers being called and did not even know he/she had a bingo until the Activity Director checked his/her bingo card. The resident said he/she did a verbal grievance to the Administrator on 2/1/24. The resident said the Administrator did not follow up with the resident after the grievance was voiced for him/her and other residents. The Administrator only told the resident if more people did not start showing up for activities that the activity room would be closed and all activities would be done in the dining room. The resident said some residents just did not show up for bingo in the dining room. 3. Review of Resident #16's annual MDS, dated [DATE], showed: -Cognitively intact; -Hearing: minimal difficulty in some environments when person speaks softly or setting in noisy; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). Review of the resident's current care plan, showed: -Focus: Resident is social and enjoys interacting with others. Resident prefers to choose his/her own level of participation; -Goal: Resident will attend/participate in activities of choice through review date; -Interventions: -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. -The resident's preferred activities are: bingo, morning chat, chair exercise, happy hours and some arts and crafts. During an interview on 2/5/24 at 10:55 A.M., the resident said bingo has been recently changed from the activity room to the dining room. The resident said this changed when the new Administrator came. The resident said that bingo is one of the only activities that he/she can do on his/her own. The resident said he/she went to play bingo last week in the dining room because Resident #17 said he/she would help him/her. The resident said the Activity Director knows how the residents feel but the Activity Director is obligated to do what she is told by the Administrator. The resident said he/she has never seen or spoken to the new Administrator. The resident said he/she will not be attending bingo if it is held in the dining room. During an interview on 2/6/24 at 10:32 A.M., Resident #16 said he/she would not attend bingo because it is being held in the dining room and he/she cannot see or hear in the dining room. During an interview on 2/7/24 at 10:14 A.M., the resident said he/she voiced his/her concern about playing bingo in the dining room to the Activity Director last week after playing bingo in the dining room. The Activity Director said she understood but the Administrator said bingo is to be done in the dining room. 4. Observations on 2/6/24 showed: -10:25 A.M., overhead announcement made that bingo will be held in the dining room at 10:30 A.M., floors in the dining room were actively being cleaned with a large machine, one resident playing piano in the dining room, TV on in the dining room; -10:35 A.M., Activity Director asked the resident playing the piano to stop playing because they were getting ready to play bingo, and the Activity Director also turned off the TV in the dining room; -10:38 A.M., two residents in the dining room talking to each other from one table to another table and then responding, I can't hear you. One resident left the table he/she was sitting at and propelled him/herself to the other table to speak with the other resident; -10:43 A.M., Activity Director announced getting ready to start and then began calling numbers; -10:44 A.M., resident asked Activity Director to repeat the number called; -10:46 A.M., soda machine in dining room making a loud humming sound, staff talking and laughing at receptionist desk, Maintenance Director working on reception desk using a power drill; -10:48 A.M., Resident #54 looking at the receptionist desk with a scowl on his/her face; -10:49 A.M., Maintenance Director continuing to use power drill on receptionist desk; -10:50 A.M., resident entering the dining room area walking to smoking area door and exiting through the door; -10:53 A.M., staff getting soda out of vending machine, soda loud when dispensed and echoing in dining room; -10:54 A.M., second staff member getting soda out of the vending machine, the soda was loud when dispensed and echoing in dining room; -10:56 A.M., Director of Nursing (DON) walking through the dining room and speaking to a resident; -10:57 A.M., resident propelling self to the soda machine; -10:59 A.M., receptionist paging on the overhead intercom; -11:00 A.M., staff at soda machine talking and assisting a resident with getting a soda, soda loud when dispensed and echoing in the dining room, another resident entered the dining room and exited through the smoke area door; -11:02 A.M., staff assisting a resident at the vending machine next to the soda machine to purchase snacks, phone ringing at receptionist desk and people talking at receptionist desk; -11:04 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, Maintenance Director using a hammer at receptionist desk, when hammer is struck it echoes loudly through the dining room, receptionist talking to people at the desk; -11:06 A.M., resident asking what Activity Director said; -11:06 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:07 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff talking at the receptionist desk and laughing, phone ringing at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:08 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room; -11:09 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the entrance, phone ringing from receptionist desk; -11:10 A.M., dietary staff rolling cart of dishes through the dining room, loud clanging of dishes as dietary rolled the cart through the dining room; -11:11 A.M., loud talking at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:11 A.M., dietary staff loading dishes off cart onto a table in the dining room, dishes loudly clanging together and echoing through the dining room; -11:12 A.M., staff at vending machine purchasing snack then at soda machine purchasing soda, when soda dispenses echoes loudly though dining room; -11:13 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:13 A.M., Maintenance Director using air nail hammer on receptionist desk, very loud and echoing through the dining room, alarm sounding at door next to Administrator's office, all noises echoing through the dining room; -11:14 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk, noise very loud and echoing in the dining room, resident at soda machine; -11:15 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk; -11:16 A.M., resident at soda machine purchasing soda, soda loud when dispensed and echoing in dining room; -11:19 A.M., door next to Administrator's office leading to administrative offices opening and then closing loudly and echoing through the dining room; -11:21 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to the Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:22 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking loudly at receptionist desk, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:23 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:24 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:26 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:27 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:29 A.M., resident having a conversation with someone walking through the dining room; -11:30 A.M., door next to the Administrator's office opening and then closing loudly, echoing through the dining room, resident entering the dining room and walking to smoking area door and exiting out the door; -11:31 A.M., Resident #17 asking Activity Director if she called number 58, Activity Director said yes and walked over to Resident #17 and checked his/her bingo card and Resident #17 said he/she had a bingo too; -11:32 A.M., several people around receptionist desk and talking loudly, resident at the soda machine to purchase a soda, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:33 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:35 A.M., soda machine making loud buzzing noise again; -11:36 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot, door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the receptionist desk; -11:37 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:38 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room; -11:39 A.M., staff rolling computer stand cart with computer through the dining room, cart wheels echoing in dining room; -11:40 A.M., resident getting ice out of cooler at hydration station in dining room, when ice is moved crunching sound loudly echoes through dining room, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:41 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff brining residents into the dining room for lunch and asking the residents where they would like to sit; -11:42 A.M., dietary staff moving plates around and clinking the plates together while moving them; -11:43 A.M., staff asking residents who were brought into the dining room what they would like to drink; -11:44 A.M., staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup, staff putting ice into second cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cups; -11:45 A.M., resident speaking loudly to receptionist at receptionist desk, staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cups; -11:46 A.M., resident who was brought in for lunch by staff began yelling out help in dining room, while sitting in broda chair (a specialized reclining chair propelled by staff) in front of dining table, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room; -11:47 A.M., visitor walking through dining room with keys hanging on side and clanking together as walking through dining room; -11:48 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:49 A.M., people talking at the receptionist desk, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room, resident called bingo for cover all game. 5. During an interview on 2/6/24 at 12:10 P.M., the Activity Director said examples of activities that are normally done in the dining room are when entertainment comes, and events with parties. The Activity Director said bingo has not always been played in the dining room and the Administrator told the Activity Director right before the February activity calendar came out that bingo needs to be done in the dining room. The Administrator said if activities did not start incorporating more activities in the dining room, she was going to move the Activity Director's office to a smaller office and have all activities performed in the dining room. The Activity Director said the Administrator did not say why but she thought the Administrator was trying to get more residents to participate in activities. The Activity Director said there are problems with the noise level in the dining room when playing bingo and several residents have complained about the noise level. Resident #16 came to the bingo game on 2/1/24 and stayed the entire game and at the end of the game Resident #16 said he/she cannot hear or see in the dining room. Resident #16 usually sits next to Resident #17 and Resident #17 helps Resident #16 while playing bingo. Resident #16 declined to come to bingo today and that is abnormal for him/her to decline. Resident #16 attended every bingo prior to changing it to the dining room. Resident #16 told the Activity Director that he/she cannot see in the dining room due to the light in the dining room. Resident #16 said the lighting makes it hard for him/her to see. The Activity Director said that Resident #16 has some issues when playing bingo in the activity room but in the dining room it is a lot worse for Resident #16. Resident #16 also had complaints of not being able to hear while playing bingo in the dining room. The Activity Director said the Administrator is aware that residents have complaints about the noise level in the dining room. Resident #17 went and spoke to the Administrator on 2/1/24 and told the Administrator that residents do not like going to the dining room for bingo due to the noise and distractions. The Activity Director said she gets more participation in the activity room for bingo than in the dining room. The Activity Director said there is nothing that can be done in the dining room to decrease the noise levels. The Activity Director said staff will bring residents into the dining room who are not participating in bingo and some of those residents will yell out things like help while the other residents are participating in bingo. There have been other times when residents have come into the dining room themselves and they are not participating in bingo and will yell out bingo or call out numbers after the Activity Director has called out a number. This confuses and frustrates the residents who are participating in the bingo activity. There is also a resident who likes to play the piano in the dining room and that resident sometimes goes to the piano and plays while bingo is being played. Family members will walk in and talk at the receptionist desk, employees will pass through the dining room and talk to people in the front receptionist area. The Activity Director said there is no way to shut the dining room off from the noise because there is no door to close the dining room off from the front receptionist area. The Activity Director said most of the noise comes from the front receptionist area and there is nothing that can be done about that. The Activity Director said she is aware that some residents are not attending bingo due to it being held in the dining room. The Activity Director said residents will voice to her after bingo is over, in private, that they are having problems hearing. Some residents may ask during bingo for a number to be repeated but some will wait and talk to her afterwards in private. 6. During an interview on 2/7/24 at 9:06 A.M., Registered Nurse (RN) D said several residents have voiced concerns about going to the dining room for bingo. RN D said he/she is not sure of the resident's names from the other hall but Resident #17 says it is too loud in the dining room and they cannot hear. People that are not doing activities such as a resident that yells out and sits in a broda chair will be brought into the dining room while bingo is being called and the resident will yell out for help. Resident #16 said that it is too loud and people that are not participating in activities are in the dining room yelling, the TV will be on and can't hear numbers being called because it is too big of a room, and everything echoes in the room. 7. During an interview on 2/7/24 at 10:23 A.M., Certified Medication Technician (CMT) H said Resident #17 has voiced concerns about playing bingo in the dining room because he/she cannot hear and there are too many people who are talking, and the room is huge, and they cannot hear. CMT H said the residents were playing bingo in the activity room but now they are playing in the dining room. 8. During an interview on 2/7/24 at 10:35 A.M., six Resident Council members, whom the facility identified as alert and oriented, said they like activities to be held in the activity room. The residents said the dining room is too loud and it is hard to hear. The residents said some residents have stopped going to activities when they are held in the dining room due to the noise level. 9. During an interview on 2/8/24 at 1:30 P.M., the Administrator said that Resident #17 came into her office and voiced a concern about having bingo in the dining room and said he/she wanted bingo to be moved back into the activity room. The Administrator said Resident #17 came in the first time bingo was played in the dining room and said that him/her and a couple of other residents wanted bingo to be in the activity room instead of the dining room. The Administrator said she told Resident #17 that she wants a bigger crowd to come to bingo. The Administrator said bingo is a popular activity and she wanted more people to come. The Administrator said she was hoping he/she might like it after a couple more times of playing in the dining room. The Administrator felt like this was something Resident #17 was not willing to give a chance and that he/she did not like change and the Administrator was asking for him/her to give it a chance. The Administrator said the reason Resident #17 gave for not wanting bingo in the dining room was because it is loud in the dining room, and it makes it hard to hear. The Administrator said she has not followed up with Resident #17 related to the concern of it being loud in the dining room and that it is hard to hear. The Administrator also said no adjustments have been made while playing bingo in the dining room related to the noise level. The Administrator said she was not aware that several residents did not like having bingo in the dining room because of the noise level and not being able to hear well. The Administrator was also not aware that one resident was no longer attending bingo because it was being held in the dining room and the resident was having problems seeing due to the lighting in the dining room and hearing in the dining room due to it being loud. The administrator said activities should accommodate resident's preferences and accommodate the residents physical needs to include hearing and vision difficulties.

Based on observation, interview and record review, the facility failed to make prompt efforts to resolve grievances when the facility did not file the grievance and/or the resolution for two residents (Resident #17 and Resident #16). The facility failed to make information on how to file a grievance available to the residents, notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, and the contact information of the Grievance Official with whom a grievance can be filed. In addition, the facility failed to have access to the grievance box that was locked and located in the dining room with grievances in the box. The sample was 18. The census was 86. Review of the facility's undated Grievance Committee Policy and Procedure, showed: -Purpose: The facility Grievance Committee is established for the sole purpose of resolving complaints, which are referred to the committees by residents, sponsors, family members or other interested parties on behalf of the resident. The Grievance Committee will also receive and respond to complaints referred by the Ohio Department of Health. The resident and/or responsible party has the right to file a grievance anonymously, orally or in writing; -Committee Composition: -The Grievance Committee shall be composed of six members. The facility representative will be the Director of Nursing or assigned designee and the facility Social Worker. The remaining four members will be residents, sponsors and/or outside representatives; -Staff members will serve on the Committees as permanent members. Residents, sponsors, and/or outside representatives will be selected for the Committee by the facility Administrator. These members shall serve on the Committee until their participation becomes impractical or a resignation occurs. The Grievance Committee Chairperson will be the facility Administrator or assigned designee. You may contact the grievance official at (information for Administrator listed); -Committee meetings and documentation: -The Committee will meet at least annually to review any policies or activities deemed necessary by the Committee Chairperson. Meetings will be held on an as needed basis when complaints or grievances are received from residents, sponsors, or the Missouri Department of Health and Senior Services. The facility will first try to resolve concerns or complaints by residents or resident sponsors through meeting with facility administration. If the concern or complaint cannot be resolved through the facility administration, the full committee will meet within two business days to review and resolve the complaint. Whenever necessary, the Committee Chairperson will select temporary substitute representatives and assure the proper ratio of Committee members. The ratio will be maintained at one facility member per two residents or sponsors; -Committee Documentation: -Whenever possible, residents or sponsors will be encouraged to make complaints in writing to the Committee utilizing a standard Resident Concern Form. Meetings will be documented, and records will be maintained on file for three years; -Complaint Resolution: -The Grievance Committee will determine if a violation of Residents Rights has occurred. If a violation is found, the Committee will attempt to resolve the complaint. The facility Administrator will be notified of the steps the Committee will take to resolve the issue. If the Grievance Committee is unable to resolve a complaint referred by the Missouri Department of Health and Senior Services within ten days, the complaint will be returned to the Missouri Department of Health and Senior Services for further documentation. All actions taken by the Grievance Committee on complaints referred by the Missouri Department of Health and Senior Services will be documented on the form issued by the Missouri Department of Health and Senior Services and returned to them within 30 days from the date of notice. Any issues or concerns regarding violation of Resident Rights that is discussed in Resident Council will be referred to the Grievance Committee. All actions taken by the Grievance Committee that directly affect the residents of the home will be followed up on and discussed in Resident Council. The resident and/or responsible party also may contact the Missouri Department of Health and Senior Services and the State Long Term Care Ombudsman Program. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/21/23, showed: -Cognitively intact; -Hearing: adequate, no difficulty in normal conversation, social interaction; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnoses included stroke, high blood pressure, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild loss of strength to one side of the body) flowing stroke. Review of the resident's current care plan, showed: -Focus: Resident participates in activity program; -Goal: Resident will attend/participate in activities of choice three to five times weekly by next review date, resident will help lead some activities by next review date; -Interventions: -Resident is a big bingo player and plays bingo every Tuesday, Thursday and Saturday; -Resident participates in morning chat, arts and crafts, bingo and entertainment parties of choice. During an interview on 2/5/24 at 12:39 P.M., the resident said he/she spoke to the Administrator last week regarding playing bingo in the dining room. The resident said he/she told the Administrator that he/she and other residents could not hear the numbers being called because of all the other noise in the dining room such as people talking, dietary staff pushing carts through the dining room to set up for lunch, and other noise. The resident said the Administrator told him/her that she wanted the activity room full and if there are not enough residents participating in activities that she will close the activity room and move all activities to the dining room. The resident said he/she normally helps Resident #16 with bingo because Resident #16 cannot hear or see well. Resident #17 said he/she cannot help Resident #16 while playing bingo in the dining room because Resident #17 cannot hear well in the dining room himself/herself. Resident #16 told Resident #17 he/she will not go to the dining room to play bingo anymore because of how loud it is in the dining room. The resident also said there are three or four residents who will not go to the dining room to play bingo anymore. The resident said when playing bingo in the activity room, if it gets loud in the hallway outside the activity room, they can close the door to limit distractions and noise. The resident said in the dining room there is not a door to close to limit distractions and noise. During an interview on 2/6/24 at 6:55 A.M., the resident said he/she might go play bingo today but he/she does not want to go because it is in the dining room. During an interview on 2/7/24 at 9:50 A.M., the resident said the experience of playing bingo in the dining room yesterday was quieter than it normally is. The resident said he/she still had problems hearing during bingo because of the carts going back and forth and people talking all the time. The resident said he/she did not hear all the numbers being called and did not even know he/she had a bingo until the Activity Director checked his/her bingo card. The resident said he/she made a verbal grievance to the Administrator on 2/1/24. The resident said the Administrator did not follow up with the resident after the grievance was voiced for him/her and other residents. The Administrator only told the resident that if more people did not start showing up for activities, the activity room would be closed and all activities would be done in the dining room. The resident said some residents just did not show up for bingo in the dining room. 2. Review of Resident #16's annual MDS, dated [DATE], showed: -Cognitively intact; -Hearing: minimal difficulty in some environments when person speaks softly or setting in noisy; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). Review of the resident's care plan, showed: -Focus: Resident is social and enjoys interacting with others. Resident prefers to choose his/her own level of participation; -Goal: Resident will attend/participate in activities of choice through review date; -Interventions: -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. -The resident's preferred activities are: bingo, morning chat, chair exercise, happy hours and some arts and crafts. During an interview on 2/5/24 at 10:55 A.M., the resident said bingo has been recently changed from the activity room to the dining room. The resident said this changed when the new Administrator came. The resident said that bingo is one of the only activities that he/she can do on his/her own. The resident said he/she went to play bingo last week in the dining room because Resident #17 said he/she would help him/her. The resident said the Activity Director knows how the residents feel but the Activity Director is obligated to do what she is told by the Administrator. The resident said he/she has never seen or spoken to the new Administrator. The resident said he/she will not be attending bingo if it is held in the dining room. During an interview on 2/6/24 at 10:32 A.M., the resident said he/she would not attend bingo because it is being held in the dining room and he/she cannot see or hear in the dining room. During an interview on 2/7/24 at 10:14 A.M., the resident said he/she voiced his/her concern about playing bingo in the dining room to the Activity Director last week after playing bingo in the dining room. The Activity Director said she understood but the Administrator said bingo is to be done in the dining room. 3. Observations on 2/6/24 showed: -10:25 A.M., overhead announcement made that bingo will be held in the dining room at 10:30 A.M., floors in the dining room actively being cleaned with large machine, one resident playing piano in dining room, TV on in dining room; -10:35 A.M., Activity Director asked the resident playing the piano to stop playing because they were getting ready to play bingo, and Activity Director also turned off the TV in dining room; -10:38 A.M., two residents in the dining room talking to each other from one table to another table and then responding, I can't hear you. One resident left the table he/she was sitting at and propelled self to the other table to speak with the other resident; -10:43 A.M., Activity Director announced getting ready to start and then began calling numbers; -10:44 A.M., resident asked Activity Director to repeat number called; -10:46 A.M., soda machine in dining room making a loud humming sound, staff talking and laughing at receptionist desk, Maintenance Director working on reception desk using a power drill; -10:48 A.M., Resident #54 looking at the receptionist desk with scowl on his/her face; -10:49 A.M., Maintenance Director continuing to use power drill on receptionist desk; -10:50 A.M., resident entering the dining room area walking to smoking area door and exiting through the door; -10:53 A.M., staff getting soda out of vending machine, soda loud when dispensed and echoing in dining room; -10:54 A.M., second staff member getting soda out of the vending machine, soda loud when dispensed and echoing in dining room; -10:56 A.M., Director of Nursing (DON) walking through dining room and speaking to a resident; -10:57 A.M., resident propelling self to soda machine; -10:59 A.M., receptionist paging on the overhead intercom; -11:00 A.M., staff at soda machine talking and assisting a resident with getting a soda, soda loud when dispensed and echoing in dining room, another resident entered the dining room and exited through the smoke area door; -11:02 A.M., staff assisting a resident at the vending machine next to soda machine to purchase snacks, phone ringing at receptionist desk and people talking at receptionist desk; -11:04 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, Maintenance Director using hammer at receptionist desk, when hammer is struck it echoes loudly through the dining room, receptionist talking to people at the desk; -11:06 A.M., resident asking what Activity Director said; -11:06 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:07 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff talking to receptionist desk and laughing, phone ringing at receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:08 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room; -11:09 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the entrance, phone ringing from receptionist desk; -11:10 A.M., dietary staff rolling cart of dishes through the dining room, loud clanging of dishes as dietary rolled the cart through the dining room; -11:11 A.M., loud talking at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:11 A.M., dietary staff loading dishes off cart onto table in dining room, dishes loudly clanging together and echoing through the dining room; -11:12 A.M., staff at vending machine purchasing snack then at soda machine purchasing soda, when soda dispenses echoes loudly though dining room; -11:13 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:13 A.M., Maintenance Director using air nail hammer on receptionist desk very loud and echoing through the dining room, alarm sounding at door next to Administrator's office, all noises echoing through the dining room; -11:14 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk, noise very loud and echoing in dining room, resident at soda machine; -11:15 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk; -11:16 A.M., resident at soda machine purchasing soda, soda loud when dispensed and echoing in dining room; -11:19 A.M., door next to Administrator's office leading to administrative offices opening and then closing loudly and echoing through the dining room; -11:21 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:22 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking loudly at receptionist desk, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:23 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:24 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:26 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:27 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:29 A.M., resident having a conversation with someone walking through the dining room; -11:30 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, resident entering the dining room and walking to smoking area door and exiting out the door; -11:31 A.M., Resident #17 asking Activity Director if she called number 58, Activity Director said yes and walked over to Resident #17 and checked his/her bingo card and Resident #17 said I have a bingo too; -11:32 A.M., several people around receptionist desk and talking loudly, resident at the soda machine to purchase a soda, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:33 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:35 A.M., soda machine making loud buzzing noise again; -11:36 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot, door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the receptionist desk; -11:37 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:38 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room; -11:39 A.M., staff rolling computer stand cart with computer through the dining room, cart wheels echoing in dining room; -11:40 A.M., resident getting ice out of cooler at hydration station in dining room, when ice is moved crunching sound loudly echoes through dining room, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:41 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff brining residents into the dining room for lunch and asking the residents where they would like to sit; -11:42 A.M., dietary staff moving plates around and clinking the plates together while moving them; -11:43 A.M., staff asking residents who were brought into the dining room what they would like to drink; -11:44 A.M., staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup, staff putting ice into second cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup; -11:45 A.M., resident speaking loudly to receptionist at receptionist desk, staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup; -11:46 A.M., resident who was brought in for lunch by staff began yelling out help in dining room, while sitting in broda chair (a specialized reclining chair propelled by staff) in front of dining table, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room; -11:47 A.M., visitor walking through dining room with keys hanging on side and clanking together as walking through dining room; -11:48 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:49 A.M., people talking at the receptionist desk, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room, resident called bingo for cover all game. 4. During an interview on 2/6/24 at 12:10 P.M., the Activity Director said examples of activities that are normally done in the dining room are when entertainment comes, and events with parties. The Activity Director said bingo has not always been played in the dining room and the Administrator told the Activity Director right before the February activity calendar came out that bingo needs to be done in the dining room. The Administrator said if activities did not start incorporating more activities in the dining room that she was going to move the Activity Director's office to a smaller office and have all activities preformed in the dining room. The Activity Director said the Administrator did not say why but she thought the Administrator was trying to get more residents to participate in activities. The Activity Director said there are problems with the noise level in the dining room when playing bingo and several residents have complained about the noise level. Resident # 16 came to the bingo game on 2/1/24 and stayed the entire game and at the end of the game Resident #16 said he/she cannot hear or see in the dining room. Resident #16 usually sits next to Resident #17 and Resident #17 helps Resident #16 while playing bingo. Resident #16 declined to come to bingo today and that is abnormal for him/her to decline. Resident #16 attended every bingo prior to changing it to the dining room. Resident #16 told the Activity Director he/she cannot see in the dining room due to the light in the dining room. Resident #16 said the lighting makes it hard for him/her to see. The Activity Director said that Resident #16 has some issues when playing bingo in the activity room but in the dining room it is a lot worse for Resident #16. Resident #16 also had complaints of not being able to hear while playing bingo in the dining room. The Activity Director said the Administrator is aware residents have complaints about the noise level in the dining room. Resident #17 went and spoke to the Administrator on 2/1/24 and told the Administrator that residents do not like going to the dining room for bingo due to the noise and distractions. The Activity Director said she gets more participation in the activity room for bingo than in the dining room. The Activity Director said there is nothing that can be done in the dining room to decrease the noise levels. The Activity Director said staff will bring residents into the dining room who are not participating in bingo and some of those residents will yell out things like help. There have been other times when residents have come into the dining room themselves and they are not participating in bingo and will yell out bingo or call out numbers after the Activity Director has called out a number. This confuses and frustrates the residents who are participating in the bingo activity. There is also a resident who likes to play the piano in the dining room and that resident sometimes goes to the piano and plays while bingo is being played. Family members will walk in and talk at the receptionist desk, employees will pass through the dining room and talk to people in the front receptionist area. The Activity Director said there is no way to shut the dining room off from the noise because there is no door to close the dining room off from the front receptionist area. The Activity Director said most of the noise comes from the front receptionist area and there is nothing that can be done about that. The Activity Director said she is aware some residents are not attending bingo due to it being held in the dining room. The Activity Director said residents will voice to her after bingo is over in private that they are having problems hearing. Some residents may ask during bingo for a number to be repeated but some will wait and talk to her afterwards in private. 5. During an interview on 2/6/24 at 12:11 P.M., the DON said there have been no grievances filed to date in 2024. She attended the last Resident Council and there were no concerns. 6. During an interview on 2/7/24 at 9:06 A.M., Registered Nurse (RN) D said several residents have voiced concerns about going to the dining room for bingo. RN D said he/she is not sure of the resident's names from the other hall but Resident #17 says it is too loud in the dining room and they cannot hear. People that are not doing activities such as a resident that yells out and sits in a broda chair will be brought into the dining room while bingo is being called and the resident will yell out help. Resident #16 said that it is too loud and people that are not participating in activities are in the dining room yelling, the TV will be on and can't hear numbers being called because it is too big of a room, and everything echoes in the room. RN D said that he/she could assist residents in filling out a grievance, but he/she knows the Activity Director and will just go to her and let her know the concerns. RN D said if it was a big deal he/she would imagine he/she would need to fill out a grievance for residents because some of them cannot write. RN D said blank grievances can be located at the nurse's station and looked at the nurse's station and was unable to locate a grievance form. RN D said if he/she needed a grievance form and could not locate one at the nurse's station he/she would ask Clinical Supervisor C for a grievance form. RN D said if he/she filled out a grievance form for a resident, he/she would turn it into the Assistant Director of Nursing (ADON). 7. During an interview on 2/7/24 at 10:23 A.M., Certified Medication Technician (CMT) H said Resident #17 has voiced concerns about playing bingo in the dining room because he/she cannot hear and there are too many people that are talking, and the room is huge, and they cannot hear. CMT H said the residents were playing bingo in the activity room but now they are playing in the dining room. 8. During an interview on 2/7/24 at 10:35 A.M., six Resident Council members, whom the facility identified as alert and oriented, said they do not feel that their grievances are followed up on. The residents said they will file a grievance with staff and will either not hear back or will hear back but not in a timely manner. 9. During an interview on 2/7/24 at 12:13 P.M., the DON knocked on the conference room door that is located directly across from the receptionist desk and then opened the door stating she could not hear if anyone said come in because of the noise outside the conference room. 10. During an observation on 2/8/24 at 8:35 A.M., showed the grievance box located in the dining room. The grievance box looked like a mailbox with a clear window on the front that goes down the middle of the box, there was a lock on the box. Several papers could be visualized through the clear window, that are inside the grievance box that had not been removed. Next to the grievance box was a folder on the wall with blank grievance sheets in it. No postings next to the grievance box or in the folder with information or directions on how grievances can be filed out. No information posted on who the grievance officer was or contact information for the grievance officer. 11. During an interview on 2/8/24 at 8:45 A.M., Certified Nurse Assistant (CNA) K said if a resident has a complaint, he/she would assess it and then would take the concern to the charge nurse. CNA K said he/she would assist a resident with filling out a grievance if needed. CNA K said blank grievance forms can be located at the nurse's station and in the DON's office. CNA K said he/she would turn in the filled out grievance form to the DON or Administrator. 12. During an interview on 2/8/24 at 8:52 A.M., CNA J said if a resident had a complaint, he/she would alert the nurse. CNA J said he/she did not think he/she could fill out a grievance for a resident. CNA J said blank grievance forms can be located in the dining room. CNA J said he/she would direct the resident to turn in the grievance form they filled out to the charge nurse or the DON. 13. During an interview on 2/8/24 at 9:10 A.M., CMT H said if a resident had a complaint, he/she would start by talking to the resident and see if he/she could help with the complaint. If CMT H could not help with the complaint he/she would refer the resident to the person that could help them. CMT H said he/she would fill out a grievance for a resident, but CMT H said he/she has never filled one out for a resident. CMT H said he/she would only fill one out if the resident could not write. CMT H said blank grievance forms can be located in the ADON office, DON office, and in the cubby next to the Human Resources (HR) office. CMT H said he/she is unsure on the exact person to turn in a grievance form that has been filled out. He/She would give the grievance form that has been filled out to the Social Worker, DON, or Clinical Supervisor C. 14. During an interview on 2/8/24 at 11:20 A.M., the DON said she expected staff to fill out a grievance for a resident if the resident voices a concern that staff cannot resolve themselves. After filling out the grievance for the resident, the staff member should let the resident read the grievance and make sure it is correct and have the resident sign or initial the grievance, if possible, to show that the grievance is correct. Grievances can be located at the front desk and at the nurse's station. The grievance process is the Social Worker and the Administrator keep the grievance book. If someone turns in a grievance the grievance is discussed with the interdisciplinary team (IDT) to find a solution. The DON said there have not been any grievances in the month of January. The DON said if a resident voices a verbal concern and she cannot fix the concern, it would become a grievance and the DON would offer to help the resident write the grievance if he/she could not write. Grievances should be turned into the Social Worker or Administrator. The DON also said she believes there is also a grievance box in the dining room where they can be turned into, but she would personally take it to the Social Worker or Administrator. The Social Worker is responsible for following up with the person filling out the grievance. Anyone on the management team can also follow up with a person filling out a grievance. The DON said she is not sure on what the timeframe is that the grievance needs to be followed up on. If there are grievances, they are discussed daily in morning meeting and during the weekly risk meeting on Thursdays. 15. During an interview on 2/8/24 at 12:09 P.M., the Administrator said if a grievance was vocalized, she would fill out a grievance for the resident. The Administrator said that she has asked residents before if they want to file a grievance and she will if the resident wants one filled out and sometimes the residents say no, they do not want a grievance filled out. They just wanted to talk. The Administrator said she would follow up with the resident regarding any concerns they have. The Administrator said anyone can file a grievance. The Administrator said the Social Worker is the Grievance Officer and she and the DON are the back up for the Social Worker. The Administrator said a grievance can be brought up at anytime and does not have to only be voiced during Resident Council meetings. The Social Worker is responsible for following up with any grievances unless the Social Worker cannot fix the problem. If the Social Worker cannot fix the problem, the department manager

Based on observation, interview and record review, the facility failed to ensure each resident receives assistance to prevent accidents, for three residents observed to be propelled down the hall in a wheelchair with their feet dragging (Residents #37, #14, and #86). In addition, the facility failed to use a gait belt to transfer one resident observed to be transferred from the bed to wheelchair (Resident #19). 1. Review of Resident #37's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/23/23, showed: -Severe cognitive impairment; -Does the resident use a wheelchair or a scooter: Yes; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has an activity of daily living (ADL) self-care performance deficit related to overall decline in functioning ability; -Goal: Improve current level of function; -Interventions: The resident requires moderate to total assistance by staff to move between surfaces. Observation on 2/6/24 at 7:39 A.M., showed a staff person propelled the resident down the hall, past 17 rooms and into the dining room. No footrests were in place on the wheelchair and the resident held his/her feet up. The resident wore socks and his/her right heel drug on the ground as staff propelled the resident down the hall. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Mobility devices: Wheelchair; -Diagnoses included traumatic brain dysfunction. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Moderate assist with ADLs. Weakness and history of traumatic brain injury and decreased mobility; -Goal: Maintain participation in functioning in ADLs; -Resident requires moderate assistance with bed mobility and transfer. Observation on 2/7/24 at 1:18 P.M., showed Occupational Therapist E propelled the resident down the hall. His/Her feet lightly touched the floor with a shuffle sound while his/her feet drug. The resident's feet suddenly dropped, causing an abrupt stop of the wheelchair. The resident's upper body flexed forward then fell back gently against back of the chair. Occupational Therapist E then proceeded to propel the resident into his/her room. 3. Review of Resident #86's admission MDS, dated [DATE], showed: -Cognitively intact; -Does the resident use a wheelchair or scooter: No; -Diagnoses included other neurological conditions. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: ADL self-care performance deficit related to impaired balance; -Goal: Improve current level of function in ADLs; -Interventions: The resident requires partial assistance by staff to move between surfaces. Observation on 2/6/24 at 8:01 A.M., showed a staff person transferred the resident down the hall in a wheelchair from the dining room to his/her room. No footrests were on the wheelchair. The resident wore socks and held his/her feet up. The resident's feet hung only a half of an inch from the floor. As the staff turned the resident into his/her room, his/her left foot dropped and drug the floor. 4. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said when propelling a resident in a wheelchair, the resident's feet should be placed on foot pedals. They should not drag on the ground. The facility purchased bags for the wheelchair for the foot pedals to be stored when not in use. The risk of the resident's feet dragging is a possible fall from the wheelchair. 5. Review of the facility's Gait Belt Transfer policy, dated 10/2023, showed: -Purpose: Minimize the risk of injury to caregiver while performing transfers; -Procedure included: Fasten the gait belt securely around the resident's waste with the buckle at the side. The belt should not come in contact with the resident's skin; -Position one hand under the buckle; -Position the other hand under the belt, The belt should be snug; -Transfer the resident using proper body mechanics. Review of Resident #19's medical record, showed diagnoses included: stroke, hemiplegia (paralysis on one side of the body) or hemiparesis (weakness to one side of the body), and thoracic 7-8 vertebra fracture (a fracture of the mid back). Review of the resident's care plan, in use at the time of the survey, showed the resident had an ADL self-care performance deficit related to overall decline in functioning, transferring requires moderate assist of one staff to move between surfaces. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Impairment on one side for functional limitation in range of motion; -Partial/moderate assistance to roll left and right for mobility; -Substantial/maximal assistance - helper does more than half the effort for chair/bed to chair transfer; Lying to sitting on side of bed: The ability to move form lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Observation on 2/7/24 at 6:20 A.M., showed Certified Nursing Assistant (CNA) G announced to the resident that he/she was going to transfer the resident to the wheelchair. He/She assisted the resident from a laying position, to sitting on the side of the bed. The CNA then positioned his/her arms under each of the resident's arms, in the armpits. The CNA then lifted the resident and pivoted the resident to the wheelchair. No gait belt was used. During an interview on 2/7/24 at 1:18 P.M., the DON said residents should be transferred with a gait belt if they are a moderate assist of one. 49992

Based on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee, in accordance with the facility's abuse policies, for four of 10 employee files reviewed. The census was 86. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation of Resident Property policy and procedure, revised 9/12/18, showed: -Policy: The facility will follow state and federal guidelines on abuse, neglect; -Screenings included: -1. Prior to hiring a new employee, the facility will: -a. Check with the nurse assistant registry and any other nurse assistant registries that the facility has reason to believe contain information on an individual, prior to using the individual as a nurse assistant; -The policy did not specify that the NA registry check should be performed for employees hired in positions other than nurse assistants. 1. Review of Licensed Practical Nurse (LPN) M's employee file, showed: -Date of hire: 11/2/22; -No NA registry federal indicator check. 2. Review of Receptionist S's employee file, showed: -Date of hire: 8/14/22; -NA registry federal indicator check completed 10/9/23. 3. Review of Housekeeper Q's employee file, showed: -Date of hire: 5/20/23; -NA registry federal indicator check completed 10/9/23. 4. Review of Housekeeper R's employee file, showed: -Date of hire: 5/22/23; -NA registry federal indicator check completed 10/9/23. 5. During an interview on 2/7/24 at 8:23 A.M., the Human Resources (HR) said she runs background checks, including the NA registry check on all prospective new hires, before they are extended a job offer. The background checks should be completed before an employee begins working in the facility as part of the facility's abuse prevention program. 6. During an interview on 2/8/24 at 10:17 A.M., the Administrator said she expected pre-employment background screening to include checking the NA registry for all new hires. The NA registry check should be completed by the HR Manager before the employee starts working in the facility, which is part of the facility's abuse prevention policy. All pre-employment background screenings should be retained in the employee files.

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund (RTF) reconciliations. This facility identified 77 residents with funds handled by the facility. The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised 5/1/20, showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -All written accounts of the residents' funds shall be reconciled monthly and a written statement showing the current balance and all transactions shall be given to the resident, his/her designee, guardian and conservator, or conservator on a quarterly basis; -The policy did not provide guidance for follow-up on outstanding checks. Review of the facility's monthly RTF reconciliations from February 2023 through January 2024, showed outstanding checks as follows: -Check #1125, dated 7/1/20: $100.00; -Check #1265, dated 11/4/20: $1,000.00; -Check #1266, dated 11/4/20: $1,000.00; -Check #1277, dated 11/18/20: $0.38; -Check #1323, dated 1/7/21: $150.00; -Check #1449, dated 4/13/21: $30.15; -Check #1466, dated 4/28/21: $24.17; -Check #1504, dated 5/17/21: $0.02; -Check #1702, dated 1/13/22: $0.01; -Check #1766, dated 3/31/22: $58.00; -Check #1777, dated 4/19/22: $25.00; -Check #1787, dated 4/28/22: $25.58; -Check #1927, dated 10/18/22: $20.01; -Check #1984, dated 12/21/22: $100.00; -Check #2036, dated 2/23/23: $50.00. During an interview on 2/8/24 at 7:47 A.M., the Business Office Manager (BOM) said she is responsible for reconciling the RTF account monthly. The account has outstanding checks dating back to 7/1/20 that have not cleared, and the money is factored into the monthly reconciliation. She has not followed up on checks that have not cleared. There should be some follow up on outstanding checks within a reasonable timeframe. During an interview on 2/8/24 at 8:08 A.M., the Administrator said during the BOM's monthly reconciliation of the RTF account, she expects the BOM to investigate outstanding checks that have not cleared after an extended period. She expects the facility's policy to provide guidance on timeframes for investigating outstanding checks in the RTF account.

44948 46104 46888 Based on observation, interview and record review, the facility failed to ensure residents (Residents #16, #31, #56, #69, and #82) received room trays with food that was palatable and at the required temperatures for safe consumption. The sample was 18. The census was 86. Review of the facility's Meal Service Temperatures policy, revised 1/2019, showed: -Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: Meal temperatures shall be monitored by the Director of Dietary and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees, food which does not meet the appropriate temperatures shall be removed and reheated or rechilled prior to meal service, foods which are requested by residents/patients to be reheated shall be reheated or replated to ensure satisfaction; -The policy did not address the serving temperatures of food. 1. Observation on 2/6/24 at 8:32 A.M., of a 200 hallway breakfast tray, showed: -Biscuits and gravy measured at 114.2 degrees Fahrenheit (F) and was cold to taste. 2. Observation on 2/7/24 at 8:33 A.M., of a 200 hallway breakfast tray, showed: -Pancakes measured at 111.2 degrees F and were cool to taste; -Bacon measured at 91.5 degrees F and was cold to touch. 3. Observation on 2/8/24 at 8:15 A.M., of a 200 hallway breakfast room tray, showed: -Scrambled eggs measured at 105.6 degrees F and were cold to taste; -Hash browns measured at 116.9 degrees F and were cold to taste. 4. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24, showed: -Cognitively intact; -Setup or clean-up assistance with eating; -Diagnoses included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). During an interview on 2/5/24 at 10:55 A.M., the resident said the food is terrible, the food is cold and the coffee is always cold. The resident said the food and coffee must be hot to be good. During observation and interview on 2/6/24 at 8:26 A.M., the resident had his/her breakfast tray and was attempting to stir the oatmeal. The resident said the oatmeal was so thick, the resident could hardly stir it. Observation of the resident attempting to stir the oatmeal showed one solid lump moving around in the bowl, as the resident moved the spoon in the bowl. The resident said the oatmeal was barely warm, and the eggs were cold. 5. Review of Resident #31's admission MDS, dated [DATE], showed: -Usually understood and usually understands others; -Partial/moderate assistance required for eating; -Diagnoses included stroke and aphasia (language disorder). Observation on 2/6/24 at 1:44 P.M., showed the resident seated in front of a bedside table with a plate of chopped ham, coleslaw and a slice of pie. During an interview, the resident was unable to speak and nodded his/her head in response to questions. The resident indicated his/her food was served cold and should have been hot. 6. Review of Resident #56's MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, hypertension (high blood pressure), chronic atrial fibrillation (a cardiac arrythmia caused by rapid beating in the upper chambers of the heart) and the presence of a cardiac pacemaker; -The resident required set-up assistance for meals and staff supervision for all other care areas. During an interview on 2/5/24 at 10:16 A.M., the resident said meals were often served to the resident rooms cold, and this morning's meal was served on Styrofoam plates, which has not happened before. The resident said all meals at the facility were served late and almost always come to the resident rooms cold. During an interview on 2/7/24 at 11:48 A.M., the resident said his/her breakfast was served cold this morning. In particular the bacon and pancakes were cold to the touch when they arrived. 7. Review of Resident #69's annual MDS, dated [DATE], showed: -Cognitively intact; -Independent for eating; -Diagnoses included high blood pressure, unstable burst fracture (breaks in multiple directions) of fourth lumbar vertebra, rheumatoid arthritis (RA, chronic joint disease that causes pain and swelling) and weakness. During an interview on 2/5/24 at 11:57 A.M., the resident said the food was terrible, unseasoned and always cold. 8. Review of Residents #82's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia (low red blood cell count), high blood pressure, renal (kidney) failure, and end stage renal disease (ESRD); -Eating: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as resident completes activity. During an interview on 2/6/24 at 6:54 A.M., the resident said the temperature of the food was hit or miss and there was no microwave to heat up food. Observation and interview on 2/6/2024 at 8:32 A.M., showed the breakfast meal hall tray delivered by staff to the resident's room. The resident said the biscuits were like rocks and not hot. Observation and interview on 2/6/24 at 1:36 P.M., showed staff delivered the lunch meal hall tray to the resident's room. The resident said the ham was really salty, and he/she would rather have had the chicken, but staff said there was no more chicken. The food was cold. Observation and interview on 2/7/24 at 8:27 A.M., showed staff delivered the breakfast meal hall tray to the resident's room. The resident said the pancakes were cold. 9. During an interview on 2/8/24 at 9:03 A.M., Certified Nurse's Assistant (CNA) K said if a resident complained their food was cold, he/she was supposed to go to the kitchen to get a new tray for the resident. He/She expected food to be served at a safe and palatable temperature. 10. During an interview on 2/8/24 at 8:35 A.M., the Director of Dietary said she expected food to be served at the safe and required temperature. She said if a resident complained of cold food on a hall tray, nursing staff should come to the kitchen to get a new tray for the resident. 11. During an interview on 2/8/24 at 11:31 A.M., the Administrator said she expected all staff to ensure residents are served food at the required temperatures. 49992

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected one of two sampled residents who expired and had money in their accounts (Resident #142). The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised [DATE], showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -Upon the death of a resident, the operator shall contact the Department of Social Services (DSS), MO HealthNet Division, TPL Unit, to determine if the deceased resident is a MO HealthNet participant or has been a recipient of aid, assistance, care, services, or if the resident has had moneys expended on his/her behalf of DSS. The facility shall document the contact(s) with and response(s) from DSS; -The policy failed to identify the federal requirement for notice and conveyance of funds to be completed within 30 days upon the death of a resident with funds remaining in the their account. Review of Resident #142's resident fund account, showed: -Expired [DATE]; -Ending account balance: $4,846.23; -On [DATE], the day the Department of Health and Senior Services (DHSS) onsite visit began, a TPL form completed. During an interview on [DATE] at 7:47 A.M., the Business Office Manager (BOM) said when a resident expires and has money left in the resident trust account, she is required to send a TPL to MO HealthNet regarding the remaining account balance. She thought the TPL had to be submitted within 60 days of the resident's expiration. She was not aware of the federal requirement for notice to be submitted within 30 days. During an interview on [DATE] at 8:08 A.M., the Administrator said when a resident expires leaving money in the resident trust account, she expects the BOM to submit a TPL within the federally required timeframe.

See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the resident's comprehensive care plan, by failing to ensure one resident was provided with his/her scheduled pain medication as ordered. The resident was out of his/her scheduled pain medication on 6/28/23 and remained out of his/her medication through 7/10/23 (Resident #8). The sample was 17. The census was 86. Review of the facility's Pain Management Policy and Procedure, revised 7/11/22, showed: -Purpose: To assess all residents for pain and to provide our residents with the highest level of comfort possible, using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Policy: All residents will be assessed on admission and in conjunction with initial assessment and as needed (PRN) for pain. The assessment should include an interdisciplinary team (IDT) approach; -Overview: Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying, and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, disturb sleep, and diminish quality of life. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated; -Certain factors may affect the recognition, assessment, and management of pain. For example, residents, staff, or practitioners may misunderstand the indications for, and benefits and risks of, opioids and other analgesics; or they may mistakenly believe that older individuals have a higher tolerance for pain than younger individuals, or that pain is an inevitable part of aging, a sign of weakness, or a way just to get attention. Other challenges to successfully evaluating and managing pain may include communication difficulties due to illness or language and culture barriers, stoicism about pain, and cognitive impairment; -It is a challenge to assess and manage pain in individuals who have cognitive impairment or communication difficulties. Some individuals with advanced cognitive impairment can accurately report pain and/or respond to questions regarding pain; -Those who cannot report pain may present with nonspecific signs such as grimacing, increases in confusion or restlessness or other distressed behavior. Effective pain management may decrease distressed behaviors that are related to pain. However, these nonspecific signs and symptoms may reflect other clinically significant conditions (e.g. delirium, depression, or medications-related adverse consequences) instead of, or in addition to, pain. To distinguish these various causes of similar signs and symptoms, and in order to manage pain effectively, it is important to evaluate (e.g. touch, look at, move) the resident in detail, to confirm that the signs and symptoms are due to pain; -Strategies for Pain Management may include but are not limited to the following: -Assessing the potential for pain, recognizing the onset, presence and duration of pain, and assessing the characteristics of the pain; -Addressing/treating the underlying causes of the pain, to the extent possible; -Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic (occasionally), continuous, or both; -Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Monitoring appropriately for effectiveness and/or adverse consequences (e.g. constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief; -Modifying the approaches, as necessary. -Use of Opioids (a class of drugs used to reduce pain) for Pain Management: -The physician/designee may find that opioid medications are the most appropriate treatment for acute pain as well as chronic pain in residents who are at a high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life; -Medication regimes for residents receiving end of life, palliative, or hospice care may include opioids alone or combining opioids and benzodiazepines (class of depressant drugs); their use must be consistent with accepted standards of practice for this specialty of care; -These strategies may include continuation of medication assisted treatment, if appropriate, non-opioid pain medication, and non-pharmacological approaches. -Procedure: -All residents will be assessed on admission for pain on the nursing admission assessment in the electronic medical record (EMR); -Identify the target signs and symptoms of pain utilizing the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff); -Once the resident's comprehensive assessment is completed the facility will develop an ongoing comprehensive person centered plan of care that will include not limited to: residents/representatives goals and preferences for pain management, triggers for pain, non-pharmacological interventions, pharmacological interventions, Narcan administration if indicated, identify if history of opioid use disorder (OUD) or substance abuse disorder, identify a time of day or a pattern to the residents reports of pain, monitoring for side effects of which include but not limited to: tolerance, dependence, increased sensitivity to pain, constipation, nausea/vomiting, dry mouth, sleepiness, dizziness, confusion, depression; -Pain assessment in EMR will be done with each full assessment and if the resident is coded as being in pain or receives chronic pain medication; -Assess/evaluate history of addiction, past and/or ongoing and related treatment for OUD; -Residents receiving chronic/routine medication will be assessed and documented on the treatment administrative record/medication treatment record (TAR/MAR); -When PRN pain medications are administered the nurse will document pain level on the MAR and effectiveness; -Review residents' orders for bowel regime and obtain orders as needed; -Review residents' orders for Narcan and obtain orders if indicated; -Follow pharmacy recommendations for appropriate medication use for population. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene; -Diagnoses included diabetes, depression and hemiplegia (paralysis of arm, leg, and trunk on one side of the body): -Section J, Health Conditions, showed: -Pain Management: At any time in the past 5 days, has the resident: -Been on a scheduled pain management regime: Yes; -Received PRN pain medications: No; -Received non-medication intervention for pain: Yes. -Should pain assessment interview be conducted: Yes. -Pain Presence: Yes. -Pain Frequency: Occasionally. -Pain Effect on Function: -Has pain made it hard for you to sleep at night: Yes; -Have you limited your day-to-day activities because of pain: Yes. -Pain Intensity: -Numeric Rating (00-10): Blank; -Verbal Descriptor Scale: Moderate. -Should the staff assessment for pain be conducted: No. Review of the resident's care plan, undated, showed the following: -Problem: The resident experiences pain post-surgery 3/6/23. The resident experiences phantom limb pain (the perception of pain or discomfort in a limb that is no longer there); -Goal: The resident will verbalize adequate relief of pain or ability to cope with incomplete relieved pain through the review date; -Intervention: Evaluate the effectiveness of pain interventions routinely. Review for compliance, alleviating of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability and impact on cognition. Evaluate resident's ability to communicate pain. Identify any barriers that may impede the resident's ability and address (communication difficulties, language barrier, and cognitive deficits) as appropriate; Combining opioids and benzodiazepines should be avoided unless clinically indicated for the resident. Discuss any concerns with the medical provider; -Problem: Resident has moderate impaired cognition function/or impaired though processes related to impaired decision making, difficulty finishing thoughts and words; -Goal: Resident will be able to communicate basic needs on a daily basis through the review date; -Interventions: Ask yes/no questions in order to determine the resident's needs, cue, reorient, and supervise as needed. Identify yourself at each interaction. The resident understands consistent, simple, directive sentences; -Problem: The resident has a behavior problem; yells out and curses every day in his/her room and dining room; -Goal: Resident will have fewer episodes by review date; -Interventions: Anticipate and meet the resident's needs, encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 9/29/22, Pain assessment every day and night shift; -An order, dated 10/25/22, Tylenol extra strength 500 milligram (mg) tablet. Give 2 tablets three times a day for pain; -An order, dated 3/7/23-7/7/23, Morphine 20 mg/milliliter (ml). 0.25 ml by mouth every two hours PRN for pain/shortness of breath (SOB); -An order, dated 4/10/23-7/7/23, Norco (hydrocodone-acetaminophen, combination medication used to relieve moderate to severe pain) 5-325 mg. One tablet by mouth twice a day related to acquired absence of right leg above knee; -An order, dated 4/10/23-7/7/23, Norco 5-325 mg. One tablet by mouth every 24 hours as needed for pain related to acquired absence of right leg above knee; -An order, dated 7/8/23, Morphine 20 mg/ml. Give 0.25 ml by mouth two times a day for pain/SOB; -An order, dated 7/8/23, Morphine 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain/SOB. Review of the resident's June 2023 MAR, showed: -Tylenol extra strength 500 mg tablet. Two tablets three times a day for pain: -4:00 P.M. dose blank on 6/2/23, 6/5/23, 6/6/23, 6/10/23 and 6/13/23; -9:00 P.M. dose blank on 6/11/23 and 6/25/23. -Hydrocodone-acetaminophen 5-325 mg. One tablet twice a day: -A.M. dose blank on 6/7/23; -H.S. (bedtime) dose blank on 6/11/23, 6/12/23 and 6/25/23; -H.S. dose 9 (see progress note) on 6/1/23, 6/10/23, and 6/28/23; -A.M. dose 9 on 6/29/23 and 6/30/23. -Morphine 20 mg/ml. 0.25 every two hours PRN pain/SOB: -6/13/23 at 9:25 P.M., one dose given and effective; -6/14/23 at 5:01 A.M., dose not documented on MAR (the progress notes show a 0.25 ml dose was given and effective). Review of the resident's progress notes, showed: -6/8/23 at 11:35 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Waiting for prescription from physician; none in Pyxis (an automated medication dispensing system); -6/9/23 at 7:00 A.M., Notified physician and Nurse Practitioner (NP) that a new prescription is needed as soon as possible; -6/9/23 at 9:41 A.M., Primary Care Physician (PCP) stated to get a hold of hospice to retrieve prescription. Hospice number was called. Receptionist stated they will get the refill request sent over right away; -6/13/23 at 9:25 P.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB. Resident complained of pain; -6/14/23 at 5:01 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB. PRN administration was: Effective, Follow-up Pain Scale was: 0; -6/19/23 at 10:41 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Medications were given as per Narcotics sheets; -6/28/23 at 8:05 P.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Resident out on pass, hospice to refill; -6/29/23 at 8:50 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Resident needs new script signed; -6/30/23 at 7:52 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Resident needs new script signed. Review of the resident's July 2023 MAR, dated 7/1/23 through 7/7/23, showed: -Tylenol extra strength 500 mg tablet. Two tablets three times a day for pain: -9:00 P.M. dose blank on 7/4/23. -Hydrocodone-acetaminophen 5-325 mg. One tablet twice a day: -A.M. dose 9 on 7/1/23, 7/2/23, 7/3/23, 7/4/23 and 7/7/23; -H.S. dose blank on 7/4/23; -H.S. dose 9 on 7/1/23 and 7/2/23. -Morphine 20 mg/ml. 0.25 every two hours PRN pain/SOB: -Administered and effective: -7/4/23 at 11:44 A.M.; -7/6/23 at 10:47 A.M.; -7/7/23 at 8:47 A.M. Review of the resident's progress notes, showed: -7/1/23 at 11:32 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Resident needs new script signed; -7/1/23 at 8:09 P.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee; No documentation if effective; -7/2/23 at 8:33 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Need signed prescription; -7/2/23 at 9:39 P.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee; No documentation if effective; -7/3/23 at 11:01 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. 8:00 A.M. awaiting from pharmacy; -7/4/23 at 11:44 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB; No documentation if effective; -7/4/23 at 11:47 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Need new signed prescription. Nurse is aware; -7/4/23 at 3:22 P.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, sob. PRN administration was: Effective, Follow-up Pain Scale was: 5; -7/6/23 at 10:47 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB; No documentation if effective; -7/6/23 at 11:19 P.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. None available so zero given; -7/7/23 at 7:17 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, sob. PRN administration was: Effective has voiced no other complaints of pain or discomfort, Follow-up Pain Scale was: 1; -7/7/23 at 8:47 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB. Pain all over; No documentation if effective; -7/7/23 at 8:49 A.M., Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give one tablet by mouth two times a day related to acquired absence of right leg above knee. Waiting for doctor to sign new prescription. -7/7/23 at 12:22 A.M., Morphine Sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain, SOB. PRN administration was: Effective, Follow-up Pain Scale was: 1; -7/10/23 at 4:43 P.M., This nurse called Hospice and an order to change medications to discontinue Hydrocodone and schedule Morphine 0.25 ml twice a day with 0.25 ml PRN every 2 hours. Resident's family notified of order. Resident denies pain at this time. During an interview on 7/7/23 at 9:24 A.M., a representative from the facility's pharmacy said the resident had two orders on file for Norco 5/325 mg. The first order is scheduled for one tablet two times a day. The second order for Norco 5/325 is one tablet daily PRN. The representative had not received an order or request from the facility since 6/8/23 and he/she checked the email inbox to confirm this date. During observation and interview on 7/7/23 at 11:05 A.M., Certified Medication Technician (CMT) C opened the narcotic box located in his/her medication cart. CMT C said the resident is out of his/her Norco 5/325. CMT C also said the resident has been out of the medication for over a week. CMT C gives the resident his/her PRN morphine and scheduled Tylenol instead for pain management. Observation on 7/7/23 at 3:15 P.M., showed the resident lay in bed quietly. The resident responded no when asked if he/she was in pain. During an interview on 7/7/23 at 3:22 P.M., Nurse A said the resident acts like he/she is in pain because of his/her behaviors. The resident likes to scream out for help a lot, then does not always know what he/she needed when the resident is asked. Nurse A said the resident is only oriented to himself/herself so the nurse is not sure if the resident is cognitive enough to know he/she is in pain or if the resident is just confused. However, the resident does show nonverbal signs of pain. The resident will grimace when he/she is touched. During an interview on 7/7/23 at 3:30 P.M., CMT C said the resident will answer yes or no when he/she is asked a question. If the resident is asked if he/she is in pain, the resident can tell and will say yes. The CMT said yesterday the resident was really hollering/screaming. CMT C said he/she had never heard the resident yell out like that. The resident was yelling and whistling. Once the resident got pain medication, he/she stopped screaming. The hospice social worker was in the facility and also talked to the resident. CMT C said the resident does not seem anxious, just uncomfortable and in pain. The CMT was informed by the nurse they are waiting for the signed prescription from the physician for the hydrocodone-acetaminophen 5/325. The resident has never told him/her no when the resident is asked if he/she is in pain. During an interview on 7/7/23 at 3:40 P.M., Nurse B said the resident is not cognitively intact. The resident can communicate and answer yes/no questions when asked a question. The resident will holler out when he/she is in pain. The facility needs a signed prescription from the physician to get a refill of the scheduled pain medication. During an interview on 7/7/23 at 3:45 P.M., Certified Nursing Assistant (CNA) D said the resident can communicate his/her basic needs. The resident acts like he/she is in pain and will holler out when he/she hurts. CNA D said he/she will inform the CMT and nurse if the residents acts like he/she is in pain when CNA D provides care or if the resident tells the CNA he/she is hurting, or if the CNA hears the resident holler out a lot from his/her room. During an interview on 7/7/23 at 3:55 P.M., the Director of Nursing (DON) said she is aware the resident has been out of his/her scheduled Norco 5/325 medication for over a week. The CMTs and nurses have utilized the PRN orders for Morphine and Ativan (anxiety medication) while they wait for the physician to sign the new prescription. The DON said they reach out to the pharmacy and the pharmacy reaches out to the physician. She said there is nothing she can do if the physician will not sign the prescription but she understands there are regulations and the responsibility will always fall on the facility. They cannot do anything to make the physician sign the medication prescription faster. They are doing all they can, they complete the pain assessments every shift and the PRN morphine can be given every two hours. The morphine will help more than the Norco 5/325 for pain anyway. If the resident needs something routine then staff can maybe get him/her something scheduled and PRN. The DON will work with hospice to see what they think the resident needs and she will try to contact the physician again. During an interview on 7/7/23 at 4:10 P.M., the Administrator said she was not aware the resident had been out of his/her scheduled pain medications since 6/30/23. She was also not aware the DON had been aware and had not followed up. She expected the DON to check on the medication still not in stock before it was brought to her attention today. She expected the DON to do this within the past week, a routine pain medication should not be out for a week without a follow up. During an interview on 7/10/23 at 9:13 A.M., the hospice nurse said he/she was not aware the resident was out of his/her scheduled pain medication Norco 5/325 since 6/30/23. The nurse said he/she was first made aware on 7/7/23. The facility told him/her that they were going to discontinue the Norco 5/325 and instead use Morphine 20 mg/ml with dosage 0.25 ml twice a day and two hours PRN. The nurse said he/she is not sure why he/she was not informed before 7/7/23. He/She would have called the pharmacy they use immediately to get a prescription for the resident. The nurse regularly talks to the staff nurses to see if anything is needed for the resident and no one informed him/her about the medication being out. The nurse said the resident should not have been out of his/her scheduled pain medication for that long. During an interview on 7/21/23 at 4:06 P.M., the resident's physician said if the resident is on hospice, he/she would expect the hospice physician to monitor and treat pain management. There would be no need for two physician's to monitor pain management. During an interview on 7/21/23 at 4:48 P.M., the resident's hospice physician said the hospice nurse should have been notified there was an issue with the resident's medication. If the facility has a problem with the resident's prescription, the facility should notify the hospice nurse and the hospice will contact the hospice physician for an order or a refill. The response for the order is pretty quick. The hospice physician said he/she would not want the resident in any pain.

Based on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the residents' comprehensive care plans, by failing to ensure two residents were provided with pain medication (Resident #8 and Resident #3). The sample was 16. The census was 91. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderate cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene; -Opioid (a class of drugs used to reduce pain) medications: 7; -Diagnoses included diabetes, depression and hemiplegia (paralysis of arm, leg, and trunk on one side of the body). Review of the resident's care plan, undated and in use at the time of the survey, showed: -Problem: The resident experiences pain post surgery [DATE]. The resident experiences phantom limb pain; -Goal: The resident will verbalize adequate relief of pain or ability to cope with incomplete relieved pain through the review date; -Intervention: Evaluate the effectiveness of pain interventions routinely. Evaluate resident's ability to communicate pain. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated [DATE], Pain assessment every day and night shift; -An order, dated [DATE], Tylenol extra strength 500 milligram (mg) tablet. Give 2 tablets three times a day for pain; -An order, dated [DATE], Morphine 20 mg/milliliter (ml). 0.25 ml by mouth every two hours as needed (PRN) for pain/shortness of breath (SOB); -An order, dated [DATE], Norco (hydrocodone-acetaminophen, combination medication used to relieve moderate to severe pain) ,d+[DATE] mg. One tablet by mouth twice a day for pain. Discontinued [DATE]. Review of the resident's progress notes, showed: -[DATE] at 1:56 P.M. Hospice nurse visited resident and obtained a new order to discontinue all tramadol (treats moderate to severe pain) orders due to medication being ineffective and start Norco ,d+[DATE] twice a day and increase gabapentin (relieves nerve pain) to 200 mg. Resident and family notified of change; -[DATE] at 3:55 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Pharmacy needs script, physician notified; -[DATE] at 7:27 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Medicine on order; -[DATE] at 10:10 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Pending delivery. Review of the resident's [DATE] Medication Administration Record (MAR), showed: -Norco ,d+[DATE] mg: Start [DATE], Stop [DATE]; -Not documented as administered: [DATE], [DATE] and [DATE]; -Morphine 20 mg/ml. 0.25 every two hours PRN pain/SOB: -Documented as administered [DATE], [DATE], and [DATE]. Review of the resident's progress notes, showed: -[DATE] at 10:12 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. 8:00 A.M. awaiting Norco from pharmacy; -[DATE] at 7:20 P.M. [DATE] at 10:10 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Medication not available; -[DATE] at 9:55 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. 8:00 A.M. awaiting Norco from pharmacy; -[DATE] at 10:50 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Drug unavailable and ordered; -[DATE] at 9:26 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Drug currently unavailable and ordered; -[DATE] at 12:25 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. On order from pharmacy; -[DATE] at 9:57 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Medication unavailable; -[DATE] at 10:46 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Not available; -[DATE] at 11:12 P.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Not on med cart; -[DATE] at 9:31 AM. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. 8:00 A.M. awaiting Norco from pharmacy; -[DATE] at 5:39 P.M. Pharmacy contacted facility. Needs new script for Norco tab 5 mg-325 mg. No quantity left. Physician contacted, waiting on response; [DATE] at 7:18 P.M. Morphine sulfate (Concentrate) Solution 20 mg/ml. Give 0.25 ml by mouth every two hours PRN for pain, SOB. Resident states his/her neck is hurting and requesting pain medications. Norco not available. Morphine administered and doctor has been notified about needing a new script for Norco. Review of the resident's ePOS, showed: -An order, dated [DATE], hydrocodone-acetaminophen ,d+[DATE] mg. One tablet every twenty-four hours PRN for pain; -An order, dated [DATE], hydrocodone-acetaminophen (Norco) ,d+[DATE] mg. One tablet by mouth twice a day for pain related to acquired absence of right knee. Review of the resident's progress notes, showed: -[DATE] at 10:08 AM. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. [DATE] at 10:35 A.M. Physician wrote a script for Norco ,d+[DATE] mg. Routine one tab by mouth twice a day; and PRN script for one tablet by mouth daily. Script is 90 tabs; -[DATE] at 9:13 A.M. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Took other pain pill; -[DATE] at 10:08 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Norco ,d+[DATE] mg. Duplicate order; -[DATE] at 9:47 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Norco ,d+[DATE] mg. Duplicate order; -[DATE] at 10:46 A.M. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. On order; -[DATE] at 10:27 P.M. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Medication on order; -[DATE] at 1:30 P.M. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Duplicate order; -[DATE] at 12:14 A.M. Norco Oral Tablet ,d+[DATE] mg. Give one tablet two times a day for pain. Duplicate order. Review of the resident's April, 2023 MAR, showed: -Hydrocodone-Acetaminophen ,d+[DATE] mg: Start [DATE]; -Not documented as administered: A.M. [DATE] and [DATE]. Bedtime (HS) [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. -Norco ,d+[DATE] mg: Start [DATE], Stop [DATE]; -Not documented as administered: A.M. dose [DATE], [DATE], [DATE]. HS dose [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. -Tylenol extra strength 500 mg tablet. Give 2 tablets three times a day for pain; -Not documented as administered: 4:00 P.M. dose, [DATE] and [DATE]. -Hydrocodone-acetaminophen ,d+[DATE] mg. One tablet every twenty four hours PRN for pain; -Documented as administered [DATE]; -Morphine 20 mg/ml. 0.25 every two hours PRN pain/SOB: -Documented as administered on [DATE]; -[DATE] at 9:55 P.M.: PRN Administration was: Effective Follow-up Pain Scale was: 0. Review of the resident's May, 2023 MAR, showed: -Hydrocodone-Acetaminophen ,d+[DATE] mg: Start [DATE]; -Not documented as administered: A.M. [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; HS [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. -Norco ,d+[DATE] mg: Start [DATE], Stop [DATE]; Not documented as administered: A.M. dose [DATE] and [DATE]; -Tylenol extra strength 500 mg tablet. Give 2 tablets three times a day for pain; -Not documented as administered: [DATE] at 8:00 A.M., [DATE] at 4:00 P.M., [DATE] at 9:00 P.M. and [DATE] at 9:00 P.M. Review of the pain assessments, showed none were completed on the night shifts of [DATE] and [DATE]. 2. Review of Resident #3's discharge MDS, dated [DATE], showed: -Cognitive impairment; -Total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Always incontinent of bowel. Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine); -Opioid Medications: 6; -Diagnosis included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). Review of the resident's care plan, undated, showed: -Problem: The resident is experiencing factors contributing to pain/potential for pain including right hip fracture; -Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; -Intervention: Evaluate the effectiveness of pain medications. Monitor for side effects and report to physician. Review of the progress notes, dated [DATE] at 2:17 P.M., showed Norco Oral Tablet ,d+[DATE] mg. Give 0.5 tablet one time a day for pain. Medication on order. Review of the ePOS, showed: -An order, start date [DATE], Norco oral ,d+[DATE]. Give 0.5 tab by mouth once a day for pain. Discontinued [DATE]; -An order, start date [DATE], Norco oral ,d+[DATE]. Give 1 tab via gastric tube (g-tube, surgical insertion of a tube through the abdominal wall into the stomach under endoscopic guidance) two times a day for pain. Review of the March, 2023 MAR, showed: -An order, start [DATE], Acetaminophen 325 mg. Give one tablet via g-tube. Three times a day for pain; -4:00 P.M.: [DATE] blank -An order, start [DATE], Tramadol hcl 50 mg. Give one table by mouth two times a day for pain; -A.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE] blank; -HS: ,d+[DATE] blank. -An order, start date [DATE], Norco oral ,d+[DATE]. Give 0.5 tab by mouth once a day for pain. Discontinued [DATE]. -12:00 P.M.; ,d+[DATE], ,d+[DATE], ,d+[DATE] blank; -An order, start date [DATE], Lidocaine Patch 4%. Apply to right leg topically one time a day for pain and remove per schedule. Discontinue date [DATE]; -Remove: ,d+[DATE], ,d+[DATE], blank; -Apply: ,d+[DATE], ,d+[DATE] blank. Review of the April, 2023 MAR, showed: -An order, start date [DATE], assess pain every shift. Every day and every night; -Days: ,d+[DATE] blank; -Nights: ,d+[DATE], ,d+[DATE], ,d+[DATE] blank. -An order, start date [DATE], Acetaminophen 325 mg. Give one tablet via g-tube. Three times a day for pain; -8:00 A.M.:,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] blank; -4:00 P.M.: ,d+[DATE], ,d+[DATE] blank; -9:00 P.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] blank. -An order, start date [DATE], Tylenol Extra Strength oral tablet. 500 mg. Give 1000 mg by mouth in the morning for pain; Discontinued [DATE]; -9:00 A.M.: ,d+[DATE] missed. -An order, start date [DATE], Norco oral ,d+[DATE]. Give 1 tab via G-tube two times a day for pain. -A.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] missed. -The dates ,d+[DATE] and ,d+[DATE] were marked with 9 which means: other, see progress notes; -P.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] missed. -The date ,d+[DATE] P.M. dose shows the medication administered at 6:48 P.M. in the progress notes and the resident had a pain rating of ,d+[DATE] on the MAR. -The date ,d+[DATE] P.M. dose was marked with 9 which means: other, see progress notes. Review of the progress notes, showed: -[DATE] 6:58 A.M., Norco Oral Tablet ,d+[DATE] mg. Give 1 tablet via g-tube two times a day for pain. Drug unavailable, ordered. -[DATE] 10:37 A.M., Norco Oral Tablet ,d+[DATE] mg. Give 1 tablet via g-tube two times a day for pain. Out of stock; -[DATE] 6:48 P.M., Norco Oral Tablet ,d+[DATE] mg. Give 1 tablet via g-tube two times a day for pain. Medication shows administered on the MAR with the resident's pain rated at ,d+[DATE]. Review of the May, 2023 MAR, showed: -An order, start [DATE], Acetaminophen 325 mg. Give one tablet via g-tube. Three times a day for pain. -4:00 P.M.: ,d+[DATE] missed; -9:00 P.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] missed. -An order, start date [DATE], Norco oral ,d+[DATE]. Give 1 tab via g-tube two times a day for pain. -A.M.: ,d+[DATE], ,d+[DATE] blank, -,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] marked 9; -P.M.: ,d+[DATE], ,d+[DATE], ,d+[DATE] blank; -,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] marked 9. Review of the progress notes, showed: -[DATE] 8:10 A.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication on order; -[DATE] 3:29 P.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication on order; -[DATE] 1:45 P.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication on order; -[DATE] 10:03 A.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication on order; -[DATE] 10:46 A.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication unavailable; -[DATE] 1:54 P.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication unavailable; [DATE] 10:33 A.M., Norco Oral Tablet ,d+[DATE]. Give 1 tablet via g-tube two times a day for pain. Medication on order. During an interview on [DATE] at 9:40 A.M., the pharmacy technician said the last time the facility sent in a prescription or requested a refill on this medication was [DATE]. Prior to [DATE], the last request for this medication for this resident was [DATE] at 7:59 P.M. That prescription expired on [DATE]. A new script from the physician should have been sent. There were no requests or new prescriptions sent from the facility to the pharmacy between [DATE] and [DATE]. 3. During an interview on [DATE] at 2:20 P.M., the Director of Nursing said if there is a blank spot on the MAR, then the medication was not given. If something is not signed, then it did not happen. MO00218101 MO00218164

Based on observation, interview and record review, the facility failed to ensure three residents with a pressure ulcer (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing (Resident #5, Resident #8 and Resident #3). The sample size was 16. The census was 91. Review of the facility's Skin Program Policy and Procedure, dated 5/28/19, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed upon admission and as needed (PRN) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin Care team meetings will be held weekly to address all ulcers and any other pertinent skin problems; -Procedure: The nurse assesses/evaluates all residents upon admission. The initial skin assessment is a full body audit and completion of the Braden Skin Risk Assessment (a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure). After admission, the Braden Skin Risk Assessment will be completed weekly times three weeks and then a minimum of quarterly, a significant change of condition, and annually; -A plan of care is initiated and individualized by the nurse on the day of admission; -Director of Nursing (DON)/Designee to review all residents weekly with skin ulcers for condition of wound, treatment changes, and additional barriers to healing and will document weekly; -DON/Designee will conduct regular in-services on skin care, condition, aseptic technique (a method used to prevent contamination with microorganisms), and wound care; -The Nurse/Designee will notify the resident's responsible party if the resident is admitted /readmitted from the hospital or another healthcare facility with a skin ulcer and document notification in the clinical record. The nurse/designee will continue to notify/update MD, resident/sponsor weekly of progress/lack of progress of healing of all Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) and Stage 4 (Full thickness deep tissue loss with exposed bone, tendon, or muscle) ulcer, and surgical wound. Resident/Sponsor will be educated by the nurse to skin care and the prevention of skins injury as needed (PRN). All education as well as the resident/sponsor response will be documented in the clinical record. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/5/23, showed: -Cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Required extensive assistance with eating; -At risk for developing pressure ulcers; -Resident has Stage 1 (a reddened area on the skin that does not turn white (blanch) when pressed) or greater, a scar over a bony prominence or a non-removable dressing/device; -Has one or more unhealed pressure ulcers at Stage 1 or higher; -Stage 3 Pressure Ulcers: 3, Present upon admission: 2; -Diagnosis included obstructive uropathy (urinary tract disorder due to obstruction of urinary flow). Review of the resident's care plan, undated and in use at the time of the survey, showed: -Focus: Resident admitted with sacral unstageable (full thickness tissue loss in which the depth of the ulcer is obscured by slough (yellow or tan dead tissue) and/ or eschar (black or brown dead tissue) to the wound bed); -Pressure ulcer. Resident has multiple open areas; -Goals: Wound will show signs of improvement; -Intervention: Administer pain medication prior to treatment. Monitor bony prominences for redness. Offer pain medication before treatment. Weekly wound documentation. Turn and reposition every two hours. Review of the wound report provided by the facility, showed: -Right hip Stage 4, Start date 10/3/21, Interventions: low air loss (LAL) mattress (a mattress designed to prevent and treat pressure wounds): -March, 2023: -Week 1 (Length x Width x Depth): 0.8 x 2.8 x 0.1 centimeter (cm); -Week 2: 1.6 x 1.2 x 0.4 cm; -Week 3: 1.5 x 0.6 x 0.2 cm; -Week 4: 1.1 x 0.6 x 0.3 cm; -April, 2023: -Week 1: 2.1 x 0.5 x 0.2 cm; -Week 2: 1.3 x 0.8 x 0.2 cm; -Week 3: 1.0 x 2.0 x 0.1 cm; -Week 4: 1.4 x 0.7 x 0.4 cm; -May, 2023 (5/1/23-Week 3): -Week 1: 1.3 x 1.3 x 0.2 cm; -Week 2: 1.3 x 1.5 x 0.2 cm; -Week 3: 5.0 x 1.2 x 0.2 cm; -Superior sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis). Stage 3, Start date 9/10/22: -March, 2023: -Week 1: 1.0 x 3.8 x 0.1 cm; -Week 2: 1.0 x 3.3 x 0.2 cm; -Week 3: 0.6 x 2.5 x 0.2 cm; -Week 4: 1.6 x 0.9 x 0.3 cm; -April, 2023: -Week 1: 0.7 x 2.9 x 0.2 cm; -Week 2: 0.8 x 1.3 x 0.2 cm; -Week 3: 1.1 x 2.5 x 0.6 cm; -Week 4: 1.0 x 0.3 x 0.2 cm; -May, 2023 (5/1/23-Week 3): -Week 1: 5.8 x 2.2 x 0.3 cm; -Week 2: 5.5 x 1.2 x 0.2 cm; -Week 3: 5.0 x 1.2 x 0.3 cm; -Left hip, moisture, Start date 2/4/23: -March, 2023: -Week 1: 0.4 x 0.3 x 0.1 cm; -Week 2: 1.0 x 2.1 x 0.1 cm; -Week 3: 0.8 x 2.1 x 0.1 cm; -Week 4: 2.6 x 1.2 x 0.4 cm; -April, 2023: -Week 1: 0.5 x 1.9 x 0.3 cm; -Week 2: 0.4 x 2.0 x 0.2 cm; -Week 3: 1.0 x 2.5 x 0.3 cm; -Week 4: 0.5 x 2.1 x 0.3 cm; -May 2023 (5/1/23-Week 3): -Week 1: 0.8 x 2.6 x 0.2 cm; -Week 2: 2.0 x 3.0 x 0.1 cm; -Week 3: 0.6 x 3.2 x 0.3 cm; -Posterior sacrum, moisture, Start date 4/18/23: -Week 3: 1.4 x 0.3 x 0.1 cm; -Week 4: resolved. Review of the resident's Treatment Administration Record (TAR), dated March 1, 2023 through May 20, 2023, showed: -An order, dated 2/15/23, for Mupirocin External Ointment 2% (a topical medication used to treat small areas of bacterial skin infections). Apply to left hip topically one time a day for wounds; -Treatments not documented as administered on 4/3, 4/6, 4/8, 4/9, 4/11 through 4/16, 4/18, 4/21, and 4/29/23; -An order, dated 2/28/23, for wound care to right hip. Cleanse area. Apply Medihoney (wound and burn gel) and alginate calcium with silver (barrier to bacterial penetration in moderately to heavily exuding wounds) and cover with bordered foam daily and as needed; -Not documented as administered on 4/8, 4/9, 4/14, 4/16, 4/23, 4/29, 5/7 and 5/20/23; -An order, dated 2/28/23, for wound care to right superior sacrum. Cleanse area. Apply Medihoney to open site and cover with bordered foam daily and as needed; -Treatments not documented as administered on 4/8, 4/9, 4/15, 4/1, 4/23, 4/29 and 5/7/23; -An order, dated 3/15/23, wound care to left hip. Cleanse area. Apply Mupirocin ointment and calcium alginate with silver to open area and cover with bordered foam twice a day and as needed; -Not documented as administered: -9:00 A.M. 4/8, 4/9, 4/14, 4/16, 4/23, 4/29, 5/7 and 5/20/23; -9:00 P.M. 4/1 through 4/6, 4/8, 4/9, 4/11 through 4/16, 4/18, 4/19 through 4/29 5/1, 5/2, 5/4, 5/6 through 5/11, 5/13, 5/16 and 5/18 through 5/20/23; -An order, dated 3/20/23. Ensure intact and functional every shift related to pressure ulcer; -Treatments not documented as completed on the TAR: -Day: 3/22, 3/23, 3/24, 3/27, 3/28, 3/30, 3/31, 4/2, 4/6, 4/8, 4/9, 4/11, 4/12 through 4/16, 4/18, 4/21, 4/25, 4/29, 5/1, 5/2, 5/4, 5/5, 5/7 through 5/10, 5/12, 5/18 and 5/20/23; -Evening: 4/14, 4/18, 4/22, 4/25, 4/29, 5/1, 5/7, 5/9, 5/10, 5/11, 5/18 and 5/20/23; -Nights: 3/26, 4/14, 4/17, 4/24, 4/28, 5/1, 5/6, 5/7, 5/9, 5/11 and 5/19/23. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene; -Required limited assistance with eating; -At risk for developing pressure ulcers; -Resident does not have Stage 1 or greater, a scar over a bony prominence or a non-removable dressing/device; -Resident has moisture associated skin damage; -Diagnoses included diabetes, depression and hemiplegia (paralysis of arm, leg, and trunk on one side of the body). Review of the resident's care plan, undated and in use at the time of the survey, showed: -Focus: Wound Management -Goal: Wound will show signs of improvement and be free of signs or symptoms of infection; -Intervention: Monitor ulcer for signs of progress or declination. Weekly wound documentation. Notify provider if no signs of improvement on current wound regimen. Provide wound care per treatment order. Weekly documentation per wound nurse. Offer pain medication before treatments if necessary. Review of the wound report provided by the facility, showed: -Sacrum, moisture Start date 10/31/22, Interventions: LAL Mattress: -March, 2023: -Week 1: 2.0 x 1.0 x 0.2 cm; -Week 2: 2.0 x 0.4 x 0.2 cm; -Week 3: 1.8 x 0.5 x 0.3 cm; -Week 4: 2.0 x 0.4 x 0.2 cm; -April, 2023: -Week 1: 1.1 x 0.3 x 0.1 cm; -Week 2: 1.5 x 0.5 x 0.2 cm; -Week 3: 1.6 x 0.8 x 0.2 cm; -Week 4: 1.3 x 0.5 x 0.2 cm; -May, 2023 (5/1/23 through Week 3): -Week 1: 1.9 x 0.5 x 0.2 cm; -Week 2: 1.7 x 1.3 x 0.2 cm; -Week 3: 1.4 x 0.5 x 0.2 cm. Review of the resident's TAR, dated March 1, 2023 through May 20, 2023, showed: -An order, dated 2/15/23, for Mupirocin ointment. Apply to coccyx (a small triangular bone at the base of the spinal column) topically one time a day for wounds; -Treatments not documented as administered on 4/1, 4/2, 4/4, 4/7 through 4/10, 4/12, 4/13, 4/18, 4/20, 4/22 through 5/2, 5/4, 5/7 through 5/10, 5/12, 5/13 and 5/19/23; -An order, dated 3/20/23, for LAL mattress. Ensure intact and functional every shift related to hemiplegia; -Not documented as administered on the TAR: -Day: 3/22, 3/23, 3/24, 3/27, 3/28, 3/30, 3/31, 4/3, 4/6, 4/8, 4/9, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/18, 4/21, 4/25, 4/29, 5/1, 5/2, 5/4/ 5/5, 5/7, 5/8, 5/9, 5/10, 5/12, 5/18 and 5/20/23; -Evening: 4/14, 4/18, 4/22, 4/25, 4/29, 5/1, 5/7, 5/9, 5/10, 5/11, 5/18 and 5/20/23; -Nights: 3/26, 4/14, 4/17, 4/24, 4/28, 5/1, 5/6, 5/7, 5/9, 5/11, 5/19 and 5/21/23; -An order, dated 3/22/22, for wound care to posterior medial sacrum. Cleanse area. Apply Gentamycin ointment, collagen powder, and calcium alginate with silver to open area daily and as needed; -Treatments not documented as administered on 4/20/23 and 5/7/23; -An order, dated 3/24/23, for Gentamycin ointment. External Ointment 2%. Apply to open area on sacrum topically every days for wounds; -Treatments not documented as administered on 4/1, 4/2, 4/4, 4/5, 4/7, 4/8, 4/9, 4/10, 4/12, 4/13, 4/18, 4/20, 4/22 through 4/30, 5/1, 5/2, 5/4, 5/5, 5/7 through 5/10, 5/12, 5/13 and 5/18/23. 3. Review of Resident #3's discharge MDS, dated [DATE], showed: -Cognitive impairment; -Total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -At risk for developing pressure ulcers; -Resident has Stage 1 or greater, a scar over a bony prominence or a non-removable dressing/device; -Has one or more unhealed pressure ulcers at Stage 1 or higher; -Stage 3 Pressure Ulcers: 3, Present upon admission: 2; -Diagnosis included obstructive uropathy. Review of the resident's care plan, undated, showed: -Problem: The resident is at risk for skin breakdown related to immobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection through review date. The resident will have intact skin, free of redness, blisters or discoloration by/through review date; -Interventions: Administer treatments as ordered and monitor for effectiveness. Family will be educated to ask for assistance with skin issues and the consequence of family doing it themselves. Treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Review of the wound report provided by the facility showed: -Left elbow Stage 3, no start date: -March, 2023: -Week 2: hospital; -Week 3: 1.0 x 0.5 x 0.1 cm; -Week 4: 1.0 x 0.5 x not measurable (NM) cm; -April, 2023: -Week 1: 1.0 x 0.6 x 0.1 cm; -Week 2: 1.2 x 1.2 x 0.2 cm; -Week 3: 0.8 x 8.4 x 0.1 cm; -Week 4: 1.4 x 1.1 x 0.2 cm; -May, 2023 (5/1/23-Week 1): -Week 1: 1.5 x 1.0 x 0.2 cm; -Week 2: hospital; -Sacrum, unstageable, no start date: -March, 2023: -Week 1: 6.0 x 7.2 x NM cm; -Week 2: 8.0 x 4.5 x NM cm; -Week 3: 7.8 x 5.0 x NM cm; -Week 4: 7.8 x 5.0 x 0.3 cm; -April, 2023: -Week 1: 5.2 x 8.0 x 0.4 cm; -Week 2: 5.8 x 7.0 x 1.5 cm; -Week 3: 5.4 x 8.4 x 1.1 cm; -Week 4: 7.0 x 9.0 x 1.1 cm ; -May, 2023 (5/1/23-Week 1): -Week 1: 8.3 x 9.0 x 0.5 cm; -Week 2: hospital; -Right lower back, unstageable, no start date: -March, 2023: -Week 4: 1.0 x 0.5 x NM cm; -April, 2023 (Not on report); -May, 2023 (Not on report); -Right ankle, Stage 3, Start date 4/30/23: -May, 2023: -Week 1: 1.5 x 1.0 x 0.2 cm; -Week 2: hospital. Review of the resident's TAR, dated March 1, 2023 through May 8, 2023, showed: -An order, start 3/7/23, for wound care to posterior sacrum. Cleanse area with wound cleanser or saline. Apply Santyl and calcium alginate to open area and cover with bordered foam daily and as needed every day shift as needed for wounds. Discontinued 3/28/23; -3/17/23, not documented as administered; -An order, dated 3/20/23, LAL mattress. Ensure intact and functional every shift related to Chronic Stage 3 kidney disease; -Treatment not documented as completed: -Day: 3/21, 3/24, 3/28, 3/29, 4/1, 4/3, 4/4, 4/5, 4/13, 4/14, 4/20, 4/25 through 4/28, 5/1, 5/2, and 5/7/23; -Evening: 4/1, 4/3, 4/5, 4/11, 4/14, 4/20, and 5/7/23; -Nights: 4/3 and 4/12. -An order, start 3/29/23, for wound care to posterior sacrum. Cleanse area with wound cleanser or saline. Apply Medihoney and calcium alginate to open area and cover with bordered foam daily and as needed every day shift as needed for wounds. Discontinued 4/25/23; -Treatments not documented as administered on 4/1, 4/8, 4/15, 4/22, and 4/25/23; -An order, start 3/29/23, for wound care to left elbow. Cleanse area with wound cleanser or saline. Apply Medihoney to open area and cover with bordered foam daily and as needed every day shift as needed for wounds; -Not documented as administered on 4/1, 4/8, 4/16 and 4/22/23; -Not documented as administered on 5/7/23; -An order, start date 4/19/23, for wound care to inferior abdominal blister. Cleanse area with wound cleanser or saline, apply Xeroform gauze to site and cover with bordered gauze to site and cover with bordered gauze daily and as needed every day shift for wounds. Discontinued 5/3/23; -Not documented as administered on 4/22/23; -Not documented as administered on 5/3/23; -An order, start 4/27/23, wound care to right ankle. Cleanse area with wound cleanser or saline. Apply Medihoney to open area and cover with bordered foam daily and as needed every day shift as needed for wounds; -Treatments not documented as administered on 4/27, 4/28, 4/29 and 4/30/23; -Treatments not documented as administered on 5/1 and 5/7/23. 4. During an interview on 5/22/23 at 2:20 P.M., the DON said she expected treatments to be completed as ordered. She said if there is a blank spot on the MAR or TAR, then it was not done. MO00218164

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff failed to notify the physician of Resident #22's positive urinalysis (a urine test, used to check for a urinary tract infections (UTI), kidney problems, or diabetes) on 8/30/2022. On 9/4/22, the resident was transferred to the hospital upon his/her request with complaints of pain during urination, foul smelling and blood tinged urine. The census was 88. 1. Review of Resident 22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 6/20/22, showed: -No cognitive impairment; -One staff person assist for bed mobility, dressing, toileting and personal hygiene; -Two staff person assist for transfers; -On scheduled pain management regimen: No; -Verbal descriptor pain scale: Moderate; -Diagnoses included heart failure, UTI, high blood pressure, chronic lung disease and anxiety. Review of the resident's nurse's notes showed: -On 8/29/22 at 2:13 A.M., the resident voiced complaints of urinary discomfort, and wanting to go to hospital regarding previous diagnosis of recurrent UTls, upon entering resident's room this nurse noted resident resting with eyes closed, no signs or symptoms of distress, this nurse called this resident's name several times to arouse resident, upon resident opening his/her eyes, this nurse asked resident what was bothering him/her and where was his/her pain located, resident voiced to this nurse I want to go to the hospital because I am out of pain medication and this helps with my UTls. Resident received PRN Tylenol for pain, upon departure from resident's room, this resident went back to sleep, will report to A.M. nurse regarding above, fluids offered and encouraged; -On 8/29/22 at 6:30 P.M., Late Entry: resident called this nurse to the room, this resident voiced he/she has been in urinary discomfort throughout the day, resident voiced to this nurse I want to go to the hospital, I have been asking to speak with someone regarding this matter because I think my UTI has gotten worse. Resident voiced constant sharp pain and burning to genital area, resident afebrile (without fever), Temperature 97.2 degrees Fahrenheit (F), call placed to physician regarding above, this nurse voiced resident's request to go to the hospital, new orders given as follows, new order (N.O.) Pyridium 100 mg two times per day (BID) for three days for urinary discomfort, collect a UA with culture and sensitivity, UA collected with two attempts, dark, foul smelling urine noted with presence of blood, resident tolerated urine collection without difficulty. First dose of Pyridium given with evening medication, resident voiced feeling relieved and stable at facility, in bed, resting quietly, will continue to monitor for change. Fluids and cranberry juice offered and encouraged, resident remains stable at this time, UA pending pick up from lab. Review of the resident's laboratory UA, dated 8/30/22 and reported at 11:08 A.M., showed: organism 1 E. coli (Escherichia coli) extended-spectrum beta-lactamases (ESBL Producer, are most often made by E. coli and can cause a wide range of infections, ranging from urinary tract infections to severe blood poisoning) greater than 100,000 colony-forming unit (CFU, is a unit which estimates the number of microbial cells) per millimeter. During an interview on 9/20/22 at 12:39 P.M., laboratory technician F said the preliminary results indicating a positive urinary tract infection were faxed to the facility on [DATE] at 11:08 A.M., the culture and sensitivity test (C&S, a test that determines which antibiotic an organism is resistant and/or susceptible) results were faxed on 9/5/22. Further review of the resident's nurse's notes showed: -On 9/4/22 at 1:24 P.M., transfer to hospital summary. Patient complaint of pain during urination. Urine has foul odor. Blood tinged urine noted. Patient requesting to go to emergency room . Physician made aware of clinical situation and transfer; -No additional documentation noted regarding the pending UA results collected on 8/29/22. During an interview on 9/20/22 at 12:52 P.M., Licensed Practical Nurse (LPN) E said he/she was assigned to the resident on 8/30/22. He/she said an order for the UA should have been on the 24 hour report sheet, and given verbally as well, in case someone doesn't look at the sheet. He/she said he/she was either not aware of the pending UA on the 24 hours report sheet, or it was not communicated to him/her. The laboratory test results come in by fax, and if he/she had been aware of the pending results, he/she would have looked for them. They are supposed to call the physician with the results. During an interview on 9/9/22 at 10:20 A.M., the resident said he/she was in horrific pain. It felt like a hot curling iron inside me. He/she was in so much pain, he/she wanted to call an ambulance his/herself. When staff obtained the urine sample, the staff person said, Oh, blood! The resident said he/she saw there was blood in the urine. The resident said he/she was suffering so badly, he/she cried. The resident said the Pyridum didn't help the pain, it still burned after taking the Pyridium. Review of the resident's hospital record, showed: -On 9/4/22, no time noted, patient presented with dysuria (painful urination); -Patient arrived with severe pain dysuria, and flank pain (pain in one side of the body between the upper belly area (abdomen) and the back). This is similar symptoms to his/her recurrent infection. In the emergency department he/she was positive for UTI on the UA. During an interview on 9/13/22 at 10:15 A.M., the resident's physician said staff had not called her with the results of the UA. Had they called, she would have ordered the resident an antibiotic. She expected staff to have called regarding the resident's continuous complaints of pain. The possible complications of a UTI are the symptoms getting worse, and they can become septic (the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an existing infection triggers a chain reaction throughout the body). During an interview on 9/15/22 at 2:24 P.M., the administrator said she expected staff to document the results of the UA and call the physician with the positive results. 36151

Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who require such services, by failing to adequately assess and treat pain for one resident. The resident developed an infection, experienced severe pain and was not provided effective pain management (Resident #22). The facility also failed to administer pain medication to alleviate pain during dressing changes for two residents (Residents #19 and #21) with pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The census was 88. Review of the facility's Pain Management Policy and Procedure, revised on 7/11/22, showed: -Purpose: To assess all residents for pain and to provide our residents with the highest level of comfort possible, using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Policy: All residents will be assessed on admission and in conjunction with initial assessment and as needed (PRN) for pain. The assessment should include an interdisciplinary team (IDT) approach; -Overview of Pain Recognition and Management: -Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain; -Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life; -The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. The resident's needs and goals as well as the etiology, type, and severity of pain are relevant to developing a plan for pain management; -Certain factors may affect the recognition, assessment, and management of pain. For example, residents, staff, or practitioners may misunderstand the indications for, and benefits and risks of, opioids (pain relieving drug) and other analgesics (pain relieving medication); or they may mistakenly believe that older individuals have a higher tolerance for pain than younger individuals, or that pain is an inevitable part of aging, a sign of weakness, or a way just to get attention; -Some individuals with advanced cognitive impairment can accurately report pain and/or respond to questions regarding pain; -Those who cannot report pain may present with nonspecific signs such as grimacing, increases in confusion or restlessness or other distressed behavior. Effective pain management may decrease distressed behaviors that are related to pain. However, these nonspecific signs and symptoms may reflect other clinically significant conditions (e.g., delirium, depression, or medication-related adverse consequences) instead of, or in addition to, pain. To distinguish these various causes of similar signs and symptoms, and in order to manage pain effectively, it is important to evaluate (e.g., touch, look at, move) the resident in detail, to confirm that the signs and symptoms are due to pain; -Pain is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent. The following are descriptions of several different types of pain: -Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness; -Incident pain refers to pain that is typically predictable and is related to a precipitating event such as movement (e.g., walking, transferring, or dressing) or certain actions (e.g., wound care); -Persistent pain or chronic pain refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years; -Standards of Practice refers to approaches to care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies; -Strategies for Pain Management: Strategies for the prevention and management of pain may include but are not limited to the following; -Assessing the potential for pain, recognizing the onset, presence and duration of pain, and assessing the characteristics of the pain; -Addressing/treating the underlying causes of the pain, to the extent possible; -Developing and implementing both non-pharmacological and pharmacological interventions, approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both; -Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Monitoring appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief; and modifying the approaches, as necessary. Review of the facility's Skin Program Policy and Procedure, dated revised on 5/10/21, showed: - Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed upon admission and as needed (PRN) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin Care team meetings will be held weekly to address all ulcers and any other pertinent skin problems. Performance Improvement/quality assurance (QA) tracking and monitoring are done according to the performance improvement/QA schedule. All Performance Improvement/QA Tracking & Monitoring are attorney/client privileged information; -Procedure: --The nurse will assess resident pain originating from skin areas during assessment and treatment and care plan appropriately. 1. Review of Resident 22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/22, showed: -No cognitive impairment; -Required one staff person's assistance for bed mobility, dressing, toileting and personal hygiene; -Required two staff persons' assistance for transfers; -On scheduled pain management regimen: No; -Verbal descriptor pain scale: Moderate; -Diagnoses included heart failure, urinary tract infection (UTI), high blood pressure, chronic lung disease and anxiety. Review of the resident's physician's orders, dated 9/1/22 through 9/30/22, showed: -On 6/10/22, an order for pain assessments, every day and night shift; -On 6/10/22, an order for Acetaminophen (for pain relief/fever reduction, brand name includes Tylenol) Extra Strength Tablet, 500 milligrams (mg), give two tablets by mouth every 6 hours as needed for pain; -On 8/5/22, an order for Oxycodone (a medication used to help relieve moderate to severe pain) HCI Tablet, 15 mg, give 1 tablet by mouth every 4 hours as needed for pain. -On 8/30/2022, an order for Pyridium (used to relieve the pain, burning, and discomfort caused by urinary tract infections) tablet, 100 mg, give 100 mg by mouth two times a day for urinary discomfort for three days. Review of the resident's August 2022 medication administration record (MAR), showed: -An order, dated 6/10/22, for pain assessments, day and night shift, (pain levels ranging from 1 through 10, with 10 the most severe); -Staff documented: -8/27, night shift: 10; -8/28, day shift: 3, night shift: 3; -8/29, day shift: 7, night shift: 6; -8/30, day shift: 9, night shift: 7; -8/31/22, day shift: 0, night shift: 10. Further review of the resident's August 2022 MAR, showed: -An order, dated 6/10/22, for Acetaminophen, Extra Strength Tablet 500 mg, none documented as given on 8/29, 8/30 or 8/31/22; -An order, dated 8/5/22, for Oxycodone HCI Tablet, 15 mg, give 1 tablet by mouth every 4 hours as needed for pain, documented as administered on 8/30/22 at 10:11 A.M. Review of the resident's nurse's notes, showed: -On 8/29/22 at 2:13 A.M., the resident voiced complaints of urinary discomfort, and wanting to go to hospital regarding previous diagnosis of recurrent UTls, upon entering resident's room this nurse noted resident resting with eyes closed, no signs or symptoms of distress, this nurse called this resident's name several times to arouse resident, upon resident opening his/her eyes, this nurse asked resident what was bothering him/her and where was his/her pain located, resident voiced to this nurse I want to go to the hospital because I am out of pain medication and this helps with my UTls. Resident received PRN Tylenol for pain, upon departure from resident's room, this resident went back to sleep, will report to A.M. nurse regarding above, fluids offered and encouraged; -On 8/29/22 at 6:30 P.M., Late Entry: resident called this nurse to the room, this resident voiced he/she has been in urinary discomfort throughout the day, resident voiced to this nurse I want to go to the hospital, I have been asking to speak with someone regarding this matter because I think my UTI has gotten worse. Resident voiced constant sharp pain and burning to genital area, resident afebrile (without fever), Temperature 97.2 degrees Fahrenheit (F), call placed to physician regarding above, this nurse voiced resident's request to go to the hospital, new orders given as follows, new order (N.O.) Pyridium (medication used for pain caused by UTIs) 100 mg two times per day (BID) for three days for urinary discomfort, collect a UA with culture and sensitivity, UA collected with two attempts, dark, foul smelling urine noted with presence of blood, resident tolerated urine collection without difficulty. First dose of Pyridium given with evening medication, resident voiced feeling relieved and stable at facility, in bed, resting quietly, will continue to monitor for change. Fluids and cranberry juice offered and encouraged, resident remains stable at this time, UA pending pick up from lab; -On 9/4/22 at 1:24 P.M., transfer to hospital summary. Patient complaint of pain during urination. Urine has foul odor. Blood tinged urine noted. Patient requesting to go to emergency room . Respiration even and non-labored. No shortness of breath noted. PRN pain medication administered. Physician made aware of clinical situation and transfer. During an interview on 9/9/22 at 10:20 A.M., the resident said he/she was in horrific pain. It felt like a hot curling iron inside me. He/she was in so much pain, he/she wanted to call an ambulance his/herself. When staff obtained the urine sample, the staff person said, Oh, blood! The resident said he/she saw there was blood in the urine. The resident said he/she was suffering so badly, he/she cried. The resident said the Pyridum didn't help the pain, it still burned after taking the Pyridium. Review of the resident's September 2022 MAR, showed: -An order, dated 6/10/22, for pain assessments, day and night shift; -Staff documented: -9/1, day shift: 0, night shift: 8; -9/2, day shift: 0, night shift: 9; -9/3, day shift: 0, night shift: 8. Further review of the resident's September 2022 MAR, showed: -An order, dated 6/10/22, for Acetaminophen, Extra Strength Tablet 500 mg, none documented as administered; -An order, dated 8/5/22, for Oxycodone HCI Tablet, 15 mg, give 1 tablet by mouth every 4 hours as needed for pain, documented as administered on 9/1 at 10:44 P.M., on 9/2 at 5:54 A.M. and 9/3 at 7:50 A.M., 1:09 P.M., and 9:29 P.M. Review of the resident's hospital record, showed: -On 9/4/22, no time noted, patient presented with dysuria (painful urination); -Patient arrived with severe pain dysuria, and flank pain (pain in one side of the body between the upper belly area (abdomen) and the back). This is similar symptoms to his/her recurrent infection. He/she denies any fever, any chills, night sweats, nausea, vomiting or abdominal pain. In the emergency department he/she was positive for UTI on the UA. During an interview on 9/13/22 at 10:15 A.M., the resident's physician said she expected staff to have called regarding the resident's continuous complaints of pain. The possible complications of a UTI are the symptoms getting worse, and they can become septic (the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an existing infection triggers a chain reaction throughout the body). 2. Review of Resident #19's face sheet, showed he/she was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: -Dementia without behaviors; -Severe protein calorie malnutrition (associated with low muscle mass and function, and increased prevalence of physical frailty); -Pressure ulcers of unspecified stage; -Osteomyelitis (Inflammation of bone caused by infection, generally in the legs, arm, or spine. Infections can reach bones by traveling through the bloodstream or spreading from nearby tissue. Common symptoms include pain, fever, and chills). Review of the resident's quarterly MDS, dated [DATE], showed: -Severely cognitively impaired; -Understood others and made his/her needs known; -Total dependence of one staff member for bed mobility, mobility on and off the unit, dressing, toileting, personal hygiene and bathing; -At risk for developing pressure ulcers; -Three unhealed Stage IV pressure ulcers (Full thickness deep tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, thick, leathery tissue over wound bed) may be present on some parts of the wound bed. Often include undermining and tunneling); -Skin and pressure ulcer/injury treatments. Review of the resident's care plan, revised on 2/18/22, showed: -Focus: the resident was admitted with one unstageable sacrum (located at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone) pressure ulcer, one right hip Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous (the layer of tissue that underlies the skin) fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) and tunneling (has progressed to form passageways underneath the surface of the skin). ); 1/30/22, following new wounds added: sacrum Stage IV, right hip Stage IV pressure ulcer, left hip Stage IV pressure ulcer; 7/28/2022, following new wounds added: sacrum Stage IV pressure ulcer, right hip Stage IV pressure ulcer, left hip Stage IV pressure ulcer, right buttock Stage III; -Goal: Wound will show signs of improvement; -Interventions included: --Encourage resident to frequently shift weight; --Low air loss (LAL) mattress with bolsters. Further review of the care plan, showed no interventions to address the resident's potential for pain. Review of the resident's electronic medical record (EMR), showed the following physician orders: -Pain assessment every day and night shift, dated 6/29/22; -Wound care treatment to left hip: cleanse with wound cleanser (WC) or normal saline (NS), apply Santyl (removes dead tissue from wounds so they can start to heal) to wound bed, apply calcium alginate (dressing used on moderate to heavily exudative (draining) wounds during the transition from debridement (the removal of damaged tissue or foreign objects from a wound) to repair phase of wound healing), skin prep to peri wound (skin area around the wound), cover with border gauze. Change daily and if dressing becomes saturated, soiled or dislodged every day shift, dated 6/21/22; -Wound care: Cleanse right hip with WC and apply antifungal cream every day shift and as needed, dated 8/9/22; -Wound care: Cleanse sacrum with WC and apply antifungal cream to wound and peri wound every day shift and as needed, dated 8/9/22; -Acetaminophen (non-narcotic pain reliever) 325 milligrams (mg), give 650 mg by mouth (PO) every four hours and PRN, 6/18/22; -Santyl ointment 250 units per gram (unit/gm), apply topically to left hip wound every day shift, 8/22/22. Review of the resident's Medication Administration Record (MAR), dated 9/1/22 to 9/30/22, showed: -Pain assessment every day and night shift with 14 out of 17 assessments indicating no pain, pain score at 1 out of 10 on 9/3/22 night shift, and pain score at 8 out of 10 on 9/6/22 day and night shifts. Observation on 9/9/22 at 7:45 A.M., showed the resident lay on his/her back, leaning to the right with one pillow behind his/her left side of the back and one pillow between his/her knees. Observation on 9/9/22 at 9:09 A.M., showed the resident lay on his/her back, leaning to the right with one pillow behind his/her left side of the back and one pillow between his/her knees. Observation and interview on 9/9/22 at 10:26 A.M., showed the resident lay on his/her back, leaning to the right with one pillow behind his/her left side of the back and one pillow between his/her knees. The wound nurse turned the resident for wound care, and then placed the resident into the same position on his/her back as prior to wound care. The resident said staff never give him/her pain medication when he/she is in pain, including wound pain, or prior to wound care. The wound hurts when wound care is provided and he/she would like pain medication prior to wound care. His/her wounds become painful when lying in one position too long. The wound nurse left the room without notifying the charge nurse or CNA the resident was in pain after/related to wound care. He/she does have pain to the wound on a regular basis. Wound care increases the pain to the wound. Observation on 9/9/22 at 12:42 P.M., showed the resident lay on his/her back leaning to the right with one pillow behind his/her left side of the back and one pillow between his/her knees. Observation and interview on 9/9/22 at 1:49 P.M., showed the resident lay on his/her back with one pillow between his/her knees. He/she was uncomfortable and would like to be repositioned, but no one ever comes in to move or help him/her. 3. Review of Resident #21's face sheet, showed he/she was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus II, dementia without behaviors, Stage IV pressure ulcer of the sacrum and hereditary and idiopathic (unknown cause) neuropathy (abnormality of the nervous system). Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Understood others and made his/her needs known; -One unhealed Stage IV pressure ulcer; -Skin and pressure ulcer/injury treatments: --Pressure relieving device for chair; --Pressure relieving device for bed; --Turning/repositioning program. Review of the resident's care plan, initiated 9/8/22, showed: -Focus: admitted with a Stage IV pressure ulcer to the sacrum and decreased mobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection through review date; -Interventions: --Administer treatments as ordered and monitor for effectiveness; --Followed by wound physician; --If the resident refuses treatment, confer with the resident, IDT and family to LPN determine why and try alternative methods to gain compliance. Document alternative methods; --Monitor dressing, if dressing becomes soiled, loose or comes off notify nurse; --Monitor/document/report PRN any changes in skin status including appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), and stage; --The resident required LAL mattress on bed and cushion in wheelchair. The resident did not have a LAL mattress on his/her bed; --Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Further review of the resident's care plan, showed the potential for pain was not identified. Review of the resident's admission Skin Only Evaluation, dated 8/24/22, showed: -One Stage IV pressure ulcer to the coccyx; -The pressure ulcer had no odor; -The pressure ulcer was painful; -No other skin issues noted; -No other skin assessments noted in the resident's EHR. Review of the wound physician's Initial Wound Evaluation and Management Summary, dated 9/2/22, showed: -Stage IV pressure ulcer to sacrum; -Wound size (L x W x D): 15.8 cm by 9.8 cm by 2.2 cm; -Recommendations: --Off-load wound; --Reposition per facility protocol; --Turn side to side and front to back in bed every 1-2 hours if able. Observation on 9/9/22 at 7:33 A.M., showed the resident lay on his/her back, in bed. The resident said he/she has pain during certain parts of wound care. Observation and interview on 9/9/22 at 10:44 A.M., showed the resident lay on his/her back, in bed. No LAL mattress noted to the bed. The resident said staff do not turn/reposition him/her unless asked to, and then sometimes they say they will be back to do it and they do not come back. Observation of wound care, showed the resident said ouch, this is where the wound care is painful, when she cleans the wound and applies the Dakin's soaked gauze. After wound care, the wound nurse positioned the resident into the same position on his/her back. Observation on 9/9/22 at 12:42 P.M., showed the resident lay on his/her back, in bed. Observation and interview on 9/9/22 at 1:49 P.M., showed the resident lay on his/her back in bed. No LAL mattress noted to the bed. The resident said staff had not attempted to reposition/turn him/her all shift. He/she was not offered pain medication prior to, during or after wound care. He/she would accept it if it was offered. After wound care, he/she had to ask for pain medication. He/she just received a Tylenol. He/she rated his/her pain at a 7 out of 10. 4. During an interview on 9/9/22 at 12:06 P.M., the Wound Nurse said: -He/she does not provide residents with pain medication. That is the charge nurse's job, he/she has the keys to the medication cart; -He/she would have to notify the charge nurse to provide pain medication to the resident during or before treatments, as needed; -He/she does not assess the residents for pain prior to, during, or after wound care; -He/she does not see any evidence of pain during wound care to any of the residents; -Resident #21 had never indicated pain during wound care; -Resident #19 complains of pain all the time and asks to be repositioned for the pain frequently, but staff does not do it as far as he/she can tell. During an interview on 9/9/22 at 2:10 P.M., Licensed Practical Nurse (LPN) B said: -He/she expected the wound nurse or other staff to let him/her know if the resident states they are in pain so he/she can provide pain medication; -The CNA notified him/her Resident #21 was in pain and he/she provided the resident with pain medication, if he/she was aware the resident was in pain during wound care, he/she would have provided pain medication earlier; -He/she was not aware Resident #19 was in pain and required pain medication. During an interview on 9/9/22 at 2:36 P.M., CNA C said: -If a resident is in pain, it should be reported to the nurse immediately; -He/she did not know Resident #19 was in pain; -Resident #21 complained of wound pain and he/she reported it to the nurse. During an interview on 9/9/22 at 3:00 P.M., the Assistant Director of Nursing (ADON) said: -When a resident voices pain, he/she expected the nurse to assess the resident's pain, ask the resident to rate the pain on a scale of 1-10, check to see what the resident has ordered, and provide pain medication based on the resident's level of pain. That is just basic nursing; -A resident pain rating of 2 to 5 would indicate providing the resident with Tylenol if ordered; -A resident pain rating over 5 would indicate providing the resident with narcotic pain medication if ordered; -He/she expected the wound nurse to report any statement of pain during wound care to the charge nurse for follow up and pain medication administration; -He/she expected the wound nurse to address pain with the resident before starting wound care; -If the resident voices pain, the wound nurse should notify the charge nurse so he/she can provide pain medication, let the pain medication take effect and then start wound care; -He/she expected the wound nurse to stop treatment if a resident voices pain during wound care, notify the charge nurse of voiced pain, and let the provided pain medication take effect before resuming wound care. During an interview on 9/13/22 at 10:14 A.M., Residents #19 and #21's physician/medical director said: -If a resident complains of pain during wound care, she expected staff to immediately inform the charge nurse the resident is in pain; -It should be up to the resident if staff continues the wound care at that time or wait to continue after the medication has taken effect; -If a resident complains of pain prior to wound care beginning, she expected staff to notify the charge nurse of the resident pain and wait until the medication has taken effect prior to beginning wound care; -He/she expected staff to notify the charge nurse of resident pain immediately; -He/she expected pain management to be provided as soon as possible. MO00206339 36151

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when staff failed to recognize, assess and notify the physician regarding a resident's expressed pain experienced during the resident's care (Resident #1), and failed to provide pain medications for approximately 12 hours after a resident suffered a fractured proximal ulna (tip of the elbow) (Resident #2). The facility census was 89. Review of the facility's Pain Management Policy and Procedure, revised on 7/11/22, showed: -Purpose: To assess all residents for pain and to provide our residents with the highest level of comfort possible, using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Policy: All residents will be assessed on admission and in conjunction with initial assessment and as needed (PRN) for pain. The assessment should include an interdisciplinary team (IDT) approach; -Overview: Overview of Pain Recognition and Management: -Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain; -Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life; -The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. The resident's needs and goals as well as the etiology, type, and severity of pain are relevant to developing a plan for pain management; -Certain factors may affect the recognition, assessment, and management of pain. For example, residents, staff, or practitioners may misunderstand the indications for, and benefits and risks of, opioids (pain relieving drug) and other analgesics (pain relieving medication); or they may mistakenly believe that older individuals have a higher tolerance for pain than younger individuals, or that pain is an inevitable part of aging, a sign of weakness, or a way just to get attention; -Some individuals with advanced cognitive impairment can accurately report pain and/or respond to questions regarding pain; -Those who cannot report pain may present with nonspecific signs such as grimacing, increases in confusion or restlessness or other distressed behavior. Effective pain management may decrease distressed behaviors that are related to pain. However, these nonspecific signs and symptoms may reflect other clinically significant conditions (e.g., delirium, depression, or medication-related adverse consequences) instead of, or in addition to, pain. To distinguish these various causes of similar signs and symptoms, and in order to manage pain effectively, it is important to evaluate (e.g., touch, look at, move) the resident in detail, to confirm that the signs and symptoms are due to pain; -Pain is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent. The following are descriptions of several different types of pain: -Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness; -Incident pain refers to pain that is typically predictable and is related to a precipitating event such as movement (e.g., walking, transferring, or dressing) or certain actions (e.g., wound care); -Persistent pain or chronic pain refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years; -Standards of Practice refers to approaches to care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies; -Strategies for Pain Management: Strategies for the prevention and management of pain may include but are not limited to the following: -Assessing the potential for pain, recognizing the onset, presence and duration of pain, and assessing the characteristics of the pain; -Addressing/treating the underlying causes of the pain, to the extent possible; -Developing and implementing both non-pharmacological and pharmacological interventions, approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both; -Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Monitoring appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief; and modifying the approaches, as necessary. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/29/22, showed: -Moderate cognitive impairment; -Dependence of one staff person required for eating, dressing, toileting and personal hygiene, -Dependence of two staff required for transfers; -No behaviors; -Upper and lower extremity impairment on both sides; -Wheelchair for mobility; -Scheduled pain medication, yes; -PRN pain medication, no; -Interview: Pain presence, moderate pain, occasionally, caused difficulty sleeping and limited activities; -Should staff assessment for pain be conducted, no; -Unhealed pressure ulcers (Damage to an area of the skin caused by constant pressure on the area for a long time) upon admission, yes; -Number of pressure ulcers, four Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough (necrotic (dead) tissue or eschar (a dry, dark scab or falling away of dead skin) may be present on some parts of the wound bed. Often include undermining (a closed passageway under the surface of the skin that is open only at the skin surface) and tunneling (a passageway under the surface of the skin, most of the tunneling is not visible)); -Medications received last seven days, Opioids, 0; -Diagnoses included quadriplegia (paralysis of all four limbs), septicemia (blood poisoning by bacteria) and kidney failure. Review of the resident's physician's orders, showed: -An order, dated 6/23/22 for pain assessments, every day and night shift; -An order, dated 6/23/22, for Aspirin, 81 milligram (mg), give 1 tablet by mouth one time a day for wound care; -An order, dated 6/23/22, for Oxycodone HCI (used to treat moderate pain), 10 tablet, give 10 mg by mouth every four hours as needed for severe pain (5-10); -An order, dated 6/23/22, for Acetaminophen Tablet 325 mg, give 650 mg by mouth every four hours as needed for mild pain (1-4); -An order, dated 6/23/22, for Dakins (antiseptic to cleanse wounds in order to prevent infection), 1/4 strength solution (Sodium Hypochlorite, disinfectant/antimicrobial agent), apply to wounds topically one time a day for wound care and pain; -An order, dated 6/24/22, for wound care: Cleanse left forearm with wound cleanser (WC) and apply calcium alginate (absorbs wound exudate (fluid and leukocytes (white blood cell) and forms a gel-like covering over the wound, helping to maintain a moist wound healing environment), three times a week, every Monday, Wednesday and Friday and as needed; -An order, dated 6/27/22, for wound care: Cleanse left and right hand with WC and apply foam dressings on Monday, Wednesday and Friday, as needed; -An order, dated 7/1/22, for wound care, Cleanse sacrum (bone structure at the base of the spine) with WC and apply negative pressure wound therapy (NPWT, a method of drawing out fluid and infection from a wound), set to 125 (mmHg, millimeters of mercury, a measurement of pressure), every Monday, Wednesday and Friday as needed; -An order, dated 7/12/22, for wound care: Cleanse left heel with WC and apply Santyl (an enzyme used to break up and remove dead skin and tissue) and calcium alginate and cover with a foam dressing. Daily and PRN. Review of the resident's care plan, showed: -Focus: Documented pressure ulcers, admitted with Stage 4 right lateral hand, Stage 4 left lateral forearm, Stage 4 pressure ulcer sacrum; -Interventions: Low air loss mattress (LAL), monitor nutritional status, multi-podus boots (positions heel in floating position to prevent pressure areas) on at all times, notify nurse if any wound dressings become loose, soiled or come off, treatment to pressure ulcers per orders and weekly wound documentation; -The Care Plan shows no direction to staff regarding assessing pain during pressure ulcer treatments or if pain is present during treatments. It does not direct staff to notify the physician regarding the pain for further direction. Review of the weekly wound reported, dated 7/11/22, showed: -Right Hand, Stage 4, 2.7 centimeters (cm) length x 2.4 cm width x 0.2 cm depth; -L Hand, Stage 4, 1.8 cm x 1.5 cm x 0.3 cm; -Left Arm, Stage 4, 2 cm x 1.5 cm x 0.5 cm; -Sacrum, Stage 4, 10.4 cm x 4.8 cm x 1.4 cm; -Left heel, onset 7/11/22, 5.5 cm x 2.8 cm x .2 cm. Review of the resident's medication administration record (MAR), dated 6/1/22 through 6/30/22, showed: -An order, dated 6/23/22, for Aspirin, 81 MG, give 1 tablet by mouth one time a day for wound care, documented as administered daily, pain level on 6/23/22, documented as 10, all additional pain levels documented as 0; -An order, dated 6/23/22, for pain assessments, every day and night shift, pain levels for both shifts 6/23/22 through 6/30/22, documented as 0; -An order, dated 6/23/22, for Acetaminophen tablet 325 MG, give 650 mg by mouth every four hours as needed for mild pain (1-4), not initialed as administered 6/23/22 through 6/30/22; -An order, dated 6/23/22, for Oxycodone HCI, give 10 MG by mouth every four hours as needed for severe pain (5-10), not initialed as administered 6/23/22 through 6/30/22; -An order, dated 6/23/22, for Dakins, apply to wounds topically one time a day for wound care and pain, not initialed as administered on 6/23, 6/26 and 6/28/22; - An order, dated 6/24/22, cleanse left forearm with WC and apply calcium alginate, three times a week, every Monday, Wednesday and Friday and as needed, documented as administered on 6/27 and 6/29; -An order, dated 6/27/22,cleanse left and right hand with WC and apply foam dressings on Monday, Wednesday and Friday, as needed, documented as administered on 6/27/22 and 6/29/22. Review of the resident's MAR, dated 7/1/22 through 7/16/22, showed: -An order, dated 6/23/22, for pain assessments, every day and night shift, pain levels for both shifts; on 7/5/22, day shift, documented as 5, no pain medication documented as administered; -An order, dated 6/23/22, for Oxycodone HCI, give 10 MG by mouth every four hours as needed for severe pain (5-10), not initialed as administered 7/1/22 through 7/16/22; -An order, dated 6/23/22, for Aspirin, 81 MG, give 1 tablet by mouth one time a day for wound care, documented as administered daily, 7/1/22 through 7/16/22, daily pain levels documented as 0; -An order, dated 6/23/22 for Acetaminophen Tablet 325 MG, give 650 mg by mouth every four hours as needed for mild pain (1-4), documented as administered on 7/6/22, pain level documented as an 8; -An order, dated 6/23/22, for Dakins, apply to wounds topically one time a day for wound care and pain, not initialed as administered on 7/2/22, 7/3/22, 7/4/22, and 7/8/22 through 7/15/22; -An order, dated 6/27/22, to cleanse left and right hand with WC and apply foam dressings on Monday, Wednesday and Friday, as needed, documented as administered on 7/1, 7/4, 7/6, 7/8, 7/11, 7/13 and 7/15/22; -An order, dated 7/1/22, to cleanse sacrum with WC and apply NPWT, set to 125 mmHg, every Monday, Wednesday and Friday as needed, documented as administered on 7/1, 7/4, 7/6, 7/8, 7/11, 7/13 and 7/15/22; -An order, dated 7/12/22, for coccyx, cleanse with wound cleanser and apply dressing with Kerlix soaked Dakins, two times a day, documented as administered on 7/12 and 7/13/22; -An order, dated 7/12/22, to cleanse left heel with WC and apply and calcium alginate and cover with a foam dressing daily and PRN, documented as administered on 7/1, 7/4, 7/6, 7/8, 7/11, 7/13 and 7/15/22; -An order, dated 6/24/22, to cleanse left forearm with WC and apply calcium alginate, three times a week, every Monday, Wednesday and Friday and as needed, documented as administered on 7/1, 7/4, 7/6, 7/8, 7/11, 7/13 and 7/15/22. Further review of the resident's medical record, showed no documentation staff administered pain medication prior to wound care or documentation if the resident complained of pain during wound care. During an interview on 8/8/22 at 8:15 A.M., the wound nurse said the resident screamed all the time during care. He/she cussed and would scream It hurts! It's hurting! The wound nurse said during dressing changes, she would explain to him/her she had to treat the wound. She said she was surprised almost all his/her pain assessments were documented as zeros. She did his/her wound treatments after his/her morning medications and assumed the resident was getting pain medications. During an interview on 8/8/22 at 8:20 A.M., Certified Nurse's Assistant (CNA) A said the resident would complain of pain all the time. He/she had skin problems. He/she would scream and cuss you out if you touched him/her or rolled him/her over. He/she would scream and yell when staff provided care. During an interview on 8/8/22 at 8:24 A.M., Licensed Practical Nurse (LPN) B said the resident had a lot of bed sores. When moving him/her, he/she would scream out. When you touched or moved him/her, he/she would scream. The resident had wounds all over. He/she had wounds on his/her hands, he/she was in a lot of pain. LPN B said he/she would definitely not document a 0 for his/her pain level. The resident would be more sore after wound treatments and LPN B would expect someone to provide pain medications prior to treatments. During an interview on 8/8/22 at 2:05 P.M., the wound doctor said he remembered the resident would call out in pain. He said the newly developed heel wound on 7/11/22 could have developed quickly due to the resident's compromised state, he said he saw the resident on 8/8/22 and his heel wound was not identified at that time. He said he would have expected staff to notify him regarding the resident's complaints of pain. He expected staff to provide pain medication prior to his/her treatments, it would have helped provide comfort during the treatments. He said the order for the daily aspirin, 81 mg, described as for wound pain was incorrect and should have been corrected. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependence of one staff person required for eating, dressing, bed mobility and personal hygiene, -Dependence of two staff required for transfers and toileting; -No behaviors; -Upper extremity impairment on one side; -Wheelchair for mobility; -Pain presence: No; -PRN pain medication: No; -Diagnoses included high blood pressure, stroke, multiple sclerosis (MS, a disabling disease of the brain and spinal cord/central nervous system), seizure disorder and depression. Review of the resident's care plan, undated, showed: -Interventions: The resident's pain is alleviated/relieved by: rest and PRN medication. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Monitor/record/report to nurse any signs/symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); -Focus: The resident experiences increased difficulty with projecting his/her voice related to MS and recent stroke; -Interventions: Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking and make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed; -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to diagnosis of MS with spasticity and paralysis. Resident requires moderate to total assist with ADLs; -Interventions: Bed mobility: The resident is totally dependent on one staff for repositioning and turning in bed routinely and as necessary. Skin inspection: The resident requires skin inspection weekly and during bathing. Observe for redness, open areas, scratches. Check on resident routinely every day. Review of the resident's physician's orders, dated 6/1/22 through 6/30/22, showed: -An order, dated 7/1/2019, for pain assessments, every day and night shift; -An order, dated 6/29/22, for Hydrocodone-Acetaminophen tablet 5-325 MG, give one tablet every 6 hours as need for pain. Review of the resident's MAR, dated 6/1/22 through 6/30/22, showed: -An order, dated 7/1/2019, for pain assessments, every day and night shift: on 6/26/22 through 6/28/22, day and night shift, 0; on 6/30/22 on day shift, a 4 level of pain out of a possible 10; -An order, dated 6/29/22, for Hydrocodone-Acetaminophen tablet 5-325 MG, give one tablet every 6 hours as need for pain: on 6/29/22 and 6/30/22, pain level, blank, PRN administered, blank. Review of the resident's progress notes, showed: -On 6/27/22 at 7:05 P.M., Note Text: This nurse notified physician in regards to resident's right arm at the elbow, resident has cried when moved this shift and elbow looks a little swollen. Physician advised resident's MS has caused resident arm to be disfigured. Advised next shift to monitor area for increased swelling and guarding of the area. At this time no imaging is ordered; -On 6/27/22 at 7:15 P.M., Late Entry: Note Text: This nurse was notified by the CNA that the resident's right arm near the elbow was swollen, also that resident had been tearful and crying during turns to reposition and change briefs. This nurse went to observe resident arm and notified MD of findings, and seek an order for imaging to be performed. Resident had been in bed during this shift non tearful, no guarding noticed until assessing of arm when notified. The mobile imagine unit was called for order placement and management was notified with an update on resident status. Next shift was advised as well and made aware to keep watch for changes and guarding to area; -On 6/27/22 at 7:57 P.M., Note Text: Physician returned call and gave ok for imaging to be performed, imaging ordered via STAT (immediate) order and face sheet printed for exam; -On 6/28/22 at 9:00 A.M., Late Entry: Note Text: Night shift nurse reported to day shift nurse that resident right arm was swollen and bruised and x ray images were done and was awaiting results. Portable imaging x-ray faxed results on 6/27/22 at 9:00 A.M. Day shift nurse called physician and reported the results and the physician informed to send resident to emergency room (ER). ER was called and ambulance arrived at 9:30 A.M. Resident's family was notified of the incident and that resident was being sent out to the hospital. Ambulance arrived and resident was transported without incident. Review of the radiology results, dated 6/27/22 at 9:06 P.M., showed: -Procedure: Right elbow, two views; -Interpretations: Pain, swelling, deformity, resident guarding right upper extremity; -Findings: Acute fracture of the proximal ulna (elbow). Review of the facility investigation related to the right arm pain, dated 6/30/22, showed: -In a written statement, dated 6/28/22, CNA E wrote, the resident had been very upset and emotional all day. On his/her last rounds. Around 6:00 P.M., while changing the resident, he/she started crying again and grabbed his/her arm. CNA E moved the resident's hand away from his/her arm and noticed his/her arm was discolored and swollen and CNA E notified LPN D; -An emailed statement, sent by LPN D to the administrator on 7/30/22 at 1:15 A.M., which read, this nurse was notified by the CNA E in the mid 6:00 P.M. hour the resident's right arm had been swollen and that may have been the reason he/she had some crying episodes earlier that shift. This nurse did not witness any crying episodes but had earlier that shift asked the reported CNA reasons as to why he/she had not gotten the resident up for lunch that day. The CNA stated the resident was crying and said he/she did not want to get up that day. This nurse went to the resident and asked him/her personally if he/she wanted to go to the dining room for lunch and the resident said no. Throughout the shift this resident seemed calm and quiet, which is not unusual from his/her baseline from this nurse's perspective. This nurse assisted the resident with eating his/her dinner and the resident even assisted throughout the meal. There were no signs/symptoms verbally or non-verbally that warranted any discomfort. At 6:00 P.M. during shift change, this nurse is notified via the CNA that the resident's arm is swollen. After assessing the resident's arm, this nurse called the physician and made them aware of findings, and sent images of findings. At this time the relief for night shift is present and made aware of the situation, and that this nurse was awaiting a response from the physician to order imaging. There was some time lapse between the images being sent from this nurse's phone to physician's phone and a few phone calls back to the physician to see what her verdict was. The physician called back and stated the images had not yet been received on her end. This technical difficulty resulted in the images needing to be sent from the relief nurse's phone which is an iPhone just like the physician's. While awaiting response from the physician, this nurse notified management to make them aware of the situation and inquire of which imaging company the facility uses again. This nurse began placing an order for imaging to be performed on the resident. This nurse informed the evening nurse that orders were placed and printed out and placed atop the printer at the nurses' station and that imaging should be performed on the resident some time that shift because a STAT order was placed. The physician did give her approval of imaging to be performed ultimately. As this nurse was exiting the facility around early 8:00 P.M., the portable imaging unit was seen in the parking lot and this nurse asked if they were there for the resident and technician stated yes; -Review of the resident's facility incident investigation conclusion, dated 6/30/22, showed: -On 6/27/22, day staff reported that the resident was tearful, and they left him/her in bed which is often normal routine when he/she is uncomfortable. The aide reported near the end of his/her shift he/she noticed the swelling to the right arm and immediately reported it to the nurse. The nurse took immediate action. An X-ray was orders as STAT and mobile X-ray services arrived by 8:00 P.M. The results were not called to the facility until the next day for staff intervention that evening. Staff may have been unaware that they were already available due to the lateness of obtaining them. Staff took appropriate action when the injury was found and after the results were obtained. The fracture was likely pathologic in nature due to the resident's diagnosis and overall fragile conditions. There is no indication of intentional staff misconduct. The resident's surroundings were evaluated by the administrator and assistant director of nursing for any changes that needed to be made to accommodate his/her care. The resident prefers his/her bed against the wall for a feeling of safety and security. No changes will be made at this time. Possible causes of the injury could be, positioning of arm while providing care, turning and positioning techniques, positioning while transferring in Hoyer (a manual hydraulic lift) or spontaneous fracture due to osteoporosis (a condition in which bones become weak and brittle). Unable to determine specific cause due to underlying medical conditions. The resident returned from the hospital the same day he/she was sent out. Staff had him/her up in a geri-chair (a medical recliner, a large, padded, comfortable reclining chair with casters) on 6/29/22 and he/she tolerated it well. Resident was observed by the administrator in the dining room watching entertainment with no signs or symptoms of pain or discomfort noted. Staff was initially educated on reporting signs/symptoms of injury or abuse. Staff will be educated by therapy department on techniques of positioning, care and transfers that will support the resident's fragile extremities. During an interview on 7/28/22 at 1:05 P.M., the resident's physician said the resident had a stroke and he/she can't talk. Staff just found his/her arm fractured and he/she can't say what happened. It was a fresh fracture, that arm can't bend, he/she has osteoporosis. It could have happened by lifting him/her with the Hoyer's pad pressing against his/her arm during the lift. The physician said she tried asking him/her what happened, but he/she can't answer, he/she can't answer yes or no. During an interview on 8/2/22 at 2:39 P.M., LPN D, said he/she was not aware of the resident having complaints of pain. The resident is usually calm, not much facial grimacing. He/she said he/she is agency and it was near shift change, at 6:00 P.M., when one of the CNAs made him/her aware resident's arm looked swollen, and he/she was guarding his/her arm. The resident's arm did look swollen, and he/she called the physician and got an order for imaging. The x-ray is provided by a third party mobile imaging unit. A STAT x-ray order was received and he/she placed the order before he/she left. LPN D did see the technician arriving while on his/her way to the car. It might have been a CNA that told him/her the resident's arm was hurting. During an interview on 8/2/22 at 3:38 P.M., LPN C, said the imaging results fax was received on 6/27/22 at 9:00 P.M., LPN D said he/she was watching for the results of the fax. LPN C said he/she checked and they arrived around 9:00 P.M., and the results had not been opened. The x-ray had been completed and the facility had the results, LPN D told him/her about the x-ray at 6:00 P.M. LPN C said he/she printed off a copy and sent a text message to the physician and another other copy went to the office. LPN C said imaging results can be viewed on the facility computer system, by going to the resident's profile, click results, and then staff should have the results. LPN C said the resident wasn't crying, but he/she was holding his/her arm with his/her other arm. LPN C said he/she didn't know if the resident gets any pain medication, maybe Tylenol. LPN C said he/she was very disappointed in the timeframe, the physician should have had the results, the resident's arm was not immobilized, and without immobilization, it can be painful, and could potentially cause additional harm. A person can be left in agonizing pain. The resident is unable to verbalize pain because he/she can't tell you. Further review of the resident's medical record, showed no pain medication was documented as administered while the resident waited for the x-ray results to be read, and prior to being sent to the hospital for treatment, approximately 12 hours (9:00 P.M. through 9:00 A.M.). During an interview on 8/9/22 at 2:30 P.M., the administrator said she would expect staff to keep an eye out for the imaging results several times during their shift. During an interview on 8/4/22 at 6:47 P.M., the resident's physician said she would have expected staff to call her when the resident was expressing signs/symptoms of pain. If the resident was having episodes of crying, and unable to say why, she would expect to be notified. She would have expected staff to be watching for the results of the x-ray and been notified of the results when they were delivered to the facility. The resident should have been given medication for pain, if he/she had a PRN medication. The pain should have been treated and if the medication was not sufficient, she should be called and she could prescribe something stronger. MO00203217 MO00204192

Based on observation, interview and record review, the facility failed to have a process to ensure Certified Nurse Aides (CNAs) reported new or worsening skin conditions and soiled or missing dressings to the nurse when identified. In addition the facility failed to ensure nurses applied treatments to wounds with soiled or missing dressings timely, completed weekly skin assessments and ensure treatments were applied as ordered. The facility identified 13 residents with pressure ulcers. Of those 13, six were included in the sample and problems were found with all six. In addition, the survey team identified three residents with new pressure ulcers, not identified by the facility. (Residents #19, #224, #46, #63, #51, #45, #3, #22 and #55). The census was 75. The administrator was notified on 5/11/21 at 3:09 P.M., of an immediate jeopardy (IJ) which began on 5/3/21. The IJ was removed on 5/12/21, as confirmed by surveyor onsite verification. Review of the facility's pressure ulcer policy, updated 5/28/19, showed; -Pressure Ulcer Prevention included: Reposition at least every two hours. Use pillows, foam wedges, etc to keep bony prominences from direct contact. Use devices that reduce pressure on the heels. If indicated. Place on pressure redistribution mattress. Use pressure redistribution devices for seating surfaces. Inspect skin during care and report and changes; -Measuring Skin Ulcers Policy and Procedure: All residents with skin ulcers will have measurements taken weekly or PRN (as needed) to chart increase or decrease in ulcer size; -Best Practices included: Daily skin inspection, reposition at least every 2 hours, float heels in bed, protect bony prominences with positioning devices, complete bath sheets/eval as scheduled, complete weekly measurements/documentation, notify family and physician weekly of progress and document, for all wound care always follow MD orders. Refer to wound MD/wound clinic if applicable; The policy failed to show what staff should do when a dressing is found soiled or off. Review of the facility's Wound Care Education for all New Hires policy, undated, showed: -CNAs: Upon finding any area/skin issue, report to charge nurse immediately. If a dressing is saturated or has fallen off, report to nurse immediately. During care/bathing, never wash a wound with a wash cloth, and only pat dry if not covered with dressing. Shower sheets must be completed noting any area found; -Nurses: When skin issue, if found, is reported, immediately obtain order from the physician. Notify the Director of Nurses (DON)/designee to add to weekly wound rounds. Skin assessments must be completed weekly, when scheduled, and entered under assessments. 1. Review of Resident #19's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/21, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Short/long term memory loss; -Required total staff assistance for all activities of daily living (ADLs); -Has an indwelling urinary catheter (hollow tube inserted through the urethra into the bladder to drain the bladder of urine); -Has a [CONDITION(S)] (a piece of the colon is diverted to an artificially created opening in the abdominal wall for stool to pass and be collected into a bag outside of the body); -Stage I (Intact skin with nonblanchable (blood flow does not return when pressure is applied and then released, redness of a localized area usually over a bony prominence) pressure ulcer; -Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer; -Two Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mutinous) or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, maybe softer or harder than surrounding skin, may be present on some parts of the wound bed) pressure ulcers. Review of the resident's care plan, updated 4/13/21, showed: -Focus: Stage IV on buttock, Stage II (Partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) on right knee, Stage III healing ulcer right calf, Unstageable (Known but not stageable due to coverage of wound bed by slough and or eschar) pressure ulcer; -Interventions: Continue treatments as ordered. Continue treatments to pressure ulcers. Continue weekly assessment and documentation. Continue low air loss (LAL, reduces the contact pressure at the skin-mattress contact) mattress, heel float and wedges. (3/28/19) Educated CNAs upon finding any areas/skin issues, report to the charge nurse immediately. If dressing is saturated or fallen off, report to the nurse immediately. During care never wash a wound with a wash cloth and only pat dry if not covered with dressing. Nurse education: When skin issue is reported, immediately obtain physician order. Notify DON/designee to add to weekly rounds. Skin assessments must be completed weekly -Focus: Resident has a history of [CONDITION(S)] (an infection of the bone) of the buttock, sacral and hip wounds; -Interventions: Maintain universal precautions when providing resident care. Monitor sites for infection and report to physician. Resident remains on long term antibiotic related to [CONDITION(S)]. Review of the facility's Wound Report, dated 4/26/21 through 4/30/21, showed: -Location: Sacral (area located at the base of the spine, just above the coccyx (tailbone), Stage IV, start date: 5/9/19, acquired, size: 12.5 centimeter (cm) by 14.0 cm by 6.0 cm; -Location: Left hip, Stage IV, start date: 5/16/19, acquired, size: 4.0 cm by 2.5 cm by 0.5 cm; -Location: Right inner knee, Stage II, start date: 2/1/20, acquired, size: 4.5 cm by 3.0 cm by 0.2 cm; -Location: Left heel, Unstageable, start dated: 1/11/21, acquired, size: 2.5 cm by 4.0 cm by 0.2 cm; -Location: Right calf, Stage III, start date: 7/3/20, acquired, size: 0.5 cm by 0.3 cm by 0.5 cm; -Location: Coccyx, Unstageable, start date: 4/27/21, new acquired, size: 4.5 cm by 2.0 cm by 0.2 cm; -Location: Right under knee, Stage II, start date: 4/10/21, acquired, size: 1.0 cm by 0.7 cm by 0.2 cm. Review of the resident's progress notes, dated 4/30/21, at 3:15 P.M., showed: -Resident was seen by outside Wound Company on 4/27/21; -The resident's physician watched dressing changes on Thursday, 4/29/21; -Agreed with all orders from outside Wound Company; -Left hip Stage IV measures 4.0 cm x 2.5 cm x 0.5 cm. Wound bed 50% pink, 50% yellow. Undermining (occurs when tissue under the wound's edge becomes eroded resulting in a pocket) 8 - 10 (o'clock) with a depth of 3.3 cm; -Right hip/ischium/scrotal wound area measures 12.5 cm x 14.0 cm x 6.0 cm. Depth is at two open areas that connect around the hip joint. Wound bed 20% purple, 20% hypergranulation (excessive tissue growth above the wound surface), 30% pink, 20% epithelial; -Coccyx Unstageable measures 4.5 cm x 2.0 cm x 0.2 cm. Wound bed 50% pink, 50% yellow; -Right lateral (outer) knee measures 1.0 cm x 0.7 cm x 0.2 cm. 100% yellow wound bed; -Right medial (inner) knee measures 4.5 cm x 3.0 cm x 0.2 cm. 80% hypergranulation and 20% pink. Stage 2; -Right lateral LE (lower extremity) 0.5 cm x 0.3 cm x 0.5 cm. 100% pink wound bed. Some fungal [CONDITION(S)] to periwound area; -Left heel Unstageable measures 2.5 cm x 4.0 cm x 0.2 cm. Wound was debrided by NP (nurse practitioner). 30% pink, 70% unstable eschar; -Right anterior thigh measures 1.5 cm x 0.7 cm x 0.2 cm; -LAL mattress, protein supplements, wedges and heel float, long term antibiotic for [CONDITION(S)]. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Dated 4/29/21: Cleanse pressure ulcer to left buttock, right and left of the scrotum, with Dakin's solution (a diluted bleach solution used as an antiseptic), apply [MEDICATION(S)] (antibiotic) cream, [MEDICATION(S)] gauze (petroleum jelly impregnated gauze) to wound bed and cover with foam dressing once a day; -Dated 4/30/21: Cleanse pressure ulcer to coccyx, right lateral lower extremity and left heel with Dakin's solution, apply [MEDICATION(S)] cream, calcium alginate (a dressing that absorbs wound drainage (exudate)) and cover with bordered foam once a day; -Dated 4/29/21: Cleanse pressure ulcer to right hip/right ischium, under scrotum, with Dakin's solution, apply [MEDICATION(S)] cream and crushed [MEDICATION(S)] (antibiotic) tablet to wound bed, pack lightly with Dakin's soaked roll, cover with alginate and large pad dressing daily and as needed; -Dated 4/30/21: Cleanse pressure ulcer to left hip with 1/4 strength Dakin's solution soaked gauze, apply [MEDICATION(S)] cream, alginate and cover with bordered foam dressing every Monday, Wednesday and Friday. Observation on 5/3/21, showed: -At 9:03 A.M.: During the facility tour, the resident lay on a low air loss mattress with his/her side rails up on both sides of the bed. The resident appeared disheveled, the pad appeared soiled, and the bed linens were wrinkled and dirty. The dressing on his/her right inner knee was dated 4/30/21; -At 12:32 P.M.: The resident lay on his/her back, with bolster under legs to lift feet, heels remain on bed, undated dressing coming off left heel; -At 2:03 P.M.: During a skin assessment, the resident lay in bed on a low air loss mattress. The Wound Nurse and unknown staff member, removed the positioning device under the resident's legs and turned him/her to his/her right side, revealing saturated dressings dated 4/30/21. All dressings were saturated with a large amount of strong, foul smelling drainage. The disposable pad and draw sheet were saturated with the same drainage. The odor from the dressing permeated the room. The Wound Nurse removed the saturated dressings revealing large pressure ulcers to the resident's coccyx, buttocks, hips and ischials, with slough and drainage noted. The Wound Nurse said all dressings on the resident's buttocks should be changed daily. They should have been changed over the weekend. She last changed the resident's dressings on Friday, 4/30/21. The wound nurse said frequently on Monday after the weekend, he/she observes staff has failed to change the dressings. This has occurred frequently. She said it's frustrating because she works on the wounds all week to heal them. Review of the resident's progress notes, dated 5/9/21 at 5:52 P.M., showed: -Seen by outside wound company this week; -Treatment discontinued to right lateral knee, healed; -Right ischium, Stage IV, treated by NP for excessive bleeding with silver [MEDICATION(S)] (used to cauterize infected tissues. Also used to help stop bleeding), measured: 11.5 cm by 15.5 cm by 6.0 cm, wound bed 40% pink 60% yellow; -Left of scrotum: 1.0 cm by 0.5 cm by 0.2 cm, wound bed 100% pink; -Coccyx: Unstageable, measured 3.5 cm by 2.4 cm by 0.2 cm, 50% pink, 50% yellow; -Right buttock: New, unstageable, measured 2.4 cm by 1.8 cm by 0.2 cm, 50% pink, 50% yellow; -Left buttock: Has an opened draining area that has developed a wound bed surrounding: 2.0 cm by 0.7 cm by 0.5 cm, 50% pink, 50% yellow; -Left heel: unstageable, was debrided by NP, measured 2.5 cm by 3.0 cm by 0.2 cm, 70% pink, 30% yellow/brown; -Right lower extremity: Stage III, nearly healed, measured 0.6 cm by 0.2 cm by 0.1 cm with 100% pink wound bed; -Right anterior thigh: 0.5 cm by 0.5 cm by 0.1 cm; -Right medial knee: 4.5 cm by 3.0 cm by hypergranulation; -Left hip: Stage IV, measured 5.0 cm by 3.5 cm by 1.0 cm, 40% pink, 40% yellow; -Resident's physician assessed the wounds this week, updated about new orders, and agreed with treatment orders. During an interview on 5/11/21 at 6:10 A.M., CNA Y (agency staff) said he/she works the night shift at the facility. He/She took care of the resident approximately two weeks ago. Prior to that he/she hadn't taken care of the resident for several weeks. When he/she turned the resident on his/her side, the dressings on his/her buttocks were saturated and some of them had fallen off. The CNA said the appearance of the resident's buttocks frightened him/her because he/she didn't know what to do. He/She asked a facility CNA to help him/her. He/She doesn't know the staff member's name. The facility CNA said the facility was aware of the wounds on the resident's buttocks. He/She cleaned the wound and applied a clean dressing. CNA Y said he/she has reported when dressings have come off in the past, but the charge nurses say they would report it to the day shift nurse. Most of the time they won't replace the dressing. During an interview on 5/11/21 at 4:56 P.M., CNA Z said he/she is employed by the facility. He/She has taken care of the resident on the day shift. He/She has found the resident's dressings to be soaked and soiled. On two prior occasions he/she has changed the resident's dressings because the agency nurse said they would apply a clean dressing when they get to it, but they don't do it. The resident also has a large oozing wound which he/she feels the nurse should address. He/she has squeezed it on occasion to make the pus come out. He/she has also applied antibiotic powder to the resident's groin area because it was red. The nurse has opened the treatment cart so he/she can get supplies. He/she had a recent in-service regarding wounds and knows he/she should report it to the nurse when a dressing comes off or is soiled. During an interview on 5/12/21, the outside wound company Nurse Practitioner said she has evaluated the resident's pressure ulcer twice, 4/27/21 and today, 5/12/21. She found the Unstageable coccyx wound on the initial visit on 4/27/21. She said it would impact the healing of the wounds if staff aren't consistently changing the dressings as ordered. She would expect staff to complete the treatments as ordered and replace dressings when soiled or when they come off. Review of the resident's progress notes, dated 5/13/21 at 10:12 A.M., showed: -An outside wound company assessed pressure ulcers and treated this week; -Right medial knee: Stage II, measured 5.2 cm by 3.0 cm by hypergranulation, wound bed fragile, sliver [MEDICATION(S)] applied; -Right anterior (front) thigh: Draining area from abscess, measured 0.5 cm by 0.5 cm by 0.1 cm, 100% pink; -Right lower extremity: Healing Stage III, wound has split wound bed, distal (away from the center of the body) area measured 0.8 cm by 0.5 cm by 0.1 cm with 100% pink wound bed, proximal (closer to the center of the body) area measured 1.2 cm by 0.2 cm by 0.1 cm, 10% pink, 90% yellow; -Left hip: Stage IV, measured 4.5 cm by 3.5 cm by 1.0 cm, undermining 8 - 10 (o'clock) at 2.5 cm, wound bed 50% pink, 50% yellow; -Coccyx: Unstageable, measured 3.5 cm by 2.4 cm by 0.2 cm, wound bed 40% pink and 60% yellow; -Left buttock: Has small draining area, 0.7 cm by 0.5 cm by 0.2 cm, 100% pink; -Left of scrotum: Stage II; -Right buttock: Unstageable, measured 1.8 cm by 1.8 cm by 0.2 cm with 100% yellow wound bed; -Right hip/ischium/scrotum: measured: 15 cm by 15 cm by 6.0 cm, depth around hip joint. Measures through two tunneling (are channels that extend from the wound into surrounding tissue). holes to either side of joint, top opening 2.0 cm by 0.8 cm, lower opening 3.0 cm by 1.0 cm, wound bed beefy red with sanguineous (bloody) drainage. 2. Review of Resident #224's POS, dated 4/9/21, showed: -admitted d of 4/9/21; -Order date: 4/9/21: NPWT (Negative Pressure Wound Therapy (wound vac) is a method of drawing out fluid and infection from a wound to help it heal) to sacrum, Change Monday and Thursday; -Order date: 4/9/21: Ensure NPWT is sealed and functioning every shift. Change canister if full; -Order date: 4/27/21: Left iliac crest (top of hip) of hip, treat with wound gel, gauze and dry dressing once a day. Review of the resident's treatment administration record (TAR), showed: -April: Order dated 4/9/21: Ensure NPWT is sealed and functioning every shift. Change canister if full. A.M.: Staff initialed as complete: 4/11 - 4/21, 4/23, 4/25 - 4/30. No staff initials on: 4/10, 4/22 and 4/24/21. P.M.: Staff initialed as complete: 4/9 - 4/25, 4/27 - 4/29/21. No staff initials: 4/26 and 4/30/21. -April: Order dated 4/27/21: Left iliac crest of hip, treat with wound gel, gauze and dry dressing once a day. Staff initialed as complete: A.M.: 4/27 - 4/30/21. Review of the facility's Wound Report, dated 4/26/21 through 4/30/21, showed: -Location: Sacral: Stage IV, start date 4/9/21, admitted with, measured 6.9 cm by 7.9 cm by 0.8 cm; -Location: Left Hip: Stage II, start date 4/26/21, new acquired, measured 0.9 cm by 0.3 cm by 0.2 cm. Review of the resident's TAR, dated 5/1/21 through 5/31/21, showed: -Order dated 4/9/21: Ensure NPWT is sealed and functioning every shift. Change canister if full. A.M.: May: A.M.: Staff initialed as complete: 5/1 and 5/2/21. P.M.: 5/1 and 5/2/21; -Order dated 4/27/21: Left iliac crest of hip, treat with wound gel, gauze and dry dressing once a day. Staff initialed as complete: A.M.: May: 5/1 and 5/2/21. Observation on 5/3/21 (Monday), showed: -At 8:42 A.M., during the tour of the facility, the resident lay on his/her back in bed, on a pressure-reducing mattress, dressed in a hospital gown. No boots or socks on the resident's feet; -At 9:21 A.M., the resident lay on his/her back in bed. A NPWT (wound vac) to the left of the resident's bed beeped and flashed Full. The wound vac canister was full of red, yellow, and white secretions; -At 10:47 A.M. and 11:45 A.M., and 12:01 P.M., the resident lay on his/her back in bed. A flat sheet covered his/her legs. The wound vac beeped and flashed Full. The wound vac canister full of red, yellow, and white secretions. The beeping could be heard from the hall; -At 12:13 P.M., CNA N entered the resident's room and shut the door. He/She exited the room at 12:25 P.M. The resident remained on his/her back in bed with eyes closed. The wound vac was off and canister was full; -At 1:06 P.M., the resident lay on his/her back in bed. The wound vac was off and canister was full; -At 2:20 P.M., during care, the resident lay in bed. CNA CC turned the resident to his/her right side revealing a dressing to the left hip dated, 4/26/21 (Monday). Below the wound vac dressing was a pressure ulcer, with yellow slough covering the wound bed, approximately 3 cm in size. The wound vac remained off and was full of secretions. CNA CC covered the resident and left the room. He/She did not indicate he/she would report the pressure ulcer to the nurse; -At 2:38 P.M.: During a skin assessment: The Assistant Director of Nurses (ADON) and Wound Nurse entered the room. The Wound Nurse acknowledged the resident's wound vac was off and full of secretions. She said she did a recent in-service with nurses on how to change a full wound vac canister. She was sure that's the reason the wound vac was off, or it was turned off because it was beeping. She removed wound vac dressing, and packing from the pressure ulcer. The pressure ulcer measured 7.4 cm by 8 cm, the undermining measured 5 cm to 8 cm. She said the wound vac is changed on Monday and Thursday. The left hip dressing should be changed every 3 days. It should have been changed on 4/29/21. The Wound Nurse said pressure ulcer on the coccyx was new and was not there on Thursday, 4/29/21, when she checked the resident's wound vac dressing. No one reported the new pressure ulcer or that the wound vac was off. She was pulled to work as a charge nurse that day, 5/3/21. The coccyx pressure ulcer was Unstageable and measured 2.2 cm by 3.2 cm with 50% slough and 50% pink tissue. She removed the left hip dressing, dated 4/26/21, revealing a hole in the left hip, with a large amount of dark brown drainage on the dressing. She said the physician said he/she believes the wound is tunneling. The treatment nurse said she would call the physician and obtain a treatment order for the coccyx pressure ulcer. Review of the resident's progress note, dated 5/3/21, showed: -New pressure ulcer noted during dressing change to NPWT; -Unstageable coccyx pressure ulcer noted; -50% pink, 50% slough; -New per physician: Comfort foam (a dressing used to provide a moist wound environment, used for wounds with moderate to heavy exudate) every two days. Review of the resident's POS, dated 5/1/21, showed an order dated 5/3/21, for Comfort foam dressing to coccyx every two days. Review of the resident's TAR, dated 5/1/21 - 5/31/21, showed: -Comfort foam to coccyx every two days; -Staff initialed as complete: 5/4, 5/6 and 5/8. Review of the resident's progress note, dated 5/9/21, showed: -At 3:48 P.M.: Physician updated: Left hip treatment changed to every two days; -At 6:07 P.M.: Stage IV pressure ulcer to sacral area measured 6.9 cm by 6.8 cm by 0.8 cm, undermining from 5 - 7 o'clock with a depth of 6 cm. NPWT applied at -120 mmhg, change Monday and Thursday; -Left hip: Stage II, measured 0.4 cm by 0.1 cm by 0.1 cm, mild serous (thin watery) drainage. Do not use or leave brief open to prevent pressure to the area; -Coccyx Unstageable pressure ulcer, below NPWT, measured 1.0 cm by 1.0 cm, 100% yellow. It appears the sacral pressure ulcer wound has tunneled under the coccyx pressure ulcer and expects the area to open; -The physician has been updated, orders to continue the NPWT. Observation on 5/10/21, showed: -At 7:00 A.M.: During a skin assessment, the resident lay in bed on a pressure relief mattress. CNA DD positioned the resident on the right side, the left hip dressing was dated 5/9/21, the dressing above the coccyx was intact, attached to the wound vac and dated 5/9/21. The pressure ulcer, to the right of the coccyx had no dressing. To the left of the coccyx was a small pressure ulcer with slough covering the wound bed, approximately 1 cm in size. CNA DD made no acknowledgement of the pressure ulcers. He/she said he/she didn't take care of the resident last night; -At 9:45 A.M.: During a skin assessment the Wound Nurse, turned the resident to the right side and said no one reported the dressing was off the pressure ulcer to the right of the coccyx. She said the pressure ulcer looked visibly worse. She was worried about the pressure ulcer tunneling when she saw it on Friday, 5/7/21. She said the pressure ulcer to the left of the coccyx was new. No one reported it to her. It was not there on Friday 5/7/21, when she last did the resident's treatment. She would have expected staff to report the new pressure ulcer on the left of the coccyx. In addition she would have expected the night nurse to replace the dressing to the pressure ulcer to the right of the coccyx During an interview on 5/10/21 at 10:09 A.M. The Wound Nurse said the pressure ulcer to the right the right of the coccyx measured 2.5 cm by 1.4 cm, and was Unstageable. The new pressure ulcer to the left of the coccyx measured 0.5 cm by 0.4 cm with yellow slough. It is Unstageable. She said it looked as if staff failed to turn the resident and he/she laid on his/her buttocks over the weekend. 3. Review of Resident #46's admission MDS, dated [DATE], showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Short/long term memory loss; -Required total staff assistance for bed mobility, transfers, dressing, toilet, personal hygiene and bathing; -Required extensive assistance of staff for eating; -Incontinent of bowel and bladder; -admitted with two Unstageable pressure ulcers. Review of the facility's Wound Report, dated 3/29/21, showed: -Wound: Coccyx; -Stage: Unstageable; -Start date: 2/19/21; -admitted with; -Size: 8.0 cm by 3.2 cm. Review of the resident's care plan updated 4/1/21, showed: -Focus: Resident admitted with Unstageable pressure ulcer to coccyx; -Goal: Pressure will show signs of healing and free from infection; -Intervention: Pressure foam mattress and cushion when in chair. Out of chair as tolerated. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the facility's Wound Report, showed: -Date: 4/5 through 4/9/21: Wound: Coccyx, Stage: Unstageable, start date: 2/19/21, admitted with, size: 7.8 cm by 4.1 cm; -Date: 4/12 through 4/16/21: Wound: Coccyx, Stage: Unstageable, start date: 2/19/21, admitted with, size: 7.5 cm by 4.0 cm; -Date: 4/26 through 4/30/21: Wound: Coccyx, Stage: Unstageable, start date: 2/19/21, admitted with, size: 7.5 cm by 4.1 cm. Review of the outside wound company's Initial Visit Case Report, dated 4/27/21, showed: -Physical Exam: Skin: Pressure ulcer to coccyx covered with soft eschar and yellow around the edges; -Wound location: Coccyx, Stage: Unstageable, Measurement: 7.5 cm by 4.0 cm, mild pain, moderate serosanguineous (fluid that contains blood and serum) drainage, Necrotic tissue: 100% yellow and black eschar. Review of the resident's POS, dated 5/1/21 through 5/31/21, showed: -Order dated 4/28/21; -Cleanse coccyx pressure ulcer with Dakin's 1/4 strength solution soaked gauze, apply [MEDICATION(S)] (antibiotic cream) 2% cream and alginate to wound bed and cover with foam dressing on Monday, Wednesday and Friday. Review of the resident's TAR, dated 5/1/21 through 5/31/21, showed: -Cleanse coccyx pressure ulcer with Dakin's 1/4 strength solution soaked gauze, apply [MEDICATION(S)] 2% cream and alginate to wound bed and cover with foam dressing on Monday, Wednesday and Friday; -Staff initialed as complete 5/3/21. Observations on 5/3/21, showed: -At 8:51 A.M., during the initial tour of the facility, the resident lay on a low air loss mattress with a fall mat to the left side of the bed. During an interview at that time, the resident said he/she had a sore on his/her buttocks, but staff aren't changing the dressings. He/she pointed to his/her buttocks and said there wasn't a dressing on his/her buttocks. She doesn't understand how the wounds would heal if they don't change the dressings; -At 12:37 P.M., the resident lay in bed. The resident said staff came in to dry him/her, but they did not put a dressing on his/her buttocks. CNA F and CNA X entered at that time and positioned the resident in bed; -At 1:44 P.M., during a skin assessment, the resident lay in bed. The Wound Nurse turned the resident to the right side, removed the brief and revealed a large pressure ulcer covered with eschar to the resident's coccyx. The Wound Nurse said no one reported the resident's dressing was off. She would have expected the staff to report whenever a resident's dressing comes off so it can be reapplied. Review of the resident's progress note, dated 5/9/21 at 6:03 P.M., showed: -Resident seen by outside wound company; -The resident's physician assessed the resident's pressure ulcer during dressing change; -Coccyx: 7.5 cm by 3.5 cm, wound bed: soft eschar: 20% yellow, 80% dark eschar; -Pressure ulcers to be debrided (the removal of unhealthy/damaged/dead tissue from a wound to promote wound healing). Observations on 5/10/21, showed: -At 6:50 A.M., the resident lay in bed. The resident said there wasn't a dressing on his/her buttocks. He/she said the dressing was off during the night; -At 9:56 A.M., the resident lay in bed. Observation during a skin assessment with the Wound Nurse showed there was no dressing on the resident's coccyx. The Wound Nurse said no one reported the resident's dressing was off. She was not aware the resident's dressing was off last night. She would expect staff to report it to the charge nurse so he/she could replace it. During an interview on 5/10/21 at 7:05 A.M., CNA NN (agency staff) said he/she worked last night. The CNA who took care of the resident left at 5:00 A.M., which left the floor with two CNAs. When asked what he/she would do if dressings were soiled, the CNA said he/she would remove the soiled dressing and report it to the charge nurse. The charge nurse usually records the information in the report book that the dressings need to be replaced or that they are off. The night nurse usually notifies the day nurse that a dressing was off and report it to the Wound Nurse. Most of the agency nurses will not replace the dressing if it is soiled or comes off. Review of the resident's progress notes, dated 5/13/21 at 10:29 A.M., showed: -Resident see by Outside Wound Company; -Coccyx pressure ulcer: 8.0 cm by 4.0 cm by 0.2 cm; -Wound bed: 20% yellow slough, 80% soft brown eschar; -[CONDITION(S)] (redness and inflammation) to periwound (area surrounding the wound); -Drainage: green; -NP suggest antibiotic. The resident's physician declined antibiotic. 4. Review of Resident #63's quarterly MDS, dated [DATE], showed: -Cognitively intact, able to make needs and wants known; -No behaviors; -Total staff assistance needed for hygiene, bed mobility, transfers and eating; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Used urinary catheter and a [CONDITION(S)]; -At risk to develop pressure ulcer or pressure injury; -No unhealed wounds; -Used a pressure reducing device on the bed and chair; -Used a turn and reposition program; -Staff applied dressings other than to the resident's feet. Review of the resident's undated care plan, in use during the survey, showed: -Focus: The resident is at risk for skin breakdown. He/she has a history of skin breakdown and requires total care from staff; -Goal: The resident will have intact skin, free of redness, blisters or discoloration; -Interventions: Staff administer treatments as ordered and monitor for effectiveness, assess skin routinely, ensure pressure relief mattress on bed and cushion in the wheelchair, the resident should be placed back in bed after four hours in the wheelchair, staff use wedge or pillows to reduce pressure to ankles and heels, place a donut in between the knees and the resident should wear soft boots at all times. Review of the resident's POS, showed an undated order, to avoid pressure to the right ankle. Turn the resident to the left side or turn the right leg to the left side or up. Avoid the right side down during every day and night shift. Review of the resident's Comprehensive CNA shower sheets, showed: -On 3/27/21: No irregular skin concerns, signed by the aide and no nurse signature; -On 3/30/21: The resident received a bed bath, no irregular skin concerns, signed by the aide and the nurse; -On 3/31/21: The resident received a bed bath, no irregular skin concerns, signed by the aide and the nurse; -On 4/4/21: No irregular skin concerns, signed by the aide and no nurse signature; -No further shower sheets available after 4/4/21. Review of the resident's weekly skin assessment, dated 4/17/21, showed no skin concerns. No further weekly skin assessments available or located. Observations and interviews, showed: -On 5/3/21 at 9:17 A.M., 11:51 A.M., 12:45 P.M., and 2:13 P.M., the resident lay in bed on his/her back with a blue wedge under his/her lower legs. The wedge was in direct contact with the resident's lower leg skin. The resident said he/she needed staff to move him/her in bed and provide all care needs. Staff do not turn him/her very often in bed and he/she often lay on his/her back for long periods of time. The wedge is always under his/her lower legs to keep his/her feet off of the bed. He/She cannot feel pain or d

Based on observation, interview and record review, the facility failed to notify one resident's (Resident #374) physician of a critical lab result and that resident was later admitted to the hospital for a related condition. The facility failed to administer medications per facility policy for one resident (Resident #46) and obtain orders to maintain one resident's peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of heart. Used to give IV fluids and medications) (Resident #51). The sample was 18. The census was 75. 1. Review of the facility's Notification of Resident Change in Condition policy, updated 8/1/18, showed: -Protocol: The facility's clinician's will notify the physician and family or legal representative if there is a change in the resident's condition; -Procedure: 1. Notify the physician and family or legal representative at the earliest possible time, during waking hours, if there is a change in condition (unless requested to do otherwise). 2. Notify the physician and family or legal representative if there is a significant change in condition regardless of the time. If the resident's change in condition merits immediate attention the nurse will provide immediate assistance and will call 911 for medical intervention. If the attending physician is not available (does not respond) to physician notification and there is no physician on call. The nurse can call the facility's Medical Director regarding the resident change in condition with follow up with attending physician. 3. Document in the nurses notes the time the notification was made, the names of the persons to whom they spoke to, and sign the entry. Review of Resident #374's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/6/20, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Short/long term memory loss; -Extensive staff assistance for bed mobility and dressing; -Total staff assistance for transfers, dressing, toileting, personal hygiene and bathing; -No oxygen use. Review of the resident's progress notes, showed: -9/28/20 at 1:03 P.M.: At approximately 11:50 A.M., a certified nursing assistant (CNA) came to the nurse's station to report the resident had complaints of shortness of breath (SOB) and that he/she seemed to struggle to breathe. He/She was breathing rapidly and was wheezing slightly when staff got him/her up to a chair. Nursing assessment showed his/her lungs sounds had respiratory wheezes in upper lobes. O2 (oxygen) Saturation (SATs) (normal range is 95 - 100%) was 80% initially, heart rate was 90 (normal range is 60 - 100 beats per minute). Encouraged him/her to cough. Cough was productive and his/her O2 SATs increased quickly to 89%. He/She was placed on 2 L (liters) of oxygen per nasal cannula. The physician was notified and new orders were received for chest x-ray, [MEDICATION(S)] (an [MEDICATION(S)], helps thin [MEDICATION(S)] and loosen congestion) and [MEDICATION(S)] (a combination medication relax muscles in the airways and increase airflow to the lungs) treatment. O2 SATs remain at greater than 95% on 2 L of oxygen. Will continue to monitor. Blood pressure (BP) is 150/90 (normal is 120/80), taken manually, sitting upright in chair; -9/28/2020 at 4:30 P.M.: X-ray here at this time, resident has refused x-ray. Combative with staff and x-ray technician. Will try again tomorrow; -No further documentation regarding resident's condition until 9/29/20. Review of the resident's chest x-ray results, dated 9/29/21 at 7:29 A.M., showed the the findings most consistent with congestive heart failure (CHF) and pulmonary [CONDITION(S)]. Review of the resident's progress notes, showed: -9/29/2020 at 9:53 A.M.: Spoke with the physician's nurse practitioner (NP) regarding chest x-ray results. New order received for STAT (immediate) BMP (Basic Metabolic Panel, a blood test used to give information about the body's fluid balance), BNP (Brain Natriuretic Peptide, a blood test which measures cardiac function), CBC (Complete Blood Count, blood test that evaluates blood cells), Daily weights x 5 days (If 2-3 pound increase in 1 day or 5 pound increase in 5 days, notify the physician office), give 20 milligram (mg) of [MEDICATION(S)] (diuretic) now, cardiology consultation, and obtain speech evaluation all related to (r/t) CHF findings on chest x-ray results. STAT labs ordered; -9/29/2020 at 3:19 P.M.: Resident is scheduled at hospital on October 5, 2020 at 2:30 P.M., for new cardiology consult r/t CHF findings upon x-rays. Order and all necessary paper-work have been faxed to office; -9/29/2020 at 5:24 P.M.: Late Entry Note: Stat CH (Critical High) BNP lab results of 808 (normal is less than 100 picograms per milliliter (ml) of blood) called to the physician's office. Messages left. No one answered or responded this shift; -9/29/2020 no time noted, late entry documented on 9/30/21 at 9:46 P.M.: Resident alert but resting in bed. O2 on at 2 L per nasal cannula. Refused his/her bedtime medication, accucheck and insulin. O2 Sat was 100%. Resting quietly in bed most of the night with eyes closed. No distress noted; -No further documentation regarding the resident's condition until 9/30/20; -9/30/2020 at 8:52 A.M.: SBAR (Situation, Background, Assessment and Recommendation) Summary for Providers Situation: The Change In Condition/reported were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Shortness of breath. At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 154/82 Position: Sitting left/arm, Pulse (heart rate): (P) 66 Regular, Respirations R 22 (normal range is 12 - 20 breaths per minute), Temp: T 98.2 (normal is 98.6), Forehead (non-contact), Pulse Oximetry: O2 89%, Oxygen via Nasal Cannula, Blood Glucose: BS 173 (normal range is less than 140), Resident in the facility for: Long Term Care, Code Status: Full code; -Resident had the following medication changes in the past week: [MEDICATION(S)] 20 mg x 1; -Nursing observations, evaluation, and recommendations are: resident needs to be sent to hospital; -Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send to ER; -9/30/2020 at 9:08 A.M.: Resident currently in bed with O2 on at 4 liters per nasal cannula. Respirations at 22 per minute. Resident lab work BNP 808. NP notified and order received to send resident to ER. VS 154/82, 66, 22, O2 Sat 89% and Temp: 98.2. Respirations are labored at times. Ambulance called and waiting for transfer to hospital; -9/30/2020 at 9:17 A.M.: POA notified of transfer to hospital. Review of the resident's Hospital History and Physical dated 9/30/20, showed: -admitted d of 9/30/20; -Reason for admission: Bilateral Pleural Effusion (fluid buildup on the lungs), pulmonary [CONDITION(S)] (excess fluid in the lungs usually caused by a heart condition); -BNP elevated on admission. Review of the resident's Hospital Discharge/Transfer papers, dated 10/4/20, showed the following: -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -History of presenting illness: Presents to the emergency room with acute onset of shortness of breath, lived at the nursing home since his/her stroke and did not required oxygen. That morning he/she was found severely short of breath, required eight liters of oxygen and was transported to the emergeny room; -In the emergency room , chest xray showed bilateral interstitial infiltrates (double pneumonia) and pulmonary [CONDITION(S)] (excess fluid in the lungs) and given IV (intravenous) [MEDICATION(S)] (medication used to treat fluid retention); -Labs: elevated BNP in the 700's; -admitted for further management; -Hospital Course: He/she was admitted to Cardiology. He/she was found to be in [MEDICATION(S)] [CONDITION(S)] (slow heart rhythym), medications [MEDICATION(S)] (used to treat heart rhythm problems) and a beta blocker (medication used to treat high blood pressure) were held. He/she was diuresed (increased fluid removal) with improvement in oxygenation. He/she did not require oxygen at the time of discharge; - Resident was discharged back to facility on 10/4/20. During an interview on 5/14/21 at 10:22 A.M., the Director of Nurses (DON) said after review of the resident's record, staff failed to notify the physician of a critical lab. She would have expected staff to make her aware of the critical lab. She would have given the staff instructions to send the resident to the hospital. Staff should have continued to try to call the physician to notify him/her of the critical lab. She also would expect staff to notify the Medical Director if they unable to reach the primary physician. 2. Review of facility's medication administration policy, last revised on 5/1/11, showed: -Purpose: To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; Right time; -Read the medication administration record (MAR) for the ordered medication, dose, dosage form, route, and time; -Verify the correct medication, dose, dosage form, route, and time again by comparing to MAR before administering; -Document the following as applicable: -Administration of medication on the MAR as soon as medications are given; -Omitted dose by circling your initials in the appropriate block on the medication MAR; -Reason for omission in the Nursing Progress Notes or on the back of the MAR; -As needed (PRN) medication, reason for administration, and effectiveness in the nursing progress notes or on the back of the MAR; -When medication has been discontinued by writing D/C (discontinued) next to the last dose of the medication on the MAR; block out the rest of the days that month; -Notify physician of changes in resident or with refusal of medication. Review of Resident #46's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 3/10/21 and discontinued on 3/17/21, for [MEDICATION(S)] (HCL) solution (antibiotic used to treat infections) 1000 mg, Use 1000 mg intravenously (IV, administer through the veins) every 12 hours for infection. Review of the resident's MAR, dated 3/1/21 through 3/31/21, showed documentation for [MEDICATION(S)] HCL 1000 mg intravenous (IV) was left blank on the following days: -3/13/21 at 8:00 A.M. medication pass; -3/14/21 at 8:00 A.M. medication pass. Further review of the resident's medical record, showed no documentation staff had administered the medications. There was no documentation that staff alerted the physician of failure to administer the medication. Further review of the resident's medical record, showed an order, dated 4/7/21 and discontinued on 4/21/21, for [MEDICATION(S)] HCL 1000 mg/200 ml of normal saline (NS), Use 1000 mg IV every 12 hours for infection. Review of the resident's MAR, dated 4/1/21 through 4/30/21, showed documentation for [MEDICATION(S)] HCL 1000 mg/200 ml was left blank on the following days: -4/9/21 at 9:00 P.M. medication pass; -4/18/21 at 9:00 P.M. medication pass. Further review of the resident's medical record, showed no documentation that staff had administered the medications. There was no documentation staff alerted the physician of failure to administer the medication. Further review of the resident's medical record, showed: -An order, dated 5/1/21, for [MEDICATION(S)] HCL 1000 mg/200 ml NS, Use 1000 mg IV one time a day for abscess (an infection that causes a confined pocket of pus that collects in tissues, organs, or spaces inside the body); -A progress note, dated 5/3/21 at 10:38 A.M., showed [MEDICATION(S)] IV was discontinued per physician. The resident would follow up at a later time with infectious disease physician but the resident had already completed months of IV antibiotic and his/her abscess was not seen on scans. Observation on 5/4/21 at 8:25 A.M., showed Nurse A prepared a bag of [MEDICATION(S)] HCL 1000 mg/250 ml of NS, with the directions to administer over 90 minutes or 167 ml/hour. The nurse entered the resident's room, hung the bag of [MEDICATION(S)] on the resident's IV medication pump and programmed the pump to run the medication at 167 ml/hr. The nurse then attached the IV tubing from the [MEDICATION(S)] to the resident's PICC located at the resident's right arm. Nurse A then turned the IV medication pump on and medication was seen flowing from the bag of [MEDICATION(S)] into the resident's PICC. During an interview on 5/4/21, at 12:53 P.M., Nurse A said: -Each medication must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Nursing staff were expected to administer medications exactly as the physician ordered; -If he/she had any questions regarding the medication, he/she would clarify the order with the physician before administering the medication; -When a medication was discontinued, it would show up in the resident's MAR, lit up in white, and labeled D/C; -He/she was unaware the [MEDICATION(S)] was discontinued. Further review of the resident's medical record, on 5/6/21 at 8:00 A.M., showed no documentation staff alerted the physician of the administration of the [MEDICATION(S)] on 5/4/21. During an interview on 5/6/21, at 9:00 A.M., the DON said: -She expected staff to follow manufacturer's instructions and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Administering discontinued medications, such as [MEDICATION(S)], could cause significant harm to residents; -She expected staff to report a medication error to the physician, the DON, the resident or the resident's responsible party; -She expected staff to document medication errors in resident progress notes, detailing what occurred, who was notified and when, if there were new orders, and what follow up occurred; -She expected staff to administer all doses of antibiotics; -Missed doses of antibiotics could cause significant harm to residents as it could delay healing, bacteria could render resistance to the antibiotic causing the infection to deteriorate; -Missed doses of antibiotics was a medication error; -She expected staff to fill out MARs completely; -If there was a blank in a resident's MAR, other staff would not know if the medication was administered, not administered, not available, or refused and could affect patient care; -She expected staff to follow facility policies. 3. Review of the facility Care of Peripherally Inserted Central Catheters policy, dated 2004 and last revised in 2013, showed: Introduction: -The PICC line is a central venous access device that is inserted by accessing on the the large veins of the upper extremities, usually in the area of the basillic vein; -The PICC line can be used from seven days and up to six months or longer if necessary; -PICC lines come in various types and number of lumens (access port), single or double; -PICC lines allow access for blood sampling and IV administration without the trauma of repeated venipunctures; -Assess the insertion site for bleeding, redness or swelling minimally every 12 hours; Care and Maintenance of the PICC: -Regular flushing of the PICC is required to prevent or delay catheter occlusion (blockage) related to [MEDICATION(S)] (a protein involved in the clotting of blood) formation. This is accomplished by flushing the PICC with 20 ml of NS following drug administration or blood sampling and every 7 days when not in use; Infection: -Systemic (affecting the whole body) and local infections are possible complications of a central line. A common source of infection is the catheter hub (central venous catheter (CVC) Hub refers to the end of the CVC that connects to the blood lines) but other potential causes include migration of skin flora (microorganisms that reside on the skin) up the catheter tract; -Change dressings and adaptors as outlined in nursing procedures; -Change dressing if it becomes soiled or wet; Self-Test for staff: -The adaptor (connector) of the PICC should be changed every 7 days; -Following the initial dressing change, the PICC line dressing is changed once weekly. Review of Resident #51's admission MDS. dated 3/22/21, showed: -admitted [DATE]; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands; -Brief Interview for Mental Status score of 15 out of a possible 15 (a score of 13-15 indicates cognitively intact); -Rejection of care: Behavior not exhibited; -Total dependence of one person required for bed mobility, toilet use and bathing; -Total dependence of two (+) persons required for transfers; -Extensive assistance of one person required for dressing and personal hygiene; -Functional limitation of both lower extremities (hip, knee, ankle, foot); -Indwelling urinary catheter (inserted through the urethra into the bladder to drain the bladder of urine); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes, showed: -4/13/21 at 10:26 A.M.: Upon assessment the resident presented with a temperature of 101.2 orally and a pulse of 151. The resident also presented with a productive cough that produced a moderate amount of thick yellow mucous. The resident's bladder was also distended and the indwelling urinary catheter was not draining. The catheter was removed and the bladder did empty a large amount of urine. The resident was also vomiting and did vomit 350 ml. Emergency medical services was called and the resident has been taken to the hospital; -On 4/17/21 the resident was discharged from the hospital and readmitted to the facility; -4/17/21 at 2:38 P.M.: [MEDICATION(S)] (IV antibiotic) and [MEDICATION(S)] solution (sugar/water mixture) reconstitute, 2 grams (gm) ([MEDICATION(S)]) and 50 ml ([MEDICATION(S)] solution). Use 2 gm IV every 12 hours to infection for 11 days. Medication will start the evening of 4/17/21. Review of the resident's POS, on 5/3/21, showed: -4/17/21: [MEDICATION(S)] and [MEDICATION(S)] solution, 2 gm every 12 hours per IV for 11 days; -No order to flush the PICC line after the antibiotics finished in 11 days; -No orders to routinely change the PICC line adaptor or dressings. Review of the resident's care plan, showed: -No information about the resident receiving IV antibiotics or why; -No information about maintenance of the resident's PICC line, including dressing changes, cap and adapter changes, and flushes. Review of the resident's MAR and treatment administration record (TAR), dated 4/1/21 thru 4/30/21, showed: -4/17/21: [MEDICATION(S)] 2 mg/50 ml IV every 12 hours (8:00 A.M. and 9:00 P.M.) for 11 days. Last dose received documented on 4/28/21 at 8:00 A.M.; -No orders to change the PICC dressing, and adapter changes; -No order to flush the PICC line after the antibiotic therapy was completed in 11 days. Observation on 5/4/21 at 6:50 A.M., showed the resident lay in bed. A single lumen PICC line was noted in the resident's right upper arm. A dressing with rolled up edges and several pieces of tape covered the PICC insertion site. The resident's skin could not be clearly seen through the pieces of tape. The dressing covering the PICC insertion site was dated 4/16/21. The resident said the dressing was put on at the hospital when the PICC line was inserted. No one at the facility had changed the dressing. The edges of the dressing keeps rolling up. CNA W told the nurse's the dressing needs changed and brought him/her tape to tape the dressing down. Observation and interview on 5/5/21 at 11:03 A.M., showed the resident lay in bed. The resident said last night he/she told the 100 hall night nurse (his/her nurse) about the PICC dressing needing to be changed. The 100 hall night nurse looked at the PICC dressing in his/her right upper arm. The 200 hall night nurse got a PICC dressing change kit for the 100 hall night nurse who laid it on his/her bed table and it is still laying there. Observation at that time, showed a PICC dressing kit laid on the resident's bed table and the current dressing covering the resident's PICC insertion site was dated 4/16/21. Observation on 5/5/21 at 12:43 P.M., showed the resident's PICC dressing had been changed. During an interview on 5/5/21 at 12:44 P.M., Nurse B said he/she usually works on the 200 hall but was filling in that day on the 100 hall. He/she changed the resident's PICC dressing and adaptor. He/she reviewed the resident's orders in the electronic medical records and could not find orders for the PICC line dressing and adaptor changes or routine flushes. He/she looked for hospital discharge orders in the resident's hard chart and could not find any dated 4/17/21. He/she could not find documentation the dressing or adaptors had been changed or the PICC had been flushed since the antibiotics had finished on 4/28/21. He/She said he/she would assume all of those things should be done at least weekly. He/She would call the physician for orders. The facility wound nurse, present at the time of the interview, stated she had looked in the resident's records and found no order to discontinue the PICC line, no order for a PICC dressing change and no orders for flushes after the antibiotics had finished. Review of the resident's POS and TAR on 5/6/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/5/21 at 1:00 P.M., CNA W said he/she recalled giving the resident tape for the PICC dressing. The resident told him/her the area at the PICC insertion site was sore and he/she (CNA W) told the nurse. He/She also told the nurse the resident was applying tape to the current PICC dressing because the dressing was peeling off. He/she did not recall the day or what nurse he/she had told. During an interview on 5/10/21 at 10:40 A.M., the DON said if orders are not received on admission for the maintenance of a PICC line, she would expect the nurse's to contact the resident's physician for orders within 24 hours after admission. The IV antibiotics, PICC line and the maintenance of the PICC line should have been documented on the care plan. The facility has a pharmacy policy for PICC lines and she expects staff to follow that policy.

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for one of three sampled residents. The facility failed to monitor the resident after a choking incident. The facility also failed to properly administer abdominal thrusts (the [MEDICATION(S)] maneuver (a first aid procedure used to treat upper airway obstructions or choking by foreign objects)) or call 911 after the resident became unresponsive. The resident expired at the facility (Resident #1). The census was 69. The administrator was notified on [DATE] at 4:00 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 Resident #1's most recent quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted [DATE]; -No cognitive impairment; -Understood others; -Adequate hearing and vision; -Supervision needed with transfers; -Supervision needed with eating - oversight, encouragement or cuing. Set up help only; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Diet: No added salt. Regular texture. Regular consistency; -Continuous oxygen at 3 liters/nasal cannula every day and night for shortness of breath; -A Do Not Resuscitate (DNR) order (a medical order instructing health care providers not to do cardiopulmonary resuscitation if a resident's breathing stops or if resident's heart stops beating). Review of the resident's progress notes, dated [DATE], showed the following: -At 6:10 P.M., staff called the nurse to the resident's room due to the resident choking on his/her supper. The resident was alert and answered questions. He/she sat in a high fowler position (upright seated position) in bed. The resident was able to cough up some bread and cleared his/her throat. Vital signs were temperature 97.4 F (normal 97.,d+[DATE].1), pulse 114 (normal ,d+[DATE]), respirations 28 (normal ,d+[DATE]) and blood pressure was ,d+[DATE] (normal ,d+[DATE] to ,d+[DATE]); -At 6:20 P.M., the staff called the nurse back to the room. The resident was pale in color and cyanotic (bluish discoloration of the skin due to lack of oxygen) around his/her mouth and lips. The resident was breathing. A second nurse came to the room and listened for but could not find a heart beat; -At 8:48 P.M., staff noted the resident passed away as the nurse came onto shift. The nurse tried to detect a pulse or breaths with the other nurse for approximately 20 minutes. The off going nurse contacted the family, physician and coroner. During an interview on [DATE] at 12:00 P.M., certified nurse's aide (CNA) H said on [DATE] around 6:00 P.M., he/she was in the resident's room assisting his/her roommate with eating. The resident was seated in his/her bed eating his/her dinner of a turkey sandwich and milk. The CNA asked the resident if he/she was done eating and the resident told him/her yes and ate the last bite of his/her sandwich and took a big drink of milk. The CNA gathered the resident's trash and left the room. He/she immediately returned to the room and heard the resident start coughing. He/she saw milk come out of the resident's nose and go into his/her oxygen tubing. The CNA called for help. CNA I responded and ran to get the nurse. CNA H noticed the resident spitting out bread, grabbed a chux (paper pad) and encouraged him/her to keep spitting out the bread onto the pad. The resident finally stopped coughing. It took a couple of minutes for him/her to catch his/her breath, and he/she was not talking. He/she nodded when asked if he/she was okay. The nurse took the resident's vitals and left the room. He/she did not ask the CNA to monitor the resident. The CNA left the room and walked down the hall to another resident's room. The CNA said something did not feel right about the resident, so the CNA went back to the resident's room to check on him/her. When he/she returned to the room, the resident was almost white in color and would not respond to questions. The CNA ran to the front desk to get licensed practical nurse (LPN) C. LPN C was giving report to LPN J. LPN C immediately ran to the resident's room to check on him/her. The resident was making breathing noises that sounded like hiccups. LPN C said the resident had a pulse. The resident was still seated in his/her bed with his/her head slumped forward. He/she did not see the nurse attempt to do the [MEDICATION(S)]. The resident's stomach was moving up and down as he/she tried to breathe. LPN J arrived at the room soon after this. The CNA did not see either nurse attempt the [MEDICATION(S)]. The CNA asked if they should call 911 and both nurses told him/her that the resident was a DNR, and the family did not want him/her sent to the hospital. The CNA became upset and called LPN K. During an interview on [DATE] at 11:00 A.M., LPN C said CNA H called him/her to the resident's room on [DATE] between 6:00 P.M. and 6:30 P.M. The CNA told him/her the resident was choking on his/her food. When he/she got to the room, the resident was coughing and spitting up bread. The resident was alert, breathing and answering questions. He/she had choked on a turkey sandwich followed up with a drink of milk. He/she spit up several balls of bread. The LPN did not see any milk coming out of the resident's nose or in the oxygen tubing. The resident could not talk, but nodded he/she was okay. LPN C did not know CNA H had witnessed milk come out of the resident's nose or get in his/her oxygen tubing. LPN C thought he/she told the CNA to keep an eye on the resident, but might not have done so because everything happened so fast. After about ten minutes, the CNA called the LPN back to the room and said he/she thought the resident was dead. The resident was slumped over in bed. He/she was pale and cyanotic around his/her mouth. He/she was semi-breathing. The LPN performed a sternum rub (painful stimulus with knuckles rubbed against chest), and attempted verbal and painful stimuli, but the resident did not respond. The LPN removed the resident's dentures and did a finger sweep and attempted the [MEDICATION(S)] by putting an arm in front of the resident and behind the resident, but it was unsuccessful due to how the resident was positioned with his/her back against the bed. He/she lowered the resident back onto the bed. LPN J arrived, assessed the resident and said he/she was gone. The resident had recently had a decline in health and the LPN thought he/she had a cardiac event and it was not related to the earlier choking episode. He/she did not call 911 due to the resident being a DNR, and the family did not want him/her sent to the hospital. During an interview on [DATE] at 2:00 P.M., LPN J said he/she had just arrived at work and was getting report from LPN C when staff ran up and told them the resident might be dead. LPN C immediately ran to the room and LPN J put his/her stuff away and got a stethoscope. He/she got to the resident's room a few minutes later and did not see the resident breathing or gasping, and he/she did not have a pulse. He/she assessed the resident as a second look for the other nurse. They did not do the [MEDICATION(S)] or call 911, because the resident was already gone. He/she did not know the resident had a prior choking episode. During an interview on [DATE] at 2:30 P.M., LPN K said he/she was not the nurse on the resident's hall on [DATE]. He/she was called to the room by CNA H who was upset about the resident and thought he/she could help. He/she could see the resident gasp for breath as LPN C and LPN J attempted to assess him/her. He/she did not see anyone attempt the [MEDICATION(S)] Maneuver. LPN K asked them what happened and they told him/her the resident choked earlier and became unresponsive. Neither nurse had a stethoscope so he/she offered to let them use his/hers. He/she saw the resident having agonal breathing (an abnormal and often brief and inadequate pattern of breathing and gasping for breath) and asked if he/she was on hospice as this type of breathing is painful and there is medication that can relieve this pain. He/she saw the resident take at least two breaths with a forceful intake of air. The nurses told him/her they could not feel a pulse or heart sounds, the resident was a DNR and the family did not want him/her sent to the hospital. No one offered to call 911, and LPN K was not in charge, so he/she left it up to the other nurses to make that decision. Review of the resident care policy and procedure (provided by the corporate office), dated [DATE], showed the following: -If the following clinical signs are present, the [MEDICATION(S)] Maneuver should be performed: a. Cannot speak or breathe; b. Turns blue; c. [MEDICATION(S)] sign - Hand to neck signals; d. Collapses (Death occurs in four (4) minutes after collapsing); -If a person is choking on food or a foreign body, act immediately. (To save the resident's life); -Stand behind the resident and wrap your arms around the victim's abdomen, slightly above the umbilicus (navel) and below the rib cage; -Place your fist thumb side against the victim's abdomen, slightly above the umbilicus and below the rib cage; -Grasp your fist with your other hand and press into the resident's abdomen with a quick upward thrust; -Repeat several times if necessary until food or foreign body has been removed. (Pressure forces the diaphragm upward, compressing the air in the lungs, and expelling the object blocking the breathing passage); -If the resident is sitting, stand behind the chair and perform the maneuver in the same manner; -If the resident is lying on back, face the resident and kneel astride the hips; -With one hand on top of the other, place the heel of the bottom hand on the abdomen slightly above the umbilicus and below the rib cage; -Press into the resident's abdomen with a quick upward thrust; -Repeat several times if necessary until food or foreign body has been removed (call 911 if object is not immediately expelled); -If unsuccessful, check airway, breathing and circulation and start CPR as indicated; -Notify physician immediately after the emergency maneuver; -Notify dietary department of incident (if food item) for further evaluation; -Chart emergency procedure, time, nature of food or foreign body and resident response. Include all pertinent observations. During an interview on [DATE] at 3:00 P.M., the Director of Nursing (DON) said if a resident was choking, staff should attempt the [MEDICATION(S)] and call 911 if this was not working. It was not appropriate to try and do the [MEDICATION(S)] Maneuver by putting an arm in front of and behind the resident to push. Staff should have moved the resident so it could have been done safely. They did not have a policy related to choking, but followed standard nursing practices. Staff should call 911 even if a resident was a DNR. Staff absolutely should have stayed and monitored the resident after the initial choking incident to make sure he/she was back at his/her baseline breathing. This would have included the resident being able to verbally answer questions. During interviews on [DATE] at 3:15 P.M. and on [DATE] at 4:30 P.M., the administrator said staff should have stayed in the room and monitored the resident after the initial choking episode. Staff should perform the [MEDICATION(S)] appropriately if a resident is choking and if this is not effective, someone should be directed to call 911. During an interview on [DATE] at 2:15 P.M., the resident's physician said if the resident was in acute distress such as gasping for air and the staff could not dislodge the item in his/her throat, they should have called 911. MO 899 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on 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 to be taken to address Class I violation(s).

Based on interview and record review, facility staff failed to call emergency personal (911) and provide basic life support, including cardiopulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped, for one resident who had a full code status and was without signs of life. The facility identified 45 residents as having a full code status, three were sampled and problems were found with one(Resident #1). The census was 86. The administrator was notified on [DATE] at 12:15 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) became aware of the violation of the facility CPR policy. The staff member was suspended pending investigation. The facility inserviced staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. Review of the facility's CPR policy, dated [DATE], showed: -It is the protocol that the following process be in place to indicate the code status of each resident: --Each resident with a No CPR will have their code status indicated by a red dot on corresponding chart and CPR documentation in the medical record: ---If red dot, it is DNR, do not initiate CPR; ---If green dot, begin CPR and call 911; --Response: ---Upon finding a resident unresponsive, summon staff loudly by calling for help and pulling the emergency cord, if one is accessible; ---Call a Code Blue using the overhead speaker system and indicate the room number, or if not in a resident room, the location of the code; ---If CPR certified, begin CPR. If not CPR certified, do not leave the resident alone and await help from CPR certified staff; --The charge nurse will quickly obtain the CPR and bring it to the site of the code; --The nurses will notify the following persons simultaneously with the initiation of CPR: ---EMS (911); ---Physician; ---Family/Legal Representative; ---DON, ADON and administrator; --Document all actions in the medical record. Review of the Resident #1's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Full Code (perform CPR in the event of [MEDICAL CONDITION]). Review of the facility's investigation showed: -On [DATE] at 11:55 P.M., the resident was found by Certified Medication Technician (CMT) A to be unresponsive. CMT A immediately headed to get Nurse B, who assessed the resident. -Findings: --Review of the timeline as identified by camera: ---On [DATE] at 11:55 P.M., CMT A entered and came out of the resident's room and proceeded down the hall to get Nurse B; ---At 11:57 P.M., Nurse B entered the resident's room with CMT A; ---At 11:58 P.M., Nurse B left the resident's room and headed back to the nurse's station; ---Cameras were viewed on the 100 hall and nurse's station and did not show Nurse B enter the resident's room again until 12:06 A.M. on [DATE], with Nurse C; ---Nurse B and C left the resident's room at 12:07 A.M.; --At 12:14 A.M., Nurse B sent a text messages to the administrator, DON and ADON, informing them the resident had passed away and showed no signs of life; ---Nurse B did not call management phones, only texted; ---In a call with the DON later in the morning after leaving the facility, Nurse B stated she gave CPR, but did not call 911; --CMT A stated she entered the resident's room to give ice and saw the resident was not responsive; --CMT A immediately went to get Nurse B; --CMT A did not see Nurse B perform CPR on the resident; --Nurse C stated Nurse B did not perform CPR on the resident; -Conclusion: Evidence showed that Nurse B did not perform CPR or call 911 on resident, who was a full code; -Recommendation: Nurse B should be terminated and reported to MO State Board of Nursing; -Plan of Action: --Nurse B terminated; --Educate Nurse C and licensed nurses on emergency response and proper procedure for residents that are full code; --Educate all nursing staff on reporting residents emergent needs and change in condition; --Review code status of all residents and ensure the code status in the electronic medical record matches code the status in the hard chart. Any code status updates would be completed as soon as possible; --Hold emergency QAPI meeting to further develop an action plan and guarantee follow through; --Emergency Governing Board meeting had been held and board members were updated. Review of the resident's nurses's notes, documented by Nurse B, dated [DATE] at 1:21 A.M., showed: -Resident was found by CMT A, who was doing rounds, passing ice and noticed the resident was not moving; -CMT A made Nurse B aware, who went to the room to check on the resident; -At 12:10 A.M. on [DATE], Nurse A and Nurse C checked the resident's vital signs and found no breaths, heartbeat or blood pressure noted; -All parties notified, including daughter, administrator, DON and physician; -Physician gave [DIAGNOSES REDACTED]. -Contacted coroner for case identification number; -Contacted crematory to have the body picked up. Review of night shift (11:00 P.M. to 7:00 A.M.) CMT A's statement, dated [DATE], showed: -On [DATE] at 11:40 P.M., CMT A was passing ice in the resident's room; -CMT A found the resident in bed unresponsive and did not feel any rise or fall of his/her chest; -CMT A went to get Nurse B; -Nurse B tried to get a pulse on the resident, said he/she passed away, and then left the room; -CMT A started to clean the resident; -Nurse B came back with Nurse C to verify the resident had passed away. During an interview on [DATE] at 2:30 P.M., CMT A said: -On [DATE] at 11:40 P.M., he/she found the resident in his/her room unresponsive; -CMT A went to get Nurse B, who came in the resident's room, tried to get a pulse, said the resident had passed away, and then walked out; -Nurse B did not do CPR on the resident; -Nurse B said he/she did CPR on the resident for 20 minutes, because the resident was a full code and his/her job was on the line. Review of night shift Nurse B's statement showed: -On [DATE] (no time indicated), CMT A came to tell Nurse B that the resident was not breathing; -Nurse B entered the resident's room, found he/she was not breathing and had no pulse; -Nurse B went to the nurse's desk and found out the resident was a full code; -Nurse B went back to the resident's room and did CPR on the resident for a few minutes; -The resident was kind of cold, so Nurse B stopped CPR; -Nurse B went to the other side of the facility to get Nurse C, to verify the resident was expired; -Nurse B and Nurse C checked the resident's vital signs; -Nurse B went to the nurse's desk to make telephone calls to the resident's family, physician, coroner and crematory. During an interview on [DATE] at 12:26 P.M., Nurse B said; -He/she last saw the resident on [DATE] at 10:20 P.M., to give him/her medication; -At 11:45 P.M., CMT A told Nurse B that the resident was not responsive or breathing; -Nurse B went and observed the resident was not breathing, had no pulse or heart beat and was cold; -Nurse B went to the nurse's desk to check the resident's code status and saw he/she was a full code; -Nurse B went and performed CPR, did chest compressions only, on the resident for 7 to 10 minutes, because he/she thought it might help; -Nurse B went to the other side of the facility to get Nurse C, to verify the resident was expired; -Nurse B texted the administrator and ADON; -Nurse B did not remember the proper procedure for CPR at that moment, because it was a scary situation; -Nurse B should have called a code, 911 and done CPR appropriately on the resident. Review of night shift Nurse C's statement, dated [DATE], showed: -On [DATE] (no time indicated), Nurse B from 100 hall came to the nurse's station on 200 hall to tell Nurse C that he/she needed to come and look at the resident who passed away to make sure he/she was actually gone; -Nurse C went with Nurse B to the resident's room to see the resident; -Nurse B told Nurse C that the resident was deceased and had been for at least 45 minutes; -Nurse C assessed the resident, who showed no signs of life; -Nurse C asked Nurse B if they should do CPR and call 911; -Nurse B said no, because the resident was already dead; -Nurse C showed Nurse B where the paperwork was that he/she needed to do; -Nurse C told Nurse B that he/she needed to notify the physician, family and ADON; -Nurse C said he/she would text the ADON. During an interview on [DATE] at 8:30 A.M., Nurse C said: -On [DATE], Nurse B came from the 100 hall to the nurse's station on 200 hall to tell Nurse C that he/she needed to come look at the resident who passed away, to make sure he/she was actually gone; -Nurse C went with Nurse B to the resident's room to see the resident; -Nurse C assessed the resident, who showed no signs of life; -Nurse B said he/she did CPR on the resident for 20 minutes, but there was no crash cart in the room; -Nurse B should have called a code, 911 and CPR should have been done on the resident; -Nurse C texted, but should have called the ADON to let her know about the resident; -Nurse C made a mistake and regretted it. During an interview on [DATE] at 1:13 P.M., the administrator said: -On [DATE] at 12:14 A.M., Nurse B texted the administrator, DON and ADON instead of calling on the telephone about the resident; -The administrator did not see the text message until 6:30 A.M.; -The text message said the resident passed away just now, no signs of life; -Staff are supposed to call the administrator when a resident passes away; During an interview on [DATE] at 1:13 P.M., the ADON said: -On [DATE] at 12:12 A.M., Nurse C texted, then at 12:14 A.M., Nurse B texted the ADON instead of calling on the telephone about the resident; -The ADON did not see the text message until 6:30 A.M.; -Staff are suppose to call the ADON when a resident passes away. During an interview on [DATE] at 1:10 P.M., the ADON said that on [DATE], Nurse B should have called a code, 911 and performed CPR on the resident. During an interview on [DATE] at 1:20 P.M., the DON said that on [DATE], Nurse B should have called a code, 911 and performed CPR on the resident. During an interview on [DATE] at 2:30 P.M., the administrator said: -On [DATE], Nurse B should have called a code, 911, and performed CPR on the resident. During an interview on [DATE] at 11:55 A.M., the resident's physician said: -Staff should have called 911 and performed CPR for the resident when he/she was found without signs of life on [DATE]; -It would not have made a difference with the outcome of the resident. MO 686

Based on observation, interview and record review, the facility failed to provide appropriate care and treatment to aide in healing and prevent deterioration of pressure ulcers for resident's with pressure sores who were observed without treatments applied, not positioned in accordance with the care plan, were left with soiled dressings on and dietary recommendations were not carried out. This resulted in residents developing and having worsened pressure ulcers, for three of 15 sampled residents (Resident #7, #8 and #1). The census was 86. 1. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/13/16, showed: -Brief interview of mental status (BIMS) score of 15 out of a possible score of 15; -A BIMS score of 13-15, showed the resident was cognitively intact; -Extensive assistance of one person required for bed mobility; -Total dependence on one person required for dressing, toilet use and personal hygiene; -At risk for the development of pressure ulcers; -One stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) present on admission; -Slough (yellow or white dead tissue) present; -Skin and ulcer treatments: -Turn and repositioning program; -Nutrition or hydration interventions to manage skin problems; -Pressure ulcer care; -Application of non surgical dressings and ointments/medications. Review of the residents quarterly MDS, dated [DATE], showed: -A BIMS score of 15; -Total dependence of one person required for bed mobility, dressing, toilet use and personal hygiene; -At risk for the development of pressure ulcers; -One stage II pressure ulcer (a 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); -Date of oldest stage II pressure ulcer, 9/22/16; -One stage IV pressure ulcer present on admission; -Skin and ulcer treatments: -Turn and repositioning program; -Nutrition or hydration interventions to manage skin problems; -Pressure ulcer care; -Application of non surgical dressings and ointments/medications. Review of the resident's pressure ulcer risk evaluation, showed: -On 6/18/16, a score of 10 (a score of 8 or above represents high risk); -On 7/27/16, a score of 10; -On 10/10/16, a score of 11; -No further assessments completed. Review of the resident's care plan, for the readmission date of [DATE], showed: -Problem onset 4/6/16, stage IV coccyx (tailbone area) ulcer: -Goal: Wounds will show evidence of healing and be free of infection; -Approaches: -Provide treatment for [REDACTED]. -Follow facility's skin protocol for initial interventions: i.e. turning, keep positioned off pressure ulcer, etc; -Skin inspections by caregivers daily, report findings to charge nurse immediately; -Pressure relieving mattress; -Schedule registered dietician consult for diet review; -Turn every 1-2 hours; -Position off affected area; -Wound assessment weekly; -Treatment per physician's orders [REDACTED].>-Problem updated 8/19/16, sacrum (tailbone area) 3 centimeters (cm) by 2.6 cm by 1 cm. Undermining (wound open underneath the border of the wound) 1.4 cm circumference; -Problem updated 10/12/16, stage IV coccyx on admit. Stage II right gluteal (lower buttocks fold), [MEDICATION NAME] (a wound drainage absorbent product) 9/22/16: -Approaches: Treatment to pressure ulcer right gluteal as ordered, monitor weekly; -Problem updated 1/4/17, stage IV coccyx, stage II right gluteal. Continue treatments as ordered; -Problem updated 2/9/17, stage II now stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) right gluteal area: -Approaches: Low air loss mattress (LAL, a mattress that provides a constant flow of air in the mattress to help prevent pressure ulcers), continue treatment as ordered; -Problem onset 4/6/16, requires staff assistance with mobility, transfer, locomotion, bed mobility: -Goal: Mobility will occur safely; -Approaches: Required one/two person extensive assistance with transfer, locomotion and bed mobility; -Problem onset 4/6/16, extensive assist of two staff with bed mobility, transfer, dressing, toileting, personal hygiene and bathing and requires extensive assist of one with locomotion when up in the wheelchair: -Goal: Continue to have cares met; -Approaches: Observe skin during routine care for red or open areas and notify the nurse, nurse to notify the physician. Turn and reposition every 2 hours and as needed. Review of the resident's nutrition progress notes, showed the following registered dietician notes: -On 8/8/16, would change multivitamin (MVI) to MVI with minerals to promote wound healing; -On 9/5/16, continue with previous recommendation to change MVI to MVI with minerals. Will monitor skin; -On 10/5/16, stage IV and stage II wound noted, would change MVI to MVI with minerals. Would add 500 milligram (mg) vitamin C and 220 mg zinc sulfate (supplement which can aide in wound healing) times 14 days; -On 11/11/16, wounds continue. Would change MVI to MVI with minerals, would add 500 mg of vitamin C and 220 mg of zinc sulfate times 14 days for wound healing; -On 12/5/16, stage IV and stage II wound. Would continue with previous recommendations to change MVI to MVI with minerals and to add 500 mg vitamin C and 220 mg zinc sulfate times 14 days; -On 1/6/17, stage IV and stage II wounds continue. Would change MVI to MVI with minerals, would add 500 mg vitamin C and 220 mg zinc sulfate times 14 days; -On 2/1/17, wounds continue. Would change MVI to MVI with minerals, add 500 mg vitamin C and 220 mg zinc sulfate times 14 days. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 9/11/16, to cleanse the left upper back leg with normal saline, apply Santyl (sterile enzymatic [MEDICATION NAME] ointment) and cover with dry dressing; -An order dated 9/22/16, to discontinue Santyl to left upper back leg. Start Santyl with wet to dry dressing to lateral (outer) buttocks along gluteal fold, cover with dry dressing daily; -An order dated 9/22/16, cleanse wound on coccyx with wound cleanser, coat Aqualcel AG with thin layer of Santyl and gently pack bed of wound. Cut out center of [MEDICATION NAME] the size of the wound and place over the wound. Then apply full [MEDICATION NAME]. Apply skin prep (protective barrier wipes) to peri-wound (wound edges) prior to the [MEDICATION NAME], daily. During an interview on 3/3/17 at 10:45 A.M., the Director of Nursing (DON) clarified the description of left upper back leg would describe the left upper posterior leg and could be considered the left gluteal area. Review of a progress note, dated 9/22/16, showed three new areas noted to the left buttocks near gluteal fold with measurements of the first area 2.3 by 1.2 (no unit of measurement documented) 90 percent slough and 10 percent red tissue, unstageable. The second area 4.5 by 3 (unit of measurement not documented) purple/red tissue, stage II. The third area 3.5 by 0.8 (no unit of measurement documented) purple/red tissue, stage II. The stage IV wound to the coccyx continues to improve. It measured 2.5 cm by 1.9 cm by 2 cm with left lateral undermining 1.8 cm, right lateral undermining 1.2 cm and superior undermining 1.3 cm. Area is 30 percent macerated (softened tissue) edges, wound bed 90 percent slough and 10 percent red granulating tissue. Review of the facility's pressure wound report, showed the following documentation for the resident: -On 9/23/16: -Pressure wound start date, 5/22/16; -admitted to the facility with the wound, stage IV; -Sacrum; -Pink, undermining; -Size: 2.5 cm by 1.9 cm by 1.2 cm, undermining 1.8 cm lateral left, 1.2 cm lateral left, 1.3 cm superior; -Treatment: [MEDICATION NAME] AG with [MEDICATION NAME] (occlusive absorbent dressing) every three days; -On 9/23/16: -Pressure wound start date, 9/22/16; -Acquired stage II; -Right gluteal area; -Three areas, slough with some red granulating (the pink-red moist tissue that fills an open wound, when it starts to heal. It contains new blood vessels, collagen and [MEDICAL CONDITION] cells) tissue; -Size: 2.3 cm by 1.2 cm, 4.8 cm by 3 cm and 3.5 cm by 0.8 cm; -Treatment: Santyl to slough areas with moist gauze, cover with [MEDICATION NAME] (foam dressing) every three days; -On 9/28/16: -Pressure wound start date, 5/22/16; -admitted to the facility with the wound, stage IV; -Sacrum; -Pink, undermining; -Size: 2 cm by 12.1 cm by 1.1 cm, undermining 1.3 cm lateral left, 1.2 cm lateral left, 1.3 and 1.3 superior; -Treatment: [MEDICATION NAME] AG with [MEDICATION NAME] every three days; -On 9/28/16: -Pressure wound start date, 9/22/16; -Acquired stage II; -Right gluteal area; -Two areas, slough with some red granulating tissue; -Size: 2.3 cm by 4 cm and 4.5 cm by 1.7 cm; -Treatment: Santyl to slough areas with moist gauze, cover with [MEDICATION NAME] every three days. During an interview on 3/3/17 at 10:45 A.M., the DON said the wound reports indicated that the resident's wound was on the right gluteal is supposed to be documented as being on the left, but she would clarify this with the wound nurse. Review of the resident's POS, dated 10/1/16 through 10/31/16, showed: -An order dated 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily; -No order dated 9/22/16, for Santyl with wet to dry dressing to lateral buttocks along gluteal fold, cover with dry dressing daily. Review of the resident's treatment administration record (TAR), dated October 2016, showed: -Treatment start date 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily: -A line hand drawn over the part of the order that stated and cover with dry dressing daily; -Hand written in with wet to dry dressing, cover with dry dressing every three days and as needed; -An X drawn in for the dates of 10/5, 10/6, 10/27 and 10/28/16 with no documentation the treatment completed; -The dates of 10/8, 10/9, 10/13, 10/19, 10/21 through 10/23, 10/25, 10/30 and 10/31/16, blank with no documentation the treatment completed; -A treatment undated, cleanse wound on coccyx with wound cleanser, coat [MEDICATION NAME] AG with thin layer of Santyl and gently pack, apply skin prep to the peri-wound, cut out center of [MEDICATION NAME] the size of the wound, place over the wound and then apply a full [MEDICATION NAME] daily: -A line drawn over the word daily; -Hand written in every three days and as needed; -The dates of 10/5, 10/6, 10/9, 10/13, 10/19, 10/22, 10/23, 10/25, 10/27, 10/28, 10/30 and 10/31/16, blank with no documentation the treatment completed. Review of the resident's POS, dated 11/1/16 through 11/30/16, showed: -An order dated 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily; -A line hand drawn over the part of the order that stated with dry dressing daily; -Hand written in with wet to dry dressing; -Frequency for the hand written changes not specified. Review of the resident's TAR, dated November 2016, showed: -Treatment start date 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily: -A line hand drawn over the part of the order that stated with dry dressing daily; -Hand written in with wet to dry dressing, cover with dry dressing, change every three days; -The dates of 11/5, 11/6, 11/9, 11/10, 11/15, 11/16, and 11/21 through 11/25/16, blank with no documentation the treatment completed; -Treatment order dated 9/27/16, cleanse wound on coccyx with wound cleanser, coat Aqualcel AG with thin layer of Santyl and gently pack bed of wound, cut center of [MEDICATION NAME] to the size of the wound, then apply full [MEDICATION NAME], apply skin prep to the peri-wound prior to the [MEDICATION NAME] daily: -A line drawn over the word daily; -Hand written in every three days and as needed; -The dates of 11/5, 11/9, 11/10, 11/15, 11/17 and 11/21 through 11/25/16, blank with no documentation the treatment completed. Review of the resident's POS, dated 12/1/16 through 12/31/16, showed: -An order dated 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily: -A line hand drawn over the part of the order that stated with dry dressing daily; -Hand written in with wet to dry dressing; -Frequency of the hand written changes not specified; -An order dated 12/12/16, for left gluteal fold, cleanse with normal saline, apply Santyl to slough, pack with alginate rope (a product that manages wound moisture to promote faster healing), cover with [MEDICATION NAME] daily. Review of the resident's TAR, dated December 2016, showed: -Treatment start date 9/11/16, cleanse left upper back leg with normal saline, apply Santyl and cover with dry dressing daily: -Hand written in with wet to dry; -Order discontinued on 12/12/16; -The dates of 12/3 and 12/9/16, blank with no documentation the treatment completed; -Treatment start date 12/12/16, left gluteal fold, cleanse with normal saline, apply Santyl to slough, pack with alginate rope, cover with [MEDICATION NAME] daily: -The dates of 12/25 and 12/26/16, blank with no documentation the treatment completed; -Treatment order date 9/27/16, cleanse wound on coccyx with wound cleanser, coat [MEDICATION NAME] AG with thin layer of Santyl and gently pack bed of wound, cut center of [MEDICATION NAME] to the size of the wound, then apply full [MEDICATION NAME], apply skin prep to the peri-wound prior to the [MEDICATION NAME] daily: -The dates of 12/3, 12/25 and 12/26/16, blank with no documentation the treatment completed. Further review of the facility's pressure wound report, showed the following documentation for the resident: -On 12/2/16: -Pressure wound start date, 5/22/16; -admitted to the facility with the wound, stage IV; -Sacrum; -Pink; -Size: 1.5 cm by 1.5 cm by 0.9 cm; -Treatment: [MEDICATION NAME] AG with Santyl, cover [MEDICATION NAME] every three days; -On 12/2/16: -Pressure wound start date, 9/22/16; -Acquired stage II; -Right gluteal; -Area is deteriorating; -Size: 4.5 cm by 3.5 cm by 3 cm, undermining at 12:00 o'clock (indicates the location of the undermining when compared to the face of a clock), size 1.6 cm; -Treatment: Santyl to slough areas, [MEDICATION NAME], dry dressing daily. Review of the resident's POS, dated 1/1/17 through 1/31/17, showed: -An undated order, cleanse left gluteal fold with normal saline, apply Santyl to slough, pack with alginate rope, cover with [MEDICATION NAME] daily; -An order dated 1/25/17, discontinue previous treatment to left gluteal area. Left gluteal, cleanse with normal saline, mix wound gel with collagen powder and apply to wound bed, pack with alginate rope and secure with [MEDICATION NAME] daily; -An order dated 9/27/16, cleanse wound on coccyx with wound cleanser, coat [MEDICATION NAME] AG with thin layer of Santyl and gently pack bed of wound, cut center of [MEDICATION NAME] to the size of the wound, then apply full [MEDICATION NAME], apply skin prep to the peri-wound prior to the [MEDICATION NAME] daily; -An order dated 1/25/17, discontinue previous treatment to the coccyx. Coccyx, cleanse with normal saline, mix wound gel with collagen powder and apply to the wound bed. Cover with [MEDICATION NAME] every other day and as needed. Review of the resident's TAR, dated January 2017, showed: -A treatment undated, left gluteal fold, cleanse with normal saline, apply Santyl to slough, pack with alginate rope, cover with [MEDICATION NAME] daily; -The date of 1/12/17, blank with no documentation the treatment completed. Further review of the facility's pressure wound report, showed the following documentation for the resident: -On 1/6/17: -Pressure wound start date, 5/22/16; -admitted to the facility with the wound, stage IV; -Sacrum; -Pink; -Size: 1 cm by 1.5 cm by 0.7 cm; -Treatment: [MEDICATION NAME] AG with Santyl, cover [MEDICATION NAME] every three days; -On 1/6/17: -Pressure wound start date, 9/22/16; -Acquired stage III; -Right gluteal; -Area is deteriorating; -Size: 3.5 cm by 2 cm by 2.2 cm, undermining at 12, size 3.2 cm; -Treatment: Santyl to slough areas, [MEDICATION NAME], dry dressing daily; -On 1/27/17: -Pressure wound start date, 5/22/16; -admitted to the facility with the wound, stage IV; -Sacrum; -Pink; -Size: 1.5 cm by 1.8 cm by 0.5 cm; -Treatment: Wound gel (a gel in which water is the dispersion medium for wound healing) with collagen powder; -On 1/27/17: -Pressure wound start date, 9/22/16; -Acquired stage III; -Right gluteal; -Pink/red granulating tissue; -Size: 2.3 cm by 2.5 cm by 1.8 cm, undermining at 12, size 3.5 cm, undermining at 3, size 1.5 cm; -Treatment: Wound gel with collagen powder, pack with alginate rope, cover with dry dressing daily. Observation on 3/1/17 at 11:15 A.M., showed Wound Nurse I and Registered Nurse (RN) J changed the dressing to the resident's left gluteal fold. The dressing on the left gluteal fold was undated. They removed the old dressing. A large amount of yellowish/brown tinged drainage was present on the old dressing. Wound Nurse I cleansed the wound with normal saline. The resident yelled ouch. The wound appeared deep and the wound bed not visible. The wound had pink edges. Wound Nurse I wiped the wound with gauze and measured the wound at 2 cm by 1 cm by 1.3 cm with undermining at 12:00 o'clock of 1.7 cm. Wound Nurse I said the wound was a stage III and acquired at the facility. Wound Nurse I removed his/her gloves, washed his/her hands and placed new gloves on. He/she mixed wound gel and collagen powder and applied to the wound bed. He/she applied a foam dressing over the wound and dated it 3/1/17. Wound Nurse I failed to pack the wound with alginate rope. Wound Nurse I and RN J then changed the dressing to the resident's coccyx wound. The dressing labeled 2/27. RN J said the dressing is good for three to seven days. They removed the dressing. The wound bed appeared deep, with pink edges. The dressing had a brownish/yellow drainage present. Wound Nurse I said the resident was admitted with the wound as a stage IV. He/she measured the wound as 1.2 cm by 0.7 cm by 0.8 cm deep, stage IV. He/she cleansed the wound with normal saline, applied wound gel and mixed collagen powder and applied it to the wound bed. He/she applied the foam dressing and dated it 3/1/17. During an interview on 3/1/17 at 1:20 P.M., Wound Nurse I said treatments should be completed as ordered. He/she should have packed the resident's wound with alginate rope and he/she does not know why it was not used. The dressing on the resident's wound prior to the dressing change should have been dated. During an interview on 3/3/17 at 10:45 A.M., the DON verified that the sacrum and coccyx are the same location. During an interview on 3/3/17 at 10:45 A.M., the DON said the difference in the order dated 9/22/16 on the POS and the TAR showing the same treatment with an order date of 9/27/16 is likely an error in entering the order date. The specifics of the order are the same. Review of the resident's nutritional assessment, dated 3/1/17, showed: -Skin breakdown: Yes, stage IV and stage III wound; Plan/recommendations: Add MVI with minerals, add 500 mg vitamin C and 220 mg zinc sulfate times 14 days. During an interview on 3/1/17 at 10:58 A.M., Registered Dietician M said he/she had been making dietary recommendations for the resident's wound healing for months. Every month, when he/she makes a recommendation, he/she documents the recommendations in the dietary notes. He/she then writes the recommendation on a communication sheet. A copy is then given to the DON, assistant DON and dietary manager. He/she has provided communications sheet for the monthly dietary recommendations for the resident to the facility staff monthly and he/she is not sure why there had been no follow up. During an interview on 3/1/17 at 1:05 P.M., Certified Nursing Assistant (CNA) N said the pressure ulcer prevention interventions that are set in place for the resident is that the staff frequently turn and reposition the resident. Observations of the resident on 3/2/17 at 8:56 A.M., 11:03 A.M., 2:36 P.M. and 2:40 P.M., showed the resident lay in bed on his/her back, tilted slightly onto the left side. His/her head rested on a pillow on the left side rail. During an interview on 3/2/17 at 12:15 P.M., the facility's Medical Director said she would expect physician orders [REDACTED]. She is not the physician that follows the residents care and is unsure if the resident's physician was notified of the change in frequency of the resident's dressing changes. She is not notified of dietary recommendations for residents who are followed by other physicians. Regarding the resident's recommendations made by the registered dietician, she is not familiar with the resident enough to say if she would have ordered all of the recommendations; however, she would have ordered the zinc because it would be beneficial for wound healing. During an interview on 3/3/17 at 10:45 A.M., the DON said when the registered dietician makes a recommendation; he/she communicates the recommendation to nursing staff per the communication form. The nurse is then responsible to notify the physician and document the physician's response. If the recommendations are accepted, the nurse writes the order. During an interview on 3/3/17 at 10:45 A.M., the DON said the resident should be repositioned every two hours. Over five hours is too long for the resident to be in the same position, even with a pressure relieving mattress. She would expect treatments be completed as ordered. If the frequency of an order was changed, she would expect the physician be notified and a new order obtained. The treatment nurse is responsible for treatments, but the nurses assigned to the residents are able to provide the treatment when the treatment nurse is not available. Treatments should be documented when completed by the person who completes the treatment. If it was not documented, it was not done. The location of the wound should match what is documented on the wound report. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed: -BIMS score of 15 out of 15; -Dependent on staff for bed mobility and personal hygiene; -Has an indwelling urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) and a [MEDICAL CONDITION] (a surgical procedure that brings one end of the large intestine out through the abdominal wall); -[DIAGNOSES REDACTED]. Symptoms can include overflow incontinence, frequency, urgency, urge incontinence and retention), [MEDICAL CONDITION] (paralysis from the neck down) and pressure ulcers; -Stage II pressure ulcer to right gluteal thigh, acquired on 6/29/15; -Stage III pressure ulcer to left buttock, (no date when acquired); -admission date of [DATE]. Review of the facility's pressure wound report, showed the following documentation for the resident, on 8/5/16: -Left buttock wounds acquired on 6/29/15: -Healing stage III, pink/red in color; -Size: 1 cm by 0.5 cm by 0.5cm; -Treatment: Santyl and [MEDICATION NAME] (antibiotic) ointment; -Right gluteal thigh wound acquired on 6/29/15: -Healing stage II, red granulating tissue; -Size: 12.8 cm by 11 cm; -Treatment: Santyl covered with a dry dressing. Review of the resident's care plan, with an initial date of 1/22/13, showed: -Problem: Impaired skin integrity related to [MEDICAL CONDITION], multiple pressure ulcers, history of [DIAGNOSES REDACTED] (infection of the bone) and dependence on staff for mobility: -Goal: Resident will have decrease in size of wounds by next review; -Interventions: LAL mattress, wound care per physician orders, wheelchair cushion, float heels, monitor nutritional status and monitor skin for any new reddened or open areas; -Problem updated on 8/8/16, right gluteal thigh stage II healing, 12.5 cm by 8.5 cm and left buttock stage III healing, 1 cm by 0.4 cm by 0.5 cm. Continue plan of care; -Problem updated 105/16, nursing continues to monitor wounds weekly and treat per physicians orders; -Problem updated 12/28/16, wounds continue to heal well. Review of the resident's dietician's progress notes, showed: -On 8/22/16, wounds noted; -On 9/5/16, multiple wounds continue; -On 10/5/16, would add MVI with minerals for wound healing; -On 10/25/16, wounds noted. Would add MVI with minerals; -On 11/11/16, wounds continue. Would add MVI with minerals for wound healing; -On 11/21/16, wounds continue. Would add MVI with minerals; -On 12/23/16, wounds continue. Would add MVI with minerals; -On 2/1/17, would add MVI with minerals for skin integrity; -On 2/18/17, wounds noted. Further review of the facility's pressure wound report, showed the following documentation for the resident, on 9/9/16: -Left buttock: -Healing stage III, pink/red in color; -Size: 1 cm by 0.8 cm by 0.2 cm; -Treatment: [MEDICATION NAME] powder (enzyme that breaks down collagen in damaged tissue and helps the body generate new healthy tissue); -Right gluteal thigh: -Healing stage II, red granulating tissue; -Size: 11 cm by 6 cm and 3.5 cm by 1.5 cm; -Treatment: [MEDICATION NAME] powder. Review of the resident's POS, dated 2/1/17 through 2/28/17, showed: -An order dated 9/26/16, to cleanse left hip with normal saline (NS), apply collagen powder with small piece of alginate rope and cover with [MEDICATION NAME] every three days and as needed; -An order dated 9/26/16, to cleanse the right buttock with NS, apply collagen powder and cover with [MEDICATION NAME] every day and as needed; -The orders did not show treatment orders for the left buttock or the right gluteal thigh area. Further review of the facility's pressure wound report, showed the following documentation for the resident: -On 9/28/16: -Left buttock: -Size: 1.3 cm by 1 cm by 0.4 cm; -Treatment: [MEDICATION NAME] powder and alginate rope; -Right gluteal thigh: -Size: 11.5 cm by 9 cm; -Treatment: Unchanged; -On 12/2/16: -Left buttock: -Size: 0.9 cm by 0.4 cm by 0.2 cm; -Treatment: Hydrogel (gel that keeps the wound moist), collagen powder and covered with a cushioned dressing; -Right gluteal thigh: -Size: 7 cm by 9 cm and 2.5 cm by 1.5 cm; -Treatment: Unchanged. Observations of the resident, showed: -On 2/27/17 at 12:05 P.M. and 3:50 P.M., the resident lay in bed on his/her back; -On 2/28/17 at 5:33 A.M., 8:30 A.M., 12:25 P.M. and 2:10 P.M., the resident lay in bed on his/her back; -On 3/1/17 at 11:00 A.M. and 12:40 P.M., the resident lay in bed on his/her back; -On 3/2/17 at 6:35 A.M. and 2:00 P.M., the resident lay in bed on his/her back; -On 3/3/17 at 7:45 A.M., 10:30 A.M. and 2:15 P.M., the resident lay in bed on his/her back. Observation on 3/1/17 at 4:45 A.M., showed CNA K and CNA L turn the resident to his/her right side. The dressing on his/her left buttock was dated 2/27/17, the dressing and disposable pad that lay under the resident was soiled with bloody and serosanguineous (a mixture of serum and blood which is pink to light red in color) drainage. The CNA's turned the resident to his/her left side and the right gluteal thigh dressing,was saturated and dripped bloody and serosanguineous drainage, dated 2/27/17. The right gluteal thigh/buttock area also had three open areas reddish pink in color and measured approximately 2 inches long by 1/4 inch wide. The CNA's changed the resident's pad. The dressings continued to ooze. The CNA's positioned the resident to his/her back. During an interview on 3/1/17 at 5:25 A.M., Licensed Practical Nurse (LPN) Q said if a resident's dressing is off or soiled the CNA should tell the nurse and the nurse would either apply or change the dressing. No one told him/her about the soiled dressings on the resident. Observation on 3/1/17 at 8:45 A.M., showed Wound Nurse I and LPN V in the resident's room. The resident's dressings removed and were dated 2/27/17. The resident lay on his/her right side, LPN V cleansed the left buttock pressure sore with NS and measured the length as 0.4 cm by 0.5 cm in width by 0.3 cm deep. He/she staged the wound as a healing stage II. Staff dressed the wound with collagen powder followed by alginate rope and covered with a foam border dressing. Wound Nurse I and LPN V turned the resident to his/her left side, cleansed the right gluteal thigh wound with NS and measured the wound as 8 cm in length by 7.1 cm in width. Four other smaller open areas around the wound measured 3.5 cm by 1 cm, 3 cm by 0.6 cm, 1.3 cm by 0.5 cm and 2.5 cm by 0.9 cm. LPN I staged all of the wounds as a stage II he/she dressed the larger wound with collagen powder and covered with [MEDICATION NAME] dressing. The four smaller stage II pressure ulcers were cleansed with NS and left open to air. During an interview on 3/1/17 at 9:10 A.M., Wound Nurse I said the floor nurse should have changed the resident's dressings 2/28/17 because he/she did not have the time. Due to the date of 2/27 on the dressing, it was obvious that it had not been changed on 2/28/17. If he/she is assigned to work the floor, then the resident's nurse is responsible for changing the dressing and if it is not done then the night nurse is responsible. The resident's wounds are difficult to heal because he/she refuses to get out of bed and refuses to lay on his/her side; however, there has been improvement. LPN V said the resident's physician reported that the wounds will never heal due to his/her history of [DIAGNOSES REDACTED]. During an interview on 3/1/17 at 12:40 P.M., the resident said he/she does not like to lay on his/her side. The staff try to turn him/her sometimes and he/she wiggles onto his/her back. During an interview on 3/2/17 at 12:10 P.M., the resident's physician and facility medical director said the resident had a skin flap (healthy skin and tissue that is partly detached and moved to cover a nearby wound. A skin flap may contain skin and fat, or skin, fat and muscle) on his/her buttocks years ago due to a large deep wound that would not heal. Due to that surgery, the resident's skin on his/her buttocks and hips is fragile and provides only a thin layer of tissue over the bone. She never said that the present wounds would never heal, but his/her wounds are difficult to heal. The dressings should be changed every day and it should absolutely be changed when soiled. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed: -BIMS score of 11 out of a possible score of 15; -A BIMS score of 8-12, showed the resident had moderately impaired cognition; -[DIAGNOSES REDACTED]. -Total dependence of one person required for bed mobility, dressing and personal hygiene; -Total dependence of two persons required for transfer; -Functional limitation of range of motion on one side of the upper extremities; -Frequently incontinent of urine and bowel; -At risk for the development of a pressure ulcer; -No pressure ulcers present; -Pressure reducing device for chair and bed. Review of the resident's care plan, with an initial date of 7/28/12, showed: -Problem: Resident at risk for skin breakdown. Resident had a stroke with [MEDICAL CONDITION]. Resident has episodes of incontinence. He/she is totally dependent on staff to keep his/her skin clean and dry. Resident ha

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place, the circumstances surrounding falls were thoroughly investigated and documented, and the interventions were evaluated for appropriateness and modified as needed to prevent or decrease the risk of falls. One of three sampled residents identified as at risk for falls, had multiple falls from 6/7/16 and 7/27/16, with the last fall resulting in a hip fracture. The only interventions listed on the care plan were the use of a bed/wheelchair personal safety alarm (PSA), which staff were aware the resident removed. At the time of the resident's last fall the personal safety alarm was not in place. (Resident #4) The census was 98. Review of an untitled, undated document, provided by the facility, showed when an incident or accident occurred staff should do the following: -Complete an incident report; -Document detailed nurse's notes, including the time and date; -Document the fall and an intervention in the nurse's notes and on the resident's care plan, if a resident is not alert and orientated initiate neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) after an unwitnessed fall; -Call the resident's family, physician and the on-call nurse supervisor. Review of the facility's fall management policy, dated 5/1/2016, showed the following: -Protocol: the facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for fall risk factors. The interdisciplinary team works with the resident and family to identify and implement appropriate interventions to reduce the risk for falls or injuries while maximizing dignity and independence; -Definition: fall: is an episode when a resident lost his/her balance and would have fallen, where it not for staff intervention, was a fall. An intercepted fall was still a fall; -Procedure: assess and review risk factors for falls and injuries. Review the completed Nursing Comprehensive Admission Assessment and the Fall Risk Assessment. Review and evaluate other interdisciplinary assessments. Discuss goals and interventions with resident for inclusion in the Interdisciplinary Plan of Care (IPOC). Schedule an IPOC meeting. Implement the plan of care; fall risk reduction based on individual resident needs. Complete the resident's individual resident care plan. Communicate interventions during shift report and daily clinical rounds. Provide training to staff as needed. Review and revise interdisciplinary plan of care at subsequent IPOC meetings. Educate the resident and family as indicated. Review of Resident #4's face sheet, showed the following: -admitted [DATE]; -Diagnoses: [REDACTED]. Review of the resident's care plan, dated 6/3/15, showed the following: -Problem onset 6/3/15: At risk for falls related to weakness, unsteady gait and a history of poor safety awareness; -Goal: Will not experience a preventable fall with injury over the next 30 days; -Approaches: Complete fall risk assessments upon admission to determine risks. Orient resident to surroundings, ensure he/she knows how to use the call light. Assist for toileting and transfers whenever necessary (PRN). Keep room environment free of unnecessary furniture and/or clutter. Evaluate medications to determine possibility to discontinue; discuss with physician. Provide verbal cueing for safety awareness. Provide appropriate support/safety and enabler devices as needed in wheelchair/bed and as ordered by the physician and therapy recommendations. Report falls to the physician and responsible party. Use a fall risk screen to identify risk factors. Observe for side effects to medications (gait disturbance, weakness, orthostatic hypotension (a sudden drop in blood pressure when rising from a lying or sitting position), sedation, light headedness, dizziness or change in mental status). Report to physician any side effect noted. Invite the resident to participate in activity programs. Place frequently used items within reach. Appropriate non-skid sole footwear. Assess pain and tolerance levels before transfers. Keep fluids within easy reach unless contraindicated. Enlist family support and participation. PSA in wheelchair and bed, check for placement every shift; -Staff crossed out an approach evaluate for safety device: walker or cane. -Problem onset 5/3/16: admitted to hospice on 4/27/16 related to weight loss and dementia. -Problem onset 5/3/16: Required staff assistance with mobility; -Approaches: Required one person limited assistance with ambulation, transfers, locomotion, and bed mobility. Used a wheelchair for long distance. Used a wheeled walker for all ambulation. Review of the resident's Fall Risk Assessment, dated 3/20/16, showed a score of 14 (a score of 10 or above represents high risk). Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/3/16, showed the following: -Severely impaired cognition; -Understood/understands; -Frequently incontinent of and bowel and bladder; -Total assist of one for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing; -Independent with locomotion on the unit; -Extensive assist of one for locomotion off the unit; -Non-ambulatory; -Wandering behaviors occurred daily; -Not steady, but able to stabilize without staff assistance when moving from seated to a standing position, walking with an assistive device, turning around and facing the opposite direction while walking, moving on and off the toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair); -No functional limitation in upper and lower extremity range of motion; -Two falls since prior assessment with no injury; -One fall with injury (except major) since prior assessment (skin abrasions, lacerations, superficial bruises, hematomas, and sprains). Review of the resident's physician's orders [REDACTED]. -6/22/15, bed and wheelchair alarm to decrease risk for falls, monitor placement every shift; -2/29/16, monitor bed and wheelchair alarm for function at bedtime. Review of the resident's treatment record (TAR), dated 6/1/16 through 6/30/16, showed staff documented the bed and chair alarms were on and working properly once a day. Review of the resident's progress note, dated 6/7/16 at 1:00 P.M., showed staff documented they found the resident on the bedroom floor next to his/her wheelchair. The resident attempted to transfer from his/her wheelchair to bed. The resident did not hit his/her head, no visible injuries and did not complain of pain or discomfort. The resident said, I did not hit my head, I want my bed. Vital signs documented were within normal limits (WNL). Sleeping in bed, will continue to monitor. Responsible party and physician were notified of the fall. No new orders from the physician. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 6/7/16, Fall with no injury. No additional interventions were added to the care plan. Review of the resident's progress notes, dated 6/8/16 through 6/14/16, showed no documentation or assessment regarding the fall on 6/7/16. Review of the resident's progress note, dated 6/15/16 at 8:00 A.M., showed the resident fell trying to get into bed from his/her wheelchair without assistance. He/she landed on his/her buttocks and sustained a right lower leg skin tear. Treated with triple antibiotic ointment (TAO) and a dry dressing. Placed on incident follow up (IFU) for 72 hours. Vital signs documented were WNL. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 6/15/16, Fall right lower leg skin tear. TAO and a dry dressing. No additional interventions were added to the resident's care plan. Review of the resident's progress notes, dated 6/16/16 and 6/17/16, showed no documentation or assessment of the resident's fall on 6/15/16. Review of the resident's progress note, dated 6/18/16 on the 6 P.M. to 6 A.M. shift, showed staff found him/her sitting on the night stand with a lamp broken on the floor and a 1/2 centimeter laceration to the outer right knee and wheelchair directly in front of him/her. Cleansed and treated wound. Physician notified and attempted to contact responsible party. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 6/18/16, Found sitting on night stand. No additional interventions were added to the care plan. Review of the resident's Fall Risk Assessment, dated 6/21/16, showed a score of 16. Review of the resident's progress notes, dated 6/24/16, showed the following: -At 5:30 A.M., attempted to self transfer back to bed, his/her legs weakened and he/she sat on the floor. No injuries assessed. Fall reported to day shift, will call the resident's responsible party and physician; -At 9:00 P.M., denied discomfort and range of motion (ROM) was WNL. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 6/24/16, Fall no injury. No additional interventions were added to the care plan. Review of the resident's medical record, dated 6/25/16 through 7/2/16, showed no progress notes documented. Review of the resident's POS, dated 7/1/16 through 7/31/16, showed the following: -6/22/15, bed and wheelchair alarm to decrease risk for falls, monitor placement every shift; -2/29/16, monitor bed and wheelchair alarm for function at bedtime. Review of the resident's TAR, dated 7/1/16 through 7/31/16, showed the following: -Staff documented the bed and chair alarms were on every day, on the 6:00 A.M. through 6:00 P.M. shift. The bed and chair alarms were not documented as on, for the 6:00 P.M. through 6:00 A.M. shift on 7/22/16 through 7/24/16; -Staff did not document the bed and chair alarms were working properly on 7/22/16 through 7/24/16, for the 6:00 P.M. through 6:00 A.M. shift. Review of the resident's progress notes, dated 7/5/16, showed he/she fell on his/her buttocks next to his/her roommate's wheelchair, did not hit his/her head and did not sustain any injuries. Vital signs documented were WNL. Confused and disorientated as usual. Responsible party and physician notified of the fall, no new orders from the physician at that time. Will continue to monitor. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 7/5/16, Fall no injury. No additional interventions were added to the care plan. Review of the resident's medical record, showed no progress notes documented, from 7/6/16 through 7/17/16, regarding the fall on 7/5/16. Review of the resident's progress note, dated 7/17/16 at 1:00 P.M., showed he/she was found in his/her room sitting on the floor between his/her wheelchair and bed. Trying to get out of bed into his/her wheelchair. No complaint of pain or discomfort. No injuries sustained. Did not hit his/her head. Vital signs documented were WNL. Responsible party and physician notified of the fall, no new orders from the physician at that time. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 7/17/16, Found sitting on the floor. No additional interventions were added to the care plan. Review of the resident's medical record, showed no progress notes documented from 7/18/16 through 7/25/16. Review of the resident's progress notes, dated 7/26/16 at 9:00 P.M., showed he/she was found sitting on the floor beside his/her bed. Trying to get out of bed and into his/her wheelchair. No injuries sustained. No complaint of pain. Vital signs documented were WNL. Responsible party and physician notified of the fall, no new orders from the physician at that time. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 7/26/16, found on floor at bedside, no injury. No additional interventions were added to the care plan. Review of the resident's progress notes, dated 7/27/16, showed the following: -At 9:00 A.M., the resident remained on IFU for fall. No complaint of pain or discomfort voiced. No apparent injuries; -At 2:30 P.M., fell trying to throw something away. He/she sat on the floor with his/her right leg turned. Responsible party and physician notified of the fall, no new orders from the physician at that time. Dry dressing to skin tear on right leg and elbow. The resident could not straighten his/her right leg. Received physician's orders [REDACTED]. Review of the resident's hospital records, dated 7/27/16, showed he/she sustained a right hip fracture. Review of the resident's care plan, dated 6/3/15, showed the following handwritten notation: 7/27/16, Found sitting on floor in middle of room. Complained of right leg/hip pain. Sent to the hospital for further evaluation. During an interview on 7/28/16 at 10:35 A.M., the administrator said the resident was very confused, propelled himself/herself around the facility, but could ambulate at times though he/she should have staff assistance. Since shortly after admission in June of 2015, orders were obtained for a bed and wheelchair PSA. On 7/27/16 at round 3:00 P.M., staff found the resident on the floor in his/her room and the alarm was on the dresser. The resident was sent to the hospital were it was discovered he/she had a fractured hip. Review of the resident's hospital discharge summary, dated 8/3/16, showed the following: -admitted [DATE]; -Diagnosis: [REDACTED]. -Hip repair surgery on 7/28/16; -discharge date [DATE]. Review of the resident's Fall Risk Assessment, dated 8/3/16, showed a score of 16. Review of the resident's care plan, dated 6/3/15, on 8/10/16, showed no new interventions added regarding falls. Observation of the resident on 8/10/16, showed the following: -At 10:20 A.M., he/she lay in bed with his/her eyes open wearing a hospital gown. There was no wheelchair or assistive devices in the room. He/she did not recall falling, smiled and shook his/her head yes to all questions asked; -At 1:20 P.M., he/she lay in bed with his/her eyes open. Staff at the bedside feeding him/her lunch; -At 1:55 P.M., he/she lay in bed with his/her eyes closed. During an interview on 8/10/16 at 10:25 A.M. Nurse H said she worked the day shift, on 7/27/16, and was assigned to the resident. Staff found the resident on the floor in his/her room. He/she complained of right leg pain and could not straighten the leg. Staff notified the resident's physician, obtained an order to send him/her to the hospital and he/she was transported to the hospital via emergency medical services (EMS). The resident had a physician's orders [REDACTED]. Staff were aware he/she took the wheelchair alarm off and would leave it in random places. Staff put the wheelchair alarm back on the resident's wheelchair and a few minutes later the resident took it back off. Nurse H could not recall if the resident had non-slip socks or shoes on when he/she assessed the resident on the floor. The information about the fall and what the resident was wearing at the time should be documented in the resident's medical record in the nurse's notes section. The resident's wheelchair alarm did not sound. Staff found it on the resident's dresser after they assessed him/her. Nurse H said he/she was not paying attention to detailing the progress notes, he/she worked on getting the resident to the hospital as soon as possible. During an interview on 8/10/16 at 10:10 A.M. Certified Medication Technician (CMT) I said he/she was assigned to the resident that day. The resident did not get up anymore, he/she used to walk and fall a lot. The resident recently fell and broke his/her hip and now he/she did not get up on his/her own anymore. He/she had a wheelchair alarm that he/she took off all the time. All staff were aware the resident removed the wheelchair alarm. During an interview on 8/10/16 at 10:30 A.M., Nurse J said the resident fell often. He/she ambulated without assistance and had an unsteady gait. The resident had a wheelchair and bed alarm. The resident took the wheelchair alarm off often, all staff were aware of that. Nurse J checked the wheelchair alarm was on and functioning properly once a shift. During an interview on 8/10/16 at 12:45 P.M., the Clinical Liaison said staff discussed falls in the morning meeting. Residents that fell were screened by therapy within 24 hours and nurses assess and document a 72 hour incident follow up in the progress notes. An intervention should be added to the resident's care plan after each fall. During an interview on 8/10/16 at 2:35 P.M., the Assistant Director of Nurses (ADON) said she read the resident's progress notes regarding the falls in June and July 2016. She also read the resident's care plan and realized there were no additional interventions in place after each fall. The ADON said she was not responsible for falls, the Director of Nurses (DON) was responsible for tracking falls and adding interventions to the resident's care plan. During an interview on 8/10/16 at 8:45 A.M., the administrator said she was unaware the resident took the wheelchair alarm off. She was also unaware the DON did not update the resident's care plan with a new intervention after each fall. She expected staff to document the nurse's assessment regarding each fall in the resident's progress notes. After a fall, staff were expected to document a 72 hour IFU in the resident's progress notes. Staff were to document a detailed progress note that included everything they saw and heard the resident say at that time. The DON was responsible for updating residents' care plans with a new intervention after each fall. She was unaware the resident did not have new interventions documented and in place after each fall. During an interview on 8/18/16 at 9:50 A.M., the resident's physician said she would expect staff to look into the reason for each fall to see if anything different could be done to prevent future falls. They should look into the circumstances surrounding each fall to see what is working and what isn't and find appropriate interventions to prevent or reduce falls. MO 368

Based on observation, interview and record review, the facility failed to address one of 17 sampled resident's complaints of pain and failed to complete an assessment of the resident after complaints of increased pain. The resident exhibited signs and symptoms of extreme pain one morning, went to the hospital ten hours later, for abnormal laboratory results and was found to have a fractured left hip. (Resident #6) The census was 98. Review of Resident #6's quarterly Minimum Data Set MDS, a federally mandated assessment instrument completed by facility staff, dated 1/19/11, showed the following: -Usually understands; -Cognitively impaired; -Long and short term memory problems; -Always incontinent of bladder; -Frequently incontinent of bowel; -Extensive assistance for toileting, bathing and personal hygiene. -High risk for falls; -Limited assistance for transfers; -Limited assistance of staff to ambulate; -Alert to self -Pain assessment interview-unable to answer; -Staff pain assessment-able to verbalize pain; -Pain noted on 1-2 days in the past 5 days. Review of the resident's care plan initially dated, 6/3/10 and last updated on 1/17/11, showed staff addressed altered comfort related to pain with the following interventions: -Assess pain on scale of 0 - 10; -Administer pain medication as ordered; -Assess effectiveness of pain medication; -Notify physician if pain unrelieved; -Reposition for comfort; -Attempt alternative methods for pain reliever, ie, heat, cold pack, massage, deep breathing. Review of the resident's nursing restorative care program flow sheet, showed the following: -Date restorative initiated 3/22/11; -Duration of program 3/22/11 through 6/7/11; -Frequency of program three times a week; -Goals: maintain active range of motion (AROM) to bilateral upper and lower extremities and maintain ambulation distance with a roller walker at least 200 feet; -Approaches with frequency: AROM bilateral upper and lower extremities with up to two pound weights 20 repetitions; -Ambulate at least 150 feet with roller walker; -Nu Step cross training machine (a recumbent exercise machine that simulates upper and lower body motion to work all the major muscle groups, helping users build strength) for 10 minutes. Review of the resident's monthly summary, dated April 2011, showed the following: -Long and short term memory deficits; -Orientated to person and place; -No change in cognitive status since last summary; -Assist with activities of daily living; -No hearing problems; -No complaints or evidence of pain; -Wheelchair and bed alarm; -No limitation of functional abilities to move his/her neck, bilateral shoulders, elbows, wrists, fingers, hips, knees, ankles and toes; -Continent of bowel and bladder; -No toileting plan; -Eats in main dining room for meals, required set up and encouragement of staff during meals. Review of the resident's physician's orders [REDACTED]. -Diagnoses: [REDACTED]. -Restorative therapy three times a week for active range of motion to upper and lower extremities and ambulation; -An order, dated 5/26/10, for Tylenol 650 mg by mouth every four hours for pain/temperature when needed (PRN); -Wheelchair and bed alarm for safety. Review of the nurse's progress notes, dated 4/1/11, showed the following: -At 2:30 P.M., the resident fell at 10:30 A.M. Nurse O documented he/she heard the resident's alarm sounding and when he/she entered the room he/she found the resident standing. Nurse O assisted the resident to the floor and the resident landed on the left side. The resident did not hit his/her head. Range of motion of extremities was within normal limits at time of the fall. The resident complained of pain to the left side. Nurse O notified the resident's physician; -At 5:30 P.M., Nurse P documented the resident was complaining of left hip pain when trying to stand. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. Review of the resident's April 2011 POS, showed an order dated 4/1/11, for an x ray of the left hip related to pain. Review of the resident's nurse's progress note, dated 4/1/11 at 8:30 P.M., showed completion of the x-ray. Review of the nurse's progress note, dated 4/1/11 at 8:45 P.M., showed the following: -Nurse O documented the resident lay in bed and complained of left hip pain; -PRN Tylenol 650 mg administered to the resident for pain; -Call light within reach; -Alarm functioning properly on bed, awaiting x-ray results. Review of the incident report related to the fall, on 4/1/11 at 10:30 A.M., showed the following: -Fall without injury; -Narrative of incident: Nurse O heard the resident's alarm sounding and entered the room. Nurse O assisted the resident to the floor. The resident fell hitting the left side and landed with his/her left arm under his/her head. The resident did not hit his/her head. The resident was trying to go to the bathroom; -Immediate actions taken: the resident was assisted to his/her wheelchair and chair alarm was placed, staff educated the resident not to attempt to get up without help; -PCP (Primary Care Physician) and family notified of fall; -Medications taken within the last eight hours: [MEDICAL CONDITION]/antipsychotics -Medical risk factors possibly related to incident: history of falls and incontinence; -Reinforce bowel and bladder program; toilet the resident before and after meals and at bedtime. -Resident receiving restorative therapy at this time. Review of the resident's radiology report, dated 4/2/11, showed mild [MEDICAL CONDITION] of the left hip. No fracture or dislocation of the left hip assessed. Review of the nurse's progress notes, dated 4/2/11, showed the following: -At 3:30 A.M., Nurse Q documented the resident lay in bed, bed in low position, alarms on and functioning, rounds every two hours. The resident able to move all extremities, assisted to toilet and back to bed. Left hip area no redness or swelling assessed. The resident had a relaxed expression on his/her face. Call light within reach. No signs or symptoms of distress. -At 9:00 A.M., Nurse R documented the resident had no complaints of pain or discomfort. Call light within reach. No new orders from the resident's PCP related to the fall. Review of the nurse's progress note, dated 4/3/11 at 9:00 A.M., showed Nurse R documented the resident had no complaints of pain or discomfort. Review of the resident's nurse's progress notes, dated 4/4/11, showed the following: -At 12:00 A.M., Nurse S documented no complaints of pain, alarm on and working. -At 2:00 A.M., Nurse S documented the Certified Nurse Aide (CNA) called nurse to the room. The resident was found on the floor, on his/her knees, beside the bed. The resident was unable to say what happened. Full body assessment completed, no bruising noted, slight redness to bilateral knees. Neurological checks completed on the nurse flow sheet. Staff assisted the resident to the bathroom then back to bed. Nurse S instructed the resident to push the red button (call light) and staff will assist him/her with needs. The resident had no complaint of pain at that time. -At 6:00 A.M., Nurse S notified the resident's daughter and the resident's PCP about the fall. No new orders from the physician. -At 12:50 P.M., Nurse O documented the resident remained status [REDACTED]. The resident had no sign or symptoms of pain. -At 7:00 P.M., Nurse P documented the resident was propelling self throughout the facility. No complaint of pain noted. -At 7:30 P.M., Nurse P documented the resident was taken to bed, call light within reach. Review of the incident report related to the fall, on 4/4/11 at 2:00 A.M., showed the following: -Fall without injury; -Narrative of incident: the resident was found on his/her knees; beside his/her bed. The alarm did not sound; the alarm was turned off. CNA T counseled regarding checking alarms for being turned on; -Immediate actions taken: staff took the resident to the bathroom, returned to bed alarm on, call light within reach; -Physician and family notified of fall; -Medications taken within the last eight hours: [MEDICAL CONDITION]/antipsychotics and laxatives; -Medical risk factors possibly related to incident: history of falls, incontinence, bowel and bladder urgency, inability to understand directions, [MEDICAL CONDITION] and confusion/disorientation. -Reinforce bowel and bladder program; -Scoop mattress to be placed. Review of the nurse's progress notes, dated 4/5/11, showed the following: -At 3:00 A.M., Nurse Q documented the resident was resting in bed quietly. No complaints of pain. Assist of one to toilet the resident. Bed alarm on and functioning, staff rounding on the resident every two hours, call light within reach; -At 7:15 P.M., Nurse P documented the resident went to the dining room for dinner; appetite good; no complaints of pain related to previous fall; the resident lay in bed with call light within reach. Review of the nurse's progress notes, dated 4/6/11, showed the following: -At 4:10 A.M., Nurse Q documented the resident lay in bed quietly, denies pain, bed in low position, alarm on and functioning. Assist of one staff to toilet the resident and then went back to bed. Continued 72 hour post fall assessment, no delayed injury assessed. Staff rounding on resident every two hours; call light within reach. Neurological checks within normal limits; -At 2:00 P.M., Nurse O documented the resident remains status [REDACTED]. The resident is propelling self throughout the facility; -At 8:00 P.M., Nurse P documented the resident had no complaint of pain or discomfort. The resident lay in bed call light within reach. Review of the nurse's progress notes, dated 4/7/11, showed the following: -At 3:00 A.M., 24 hour post fall observation. Nurse Q documented the resident was quiet with no complaint of pain or discomfort. The staff rounded on the resident every two hours. Staff assisted the resident to the bathroom. The resident was continent of bowel and bladder. No changes in the resident's baseline level of care. The resident had a relaxed expression while he/she rested; the call light was within reach. Temperature 96.7, pulse 80, respirations 22, blood pressure 132/80. This was the last entry regarding any type of assessment until 4/19/11. During an interview on 6/6/11 at 2:15 P.M., Restorative CNA Z said he/she completed restorative therapy with the resident on the following dates: -On 4/5/11 no complaints of pain; -On 4/6/11 no complaints of pain; -On 4/7/11 restorative CNA Z said the resident was complaining of feeling really tired, the resident did all the exercises but refused to do the Nu Step cross training machine; -On 4/11/11 no complaint of pain. Review of the goals and the resident's response flow sheet on 4/7/11, showed Restorative CNA Z documented the resident was very sleepy this week and weak. The resident was too tired and weak to do the Nu Step cross training machine. The CNA said he/she notified the physical therapist about the resident's complaints. The restorative CNA said he/she did not notify the charge nurse. The restorative CNA Y said he/she notified the physical therapist of the resident's increased weakness and complaint of fatigue. The restorative CNA thought the physical therapist would notify the charge nurse. The resident continued on the restorative program to maintain his/her goals. Review of the resident's next nurse's progress note, dated 4/8/11, showed an order for [REDACTED]. During an interview on 6/7/11 at 9:10 A.M., Restorative CNA Y said he/she attempted to do restorative therapy with the resident on 4/13/11. The CNA said the resident did the upper extremity and right leg exercises with no complaints of pain, but as soon as the resident started doing lower leg exercises with the left leg the resident said it hurt so badly. CNA Y said he/she could tell the resident was in pain because the resident was grimacing and had a frown on his/her face. Restorative CNA Y attempted to assist the resident to ambulate, but as soon as the resident stood up the resident's left leg started to slide forward. The resident was very shaky and the restorative CNA assisted the resident to sit back down in his/her wheelchair. CNA Y said he/she notified the physical therapist about the resident's complaint of pain related to the left leg and the physical therapist told him/her to put the resident's restorative therapy on hold due to the pain the resident had experienced. Review of the restorative therapy goals and the resident's response flow sheet, dated 4/15/11, showed Restorative CNA Y documented the resident was maintaining his/her goals, but often complained about his/her left leg hurting. Restorative CNA Y said he/she just takes it slow with the resident. During an interview on 6/8/11 at 9:30 A.M. Nurse O said he/she was assigned to the resident, on 4/13/11 and 4/15/11, and did not recall Restorative CNA Y, Restorative CNA Z or the physical therapist notifying him/her the resident had complained of left leg pain. Review of the resident's next nurse's note, dated 4/14/11, showed an order for [REDACTED].M. Review of the resident's Initial Treatment Plan for Rehabilitation, dated 4/15/11, showed a plan for physical therapy three times a week for eight weeks to address bilateral lower extremity strength, balance, gait and transfers to promote the highest functional level in preparation for discharge to functional maintenance program. During an interview on 6/7/11 at 7:50 A.M., the physical therapist said the resident's baseline for walking was approximately 150 feet with a roller walker and modified assist of staff. When he/she assessed the resident during the initial evaluation on 4/15/11, the resident complained of left hip pain after ambulating 20 feet. The physical therapist could not recall if the resident complained of pain during the other exercises. The resident complained of pain in the left groin area, and at one point he/she applied a moist hot pack on that area for 15 minutes. The physical therapist said he/she did not feel it was appropriate to continue therapy due to the complaint of pain. The physical therapist said he/she notified the charge nurse for the 100 hall about the resident's complaint of left groin pain during therapy. Review of the resident's nurse's progress notes, showed no entries for 4/15 through 17/11. During an interview on 6/7/11 at 9:10 A.M., Restorative CNA Y said he/she took the resident to the bathroom on 4/18/11. The resident complained of left leg pain while getting up from the wheelchair and ambulating into the bathroom. The restorative CNA said he/she notified the physical therapist about the resident's complaint of leg pain, but he/she did not notify the charge nurse. The restorative CNA said he/she thought the physical therapist would notify the charge nurse. Review of the resident's nurse's progress notes, showed no entry for 4/18/11. During an interview on 6/8/11 at 12:00 P.M., the physical therapist said he/she could not recall either restorative aide notifying him/her of the resident complaining of pain, on 4/13/11 or 4/18/11. The physical therapist said any time a resident complained of pain or had a change in functional status it was policy/procedure for the hall charge nurse to be notified. During an interview on 6/7/11 at 9:25 A.M., Nurse U said he/she was not assigned to care for the resident on 4/13/11, 4/15/11 or 4/18/11. Nurse U said she did not recall Restorative CNA Y, Restorative CNA Z or the physical therapist notifying him/her the resident had complained of left leg pain. Review of the resident's physical therapy flow sheet, dated 4/19/11, showed the physical therapist documented the following: -Ambulated 22 feet with assist of one staff member with a roller walker with modified assist of staff; -Completed 15 minutes on the Nu Step cross training machine; -Completed 20 repetitions of seated bilateral lower extremity exercises which worked the hips, ankles and knees. Review of the resident's Range of Motion Data Collection and Assessment form, dated 4/19/11, showed assistant Director of Nurse (ADON) A documented the resident had no limitation of functional ability to move his/her neck, bilateral shoulders, elbows, wrists, fingers, hips, knees, ankles and toes. During an interview on 6/7/11 at 9:00 A.M., CNA V said on 4/19/11, he/she was assigned to care for the resident. When he/she attempted to get the resident up for breakfast at approximately 7:00 A.M., the resident lay in bed complaining of left leg pain. The CNA said the resident refused to sit up or allow staff to assist him/her with activities of daily living. CNA V said the resident was yelling out and cursing saying she was in pain. The CNA notified Nurse U that the resident refused to get up and complained of pain and he/she also notified the physical therapist of the resident's pain. During an interview on 6/7/11 at 9:30 A.M., Nurse U said he/she was not assigned to care for the resident on 4/19/11, it was Nurse X. Nurse U said CNA V notified him/her the resident lay in bed in severe pain and Nurse U notified the physical therapist to assess the resident's hip area. The nurse said he/she did not assess the resident; the physical therapist did. During an interview on 6/8/11 at 11:15 A.M., the Director of Nurses (DON) said Nurse X no longer worked at the facility and had moved out of state. During an interview on 6/8/11 at 12:15 P.M., the physical therapist said on 4/19/11, Nurse U asked her to assess the resident for complaints of pain in the left leg. The physical therapist said he/she tried to assess the resident, but he/she lay in bed grimacing, yelling and crying out in pain and would not let anyone touch him/her. The physical therapist said he/she did not recall the resident's left leg to be shortened or externally rotated. During an interview on 6/10/11 at 2:00 P.M., Nurse P said he/she worked on 4/19/11, and his/her shift started at 2:30 P.M. On 4/19/11, he/she was also the Certified Medication Technician. Nurse P said ADON A helps out on the hall when it gets busy and he/she thought ADON A and Nurse X had assessed the resident. Nurse P did not assess the resident. During an interview on 6/9/11 at 8:40 A.M., the DON said she would have expected the nurses assigned to the resident on 4/19/11, to assess the area of pain. Review of the resident's MAR, dated 4/19/11, showed the following: -PRN Tylenol 650 mg given at 8:00 A.M., for complaint of bilateral leg pain; "Don't touch them", noted. No follow up to pain medications effectiveness. -PRN Tylenol 650 mg given at 12:00 P.M., for complaint of leg pain. "Effective", noted at 2:00 P.M. Review of the resident's first nurse's progress note, since 4/14/11, dated 4/19/11, showed at 12:40 P.M., Nurse U documented the resident complained of severe pain in the hips, that morning and did not want to be touched or moved. The resident would not sit up to eat. Nurse U notified the resident's PCP and the resident's family. No vital signs noted. During an interview on 6/10/11 at 9:40 A.M., Nurse U said she called the resident's PCP and notified him/her of the resident's complaints of severe pain in the hips. Nurse U could not recall what time he/she notified the resident's PCP but said he/she always notifies the PCP of any issues promptly. Nurse U said the resident's PCP returned the call immediately and gave new orders. Review of the resident's POS, dated 4/19/11, showed the following new orders: -Push fluids; -Bilateral hip/pelvis x-ray; -As soon as possible (STAT) laboratory tests. Review of the scheduling log sheet for the company that drew the resident's blood, on 4/19/11, showed the laboratory tests were ordered by Nurse U at 12:41 P.M. Review of the resident's x-ray order form, dated 4/19/11, showed Nurse U ordered the x-ray at 1:31 P.M. Review of the nurse's progress note, dated 4/19/11 at 4:30 P.M., showed ADON A documented the laboratory results were reported to the PCP and the resident's white blood cell count was abnormally high. Temperature 97.7, pulse 91, respirations 18, blood pressure 153/79. During an interview on 6/10/11 at 10:00 A.M., the DON said STAT laboratory orders were to be collected/drawn within four hours. The DON said he/she did not know why it had taken so long. Review of the resident's laboratory report, dated 4/19/11, showed the following: -White blood cell count 15.6; high (normal is 5.4-9.9). Review of the April POS, showed an order dated 4/19/11, to send the resident to the hospital for evaluation and treatment. Review of the nurse's progress notes, dated 4/19/11 showed Nurse P documented the following: -At 5:00 P.M., an ambulance arrived to transport the resident to the hospital; -At 5:30 P.M., the x-ray company reported the resident had a fractured left hip. Review of the resident's radiology report, dated 4/19/11, showed an examination of bilateral hips and pelvis noted a left [MEDICAL CONDITION] with modest displacement, new since 4/1/11, modest [MEDICAL CONDITION], but no pelvic or right [MEDICAL CONDITION]. During an interview on 6/14/11 at 2:40 P.M., the paramedic said he/she arrived to the facility on [DATE] at 4:58 P.M. He/She requested report from a nurse, but did not remember the nurse's name. The paramedic said the nurse told him/her the resident was being discharged to the hospital emergency room due to abnormal laboratory values. The paramedic said when he/she and facility staff transferred the resident from the bed to the stretcher the resident complained of severe left hip pain. The paramedic said he/she did a complete body assessment in the ambulance on the way to the emergency room . Upon assessment the resident continued to complain of severe left hip pain. The paramedic said he/she removed the resident's cover to assess the left hip area and saw the resident's left leg was shortened and externally rotated. The paramedic said the resident was unable to explain what happened to his/her leg. The paramedic documented his/her findings and notified the emergency room staff upon arrival to the hospital. Review of the emergency room record, on 4/19/11 at 5:38 P.M., showed the resident was sent to the emergency room for elevated white blood cell count. The resident complained of pain in his/her left hip. The resident's left leg had positive shortening and external rotation noted. Review of the hospital assessment and plan, for the resident dated 4/22/11, showed the white blood cell count was probably abnormally high related to the inflammation from the recent fracture. Review of the facilities pain management policy, revised on 5/1/11, showed the following: -The facility recognizes that a resident's response to pain is subjective and individual. All resident's are initially screened for pain upon admission, quarterly, and or with a significant change in condition that may cause an onset or increase in pain. If acute or chronic pain is identified, the Interdisciplinary Plan of Care Team (IPOC) will re-evaluate pain management interventions at more frequent intervals until the pain is managed. Pain is recognized as the fifth vital sign. The IPOC team encourages the resident to self report pain and works with the resident and significant other to identify if pain is acute or chronic, origin of pain and severity of the pain; -Assessment also evaluates alleviating and/or exacerbating factors, reviewing effectiveness of past and current treatment and specific spiritual and cultural issues related to pain; -Residents with a cognitive impairment will be assessed for pain based on objective clinical assessments, use of proxy (family/visitors) pain reporting and behavioral characteristics; -Residents are re-assessed with [REDACTED]. -Identify the potential cause for the residents pain and factors that increase or decrease the pain. -Determine interventions to manage the pain and side effects. Appropriate interventions include pharmacologic as well as non-pharmacologic interventions. During an interview on 6/9/11 at 8:45 A.M., the DON said he/she could not be 100% sure the resident's [MEDICAL CONDITION] was the result of the previous falls on 4/1/11 and or 4/4/11. The DON said it was routine/policy and the restorative CNAs should have notified the hall charge nurse and the head of therapy when the resident complained of left leg pain on 4/13/11 and 4/18/11. The DON also said she would expect the physical therapist to document when residents were experiencing pain and who they notified. During an interview on 6/6/11 at 10:30 A.M., the DON said the facility attributed the [MEDICAL CONDITION] hip to the fall from 4/1/11 and or 4/4/11, because sometimes a fracture does not show up on the x-ray at first. He/She said facility staff reported to him/her the resident ambulated in the hall by him/her with no complaint of pain on 4/18/11. On the morning of 4/19/11, the DON said the resident complained of pain all over and would not let anyone touch his/her. The PCP was notified and new orders were obtained. When the resident's laboratory results came back showing elevated white blood cells, he/she thought the resident had an infection. The PCP was notified and sent the resident to the emergency room . After the resident left the building the x-ray results came back positive for a left [MEDICAL CONDITION]. During an interview on 6/7/11 at 11:00 A.M., the resident's PCP said the resident did not ambulate without staff assistance due to a very unsteady gait. He/She did not recall being notified of the resident complaining of pain during the time period, of 4/1/11 through 4/19/11, but he/she did not have access to the resident's chart at the time. The PCP said that he/she could not say with 100% certainty that the fracture happened from the previous falls, on 4/1/11 and/or 4/4/11, but that was what he/she suspected. The resident also has the [DIAGNOSES REDACTED]. The doctor said he/she would have expected the facility to investigate cause of the injury and expects to be notified when residents have a change in status, for example, pain.