Every finding on record at Blue Springs Wellness & Rehabilitation

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) out of four sampled residents was treated with dignity and respect. On 7/3/26 Licensed Practical Nurse (LPN) A directed profane language toward the resident while the resident was showering. The facility census was 50 residents.The Administrator was notified on 7/15/26 of the past noncompliance which began on 7/3/26. The facility immediately completed education for Abuse/Neglect/Reporting education and customer service to all staff with 100% pass rate. The resident was assessed for any psychosocial needs. The deficiency was corrected on 7/10/26. Review of the facility's Privacy and Dignity Policy dated 1/26 showed the facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect in full recognition of each resident's individuality. 1. Review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Bipolar disorder, unspecified (A mental health disorder characterized by episodes of mood elevation and depression that may affect judgment, impulse control, emotions, behavior, and the ability to function in daily activities). -Major depressive disorder, recurrent, moderate (A mental health disorder characterized by repeated episodes of depression that may cause persistent sadness, loss of interest in activities, changes in sleep or appetite, difficulty concentrating, and decreased ability to function). -Post-traumatic stress disorder (PTSD) (A mental health disorder that may develop after experiencing or witnessing a traumatic event. Symptoms may include intrusive memories, avoidance behaviors, heightened alertness, anxiety, irritability, and emotional distress). -Generalized anxiety disorder (A mental health disorder characterized by persistent and excessive worry that may interfere with daily functioning and may be accompanied by restlessness, difficulty concentrating, irritability, muscle tension, and sleep disturbances). Review of the resident's Care Plan Report dated 6/4/26 showed the resident had a psychosocial well being problem related to anxiety. Interventions included allowing the resident to answer questions, verbalize feelings and fears as needed. Review of the facility Investigation Summary dated 7/10/26 showed:-Resident #1 alleged LPN A used profanity while he/she was in the shower with Certified Nurse's Aide (CNA) A.-CNA A corroborated the resident's statement.-LPN A's statement acknowledging knocking and requesting the shower to end due to staff coverage needs. Review of the resident's Trauma Screen dated 7/6/26 at 2:53 P.M. showed:-He/She had a history of trauma related events in his/her life.-The event did not trigger any past trauma.-The event did not cause him/her to feel scared, helpless or horrified.-The event did not make him/her constantly on guard, watchful or easily startled.-The event did not cause him/her to feel numb, detached from others, activities or his/her surroundings.-He/She stated he/she was fine, just did not like being talked to in the way.-Mental health services were offered if needed. During an interview on 7/15/26 at 11:45 A.M., the resident said: -He/She was in the shower on 7/3/26 at approximately 2:30 P.M., and CNA A was in the shower room with him/her.-He/She could bathe independently. -He/She was supposed to have someone present just in case he/she fell, as stand-by assistance. -Staff locked the door so people did not come in and out while someone was in the shower. -He/She heard LPN A banging on the door. -He/She heard LPN A say, Get the fuck out of the shower. -He/She had no clue why LPN A would do that. -He/She knew LPN A was talking directly to him/her because LPN A said his/her name. -He/She finished the shower and went into the hallway, where LPN A chastised him/her again. -LPN A was angry. -LPN A then got into it with CNA A, and they had a blowout between them.-He/She said LPN A had never talked to him/her like that before. -He/She felt shocked. - One of the other nurses told him/her that he/she was not the only person LPN A had snapped at.-He/She guessed he/she felt safe living at the facility. -He/She wrote a grievance on 7/3/26 but did not give it to anyone until 7/6/26. -He/She then told the Assistant Director of Nursing (ADON) about the incident. Review of CNA A's written Witness Statement dated 7/9/26 showed:-He/She was on hall 200 with the resident assisting him/her a shower.-All of the resident's clothes were off and he/she had transferred into the shower chair.-The resident had just put shampoo on his/her hair.-LPN A knocked on the door and told the resident to hurry up.-This happened several times during the shower.-LPN A told him/her to come out and watch another resident and he/she would send someone else out from the unit to finish the shower.-The resident told him/her to lock the door and keep it locked.-He/She asked LPN A to please be quiet as he/she was upsetting the resident.-LPN A stated, So what!-The resident told him/her to not leave him/her until he/she was done.-LPN A already knew the resident would not let anyone else complete his/her shower.-Throughout the shower, LPN A kept screaming through the door.-The resident kept saying not to open the door until he/she was done with his/her shower, because he/she had not a way to stick up for him/herself or protect him/herself until he/she was dressed.-When they were finished, he/she opened the door and LPN A was standing there.-LPN A said, I told you to come out!-He/She told LPN A he/she made the resident very uncomfortable, and he/she asked him/her to stay until he/she was done.-LPN A said he/she was the fucking charge nurse.-The resident stated he/she was going to report LPN A.-LPN A said, Go ahead. I'm not the one. I'm not the fucking one. Report me and you will regret it. During an interview on 7/15/26 at 12:18 P.M., CNA A said: -He/She was assigned to provide the resident's shower. -He/She disinfected and cleaned the shower room while the resident was getting his/her belongings ready for the shower. -He/She assisted the resident in the shower room on the 200 hall. -The resident showered independently but needed help drying, dressing, undressing, and transferring into and out of the shower chair.-LPN A knocked on the door several times during the shower and hollered at both of them through the door. -He/She heard LPN A tell them to hurry up and get done.-He/She heard LPN A repeatedly tell the resident to hurry up and that he/she needed to get out. -He/She heard LPN A tell the resident that he/she needed to get out of the fucking shower. -He/She heard LPN A use the resident's name. -The resident asked him/her to lock the door and not leave him/her under any circumstances because he/she was very uncomfortable with LPN A yelling.-LPN A's screaming made the resident nervous and uncomfortable. -He/She told LPN A they were almost finished and that he/she was making the resident uncomfortable. -He/She heard LPN A respond, So what? -LPN A was loud and used a not-nice tone.-He/She remained with the resident and finished the shower.-He/She handed the resident his/her belongings after he/she was dressed and the shower was completed.-He/She opened the door and saw LPN A standing outside the shower room. -He/She heard the resident tell LPN A that he/she was going to reporthim/her.-He/She heard LPN A respond, I promise you, I am not the fucking one, and you will regret it.- The resident said he/she was uncomfortable. -LPN A had been hollering at staff that day. -The interaction was very loud and believed other residents could have heard it because they were out and about. -The Social Worker was in the office outside the shower room when LPN A had yelled at the resident during the shower. During an interview on 7/15/26 at 12:00 P.M., the ADON said: -He/She received the resident's grievance at approximately 8:30 P.M. on 7/6/26. -The resident told him/her the incident happened on Friday and that he/she wanted the ADON to know about it. -He/she provided the information to administration to begin an investigation. During an interview on 7/16/26 at 12:50 P.M., the Social Worker said:-His/Her office was located beside the shower room.-He/She was present at the facility on 7/3/26, as was the Administrator, and nobody, including Resident #1, reported the incident that day.-He/She did not hear any cussing and said he/she would have immediately gone into the hallway if he/she had heard cussing.-His/Her office door had been open and believed he/she would have heard LPN A yelling. -He/She was leaving the office to speak with LPN A about something else when he/she saw LPN A and asked him/her to come into the office. -He/She believed the conversation sounded like two people who were frustrated with each other. -The resident also told him/her LPN A had never talked to him/her that way before and that he/she did not know what was going on with LPN A that day. -He/She first saw the grievance on 7/7/26. -He/She brought the grievance to the Administrator and asked whether he/she knew about it. During an interview on 7/16/26 at 1:25 P.M., the Regional Nurse Consultant, who was serving as the acting Director of Nursing said: -LPN A could have handled the situation better. -The incident was a customer service issue and an issue between staff members. During an interview on 7/16/26 at 2:16 P.M., the Administrator said: -The incident between LPN A and the resident was a customer service issue. -The event was unwitnessed. -Training was completed on customer service and abuse as a refresher for all staff. 3078923

Based on observation, interview and record review, the facility failed to protect two sampled residents (Resident #2 and Resident #3) from abuse. On 7/14/26 Resident #2 hit Resident #3 with a cane and then Resident #3 took the cane and hit Resident #2; resulting in a small red area on Resident #2's right arm and multiple superficial reddened areas and cuts to both Resident #3's arms out of four sampled residents. The facility census was 50 residents.The Administrator was notified on 7/16/26 of the past noncompliance which began on 7/14/26. The facility immediately began education for Abuse/Neglect/Reporting education to all staff persons. The residents were separated and psychiatry followed up with both residents. The deficiency was corrected on 7/16/26 Review of the facility's Abuse Prevention and Prohibition Program policy dated 10/24/22 showed:-The purpose of the policy was to ensure the facility established, operationalized, and maintained an abuse prevention and prohibition program designed to screen and train employees, protect residents and ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, misappropriation of property and crime in accordance with state and federal requirements.-Each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility had zero tolerance for abuse, neglect, mistreatment and/or misappropriation of resident property. -Staff must not permit anyone to engage in verbal, mental, sexual or physical abuse, neglect, mistreatment or misappropriation of resident property. Review of the facility's Violence Between Residents policy dated August 2020 showed:-The facility would act promptly and conscientiously to prevent and address altercations between residents.-The facility staff should monitor residents for aggressive or inappropriate behavior toward other residents, family members, visitors or facility staff. 1. Review of Resident #2's admission Record Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, (paralysis or weakness on the left side of the body resulting from a stroke). Review of Resident #2's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/12/26, showed he/she was cognitively intact and did not have behaviors. Review of Resident #3's admission Record Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Generalized muscle weakness.-Cognitive communication deficit.-Mild cognitive impairment of unknown etiology.-Unspecified lack of coordination.-Difficulty in walking. Review of Resident #3's Quarterly MDS dated [DATE], showed he/she was cognitively intact and did not have behaviors. Review of the facility's Summary of Incident dated 7/14/26 showed:-Resident #3 was in his/her room. -Resident #2 entered the room to set his/her food down. -Resident #3 made a comment to Resident #2 regarding some clothing on the floor.-Resident #2 replied to Resident #3's comment calling him/her out of his/her name. -Resident #3 responded again then Resident #2 threatened Resident #3. -Then the physical engagement happened.-Staff heard the commotion in the room and called for additional support. Review of Resident #3's Skin Check dated 7/13/26 showed he/she had reddened areas on both of his/her arms. Review of Resident #3's Skin Check dated 7/14/26 showed he/she had two skin tears, bruising and redness on his/her left arm and a red mark on his/her abdomen. Review of Resident #3's Trauma Screen dated 7/14/26 showed:-He/She stated his/her roommate would not leave him/her alone and he/she finally had enough.-He/She was encouraged to follow up with psychiatry as needed. Review of Resident #2's Skin Check dated 7/14/26 showed he/she had a small red area inside his/her left elbow. Review of Resident #2's Trauma Screen dated 7/14/26 showed:-He/She stated he/she felt helpless in the manner that he/she would not be able to protect himself/herself in the event that he/she needed to.-He/She was aware he/she could get staff assistance if needed. Review of Resident #3's Progress Notes dated 7/14/26 showed:-He/She was heard screaming and yelling at another resident in his/her room.-The Administrator responded and separated the residents.-The resident was sitting in his/her wheelchair with two skin tears on his/her left arm and one on his/her right arm, and redness on his/her upper abdomen.-Vital signs were within normal limits.-He/She had no complaints of pain at the time.-The skin tear was clean and dressed.-Physical assessment showed no other apparent injury.-The nurse asked if the resident felt safe and he/she stated, Not living in the room with him/her.-The nurse reassured the resident other sleeping quarters would be reassigned for safety. Review of Resident #3's Progress Notes dated 7/14/26 showed:-He/She was alert and oriented and able to make his/her needs known.-He/She had scattered dark discoloration to bilateral arms.-He/She had one skin tear of 2.5 centimeters (cm) on the right forearm and two skin tears on the left arm.-The skin tear on the right arm was noted from a previous fall.-He/She denied pain or discomfort.-He/She felt safe and was upset because he/she and his/her roommate were friends and he/she was not sure what happened or started anything between the two.-He/She did not want to go out for emergency care. During an interview on 7/15/26 at 3:05 P.M., Resident #2 said:-Resident #3 came into the room and wanted to argue and fight.-He/She used the cane to push Resident #3's wheelchair backward.-He/She did not want to get hit. -He/She was defending himself/herself.-He/She and Resident #3 were roommates.-He/She had been at the facility for two months.-He/She did not want to get hurt.-He/She heard Resident #3 shout, I'll kill you!-He/She believed Resident #3 had a serious anger problem. Observation and interview with Resident #3 on 7/15/26 at 3:30 P.M. showed:-An approximately quarter sized reddened area with an approximately 1/2 inch scratch in the center of his/her left arm.-An approximately 2-inch reddened area on his/her left arm above the elbow.-An approximately dime sized reddened area with open center on his/her right arm, covered by a bandage.He/she said: --Resident #2 hit him/her with a cane.--Resident #2 had a four-prong cane, and he/she used his/her arms to block Resident #2 from hitting him/her.--The injuries to his/her arms occurred while blocking the cane.--Resident #2 swung the cane overhead.--He/She became angry and grabbed the cane.--He/She told Resident #2 he/she had better stop hitting him/her or he/she would grab the cane and show Resident #2 how it felt.--Resident #2 did not stop.--He/She shoved Resident #2's wheelchair, and it struck the resident in the groin, causing Resident #2 to bend over.--He/She told Resident #2, You hit me one more time and I'm going to shove this cane up your ass.--Resident #2 hit him/her nine times.--He/She did not want to hurt Resident #2.--He/She yelled for help, but nobody came.--He/She denied taking any pain medication. During an interview on 7/16/26 at 11:00 A.M., the Regional Nurse Consultant, who was serving as the acting Director of Nursing, said:-Resident #2 did not have any injuries.-Resident #2 had a small red area on the inside of his/her left arm.-Resident #3 had a 3 cm skin tear on his/her right forearm from fall the previous night.-Resident #3 had other skin tears. Review of Resident #4's Quarterly MDS dated [DATE], showed he/she was cognitively intact.During an interview on 7/16/26 at 2:05 P.M., Resident #4 said:-He/She was lying on his/her bed the day of the altercation.-He/She heard arguing but didn't know what it was about.-He/She saw Resident #2 go after Resident #3.-Resident #3 tried to push Resident #2 back.-Resident #2 was swinging the cane at Resident #3 and Resident #3 took the cane and started swinging back.-There were not any staff present; the residents were in their room.-Resident #3 was calling, Help, help!-Then the staff came to assist. Observation of the cane used in the altercation on 7/16/26 at 2:16 P.M. showed:-It was a metal cane with a four-arm base.-It was kept in the administrator's office. During an interview on 7/16/26 at 2:16 P.M., the Administrator said:-He/She was in the office when he/she heard someone say the residents were fighting.-He/She immediately went toward the residents' room.-He/She entered the room and saw Resident #3 holding the cane up and yelling.-He/She saw Resident #2 behind the wheelchair, leaning against the vanity and yelling back.-He/She got between the residents.-He/She directed a staff member to escort Resident #2 from the room-Resident #3 had three skin tears, however the one on the right arm was due to a fall the previous day.-A resident should be able to live without being hit.-The incident was abuse. 3093557

Based on observation, interview and record review, the facility failed to ensure two sampled residents (Resident # 8 and #9), out of 10 sampled residents, were free from abuse when on 8/31/25 Resident #7 pushed Resident #8 out of his/her wheelchair resulting in Resident #8 sustaining a laceration to his/her midforehead; and on 9/2/25 Resident #7 punched Resident #9 in the arm and began pulling on his/her arm causing immediate and residual arm pain and feelings of being attacked. The resident census was 92 residents. On 9/16/25 the Administrator was notified of the past noncompliance which occurred on 8/31/25. The facility had completed interventions for residents and training for all staff prior to state agency investigation. The deficiency was corrected on 9/6/25. Review of the facility Abuse Prevention and Prohibition Program dated 10/24/22 showed:-To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.-The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.-Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.-The Facility is committed to protecting residents from abuse by anyone, including but not limited to other residents.-The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems.-Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring.-The Facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse.-Resident-to-resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain.-The Administrator will submit initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies. 1.Review of Resident #7's admission Record showed the resident was admitted on [DATE] with diagnoses including patient's noncompliance with other medical treatment and regimen. Review of Resident #7's undated Care Plan showed:-The resident has the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental / emotional illness, date Initiated: 01/23/2025.- When the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 01/23/2025. Revision on: 06/27/2025. Review of Resident #8's admission Record showed the resident was admitted on [DATE] with diagnoses including bipolar disorder, anxiety disorder, and history of falling. Review of Resident #8's undated Care Plan showed the resident had a history of impulsive behavior and the ability to be disruptive. Review of Resident #9's admission Record showed the resident was admitted on [DATE] with diagnoses including bipolar disorder and post-traumatic stress disorder. Review of Resident #9's undated Care Plan showed the resident:-Had a mood problem related to depression.-Had a history of trauma related to sexual assault at age [AGE] years. Review of the undated facility Investigation for the 8/31/25 altercation showed:-On 8/31/25 at approximately 4:30 P.M. the charge nurse was alerted to Resident #8's room by staff.-Resident #8 accused Resident #7 of pushing him/her.-Resident #7 admitted to pushing Resident #8.-Resident #8 was moved out of the room and all parties were notified.-There were no injuries noted to Resident #7.-Resident #8 had a small laceration to the middle of his/her forehead and a small abrasion adjoined. -During the interview, Resident #8 disclosed he/she had been shoved out of his/her wheelchair onto the floor by Resident #7.-First aid was provided for Resident #8 and neurological checks were initiated.-Resident #8 was relocated for his/her protection and separation.-Law enforcement was contacted as this was the second resident assault in a week.-Law enforcement responded and charges were pending for Resident #7.-1:1 (one on one) supervision was in place for Resident #7.-Monitoring was continued for both residents.-Education for staff was initiated. Review of #7's Progress Notes dated 8/31/25 showed:-Alerted to resident room by staff.-Roommate (Resident #8) accused resident of pushing him/her, resident denied pushing or hitting Resident #8, did verbalize to other staff that he/she did push/hit the roommate.-Resident #8 removed from the room and Resident #7 placed on 1:1.-All parties notified. Review of Resident #8's Progress Notes dated 8/31/25 showed:-Registered Nurse (RN) A was alerted to the resident room by staff.-Noted Resident #8 in wheelchair with a bloody abrasion to his/her forehead.-Resident stated he/she knocked me out of my wheelchair and pointed to Resident #7.-Resident #8 was removed from the room, abrasion cleaned and covered.-Neurological checks initiated, vital signs taken and all within normal limits.-Resident stated I don't know why he/she pushed me.-All parties notified. Review of Resident #7's Progress Note dated 9/2/25 showed:-Mental health in the facility to follow up and evaluation.-Resident refused services from mental health.-All parties notified of resident's refusal of mental health services. Review of Resident #7's Progress Note dated 9/3/25 showed:-The resident was heard yelling in his/her room at staff about food in his/her room.-The resident started going out of his/her room.-The housekeeper doing 1:1 stepped in the resident's way and attempted to verbally redirect the resident to stay in the room.-The resident then began shoving the housekeeper several times while scooting out of the room.-The resident made his/her way to the vending machine room where Resident #9 was wheeling out of the room.-The resident reached up with both hands and pushed Resident #9 in the back.-Resident #9 then yell and threw his/her ice in the resident's face.-Th residents were separated to their rooms.-All parties were notified and law enforcement was contacted.-The resident was sent to the hospital. Review of the undated facility Investigation for resident altercation showed:-On 9/3/25 at approximately 8:10 P.M. Resident #7 could be heard yelling at the staff about food being in his/her room.-The resident then started attempting to leave his/her room.- The housekeeper doing 1:1 stepped in the resident's way and attempted to verbally redirect the resident to remain in the room.-Resident #7 then shoved the housekeeper several times and entered into the hallway.-Resident #7 continued shoving the housekeeper as he/she went into the hallway and was yelling.-Resident #7 then made his/her way to the vending machine area where Resident #9 was wheeling him/herself out of the alcove.-Resident #7 then reached with both hands and shoved Resident #9 in the back.-Resident #9 yelled and threw his/her ice into the face of Resident #7.-The residents were separated immediately.-All parties were notified and law enforcement was called.-Law enforcement was familiar with Resident #7 and strongly gave him/her a choice to seek treatment or be arrested given the recent rash of aggressive behavior he/she had displayed.-The resident was transported for psychiatric evaluation and possible treatment. During an interview on 9/9/25 at 12:07 P.M. Resident #9 said:-On 9/3/25 he/she was getting ice in his/her mug and was headed back to his/her room.-Resident #7 was pushing the housekeeper like a rag doll and punched him/her in the chest.-He/She asked Resident #7 what was going on and Resident #7 hit him/her in the left arm and grabbed his/her arm.-He/She pulled his/her arm away from Resident #7's grip and threw his/her cup of ice on him/her.-Resident #7 has called him/her names and been verbally abusive towards him/her in the past.-This was the first time Resident #7 got physical with him/her.-It hurt when Resident #7 hit him/her and grabbed his/her arm, his/her arm was sore the next day. During an interview on 9/9/25 at 1:00 P.M. Licensed Practical Nurse (LPN) C said:-Resident #8 recently moved to the unit he/she works on and was doing ok.-Resident #8 is allowed to have access to the north side of the facility.-He/She was not sure why Resident #8 was moved.-Resident #8 does have a laceration on the forehead that he/she does wound care on. During an interview on 9/9/25 at 1:53 P.M. the housekeeper said:-He/She was involved in one of the altercations with Resident #7.-On 9/3/25 at 6:20 P.M. in the evening he/she was doing the 1:1 observation with Resident #7 from the prior situation.-He/She had training for 1:1- through the facility system and around 4-5 years ago he/she had an in-service.-Through the current corporation he/she had an in-service, but cannot recall the date, between February and April.-He/She was expected to keep Resident #7 in the line of sight, keep at arm's length, ensure safety, anticipate needs.-He/She was under the understanding that Resident #7 was not to leave his/her room.-Resident #7 was hard of hearing so he/she had leaned towards the resident to communicate with him/her.-Resident #7 started cussing at him/her and pushing him/her.-Resident #7 was using his/her hands under his/her ribs full force to push him/her repeatedly.-He/She was not to put his/her hands on the resident.-Another staff came to attempt to verbally redirect the resident and the resident cussed at him/her as well.-Resident #9 was coming out of the alcove and Resident #7 forced his/her way into the alcove and cussing at Resident #9 to get the F out of the way.-Resident #7 was hitting the other resident as he/she made his/her way into the alcove.-He/She was trying to keep the residents separated and LPN D prevented Resident #7 from punching him/her.-Resident #7 pulled on Resident #9 arm and was cussing at him/her.-He/She did not see the push, only that Resident #7 pulling on Resident #8.-Resident #9 did throw his/her water on Resident #7.-He/She has seen Resident #7 behave like this when he/she first arrived.-Resident #7 was very territorial over his/her space.-When they go in to clean Resident #7's room he/she does get vocal.- If you watch Resident #7 you can tell he/she is in that aggression mood.-When Resident #7 woke up and started out he/she could tell the resident was in a foul mood.-Resident #7 was upset with the food tray and was going to throw it so he/she removed it.-Once Resident #7 got his/her coffee and the tray was removed and he/she was fine, was still cussing but not going after anyone.-He/She had not observed any physical aggression prior to the last 2 incidents. During an interview on 9/9/25 at 2:26 P.M. the Assistant Director of Nursing (ADON) said: -He/She was not in the facility for the 8/31/25 incident with Resident #7 and #8.-He/She had not seen Resident #7 get physical prior to the incident.-Resident #8 has not gotten aggressive with others.-Resident #8 did get laceration to his/her mid-forehead and he/she understood neuros, pressure applied, it was cleaned and bandaged.-It was easier to move Resident #8 than Resident #7, as Resident #7 would not be cooperative.-Resident #8 did agree to move and was in with another resident.-Expectation for 1:1 was for staff to be with the resident at all times within arm's reach until directed otherwise, document and monitor for mood and behaviors changes.-During an outburst he/she expects the staff to not argue and report to the charge nurse.-Staff may need get someone else to intervene, especially if personality issue.-Charge nurse to intervene, try to find a solution.-Call police and ambulance. During an interview on 9/9/25 at 3:26 P.M. LPN D said:-He/She was preparing the medication cart for 300 hall, when he heard Resident #7 yelling about the food.-Resident #7 was yelling Where did this food come from, he didn't order it, how long had it been there?-Resident #7 continued yelling about the food and started out the door.-The housekeeper tried to verbally redirect Resident #7 to stay in his/her room and stepped in front of him/her.-Resident #7 shoved the housekeeper repeatedly as he/she made his/her way to alcove.-The housekeeper tried to redirect Resident #7 due to him/her not supposed to be out of his/her room while other residents present.-Resident#9 was close by and Resident #7 shoved Resident #9 out of the way aggressively and Resident #9 threw his/her ice on Resident #7.-Resident #7 was not redirectable at that time.-Resident #7 was headed to the ice machine and shoving anyone who got in his/her way.-He/She has seen Resident #7 like this before.-Resident #7 injured another resident a few days before and that is why he/she was already on one to one.-Resident #7 gets upset about his/her personal space and seemed to be escalating more and more.-In about two week's time Resident #7 was getting more and more aggressive.-Resident #9 was the only other resident involved during this time on 9/3/25. During an interview on 9/9/25 at 4:02 P.M. RN A said:-He/She was working a couple of weekends ago and was in a room with x-ray for another resident when a Medication Technician came to get him/her.-When he/she got to the resident room, Resident #8 said Resident #7 hit him/her or knocked him/her out of his/her wheelchair.-Resident #8 did have an abrasion on his/her forehead.-Resident #7 denied contact with Resident #8 to him/her.-At one time Resident #7 did say he/she did make contact with Resident #8.-He/She notified the Administrator and law enforcement was notified.-Training for aggressive behavior was the basic policy.-He/She was expected to remove the resident and put someone with the aggressor.-This was the first time he/she has had to call law enforcement for a resident-to-resident altercation.-It is expected when residents get aggressive to remove/separate residents and put someone with the aggressor and contact the administrator, that is after contact has happened.-Beforehand he/she should try to keep them separated, use distractions, and diffuse situation by talking, find out what is going on.-Sometimes people just need to be separated.-It was not the first time there was aggression by Resident #7.-In the moment of aggression he/she will try to separate, stop and engage residents.-He/She would try to stay an arm lengths away, but will try to step in between them if needed.-He/She will try to verbally redirect calmly and call for help from other staff.- Resident #7 did admit to the activity's person that he/she did push Resident #8. During an interview and observation on 9/16/25 at 9:45 A.M. Resident #8 showed:-The resident has a discolored area to his/her midforehead, with pick scarring approximately 1 inch in length.-Resident #7 was his/her roommate and had been no issues prior to 8/31/25.-He/She had fallen asleep in his/her wheelchair in the room.-Resident #7 shoved him/her 3 times, pushing him/her out of his wheelchair.-He/She fell out of his/her chair and hit his/her head.-He/She said it scared the hell out of him/her.-He/She has not had any other issues with anyone other than Resident #7.-He/She yelled for help and a nurse came to help him/her.-He/She did have to talk to the police.-They did move him/her to the other side, he/she is not ok with it.-He/She feels like everyone is crazy there and does not get the care he/she did when he/she was on the other side.-He/She wants to move back where his/her friends are.-He/She feels safe here, now that Resident #7 is gone. During an interview on 9/9/25 at 10:12 A.M. the Director of Nursing (DON) said:-There has been a goal to make some room changes due to some of the renovations.-There is no reason the resident would not be able to move other than the space is limited and not able to move him/her back his/her old room at this time.-Expectation of the direct care staff when a resident was aggressive was separation and safety.-Depends on the residents and situation, physical separation, keeping themselves safe as well.-Use de-escalation, offer drink, snacks, and diversion tactics.-When Resident #7 was upset he/she may need space.-Resident #7 was impacted by the trauma of his/her life while being homelessness and was part of the reason he/she was not moved at the time of that incident with Resident #8.-Resident #7 wanted Resident #8 out of the way and that is why he/she pushed. During an interview on 9/9/25 at 10:22 A.M. the Administrator said:-He/She has spoken to Resident #8, and he/she has not said anything about moving.-Resident #8 did complain about three people in the room and that was one of the reasons he/she was ok with moving to his/her new room, there is only two in the room-He/She will have social services and mental health for Resident #8 to assist with resolving his/her concerns.-He/She felt like the 1:1 staff did what he/she needed to do.-There was no physical means to be used, that law enforcement would need to be contacted. 2604626, 2608795

Based on interview and record review, the facility failed to ensure accurate accounting of narcotics for two sampled residents (Resident #4 and #5) when seven narcotic pain medications were unaccounted for out of 10 sampled residents. The facility census was 92 residents. The Administrator was notified of past noncompliance on 9/16/25 which occurred on 6/17/25. Staff training was completed, and the deficiency was corrected 7/8/25. Review of the facility Controlled Substances Policy dated 8/2020 showed:-Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with state and federal laws and regulations.-All controlled substances are stored and maintained in a locked cabinet or compartment.-Accurate inventory of all controlled medications is maintained at all times.-When a controlled substance is administered, the licensed nursing personnel administering the medications immediately enters the following information on the accountability record and the Medication Administration Record (MAR):--Date and time of administration on MAR and accountability record.--Amount administered on accountability record.--Remaining quantity on accountability record.--Signature of the nursing personnel administering dose on accountability record.--Initials of the nurse administering dose, completed after the medication has been administered on the MAR.-When a dose of controlled medication is removed from the container for administration but is refused by the resident or not given for any reason, the dose must be destroyed according to facility policy and the disposal documented on he accountability record on the line representing that dose.1.Review of Resident #4's admission Record showed the resident was admitted on [DATE] with diagnoses including dementia, and pain in his/her right leg. Review of the resident's Order Summary Report dated 6/18/25 showed:-Pain assessment before and after as needed (PRN) meds.-Hydrocodone-Acetaminophen (Norco) oral tablet 5-325 milligrams (mg), give one tablet by mouth two times a day for pain. Review of the resident's MAR dated 6/1/25 through 6/18/25 showed the resident was receiving Norco for pain twice daily. Review of the resident's Controlled Drug Administration Record dated 6/7/25 through 6/17/25 showed:-There were seven tablets of Norco 5-325 mg left after the last administration on 6/17/25 at 5:00 P.M.-There were six tablets of Norco 5-325 mg left with no documented administration on 6/18/25 at 12:00 A.M. 2.Review of Resident #5's admission Record showed the resident was admitted on [DATE] with diagnoses including senile dementia and adult failure to thrive. Review of the resident's Order Summary Report dated 6/18/25 showed:-Pain assessment before and after as needed (PRN) meds.-Hydrocodone-Acetaminophen (Norco) oral tablet 10-325 mg, give one tablet by every six hours for pain. Review of the resident's MAR dated 6/1/25 through 6/18/25 showed the resident was receiving Norco for pain. Review of the resident's Controlled Drug Reconciliation Record/Disposition Form dated 6/8/25 through 6/17/25 showed:-There were 52 tablets of Norco 10-325mg left after the last administration on 6/17/25 at 5:00 P.M.-There were 48 tablets of Norco 10-325 mg and no documented administration on 6/18/25 at 12:00 A.M. 3. Review of the undated facility investigation showed:-On 6/17/25 Licensed Practical Nurse (LPN) A was working as a medication nurse and was to work the floor at 10:00 P.M.-At approximately 6:00 P.M., LPN A and LPN B conducted a change of shift narcotic count for the north halls (100, 200, and 300 halls), which was without discrepancies.-At approximately 10:04 P.M., the Director of Nursing (DON) received a call because there was an off-going narcotic count between Registered Nurse (RN) A and LPN A, where RN A contacted the Assistant Director of Nursing (ADON) to let him/her know he/she was not accepting the controlled substance count.-There was a total of seven Norco tablets not accounted for, three tablets of 5-325 milligram(mg) Norco for Resident #4 and four tablets of 10-325 mg Norco for Resident #5.-The DON instructed the ADON to contact 911 so that law enforcement could become involved and intervene if need be in the misappropriation.-When law enforcement arrived at the facility, the officer was made aware of the missing narcotics that was noted during the change of shift controlled substance count.-The ADON began an audit of the medications and confirmed the missing narcotics.-Per practice once medications are discovered missing, an investigation is immediately launched and the two subjects counting were to stay together until released by the DON/designee. -LPN A denied knowing what happened to the missing narcotics. Review of the police report dated 6/23/25 showed:-Law enforcement was contacted on 6/17/25 at 11:15 P.M for stealing controlled substances.-Resident #4 and Resident #5 were listed as victims in which the narcotics were stolen from.-ADON and RN A were listed as witnesses.-Upon arrival at the facility, the officer was informed of seven pills of narcotics missing at the time of shift change controlled substance count.-The ADON and RN A completed the count and noted there was a total of seven pills of narcotics missing.-LPN A said he/she did not know what happened to the missing narcotics.-There two residents identified as missing pills. During an interview on 9/9/25 at 2:26 P.M. the ADON said:-He/She recalled the alleged diversion that happened about two months ago.-LPN A was passing night medications because there was an extra nurse.-After passing medications LPN A was to go to the floor and help the Certified Nursing Assistant (CNA).-ADON started looking the narcotic book and something looked off.-He/She got the other nurse RN A to witness counting of the controlled medications.-He/She started to count with LPN A and noted the count was off.-RN A verified count was off.-He/She advised both nurses they needed to stay in place while ADON contacted DON.-LPN A could not tell anyone where the medication went.-LPN A had accepted the count at the start of his/her shift.-ADON asked LPN A to write a statement.-No loose medications were located in the cart or anywhere else to indicate pre-popping.-LPN A tried to sign one out, but didn't have a time. During an interview on 9/9/25 at 4:02 P.M. RN A said:-He/She had just started and was working nights.-LPN A was going to be here for his/her last night of orientation.-When they went to count, the count was not correct, so he/she went to the ADON who stepped in and took care of it.-He/She doesn't recall the exact date, but it was June when he/she first started.-He/She came on at 6:00 P.M. to pass 300 hall medications and LPN A was passing 100 and 200 hall medications.-RN A then reported to the ADON, who then tried to complete the count with LPN A.-ADON asked RN A to count with LPN A, and count was not correct.-RN A and ADON confirmed the count was not correct.-The narcotic pain medications were in a bottle for one, and the card for the other resident's narcotic pain medication.-The bottle had 4 missing pills, and they had not been on shift long enough to use that many for the one resident. During an interview on 9/17/25 at 2:53 P.M. LPN A said:-He/She confirmed his/her employment at the facility for a month.-He/She was told there was a narcotic missing.-He/She denied knowing there were missing narcotics or what happened.-He/She recalled counting narcotics when coming on shift with an RN and the count was correct.-He/She denied remembering the second time narcotics were counted. 1539506

Based on interview and record review, the facility failed to ensure a drug regimen review was completed monthly for three sampled residents (Resident #59, #53 and #14) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Drug Regimen Review policy dated June 2020 showed: -The intent was the facility maintained the resident's highest practicable well-being and prevented or minimized adverse (negative or harmful) consequences related to medication. -The pharmacist would review at least once monthly to identify irregularities and any clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. -The Director of Nursing (DON) was responsible for following up with the physician as indicated. 1. Review of Resident #59's Physician's Order Sheet (POS) dated March 2025 showed physician's orders for: -Allopurinol 100 milligrams (mg) at bedtime for gout (type of arthritis that usually affects one joint at a time, often the big toe and causes periods of severe pain and swelling). -Amlodipine Besylate 2.5 mg in the evening for high blood pressure. -Aspirin 81 mg a day for prophylaxis (reducing the risks of heart disease and cancer). -Atorvastatin Calcium 40 mg at bedtime for hyperlipidemia (high levels of fats in the blood). -Clopidogrel Bisulfate 75 mg on time daily for stroke prevention. -Cyanocobalamin 1000 micrograms (mcg) daily for vitamin B12 supplement. -Duloxetine 30 mg at bedtime for depression. -Famotidine 20 mg at bedtime for gastroesophageal reflux disease (GERD - a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). -Fish oil 1000 mg daily for dietary supplement. -Furosemide 20 mg daily related to acute kidney failure (sudden decline in the functioning of your kidneys). -Losartan 50 mg in the afternoon for high blood pressure. -Methimazole 10 mg in the evening for hypothyroidism (underactive thyroid). -Mirtazapine 7.5 mg at bedtime for depression, appetite stimulant. -Oxybutynin 15 mg daily for overactive bladder. -Polyethylene glycol one scoop in the afternoon for constipation. -Sodium bicarbonate 650 mg daily for acute kidney failure. -Timolol solution 0.2-0.5% one drop in both eyes two times daily for glaucoma (increased pressure in the eye). -Carvedilol 25 mg two times daily for high blood pressure. -Cranberry 500 mg tablet two times daily for prevention of urinary tract infection (UTI). -Senokot 8.6-50 mg two tablets twice daily for constipation. -Midodrine 5 mg three times daily for orthostatic hypotension (a sudden drop in blood pressure that occurs upon standing). -Novolin 70/30 insulin 8 units at bedtime for diabetes. -Novolin 70/30 insulin 8 units in the morning for diabetes. -Oxycodone (opioid pain medication) 5 mg every eight hours as needed for pain. Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record. 2. Review of Resident #53's POS dated March 2025 showed physician's orders for: -Ondansetron 4 mg every 8 hours as needed for nausea. -Lorazepam 0.5 mg every 4 hours as needed for anxiety/restlessness. -Morphine Sulfate 15 mg tablet two times a day for pain/discomfort. -Morphine Sulfate Oral Solution 100 mg/5 milliliter (ml), give 0.25 ml by mouth every 1 hour as needed for shortness of air (a severe feeling of being unable to breathe). -Buspirone 10 MG tablet by mouth three times daily for anxiety. -Lorazepam 0.5 mg, one tablet every 4 hours as needed for anxiety/restlessness. -Carvedilol 12.5 mg, two times a day for high blood pressure. -Escitalopram Oxalate 20 mg, one time a day for depression. -Eliquis 5 mg, one tablet two times a day for stroke prevention. -Bumetanide 2 mg, one time a day for edema. -Mirtazapine 7.5 mg one time daily for depression/appetite stimulation. Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record. 21003 3. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, which is a surgical opening into the stomach, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking, high cholesterol, high blood pressure, edema (swelling in the tissues), seizures (a neurological condition characterized by recurrent, unprovoked brief episodes of involuntary movement or altered awareness caused by abnormal electrical activity in the brain), depression, bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), schizophrenia (a chronic mental health condition characterized by persistent disruptions in thought processes, perceptions, emotions, and social interactions) and anxiety disorder. Review of the resident's POS dated March 2025 showed physician's orders for: -Atorvastatin 40 milligrams (mg) daily for high cholesterol (1/16/25). -Baclofen 10 mg every 12 hours as needed for muscle spasms (12/6/24). -Benztropine Mesylate 0.5 mg twice daily for Parkinson's Disease (12/6/24). -Buspirone 15 mg three times daily for anxiety (12/6/24). -Celecoxib 200 mg daily for pain (12/6/24). -Divalproex Sodium 500 mg two tablets twice daily for seizures (12/6/24). -Furosemide 20 mg on Monday, Wednesday and Friday for edema (swelling) (12/6/24). -Gabapentin 50 mg at bedtime for pain (3/17/25). -Levetiracetam 500 mg twice daily for seizures (12/6/24). -Loperamide 2 mg every four hours as needed for loose stools (12/6/24). -Melatonin 5 mg at bedtime (3/7/25). -Metoprolol 12.5 mg once daily for high blood pressure (12/19/24). -Ondansetron 4 mg every 8 hours as needed for nausea (12/6/24). -Oxybutynin 5 mg daily for overactive bladder (12/6/24). -Oxycodone 5 mg every 6 hours as needed for pain (12/6/24). -Prazosin 2 mg at bedtime for nightmares (12/6/24). -Pregabalin 50 mg twice daily for pain (12/6/24). -Sertraline 100 mg two tablets daily for depression (1/2/25). -Trazodone 150 mg at bedtime for depression (12/6/24)' -Vraylar 3 mg daily for schizophrenia (12/6/24). Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record. 4. Review of the facility's Drug Regimen Review binder dated January 2024 to March 2025, showed: -The pharmacist visited the facility in November 2024 and December 2024, but the resident's medications were not reviewed in either month. -There were no Drug Regimen Reviews documented for January 2025, February 2025 and March 2025 for Resident #59, Resident #53, or Resident #14. During an interview on 3/26/25 at 1:52 P.M., the Regional Nurse Consultant said: -The pharmacy had not been coming out for the past three months. -He/She was told that they had not had any gradual dose reductions or any pharmacy recommendations since they purchased the facility in December 2024. -The company had a pharmacist that was contracted to come to all of their facilities including this one. -The pharmacist they were contracted with had not been coming to review the medications in the facility since December 2024. -There was a miscommunication with the pharmacist, they were under the impression there was no longer a contract to provide services to the facility. -Facility staff had not notified him/her that the pharmacist was not coming to the facility to complete the Drug Regimen Reviews. -The Director of Nursing (DON) was responsible for ensuring the drug regimen reviews were completed monthly. During an interview on 3/28/25 at 2:47 P.M., with the Assistant Director of Nursing (ADON) and the Infection Control Preventionist (ICP) present, the ADON said: -The facility completed a drug regimen review upon admission, but the pharmacist completed monthly reviews. -The physician would review the resident's medication list within a weeks time post admission, but the pharmacist may not see the resident for up to a month after admission. -The pharmacist had not been coming to the facility to review resident medications.

Based on interview and record review, the facility failed to honor refusal of treatment for one sampled resident (Resident #6) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Resident's Rights Policy dated August 2020 showed treat the decisions of a resident representative as the decision of the resident to the extent required by court or delegated by the resident, in accordance with applicable law. 1. Review of Resident #6's Probate (court division that handles cases involving guardianships) Court order dated 4/18/13 showed: -The resident was determined to be an incapacitated (physically and/or mental unable to make informed, rational judgments and decisions) person. -His/her brother was appointed guardian of his/her person (In Missouri, a guardian of the person, appointed by the Probate Court, was entrusted with the care and custody of an adult legally determined to be incapacitated, and had the authority to make decisions for their ward regarding care, treatment, shelter, education, support, and maintenance). Review of the resident's Face Sheet showed he/she admitted to the facility with the following diagnoses Traumatic Brain Injury (TBI - a brain injury caused by an external force, such as a blow to the head; TBI's can cause physical, cognitive, emotional, and behavioral problems). Review of the resident's Intravenous (IV) Therapy Consent Form dated 3/13/25 showed: -The resident's legal guardian refused consent for the resident to receive IV fluids. -The form was signed and dated by Medical Records staff A. Review of the resident's Physician's Orders Sheet (POS) dated March 2025 showed: -Start peripheral IV dated 3/17/25. -Derma IV therapy infusion - one time - 500 milliliters (ml) normal saline (salt solution of the same concentration as blood) at 500 ml per hour, total additive volume 17 ml including vitamins and minerals and other supplements for micronutrient hydration therapy, dated 3/17/25. Review of the resident's Medication Administration Record (MAR) dated March 2025 showed Derma IV therapy infusion - one time - 500 ml normal saline at 500 ml per hour, total additive volume 17 ml including vitamins and minerals and other supplements for micronutrient hydration therapy was administered on 3/17/25. Review of the resident's nurse's note dated 3/17/25 at 2:15 P.M. showed: -Assessment completed by IV Infusion Registered Nurse (RN). -Infusion started at 2:15 P.M. -Infusion completed at 3:15 P.M. -Dressing applied. -Report of infusion of infusion completed given to facility staff licensed nurse. During an interview on 3/27/25 at 1:13 P.M. Medical Records staff A said: -In March 2025 he/she had been assigned to call resident representatives for verbal consent for IV Therapy. -He/she called the resident's guardian on 3/17/25 and the resident's guardian said no to the resident having IV therapy. -He/she wrote on the form that the guardian refused consent, dated and timed the form for 3/13/25 at 12:46 P.M. -On 3/13/25 he/she told the Director of Nursing (DON) that the resident's guardian had refused for the resident to have IV therapy. -He/she recalled that the DON acknowledged that he/she understood that the resident's guardian had refused IV therapy. -He/she uploaded the form to the resident's Electronic Medical Record (EMR) on 3/14/25. -NOTE: the DON was unavailable for interview during the survey. During an interview on 3/27/25 at 2:16 P.M. the Assistant Director of Nursing (ADON) was asked to review the resident's IV Therapy Consent Form dated 3/13/25; March 2025 MAR, and Nurse's Notes dated 3/17/25 regarding the resident receiving IV fluids; he/she said: -The resident's guardian had refused for the resident to have IV therapy. -He/she had not previously been aware that the resident's guardian had refused for the resident to have the IV therapy. -It looked like the resident had received the IV therapy. -He/she declined to say what should have happened and said that was all new information to him/her. During an interview on 3/27/25 at 2:57 P.M. the resident's guardian said: -He/she was contacted by telephone on 3/13/25 and was asked to consent to the resident having IV fluids with vitamins. -He/she said no to the resident having IV fluids because the resident had bad veins, when he/she was in the hospital special equipment had to be used to visualize his/her veins because of his/her skin condition from having had severe burns over most of his/her body and he/she did not think it would be a good idea to try to start an IV at the facility. -Hopefully the facility had not started an IV and had not given the resident IV fluids because he/she had said no. During an interview on 3/28/25 at 2:48 P.M., the ADON said: -The DON had been responsible for IV therapy, and he/she could not answer for him/her. -He/she assumed the IV nurse would have verified consent for IV therapy. -The IV therapy should not have been given.

Based on observation, interview and record review, the facility failed to follow manufacturers recommendation and ensure priming (helps ensure that the needle is clear of air bubbles and that the insulin flows freely, guaranteeing you receive the correct dose) Novolog Insulin Flex-Pen (is a pre-filled, disposable insulin pen containing intermediate-acting U-100 isophane insulin human solution) prior to use for one sampled resident (Resident #5) out 20 sampled residents. The facility census was 84 residents. Review of the facility Injectable Medication Administration policy dated September 2018 showed Insulin Pen Devices, dial the dose as instructed by the pen manufacturer. Review of the Novolog Flex Pen manufacturer instruction pamphlet revised February 2023 showed: -Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units of insulin. -Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -Keep the needle pointing upwards, press the push-button all the way in. The dose selector until returns to 0. -Turn the dose selector to the number of units you need to inject. The pointer should line up with your dose prescribed. -Insert the needle into the resident skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Be careful only to push the button when injecting. -Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. 1. Review of Resident #5's Admission Record showed the resident admitted with following diagnoses: -Type II Diabetes Mellitus (is a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Diabetic nephropathy (damage to the nerves resulting in sensory loss in the extremities). Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/27/24, showed he/she: -Was cognitively intact. -Was able to understand others and make his/her needs known. -Required total assistant for staff for all cares and transfers. Review of the resident's Physician Order Sheet dated 3/12/25 showed: -NovoLog Flex-Pen (insulin) Subcutaneous (SQ) Solution Pen-injector 100 unit/Milliliter (ml) Inject as per sliding scale (amount of insulin to be given pending blood sugar results); if blood sugar range was 0 - 150 = 0 units of insulin; 151 - 200 = 1 unit; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units; 401 - 450 = 8 units; 451 - 1000 = 8 units, if over 450 give 8 units insulin and call provider. Give insulin subcutaneously with meals related to Type II Diabetes Mellitus with Diabetic Nephropathy. Observation on 3/25/25 at 11:36 A.M. of the resident's insulin administration showed: -Licensed Practical Nurse (LPN) C checked the resident's blood sugar which was 369. -Physician's orders showed to give NovoLog Flex-Pen Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale: --The resident's blood sugar reading was 369, following the sliding scale range from 351- 400, the resident was to be given 6 units of Novolog insulin. -LPN C obtained the resident's flex-insulin pen, cleaned the tip, placed the needle on the tip and dialed up 6 units of NovoLog insulin. He/she had gave the 6 units of insulin in the resident left lower stomach area. -LPN C did not prime flex insulin pen with 2 units of insulin prior to use and then dialing up the required amount of insulin. During interview on 3/25/25 at 11:55 A.M., LPN C said: -He/She was not aware it was required to prime the flex-insulin pen with 2 units of insulin and then waste it, prior to providing the required dose of insulin. -He/She was not aware of the facility insulin pen policy related to priming the insulin pen prior to each use. During an interview on 3/27/25 12:38 P.M., Certified Medication Technician (CMT) A said: -He/She was an insulin certified CMT. -He/She would clean the insulin pen tip with an alcohol wipe, then put the needle on, and then dial up the amount of insulin prescribed by the physician orders. -During CMT training he/she was never taught to prime the insulin pen prior to use and had not been educated by the facility on priming the insulin pen prior to use. -The facility nursing staff were responsible for completing resident blood sugar checks and insulin administration. -He/She would only assist with administration of insulin if requested by licensed nurse. During an interview on 3/28/25 at 10:25 A.M., LPN A said: -He/She would clean the tip of the pen with alcohol wipe, then place the needle. -He/She would dial up the prescribed amount of insulin ordered and give the insulin as ordered. -He/She was new to the facility and was not aware of the recommendation to prime with 2 units of insulin prior to dialing up the amount of insulin ordered. -He/She had not been educated or reviewed the facility insulin pen policy. During an interview on 3/28/25 at 10:35 A.M., LPN B said: -He/She would check the physician's orders and dosage needed prior to administration. -He/She would clean the tip of the flex pen, place the needle on the pen, then prime with 2 units of insulin prior, then dial up the prescribed insulin dose to be given. -Facility policy was to prime the insulin flex pens prior to use. -He/she was not aware any current training related to insulin pen priming. During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP) said: -Administration of insulin by a pen would include cleaning the tip of the pen, then applying the needle. Dial up 2-units to prime the pen, waste those 2-units and then dial up prescribed insulin dosage for the resident. -He/she would expect staff to follow the facility policy from pharm script insulin pen process. -He/she would expect nursing staff to prime the insulin pen with 2-units prior to use to ensure giving amount insulin prescribed without air bubbles. -Insulin certified CMT's and licensed nursing staff should have been educated on priming insulin pens during orientation and during compliance skill check off.

Based on observation, interview and record review, the facility failed to ensure physician's orders were complete and contained details for how nursing staff was to check placement of the gastronomy tube (a feeding tube surgically inserted through the abdomen and into the stomach to provide nutrition and medication delivery, or to drain stomach contents), including orders to check residual (the amount of fluid, including formula and gastric secretions, remaining in the stomach after a feeding) prior to adding any fluid to the stomach; failed to ensure handwashing was completed to prevent contamination during care and failed to update the resident's care plan to show the resident no longer received liquid nutrition through the tube for one sampled resident (Resident #14) with tube feeding flushes only out of 20 sampled residents. The facility census was 84 residents. Review of the facility Gastronomy Placement policy and procedure dated June 2020, showed the purpose was to ensure correct placement of the gastronomy tube prior to initiating a feeding, hydration and or medication. The procedure showed: -Prior to the administration of feeding, hydration and or medication through a gastronomy tube, the placement of the tube shall be verified. -This process should be completed by a nurse. -There must be a physician's order for feeding, hydration and or medication through a gastronomy tube. -The nurse should assess the resident for bowel sounds and distention. -Check the placement of the feeding tube externally to be sure it hasn't slipped out since the last feeding-observe for a change in the external length of the tube by determining whether the mark placed at the tube's exit site has moved. -To assess gastric emptying aspirate (to withdraw fluid or contents from the stomach through the tube, often to check for gastric residual volume (GRV) or to remove excess fluid or gas) and measure residual volume-hold feeding if residual volume is greater than the specified physician order. -Inform the physician if feeding or hydration is held. 1. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, which is a surgical opening into the stomach, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking and anxiety disorder. Review of the resident's revised Care Plan dated 3/3/25 showed the resident required tube feeding related to a chewing problem, depression and dysphagia. The goal was for the resident to maintain adequate nutrition and hydration status, and maintain stable weight with no signs or symptoms of malnutrition or dehydration. Interventions showed: -Check for tube placement and gastric contents/residual volume per facility protocol. And record. Hold feeding when greater than that amount. -Clean the insertion site daily as ordered, monitor for signs and symptoms of infection or skin breakdown. -Monitor, document and report to the physician all signs and symptoms of abnormal lab values, abdominal pain, distension (swollen abdomen), abnormal lung sounds, nausea/vomiting, infection, displacement of the tube. -Obtain and monitor lab work as ordered and report to physician. -Provide local care to the site as ordered and monitor. -The Registered Dietician is to evaluate nutritional status quarterly-caloric intake and make recommendations as needed. -Speech Therapist to evaluate if needed. -The resident needed assistance and supervision with tube feeding and water flushes. See physician's orders for current feeding orders. -Keep the head of the resident's bed elevated at least 30 degrees during and thirty minutes after tube feeding. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/4/25, showed the resident: -Was alert and oriented with minimum memory loss. -Needed only set up to eat and ate independently. -Had no chewing or swallowing problems. -Had a feeding tube, but took in less than 25 percent of fluids through the tube and less than 500 cubic centimeters (cc) of fluids. Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed physician's orders for: -A regular diet with regular texture and thin liquids (ordered 2/14/25). -Flush gastronomy tube with 30 milliliters (ml) of water to maintain patency every shift (ordered 12/6/24). -Check gastronomy tube placement every shift (ordered 12/6/24). -Cleanse gastronomy area daily with normal saline, pat dry, use split dressing on site every shift (ordered 12/7/24). -NOTE: The physician's orders did not show how staff should check for residual contents in the resident's stomach and when to hold the flush; and did not show how staff was to check the placement of the gastronomy tube to ensure it was in place. Review of the resident's Nursing Note dated 3/18/25, showed the physician visited the resident on 3/17/25 and wrote a new order to schedule the resident with the specialty clinic to have his/her gastronomy tube removed. Observation and interview on 3/24/25 at 3:26 P.M., showed the resident was sitting in his/her wheelchair in his/her room watching television. He/She said: -He/She ate by mouth and no longer used a feeding tube. -He/She only received water through the tube and the nurse completed the flushes daily. Observation and interview on 3/26/25 at 2:53 P.M., showed Registered Nurse (RN) A was preparing to flush the resident's gastronomy tube. He/She had already prepared a clean table and placed the distilled water and syringe to flush the tube. He/She pulled a red biohazard bag, donned a gown and a mask. Once inside the resident's room, he/she gloved. The syringe was already filled with 30 cc of water and was laying on a paper towel on the resident's vanity. The resident was sitting up in his/her wheelchair. The resident lifted his/her shirt and RN A opened the tube and unclamped the tubing. Without checking for residual, he/she inserted 30 cc of water that was already in the syringe into the tube. After the water went in he/she clamped the end of the tube. The resident said he/she was not in any pain or overfull. RN A then removed his/her gown and gloves and put them in the trash bin. RN A said: -When he/she was in nursing school they were taught to check for placement of the tube in the stomach by aspirating but here they checked for placement by looking at the marking on the tube. -There was a black mark on the resident's tube that indicated the tube was in place. -He/She was also taught to check for residual by inserting the syringe in the tube and pulling back fluid to see how much fluid was in the resident's stomach prior to adding fluids. -He/She would assume that they would check for residual to ensure there was nothing in the resident's stomach or it was not too full or to check for acidity, but at this facility he/she was told that because the resident did not take liquid nutrition, they didn't need to check for residual prior to flushing the resident's tube. During an interview on 3/27/25 at 12:38 P.M., RN A said: -The physician's orders should include specifically how they need to check for placement. -They should check for residual and it should show what they were to do when they drew back so much fluid or when to notify the physician. During an interview on 3/28/25 at 2:47 P.M. with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), the ADON said: -The physician's orders for tube feeding should show the amount of tube feeding, rate, how administered (continuous or as needed), on and off time, and type of feeding. -It should also show to check placement of the tube. The orders didn't state to verify placement-their policy showed they should observe for placement by noting the mark on the tube which indicated the tube was in place. -The order should also show to check residual and to notify the physician if the residual was greater than a certain amount. -They did expect staff to check residual before adding any contents through the tube. -If the resident no longer received nutrition through the tube, that should be updated on the resident's care plan and the care plan should be updated within a few days after the order was changed.

Based on observation, interview and record review, the facility failed to properly store respiratory nebulizer mask/mouthpiece ( medical device used to deliver medication in the form of mist) and tubing when not in use for two sampled residents (Resident #9 and #18) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Oxygen Administration policy dated June 2020 showed all oxygen tubing and masks will be changed weekly and when visibly soiled. 1. Review of Resident #9's Admission Record showed the resident had a diagnosis of Chronic Bronchitis (refers to a chronic cough with the production of phlegm resulting from inflammation in the airways). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/17/25, showed he/she: -Was moderately cognitively impaired. -Was able to understand others and make his/her needs known. Review of the resident's Physician Order Sheet (POS) dated March 2025 showed: -DuoNeb Solution 0.5-2.5 (3) Milligrams (mg)/3 milliliter (ml) (Ipratropium-Albuterol, (It works by opening airways and reducing inflammation in your lungs to help you breathe better) one vial inhale orally via Nebulizer two times a day for Shortness of breath and cough. (ordered on 2/5/25). -Change respiratory tubing, mask, bottled water, clean filter every seven days during night shift on Sundays. Date and initial the tubing when changed. (ordered on 2/9/25) -Oxygen (O2) at 2 liters (of oxygen flowing into the patient's lungs every minute). via Nasal Cannula (NC) as needed to maintain Oxygen Saturation (O2 Sat, is a measure of how much oxygen is in your blood) above 90% (ordered on 12/10/24) Review of the resident's Nursing Medication Administration Record (MAR) dated 3/1/25 to 3/31/25 showed: -DuoNeb Solution 0.5-2.5 (3) mg/3 ml give one vial inhale orally via Nebulizer two times a day. -Change respiratory tubing, mask, bottled water, clean filter every seven days during night shift and Sundays. Date and initial the tubing when changed. Observation on 3/24/25 at 9:05 A.M., of the resident's room showed: -He/She had Nebulizer tubing and mask not stored in a plastic bag. -Tubing was laid on top of the Nebulizer machine uncovered. Observation on 3/24/25 at 12:06 P.M., of the resident's room showed his/her Nebulizer face mask and tubing laid uncovered on top of his/her bedside dresser. Observation on 3/26/25 at 9:46 A.M., of the resident's room showed his/her Nebulizer face mask and tubing were not covered or stored in a plastic bag when not in use. Observation on 3/26/25 at 11:31 A.M., of the resident's room showed: -His/Her Nebulizer machine was located on top of the resident dresser. -The Nebulizer face mask and tubing remained uncovered or not stored in plastic bag when not in use. -The Nebulizer tubing was not dated when last changed. 2. Review of Resident #18's Admission Record showed, he/she had diagnoses that included: -Chronic Obstructive Pulmonary Disease (COPD, prevents airflow to the lungs, causing breathing problems). -Chronic Respiratory Failure (occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia, is a lack oxygen). Review of the resident's POS dated 12/24/24 showed: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml give 3 ml inhale orally four times a day related to COPD. -Change respiratory tubing and mask every 7 days during the night shift. Review of the resident's Plan of Care dated 12/24/24 showed he/she did not have a care plan for oxygen therapy or Nebulizer treatments provided. Review of the resident's Admission MDS dated [DATE], showed he/she: -Was cognitively intact. -He/she was able to understand others and make his/her needs known. -Required oxygen therapy while a resident at the facility. -Required assistance from staff for setup assist with personal care and treatments. Review of the resident Nursing MAR dated 3/1/25 to 3/31/25 showed: -Change respiratory tubing and mask every 7 days during the night shift. --Last changed on 3/23/25. -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml give 3 ml inhale orally four times a day. Observation on 3/24/25 at 2:28 P.M., of the resident showed: -He/She was in his/her room in bed with the O2 in place. -His/Her Nebulizer machine located on tall dresser with Nebulizer tubing and face mask not covered and did not have plastic bag to store when not in use. Observation on 3/25/25 at 9:33 A.M., of the resident showed: -He/She was sitting in his/her wheelchair with O2 in place. -The Nebulizer tubing and mouthpiece were not covered and did not have a plastic bag to store breathing supplies in when not in use. Observation on 3/26/25 at 9:01 A.M., of the resident showed: -His/Her Nebulizer tubing was uncovered on top of the dresser. -He/She was in bed with O2 in place set at rate 3-4 liter per minute. Observation on 3/26/25 at 9:15 A.M., of the resident's breathing treatment showed: -Registered Nurse (RN) A provided breathing treatment for the resident. -The resident's O2 sat was at 96% with O2 in place. (Normal range O2 sats from 95% to 100%) -He/she removed the uncovered old Nebulizer mask & tubing, he/she replaced with new Nebulizer supplies. -He/she listened to the resident's lungs and noted the left lobe was diminished (hard to hear breath sounds), and wheezes (noise make when breathing) were noted. -RN A prepped the breathing medication of Ipratropium-Albuterol Inhalation Solution place in mouthpiece setup. -Resident was able to hold the mouthpiece to provide breathing treatment. Observation on 3/26/25 at 11:15 A.M., of the resident showed his/her Nebulizer mouthpiece and tubing were uncovered on top of the dresser. 3. During an interview on 3/27/25 at 12:38 P.M., Certified Nursing Assistant (CNA) B said: -O2 and Nebulizer supplies should be stored in a plastic bag when not in use. -Nebulizer mouthpiece should be rinsed after use and placed on a paper towel barrier to dry. During an interview on 3/27/25 12:55 P.M., CNA A, said: -CNA's and nursing staff would ensure Nebulizer tubing was stored in a plastic bag when not in use. -The storage bag should be labeled with the date changed by nursing staff. During an interview on 3/28/25 10:25 A.M., Licensed Practical Nurse (LPN) A said: -Nebulizer tubing, mask/mouthpiece should be stored in a plastic bag when not in use. -The Nebulizer tubing and storage bag should be dated and have the name of the resident. -Nursing staff were responsible for ensuring Nebulizer supplies were stored in a bag and Nebulizer mouthpieces were cleaned after use. During an interview on 3/28/25 at 10:35 A.M., LPN B said: -Nebulizer tubing/mask/mouthpiece should be stored in a plastic bag when not in use. -Nursing staff or CMT's would be responsible to ensure mouthpieces were cleaned and stored in a plastic bag when not in use. During the interview on 3/28/25 at 2:48 P.M., Infection Control Preventionist (ICP) A and Assistant Director of Nursing (ADON) said: -He/she would expect the Nebulizer face mask/mouthpiece to be stored in a plastic bag when not in use. -The night nursing staff were responsible to ensure the resident had a dated and labeled storage bag for oxygen therapy supplies including Nebulizer tubing and mask. -The night nursing staff were responsible for changing out the O2 and Nebulizer tubing and mask weekly as ordered. -The Nebulizer storage bag should be labeled with the date changed and the resident's name. -All nursing staff would be responsible to ensure Nebulizer face masks and tubing were stored in a plastic bag when not in use.

Based on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #34), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 20 sampled residents. The facility census was 84 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation. -Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors. -Trauma-informed care seeks to: --Realize the widespread impact of trauma and understand paths for recovery; --Recognize the signs and symptoms of trauma in patients, families, and staff; --Integrate knowledge about trauma into policies, procedures, and practices; and --Actively avoid re-traumatization. A policy was requested, and the facility did not have a policy on PTSD/trauma informed care. 1. Review of Resident #34's Level One Pre-Admissions Screening and Resident Review (PASRR) (federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment.) dated 3/15/21 showed the resident had a diagnosis of PTSD. Review of the resident's Admission Record showed the resident was admitted to the facility with a diagnosis of PTSD. Review of the Order Summary Report (OSR) dated 2/25/25 showed the following physician's orders for Escitalopram Oxalate ((a type of antidepressant drug (used to relieve depression) that inhibits the reabsorption of serotonin (a compound present in blood platelets and serum, which constricts the blood vessels and acts as a neurotransmitter (a chemical substance that is released at the end of a nerve fiber by the arrival of a nerve impulse and, by sending it across the nerve junction, causes the transfer of the impulse to another nerve fiber, a muscle fiber, or some other structure) by neurons, so increasing the availability of serotonin as a neurotransmitter) medication give 10 milligrams (mg) by mouth in the evening for Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's care plan revised 3/5/25 showed: -PTSD was not addressed in the care plan. -The resident's triggers were not addressed. -The resident's interventions were not addressed. Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/17/25 showed: -The resident had severe cognitive impairment. -Had PTSD. During an interview on 3/25/25 at 11:26 A.M. the resident was non-interviewable. During an interview on 3/27/25 at 9:33 A.M., Certified Nurse's Assistant (CNA) C said: -If a resident had a medical diagnosis of PTSD the resident's triggers would be listed in the computer health record. -The triggers and interventions would be in the care plan. -If the resident was missing this in the care plan he/she would inform the nurse. -He/She did not know if the interventions or triggers were in the care plan. During an interview on 3/27/25 at 9:38 A.M., Licensed Practical Nurse (LPN) B said: -The MDS Coordinator was responsible for care plan development. -He/She did not know if the resident had a diagnosis of PTSD. -He/She did not know the resident's triggers or interventions. -Triggers and interventions would be written down at the nurses station. -The information of the resident's triggers and interventions should have been in the care plan. -The cause of the PTSD would have been listed in the care plan. -If PTSD was not addressed in the care plan the Director of Nursing (DON) and Assistant Director of Nursing (ADON) should have been told. During an interview on 3/28/25 at 8:46 A.M., the MDS Coordinator said: -He/She was responsible for care plan development. -The care plan should accurately reflect the resident's condition at the time it was developed along with diagnosis. -He/She just found out that a resident with a diagnosis of PTSD needed a care plan for that diagnosis. -The care plan should have had the triggers and the interventions. -The staff should have been made aware of the resident's triggers and interventions. -The care plan did not address a PTSD diagnosis. -No one audited the care plans as far as he/she knew. During an interview on 3/28/25 at 9:13 A.M., Certified Medication Technician (CMT) A said: -The resident had PTSD. -He/She was unsure what his/her triggers were, or what his/her interventions were. -The resident had not had any behaviors. -He/She would look at the care plan for the triggers and interventions. During an interview on 3/28/25 at 2:48 P.M., the ADON said: -The MDS Coordinator was responsible for the care plans. -It was his/her expectation that if the resident had a diagnosis of PTSD, it would be addressed in the care plan to include triggers and interventions. -The MDS Coordinator was responsible for the information for the PTSD care plan. -The care plan should have addressed the triggers and the interventions.

Based on interview and record review, the facility failed to ensure residents with a diagnosis of dementia had a personalized care plan to ensure services to promote the resident's highest level of functioning and psychosocial needs for one sampled resident (Resident #22) out of 20 sampled residents. The facility census was 84 residents. A policy was requested on dementia care planning and the facility failed to provide one. 1. Review of Resident #22's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) in other diseases classified elsewhere, moderate, with mood disturbance. -Unspecified psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning) not due to a substance or know physiological condition. -Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). - Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) Review of the resident's undated care plan dated showed: -Dementia was not addressed in the care plan. -Alzheimer's disease was not addressed in the care plan. -The resident had the potential to be verbally/physically aggressive, at risk for harm to self and others due to impaired judgment, impaired cognition, and decreased safety awareness. -The resident would yell at staff and peers, cuss at staff, refuse his/her medications, and could be sexually inappropriate with staff. --Staff were directed to monitor his/her behaviors and to document observed behaviors and attempted interventions. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/15/25 showed he/she: -Was severely cognitively impaired. -Required maximal staff assistance for bed mobility, transfers, walking, locomotion, dressing, bathing, toileting, and personal hygiene. -Had diagnoses of Dementia and Alzheimer's Disease. -Had psychosis. -Had no behaviors during the look-back period. -Was taking an antipsychotic medication (used to treat mental health conditions characterized by psychosis, such as schizophrenia and bipolar disorder). -Was taking an antidepressant medication (used to treat depression and other mental illnesses) . During an interview on 3/28/24 at 8:46 A.M., the MDS Coordinator said he/she did not know that a resident needed to have a care plan for dementia/Alzheimer's when the resident had those diagnoses. During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said: -Resident's that had diagnoses of dementia/Alzheimer's needed to have a care plan for those diagnoses. -It was his/her expectation that the nurses would have informed the MDS Coordinator when things needed to be added to the care plan and this included required items. -The Director of Nursing (DON) signed off on all the care plans. -The DON was ultimately responsible for all care plans.

Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 84 residents. Review of the facility's Storage of Controlled Substances policy revised on September 2018 showed: -Medications classified by the Drug Enforcement Administration (DEA) as controlled substances were subjected to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. -The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintained the facility's compliance with federal and state laws and regulations in the handling of controlled substances. -At each shift change, or when keys were transferred, a physical inventory of all controlled substances was conducted by two licensed personnel and was documented. -Current controlled substances accountability records were kept in the Medication Administration Record (MAR) or a designated book. 1. Review of the facility's Controlled Drug Count sheet dated 1/24/25 through 2/1/25 for the 400 hall medication cart showed: -Seven out of 46 opportunities were not signed by either the on-coming or off-going staff. -Three out of 23 opportunities where the number of narcotic packages were not documented on the sheet. Review of the facility's Controlled Drug Count sheet dated 2/2/25 through 2/10/25 for the 400 hall medication cart showed: -Five out of 46 opportunities were not signed by either the on-coming or off-going staff. -One out of 46 opportunities were not signed by both the on-coming or off-going staff. -One out of 23 opportunities where the number of narcotic packages were not documented on the sheet. Review of the facility's Controlled Drug Count sheet dated 2/11/25 through 2/22/25 for the 400 hall medication cart showed: -One out of 46 opportunities were not signed by either the on-coming or off-going staff. -Four out of 23 opportunities where the number of narcotic packages were not documented on the sheet. Review of the facility's Controlled Drug Count sheet dated 2/22/25 through 3/2/25 for the 400 hall medication cart showed: -One out of 46 opportunities were not signed by either the on-coming or off-going staff. -Two out of 23 opportunities where the number of narcotic packages were not documented on the sheet. Review of the facility's Controlled Drug Count sheet dated 3/3/25 through 3/13/25 for the 400 hall medication cart showed: -Seven out of 46 opportunities were not signed by either the on-coming or off-going staff. -Three out of 23 opportunities where the number of narcotic packages were not documented on the sheet. Review of the facility's Controlled Drug Count sheet dated 3/21/25 through 3/26/25 for the 400 hall medication cart showed: -One out of 46 opportunities were not signed by either the on-coming or off-going staff. -One out of 23 opportunities where the date was not documented for the count. -Two out of 23 opportunities where the number of narcotic packages were not documented on the sheet. During an interview on 3/26/25 at 11:25 A.M., Certified Medication Technician (CMT) A said: -The narcotics were counted at the beginning and end of each shift by the on-coming nurse and off-going nurse or CMT. -Both nurses and/or CMT signed the count sheet when the count has been completed to verify the count was correct. -The number of packages or narcotics was to be recorded on the sheet. -The date would be listed for each narcotic count. -If the narcotic count was not signed by both the CMT and nurse then the count was not done. During an interview on 3/26/25 at 11:30 A.M., Licensed Practical Nurse (LPN) B said: -The narcotics were counted at the beginning and end of each shift by the on-coming nurse and off-going nurse or CMT. -Both nurses and/or CMT signed the count sheet when the count had been completed to verify the count was correct. -The number of packages or narcotics was to be recorded on the sheet. -The date would be listed for each narcotic count. -If the narcotic count was not signed by both the CMT and nurse then the count was not done. During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said: -The on-coming and off-going shifts should count the narcotics and sign the narcotic book each shift. -The number of packages or narcotics was to be recorded in the narcotic book. -The narcotic count should be dated. -The unit managers were to have audited the narcotic count books to ensure that counts were done correctly and signed by both the on-coming and off-going shifts.

2. Review of Resident #181's Face Sheet showed the resident was admitted on [DATE], with diagnoses including emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage), malnutrition (a condition resulting from deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients, leading to measurable adverse effects on body composition, function, and clinical outcomes), iron deficiency, open wound to the left foot, malaise (a general feeling of discomfort, illness, or uneasiness) and Chronic Obstructive Respiratory Disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing). The Face Sheet did not show a psychological diagnosis, dementia or mental health diagnosis. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/21/25, showed it had not been completed yet. Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed a physician's order for: -Olanzapine Oral Tablet 2.5 milligrams (mg), give 1 tablet by mouth two times a day for 30 days for confusion (ordered 3/22/25). -The POS did not show a diagnosis associated with the symptom of confusion. Review of the resident's admission Care Plan dated 3/22/25, showed the resident had no interventions showing he/she had a mental health disorder or mental health need. It did not show he/she had a psychological diagnosis that required psychotropic medication and did not show the resident had confusion that resulted in behaviors that would require a psychotropic medication. There were no interventions for monitoring Olanzapine. Review of the resident's Drug Regimen Review dated 3/22/25 showed: -No recommendations. -There was no indication that there was a rationale needed for Olanzapine. Review of the resident's Hospital Discharge record dated 3/22/25, showed: -The resident was homeless and was admitted due to an untreated foot wound. -While in the hospital, the resident received a partial foot amputation and was placed on antibiotics for a wound infection. -The resident had confusion but did not show a psychiatric condition, mental health condition or behaviors that indicated mental health issues/concerns warranting a psychiatric medication. -The psychiatric assessment in the hospital record showed resident was inattentive, perceived auditory hallucinations, mood was anxious, affect was flat, speech was rapid and pressured, behavior was cooperative, cognition and memory were impaired, and judgement was impulsive. -The record showed the resident received Olanzapine for confusion without an associated diagnosis. Review of the resident's Nursing assessment dated [DATE], showed there were sections to describe the resident's mental health needs, behavioral concerns, psychiatric recommendations and the entries showed the resident had no behavioral health concerns, mental health needs or psychiatric recommendations for medication or care/therapy. Review of the resident's Medical Record showed there were no physician's notes or assessment nor was there a psychiatric assessment. Observation and interview on 3/24/25 at 10:14 A.M., showed the resident was sitting on his/her bed dressed for the weather. Facility staff was in the resident's room assisting him/her. The resident was alert and oriented and was tearful about a pet he/she had that was no longer with him/her. Staff was consoling the resident and trying to divert his/her attention. Certified Nursing Assistant (CNA) D said the resident just came into the facility on Friday and had been tearful because he/she did not have his/her pet and was new to the facility. He/She did not know if or why the resident was on Olanzapine. Observation and interview on 3/24/25 at 2:49 P.M., showed the resident was sitting in his/her wheelchair in the lobby congregational area talking with other residents and staff. The resident spoke about receiving a television and was no longer tearful nor did he/she talk about his/her pet. No adverse behaviors were noted. Observation and interview on 3/25/25 at 10:00 A.M., showed the resident was dressed for the weather and was sitting in his/her wheelchair watching television. He/She said he/she was homeless before entering the hospital and received the amputation of part of his/her foot and medications while in the hospital. He/She was not sure of all of the medications he/she was prescribed. He/She did not say he/she had any mental health issues or was being treated for a mental health diagnosis. The resident was pleasant. No issues were noted. During an interview on 3/27/25 at 12:48 P.M., Registered Nurse (RN) A said: -Usually when a resident was prescribed an antipsychotic medication, there was a corresponding mental health diagnosis for the script. -He/She had not seen residents being prescribed an antipsychotic for a diagnosis of confusion. -When a resident entered from the hospital, if they had a prescription for the antipsychotic, they would give the medication according to the physician's orders. -Usually the physician came in to review the medications and would determine any changes to the medication that were needed or they would notify the physician of the medications so he/she could authorize the medications to be given and make any changes needed. During a telephone interview on 3/27/25 at 1:07 P.M., Pharmacist A said: -Olanzapine was an antipsychotic medication used to treat schizophrenia (a chronic mental health condition characterized by persistent disruptions in thought processes, perceptions, emotions, and social interactions.), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), psychosis (a mental health condition characterized by a loss of touch with reality), delirium (a temporary state of mental confusion and disorientation that can cause significant changes in a person's behavior, thinking, and perception) and treatment of resistant depression (occurs when a person's depression symptoms persist despite adequate treatment with multiple antidepressants and/or other therapies). -Confusion was not a diagnosis. It was a symptom and it was a very broad term that would need to be more specific to the behavior exhibited to warrant the medication. -The physician would need to clarify the use of this medication prior to ordering it for the resident. -He had seen Olanzapine prescribed for confusion but this was not common. There would need to be a diagnosis, a more descriptive and specific use for the medication. During an interview on 3/28/25 at 2:47 P.M., with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), The ICP said: -With a resident that was admitted from the hospital with medication orders, the first person to review the orders was the admitting nurse. -They call the physician or Nurse Practitioner (NP) to authorize and verify the orders the same day the resident was admitted and the physician or NP would authorize the orders or make any changes necessary to the orders. -The same day or following day the clinical manager would review the resident's admission orders and medications and they would notify the physician of anything that they think was [NAME] or needed to be reviewed again by the physician. -Psychotropic medications should not be prescribed for a resident without an adequate clinical diagnosis for use. -Olanzapine was considered a psychotropic medication and was used for mood disorders, psychosis, and other mental health diagnoses. -Cognition on its own was not an adequate diagnosis for Olanzapine, but if there was another diagnosis to go along with it then it could be included on the order. -He/She was not aware the resident was on Olanzapine for cognition. The resident did have a mental health diagnosis but he/she was not sure what his/her diagnosis was. Based on observation, interview and record review, the facility failed to ensure a drug regimen review (DRR)was completed monthly for one sampled resident (Resident #22), that was on psychotropic medications; failed to complete a gradual dose reduction when needed since the drug regimen review was not performed; and failed to ensure that the resident's psychotropic medication was ordered and used to treat a psychological condition for one sampled resident (Resident #181) out of 20 sampled residents. The facility census was 84 residents. Review of facility policy entitle Drug Regimen Review revised June 2020 showed: -The pharmacist would review each resident's medication regimen at least once a month to identify irregularities and to identify irregularities, clinically significant risks and/or actual or potential adverse consequences which might have resulted from or be associated with medications. -It might have been necessary for the pharmacist to have conducted the DRR more frequently. -The requirement for the DRR applied to all residents (whether short or long-stay) without exception. -DRR's may be needed for residents who experienced and acute change of condition. -The pharmacist would report any irregularities to the attending physician to identify clinically significant risks and/or potential adverse consequences which might have resulted from or be associated with medications. -The Director of Nursing (DON) or designee would have reviewed any irregularities as identified. Review of undated facility policy entitled Guidelines for Psychotherapeutic Medications showed: -Residents with a mental health diagnosis could be admitted on psychotropic (drugs which affect psychic function, behavior, or experience) medications were not subject to dose guidelines; however the lowest maintenance dose would be given. -Residents unless clinically contraindicated, had a gradual dose reduction of the antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis(when people lose some contact with reality) medication attempted twice in one year. -If the dose reduction resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the Gradual Dose Reduction (GDR), or a return to previous dose was necessary, it was not necessary to have continued the dose reduction attempts. The physician would document this justification in the physician progress notes. 1. Review of Resident #22's admission Record showed the resident admitted to the facility on [DATE] with the following diagnosis: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's order summary report dated 1/13/25 showed the resident was taking the following medications: -Sertraline (an antidepressant that belongs to a group of medicines called selective serotonin reuptake inhibitors (stop or delay the body from reabsorbing a substance called serotonin, which leaves more of it available for the body to use raising serotonin levels can help regulate mood, appetite, digestion, sleep, and many other bodily functions) 50 milligrams (mg) one time a day for depression order dated 12/15/2024 -Olanzapine (an antipsychotic that may be used to treat schizophrenia (serious mental health condition that affects how people think, feel and behave) or bipolar disorder (a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration) 2.5 mg two times a day take after lunch and at bedtime for psychosis order dated 12/15/2024. Review of the residents undated care plan showed: -Antipsychotic medications were not addressed in the care plan. -Monthly drug regimen reviews were not addressed in the care plan. -Gradual dose reductions were not addressed in the care plan. Review of the resident's progress notes dated April 2024 to March 2025 showed: -No gradual dose reductions had been done. -No documentation of why a gradual dose reduction had not been done for the past year. Review of the resident's monthly drug regimen reviews showed: -There were no drug regimen reviews dated April 2024, June 2024, July 2024, September 2024, October 2024, November 2024, December 2024, January 2025, and February 2025. -The monthly drug regimen reviews dated March 2024, May 2024, and August 2025 had no recommendations for psychotropic medications gradual dose reductions. -There were no gradual dose reductions requested from the pharmacist. During an interview on 3/26/25 at 1:52 P.M., the Regional Nurse Consultant said: -Pharmacy had not been coming to the building for the past two months. -Monthly drug regimen reviews and gradual dose reductions were not being performed since the new company took over operations in December 2024. -It was the DON's responsibility to ensure the monthly drug regimen reviews and gradual dose reductions were being performed, or the rational as to why no gradual dose reduction was documented in the resident's electronic medical record. -Resident #22 did not have any drug regimen reviews done. -Resident #22 did not have any gradual dose reduction recommendations because the drug regimen reviews had not been done. -The drug regimen reviews and the gradual dose reductions should have been done for Resident #22. During an interview on 3/27/25 at 9:02 A.M., Licensed Practical Nurse (LPN) B said: -He/She did not follow up on the monthly drug regimen reviews or gradual dose reductions. -The DON handled the monthly drug regimen reviews and gradual dose reductions. During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said: -Drug regimen reviews should be done monthly to include psychotropic medications. -Any recommendations from the pharmacist would be sent to the physician to be addressed. -The monthly drug regimen reviews came to the Administrator and DON, and then were printed. -The monthly drug regimen review was where the Pharmacist addressed the gradual dose reductions for residents that required them. -If a resident had not received a monthly drug regimen review for two months, the facility should have reached out to the Pharmacist. -He/She would have expected the DON to have done this. -Residents on psychotropic medications needed to have a gradual dose reduction done at least twice in the first year unless there was a clinical rational documented in the residents' medical record. -The facility should have been able to show why a gradual dose reduction was not being performed for the resident and the past year of monthly drug regimen reviews. -Resident #22 should have had drug regimen reviews and gradual dose reductions done or documentation indicating why a gradual dose reeducation was not recommended.

Based on observation, interview and record review, the facility failed to label medications with resident's name on the medication container when the box was first opened. The facility census was 84 residents. Review of the facility Medication Storage policy dated September 2018 showed: -The provider pharmacy dispensed medications in containers that met regulatory requirements, included standards set forth by the United States Pharmacopeia (USP). -Medication storage conditions were monitored on a regular basis by the consultant pharmacist and corrective actions were taken if a problem was identified. -The policy did not show where the individual medication container needed to be labeled when the box was labeled. 1. Observation on 3/26/25 at 10:50 A.M. of the 400/500 hall Certified Medication Technician (CMT) medication cart showed: -One Ellipta inhaler (for Chronic Obstructive Pulmonary Disease (COPD process that decreases the ability of the lungs to perform ventilation), which includes chronic bronchitis (an inflammation of the lining of your bronchial tubes) and emphysema (inner walls of the lungs' air sacs called alveoli are damaged, causing them to eventually rupture and creates one larger air space instead of many small ones and reduces the surface area available for gas exchange) the box was opened and the medication container was not labeled with the residents name. -One Trelegy inhaler (prescription medicine used long term to treat COPD, including chronic bronchitis, emphysema) the box was opened, and the medication container was not labeled with the resident's name. 2. Observation on 3/26/25 at 11:04 A.M. of the 100/200 hall CMT medication cart showed two Over the Counter (OTC) Nasal allergy medication with box open and no resident names on the medication container. 3. During an interview on 3/26/25 at 11:25 A.M., CMT A said: -He/She did not know that the residents name needed to be on the actual medication container when the medication came in a box and the box was labeled. -He/She was not told that the resident's name needed to be on the medication container. During an interview on 3/26/25 at 11:30 A.M., Licensed Practical Nurse (LPN) B said: -He/She did not know that the residents name needed to be on the medication container when the medication came from pharmacy in a box. -No one had ever told him/her that the name of the resident needed to be on the actual medication when the medication came from pharmacy in a box and was labeled. During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said: -Medications should be labeled with residents name on the actual medication container when the medication came from pharmacy in a box that was labeled. -Unit mangers were responsible for auditing and checking the medication carts. -The Director of Nursing was responsible to ensure the staff were educated on these things along with himself/herself.

Based on observation, interview and record review, the facility failed to serve pureed (food that has been processed into a smooth, uniform, and pudding-like texture, often by blending, mashing, or straining) food items in the correct texture. This deficient practice had the potential to affect all residents who received pureed diets. The facility census was 84 residents. Review of the Facility Instructions for pureed food items dated 2025, showed: -Any liquid specified in the recipe is a suggested amount of liquid if needed. -Some recipe items will require no liquid added to achieve the desired consistency. -If the product needs thinning, gradually add an appropriate amount of liquid, not water, to achieve a smooth, pudding or soft mashed potato consistency. -If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 1. Observation and interview on 3/25/25 at 12:46 P.M., showed the test tray contained the pureed hamburger, pureed rice and pureed cream of corn. All textures were smooth and with a potato consistency except the pureed rice which was not pureed to a smooth texture and the rice kernels were visible in the puree. [NAME] A said: -He/She had tasted all of the the pureed food items prior to serving. -Could see the rice in the puree. Observation on 3/26/25 at 11:03 A.M., showed [NAME] A was preparing the pureed food items-beans, greens and cornbread. The Dietary Manager and Registered Dietician were both observing. [NAME] A prepared all pureed items according to the recipes. When blending the greens, [NAME] A added thickener and continued to blend. Once he/she completed blending he/she scooped the greens into a serving pan. Upon tasting the pureed greens, they were not smooth and there were small pieces of onion and stalk that needed more grinding. When completing the cornbread puree, [NAME] A added milk as needed to thin it. When done, [NAME] A poured the pureed cornbread into a serving pan. The Registered Dietician tasted the puree and said it tasted gritty. [NAME] A put the cornbread back into the blender and ground it to a smoother consistency. The taste of the corn bread was then smooth like mashed potatoes. [NAME] A also ground the greens to a smooth consistency prior to putting on the steam table. During an interview on 3/26/25 at 12:59 P.M., the Dietary Manager said: -They could use other vegetables because greens were difficult to blend as was rice. -All of the cooks were experienced and knowledgeable on how to prepare puree foods. -He/She ordered a new blade for the blender. -The consistency of the pureed foods should be mashed potato smooth, not chunky. -He/She didn't see the pureed rice that was served yesterday, but was aware it was not a smooth consistency. -The correct texture and consistency should be served to residents who required a pureed diet.

Based on observation, interview and record review the facility failed to ensure infection control handwashing practice was followed to prevent cross contamination during a gastronomy (which is a surgical opening into the stomach) water flush for one sampled resident (Resident #14); and failed to ensure infection control practices performed hand hygiene between each glove change during care of indwelling Foley Catheter (a urinary bladder catheter inserted through urethra); and failed to ensure to place Personal Protective Equipment (PPE, refers to protective clothing for the eyes, head, ears, hands, respiratory system, body, and feet. To be worn to minimize exposure to a variety of hazards) while providing direct contact care for one sampled resident (Resident #5) who required Enhanced Barrier Precaution (EBP, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug-resistant organism status) due to the indwelling Foley catheter and was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Hand Hygiene Policy dated June 2020 showed: -The use of gloves did not replace hand hygiene. -Hands should be washed after removal of personal protective equipment (PPE) and before moving to another resident in the same room or before exiting the room. Review of the facility Standards and Enhanced Precaution Policy dated 4/1/24 showed: -EBP should be used for residents when performing the following high-contact resident care activities to include dressing, personal care and providing urinary catheter care. Review of the facility Indwelling Foley Catheter Care Policy dated June 2020 showed: -Wash hands and don (put on) gloves prior to handling catheter. -Cleanse the perineum and urinary meatus with soap and water, cleansing wipe or a perineal rinse as part of care. -Cleanse the outside of the catheter wiping away from the meatus. -Remove gloves and wash hands. -Clean the drainage spout tip with alcohol wipe before and after when emptying the drainage bag. 1. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/4/25, showed the resident: -Was alert and oriented with minimum memory loss. -Needed only set up for eating, transfers and toileting; minimal assistance to substantial assistance for bathing, dressing, transfers, and mobility. -Used a wheelchair for mobility. -Had a feeding tube but took in less than 25 percent of fluids through the tube and less than 500 cubic centimeters (cc) of fluids. Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed physician's orders to: -Flush gastronomy tube with 30 milliliters (ml) of water to maintain patency every shift (ordered 12/6/24). -Check peg tube placement every shift (ordered 12/6/24). -Cleanse gastronomy area daily with normal saline, pat dry, use split dressing on site every shift (ordered 12/7/24). Observation and interview on 3/26/25 at 2:53 P.M., showed: -Registered Nurse (RN) A was preparing to flush the resident's gastronomy tube. -He/She had already prepared a clean table and placed the distilled water and syringe to flush the tube. -He/She pulled a red biohazard bag, donned a gown and a mask. -Once inside the resident's room, without washing or sanitizing his/her hands, he/she gloved. -Once RN A completed the resident's flush, he/she removed his/her gown and gloves and put them in the trash bin. -RN A collected the trash and without washing or sanitizing his/her hands, left the resident's room. During an interview on 3/27/25 at 12:38 P.M., RN A said he/she should have washed or sanitized his/her hands before and after completing the resident's care or procedure, before putting on gloves and after completing resident care. During the interview on 3/28/25 at 12:06 P.M., Infection Control Preventionist (ICP) A and the Assistant Director of Nursing (ADON) said he/she would expect care staff to use hand sanitizer or wash hands, upon entering the resident's room, before and after resident care, going from a dirty to clean process and between each glove change. 33409 2. Review of Resident #5's Admission Record showed the resident admitted with following diagnoses: -Benign prostatic hyperplasia (BPH, is a condition in which the prostate gland grows larger than normal) with lower urinary tract symptoms. -Chronic Urinary Retention (bladder does not empty completely or does not empty at all). -History of UTI. Review of the resident's Admission MDS dated [DATE], showed he/she: -Was cognitively intact. -Was able to understand others and make his/her needs known. -Required total assistant from staff for all cares and transfers. -Had a UTI in the last 30 days of admission. -admitted with an indwelling Foley catheter. Review of the resident's POS dated December 2024 showed: -Indwelling Foley Catheter Care and Monitor every shift and as needed (Ordered 12/24/24). -Indwelling Foley Catheter 16 French (Fr) 10 ml balloon. Indwelling Catheter Indication for Chronic Urinary Retention (ordered on 12/24/25). -EBP: staff to wear a clean gown and gloves while performing high contact resident care activities to include personal hygiene cares and caring for indwelling devices, Foley catheter. (ordered 12/26/24) Review of the resident's Care Plan dated 1/17/24 showed: -The resident had a Foley catheter. -Monitor for signs and systems of a urinary infection. Review of the resident's POS dated March 2025 showed: -Indwelling Foley Catheter 16 Fr, 5 ml balloon, Indwelling Catheter Indication for wound healing and Urinary Retention (ordered on 3/7/25). -Urinalysis (UA, check urine sample for infections) due to urethra meatus (opening were urine exits the body) pain (ordered on 3/17/25). Review of the resident's Medication Administration Record (MAR) dated March 2025 showed Ampicillin Oral Capsule 500 milligram (mg) (Antibiotic) give one tablet by mouth three times a day for UTI ordered on 3/10/25 and last dose given on 3/17/25. Observation on 3/24/25 at 9:44 A.M., of the resident showed: -Was on EBP and had an isolation cart outside his/her room. -The resident had a Foley catheter located on side of the bed in a privacy bag. Observation on 3/25/25 at 11:58 A.M., of the resident showed his/her catheter bag was under his/her wheelchair in a privacy bag. Had clear yellow urine in tubing. Observation on 3/26/25 at 9:50 A.M., of the resident's catheter care showed: -Had EBP signage posted outside of his/her room and had a isolation cart outside room with PPE supplies. -Certified Nursing Assistant (CNA) A, entered the resident room to provide the resident's catheter care. -CNA A did not put on a gown or mask prior to entering the resident's room and he/she did not wear a PPE of gown or mask during the resident's direct high-contact Foley catheter care process. -He/she washed his/her hands prior to donning clean gloves. -CNA A with clean gloved hands, assisted the resident in removing under garments for care. -CNA A started to clean the resident's urethral meatus with alcohol wipes, resident voiced did sting while cleaning the area. -CNA A continued to use the alcohol wipe to clean stuck on substance around that area. -CNA A removed his/her gloves, did not wash or sanitize his/her hands prior to donning clean gloves. -He/she cleansed the urethral meatus using a wash cloth with soap and water. -CNA A removed his/her gloves and did not wash or sanitize his/her hands prior to donning clean gloves. -He/she then used alcohol wipe and cleaned the drainage tubing in a downward motion. -He/she completed catheter care removed his/her gloves and exited the resident room. -When he/she entered the hallway, CNA A performed hand hygiene using the wall hand sanitizer. During an interview on 3/26/25 at 10:15 A.M. CNA A, said: -He/she was not aware of any Foley catheter care issue during resident care process. -He/she did not remember if he/she was observed performing Foley catheter care and going over EBP during the skills check off during orientation. During an interview on 3/27/25 at 12:38 P.M., CNA B said: -He/She had training related to the facility policy on EBP. -During high-contact care (Foley catheter care) for a resident on EBP, he/she was required to wear PPE to include gloves, gown, face shield or mask if potential splatter. -The resident was placed on EBP related to his/her catheter and wounds. -When providing Foley catheter care staff would be required to wear gown, mask and gloves. -Alcohol wipes should only be used to clean catheter tubing not on any open skin area. -He/She would wash or sanitize his/her hands before and after care, from a dirty to clean process and between each glove change. During an interview on 3/27/25 at 12:55 P.M., CNA A, said: -When working with resident's on EBP, staff should wear gown and gloves for any direct high-contact resident care. -He/She did put on a gown prior or during catheter care. -Staff should wash or sanitize their hands before and after care and between each glove change. -Should only clean Foley catheter insertion site with soap and water or personal hygiene wipes. -He/She used alcohol wipes to try and get the substance that was on and around catheter insertion site. During an interview on 3/28/25 10:25 A.M., Licensed Practical Nurse (LPN) A said: -He/she would expect nursing staff to provide Foley catheter care as ordered. -CNA's would be responsible for daily care of the Foley catheter site while providing incontinence care. -Resident's with a Foley catheter would be on EBP and during direct contact resident care, staff would be required to wear PPE to include gown and gloves. -Staff should clean the Foley catheter insertion site area with personal care wipes, or with soap and water. -Staff should not use alcohol wipes to clean around the Foley catheter insertion site/opening. -Use the alcohol wipe or personal care wipe to clean the Foley catheter drainage tubing. During an interview on 3/28/25 at 10:35 A.M., LPN B said: -CNA's would be responsible for daily care of the Foley catheter site during peri care. -Resident's with Foley catheters would be on EBP and direct care contact with the resident would require PPE of gown and gloves. -He/She has not had recent training related to EBP. During the interview on 3/28/25 at 12:06 P.M., Infection Control Preventionist (ICP) A and the Assistant Director of Nursing (ADON) said: -He/She would expect care staff to use hand sanitizer or wash their hands before and after resident care, from a dirty to clean process and between each glove change. -Hand Hygiene skills competency would be included in the facility training calendar for the year and ICP and the ADON would provide hand hygiene training if they saw a trend of infection on a hallway related to resident care. -Resident #5 was placed on EBP, he/she was at risk for infection due to having an indwelling device in place, such as his/her Foley catheter. -He/she would expect all care staff to don PPE to include gown and gloves while providing direct high-contact care for a resident on EBP, which would include Foley catheter care. -He/She would expect care staff to clean the Foley catheter insertion site with with soap and water. -Should not use alcohol wipe to clean around Foley catheter insertion site/opening.

Based on observation and interview, the facility failed to maintain the floors of the following rooms in a clean condition in resident rooms 204, 105, 101, 304, 310, 514, 504, 501, 411, 406, and 407. This practice potentially affected 12 residents. The facility census was 68 residents. 1. Observation on 12/2/24 with the Housekeeping Supervisor showed: - At 12:59 P.M., there was a buildup of cobwebs along the floor and wall area next to the refrigerator in resident room [ROOM NUMBER]. - At 1:01 P.M., there was a buildup of cobwebs in the corners of room [ROOM NUMBER]. - At 1:04 P.M., there was a buildup of dust and debris along the wall in resident room [ROOM NUMBER]. - At 1:05 P.M., there was a buildup of hair and dust along the wall in resident room [ROOM NUMBER]. - At 1:08 P.M., there was a buildup of dust under the bed in resident room [ROOM NUMBER]. - At 1:10 P.M., there was a buildup of dust and cobwebs behind the bed and long the walls at the floor level in resident room [ROOM NUMBER]. - At 1:15 P.M., there was a buildup of dust cobwebs behind the dresser in resident room [ROOM NUMBER]. - At 1:17 P.M., there were dead insects under the bed and hairs on the floor in resident room [ROOM NUMBER]. - At 1:19 P.M., there was a buildup of cobwebs behind the dresser in resident room [ROOM NUMBER]. During an interview on 12/2/24 at 1:20 P.M., the Housekeeping Supervisor said the housekeepers are not pulling furniture out from the walls so they can get behind those areas. During an interview on 12/2/24 at 1:22 P.M., Housekeeper A said he/she cleaned the rooms daily, but sometimes it was difficult to pull the furniture out from the walls. MO00245581.

Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt (a device that helps prevent falls) during transfers and ambulation for one sampled resident (Resident #1) out of eight sampled residents. CNA A assisted the resident into the shower room to provide incontinence care. CNA A assisted the resident into a standing position without the use of a gait belt. The resident slid to floor, which resulted in the resident being impaled by his/her wheelchair break lever, causing a penetrating wound (trauma that occurs when a foreign object enters the body) and laceration (a wound produced by the tearing of skin and underlying soft tissue) and was hospitalized for three days. The facility census was 65 residents. The Administrator was notified on 10/1/24 at 12:47 P.M., of the Immediate Jeopardy (IJ) which began on 9/13/24. The IJ was removed on 10/1/24 at 4:24 P.M., as confirmed by surveyor onsite verification. Review of the facility's undated Transfer Belts/Gait Belts policy showed: -To promote safety in transferring and ambulating residents, a gait belt is utilized when deemed appropriate by nursing staff or therapy staff. -All Certified Nursing Assistants (CNA) and licensed nursing staff engaged in the lifting and transferring of residents will use gait belts. -The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and staff. -After orientation to facility policy and training in the use of gait belts, staff who fail to use them or to use them appropriately, should be considered subject to disciplinary measures. - GAIT BELTS ARE MANDATORY. -CNAs will routinely have a gait belt on their person. -Report any changes in a resident's performance during transfers to the charge nurse. Review of the facility's undated Fall Prevention policy showed: -Fall prevention interventions included use of a gait belt. Review of the facility's undated Dress Code Policy showed: -All CNAs are required to wear a gait belt at all times. Review of the facility's Inservice Attendance titled Safe Resident Handling - Gait Belt, dated 9/10/24, showed CNA A signed the sheet indicating he/she had attended the inservice education. 1. Review of Resident #1's Face Sheet, dated 3/4/24, showed the following diagnoses: -Stroke. -Dementia. -Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move one side of the body) following stroke affecting right dominant side. -Aphasia (an impairment of language, affecting the production or comprehension of speech and the ability to read or write). -Unsteadiness on his/her feet. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 8/9/24, showed: -He/she had moderately impaired cognitive skills. -He/she had unclear speech. -He/she was sometimes understood by others. -He/she usually understood others. -He/she needed substantial/maximum assistance for sitting to standing. -He/she used a wheelchair for mobility. -He/she needed partial to moderate assistance for toileting, hygiene, and lower body dressing. -He/she had one non-injury fall since the previous MDS (approximately 90 days). Review of the resident's care plan, reviewed on 8/7/24, showed: -He/she had impaired physical mobility and was at risk for falls related to right sided weakness due to a stroke. -Staff were to observe him/her for unsteady/unsafe transfer or walking and provide stand by or balance support as needed. -He/she had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of his/her right hand. -He/she needed one staff persons assistance at times. -He/she was incontinent of bladder and staff were to change his/her incontinence brief. Review of the resident's Nurse's Notes, dated 9/13/24, showed Licensed Practical Nurse (LPN) A documented: -At 8:15 A.M. the resident was in the shower room and a CNA was calling for help. -LPN A went into the shower room and the CNA was holding the resident's wheelchair sideways to the resident, the resident was lying on the floor on his/her side. -LPN A saw that the wheelchair lock was imbedded under the resident's skin up and to the left of his/her rectum. -911 was called, the wheelchair was held in place by two staff members to keep the object under the resident's skin and the resident still until Emergency Medical Services (EMS) arrived. -EMS staff instructed LPN A to hold the resident's wheelchair in place while EMS took the resident's wheelchair apart with tools to get him/her to the hospital. -The wheelchair brake slid out of the resident's rectum leaving a large baseball size opening with exposed yellow and pink tissue three inches from the left of the resident's rectum. -EMS then transported the resident to the hospital. -The resident was alert during the entire incident. Review of CNA A's Witness Statement, dated 9/13/24, showed: -CNA A was toileting the resident and taped one side of the resident's brief, started to go to the other side and saw him/her sliding. -CNA A let the resident down to the floor. -He/she made sure the resident was safe and got help. Review of LPN A's Witness Statement, dated 9/13/24, showed: --CNA A had walked to the shower room door, opened it and said he/she needed help now. -When LPN A walked into the shower room the resident was lying on the floor and no gait belt was on the resident or in the surrounding area. -The resident's wheelchair was tipped sideways and had to be held due to the angle and the wheelchair lock having impaled the resident's rectum. -From LPN A's angle on the ground holding the resident's wheelchair while waiting for EMS, the resident's rectum had a one to two inch tear going up his/her back. Review of Certified Medication Technician (CMT) A's Witness Statement, dated 9/13/24, showed: -At approximately 8:15 A.M. CMT A heard LPN A yelling out his/her name from the 500-hall shower room. -Upon entering the shower room, he/she saw the resident on the floor and his/her wheelchair was lying behind him/her on its side; CNA A was with the resident. -CMT A stayed with the resident until LPN A called 911 ensuring the resident did not get up due to the injury. Review of the resident's undated facility investigation Re-enactment Summary of events as told by CNA A of the resident's fall on 9/13/24 showed: -CNA A assisted the resident into the shower room for incontinence care, he/she positioned the resident's wheel chair facing towards the grab bar (a safety device designed to enable a person to maintain balance, lessen fatigue while standing, hold some of their weight while maneuvering, or have something to grab onto incase of a slip or fall) on the right-side wall of the room in relation to the entrance to the shower room. -The resident used his/her stronger arm and hand (her left arm and hand) to hold onto the grab bar. -CNA A assisted the resident into a standing position without the use of a gait belt, CNA A said that the resident's preference was to not use a gait belt and the resident would become agitated if a gait belt was used on him/her. -CNA A then went to the resident's right side and assisted pulling down the resident's pants and unfastened the right side of the resident's soiled brief. -CNA A walked around the back of the resident's wheelchair, took the brief off of the resident, and disposed of it in the nearby trash can. -CNA A cleansed the resident's perineal (between the thighs extending from the pubic bone to the tail bone) area, placed a clean brief on the resident and fastened the brief on the resident's left side, using one hand to hold the brief in place and his/her other hand to pull the brief's fastening strap on the left side of the resident around the resident's left hip and used the same hand to fasten it to the front of the resident's brief. -CNA A moved to the resident's right side by walking behind the resident's wheelchair to the resident's right side at approximately at an eight o'clock position behind the resident. -While CNA A was relocating to the resident's right side, he/she heard the resident say, It's what it was with an inflection tone of the way in which the resident indicated to him/her that the resident was expressing fright; and appeared to be losing his/her balance and falling. -CNA A said his/her natural instincts took over and he/she grabbed for the resident who appeared to be falling towards his/her right side, grabbing a hold of the left-shoulder portion of the resident's shirt and pulling the resident towards himself/herself. -CNA A said his/her grabbing the resident to prevent him/her from falling or prevent the resident from falling face and head-first onto the floor resulted in the resident turning his/her position to where his/her body now was at approximately a ten o'clock' angle in relation to the grab bar, where previously the resident's body was at a two o'clock angle in relation to the grab bar. -CNA A witnessed the resident fall backwards toward his/her wheelchair and to his/her right side, resulting in the resident being on the floor along with his/her wheelchair with the right wheel of his/her wheelchair being on the floor and the left wheelchair wheel up towards the ceiling. -When moving to the side on which the resident fell, CNA A noticed something was wrong with the resident and the resident needed help. -He/she asked the resident to remain as still as possible, ran to the shower room door, opened it and yelled out that he/she needed help immediately. -LPN A ran into the shower room to assess the situation. -LPN A noticed the resident on the floor and went to the resident's side and CNA A told LPN A not to move the resident's wheelchair, as part of it had impaled (penetration of the human body by a pointed object) the resident's rectum. -CNA A remained with the resident and LPN A called down the hallway to CMT A he/she needed assistance immediately. -LPN A told CMT A his/her assessment of the resident and said 911 would have to be called for EMS for the resident. -911 was called and EMS arrived at the facility shortly afterward, bringing tools to disassemble, disconnect, or remove the object that was impaled in the resident's rectum. -EMS started an intravenous vein (IV) access, gave medication through the IV to the resident to help him/her with his/her pain from the incident, and then the object was able to be removed from the resident's rectum. -EMS then transported the to the hospital. Review of the resident's EMS records, dated 9/13/24, showed: -The Emergency Medical Technicians (EMTs) were dispatched to the scene due to a fall with impalement. -Upon arrival, the resident was found lying on his/her left side in the shower area with staff present. -The resident had aphagia and could not communicate verbally. -The staff were trying to change the resident's brief and the resident slipped, fell, landing on the wheelchair pedal and brake handle. -The brake handle inserted into the resident's rectum (the last several inches of the large intestine closest to the anus (the opening between the buttocks through which gas and feces is ejected from the body) and then tore laterally to the left. -The was insignificant bleeding. -The foreign body was still in the resident and he/she was yelling in distress. -Pain medications were given through IV. -The crew started removing bolts from the wheelchair brake, however the brake handle was wedged in place and would require hammering and jostling to remove it. -The resident was squirming so only a small part of the foreign body was in the resident. -A decision was made to remove the object and monitor for bleeding. -The area was briefly irrigated with normal saline then covered and no increase in bleeding was seen. -The resident was moved to a stretcher and began to yell in discomfort again. -IV pain medication as administered. -The resident was transported to the hospital. Review of the resident's hospital records, dated 9/13/24 - 9/16/24, showed: -He/she was seen for rectal trauma. -He/she was in the shower area at the nursing home and fell. -He/she had a foreign body anal penetration with laceration (a deep cut or tear in skin or flesh). -A lever on his/her wheelchair penetrated his/her gluteal (buttock) area his/her wheelchair lever penetrated one centimeter (cm - just under 3/8 inch) into his/her gluteal (buttock) area. -He/she received diagnostic radiology, intravenous (into a vein) antibiotics, narcotic pain medication by IV and by mouth, a tetanus vaccine (a bacterial infection caused by bacteria entering the body through cuts and punctures that can cause life-threatening muscle spasms and convulsions), and wound care. -His/her discharge instructions included a new medication of hydrocodone/acetaminophen (narcotic pain medication), 5-325 milligrams (mg), one every four hours as needed for severe pain and wound care of wet to dry packing (WTD - a wound care technique that involves applying moist gauze dressing to a wound, allowing it to dry, and then removing it to remove dead tissue and wound drainage), daily and as needed to his/her gluteal laceration. Review of the resident's fall facility investigation final summary, dated 9/16/24, showed: -Upon reviewing the information regarding the resident's fall, there was mention of CNA A not using a gait belt. -The Administrator requested immediate re-education for CNA A on the facility gait belt policy, which was completed on 9/13/24. -The Administrator and the Director of Nursing (DON) interviewed CNA A and requested him/her to reenact and spoke with him/her, clarifying details. -Upon reviewing the information presented, it was not believed that there was any willful abuse or deliberate negligence, but instead the need for supervisory counseling. During an interview on 9/17/24 at 10:10 A.M., the Administrator said: -On 9/13/24 CNA A took the resident into the shower room for incontinence care and had the resident stand and hold onto a grab bar. -CNA A did not use a gait belt and the resident fell, resulting in him/her being injured and sent out to hospital. -The resident was now back from the hospital. During an interview on 9/18/24 at 10:07 A.M., CNA A said: -On 9/13/24 he/she took the resident to a shower room to provide incontinence care for the resident. -Without using a gait belt, he/she assisted the resident to stand by pulling on the back of the resident's pants, and had the resident take hold of the grab bar. -He/she provided incontinence care for the resident while the resident held onto the grab bar. -He/she fastened the resident's brief on his/her right side, moved around the resident's wheel chair, to the resident's left side. -He/she began to fasten the resident's brief on his/her left side, heard the resident saying something with a tone as if he/she was scared. -He/she saw the resident was beginning to fall to his/her right side. -He/she grabbed the resident's blouse left sleeve. -The resident continued to fall and ended up on his/her side, his/her wheelchair on its side and a part of the wheelchair was inside the resident's rectum. -He/she saw the resident needed help and hearing a resident yelling in the area near the shower room, he/she asked the resident to not move and he/she went to the shower room door and yelled for LPN A to come to the shower room; -LPN A came the shower room and he/she told LPN A to not move the resident because something from the wheelchair was inside the resident. -LPN A went to the shower room door and told CMT A to come to the shower room and had him/her stay with the resident while LPN A called 911. -When LPN A returned to the shower room, he/she had CMT A prepare the paperwork for the resident to go to the hospital. -He/she and LPN A stayed with the resident until EMS took the resident to the hospital. -He/she saw that EMS left with the resident. -He/she had not used a gait belt with the resident; the resident did not like the gait belt being on him/her. -He/she knew this because when he/she had previously tried to use the gait belt with the resident he/she said, No, no, no. -He/she had never actually tried to put a gait belt on the resident, because the resident had said no. -He/she did not use a gait belt on any other resident's as long as they could stand and hold onto a grab bar. -Looking back, there was nothing different he/she would have done regarding using a gait belt with the resident. -After the Administrator and the DON talked with him/her, he/she would get another staff person or tell the charge nurse. -He/she had attended a recent gait belt in-service on 9/10/24 during which the DON said use of gait belts were for resident and staff safety. -He/she asked what to do if a resident refused a gait belt and the DON said not to assist/transfer the resident without a gait belt and tell the charge nurse the resident had refused the gait belt. -The purpose of the gait belt was for safety, if the resident was falling, to have a hold of the resident and in case of falling, he/she could in case he/she could slide the resident down to the floor. -If a resident told me no, he/she was not going to us a gait belt on them. -Resident's had rights, if a resident said no and he/she put a gait belt on the resident anyway, it would be abuse. During an interview on 9/18/24 at 11:08 A.M., LPN A said: -The resident had right sided weakness and aphasia due to having a stroke in the past. -The resident needed one staff person assistance with a gait belt for standing and transferring. -The resident never refused care and had never refused use of a gait belt. -He/she had not seen CNA A not use a gait belt with the resident. -He/she had seen CNA A not use a gait belt with two other residents. -He/she told CNA A to use a gait belt when transferring residents and CNA A said for him/her to not tell him/her what to do. -About one month prior, he/she told the previous Administrator that CNA A had not used a gait belt with two residents, that CNA A had said for him/her to not tell him/her what to do, talked back, wouldn't listen and was argumentative. -When he/she entered the shower room, the resident was lying on the floor with his/her wheelchair on its side on the floor next to the resident, his/her wheelchair brake lever was in his/her anus. -He/she went to the shower room door and called for CMT A to come to the shower room. -When CMT A arrived in the shower room, he/she told him/her what was going on and to prevent the resident from moving. -He/she went to the nurse's station and called, called 911 and advised that EMT's needed to bring tools to remove the resident's wheelchair break lever from the resident's wheelchair. -He/she returned to the resident and had CMT A go and prepare the needed paperwork for the resident's transfer to the hospital and he/she and CNA A remained with the resident until EMS arrived on the unit. -EMS started an IV and removed the resident's wheelchair lever from the resident's wheelchair. -The lever penetrated the resident's left buttock and exited the resident's left buttock leaving a laceration on the resident's left buttock. -EMS staff immediately packed the resident's left buttock laceration with gauze to control bleeding and then transported the resident to a trauma hospital. -During the time EMS was removing the resident's wheelchair brake lever from the resident's wheelchair, the resident was alert and EMS administered Ketamine (a medication that can induce a state of sedation - feeling calm and relaxed, immobility - the state of not moving or inability to move, relief from pain and amnesia - no memory of events while under the influence of the drug) intravenously into a vein for pain. -CNA A told him/her he/she had not used a gait belt during the resident's care and the resident fell. During an interview on 10/2/24 at 10:02 A.M., EMT A said: -On 9/13/24 when he/she arrived at the resident's location in a facility shower room, he/she saw that the resident was on his/her side, his/her wheelchair was on top of him/her. -He/she saw the wheelchair break lever had entered into or very near the resident's rectum and had torn across the resident's mid left gluteus muscle. -It was difficult for EMS to assess the resident's heart rate and blood pressure due to the resident's position with his/her wheelchair being on him/her. -It was difficult to assess the resident's pain, because at his/her baseline he/she had communication difficulties due to his/her past medical history of stroke. -The resident was squirming (made twisting/jerking movements because of pain or distress) and yelling out. -Other EMS staff and a facility nurse were trying to keep the resident still. -He/she started an IV line, while EMS staff worked to remove the wheelchair brake lever from the resident's wheelchair. -He/she administered Ketamine IV which had a temporary effect of mildly reducing the resident's squirming. -EMS staff worked to remove the wheelchair lever from the resident's wheelchair, but could not without a lot of jostling due to the position of the wheelchair and the resident. -The resident's wheelchair brake lever slipped out of the resident from his/her already three to five-inch torn flesh on his/her rectal area to his/her left gluteus muscle. -The resident's wound had minimal bleeding. -He/she placed five by nine-inch trauma pad over the resident's wound to control and assess bleeding and provide a barrier to help prevent contamination of the wound. -When placed on a wheeled stretcher, the resident began to show increased movement and began to yell out. -He/she administered a second dose of Ketamine IV - it was typical for a first dose effect to be short in duration and for a second dose to be needed. -He/she had concern about possible rectal perforation (a rare but serious condition that occurs when there is a hole in the rectum, most commonly caused by trauma). During an interview on 9/18/24 at 11:48 A.M. the DON said: -The resident had a stroke in the past and could say It is what it is. And a few other words. -When frustrated he/she would repeatedly say no. -He/she and the Administrator did the resident's 9/13/24 fall investigation, including interviewing CNA A and having him/her reenact the resident's fall. -On 9/13/24 CNA A had taken the resident into a shower room to provide incontinence care. -Without using a gait belt, CNA A had the resident stand up and hold onto a grab bar. -CNA A moved to the resident's left side and as he/she was starting to fasten the residents brief on his/her left side and saw the resident was starting to fall and grabbed the resident's blouse left arm sleeve. -As the resident continued to fall his/her wheelchair lock penetrated his/her rectum. -The resident's wheelchair ended up on its side and the resident on the floor on his/her side with a wheelchair brake having punctured the resident. -He/she saw the resident as EMS was leaving the facility with the resident and the resident appeared to be in pain by his/her voice tone when repeating words. -Had CNA A used a belt for the resident, he/she would have had something to have assisted the resident to a sitting position in his/her wheelchair rather than falling. -CNA A said the resident would not wear a gait belt. -Any resident who was assisted by staff in standing/transferring was to use a gait belt. -If any resident had refused a gait belt, CNA A should have told the charge nurse and should not have had the resident stand or transfer the resident without using a gait belt. -He/she had not known prior to 9/13/24 that CNA A did not use a gait belt when caring for the resident and when caring for other residents. -Staff needed to use a gait belt with any resident who needs staff assistance with standing or transferring. Observation on 9/18/23 at 11:48 A.M., showed: -The resident had a laceration on his/her left buttock above his/her left gluteal fold left gluteal fold (the side-to-side crease in the skin that separates the buttocks from the upper thigh) to the left of his/her gluteal cleft (the groove between the buttocks). -The DON measured the resident's laceration with results of 1.5 centimeters (cm) (over one-half inch) by 4.1 cm (approximately one and ½ inches) and with a depth of 7.2 cm (approximately two and ¾ inches). -DHSS staff attempted to interview the resident during this observation, the resident was not interviewable, and was only able to answer simple yes or no questions. During an interview on 9/17/24 at 1:12 P.M., CNA B said: -The resident was a one-person assistance with transfers. -The resident had not refused a gait belt during care. -He/she always used a gait belt when transferring the resident or when having the resident stand. During an interview on 9/17/24 at 12:45 P.M., CNA C said: -The resident was a one person assist with a gait belt for standing and transferring between surfaces. -He/she used a gait belt when transferring the resident or when having the resident stand. -The resident had not refused to wear a gait belt. -All care staff were to wear a gait belt when working the floor (providing direct resident care). Record review of the resident's Nurse Practitioner (NP-a registered nurse who has advanced clinical education and training and is qualified to perform physical exams, diagnose and treat illnesses and prescribe medications/treatments) progress note, dated 9/18/24, showed: -He/She was seen for a readmission post hospitalization open wound on his/her left buttock. -On 9/13/24 the resident was being assisted by a staff member in the restroom. -He/she came down and caught his/her left buttock on his/her wheelchair brake lever which impaled his/her left buttock in the cleft area. -He/she was sent to the hospital, received antibiotics and a colorectal (specialist in diagnosing and treating conditions that affect the lower gastrointestinal tract) surgery consultation. -The hospital colorectal surgeon decided not to do surgery and instead to discharge the resident with instructions for loose pack wet-to dry dressing daily and as needed. -The NP ordered empiric antibiotics asked the DON and the Assistant Director of Nursing (ADON) to reinforce to nursing staff to monitor the resident for signs and symptoms of infection due to the area of the resident's wound had a high propensity for infection. -The NP would ask the resident's physician to see the resident that week. -The wound care company would assume the resident's wound care the following week on 9/25/24. During an interview on 9/18/24 at 2:16 P.M., CNA D said: -The CNAs all knew to use a gait belt with the resident. -The resident needed one-staff person assistance with standing and transfers. During an interview on 9/18/24 at 2:24 P.M. CMT B said: -He/she used a gait belt with the resident when having the resident stand and when transferring the resident. -The resident needed one-staff person assistance with standing and transfers. During an interview on 9/18/24 at 2:12 P.M. CNA A said: -He/she did not use a gait belt for any of the residents when having a resident stand or transfer as long the resident could hold onto a grab bar. During an interview on 9/18/24 at 2:29 P.M., the Director of Rehabilitation and Physical Therapist (PT) A said: -The resident was discharged from therapy on 9/6/24. -Rehabilitation Services determined during the resident's skilled therapy that he/she needed one person assistance with a gait belt for transfer, standing and walking. -During therapy the resident had not been resistant to or refused use of a gait belt. During an interview on 9/18/24 at 2:54 P.M., the ADON said: -Unless a mechanical lift was used, direct care staff were to use gait belts when assisting residents with transfer/standing. During an interview on 9/18/24 at 3:22 P.M., the Administrator said the fall investigation regarding the resident's 9/13/24 fall identified the root cause of the resident's fall was the lack of use of a gait belt by CNA A. During an interview on 9/19/24 at 1:55 P.M., the resident's physician said: -He/she did expect that if it was the facility policy, the facility staff would use a gait belt when assisting the resident to stand or when having the resident stand when receiving care and for other mobility assistance. -The only time he would think the facility wound not us a gait belt when assisting the resident with movement was if there were an emergency that required immediate movement, such as a fire. Record review of the resident's physician progress note, dated 9/20/24, showed: -He/she had been seen by the physician's Nurse Practitioner who asked the physician to follow up on the resident prior to the weekend due to a fall with a wound on his/her left buttock. -He/she had a mild amount of pain. -He/she was empirically (based on experience and observation) observation) started on Keflex earlier in the week. -His/her wound was clean, had no drainage (fluid that comes out of a wound) - there was a little bit of blood but no erythema (redness caused by increased blood flow). -His/her diagnosis was puncture wound of left buttock. Record review of the resident's NP progress note, dated 9/25/24, showed: -The resident had a puncture wound on his/her left buttock that he/she sustained during a fall and was followed by the wound care company. -He/she had hemiparesis affecting his/her right side and was dependent on staff for toileting assistance, transfers and most of his/her activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) due to unsteadiness on his/her feet. -He/she had an unsteady gait (manner of walking), used a wheelchair and required staff assistance for transfers. Record review of the wound care company documentation, dated 9/25/24, showed: -The resident was new to the wound care company. -He/she was being evaluated for a trauma wound to his/her left buttock. -He/she reportedly fell while transferring and part of his/her wheelchair went into his/her rectum and tore open his/her left medial buttock. -The wound company ordered wound care of calcium alginate and bordered gauze daily. -His/her left open buttock wound measured 5.5 centimeters (cm) - a little over two inches by 2.1 cm (about ¾ inch) and had a depth of 0.4 cm - less than ¼ inch. -His/her left buttock wound was full thickness (damage extends below all the skin layers and into/ beyond the tissue under his/her skin). - His/her left buttock wound had undermining (a wound complication that occurs when the edges of a wound separate from the surrounding healthy tissue, creating a pocket under the wound surface) within the area from 12 o'clock to 6:00 o'clock (in the area uppermost toward his/her head to the are lowest toward his/her legs). -The origin of his/her open wound on his/her left buttock was trauma (a severe injury that occurs suddenly due to sudden onset that requires immediate medical attention). - It was anticipated he/she would need to be under the care of an advanced wound specialist for six to nine months. -The wound care company changed his/her wound orders to calcium alginate (a wound dressing that absorbs excess moisture but maintains a moist environment that promotes wound healing and helps prevent/treat infections in wounds) and a super absorbent non adhesive non-bordered pad daily. During an interview on 10/2/24 at 2:08 P.M., the resident's physician said: -The resident had a wound on h

Based on interview and record review, the facility failed to promote and facilitate one sampled resident's (Resident #3) self determination out of four sampled residents. The facility census was 76 residents. Review of the facility's undated Nursing Home Resident's Rights showed: -The law requires nursing home to promote and protect the rights of resident and stresses individual dignity and self-determination. -Right to dignified existence. --Be treated with consideration, respect, and dignity, recognizing each resident's individuality. --Quality of life is maintained or improved. --Exercise rights without interference, coercion, discrimination, or reprisal. -Right to self-determination. --Reasonable accommodation of needs and preferences. --Participate in developing and implementing a person-centered plan of care that incorporates person and cultural preferences. --Choice about designating a representative to exercise his/her rights. --Request, refuse, and/or discontinue treatment. -Right to be fully informed of . --The type of care to be provided, and risks and benefits of proposed treatments. --Changes of the plan of care, or in medical or health status. -Rights during discharge/transfer. --Receive 30-day written notice of discharge or transfer that includes, the reason, the effective date, the location going to, appeal rights and process for filing an appeal, and the name and contact information for the long-term care ombudsman. --Preparation and orientation to ensure safe and orderly transfer or discharge. Review of the facility's undated Admission Policy showed: -It is the policy of the corporation to admit and/or retain only those residents whose health care needs can be met through services of the facility and staff, in cooperation with outside resources under contract with the facility. --Involuntary transfers or discharges. --Except for the case of late payment or nonpayment, the facility shall notify the resident and the resident family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. 1. Review of Resident #3's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including dementia (a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging) and major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Review of the Resident's Power of Attorney (POA) document showed the resident's POA had been invoked with two physician signatures. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 2/26/24 showed the resident was moderately cognitively impaired. Review of the resident's Nurse's Notes on 4/7/24 showed: -It was reported the resident had his/her hand in another resident's pants. -The resident placed in line of sight. -The resident unable to recall the alleged incident. -The Administrator was notified. -The resident placed on one on one. -The resident family/POA notified. -The POA came to facility and spoke to Administrator. During an interview on 4/7/24 at 11:00 A.M., the Administrator said the resident had only grabbed the elastic of the another residents' pants, pulled the elastic back and let go. The resident never placed his/her hand in the pants of the other resident. The resident had no known history of touching other residents inappropriately. Review of the Resident's Social Service Progress Note dated 4/9/24 at 10:00 A.M. showed: -The Social Service Designee (SSD) was asked by the facility Administrator to send referral to a locked same sex facility. -Three referrals were made for the resident. Review of the resident's Nurse's Note dated 4/7/24 through 4/15/24 showed he/she continued on one on one observation with no behaviors. Review of the facility Investigation Report dated 4/16/24 showed: -On 4/7/24 at approximately 11:45 A.M. the Administrator was notified the resident had his/her hand inside the waist band of another residents' clothing by the Director of Nursing (DON). -Interventions include a one on one facility staff presence (one staff person assigned to one resident) with the resident. -The resident was sent to the hospital for evaluation per physician request. -The POA was upset and was informed the resident would remain on one on one supervision during waking hours while the Administrator worked on his/her investigation. -In conclusion, no sexual abuse had occurred. -Per the facilities Admission, Transfer and Discharge Policy and Procedure, a transfer or discharge was necessary to meet the resident's welfare, and the resident's welfare could not met in the facility. -The resident would remain on a one on one supervision during waking hours until a same sex unit in another facility was located. During an interview on 4/16/24 at 10:19 A.M. the resident POA said: -He/she spoke to SSD on 4/8/24 and was told the steps were to notify the family, then Administrator of the allegations, then the Administrator appoints the DON or someone to investigate the allegations. -When notified of the incident, he/she came to the facility right away, spoke with the Administrator and a nurse had given him/her the Administrator's phone number. -The Administrator said there was video of the incident but refused to allow him/her to view the video. -No facility staff had spoken to him/her about transferring the resident to another location and the facility staff were now not communicating at all with him/her. -When he/she contacted the Administrator for further communication, the Administrator said it was his/her personal phone number and not to call it again. -He/she had contacted the Ombudsman. -The Administrator informed him/her the resident would be sent to a locked same sex facility. -He/she contacted the hospital social worker who contacted the Administrator and reminded him/her they could not transfer the resident without communication with the POA. -The hospital social worker was helping the POA seek alternate placement for the resident. During an interview on 4/16/24 at 11:46 A.M. the resident said all questions should go to his/her POA. During an interview on 4/16/24 at 12:28 P.M. the SSD said: -He/she was responsible for admissions, discharges and transfers for the residents in the facility. -He/she was actively working on transferring the resident. -On 4/9/24 during the morning meeting the Administrator had said the POA would not be notified of the intent to transfer. -The POA had not been notified of the referrals made or the intent to transfer the resident or the acceptance of the referral to another facility. -The Administrator shut down all communication about the resident. During an interview on 4/16/24 at 2:00 P.M. the DON said: -He/she had reviewed the video and did not see the resident have his/her hands in another resident pants. The resident had no prior inappropriate behaviors. -The resident was sent out for medical and psychological evaluation. -He/she was not aware of a discharge notice or any discussion with the POA. -The one on one supervision for the resident was not necessary and could be discontinued once a final decision had been made. During an interview on 4/17/27 at 7:30 A.M. Certified Medication Technician (CMT) A said: -He/she witnessed the incident of alleged sexual abuse with the resident. -He/she did see contact between the residents, but could only assume the intentions were sexual in nature so he/she reported it. During an interview on 4/17/24 at 7:44 A.M. the POA said: -The facility called local law enforcement on 4/8/24 related to the allegations the day after the alleged incident. The resident did not understand why the police were called. -LPN A told the POA the resident cried when the police came and did not know why law enforcement was called. -The staff told him/her on 4/8/24 they were not talking to him/her and then called to notify him/her they were sending the resident to the hospital. -The resident was unable to process what had happened and he/she was concerned about the resident's overall safety. -If the resident was in his/her right mind, he/she would feel like his/her whole world was going down. -None of the allegations was the character of the resident and the resident would be blown away by the allegations. -The resident was made to feel less than a person and as a criminal. -The whole situation would negatively impact the resident dignity if he/she was in his/her right mind. -He/she had made multiple attempts to communicate with the facility. -He/she was concerned about the outcome of the investigation and not aware of his/her rights to locate alternate placement for the resident. -On 4/8/24 he/she brought an advocate to the facility to speak with the Administrator, and when any questions were asked the Administrator would shut them down. The Administrator did not want to answer questions about their protocol. -When he/she tried to get clarification as to what actually happened, the Administrator stated he/she was not going to tell the POA anything. -The DON agreed the facility did not have to answer any of the POA's questions. -On 4/9/24 the POA and his/her spouse went again to try to speak to the Administrator. -They attempted to communicate their desire to relocate the resident due to the adversarial environment, but needed to know what had happened to find appropriate placement. -The Administrator refused to give them any information and stated that he/she would have to finish the investigation. The Administrator stated he/she was going to send the resident to an same sex facility. -The POA was afraid the Administrator was going to ship the resident somewhere without his/her permission. -He/she felt the resident and the resident's representative should have a choice on where the resident goes. -He/she was willing to work with the facility to transfer the resident to an appropriate facility. During an interview on 4/17/24 at 9:14 A.M. Advocate A said: -On 4/8/24 he/she went with the POA to mediate conversation with the facility. -When they spoke with the SSD about protocols (steps for the investigation), the SSD told them nothing had been done at that time. -They asked to speak with the Administrator. -He/She reiterated to the Administrator the need for a conversation about what happened and how to work together to get the resident moved. -The Administrator stated he/she was not obligated to speak to the POA, it was just a document and he/she didn't have to recognize it. -He/she was upset the Administrator said the facility did not have to honor the POA and that the Administrator didn't need the POA because he/she was going to have the resident sign the discharge papers. During an interview on 4/17/24 at 10:25 A.M. LPN A said: -On 4/7/24 there was an allegation of sexual abuse involving the resident made by CMT A. -He/she was called by the DON and told to put the resident on one on one supervision. -The incident occurred in the hallway and wanted to start the investigation knowing there were cameras in that area. -He/she was instructed to notify the resident family of the alleged sexual behavior while waiting for further instruction from the Administrator. -He/she questioned speaking to the family before the video footage was viewed, but the Administrator wanted the family contacted anyway. -The DON said the Administrator said not to talk to the family about anything. -The resident continued to be on one on one supervision . -The Administrator said he/she had five days to make decisions, it has been more than five days and the resident still has one on one supervision. During an interview on 4/17/24 at 5:24 P.M. Officer A said there was no credibility to the allegations of sexual abuse and did not require further law enforcement investigation. During an interview on 4/22/24 at 1:58 P.M. the ADON said: -His/her role since the alleged incident has been to ensure there was appropriate staffing for the resident's one on one supervision. -He/she was told the resident would be on one on one supervision until further notice by the Administrator and the DON; there was no explanation for the one on one or why it was until further notice. -In the past when a resident has been on one on one, it is removed after 72 hours, then 15 minute checks are done, so he/she doesn't understand why the resident was still on one on one. During an interview on 4/22/24 at 2:51 P.M. the DON said: -The facility's escalation of the situation was due to the resident's family overreaction. -The reason they had not been talking to the family was because they were not supposed to share opinions and the facility plan of correction. -It was the facility's responsibility to keep the family informed; as far as he/she was concerned the family has been informed. During an interview on 4/22/24 at 3:28 P.M. the Administrator said: -The goal was to transfer the resident to a same sex facility. -The reason was because if the resident's starting to change mentally, he/she questioned if the resident was safe around other residents of the opposite sex. -He/she was not able to determine the resident's thought processes. -His/her first thought the interaction was sexual in nature because the resident touched Resident #2's nightgown and waist band. -The resident interaction was not sexual abuse. -He/she was continuing the one on one, and the plan to transfer the resident to prevent behaviors with another resident. -He/she with the Regional Director was the investigator of the allegations and would determine when the one to one was no longer needed, the situation was resolved and everyone was safe. -One on one is someone sitting relatively close, keeping close contact with the person to make sure everyone is well protected. -He/she was responsible to provide 30 day notice in writing when a discharge was initiated to the resident and/or resident representative when needs could no longer be met. -He/she instructed the SSD to make referrals to alternative placement. -He/she had not spoken to the family/POA since the alleged incident on 4/7/24 and informed them at that time the resident may go to an same sex locked facility. -The resident enjoyed conversation with staff and the one to one had no negative outcome. -He/she was unsure if the resident understood he/she was a safety risk and required someone with him/her at all times. During an interview on 4/23/24 at 12:15 P.M. the Ombudsman said: -The Administrator contacted him/her because he/she wanted to issue a discharge notice to the resident. -The administrator was not communicating with POA. -The facility was not respecting the rights of the resident through the discharge process or communicating with the resident legal authorized representative, the POA. MO00234382

Based on observation, interview, and record review, the facility failed to maintain a comfortable environment with air temperatures at or below 81 F (degrees Fahrenheit) on 8/21/23 and 8/22/23 in the following resident use areas: the 100 Hall, 200 Hall, 300 Hall, 400 Hall, 500 Hall corridors, the South and North Dining Rooms; Resident rooms 408, 405, 406, 403, 404, 402, 507, 512, 513, 514, 204, 201, 206, 208, 206, 208, 207, 109, 108, 107, 106, 105, and 102; failed to implement its plan to monitor temperatures when the temperatures went above 81 F; and to evacuate residents from those rooms or cease using the common spaces when the temperatures were above 81 F. This failure affected all residents who resided in or used those areas, including 7 sampled residents (Residents #3, #5, #6, #8, #10, #13 and #16) out of 17 sampled residents. The facility census was 76 residents. The Administrator was notified on 8/22/23 at 8:23 P.M., of the Immediate Jeopardy (IJ) which began on 8/22/23. The IJ was removed on 8/24/23, as confirmed by surveyor onsite verification. Review of the facility's Hot Weather and Policy and Procedure dated 11/30/17, showed: - It was the policy of the corporation to implement measures to assure the comfort and safety of resident and to prevent heat stress of residents during periods of extreme heat. - Measures shall be implemented by departments under the overall direction of the Administrator when conditions in the living, activity or dining areas reach conditions exceeding a heat index/apparent temperature of 80 F (degrees Fahrenheit). - Residents most susceptible to adverse effects of the heat shall be determined and monitored. - All residents are to be observed by nursing staff for effects of heat related stress. - Residents displaying such stress shall be immediately reported to the charge nurse. - Outside temperatures may be monitored through local radio or weather television station or by a facility thermometer outside the facility. - If the inside temperature and/or humidity exceeds a heat index apparent temperature 80 F, he charge nurse should take action to cool the living , dining, and activity areas of the facility. - Nursing staff shall observe all residents for symptoms of heat stress. - Those residents determined to be high risk shall be monitored closely. - Regular cleaning of air conditioning filters monthly is essential. - Maintenance personnel shall be responsible for ensuring air conditioning units are operational at all times - No section about monitoring temperatures of resident occupied spaces including resident rooms and resident common areas. Review of the Loss of Air Conditioning Policy section of the Facility's Emergency preparedness binder reviewed on 7/23, showed: Overview: A high temperature/heat situation can be a true emergency, particularly, to an elderly population. The ability to regain power, access portable air conditioning units or other mitigating efforts should be considered at the onset of the situation. General Actions Applicable to all staff: - Use fans and portable air conditioning units, if available. Notify staff member responsible for infection control. - Keep blinds, curtains, drapes etc. closed in areas of building that receive direct sunlight. Open doors and windows, as necessary, to take advantage of available breezes. - Avoid activities that may excite residents or require physical exertion. - Keep residents out of direct sunlight. - Turn off lights as well as their heat producing appliances whenever possible. - Provide plenty of liquids for residents and staff. - Monitor vital signs of residents and staff. Administrator/Incident Commander: - Activate the Command Center by notify the Section Chiefs and Command center personnel by phone or pager notification indicating a Code Alert as necessary. - Ensure all essential departments are functioning . - Meet with Plant Operations to assess situation and develop an action plan. - Consider relaxing the dress code and consider reduction of work time rotating staff in high heat producing areas. Continue to monitor the situation through appropriate department heads. -Monitor the television or radio for important heat-related announcements. -Determine the need to report situation to local or other regulatory agency. - Report any heat related illnesses /deaths to the Department of Public Health immediately. Determine if any evacuation is necessary 1. Record review of data from the National Weather Service Kansas City Missouri showed: -On 8/20/23 a high temperature of 98 F. -On 8/21/23 a high temperature of 99 F. -August 19-25 Historic Heatwave: Starting on 8/19/23 well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. This stretch of hot weather was accompanied by extremely high dewpoints, with frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from August 19 through August 25 to rise to 120-130 degrees. Observation of the facility temperatures on 8/21/23, 12:12 P.M. to 12:42 P.M., showed: -There were 21 residents in the south dining room. -The south dining room and hall corridors had the following temperatures: --The south dining room was 82.6 F. --The 100 hall corridor was 82.1 F. --The 200 hall corridor was 82 F. --The 300 hall corridor was 82.7 F. --The 400 hall corridor was 83.5 F. --The 500 hall corridor was 83.4 F. During an interview on 6/21/23 at 2:22 P.M., the Business Office Manager (BOM) said there was no one who was monitoring air temperatures within the facility. Review of data from the National Weather Service Local Data for Kansas City Missouri showed on 8/22/23, a high temperature of 95 F. Observations of facility temperatures on 8/22/23, 12:10 P.M. to 12:37 P.M., showed: -The south dining room and hall corridors had the following temperatures: --The south dining room was 82.4 F. -The 100 hall corridor was 82.9 F. --The 400 hall corridor was 85.0 F. --The 500 hall corridor was 83.8 F. During an interview on 8/22/23 at 12:37 P.M., the Housekeeping Supervisor said it has been hot in the facility since, 8/18/23 and he/she has not seen anyone monitor temperatures in the corridors or the resident rooms. During an interview on 8/22/23 at 12:42 P.M., Licensed Practical Nurse (LPN) A said: -He/she had worked as a Charge Nurse in the facility on Friday 8/18/23, Sunday 8/20/23, and Tuesday 8/22/23, and it had felt hot in the facility during those days. -He/she did not see anyone monitor temperatures in the back (South) Unit. During an interview on 8/22/23 at 1:03 P.M., the Administrator said: -Central Air conditioning was not available in any of the corridors of the facility. -The system that was used to track the corridor temperatures, was installed before his/her time. -He/she was not sure the system was used to keep track of the corridor temperatures in the facility was calibrated (correlate the readings of (an instrument) with those of a standard in order to check the instrument's accuracy). -If the temperatures of the resident rooms, were comfortable for the residents as opposed to the temperatures of the corridors, than that was where the residents should be. Review of Resident #3's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 5/10/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information) of 15 out of 15. Observation and interview on 8/22/23 at 2:19 P.M., Resident #3 said: -He/she was not comfortable in his/her room. -Sometimes he/she had trouble sleeping due to the increased temperatures. -His/her room was 86.4 F and the window air conditioning unit was not blowing out cool air. Review of Resident #5's quarterly MDS dated [DATE], showed the resident had severe cognitive impairment with a BIMS of 6 out of 15, had clear comprehension of others and made himself/herself understood by others. Observation and interview on 8/22/23 at 3:55 P.M., Resident #5 said: -He/she had felt hot in his/her room for several days. -His/her room was 82.5 F and the window air conditioning unit did not blow out cool air. Review of Resident #6's annual MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 15 out of 15, had clear comprehension of others and made himself/herself understood by others. Observation and interview on 8/22/23 at 3:57 P.M., Resident #6 said: -He/she had felt warm in his/her room and for the two days prior to 8/22/23, he/she had to place a cool wash cloth on his/her face to go to sleep. -His/her room was 82.5 F and the window air conditioning unit did not blow out cool air. Review of Resident #8's quarterly MDS dated [DATE] showed the resident was cognitively intact, with a BIMS of 12 out of 15, made himself/herself understood and usually understood others. Observation and interview on 8/22/23 at 4:07 P.M., Resident #8 said: -His/her room was always real warm any day of the week. -His/her room was 82.9 F. Review of Resident #10's quarterly MDS dated [DATE], showed the resident had severe cognitive impairment with a BIMS of 7 out of 15, usually understood others and made himself/herself understood by others. Observation and interview on 8/22/23 at 4:13 P.M., Resident #10 said: -He/she felt hot in his/her room for a few days. -His/her room was 84.0 F and the window air conditioning unit did not blow out cool air. Review of Resident #13's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 15 out of 15, made himself/herself understood to others and had clear comprehension of others. Observation and interview on 8/22/23 at 4:32 P.M., Resident #13 said -He/she felt hot in his/her room in the past few days. -His/her room was 82.2 F and the window air conditioning unit in his/her room was not blowing out cool air. Observation and interview on 8/22/23 at 4:37 P.M., Restorative Aide (RA) A said: -room [ROOM NUMBER] was very warm. -The resident was in the restroom. -The room temperature was 86.1 F and the window air conditioning unit was not blowing out cool air. Observation on 8/22/23 from 4:45 P.M. through 6:30 P.M., showed the absence of facility staff monitoring air temperatures throughout the facility. Observation on 8/22/23 at 6:31 P.M., showed the Housekeeping Supervisor had just purchased two probe thermometers from a local hardware supply store. Observation with the Housekeeping Supervisor on 8/22/23, 6:37 P.M. to 8:45 P.M., showed: -There were 3 residents in in the south dining room. -The south dining room and occupied resident rooms had the following temperatures: --The south dining room was 84.0 F; --Resident room [ROOM NUMBER] was 87.6 F; --Resident room [ROOM NUMBER] was 88.5 F; --Resident room [ROOM NUMBER] was 87.4 F; --Resident room [ROOM NUMBER] was 86.7 F; --Resident room [ROOM NUMBER] was 85.6 F; --Resident room [ROOM NUMBER] was 84.0 F; --Resident room [ROOM NUMBER] was 85.1 F; --Resident room [ROOM NUMBER] was 83.8 F; --Resident room [ROOM NUMBER] was 85.6 F; --Resident room [ROOM NUMBER] was 86.0 F; --Resident room [ROOM NUMBER] was 84.2 F; --Resident room [ROOM NUMBER] was 85.6 F; --Resident room [ROOM NUMBER] was 82.0 F; --Resident room [ROOM NUMBER] was 82.4 F; --Resident room [ROOM NUMBER] was 87.1 F; --Resident room [ROOM NUMBER] was 85.6 F; --Resident room [ROOM NUMBER] was 82.8 F; --Resident room [ROOM NUMBER] was 81.3 F; --Resident room [ROOM NUMBER] was 81.5 F. Record review of data from the National Weather Service Local for Kansas City Missouri showed on 8/23/23, a high temperature of 95 F and on 8/24/23, a high temperature of 99 F. Review of Resident #16 MDS dated [DATE] showed the resident had moderate cognitive impairment with a BIMS of 8 out of 15, had clear comprehension of others and made himself/herself understood by others. During an interview on 8/24/23 at 1:21 P.M., Resident #16 said: -He/she felt very uncomfortably hot in his/her room until 8/23/23 when the facility personnel placed a fan in his/her room with the air conditioning unit. -He/she was not aware any facility staff member checked the temperature in his/her room. During an interview on 8/24/23 at 1:47 P.M., the Regional Director of Maintenance said: -He/she had been out of the building since 8/18/23. -The maintenance staff at the facility should have known to monitor air temperatures. -Several of the air conditioning units had coils (the component in the air conditioning system which absorbs the heat from the air which works with a condenser coil to complete the heat exchange process that produces cool air) which needed to be cleaned at least once per month during the summer months. -He/she found several coils that were not cleaned. -Air temperatures should be monitored in resident rooms if it began to feel hot within the facility. During an interview on 8/24/23 at 11:57 A.M., the Administrator said: -If the facility staff noticed anything above comfortable temperatures the facility staff should monitor those temperatures every shift. -He/she would have expected facility staff to monitor air temperatures in the resident rooms even if he/she were not in the building. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 00223229

Based on interview and record review, the facility failed to ensure staff reported a change in condition to the charge nurse for a resident with an injury of unknown origin, when a resident reported pain, decreased mobility, and observable changes in appearance of his/her knee during transfers by two agency staff throughout the day on 10/28/20, resulting in the resident's femur (the large bone in the leg) fracture for one sampled resident (Resident #1) out of three sampled residents. The facility census was 69 residents. Record review of the facility's Emergency Care policy, revised 12/21/17, showed: -Emergency care shall be provided in a calm and confident manner in an effort to preserve life, prevent worsening of the situation, and promote recovery. -Nursing staff were to assess situations, isolate the resident from further injury or worsening of condition whenever possible, and report resident conditions and injuries to the charge nurse immediately. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Comprehensive Care Plan, dated 7/2/18 showed: -An Impaired Communication Care Plan showing English was the resident's second language and the resident had difficulty with verbal communication. -An Impaired Physical Mobility due to History of [MEDICAL CONDITION] ([MEDICAL CONDITION] - a stroke (brain damage due to loss of blood flow) Care Plan showing: --Staff were to report changes in the resident's mobility. --Staff were to provide one-person assistance with transfers using a gait belt (assistive device to help staff safely transfer a resident). --Staff were to allow the resident to actively participate in repositioning and transfers. --The resident utilized a wheelchair and self-propelled. -A Fall Risk Care Plan showing: --The resident had impaired physical mobility with right-sided weakness due to [MEDICAL CONDITION], requiring assistance with transfers and repositioning. --Staff were to observe for unsteadiness and unsafe transfers and provide balance support as needed. --Staff were to monitor for changes in condition such as balance, Activities of Daily Living (ADL - bathing, toileting, transfers, and hygiene) abilities, assistance levels, swelling, muscle weakness and decreased socialization and to report to the charge nurse for follow-up and physician notification. -An [MEDICAL CONDITION] (a condition in which bones become weak and brittle) Care Plan showing the resident had a goal of not sustaining a fracture. Record review of the resident's Minimum Data Set (MDS - an assessment tool used for care planning purposes), dated 8/27/20 showed he/she: -Was cognitively intact. -Required extensive one-person physical assistance with transfers and toileting. -Had functional limitations in Range of Motion (ROM - amount of movement in a joint) due to upper extremity (shoulders, arms and hands) and lower extremity (hips, legs and feet) impairments on one side of the body. -Utilized a wheelchair for mobility. -Received services through the Restorative Nursing program (interventions to promote independence, safety and ability by maintaining optimal physical and mental functioning) for ROM and training in bed mobility and transfers. Record review of the resident's Nurses' Note, dated 10/28/20 at 9:00 A.M. showed he/she complained of right knee pain stating it started during a staff-assisted transfer that morning. The knee was swollen with no discoloration and appeared off-centered towards the inner leg. Blood Pressure (BP) readings were 76/47 and 78/50 (readings lower than 90 millimeters (mm) of mercury (Hg) for the systolic (top number) or 60 mm Hg for the diastolic (bottom number) are lower than normal). Oxygen (O2) saturation (sat) levels (amount of oxygen in the bloodstream) were 87 percent (normal adult O2 sat levels are 94 to 99 percent). The Physician was notified and orders were obtained to send the resident to the emergency room (ER). The resident exited the facility at 8:50 A.M. The resident's primary contacts, Administrator and Director of Nursing (DON) were notified. Record review of the facility's internal investigation, undated, showed: -The resident was transferred to the hospital following right knee pain with his/her knee cap off center towards the inner leg with localized swelling. -The following statements were obtained from staff: --Certified Nurses Aide (CNA A)'s written statement, undated, showed he/she noticed nothing wrong with the resident and the resident had transferred without any problems. ---(No date was given for when he/she worked with the resident, but review of the staffing sheets and time punch sheet for the week showed CNA A worked on the resident's hall the day shift (6:00 A.M. to 2:00 P.M.) on 10/27/20.) --Licensed Practical Nurse (LPN) A's written statement, undated, showed the resident had no complaints of pain or discomfort on 10/27/20. The resident sat in his/her wheelchair and used his/her call light for assistance to the bathroom. The statement did not show if he/she directly worked with the resident. ---(Staffing and time punch sheets showed LPN A worked on the resident's hall the evening shift (2:00 P.M. to 10:00 P.M.) on 10/27/20.) -- CNA B's statement, written by the DON dated 10/29/20, showed that CNA B stated he/she transferred the resident during his/her last shift worked. CNA B did not mention an incident related to transferring the resident and did not mention the resident complained of pain. ---(The staffing sheet for 10/27/20 showed CNA B was an agency staff who worked the evening shift beginning at 2:00 P.M. and worked the night shift beginning at 10:00 P.M. and ending at 6:00 A.M.) -- CNA C's written statement, dated 11/9/20, showed on 10/28/20 he/she went into the resident's room to assist with toileting. As the resident was being assisted in transferring from his/her wheelchair to the toilet the resident's left knee buckled. The resident said his/her right knee was hurting. He/She peeked out the resident's doorway to see if he/she could see the nurse. The nurse was not in the hallway so he/she transferred the resident back into his/her wheelchair. He/She then looked for the nurse. He/She didn't see the nurse on the unit so he/she answered another call light. When he/she exited the second resident's room he/she noticed the resident was talking with the nurse about his/her knee. ---(The staffing sheet for 10/28/20 showed CNA C was an agency staff person who worked on the resident's hallway on the day shift.) -- CNA D's written statement, undated, showed he/she went to the resident's room (the date was not given) to help him/her in the restroom and noticed there was something wrong with the resident's leg. He/She immediately got LPN B. The previous day (the date was not provided) he/she worked with the resident and there was nothing wrong with his/her knee. ---(Staffing sheets for the day shift on 11/27/20 showed CNA D was an agency staff person and his/her name was written down for the resident's hall. A line had been drawn through CNA D's name, and was not added to any other hallway. CNA D's name was also on the 11/28/20 staffing sheet to work the day shift on the resident's hall.) --LPN C's written statement, dated 11/8/20, showed he/she worked the night shift beginning at 10:00 P.M. on 10/27/20. At approximately 5:30 A.M. the resident was observed rubbing his/her right knee and said it was sore. He/She felt the knee and did not notice any injury. When he/she went to the clean room the CNA (the name was not specified) stated the resident was weaker and the CNA had to pivot him/her. He/She wrote the resident's concerns on the shift report and verbally gave the information to LPN B at morning shift report. He/She gave the resident Tylenol. ---(The staffing sheet for 10/27/20 showed CNA B as the only CNA assigned to the resident's hall for the night shift, ending the morning of 10/28/20.) --LPN B's written statement, dated 10/30/20, showed on 10/28/20 the resident had a swollen, off-centered right knee upon assessment and complained that the right knee pain started while transferring with staff assistance that morning. The resident denied falling and didn't know which CNA was assisting him/her when the pain began. He/She was given information at shift report from the Night shift nurse that the resident complained of right knee pain during his/her shift. The resident was reassessed with [REDACTED]. ---(The 10/28/20 staffing sheet showed LPN B worked the day shift and LPN C worked the previous night.) --LPN D's statement, dated 10/30/20, showed on 10/28/20 the resident complained of knee pain. When asked when it happened the resident said it happened when he/she got up that morning while being assisted by staff. The resident's leg and knee were swollen. ---(Staffing sheets showed LPN D worked the Day shift on 10/28/20 on a hall other than where the resident was residing.) -The facility's investigation timeline, dated 10/29/20 showed: --On 10/29/20 at 9:44 A.M. a staff person from the hospital reported to the facility Community Relations Coordinator (CRC) that the resident did not want to return to the facility because a CNA was rough with him/her. The resident did not know the name of the CNA. --The CRC contacted the Administrator and DON, who reported to the Regional Director (RD). The RD made a report to the State Agency. --The staffing agency was called and the CNA (the timeline does not indicate which CNA) was taken off the roster. --No staff were allowed at the hospital so hospital staff were going to try to interview the resident. --The CRC called the resident twice while he/she was in the hospital to discuss the incident and was disconnected both times. -Documentation showed that resident interviews were conducted on the resident's hall on 10/29/20 related to cares received the morning of 10/28/20. Most residents described staff as very nice, fine, or said there were no issues. One resident spoke about staff in general and said staff usually were good. -An undated investigation summary, written by the Administrator, showed: --The resident did not know the name of the staff person who assisted him/her when he/she was injured and couldn't remember details of the incident and thought it was an accident. --The facility did not find evidence of abuse. Record review of the resident's X-Ray, three views, dated 10/28/20 at 9:40 A.M. showed oblique (a fracture characterized by a break that is curved or at an angle to a long bone) distal (further from the center of the body) femur (thigh bone) fracture with step off (bones that are not lined up properly) of the distal fragment medially (towards the body's center) by 7 mm and dorsally (towards the back) by 12 mm. Extension into the joint is not definitively seen, however findings are suspicious for tension near the joint space. Further evaluation with computerized tomography (CT - a series of X-ray images taken from different angles to create cross sectional images) should be considered. Record review of the resident's CT of the lower extremity, dated 10/28/20 at 11:00 A.M. showed comminuted (splintering of the bone into more than two fragments, often occurring after a high impact trauma), multidirectional stellate (a radiating pattern like that of a star) of the medial aspect of the distal femoral region with extension of this fracture inferiorly (downward) and intra-articularly (occurring within) throughout the anterior (near the front) and inferior aspects of the medial femoral condyle (round prominence at the end of a bone, most often part of the joint). A longitudinal fracture line is also seen between the medial and lateral femoral condyles. There is depression of the medial aspect of the trochlea (groove at the end of a bone forming part of a joint) by up to 4.5 mm. The main fracture gap within the medial aspect of the distal femoral metaphyseal (neck portion) region measures up to 10.0 mm. Small lipohemarthrosis (fat and blood escaping from the bone marrow into the joint) of the right knee. Diffuse osteopenia (early to mid-stage [MEDICAL CONDITION]). Record review of the resident's orthopedic (a branch of medicine dealing with the correction of deformities) follow-up, dated 10/29/20 showed treatment options were discussed, including surgical interventions. A non-operative treatment was recommended at the time with follow-up two weeks following hospital discharge and the resident being COVID-19 (a respiratory illness caused by the [DIAGNOSES REDACTED]-CoV-2 virus) negative. A 3D hinge (an immobilizing brace) for the right knee was ordered with approval for Physical Therapy (PT - services to improve or maintain gross motor function) and Occupational Therapy (OT - services to improve or maintain fine motor skills). Record review of the resident's Nurses' Notes for 11/3/20 through 11/6/20 showed: -On 11/3/20 the resident returned to the facility with a brace to his/her right lower extremity due to the femur fracture. His/Her transfer status was non-weight-bearing. -On 11/4/20 the resident had periods of confusion and was being transferred with the use of a mechanical lift. -On 11/5/20 and 11/6/20 the resident had frequent yelling out episodes. The note on 11/5/20 showed the resident wanted help in taking off the right lower extremity brace. The note on 11/6/20 showed the resident was redirected easily and encouraged to use the call light. During a telephone interview on 10/29/20 at 12:45 P.M. the RD said: -The resident had complained of pain in his/her leg on 10/28/20 and the knee cap was not where it should be so the resident was sent to the hospital. -The resident has had a stroke and the injured leg is dead and gets caught by stopping and twisting, making the resident difficult to transfer. -The DON called CNA B, an agency staff person, who came in at 2:00 P.M. on 10/27/20 and left at 6:00 A.M. on 10/28/20. CNA B said he/she did not recall the resident complaining of pain during his/her shift. -CNA B did not work during the investigation because the resident's knee pain started before 6:00 A.M. after being transferred by CNA B. -The resident was sent to the hospital the morning of 10/28/20. -The resident did not complain of the CNA being rough with him/her on 10/28/20. At some point he/she told hospital staff a CNA was rough with him/her. -The hospital contacted the facility the morning of 10/29/20 and the facility started their internal investigation. During a telephone interview on 10/29/20 at 1:04 P.M. the Resident's Primary Contact A said: -The resident is difficult to understand related to a stroke. When the resident initially said the aide broke his/her leg, the resident had to repeat his/her statement multiple times in order to be understood. The resident did not give a name or description of the CNA and said the aide grabbed his/her arm in a rough manner. -The resident said multiple times the evening of 10/28/20 he/she didn't want to return to the facility. -The resident fell several years before and broke his/her right knee and the break had been repaired. -At this time the resident has an immobilizer on his/her knee. During a telephone interview on 10/29/20 at 9:47 A.M. the resident said a staff person at the facility hurt his/her leg. He/She was unable to tell the surveyor the name of the staff person or indicate if it was a male or female. He/She was very difficult to understand over the phone and was possibly sedated or sleepy. Before he/she could be fully interviewed the phone cut off. During a telephone interview on 10/29/20 at 10:20 A.M. Hospital Case Manager (HCM) A said: -The resident was forgetful and difficult to understand due to [MEDICAL CONDITION] (loss of ability to understand or express speech caused by brain damage such as a stroke). -The resident said a facility aide was rough with him/her and was unable to recall further information about the incident. The resident did not know the name of the staff member. -The resident said he/she liked living at the facility. During an interview on 10/30/20 at 11:30 A.M. CNA A said: -He/She had worked on the resident's hall the day shift on 11/27/20. When the day shift started at 6:00 A.M. the resident was already in his/her wheelchair. -The resident turned on his/her call light around 9:30 A.M. to use the rest room. He/She assisted the resident and took the wheelchair foot rests off prior to the transfer. The resident held onto a bar at the toilet, stood up without difficulty, was able to bear some weight on the right leg and transferred without difficulty. -At approximately 1:30 P.M. that same day he/she took the resident to the restroom. The resident bore some weight on the right leg and transferred smoothly. The resident had tapped him/her with his/her left foot and laughed in a playful, joking manner. -He/She was the only CNA who worked the resident's hall on the Day shift on 10/27/20. During an interview on 10/30/20 at 1:21 P.M. LPN B said: -The resident had required supplemental oxygen, possibly beginning on 10/26/20. He/She had not been compliant with wearing the nasal cannula (a device consisting of a lightweight tube which splits into two prongs on one end which are placed in the nostrils from which a mixture of air and oxygen flows). -He/She had lengthy interactions with the resident on the day shift on 11/27/20. The resident made no complaints of pain and he/she believed CNA A would have notified him/her if the resident had difficulty transferring. -The resident was able to bear some weight with his/her right leg and had no difficulty pivoting. -During the Day shifts of 10/27/20 and 10/28/20 there had been no complaints from the resident of any aide being rough. Additionally he/she had no such complaints within the past month from any resident. -He/She received report the morning of 10/28/20 from the night shift charge nurse that the resident had complained of right knee pain which started prior to 6:00 A.M. -The morning of 10/28/20 the resident did not say or give any indication that an aide was rough with him/her. The resident is capable of reporting abuse and neglect. The resident comes to him/her with any and every little thing as well as with big issues. That morning the resident seemed a little off and might have been slightly confused. Sometimes the resident had difficulty with timelines. That morning the resident said he/she could not stand up and the injury happened when he/she tried to stand with staff assistance. -He/She spoke with the resident around 7:30 A.M. and the resident was sent out to the ER around 8:30 A.M. due to the resident's leg condition as well as due to low oxygen levels. -CNA B was new within the past couple of weeks and he/she hadn't observed problems with the CNA during shift change. During an interview on 10/30/20 at 1:34 P.M. CNA E, an agency staff, said: -He/She didn't work on the resident's hall the evening shift of 10/27/20. Instead he/she worked another hall and worked the evening shift on 10/28/20 on a hall other than the resident's. It had been at least a couple of weeks since he/she had worked with the resident. The resident has said and he/she noticed the resident's right leg didn't move as well as it once did. The resident's right side had no strength and the resident couldn't stand on it and had difficulty pivoting with the leg. -He/She had never observed staff being rough with the resident and had not known the resident to complain of staff being rough with him/her. The resident will let staff know when he/she wants something such as adjusting his/her room temperature. During a telephone interview on 10/30/20 at 1:48 P.M. agency staff CNA B said: -He/She came to work at the facility on 10/27/20 at 2:00 P.M. and left work at 6:00 A.M. on 10/28/20. He/She worked with the resident, who needs assistance going to the rest room and getting dressed. -He/She took the resident to the rest room before supper on 10/27/20 and the resident seemed a little different and was weaker. -While getting the resident dressed for bed after supper he/she and the resident normally chatted a little. When he/she spoke to the resident the resident did not respond as much as usual and he/she continued to seem physically weak. He/She normally supported his/her own weight. Although the resident supported his/her own weight the evening of 10/27/20 he/she seems a little limper. He/She told the nurse who said he/she would keep an eye out on the resident. Throughout the night the nurse checked on the resident's oxygen levels and vital signs (temperature, BP, pulse and respirations). The resident was provided oxygen supplementation that night. The resident typically didn't require help once he/she went to bed and he/she didn't recall the resident putting on his/her call light during the night. -He/She got the resident up around 5:30 A.M. the morning of 10/28/20. The resident seemed extremely weak and was weaker than he/she was the previous day. The resident was able to bear weight that morning, but seemed limper than the previous evening. -He/She thought the resident was properly aligned for a transfer. He/She put the resident's pants and shoes on prior to transferring him/her from the bed into his/her wheelchair. Then he/she transferred the resident onto the toilet. He/She did not leave the resident alone on the toilet as he/she normally did because of the resident's extreme weakness and because the resident seemed off. He/She transferred the resident back into his/her wheelchair. At that point the resident asked to be transferred back into his/her bed after using the toilet. When transferring the resident from his/her wheelchair into his/her bed after toileting the resident was not able to bear weight much at all. His/her leg did not twist or drag during the transfer. When he/she transferred the resident onto his/her bed the resident said ow (the first sounds of ouch) and started rubbing his/her right knee with his/her right hand. -He/She asked the resident if he/she wanted to sit in his/her wheelchair and then transferred the resident back into the wheelchair. When transferring the resident a second time from the bed into his/her wheelchair the resident continued to be weak. -LPN C checked the resident out and said the knee did not seem swollen and told the resident he/she would get him/her some Tylenol. LPN C was still in the resident's room at the time he/she left the facility that morning. -It was clear at the time of the transfers that morning there had been a change in the resident related to extreme weakness. No body parts seemed twisted or out of alignment during any of the transfers. -He/She told LPN C, the Night shift charge nurse, that the resident complained of right knee pain and seemed weaker during transfers. The only time he/she left the resident since first getting the resident out of bed was to get the nurse. -He/She was unaware there was a problem with the resident until he/she came to work again at 2:00 P.M. the afternoon of 10/28/20. He/She did not know how much the resident had been moved after he/she left the facility at approximately 6:00 A.M. on 10/28/20. During an interview on 10/30/20 at 2:18 P.M. agency staff CNA C said: -The resident's weak side is his/her right side. He/She transferred with one-person assistance and always used the assist bar when transferring to the toilet. He/She could stand without difficulty and never had a problem with transferring. -He/She worked with the resident early the morning of 10/28/20 during the Day shift. Approximately five or ten minutes after he/she arrived at work the resident put on his/her call light. He/She took the resident to the toilet as he/she always did. While transferring the resident said his/her knee hurt. He/She noticed the resident was weaker and wobbly. He/She supported the resident with the gait belt onto the toilet and then noticed the resident's knee was swollen. It was probably 6:15 A.M. to 6:30 A.M. by then. -Nobody had told him/her when he/she started the shift that there was a problem with the resident's knee. The CNA from the Night shift told him/her everything was fine and there was nothing unusual except the resident, as well as a few other residents, required oxygen during the night. (The staffing sheet for 10/27/20 showed CNA B as the only CNA for the resident's hall the night beginning on 10/27/20). -He/She assisted another resident and noticed after that LPN B called Emergency Medical Services (EMS). EMS came within approximately 20 minutes. -CNA D did not assist the resident at all that morning. During an interview on 10/30/20 at 2:40 P.M. LPN C said: -CNA B reported that when he/she got the resident up the resident complained of the right knee hurting, which was not that unusual for the resident. -The morning of 10/28/20 the resident called out for assistance when he/she normally used the call light. -Around 5:30 or later the resident told him/her he/she wanted Tylenol because his/her knee hurt, which he/she was given. The resident did not appear to be in excruciating pain. The resident was rubbing his/her right knee and saying it hurt. He/She looked at the knee and found it was not swollen, red or out of alignment at the time. -When he/she gave LPN B the shift report he/she told him/her the resident had been given Tylenol for knee pain and had called out instead of using the call light. LPN B said the resident had done that the previous day. -The resident required oxygen on 10/27/20 during the Night shift. At first an oxygen tank was used and then an oxygen concentrator. -He/She noticed the night of 10/25/20 into the early morning of 10/26/20 the resident would sometimes call out when wanting help instead of using the call light which was different for the resident. During a telephone interview on 10/30/20 at 3:56 P.M. agency staff CNA B said: -The afternoon of 10/27/20 he/she knew something wasn't right as the resident seemed weaker and grimaced while transferring. He/She told the Evening charge nurse, LPN A, before supper on 10/27/20 that the resident didn't seem right and was weaker. He/She did not know if LPN A looked at the resident before supper. The nurse did not communicate with him/her any special instructions for transferring the resident. When he/she noticed the resident was weak during the after-supper transfers he/she did not recall if he/she reported a second time his/her concerns to LPN A. -When the resident got up the morning of 10/28/20 around 5:30 P.M. he/she transferred the resident from the bed into his/her wheelchair. He/She could tell the resident was weaker than he/she had been the evening before. He/She yelled for LPN C (CNA B did not mention yelling for help during the first interview), the Night charge nurse, from the resident's room and the nurse did not come. He/She was probably in a resident's room and didn't hear him/her so he/she transferred the resident from the wheelchair onto the toilet. He/She was afraid to leave the resident alone and did not think to put the call light on for the nurse's assistance. He/She then transferred the resident from the toilet back into his/her wheelchair. The resident wanted to go back to bed, which was unusual for the resident. Before he/she transferred the resident to bed he/she hollered for LPN C. He/She asked the resident if he/she wanted to sit back in his/her wheelchair to be ready for breakfast and then transferred the resident back into his/her wheelchair. -With each transfer that morning the resident kept grimacing and could still bear weight on his/her right leg and pivot, but could not take a step with the right leg. He/She used a gait belt on all transfers with the resident on 10/27/20 and 10/28/20. -He/She should have left the resident on the toilet and gotten the nurse or gotten the nurse before taking the resident to the toilet. Two telephone messages were left with a call-back number for LPN A in an attempt to interview him/her. LPN A was unable to be contacted by telephone. During an interview on 10/28/20 at 4:22 P.M. LPN C said: -CNA B should have told him/her immediately after the first transfer on 10/28/20 when he/she first noticed the resident was much weaker and had grimaced in pain. CNA B didn't say anything about the resident grimacing. -Because of the number of residents at the facility who had tested positive for COVID-19 many residents were weaker than normal. -He/She did not hear CNA B yell for help and had been passing medications. Had he/she been notified about the resident after the first transfer he/she could have assessed the resident at that time, which is what should have happened. During an interview on 10/30/20 at 4:40 P.M. the DON said: -He/She expected CNAs to report immediately to the charge nurse the first time they notice a change in a resident. -The nurse should always be notified upon the first signs of pain. A femur fracture is very painful even when the leg is at rest. -CNAs should always get the charge nurse immediately so they can assess the resident and provide guidance for the resident's care. During a telephone interview on 11/3/20 at 4:25 P.M. the resident's Physician said: -The charge nurse contacted him/her about the knee dislocation and the resident was sent to the emergency room (ER). -The resident's injury would be consistent with a turning injury. If the resident had been slung sideways the resulting rotation could have caused the fracture. If the resident's foot was planted on the floor and did not move along with the resident during the transfer the fracture could have happened then. If the resident's leg was twisted because he/she didn't lift or move the right leg it could have caused the fracture. -There could have been a hairline break prior to the full fracture. The fracture could have happened two or three transfers after a bad transfer if there had been just a small break originally. Fractures involving the knee can be bad. -The resident has always been weaker on his/her right side. -He/She did not think a break could have been covered up all night long. He/She thought the resident would have been hollering out in pain during the night. The leg would have swollen within a half-hour's time. He/She would find it hard to believe a break would have happened the night before and not be swollen and very painful. He/She thought the injury most likely happened the morning of 10/28/20, very soon before he/she was contacted about the knee injury. -He/She expected staff to follow policy protocol and immediately report any concerns and changes in the resident to the nurse. During an interview on 10/28/20 at 9:20 P.M. the resident said: -The injury happened in the morning before breakfast when he/she first woke up when a female aide was putting him/her to bed. (He/She was unable to provide a date). He/She did not know the staff person's name. -It happened when he/she was being transferred from the bed into his/her wheelchair (a discrepancy in the comment he/she had just made where he/she said the injury happened while being transferred into bed). -His/Her right leg was hurt just above the knee. -He/She was able to stand on his/her right leg, but after the injury he/she was no longer able to stand on the leg. -First he/she got out of bed and into his/her wheelchair in the morning. After his/her leg was hurt the aide took him/her to the bathroom. At that time he/she said something to let the aide know his/her leg was hurt. He/She said ouch and at some point told the aide his/her leg was broken and he/she couldn't stand on it any more. -After letting the aide know of his/her pain and injury the aide transferred him/her back into his/her wheelchair. -Soon after his/her leg was injured he/she told the nurse about it. -His/her leg was sore anyway and af

Based on interview and record review, the facility failed to ensure a resident's [DEVICE] Assisted Closure (Wound V.A.C. - negative pressure wound therapy, a type of therapy to help wound healing by decreasing air pressure around the wound with a vacuum pump which pulls fluid and infection from a wound) order was complete to include the suction settings, failed to provide education to the facility staff regarding [DEVICE], and failed to ensure the resident's wound vac dressing was changed per the resident's physician's orders [REDACTED].#6) out of eight sampled residents. The facility census was 103 residents. Record review of the facility's policy, revision date 01/02, Skin Condition Monitoring, showed: -The policy was to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. -The responsibility was for licensed nursing personnel. -Upon notification of a skin wound, the Charge Nurse was to assess the wound. -The Charge Nurse was to document the findings. -The Charge Nurse would notify the physician to obtain a treatment order if needed. -The treatment order would include; the type of treatment, the location of area to be treated, the frequency of how often the treatment was to be performed, how the area was to be cleansed, and a stop date if needed. -Documentation of the skin abnormality must occur upon identification. -Documentation of the skin abnormality must occur at least weekly thereafter until the area was healed. -Documentation of the area must include; size, shape, depth, color, presence of granulation tissue or necrotic tissue. -Documentation must include the treatment. -Documentation must include response to the treatment. -Documentation must include prevention techniques. Record review of the facility's policy, revision date 5/1/2016, Interim Assessment and Care Planning, showed: -It was the policy of Petersen Health Care to promptly assess and plan care for each Resident admitted to the facility. -A plan of care shall be developed appropriate to treat Resident based on his/her initial assessment to serve as a functional guide in delivery of care. -The Interim care plan is void upon completion of the comprehensive care plan or 21 days after admission. A wound vac policy was requested and not received from the facility. 1. Record review of Resident #6's undated face sheet showed the resident was originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Sepsis (a potentially life threatening condition caused by the body's response to an infection). -Heart failure (when the heart muscle does not pump blood as well as it should). -[MEDICAL CONDITION] (an irregular and often rapid heart rate). -Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). -Type 2 Diabetes (a group of diseases that result in too much sugar in the blood). -[MEDICAL CONDITION] ([MEDICAL CONDITION] - a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs). Record review of the resident's care plans, dated 10/13/19 and revised on 2/25/20, showed: -There was an admission care plan dated 10/13/19. -Updates to the baseline care plan; wound vac, abdominal incision dated 2/25/20. -The comprehensive care plan was dated 10/29/19. -(There were no quarterly updates). -(The resident was readmitted on [DATE]). -Monitor surgical wound daily was hand written in with no date or signature. -Monitor wound vac was hand written in with no date or signature. -Change canister as needed was hand written in with no date or signature. Record review of the resident's Hospital Physician's plan for the resident, dated 2/24/20, showed: -Repair left common femoral artery (supplies [MEDICATION NAME] blood to the leg) pseudoaneurysm (when a blood vessel wall is injured and the leaking blood collects in the surrounding tissue). -1000 milligrams (mg) of amniofill (tissue that is used to replace damaged tissue made from the placenta - an organ that develops in the uterus during pregnancy) to left groin wound. -Wound vac placement to left groin wound. Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) Entry, dated 2/24/20, showed: -The resident was totally dependent on staff for cares. -The resident needed the assistance of two staff members for bed mobility. -The resident was totally dependent on staff for bathing. -The resident needed a pressure reducing device for his/her bed. -Surgical wounds were not checked. Record review of the resident's History and Physical from the hospital, dated 2/27/20, showed: -The resident had been at a local hospital from 2/7/20 - 2/25/20. -The resident had been treated for [REDACTED]. -The resident had been treated for [REDACTED]. Record review of the February 2020 physician's orders [REDACTED]. -Daily skin checks 6 A.M. - 2 P.M. daily (dated 2/24/20). -Chart skin condition weekly on the back of the Treatment Administration Record (TAR) on Mondays (dated 2/24/20). -Wound team to consult for wound vac (dated 2/25/20). -Change dressing to the wound vac on the left groin Monday, Wednesday, and Friday between 6 A.M. to 2 P.M. -Check for the seal (on the wound vac) every shift 6 A.M. - 2 P.M., 2 P.M. - 10 P.M., and 10 P.M. - 6 A.M (dated 2/25/20). -The resident to have a shower on Tuesdays and Fridays 6 A.M. - 2 P.M. (dated 2/25/20). --Note: the orders did not include the wound vac settings. Record review of the resident's February 2020 TAR showed: -The wound vac dressing was to be changed Monday, Wednesday, and Friday on the 6 A.M. - 2 P.M. shift. -(The resident was admitted on [DATE]). -On the 27th no documentation by the facility staff the wound vac dressing change was completed. -On the 28th the staff had written their initials then circled them denoting the wound vac dressing change was not done. -On the back of the TAR staff had written that the wound vac representative was coming (it would be changed then). -(The representative did not come). -Note: the orders did not include the wound vac settings. Record review of the resident's February 2020 Nurse Notes showed: -On 2/25/20 the resident was admitted to the facility with a wound vac to the left groin. The wound vac was plugged in and running without problems. --Wound vac orders; dressing to be changed Monday, Wednesday, and Friday. --The wound care team was to follow up. -On 2/26/20 the wound vac remained running without problems. -On 2/27/20 the wound vac seal remained intact and the wound vac was running. -On 2/28/20 the wound vac was plugged in and the wound vac was running without issues. -On 2/29/20 the wound vac continued. Record review of the resident's February 2020 and March 2020 shower/abnormal skin report showed: -On 2/25/20 the sheet showed the resident was given a bed bath. --There was no notation on the diagram that there was a wound vac. --The sheet was signed by the Certified Nursing Assistant (CNA) and the nurse. -On 2/28/20 no documentation of a bath. -On 3/3/20 the sheet showed the resident was given a bed bath. --There was no notation on the diagram that there was a wound vac. --The sheet was signed by the CNA and the nurse. -On 3/6/20 the sheet showed the resident was given a bed bath. --There were notations on the diagram showing staples to the abdomen (47), a wound on his/her heel, wounds on his/her toes, and a wound on his/her left groin. --The sheet was signed by the CNA and the nurse. -On 3/10/20 no documentation of a bath. -On 3/13/20 the sheet showed the resident was given a bed bath. --There was no notation on the diagram that there was a wound vac. -There was a notation on the diagram the coccyx area was red, barrier cream was applied. -On 3/17/20 the sheet showed the resident was given a bed bath. -There was a notation on the diagram the coccyx area was red, barrier cream was applied. -There was a notation to see the nurse's notes regarding his/her feet. Review of the residents medical record, dated February 2020 to March 2020, showed no wound assessments done. Record review of the resident's March 2020 POS showed: -The resident should be sent out to the hospital for evaluation and treatment of [REDACTED]. -The telephone order was signed by the DON on 3/20/20. -The order was co-signed by the Nurse Practitioner (NP) on 3/25/20. Record review of the resident's March 2020 TAR showed: -The wound vac dressing was to be changed Monday, Wednesday, and Friday on the 6 A.M. - 2 P.M. shift. --Note: the orders did not include the wound vac settings. -The dressing was changed on 3/1/20. -The dressing was changed on 3/3/20. -On 3/6/20 the staff had written their initials then circled them denoting the wound vac dressing change was not done. -No documentation by the facility staff on 3/9/20 and 3/11/20 the resident's wound vac dressing change was completed as ordered by the resident's physician. -On 3/13/20 the staff had written their initials then circled them denoting the wound vac dressing change was not done. -On 3/16/20 the staff had written their initials then circled them denoting the wound vac dressing change was not done. --On the back of the TAR the staff had written the wound vac dressing was intact. --The wound vac was running. --The dressing was not changed do to lack of experience. --The DON was notified. -On 3/18/20 the staff had written their initials then circled them denoting the wound vac dressing change was not done. -(The resident's wound vac dressing was not changed between 3/9 -3/20/20). -The nurse had attempted to change it on 3/20/20, then sent the resident to the hospital. Record review of the March 2020 Nurse's Notes showed: -On 3/2/20 the wound vac was working. -On 3/3/20 the wound vac dressing was changed that shift and the left groin wound vac seal was good. -On 3/4/20 the wound vac was running, the wound vac was changed without difficulty, and the wound vac was in place. -On 3/5/20 the wound vac was running without issues and the wound vac was changed during the night. -On 3/6/20 the wound vac was running without issue. -On 3/10/20 the wound vac remains running without issues and the wound vac remained in place with no issues noted. -On 3/11/20 the wound vac was in place, the wound vac was running, and the canister was emptied earlier that shift. -On 3/12/20 the wound vac was running without issue. -On 3/13/20 the wound vac dressing to the left groin was secure and the wound vac was operating without difficulty. -On 3/14/20 the wound vac was running, the seal was good, the wound vac was intact, and the seal was intact. -On 3/17/20 the wound vac was functioning normally, the dressing seal was intact, the nurse spoke with the DON regarding wound vac supplies due to the canister was nearly full, the nurse could not find another canister in the building. The DON said the order had been placed. An unused canister was found in the medication room. The canister was replaced and the wound vac was functioning without difficulties at that time. -On 3/18/20 the wound vac was in place and functioning properly. -On 3/19/20 the wound vac was functioning normally and the seal was intact. -On 3/20/20 the nurse attempted to change the wound vac dressing due to it not being changed for at least a week. --The nurse removed the clear seal with some difficulty after turning the machine off. --The nurse noted that the black foam was too big for the area. --The nurse tried to pull the foam out but the foam was firmly stuck in the wound bed. --The nurse attempted to very carefully cut away the top layer. --The nurse was unable to remove the foam. --The nurse sprayed the foam with copious amounts of wound cleanser, then allowed it to soak for a few minutes. --A small piece of the bottom of the foam did release from the tissue. --The nurse noted bright red, beefy, tissue underneath. --The nurse attempted to pry up the rest of the foam carefully without success. --The nurse noted the foam was embedded in healthy tissue. --The wound bed started to bleed after a few seconds of trying to manipulate the foam. --The nurse stopped trying to manipulate the foam. --The nurse explained to the resident that the foam had tissue granulated inside causing it to be embedded in the skin. --The resident requested to go to the hospital to have it removed under local anesthesia. --The DON was notified. --The resident was sent to the hospital via ambulance. --There was no documentation that the Physician was notified at the time the resident had been sent to the hospital. -There was no documentation the family was notified. -There was no documentation of the wound vac settings. -There was no documentation of the drainage from the wound vac (color or amount). -There was no documentation of what the wound looked like (color, presence of infection, size). -There was no documentation of what was used for the dressing change. -There was no documentation of how the resident tolerated the dressing change. Record review of the resident's 3/20/20 hospital stay showed: -The resident was discharged from a hospital on [DATE] to the facility. -The resident's wound vac had not been changed for 17 days (while at the facility) when it was attempted (to be removed at the hospital) on day of admission (3/20/20). -The nurse was not able to remove the sponge from the resident. -The sponge was firmly adhered to the wound. -The resident was taken to the operating room by the physician on the day of admission (3/20/20). -The physician had to complete the removal of the sponge. -The physician placed a new wound vac on the resident. -The physician was considering further debridement (the removal of dead tissue) for removal of retained foam from the left groin. Record review of the Physician's Attestation (proof of something) by the NP, dated 3/23/20, showed: -The wound vac was removed by him/her and assessed. -Pink tissue and healthy with granulation present. -OK to discharge with regular wound vac only if case management can ensure the resident received adequate wound care after leaving (the hospital). -The resident was not to return to the same facility (he/she had resided in prior to hospitalization ). -The wound vac was to be changed three times a week, two times minimum. -The patient was to follow up in two weeks for wound evaluation in the physician's office. Record review of the 3/23/20 Administrator's investigation showed: -There had been an inservice on 2/10/20. -14 staff members had attended (five of the staff were nurses). -The inservice was titled Wound suctioning Device Emptying and Restarting (Hemovac, Davol, and Jackson Pratt). -The three devices were drainage devices and not a wound vac. -There had been an inservice on 3/23/20 on the wound vac and pressure care. -There were no instructions on how to use the wound vac attached to the attendance sheet. -13 Nurses had attended the inservice. -A telephone report from the hospital (undated) from a vascular surgeon had said the resident had been worked on for and hour and half. -The resident needed a reconstruction interventions to his/her left groin. -The resident still had foam in his/her skin. -The resident would have to go back to the operating room. During an interview on 9/28/20 at 10:00 A.M. the Director of Nursing (DON) said: -He/she had only been at the facility a couple of months. -He/she was not there at the time of the incident. -There should have been a better description of where the wounds were located at on the shower sheet. -He/she would expect the staff to fill out a shower sheet every day that the resident was scheduled to have had a shower. -The staff should have written on the shower sheet that the resident had refused or was too ill to have a shower on the shower sheet on the date they were scheduled. -The facility had change the wound team recently. -The wound team currently is made up of one of the physicians and a Licensed Practical Nurse (LPN) who round on each resident every week. -The LPN was recently promoted to the position of Wound Care Nurse. -He/she rounded with the physician so he/she could see what the wounds looked like. -He/she rounded with the physician so he/she could be educated from the physician on treatment cares for the residents. During an interview on 9/28/20 at 11:15 A.M., LPN C said: -He/she had worked with the resident. -He/she thought that the facility had an inservice about the wound vac before the resident came to the facility but he/she did not go to it. -He/she was scheduled to change the dressing on the wound vac but did not feel comfortable changing it. -He/she told the DON that he/she did not feel comfortable changing the dressing on the wound vac. -The DON told him/her not to worry about it, he/she would get someone else to do it. -He/She circled his/her initials on the TAR signifying that he/she had not done the dressing change. -After the resident went to the hospital, the DON had an inservice on the wound vac. -Although his/her signature was on the sign-in sheet, he/she didn't remember anything about it. -He/she does not check the care plans. -The wound care team would have been looking at the wounds weekly. -At the time there was a Nurse Practitioner (NP) who was doing wound care. -He/She remembered that the NP came into the building but, he/she did not see anyone because of COVID (a new disease caused by a novel (new) coronavirus). -The facility had a different wound care team now. -The CNA's did the showers. -They had a list of residents to give a shower to and on which day. -The resident was getting bed baths because of the wound vac. -If the CNA did not give the resident a bath/shower they were to tell the nurse. -It would be documented that the resident had refused on the shower sheet. -Staff should always follow the physician's orders [REDACTED]. -The physician should be called if the staff did not follow the order. -The wound vac should have been in the Care Plan. -He/She had not been told to check the setting or drainage from the wound vac. -It was the Charge Nurse's responsibility to see if the wound vac dressing was changed. During an interview on 9/28/20 at 11:50 A.M., CNA E said: -The CNA's have an assignment sheet that tells them which resident was to have a shower on their shift. -The Nurse made out the assignment sheets. -They were to look at the resident during their shower or bath. -If there were any new issues, they were to notify the nurse. -Staff were supposed to mark any wounds on the shower sheet. -Staff were supposed to fill out a shower sheet every time on every resident. -If a resident refused to take a shower for any reason, it was supposed to be written on the sheet. -Staff would tell the nurse that the resident had refused the shower. -Very few people refused to take showers from him/her. -There were a lot of agency people who did not fill out the shower sheets. -The Charge Nurse was responsible to make sure the physician's orders [REDACTED]. During an interview on 9/28/20 at 12:00 P.M., LPN D said: -On paycheck day the facility had an inservice on the Hemovac but his/her replacement was late so he/she was only there the last couple of minutes. -He/she did not remember anything about the inservice (his/her name was the last one on the sign-in list). -He/she remembered someone had brought a plastic buttocks for the in-service. -He/she had taken care of the resident on the days he/she was scheduled to have the wound vac dressing changed. -He/she told the DON, ADON, and MDS coordinator that he/she did not know how to do it. -They said someone else could do it. -He/she did not chart anything about the drainage or what it looked like. -The nurses were responsible to follow the physician's orders [REDACTED]. -The CNA's had a list of who got a shower that day. -They were to document whether or not the resident got a shower that day on the shower sheet. -The CNA signed their name on the shower sheet. -If the resident refused or was sick, that should be written on the shower sheet. -There was a diagram of a person on the shower sheet. -They were to indicate on the diagram where there was something abnormal on the resident's skin. -The shower sheet was turned in to the ADON. -He/she kept a log. -The ADON was ultimately responsible to make sure they were done. -The nurses did skin assessments on the TAR. -They should follow the physician's orders [REDACTED]. -If for some reason staff could not follow the order they were to call the resident's physician to notify him/her. -This would have been documented on the Nurse's notes. -The wound vac/dressing changes would have been care planned. -He/she did not read them. -There should have been an Admission care plan done upon admission by the nurse who had admitted the resident within the first 48 hours. -There should have been a care plan updated every quarter. -The nurse should have done a weekly skin check. -It should have been documented in the chart. During an interview on 9/28/20 at 12:35 P.M., CNA D said: -He/she remembered doing showers with the resident. -The resident always had a bed bath. -Each hallway had a list of who got a bath that day. -On the shower sheet staff should document any problems with the resident's skin. -That area was to be circled. -Staff would fill out the shower sheet for each time the resident was to have a bath or shower. -If the resident would refuse it would be written on the shower sheet. -The nurse signed the shower sheet. -It would then go to the ADON's office. -The nurse on the unit was ultimately responsible. During an interview on 9/28/20 at 12:45 P.M., LPN E said: -Staff would always follow the physician's orders [REDACTED]. -The wound vac orders including the suction should have been on the resident's POS. -When the wound vac canister or tubing was changed it should have been documented on the TAR. -There should have been documentation of the output from the wound vac. -There should have been documentation of what the output looked like. -He/she had experience with a wound vac when he/she had worked at a hospital. -The facility did not have a wound care team when the resident was there. -The nurse who was assigned for the resident was to do the wound care that day. -The nurse who did the wound care should have charted what it looked like. -He/she had taken care of the resident one time. -The wound vac/dressing change should have been care planned. -The CNA's should document on the bath sheets every time a bath was given or refused. -If there was anything different on their skin it should have been documented. -The nurse taking care of that resident was responsible to ensure the resident had a bath. -The nurse was responsible to ensure the bath sheet was filled out correctly. -The nurse was required to sign the bath sheet. -Agency CNAs often forgot to fill out the bath sheet. -Any change to a resident would be on the care plan. -The wound vac, incisions, and low air loss mattress would need to be on the care plan. -Some of the admission care plans seem to get lost. -Skin assessments would be done weekly. -It would be documented on the back of the TAR. -The nurse was ultimately responsible for ensuring the cares were charted correctly. -The nurse was ultimately responsible for ensuring the cares were were completed by the staff. During an interview on 9/28/20 at 1:30 P.M. the Administrator said: -He/she was notified of the wound vac dressings were not being changed as the physician had ordered which resulted in a nurse unable to change the dressing which resulted in the resident having been sent to the hospital to fix the wound, incident on the weekend. -There had been an in-service on 2/20/20 with the staff on [DEVICE]. -The educational material was attached to the sign in sheet. -Disciplinary actions were taken with the staff. -The DON who was ultimately responsible was suspended without pay and he/she was no longer with the facility. Unable to interview the former DON two attempts were made to contact him/her by phone on 9/28/20. During an interview on 9/28/20 at 1:55 P.M., the MDS/Care Plan coordinator said: -Care plans would be updated whenever there was a change in the resident's condition. -The date on the computer was wrong. -Baseline care plans were done separately. -Wounds were all put under pressure ulcers, there was no other place to put them. -The surgery should have been on the care plan but it was not on the computer. -The wound vac should have been on the care plan but it was not on the computer. During an interview on 9/28/20 the DON said: -The staff should have had education on the wound vac prior to the resident being admitted from the hospital. -The staff should have been educated on charting for the resident with a wound vac. -The staff should have been educated on which parameters needed to be called to the physician. -The staff should have been educated on the resident's intake and output while on a wound vac. -The staff should have been educated on instructions for operating the wound vac. -The staff should have been educated on dressing change instructions. -The staff should have been educated on what to do if the wound vac had a malfunctioned. -There should have been a wound tracking form completed by the wound nurse. -There was also a skin packet that would describe the wound, the wound measurements, and a description of the wound. -Wounds should have been seen on a weekly basis. -The DON was ultimately responsible. -The Administrator monitors the TARS weekly. -If there was an order that said wound care team to follow that would mean a wound company. -The NP came into the building, but because of COVID did not see any residents. -There had been a change in wound care companies. -The facility just promoted one of the LPNs to be the wound nurse. -The LPN now rounded with the physician so he/she knew what to do for each resident's treatment. -The DON was ultimately responsible to have made sure the physician's orders [REDACTED]. -The DON was ultimately responsible to make sure wound care was done appropriately. -The MDS coordinator was responsible to make sure care plans were done accurately. -The MDS coordinator was responsible to make sure care plans were done on time. -All staff should follow the physician's orders [REDACTED]. -The wound vac orders including the suction should have been on the resident's POS. -Bath sheets should have been filled out every time even if the resident refused. -Bruises, skin tears, and wounds should have been marked on it. -The charge nurse should be notified if the resident refused. -They were given to the ADON to monitor and his/her expectation was that it would be done. -He/she was not able to find any paperwork showing the Nurse Practitioner (NP) had seen the resident. During an telephone interview on 9/28/20 at 2:45 P.M. the NP for the resident's Physician said: -The resident had orders for a wound vac dressing change on Monday, Wednesday, and Friday. -There should have been orders from the surgeon concerning the wound vac. -The orders should have included what the setting on the machine was, usually at 75 millimeter of mercury (mmHg - a pressure setting) of suction. -The wound vac orders including the suction should have been on the resident's POS. -There should have been orders concerning the drainage. -He/she would have expected the nurses to document the amount of drainage, the color of the drainage, the size of the wound, the condition of the wound, and any infection in the wound. -He/she would have expected the nurses to have documented what wound care was done. -They should not have to have an order to do this they should know this. -They should have had education before the resident came from the hospital. -The facility did not call the physician when the resident went to the hospital. -The hospital had notified the resident's physician he/she was admitted to the hospital. -The facility should have also call the resident's family. -The facility should follow the physician's orders [REDACTED]. -The staff should chart what they have done. Complaint #MO 290

Based on observation, interview, and record review, the facility failed to ensure a sampled resident (Resident #108) was free from abuse when he/she sustained swelling to his/her right wrist and forearm, a deep purple bruise to his/her right wrist, a bluish-purple oblong fluid-filled pocket discolored area on the outer portion of his/her right forearm near the elbow measuring 5.4 centimeters (cm) by 2.7 cm, and had a cringed/grimacing look on his/her face as if he/she were going to cry, was scared, and did not want to be alone after the incident involving agency Certified Nursing Assistant (CNA) E. The facility further failed to monitor the whereabouts of agency CNA E after having been notified of the potential abuse, which potentially left other residents in the facility at risk and failed to complete a thorough investigation, including an assessment and interview with all residents who were potentially at risk. Seventeen residents were sampled. The facility census was 80 residents. Record Review of the facility Abuse prevention Program Policy revised [DATE] showed: -The administrator or designee would inform the resident representative of a report of an occurrence of potential abuse investigation was being conducted. -Then after the five days they were to inform the resident representative the conclusion of the investigation -If possible, abuse the investigation shall consist of the following: --Do a full body exam of the resident. Particularly in areas of resident complaint. --Check the resident range of monition. --Interview the resident's roommate, if appropriate. --Interview all residents to which the accused individual has regular contact. --Obtain a written or typed statement of incident, signed and dated by person being interviewed or witness. -Employees of this facility who had been accused of abuse would be immediately removed from resident contact until administrator or designee had reviewed the results of the investigation. Review of the facility contract with Staffing Agency dated [DATE] showed: -Section 1, The agency shall provide the client (the facility) with the following background information for each Healthcare Associate prior to commencement of each assignment, if required: --Skills checklist, Evidence of CPR, license verification and Criminal Background Check. -Section 2, the client obligation, representation and warranties obligation showed: --Orientation/training; client (the facility) shall provide health care associates approved for assignment with orientation and training sufficient to allow the health associate to effectively discharge duties at the client facility. --Management; Client shall assume all responsibility for the day-day management of Healthcare associates. --The client represents and warrants that it shall provide a healthcare associate with a reasonable, safe and healthy working environment in accord with all federal, state, local and professional laws, statutes and regulation. -The policy provided no details on training provided on abuse and neglect. 1. Record review of Resident #108's Profile Face Sheet showed he/she was admitted to the facility on [DATE] with following Diagnosis: [REDACTED].>-Dementia with behavioral disturbance (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -[MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's Care Plan dated of [DATE] showed he/she: -Had a known history of displaying inappropriate behavior and/or resisting care and services related to his/her [DIAGNOSES REDACTED]. -Was allowed time to express and verbalize frustration. -Should have facility staff introduce themselves upon contact, make eye contact, approach from the front, explain all procedures prior to start, seek resident input, and provide reassurance with all cares. -Should have facility staff use a consistent, calm, firm approach and use resident's name to help divert inappropriate behavior. -Had a self-care performance deficit and he/she needed supervision, required assistance to complete quality of care, and was poorly motivated to complete all Activities of Daily Living (ADL's), related to senile degeneration of the brain (decline or loss of nerve brain cells, gradually deteriorates, the patient loses intellectual function in key areas like speech, memory and spatial skills). -Required assistance of one staff member for transferring out of his/her bed and to his/her wheel chair and back. Record review of resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed he/she: -He/she had a Brief Interview for Mental Status (BIMS- an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 3; indicating he/she was severely cognitively impaired. -Was able to express ideas and wants. -Had the ability to understand others, he/she had clear comprehension. -Was on hospice (end of life) services. -Had no pain or skin issues noted. Record review the resident's physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. -Had an undated hand written physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. Record review of the facility security video footage of 500 hallway with Administrator, dated [DATE] showed: -Video camera time of 4:21:37 P.M., when Licensed Practical Nurse (LPN) D and Certified Nurses Aide (CNA) D were walking from the back of the 500 hallway. -At 4:21:40 P.M., the door to Resident #108 room door opened, agency CNA E, was wearing gray scrubs, at the entrance of the resident doorway and had begun to wheel the resident out of his/her room. -At 4:21:48 P.M., the resident was sitting in his/her wheelchair, when agency CNA E had pushed the resident's wheelchair and let go of his/her wheelchair into the hallway. --Agency CNA E said as he/she was exiting the resident's room You beat me up. --The resident was observed holding his/her right upper forearm and had grimaced look on his/her face. --The resident said, OhOh. -At 4:21:54 P.M., the agency CNA E turned and went back into the resident's room. -At 4:22:20 P.M., CNA D and Nurse LPN D were in the hallway when resident in his/her wheelchair was freely wheeling out into the hallway. --LPN D, turned around, the resident was moaning and LPN D went over to check on the resident. --The resident said, Oh, he/she hurt me, Oh Lord and had grimaced look on his/her face, while holding his/her right forearm. --CNA D walked up behind the resident in the hallway and asked LPN D What's the matter? --CNA D and LPN D, were observed talking with the resident and looking at his/her right forearm. --The resident again said Oh and had a grimaced look on his/her face. -Agency CNA E had walked out of the resident room with linens in his/her hands, walked past the resident, LPN D and CNA D and said, He/she can talk about stuff, but he/she beat me up. -LPN D had pulled the resident's right sleeve up and assessed the resident's arm. -Agency CNA E had then walked into the 500-hall shower room. -LPN D immediately wheeled the resident off the 500 hall. -At 4:22:44 P.M., CNA D and agency CNA E came out of the shower room. -Agency CNA E said, Talk about a beat down and then said he/she can be sweet as pie and he/she can be feisty. -The Administrator said the time stamp on the video was not correct and was off about 5 hours. **Note: the above time stamp of the video was not correct, the incident actually took place at 11:21 A.M. Record review of facility video footage dated [DATE] of the memory care main living area showed: -At 4:22:34 P.M., the resident was at the nursing station with Certified Medication Technician (CMT) A. -At 4:22:44 P.M., agency CNA E had walked behind the resident while he/she was seated by the nurse's station. -At 4:23:43 P.M., the agency CNA E had exited the memory care unit. **Note: the above time stamp of the video was not correct, the incident actually took place at 11:21 A.M. Record review of facility video footage dated [DATE] of the 300 hall showed: -At 4:23:31 P.M., LPN D exited the memory care unit. -At 4:23:44 P.M., LPN D walked up the 300 hall toward the front of the building. -At 4:24:10 P.M., agency CNA E left memory care unit and walked down the 300 hall. -At 4:26:28 P.M., the Director of Nursing (DON) and MDS Coordinator walked down the 300 hall toward the memory care unit. -At 4:29:06 P.M., the DON had exited the memory care unit. **Note: the above time stamp of the video was not correct, the incident actually took place at 11:21 A.M. Record review of facility video footage dated [DATE] of the main dining hall entrance, off the 300 hall showed at 4:25:10 P.M., CNA E walked off the 300 hall and turned toward the 200 hall. **Note: the above time stamp of the video was not correct, the incident actually took place at 11:21 A.M. Record review of the resident's Nurses Progress Note dated [DATE] at 11:20 A.M. showed: -He/she was cringing as if he/she were about to cry and was holding his/her right arm. -Assessment found a red bruise to his/her right posterior forearm. -The physician was notified and provided orders to obtain an x-ray of his/her right arm and to apply skin prep two times a day to the area until healed. Record review of the resident's Nurses Progress Notes dated [DATE] at 2:00 P.M.-10:00 P.M. shift note showed he/she: -Was on incident follow-up charting. -Had continued bruising on his/her right forearm, the bruising appeared more purple as the day went on. -Had negative and unremarkable X-ray results. During an interview on [DATE] at 2:05 P.M., the Administrator and DON said: -The resident resided on the memory care unit, on the 500 hall. -The resident had sustained a new bruise to his/her right forearm, alleged after direct care provided by agency CNA E. -The administrative staff escorted agency CNA E out of the building on morning of [DATE]. -[DATE] was the first time the DON had met agency CNA E and he/she was not sure if CNA E had worked at the facility prior to [DATE]. -The Administrator collected two staff witness statements from LPN D and CNA D for the investigation. During an interview on [DATE] at 2:20 P.M., LPN D said: -On [DATE] around 11:20 A.M., he/she was coming up the 500 hallway from another resident room, when he/she witnessed the resident, who was in his/her wheelchair, being shoved into the hallway, where the wheelchair was wheeling freely. -He/she heard agency CNA E say: Stop a derogatory word beating on me! as the resident wheeled out. -The resident was holding his/her right arm and he/she had a cringed look on his/her face, as if he/she were going to cry. -The resident said, the agency CNA E hurt him/her. -He/she in the presence of CNA D assessed the resident's right forearm and had noted a large fresh bruise. -He/she wheeled the resident to the nursing station and went to inform the Administrator and the DON of what happened. -The Administrator had him/her make a written witness statement. -He/she notified the resident's physician, and the resident's hospice nurse of the incident. -The physician ordered an x-ray of the resident's right forearm. -The resident was scared and did not want to be left alone. -He/she reassured the resident that the agency CNA E was gone and would not hurt him/her again. -The resident was able to make his/her needs known. -He/she did not assess or interview any other residents on the memory care unit after the incident. -He/she was not sure which residents agency CNA E might have assisted with cares on the morning of [DATE]. During an interview on [DATE] at 2:35 P.M., CNA D said: -He/she saw agency CNA E push the resident out into the hallway. -CNA E said the resident was beating him/her up, while trying to get the resident dressed. -The resident was holding his/her arm and showed signs of pain. -He/she asked the resident if his/her arm hurt and the resident said Yes. -He/she was with LPN D during assessment of the resident's right forearm when a new bruise was found. -LPN D notified administrative staff about the incident. -Agency CNA E had provided bath and showers for the resident on the morning of [DATE]. -The resident can become difficult with care at times and facility staff should know when he/she was resistant to care, facility staff were expected to wait and try again later at another time. -The resident needed coaching through his/her cares. Observation and interview on [DATE] at 2:45 P.M., showed: -The resident had on a brown sweater, was sitting in his/her wheelchair by the front desk area and was holding his/her right arm. -He/she said his/her right arm hurt and pointed from his/her wrist area to the elbow. -He/she was unable to be interviewed. During an interview on [DATE] at 2:50 P.M., Resident #109 said: -He/she was the roommate of Resident #108. -He/she had heard the resident say, Your hurting me, over and over. -He/she had heard agency CNA E tell the resident Don't hit me anymore, you are hurting me. -His/her beds faces in a different directions so he/she was not able to see what had happened. -Record review of the Resident #109's quarterly MDS dated [DATE] showed he/she had a BIMS of 13 and was cognitively intact. Record review of the Memory care CNA Shower sheets dated for [DATE] showed agency CNA E provided showers to six residents on memory care unit, not including Resident #108. During interview on [DATE] at 3:15 P.M., the Assistant Director of Nursing (ADON) and DON said: -They were not aware if LPN D had interviewed or assessed any other resident's that the agency CNA E may of provided showers or care to for on [DATE]. -They did not think about the need to assess other residents at that time. -The DON had performed a focused assessment of the resident's right forearm. Observation on [DATE] at 3:30 P.M., of the resident's right forearm with the ADON showed: -He/she had favored his/her right arm. -He/she had very frail thin skin. -He/she had an old yellowish discolored area on the top of right middle upper forearm. -He/she had a discolored deep purple area, size of quarter located just above the right wrist area. -The outer side of his/her right arm by the elbow was discolored bluish-purple with a fluid filled pocket area and was oblong in shape. -The ADON had measured the new area on the resident's right forearm by his/her elbow at 5.4 cm by 2.7 cm. -Record review of the resident's medical record did not find the description of the discolored area of the resident's right forearm or measurement of area affected. During an interview on [DATE] at 4:15 P.M., CNA C said he/she had the abuse and neglect training, if he/she had seen any issue related to abuse, he/she would notify the Administrator or the DON of the incident and ensure the safety of the resident involved. During an interview on [DATE] at 4:40 P.M., the DON said: -LPN D witnessed agency CNA E push the resident into the hallway and the resident complained of discomfort of the right forearm and had potential new bruising on his/her arm. -LPN D stayed in office to complete a witness written statement and he/she went to locate and remove agency CNA E on the memory care unit, when CNA E was found, he/she was had already left the unit for a lunch break and was in the staff breakroom eating lunch. -The Administrator and the DON interviewed agency CNA E on the incident. -They facility did not have agency CNA E write a written statement or have him/her sign a statement of what had happened. -He/she documented the interview on paper and agency CNA E had denied any wrongdoing. -He/she had called the staffing agency to inform them agency CNA E was asked to leave the facility until the investigation was completed. -He/she and the Administrator escorted agency CNA E out of the facility on [DATE] around 11:50 A.M. -The resident during assessment said, CNA E hurt me and twisted my arm. -LPN D had assigned a staff member to provided one-one observation for the resident when the report was made. -He/she and the Administrator notified the resident family member of the incident and the resident's physician had ordered an x-ray of the resident right wrist. -He/she had not notified law enforcement. -The facility's main goal was to ensure the safety of the resident from further potential abuse. During interview on [DATE] at 5:00 P.M., Administrator said: -LPN D notified them of potential abuse. -Immediate action was taken to remove agency CNA E off the memory care unit and to interview on what had happened. -Agency CNA E said the resident was combative while trying to provide care and agency CNA E had denied any wrongdoing. -He/she had not contacted law enforcement. Record review of CNA E employee file on [DATE] showed the facility did not have documentation of any abuse and neglect training. During a telephone interview on [DATE] at 10:29 A.M., the Administrator said he/she had contacted law enforcement the evening of [DATE]. Record review of the resident's Nurses Progress Notes dated [DATE] at 6:51 A.M. showed he/she had bruising to the right forearm remained black, purple and green with swelling. During telephone interview on [DATE] at 11:10 A.M., the physician said: -He/she was notified [DATE] by LPN D of the incident. -The facility had found a new bruise on the resident right forearm and the resident had complained of pain. -He/she had given a physician's orders [REDACTED]. -The facility staff was to monitor the resident for any changes to that area. -On [DATE], the resident had a telehealth physician visit and the physician had observed the resident's right arm and overall appearance. -The resident had a few more patching bruises on his/her arms. -He/she did not see any finger or palm print patterns. -The resident had elderly thin frail skin which easily bruised. -The resident was calm and was not in distress during the telehealth exam. -The resident denied any pain, but could not tell the physician what had happen. -The resident's X-ray results showed no fractures. -He/she was not aware or remembered any aggressive behavior by the resident. During an interview on [DATE] at 11:19 A.M., the Staffing Agency Branch Manager said: -He/she had received a call from the facility that agency CNA E, had been escorted from the facility. -The facility did not give details for the reason agency CNA E was sent away. -Agency CNA E provided a written statement to the staffing agency; the agency legal advice denied release of agency CNA E statement to the state agency. -Agency CNA E said he/she did nothing wrong, the resident was aggressive toward agency CNA E. -Agency CNA E employee work file had no personnel right ups or other action taken against him/her. During a telephone interview on [DATE] at 1:53 P.M., the resident's family member said: -The facility had notified him/her on [DATE] and was told the resident had come out of his/her room, crying and rubbing his/her arm. -The facility staff did not tell him/her how it happened and did not inform him/her any details of possible abuse. -On [DATE], he/she received a phone call from the local police officer, who said I bet you was expecting my call. He\she was surprised the police were calling. -The police officer informed the family member that, an employee had pushed the resident. -The police officer said he/she had reviewed the facility video system and saw what had happened. -He/she called the facility talked with the administration and asked why they did not inform him/her what actual happened to the resident. -The Administrator said he/she was not sure of all the details of what had happened or if agency CNA E had actually pushed the resident wheelchair. -He/she was not happy with the facility for not informing him/her with details of the incident. During an interview on [DATE] at 11:10 A.M., with Administrator said: -The facility's video cameras recordings times were not correct time of when the occurrence happen. -Each of the facility's video cameras varied on the timestamp. -The occurrence happened on [DATE] at around 11:20 A.M. in the 500 hallway, the facility video had the start time of 4:21 P.M. -The facility security video footage from [DATE] time were off about five hours and each section of hallway camera footage had difference in the minutes and seconds. During an interview on [DATE] at 11:50 A.M., Resident #109 said: -He/she did not hear or see any slapping or any smacking noises. -If he/she had, then he/she would had reported to nursing staff right away. -He/she heard the Resident #108 say over and over Stop It, Stop it, Hurting me! -He/she said Resident#108 had a history of [REDACTED]. -Facility staff had not interviewed him/her about the incident related to Resident #108. During interview on [DATE] at 11:55 A.M., LPN D said: -He/she did not assign any staff member to monitor the agency CNA E whereabouts after the occurrence. -His/her main concern was to ensure the safety of the resident and immediately inform the Administrator and DON of the incident. -The Administrator and DON would be responsible for the removal of agency CNA E from the unit and the building. -Agency CNA E said, as he/she walked by the resident, CNA D and LPN D the resident was beating on me. -No other resident had complaint of abuse or concern with cares. -He/she did not assess or ask question of other residents on the unit after the alleged incident. -He/she was not aware of any behaviors of the resident. -He/she provided cares for the resident that were physician ordered and on the resident's Medication Administration Record [REDACTED]. -He/she had not reviewed the resident Care plan, the MDS Coordinator updates the care plan. -Agency staff should ask questions if they do not know how to care for a resident. During interview on [DATE] at 12:10 P.M., CNA F said: -He/she worked on [DATE], but was on lunch break when the occurrence happen. -Early that morning, another resident was asking for assistance and CNA E said: --Hey! Hey!, agency CNA E turned and told the resident My momma did not name me Hey! --You need to call me by my name. -Agency CNA E had provided showers for memory care residents on the morning of [DATE]. -If a resident had refused care or swing, fight care, then he/she would walk away and come back try again later, or ask another staff member assistance. -He/she tried to let the new staff or agency staff know how to assist residents at the start of shift. -He/she had Abuse and Neglect in-service on [DATE] by the Assistant MDS Coordinator. During an interview on [DATE] at 1:10 P.M., DON said: -On ,[DATE] at 11:35 A.M., the DON and Administrator interviewed Agency CNA E on the incident and he/she had documented the statement. -CNA E was escorted out of the building at 11:50 A.M. -The facility main concern was to get agency CNA E out of the building for the safety of the resident. -LPN D did what he/she was instructed to do, he/she ensured the safety of the resident and immediately report to the administration. -LPN D had assigned a staff person to monitor the resident at the nurse's station. -The agency staff were responsible for asking facility charge nurse and CNA's questions on how to care for the residents. -CNA's may give report before each shift change to the next CNA on shift. -Agency staff were expected to ask the charge nurse if not sure on how to care for the resident or look at the residents medical records. -The administrator had notified the resident family member of the incident. During an interview on [DATE] at 1:40 P.M., the Administrator said: -He/she had notified the resident family member on [DATE] per the protocol immediately, he/she did not document the details. -He/she could not recall what he/she initially had said to the resident's family member. -It would depend on what the incident was and where the facility was at in the investigation on what was told to a family member. -The facility followed protocol, to ensure the safety of the resident. -He/she was not sure about the protocol of monitoring and would need to review the facility policy in monitoring the whereabouts of agency CNA E once the allegation was made. -He/she had found agency CNA E in the staff breakroom after the incident. -He/she and the DON had interviewed the agency CNA E and then escorted him/her out of the facility on morning of [DATE]. During a telephone interview on [DATE] at 8:03 A.M., agency CNA E said: -He/she had worked with the resident in the past. -On [DATE], he/she was getting the resident ready for lunch, He/she had changed the resident brief and was trying to transfer the resident from bed to wheelchair, when the resident became combative, hitting and scratching him/her. -He/she moved the resident's hand out of the way from hitting him/her. -Once the resident was in his/her wheelchair, agency CNA E had pushed the resident's wheelchair into the hallway, to pass the resident to CNA D. -CNA D said, Oh my god he/she was a hitter. -He/she then went on to lunch. -He/she had ask other CNAs how to transfer the resident, but they did not know. -He/she would never every hurt a resident. -He/she sent an email statement to his/her agency branch manager. -He/she tried to reassure the residents during care if they were to become combative or resistant with care, this was part of the dementia process. -He/she would just continue with resident care even if the resident was combative or swing at staff. -He/she did not stop care and ask for assistance for any other staff members for the care of the resident. -He/she had been a CNA for a long time and with a behavior unit you are going to have residents which can be aggressive and you just have to work with residents to finish the task. -He/she was not aware of any bruising on the resident arm. Record review of agency's CNA E email dated ,[DATE] at 1:25 P.M. to the agency staffing branch manager on [DATE] at 8:18 A.M. showed: -He/she worked on the Alzheimer's unit and helped the resident get out of bed. -The resident was hitting him/her with his/her fists and hands during cares. -He/she moved the resident hands to avoid it occurring anymore and assisted the resident into his/her wheelchair. -Resident #109 told Resident #108 to calm down. -This was not the first time Resident #108 had hit him/her, and he/she was not told that by any facility staff the resident hits and could become abusive. -The DON came into the breakroom and told him/her to come to the office after lunch break, then 5 minutes later the Administrator came and told me to come to the office immediately. -The DON asked questions about the incident, wrote agency CNA E's answers down. -He/she was asked to leave for the day because the administration had to investigate the incident. During interview on [DATE] at 9:22 A.M., DON said: -If a resident were to become aggressive or resistant during care, he/she expected direct care staff members to immediately stop care and grab another staff member to assist. -Would expect an agency CNA to ask for assistance if a resident became combative or resistant with care. -He/she expected all staff to report any behavior changes in a resident or if the resident became combative during cares. -Charge nurses should document in the resident's progress notes any behaviors reported. -Would expect the resident's care plan to be updated when there were reports of ongoing behaviors issue or behavior changes, combative or resistant with care. Review of the facility completed self-report investigation received by email on [DATE] included the following information: -On [DATE], LPN D charge nurse reported suspected physical abuse against the resident by agency CNA E. -Administration notified at 11:30 A.M. and went to find CNA E. -Agency CNA E was not found on the unit, agency CNA E was in the break room eating lunch at 11:35 A.M. -Agency CNA E was brought to administration office to get a statement. -Agency CNA E said the resident was hitting on him/her, called him/her out, called him/her names, when he/she picked up his/her arms. -Agency CNA E demonstrated the action on the DON by placing his/her hand on the DON's hand as if to lower from a raised position. -Agency CNA E gave his/her statement orally both to the Administrator and the DON, then was escorted to get his/her belongings and removed from the facility at 11:50 A.M. -Statements were collected from facility staff members who were mentioned during the course of the investigation. -Abuse and Neglect in-service for all staff was initiated. -The facility video footage on the incident showed agency CNA E rolling the resident into the hallway, the resident was clutching his/her arm stating, Ouch he/she hurt me. -LPN D took immediate action in assessment and protection of the resident. -Agency CNA E walked out of the shower room stating, Girl, he/she can be sweet as pie or he/she can be feisty. -It was determined abuse occurred by CNA E. -The staffing agency was notified of the allegation and investigation at the time of the incident and put on the do not return list. -The police were notified upon the exit of state surveyor on [DATE]. -The investigation had no resident interviews from the memory care unit noted. Review of facility's Supervisor Report of Counsel dated [DATE] showed: -LPN D listed as employee to receive counsel. -Date of Occurrence of [DATE] and Description of occurrence showed: --LPN D witnessed a potential abuse situation by agency CNA E to a resident. --LPN D took immediate action to assess the situation and address the resident's needs. --He/she then provided the resident with protective oversight by taking him/her to the nursing station and had another CNA watch over him/her as LPN D went to report the situation. --No one was assigned to the potential perpetrator. -Potential or actual consequences: not having the potential perpetrator monitored and or sent out could potentially leave other residents at risk. -Counseling showed: Although LPN D did an excellent job in recognizing the situation and protecting the resident involved. Education had been given on; also making sure that a potential perpetrator is not left without an escort or removed from the building even when going to report suspected abuse. During telephone interview on [DATE] at 1:37 P.M., the Administrat

Based on observation, interview, and record review, the facility failed to maintain a comfortable environment with air temperatures at or above 71 ºF (degrees Fahrenheit) on 1/18/2020, 1/19/2020, 1/20/2020, and 1/21/2020 in the following resident use areas: Resident rooms 201, 202, 205, 206, 207, 208, 210, 212, 102, 304 and 306, the front dining room and the Village Bistro; failed to implement a plan to monitor temperatures when the temperatures fell below 71 ºF; and failed to evacuate residents from those rooms or cease using the dining rooms when the temperatures dropped below 71 ºF. This failure affected all residents who resided in or used those areas, including twenty-one sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21) out of 21 sampled residents. The facility census was 82 residents. The Administrator was notified on 1/19/2020 at 11:03 P.M., of the Immediate Jeopardy (IJ) which began on 1/18/2020. The IJ was removed on 1/20/2020, as confirmed by surveyor onsite verification. Record review of the undated Cold Weather Policy and Procedure section of the facility's disaster response plan, showed: -It is the policy of the facility to provide continuing, safe and comfortable care to the residents in the event the facility power source becomes non-operational or the facility heating and furnace systems fail during periods when unseasonably cold outside temperatures are present and such systems are required for resident safety and comfort. If the facility heating systems fail, facility personnel shall take the following action: -A staff member will be designated to call the local electric department to determine the cause of the problem and the duration of the outage. If the problem is determined to be in the facility's own heating systems, the maintenance man or Administrator will determine the appropriate course of action; -Staff will be assigned to bring all residents to the central core of the building, including the dining area or lounge areas; -Staff will keep doors and windows closed to retain as much heat as possible; -Staff will be assigned to do 10 minute checks on all residents to determine their safety and comfort level; -Staff will be assigned to do 15 minute temperature checks throughout all areas of the building; -If the core temperature of the area occupied by the residents and staff drops below 55 ºF (degrees Fahrenheit) for more than 12 hours, the facility will immediately implement the evacuation procedures outlined in the Facility Disaster Plan; -The cold weather policy did not include a plan to move residents to a warmer part of the building. Record review of Resident #1's quarterly Minimum Data Set (MDS - a required, federally mandated assessment tool completed by facility staff for care planning), dated 11/22/2020, showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her activity of daily living (ADLs). Record review of Resident #2's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #3's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #4's quarterly MDS, dated [DATE], showed: -He/She was cognitively impaired; -He/She required extensive assistance for his/her ADLs. Record review of Resident #5's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #6's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #7's annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #8's quarterly MDS, dated [DATE], showed: -He/She was not cognitively intact; -He/She was totally dependant for all ADLs. Record review of Resident #9's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #10's admission MDS, dated [DATE], showed: -He/She was cognitively impaired; -He/She required extensive assistance for his/her ADLs. Record review of Resident #11's MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She was totally dependant for all ADLs. Record review of Resident #12's PPS 5 day MDS, dated [DATE], showed: -He/She was not cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #13's annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required set up assistance only for his/her ADLs. Record review of Resident #14's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #15's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #16's quarterly MDS, dated [DATE], showed: -He/She was not cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #17's annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He She was totally dependant for all ADLs. Record review of Resident #18's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She was totally dependant for all ADLs. Record review of Resident #19's annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required supervision or oversight for his/her ADLs. Record review of Resident #20's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of Resident #21's admission MDS, dated [DATE], showed: -He/She was not cognitively intact; -He/She required extensive assistance for his/her ADLs. Record review of the weather underground official local weather for the city and state where the facility was located from 1/18/2020 till 1/21/2020, showed: -On 1/18/2020 at 3:00 A.M. temperature was 40ºF; 6:00 A.M. temperature was 34ºF; 9:00 A.M. temperature was 23ºF; 12:00 P.M. temperature was 26ºF; 3:00 P.M. temperature was 31ºF; 6:00 P.M. temperature was 28ºF; 9:00 P.M. temperature was 27ºF; -On 1/19/2020 at 12:00 A.M. temperature was 23ºF; 3:00 A.M. temperature was 18ºF; 6:00 A.M. temperature was 11ºF; 9:00 A.M. temperature was 13ºF; 12:00 P.M. temperature was 17ºF; 3:00 P.M. temperature was 20ºF; 6:00 P.M. temperature was 16ºF; 9:00 P.M. temperature was 13ºF; 11:00 P.M. temperature was 11ºF; -On 1/20/2020 at 3:00 A.M. temperature was 13ºF; 6:00 A.M. temperature was 13ºF; 9:00 A.M. temperature was 14ºF; 12:00 P.M. temperature was 15ºF; 3:00 P.M. temperature was 17ºF; 6:00 P.M. temperature was 11ºF; 9:00 P.M. temperature was 8ºF; 10:00 P.M. temperature was 7ºF; -On 1/21/2020 at 12:00 A.M. temperature was 6ºF; 3:00 A.M. temperature was 5ºF; 6:00 A.M. temperature was 9ºF; 9:00 A.M. temperature was 14ºF; 12:00 P.M. temperature was 21ºF; 3:00 P.M. temperature was 29ºF; 6:00 P.M. temperature was 29ºF. Observations of facility temperatures on 1/19/2020 between 7:21 P.M. and 7:36 P.M. showed: -The front dining room was 65.4 ºF and contained at least six residents and one staff person; -The Village Bistro, a side dining room across the hall from the front dining room was 64.4 ºF; -The corridor between resident rooms [ROOM NUMBERS] was 64.0 ºF; -The corridor outside resident room [ROOM NUMBER] was 62.5 ºF; -Resident room [ROOM NUMBER] was 66.0 ºF. During an interview on 1/19/2020 at 7:34 P.M., Registered Nurse (RN) A, the weekend supervisor, said: -He/She did not know what the acceptable range of air temperatures should be; -He/She had taken only one temperature during the day and he/she did not write the temperature down; -He/She did not recall specifically where in the facility the temperature was taken from. During an interview on 1/19/2020 at 8:06 P.M., the Maintenance Director said the following: -RN A took one temperature measurement earlier on 1/19/2020 somewhere on the 100 Hall and the temp was 71 ºF or so; -Repairs were done to the heating system on 1/16/2020; -There were 2 boilers in a series that provided heat for the baseboard heating system. Observation with the Maintenance Director on 1/19/2020 at 8:09 P.M., showed a temperature of 61 ºF on the thermostat in the front dining room. Observation with the Administrator on 1/19/2020 at 8:12 P.M., showed the temperature of the front dining room was 63.1ºF. During an interview on 1/19/20 at 8:16 P.M., the Maintenance Director and the Administrator both said they did not take temperatures in the 200 Hall when they came in on the afternoon of 1/19/2020. Observation of resident room [ROOM NUMBER] on 1/19/2020 at 8:19 P.M., showed the resident room temperature was 66.0 ºF. Observation of resident room [ROOM NUMBER] on 1/19/2020 at 8:24 P.M., showed the resident room temperature was 68.5 ºF. During an interview on 1/19/2020 at 8:29 P.M., Resident #1 said: -He/She had been cold and had been sitting under blankets all day; -He/She felt no heat from the baseboards; -He/She would be more comfortable if there was more heat. During an interview on 1/19/2020 at 8:35 P.M., Resident #2 said: -The temperature had been cold throughout the day; -He/She used a blanket to stay comfortable; -Observation showed he/she had one extra blanket. During an observation and interview on 1/19/2020 at 8:59 P.M., Licensed Practical Nurse (LPN) A said: -He/She had been wearing his/her coat since his/her shift had begun; -It was cold on 1/18/2020, but it got worse on 1/19/2020; -Observation showed LPN A wearing a coat. During an interview on 1/19/2020 at 9:01 P.M., the Maintenance Director and Administrator said: -On 1/16/2020, he/she had contacted Local Heating Repair Company A; -The repair person sent by Local Heating Repair Company A told them to bleed the pipes (a process to release air that blocked the heat from the boilers (a closed vessel in which fluid (generally water) is heated. The fluid does not necessarily boil. The heated or vaporized fluid exits the boiler for use in various processes or heating applications, including water heating, central heating); -Once the pipes were bled, the pipes from the boilers got hot; -1/16/2020, the temperatures were right around 70 ºF; -1/16/2020 and 1/17/2020, temperatures in the building were not documented; -1/18/2020, the outside temperature started to drop after being in the upper 50's; -1/18/2020 and 1/19/2020, temperatures in the building were not documented; -There was no contact with a local heating repair company from 1/17/2020 through 1/19/2020 before the state surveyor was onsite; -On 1/20/2020, in the late afternoon the Maintenance Director called a local heating repair company after the surveyor was onsite. During an interview on 1/19/2020 at 9:12 P.M., Resident #3 said: -It had been cool for about 3-4 days; -He/She had noticed the front dining room was cold. During an interview on 1/19/2020 at 9:15 P.M., RN A said: -The facility had been cool since the evening of 1/18/2020; -1/19/2020 was the coldest day and night; -He/She had not noticed that anyone took temperature measurements in the facility. During an interview on 1/19/2020 at 9:35 P.M., Certified Nurse's Assistant (CNA) A said: -The temperature was kind of cold; -He/She had not been trained in how to respond to cold temperatures in the facility. Observations with the Maintenance Director on 1/19/2020 from 9:52 P.M. through 10:22 P.M., showed: -The front dining room and occupied resident rooms had the following temperatures: --The front dining room was 63.1 ºF; --Resident room [ROOM NUMBER] was 69.9 ºF; --Resident room [ROOM NUMBER] was 68.8 ºF; --Resident room [ROOM NUMBER] was 66.1 ºF; --Resident room [ROOM NUMBER] was 67.4 º; --Resident room [ROOM NUMBER] was 66.0 ºF; --Resident room [ROOM NUMBER] was 65.0 ºF; --Resident room [ROOM NUMBER] was 66.6 ºF. Observation of Resident #16's room on 1/19/2020 at 10:53 P.M., showed the air temperature was 65.0 ºF. During an interview on 1/19/2020 at 10:05 P.M., Resident #4 said: -He/She had been cold since last week; -He/She had been really cold since the night of 1/18/2020; -A CNA had placed a plastic bag over the air conditioner unit. During an interview on 1/20/2020 at 12:36 A.M., LPN B said: -He/She noticed the front area of the facility started to get cold during the 10 P.M. through 6 A.M., shift on 1/18/2020. Observation with the Corporate Maintenance Person on 1/20/2020 at 12:04 P.M., showed: -At least fourteen residents were in the dining room for the noon meal and many had their coats on; -The front dining room and occupied resident rooms had the following temperatures: --The front dining room was 63.5 ºF; --room [ROOM NUMBER] was 64.0 ºF; --Village Bistro was 65.8 ºF; --room [ROOM NUMBER] was 68.8 ºF; --room [ROOM NUMBER] was 67.3 ºF; --room [ROOM NUMBER] was 65.7 ºF; --room [ROOM NUMBER] was 65.8 ºF; --room [ROOM NUMBER] was 64.5 ºF; --room [ROOM NUMBER] was 68.5 ºF; --room [ROOM NUMBER] was 66.3 ºF; --room [ROOM NUMBER] was 66.8 ºF; --room [ROOM NUMBER] was 66.2 ºF. During an interview on 1/20/2020 at 1:10 P.M., the Director of Nurses (DON) said: -Three residents, Resident #6, Resident #8 and Resident #12, were moved to a different room in the facility for comfort related to the air temperature. Observation on 1/20/2020 at 1:15 P.M., showed sixteen residents remained in identified compromised air temperature resident rooms. During an interview on 1/20/2020 at 2:15 P.M., the Administrator said: -He/She had not looked at the disaster plan in reference to the Emergency Preparedness regulations that were promulgated (put into effect) in 2017; -He/She understood the temperature ranges mentioned should be congruent with actual regulations. During an interview on 1/20/2020 at 2:29 P.M., LPN C said: -It had been chilly in the facility since 1/17/2020. During an interview on 1/20/2020 at 2:31 P.M., the Care Plan Coordinator said: -The staff had been wearing jackets and coats since 1/17/2020. Observation on 1/20/2020 at 2:45 P.M., showed facility staff had begun to clear out empty rooms where air temperature was within the expected range to move the remaining sixteen residents identified with compromised rooms. Observation on 1/20/2020 at 3:59 P.M., showed: -Resident #4 was in bed with two blankets and a coat on while he/she spoke with the DON. During an interview on 1/21/2020 at 9:50 A.M., Family Member 1 said: -He/She was at the facility on 1/18/2020 from 4:30 A.M. to 2:30 P.M.; -He/She had his/her coat on to keep warm during the visit with Resident #21; -Resident #21 had four blankets on; -Resident #4 had asked him/her to ask facility staff for another blanket; -He/She had requested a facility staff person to turn the heat up and the facility staff person said the facility had been trying to fix the boiler for a week; -The hallway outside the resident room was warmer; -He/She observed two old dial thermostats in the hallway on either side of the resident room, one was set at 72 F and read only 60 F, the other was set at 85 F and read only 69 F; -Resident #21's bed was pushed against the wall which was colder from the draft in the window; -He/She had observed a few windows outside covered in plastic. During an interview on 1/21/2020 at 1:26 P.M., the Maintenance Director said: -Local Heating Repair Company A was onsite earlier in the day, but the company could not perform the repair, because their person who repaired boilers was not available; -The facility had to contact Local Heating Repair Company B; -He/She received notification from Local Heating Repair Company B at 1:28 P.M., that Local Heating Repair Company B was on the way to the facility. During an interview on 1/21/2020 at 1:59 P.M., the Regional Director of Operations said: -The temperatures were not monitored in the areas where the temperatures were below 71 ºF on an hourly basis; -There was a miscommunication to LPN B on the night of 1/19/2020. LPN B thought he/she had to check only two rooms per hour. During an interview on 1/21/2020 at 4:17 P.M. the Hospice Social Worker said: -He/She was at the facility on 1/18/2020 from 9:20 A.M. to 12:04 P.M. to sit with Resident #21 who was actively dying; -The building was chilly; -He/She kept his/her coat on the entire visit; -Resident #21 had four blankets on him/her for comfort; -Resident #4 said he/she had given Resident #21 his/her comforter; -Resident #4 said the heater had been broken for several days. During an interview on 1/22/2020 at 3:55 P.M. Hospice Staff A said: -He/She was at the facility on 1/18/2020 from 3:00 P.M. to 7:00 P.M. to sit with Resident #21 who was actively dying; -The building was cold; -He/She had spoken to the nurse when the nurse was passing medication and the nurse said the heater was not working; -The nurse had a two jackets and a scarf on; -He/She sat with his/her coat on the entire visit; -Resident #21 had four blankets on; -Resident #4 had said on 1/17/2020, Resident #21 was cold and gave his/her blanket to Resident #21; -Resident #4 had four blankets on; -While at the facility neither Resident #4 or Resident #21 was offered a room change. During an interview on 1/22/2020 at 10:29 A.M., Local Heating Repair Company B Technician said: -The heating system malfunctioned, because the system had an air lock (a blockage of the heating system pipes caused by air); -The air lock was in the pipes going from the boilers to the baseboard heating system; -The air lock was located closer to the baseboards because of the malfunctioning air vents, because air takes the place of water; -Air vents were replaced on all three boilers, because the previous air vents were clogged with calcium from hard water (water that has high mineral content) deposits; -Once the air was moved out, water started circulating through the pipes and delivering heat through those pipes. During an interview on 1/22/2020 at 4:11 P.M. the facility physician said: -The facility had not notified him/her directly the facility was not able to maintain air temperatures for the residents; -He/She was at the facility on 1/21/2020, while he/she did not know the temperature it did not feel like the normal air temperature; -He/She expected the facility to maintain air temperatures for resident comfort, following the facility plan. During an interview on 1/23/2020 at 9:12 A.M., the Administrator and the Maintenance Director said: -RN A had brought it his/her attention on the afternoon of 1/18/2020 the facility temperatures had begun to drop in the building; -No one was assigned to take the facility temperatures inside the building at that time. During an interview on 1/23/2020 at 9:15 A.M., the Administrator said: -He/She was not aware of anyone who had notified resident family members or responsible parties when the facility temperatures had begun to drop on 1/18/2020 or after. During an interview on 1/23/2020 at 9:20 A.M., the Maintenance Director said: -The first temperature was taken on the evening of 1/19/20, when the state surveyor was onsite. During an interview on 1/23/20 at 9:29 A.M., the Corporate Regional Director said: -Thermometers were in the facility corridors, but the thermometers were not reliable at this time; -The thermometers needed to be replaced. During an interview on 1/23/20 at 10:45 A.M., Resident #6 said: -His/Her room was cold on the north side; -He/She was moved to his/her new room on 1/20/2020. During an interview on 1/23/2020 at 10:53 A.M., Resident #18 said: -His/Her former room got cold; -He/She slept in the dining room on the night of 1/19/2020 through the morning of 1/20/2020; -He/She preferred the warmer temperatures today, 1/23/20 as opposed to the temps that existed on 1/18/2020, 1/19/2020 and 1/20/2020. During an interview on 1/23/2020 at 10:57 A.M., Resident #17 said: -He/She was cold this past weekend; -He/She had to wear his/her jacket; -He/She was not moved from his/her room; -He/She preferred the warmer temperatures of today. During an interview on 1/23/2020 at 11:02 A.M., Resident #13 said: -He/She was moved to a new room with warmer air temperature on 1/20/2020 in the afternoon; -His/Her room was cool this past weekend; -He/She returned to her room [ROOM NUMBER]/23/2020. During an interview on 1/23/2020 at 1:22 P.M., the DON said: -The facility staff should have started monitoring the residents for signs and symptoms of hypothermia quicker and he/she should have insisted on moving the residents to the warmer areas of the facility upon notification of the colder temperatures on 1/19/2020. During an interview on 1/23/2020 at 1:56 P.M., the Administrator said: -He/She should have reported to the state agency, and began monitoring air temperatures on the first day cold temperatures were reported; -He/She was notified 1/18/2020 of the air temperature feeling cold. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 671

Based on observation, interview and record review, the facility staff failed to complete ongoing skin assessments for one sampled resident's (Resident #9) unavoidable pressure ulcers and failed to adequately monitor and document the resident's pressure ulcers which showed the resident had one Stage IV wound on his/her coccyx/pelvis sacrum, one Stage IV wound on his/her right hip and four Stage II wounds on his/her left hip; and failed to complete weekly skin assessments on two sampled residents (Resident #13 and Resident #7) who were at risk for pressure ulcers. The facility failed to document one resident's (Resident # 11) wound measurements and the description of the resident's Unstageable pressure ulcer that was pre-existing, which the resident had when the resident was admitted to the facility on [DATE], failed to accurately complete the resident's daily skin assessment who was at high risk for further skin breakdown, and failed to accurately complete an Interim Care Plan on admission that instructed staff on the resident's needs; further, the facility staff failed to document wound measurements and descriptions of two Stage II pressure wounds for one resident (Resident #10); failed to document wound measurements and descriptions of two Stage III pressure wounds for one sampled resident (Resident #4); and failed to accurately complete daily skin assessments on residents who were at high risk for skin breakdown for five sampled residents (Residents #3, #4, #5, #6 and #10) out of 17 sampled residents. Also, the facility staff failed to consistently follow the facility's policies and procedures for their Preventative Skin Care policy, Pressure Sore Prevention Guidelines, Decubitus Care/Pressure Areas policy, and Pressure Ulcers-Nutritional Interventions policy. Four of the 17 sampled residents (Residents #4, #9, #10, and #11) had pressure ulcers. The facility identified seven residents with pressure ulcers (excluding Stage I), with two of the residents entering the facility with their pressure ulcers. The facility census was 82 residents. Record review of National Pressure Ulcer Advisory Panel (NPUAP) at www.npuap.org, Prevention and treatment of [REDACTED]. -A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. -The NPUAP developed a common definition and classification system for pressure ulcers and describes the levels of injury: - Stage I: Intact skin with Non-blanchable [DIAGNOSES REDACTED] (redness); (Blanching is when blood (redness) presses away and then returns when skin is pressed on with fingertip pressure) Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons. -Stage II: Partial thickness skin loss: Partial thickness loss 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 fluid-filled blister. Presents as a shiny or dry shallow ulcer without slough (yellow, tan, gray, green or brown tissue) or bruising. Bruising indicates deep tissue injury. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. -Stage III: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (yellow, tan, gray, green or brown tissue) may be present but does not obscure (hide) the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies by body location. The bridge of the nose, ear, back of head and side of ankle do not have adipose (fat tissue) and Stage III ulcers can be shallow. In contrast, areas of significant adiposity (fat tissue) can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable (able to be felt). -Category/Stage IV: Full thickness skin loss: Full thickness skin tissue loss with exposed bone, tendon or muscle. Slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) may be present in the wound bed. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by body location. The bridge of the nose, ear, back of head and side of ankle do not have fat tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis (bone infection) likely to occur. Exposed bone/muscle is visible or directly able to be felt. -Unstageable/ Unclassified: Full thickness skin loss, Depth unknown: Full thickness skin tissue loss in which the actual depth of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; But, it will be either a Stage III or IV. Stable (dry, attached, intact without redness or movement) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. -Suspected Deep Tissue Injury (SDTI), depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to surrounding tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution (progression of the wound) may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. NPUAP Recommended Risk Assessment Policy: 1. Establish a risk assessment policy in all health care settings. -Each health care setting should have a policy in place that includes clear recommendations for: A structured approach to risk assessment relevant to that health care setting; Clinical areas to be targeted; The timing of risk assessment and reassessment; Documentation of risk assessment; and Documentation of that information to the wider health care team. 2. Educate health care professionals on how to achieve an accurate and reliable risk assessment. 3. Document all risk assessments. Documentation of risk assessments ensures communication within the multidisciplinary team, provides evidence that care planning is appropriate, and serves as a benchmark for monitoring the individual's progress. NPUAP Recommended Risk Assessment Practice: 4. Use a structured approach to risk assessment to identify individuals at risk of developing pressure ulcers. A structured approach may be achieved through the use of a Risk Assessment Scale in combination with a comprehensive skin assessment and clinical judgment. Evidence suggests that the introduction of those elements, in conjunction with the establishment of skin-care teams, education programs, and care protocols, can reduce the incidence of pressure ulcers. 5. Use a structured approach to risk assessment that includes assessment of activity and mobility. Consider individuals who are bedfast and/or chair-fast to be at risk of pressure ulcer development. 6. Use a structured approach to risk assessment that includes a comprehensive skin assessment to evaluate any alterations to intact skin. Consider individuals with alterations to intact skin to be at risk of pressure ulcer development. Alteration in skin condition may include dry skin, [DIAGNOSES REDACTED], and other alterations. The presence of non-blanching redness also increases the risk of further pressure ulcer development. 7. Use a structured approach to risk assessment that is refined through the use of clinical judgment informed by knowledge of key risk factors. 8. Consider the impact of the following factors on an individual's risk of pressure ulcer development: -Nutritional indicators: Nutritional indicators include [MEDICAL CONDITION], hemoglobin and serum [MEDICATION NAME] levels, measures of nutritional intake, and weight; -Factors affecting perfusion and oxygenation: Factors affecting perfusion include Diabetes, [MEDICAL CONDITION], Low blood pressure, and Supplemental oxygen use; -Skin moisture: Both dry skin and excessive skin moisture are risk factors; and -Advanced age. 9. Consider the potential impact of Friction and shear, Sensory perception, General health status, and Body temperature on an individual's risk of pressure ulcer development. 10. Conduct a structured risk assessment on admission, and repeat regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition. 11. Develop and implement a prevention plan when individuals have been identified as being at risk of developing pressure ulcers. Risk factors identified in a risk assessment should lead to an individualized Plan of Care to minimize the impact of those variables. NPUAP Recommended Skin Assessment: 1. Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care settings. Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment relevant to the setting, as well as for clinical areas to be targeted and the timing of assessment/reassessment. It should make clear recommendations for documenting skin assessment and communicating information to the wider health care team; 2. Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION] (swelling), and induration (hardness). These additional assessment techniques can be used in caring for all individuals. However, there is evidence that Stage I pressure ulcers are under-detected in individuals with darkly pigmented skin because areas of redness are not as easily seen. 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. On-going assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration, especially in individuals with darkly pigmented skin. Localized heat, [MEDICAL CONDITION], and induration have all been identified as warning signs for pressure ulcer development. As it is not always possible to see signs of redness on darkly pigmented skin, these additional signs should be considered in assessment. 5. Ask individuals to identify any areas of discomfort or pain that could be attributed to pressure damage. A number of studies have identified pain as a major factor for individuals with pressure ulcers. Several studies also offer some indication that pain over the site was a precursor to (early sign of) tissue breakdown. 6. Observe the skin for pressure damage caused by medical devices. Many different types of medical devices have been reported as having caused pressure damage (Example: bladder catheters, oxygen tubing, neck collars, casts, splints, etc.). 7. Document all skin assessments, noting details of any pain possibly related to pressure damage. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals. 8. Whenever possible, do not turn the individual onto a body surface that is still reddened from a previous episode of pressure. Redness indicates that the body has not recovered from the previous pressure loading and requires further rest from repeated pressure. 9. Do not use massage for pressure ulcer prevention. Massage is contraindicated in the presence of acute inflammation and where there is the possibility of damaged blood vessels or fragile skin. Massage can not be recommended as a strategy for pressure ulcer prevention. 10. Do not vigorously rub skin that is at risk for pressure ulceration. As well as being painful, rubbing the skin can also cause mild tissue destruction or provoke an [MEDICAL CONDITION] reaction, particularly in the frail elderly person. 11. Use skin [MEDICATION NAME] (lotions) to hydrate (moisturize) dry skin in order to reduce risk of skin damage. Dry skin seems to be a significant and independent risk factor for pressure ulcer development. 12. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. The mechanical properties of the skin is are changed by the presence of moisture and as a function of temperature. NPUAP Recommendations for repositioning for the Prevention of Pressure Ulcers: -The use of repositioning should be considered in all at-risk individuals. Repositioning should be undertaken to reduce the time and amount of pressure over vulnerable areas of the body. -High pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure exposure. -The use of repositioning as a prevention strategy must take into consideration the condition of the patient and the support surface in use. -The frequency of repositioning will be influenced by variables concerning the individual and the support surface in use. -The repositioning frequency will be determined by the individual's skin tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the individual's skin condition. -Assess the individual's skin condition and general comfort. If the individual is not responding as expected to the repositioning regime, reconsider the frequency and method of repositioning. -The repositioning frequency should be influenced by the support surface used. -An individual should be repositioned with greater frequency on a non-pressure- redistributing mattress than on a viscoelastic (pressure relieving) foam mattress. The repositioning frequency should depend on the pressure redistributing qualities of the support surface. NPUAP Recommendation for Repositioning Technique: -Repositioning contributes to the individual's comfort, dignity, and functional ability. -Reposition the individual in such a way that pressure is relieved or redistributed. -Avoid subjecting the skin to pressure and shear forces. -Use transfer aids to reduce friction and shear. Lift, don't drag, the individual while repositioning. -Avoid positioning the individual on bony prominences with existing non-blanchable [DIAGNOSES REDACTED]. -Repositioning should be undertaken using the 30-degree tilted side-lying position (alternately, right side, back, left side) or the prone position (resting on the front stomach area )if the individual can tolerate this and her/his medical condition allows. Avoid postures that increase pressure, such as the 90-degree side-lying position. -If sitting in bed is necessary, avoid head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx (tailbone). -Avoid positioning the individual directly on to medical devices, such as tubes or drainage systems. Record review of the facility policy titled, "Preventative Skin Care", dated October 2006, showed the policy purpose was to provide preventative skin care through repositioning of the resident with careful washing, rinsing, drying and observation of the resident's skin condition to keep residents clean, comfortable, well groomed and free from pressure ulcers with the following procedure: -All resident's will be assessed using the Braden Pressure Ulcer Scale at the time of admission followed by weekly, for four weeks; and then the resident will be reassessed at least quarterly and/or as needed; -After the thorough cleaning of the resident's skin, lotion is to be applied and the observation of any reddened area will be reported to the Charge Nurse; -Any resident identified as being high risk for skin breakdown shall be turned and repositioned a minimum of every two hours; -Lotions or barrier cream may be applied as a protective barrier for incontinent residents; -Pressure relieving devices, mattresses and or chair cushions will be used with any resident identified as being high risk for potential skin breakdown; -Provide adequate nutrition (food and fluids) and Nursing Assistants are to report decreased intake to the Charge Nurse to evaluate and contact the physicians, if indicated; -The resident's weight will be monitored at least monthly, and more frequently if indicated; -Staff will practice care in moving or lifting residents to prevent shearing forces on the skin, not pulling the resident across bed sheets, avoiding scratches, bruises and irritation of skin; -Maintain wrinkle-free, clean, dry bed linens; -Keep incontinent residents clean and dry; -Encourage resident activity, when feasible, Use repositioning techniques and Range of Motion Exercises, when indicated; -Maintain the resident's fingernails and toenails short and smooth to prevent accidentally scratching themselves. Record review of the facility policy titled, "Pressure Sore Prevention Guidelines", dated April 2006, showed the policy purpose was to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown as determined by the Braden Scale. It is the responsibility of all nursing staff and the Dietary Manager to implement the procedure: -The nurse will complete a skin assessment on all residents: --Upon admission; then --Weekly for four weeks, then --Quarterly and Annually with the Minimum Data Set (MDS -a federally mandated assessment instrument required to be completed by a facility) assessment, and --With any significant change in condition, or --If the resident develops a pressure sore. -Any resident scoring High or Moderate risk for skin breakdown will be (documented) noted on the Treatment (Treatment Administration Record- TAR) and signed of by the Nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the TAR; -Interventions for residents who are at High Risk for skin break down will be: --Turned and repositioned every two hours; --Have Range of Motion exercises as indicated by the resident's need and/or assessment and the approaches will be specified on the resident's Care Plan; --Have a pressure relieving mattress, with specified type, listed on the Care Plan; --Postioning devices will be used, as needed and will be listed on the Care Plan; --Incontinence Care will be provided and may include lotions or barrier creams; --Daily Skin Checks will be performed and the following protocol for coding of (documenting) the skin condition will on the TAR: -"C" will show the resident's skin was clear of any skin breakdown; -"R" will show the resident's skin had an area of redness; -"O" will show the resident's skin had an area of concern listed as "Other"; -"P" will show the resident's skin had an area of concern for "Pressure"; with instructions that any area that remains reddened that does not resolve within 30 minutes after the pressure is relieved must be documented as a "Stage I" pressure area; and -"S" will show the resident skin had a "skin tear", And, -A list of residents that are at High or Moderate risk for skin breakdown will be maintained by the Dietary Manager and will be reviewed Quarterly; -Nutritional Supplements will be provided (to aid healing); -Entry should be made on the resident's Care Plan regarding the resident's risk of skin breakdown and the appropriate interventions being used; and -If the resident develops a pressure ulcer in spite of the interventions in use, the Care Plan must reflect updated interventions for the healing of the ulcers and additional interventions for further prevention of pressure ulcers; -Interventions for the residents who are at Moderate Risk for skin break down are the same as High Risk interventions with the exception that a specialty mattress was not indicated and weekly instead of daily skin checks were to be performed and the weekly skin checks will use the same documenting format. Record review of the facility policy titled, "Decubitus Care / Pressure Areas", dated May 2007, showed the policy purpose was to ensure that proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified; And, it is the responsibility of the licensed nursing personnel to use the following procedure: 1. Upon notification of skin breakdown, a "Newly Acquired Skin Condition Report" will be completed and forwarded to the Director of Nursing (DON); 2. The pressure area will be assessed and documented on the TAR; 3. Staff should complete all areas of the TAR including: -Document the size, stage, site, depth, drainage, color, odor, and any treatment order (upon obtaining physician orders); -Document the stage of the pressure ulcer as follows: -- Suspected Deep Tissue injury; purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear; --Stage I: "Redness, which does not resolve 30 minutes after pressure is relieved, no broken skin". (Note: The facility description fails to describe non-blanchable [DIAGNOSES REDACTED] (redness); (Blanching is when blood (redness) presses away and then returns when skin is pressed on with fingertip pressure) or that darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.); --Stage II: "Broken skin, an abrasion, blister or shallow crater"; (Note: The facility description fails to describe a Stage II as a Partial thickness loss 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 fluid-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.) --Stage III: "Broken skin, affects full thickness and presents as a deep crater"; (Note: The facility description fails to describe a Stage III as Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (yellow, tan, gray, green or brown tissue) may be present but does not obscure (hide) the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies by body location. The bridge of the nose, ear, back of head and side of ankle do not have adipose (fat tissue) and Stage III ulcers can be shallow. In contrast, areas of significant adiposity (fat tissue) can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable (able to be felt).) --Stage IV: "Broken skin, muscle and/or bone exposed"; (Note: The facility description fails to describe a Stage IV as Full thickness skin tissue loss with exposed bone, tendon or muscle. Slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) may be present in the wound bed. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by body location. The bridge of the nose, ear, back of head and side of ankle do not have fat tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis (bone infection) likely to occur. Exposed bone/muscle is visible or directly able to be felt.) (Note: The facility description fails to describe any wounds as -Unstageable/ Unclassified: Full thickness skin loss, Depth unknown: Full thickness skin tissue loss in which the actual depth of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; But, it will be either a Stage III or IV. Stable (dry, attached, intact without redness or movement) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.) And, (Note: The facility description fails to describe any wound as -Suspected Deep Tissue Injury (SDTI)- depth unknown; Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to surrounding tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution (progression of the wound) may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.) -Staff should document the color according to the following: --Red: Pale pink to beefy red with or without healthy granulation tissue; --Yellow: Whitish yellow, creamy-yellow, yellow-green or beige; --Black: Black, stringy gray or gray scab. 4. Staff should contact the physician for treatment orders and the treatment orders should include: The type of treatment; The frequency of the treatment (how often); How to clean the wound, if needed; The site of application; With the notation that no"As Needed" (PRN) order is acceptable for a pressure ulcer and the order was to be placed on the TAR; 5. Documentation of the pressure area must occur upon notification and at least once each week on the TAR and the assessment must include: -The wounds description including size, shape, depth, color, presence of granulation tissue, necrotic (black) tissue, etc.; -The treatment prescribed and the response to treatment. 6. Staff should reevaluate the treatment response at least every two to four weeks. Most pressure areas will respond to treatment in that amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 7. Nursing staff are to notify Dietary staff of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician; 8. Initiate the problem (document the pressure ulcer) on the resident's Care Plan. 9. When the pressure area is healed, a preventative program must be instituted (begun). Record review of the facility policy titled, "Pressure Ulcers- Nutritional Interventions", dated July 2008, showed the policy purpose was to ensure that nutritional interventions are used as one of the means of preventing and treating pressure ulcers with the following procedure: 1. All residents will be assessed for pressure ulcers; 2. Resident's that are determined to be at High risk for developing pressure ulcers or actually having pressure ulcers will have a program of increased protein, calories, vitamins, minerals and fluids developed by the Dietician and ordered by the resident's physician. 3. The facility will incorporate the additional nutrients into the meal or snack pattern of the resident's diet according to intake. 4. Nourishments will vary depending on the stage of the pressure ulcer and on the potential intake of the resident. 5. Approaches to increase calories, protein, vitamins, minerals and fluid may be included but are not limited to: -One half cup vitamin C containing juice, three times a day; -An extra protein portion at breakfast or at all meals; -Provide "Super-cereal" ([MEDICATION NAME] cereal) at breakfast; -"Med pass" (A nutritional supplement drink); -"House supplements" (A nutritional supplement ); -"Protein powder" (A nutritional supplement); -A Multi-vitamin tablet supplement; -Vitamin C tablet supplement, 500 to 1000 mg per day, ordered by the physician; -Zinc supplement tablet, 220 mg a day (not to exceed six weeks), ordered by the physician; -Provide extra portions of any food which the resident consumes well; and -"[MEDICATION NAME]" (a supplement drink that may help to promote wound healing) to be used for stage III or IV pressure ulcers. 6. The Residents admitted or identified with a Stage III or IV pressure ulcer are to be referred to the Dietician, in a telephone consultation, to determine needs. 7. The resident's tolerance to nutritional approaches for the management of pressure ulcers will be monitored. It is important the Food Service Manager visit the resident and explains the importance of nutrition in the healing process. 8. Residents on modified diets will have a supplement regimen determined by the Dietician, and ordered by the physician. 1. Record review of Resident #9's nursing admission assessment dated [DATE] showed the resident('s): - Was admitted to the facility on [DATE]. - Was alert but forgetful. - Used a wheelchair. - Was incontinent of bowel and bladder. - Skin turgor (skin turgor is an abnormality in the skin's ability to change shape and return to normal (elasticity)) was fair. - Skin was dry and pale. - Had a skin tear on his/her left elbow, a skin tear on his/her right upper arms and bruising to both arms. - Required assistance with most activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). - had a history of [REDACTED]. - Did not have any pressure ulcers. Record review of the resident's admission care plan dated 4/18/12 showed: - The resident's weaknesses were his/her confusion and his/her fall risk. - The mandatory care plan areas that were circled included skin care, oral/dental care, potential for falls and locomotion. They did not include any interventions. - The resident's additional care plan area included incontinence. Record review of the resident's Braden Scale (a pressure ulcer risk assessment instrument) dated 4/18/12 showed the resident was at moderate risk for the development of pressure ulcers. Record review of the resident's physical therapy discharge note for services provided 4/18/12 through 7/4/12 showed the resident ambulated with a merry walker. Record review of the resident's initial admission nutrition assessment data collection dated 4/24/12 showed the resident('s): - Body mass index (BMI - a number calculated from one's height and weight that is a fairly reliable indicator of most adults' body fat) was within normal range (normal range = 18.5-24.9). - Consumed 75 to 100 percent of his/her meals. - Consumed 1500 to 2000 cubic centimeters (cc)s a day. - Had a [DIAGNOSES REDACTED]. - Had one abnormal skin condition, which was a skin tear on his/her left elbow. Record review of the resident's admission Minimum Data Set (MDS)(a federally mandated assessment instrument completed by facility staff) dated 4/25/12 showed the following staff assessment of the resident: - Had adequate hearing. - Had adequate vision with corrective lenses. - Was usually understood by others. - Understood others. - Had clear speech. - Had severely impaired cognitive skills. - His/her ability to focus his/her attention fluctuated. - Required extensive assistance with bed mobility, transferring from one surface to another, locomotion on and off the unit, dressing, using the toilet, personal hygiene and bathing. - Required limited assistance with walking and eating. - Used a walker and a wheelchair. - Was frequently incontinent of bladder and bowel. - Some of his/her [DIAGNOSES REDACTED].

Based on observation, interview and record review, facility staff failed to provide the necessary assessments, monitoring, and services to prevent the development of pressure ulcers (a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), failed to evaluate the clinical condition and/or pressure ulcer risk factors upon admission, failed to define and implement an initial care plan, failed to identify risk factors that increase a resident's susceptibility to develop a pressure ulcer, failed to implement a comprehensive care plan, failed to follow the facility policy for pressure ulcer prevention, failed to have a system and/or procedure in place to assure assessments were timely and appropriate to reduce the development and progression of pressure ulcers, failed to have a system and/or procedure in place to assure staff communication for the needs of residents, failed to monitor for repositioning to provide off loading for pressure relief, failed to monitor a low air loss specialty mattress according to the manufacturer's recommendations, and failed to conduct a thorough skin assessment upon admission and routinely for one resident (Resident #7) who developed two suspected deep tissue pressure areas out of 17 sampled residents. The facility failed to complete skin assessments and bath sheets for a resident with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) for one resident (Resident #1) and failed to complete an admission Braden scale (a pressure sore risk assessment instrument) for one resident (Resident #3) out of 15 sampled residents. The facility failed to complete skin assessments and bath sheets for a resident with a history of skin impairment for one resident (Resident #19) out of 15 sampled residents. This deficient practice has the potential to affect every resident admitted to the facility and every resident in the facility at risk for skin alteration. The facility census was 88 residents. Review of the 2004 Centers for Medicare and Medicaid Services (CMS) regulatory language specifically reads: Based on the comprehensive assessment of an individual, the facility must ensure that an individual who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Record review of the facility's revised Pressure Sore Prevention Guidelines dated ,[DATE] said: - Policy: -- To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. - Responsibility: -- All nursing staff and the Dietary Manager. - Procedure: -- The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks. After the weekly assessments are completed they must then be done with the annual and quarterly Minimum Data Set (MDS), with a significant change in condition, or if a pressure sore develops. The following guidelines will be implemented for any resident assessed at a Moderate or High skin risk. --- Intervention: Turn and reposition every two hours, but may be more often for high risk if indicated. --- Intervention: Range of Motion as indicated by the resident's need and/or assessment. Specify approaches on the Care Plan. --- Intervention: A special mattress for high risk resident and specify the mattress type on the care plan. --- Intervention: Positioning Devices while in chair or in bed as needed to maintain turning. Specify on the Care Plan. --- Intervention: Daily skin checks to follow protocol for coding skin condition. C-clear, R-red, O-other, P-pressure, S-skin tear. Any reddened area that doesn't resolve within 30 minutes after pressure is relieved must be documented as a Stage I. --- Intervention: Weekly Skin Checks to follow protocol for coding skin condition as above. --- Intervention: A Quarterly Review by the Dietary Manager and the Dietary Manager should maintain a list of residents who are at high and moderate risk. --- Intervention: Nutritional Supplements to be used as a dietary intervention for pressure sores. --- Intervention: A Care Plan Entry for skin risk and appropriate interventions. If despite the interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of pressure ulcers. - Any resident scoring a high or moderate risk for skin breakdown will be noted on the treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. Record review of the facility's revised "Tube Fed Resident" dated ,[DATE] said: - It is the policy that the facility will provide a nutritionally complete enteral (tube) feeding for residents who are unable to obtain adequate nutritional intake orally and/or whose clinical condition makes tube feeding unavoidable. - Procedure -- The dietitian will be notified of each new admission or re-admission of tube fed residents via fax or phone. All communications with the dietitian will be documented by the nurse or food service manager in the resident's medical record. -- The dietitian will assess the residents and fax the assessment to the facility within 48 hours of admission. This assessment will include recommendations if needed which the nurse will relay to the physician. -- Residents receiving tube feedings will be weighed once a week for four weeks after admission. Then the weight will be obtained monthly per the resident weight monitoring policy unless otherwise specified by the nursing department or physician. -- Nursing will notify the food service manager or dietitian of any problems the resident may be experiencing on the tube feeding. Intolerance of the tube feeding will be documented in the resident's medical record along with corrective measures. -- The dietitian will reassess all tube fed residents on at least on a monthly basis. -- If the resident is also receiving an oral diet the following applies: oral intake will be monitored and recorded, the dietician may recommend weaning the tube feeding when the oral intake is estimated at 50% or more of resident's needs, and when the resident is totally weaned, the dietician will continue to monitor the resident closely to ensure that intake remains adequate to meet the resident's needs. Record review of the facility's revised Preventative Skin Care policy dated ,[DATE] said: Policy: --To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. -Responsibility: -- All nursing staff. - Equipment: -- Lotion, Barrier Cream, Special mattresses (i.e. gel, foam, water, air, ect.), and Pillows or positioning devices. - Procedure: -- All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be reassessed at least quarterly and/or as needed. -- Staff on every shift and as necessary will provide skin care. -- After thorough cleansing of the skin, lotion is to be applied and observation of any reddened areas will be reported to the charge nurse. -- A thin lotion of body lotion and/or barrier cream may be applied as a protective barrier to areas exposed to incontinence. -- Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. --Special mattresses and/or chair cushions will be used on any resident identified as being at high risk for potential skin breakdown. -- Pillows and/or bath blankets may be used between two skin surfaces or to slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. -- If the resident is able to understand, teach the resident about good skin care. Inform them of the cause of pressure ulcers and encourage them to actively participate in the prevention of pressure ulcers. -- Ensure proper fit of wheelchairs, splints, braces, prosthesis, ect .... -- Provide good nutrition and adequate hydration: --- Nursing assistants are to report decreased food or fluid intake to the charge nurse, who will evaluate and contact the physician if indicated. --- Keep fluids within reach of the resident and/or offer frequently. --- Monitor weight at least monthly, more frequently if indicated. -- Practice care in moving and lifting residents: --- Prevent shearing forces during moving and transfers. --- Prevent pulling resident across the sheets. --- Avoid scratches, bruises, and skin irritation. -- Maintain wrinkle free, clean, dry bed linen. -- Encourage resident activity, when feasible. Use repositioning techniques and range of motion exercises when indicated. -- Keep incontinent residents clean and dry. -- Keep the resident's fingernails and toenails short and smooth to prevent them from accidentally scratching themselves. - Treatment Protocol Guidelines: -- Ointments and cleansers are to be stored separately from dry supplies/dressings. -- Remove discontinued and expired items from the cart. -- Keep the cart clean and organized at all times with resident supplies stored apart. -- Follow the Treatment Administration Record (TAR) for all cleansing, medication application, and dressings. -- If you don't understand a treatment, clarify it before beginning. -- Always inform the resident what you are doing and what to expect. -- Always position the resident comfortably before beginning. -- Always maintain the resident's privacy-pull curtains (privacy and window), close the door. -- Expose only the areas to be treated. -- Always maintain a clean field - Sterile if ordered. -- Wash hands after removing old dressings, cleansing, and before applying new dressings. -- Sanitizer should be rubbed in for at least 30 seconds. -- Always cleanse, apply medications and dress from the inside out. -- The treatment cart is never to enter a resident's room. -- Lock the cart whenever it will not be within your visual control. -- Document the treatment on the TAR immediately upon completion. -- Document treatment progress at least weekly. -- Notify the Physician if a treatment is not producing progress within two weeks of starting. Record review of the facility's revised Decubitus Care/Pressure Areas dated ,[DATE] said: -Policy: -- To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. - Responsibility: -- Licensed Nursing Personnel. - Procedure: -- Upon notification of skin breakdown, a Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. --- The pressure area will be assessed and documented on the TAR. --- Complete all areas of the TAR. ---- Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). ---- Document the stages of the pressure ulcer as follows: Suspected deep tissue injury; a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear, Stage 1; redness which does not resolve 30 minutes after pressure is relieved with no broken skin, Stage 2; broken skin, an abrasion, blister or shallow crater, Stage 3; broken skin affecting full thickness and presents as a deep crater, Stage 4; broken skin, muscle and/or bone exposed. ---- Document the color according to the following: Red; pale pink to beefy red with or without healthy granulation tissue, Yellow; whitish yellow, creamy-yellow, yellow-green, or beige, and Black; black, stringy gray or gray scab. -- Notify the physician for treatment orders. The physician's orders [REDACTED]. No as needed (PRN) order is acceptable for a pressure ulcer. The order must have specific frequencies. Initiate physician order [REDACTED]. -- Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include the characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, ect.), and treatment and response to treatment. -- Reevaluate the treatment for [REDACTED]. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. -- Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician. -- Initiate problem on care plan. -- When the pressure area is healed, a preventative regimen must be instituted. Record review of the facility's User Manual for the P1500 Air Express Low Air Loss Therapy System showed: - The device was intended to assist in treating and preventing pressure ulcer; - The facility received the User Manual on [DATE] at 12:41 P.M. by fax; - Instructions for the C1500 Control Unit; - Instructions for the M1500 Mattress; - For proper inflation and patient comfort, adjust pressure by rotating the dial initially to MAX. After maximum inflation has been attained, sequentially reduce the pressure setting until four fingers (stacked vertically) clearance exists between the underlying foam and the patients pelvic region; - Instructions for transferring patients in and out of the bed the turn dial should be in the maximum inflate position to provide a firm and stable support surface. Upon completion of the transfer, the control unit should be turned to the appropriate patient comfort setting; and - To reduce the risk of skin break down, Max inflate should not be maintained for greater than 30 minutes. 1. Record review of Resident #7's face sheet showed the resident was admitted on [DATE]. Record review of the resident's face sheet dated [DATE] showed the following admission Diagnoses: [REDACTED]. - Stroke with [MEDICAL CONDITION] (partial loss of movement or feeling) affect of the dominant side; - Dysphagia (inability or difficulty swallowing) due to the stroke; - [MEDICAL CONDITION] (loss of ability to produce or comprehend language due to [MEDICAL CONDITION]); - Hypertension (HTN- high blood pressure); - History of Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system); - [MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulated metabolism); - Pneumonia (inflammation of one or both lungs with consolidation); - Peg Tube (percutaneous endoscopic gastrostomy - a surgical procedure to place a tube into the stomach for artificial feedings); - [MEDICAL CONDITION] - Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses); - History of oral thrush; and - Severe protein calorie [MEDICAL CONDITION].(diets are deficient in both proteins and calories.) Record review of the resident's Long Term Care Hand Off Communication form dated [DATE] at 1:55 P.M., showed: - Documented skin alterations with the use of geri sleeves for protection; - The resident's chronic condition of post stroke with right sided weakness; - The resident had speech impairment; - The resident used a wheelchair for mobility; - The resident had a noninjury fall within the last 30 days; and - Eyeglasses and dentures were sent with the resident. Record review of the resident's New Admission Chart Audit form dated [DATE] showed: - The resident's personal effects inventory was completed; - The first step [MEDICATION NAME] (TB) was administered to the resident; - The initial 24 hour audit was to include the nursing admission progress note, orders transcribed to the physician's orders [REDACTED]. glasses and dentures; temporary plan of care completed and in cardex. Note: No temporary care plan, cardex, and/or functional assessments of skin, bowel and bladder, and [MEDICAL CONDITION] were found in the medical record. Record review of the resident's New Admission Chart Audit form dated [DATE] showed the 72 hour audit was to include an admission social services note, activity note, dietary note, a preference list, a doctor note, a completed face sheet, copies of do not resuscitate (DNR) or durable power of attorney (DPOA) in chart, and the transfer packet completed. Note: The 72 hour audit form was found to be blank and in the medical record. Record review of the resident's Nursing Admission Assessment on [DATE] at 2:40 P.M., showed the resident: - Had no admitting diagnoses; - Was not understandable when he/she spoke; - Was alert, uncooperative, and forgetful; - Was drooling due to an old stroke; - Had dentures; - Was incontinent; - Had a mechanical soft diet with nectar thick liquids by mouth and percutaneous endoscopic gastrostomy (PEG) tube feedings with [MEDICATION NAME]; - Had skin tears on both arms and sores on both legs; and - Was dependent with activity of daily Living (ADL) and used a wheelchair for mobility. Record review of the resident's admission medication orders dated [DATE] showed [MEDICATION NAME] 1.2 one can [MEDICATION NAME] via Peg Tube four times a day if eating less than 50% at meals. Record review of the OT (Occupational Therapy) Evaluation and Plan of Treatment dated [DATE] showed the resident was: - Totally dependent on transfers, hygiene, grooming, dressing, and toileting; - Maximum assist of two to safely stand and/or transfer; and - At risk for further decline in function, falls, and increased dependency upon caregivers due to documented physical impairments and associated functional deficits. Record review, of the resident's Social Services Admission Care Plan dated [DATE] showed: "24 hour long term care resident". The resident's weaknesses based on the admission assessment showed: left side weakness, fall risk, and ADLs. Note: The resident was admitted with right side weakness. Record review, of the resident's Physician History and Physical dated [DATE] showed the resident: - Was admitted with tube feeding and oral feeding; and - Current [DIAGNOSES REDACTED]. Record review of the resident's lab (laboratory) results dated [DATE] showed: - BMP (Basic Metabolic Panel) was within the normal range of the test; - TSH ([MEDICAL CONDITION] Stimulating Hormone) was high at 6.30 with a ref (Reference) range of 0XXX,[DATE].20; - The resident's physician was notified on [DATE] of the high TSH result; and - CBC (complete blood count) with in the normal range for this resident. Record review of the resident's Initial Nutrition Assessment by the (RD) Registered Dietician dated [DATE] showed the resident: - At low risk of weight change; - At moderate risk of intake by tube feeding of ,[DATE]% of meal and would consume ,[DATE] cc per day by tube feeding; - At moderate risk for skin conditions related to incontinence; - At high risk for decreased nutrition related to the resident's [DIAGNOSES REDACTED]. - Needed an increase in tube feedings with a [MEDICATION NAME] of [MEDICATION NAME] 1.2 at 1.5 cans four times a day and 175 ml (milliliters) water flushes. Note: No current follow up monthly RD note was found in the medical record. Record review of the resident's Dietary Recommendations sent to the nursing department on [DATE] showed the resident's name, date, physician, concern note, recommendation made, and the registered dietician's signature. Note: The portion of the form that was to be filled out by the nursing department was blank and no nursing signature. At the bottom of the form it read, "Return Completed Form to Director of Nursing". Note: The (DON) Director of Nursing had not received the dietary recommendation form. Record review, of the resident's Screening for Harmful Behaviors dated [DATE] showed a total score of 4 which equals minimal to low risk. The summary on the prescreen of risk showed the resident was aggressive with staff during ADL care and the resident was unable to make his/her needs known. A monitor for changes in the resident's mood and behaviors were initiated. Note: No behavior monitor was found was found in the medical record. Record review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated [DATE] showed the resident: - Had a moderate amount of difficulty hearing without hearing aides; - Was sometimes understood; - Usually understood and comprehended conversation; - Had highly impaired vision; - BIMS (Brief Interview for Mental Status) score of one - highly impaired; - Had behaviors of physical symptoms directed toward others, verbal symptoms directed toward others, and other behavioral symptoms not directed toward others four to six days of the assessment period; - Had wandering tendencies four to six days of the assessment period; - Needed extensive assistance of two persons for bed mobility; - Was totally dependent on assistance of two persons for transfers, dressing, toilet use, personal hygiene, and bathing; - Was totally dependent on assistance of one person for eating and mobility on and off of the unit; - Used a walker and wheelchair for mobility; - Was always incontinent of bowel and bladder with no toileting program in place; - Had current [DIAGNOSES REDACTED]. - Reported no pain; - Had two non injury falls since admission; - Had a swallowing problem, a feeding tube, and a mechanically altered diet; - Received 51% or more of total calories by tube feedings and 501 cc per day or more of fluids per tube; - Had a clinical assessment for determination of pressure ulcer risk and a formal assessment tool (e.g. Braden, Norton, or other) was done; - Had no pressure ulcers; - Had a pressure reducing device for the bed; - Received antipsychotic and antianxiety medications; - Used a chair daily that prevented the resident from rising; - Care Area Assessments (CAAs)addressed in the care plan were cognitive loss and/or dementia, communication, ADL, urinary incontinence, behavioral symptoms, activities, falls, nutritional status, feeding tube, dehydration/fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use, physical restraints, and pain; and - Had no signature of person and/or persons completing the assessment and no signature of an Registered Nurse (RN) Assessment Coordinator verifying the assessment completion. Note: No initial care plan was found on admission and/or comprehensive care plan was found. Record review of the resident's CAAs dated [DATE] showed: All of the triggered CAAs "Will proceed with the plan of care". Record review showed the resident was receiving Speech Therapy dated [DATE] through [DATE] related to having a PEG Tube and an oral pureed diet with nectar thick liquids. Record review of the resident's POS dated [DATE] showed: - The resident was sent to the ER (Emergency Department) to be evaluated; - The resident was treated for [REDACTED]. - The resident was sent back to the facility with an order for [REDACTED]. Record review of the resident's Comprehensive Care Plan dated [DATE] showed the resident was at risk for: - Poor decision making related to long and short term memory loss; - Poor communication related to hearing and speech impairment; - Increased dependence on caregivers for his/her personal care related to stroke with right sided paralysis; - Skin impairment related to bowel and bladder incontinence, decreased mobility, decline in physical condition, and skin alterations upon admission; - Aspiration and respiratory problems related to dysphagia, altered mechanical diet, Peg Tube feeding, and nectar thick liquids; - Falls related to [MEDICAL CONDITION], poor safety awareness, [MEDICAL CONDITION] medications, maximum dependence on staff for transfers, and history of falls prior to admission and after admission; and - Side effects related to antianxiety, antidepressant, and antipsychotic medications. Record review on [DATE] found no resident admission assessments for fall risk, Braden scale for predicting pressure ulcer risk, pain, range of motion, hydration, bowel and bladder, [MEDICAL CONDITION] medications, depression scale for dementia, and/or AIMS (abnormal involuntary movement scale). Observation on [DATE] at 10:00 A.M., showed the resident: - Had mumbled speech; - Sitting in a wheelchair on a six inch cushion; - Leaning to the right without support for proper body alignment; - Had a body alarm attached to the wheelchair; - Had a lap buddy in place to prevent the resident from leaning forward, and - Able to propel his/her wheelchair with his/her feet short distances. Record review of the resident's physician telephone order dated [DATE] showed: - The resident was discontinued from PT and OT for achieving his/her highest practical level; and - A Restorative Care Program was initiated for strengthening. Observation on [DATE] at 9:10 A.M. showed the resident: - Sitting in his/her wheelchair drooling on the lap buddy attached to his/her wheelchair arms; and - Had a body alarm attached to the wheelchair. Observation on [DATE] at 9:30 A.M., showed the resident: - Sitting in his/her wheelchair leaning to the right; - Had a large amount of emesis; - The resident was assisted to his/her room; - Certified Nurses Aide (CNA) A attempted to lower the electric bed from the high position without results; - The resident's bed had a low air loss mattress with bolsters; - CNA A and CNA D transferred the resident into the resident's bed in high position from the wheelchair; - The resident was unable to bear weight for the stand pivot transfer; - The resident's body alarm was attached to the bed; - The resident was assisted by CNA A and D to turn on his/her left side using a rubberized pad; - The resident's right ischial tuberosity (a bony prominence of the buttocks); area was dark red; and - The left ischial tuberosity area was dark red with non draining open area approximately 1 centimeters (cm) x 2 cm. -The resident's bed was up against the wall. During an interview on [DATE] at 9:40 A.M., CNA A and CNA D said, "we don't normally move the bed away from the wall to turn the resident". Record review on [DATE] at 10:30 A.M., of the resident's Daily Skilled Nurse's Note showed: - The Licensed Nurse was notified of a wound to the resident's left and right buttocks observed during peri care; - The right buttocks wound was .1 cm x .5 cm; - The left buttocks wound was 1 cm x .2 cm; and - No redness, odor, drainage, or depth was noted. During an interview on [DATE] at 12:20 P.M., Licensed Practical Nurse (LPN) B said: - He/she did not know who was specifically responsible for the care cards; - He/she did not know who was responsible for keeping the care cards updated; and - "It use to be the DON or the Assistant Director of Nursing (ADON) that was responsible for the care cards". During an interview on [DATE] at 2:00 P.M., CNA D said: - The resident had not been turned while in bed since 10:00 A.M.; - He/she did not want to turn the resident on other side "because he/she would fall out of the bed and the bed was still in the higher position"; and - The bed had been reported to the maintenance staff for the inability of the CNA's to raise and lower the bed as needed. During an interview on [DATE] at 2:15 P.M., CNA E said: - He/she had been employed one week; - He/she was not aware of resident care cards; - Other CNA's and/or nurses give him/her resident report; - "I don't remember anything mentioned about care cards in orientation but it was a large packet of stuff". Observation on [DATE] at 2:30 P.M., showed: - The resident's non working bed was replaced with a bed with working controls for lowering and raising his/her bed and had a quarter side rail attached to the upper part of the bed frame; - The resident's low air loss mattress with bolsters was transferred to the current bed; and - The low air loss mattress setting was on high. Record review of the resident's POS on [DATE] showed: - [MEDICATION NAME] treatment initiated to the left and right side of the resident's buttocks every shift and as needed; - Multivitamin, Vitamin C, Zinc Sulfate was added to the daily medication regimen for 14 days; - [MEDICATION NAME] (mixture of vitamin C and E with L-[MEDICATION NAME]) one package in water two times daily for supplement in wound healing; - Lab orders for CBC, TSH ([MEDICAL CONDITION] function test), folate (vitamin), B12 (vitamin B test), [MEDICATION NAME] (plasma protein in the blood), and [MEDICATION NAME] Note: These orders are typical when a resident presents with a high risk for skin alterations and/or actual pressure wounds. Record review on [DATE] of the resident's care cards (Cardex) for the CNA's showed another resident's name, was independent of ADLs, and no CNA instructions for needs. Note: No care card was found for the resident. During an interview on [DATE] at 10:00 A.M., CNA B said: - He/she had not used or seen the care cards; and - "I find out about the residents through the nurse". During an interview on [DATE] at 10:05 A.M., LPN B said: - The CNA's give shift to shift resident reports; and - The CNA's ask the nurses if they have questions about resident care. Record review of the resident's lab reports dated [DATE] and received at 11:24 A.M. showed: - [MEDICATION NAME] result was low at 2.5 with a ref (reference) range of 3.5 - 5.7; - [MEDICATION NAME] result was low at 10 with a ref range of 17 - 34; - CBC showed: -- WBC (white blood count) high 12.5 with a ref range of 4.5 - 10.5; -- RBC (red blood count) low at 3.22 with a ref range of 4.40 - 5.80; -- HGB (hemoglobin) low at 9.9 with a ref range of 14.0 - 18.0; -- HCT (hematocrit) low at 29.0 with a ref range of 42.0 - 52.0; -- PLT (platelet) low at 90 with a ref range of 140 - 440; -- Lysophils low at 6.8 with a ref range of 15.0 - 35.0; and -- [DIAGNOSES REDACTED]s high at 86.2 with a ref range of 60.0 - 80.0. - BMP (Basic Metabolic Panel - blood test for electrolyte results) showed: -- BUN (blood urea nitrogen - provides information about kidney function) was high at 37 with a ref range of 7 - 25; -- CA (calcium) was low at 8.2 with a ref range of 8.6 - 10.3; and - The resident's physician was notified of the lab results at 9:30 P.M. Note: From the time the nurse received the resident's lab results until the resident's physician was notified was eight hours. Record review of the resident's lab report dated [DATE] and received at 3:36 P.M., showed the resident had a probable UTI (urinary tract infection) and an antibiotic order was received by the resident's physician and was noted on the lab report [MEDICATION NAME](antibiotic) 500 mg to be given two times daily for seven days. Record review on [DATE] showed the resident admission assessments had been done on [DATE] and showed the resident: - Had a score of 29 on the fall assessment (10 or above equals a high risk for falls); - Had a Braden score of 13 (16 or less equals a high risk for skin alterations); - Had a pain assessment documentation of no pain; - Had a hydration assessment indicating a hydration program was to be implemented; Note: No hydration program was found. - Had interventions initiated for intake monitoring at meals, strict I (intake) and O(output) of fluids, and to offer fluids between meals and at night; - The summary of the plan initiated included staff notification of the residents interventions of monitoring intake of meals and the I and O was initiated; -