Every finding on record at Bluffs, The

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to develop and review the program, policies and procedures annually. Facility staff failed to use enhanced barrier precautions ((EBP) - infection control intervention designed to reduce transmission of multi-drug-resistant organisms), and/or failed to have EBP signs posted, perform appropriate hand hygiene and glove changes during wound care for three residents (Resident #7, #103, and #123) out of three sampled residents, catheter care for one resident (Resident #8) of two sampled residents. Facility staff failed to ensure sanitary conditions for catheter tubing when they failed to keep the tubing off the floor for one resident (Resident #7) out of two sampled residents. Facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis (TB)) was completed for four (Director of Food Services, Certified Medication Technician (CMT) BB, Certified Nurse Aide (CNA) B and CNA X) out of ten employee files reviewed. The facility census was 115.1. Review showed the facility failed to provide a policy in regard to IPCP.Review showed the facility did not have documentation that a program was in place to record infection control incidents.During an interview on 01/29/26 at 2:59 P.M., the Director of Nursing (DON) said they will look at updates here and there to the IPCP as it comes up but have not done it annually. He/She said he/she knows it should be reviewed on a regular basis annually and as guidance changes. During an interview on 01/30/26 at 5:40 P.M., the Administrator said the Infection Preventionist (IP) is responsible for maintaining the IPCP. He/She said he/she thought the DON and IP were reviewing the policies and procedures annually. He/She was not aware it wasn't being done.2. Review of the facility's policy titled, Hand Hygiene and Glove Changes, dated 06/01/24, showed all staff members shall practice hand hygiene and glove changes in accordance with these procedures and applicable standards of practice to reduce the spread of infections and prevent cross contamination. Staff are directed to wash hands as follows: - When hands are visibly soiled (hand washing with soap and water); - Before and after direct resident contact or after handling a resident's belongings; - Before and after performing any invasive procedure; - Before and after entering isolation precaution settings; - Before putting gloves on; - In between glove changes; - After taking gloves off; - Before and after changing a dressing; - After handling soiled or used linens, dressings, bedpans, catheters and urinals; Staff are directed to change gloves when gloves are visibly soiled, when gloves are contaminated, and when moving between different tasks.Review showed the facility failed to provide a policy for wound care procedures. Review of the facility's EBP policy, dated 04/01/24, showed it is the policy of this facility to implement EBP. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions, and all staff receive training on high-risk activities and common organisms that require EBP. An order for EBP will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers, and/or indwelling medical devices (e.g., urinary catheters). Implementation of EBP is to make gowns and gloves available immediately near or outside of the resident's room. EBP is only necessary when performing high-contact care activities. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheters), and wound care (any skin opening requiring a dressing). EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical devices that placed them at higher risk. 3. Review of Resident #7's Significant Change Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 01/19/26, showed staff assessed the resident as:-Moderate cognitive impairment; -Partial/Moderate assistance for shower/bathing and upper body dressing;-Dependent assistance for lower body dressing, putting on/taking off footwear, and personal hygiene; -One or more unhealed pressure ulcers;-Two unstageable pressure ulcers;-Indwelling catheter. Review of the resident's Physician Order Sheet (POS), dated January 2026, showed an order to cleanse bilateral heels with wound cleanser, pat dry, apply betadine, cover with dry four by fours, wrap with kerlix and secure with tape once a day.Observation on 01/27/26 at 10:45 A.M., showed the resident in bed, urinary catheter bag hung on side of bed. The resident's room did not contain posted EBP signs.Observation on 01/28/26 at 2:25 P.M., showed the resident in bed, urinary catheter bag hung on side of bed. The resident's room did not contain posted EBP signs.Observation on 01/29/26 at 10:45 A.M., showed CNA N assisted the resident with his/her shower. The CNA did not place a barrier on the resident's foot pedals before he/she rested his/her bare heels on the pedal. Observation on 01/29/26 at 10:52 A.M., showed Licensed Practical Nurse (LPN) I did not don a gown when he/she performed wound care for resident. The wheelchair foot pedal had a wet spot on it when the LPN picked up resident's right heel. LPN I did not clean the foot pedal off with an approved cleaner. During an interview on 01/30/26 at 4:18 P.M., CNA N said the foot pedals are dirty and agrees that there should have been some type of barrier between the foot pedals and the resident's heels due to risk of infection.During an interview on 01/30/26 at 11:53 A.M., LPN I said EBP is only required for open wounds. He/She said he/she did not feel the resident's wound was significant enough to warrant wearing more than gloves during care. LPN I said there is usually an EBP sign on the door that alerts staff what to put on. He/she said the risk of not using EBP is that if the resident has an infection, staff could get it, or the reverse could happen if staff have bacteria on him/her, he/she could give it to the resident. He/She said he/she should have had a barrier between resident's heels and the foot pedals and should have used a disinfecting wipe to clean wetness from foot pedal. 4. Review of Resident #103's quarterly MDS assessment, dated 11/20/25, showed staff assessed the resident as:- Severely cognitively impaired; - Dependent on staff for all self-cares and mobility; - Is at risk for pressure ulcers.Review of the resident's POS, dated January 2026, showed an order dated 01/13/26, for right great toe: skin prep and cover daily until healed, once a day.Observation on 01/27/26 at 12:23 P.M., showed the resident's room did not contain posted EBP signs. Observation on 01/28/26 at 8:20 A.M., showed the resident's room did not contain posted EBP signs. Observation on 01/29/26 at 10:23 A.M., showed the resident's room did not contain posted EBP signs. Observation on 01/29/26 at 10:24 A.M., showed LPN I did not wear a gown when he/she performed wound care on the resident. The LPN performed the resident's wound care and did not change his/her gloves before he/she applied skin prep to the resident's toe. The LPN removed his/her gloves and did not perform hand hygiene before he/she applied new gloves to place the dressing on the resident's toe. Observation on 01/30/26 at 8:46 A.M., showed the resident's room did not contain posted EBP signs. During an interview on 01/30/26 at 11:53 A.M., LPN I said EBP is only required for open wounds. The LPN said staff should wear a gown, gloves, face mask, goggles or face shield if he/she cannot wear goggles, and it is to protect staff and to not introduce anything to the resident. LPN I said he/she had received education on EBP, and it is done during monthly in-services as a refresher. LPN I said the IP would post signage outside the door. LPN I said he/she would help with posting signs if the IP is not available, otherwise the charge nurse would post them and then notify the IP. The LPN said the sign on the door alerts staff what to put on. He/she said the risk of not using EBP is that if the resident has an infection, staff could get it, or the reverse could happen if staff have bacteria on him/her, he/she could give it to the resident. LPN I said hand hygiene should be done when entering the resident's room, in between glove changes, and before leaving the room, and it should also be done when going from a dirty procedure to a clean procedure, like wound treatments. He/she said the risk of not doing it correctly could be infection for the resident. LPN I said he/she should have performed hand hygiene in between glove changes, and he/she knows when it should be done, but he/she was nervous, as the he/she did not even realize he/she had not done it during the treatment. During an interview on 01/30/26 at 4:30 P.M., the DON said EBP is for urinary catheters, feeding tubes, wounds, and all wounds should have EBP. The DON said residents get signs posted and boxes of PPE as well, and his/her sign should indicate EBP, which requires gown, gloves, face masks, and/or face shield. The DON said the IP is now responsible for putting up the signs, and if a resident is admitted at night or on the weekends, the charge nurse would call him/her to let him/her know. The DON said if the resident has a chronic condition, like a long-term urinary catheter or chronic wound the signs would be posted inside his/her room. The DON said he/she did not know the resident did not have an EBP sign posted, and that gowns and gloves were not being used. The DON said he/she did not know that staff need to wear EBP for high contact care activities, and he/she thought it was only needed during wound care or catheter care, when staff would be dealing directly with the concerned area. The DON said that is on him/her, he/she did not know. During an interview on 01/30/26 at 5:39 P.M., the Administrator said he/she did not know that the resident was not on EBP, and he/she was not sure if it was required for wounds or not, but if they have a wound the resident would have EBP in that situation. 5. Review of Resident #123's Discharge MDS, dated [DATE], showed staff assessed the resident as:-Cognitively Impaired;-Substantial/Maximal assistance with toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene;-One or more unhealed pressure ulcers;-Two unstageable pressure ulcers;-Indwelling catheter.Observation on 01/27/26 at 10:18 A.M., showed the resident in bed, urinary catheter bag hung on side of bed. The resident's room did not contain posted EBP signs. Observation on 01/28/26 at 12:01 P.M., showed the resident in bed, urinary catheter bag hung on side of bed. The resident's room did not contain posted EBP signs.Observation on 01/29/26 at 8:41 A.M., showed the resident's room did not contain posted EBP signs.Observation on 01/29/26 at 9:27 A.M., showed LPN I and CNA N did not wear a gown when they assisted the resident to bed via mechanical lift. LPN I gathered the wet linens, removed gloves and did not perform hand hygiene before he/she left the resident's room. CNA A did not perform hand hygiene, apply gloves or a gown before he/she applied a gown on the resident. CNA A and CNA P did not put on a gown or perform hand hygiene before they applied gloves and assisted the resident with linens. CNA A applied lotion, covered up the resident, removed his/her gloves and did not perform hand hygiene before he/she exited the resident's room. During an interview on 01/30/26 at 11:24 A.M., CNA N said he/she is aware of EBP and said it's for residents with certain sickness like Flu or covid. He/She said he/she was not aware that residents with catheters or wounds need to have EBP during cares. He/She said he/she knows what residents are on EBP by a sign on their door, but he/she said there was no sign on resident's door. He/She said he/she should have washed hands between gloves changes and when entering and before leaving the room. He/She said it is a risk of spreading infection by not washing hands.During an interview on 01/30/26 at 4:18 P.M., CNA P said EBP is for open wounds, catheters, or any open areas. He/She said EBP should be worn with care where you are in direct contact with the resident. He/She said there is usually an EBP sign on the resident door or supplies in the room if they require EBP. He/She said he/she does not remember seeing an EBP sign on resident's door. He/She said the importance of using EBP is infection control. He/She said hand hygiene should be performed when entering a room, between glove changes, and when exiting the room to avoid the spread of infections. During an interview on 01/30/26 at 11:53 A.M., LPN I said EBP should be used whenever staff are doing catheter care, or if a resident is on isolation for any reason, and he/she thinks EBP is only required for open wounds. He/She said he/she did not wear EBP during cares with the resident because he/she was not in direct contact with the catheter. LPN I said there is usually an EBP sign on the door that alerts staff what to put on, and there should be signs in the room on how to put on and take off the PPE. He/she said the risk of not using EBP is that if the resident has an infection, staff could get it, or the reverse could happen if staff have bacteria on him/her, he/she could give it to the resident. He/She said staff should wash hands when entering a resident's room, between dirty and clean cares, and before exiting the room.During an interview on 01/30/26 at 2:55 P.M., the IP said the admitting charge nurse should put EBP signs up if a resident is admitted and warrants precautions. He/She said he/she goes around every morning and ensures EBP signs are posted, and PPE supplies are available. He/She said the EBP signs must have just got missed in the process. He/She said EBP is for residents with infected wounds and catheters. He/She said staff should wear EBP when during cares when they are directly touching the resident. He/She said he/she does not think that transferring a resident requires wearing EBP, but if staff see resident is wet and soiled they would need to wear EBP to change resident. He/She said the wound nurse and providers decide if a resident needs to be on EBP. He/She said he/she is not sure what the policy says about who requires EBP. He/She said staff should wash hands when entering room, between dirty and clean cares, and before leaving the room. He/She said EBP and hand hygiene are important because if not done it's a risk for deterioration in the residents care by spreading infections or contamination.6. Review of the facility's policy titled Hand Hygiene and Glove Changes, dated 06/01/24, showed all staff members shall practice hand hygiene and glove changes in accordance with these procedures and applicable standards of practice to reduce the spread of infections and prevent cross contamination. Staff are directed to change gloves when gloves are visibly soiled, when gloves are contaminated, and when moving between different tasks.7. Review of Resident #8's quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment; -Partial/Moderate assistance for personal hygiene; -Indwelling catheter.Review of the resident's care plan, dated 10/21/25, showed the resident was at an increased risk for infection due to foley catheter and a positive urine culture for methicillin-resistant Staphylococcus aureus (MRSA) (a type of bacterium responsible for severe infections that are resistant to several common antibiotics, including methicillin, penicillin, and oxacillin).Observation on 01/30/26 at 9:22 A.M., showed CNA A entered the resident's room to provide catheter care. CNA A did not change his/her gloves after he/she raised the resident's bed, unzipped his/her jacket, removed his/her belt, pulled down his/her brief, pulled the trash can closer to the bed, or before he/she provided catheter care.During an interview on 01/30/2026 at 9:41 A.M., CNA A said it is important to keep gloves clean and not touch any dirty items before providing catheter care. He/She said not providing catheter care with clean gloves, puts resident at risk for infections such as urinary tract infections. He/She said he/she would consider touching the resident, the remote, and the trash can as an infection concern. He/She said the purpose of gloves is to manage the spread of infections.During an interview on 01/30/2026 at 9:45 A.M., the IP said it is his/her expectation that staff keep their gloves clean before providing catheter care to prevent the spread of infections. He/She said he/she considered touching clothing, remote controls, and trash cans is an infection control concern. During an interview on 01/30/2026 at 4:31 P.M., the DON said it is his/her expectation that staff change gloves and perform hand hygiene when going from a dirty to clean task. He/She said if gloves are not clean before performing catheter care there is a risk of spreading infection. During an interview on 01/30/2026 at 5:40 P.M., the Administrator said it is his/her expectation that staff wash hands and change gloves when they are dirty. He/She said staff should not touch something dirty then touch something clean. He/she said staff should not touch the trash can or remote before providing catheter care. He/She said not having clean gloves puts the residents at risk for infection.8. Review showed the facility failed to provide a policy for urinary catheter tubing.9. Review of Resident #7's Significant Change, MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment; -Dependent assistance for lower body dressing, putting on/taking off footwear, and personal hygiene; -Indwelling catheter. Observation on 01/28/26 at 11:19 A.M., showed the resident in his/her wheelchair as his/her catheter tubing touced the ground.Observation on 01/29/26 at 10:45 A.M., showed CNA N pushed the resident in his/her wheelchair as his/her catheter tubing dragged the ground.Observation on 01/30/26 at 8:40 A.M., showed the resident in his/her wheelchair in dining room as his/her catheter tubing touched the ground. During an interview on 01/30/26 at 11:24 A.M., CNA N said catheter tubing should not drag or rest on the floor at any point due to risk of infection control. He/She said did not realize the tubing was dragging the floor while pushing resident.During an interview on 01/30/26 at 11:53 A.M., LPN I said catheter bags and tubing should not be dragging the floor or laying on the floor. He/She said it's a risk for infection. During an interview on 01/30/26 at 2:55 P.M., the IP said catheter tubing should not be dragging the floor or laying on the floor due to risk of infection and contamination. During an interview on 01/30/26 at 4:50 P.M., the DON said catheter tubing should not be dragging the ground due to risk for infection. During an interview on 01/30/26 at 5:50 P.M., the administrator said he/she expects catheter tubing not to be dragging the ground or touching the floor due to risk of infection.10. Review of the facility's policy titled, Employee Tuberculosis Testing (TST), revised 11/14/26 showed:-Each newly hired employee will be screened for TB infection and disease afteran employment offer has been made but prior to the employee's dutyassignment;-The facility's employee health coordinator will administer a TST to all newly hired employees;-After reading results of the first step, if negative, the employee should have the second step administered within one to two weeks.11. Review of Director of Food Services' personnel file showed his/her first day as 01/06/25. The record did not contain documentation a first or second step TB was completed.12. Review of CMT BB's personnel file showed:-Date of hire 05/13/25;-First step TB placed on 05/09/25 and read on 05/11/25;-Second step TB placed on 05/14/25 and read on 05/16/25; -Staff did not wait seven to 14 days between the first and second step. 13. Review of CNA B's personnel file showed:-Date of hire 06/24/25;-First step TB placed on 08/12/25 and read on 08/14/25;-Second step TB placed on 08/18/25 and read on 08/20/25;-Staff did not administer the first step prior to hire;-Staff did not wait seven to 14 days between the first and second step. 14. Review of CNA X's personnel file showed:-Date of hire 12/23/25;-First step TB placed on 12/23/25 and read on 12/26/25;-Second step TB placed on 01/06/25 and read on 01/09/25;-Staff did not administer the first step prior to hire. During an interview on 01/30/26 at 12:00 P.M., the IP said the first step of TB should be placed and read before staff start work. The IP said there should be 10 to 14 days between step one and step two of the TB screening for employees. The IP said he/she doesn't know why the staff were started before without TB screenings and were given their 2nd step so close to the reading of their first step, they should not have been. During an interview on 01/30/26 at 3:43 P.M., the DON said staff should wait a week to two weeks, to give the second step of TB after first step is read. The DON said now the IP does the TB screening, but when the ones done wrong, were completed, the facility had the unit managers doing the TB screenings. The DON said we need to do a better job.During an interview on 01/30/26 3:57 P.M., the administrator the IP does the TB screenings, he/she is new and tracks the results, but any nurse can place it. The administrator said it should be two to three weeks between first and second step TB. The administrator said it is not appropriate to give the two steps, three to four days apart. The administrator said the first step should be administered and read before the staff works in the building.

Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to ensure wound care orders were in place for one resident (Resident #123), failed to follow wound care orders for one resident (Resident #7), failed to follow orders for wrist splints to prevent or maintain contractures for one resident (Resident #19), and failed to complete neurological assessments after falls for two residents (Resident #103 and #63), out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff in regard to physician's orders.2. Review of Resident #123's discharge Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/26, showed staff assessed the resident as:-Cognitively Impaired;-Substantial/Maximal assistance with shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene;-One or more unhealed pressure ulcers (damage to skin and underlying tissue caused by prolonged pressure, friction, or shear, commonly occurring over bony prominences like heels, tailbone, or hips);-Two unstageable pressure ulcers.Review of the resident's progress notes showed staff documented the resident went to hospital on [DATE] and returned to the facility on [DATE].Review of the resident's Physician Order Sheet (POS), dated 01/22/26, did not contain documentation of a treatment order for two unstageable pressure ulcers on right lateral foot.Observation on 01/29/26 at 9:27 A.M., showed the resident had two pressure ulcers to right lateral foot.Observation on 01/29/26 at 2:45 P.M., showed resident in bed with no dressings to right lateral foot pressure ulcers.During an interview on 01/29/26 at 3:30 P.M., Licensed Practical Nurse (LPN) I said he/she was unsure if the resident's dressing has been done yet. He/She said he/she was not aware that resident does not have a treatment order for right lateral foot pressure ulcers since returning from hospital. He/She said the resident returned from hospital at the end of last week and it must have gotten missed when entering orders. He/She said the wound clinic, was here on Tuesday 01/27/26 and gave new orders for pressure ulcers but he/she is behind and had not had a chance to enter the new treatment orders into the computer. He/She said if there is no order in computer, then the nurse does not know to complete the treatment as ordered.During an interview on 01/30/26 at 5:04 P.M., the Director of Nursing (DON) said he/she expects staff to follow physician orders. He/She was not aware that the resident had no treatment orders since returning from the hospital. The DON said the wound nurse should have entered them into computer, but he/she should have checked to ensure it was done. He/She said the admitting charge nurse puts the orders in from hospital and then once they perform a readmit skin assessment they should have reached out to the wound nurse or doctor for treatment orders for the pressure ulcers.During an interview on 01/30/26 at 5:43 P.M., the administrator said he/she expects staff to follow physician's orders. He/She said he/she was not aware that the resident did not have treatment orders since returning from hospital. He/She said the admitting charge nurse, or the wound nurse should have entered the orders in. 3. Review of Resident #7's Significant Change MDS, dated [DATE], showed staff assessed the resident as:-Moderately cognitively impaired;-Required partial/moderate assistance from staff for shower/bathing and upper body dressing;-Dependent on staff assistance for lower body dressing, putting on/taking off footwear, and personal hygiene;-One or more unhealed pressure ulcers;-Two unstageable pressure ulcers.Review of the resident's POS, dated January 2026, showed an order to cleanse bilateral heels with wound cleanser, pat dry, apply betadine, cover with dry four by fours, wrap with kerlix (crinkle-weave gauze) and secure with tape.Observation on 01/29/26 at 10:52 A.M., showed LPN I performed a dressing change to bilateral heels. LPN I cleansed heels, patted dry, applied betadine, and wrapped heels with kerlix and secured with tape. LPN I did not cover the resident's heels with dry four by fours before wrapping with kerlix.During an interview on 01/29/26 at 3:30 P.M., LPN I said there should have been a piece of sterile gauze between the pressure ulcers and kerlix. He/She said he/she realized it after he/she wrapped the heels. He/She said he/she should have taken the dressings back off and done it correctly but did not. He/She said it is important to follow physician's orders to ensure the wound heals appropriately.During an interview on 01/30/26 at 5:04 P.M., the DON said it is important to follow physician's orders so that staff know if the treatment is working or not or if something else needs to be done.During an interview on 01/30/26 at 5:43 P.M., the administrator said he/she expects staff to follow physician's orders. He/She said if staff do not follow physicians orders the pressure ulcer could get worse. 4. Review showed the facility failed to provide a policy that directs staff on contractures, assistive devices, and/or limited range of motion.5. Review of Resident #19's significant change MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Did not reject care;- Impairment of upper extremity on one side;- Dependent on staff for all mobility;- Diagnoses of arthritis, osteoporosis, and amyotrophic lateral sclerosis (ALS - a progressive neurodegenerative disease that destroys motor neurons controlling voluntary muscles, leading to muscle weakness, twitching, and eventual paralysis), and generalized muscle weakness.Review of the resident's POS, dated January 2026, showed an order dated 09/25/25, for wrist splints: on in the A.M. and off in the P.M., once a day.Review of the resident's Treatment Administration Record (TAR), dated January 2026, showed staff documented resident refused splints as ordered on 01/01/26, 01/02/26, 01/06/26, 01/11/26, 01/13/26, 01/15/26, 01/16/26, 01/17/26, 01/18/26, 01/19/26, 01/20/26, 01/22/26, 01/23/26, 01/24/26, 01/26/26, 01/27/26, 01/29/26 and 01/30/26.Review of the resident's care plan, dated 01/15/26, did not contain documentation of wrist splints or refusals of care.Observation on 01/28/26 at 8:23 A.M., showed the resident in his/her wheelchair in the assisted dining area not wearing his/her wrist splints.Observation on 01/28/26 at 8:59 A.M., showed the resident in his/her power wheelchair with his/her left hand curled in his/her lap.Observation on 01/29/26 at 8:22 A.M., showed the resident in the assisted dining room without his/her wrist splints on. Observation on 01/29/26 at 10:38 A.M., showed the resident in his/her room without his/her wrist splints on. The wrist splints sat on top of a pile of papers.Observation on 01/30/26 at 10:40 A.M., showed the resident in his/her power wheelchair in assisted dining room, without splints on his/her wrists.Observation 01/30/26 at 10:41 A.M., showed the resident's splints on top of a printer on a table in the resident's room.During an interview on 01/28/26 at 9:10 A.M., the resident said staff do not put any rolls or wash cloths in his/her hand to help with the contracture.During an interview on 01/29/26 at 10:38 A.M., the resident said staff does not ask him/her if he/she wants to wear the splints, and said he/she has not refused them, he/she would like to wear them, and the splints are newer.During an interview on 01/30/26 at 3:07 P.M., Certified Nurse Aide (CNA) N said he/she did not personally know about the splints, but said the resident does wear them to bed, and the resident will ask to put them on at night.During an interview on 01/30/26 at 3:12 P.M., CNA O said the resident wears the splints when he/she sleeps, and nurses document on the TAR when they are on the resident. During an interview on 01/30/26 at 3:15 P.M., LPN K said the resident refuses to wear the splints almost every day, they are ordered to be put on in the morning and taken off at bedtime. LPN K said the resident has good days and bad days, but never wants to wear the splints, and it should be documented if he/she refuses.During an interview on 01/30/26 at 3:27 P.M., LPN I said the resident does not wear the splints during the day, he/she wears them at night, and was not familiar with the resident's order off the top of his/her head, he/she would have to look at it. LPN I said the resident has a power wheelchair and manual wheelchair and is unable to steer himself/herself with the splints in place. The LPN said the order should be changed.During an interview on 01/30/26 at 4:30 P.M., the DON said he/she is not sure if the resident is supposed to be wearing splints. The DON said the resident has changed in the last few weeks, and the resident was wearing them daily all the time when he/she was first admitted . The DON said the resident's ALS is progressing and he/she has been refusing medications and other things more often.During an interview on 01/30/26 at 5:39 P.M., the Administrator said physician orders should be followed, and if the resident refuses staff should document and it should be on the care plan or progress note.6. Review showed the facility failed to provide a policy that addressed neurological checks.Review of the facility's Neurological Assessment Flowsheet, undated, showed staff are to document neurological checks as follows: initial set, then every 15 minutes times one, every 60 minutes times two, every two hours times one, every four hours times five, and every shift times four.7. Review of Resident #103's quarterly MDS assessment, dated 11/20/25, showed staff assessed the resident as:- Severely cognitively impaired;- Dependent on staff for all self-cares and mobility;- Has had falls since prior assessment; had two or more falls with no injury; had one fall with injury;- Diagnoses of Alzheimer's disease, dementia, and anxiety.Review of the resident's progress notes showed, staff documented the resident had unwitnessed fall without injury on 10/19/25. The record did not contain five of the 15 neurological checks.Review of the resident's progress notes showed staff documented the resident had an unwitnessed fall without injury on 10/24/25. The record did not contain three of the 15 neurological checks.Review of the resident's progress notes showed staff documented the resident had an unwitnessed fall without injury on 10/29/25. The record did not contain four of the 15 neurological checks.8. Review of Resident #63's annual MDS, dated [DATE], showed staff assessed the resident as:- Cognitively intact;- Used a wheelchair;- Dependent on staff to assist with coming to a standing position;- Diagnoses of anxiety disorder, depression, osteoporosis, and arthritis;- Two or more non injury falls since the prior MDS assessment.Review of the resident's care plan, dated 11/26/26, showed staff assessed the resident at risk for falling due to muscle weakness and debility.Review of the resident's nursing progress notes, dated 01/21/26, showed staff documented the resident was heard calling out for help Staff found the resident laying on floor face down next to bed. When staff asked what he/she was doing, resident stated, I don't know what I was doing, one minute I was in the chair and the next thing I know I was on the floor. Hematoma to right side of forehead, bruise to the back of right hand, and what appears to be a bruise starting to the right inner thigh. Resident complained of headache, given prn Tylenol, and vital signs completed.Review of the resident's neurological assessment flow sheet, dated 01/21/26 to 01/24/26, did not contain documentation staff assessed the resident every shift times four as directed by the neurological assessment flow sheet. The flow sheet did not contain documentation staff assessed the resident during the 6 P.M. to 6 A.M. shift on 01/23/26, and did not assess the resident on either shift on 01/24/26.During an interview on 01/30/26 at 3:15 P.M., LPN K said the charge nurse is responsible for completing the neurological checks, they are done initially, then 15 minutes times one, 60 minutes times two, every four hours times five, and then every shift for five shifts. LPN K said neurological checks are important to determine the resident's baseline, and to be able to see if there is something off or a deviation, or if they have a brain bleed, because he/she would see alterations in their status, and he/she would expect the neurological checks to be completed. LPN K said it should be a priority to complete, and should be documented for all unwitnessed falls, or any falls with involvement of the head, even if witnessed. LPN K said sometimes the resident will refuse neurological checks, and they should be reattempted, and then a progress note should be made and documented on the neurological form as well if he/she refuses.During an interview on 01/30/26 at 3:27 P.M., LPN I said whoever is the charge nurse when a resident has a fall should initiate the neurological checks and are responsible for their shift, and then the charge nurse for any other shifts should complete them. LPN I said it is important to complete neurological checks because if the resident hits his/her head they could have a slight brain bleed and it may not be noticed for a while, so staff need to keep track to make sure there are not any changes of consciousness or mental status for 72 hours, and if the resident refuses, staff should try to encourage the resident and put it in a progress note that they refused. LPN I said he/she was not aware they were not being completed, and he/she tries to check to make sure the neurological checks are done completely, then staff turn them into the medical record box. He/she said the process is currently being tweaked, because there have been issues with the neurological checks being completed.During an interview on 01/30/26 at 4:30 P.M., the DON said neurological checks should be completed for any unwitnessed fall, or any witnessed fall with head involvement because it is important to make sure there is not a head injury or brain bleed going on. The DON said the charge nurse that is working is responsible for completing the neurological checks, and falls are discussed in clinical meetings every morning and if neurological checks were initiated. The DON said the nurse managers are supposed to audit, but ultimately it is his/her responsibility. He/she said the neurological checks are completed for 72 hours at different intervals and a paper form is used to document. He/she did not know neurological checks were not completed for the resident, and if the resident refuses staff should still assess, or try to do quick stroke questions; and if they continue to refuse staff should let the physician and himself/herself know as well as document on the paper form and progress note.During an interview on 01/30/26 at 5:39 P.M., the Administrator said neurological checks should be completed when a resident falls when unwitnessed or if the resident hit his/her head. The Administrator said the charge nurse is responsible to complete the neurological checks and ultimately it is his/her responsibility to make sure they are done. He/she said staff should document on the form and progress note if the resident refused, and they are important to do to make sure there is not a problem or a brain bleed.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 115.1. Review of the facility lunch menus, dated 01/28/26 (Week 1, Day 4), showed the menus directed staff to provide the residents who receive pureed diets with a: -#8 (four ounces (oz.)) scoop of pureed barbequed pork;-#8 scoop of mashed potatoes with thick gravy;-#10 (3.2 oz.) scoop of pureed spinach;-#16 (two oz.) scoop of pureed dinner roll with margarine. Observation on 01/28/26 during the lunch meal service which began at 11:24 A.M., showed staff served the residents who received pureed diets with #10 scoops of pureed barbequed pork and mashed potatoes and a #12 (2.6 oz.) scoop of pureed spinach (less than directed by the menus). Observation also showed staff did not prepare, serve or offer the pureed dinner roll with margarine as directed by the menus. Review of the facility lunch menus dated, 01/29/26 (Week 1, Day 5), showed the menus directed staff to provide the residents who receive pureed diets with #8 scoops of pureed beef tips with gravy and pureed rice pilaf. Observation on 01/29/26 during the lunch meal service which began at 11:30 A.M., showed staff served the residents who received pureed diets with a #10 scoop of pureed beef tips with gravy and a #12 scoop of pureed rice pilaf (less than directed by the menus). 2. Review of the facility lunch menus dated 01/28/26 (Week 1, Day 4), showed the menus directed staff to provide the residents who received dental soft/mechanical soft diets with a #8 scoop of ground barbequed pork with sauce and a buttered, soft dinner roll. Observation on 01/28/26 during the lunch meal service, which began at 11:24 A.M., showed staff did not prepare, serve or offer the residents who received dental soft/mechanical soft diets the buttered dinner roll as directed by the menus. Observation also showed the staff served the residents a #10 scoop of ground barbequed pork with sauce (less than directed by the menus). Review of the facility lunch menus dated, 01/29/26 (Week 1, Day 5), showed the menus directed staff to provide the residents who receive dental soft/mechanical soft diets with a #8 scoop rice pilaf and four oz. of chopped buttered carrots. Observation on 01/29/26 during the lunch meal service, which began at 11:30 A.M., showed staff served the residents who received dental soft/mechanical soft diets with a #10 scoop of rice pilaf and a #12 scoop of chopped butter carrots (less than directed by the menus). 3. Review of the facility lunch menus dated, 01/28/26 (Week 1, Day 4), showed the menus directed staff to provide the residents who receive regular diets with a dinner roll and margarine. Observation on 01/28/26 during the lunch meal service, which began at 11:24 A.M., showed staff did not prepare, serve or offer the residents who received regular diets the dinner roll and margarine as directed by the menus. Review of the facility lunch menus dated, 01/29/26 (Week 1, Day 5), showed the menus directed staff to provide the residents who receive regular diets with six oz. of beef tips with gravy and a #8 scoop of rice pilaf. Observation on 01/29/26 during the lunch meal service, which began at 11:30 A.M., showed staff served the residents who received regular diets with four oz. of beef tips with gravy and a #10 scoop of rice pilaf. 4. During an interview on 01/29/26 at 12:00 P.M., Dietary Aide (DA) NN said staff are expected to serve meals in accordance with the menus. The DA said he/she reviewed the menus prior to service for what portion sizes to serve, but he/she could not find all the right scoops to use. The DA said if he/she does not have the correct sized serving utensils, he/she is to notify his/her supervisor. The DA said he/she notified his/her supervisor prior to the meal service and the supervisor told him/her that the utensils were being washed so he/she used what was available because he/she needed to start service on time. During an interview on 01/29/26 at 12:10 P.M., the Director of Food Services said staff are expected to prepare and serve food in accordance with the nutritionally calculated menus, which would include the portion sizes listed for all diet types, and staff are trained on this requirement. The Director of Food Services said if staff cannot find the correct size of serving utensil, they should ask their supervisor for assistance to get the right one or its equivalent and not just use what is available. The Director of Food Services said staff had not notified him/her that they did not have the correct size of serving utensils and he/she did not know staff did not serve all food items as directed by the menus at the lunch meal for two consecutive days. During an interview on 01/29/26 at 4:00 P.M., the administrator said he/she did not have a policy related to the use of menus for meal service. The administrator said staff are expected to prepare and serve food in accordance with the nutritionally calculated menus, which would include the portion sizes listed for all diet types, and staff are trained on this requirement. The administrator said they have plenty of properly sized serving utensils and if staff cannot find the correct size of serving utensil, then they should notify the Director of Food Services and get one that is right and not just use what is available. The administrator said the Director of Food Services is responsible to monitor the meal services daily to ensure they are served correctly and he/she did not know did not follow the lunch menus for two consecutive days.

Based on observation, interview and record review, facility staff failed to preform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of foodborne pathogens. These failures have the potential to affect all residents. The facility census was 115.1. Review of the facility's Hand Hygiene & Glove Changes policy, dated 06/01/24, showed All staff members shall practice hand hygiene and glove changes in accordance with these procedures and applicable standards of practice to reduce the spread of infections and prevent cross-contamination. Review showed the policy directed staff to apply soap and, using friction, rub hands together for at least 30 seconds when they washed their hands and to wash their hands, at a minimum, when: -When coming on duty;-When hands are visibly soiled;-Before putting on gloves;-In between glove changes;-After taking gloves off;-Before and after eating or handling food;-Before and after assisting a resident with meals;-After handling soiled equipment or utensils;-After performing personal hygiene;-After completing duty. Review of the handwashing procedure sign posted at the handwashing sink in the kitchen, showed the sign directed staff to scrub their hands with soap for at least 20 seconds. Observation on 01/28/26 at 10:35 A.M., showed Dietary Aide (DA) OO scrubbed his/her hands with soap for five seconds when he/she washed his/her hands. Observation showed after he/she washed his/her hands, the DA put on a pair of gloves, retrieved a package of cheese from the walk-in refrigerator and delivered it to the cook and then got a cart of glasses and prepared beverages for meal service. Observation on 01/28/26 at 10:40 A.M., showed DA PP adjusted the glasses and mask on his/her face with his/her bare hands and then, without performing hand hygiene, used his/her bare hands to wrap silverware in napkins for meal service. Observation on 01/28/26 at 10:53 A.M., showed DA PP used his/her finger to pick out something from his/her ear and adjusted the glasses on his/her face. Observation showed, without performing hand hygiene, the DA then used his/her bare hands to wrap silverware in napkins for meal service. Observation on 01/28/26 at 10:56 A.M., showed [NAME] QQ entered kitchen and, when he/she washed his/her hands, he/she scrubbed his/her hands with soap for five seconds. Observation showed the cook then put on an apron and prepared cups of peaches for service to residents at the lunch meal. Observation on 01/28/26 at 10:59 A.M., showed DA PP used his/her bare hand to pull down his/her facemask to take a drink of his/her beverage and then, without performing hand hygiene, used his/her bare hands to wrap silverware in napkins for meal service. Observation on 01/28/26 at 11:11 A.M., showed DA PP adjusted the glasses on his/her face with his/her bare hands and then, without performing hand hygiene, placed insulated plate holders on a heating pad. During an interview on 01/28/26 at 11:34 A.M., DA PP said he/she had worked in the kitchen for two to three weeks and staff trained him/her on hand hygiene when he/she started. The DA said he/she should wash his/her hands between tasks and after he/she touches his/her body, glasses and facemask. The DA said he/she did not wash his/her hands because he/she just got too busy with his/her tasks. Observation on 01/28/29 at 11:39 A.M., showed when DA CC washed his/her hands, he/she scrubbed his/her hands with soap for five seconds. Observation showed the DA put on a pair of gloves and served food from the steamtable to residents at the lunch meal. Observation on 01/29/26 at 10:07 A.M., showed when DA RR washed his/her hands, he/she scrubbed his/her hands with soap for five seconds and then retrieved food from the refrigerator. During an interview on 01/29/26 at 10:08 A.M., DA RR said the facility staff did not train him/her on proper hand hygiene procedures, but he/she had worked in food service for years and had been trained before. The DA said when staff wash their hands, they should scrub their hands with soap long enough to sing the alphabet song twice. The DA said he/she did not know how long it should take to sing the alphabet song twice because it depended on how fast he/she sang it. During an interview on 01/29/26 at 10:20 A.M., the Director of Food Services said staff are trained on proper sanitation and infection control procedures, which includes hand hygiene, upon hire and during routine in-services. The director said staff should wash their hands when they enter the kitchen, before they handle food, before and after glove use and after they touch anything dirty, which would include their body, glasses and facemask and they should scrub their hands with soap for at least 20 seconds. The director said he/she is responsible to do quarterly hand hygiene audits, but he/she had gotten behind and had not completed a hand hygiene audit since 05/28/25. During an interview on 01/29/26 at 4:00 P.M., the administrator said staff should perform hand hygiene before and after they use gloves, after they touch anything dirty, which would include their body, glasses, and facemasks, and before they prepare food. The administrator said staff should scrub their hands with soap for at least 20 seconds when they wash their hands and all staff are trained routinely on proper hand hygiene procedures. The administrator said the Director of Food Services is responsible to conduct quarterly audits on hand hygiene to discuss at their Quality Assurance meetings. The administrator said he/she had not reviewed the Director of Food Services' quarterly audits, but the director said that he/she had completed them and he/she did not know the director had not done a hand hygiene audit since May 2025. 2. Observation on 01/28/26 at 10:45 A.M., showed 10 plastic service trays and nine Insulated plate holders stacked together wet by steamtable. Observation on 01/28/26 at 10:50 A.M. five insulated plate holders and three plates stacked together wet on the service cart by the dish storage rack. Observation on 01/28/26 at 11:11 A.M., showed 32 insulated dome plate covers stacked together wet by the steamtable. Observation on 01/29/26 at 10:05 A.M., showed staff wheeled a utility cart of sanitized dishes from the mechanical dishwashing station and placed it by the dish storage racks. Observation showed the plastic service trays on the cart were stacked together wet. During an interview on 01/29/26 at 10:05 A.M., the Director of Food Services said staff should allow clean dishes to air-dried before they are put away and staff are trained on this requirement. During an interview on 01/29/26 at 4:00 P.M., the administrator said he/she could not locate a policy related to dish washing and storage, but the Director of Food Services is responsible to monitor dish washing and storage daily when on duty and make corrections as needed. The administrator said clean dishes should be air-dried before they are put away and staff are trained on this requirement.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 115.1.Review of the facility's policy titled, Antibiotic Stewardship Program, revised 10/30/18, showed the objective: to promote the highest possible quality of care by optimizing the treatment of infections while reducing unnecessary laboratory tests and antibiotic use through promotion of antibiotic stewardship principles and development of activities aimed at improving jhow antibiotics are used and prescribed. Review showed:-Policy: Antibiotic Stewardship is a set of commitments and actions intended to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This policy establishes an Antibiotic Stewardship Program (ASP) as part of the infection prevention and control program (IPCP) with key directives to improve the responsible and effective use of antibiotics The Bluffs facilities. To achieve our goal, The Bluffs has established an Antibiotic Stewardship Team; adopted antibiotic prescribing processes; tracks and reports antibiotic use, infection rates, and epidemiology date; provides access to expert clinical advice and; provides education resources and materials to the care team, residents and families;-Tracking and Reporting: the ASP incorporates a range of data collection to monitor antibiotic usage, infections rates, and microbiology data;-Performance Evaluation: The performance of the ASP is evaluated by monitoring the facility's rates of antibiotic-associated adverse drug events, rates of multidrug-resistant organisms ([NAME]), rates of clostridium difficile infections, and trends in reduction of use of high-risk antibiotics. A review of the ASP is conducted annually to review the progress in expanding stewardship activities and is included in the annual review of the infection prevention and control program and updated, as necessary.2. Review of the facility's antibiotic stewardship program showed staff did not have a process in place to track and trend antibiotic usage.During an interview on 01/28/26 at 3:05 P.M., the Infection preventionist (IP) said he/she is responsible for maintaining the antibiotic stewardship Program. He/she said he/she goes over all infections and antibiotics at the end of the month, he/she fills out the tracking form and then color codes them on a facility map to track the information. He/She said tracking is important for identifying areas of concern. He/She said they use the information to see if infections are associated with one area/hall. He/She said he/she then takes the information learned through the tracking and trending and goes over the information during their QAPI meeting the next month. He/She said/she just stared as the IP in December. He/She filled out the tracking and trending for that month. He/She said he/she has not started the tracking/trending for January. He/She said someone else did the Antibiotic Stewardship before him/her and he/she is not sure about why the information is not completed previously. During an interview on 01/29/26 at 2:59 P.M., the Director of Nursing (DON) said he/she thought the antibiotic Stewardship was being completed monthly. He/She said they had another nurse doing the program before, and he/she may not have added all the documentation monthly into the Antibiotic Stewardship binder. He/She said he/she is aware that antibiotics and infections were not being tracked on paper and through graphs daily/weekly but that they do go over information and communicate in morning meetings and during interdisciplinary team (IDT) meetings. He/She said the ASP is important to prevent the overuse of antibiotics and to track infection numbers and trend locations to certain halls/units and to narrow down possible causes to things like hand hygiene practices. He/She said it is important to identify possible causes so they can implement interventions.During on interview on 01/30/26 at 5:40 P.M., the administrator said it is the responsibility of the IP to maintain the ASP. He/She said their IP is new to the position, and he/she was unaware they were not completing the ASP monthly. He/She said the ASP is important because there is a concern for antibiotic usage not being done appropriately. He/she said he/she knows they have been discussing the ASP monthly, but it is his/her expectation that the ASP is being reviewed daily/weekly. His/She concern is that when the information is not being done daily/weekly and being done monthly that the information and/or concerns are too late to act on.

Based on interview and record review, the facility failed to ensure residents were offered COVID-19 (an infectious disease caused by the SARS-CoV 2 virus) vaccination, that education was provided regarding the benefits and risks of the COVID-19 vaccine and signed consent, or refusal obtained from the resident or the resident's representative, for four residents (Residents #7, #19, #21, and #28) out of five sampled residents and for three staff members (Director of Food Services, Certified Nurse Aide (CNA) B and Resident Service Assistant (RSA) C) of three sampled staff members. The facility census was 115.1.Review of the facility's policy titled, Covid 19 Vaccine Policy, revised 05/30/23, showed Covid-19 vaccine will be ordered from either our long-term care pharmacy or local or state public health agency or arrangements will be made with a vaccine provider to administer the vaccine to the staff or residents. In case of lack of availability of the covid-19 vaccine, or other issue with the availability leading to an inability to implement the Covid-19 vaccine program, the facility will demonstrate that attempts to order vaccines have been exhausted, including long term care pharmacies and the state health department. Covid-19 vaccinations will be offered to all staff and residents (or their representative if they cannot make health care decisions) per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine. 2. Review of Resident #7's medical record showed:-admitted to the facility on [DATE];-The record did not contain documentation the resident received education, refused, or an updated booster of the COVID-19 vaccine. 3. Review of Resident #19's medical record showed:-admitted to the facility on [DATE];-The record did not contain documentation the resident received education, refused, or an updated booster of the COVID-19 vaccine. 4. Review of Resident #21's medical record showed:-admitted to the facility on [DATE];-The record did not contain documentation the resident received education, refused, or an updated booster of the COVID-19 vaccine. 5. Review of Resident #28's medical record showed:-admitted to the facility on [DATE];-The record did not contain documentation the resident received education, refused, or an updated booster of the COVID-19 vaccine. During an interview on 01/29/2026 at 2:59 P.M., The Director of Nursing (DON) said they have not given or offered the Covid-19 vaccine in a year to any residents. He/She said the vaccine was not available for a period of time and then the person who runs the covid clinics was out on maternity leave do they have not had the vaccine to offer. He/She said the covid vaccine is important for preventative health.During an interview on 01/30/2026 at 5:40 P.M., the administrator said residents were up to date on the covid-19 vaccination until the newest version came out. He/She said it has been a year since they offered the covid-19 vaccination. He/She said he/she was told that the vaccine was unavailable. 6. Review of the Director of Food Service's employee file showed:-Date of hire on 01/06/25;-The record did not contain documentation the staff member received education, refused, or were offered the COVID-19 vaccine. 7. Review of CNA B's employee file showed:-Date of hire on 6/24/25;-The record did not contain documentation the staff member received education, refused, or were offered the COVID-19 vaccine. 8. Review of RSA B's employee file showed:-Date of hire on 11/28/25;-The record did not contain documentation the staff member received education, refused, or were offered the COVID-19 vaccine. During an interview on 01/29/2026 at 2:59 P.M., The Director of Nursing (DON) said they have not given or offered the Covid-19 vaccine in a year to any staff. He/She said the vaccine was not available for a period of time and then the person who runs the covid clinics was out on maternity leave do they have not had the vaccine to offer. He/She said the covid vaccine is important for preventative health. During an interview on 1/30/2026 at 2:55 P.M., the infection preventionist said he/she could not find documentation of staff vaccinations for covid-19 or education. He/She said to his/her knowledge, they have not offered the covid-19 vaccination to staff in the last six months. He/She said he/she started in the last 6 months and was not offered the covid-19 vaccination. During an interview on 01/30/2026 at 5:40 P.M., the administrator said staff were up to date on the covid-19 vaccination until the newest version came out. He/She said it has been a year since they offered the covid-19 vaccination. He/She said he/she was told that the vaccine was unavailable.

Based on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner when staff failed to discard expired medications/supplies for two out of five medication carts, and one of three medication storage rooms. The facility census was 115.1. Review of the facility's Storage and Labeling of Drugs Policy, dated 12/02/13, showed nursing staff shall check all stock medications routinely (no less than monthly) for expired medications the need for restocking and that the stock be rotated. Central supply staff or Director of Nursing (DON) Designee is responsible for checking expiration dates of all stock medication at least monthly. As new stock medications are brought in, stock is rotated to ensure oldestsamples are at the front. Expired medications are to be destroyed through use of drug buster. When a multi-dose medication vial is opened, the date opened is written on the vial or box. The vial is disposed within 30 days after it is opened. 2. Observation on 01/27/26 at 2:02 P.M., showed the Cherry hall medication cart contained:-Two bottles of Naxolone Hydrochloride (HCL) (used to reverse opioid overdose) 4 Milligram (MG) spray with an expiration date of 09/25; and-One eye drop bottle with an expiration date of 09/25. 3. Observation on 01/27/26 at 2:47 P.M., showed the Elm hall nurse's medication cart contained:-One flex touch insulin pen, opened and undated;-One Insulin Lispro pen, opened and undated;-One insulin safety syringe with an expiration date of 11/30/24;-One Luer-Lok Tip Syringe with an expiration date of 5/31/23;-One Safety Needle with an expiration date of 03/22;-One box of Prochlorperazine (Used to treat severe nausea/vomiting/vertigo/schizophrenia and anxiety) Suppositories 25 mg, with an expiration date of 03/31/25;-One tube of Clotimazole (antifungal used to treat various infections caused by fungus and yeast) cream one percent 30 gram (GM), opened with an expiration date of 12/25;-One tube of Preparation H one percent cream opened with an expiration date of 02/25;-One tube of Triamcinolone Acetonide Cream (used to treat inflammation, allergies and skin conditions) 0.5 %, opened with an expiration date of 07/25;-One bottle of Ketoconazole Shampoo (broad spectrum antifungal medication) two percent, opened with an expiration date of 06/25;-One bottle of Clobetasol Propionate topical Solution (corticosteroid used to treat severe skin conditions), opened with an expiration date of 07/25;-One tube of Lidocaine anesthetic cream (used to relieve pain or numb tissues) four percent, opened with an expiration date of 04/25; and-One tube of Hemorrhoidal Ointment, opened with an expiration date of 03/24. 4. Observation on 01/28/26 at 8:31 A.M., showed the Elm hall medication storage room contained:-One box of Bismuth Subsalicylate (used to treat temporary upset stomach, heartburn, indigestion, gas, nausea and diarrhea) chewable tablets opened with an expiration date of 06/25;-One Sterile Medium tip foam swab, with an expiration date of 06/30/25;-One straight tip self-catheter, with an expiration date of 12/22/25;-Three specimen collection swabs with vials, with an expiration date of 08/19/25;-One disposable syringe needle, with an expiration date of 02/15/24. During an interview on 01/28/26 at 8:54 A.M. Registered Nurse (RN) KK said the facility may have a policy, but he/she is not sure when medication carts and storage rooms should be checked for expired medications and supplies. The RN said he/she doesn't know if there is an assigned staff to check for the expired. The RN said the Central Supply Coordinator does the supplies and over-the-counter medications, he/she goes through and checks the medication storage rooms and pulls the expired ones. 5. Observation on 01/28/26 at 9:04 A.M., showed Cherry hall medication storage room contained:-One wound dressing change kit, with an expiration date of 09/15/25;-One Hypodermoclysis (subcutaneous fluid administration, often used to treat dehydration) kit, with an expiration date of 09/30/25;-60 vials of Albuterol (used to dilate bronchial and open airways) solution 2.5 mg/3mL, with an expiration date of 05/25;-21 vials of Albuterol solution 2.5 mg/3mL, with an expiration date of 09/30/25;-27 packets of Budesonide Inhalation Suspension (used to treat Asthma and allergies) 0.25 mg/2 mL, with an expiration date of 12/25;-19 vials of Ipratropium Bromide (used to treat breathing problems, by dilating the bronchial) 0.5 mg and Albuterol Sulfate 3 mg in halation solution, with an expiration date of 06/24. 6. During an interview on 01/28/26 at 9:20 A.M., RN MM said it looks like staff are not doing first in first out policy with medications and supplies. During an interview on 01/28/26 10:26 A.M., Licensed Practical Nurse (LPN) LL said the Central Supply Coordinator does the stocking, and makes sure all expired medications and supplies are taken out, and stored appropriately. During an interview on 01/29/26 at 2:11 P.M., RN T said for medication and supply storage we have a system that is setup to check carts and room for expired medications. There is a central supply person who stocks the medication rooms. The RN said he/she personally does not check for expired medications. The supply person checks the expirations when they get in new stock, and stock it. The RN said staff should date insulin, when staff put open the insulin and put it on the medication cart. The RN said staff should destroy the insulin if it does not have an open date. During an interview on 01/30/26 at 12:05 P.M., the Central Supply Coordinator said he/she stocks the over-the-counter medications and supplies in the Walnut medication storage room, he/she does not stock the other storage rooms, nurses just come and get what they need from the Walnut medication storage room and take it back to their medication storage rooms. The Central Supply Coordinator said he/she checks treatment supplies for expiration, every six months or so. The Central Supply Coordinator said someone from the pharmacy comes in every month to check the medications on the medication carts for expiration. The Central Supply Coordinator said he/she is not aware of the expired medications and supplies. During an interview on 01/30/26 at 3:43 P.M., the Director of Nursing (DON) said Central Supply is supposed to be taking the expired supplies and medications out, he/she is supposed to do all the medication rooms. The DON said the Certified Medication Technicians (CMT)s are supposed maintain the medication carts and Nurse Managers are supposed to do audits to checks the medication carts for expired medications. The DON said he/she is responsible to make sure the Nurse Manager are completing the audits. During an interview 01/30/26 at 3:57 P.M., the administrator said he/she would expect the CMT, or nurse to remove expired over the counter medications and supplies, but it is all his/her responsibility, to ensure it gets done.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over four residents (Residents #58, #78, #34 and #19) of 27 sampled residents as they fed them during mealtime. The facility census was 115.1.Review of the facility's Nursing Home Residents' Rights policy, undated, showed residents have a right to a dignified existence; to be treated with consideration, resident, and dignity, recognizing each resident's individuality; quality of life maintained or improved; and a homelike environment. Review of the facility's policies showed staff did not provide policy for staff assisting residents at mealtime. 2. Review of Resident #58's Annual Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment;-Range of Motion (ROM) impairment to one side of upper extremities;-Set up assistance from staff members with eating. Observation on 01/27/26 at12:25 P.M., showed Certified Nurse Aide (CNA) R stood over the resident, picked up the resident's silverware and offered the resident bites of his/her food. The CNA took scoops of food off the resident's plate and held it to the resident's lips, until the resident opened his/her mouth for a bite. The CNA continued to feed the resident and did not engage in conversation with the resident.3. Review of Resident #78's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment;-ROM impairment to one side of upper extremities;-Supervision, or touch assistance from staff members with eating. Observation on 01/28/26 at 11:58 A.M., Certified Medication Technician (CMT) G stood over the resident as he/she fed the resident. Observation on 01/29/2026 at 11:50 A.M., showed CNA R stood over the resident as he/she fed the resident. 4. Review of Resident #34's Annual MDS, dated [DATE], showed staff assessed the resident as:-Moderate cognitive impairment;-ROM impairment to one side of upper extremities;-Set up assistance from staff members with eating. Observation on 01/29/26 at 11:50 A.M., showed CNA R stood as he/she fed the resident. The CNA continued to stand for the entire time he/she assisted the resident. During an interview on 01/29/26 at 2:02 P.M., CNA R said he/she has not been told not stand up when he/she feeds residents. The CNA said he/she stands, so he/she can get to each of the residents. The CNA said he/she knows he/she is supposed to set down, but he/she wants to help the other residents too. The CNA said if he/she sets down, he/she can only help one resident, if he/she stands, he/she can help more than one resident. 5. Review of Resident #19's Significant Change in Status Assessment (SCSA), dated 01/13/26, showed staff assessed the resident as:-Cognitively intact;-Does not reject care;-Impairment of upper extremity on one side;-Required substantial/maximal assist for eating.Observation on 01/28/26 at 12:37 P.M., showed CNA D stood over the resident with a bite of food on a fork. The CNA did not talk to the resident before putting the food into his/her mouth.6. During an interview on 01/29/26 at 2:11 P.M., Registered Nurse (RN) T said staff should be sitting adjacent to a resident when they are feeding the resident. The RN said he/she would not want staff standing over the residents. The RN said staff should not be assisting three residents at a time, that is too much of division of the staff's attention, and the resident's patience. Staff should take time with the resident at mealtime, it should be enjoyable, not a forced act. The RN said it would not be dignified for a resident to wait for bites of food, while staff leave to feed other residents. The RN said in a perfect world, one staff for each resident who needed assistance with eating. During an interview on 01/30/26 at 3:07 P.M., CNA N said it would not be appropriate to stand over a resident while assisting with feeding, it is disrespectful and would not be dignified.During an interview on 01/30/26 at 3:12 P.M., CNA O said staff should sit down when feeding a resident, it is not dignified to stand over a resident to feed them.During an interview on 01/30/26 at 3:15 P.M., Licensed Practical Nurse (LPN) K said staff should not stand over a resident while feeding them, it is intimidating and disrespectful. The LPN said staff should be sitting at the resident's level to be able to communicate face to face.7. During an interview on 01/30/26 at 3:27 P.M., LPN I said it is not appropriate for staff to stand while feeding a resident, they should sit down and be at eye level, it may make the resident feel overpowered or uncomfortable and it would not be dignified to stand over them. LPN I said staff should always try to be on the resident's level, even when just speaking or interacting with them. During an interview on 01/30/26 at 4:30 P.M., the Director of Nursing (DON) said it is not appropriate for staff to stand over residents when feeding them, staff should sit beside the resident, and it is not dignified and would be rude.During an interview on 01/30/26 at 5:39 P.M., the Administrator said staff should not stand over residents, it is not dignified, and he/she would expect staff to sit next to residents that need assistance with eating.

Based on interview and record review, facility staff failed to document residents' code status (Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation (CPR)) consistently for two residents (Resident #2, and #100). The facility census was 115.1. Review of the facility's policies showed did not contain a policy for advance directives or resident code status. 2. Review of Resident #2's Electronic Medical Record (EMR) Face Sheet, showed the resident admitted to the facility on [DATE] with a code status as DNR. Review of the resident's Physician Order sheet (POS), dated 12/2025, showed the physician signed an order for Full Code status. Review of the resident's Care Plan, dated 12/2025, showed staff documented the resident as DNR status. Observation of the resident's door showed a red dot by the resident's name indicated a code status of DNR. Review of the facility's code status binder did not contain the residents code status for staff to use when resident's leave the building. 3. Review of Resident #100's EMR Face Sheet, showed the resident admitted to the facility on [DATE] with a DNR code status. Review of the resident's POS, dated 10/2025, showed the physician signed an order for Full Code status. Review of the resident's Care Plan, dated 10/2025, showed staff documented the resident as DNR status. Observation of the resident's door showed a green dot by the resident's name indicated a code status of Full Code. Review of the facility's code status binder showed the resident had an Outside the Hospital DNR form on file. 4. During an interview on [DATE] at 3:50 P.M., certified nurse assistant's (CNA) GG and CNA HH said they know what a resident code status is by looking at the dot on the outside of the resident's room next to his/her name. The CNAs said the red dot means Do Not Resituate and the green dot means Full Code, do everything. CNA GG and CNA HH said the nurse is responsible for sending the paperwork with the resident if they leave the facility, and believes social services put the dots on the resident's door. During an interview on [DATE] at 3:53 P.M., Licensed Practical Nurse (LPN) L said the dots outside of a resident room is for a quick reference, and they also have a binder kept at the nurse's station where they keep all residents code status in for quick access. LPN L said the green dot is for full code and the red dot is for DNR. During an interview on [DATE] at 3:59 P.M, Social Services Director (SSD) said he/she does the residents code status at admission and at that time he/she asks them to fill out the form. If there is a change in code status the nursing staff let him/her know and then he/she updates. The SSD said he/she puts the code status on the face sheet and the dots on the door of the resident's room. The SSD said the green dot is for full code and the red dot is for DNR. He/She was not aware of the code status not being consistent for either resident. The SSD said it is important to have this information correct so staff don't give CPR to a resident if they are not supposed to receive it, and the other way around. During an interview on [DATE] at 5:20 P.M., the Director of Nursing (DON) said staff know what a resident's code status shows on the ribbon at the top of their EMR, and by the red and green dots on the doors. The DON said the POS will have that information also. The concern is providing the wrong life sustaining care for the resident. The DON said SSD is responsible for adding the code status dots to the resident's room upon admission and with change. The DON said the green dot is for full code and the red dot is for DNR, staff are educated at hire. During an interview on [DATE] at 6:15 P.M., the Administrator said the residents code status can be found on the top ribbon of the matrix, or dots next to the resident name outside of their room. The SSD is responsible for the code status upon admission and places the dots outside the resident's room. The administrator said ultimately the nurse should double check the information was correct. The administrator said not having the correct resident code status can be a big deal because we don't want to do the wrong thing.

Based on observation, interview and record review, facility staff failed to notify the physician or registered dietician of the refusal of nutritional supplements for one resident (Resident #44), and failed to obtain a nutritional supplement in a timely manner for one resident (#61), out of 27 sampled residents. The facility census was 115.1. Review of the facility's policies did not contain a policy to direct staff on when to notify the physician or dietician if a resident refuses prescribed supplements or a policy on when to obtain a physician's order for supplements.2. Review of Resident #44's quarterly Minimal Data Set (MDS), a federally mandated assessment tool, dated 12/10/25, showed staff assessed the resident with impaired cognition, and weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months.Review of the resident's care plan, dated 03/23/25, showed the resident has experienced weight loss, has a med pass 2.0 nutritional supplement (shake) ordered three times a day (TID), has protein shakes ordered twice a day (BID), and for staff to encourage oral intake of food and fluids.Review of the residents Physician Order Sheet (POS), dated January 2026, showed an order for Med Pass 2.0 give 60 milliliters (ml) TID and ordered on 09/06/24, and protein shakes BID and ordered on 04/17/24.Review of the resident's Medication Administration Record (MAR), dated November 2025, showed staff documented resident refused Med Pass 2.0 nutritional supplement 81 times and refused protein shakes 54 times.Review of the resident's MAR, dated December 2025, showed staff documented the resident refused Med Pass 2.0 nutritional supplement 84 times and refused protein shakes 56 times.Review of the resident's MAR, dated January 2026, showed staff documented resident refused Med Pass 2.0 nutritional supplement 77 times and refused protein shakes 49 times.During an interview on 01/30/26 at 11:40 A.M., Certified Medication Technician (CMT) EE said Med Pass 2.0 would be provided by a nurse and the protein shakes would be provided by the kitchen during mealtimes. CMT EE said the CMT's are responsible for observing whether a resident drinks their supplements or not and responsible for documenting it in the MAR. CMT EE said he/she was aware the resident has been refusing both of his/her nutritional supplements for a long time and said he/she has communicated this to the nursing staff, but was not sure which staff member he/she told and could not recall the last time he/she told anyone in nursing. CMT EE said he/she is not sure why the resident still has an order for both supplements if the resident almost always refuses them and said the resident's refusals of the supplements should have already been communicated to the resident's physician and the facility's registered dietician.During an interview on 01/30/26 at 11:47 A.M., the Dietary Manager (DM) said the resident's protein shake is on the resident's meal ticket and is provided with the resident's meal. The DM said he/she was not aware the resident consistently refuses the protein shakes. The DM said nursing staff should have communicated this to him/her so he/she could notify the registered dietician. He/She said that is important in order to re-evaluate what types of nutritional supplements the resident may consume.During an interview 01/30/26 at 2:42 P.M., Licensed Practical Nurse (LPN)/Charge Nurse AA said the resident receives a Med Pass 2.0 nutritional supplement and protein shakes. LPN AA said he/she was not aware the resident was consistently refusing both nutritional supplements. The LPN said if a resident refuses medications or nutritional supplements two to three days in a row, nursing staff would be expected to notify the resident's physician and the registered dietician.During an interview on 01/30/26 at 5:04 P.M., the Director of Nursing (DON) said he/she was not aware the resident was refusing his/her nutritional supplements and said if a resident is refusing a physician's order for a few days in a row, he/she would handle that like the order was not being followed. The DON said if the resident has been consistently refusing both of his/her nutritional supplements, he/she would expect the charge nurse to notify him/her and to contact the resident's physician or registered dietician to discontinue the supplements. The DON said notifying the residents physician or registered dietician is important in order to determine another type of nutritional supplement the resident may like.During an interview on 01/30/26 at 5:39 P.M., the Administrator said he/she would expect the charge nurse to communicate a resident's consistent refusal of a physician's order to the DON, the resident's physician, and registered dietician. The Administrator said this is important so the resident can be re-evaluated to see if the resident would try a different nutritional supplement. 3. Review of Resident #61's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of hyperlipidemia, and diabetes mellitus.Review of the resident's care plan, dated 03/23/25, showed the resident requires a therapeutic diet for a diagnoses to include diabetes, gastroesophageal reflux disease, hyperlipidemia, and hypertension.Review of the resident's POS, dated 12/01/25, showed an order on 10/17/2025 for brand specific protein shake BID at breakfast and lunch cannot be supplemented with other protein shakes as they do not meet the nutritional needs per the resident's bone doctor.Review of the resident's MAR dated 12/01/25, did not contain documentation staff administered brand specific protein shake as ordered and staff documented it was unavailable 42 out of 62 times.Observation on 01/27/26 at 12:35 P.M., showed the staff did not provide the resident's specific protein shake. Observation on 1/28/26 9:45 A.M., showed the staff did not provide the resident's specific protein shake. Observation on 01/30/26 at 8:50 A.M., showed the staff did not provide the resident's specific protein shake. During an interview on 01/30/26 at 8:56 A.M., the resident said the facility does not provide the type of protein shake he/she wants to drink and said his/her son provides the protein shakes. The resident said he/she is unsure about the last time his/her son brought the protein shakes. The resident said he/she believed the shakes helped him/her but it's been a long time since he/she's received them. During an interview on 01/30/26 11:34 A.M., CMT EE, said he/she informed the nurse the resident's been out of his/her shakes, but he/she is unsure if the nurse called the resident's son. The CMT said he/she is unsure if he/she documented he/she notified the nurse the resident did not have any protein shakes. During an interview on 01/30/26 2:43 P.M., LPN AA said we are responsible to notify the family and reach out when the resident is out of his/her protein shakes. The LPN said we would notify the family, the pharmacy, the doctor if the resident did not receive his/her protein shake. The LPN said the resident should not be without his/her protein shake more than a couple of shifts. The LPN said prior to today, he/she was not aware the resident was out of his/her protein shakes. He/She said he/she would notify the whole team about the resident's shakes not available. During an interview on 01/30/26 at 5:04 P.M., the DON, said he/she expects his/her staff to follow the resident's physician orders. The DON said he/she is responsible to ensure everything is done to follow the resident's physician orders. The DON said the charge nurse puts the orders in the system. He/She is in charge to follow up to ensure the care plans are followed up. He/She said the charge nurse needs to contact the doctor to follow up on the order, if the resident is out of his/her supplement. He/She said if the nurse informs the supplement missing, he/she would inform the physician. The DON said he/she was not aware the resident was out of his/her protein shakes. During an interview on 01/30/26 at 5:39 P.M., the Administrator said he/she would expect staff to follow up on the resident's protein shakes and said the facility is responsible for making sure the resident has his/her protein shakes.

Based on interview and record review, facility staff failed to screen five employees (Director of Food Services, Resident Service Assistant (RSA) D, RSA C, Dietary Aide (DA) CC and Licensed Practical Nurse (LPN) FF) out of ten new employees prior to employment to determine if the employees had any indicators on the Certified Nurse Aide (CNA) Registry. The facility census was 115. 1. Review of the Facility's policy titled, Abuse & Neglect, dated 05/31/24, showed the facility will not employ individuals who have had a finding entered the Missouri CNA Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. The facility will report to the state nurse aide registry or any other licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. 2. Review of the Director of Food Services' personnel record showed: -Hire date of 01/06/25;-Did not contain documentation a CNA Registry check was completed. 3. Review of Resident Service Assistant (RSA) D's personnel record showed: -Hire date of 11/12/25;-Did not contain documentation a CNA Registry check was completed. 4. Review of RSA C's personnel record showed: -Hire date of 11/28/25;-Did not contain documentation a CNA Registry check was completed. 5. Review of Dietary Aide (DA) CC's personnel record showed: -Hire date of 12/23/25;-Did not contain documentation a CNA Registry check was completed.6. Review of Licensed Practical Nurse (LPN) FF's personnel record showed: -Hire date of 01/09/26;-Did not contain documentation a CNA Registry check was completed. During an interview on 01/29/26 at 3:54 P.M., the Human Resource Director said he/she could not provide CNA Registry checks for the mentioned staff. The Human Resource Director said he/she did not do CNA Registry checks on positions that are not CNAs, because he/she did not know it was necessary if the position the staff had been hired for, was not a CNA. During an interview on 01/30/26 at 3:43 P.M., Director of Nursing (DON) said he/she just found out, all staff should be run through CNA registry, he/she had not been aware. The DON said the Human Resource Director is responsible to do the CNA Registry checks on new hires. During an interview on 01/30/26 at 3:57 P.M., the administrator said the Human Resource Director does the background stuff. The administrator said everyone should be checked on the CNA Registry. The administrator said he/she is responsible to make sure the Human Resource Director does the CNA Registry checks.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for six residents (Resident #7, #8, #19, #61, #78 and #103) out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff when to review or revise care plans. 2. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/26, showed staff assessed the resident as:-Moderate cognitive impairment;-One or more unhealed pressure ulcers;-Two unstageable pressure ulcers. Review of the resident's progress notes, dated 12/02/25, showed staff documented the resident seen by wound clinic for two unstageable pressure ulcers to bilateral heals.Review of the resident's care plan, revised 1/20/26, showed it did not contain documentation in regard to the resident's bilateral heal unstageable pressure ulcers.During an interview on 01/30/26 at 12:18 P.M., Licensed Practical Nurse (LPN) I said he/she does not add anything to resident's care plans. He/She said he/she gives the wound clinic nurse notes to the MDS coordinator each week, so they can update the care plan. He/She said any kind of significant change should be updated on care plans.During an interview on 01/30/26 at 3:15 P.M., the MD coordinator said he/she updates care plans after morning meetings, Medicare meetings, and gathering information from staff to add to care plans. He/She said every three months he/she gets all the provider notes and updates care plans. He/She said if there is a new wound, the wound nurse will give her a printout of the wound clinic rounds every Tuesday, or wounds are discussed during morning meetings or interdisciplinary team (IDT) meetings. He/She said wounds should be on the care plan. He/She is unsure why Resident #7's pressure ulcers are not on his/her care plan. He/She said all nurses can make edits to care plans, but most staff just give the information to him/her so it can be updated. He/She said the importance of care plans to ensure staff knows what's going on and what is expected. He/She said the care plan is a blueprint for what resident's needs are and how to care for them. 3. Review of Resident #8's quarterly MDS, dated [DATE], showed staff assessed the resident as:- Cognitively impaired;- No behaviors or rejection of care over the past seven days;- Diagnoses of post-traumatic stress disorder, depression, and non-Alzheimer's dementia.Review of the resident's nursing progress notes showed staff documented the following:- On 09/04/2025, weekly meeting to discuss recent fall, resident is having behaviors, refusing care at times. He/She appears not to have a good support system r/t refusal to allow others to be proactively involved in his care and life;- On 09/05/2025, it was reported to this nurse by the Certified Medication Technician (CMT) that resident hit her and slapped the eye drops from her hand. When the next eye drops was due this nurse went to administer, and resident became angry and stated he would not take the eye drops and they are making his eyes worse anyway.-On 09/11/2025, resident declined to participate in scheduled assessment. Resident verbalized refusal despite education on purpose of assessment;- On 09/24/2025, overhead resident speaking in an elevated voice, sounding irritable and speaking quickly. Resident stating that his urologist is trying to kill him because he is a Vet, resident also stated that he wants to go to Veteran's Home in Mexico, Missouri. Resident not agreeable to going anywhere with staff and seemed to grow more agitated with the request to walk together. Staff stepped away, continued to listen to situation from nearby office;-On 11/21/25, the resident irritated he/she has had two episodes of loose stool. Staff attempted to assist resident in the bathroom, but he/she began to yell, telling staff it was their fault he/she has loose stools. Staff was not able to assist resident as resident continue to yell and stated staff did not know what they were doing;-On 12/11/25, the resident refusing medications today, and med tech states he/she refused his/her medications yesterday as well;-On 12/18/25, the resident has been refusing medications for the past three days, resident appears quite upset, delusional and paranoid this morning. Resident is being very uncooperative despite multiple attempts to calm, distract, explain, etc .;- On 12/21/25, the resident has been verbally aggressive towards staff today. Resident approached this nurse aggressively yelling. This nurse was in the middle of taking care of a resident and he/she followed me back down the hall getting loud about his/her rights, he/she then approached a Certified Nursing Assistant (CNA) and began yelling. The resident is now sitting in the common area talking to him/herself about random things.Review of the resident's care plan, dated 11/27/26, did not contain documentation of the resident's aggressive behaviors or refusals of care.During an interview on 01/30/26 at 4:43 P.M., the MDS/Care Plan Coordinator said he/she is responsible to update resident care plans. The MDS/Care Plan Coordinator said he/she did not view the residents' aggressive behaviors and refusals as a pattern, but more isolated incidents, so he/she did not include it on the resident's care plan. He/She said if a resident does have a pattern of aggressive behaviors and/or refusals, he/she would be expected to identify that on the resident's care plan and include interventions, so staff understands how to approach the resident.During an interview on 01/30/26 at 5:04 P.M., the Director of Nursing (DON) said if a resident is having aggressive behaviors and refusing care, he/she would expect it to be on the resident's care plan.During an interview on 01/30/26 at 5:39 P.M., the Administrator said if a resident is showing a pattern of behaviors and refusing care, he/she would expect it to be on the resident's care plan. The Administrator said the importance of the care plan is to ensure staff knows how to care for residents.4. Review of Resident #19's Significant Change MDS, dated [DATE], showed staff assessed the resident as:- Cognitively intact;- Does not reject care;- Had impairment of upper extremity on one side;- Dependent on staff for mobility;- Diagnoses of arthritis, osteoporosis, and amyotrophic lateral sclerosis (ALS - a progressive neurodegenerative disease that destroys motor neurons controlling voluntary muscles, leading to muscle weakness, twitching, and eventual paralysis); dysarthria (motor speech disorders characterized by weak, slow, or difficult to understand speech), and generalized muscle weakness.Review of the resident's POS, dated January 2026, showed an order dated 09/25/25, for wrist splints: on in the A.M. and off in the P.M., once a day.Review of the resident's Treatment Administration Record (TAR), dated January 2026, showed staff documented resident refused splints as ordered on 01/01/26, 01/02/26, 01/06/26, 01/11/26, 01/13/26, 01/15/26, 01/16/26, 01/17/26, 01/18/26, 01/19/26, 01/20/26, 01/22/26, 01/23/26, 01/24/26, 01/26/26, 01/27/26, 01/29/26 and 01/30/26.Review of the resident's care plan, dated 01/15/26, did not contain documentation staff applied splints or resident's refusals.Observation on 01/28/26 at 8:23 A.M., showed resident in his/her manual wheelchair in the assisted dining area. Observation showed he/she did not have his/her wrist splints on. Observation on 01/28/26 at 8:59 A.M., showed resident in his/her power wheelchair with his/her left hand curled in his/her lap.Observation on 01/29/26 at 8:22 A.M., showed resident in the assisted dining room without his/her wrist splints on.Observation on 01/29/26 at 10:38 A.M., showed resident in his/her room and without his/her wrist splints on. Observation showed his/her wrist splints on top of a pile of papers on a table.Observation on 01/30/26 at 10:40 A.M., showed resident in his/her power wheelchair in assisted dining room, without his/her wrist splints on.During an interview on 01/28/26 at 9:10 A.M., the resident said staff do not put any rolls or wash cloths in his/her hand to help with the contractures.During an interview on 01/30/26 at 11:53 A.M., LPN I said staff discuss care plans in the interdisciplinary team meetings, and that he/she does not add to or edit the care plans, the MDS Coordinators are responsible for that. LPN I said any kind of splints or assistive devices should be on the care plan, and if a resident refuses that should be on there as well. During an interview on 01/30/26 at 3:07 P.M., CNA N said he/she did not personally know about the splints, but said the resident does wear them to bed, and the resident will ask to put them on at night. The CNA said splints should be on the care plan, so staff know the resident needs them and when to put them on. CNA N said he/she thinks the charge nurse or MDS coordinator is the person that updates them, or the nurse manager.During an interview on 01/30/26 at 3:12 P.M., CNA O said the resident wears the splints when he/she sleeps, and nurses document on the TAR when they are on the resident. The CNA thinks that splints should be on the care plan and believes the nursing department updates the care plans. During an interview on 01/30/26 at 3:15 P.M., LPN K said the resident refuses to wear the splints almost every day, they are ordered to be put on in the morning and taken off at bedtime. LPN K said the resident never wants to wear the splints, and it should be documented if he/she refuses. LPN K said the use of splints should be on the care plan and any refusals of cares so that staff know. He/she believes the MDS Coordinator is responsible for updating the care plans, he/she was never told that charge nurses can update the care plans.During an interview on 01/30/26 at 3:27 P.M., LPN I said the resident does not wear the splints during the day, he/she wears them at night, and was not familiar with the resident's order off the top of his/her head, he/she would have to look at it. The LPN said the order should be changed, and it should be on the care plan.During an interview on 01/30/26 at 4:30 P.M., the DON said he/she is not sure if the resident is supposed to be wearing splints. The DON said the resident has changed in the last few weeks, and the resident was wearing them daily all the time when he/she was first admitted . The DON said the resident's ALS is progressing and he/she has been refusing medications and other things more often, and it should be on the care plan for splints or if he/she is refusing cares. The DON said the MDS Coordinator is responsible for updating the care plans.During an interview on 01/30/26 at 5:39 P.M., The Administrator said splints should be on the care plan and refusals of care. The Administrator said physician orders should be followed, and if the resident refuses staff should document and it should be on the care plan or progress note, and the MDS Coordinator is responsible for updating the care plans. 5. Review of Resident #61's quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognition intact;-Diagnoses of anxiety disorder, depression, hyperlipidemia, hypertension, and diabetes mellitus;-Not on a therapeutic diet while a resident.Review of the resident's registered dietician progress notes, dated 12/09/25, showed the resident with a regular diet order.Review of the resident's POS, dated January 2026, showed the resident prescribed a regular diet.Review of the resident's care plan, dated 03/23/25, showed the resident requires a therapeutic diet due to his/her diabetes, gastroesophageal reflux disease, hypertension, and hyperlipemia.During an interview on 01/27/26 at 11:36 A.M., the resident said he/she is on a regular diet and not a therapeutic diet.During an interview on 01/30/26 at 4:43 P.M., the MDS/Care Plan Coordinator said he/she was attempting to show the resident's comorbidities under the nutrition section of the care plan. He/She said she's responsible to update the care plan. He/She said he/she was not aware of the resident's change in diet September of 2025. During an interview on 01/30/26 at 5:04P.M., the DON said he/she is in charge to ensure the care plans are followed up. The DON said we meet weekly to discuss the resident's care plan needs and any issues to follow up with weekly. The DON said he/she was not aware the resident's care plan was not updated.During an interview on 01/30/26 at 5:39 P.M., the Administrator said the importance of the care plan is to ensure staff know how to care for residents. He/She expects the change to be on the resident's care plan. He/She expects his/her staff to follow the care plan. The Administrator said overall, he/she is responsible to ensure the staff follow the resident's care plan. 6. Review of Resident #78's quarterly MDS assessment, dated 11/05/25, showed staff assessed the resident as:- Severe cognitive impairment;-Received Antipsychotic medication for seven of the seven day look back period;-Significant weight loss.Review of the resident's POS, dated January 2026, showed an order dated 12/10/25, Quetiapine (antipsychotic mood stabilizer) 50mg, one tablet at bedtime.Review of the resident's electronic medical record (EMR), showed staff documented the resident weighed 131 lbs. (Pounds) on 08/04/25, 112 lbs. on 08/11/25 and 110 lbs. on 09/01/25.Review of the resident's care plan, dated 12/23/25, did not contain documentation related to the resident's use of Antipsychotic medications, or interventions to monitor for related behaviors and potential adverse effects to the medication. The care plan did not contain documentation related to the resident's significant weight loss, or the interventions to direct staff for the resident.During an interview on 01/30/26 at 10:20 A.M., CNA R said the resident's care plan should include weight loss if the resident has significant weight loss. The CNA said he/she is pretty sure antipsychotic medications, and their effects should be on the resident's care plan. During an interview on 01/30/26 at 10:30 A.M., CMT U said significant weight loss should be on the resident's care plan and interventions for the weight loss should be on the care plan. The CMT said antipsychotic medications should be on the care plan, so staff know what to look for and report to the nurse. During an interview on 01/30/26 at 10:33 A.M., Registered Nurse (RN) T said antipsychotic medications and what to look for should be on the resident's care plan. The RN said weight loss and interventions should be on the care plan. During an interview on 01/30/26 at 12:30 P.M., the MDS Coordinator said typically significant weight loss and interventions should be on a resident's care plan. The MDS Coordinator said he/she missed those on the resident's care plan, it is on him/her 100%. Antipsychotic medication should be care planned with monitoring for side effects and behaviors, he/she has not updated the resident's care plan in a while. During an interview on 01/30/26 at 3:43 P.M., DON said weight loss should be on the care plan with updated interventions. The DON said antipsychotic medications and their effects should be care planned. The DON said the MDS coordinator is responsible to update the care plan. The DON said he/she is responsible to make sure the MDS Coordinators get them care planned. During an interview on 01/30/26 and 3:57 P.M., the administrator said weight loss and interventions should be care planned. The administrator said antipsychotics and the adverse effects should be care planned. The administrator said the MDS Coordinator is responsible for updating the care plans, and he/she is responsible to make sure the MDS Coordinator is updating the care plans. 7. Review of Resident #103's quarterly MDS assessment, dated 11/20/25, showed staff assessed the resident as:-Severe cognitive impairment;-Dependent on staff for care and mobility;-At risk for pressure ulcers;-Diagnoses of Alzheimer's disease, dementia, and anxiety.Review of the resident's POS, dated January 2026, showed an order dated 01/13/26, for right great toe: skin prep and cover daily until healed, once a day.Review of the resident's care plan, dated 11/21/25, did not contain documentation of the wound to the resident's right toe and the need for Enhanced Barrier Precautions (EBP).During an interview on 01/30/26 at 11:53 A.M., LPN I said that EBP, and pressure ulcers or wounds should be on the care plan. LPN I said he/she gives the MDS Coordinator a copy of the wound report each week and they should update the care plan with that information.During an interview on 01/30/26 at 3:07 P.M., CNA N said wounds should be on the care plan so staff know what interventions should be in place. During an interview on 01/30/26 at 3:15 P.M., LPN K said the resident's toe wound should be on the care plan, it is important to know about all skin changes, and he/she would communicate if there were changes or refusals.During an interview on 01/30/26 at 4:30 P.M., The DON said wound care notes are reviewed at the weekly interdisciplinary team meetings, and wound care rounds are completed on Tuesday, so that information should be on the care plan once it is identified. The MDS Coordinators usually update the care plans, and it is his/her responsibility to oversee that it gets done. The DON said it is important so that everyone knows how to take care of the residents, and he/she did not know it was not being done.During an interview on 01/30/26 at 5:39 P.M., the Administrator said wounds should be on the care plan, the MDS Coordinator is responsible for updating care plans. He/she was not aware the resident's care plan did not address his/her wound or need for EBP, but if a resident has a wound, they should have EBP.

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store medications in the memory care unit bathroom and left medications in one resident's bathroom (Resident #62). The facility census was 115.1.Review showed the facility failed to provide a policy to direct staff on medication storage safety. 2. Observation on 01/29/26 at 8:35 A.M., showed the whirlpool bathroom on the memory care unit unlocked, with the door propped open, and the following sitting out:-Nystatin (Antifungal) topical 100,000 unit/gram powder labeled with a resident's name;-Triad hydrophilic wound dressing pansement hydrophilic (a sterile, zinc-oxide based paste designed to manage light-to-moderate wound exudate by creating a moist, healing environment);-Calmoseptine ointment (a multipurpose, over-the-counter moisture barrier designed to treat skin irritations, diaper rash, incontinence, and minor wounds);-A&D ointment.3. Observation on 1/29/26 at 2:33 P.M., showed the whirlpool bathroom on the memory care unit unlocked, with the door propped open, and the following sitting out:-Nystatin topical 100,000 unit/gram powder labeled with a resident's name;-Triad hydrophilic wound dressing pansement hydrophilic;-Calmoseptine ointment;-A&D ointment.During an interview on 1/29/2026 at 2:33 P.M., Resident Service Assistant (RSA) DD said the whirlpool bathroom is usually kept unlocked for residents to use, but no items should be out where residents can get to them. He/She was unaware the items were out. He/She said they get the supplies out when they toilet residents every two hours, but supplies should be put back. He/She said it is dangerous to leave medications and ointments out where residents can ingest them, because they have a lot of confused residents on the unit.During an interview on 1/29/2026 at 2:40 P.M., the Director of Nursing (DON) said it is important to keep medications and ointments out of the reach of residents. He/She said there are residents that wander on the unit and who are not cognitive who could get ahold of and possibly ingest the ointments and medications. He/She said all medications and ointments should be kept locked in the medication carts. He/She was not aware staff were leaving ointments and prescribed medications in the whirlpool bathroom with the door open and unattended.During an interview on 1/30/26 at 11:37 AM, the administrator said is his/her expectation that any ointments and/or medications are kept behind locked doors or cabinets when it is not in use. He/She said it is especially important for safety on the locked memory care unit. He/She said he/she would expect prescriptions to be placed in the treatment cart and not left out. He/She said the residents are on the memory care unit because they wander, some are mobile, and they have cognitive impairment. He/She said items left out could care harm if ingested.4. Review of Resident #62's Comprehensive Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as severe cognitive impairment and a diagnosis of dementia.Review of the physician order sheet (POS), dated January 2026, showed an order to check wander guard placement every shift.Observation on 01/27/26 at 10:55 A.M., showed the resident wore a wander guard on his/her left ankle.Observation on 01/28/26 at 9:46 A.M., showed the resident's bathroom contained three tubes of A&D ointment and Selan plus Zinc oxide barrier cream.Observation on 01/29/26 at 8:41 A.M., showed the residents bathroom contained three tubes of A&D ointment, Selan plus Zinc oxide barrier cream.Observation on 01/29/2026 at 8:48 A.M., showed the resident wandered into the whirlpool bathroom.During an interview on 1/29/26 at 2:33 P.M., RSA DD said the ointments should not be left where residents can get to them. He/She said they have confused residents who may rub it on their skin or try to ingest it. He/She was not aware the ointments where in the resident's room, he/she said it was a safety concern.During an interview on 1/29/26 at 2:40 P.M., the DON said the resident is not cognitive and wanders. He/She said ointments and medications should not be left out where the resident can get a hold of them. He/She said items left out can be a safety risk for the resident. He/She said it is his/her expectation that staff place ointments/creams in locked medication carts when they are not in use. He/She was not aware of the issue.During an interview on 1/30/26 at 11:37 AM, the administrator said he/she was not aware medications and ointments were on the counters in the resident's room again. He/She said the resident is not cognitive, is mobile, and does wander. He/She said this is a safety concern, and these items could be dangerous if ingested.

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital with low blood sugar. The facility census was 116. The administrator was notified on [DATE] of past Non-Compliance, which occurred on [DATE] when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on [DATE]. 1. Review of the facility Medication Administration policy, dated [DATE], showed nursing personnel shall ensure the safe and effective administration of medications. A physician or authorized practitioner should give all orders for medications or treatments that include medications. Prior to administration the nursing staff member administering the medication shall verify the medication is being administered to the correct resident/patient, at the proper time, in the prescribed dose and by the correct route. 2. Review of Resident #1's Admission minimum data set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of iron deficiency, Atrial Fibrillation (causes the heart to beat irregularly), Hypertension, and renal failure. Review of the resident's plan of care, [DATE], showed the care plan did not contain documentation about the resident's medications. Review of the resident's physician order sheet, dated [DATE] to [DATE], did not show any orders for insulin or blood sugar medications. Review of the resident's progress notes, dated [DATE] at 8:56 P.M., showed Licensed Practical Nurse (LPN) A documented at 8:56 P.M., resident received Basaglar insulin (a long-acting insulin to control blood sugar levels) 40 units. Blood sugar was 152. Notified physician on call, waiting for to return call. Review of the resident's progress notes, dated [DATE] at 9:05 P.M., showed the residents blood sugar at 9:20 P.M., was 149 and at 9:40 P.M., was 142. Review of the resident's progress notes, dated [DATE] at 9:36 P.M., showed Licensed Practical Nurse (LPN) A documented new orders to check blood sugars every hour for 24 hours, give glucose gel for low blood sugar if needed, give glucagon (an emergency medicine used to treat severe low blood sugar) for low blood sugar if needed. Resident ate half a sandwich, juice and yogurt. Physician called back with orders to send the resident to the emergency room to monitor more closely. Review of the resident's hospital records, dated [DATE], showed the resident admitted to the hospital for monitoring of an insulin overdose and medication error. The resident continued to have hypoglycemia (low blood sugar) ranging ,d+[DATE] for the majority of his/her stay. Review of the facility investigation, dated [DATE], showed LPN A administered another resident's medication to Resident #1 because Resident #1 and Resident #2 have similar names. Staff documented the review sheet and the medication administration record did not match the bed numbers. LPN A unfamiliar with residents. The resident was sent to emergency room and admitted . Review showed nursing staff in-serviced on proper medication administration on [DATE]. During an interview on [DATE] at 11:14 A.M., the administrator said there was a full investigation into a medication error with the resident. The nurse gave the resident the wrong medication. The physician was contacted immediately as were the family, blood sugar checks started, snacks were given and the resident was then sent out to the hospital for monitoring. During an interview on [DATE] at 1:25 P.M., the resident said he/she got medications that was his/her roommate's medications and had to spend two days in the hospital because he/she is not a diabetic. He/She said the nurse did not ask his/her name and after he/she got the shot in his/her stomach, he/she asked the nurse if he/she was a diabetic now and the nurse said I guess so. He/She said then the nurse rushed him/her to eat something and then sent him/her to the hospital and he/she almost died . During an interview on [DATE] at 2:46 P.M., LPN A said he/she had to pass medications on a unit he/she does not normally work. He/She said he/she had the report sheet to see if the residents had any special notes he/she would need to know about. He/She said he/she followed the report sheet which showed the Resident #2 in bed A and he/she administered the insulin to that resident. After administering the insulin, the resident asked him/her if he/she was a diabetic now and he/she immediately checked the report sheet and the MAR and realized Resident #2 is in bed B and Resident #1 in bed A is not a diabetic. He/She called the physician and got new orders and tried to get the resident to eat. He/She said the physician called back and wanted the resident sent out because of the amount of insulin given. During an interview on [DATE] at 2:55 P.M., the Director of Nursing (DON) said he/she was contacted by LPN A that a major medication error had occurred. LPN A had given the resident his/her roommates insulin. LPN A said the bed assignments were mixed up on the report sheet. He/She said the physician and family was contacted immediately, blood sugar checks were ordered, and the resident was given snacks per physician orders, soon after the physician called back and decided to send the resident to the emergency room . MO00249963

Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when staff failed to lower the resident appropriately in the shower chair which resulted in a compression fracture (a break in a vertebra, or bone in your spine, causes it to collapse) the resident's spine. The facility census was 115. 1. Review of the facility's use of lift machine policy, dated 11/25/2019, showed the purpose of the policy is to help lift residents who otherwise may not be transferred manually, promote comfort and maintain good body alignment while resident is being moved, to position the resident in desired location, and use controls to slowly lower resident to that location. 2. Review of Resident #1's five day Minimum Data Set (MDS) a federally mandated assessment tool, dated 7/1/24, showed staff assessed the resident as follows: -Cognitively intact; -Required substantial maximal assistance for toileting, showers, and transfers; and -Impairments to both lower extremities. Review of Resident #1's Baseline Care plan, dated, 6/25/24, showed staff assessed the resident as required two-person assistance with bed mobility and toileting. The resident utilized a power wheelchair. Review of the facility's investigation, dated 7/6/24, showed staff documented the resident requested to be transferred to the shower chair via mechanical lift. While being assisted by two staff members with the use of the mechanical lift, the lifts knob released too quickly and the resident was abruptly lowered into the shower chair. The resident complained of pain afterwards and staff called an ambulance. Resident sent to the hospital. Review of the resident's nurse notes, dated 7/6/24 at 7:06 P.M., showed Registered Nurse (RN) A documented two staff members assisted the resident into his/her chair with the mechanical lift. Review showed after transfer was completed patient stated to Certified Nursing Assistant B he/she was sat down too hard and was now hurting and uncomfortable. The staff then transferred resident to his/her bed. Staff called 911 to go to hospital for back pain. Nurse went to room and resident said he/she did not need a nurse assessment he/she knew he/she was going no matter what because he/she was afraid of a back injury. The resident was transported to the hospital. Review of the resident hospital records, dated 7/18/24, showed the resident had a recent history of lower back region of the spine laminectomy (surgery where part or all of the bone is removed) and bilateral discectomy (surgical procedure to remove a section of two intervertebral discs to treat severe lower back pain) in April 2024 and a revision surgery on June 2024. He/She presented to the emergency department on 7/6/24 with low back pain after being lowered too quickly at his/her skilled nursing facility. Computed tomography of the lumbar spine in the emergency department showed L1-L2 compression fracture (a break in a vertebra, or bone in your spine, causes it to collapse) which is new, and neurosurgery consulted. He/She taken to the operating room [ROOM NUMBER]/16/24 for L2-L3 fusion, L2 hardware removal, facet fusion of L1-2 and L3-4. During an interview on 1/13/24 at 10:11 A.M., the administrator said the resident was in the facility because he already had a surgery to the spine, the resident was a two person mechanical lift, he/she said he/she was sat down too hard in the shower chair and staff went to get nurse and the resident called 911 and left, he/she never came back and he/she was not certain what happened to the resident. During an interview on 1/13/24 at 12:03 P.M., the administrator said after reviewing additional hospital records it looked like the resident had new damage to his/her spine. During an interview on 1/15/24 at 12:36 P.M., RN A said he/she can remember the aide on duty came to him/her and said the resident said his/her back hurt really bad. He/She said the resident called to go to the hospital for the back pain because the resident said he/she had been dropped too hard into the shower chair. The resident declined for the nurse to assess him/her. RN A said he/she questioned the aides on duty who said there were two aides present and there was no malfunction to the lift. He/She said the resident never came back to the facility. During an interview on 1/23/25 at 4:57 P.M., Certified medication technician (CMT) A said he/she was on the medication cart that day and was asked by CNA B to spot him/her on the mechanical lift. He/She said CNA B let the resident down too quick which caused the resident to drop down into the shower chair from the mechanical lift and the resident was really upset and complained about immediate back pain. MO000247806

Based on observation, interview and record review, facility staff failed to follow standard universal infection control precautions when staff used one insulin pen on three residents (Resident #7, #10, and #41), possibly creating a risk of bloodborne and bacterial pathogen transmission. The facility failed to use appropriate hand hygiene infection control practices during perineal and wound care for four (# 41, #43, #47, #105) of four sampled residents, and failed to follow Enhanced Barrier Precautions (EBP), the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms, for three (#7, #19, and #105) of four sampled residents. The facility census was 117. The administrator was notified on 10/31/24 at 8:00 A.M., of an Immediate Jeopardy (IJ) which began on 10/28/24. The IJ was removed on 10/30/24, as confirmed by surveyor onsite verification. 1. Review of the facility's policy showed staff did not provide an Insulin Administration policy. Review of the Glargine insulin pen manufacture safety information, showed to never share a pre-filled pen, insulin syringe, or needle between patients. Review of the Centers for Disease Control (CDC), Insulin Pen handout, undated showed: Insulin Pens: Recommendations For Safe Use Protecting your patients from infection is a basic standard of care. Reusing insulin pens and other injection equipment for more than one person can spread infections to your patients. -Insulin pens and other injection equipment are meant to be used on one person only. -Insulin pens should never be used for more than one person, even when the needle is changed or when there is leftover medicine. Although invisible to the eye, back flow of blood into the insulin pen can happen during an injection. This creates a risk of bloodborne and bacterial pathogen transmission to patients if the pen is used for more than one person, even when the needle is changed. Review of the facility investigation, dated 10/28/24, showed the administrator was made aware the medication cart keys were locked in the medication cart on 10/27/24. Review showed Licensed Practical Nurse (LPN) A unable to unlock the cart to administer insulin to Resident #7, #10, and #41. LPN A used one emergency medication kit Glargine insulin pen for three residents. Review showed the LPN said he/she used the same insulin pen, but changed the needles between residents. Review of Resident #7's quarterly Minimum Date Set (MDS),a federally mandated assessment, dated 09/11/24 showed staff assessed the resident as follows: -Cognitive; -Diagnosis of Diabetes; -Received insulin injection seven out of seven days. Review of Resident #7's Physician Order Sheet, dated 05/24/24, showed an order for: -Insulin Glargine 100 unit/milliliters (mL) (3 mL) 25 units subcutaneous twice a day between 6:00 A.M. and 10:00 A.M., and 7:00 P.M. and 10:00 P.M. Review of Resident #7's medication administration record (MAR), dated 10/27/24, showed: -An order for Insulin Glargine; -LPN A documented he/she administered the resident's insulin on 10/27/24 at 10:56 P.M. Review of Resident #10's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitive; -Diagnosis of Diabetes; -Received insulin injection seven out of seven days. Review of Resident #10's Physician Order Sheet, dated 08/26/24, showed an order for Insulin Glargine 100 unit/mL (3 mL) 5 units subcutaneous between 7:00 P.M. and 10:00 P.M. Review of Resident #10's MAR, dated 10/27/24, showed: -An order for Insulin Glargine; -LPN A documented he/she administered the resident's insulin on 10/27/24 between 7:00 P.M. and 10:00 P.M. Review of Resident #41's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitive; -Diagnosis of Diabetes; -Received insulin injection seven out of seven days. Review of Resident #41's Physician Order Sheet, dated 04/11/24, showed an order for Insulin Glargine 100 unit/mL (3 mL) 17 units subcutaneous between 7:00 P.M. and 10:00 P.M. Review of Resident #41's MAR, dated 10/27/24, showed: -An order for Insulin Glargine; -LPN A documented he/she administered the resident's insulin on 10/27/24 at 10:52 P.M. During an interview on 10/28/24 at 3:30 P.M., LPN P said he/she was informed on 10/27/24 by LPN A the key to the treatment cart had been locked inside and LPN A gave Resident #7, #10 and #41 their insulin with the same insulin pen due to not being able to get into the locked cart. LPN P said there is multiple phone numbers to call overnight if there is an issue like this. During an interview on 10/29/24 at 9:00 A.M., LPN C said it would be unsafe to use the same pen on multiple residents. He/She said they called the Maintenance Director to have the cart unlocked prior to leaving their shift on 10/27/24. During an interview on 10/28/24 at 1:45 P.M. the Director of Nursing (DON) said he/she was made aware on 10/28/24, LPN A had administered insulin to Resident #7, #10, and #41 using the same insulin pen with different one time use needles. During an interview on 10/28/24 at 3:30 P.M., the Medical Director said changing the needle decreased the risk, but not to zero. During an interview on 10/29/24 at 4:00 P.M., the DON said the facility does not have a specific insulin administration policy, the facility instead follows manufactures recommendation on how to safely administer insulin. He/She was made aware on 10/28/24 by the charge nurse on duty the cart keys were missing. The DON said he/she was not aware of the insulin administration from one insulin pen until the following morning. During an interview on 10/29/24 at 2:00 P.M., the administrator said he/she was made aware of the insulin being administered incorrectly the next day. The cart being locked and keys missing was the only issue he/she was made aware of during the overnight shift. He/She did not know there were no extra keys available. 2. Review of the facility's Hand Hygiene policy, revised 10/30/2018, showed staff are to wash their hands: -Before and after direct resident contact or after handling resident's personal belongings; -Before and after performing any invasive procedures; -Before and after handling peripheral vascular catheters and other invasive devices; -Before and after removing gloves or aprons. Review of Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/24, showed the CDC guidelines are to perform hand hygiene, either by handwashing with soap and water or antiseptic hand rub: -Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or patient's surroundings; -After contact with blood, body fluids, or contaminated surfaces; -Immediately after glove removal. Observation on 10/29/24 at 9:09 A.M. showed LPN Q and Certified Nurse Assistant (CNA) EE applied gloves and transferred Resident #43 to bed by mechanical lift. LPN Q provided care to the resident and with the same gloves put a clean brief on the resident. LPN Q and CNA EE removed their gloves and did not perform hand hygiene before they assisted with the resident's clothing, bedding and left the room. During an interview on 10/29/24 at 9:20 A.M., CNA EE said glove changes and hygiene should be done when going from a dirty to a clean area. He/She did not know why he/she didn't do it this time. During an interview on 10/29/24 at 9:22 A.M., LPN Q said gloves should be changed and hand washing done after wiping someone's bottom. He/She said it was not done because he/she did not want to leave the resident, afraid he/she would roll out of bed. Observation on 10/29/24 at 1:45 P.M., showed CNA GG and NA FF entered Resident #41's room to perform perineal care and applied gloves. CNA GG removed bowel movement and with the same gloves he/she touched the bottle of spray cleaner, applied cream to the resident's skin, and applied a clean brief and clothing. CNA GG removed his/her gloves and did not perform hand hygiene before he/she left the resident's room. CNA GG did not perform hand hygiene before he/she applied gloves to make the resident's bed. During an interview on 10/29/24 at 2:16 P.M., CNA GG said it is appropriate to wash hands or use hand sanitizer after removing gloves and when care is finished. He/She said handwashing and glove change should have been done after cleaning up the bowel movement. Observation on 10/30/24 at 1:50 P.M. showed Registered Nurse (RN) E applied gloves and performed perineal care for Resident #105. RN E did not perform hand hygiene after he/she performed perineal care and removed his/her gloves or before he/she left the resident's room. During an interview on 10/30/24 at 2:06 P.M. RN E said he/she had received training to wash hands before and after caring for a resident. Observation on 10/30/24 at 11:13 A.M. showed the Infection Preventionist (IP) applied gloves and performed wound care for Resident #47 and removed the resident's leg wrap and cleaned the wound. The IP removed his/her gloves, did not perform hand hygiene and put on new gloves. The IP removed scissors from his/her pocket, did not clean the scissors, and cut the medicated gauze. During an interview on 10/30/24 at 11:45 A.M., the IP said hand hygiene should be performed before and after wound care, and when you change gloves. He/She did not realize he/she missed doing hand hygiene when gloves were changed. 3. Review of the facility's Enhanced Barrier Precautions Policy, dated 4/1/24, showed: -EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities; -The facility will have the discretion on how to communicate to staff which residents require use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high contact care activities; -An order for EBPs will be obtained for residents with wounds and /or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Review of the facility's Enhanced Barrier Precaution sign used by the facility, showed staff are instructed as follows: -Everyone must clean their hands, including before entering and when leaving the room; -Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, showering/bathing, transferring, changing linens, providing hygiene, changing briefs of assisting with toileting hygiene, device care or use - central line, urinary catheter, feeding tube, tracheostomy, and wound care - any skin opening requiring a dressing. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident with one open ulcer. Review of Resident #7's care plan, dated 08/24/24, showed the resident at risk of infection due to wounds. Observation on 10/30/24 at 11:36 A.M., showed IP entered Resident #7's room to perform wound care. The IP did not wear a gown when he/she performed wound care on the resident. The resident's door frame displayed a EBP sign that indicated instructions for staff during care. Review of Resident #19's significant change MDS, dated [DATE] showed staff assessed the resident used a feeding tube. Observation on 10/30/24 at 1:48 P.M., showed LPN II entered Resident #19's room to administer medications via the resident's feeding tube. LPN II did not wear a gown when he/she administered the resident's medication via the feeding tube. The resident's door frame displayed a EBP sign that indicated instructions for staff during care. Review of Resident #105's quarterly MDS, dated [DATE], showed staff assessed the resident with an indwelling catheter. Observation on 10/30/24 at 1:50 P.M. showed RN E entered Resident #105's room to perform catheter care. RN E did not wear a gown when he/she performed catheter care. The resident's door frame displayed a EBP sign that indicated instructions for staff during care. During an interview on 10/30/24 at 2:06 P.M., RN E said he/she had received training on EBP and that it was about washing hands before and after caring for a resident. He/She said gowns are only used when the resident has an MDRO or infectious organism. This would be communicated to staff in morning huddle and a personal protective equipment cart would be placed outside the room. During an interview on 11/01/24 at 10:18 A.M., RN E said if a resident has EBPs, a gown, gloves and a mask should be put on before providing care. The precautions are for resistant infections or residents more prone to infections in order to prevent any other infections in the resident. During an interview on 11/01/24 at 9:00 A.M., LPN P said EBP differs from standard precautions because wounds and catheters use more personal protective equipment. He/she said regarding gowns, he/she would be cautious and tell staff to put them on for extra protection. He/She did not recall receiving EBP training because there have been so many inservices lately. During an interview on 11/01/24 at 9:30 A.M., LPN Q said the premise of EBP is if there is a catheter, for example, you wear gloves. He/She said a gown would be worn if you expect to be splashed or if they have some kind of infection, or emptying a catheter; you never know if it will splash. During an interview on 11/1/24 at 1:00 P.M., DON said EBP is implemented for residents who have wounds, catheters, or tubes that can be susceptible to infection. Gown and gloves are required when working with these residents. Staff have been inserviced on EBP. He/She said the IP/RN is responsible for putting signage on the doors and monitoring compliance. Hand sanitizer is readily available in each bathroom and outside each room. He/She said poor hand washing is the number one cause of transmission of disease and inservice has been provided two or three times this year. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote the facility has complied with State law (Section 198.026.1 RSMo.) requiring prompt remedial action to be taken to address Class I violation(s). MO00244239 42484 50432

42484 Based on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for four of four sampled residents (Resident #19, #48, #69, and #115). The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed the following: -Transferred to the hospital on 05/25/24; -Returned to the facility on [DATE]; -Transferred to the hospital on 07/29/24; -Returned to the facility on [DATE]; -Staff did not document they notified the resident or resident representative of the transfer in writing. 3. Review of Resident #48's medical record showed the following: -Transferred to Emergency Department on 10/9/24 with return anticipated; -Staff did not document they notified the resident or resident representative of the transfer in writing. 4. Review of Resident #69's medical record showed the following: -Transferred to the hospital on 06/05/24; -Returned to the facility on [DATE]; -Staff did not document they notified the resident or resident representative of the transfer in writing. During an interview on 10/29/24 at 3:09 P.M., the resident said no paperwork was issued regarding a notice of transfer when he/she was transferred to the hospital. 5. Review of Resident #115's medical record showed the following: -Transferred to the hospital on 09/11/24; -Returned to the facility on [DATE]; -Transferred to the hospital on 09/20/24; -Returned to the facility on [DATE]; -Staff did not document they notified the resident or resident representative of the transfer in writing. 6. During an interview on 10/30/24 at 2:50 P.M., the administrative assistant said there is no process for written notification of discharges to the resident or resident representatives. During an interview on 10/30/24 at 2:50 P.M., the Regional Nurse Consultant said when a resident is transferred to the hospital, the process should include giving the resident a copy of the notice of transfer and to have the resident sign it before leaving the building. These documents should be scanned and placed in the miscellaneous section of the resident's electronic medical record. If the nursing staff speaks with the resident representative on the phone, two nurses should talk to the family and document this on the form as well. In addition, nurses should document the notification in the progress notes and in the discharge note. During an interview on 11/01/24 at 12:33 P.M., the Director of Nursing said planned discharge paperwork such as home health are handled by Social Services, and nursing information such as medication lists are handled by the nursing staff. The administrative staff has realized there is no policy for written notifications when residents are transferred to the hospital. 50432

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two (Resident #19 and #69) of three sampled residents. The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed staff documented the resident: -Transferred to the hospital on 05/25/24 and returned to the facility on [DATE]; -Transferred to the hospital on 07/29/24 and returned to the facility on [DATE]; -Staff did not document they notified the resident or the resident representative of the bed hold policy in writing. 3. Review of Resident #69's medical record showed staff documented the resident transferred to the hospital on 06/05/24 and returned to the facility on [DATE]. Staff did not document they notified the resident or the resident representative of the bed hold policy in writing. During an interview on 10/29/24 at 3:09 P.M., the resident said no paperwork was issued regarding a bed hold when he/she was transferred to the hospital. 4. During an interview on 10/30/24 at 2:50 P.M., the administrative assistant said there is not a process for written notification of the bed hold policy for the resident or resident representatives when a resident is transferred to the hospital. During an interview on 10/30/24 at 2:50 P.M., the Regional Nurse Consultant said when a resident is transferred to the hospital, the process should include giving the resident a copy of the bed hold policy and to have the resident sign it before leaving the building. This document should be scanned and placed in the miscellaneous section of the resident's electronic medical record. If the nursing staff speaks with the resident representative on the phone, two nurses should talk to the family and document this on the form as well. Nurses should document the notification in the progress notes and in the discharge note. During an interview on 11/01/24 at 10:18 A.M., Registered Nurse E said when a resident is transferred to the hospital, the charge nurse prepares the paperwork to go with the resident. RN E said he/she did not know of any written bed hold paperwork required for the transfer. During an interview on 11/01/24 at 12:33 P.M., the Director of Nursing said planned discharge paperwork such as home health are handled by social services, and nursing information such as medication lists are handled by the nursing staff. During an interview on 11/01/24 1:38 P.M., the administrator said a new process for hospital transfers will be implemented almost immediately. 50432

Based on observation, interview, and record review, the facility staff failed to develop comprehensive care plans with resident-specific interventions to meet the resident's preferences and goals, and to address the resident's medical, physical, and psychosocial needs for five residents (Residents #45, #49, #56, #108, and #111) out of twelve sampled residents. The census was 117. 1. Review of the facility's policies showed the facility did not provide a policy for care plans. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/24, showed staff assessed the resident as: -Cognitively impaired; -Had inattentive and disorganized thinking that fluctuated; -No behaviors or wandering; -Diagnosis of dementia. Review of the resident's nurse notes, dated 08/28/24 through 10/28/24 showed staff documented: -On 08/28/24 at 2:38 P.M., intermittent behaviors; -On 09/16/24 at 12:41 P.M., resident began to get angry and yell at staff while taking resident to the bathroom; -09/18/24 at 3:47 P.M., resident being rude to staff and other residents. Refused skin assessment, called staff names and tried to hit; -09/23/24 at 5:53 P.M., resident calling staff names, not wanting to cooperate going to bed; -10/06/24 at 12:51 P.M., became very upset after lunch accusing everyone of taking his/her root beer, did not calm down until removed peers from area; -10/17/24 at 12:08 P.M., aggressive and agitated with staff trying to hit them, allowed to calm down; -10/28/24 at 5:22 P.M., agitated and verbally aggressive and yelling shut up, attempted getting out of the unit door multiple times, redirected. Review of the resident's Point of Care history, dated 09/01/24 through 11/01/24, showed on 10/24/24 staff documented verbal and physical behavior directed toward others not easily redirected. Review of the resident's care plan, dated 09/23/24, showed the care plan did not contain direction for the resident's verbal and physical behaviors or attempts/to leave the secured unit. During an interview on 10/31/24 at 10:09 A.M., Certified Nurse Aide (CNA) F said the resident can become agitated around dinner time. The resident has the past of getting physical with other residents before and will try to get out of the secured unit. Staff tries to walk with him/her when they are agitated, but it isn't always successful. When left alone, the resident will calm down after about an hour but in the meantime, staff need to keep other residents away from him/her. He/She is not sure what the care plan says regarding this resident behaviors or interventions. 3. Review of Resident #49's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Severely impaired vision; -Did not take medication for pain on a schedule or as needed; -Required moderate/partial assistance for bed mobility and transfers; -Very important to have books, newspapers, and magazines to read but could not do or had no choice. Review of the resident's care plan, dated 10/08/24, showed staff assessed the resident had pain in the back and legs due to arthritis, is blind. The care plan did not address the resident's positioning in the recliner. Observation on 10/29/24 at 9:36 A.M., showed the resident in his/her recliner flat on his/her back, with only his/her head propped with the backrest, eating breakfast. Observation on 10/30/24 at 2:07 P.M., showed the resident in his/her recliner flat on his/her back, with only his/her head propped up with the backrest. Observation on 10/31/24 at 9:30 A.M., showed the resident in his/her recliner flat on his/her back, with only his/her head propped up with the backrest. During an interview on 10/31/24 at 11:55 A.M, the resident said he/she positions himself/herself in the recliner almost flat because he/she has back pain and has difficulty sitting up because of pain. 4. Review of Resident #56's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required partial/moderate assistance for bed mobility; -Required supervision or touch assistance for transfers and walking; -Impaired functional limitation of range of motion in one leg. Review of the resident's care plan, dated 08/27/24, showed the care plan did not contain direction for the use of bed rails. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed an order for the use of bed rails. Observations on 10/29/24 at 10:16 A.M, showed the resident's bed with rails on both sides of the bed. Observation on 10/30/24 at 9:01 A.M., showed the resident's bed with rails on both sides of the bed. Observation on 10/31/24 at 9:14 A.M., showed the resident's bed with rails on both sides of the bed. During an interview on 10/29/24 at 10:16 A.M., the resident said he/she used the bed rails to help with mobility on the bed. 5. Review of Resident #108's Quarterly MDS dated [DATE] showed: -Moderate cognitive impairment; -Diagnosis' of Alzheimer's disease, dementia and heart failure; -Hospice care. Review of hospice contract signed by resident representative, dated 05/22/24 showed the resident started hospice services . Review of the resident's care plan, revised 3/21/24, showed the care plan did not contain direction for hospice services. During an interview on 11/1/24 at 9:30 A.M., Licensed Practical Nurse Q said normally the MDS Coordinator updates care plans, but charge nurses can update if a resident's status changes. He/she said a change to hospice care should be care planned and was not aware this resident's care plan had not been updated to include it. During an interview on 11/1/24 at 9:49 A.M., MDS/Registered Nurse (RN) A said he/she is responsible for updating care plans. He/She said they are updated quarterly or with a significant change. Hospice care should be care planned and he/she only recently became aware it was not for this resident. During an interview on 11/1/24 at 11:06 A.M., Social Services said care plans are reviewed at daily clinical meetings and every 92 days in a care planning meeting. He/She said she does hospice referrals when he/she receives an order, the leadership team is then notified by a group email, which triggers an MDS update. He/She does not know why this resident's care plan does not address hospice care, but the MDS Coordinator should do that part. 6. Review of Resident #111's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -No behaviors or wandering; -Diagnosis of dementia with psychosis. Review of the resident's nurse notes, dated 09/01/24 through 11/01/24, showed on: -09/25/24 at 3:17 P.M., appears quite confused, makes eye contact but unable to state his/her name or follow simple commands during assessment and likes to fidget with his/her shoelaces; -09/25/24 at 5:55 P.M., per family resident likes to walk, fidget and be active. He/She might wake up at night and walk around; Review of the resident's care plan, dated 10/09/24, showed: -The resident gets overstimulated and confused; -Behavior needs will be evaluated for improved quality of life, safety, safety of others and a behavior monitoring plan will be addressed if needed with the resident/representative, physician and/or Interdisciplinary Team (IDT); -The care plan did not contain direction for activity preferences. 7. During an interview on 10/31/24 at 10:09 A.M., CNA F said he/she is notified of resident care needs by verbal report from the nurse or the off-going shift. He/She said there is also care plans in the point of care charting but mostly gets the information from the staff. The CNA said it would be nice if specific resident interventions were in the care plan, especially on the secured unit so other staff can know what works and doesn't. During an interview on 11/01/24 at 9:38 A.M., Certified Medication Technician (CMT) AA said care plans should include the likes and the dislikes of the resident, and all of the care that needs to be done. CMT AA said care plans give details on how to best care for the resident. During an interview on 11/01/24 at 10:18 A.M., RN E said the care plan defines how staff should care for the resident, and every resident has a care plan. During an interview on 11/01/24 at 9:48 A.M., the MDS Coordinator said it is his/her responsibility along with another coordinator to keep care plans up to date. He/She said care plans should be updated at least quarterly and with any significant change. Care plans should include anything that describes the resident to include, hospice, declines that are not correcting itself, activity of daily living needs/preferences, advanced directives, behaviors and specific interventions and anything that triggers on the MDS assessment. He/She said the secured unit has not been a part of the care plan before and is not sure if it should be or not. There are report sheets that also include basic care needs for the direct care staff that will reflect the care plans. He/She said he/she was by him/herself for a while until recently and now trying to get caught up and make the care plans more resident specific. During an interview on 11/01/24 at 12:30 P.M., the DON said care plans should include use of wander guards, secured unit, specific behavior needs and paint a clear picture of the resident needs. He/She said the staff have access to a care sheet that comes from the care plan data to use as a guide to care for the residents. He/She said the MDS nurse is overall responsible for the accuracy and completeness of the care plans. He/She did not know the care plans were missing information. 42484 43327 50432

43327 Based on observation, interview, and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms in clean and good repair. The facility census was 117. 1. Review of the facility's Work Order Policy, dated 01/10/24, showed when staff noticed maintenance or repair needs, they should report this to their immediate supervisor, the charge nurse, or a member of the leadership team. 2. Observation on 10/28/24 at 11:40 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom floor with a ripped area at the shower stall. Stained floor trim that was pulled away from the wall by the shower.i Observation on 10/28/24 at 2:31 P.M., showed resident occupied room [ROOM NUMBER]'s wall behind the bed with multiple areas of gouged and chipped paint. Observation on 10/29/24 at 10:20 A.M., showed resident occupied room [ROOM NUMBER]'s wall with scuff marks next to the bed and behind the recliner. Observation on 10/29/24 at 10:25 A.M., showed resident occupied room [ROOM NUMBER] wall with multiple areas of missing drywall. Observation on 10/29/24 at 10:30 A.M.,showed resident occupied room [ROOM NUMBER]'s bathroom with a black substance on the grout around the toilet. Observation on 10/29/24 at 10:35 A.M.,showed resident occupied room [ROOM NUMBER]'s bathroom with a black substance on the grout around the toilet. Observation on 10/29/24 at 10:45 A.M.,showed resident occupied room [ROOM NUMBER]'s wall behind recliner with gouges and scratched up. 3. During an interview on 11/01/24 at 10:20 A.M., Housekeeper H said staff are to report maintenance issues to their supervisor who makes a work order for maintenance. He/She is not aware of any current issues, but would report gouged walls, chipped paint, and anything broken or needing repaired. During an interview on 11/01/24 at 10:26 A.M., Maintenance aide I said if he/she is informed of an issue, he/she would get approval to fix it as soon as possible from his/her supervisor. He/She said staff should complete a work order so maintenance knows what needs fixed. During an interview on 11/01/24 at 10:32 A.M., Certified Nurse Aide J said if he/she finds something that is broken or looks bad like chipped paint or holes in the walls, he/she reports to his/her charge nurse. He/She said some things are constant issues like the walls behind the bed get scarred from the movement of the beds. During an interview on 11/01/24 at 10:36 A.M., Registered Nurse E said if staff tell him/her of an issue, he/she fills out an email to the maintenance department who takes it from there. During an interview on 11/01/24 at 10:49 A.M., the Maintenance Director said he receives work orders from the nurses or department heads and then puts repairs in motion. He/She said gouges, chipped paint and broken things are some of the things he/she would expect staff to report. He/She did not know room [ROOM NUMBER] needed repair and would need to check his/her log for the other issues. During an interview on 11/01/24 at 12:30 P.M., the Director of Nursing (DON) said staff training includes the work order policy. Staff are directed to report issues to the nurses who then send an email to maintenance and copy it to the administrator and DON or unit manager to make them aware of the issues.

Based on interview and record review, the facility failed to effectively communicate their assessment of a resident to the resident's physician in a timely manner after the resident fell , failed to assess the resident according to their policy after the fall, and failed provide effective pain managment for the resident after the fall (Resident #2). After nurse aide staff reported the resident's increased complaints of pain, the nurse did not reassess the resident and failed to ensure the resident was sent to the hospital for evaluation and treatment of [REDACTED]. The census was 121. 1. Review of the Facility's Fall Prevention Protocol Policy, dated 10/21/17, showed the policy directs the staff as follows: -When a resident falls or is found on the floor, the licensed nurse will complete the appropriate fall documentation: fall observation, neuro checks on all unwitnessed falls or witnessed falls in which the residents hit their head, and should be continued for 72 hours. The physician should be notified by phone of any neurological changes; -The primary care physician is notified by phone if any injury or suspected injury is noted on assessment; -Follow up charting after a fall should note any status change including vital signs, changes in level of consciousness, complaints of pain, and/or any differences in ability to perform activities of daily living (ADLs); -As injuries in the elderly are not always immediately evident, all falls are considered serious. Responsible parties are called immediately after a fall, regardless of whether an injury occurred or the time of day. 2. Review of the Facility's Notification of Physicians, Family/Responsible Party Policy, dated 6/01/16, directs staff as follows: -The resident's physician should be notified by Phone for any significant changes that require immediate attention, such as possible hospitalization , the need for immediate testing, and/or anything that staff feel needs an immediate answer; -Family members should be contacted via telephone, as soon as possible, whenever the resident experiences a significant change in condition or event. The nurse should document the correspondence, or attempts thereof, in the resident's nurse's notes. 3. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/25/19, showed staff assessed the resident as: -Mild cognitive impairment; -[DIAGNOSES REDACTED]. -Required limited assistance of one staff for toileting, dressing, and personal hygiene; -Independent with only supervision of staff for bed mobility, transfers, and eating; -No falls documented; -No pain presence documented. Review of the resident's plan of care, dated 3/19/19, showed staff assessed the resident required cues and assistance with ADLs, ambulates independently with directional assistance. Staff assesed the resident at risk for falls. Review of the resident's nurse's notes, dated 10/08/19, showed staff documented: -At 3:48 [NAME]M., resident's roommate rang for help. Found resident sitting on the floor with legs straight out, states he/she slid out of bed, denies hitting his/her head. Denies pain at assessment. Was easily assisted off the floor, though was a bit shaky. Wheelchair was used to take him/her to the toilet. He/She was then seen favoring his/her left leg, there was no rotation noted in the leg when assessed. He/She was assisted to bed. Physician notified via email and daughter will be notified per phone in the morning. Resident resting quiet at this time; -At 6:29 [NAME]M.,Resident asleep after fall without any complaints at this time; -At 1:24 P.M., Resident having severe pain in left leg, crying, not able to move it without yelling in pain. This nurse was not able to do ROM (range of motion) with left leg during this shift. Resident is not bearing any weight on left leg and will not let staff touch it. This nurse emailed physician requesting an x-ray of left hip/leg. Physician replied with x-ray left hip; -At 4:59 P.M., Received orders from physician to x-ray affected hip and pelvis; this nurse in to see resident, resident in severe pain. He/She keeps saying over and over all of it hurts and points to different areas on the body, notified physician via email requesting orders to send resident to the ER (emergency room ), awaiting response, updated daughter. Review of the resident's nurses notes, dated 10/08/19, showed nursing staff did not document any assessment of resident from 6:29 [NAME]M. to 1:23 P.M., or from 5:00 P.M. to 8:00 P.M. as directed in their policy to monitor for changes in condition or increased pain. Review of the resident's Medication Administration Record, [REDACTED].M. with results not effective charted at 10:44 [NAME]M. Additional review showed staff did not documented they adminstered any additional tylenol or called the physician to report the resident's pain. Review of the resident's medical record showed it did not contain an x-ray report of left hip/pelvis. Review of the facility's email notification to the resident physician, dated 10/08/19, showed at 3:44 P.M., facility staff emailed the resident's pain was severe, keeps saying over and over All of it hurts and points to different areas of his/her body. Review showed staff requested to send resident to the ER. Review of the physician's email response dated, 10/08/19 showed the physician did not respond until 6:55 P.M., with a response of Yes. Review of the resident's nursing notes, dated 10/08/19 at 9:09 P.M., showed staff documented they received orders to send the resident to the ER for evaluation and treatment, family member at bedside, left with ambulance at approximately 8:00 P.M. Review of the resident's nursing notes, dated 10/08/10 at 10:10 P.M., showed staff documented they received a phone call from the resident's family member. Review showed staff documented the family member reported the hospital confirmed the resident had a fractured left hip. During an interview on 10/18/19 at 1:30 P.M., The Administrator said he/she was still new and trying to learn the policies so he/she was not sure of their expectations for transfers. He/She said that would probably be a nursing question. During an interview on 10/18/19 at 1:40 P.M., The Director of Nursing (DON) said if a resident has had a change in condition that is not considered emergent then he/she would expect it could be ongoing thing of working with the physician. He/She said if it is an emergent situation like a fall or something then it should take no longer than 30 minutes to get a response from the physician. He/She would think the physician can be emailed for non-emergent situations and called for emergencies and if the nurse does not get a response then the resident can be sent to the hospital for treatment and physician notified later. During an interview on 10/20/19 at 9:40 [NAME]M., LPN A said when a resident sustains a fall an assessment is done to include vital signs, range of motion, and neurological checks if the resident hit his/her head or if the fall was unwitnessed. He/She said if the resident had a significant change in condition then he/she would email the physician and if no response was received within five to ten minutes then he/she would then call him/her. If still no response and he/she felt it was an emergent situation then he/she would send the resident for treatment and notify the physician later. He/She said it would not be a realistic expectation for a resident to be in severe pain for approximately seven hours or more before being sent to the hospital. During an interview on 10/20/19 at 10:30 [NAME]M., (Registered Nurse) RN B said he/she would consider any change from the resident's baseline would be considered an emergency. He/She said in that situation he/she would page the physician and notify the family. If no response from the physician but family said send then he/she would send resident immediately and notify the physician later. He/She said depending on the situation if he/she felt the situation was emergent enough he/she would send the resident and notify the physician and family later. That can be a judgement call from the nurse that is where that change in the resident's baseline comes from. During an interview on 10/31/19 at 8:20 [NAME]M., LPN C said he/she took care of the resident on the day shift (7am-3pm) after his/her fall. He/She said staff reported to him/her the resident was yelling out in pain when moving, was not bearing weight, and staff were unable to touch the left leg. LPN C said tylenol was administered but was not effective so he/she emailed the physician. He/She said that particular physician prefers emails, and that he/she is aware the policy says to call the physician of suspected injury but that is why they have mobile x-ray company they don't just send every resident out for x-rays, each situation is handled differently. LPN C said he/she didn't do an assessment of the resident he/she just received information in report and went off what the staff reported. He/She said at change of shift the oncoming nurse assessed the resident with him/her present and said he/she felt the resident needed to be sent out. He/She left at that point and is unaware of what happened after that. During an interview on 10/31/19 at 9:37 [NAME]M., The physician said he would expect staff to email him and if they don't get a response by the end of the day or if the situation is urgent then they can page him/her. He/She said when the nurse emailed him/her saying send to ER and he/she said Yes he/she presumed it had already been done because that is normally what happens. He/She said if the nurse assessed the situation as the resident's condition warranted going to the emergency room then he/she would have expected staff to send him/her. During an interview on 10/31/19 at 1:38 P.M., LPN D said he/she went in at approximately 3:15 P.M. to assess the resident because he/she was told in report that the resident had orders for an x-ray and was having a lot of pain. He/She said once the resident was assessed he/she felt the resident needed to be sent out to the hospital because of the severe pain the resident was yelling out, I'm hurting, Oh Lord I'm hurting and with a [DIAGNOSES REDACTED]. He/She said typically the physician is quick to respond to emails and usually if not he/she would page them. LPN D said honestly the reason she didn't page him/her was because he/she only had one aid, was answering lights, and passing medication. MO 873

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat pressure ulcers and other skin damage when identified for four residents (Residents #1, #2, #3 and #4), out of five sampled residents assessed for pressure ulcers. The facility census was 126. 1. Review of the facility's Skin Care Protocol, dated 9/30/2016, showed the purpose is to identify residents who are at risk for alterations in skin integrity and to ensure prompt and appropriate treatment for [REDACTED]. -Notify physician and obtain orders; -Notify wound team; -Notify the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator of any new pressure ulcer; -Notify family; -Update care plan,Treatment Administration Record (TAR), Physician order [REDACTED]. -Ensure aides are instructed in changes in resident care; -Initiate wound documentation. 2. Review of the facility wound protocol: pressure ulcer, dated 9/30/16, showed the purpose is to identify, prevent, monitor, and treat various pressure related wounds. In order to prevent the development of pressure associated wounds, all at risk residents should be assessed and provided pressure relieving devices (i.e. low air loss mattress, boots, wedges, etc.) Additional review showed upon first detection of a pressure related wound staff are to measure and evaluate the wound, notify the wound team and the physician (either in person or by e-mail), obtain orders, update the resident's care plan, Medication Administration Record [REDACTED]. All treatment will be provided under the advisement of the wound team and the physician. The wound team monitors all wounds on a weekly and as needed basis. Treatments and dressings are updated at these times to promote wound healing. 3. Review of Resident #1's Admission Assessment, dated 07/05/17, showed staff assessed the resident as: -Alert and oriented; -Functional impairment of one lower extremity; -Incontinent of bowel and bladder; -At risk for pressure ulcers; -Does not have a stage I (an unopen, un-blanchable redened skin area ) or higher pressure ulcer. Review of a Braden Scale assessment (scale to determine pressure ulcer risk), dated 7/5/17, showed licensed staff assessed the resident at a score of 19 (not at risk). Review of nurses' notes, dated 07/05/17 at 2:05 P.M., showed staff documented the resident admitted to the facility, and staff notified the Assistant Director of Nursing (ADON/Wound Nurse) about a buttock wound. Review showed staff did not document any further information related to the wound. Review of nurses' notes, dated 07/06/17 at 1:31 P.M., showed staff documented the ADON observed the resident's buttock area. Staff did not document an assessment, measurement, or description of the area, as directed by facility policy. Review of the resident's Physician order [REDACTED]. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/06/17, showed staff identified the resident with a 1.0 Centimeter (cm) x 1.0 cm x > 0.25 cm Stage II (partial-thickness loss of skin with exposed dermis) area to the gluteal area. Staff documented the treatment as duoderm, change every 3 days. Further review found staff did not document an assessment of the wound to the upper crease of the buttocks with orders of [MEDICATION NAME], change every three days. Review of the resident's Treatment Administration Record (TAR), dated (MONTH) (YEAR) showed: -Duoderm treatment to right buttock/leg, change every three days started on 07/06/17; -[MEDICATION NAME] adhesive dressing to crease at top of buttocks, change every three days and as needed. Treatment started on 07/06/17. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/06/17, showed licensed staff assessed the resident's Stage II area (treated with duoderm) of gluteal area measuring 1.0 cm x 1.0 cm. Further review found staff did not document an assessment of the wound to the upper crease of buttocks with orders of [MEDICATION NAME], change every three days. Review of Daily Wound Charting, dated 07/09/17 (actual observation dated 07/08/17), showed staff documented area to the right buttock/leg crease appears to be same size, dressing intact, unable to assess wound as dressing is intact. Review of the resident's admission MDS, a federally mandated assessment instrument, dated 7/10/17, showed staff assessed the resident as follows: -Minimal cognitive problems; -Required extensive assistance of two or more staff with bed mobility, transfers,dressing, toilet use, and personal hygiene; -Non-ambulatory; -Required extensive assistance of one staff for locomotion; -Always incontinent of bowel and bladder; -Functional loss of one lower extremity; -At risk for a pressure ulcer; -One stage II pressure ulcer on admission; -Did not have moisture associated skin damage or other identified skin issues. Review of the resident's weekly wound assessment, dated 07/11/17 at 7:43 A.M., completed by the ADON, showed he/she identified the wound area's location and description as coccyx, identified the wound as a Stage I, and wound as healed. Staff did not document any other skin issues. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/11/17, showed licensed staff assessed the resident's Stage II wound area (treated with duoderm) of the right gluteal area as healed, and documented will monitor for one week. Further review found staff did not document an assessment of the wound to the upper crease of the buttocks with orders of [MEDICATION NAME], change every three days. Review of nurses' notes, dated 07/12/17 at 7:23 A.M., showed staff documented area to the top of buttocks is healed. Dressing change discontinued. Review of the resident's TAR, dated (MONTH) (YEAR), showed staff documented treatment of [REDACTED]. Review of the resident's TAR, dated (MONTH) (YEAR), showed staff documented duoderm treatment to right buttock/leg crease, change every three days provided 07/6 through 07/24/17. Review of the resident's care plan, dated 07/13/17, showed staff identified the resident with a Stage II pressure ulcer on the coccyx on admission to the facility. Goal is for area to heal without complications. Interventions include: -Assess and record condition of skin around the pressure ulcer; -Assess the pressure ulcer for location, stage, size (length, width, and depth), and wound bed description; -Conduct a systematic skin inspection. Report any signs of further breakdown. Additonal review of the care plan showed the resident required therapeutic diet related to wound management/enhanced healing. At risk for poor nutrition related to acute pain, diuretic use and poor appetite. Interventions include: -Provide resident with as much control as possible in routines, food preferences, etc. -Praise for good dietary compliance. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/18/17, showed staff did not include the resident on the log and staff did not document a one week follow-up. Review showed staff did not document information related to the resident's wound treatment of [REDACTED]. Review of a weekly skin assessment, dated 07/20/17, showed staff documented skin is intact, no issues of concern identified. Review showed staff did not document information related to the resident's wound treatment to right buttock/leg crease, change every three days that was provided 07/06/17 through 07/24/16. Review of nurses' notes, dated 07/23/17 at 6:18 P.M., showed licensed staff documented an aide reported the resident's coccyx had an open area. Nurse applied EPC (protective) cream to area and notified the wound nurse. Review of the resident's POS, dated (MONTH) (YEAR), showed on 07/24/17 the physician discontinued Duoderm to right buttock/leg crease wound, change every 3 days and as needed. Review of the resident's TAR, dated (MONTH) (YEAR), showed staff discontinued duoderm treatment to right buttock/leg crease, change every three days on 07/24/16. Review of a progress note, dated 07/25/17, showed the registered dietician documented the resident's spouse discussed meal dissatisfaction. The spouse said the resident does not receive food items he/she orders and has lost 14 pounds in the past two weeks. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/25/17, showed the weekly log did not contain the resident's name and staff did not identify the resident with any skin issues. Observation/interview on 07/26/17 at 1:00 P.M., showed staff transferred the resident from his/her wheelchair to bed by mechanical lift. During the transfer CNA B said he/she was aware the resident had an open area. He/She said staff were using duoderm, but we are just using barrier cream currently. Further observation showed the resident with three open areas to the buttocks. The ADON said he was not aware the resident had any current open areas. The ADON obtained the following wound measurements: A 0.5 cm x 0.5 cm area to the upper buttock, which he reported had been previously healed, an open area on the right side of the coccyx measuring 1.0 cm x 0.5 cm, and a third open area measuring 0.5 cm x 0.5 cm in the crease of the coccyx area. The ADON said he believed the open areas on/near the coccyx to be moisture related. During an interview on 7/26/17 at 1:00 P.M., the ADON said he expected staff to notify him when open areas are found. He said he did not expect the staff to document the wound measurements and description as he will complete that when he assesses the wound. He reported once he has assessed the wound, he makes recommendations to the nurse, who then contacts the physician. During an interview on 7/26/17 at 11:00 A.M. with the resident and spouse, they said they have expressed concerns the resident is not checked and toileted frequently. The spouse said he/she has also spoken to staff from dietary on three occasions about not following menus, menu followed very sporadically, and missed meals (eventually provided late, but not balanced). 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive problems; -Required extensive assistance of two or more staff for transfers, bed mobility, toilet use; -Required extensive assistance of one staff with eating, dressing and personal hygiene; -Requires limited assistance of one staff for locomotion; -Non-ambulatory; -Always incontinent; -At risk for a pressure ulcer; -No pressure ulcer or other identified skin issues. Review of the resident's nurses' notes, dated 07/03/17 through 07/17/17, showed staff did not document issues with heel conditions. Review of the resident's weekly skin assessment, dated 07/05/17 at 9:31 A.M., showed staff did not document they identified any skin issues. Review of the resident's POS, dated (MONTH) (YEAR), showed on 07/10/17 the physician directed staff to apply skin prep (Protectorate) to both heels every shift and as needed. Review of daily wound charting, dated 07/10/17 at 9:31 A.M., showed staff documented they identified issues to both heels described as redness. Staff documented wound areas the same size (no prior size documented), granulation tissue (pink or red tissue with shiny, moist, granular appearance); skin prep applied to both heels; potus (pressure reducing) boots requested. Review of the resident's Care Plan for pressure ulcer, dated 7/12/17, showed staff assessed the resident at risk for a break in skin integrity related to [DIAGNOSES REDACTED]process, incontinence, falls, and assistance needs. Interventions included: -Conduct systemic skin inspection weekly, pay particular attention to bony prominences; -Report any signs of skin breakdown (sore, tender, red, or broken areas); Review of the resident's weekly skin assessment, dated 7/12/17 at 9:31 A.M., showed staff did not document any skin issues. Review showd staff did not document daily wound charting from 07/12/17 through 07/18/17. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/18/17, showed staff did not include the resident on the log which identifies residents with skin issues. Review of the resident's Care Plan for pressure ulcer, dated 07/12/17, showed on 7/18/17 staff added see TAR for treatment to both heels. Review of nurses note, dated 7/18/17 at 1:22 P.M., showed staff documented bilateral (both) heels in worsening condition. Left heel soft and blanches sluggishly, area involved measures 4.0 cm x 3.5 cm with center being dark brown to black. Right heel blanches slowly and measures 3.0 cm x 2.5 cm with center being dark brown to black in color. Neither area is open, however deep tissue injury is likely. Skin prep applied as per order and wound nurse brought into the room to assess as well. Air mattress applied to bed and heel protectors on and in place. Review of nurses' notes, dated 7/19/17 at 8:53 P.M., showed staff documented he/she spoke with resident's family member and made them aware of the condition of the resident's heels and treatment plan. Review of daily wound charting, dated 07/19/17 at 8:55 A.M., showed staff documented area to right heel as a possible deep tissue injury, appears same size (no prior size documented), necrotic (eschar) tissue (dark, dead skin tissue) present. Wound dressing changed today, wound appears same or improving status. Review of daily wound charting, dated 07/19/17 at 8:57 A.M., showed staff documented area to left heel as a pressure ulcer, appears same size, necrotic tissue present. Wound dressing changed today, wound appears same or improving status. Review of daily wound charting, dated 07/20/17 through 7/24/17, showed staff documented area to left heel and right as a pressure ulcer, appears same size, necrotic tissue present. Wound dressing changed today, wound appears same or improving status. Review of the resident's TAR, dated (MONTH) (YEAR), showed staff documented they initiated monitoring of the application of the resident's air mattress on 07/21/17. Review of nurses' notes, dated 07/21/17, showed staff documented they spoke with the resident's family member regarding areas of bruising to both lower extremities. Explained that although we are providing an air mattress, podus boots, and leg brace because we are resisting what the resident is trying to do, there will be areas of pressure that will constantly need to be monitored and resident may develop further bruising and further pressure areas despite our best efforts. Review of daily wound charting, dated 07/25/17 at 3:48 A.M., showed RN staff assessed the resident's left heel as a deep tissue injury with necrotic tissue present and surrounding tissue intact. Review of a weekly wound assessment, dated 07/25/17 at 7:42 A.M., showed staff documented left heel identified as a deep tissue injury, acquired in house, measuring 2 cm x 1 cm, described as a dark purple blister. Left heel is discolored to a purple hue. Wound bed not visible. Review of the weekly wound assessment, dated 07/25/17 at 7:45 A.M., showed staff documented right heel identified as a deep tissue injury, acquired in house, measuring 2.0 cm x 1.5 cm, described as a purple blister. Left heel is discolored to a purple hue. Wound bed not visible. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/25/17, showed staff documented the resident with: -Suspected deep tissue injury to the right heel, area has a dark purple hue, measures 2.0 cm x 1.0 cm; -Suspected deep tissue injury to the left heel, area has a dark purple hue, measures 2.0 cm x 1.5 cm. Review of the resident's Care Plan for pressure ulcer, dated 07/12/17, showed on 07/24/17 staff documented resident used knee brace for contracture management/improvement, but developed skin breakdown on right knee. Is currently getting a dry dressing in place, change daily and as needed. Review of the residents POS, dated 07/2017, did not show an order for [REDACTED]. Review of nurses' notes (late entry on 07/25/17 at 7:30 A.M.) dated 7/24/17 at 2:00 P.M., showed staff documented that he/she spoke with therapist who informed him/her (on 7/24) of an area of pressure to the right knee related to pressure from a knee brace. Upon assessment resident had an area 2 cm x 1 cm to the right knee which is dark in color with no drainage noted. Cleaned area and applied a dry dressing for padding. Staff did not document they notified the physician or wound nurse, as directed by facility policy. Review of weekly and daily wound assessments, dated 07/25/17 through 7/26/17, showed staff did not document they identified the right knee wound on 07/24/17, as directed by facility policy. Review of daily wound charting, dated 07/26/17 at 1:39 P.M., showed staff documented the area to the right heel as a possible deep tissue injury, appears same size, necrotic(eschar) tissue present. Wound dressing changed today, wound appears same or improving status. Review of daily wound charting, dated 7/26/17 at 1:41 P.M., showed staff documented the area to the left heel as a pressure ulcer, appears same size, necrotic(eschar) tissue present. Wound dressing changed today, wound appears same or improving status. Review of the resident's POS, dated (MONTH) (YEAR), showed staff did not document any ordered treatment for [REDACTED]. During an interview on 07/27/17 at 12:45 P.M., Physical Therapist (PT) C said he/she found the area on Monday, 07/24/17. The therapist said he/she had been working with the resident with a knee brace for brief periods 1-2 hours the previous week. The PT said he/she last used the brace on Friday 07/21/17, checked the area after use and noted no redness to areas. The therapist said he/she came in on Monday and noticed what looked like shearing across the patella and bruising to the medial side of knee. The therapist said he/she was skeptical it was caused by the brace, but couldn't rule it out. Observation/interview on 07/26/17 at 2:00 P.M., showed LPN A assessed the area on the right knee. The LPN said he/she was not aware of the injury until therapy staff notified him/her about it earlier today and he/she applied a dressing. The LPN said he/she had not yet reported the area to the wound nurse or physician. The LPN said he/she was not aware of any current treatment. Observation showed the wound approximately 1.0 inch x 1/2 inch, with a half inch of the center of the wound covered in slough (mass of dead tissue) with a darkened center, and the wound bed not visible. Observation/Interview on 07/27/17 at 2:20 P.M., showed staff called the ADON (wound nurse) into the room to assess the resident. The ADON said he was not aware of the wound on the resident's knee and had not been notified. The wound nurse measured the area as 2.0 cm x 0.5 cm and said the wound is unstagable because the wound bed is not visible. Observation showed an additional unreported butterfly shape bruise to inner thigh above the knee measured 6.0 cm x 4.5 cm. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitive problems; -No behaviors, does not refuse care; -Required extensive assistance of two or more staff with bed mobility, toilet use, and transfers; -Required extensive assistance of one staff for locomotion, dressing, eating, and personal hygiene; -Non-ambulatory/Not steady; -Occasional incontinence of bowel and bladder; -At risk for a pressure ulcer; -No identified pressure ulcers or other identified skin issues. Review of the resident's care plan, dated 05/05/17, showed staff assessed the resident at risk for pressure ulcers. Staff documented the goal is resident's skin will remain intact throughout review date of 08/07/17. Interventions include: -Conduct a systematic skin inspection weekly; -Report any signs of skin breakdown (sore, tender, red, or broken areas). Review of nurses' notes, dated 07/11/17 at 4:29 P.M., showed staff documented the resident was readmitted to the facility from the hospital with no skin issues noted. Review of the resident's Braden scale, dated 07/11/17, showed staff assessed the resident with a score of 17, or at risk for pressure ulcers. Review of nurses' notes, dated 07/11/17 through 07/14/17, showed staff did not document skin issue concerns. Review of nurses' notes, dated 07/15/17 at 11:55 A.M., showed staff documented a CNA assisted the resident to the restroom and noticed a dark area on the resident's bottom, resident has a deep tissue injury to the right buttock 1.0 cm x 7.0 cm and has an open area to the left buttock measuring 1.0 cm. Review of the resident's POS, dated (MONTH) (YEAR), showed staff did not document a treatment for [REDACTED].M. Review of the resident's (MONTH) (YEAR) TAR showed staff did not document a treatment for [REDACTED].M. Review of a weekly skin assessment, dated 07/17/17 at 6:55 P.M., showed staff documented the resident has an abrasion to the right buttock. Staff did not document any further assessment of the area, and did not document they notified the wound nurse, as directed by facility policy. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/18/17, showed staff did not include the resident on the log which identifies residents with skin issues. Review of nurses' notes, dated 07/20/17 at 6:50 P.M., showed an LPN documented the resident has an area to the right inner buttock, noted to have drainage from the area today, area is on the right inner buttocks and measures 0.25 cm x 6.0 cm with base of wound being dark in color, brown to black, and cloudy drainage to wound. Staff documented they cleaned the wound with normal saline, applied santyl ointment ([MEDICATION NAME] wound treatment) to wound base, and covered with a foam dressing. Review of daily wound charting, started/dated 07/21/17, showed staff documented the resident with a skin tear/abrasion to the right inner buttocks, wound appears to be changing in condition, and wound nurse notified. Necrotic tissue present in wound bed. Wound dressing changed. Review of nurses' notes, dated 07/21/17 at 6:50 P.M., showed staff documented the facility wound nurse assessed the wound this day and new order received to clean wound to right inner buttocks with normal saline, apply santyl ointment to wound bed, and cover with foam dressing daily and as needed. Staff documented they notified the physician by electronic mail (e-mail) with the wound nurse's recommendations. Review of the resident's care plan, dated 05/5/17, showed on 07/21/17 staff documented wound to right inner buttocks 0.25 cm x 6.0 cm unstagable. Cleanse wound, apply santyl ointment to wound bed and cover with foam dressing. Review of the resident's POS, dated (MONTH) (YEAR), showed facility staff did not document they obtained treatment orders for the area identified on the right buttock on 07/17/17 until 07/21/17. Review showed on 07/21/17 the physician directed staff to: -Cleanse wound to right inner buttock, apply santyl ointment to wound bed, and cover with foam dressing. Change daily and as needed; -Check air mattress for appropriate setting every shift. Review of the resident's (MONTH) (YEAR) TAR showed staff documented: -07/21/17 the initiation and monitoring of air mattress usage. Check settings every shift; -Documentation of start of treatment of [REDACTED]. Observation on 7/26/17 showed the resident lay in bed on an air mattress. The ADON/wound nurse measured the buttocks wound as 5.5 cm x 1.0 cm. Observation showed the base of wound not visible because slough and eschar covered the wound base. The ADON said staff added the air mattress recently after staff identified the wound. 5. Review of Resident #4's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitive problems; -Behavior issues; -Does not refuse care; -Required extensive assistance of one staff with bed mobility, transfers, dressing, eating, personal hygiene, and toilet use; -Non-ambulatory/Not steady; -Occasional incontinence of bladder; -Always incontinent of bowel; -At risk for a pressure ulcer; -Did not have a pressure ulcer; -No identified pressure ulcers or other skin issues. Review of the resident's care plan, dated 06/26/17, showed staff identified the resident at risk for pressure ulcers due to activity of daily living assistance needs, stroke, incontinence, and harmful body movements. Staff documented the goal is skin will remain intact through next review of 9/27/17. Interventions include: -Conduct a systematic skin inspection weekly; -Report any signs of skin breakdown (sore, tender, red, or broken areas). Review of nurses' notes, dated 07/16/17 at 8:53 A.M., showed staff documented they toiled the resident and noticed a small open area to the coccyx. Applied EPC cream to area and notified husband. Review of a weekly skin assessment, dated 07/16/17 at 2:54 P.M., showed staff identified a pressure related area measuring 0.5 cm x 0.5 cm to the coccyx. Documentation showed staff documented pressure ulcer care is not indicated. Review of nurses' notes, dated 07/19/17 at 7:29 A.M., showed staff documented area to coccyx is in changing condition. Approximately 4.0 cm x 2.0 cm, area which was previously reddened appears to have sheered and a small amount of slough is present. A pinpoint area at the top of the wound appears deeper. EPC and foam dressing applied at this time. Wound nurse notified for recommendation. Review of nurses' notes, dated 07/19/17 at 9:32 A.M., showed staff documented new orders given for duoderm change every 3 days and as needed. Review of the resident's (MONTH) (YEAR) POS, showed staff did not obtain orders to treat areas identified on 07/16/17 until 07/19/17. On 07/19/17 staff documented orders obtained to apply duoderm to coccyx change every three days and as needed. Review of the resident's (MONTH) (YEAR) TAR, showed staff did not document the first treatment of [REDACTED]. Review showed staff documented the treatment of [REDACTED]. Review of the facility's Weekly QI Log-pressure Ulcer, dated 07/25/17, showed the resident has an open area to the coccyx due to maceration measuring 2 cm x 1 cm. Wound bed described as beefy red. Observation on 2/26/17 at 2:45 P.M. showed the resident lay in bed. The resident had an open area to the coccyx which the ADON measured 2.5 cm x 0.5 cm. Observation showed a light covering of slough in wound bed. During an interview on 7/26/17 at 1:00 P.M. the ADON said he expects staff to notify him when open areas are found. He said he did not expect the staff to document the wound measurements and description as he will complete that when he assesses the wound. He reported once he has assessed the wound, he makes recommendations to the nurse, who then contacts the physician to obtain orders. MO 617

Based on observation, interview, and record review, facility staff failed to; implement interventions to prevent the development of pressure ulcers, failed to provide treatments as ordered by the Physician after identifying pressure ulcers, and failed to plan and provide care to promote healing of existing pressure ulcers for six dependent residents with facility acquired pressure ulcers (Residents #1, #2, #3, #4, #6, and #17) of 16 sampled residents with pressure ulcers. The facility census was 121. Review of the facility's Skin Care Protocol, dated 7/1/11 and revised 10/5/11, showed the protocol directed the charge nurse to do the following after the discovery of a new skin breakdown or skin tear: - Notify the Skin Care Team Leader/Designee via phone, e-mail, or in person; - Notify physician of house protocol and obtain orders; - Inform the DON and MDS Coordinators of any new pressure ulcer via e-mail; - Call family and inform them of skin issue and treatment initiated; - Update care plan, Treatment Administration Record (TAR), physician's orders [REDACTED]. - Ensure nurse aides are instructed in any changes in the resident's care; - Document on the wound assessment form; - Wound care nurse to initiate consult from therapy department on an as needed basis. Additionally, the plan directed the Skin Care Team to report all pressure ulcers to the dietician, who reviews each case to individualize the nutrition plan. 3. Record review of Resident #1's Braden Scale (a scale used to determine pressure ulcer development risk), dated 6/28/11, showed staff assessed the resident to be at risk for the development of pressure ulcers. Record review of the resident's weekly skin assessment, dated 6/30/11, showed staff documented the resident received treatment for [REDACTED]. Staff documented the resident had an immobilizer to the left knee in place. Staff did not document any further skin problems. Record review of the resident's treatment administration record (TAR), dated July 2011, showed staff did not document they checked the resident's skin for breakdown at the immobilizer site on the left leg every shift on 7/5, 7/17, and 7/22. Record review of the resident's weekly skin assessment, dated 7/7/11, showed staff documented the resident's had a bacterial and fungal skin infection to the perineal area. Record review of the resident's nurses notes, dated 7/12/11, showed staff documented an area on the resident's left lower extremity (outer left leg) had an area rubbed by the immobilizer. Staff documented they covered the area to prevent rubbing. Record review of the resident's weekly skin assessments showed staff did not document they completed the resident's weekly skin assessment due on 7/14/11. Record review of the resident's nurses notes, dated 7/16/11, showed staff documented they found a Stage II pressure ulcer (A partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured blister.) under the immobilizer on the left lower outer leg. Staff documented they found a dressing covering the wound dated 7/13/11. Staff documented the wound measured 1.0 millimeter (ml) by 1.0 ml. Staff documented they cleansed the wound with normal saline, applied triple antibiotic ointment, covered with gauze, and secured it with tape. Staff documented they could not find an incident report, so one was filled out. Staff documented they would continue to monitor. Record review of the resident's weekly wound assessment record, dated 7/19/11, showed staff documented the resident had an unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough (dead tissue) and/or eschar (a hard crust or scab)) due to the presence of slough on the wound bed. Staff documented the pressure ulcer measured 1.0 centimeters (cm) (length) by 0.5 cm (width) and had drainage. Staff documented the wound "appeared to have been caused" the resident's leg immobilizer. Staff documented they started santyl (an enzymatic agent cream used to debride a wound) and [MEDICATION NAME] (an antibiotic powder) treatments. Record review of the resident's physician's orders [REDACTED]. -Cleanse the lower left leg wound with santyl and [MEDICATION NAME] and cover with a foam dressing (ordered on [DATE]). Record review of the resident's nurses notes, dated 7/20/11, showed staff documented the resident's physician ordered the resident to go to the wound clinic for pressure ulcer treatment. Record review of the resident's weekly wound assessment record, dated 7/22/11, showed staff documented the resident's unstageable pressure ulcer measured 1.0 cm by 0.5 cm and had drainage. Staff documented the area was "very superficial" (shallow). Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/22/11, showed staff assessed the resident as: -Totally dependent on two people for transfers and bathing; -Totally dependent on one person for dressing and ambulation; -Required extensive assistance of one person for personal hygiene; -Incontinent of bowel and bladder; -Had an unstageable pressure ulcer; -Had a weight loss of five percent or more in the last month or a loss of ten percent or more in the last six months. Record review of the resident's POS, dated July 2011, showed the resident's physician directed staff to discontinue use of the resident's immobilizer on 7/27. Record review of the resident's weekly wound assessment record, dated 7/28/11, showed staff documented the resident's unstageable pressure ulcer measured 1.0 cm by 0.5 cm and had drainage. Record review of the resident's TAR, dated July 2001, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's active medical record showed staff did not document any weekly skin assessments during the month of August 2011 for the resident. Record review of the resident's comprehensive plan of care, dated 8/3/11, showed staff were instructed to: -Confer and notify skin care team if open area occurs; -Report any red or open areas; -Treatments per order, see TAR; -Assist resident as needed every two hours with turning and repositioning; -Check for bowel incontinence every two hours and as needed; -Provide perineal care after bowel incontinence and as needed; -Provide cushion in wheelchair; -Provide pressure reduction mattress; -Provide adequate fluid and food intake; -Assess for pressure sore's sized, depth, and color every week; -Encourage visitors to promote resident's food consumption. Further review of the resident's plan of care, showed staff did not plan measurable objectives, timetables, and interventions specifically for the resident's unstageable pressure ulcer. Record review of the resident's weekly wound assessment record, dated 8/4/11, showed staff documented the resident's unstageable pressure ulcer remained the same in size, 1.0 cm by 0.5 cm, with slough present in the wound bed. Staff documented the area around the wound was red. Record review of the resident's TAR, dated August 2011, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's weekly wound assessment record, dated 8/12/11, showed staff documented the resident's unstageable pressure ulcer measured 1.5 cm by 1.0 cm, had slough, and drainage. Staff documented they applied "heavy santyl" and now the pressure ulcer is a little bigger but slough center is coming out. Staff documented the area around the wound continued to be bigger. Record review of the resident's TAR, dated August 2011, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's weekly wound assessment record, dated 8/18/11, showed staff documented the resident's unstageable pressure ulcer measured 2.0 cm by 2.0 cm, had slough, and drainage. Staff documented the pressure ulcer was "looking good", slough was almost gone with a small amount to the edges of the wound. Record review of the resident's TAR, dated August 2011, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's weekly wound assessment record, dated 8/26/11, showed staff documented the resident's unstageable pressure ulcer measured 3.0 cm by 2.5 cm by 0.1 cm (depth), had slough, and drainage. Staff documented the area continued to get larger and tendon was visible in the wound bed. Staff documented that a small amount of slough remained. Record review of the resident's TAR, dated August 2011, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's TAR, dated September 2011, showed staff did not document they completed the resident's daily pressure ulcer treatment of [REDACTED]. Record review of the resident's POS, dated September 2011, showed the resident's physician directed the staff to change the resident's wound treatment from santyl and [MEDICATION NAME] to cleanse the wound with normal saline, apply moistened silver alginate (an antimicrobial dressing used for wounds with drainage) to the wound bed, cover with gauze, and secure with a gauze wrap. The resident's physician directed staff to provide the treatment every other day. Record review of the resident's weekly wound assessment record, dated 9/2/11, showed staff documented the resident's unstageable pressure ulcer measured 3.0 cm by 2.0 cm by 0.1 cm, had slough, and drainage. Staff documented the tendon remained visible, the area continued to be slightly covered with slough, and the area around the wound was red. Record review of the resident's weekly wound assessment record, dated 9/9/11, showed staff documented the resident's unstageable pressure ulcer measured 4.0 cm by 1.5 cm by 0.1 cm, had slough, and drainage. Staff documented the area was larger, only a small amount of slough, and the tendon remained visible. Staff documented a pressure relieving heel protector was in place. Record review of the resident's weekly wound assessment record, dated 9/15/11, showed staff documented the resident's unstageable pressure ulcer measured 3.5 cm by 1.5 cm by 0.1, had slough, and drainage. Staff documented the area was slightly smaller, tendon remained visible with yellow slough covering the tendon area. Staff documented the area around the tendon was painful to touch, and the area around the wound was red. Record review of the resident's weekly wound assessment record, dated 9/23/11, showed staff documented the resident's unstageable pressure ulcer measured 4.5 cm by 2.5 cm by 0.2 cm. Staff documented a slight amount of slough to the tendon was noted. Staff documented the treatment was changed to silver alginate, and the area around the wound was "very red." Staff documented pain was noted during the cleaning of the tendon. Record review of the resident's weekly wound assessment record, dated 9/30/11, showed staff documented the resident's unstageable pressure ulcer measured 5.5 cm by 2.0 cm by 0.2 cm. Staff documented the area continued to get larger, and they spoke to hospice about changing the treatment. Record review of the resident's weekly wound assessment record, dated 10/6/11, showed staff documented the resident's unstageable pressure ulcer measured 6.0 cm by 2.5 cm by 0.2 cm. Staff documented the area around the wound was not as red, and some slough was noted to the tendon. Staff documented they were working with hospice to get an approval for the resident to have a skin graft on the pressure ulcer. During an interview on 10/7/11 at 9:05 A.M., Licensed Practical Nurse (LPN) N said he/she did not work with the resident when the pressure ulcer was acquired but was told that the resident's family brought in an immobilizer from someone in the family because he/she thought the other immobilizer was too loose on the resident. The resident's family member did not tell staff that he/she changed the immobilizer. LPN N said he/she was not sure how long the immobilizer was on the resident before any staff realized it was not the physician approved immobilizer that resident had worn. LPN N said the pressure ulcer was caused from the pressure of the ill-fitting immobilizer. LPN N said it looks like the breakdown occurred under the skin before the wound opened up. LPN N said the aides were responsible for checking the resident's skin for breakdown under the immobilizer every shift. LPN N said the aides would have noticed that the resident was wearing a different immobilizer when the resident's family member brought in the ill-fitting immobilizer but would not have thought to report that to the charge nurse. Observation on 10/7/11 at 10:17 A.M., showed the resident lay in bed on his/her back as LPN N removed the dressing to the resident's lower left leg. Observation showed the resident had an unstageable pressure ulcer on the middle of the lower left outer leg. Observation showed the wound measured approximately 6.0 cm by 2.5 cm, and tendon was exposed. There was yellow/green slough on the top part of tendon. The wound edges and surrounding area were very red. During an interview on 10/7/11 at 1:45 P.M., the MDS/Careplan Coordinator said she expects staff to plan measurable objective, timetables, and interventions for residents with pressure ulcers. Further, the MDS/Careplan Coordinator said the comprehensive plans of care should include specific information regarding current pressure ulcers that the residents have. During an interview on 10/7/11 at 1:45 P.M., the Director of Nursing (DON) said the resident had a knee immobilizer ordered by his/her physician and as the swelling in the resident's knee went down, the immobilizer became loose but still fit appropriately. The resident's family member noticed the immobilizer was loose and brought in a different immobilizer. The resident's family member did not tell staff he/she changed the immobilizer. The immobilizer the family member brought in did not fit the resident correctly and caused pressure on the resident's leg. The DON said the physician approved immobilizer was much smaller than the one the family member provided. The DON said she would not expect for the aides to have brought the change in immobilizers to the charge nurses attention. The DON said the resident did not go to the wound clinic because the resident's physician realized the resident was on hospice. The DON said the nurse who documented on 7/16 that the resident had a Stage II pressure ulcer did not stage the wound correctly because the wound had slough. Additionally, the DON said she expects staff to provide treatments to residents as ordered by the physician. The DON said blank spots without documentation on the TAR's indicate that a treatment was not done. During an interview on 10/11/11 at 3:30 P.M., Registered Nurse (RN) O said he/she assesses pressure ulcers as soon as he/she is notified about them. RN O said the wound must have been found over a weekend since he/she did not assess it until three days after it was found. RN O said the first time he/she saw the wound it was a small black area. RN O said he/she started treatment with santyl and [MEDICATION NAME] to get the slough and eschar off the wound. RN O said at that time there already was "so much dead tissue under the skin." RN O said the treatment was changed to silver alginate, which is currently being used. RN O said he/she is working with hospice to get an approval for the resident to have a skin graft because the wound will never heal completely. RN O said if there is not any documentation on the TAR's that the treatment was provided, then it was not done. During an interview on 10/17/11 at 1:25 P.M., the Executive Assistant said staff could not find any weekly skin assessments for the month of August 2011 for the resident. 2. Review of Resident #17's comprehensive MDS, dated [DATE], showed staff assessed the resident as: - Severely impaired cognitive skill for daily decision making; - Requires extensive assistance of two or more staff with bed mobility; - Totally dependent on one staff with personal hygiene; - Totally dependent on two or more staff with transfers, dressing, and toileting; - Always incontinent of bowel and bladder; - Has [MEDICAL CONDITION]; - At risk for pressure ulcers; - Has a pressure relieving device for bed and chair; - On a turning/repositioning program; - Receives application of ointments/medications other than to feet. Review of the resident's corresponding plan of care, dated 4/14/11, showed staff documented the resident is at risk for skin breakdown due to requiring assistance of staff for bed mobility, transfers, and activities of daily living (ADLs), and is incontinent of bowel. Review showed the plan of care directed staff to: - Assess for pressure ulcers with each shower and every time perineal care is provided; - Confer and notify skin team if open area occurs; - Follow skin protocol using FINES book if alteration occurs; - Notify physician and family if pressure ulcer occurs; - Position resident off of affected area if open area occurs; - Report any red or open areas. Review of the resident's Weekly Skin Assessment Record, dated 7/29/11, showed a licensed nurse documented the resident had three small open areas on his/her right hip. Review of the resident's corresponding Treatment Administration Record (TAR) dated 7/2011, showed staff did not record any information to show staff provided treatments to the resident's newly identified "three small open areas" to promote healing and prevent further decline. Review of the resident's Weekly Skin Assessment Record, dated 8/5/11, showed licensed staff documented the resident had three small areas on his/her right hip. Review of the resident's Weekly Skin Assessment Record, dated 8/12/11, showed licensed staff documented the resident had a small scabbed area over his/her right hip. Review of the resident's corresponding Treatment Administration Record (TAR) dated 8/2011, showed staff did not record any information to show staff provided treatments to the resident's newly identified "three small open areas" to promote healing and prevent further decline. Review of the resident's Weekly Skin Assessment Record, dated 9/17/11, showed licensed staff documented the resident had a "red area" to his/her right hip. Review of the resident's Weekly Skin Assessment Record, dated 9/23/11, showed licensed staff documented the resident had a "red area" to his/her right hip. Review of the resident's corresponding Treatment Administration Record (TAR) dated 9/2011, showed staff did not record any information to show staff provided treatments to the resident's newly identified "three small open areas" to promote healing and prevent further decline. Review of the resident's physician's orders [REDACTED]. - Apply [MEDICATION NAME] to perineal area and coccyx as needed for prevention (ordered 3/23/11). Observation on 10/4/11 at 3:15 P.M., showed the resident lay in bed on his/her left side. Observation showed CNAs J and K entered the resident's room and put a wedge under the resident's left side. Observation showed CNA J detached the resident's brief and looked at the resident's right hip. Observation showed an approximately pea-shape and sized stage II pressure ulcer within an approximate 4.0 centimeter (cm) long by 2.0 cm wide stage I (persistent area of redness) on his/her right hip. During an interview on 10/4/11 at 3:15 P.M., CNA J said the resident has a wound on his/her right hip that has "been there for a while." CNA J said staff put a wedge under the resident's left side to keep him/her off of the right hip. During an interview on 10/4/11 at 3:25 P.M., LPN S said the resident has an area on his/her right hip that opens and closes. LPN S said when the area is open [MEDICATION NAME] is applied. LPN S said the area has opened and closed for the last couple of months. LPN S said he/she "was not aware" the area "was opened." LPN S said he/she notifies the wound nurse of any new open areas, then the wound nurse assesses wounds and obtains orders to treat them. During an interview on 10/4/11 at 4:18 P.M., RN O/wound nurse said he/she assessed the resident's area and it measured 0.5 cm by 0.9 cm with a depth of less than 0.1 cm. RN O said he/she assessed the wound as a Stage II pressure ulcer. RN O said nurses are directed to assess each residents' skin on a weekly basis. During an interview on 10/7/11 at 9:30 A.M., the DON said the resident has had "issues" with his/her skin off and on since last fall. The DON said the resident has not had an open area since March 2011 according to the resident's TAR. 3. Review of Resident #2's faxed information to the Physician, dated 3/9/11, showed staff documented a blister on each of the resident's heels. Review of the resident's Nurse's Notes, dated 3/23/11 at 2:00 P.M., showed licensed staff documented the skin team made rounds and reported blisters "hardened" and the resident can now wear shoes. Review of the resident's comprehensive MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Requires extensive assistance of one staff with bed mobility and dressing; - Requires extensive assistance of two or more staff with transfers and toileting; - Uses a wheelchair; - Does not have any functional limitation in range of motion; - At risk for pressure ulcers; - Does not have a pressure ulcer. Review of the resident's corresponding plan of care, dated 3/31/11, showed staff documented the resident is at risk for pressure ulcer formation requiring assistance from staff. Review showed the plan directed staff to: - Assist from a lying position to sitting position and back again when in bed as needed; - Assure resident is turning and repositioning self every two hours and as needed when in bed; assist with turning and repositioning if resident is unable to do so; - Report any reddened or open areas; - Provide treatments as ordered per TAR. Review showed staff did not update the resident's plan of care after 3/9/11 to include interventions to promote healing of the resident's newly identified stage II pressure ulcers and prevent further decline in the resident's skin condition. Review of the resident's TAR, dated April 2011, showed staff documented the resident had an open area to his/her left heel. Review showed the following orders: - Apply skin prep to outer edges of open area, cover with hydrogel and gauze; change daily until healed (ordered 4/25/11); - [MEDICATION NAME] spray topically to right heel three times daily for redness (ordered 4/26/11). Review of the resident's plan of care, reviewed and revised on 4/1/11, showed staff did not add any new interventions to address the resident's open area to his/her left heel and redness to his/her right heel. Review of the resident's POS, dated May 2011, showed the physician ordered: - Consult with wound clinic (ordered 5/7/11). Review of the resident's Braden Scale (to assess pressure ulcer risk), dated 5/12/11, showed staff did not assess the resident at high risk for the development of pressure ulcers. Review of the resident's POS, dated June 2011, showed the following order from the wound clinic: - Use drop foot brace during the day in his/her chair with shoes; take off shoes at night, but leave drop foot brace on and secure it on the foot with short cotton stocking; wear compression hoes 23 hours per day, but can have on/off relief if desired (ordered 6/8/11). Review of the resident's plan of care, reviewed and revised 4/1/11, showed staff did not update the plan to address the use of the drop foot brace. Review of the resident's quarterly MDS, dated [DATE], showed staff did not assess the resident with a pressure ulcer. Review of the resident's plan of care, reviewed and revised 7/4/11, showed staff did not add any new interventions to address the resident's recent history of pressure ulcers to his/her heels. Review of the resident's Weekly Skin Assessment Progress Notes, dated 7/7/11 (no time), showed licensed staff documented the resident had a "soft and mushy" heel. Licensed staff documented they would apply skin prep to the area every shift. Review of the resident's Weekly Skin Assessment Progress Note, dated 7/10/11 at 9:10 P.M., showed licensed staff documented the resident had a "dark area" on the back of his/her right heel. Review of the resident's Weekly Wound Assessment Record, dated 7/7/11, showed RN O documented an unstageable dark purple area on the resident's heel measured 2.0 cm by 2.0 cm. RN O documented a discolored area around the dark purple area measured 8.0 cm by 4.0 cm. RN O documented the presence of "eschar" RN O documented the treatment as skin prep to the area every shift. Review of the resident's Weekly Wound Assessment Record, dated 7/15/11 (no time), showed RN O documented the resident's unstageable pressure ulcer on his/her heel had a "blackened area to it" and a "blistered area" that is open "but dry." RN O documented the black area on the heel measured 2.0 cm by 1.5 cm with eschar and the blistered area measured 6.5 cm by 3.0 cm. RN O documented staff will continue to apply skin prep and will offload pressure from the resident's heel. Review of the resident's Weekly Skin Assessment Progress Note, dated 7/17/11 at 7:30 P.M., showed licensed staff documented the resident's heel is being treated with foam dressing and Kling wrap due to the area "open and weeping." Licensed staff documented the treatment changed this morning due to the condition of the heel. Review of the resident's Weekly Wound Assessment Record, dated 7/21/11 (no time), showed RN O documented the resident went to the wound clinic where they applied an Unna boot, which is not removable. Review of the resident's Weekly Skin Assessment Progress Note, dated 7/24/11 at 6:40 P.M., showed licensed staff documented an open area to the resident's left heel. Staff documented the resident had swelling to both legs and wears compression hose. Review of the resident's most updated plan of care dated 7/4/11 did not contain any information to show staff planned new interventions to address the resident's declined skin condition including unstageable pressure ulcer on his/her left heel. Review of the resident's Weekly Wound Assessment Record, dated 8/5/11 through 9/2/11, showed RN O documented he/she did not do an assessment of the resident's heel due to the Unna boot. Review of the resident's Weekly Wound Assessment Record, dated 9/9/11, showed RN O documented the resident's unstageable heel pressure ulcer measured 3.5 cm by 2.0 cm and presented with exudate, eschar, and slough. Review of the resident's Weekly Wound Assessment Record, dated 9/16/11, showed RN O documented the resident's heel pressure ulcer measured 4.5 cm by 2.5 cm with exudate, slough, and pain. Review of the resident's Weekly Wound Assessment Record, dated 9/23/11, showed RN O documented the resident's heel pressure ulcer measured 4.0 cm by 2.5 cm with exudate, slough, and pain. Review of the resident's Weekly Wound Assessment Record, dated 9/30/11, showed RN O documented the resident's heel pressure ulcer measured 4.0 cm by 4.0 cm with exudate and slough. Observation on 10/7/11 at 10:20 A.M., showed the resident's heel contained a stage IV (full thickness loss of skin) pressure ulcer which measured approximately half-dollar size and shaped. Observation showed slough, eschar, and blood present on the wound bed (base of the wound). During an interview on 10/7/11 at 10:25 A.M., LPN I said the resident had swelling in his/her leg previously. LPN I said staff were using compression stockings and braces on her leg and that caused "some friction" to the area. During an interview on 10/11/11 at 3:17 P.M., RN O said before the resident's current pressure ulcer developed, the resident wore "shoes and braces" on his/her feet. RN O said the combination of both shoes and braces caused the increased pressure to the resident's left heel. 4. Record review of Resident #6's Braden Scale, dated 4/15/11, showed staff assessed the resident was at mild risk for the development of pressure ulcers. Record review of the resident's admission nursing assessment, dated 4/15/11, showed staff documented the resident did not have any pressure ulcers upon admission to the facility. Record review of the resident's initial comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance of two people for transfers, toileting, and bathing; -Required extensive assistance of one person for ambulation, dressing, and eating; -Did not have any pressure ulcers upon admission to the facility. Record review of the resident's comprehensive plan of care, dated 4/25/11, showed staff were instructed to: -Assess for pressure ulcers daily with routine care and on bath days; -Assist resident out of bed several times a day; -Assist/teach resident to reposition self; -Provide a cushion in the resident's wheelchair; -Encourage adequate fluid and food intake; -Keep linens dry and wrinkle free; -Keep skin clean and dry; -Notify physician and family if pressure ulcers develop; -Provide perineal care after each incontinent episode; -Provide a pressure reduction mattress to the resident's bed; -Position resident off affected areas if pressure ulcers develop; -Provide treatments as ordered, see TAR; -Turn every two hours to relieve pressure points; -Use a positioning device as needed. Record review of the resident's active medical record showed the staff faxed the resident's physician on 5/27/11 that the resident had a "round" open area on the right heel, and the left heel was "soft." Further review showed the resident's physician directed staff to apply pressure relieving heel protectors to the resident's feet except while the resident goes to physical therapy. The resident's physician directed staff to apply skin prep to both heels three times a day until healed, and provide a multivitamin, zinc, and Vitamin C for wound healing. Record review of the resident's TAR, dated May 2011, showed staff did not document they applied skin prep to the resident's heels three times a day on 5/30 and 5/31. Staff did not document the reason the treatments were not completed as ordered. Further review of the resident's comprehensive plan of care, showed staff documented on 6/5/11 the resident had a stage II pressure ulcer that was an opened healing blister. Record review of the resident's skilled nursing assessment, dated 6/6/11, showed staff documented the resident did not have any pressure ulcers. Record review of the resident's TAR, dated June 2011, showed staff did not document they applied skin prep to the resident's heels three times a day on 6/6. Staff did not document the reason the treatment was not completed as ordered. Record review of the resident's POS, dated June 2011, showed on 6/6/11 the resident's physician directed staff provide the following treatment on a daily basis: -Cleanse the right heel wound with normal saline, apply santyl and [MEDICATION NAME] powder, cover with a dry gauze, and secure with a gauze wrap. Record review of the resident's skilled nursing assessment, dated 6/7/11, showed staff documented the resident did not have any pressure ulcers. Fu

Based on observation, interview, and record review, facility staff failed to provide interventions to prevent a significant weight loss for two sampled residents (Residents #1 and #9) out of 24 sampled residents. The facility census was 121 residents. Review of the facility's Nutrition Protocol, revised 12/2/10, showed the following information: - Residents with nutritional concerns will be identified, assessed, and the plan of care updated with appropriate interventions; - Interventions will be updated on the care plans; - Weights will be printed monthly and identifies residents with greater than or equal to 5% weight change in 30 days and/or residents experiencing a 10% unplanned weight change in 180 days; - Charge nurses provide oversight at each meal to ensure residents are served the physician-ordered diet. 1. Review of Resident #9's monthly weights, dated April 2011, showed staff documented the resident weighed 157 pounds. Review of the resident's monthly weights, dated May 2011, showed staff documented the resident weighed 145 pounds. Review of the resident's comprehensive MDS, dated [DATE], showed staff assessed the resident as: - Moderately impaired cognitive skills for daily decision making; - Requires supervision and set up assistance with eating; - Has diabetes; - Has [MEDICAL CONDITION] - Has dementia; - Has [MEDICAL CONDITION]; - Has depression; - Complains of difficulty or pain with swallowing; - Weighs 145 pounds; - Has not had a weight loss of 5% or more in the last month or lost 10% or more in the last six months; - Has pressure ulcers; - Receives nutrition or hydration interventions to manage skin problems. Review of the MDS, dated [DATE], showed staff did not accurately assess the resident with a weight loss of 5% or more in one month. Review of the resident's plan of care, dated 6/4/11, showed the plan did not address the resident's recent weight loss of 12 pounds in one month. Review showed the plan addressed the resident's diet. Review showed the plan directed staff to: - Assist, cue, and direct at meal times as needed; - Diet per order; - Dietician to assess resident as needed and follow recommendations per order as needed; - Institute nutritional protocol if significant weight loss (5% of usual body weight in 30 days or 10% of usual body weight in 120 days) occurs using FINES protocol; - Offer snack at bedtime as needed; - Stay with resident during meals; - Allow resident to choose supplemental diet if possible; - Encourage resident to eat at meal times; offer snacks and food alternates when appropriate per order as needed; - Offer alternate when resident dislikes the menu item for that meal; - Encourage visitors to promote resident's food consumption. Review of the resident's monthly weights, dated June 2011, showed staff documented the resident weighed 143 pounds. Review of the resident's monthly weights, dated July 2011, showed staff documented the resident weighed 142 pounds. Review of the resident's monthly weights, dated August 2011, showed staff documented the resident weighed 134 pounds. Review of the resident's Dietary Progress Notes, dated 8/18/11, showed the RD documented the resident had a 19 pound (11%) weight loss in the past six months. The RD documented the resident is offered mighty shakes when he/she refuses to eat. The RD documented the resident refuses snacks. The RD documented the resident "may benefit" from [MEDICATION NAME] to increase appetite. Review of the resident's monthly weights, dated September 2011, showed staff documented the resident weighed 133 pounds. Review of the resident's Significant Weight Loss Report, dated September 2011, showed the RD documented the resident has lost 14% of his/her weight in six months. The RD documented the resident receives house supplements with lunch and dinner, and [MEDICATION NAME] twice daily for wound healing. The RD documented staff said the resident requests various foods, then only eats one bite of the item. The RD documented the resident's physician did not agree with his/her recommendation of [MEDICATION NAME]. Review of the resident's POS, dated October 2011, showed the following orders: -[MEDICATION NAME] 1 powder packet mixed in beverage of choice twice daily (ordered 9/19/11); - Questran powder 4 grams- dilute and administer one scoop twice daily with meals for diarrhea (ordered 9/19/11); - House supplement with lunch and dinner (ordered 9/19/11); - Mighty shakes as needed- offer when resident refuses meal (ordered 9/19/11). Review of the resident's comprehensive MDS, dated [DATE], showed staff did not assess the resident with a weight loss of 5% or more in one month or 10% or more in six months. Review of the resident's plan of care, dated 9/21/11, showed staff did not address the resident's 24 pound weight loss since April 2011. Review showed staff planned the same interventions as on the resident's care plan, dated 6/4/11. Review of the resident's monthly weights, dated October 2011, showed staff documented the resident weighed 126 pounds. Observation on 10/4/11 at 5:15 P.M., showed the resident seated in his/her wheelchair at the dining room table in the restorative dining room. Observation showed an unidentified staff member sat next to the resident while the resident drank a full cup of Questran. Observation showed a full cup [MEDICATION NAME] also on the table next to the resident. During an interview on 10/4/11 at 5:15 P.M., the unidentified staff member passing medications to the resident said the resident [MEDICATION NAME] and Questran before meals. The unidentified staff member said he/she usually sits with the resident to ensure the resident drank all of the liquids before meals. Observation on 10/4/11 at 5:25 P.M., showed the resident seated in his/her wheelchair at the dining room table in the restorative dining room. Observation showed the resident did not have a meal tray as did all other residents in the restorative dining room. During an interview on 10/4/11 at 5:25 P.M., CNA J said dietary staff put gravy on the resident's meal so he/she sent it back to the kitchen. CNA J said he/she "was waiting" for a new tray for the resident. Review of the resident's diet card showed dietary staff documented "no gravy" on the card. Observation on 10/4/11 at 5:35 P.M., showed the resident fed him/herself a meal with gravy covering all of the items. During an interview on 10/4/11 at 5:35 P.M., CNA J said dietary staff said "this is the best they can do." CNA J said he/she doesn't know why the resident's diet card says "no gravy." During an interview on 10/4/11 at 5:37 P.M., the resident said he/she would "eat a little" of the meal covered with gravy. During an interview on 10/4/11 at 5:42 P.M., LPN U said he/she spoke with kitchen staff who said they "took most of the gravy off" the food, but "couldn't take it all off." LPN U said the resident's diet card says "no gravy" because the resident doesn't like gravy, but LPN U said the resident "doesn't eat much anymore." During an interview on 10/6/11 at 12:45 P.M., the RD said the resident's diet card says "no gravy" because the resident doesn't like gravy. The RD said she expects staff to give the resident food without gravy. The RD said the resident eats what he/she "wants to eat" and "stops" when he/she wants to stop. The RD said the resident will not eat snacks. Review of the resident's Dietary Progress Note, dated 10/6/11, showed the RD documented the resident's weight loss as 21 pounds since March 2011. The RD documented the resident "eats as he/she pleases and may enjoy the attention from family and staff when he/she refuses to eat." The RD documented the resident's appetite and intake is "poor." 2. Record review of the resident's active medical record showed the resident's most recent Nutritional Assessment by the facility's Registered Dietician (RD), dated 2/15/11, showed the RD documented the weighed 133 pounds (lbs.). The RD documented the resident did not receive any ordered snacks or health supplements, and he/she did not have any pressure ulcers. The RD documented staff should continue with the current appropriate diet order and monitor the resident's weights, laboratory results, and skin conditions. Record review of the resident's weight records, dated 6/10/11, showed staff documented the resident weighed 133 lbs. Record review of the resident's weight records, dated 7/11/11, showed staff documented the resident weighed 126 lbs. The resident had a seven pound weight loss in one month (a weight loss of 5.26 percent). Record review of the resident's Weekly Wound Assessment Record, dated 7/19/11 through 10/6/11, showed staff documented the resident had an unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar) on his/her lower left leg. Record review of the resident's nurses notes, dated 8/6/11, showed staff documented they notified the resident's physician regarding the resident's seven pound weight loss noted on 7/11/11. Staff documented the resident's physician responded that the resident's weight loss was "expected - hospice case." Staff documented they would continue to monitor. Record review of the resident's weight records, dated 8/10/11, showed staff documented the resident weight 120 lbs. The resident had a six pound weight loss in one month and a 13 pound weight loss in two months (a weight loss of 4.76 percent in one month, and 9.77 percent in two months). Review of the resident's active medical record showed staff did not notify the resident's physician of the additional six pound loss noted on 8/10/11. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/22/11, showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Totally dependent on two people for transfers and bathing; -Totally dependent on one person for dressing and ambulation; -Required extensive assistance of one person for personal hygiene; -Incontinent of bowel and bladder; -Had an unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar); -Had a weight loss of five percent or more in the last month or a loss of ten percent or more in the last six months. Record review of the resident's comprehensive plan of care, dated 8/3/11, showed staff were instructed to: -Provide adequate fluid and food intake; -Encourage visitors to promote resident's food consumption. Further review of the resident's plan of care, showed staff did not plan measurable objectives, timetables, and interventions specifically for the resident's weight loss. Record review of the RD's Significant Weight Loss Report (a report which shows significant weight losses in the last six months), dated September 2011, showed the RD did not document the resident had a significant weight loss. Observation on 10/4/11 at 5:14 P.M., showed the resident sat in his/her bed and fed him/herself a turkey sandwich, mixed vegetables, mashed potatoes, and fruit. Staff did not provide the resident with a health supplement. Observation on 10/5/11 at 8:37 A.M., showed the resident sat in his/her wheelchair at the dining room table. The resident told staff he/she wanted toast and jelly with sausage. Staff offered the resident eggs, oatmeal, and bacon, but the resident declined. Observation on 10/5/11 at 9:05 A.M., showed the resident ate 100% of the toast and jelly with sausage. The resident sat in his/her wheelchair and drank his/her water and coffee. The resident drank 100% of his/her juice. During an interview on 10/6/11 at 9:17 A.M., the RD said he/she did not have any notes regarding the residents significant weight loss, therefore he/she was not aware of the weight loss so he/she must not have "triggered for a significant weight loss in the last six months." The RD said at the time of the resident's weight loss in July, the facility staff was responsible for providing a list of residents with any amount of weight loss to the RD. The RD said now the facility staff gives him/her a list of monthly weights on all residents, and the RD then figures out which residents have had a significant weight loss. The RD said he/she was also not aware the resident had a pressure ulcer. The RD said if he/she was aware of the resident's weight loss in July and August, he/she would have talked with the resident about options to prevent further weight loss, such as adding supplements, increasing food served, and adding weekly weights. Additionally, the RD said the resident's weight loss is not helping with the healing of the resident's unstageable pressure ulcer. During an interview on 10/7/11 at 9:05 A.M., Licensed Practical Nurse (LPN) N said since the resident is on hospice care, there is not much done in terms of interventions. LPN N said staff have talked with the resident about his/her weight, and the resident said he/she will eat when he/she is hungry. LPN N said if staff notice the resident did not eat well at meals, then they will offer the resident a snack. LPN N said the resident usually declines snacks. During an interview on 10/7/11 at 1:45 P.M., the Director of Nursing (DON) said the RD is given copies of wound reports and monthly and weekly weights. The RD then figures out the weight loss percentages for all residents with weight loss. The DON said the RD should have been aware of the resident's weight loss and pressure ulcer through the monthly weights and wound reports. During the same interview, the MDS/Careplan Coordinator said the resident's careplan should have been updated at the time the weight loss and pressure ulcer occurred.