Every finding on record at California Care Center

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #3, #13, and #21) out of 14 sampled residents. The facility census was 32. 1. Review of the facility's Care Plan Comprehensive policy, undated, showed an assessment of each resident is an ongoing process and the care plan's revised as changes occur in the resident's condition. The interdisciplinary care plan team is responsible to review and update care plans when a significant change in the resident's condition occurs. 2. Review of Resident #3's comprehensive admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/26, showed staff assessed the resident as cognitive, no behavioral symptoms and did not reject care, with a diagnosis of stroke with upper extremity impairment on one side and lower extremity impairment on both sides, high risk for falls. Review of the resident's care plan, dated 11/12/25, showed it did not address interventions for the resident's prosthesis on both lower extremities and did not address the need for residents' improper fit of denture use. Review of resident's nurse note, dated 04/30/26, showed staff documented the resident in therapy to assist with proper placement and use of prosthetics. During an interview on 05/07/26 at 12:26 P.M., the resident said his/her dentures do not fit as they should since his two strokes. Without his/her teeth, heshe feels ugly about him/herself. The resident said he/she suffers from depression and without his/her teeth makes it worse. During an interview on 05/07/26 at 12:55 P.M., the Care Plan Coordinator said anything abnormal should be care planned, such as adaptive equipment the use of dentures. He/She said it is important to have these things in the care plan, so staff know how to take care of the residents. The care plan coordinator said he/she did not know these things were not on the care plan. During an interview on 05/07/26 at 1:35 P.M., the Director of Nursing (DON) said staff use I Care plan which and any abnormal thing about the resident. The care plan is used so the nurse or aide knows how to care for the resident. The DON said the MDS and care plan should match. If a resident has dentures, it should also be on the care plan. During an interview on 05/07/26 at 2:05 P.M., the administrator said she would expect dentures to be care planned. If a resident has had a stroke and has limitations it should also be on the care plan. It is the care plan coordinator's responsibility to update and add to the care plan and was not aware those things were not on the care plan. 3. Review of Resident #13's MDS, dated [DATE], showed staff assessed the resident as cognitive, debility, related to cardiorespiratory conditions; heart failure, anemia, coronary artery disease. Review of the resident's nurse note, dated 02/27/26, showed the resident received an Implantable Cardioverter-Defibrillator (ICD), a small, battery-powered device surgically placed in your chest that continuously monitors your heart rate and automatically delivers electrical pulses or shocks to correct life-threatening, dangerously abnormal heart rhythms (arrhythmias) and prevent sudden cardiac arrest. Review of the resident's Cardiology Note, dated 03/26/26, showed the resident received a dual chamber ICD on 02/27/26 and an order to report a weight gain of two to three pounds in 24 hours and five pounds in a week. Review of the resident's care plan, updated on 04/15/26, showed the care plan did not address staff to report the daily and weekly weight monitoring and did not update the care plan within 14 days when the resident received an ICD. During an interview on 05/07/26 at 12:55 P.M., the Care Plan Coordinator said anything abnormal should be care planned, such as a pacemaker. The care plan coordinator said he/she did not know these things were not on the care plan. During an interview on 05/07/26 at 1:35 P.M., the DON said staff use I Care plan which documents social history, and any abnormal thing about the resident so the nurse or aide knows how to care for the resident. The DON said the MDS and care plan should match. If a resident a pacemaker it should also be on the care plan. During an interview on 05/07/26 at 2:05 P.M., the administrator said she would expect a pacemaker to be care planned. It is the care plan coordinator's responsibility to update and add to the care plan and was not aware those things were not on the care plan. 4. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, did not have behavioral symptoms and did not reject care, with a diagnosis of hemiplegia or hemiparesis (neurological conditions causing one-side body weakness or paralysis) with upper and lower extremity impairment on one side. Review of the resident's care plan, last updated 02/25/26, showed staff did not contain interventions for the resident's contracture. Observation on 05/05/26 at 12:30 P.M., showed the resident in his/her wheelchair with left hand contracted without interventions in place. Observation on 05/06/26 at 3:00 P.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. Observation on 05/07/26 at 12:00 P.M., showed the resident in his/her wheelchair with left hand contracted without interventions place. During an interview on 05/07/26 at 12:55 P.M., the Care Plan Coordinator said anything abnormal should be care planned, such as adaptive equipment and their transfer needs, He/She said weaknesses or contractures should be on the care plan. He/She said it is important to have these things on the care plan, so staff know how to take care of the residents. The care plan coordinator said he/she did not know these things were not on the care plan. During an interview on 05/07/26 at 1:35 P.M., the DON said contractures should be on the care plan so the nurse or aide know how to care for the resident. The DON said the MDS and care plan should match. During an interview on 05/07/26 at 2:05 P.M., the administrator said if a resident has limitations, it should be on the care plan. It is the care plan coordinator's responsibility to update and add to the care plan and he/she was not aware those things were not on the care plan.

Based on interviews and record review, facility staff failed to maintain professional standards of practice when staff failed to transcribe a treatment order for daily weights for one resident (Resident #13) with congestive heart failure (CHF). The facility census was 32.1. Review of the facility's Physician Orders policy, undated, showed current orders are maintained in each resident record to avoid confusion and errors. 2. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment tool, 04/16/26, showed staff assessed the resident as:-Cognitively intact;-Debility, related to cardiorespiratory conditions; heart failure, anemia, coronary artery disease. Review of the resident's Cardiology visit note, dated 03/26/26, showed an order to report a weight gain of two to three pounds in 24 hours and five pounds in a week. Review of the resident's Physician Order Sheet (POS), dated 03/31/26, showed the POS did not contain the order for daily weights or to report a weight gain of two to three pounds in 24 hours and five pounds in a week. Review of the resident's POS, dated 04/30/26, showed the POS did not contain the order for daily weights or to report a weight gain of two to three pounds in 24 hours and five pounds in a week. During an interview on 05/12/26 at 8:15 A.M., the resident's Cardiology Nurse Practitioner said he/she expects the facility to record the resident's weight as ordered. He/She said if the facility did not understand the order, he/she expects the facility to communicate for clarification of the order. He/She said if the facility does not record the resident's weights as ordered, the resident can become fluid overloaded. He/She said he/she does not have any communication or records of resident's weights. During an interview on 05/07/26 at 10:15 A.M., Licensed Practical Nurse (LPN A) said when a resident returns from the doctor's office with new orders, the charge nurse is responsible to review the orders, notify the physician to ensure an order is changed. The LPN said the charge nurse is responsible to transcribe the order as followed. The LPN said the order to complete daily weights, and weekly weights should be followed. The charge nurse is responsible for making sure they are transcribed but not to follow up. During an interview on 05/07/26 at 1:35 P.M., the Director of Nursing (DON) said the charge nurse is responsible for transcribing new orders. The DON said he/she's never seen an order like that and assumed the resident was responsible to monitor his/her weights. The DON said he/she is responsible for ensuring orders are followed per the physician. During an interview on 05/07/26 at 2:07 P.M., the administrator said the error in order should be identified. He/She said there should be clarification of an order if misunderstood. The resident is not responsible for his/her weights, we are responsible for ensuring orders are followed. He/She said the charge nurse on duty should follow up with the order, any clarifications and communicate with the physician.

Based on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of one sampled residents' physician when the resident was given another residents medication which resulted in a hospital stay. The facility census was 29. 1. Review of the facility Medications, Errors and Drug Reactions policy, undated, showed the facility shall report all medication errors and adverse drug reactions immediately to the attending physician, Director of Nursing (DON), and the Administrator. 2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/24, showed staff assessed the resident: -Cognitively intact; -Active diagnoses of Cancer (abnormal cell growth with the potential to invade or spread to other parts of the body) and renal failure. Review of the resident's plan of care, undated, showed staff documented to administer medications as ordered by the physician. Review of the residents progress notes, dated 4/17/24, showed Registered Nurse (RN) C documented, around 8:00 A.M., this nurse discovered Resident #1 was given medications that belonged to another resident at breakfast. Assessment done, no changes in condition or behavior observed. Resident played bingo where weekend manager observed the resident to be off but finished playing the game. While seated at his/her table, this nurse observed resident to be lethargic, but able to respond when talked to, vital signs were rechecked, resident hypotensive and bradycardic. Emergency Medical Services (EMS) and Director of Nursing (DON) called; resident sent to the emergency room around 11:45 A.M., later admitted to the hospital. Physician notified at 11:50 A.M. During an interview on 5/3/24 at 9:30 A.M., the administrator said he/she expects the physician to be notified immediately if there is a medication error. He/She said the physician was not contacted until the resident had an adverse reaction and was sent to the hospital. He/She said the RN C did not contact the physician immediately because he/she wanted to stay with the resident for monitoring. During an interview on 5/3/24 at 9:51 A.M., Certififed Medication Technician (CMT) A said he/she did not contact the physician and was not asked to contact the physician by anyone else. He/She said the resident was monitored for an hour by RN C and then went to bingo where the weekend manager noticed the resident was off and that is when RN C called emergency medical services and the physician. During an interview on 5/3/24 at 10:03 A.M., RN C said he/she realized he/she gave the wrong medication to resident #1 and monitored him/her for about an hour. He/She said he/she checked vital signs. He/She said the resident went to play bingo and when he/she checked on him/her again the weekend manager said he/she seemed off. RN C checked his/her vitals again and the resident was hypotensive and voiced he/she felt sleepy. He/She said he/she texted the physician after the resident was sent with EMS. He/She said he/she should have called the physician right away but was with the resident. During an interview on 5/3/24 at 10:15 A.M., the DON said he/she expects staff to contact the physician immediately with medication errors. During an interview on 5/14/24 at 1:26 P.M., the physician said he/she expects to be contacted as soon as a mistake with medications are made. He/She said he/she does not know why the facility waited to contact him/her until the resident had a negative reaction. MO00235395

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 after an adverse reaction. The facility census was 29. 1. Review of the facility Medications, Administration guidelines, undated, showed it is the purpose of this facility residents receive their medicationson timely and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physicians orders, giving the individual dose to the proper resident, and promptly recording the information. Staff are directed further as follows: -The same person preparing the doses for administration must administer medications; -The person administering the drugs must chart medications immediately following the administrations. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data; -If there is doubt as to the correct identification of a resident, medication may not be administered to that resident until positive identification has been made. Review of the medication administration policy, undated, showed staff are directed to remain in the room while the resident takes the medication. 2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/24, showed staff assessed the resident: -Cognitively intact; -Diagnoses of cancer (abnormal cell growth with the potential to invade or spread to other parts of the body) and renal failure. Review of the resident's plan of care, undated, showed staff are directed to administer medications as ordered by the physician. Review of the resident's progress notes, dated 4/17/24 at 6:00 P.M., showed Registered Nurse (RN) C documented, around 8:00 A.M., discovered Resident #1 given medications which belonged to another resident at breakfast. Review showed staff documented they assessed the resident, no changes in condition or behavior observed. RN C documented the resident respirations even and unlabored, lung sound clear, heart sounds regular, bowel sounds present in all quadrants, skin warm per usual. Staff documented the resident played bingo where weekend manager observed the resident to be off but finished playing the game. RN C documented he/she oserved the resident to be lethargic, but able to respond when talked to, vital signs were rechecked, resident hypotensive and bradycardic. Emergency Medical Services (EMS) and Director of Nursing (DON) called. RN C documented resident sent to the emergency room around 11:45 A.M., later admitted to the hospital. Physician notified at 11:50 A.M. Review of Resident #2's physician orders sheet (POS), dated 4/1/24 - 5/1/24 showed physician orders to adminsiter 6:00 A.M. to 10:00 A.M., medication pass: -Glimepiride (high blood sugar levels cause by type 2 diabetes) 2 milligrams (mg) one time daily; -Doxazosin (treat high blood pressure) 8 mg one time daily; -Eliquis (an anticoagulant used to prevent blood clots and strokes) 5 mg twice daily; -Hydralazine (treat high blood pressure) 25 mg three times daily; -Lisinopril (treat high blood pressure) 40 mg one time daily; -Metoprolol (treat high blood pressure) 50 mg one time daily; -Furosemide (treat fluid retention) 40 mg one time daily. Review of the resident's hospital records, dated 4/27/24, showed Resident #1 admitted the hospital after Skilled Nursing Facility staff administered the wrong medications. Review showed the resident received Levophed for blood pressure support. During an interview on 5/3/24 at 9:30 A.M., the administrator said Certified Medication Technician (CMT) A gave Resident #2 a medication cup with his/her medication at the dining room table and did not verify the medication was taken before leaving the resident. Resident #1 and #2 sit at the same table at meals. Dietary aide B came to clean the table off and noticed the medication cups still had pills and was in the spot Resident #1 usually sits at, he/she gave the medication to RN C stating they were Resident #1's because they were in his/her usual spot. RN C gave Resident #1 the medication in the cup not realizing it was Resident #2's medication, he/she then told CMT A he/she gave Resident #1 his/her medications but CMT A had already given Resident #1's medications. RN C began monitoring the resident vitals. The resident had to be sent out for evaluation after he/she started to have adverse effects. During an interview on 5/3/24 at 9:51 A.M., CMT A said he/she gave Resident #2 his/her pills at the breakfast table in a medication cup, he/she watched the resident take a few and walked away. He/She said after he/she finished the medication pass for the morning, he/she went on break. When he/she returned from break he/she said RN C approached him/her and said he/she gave Resident #1 his/her medication pass but he/she had given resident #1 his/her medication in the hall before break. He/She said RN C took vitals and monitored the resident until he/she had an adverse reaction and was sent to the hospital. During an interview on 5/3/24 at 10:03 A.M., RN C said he/she was by his/her medication cart when dietary aide B called out to him/her Resident #1 forgot his/her pills on the breakfast table. He/She said the dietary aide was standing where Resident #1 usually sits and the medication cup was full of pills and looked like none had been taken. He/She said he/she did not see CMT A and Resident #1 was in his/her room so he/she gave the resident the medication in the cup. He/She said he/she informed CMT A when he/she returned from break Resident #1 had not taken his/her pills at breakfast and he/she gave him/her the pills. CMT A told him/her Resident #1 already received his/her pills in the hallway. RN A said he/she went and assessed Resident #1 and everything was baseline. Resident #1 went an activity and the weekend supervisor noticed something was off with the resident and reported it to RN C. He/She took vitals again and the resident was hypotensive and said he/she was sleepy and emergency medical services were contacted. During an interview on 5/3/24 at 12:18 P.M., Dietary Aide B said he/she was cleaning off the tables after breakfast and Resident #1 and Resident #2 always sit together, he/she said he/she saw a cup of medication where Resident #1 usually sits. He/She said he/she gave the medication's to RN C without realizing Resident #1 and Resident #2 had switched seats. MO00235395

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. The facility census was 28. 1. Review of the facility's policy titled, Deep Cleaning a Resident Room, undated, showed staff were directed to do the following: -Deep cleaning is the segment of housekeeping that ensures total cleanliness of the resident room. The deep cleaning guarantees that all areas of the resident room and bathroom are cleaned and disinfected. Deep cleaning includes polishing, scrubbing, scrapping, dusting, and disinfecting everything in the resident room; -Spot wipe all walls using approved disinfectant; -Clean all corners, edges, and baseboards. Be sure to remove any buildup around closets, behind beds, furniture, and door jams. Use a scrapper to dig dirt out of corners. Dust mop and wet mop entire room. Review of the facility's policy titled, Housekeeping Department, undated, showed staff were directed to do the following: -The resident room cleaning procedure should be used for all resident rooms to maintain cleanliness and to promote infection control; -Sanitize the inside of the toilet and urinal using the bowl mop saturated with bowl cleaning solution; -Notify your supervisor of any maintenance work. The facility did not provide a policy for ensuring the resident's room were in good repair. Review of the facility's Maintenance Log, showed staff last documented needed repairs on 01/02/2023. 2. Observation on 06/12/23 at 06:13 A.M. showed room [ROOM NUMBER] had a black substance between the floor tiles and a buildup of debris on the baseboards. The bathroom floor had brown stains around the base of the toilet, and tiles separated from the floor. Further observation showed the walls with black [NAME], chipped paint, gouges. Observation on 06/14/23 at 02:09 P.M., showed the area remained unchanged. 3. Observation on 06/12/23 at 06:20 A.M. showed room [ROOM NUMBER] had a buildup of debris on the floor by the threshold, base boards, and under the sink. The bathroom floor had brown stains around the base of the toilet, and tiles separated from the floor. Further observation showed the walls with black [NAME], gouges, and several nail holes. Observation on 06/14/23 at 01:54 P.M., showed the area remained unchanged. 4. Observation on 06/12/23 at 06:44 A.M. showed room [ROOM NUMBER] had debris on the floor under the bed, black [NAME] on the bathroom door and wall, black [NAME] on the floor in front of the closet and dresser. Further observation missing trim around the sink and closet. Observation on 06/13/23 at 04:11 P.M., showed the area remained unchanged. 5. Observation on 06/12/23 at 07:31 A.M. showed the wall in room [ROOM NUMBER] had three dime sized holes and five nickel sized anchor support holes. Observation on 06/13/23 at 09:00 A.M., showed the area remained unchanged. 6. Observation on 06/12/23 at 07:44 A.M. showed the Tea Room had two green chairs with large brown stains on the armrests and seat cushions. Further observation showed a wooden framed chair with a large stain on the fabric covered seat. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 7. Observation on 06/12/23 at 10:02 A.M. showed room [ROOM NUMBER] with no base board by the closet and a large patch of canvas-like material on the wall under the window. The materials edges had peeled back and hung from the wall. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 8. Observation on 06/12/23 at 10:56 A.M. showed room [ROOM NUMBER] had a metal door frame with chipped paint and rust build up. The walls had black scuff [NAME], and the base board peeled away from the wall behind the door. Further observation showed the toilet bowl had a built up black substance. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 9. Observation on 06/12/23 at 11:01 A.M., showed room [ROOM NUMBER] had exposed concrete floor where tile had been removed. Further observation showed the wall beneath the window had a large patch made of canvas-like material on the wall which had started to peel. Observation on 06/14/23 at 02:30 P.M., showed the area remained unchanged. 10. Observation from 06/13/23 at 01:46 P.M. showed room [ROOM NUMBER] had a buildup of debris at the threshold and baseboards, and black wheelchair tire prints on the floor. Further observation showed the walls had black [NAME] and gouges, the toilet had brown stains and no sealant around the base, and a ceiling vent cover had started to separate from the ceiling. Additional observation showed an oxygen concentrator with brown steaks down the front of it. Observation on 06/14/23 at 02:03 P.M., showed the area remained unchanged. 11. Observation on 06/13/23 at 03:46 P.M., showed room [ROOM NUMBER] had gouges in the wall and missing trim in the bathroom. 12. Observation on 06/13/23 at 03:53 P.M., showed room [ROOM NUMBER] and room [ROOM NUMBER] shared a bathroom. The bathroom trim had missing paint and the toilet had rust around the base. 13. Observation on 06/13/23 at 03:59 P.M. showed room [ROOM NUMBER] had a black substance on the floor in front of the closet and dresser and paint missing from trim. 14. Observation on 06/13/23 at 04:04 P.M. showed room [ROOM NUMBER] had black [NAME] on the walls. 15. Observation on 06/13/23 at 04:17 P.M. showed room [ROOM NUMBER] and room [ROOM NUMBER] shared a bathroom. The toilet had rust around the base. 16. Observation on 06/13/23 at 04:18 P.M., showed room [ROOM NUMBER] had debris and black [NAME] on the floor, and loose trim. The walls had black [NAME] and gouges, and the toilet had rust around the base. During an interview on 06/14/23 at 09:28 A.M., Certified Nurse Aide (CNA) D said he/she told the charge nurse if he/she saw something he/she needed maintenance to repair. The CNA said the facility did not have a full time maintenance person. The CNA said the facility had a maintenance book at the nurse's station. The CNA said the facility has not had a maintenance person in a long time. During an interview on 06/14/23 at 10:14 A.M., Licensed Practical Nurse (LPN) E said if something needed repaired staff should notify maintenance. The LPN said there was a maintenance log at the nurse's station. The LPN said he/she had noticed the rust and missing paint on door frames but had not reported it to maintenance. The LPN said staff told maintenance when repairs were needed. The LPN said he/she had not noticed the missing base boards, or the canvas material peeling off of the walls, but would expect staff to report those things to him/her and they had not During an interview on 06/14/23 at 10:50 A.M., the Maintenance staff member said he/she did the maintenance and paperwork at the facility. He/She said staff told him/her verbally what needed to be repaired and there was a maintenance book by the nurse's station. He/she checked the maintenance book every day, unless staff told him/her about something that needed repair. Staff reported the base boards coming off but he/she had not ordered the replacements. He/She said no one reported missing pieces of tile or canvas material peeling off of the walls to him/her. The maintenance staff member said he/she had not noticed the stained chairs in the Tea Room. During an interview on 06/14/23 at 1:29 P.M., Director of Nursing (DON) said staff should tell him/her or the administrator if something needed repaired. The DON said the facility still did not have a full time maintenance person. The DON said he/she had not seen the peeling canvas on walls, missing base boards, or damage on the walls in room. The DON said he/she had not noticed the stained chairs in the Tea Room. The DON said he/she would expect the staff to report these issues to the maintenance staff and the chairs be disposed of. The DON said maintenance does rounds of the rooms, but he/she is not sure how it is scheduled. 37131 42815 45489

Based on observation, interview, and record review, facility staff failed to revise care plans for five residents (Resident #6, #11, #12 #21, and #66) with interventions to prevent falls. The facility census was 30. 1. Review of the facility's, Care Plan Comprehensive Policy, dated March 2015, showed the policy directed staff as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation). -Managing risk factors to the extent possible or indicating the limits of such interventions. -Evaluating treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -At least quarterly. -When changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #6's Quarterly MDS (Minimum Data Set), a federal assessment tool, dated 3/14/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from one staff for transport, bed mobility, walking in room, dressing, toileting, and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Had two or more falls with injury since last assessment. Review of the resident's care plan, last reviewed 1/15/21, showed staff documented the resident was at risk for falls and are directed to: -Be aware of the resident's risk for falls and to provide supervision/physical assistance with Activities of Daily Living (ADLs); -Be aware the resident displayed impulsive behaviors and was unaware of his/her own physical limitations; -Keep resident within line of sight as much as possible when awake. -Review showed the care plan did not contain direction for staff in regards to the use of a helmet. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Fall Assessment Tool, dated 3/13/22, showed staff assessed the resident as a high fall risk. Observation on 4/18/22 at 10:38 A.M. showed the resident sat in his/her wheelchair. He/She wore a safety helmet. Observation on 4/18/22 at 1:29 P.M. showed the resident wore a safety helmet. Observation on 4/19/22 at 1:43 P.M. showed the resident wore a safety helmet. During an interview on 4/19/22 at 8:22 A.M., Certified Nursing Assistant (CNA) G said the resident has worn a helmet since March of this year, because he/she fell out of his/her wheelchair. He/She said staff check it every two hours to make sure it does not cause problems. During an interview on 4/19/22 at 08:43 A.M., Registered Nurse (RN) B said staff removed the helmet every two hours to check for wear on the resident's head. 3. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive Impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from two staff for bed mobility, transfers, dressing and toileting; -Required extensive assistance from one staff for locomotion on and off the unit and eating; -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 4/8/22, showed the staff assessed the resident as a high fall risk. Review of the nurse's notes, dated 1/26/22, showed staff documented the resident was found wrapped in blankets on the side of the bed on the floor. Review of the nurses notes, dated 3/23/22, showed staff documented the resident was found on the floor next to his/her bed. Review of the care plan, dated 4/14/22, showed it did not contain interventions for the resident's falls on 1/26/22 and 3/23/22. 4. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive Impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from two staff for bed mobility, dressing, toileting, personal hygiene and transfers; -Required extensive assistance from one staff for locomotion on and off the unit; -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 11/10/21, showed the staff assessed the resident as a high fall risk. Review of the nurse's notes, dated 12/24/21, showed staff documented the resident was found on the floor by his/her bed. Review of the Care Plan, dated 2/17/22, showed it did not contain an intervention for the resident's fall on 12/24/21. 5. Review of Resident #21's quarterly MDS, dated [DATE], showed staff assessed resident as follows: -Severe Cognitive Impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from two staff for bed mobility, transfers and walking; -Required extensive assistance from one staff for locomotion on and off the unit, dressing, toileting, and personal hygiene. -Had one fall without injury since last assessment. Review of the resident's Fall Risk Assessment Tool, dated 2/24/22, showed the staff assessed the resident as a high fall risk. Review of the the resident's nurse's notes, dated 1/12/22, showed staff documented the resident slid out of his/her wheelchair. Review of the the resident's Care Plan, dated 2/24/22, showed it did not contain an intervention for the residents fall on 1/12/22. 6. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed resident as follows: - Severe Cognitive Impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from one staff for bed mobility, transfers, dressing, toileting and personal hygiene; -Had falls prior to admission. Review of the resident's Fall Risk Assessment Tool, dated 2/16/22, showed the staff assessed the resident as a high fall risk. Review of the resident's nurse's notes, dated 3/3/22, showed staff documented the resident slid out of his/her wheelchair. Review of the resident's Care Plan, dated 3/17/22, showed it did not contain an intervention for the resident's fall on 3/3/22. During an interview on 4/20/22 at 10:46 A.M., CNA G said if a resident is a fall risk and they look in the care plan for interventions. He/She said everything we need to know is in the resident's care plan. During an interview on 4/20/22 at 10:54 A.M., RN B said interventions for residents at high risk for falls are in the care plans. During an interview on 4/20/22 at 11:08 A.M., the Director of Nursing (DON) said falls are discussed in a weekly meeting where interventions are discussed by the staff and implemented. He/She said the facility is aware interventions are not being documented in care plans, because the facility is behind. He/She said the expectation is after every fall interventions are implemented or reevaluated for effectiveness. During an interview on 4/20/22 at 11:29 P.M., the Administrator said the care plans should have interventions for falls to direct staff on how to individually care for the residents. He/She said the facility is aware there is a care plan breakdown.

Based on interview and record review, facility staff failed to implement facility communicable disease policies and procedures to ensure all employees were screened appropriately and in a timely manner for [CONDITION(S)] (TB). The facility failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed and on file for five out of ten employee files reviewed. The facility census was 30. 1. Review of the facility's TB Screening for Long Term Care Employees Guidelines, undated, showed the following: -All employees will be screened for TB; -Once the decision has been made to employ an individual, the first step PPD will be administered by the nursing department, documented on the employee immunization record, and must be read prior to or no later than the employment start date; -All PPDs will be documented on the staff immunization record, including new hires; -Documented evidence of prior PPD will be maintained with facility employee immunization records; -The guidelines stated second step PPD given seven to twenty one days after the first if the first dose is negative along with an employee risk screening tool. 2. Review of the Business Office Manager's (BOM)'s employee file showed: -Hire date of 12/28/21; -First step PPD administered on 1/24/21 and read on 1/27/21; -The file did not contain documentation a second PPD dose was administered 7 to 21 days after the first dose. 3. Review of The Activity Director's (AD)'s employee file showed: -Hire date of 3/2/22; -First step PPD administered on 2/23/22; -The file did not contain documentation the first PPD was read, or results; -The file did not contain documentation a second PPD was administered. 4. Review of Laundry Aide C's employee file showed: -Hire date of 4/25/19; -First step PPD administered 4/22/19 and read on 4/25/19; -Second step PPD administered on 6/9/19 and read on 6/12/19, more than 7 to 21 days after the first step. 5. Review of Cook D's employee file showed; -Hire date of 4/18/19; -First step PPD administered 4/15/19 and read on 4/18/19; -Second step PPD administered on 6/9/19 and read on 6/12/19, more than 7 to 21 days after the first step. 6. Review of Nurse Aide (NA) E's employee file showed: -Hire date of 3/24/22; -First step PPD administered 3/22/22 and read on 3/25/22, one day after the hire date; -The file did not contain documentation a second PPD was administered. During an interview on 4/20/22 at 11:01 A.M., the Minimum Data Set (MDS) Coordinator said he/she was in charge of staff testing for TB, the facility policy was a two step upon hire and annually thereafter. The first step was to be read in 48-72 hours and the second step within two weeks. If the two week window was missed, he/she said you have to start over with the two step process. He/She said he/she did not think any tests had been missed. He/she said if TB tests are missed they must have got overlooked. During an interview on 4/20/22 at 11:08 A.M., the Director of Nursing (DON) said the MDS coordinator was responsible for staff TBs. He/She said the expectation was two step upon hire and then annually. He/She said all staff have their first step read before their first day. The facility should administer the second step within 14 days or two weeks from the first step and if it's not done in that time frame they do not start over, they just complete the second step. He/She said it was easy to forget the second step, but does not know why the TBs would not all be up to date. During an interview on 4/20/22 at 11:29 A.M., the Administrator said the facility was required to administer a two step TB test upon hire and then annually. There should be two weeks in between the first and second step, and if the second step was out of the required time frame then the process must start over. He/She said all results need to be read within 48-72 hours and done before staff are allowed to work on the floor. He/She said he/she was not sure why the TBs would be missed and thinks it's a documentation error.

Based on observation and interview, facility staff failed to post the required nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 30. 1. Observation on 4/18/22 at 2:23 P.M., showed the current required nurse staffing information was not posted. Observation on 4/19/22 at 3:52 P.M., showed the current required nurse staffing information was not posted. Observation on 4/20/22 at 10:34 A.M., showed the current required nurse staffing information was not posted. During an interview on 4/20/22 at 9:26 A.M., the Director of Nursing (DON) said the nurse staff posting is posted daily by the nurses station. He/She said it is the responsibility of the night nurse and he/she does not know why it is not being done. During an interview on 4/20/22 at 10:26 A.M., Certified Medication Technician (CMT) A said the nurses are responsible for filling out the nurse staff posting and it should be updated every day. During an interview on 4/20/22 at 10:32 A.M., Registered Nurse (RN) B said the nurse staff posting is hanging on the wall by the nurses station and it shows how many hours staff work in the 24 hour period. He/She said the night shift charge nurse is responsible for completing it. He/She said it should be updated every night. He/she did not know why the staff posting had not been updated, because the night shift charge nurse knows it is to be completed. During an interview on 4/20/22 at 11:13 A.M., the Administrator said that the nurse staff posting shows how many residents are in our facility, and the number of Licensed Practical Nurses (LPN), RN, CMT, and aides in the building. It also shows how many hours they work in the 24 hour period. The staff posting should be hung at the nurses station on the wall above the call light system. He/She said the night shift nurse is responsible for completing it. He/She said he/she does not know why it has not been completed.

Based on interviews and record review, facility staff failed to follow the facility policy to report to the Department of Health and Senior Services (DHSS), of any allegation of resident abuse for one resident (Resident #1). The facility census was 24. 1. Review of the facility's Abuse Prohibition Policy, dated 2018, showed it is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Additional review showed the investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. All allegations of Abuse will be reported no later than 2 hours to the State Survey Agency and if applicable, law enforcement. 2. Review of the facility's Resident Abuse Report/Investigation Form, dated 10/25/2020 and signed 10/26/2020 showed staff documented the incident occurred on 10/25/2020 at 7:50 A.M. Review showed Resident#1 accused staff member, CNA A, of punching resident in the face. Review showed the resident stated staff member punched him/her on the left side of face. The resident asked why interviewer was taking notes. Explained protocol to resident. The resident said I said I was going to tell my son the CNA balled up his/her fist and hit me to get him/her in trouble. I don't want CNA fired, I want him/her told to be nicer. Review showed housekeeper B reported witnessing staff in hallway, resident calling CNA A a [OBSCENITY] then grabbing the left side of his/her forehead stating, Ow you hit me. The housekeeper said the CNA was not near the resident when resident grabbed side of head and statement made. review showed the summary of investigators findings CNA A was removed from facility until the investigation was completed. After resident's own comments wanting to get CNA A in trouble and witness statement that CNA wasn't near resident when resident made statement of being hit. The facility documented facility did not find abuse occurred. Staff did not document they notified the DHSS of the allegation of abuse. During an interview on 10/26/2020 at 2:55 P.M. the resident said CNA A hit me in the head as hard as he/she could, (placing hand on left side of head), I had a headache for three days. The resident said CNA hit her because resident called CNA a [OBSCENITY] . During an interview on 10/26/2020 at 4:00 P.M. the Social Services Director said he/she had spoken to the resident earlier today and said the resident was angry and stated staff hit him/her on the head. During an interview on 10/26/2020 at 2:35 PM the Administrator said she did not report allegation to the Department of Health and Senior Services due to a witness (housekeeper) reported witnessing that the incident did not occur. The Administrator said she also spoke with the facility's Quality Assurance Nurse who instructed her that the incident did not need to be reported because the investgation found it to be unsubstantiated. MO 267

Based on observation and interview, facility staff failed to ensure razors and hazardous items were not accessible to residents. The facility census was 34. 1. Review of the facility's policies showed the facility did not provide a policy to direct staff related to appropriate storage of hazardous items. 2. Observation on 05/09/18 at 9:39 A.M., showed the clean utility room unlocked and unattended. Further observation showed more than 10 packs of 10 twin blade razors, 25 small bottles of hand sanitizer, more than 25 large bottles of hand sanitizer, and shaving cream in the room. There was an unknown resident in the hallway in his/her wheelchair. Observation on 05/09/18 at 9:41 A.M., showed the oxygen room unlocked and unattended. Additional observation showed 14 full canisters of oxygen and eight empty canisters of oxygen in the room. Observation on 05/09/18 at 10:52 A.M., showed the resident spa across from room [ROOM NUMBER] unlocked and unattended. Further observation showed more than 10 packages of 10 twin blade razors, hairspray, mouthwash, and shaving cream in the room. Observation on 05/09/18 at 11:51 A.M., showed the resident spa across from room [ROOM NUMBER] unlocked and unattended. Further observation showed more than 10 packages of 10 twin blade razors, and containers of hairspray, mouthwash, and shaving cream in the room. Multiple residents propelled themselves in the hallway to and from the dining room. Observation on 05/10/18 at 10:45 A.M., showed the spa across from room [ROOM NUMBER] unlocked and unattended. Further observation showed more than 10 packages of ten twin blade razors, hairspray, mouthwash, and shaving cream. Multiple residents propelled themselves in the hallway toward the dining room. Observation on 05/11/18 at 9:35 A.M., showed the clean utility room unlocked and unattended. Further observation showed more than 10 packs of 10 twin blade razors, 25 small bottles of hand sanitizer, more than 25 large bottles of hand sanitizer, and containers of shaving cream. There was an unknown resident in the hallway in his/her wheelchair. During an interview on 05/10/18 at 2:11 P.M., CNA B said all supply rooms, shower rooms, and employee bathrooms should be locked because residents could wander in them, get into stuff and get hurt. During an interview on 05/11/18 at 9:24 A.M., CNA D said chemicals are stored in locked housekeeping and maintenance rooms. He/She said razors are put in sharps containers after use and are locked up in the spa room before use. He/She said staff are expected to keep the spa rooms locked when not in use and if a staff member notices them unlocked, they should lock them. During an interview on 5/11/18 at 9:29 A.M., Licensed Practical Nurse (LPN) A said sharps and chemicals are stored in the clean utility room, and staff are expected to keep them locked away when unattended. The LPN said cleaning chemicals are stored by housekeeping in their storage rooms, and chemicals used to clean the shower rooms are kept locked by the aides. He/She said the oxygen tank storage room should also be locked when unattended. During an interview on 05/11/18 at 02:18 P.M., the DON said sharps and chemicals are kept in the spa rooms and utility rooms behind a locked door. He/She said the spa rooms should be kept locked. He/She said the used razors in the utility room are kept inside a cardboard box with a red bag so they can be picked up. He/She said the oxygen room should be kept locked. He/She said if staff notice any rooms unlocked they should lock them.

Based on interview and record review, facility staff failed to develop, maintain, and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice, and failed to vaccinate three residents (Resident #3, #23, and #27) of five sampled eligible residents with doses of the pneumococcal vaccine, as recommended by the Centers for Disease Control and Prevention (CDC). The facility census was 34. 1. Review of the facility's Pneumococcal Vaccine Policy, dated (MONTH) (YEAR), showed staff are directed the Pneumococcal vaccine is recommended for residents [AGE] years and older. A repeat dose after 6 years may be given to those at highest risk. 2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23); -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. 3. Review of the CDC's website, last updated 12/6/17, showed healthcare providers are directed: -There are two types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®) **Adults 19 through [AGE] years Old: CDC recommends pneumococcal vaccination for all adults 19 through [AGE] years old who have certain medical conditions. For anyone with the conditions listed below who has not previously received the recommended pneumococcal vaccines: -[DIAGNOSES REDACTED]s; -Cochlear implant(s); -Generalized malignancy; *Give 1 dose of PCV13 and 1 dose of PPSV23. Administer the PCV13 first, then give the PPSV23 dose at least 8 weeks later. **Adults 19 through [AGE] years Old: For anyone with the conditions listed below who has not previously received the recommended pneumococcal vaccines: -Generalized malignancy; *Give 1 dose of PCV13 and 2 doses of PPSV23. Administer the PCV13 first, then give the first PPSV23 dose at least 8 weeks later. Give the second dose of PPSV23 at least 5 years after the first. **Adults [AGE] years or Older: CDC recommends pneumococcal vaccination for all adults [AGE] years or older: -Give 1 dose of PCV13 to all adults [AGE] years or older who have not previously received a dose. -Give 1 dose of PPSV23 to all adults [AGE] years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose. -Adults who received one or two doses of PPSV23 before age 65 should receive one final dose of the vaccine at age 65 or older. 4. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment, dated 2/4/18, showed staff documented the resident was admitted at age [AGE] years old, on 5/12/14, and his/her pneumococcal vaccination was up to date. Review of the resident's records showed the resident consented to receive the recommended Pneumococcal vaccination on 5/12/14. Further review showed staff administered a dose of Prevnar13 on 5/12/14. Additional review showed staff did not document they offered or administered the PPSV23 to the resident at least one year later, as recommended by the CDC. 5. Review of Resident #23's MDS dated [DATE], showed staff documented the resident was readmitted at age [AGE] years old, on 7/6/15, with [DIAGNOSES REDACTED]. Staff documented his/her pneumococcal vaccination was not up to date, reason: resident was offered and declined. Review of the resident's records showed staff documented an unknown history of prior vaccination. Further review showed staff did not document the resident/resident representative signed a refusal for the vaccines. 6. Review of Resident #27's MDS, dated [DATE], showed staff documented the resident was admitted at age [AGE] years old, on 3/5/16, and his/her pneumococcal vaccination was up to date. Review of the resident's records showed the resident consented to receive the recommended Pneumococcal vaccination on 3/4/16. Further review of the records showed the resident received a dose of PPSV23 on 4/2/14. Additional review showed staff did not document a history of prior PCV13 vaccination, and did not offer or administer PCV13 at least one year later (after PPSV23), as recommended by the CDC. 7. During an interview on 5/10/18 at 9:23 A.M., the Director of Nursing (DON) said Resident #3, #23, and #27 have received the Prevnar 13. He/She said most of the residents have had the PPSV23, or are not due for their six-year booster as yet. The DON said facility staff have not offered the PPSV23 to any current resident, but if a new resident is admitted , the vaccination will be offered. He/She was not sure of a plan to offer the vaccine to current residents. During an interview on 5/11/18 at 9:29 A.M., Licensed Practical Nurse (LPN) A said the DON offers the Pneumonia vaccines to residents, and obtains the consent, then directs the nurse to administer the vaccine. The nurse who administers the vaccine is expected to document on the resident's Treatment Administration Record (TAR) and in the chart. The information in the resident's chart/medical records should be accurate. During an interview on 5/11/18 at 2:18 P.M., the DON said prior to yesterday (5/10/18), staff did not have a plan to administer the PPSV23 to the residents.

Based on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did not accurately code a mental health [DIAGNOSES REDACTED].#12) and failed to accurately code skin conditions/treatment for one resident (Resident #31), of 12 sampled residents. The facility census was 34. 1. Review of Resident #12's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Mild cognitive impairment; -No behaviors; -Independent in all Activities of Daily Living (ADLs); -No psychiatric or mood disorders; -Antidepressant medication seven days per week. Review of the resident's physician's orders [REDACTED]. 2. Review of Resident #31's POS, dated (MONTH) (YEAR), showed staff documented the resident was admitted [DATE] with orders for skin prep (protective barrier) to left heel every shift, and heel boots to bilateral (both) heels when in bed. Review of the resident's records showed staff documented the following on the skin assessments: -1/3/18: Left heel, callused (a hard formation of tissue, especially new tissue formed over a wound) area with dark center; -1/5/18: Skin prep to left heel, heelbos (device to protect the elbow or heel from abrasion and promotes healing of pressure ulcers) on while in bed; -1/12/18: Skin prep to left heel, lower extremities on pillow to avoid pressure to heels. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Limited assist of one person with bed mobility, transfer, locomotion on unit, dressing, toilet, and hygiene; -Uses a walker and wheelchair for mobility; -Not at risk for developing pressure ulcers, -No unhealed pressure ulcers; -Did not receive any applications of dressings to feet (with or without topical medications). Staff did not accurately code the resident's skin conditions/treatment as required on section M0150, and M1200 of the MDS. Review of the resident's nurse's notes, dated 4/10/18, showed staff documented wound to left heel assessed by Director of Nursing (DON), treatment order changed to skin prep twice daily. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Not at risk for developing pressure ulcers, -No unhealed pressure ulcers; -No [MEDICAL CONDITION]; -Did not receive pressure ulcer care, or any applications of dressings to feet (with or without topical medications). Staff did not accurately code the resident's skin conditions/treatment as required on section M0150, M0210, and M1200 of the MDS. Observation and interview on 5/09/18 at 10:29 A.M., showed the resident sat in a recliner in his/her room, with a blue heel boot on his/her left foot. The resident said the insert/sole in his/her shoes rubbed him/her wrong and he/she developed a sore to his/her left foot. He/She did not know if the sore was healing or not. During an interview on 5/11/18 at 10:34 A.M., Licensed Practical Nurse (LPN) A said in March, the resident had a Stage II (partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin) pressure ulcer to his/her left heel and in April, staff continued to perform treatments with skin prep because the wound was not completely healed. He/She said the treatment and the pressure ulcer should have been documented on the MDS dated [DATE]. 3. During an interview on 05/11/18 at 9:38 A.M., the MDS Coordinator said he/she completes the MDS assessment according to RAI guidelines. He/She said he/she does his/her part, activities does their part, dietary and social services do their parts, and then the DON signs off on them once they are complete. He/She said he/she is responsible for ensuring the MDSs are accurate. He/She said he/she reviews the chart, the medication and treatment administration reports, and interviews the residents to ensure the MDSs are accurate. He/She is unsure why Resident #12's psychiatric [DIAGNOSES REDACTED]. He/She said Resident #31's pressure ulcer was not documented on the MDS because they don't have it coded as a pressure ulcer. During an interview on 05/11/18 at 2:18 P.M., the DON said the MDS Coordinator is responsible for completing the MDSs. He/She said he/she expects the MDS Coordinator to follow RAI guidelines. He/She said he/she and the MDS Coordinator sign off on them when they are complete. He/she said they both review them for accuracy. He/She said psychiatric [DIAGNOSES REDACTED]. He/She said Resident #12's MDS does not have a psychiatric [DIAGNOSES REDACTED]. He/She said they were doing skin treatments on Resident #31's heels in (MONTH) but the skin prep treatment currently is only considered preventative. He/She said staff should have documented the resident's risk and treatment for pressure ulcer(s) on the MDS.

Based on observation, interview, and record review, facility staff failed to develop measurable goals and intervention for comprehensive care plans for two residents (Residents #26 and #31) related to [MEDICAL CONDITION] medications and failed to develop a comprehensive care plan within seven days of completion of the comprehensive assessment for two residents (Resident #26 and #29). The facility census was 34. 1. Review of the facility's policy on Comprehensive Care Plans, dated (MONTH) (YEAR), showed staff are directed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment; -A well developed care plan will be oriented to: a. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence; b. Managing risk factors to the extent possible or indicating the limits of such interventions; c. Addressing ways to try to preserve or build upon the resident's strengths; d. Applying current standards of practice in the care planning process; e. Evaluating treatment of [REDACTED]. f. Respecting the resident's right to decline treatment; g. Offering alternative treatments, as applicable; h. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities; i. Involving resident, resident's family and other resident representative as appropriate; j. Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; k. Involving the direct care staff with the care planning process relating to the resident's expected outcomes; l. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS) and Care Area Assessment (CAAs); -CAA documentation explains the basis for the care plan. 2. Review of Resident #26's comprehensive MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -Moderate cognitive impairment; -No mood symptoms; -[DIAGNOSES REDACTED]. -Received Antianxiety and Antidepressant medications for seven days during the seven day review period; -[MEDICAL CONDITION] drug use triggered in Care Area A, and triggered as a Care Planning decision in Section V (CAA summary) of the MDS. Review of the resident's comprehensive care plan, updated 12/8/17, showed staff did not update the care plan within seven days after completion of the comprehensive assessment (dated 10/15/17), and did not document any specific interventions regarding [MEDICAL CONDITION] drug use. 3. Review of Resident #29's, Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan showed staff did not create the resident's care plan until 5/11/18. Further review showed staff did not create the resident's care plan seven days after completion of the comprehensive admission MDS assessment dated [DATE]. 4. Review of Resident #31's comprehensive MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE] from the community; -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Received Antipsychotic, Antianxiety, Antidepressant, and Hypnotic medications for seven days during the seven day review period; -Antipsychotics were received on a routine basis only; -[MEDICAL CONDITION] drug use triggered in Care Area A, and triggered as a Care Planning decision in Section V (CAA summary) of the MDS. Review of the resident's comprehensive care plan, dated 1/23/18, showed staff did not document any specific interventions regarding [MEDICAL CONDITION] drug use. 5. During an interview on 5/11/18 at 9:29 A.M., Licensed Practical Nurse (LPN) A said the Director of Nursing (DON) and the MDS coordinator work together to complete the care plans for new residents, and the DON updates the care plans. The LPN said the care plan directs the resident's care, and should be up to date/accurate. Interventions for falls, [MEDICAL CONDITION] drug use, weight loss, etc., should be documented on the care plans. Resident #26 and #31 should care plan interventions for their [MEDICAL CONDITION] meds. During an interview on 5/11/18 at 2:18 P.M., the Director of Nursing (DON), said he/she creates care plans within seven days after the final signature on the MDS. He/She used the Section V and CAA triggers from the MDS to complete the care plans. He/She said Resident #29's care plan was late because it just was not done. The DON said he/she would include interventions for [MEDICAL CONDITION] drugs on Resident #26's care plan only if he/she was having behavior issues. Resident #31 takes an Antianxiety med, but he/she would not expect any interventions for that on the care plan because the resident was not exhibiting any signs or symptoms of anxiety. However, interventions on what to look for if the meds quit working would be beneficial to have on the residents' care plans.

Based on observation, interview, and record review facility staff failed to update the plan of care with changes in the resident's needs for two residents (Resident #3 and #24) out of 12 sampled residents. The facility census was 34. 1. Review of the facility's policy on Comprehensive Care Plans, dated (MONTH) (YEAR), showed staff are directed: -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: a. When a significant change in the resident's condition has occurred; b. At least quarterly; c. When changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change in assessment). 2. Review of Resident #3's quarterly MDS (Minimum Data Set), dated 11/04/17, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and personal hygiene; -Frequently incontinent of urine and occasionally incontinent of bowel; -No falls; -No unhealed pressure ulcers; -No oxygen. Review of the resident's care plan, dated 12/24/17, showed the resident fell and hit his/her head. Further review showed staff did not add fall interventions or monitoring techniques to the care plan. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and personal hygiene; -Frequently incontinent of urine and occasionally incontinent of bowel; -One fall; -No unhealed pressure ulcers; -No oxygen. Review of the resident's physician orders, dated 04/01/18 to 04/30/18, showed direction for staff to use oxygen at 2 liters (L) PRN (as needed) for Dyspnea. Additional review showed the physician directed the staff to use [MEDICATION NAME] treatments (breathing treatment) four times a day PRN for 10 days for pneumonia. Review of the resident's annual care plan meeting notes, dated 05/10/18, showed staff documented the resident has a new [DIAGNOSES REDACTED]. Further review showed staff documented the resident started Keflex (antibiotic) on 03/19/18 for an inflamed tooth, started [MEDICATION NAME] (antibiotic) on 05/07/18 for pneumonia, had a chest x-ray on 05/07/18, and started [MEDICATION NAME] treatments on 05/08/18. Staff did not update the care plan with directives for staff to know when to administer the PRN oxygen or [MEDICATION NAME] treatments and did not list any monitoring techniques to ensure the treatments are effective. 3. Review of Resident #24's MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognition intact; -No falls. Review of the resident's care plan, last updated 1/19/18, showed staff documented the resident at risk for falls and are directed to do the following: -Provide supervision assistance with activities of daily living; -Keep bed in low position; -Keep call light secured in reach; -Keep environment free of clutter and belongings in reach; -Verbal cues to help remember safety precautions; -1/19/18 found on floor by bed sent to emergency room , sustained fracture of left tibia and fibula. Review of the resident's care plan meeting notes, dated 4/12/18, showed staff documented on 1/19/18 resident was found on the floor and sustained a fracture to the left tibia/fibula. Further review of the resident's care plan showed staff did not update the resident's care plan with interventions after the resident's fall with a fracture. During an interview on 5/11/18 at 2:18 P.M., the Director of Nursing (DON) said the DON updates the care plans with changes. The DON said he/she does not always update the care plan when staff have repeated falls but if there is a broken bone the care plan should be updated with interventions. The DON said the resident's care plan should have been updated with interventions after his/her fall and he/she is not sure why it was not updated. 4. During an interview on 05/10/18 at 2:11 P.M., CNA B said staff use the care plan information to know the residents' needs. He/She is unsure when care plans are updated. During an interview on 5/11/18 at 9:29 A.M., Licensed Practical Nurse (LPN) A said the Director of Nursing (DON) updates residents' care plans. The LPN said the care plan directs the resident's care, and should be up to date/accurate, so interventions for oxygen therapy, and fall prevention should be documented on the care plans. During an interview on 05/11/18 at 9:38 A.M., the MDS Coordinator said the DON completes the care plans. He/She said he/she prints out the Section V from the MDS and gives it to the DON to use as a reference for creating the care plans. He/She said staff and the DON are responsible for updating the care plans. He/She said he/she is unsure how they are updated. He/She said care plan updates should include directives to staff on how to provide a change in care. During an interview on 05/11/18 at 02:18 P.M., the DON said he/she and the MDS Coordinator create the care plans. He/She said comprehensive care plans should be done within seven days of the last signature on the MDS. He/She said he/she used the Section V (Care Area Assessment section of the MDS) triggers to complete the care plans. He/She said care plans are updated with all changes and he/she updates them all weekly with telephone orders and personal changes. He/She said he/she hand writes updates on the care plans and only creates new care plans with significant changes, or if the resident has been to the hospital and back. He/She does not usually update comprehensive care plans with annual assessments. He/She said if a new problem is identified on the care plan the update should include monitoring and interventions. He/She said he/she updates the care plans when a resident falls but only adds interventions with some falls. He/She said he/she does not add interventions with all falls with injury only the serious injuries. He/She said the resident's fall was listed on his/her care plan but no new interventions or monitoring were put in place. He/She said the resident has had some falls but not frequent and staff already uses sit to stand and encourages the resident to lie down as fall interventions. He/She said the oxygen use and [MEDICATION NAME] treatments should be listed on the resident's care plan and it should also list interventions and directives to staff.

Based on observation, interviews, and record review, facility staff failed to promote healing of a pressure ulcer, when they did not complete skin/wound assessments in a timely manner, did not adequately respond to a change in the resident's skin integrity, and did not notify the physician and obtain orders for a new treatment for one resident (Resident #31) with changes to an unhealed pressure ulcer. The Facility census was 34. 1. Review of the National Pressure Ulcer Advisory Panel, dated (MONTH) (YEAR), showed the following definitions: -Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED], changes in sensation, temperature, or firmness may precede visual changes; -Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which can be slimy, stringy, clumpy or [MEDICATION NAME] consistency and is usually light colored), and eschar (dead tissue that sheds or falls off from health skin, usually dark brown or black in color) are not present; -Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament cartilage or bone are not exposed; -Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Deep Tissue Pressure Injury (DTI) is an area of intact or non-intact skin with a localized area of persistent non-intact skin and/or with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3, or stage 4 pressure injury). 2. Review of the facility's policy on Care and Prevention of Pressure Ulcers, dated (MONTH) (YEAR), showed staff are directed the treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the physician, and for implementing measures to prevent pressure ulcers. 3. Review of the facility's policy on Wound Care and Treatment, dated (MONTH) (YEAR), showed staff are directed: -Perform ongoing skin assessment with weekly documentation of status; -Cleanse all wounds with standard cleanser; -Use protective barrier wipe to wipe peri-wound area (area surrounding the wound) of intact skin. 4. Review of Resident #31's physician's orders [REDACTED]. Further review showed the resident had [DIAGNOSES REDACTED]. Review of the resident's Braden Scale (a tool used to assess a resident's risk of developing a pressure ulcer) dated 1/3/18, showed staff assessed the resident with a score of 19, which indicated he/she was not at risk for pressure ulcers. Review of the resident's records showed staff documented the following on the skin assessments: -1/3/18: Left heel, callused (a hard formation of tissue, especially new tissue formed over a wound) area with dark center; -1/5/18: Skin prep to left heel, heelbos (device to protect the elbow or heel from abrasion and promotes healing of pressure ulcers) on while in bed; -1/12/18: Skin prep to left heel, lower extremities (legs/feet) on pillow to avoid pressure to heels. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Limited assist of one person with bed mobility, transfer, locomotion on unit, dressing, toilet, and hygiene; -Uses a walker and wheelchair for mobility; -Not at risk for developing pressure ulcers, -No unhealed pressure ulcers; -Did not receive any applications of dressings to feet (with or without topical medications). Review of the resident's nurses' notes, dated 3/8/18, showed staff documented they identified a 0.5 cm open area to the resident's left heel, inspected his/her shoe, and noticed a raised area on his/her heel where the shoe insert met the foot. Staff documented they obtained a new order to cleanse left heel, apply hydrogel (dressing for wounds), [MEDICATION NAME] (specialized gauze pad), 4 X 4 gauze, and tape. Review of the resident's wound report, dated 3/8/18, showed staff assessed the wound as unstageable, measured 0.5 cm X 0.5 cm, no depth, light serous drainage (thin, clear fluid), 100 percent slough, and firm/well defined wound edges. Review of the resident's nurses' notes, dated 3/12/18, showed staff documented they notified the physician and resident representative, and the resident representative said he/she has had trouble with the resident's heel off and on. Staff did not notify the resident representative until four days after the resident developed an unstageable pressure ulcer to his/her heel. Review of the records showed the Podiatrist (a specialized foot doctor) assessed the resident on 3/22/18 with a [DIAGNOSES REDACTED]. He/She directed staff to examine the resident's feet nightly, and avoid being barefoot or tight-fitting shoes. Review of the resident's records showed staff did not document a skin assessment on 3/23/18, 3/30/18, and 4/6/18, and did not document a wound assessment for the week of 4/1/18 through 4/7/18. Review of the resident's nurses' notes showed staff documented on 4/10/18: Wound to left heel assessed by Director of Nursing (DON), treatment order changed to skin prep twice daily, wear shoe on left foot for therapy only. Review of the resident's care plan, updated 4/10/18, showed staff are directed: -Please report any reddened areas to the charge nurse for further evaluation and treatment as needed; -Pay special attention to feet because of nerve damage from Diabetes, and may not feel pain from sore areas; -The wound on the resident's left heel was healed, continue to use skin prep to the area to keep the callus toughened. Review of the resident's records showed staff did not document a skin assessment on 4/13/18. Staff assessed the resident on 4/14/18, with a Braden Scale score of 19, which indicated he/she was not at risk for pressure ulcers. Further review showed staff did not document a skin assessment on 4/27/18. Observation and interview on 5/09/18 at 10:29 A.M., showed the resident sat in a recliner in his/her room, with a blue heel boot to his/her left foot. The resident said the insert/sole in his/her shoes rubbed him/her wrong and developed a sore to his/her left foot. He/She did not know if the sore was healing or not. Observation and interview on 5/10/18 at 2:38 P.M., showed the resident in a recliner in his/her room. Further observation of his/her left heel showed an opened circular area approximately 0.5 cm X 0.5 cm, surrounded by dried, flaky skin. The resident said he/she could not wear shoes until his/her heel was completely healed, and it hurts in that one little spot. Certified Medication Technician (CMT) C said the nurse performs a treatment to the area in the evenings. During an interview on 5/11/18 at 10:32 A.M., the DON said the resident's wound was healed. Observation and interview on 5/11/18 at 10:34 A.M., showed the resident sat in a wheelchair in his/her room. Observation showed an uncovered, open area to his/her left heel that measured approximately 0.5 cm X 0.5 cm, with visible slough, surrounded by dried flaky skin. Licensed Practical Nurse (LPN) A said the area was opened just a little bit, with slough in the center, and no redness. The resident said it hurts a little when touched in that one spot. Observation showed the LPN applied skin prep to the entire wound bed and surrounding tissue. The LPN said he/she always applied the skin prep to the open area and around it. The LPN said if staff notices an open area, he/she is expected to notify the DON for assessment, and the nurse or DON will notify the physician for a treatment if needed. He/She did not measure the wound today because he/she measured it the day before as 0.2 cm X 0.2 cm X 0.1 cm. He/She said the charge nurse is responsible to notify the family, and document in the nurse's notes. The resident had a previous treatment with hydrogel that was stopped on 4/10/18. The LPN said the nurse is expected to do skin assessments weekly, and the DON assesses wounds once a week. Staff did not notify the physician, and did not obtain and provide an appropriate treatment to a previously identified open wound. During an interview on 5/11/18 at 11:03 A.M., the DON said he/she expects the night shift nurse to complete residents' skin assessments weekly. Once the nurse notifies him/her of a wound, he/she assesses the wound weekly, and must have just missed the resident's wound assessment for the first week of April. The last time he/she assessed the resident's wound was on 4/10/18, and it was healed. The DON said he/she expects staff to look at the wound and assess it when they perform the treatment, notify him/her immediately if they notice a new open area, document approximate measurements in the nurses notes/report book, and he/she will obtain official measurements after. The DON said he/she monitors for completion of skin assessments, and did not know why staff did not document skin assessments on 2/9, 2/16, 3/23, 3/30, 4/6, 4/13, and 4/27. During an interview on 5/11/18 at 1:56 P.M., Certified Nursing Assistant (CNA) D said he/she was not sure if the resident still had an open wound to his/her left foot, but the resident still complains of pain and soreness to that foot. During an interview on 5/11/18 at 2:03 P.M., LPN A said he/she would not normally measure the resident's heel if it was not open, but the previous evening, the resident's heel looked like the very center was opened so he/she measured the area. The LPN said he/she did not document his/her findings in the nurses notes, and did not notify the physician, or the oncoming nurse, but said he/she probably should have. The LPN said he/she notified the DON earlier that morning, prior to doing the treatment at 10:34 A.M., that he/she thought the resident's wound was opened. The LPN said he/she should have notified the physician for a new treatment order. During an interview on 5/11/18 at 3:07 P.M., the DON said staff did not notify him/her that the resident had an open area. The DON said he/she expects staff to notify the physician for a treatment if needed. He/She did not expect staff to apply skin prep to an open wound because that would hurt the resident, and said in April, the resident had an unstageable wound that was healed.

Based on observation, interview and record review, facility staff failed to provide oxygen therapy at the accurate flow rate for one sampled resident (Resident #3), who had a current respiratory infection. Staff also failed to store oxygen/nebulizer mask/tubing, clean oxygen concentrator(s), and use distilled water in humidifiers in a manner to prevent infection-causing contaminants for two residents (Resident #3 and #33), out of 12 sampled residents. The facility census was 34. 1. Review of the facility's Oxygen Administration Policy, dated (MONTH) (YEAR), showed staff are directed to: -Fill humidifiers with sterile, distilled water (used to prevent mineral dust from being expelled and invade the lungs), or de-ionized water; -Set the oxygen flow meter to the rate ordered by the physician; -Label the humidifier with the date and time opened; -Change the humidifier and tubing per cleaning guidelines; -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and assess resident's respiration to determine further need for oxygen therapy; -Place cannula tubing in plastic bag when not in use; -Check resident's respiration and observe at regular intervals to assess need for further oxygen therapy after oxygen has been discontinued. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 2/4/18, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and personal hygiene; -No oxygen. Review of the resident's physician orders, dated 4/1/18 to 4/30/18, showed staff are directed to provide oxygen at 2 liters (L) as needed (PRN) for Dyspnea (shortness of breath). Additional review showed the physician directed staff to use [MEDICATION NAME] treatments (inhaled medication) four times a day PRN for 10 days for pneumonia (an infection that inflames the air sacs in one or both lungs). Review of the resident's annual care plan meeting notes, dated 5/10/18, showed staff documented the resident has a new [DIAGNOSES REDACTED]. Further review showed staff documented the resident started Keflex (antibiotic) on 3/19/18 for an inflamed tooth, started [MEDICATION NAME] (antibiotic) on 5/7/18 for pneumonia, had a chest x-ray on 5/7/18, and started [MEDICATION NAME] treatments on 5/8/18. Staff did not update the care plan with direction for staff to know when to administer the PRN oxygen or [MEDICATION NAME] treatments and did not list any monitoring techniques to ensure the treatments are effective. Observation on 5/9/18 at 9:32 A.M., showed the resident in his/her wheelchair with the oxygen cannula in place but the tubing on the floor unlabeled and undated. Observation on 5/10/18 at 9:50 A.M., during the group interview, showed the resident's face turned red as he/she coughed and appeared to struggle for air . Further observation showed the resident's portable oxygen tank dial read empty. Observation on 5/10/18 at 12:03 P.M., showed the resident not in his/her room. Further observation showed the resident's oxygen cannula on the floor and the tubing unlabeled/undated. Observation and interview on 5/10/18 at 12:44 P.M., showed the resident in his/her wheelchair in his/her room. He/She had the oxygen cannula in place and continued to cough. Further observation showed the oxygen tubing on the floor unlabeled/undated. Additional observation showed the oxygen set to deliver 3 liters per minute. The resident said staff change his/her oxygen tubing and cannula every two weeks. He/She said he/she is unsure if staff use distilled water for the oxygen concentrator (medical device used to deliver oxygen) humidifier. Observation and interview on 5/10/18 at 3:48 P.M., showed the resident in his/her wheelchair and visited with family. He/She had the oxygen cannula in place. Further observation showed the oxygen concentrator turned off. The resident said he/she believed the oxygen concentrator was on. He/She said, why would it be turned off when I need it? During an interview on 05/10/18 at 01:25 P.M., Certified Medication Technician (CMT) C said the night shift charge nurse changes oxygen tubing on the 10th and 25th of each month. He/She said staff does not use distilled water for the concentrators and he/she does not know why. 3. Review of Resident #33's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, had a [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 4/27/18, showed staff documented the resident suffers from [MEDICAL CONDITION]/Asthma, with progressive lung disease, and directed staff: -Resident is at risk for respiratory complications; -Administer supplemental oxygen at night for comfort. Review of the resident's physician's orders [REDACTED]. Observation on 5/09/18 at 9:30 A.M., showed an oxygen concentrator at the bedside, with a build up of white debris particularly where the humidifier bottle rests. Further observation showed a nebulizer machine (device to deliver inhaled medication into the lungs) on the nightstand, and the attached undated mask/tubing laid on the nightstand. Observation and interview on 5/09/18 at 11:10 A.M., showed the resident in bed, and received oxygen via the nasal cannula, connected to the concentrator. The concentrator contained a build up of white debris near the humidifier bottle. The resident's family member said he/she has been requiring more oxygen lately. Further observation showed the resident's wheelchair next to the bed, with a portable oxygen tank on the back, an attached nasal cannula dated 4/25/18, and the prongs of the cannula rested directly on the chair. Observation on 5/9/18 at 11:51 A.M., showed the resident in bed and received oxygen via the nasal cannula, connected to the concentrator, which continued to contain a build of white debris. Observation on 5/10/18 at 1:36 P.M., showed the resident in bed with an undated nasal cannula attached to his/her face, connected to the concentrator, which continued to contain a build up of white debris. Observation showed the resident with an unproductive cough. Staff did not store the resident's oxygen tubing/nebulizer mask/tubing in a manner to prevent infection, and did not clean the oxygen concentrator as needed to prevent the risks of infection causing contaminants. 4. During an interview on 5/11/18 at 9:29 A.M., Licensed Practical Nurse (LPN) A said staff are directed to change oxygen/nebulizer masks and tubings twice a month on 10th and 25th, but staff do not officially document that anywhere. He/She said staff are expected to label the tubing with the date after they change it. Staff are expected to store the tubing in a plastic bag when not in use. If staff find a tubing on the floor they should change it, and if they find a tubing on the wheelchair itself, they should place it in a bag. The LPN said staff are expected to administer oxygen based on the physician's orders [REDACTED]. During an interview on 5/11/18 at 2:13 P.M., LPN A said staff are expected to use tap water to fill the humidifier bottles. He/She was not sure if cost was a factor or what the specific reason was why staff are not directed to use distilled water. During an interview on 5/11/18 at 2:18 P.M., the DON said Resident #3's oxygen use and [MEDICATION NAME] treatments should be listed on the resident's care plan and it should also list interventions and directives to staff. He/She said staff should know to administer oxygen or a [MEDICATION NAME] treatment if the resident has shortness of breath or low oxygen saturations due to the pneumonia. He/She said nurses should check oxygen saturation each shift to ensure the oxygen is being administered at the correct liters. He/She said he/she is unsure why Resident #3 received three liters yesterday when the POS said two liters. He/She said staff should look at the tank gauge to make sure a portable tank has oxygen before using it. He/She said if the tank gauge reads low or is in the red zone, staff should get a new tank but he/she said staff usually let it run all the way down. He/She said staff should check flow of a portable tank if a resident is having trouble breathing. He/she said he/she usually requests the physician orders [REDACTED]. He/She said humidified oxygen should be checked every night for all residents with concentrators. He/She said they do not follow their policy regarding using distilled water for oxygen concentrator humidifiers. He/She said staff use tap water out of the hot side for the oxygen concentrator humidifier because they have a water softener system. He/She said the night shift charge nurse changes the oxygen tubing on the 10th and 25th of each month. He/She said staff does not document when they change the tubing and no one monitors to make sure it is done. He/She said tubing should be stored in a plastic bag when not in use. He/She said staff should label and date the oxygen tubing. He/She said if staff see undated, soiled, or tubing lie on an unclean surface it should be changed. He/She said staff should clean the concentrator if obviously dirty, and since the nurse checks nightly, he/she should notice if the concentrator needs to be cleaned.

Based on interview and record review, the facility failed to offer pneumococcal immunizations to two residents (Resident #5 and #10) out of 15 sampled residents, as directed by facility policy. The facility census was 41. Review of the facility's Immunizations policy, dated May 2015 showed the Pneumococcal Immunization is recommended for resident [AGE] years and older. A repeat dose after six years may be given to those at highest risk. 1. Review of Resident #3's record showed the record did not contain documentation the resident received or declined the pneumococcal vaccine. During an interview on 04/06/17 at 6:16 A.M., the DON said the facility did not have documentation of a pneumonia vaccination for the resident. The DON said she did not know if staff offered the vaccine to the resident. 2. Review of Resident #5's record showed the record did not contain documentation the resident received or declined the pneumococcal vaccine. During an interview on 04/05/17 at 5:55 A.M., the Director of Nursing (DON) said the facility did not have documentation of a pneumonia vaccination for the resident. Additionally, the DON said she was not sure if staff offered the vaccine. 3. Review of Resident #10's record showed the record did not contain documentation the resident received or declined the pneumococcal vaccine. During an interview on 04/06/17 at 5:55 A.M., the DON said the resident was admitted from the hospital and the was no record of the pneumonia vaccine. During an interview on 04/06/17 at 9:15 A.M., the DON said she is responsible for finding out dates of previous vaccines. The DON said she was not sure if staff attempted to obtain dates but she does not expect them to try to get the information. Additionally, the DON said she was not sure why the vaccinations were not done. During an interview on 04/06/17 at 10:10 A.M., the Administrator said he expects staff to try to determine if the residents wants or needs the vaccine. During an interview on 04/06/17 at 10:15 A.M., the QA nurse said vaccination consents should be obtained on admission and facility staff are to obtain a physician's orders [REDACTED].

Based on observation, interview and record review, facility staff failed to store resident's oxygen nasal cannulas and masks in an appropriate manner, to prevent the spread of infection, when not in use. The facility census was 41. 1. Review of the facility's Cleaning Guidelines-Oxygen Equipment and Nebulizers/Continuous Aerosol, dated March 2015, showed: -Oxygen equipment will be cleaned to ensure safety in handling and administering oxygen; -Disposable oxygen equipment will be discarded after each patient/resident use; -Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and PRN, and marked with date and initials; -All oxygen equipment (cannulas, tubing, masks, etc.) are changed every seven days when heated humidification is used and monthly when unheated humidification is used; -Store circuit in plastic bag marked with date and resident name between uses. 2. Observation on 04/04/17 at 10:15 A.M., showed resident occupied room [ROOM NUMBER] contained oxygen tubing and a nasal cannula on an overbed table, uncovered. 3. Observation on 04/04/17 at 10:15 A.M., showed resident occupied room [ROOM NUMBER] contained nebulizer and tubing unbagged on the resident's bed. 4. Observation on 04/04/17 at 10:20 A.M., showed resident occupied room [ROOM NUMBER] contained oxygen tubing, a nasal cannula and a humidifier bottle on the floor, uncovered. Further observation showed a plastic bag attached to the oxygen concentrator, however, staff did not place the equipment in the bag as their policy directs. 5. Observation on 04/04/17 at 1:46 P.M., showed resident occupied room [ROOM NUMBER] contained oxygen tubing and a nasal cannula unbagged on the back of a wheelchair. 6. Observation on 04/04/17 at 2:05 P.M., showed resident occupied room [ROOM NUMBER] contained oxygen tubing and a nasal cannula unbagged on the back of the wheelchair. 7. Observation on 04/05/17 at 1:46 P.M., showed resident occupied room [ROOM NUMBER] contained oxygen tubing and a nasal cannula unbagged on the floor. During an interview on 04/06/17 at 9:15 A.M., the Director of Nursing (DON) said oxygen and Nebulizers tubing and humidifier bottles should be changed out two times per month. Additionally, the DON said all tubing, masks and mouthpieces should be kept in bags when not in use. The DON said the bags are accessible to staff. The DON said charge nurses do not document if they check for plastic bags. During an interview on 04/06/17 at 9:24 A.M., LPN D said all oxygen tubing and nebulizers should be stored in bags in rooms and on wheelchairs. Tubing is changed on the 10th and 25th of each month on the night shift or when needed. LPN D expects staff to notify him/her when they need to be changed and place in bags when not in use. During an interview on 04/06/17 at 10:10 A.M., CNA E said oxygen tubing in rooms and on wheelchairs should be stored in bags when not in use. CNA E reports to the charge nurse when the oxygen tubing in on the floor so it can be changed. CNA E said when doing resident care he/she will check on all tubing. CNA E said the med techs are responsible for the nebulizers and notifies them when they are not bagged or contaminated. During an interview on 04/06/17 at 10:10 A.M., the Administrator said oxygen tubing should be stored so the tubing is not touching the floor and causing a hazard for residents. Additionally, the Administrator said he would prefer the tubing or masks not be placed on the resident's overbed tables.

Based on interview and record review, facility staff failed to follow the facility's abuse and neglect policy following an allegation of verbal abuse as reported to the facility staff by one resident (Resident # 15). The facility failed to direct staff to notify the Department of Health and Senior Services (DHSS) within two hours of alleged or actual abuse and/or significant resident injury. The facility census was 42. 1. Review of the facility's Response and Reporting Guidelines for Abuse and Neglect policy, dated January 2017, showed the following: -Any and all cases of alleged resident neglect, abuse/ exploitation or mistreatment including injuries of unknown source and misappropriation of resident property by facility employees should be reported immediately; -If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made. 2. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/15/17, showed a Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive impairment) score of 9 (9-12 points= moderately impaired) Review of the resident's nurse notes, dated 3/30/17 at 1:29 P.M., showed staff documented the resident reported to Practical Nurse (LPN B) that Certified Nursing Assistant (CNA A) is mean and sneaky. The resident reported that CNA A mumbled at her, threw her clothes down and slammed the door. Review of the Facility Investigation Report, dated 3/31/17, showed the Director of Nursing (DON) documented LPN B reported on 3/30/17 at 1:45 P.M. CNA A verbally abused Resident #15. Additional review showed the facility investigation report did not contain documentation that the facility staff reported the allegation of verbal abuse to the state licensing agency in a two hour time frame. During an telephone interview on 3/31/17 at 12:17 P.M. LPN B said he/she had called the DON on 3/30/17 at 1:42 P.M. and reported CNA A had verbally abused Resident #15. During an interview on 3/31/17 at 1:10 P.M., the DON said LPN B reported the allegation of verbal abuse on 3/30/17 at 1:49 P.M. The DON said she reported the alleged verbal abuse to the state agency at 4:00 P.M. The DON said she did not report the allegation of verbal abuse within the time frame because she was in a corporate meeting.

Based on observation, record review and interview, the facility failed to prepare and serve food in accordance with the nutritionally calculated recipes and menus for two of two residents (Residents #12 and #13) with pureed diets. The facility census was 42. 1. Review of Resident #12's physician order [REDACTED]. 2. Review of Resident #13's POS, dated May 2016, showed the resident ' s physician instructed the facility to provide the resident with a pureed diet with pudding thickened liquids. 3. Review of the facility menus, dated 05/03/16, showed staff instructed to provide the following food items and portion sizes to residents with pureed diets: -A #8 (four ounce) scoop of pureed fried chicken; -Two ounces of gravy; -Four ounces of mashed potatoes and gravy; -A #16 (two ounce) scoop of pureed seasoned carrots; -A #16 scoop of pureed dinner roll; -A #12 (2.6 ounce) scoop of pureed spiced peaches. 4. Review of the facility maintained standardized recipe binder, showed the binder did not contain a recipe for pureed fried chicken. Further review showed a recipe for pureed baked chicken which instructed the staff to combine three ounces of ground chicken with two tablespoons of chicken stock and 3/4 teaspoon of food thickener to prepare one serving. Review also showed the recipe instructed staff to reheat the pureed chicken after processing to 165 degrees Fahrenheit (°F) or higher before service. 5. Observation on 05/03/16 at 10:40 A.M., showed the Dietary Manager (DM) deboned three prepared chicken breast and gave the deboned chicken to Cook A. Observation showed the cook ground the unmeasured chicken in the food processor, placed an unmeasured amount of the ground chicken into a small bowl and then placed the contents of the bowl into a pan on the steamtable. The cook returned to the food processor, added an unmeasured amount of prepared chicken gravy and processed the items. The cook removed the pureed chicken from the food processor and placed it directly into a pan on the steamtable for service. Additional observation showed the temperature of the pureed chicken measured 96°F when placed on the steamtable. Observation on 05/03/16 at 10:55 A.M., showed Cook A deboned one prepared chicken breast and placed the unmeasured chicken into the food processor. The cook added an unmeasured amount of prepared chicken gravy and processed the items. The cook removed the pureed chicken from the food processor and added it to the pan of previously prepared pureed chicken on the steamtable for service. 6. Review of the recipe for pureed carrots, showed staff instructed to combine 1/2 cup of carrots with 1.5 teaspoons of thickener (as needed) to prepare one serving. Further review showed the recipe instructed staff to reheat the pureed carrots to 165°F or higher before service. Observation on 05/03/16 at 10:50 A.M., showed Cook A placed two four ounce ladles of prepared carrots into the food processor and processed. The cook removed the pureed carrots from the food processor and placed them directly into a pan on the steamtable for service. Observation showed the temperature of the pureed carrots measured 108°F when placed on the steamtable. 7. Observation on 05/03/16 during the noon meal service, beginning at 11:00 A.M., showed Cook B served Resident #12 and Resident #13 the following items: -a #8 scoop of the unreheated pureed chicken; -two ounces of gravy; -four ounces of mashed potatoes with two ounces of gravy on top; -a #16 scoop of the unreheated pureed seasoned carrots; -a #12 scoop of pureed spiced peaches. Observation showed the cook did not serve the pureed bread as directed by the menus. 8. During an interview on 05/03/16 at 11:45 A.M., the DM said the cooks are responsible for preparing all the pureed food items. The DM said he/she expects staff to prepare foods in accordance with the recipes and to serve foods in accordance with the menus. The DM said staff should reheat pureed food items to 165°F before placing them on the steamtable for service. 9. During an interview on 05/03/16 at 11:48 A.M., Cook A said the cooks are responsible for preparing all the pureed food items. Cook A said the cooks are instructed to review the recipes for how to prepare all foods, but he/she did not review the recipes for the noon meal. Cook A said he/she did not prepare the pureed bread because he/she added the bread when preparing the pureed chicken. The cook said he/she did not reheat the pureed food items prior to service because he/she forgot.

Based on observation, interview and record review the facility failed to prevent the development of facility acquired pressure ulcers for three residents (Resident #5, #7, and #9) of 11 sampled residents. The facility census was 43. Review of the facility's Wound Care Protocol for Arterial Ulcers, dated 2001, showed arterial insufficiency is usually diagnosed with [REDACTED]. (normal range 1.0-1.2) 1. Review of Resident #7's Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/4/10, showed staff assessed the resident as follows: - Requires extensive assistance by one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene; - Limited range of motion on one side; - [MEDICAL CONDITION]; - Pain occasionally; - Surgical wound. Review of the resident's comprehensive care plan, dated 10/5/10, showed staff are directed to prevent skin breakdown due to decreased mobility related to a [MEDICAL CONDITION]: - Needs limited assistance by one staff member with bed mobility; - Complete skin assessment during showers; - Provide treatment to left heel per physician's orders [REDACTED]. Review of the resident's Admission Nursing Assessment, dated 9/22/10, showed the resident did not have any open areas, redness, abrasions or discolorations on his/her lower legs or feet. Review of the resident's Weekly Skin Assessments, dated 10/17/10, showed staff documented the resident had a black area on his/her left heel. Review of the resident's Physician order [REDACTED]. heel and change every three days and as needed. Review of the resident's Weekly Wound Report showed staff documented the following information: -10/25/10 showed staff documented the "arterial" ulcer measured 4.5 cm. x 3.3 cm. Further, the area was dark and discolored. Staff documented, "patient with a left [MEDICAL CONDITION] causing decreased mobility to left lower leg." -11/8/10 showed staff documented the "arterial" ulcer measured 3.0 cm. x 2.5 cm. Further, an antibiotic related to a foul odor in the wound bed. Staff documented, "patient with a left [MEDICAL CONDITION] causing decreased mobility to left lower leg." Staff documented "the current treatment applied as an enzymatic debridement agent and a calcium alginate dressing daily." -11/15/10 showed staff documented the "arterial" ulcer measured 2.5 cm. x 2.5 cm. x 0.2 cm. Further, the antibiotic therapy was completed. Staff documented the current treatment applied as "enzymatic debridement agent and a calcium alginate dressing daily." -11/29/10 showed staff documented the "arterial" ulcer measured 2.5 cm. x 2.0 cm. x 0.2 cm. Further, the antibiotic therapy was restarted for a wound infection due to odor. Staff documented the treatment as "enzymatic debridement agent and a calcium alginate dressing daily." -12/13/10 showed staff documented the "arterial" ulcer measured 2.0 cm. x 1.6 cm. x 0.2 cm. Further, the antibiotic therapy was completed. Staff documented the current treatment remained the same. -1/10/11 showed staff documented the "arterial" ulcer measured 1.5 cm.. x 1.3 cm. x 0.2. Staff documented the current treatment remained the same. Observation on 1/25/11 at 12:45 P.M., showed Licensed Practical Nurse (LPN) K provided ulcer care to the resident's left heel. The left heel ulcer was located on the back of the heel. The ulcer was open and approximately measured 1.5 cm. x 1.5 cm. x 0.2 cm. with a yellow callous surrounding the ulcer. LPN K applied hydrogel and a calcium alginate ([MEDICATION NAME] and moisturizing agents) secured it with gauze. During an interview at that time, LPN K said the resident's left heel "wound" was "acquired in the facility." During an interview on 1/26/11 at 2:20 P.M., the Director of Nurses (DON) said she determined the "wound" for the resident was "arterial" by the facility's Wound Care Protocol for Arterial Ulcers. The DON said the resident did not have a doppler study or an Ankle Brachial Index (tests that indicate decreased circulation and used to determine [MEDICAL CONDITION]) while in the facility. The DON said even though the resident is assessed with [REDACTED]. The DON said even though the MDS assessed the resident as requiring extensive assistance with bed mobility, the resident is able to reposition him/herself in bed. The DON said, therefore staff did not use plan care that included heel protectors. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: - Short and long term memory loss; - Requires extensive assistance with transfers, dressing and personal hygiene; - Frequently incontinent of bladder; - Other fracture; - [MEDICAL CONDITION]; - At risk of development of pressure ulcers; - Ulcer care; - Application of a dressing to the feet; - One venous or arterial (caused by poor circulation) ulcer. Review of the resident's comprehensive care plan, dated 8/4/10, showed staff are directed to do the following interventions in the prevention of skin breakdown due to decreased mobility: - Assist provided by one-two staff with bed mobility; - Complete the skin assessment during showers; - Assist to turn routinely to relieve pressure points; - Provide a treatment as ordered; - Report to physician any new skin problems that may develop. Review of the resident's Admission Nursing Assessment, dated 7/17/10, showed the resident did not have any open areas, redness, abrasions or discolorations on the lower legs or feet. Review of the resident's nurses notes, dated 7/27/10, showed staff documented that a "dark area was found" on the resident's right heel. Review showed the nurses' note did not include any measurements. Staff documented the physician directed staff to provide an Unna boot and change every three days. Further, review of the nurses notes showed staff did not document [MEDICAL CONDITION] (swelling that can indicate circulatory problems) or abnormal peripheral pulses (pulses to the lower legs that can indicated circulatory problems). Review of the resident's Weekly Wound Report showed staff documented the following information: -8/2/10 showed the facility acquired, right heel ulcer measured 5.0 cm. (centimeters) x 2.0 cm. Further, review showed the staff identified the resident's ulcer as "arterial." Staff measured the resident's right heel ulcer on 7/27/10 were 5.0 cm. x 5.0 cm. -8/9/10 showed staff documented the "arterial" ulcer as a "dark area" that measured 5.0 cm. x 4.0 cm. and "deteriorated." Staff continued to apply the Unna boot and change every three days per orders received on 7/27/10. -8/16/10 showed staff documented the resident's "arterial" ulcer as a "dark area" that measured 4.0 cm x 4.0 cm. Staff continued to apply the Unna boot and change every three days per orders received on 7/27/10. -8/23/10 showed staff documented the "arterial" ulcer as a "dark area" that measured 4.0 cm. x 4.0 cm. Staff continued to apply the Unna boot and change every three days per orders received on 7/27/10. -8/30/10 showed staff documented the "arterial" ulcer as a "dark area" that measured 4.0 cm. x 3.0 cm. Staff continued to apply the Unna boot and change every three days per orders received on 7/27/10. -9/27/10 showed staff documented the "arterial" ulcer measured 3.0 cm. x 2.0 cm. x 0.1 cm. Further, review showed staff documented a small amount of slough (dead) tissue with faint, foul odor. Staff documented the current treatment applied as an enzymatic debridement agent (used to remove dead tissue) and a calcium alginate (dressing used for drainage) dressing daily. -9/27/10 showed staff documented the "arterial" ulcer measured 2.5 cm. x 2.0 cm. x 0.1 cm. Further, review showed staff documented the physician ordered an antibiotic for a "wound infection." Staff documented the current treatment applied as "enzymatic debridement agent (used to remove dead tissue) and a calcium alginate (used for drainage) dressing daily. -10/11/10 showed staff documented the unchanged, "arterial" ulcer measured 2.5 cm. x 1.5 cm. x 0.2 cm. Further, review showed staff documented the antibiotic as "completed for the wound infection and continues to have slough tissue in the wound bed." Staff documented the current treatment remained the same. -11/15/10 showed staff documented the "arterial" ulcer measured 2.0 cm. x 1.0 cm. x 0.2 cm. Staff documented the current treatment applied as an enzymatic debridement agent (used to remove dead tissue) and a calcium alginate (used for drainage) dressing daily. -12/13/10 showed staff documented the "arterial" ulcer measured 1.8 cm. x 0.4 cm. x 0.2 cm. Staff documented the current treatment applied as hydrogel (provides moist environment for healing) with a [MEDICATION NAME] (nonstick) dressing daily. Observation on 1/25/11 at 12:30 P.M., showed LPN K provided care to the resident's right heel ulcer (located at the back of the heel, an area known to bear the weight of the foot when the resident is in bed). LPN K removed the old dressing and applied hydrogel and a non-stick dressing. LPN K then wrapped the resident's right foot in gauze to secure the dressing. Observation at this time showed the resident's right heel ulcer measured approximately 0.7 cm. x 0.5 cm. x 0.2 cm. During an interview at this time, LPN K said the resident's right heel "wound" was "acquired in the facility." During an interview on 1/26/11 at 2:20 P.M., the DON said she determined the resident's right heel "wound" was "an arterial ulcer" by using the facility's "Wound Care Protocol for Arterial Ulcers." The DON said the resident has not had a doppler study or an Ankle Brachial Index (tests that indicate decreased circulation and used to determine [MEDICAL CONDITION]). 5. Review of Resident #9's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: - Requires limited assistance by one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene; - Indwelling catheter; - At risk for developing a pressure ulcer. Review of the resident's comprehensive care plan, dated 12/3/09, directed staff on interventions to prevent skin breakdown due to decreased mobility as follows: - Assist to turn and reposition routinely to prevent pressure points; - Limited assistance by one staff member with bed mobility; - Provide treatment as ordered to stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) coccyx "wound" (dated 1/20/11); - Monitor for signs and symptoms of infection and inform physician as needed; - Perform weekly skin assessments. Review of the resident's POS showed on 1/20/11 the physician directed staff to apply hydrogel to the wound bed and cover with a non-stick dressing daily and as needed until healed. Review of the resident's Wound Report, dated 1/24/11, showed staff documented the resident's coccyx ulcer measured 1.0 cm. x 1.0 cm. Further, staff documented the wound as "caused from pressure" and as "facility acquired." Observation on 1/25/11 at 6:15 A.M., showed the resident in his/her bed and Certified Nurse Assistant (CNA) E provided perineal cleansing. Further, observation showed the resident had a dressing on his/her coccyx. CNA E said he/she did not know if the resident had any skin breakdown or open areas. Observation on 1/25/11 at 9:40 A.M., showed the LPN K removed the dressing on the resident's coccyx which showed a stage II pressure that measured approximately 1.0 cm. x 1.0 cm. with red tissue surrounding the ulcer. During an interview on 1/25/11 at 9:40 AM, LPN K said staff first assessed the resident's coccyx "wound" on 1/20/11. LPN K said the resident's "wound" is "facility acquired."