Every finding on record at Camelot Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure residents with orders for psychotropic (medication used to treat mental health conditions by affecting mood, behavior, thoughts and perception) medications were informed about the medication before its use for two residents (Residents #5 and #12) out of five sampled residents. The facility's census was 74.Review of the facility's policy titled, Psychotropic Management, reviewed 07/26/23, showed:- A psychotropic drug is any drug that affects brain activities associated with mental health processes and behavior;- Upon admission, the Licensed Nurse will implement physician order for medication including an approved diagnosis or targeted behavior;- A Psychotropic Medication Consent from resident and/or resident's responsible party;- Complete psychoactive medication review on admission, quarterly, annually, and as needed;- Implement Standardized Behavior Tracking Monitoring Tool. 1. Review of Resident #5's medical record showed:- admitted on [DATE];- Diagnoses of anxiety and depression;Physician's Order Sheet (POS), dated, 02/25/26, showed an order for buspirone (an anti-anxiety medication) five milligrams (mg), one tablet by mouth three times daily for anxiety, dated 09/22/25;- No documentation the resident and/or the representative was informed of risks and benefits of buspirone. 2. Review of Resident #12's medical record showed:- admitted on [DATE];- Diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings);POS, dated 02/25/26, showed:- An order for buspirone, five mg, one tablet by mouth every 12 hours for anxiety, dated 10/09/25;- An order for quetiapine (a drug that affects the brain activities associated with mental processes and behavior), 300 mg by mouth at bedtime for bipolar and depression, dated 12/30/25;- An order for sertraline (an antidepressant), 50 mg by mouth once a day for bipolar and depression, dated 10/09/25;- No documentation the resident or the representative was informed of risks and benefits of buspirone, sertraline, or quetiapine.During an interview on 02/25/26 at 4:30 P.M., the Administrator, Regional Nurse Consultant, Regional Director of Operations, and the Traveling Director of Nursing said they would expect residents and/or residents' representatives to be informed in advance of risks and benefits of proposed care, treatments, treatment alternatives and be able to choose a different option if preferred.

Based on interview and record review, the facility failed to inform of and provide a free basic haircut for two residents (Residents #14 and #75) out of four sampled Medicaid residents. This had the potential to affect all Medicaid residents. The facility's census was 74. Review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed:- 13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate, but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following:(K) All routine care items, including disposables and including, but not limited to, those items specified in Appendix A to this rule;- Appendix A showed the following items covered under the per diem rate for Medicaid residents:- Hair Care, Basic (including washing, cuts, sets, brushes, combs, non-legend shampoo).Review of the Appendix A in the facility's admission Packet, provided to all new residents and resident representatives, showed:- The items and services listed below are not included in the basic daily rate, and are not covered by the Medicare and Medicaid/Managed Medicaid Programs: Hairdresser, Barber;- The form did not include information regarding a free basic haircut available to residents who received Medicaid funding.Review of the price list of services posted on the door of the facility's salon showed:Beard trim $5;Hair cut $15;Hair style $15;Perm $35;All over color $35;Highlights $45;The salon price list did not include information regarding a free basic haircut available to residents who received Medicaid funding.1. Review of the facility's Resident Trust Box Log showed:- On 04/26/25, Resident #14 was charged for a haircut.- On 04/26/25, Resident #75 was charged for a haircut.During an interview on 02/25/26 at 11:50 A.M., Resident #14 said no one told him/her that he/she could get a free basic haircut. He/She would really like that because it would save him/her $15.During an interview on 02/25/26 at 1:18 P.M., Resident #75 said no one told him/her about a basic haircut. That would be great because the residents didn't get much money each month and a haircut was $15. He/She thought he/she had gotten three of them. He/She would have liked to know if the facility offered a free haircut. During an interview on 02/25/26 at 9:59 A.M., the Business Office Manager said they did not provide free basic haircuts or trims, but the nursing assistants would shave and trim resident beards. During an interview on 02/25/26 at 10:54 A.M., the Administrator said if a resident couldn't afford a haircut, the facility would pay the beautician to provide a haircut for them. During an interview on 02/25/26 at 4:30 P.M., the Administrator, Director of Operations, Regional Nurse Consultant, and the Traveling Director of Nursing said that they would expect Medicaid residents to be informed the Medicaid per diem covered the expense of basic haircuts.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #8 and #10) out of 18 sampled residents. The facility census was 74.The facility did not provide a policy regarding MDS coding for accuracy.Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services;- H0300: Code 9, not rated: if during the seven-day look-back period the resident had an indwelling bladder catheter (a flexible tube inserted into the bladder to continuously drain urine into an external bag) for the entire seven days.1. Review of Resident #8's medical record showed:- admission date of 06/22/22;- Diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), and pulmonary fibrosis (a chronic, progressive lung disease where the tissue deep within the lungs becomes scarred, thickened, and stiff);- Resident admitted to hospice on 07/07/25. Review of the resident's MDS assessments showed:- A significant change MDS assessment, dated 07/18/25, with Section J1400 (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?) coded no;- A quarterly MDS assessment, dated 10/15/25, with Section J1400 (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?) coded no.2. Review of Resident #10's medical record showed:- admission date of 12/11/25;- Diagnoses of chronic obstructive respiratory disease (COPD - lung and airway diseases that restrict breathing), respiratory failure, and obstructive and reflux uropathy (a blockage in the urinary tract preventing proper urine flow and causing backflow).Review of the resident's Physician's Order Sheet (POS), dated 02/24/26, showed:- An order for catheter care, dated 12/12/25;- An order to change the catheter bag every month and as needed starting on the 11th and ending on the 13th, dated 12/12/25 and discontinued 01/11/26;- An order to change the catheter bag every month and as needed every night shift starting on the 11th and ended on the 13th, dated 01/11/26 and discontinued 01/11/26;- An order to change the catheter bag every month and as needed every night shift every Sunday for catheter maintenance, dated 02/12/26;- An order to record the amount of output from the catheter every shift, dated 12/12/25.Review of the resident's significant change MDS assessment, dated 01/09/26, showed:- H0100A marked yes for indwelling catheter;- H0300 marked always incontinent. During an interview on 02/25/26 at 4:45 P.M., the MDS Coordinator said Section J1400 should be checked yes if someone is on hospice. Section H0300 should be marked not rated if the resident had the catheter for the seven-day lookback period. During an interview on 02/25/26 at 4:30 P.M., the Administrator and Traveling Director of Nursing said they would expect an MDS assessment for a resident on hospice to have section J1400 to be marked yes and they would expect H0300 to be marked not rated for a resident with a catheter.

Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Residents #6, #10, and #62) and failed to obtain orders for three residents (Residents #10, #15, and #62) out of 18 sampled residents. The facility's census was 74.Review of the facility's policy, Physician's Orders, reviewed 09/28/22, showed: - Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, and Physician's Assistants) authorized to prescribe orders; - Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; - Physician orders must be documented clearly in the medical record; - Physician orders that are missing required components, are illegible or unclear must be clarified before implementation; - Physician Order Sheets (POS) will be maintained with current Physician orders as new orders are received. Discontinued orders will be marked discontinued with the date, and all new orders will be written in the appropriate area on the POS with the date the order was received; - Physician orders will be transcribed to the appropriate Administration Record; Medication Administration (MAR) or Treatment Administration Record (TAR); - Pharmacist monthly review of the physician's orders will be completed to assure appropriateness, accuracy, and completeness. 1. Review of Resident #6's medical record showed: - admission date of 03/03/25; - Diagnosis of neuromuscular dysfunction of bladder (bladder does not work properly because of a nerve or muscle problem). Review of the resident's POS, dated 02/25/26, showed an order to record the amount of output from the catheter (a flexible, hollow tube inserted into the bladder to drain urine) every shift, monitoring for signs and symptoms of infection every shift for urine output, start date 03/03/25. Review of the resident's TAR, dated January 2026, showed: - Eight opportunities missed out of 31 opportunities for day shift on 01/06/26, 01/08/26, 01/13/26, 01/15/26, 01/22/26, 01/23/26, 01/27/26, and 01/30/26; - 13 opportunities missed out of 31 opportunities for night shift on 01/02/26, 01/03/26, 01/04/26, 01/12/26, 01/15/26, 01/16/26, 01/17/26, 01/21/26, 01/22/26, 01/25/26, 01/26/26, 01/28/26, and 01/30/26. Review of the resident's TAR, dated 02/01/26 through 02/23/26, showed: - Four opportunities missed out of 23 opportunities for day shift on 02/08/26, 02/15/26, 02/19/26, and 02/21/26; - Nine opportunities missed out of 23 opportunities for night shift on 02/01/26, 02/02/26, 02/05/26, 02/09/26, 02/12/26, 02/13/26, 02/14/26, 02/20/26, and 02/23/26. 2. Review of Resident #10's medical record showed: - admission date of 12/11/25; - Diagnosis of obstructive and reflux uropathy (a blockage in the urinary tract preventing proper urine flow and causing backflow). Review of the resident's POS, dated 02/24/26, showed: - An order for catheter care, dated 12/12/25; - An order to change the catheter bag every month and as needed starting on the 11th and ending on the 13th, dated 12/12/25 and discontinued 01/11/26; - An order to change the catheter bag every month and as needed every night shift starting on the 11th and ended on the 13th, dated 01/11/26 and discontinued 01/11/26; - An order to change the catheter bag every month and as needed every night shift every Sunday for catheter maintenance, dated 02/12/26; - An order to record the amount of output from the catheter every shift, dated 12/12/25; - No orders for the catheter, type and size, or when to flush or change the catheter. Observation on 02/23/26 at 9:23 A.M. showed the resident lay in bed with a Foley (a type of catheter) catheter drainage bag in a privacy bag. Review of the resident's TAR, dated December 2025, showed: - Five opportunities missed out of 31 opportunities for day shift on 12/14/25, 12/17/25, 12/20/25, 12/24/25, and 12/30/25; - Eight opportunities missed out of 31 opportunities for night shift on 12/14/25, 12/17/25, 12/18/25, 12/23/25, 12/24/25, 12/26/25, 12/27/25, and 12/28/25. Review of the resident's TAR, dated January 2026, showed: - One opportunity missed out of 31 opportunities for day shift on 01/12/26; - Seven opportunities missed out of 31 opportunities for night shift on 01/01/26, 01/04/26, 01/07/26, 01/08/26, 01/11/26, 01/24/26, and 01/31/26. Review of the resident's TAR, dated 02/01/26 through 02/24/26, showed: - One opportunity missed out of 24 opportunities for day shift on 02/03/26; - Four opportunities missed out of 24 opportunities for night shift on 02/01/26, 02/06/26, 02/07/26, and 02/08/26. 3. Review of Resident #15's medical record showed: - admission date of 01/31/26; - Diagnosis of dependency on renal dialysis (process of purifying the blood of a person whose kidneys aren't working normally), end stage renal disease (ESRD - irreversible loss of kidney function, where the kidneys can no longer support life), bladder-neck obstruction (a blockage at the base of the bladder where it connects to the urethra (tube that carries urine from the bladder to the outside of the body) and prevents it from opening properly during urination). Review of the resident's POS, dated 02/24/26, showed: - An order to change the catheter bag monthly, dated 01/31/26; - An order to obtain catheter output each shift, dated 01/31/26; - No orders for the catheter, type and size, catheter care, or when to flush or change the catheter. 4. Review of Resident #62's medical record showed: - An admission date of 12/05/24; - Diagnoses of atrial fibrillation (an irregular heart rhythm that begins in your heart's upper chambers), septic arterial embolism (a vascular obstruction caused by an infected clot originating from a distant infection), and muscle wasting and atrophy (the loss or thinning of muscle tissue). Review of the resident's POS, dated 02/23/26, showed: - An order to obtain daily weights, start date 01/21/26; - An order for daily weights, dated 02/11/26; - An order to refer for a peripherally inserted central catheter (PICC line - a long, thin tube that's inserted through a vein in the arm) placement, dated 02/03/26; - An order for normal saline 75 milliliters (ml) per hour for one liter one time for dehydration, dated 02/03/26; - An order for ceftriaxone solution (antibiotic) two grams (gm) intravenously (IV - the delivery of fluids, medication, or blood directly into a vein) every 24 hours, dated 02/04/26; - An order for vancomycin (antibiotic) 1000 milligrams (mg) intravenously two times a day for septic splenic emboli (infected clot) for four weeks, dated 02/03/26 and ending on 03/03/26; - An order for vancomycin 750 mg intravenously two times a day for septic splenic emboli for four weeks, dated 02/09/26 and ending on 03/09/26; - No order for IV or IV flushes; - No order for PICC line, dressing changes, or flushes. Review of the resident's weights, dated 01/20/26 through 02/23/26, showed: - Daily weights not obtained on 01/22/26, 01/23/26, 01/24/26, 01/25/26, 01/29/26, 02/01/26, 02/02/26, 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/13/26, 02/17/26, 02/18/26, 02/20/26, 02/21/26, 02/22/26, and 02/23/26; - 23 missed opportunities out of 35 opportunities to obtain the resident's daily weight. Review of the resident's progress notes, dated 02/04/26 through 02/23/26, showed: - On 02/04/26 at 3:44 A.M., resident had a PICC line placed on 02/04/26. Had IV line in right upper arm, flushed with normal saline (NS) and heparin with no resistance noted; - On 02/04/26 at 2:21 P.M., nurse discontinued resident's peripheral catheter on the resident's right forearm per nurse practitioner order; - On 02/06/26 at 4:51 A.M., resident continued antibiotics vancomycin and ceftriaxone for splenic septic emboli. PICC line dressing intact and flushed easily; - On 02/07/26 at 4:52 A.M., had single lumen (tube) PICC line, dressing dry and intact to right upper arm, with no redness or drainage noted. Flushed before and after infusion; - On 02/08/26 at 4:06 A.M., had single lumen PICC line, dressing dry and intact to right upper arm, with no redness or drainage noted. Flushed before and after infusion; - On 02/09/26 at 3:34 A.M., had single lumen PICC line, dressing dry and intact to right upper arm, with no redness or drainage noted. Flushed before and after infusion; - On 02/17/26 at 1:55 A.M., had single lumen PICC line, dressing dry and intact to right upper arm, with no redness or drainage noted. Flushed before and after infusion; - On 02/18/26 at 4:01 A.M., had single lumen PICC line, dressing dry and intact to right upper arm, with no redness or drainage noted. Flushed before and after infusion; - On 02/21/26 at 2:17 A.M., evening dose of vancomycin was administered via single lumen PICC line, dressing dry and intact with no redness or drainage noted. No adverse reaction noted. Flushed before and after infusion; - On 02/22/26 at 3:06 A.M., evening dose of vancomycin was administered via single lumen PICC line, dressing dry and intact with no redness or drainage noted. No adverse reaction noted. Flushed before and after infusion; - On 02/23/26 at 1:22 A.M., evening dose of vancomycin was administered via single lumen PICC line, dressing dry and intact with no redness or drainage noted. No adverse reaction noted. Flushed before and after infusion. Observations of the resident showed: - On 02/23/26 at 1:02 P.M., the resident with a single lumen PICC line to the right arm with a clear dressing dated 02/13/26; - On 02/24/26 at 11:50 A.M., the resident with a PICC line to the right arm with a clear dressing dated 02/23/26. During an interview on 02/23/26 at 2:05 P.M., Registered Nurse (RN) C and Licensed Practical Nurse (LPN) D said the resident went out to the hospital in December and had his/her gallbladder removed on 12/31/25 and came back to the facility on [DATE]. The resident had the IV from the hospital. He/She only had a PICC line put in while here, not an IV. The resident got a peripheral IV from the hospital because of contrast from a procedure he/she had, then he/she got a liter of fluids here at the facility. Then we discontinued the peripheral IV. Just a few days later, they sent him/her for PICC line placement. During an interview on 02/25/26 at 2:36 P.M., LPN B said residents that had Foley catheters should have a flush order, the size of the catheter, how often to change the catheter, and an order to change the catheter as needed (PRN) and a diagnosis. Catheter care should be documented in the electronic medication administration record (eMAR) under the nurse MAR, and both Certified Nurse Aides (CNAs) and nurses did catheter care. Daily weights were documented by the nurse or restorative aide and were located on the TAR. During an interview on 02/25/26 at 4:10 P.M., RN C said there should be orders for the PICC line, and for flushes, dressing changes, and medication administration. He/She put an order in when he/she changed the dressing, but he/she said staff had been changing the dressing without an order. During an interview on 02/25/26 at 4:30 P.M., the Administrator, Director of Operations, Regional Nurse Consultant, and the Traveling Director of Nursing said they would expect physician orders to be followed. They would expect orders to be in the chart for a catheter, when to change, the size of the balloon, intake and output, and catheter care. They would also expect catheter care to be reflected on the TAR. They would expect a PICC line to have orders, including dressing changes and flushes, and they would expect daily weights to be documented in the resident's chart if they were ordered for daily weights.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent the development and transmission of infections when staff did not utilize appropriate Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and Enhanced Barrier Precautions (EBP - an infection control strategy used in nursing homes requiring staff to use gloves and gowns during high-contact activities). The facility also failed to properly handle potentially contaminated sharps, failed to sanitize a glucometer (a small, portable device used to measure the sugar level in blood) per manufacturer's directions, and failed to perform hand hygiene during medication administration and at appropriate times during resident care. This affected three residents (Resident #3, #34, and #62) out of 18 sampled residents and two residents (Resident #9 and #42) outside the sample. The facility census was 74.Review of the facility's policy titled, Enhanced Barrier Precautions, reviewed 05/15/24, showed: - The facility may expand the use of PPE and refer to the use of gowns and gloves during high-contact resident care activities that provides opportunities for transfer of multi-drug resistant organisms (MDROs) to hands and clothing; - The use of gowns and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for facility residents with wounds or indwelling medical devices regardless of MRDO colonization; - Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, wound care that requires a dressing or device care such as urinary catheters. Review of the facility's policy titled, Hand Hygiene policy, reviewed 04/28/22, showed: - Hand hygiene should be performed before and after providing care; - Before and after performing an aseptic (practices such as hand hygiene, sterilization and barrier use, to prevent the transfer of harmful microorganisms) task; - Contact with blood, body fluids, or contaminated surfaces; - Before and after applying/removing gloves; - After handling soiled linens/items; - Employees may use an alcohol-based hand rub when hands are not visibly soiled. Review of the facility's policy titled, Catheter Care, reviewed 07/13/22, showed: - Gather supplies; - Identify resident and explain procedure; - Provide privacy; - Perform hand hygiene and apply gloves; - Avoid pulling on catheter during cleansing; - Remove gloves and perform hand hygiene; - Apply gloves and reposition resident's clothing/bedding; - Discard contaminated items in designated containers; - Remove gloves and perform hand hygiene. Review of the facility's policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed: - Hands are washed before putting on examination gloves and upon removal for administration of topical (on the skin), ophthalmic (in the eye), injectable, enteral (in the gastrointestinal tract), rectal, and vaginal medications. Review of the facility's policy titled, Blood Glucose Monitoring, undated, showed: - Blood glucose meters measure blood glucose (sugar) concentrations; - The Centers for Disease Control and Prevention (CDC) recommends that, whenever possible, blood glucose meters shouldn't be shared among patients. If a device must be shared, it should be cleaned and disinfected after every use, following the manufacturer's instructions to prevent carry over of blood and infectious agents. If the manufacturer doesn't specify how the device should be cleaned and disinfected, then it shouldn't be shared; - Implementation: verify the practitioner's orders, gather and prepare appropriate equipment, perform hand hygiene and put on gloves, confirm the patient's identity with at least two patient identifiers, provide privacy, explain the procedure, put on gloves, select puncture site, insert the test strip into the blood glucose meter, collect a sample from the fingertip, touch a drop of blood to the test strip, apply firm pressure to puncture site, discard the lancet in a puncture-resistant sharps container, remove the test strip and dispose of properly, remove and discard your gloves, and perform hand hygiene; clean and disinfect the blood glucose meter, following the manufacturer's instructions, perform hand hygiene, document and record, report critical test results to the practitioner. Review of Super Sani-Cloth Manufacturer's Guidelines for Use, on pdihc.com, showed: - Use a wipe to remove visible soil prior to disinfecting; - Unfold a clean wipe and thoroughly wet surface; - Allow treated surface to remain wet for two minutes, allow to air dry; - Do not reuse towelette. Dispose of used towelette in the trash. 1. Observation on 02/23/26 at 2:58 P.M., showed: - Resident #62 lay in bed and received a nebulizer (machine that converts liquid medication into a fine mist, allowing it to be inhaled into the lungs through a mouthpiece or mask) treatment; - Licensed Practical Nurse (LPN) D in the room with the resident without a gown or gloves; - Registered Nurse (RN) C entered the room without sanitizing or donning a gown or gloves, lay the supplies for antibiotic infusion on the resident's bedside table, knelt at the bedside, held the resident's right hand with his/her bare hand while obtaining a blood pressure reading, then held both of the resident's hands to warm them while attempting to obtain a pulse oximeter (device used to measure blood oxygen saturation) reading from the fingers on both hands; - The Nurse Practitioner (NP) entered the room without donning a gown or gloves, touched the resident's clothing and skin with both hands, and listened to the resident's lungs and heart; - The resident needed assistance with urination, so LPN D and the NP stepped out of the room, and RN C closed the resident's room door to assist the resident in private; - When the resident was finished, RN C opened the door, stepped out in the hall and sanitized his/her hands; - RN C reentered the room, did not don a gown or gloves, removed the pillowcases from the resident's three pillows, removed the urinal containing urine that hung on the side of the resident's trash can, and obtained the extra trash bag from the bottom of the trash can; - RN C, with bare hands, put the extra trash bag into the bag in use in the trash can along with the resident's three pillowcases and hooked the handle of the urinal containing urine back on the side of the trash can with his/her bare right hand and touched the resident's clothed right shoulder with his/her bare right hand while holding the trash bag in his/her left hand and exited the room; - RN C reentered the room, did not sanitize hands or don a gown or gloves, put three new pillowcases on the resident's pillows, touched the pillows and pillowcases to his/her clothing; - RN C touched the resident, obtained gloves from the supplies hanging on the resident's door, donned the gloves without sanitizing his/her hands, did not don a gown, and touched the resident's call light and bedside table with gloved hands; - The resident's roommate propelled him/herself in a wheelchair to the restroom and RN C touched the restroom doorknob, the roommate's wheelchair handles, and the restroom doorknob again; - RN C removed gloves, washed hands, donned clean gloves, touched the restroom doorknob and the roommate's wheelchair handles to back the roommate out of the restroom; - RN C removed gloves, washed hands, donned clean gloves, and did not don a gown; - RN C cleansed the port on the resident's peripherally inserted central catheter (PICC line – a long, thin, flexible tube inserted into a large upper arm vein and advanced toward the heart for long-term intravenous access) with an alcohol swab, flushed with 10 milliliters (ml) of normal saline, started antibiotic, threw trash away, and washed hands. During an interview on 02/25/26 at 4:00 P.M., RN C said none of the staff had gowns on when they were caring for Resident #62. They should wear a gown and gloves when a resident had a PICC line. He/She should wash/sanitize hands before and after care and in between glove changes. 2. Observation on 02/24/26 at 9:49 A.M., showed: - RN A obtained a medication from the medication room, crushed the medication in the pill pouch, and emptied the contents into a small cup; - RN A entered Resident #3's room, did not don a gown, and washed his/her hands; - RN A placed a syringe, graduated cylinder, and a cup on a paper towel barrier on top of the resident's night stand; - RN A donned gloves, opened the gastrostomy tube (g-tube - a tube that is surgically inserted through the wall of the abdomen directly into the stomach, and is used to deliver nutrition, fluids and medications) button, and checked placement by injecting air and listening with a stethoscope; - RN A administered medication to the resident via g-tube and flushed with water; - RN A closed the g-tube button, emptied the remaining water out of the cylinder, and lay the cylinder and syringe on the sink without a barrier; - RN A removed gloves and washed his/her hands. During an interview on 02/24/26 at 12:00 P.M., RN A said that he/she should wear a gown when administering medications to a resident with a g-tube. 3. Observations on 02/24/26 from 11:30 A.M. to 12:12 P.M., showed: - At 11:30 A.M., RN A gathered a glucometer, lancet, test strip, and alcohol wipe from the nurse cart and lay the supplies on top of his/her computer on top of the nurse cart without a barrier; - RN A entered Resident #9's room with the supplies and placed them on a paper towel barrier; - RN A washed his/her hands, donned gloves, and obtained the fingerstick blood glucose reading; - RN A removed gloves, carried the used lancet in his/her bare hand to the nurse cart, and placed in the sharps container; - RN A wiped the glucometer with a purple top Sani Cloth wipe and did not wrap the glucometer to properly sanitize; - At 11:39 A.M., RN A gathered the same glucometer, lancet, test strip and alcohol wipe from the nurse cart and lay the supplies on top of the nurse cart without a barrier; - RN A entered Resident #42's room with the supplies and placed them on a paper towel barrier; - RN A washed hands, donned gloves, and obtained the fingerstick blood glucose reading; - RN A removed gloves, carried the used lancet in his/her bare hand to the nurse cart, and placed in the sharps container; - RN A wiped the glucometer with a purple top Sani Cloth wipe and did not wrap the glucometer to properly sanitize; - At 12:12 P.M., RN A entered Resident #62's room, did not sanitize or wash hands, donned gloves, and placed a sublingual (under the tongue) medication into the resident's mouth; - RN A removed gloves and washed hands. During an interview on 02/24/26 at 12:15 P.M., RN A said he/she should wear gloves when touching used lancets. He/She just wiped the glucometer off with a Sani-wipe to sanitize it. 4. Observation on 02/24/26 at 1:47 P.M. of Resident #34's suprapubic catheter (a thin, flexible tube inserted through a small incision in lower abdomen, directly into the bladder to drain urine) care showed: - LPN B entered the resident's room, washed hands, donned gloves, and did not don a gown; - LPN B adjusted the resident's wheelchair and foot pedals, moved the bed over, and pulled the curtain; - With the same gloves, LPN B pulled the resident's pants away from the catheter site, and touched the tubing as the resident sat in the wheelchair; - LPN B removed gloves, sanitized hands, donned clean gloves, and flushed the catheter with sterile water; - LPN B soaked gauze in cleanser, cleaned around the catheter site, secured tubing to a leg clamp, removed gloves, sanitized hands, donned clean gloves, cleaned around the catheter tubing and down a few inches, applied a split gauze around the catheter site, removed gloves, and did not sanitize hands; - LPN B donned clean gloves, placed trash in the trash can, adjusted the bed and wheelchair foot pedals, removed gloves and did not perform hand hygiene before leaving the room; - LPN B took the trash bag of soiled towels to the soiled utility and washed hands. During an interview on 02/24/26 at 2:10 P.M., LPN B said he/she forgot to put on a gown and it had just slipped his/her mind. A gown should have been worn because the resident had a catheter. He/She should have sanitized and changed gloves after touching objects in the room and before touching the catheter site. 5. Observation on 02/24/26 at 3:30 P.M., showed: - RN A entered Resident 62's room with antibiotic infusion supplies, obtained gloves, and set the gloves and supplies on the counter by the sink as he/she washed his/her hands; - RN A picked up the gloves and supplies from the counter, sat them on the resident's bedside table, and exited the room to get flushes from the medication cart; - RN A reentered the room, set the flushes on the bedside table with the other supplies, did not perform hand hygiene and donned gloves; - RN A swabbed the port with an alcohol swab, hooked up the antibiotic infusion, removed his/her gloves, and washed hands. During an interview on 02/24/26 at 3:39 P.M., RN A said he/she forgot to wear a gown. Staff should wear a gown with anyone with tubes and open areas. He/She normally washed his/her hands before and after, but he/she should have washed his/her hands after getting supplies from the cart and before putting on new gloves. During an interview on 02/25/26 at 4:30 P.M., the Administrator, Regional Director of Operations, Regional Nurse Consultant, and the Traveling Director of Nursing said they would expect staff to wear the proper PPE for EBP, which was gowns and gloves, when dealing with direct care of residents with wounds, catheters, and indwelling intravenous catheters. Staff should perform hand hygiene before donning gloves, before resident care, when going from dirty to clean care, and after care. They would expect staff to wear gloves when handling used lancets and that glucometers should be sanitized per manufacturer's recommendations.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent when medications were administered. There were 28 opportunities with three medication errors made, for an error rate of 10.7%. Out of six residents observed, this affected two residents (Resident #1 and #47) out of 16 sampled residents and one resident (Resident #10) outside the sample. The facility's census was 64. Review of the facility's policy titled, Specific Medication Administration Procedures/Injectable Medication Administration, revised September 2018, showed: - Pen Devices: dial dose as instructed and prime pen needle per manufacturer guidelines. Review of NovoLog Flex Pen (insulin in a pen-type device) instructions showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button and make sure drop of insulin appears; - Select dose; - Give injection; - After dose counter reaches zero, count to six; - After injection, remove needle and place in sharps container. Review of Fiasp Flextouch Pen instructions showed: - Check your insulin type; - Attach a new needle; - Prime your pen, turn the dose selector to select two units; - Press and hold the dose button until the counter shows zero and a drop of insulin appears; - Select your dose; - Give injection; - After the dose counter reaches zero, slowly count to six; - Remove the needle and place in a sharps container; - Replace the pen cap. 1. Observation on 10/23/24 at 11:00 A.M. showed: - Licensed Practical Nurse (LPN) A obtained the finger stick blood sugar (FSBS) for Resident #1; - LPN A obtained the Novolog Flex Pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN A did not prime the pen with two units of insulin per the manufacturer's directions prior to administering insulin to the resident. 2. Observation on 10/23/24 at 11:05 A.M. showed: - LPN A obtained the FSBS for Resident #47; - LPN A obtained the Novolog Flex Pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN A did not prime the pen with two units of insulin per the manufacturer's directions prior to administering insulin to the resident. 3. Observation on 10/23/24 at 11:10 A.M. showed: - LPN A obtained the FSBS for Resident #10; - LPN A obtained the Fiasp Flextouch Pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN A did not prime the pen with two units of insulin per manufacturer's directions prior to administering insulin to the resident. During an interview on 10/23/24 at 11:15 A.M., LPN A said he/she never primes the insulin pens, but guessed he/she should start. During an interview on 10/25/24 at 1:20 P.M., the Administrator and Director of Nursing (DON) said they would expect insulin pens to be primed before administering the prescribed dose.

Based on observation, interview, and record review, the facility failed to label medication in a safe and effective manner. This affected one resident (Resident #10) outside of the 16 sampled residents. The facility's census was 64. Review of the facility's policy titled, Medication Storage in the Facility/Storage of Medications, revised November 2018, showed: - Certain medications or package types, such as IV solution, multiple dose injectable vials, opthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of the manufacturer's recommendations for Fiasp Flextouch insulin pen showed the medication is to be discarded after eight weeks of being opened. 1. Observation on 10/23/24 at 11:10 A.M. of the nurse's medication cart on A Hall showed: - Resident #10's opened and undated Fiasp FlexTouch insulin pen (insulin in a pen-type device); - Licensed Practical Nurse (LPN) A gave Resident #10 a dose of insulin from the undated pen. During an interview on 10/23/24 at 11:10 A.M., LPN A said pens should be dated when opened. This one was probably just opened this morning. Whoever opens the pen should date them. During an interview on 10/25/24 at 1:20 P.M., the Administrator and Director of Nursing (DON) said they would expect insulin pens to be dated when opened.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames for seven residents (Resident #6, #34, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. Review of the RAI Manual showed: - For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the Admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than 13 days after the Entry Date (A1600); - For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). 1. Review of Resident #6's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 05/12/22; - A comprehensive annual MDS assessment with a completion date of 05/22/23; - No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment. 2. Review of Resident #34's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 09/21/23, and MDS completion date of 09/21/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. 3. Review of Resident #50's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 07/22/22; - A comprehensive annual MDS assessment with a completion date of 07/28/23; - No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment. 4. Review of Resident #58's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 05/16/23, and MDS completion date of 05/16/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. 5. Review of Resident #61's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 06/01/23, and MDS completion date of 06/01/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. 6. Review of Resident #65's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 06/30/23, and MDS completion date of 06/30/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. 7. Review of Resident #68's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 09/25/23, and MDS completion date of 09/25/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. During an interview on 10/20/23 at 03:23 P.M., the MDS Coordinator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual. During an interview on 10/20/23 at 4:15 P.M., the Administrator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for six residents (Resident #7, #8, #44, #47, #61, and #63) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. Review of the Resident Assessment Instrument (RAI) Manual showed: - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment (Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment) + 92 calendar days); - The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 07/14/22; - A quarterly MDS assessment with a completion date of 10/17/22; - A quarterly MDS assessment with a completion date of 01/20/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment; - A quarterly MDS assessment with a completion date of 04/19/23; - A quarterly MDS assessment with a completion date of 07/26/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 2. Review of Resident #8's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 02/22/23; - A quarterly MDS assessment with a completion date of 06/07/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 3. Review of Resident #44's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 02/08/23; - A quarterly MDS assessment with a completion date of 06/02/23; - A quarterly MDS assessment with a completion date of 09/07/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 4. Review of Resident #47's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 02/22/23; - A quarterly MDS assessment with a completion date of 06/13/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 5. Review of Resident #61's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 12/01/22; - A quarterly MDS assessment with a completion date of 03/14/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment; - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 06/01/23; - A quarterly MDS assessment with a completion date of 09/06/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 6. Review of Resident #63's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 04/26/23; - A quarterly MDS assessment with a completion date of 09/13/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. During an interview on 10/20/23 at 03:23 P.M., the MDS Coordinator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual. During an interview on 10/20/23 at 4:15 P.M., the Administrator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual.

Based on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS- a federally mandated assessment) for three residents (Resident #7, #16, and #44) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, MDS 3.0, revised 04/26/23, showed: - MDS assessments will be completed per the 3.0 Resident Assessment Instrument (RAI) User's Manual guidelines. 1. Review of Resident #7's Medical Record showed: - admitted on [DATE]; - Physician's Order Sheets, dated September 2023 and October 2023, showed no orders for parenteral/interavenous (IV) feeding or feeding tube; - Diagnoses included Alzheimer's Disease (progressive mental deterioration), muscle weakness, cerebral infarction (stroke), anxiety (persistent worry and fear about everyday situations) and congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs). Review of Resident #7's significant change MDS, dated [DATE], showed: -Section K, K0510 marked for parenteral/IV feeding while a resident, as well as feeding tube while a resident. During an interview on 10/19/23 at 9:12 A.M., LPN A said he/she was not aware of a time that Resident #7 ever had IV feeding or a feeding tube. 2. Review of Resident #16's July 2023 Medication Administration Record, showed: - Resident did not receive an anticoagulant (a blood thinner which can reduce coagulation of blood, prolonging the clotting time) medication. Review of the resident's weight log record showed: - Weight of 127 pounds (lbs) on 01/10/23; - Weight of 127.4 lbs on 02/14/23; - Weight of 131.8 lbs on 07/05/23; - Weight of 137.6 lbs on 08/11/23; - Record did not show a weight loss. Review of the resident's quarterly MDS, dated [DATE], showed: - Section N, N0410 marked seven for the number of days that an anticoagulant was received in the seven day lookback period; - Section K, K0300 marked for a weight loss of 5% in one month or 10% in 6 months; - The resident's MDS did not reflect an accurate assessment of the resident. During an interview on 10/17/23 at 12:10 P.M., the resident said he/she had not had a weight loss and had not been on a blood thinner. 3. Review of Resident #44's medical record showed: - admitted [DATE]; - Diagnosis of type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar); - An order for Ozempic (a non-insulin medication used to improve blood sugar levels in people with type 2 diabetes) - An order summary report that showed no current or discontinued insulin orders. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 08/06/23, with N0350 marked one for the number of days that insulin injections were received in the seven day lookback period; - A quarterly MDS assessment, dated 09/18/23, with N0350 marked one for the number of days that insulin injections were received in the seven day lookback period; - The resident's MDS did not reflect an accurate assessment of the resident. During an interview on 10/20/23 at 03:23 P.M., the MDS Coordinator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual. During an interview on 10/20/23 at 4:15 P.M., the Administrator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual. 46460 47678

Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of side rails prior to installation or use. The facility also failed to care plan specific monitoring and supervision provided during the use of the bed rails and to obtain informed consent for use of the side rails prior to use for 11 residents (Residents #6, #7, #8, #27, #44, #47, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such are going to the bathroom or retrieving something from a closet. The facility failed to provide a policy regarding side rails or trapeze. 1. Review of Resident #6's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: - Moderately impaired cognition; - Independent for bed mobility; - Assist of one staff for transfers; - Diagnoses of traumatic subarachnoid hemorrhage (bleeding around the brain caused by injury), repeated falls, abnormalities of gait and mobility, muscle weakness, major depressive disorder (disorder that causes a persistent feeling of sadness or loss of interest), diabetes mellitus (elevated levels of sugar in the blood), high blood pressure, schizoaffective disorder-bipolar type (mental illness that can affect thoughts, mood, and behavior), and anxiety (a feeling of fear, dread, and uneasiness). Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observations of the resident showed: - On [DATE] at 12:42 P.M., resident laid in bed with a grab bar on the right side of bed; - On [DATE] at 08:26 A.M., resident laid in bed with a grab bar on the right side of bed. During an interview on [DATE] at 12:42 P.M., the resident said he/she uses the grab bar to sit up on the side of the bed. 2. Review of Resident #7's significant change MDS, dated [DATE], showed: - Severely impaired cognition ; - Assist of two staff for bed mobility; - Assist of two staff for transfers; - Diagnoses of Alzheimer's disease (progressive mental deterioration), muscle weakness, cerebral infarction (stroke), anxiety and congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs). Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rail interventions not addressed on care plan. Observations showed: - On [DATE] at 2:15 P.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 3:48 P.M., resident laid in bed with grab bar on the right side of bed. 3. Review of Resident #8's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist with one staff for bed mobility; - Limited assist of one staff for transfers; - Diagnoses of stroke, history of falling, muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observations of the resident showed: - On [DATE] at 12:12 P.M., resident laid in bed with grab bar on the right side of the bed; - On [DATE] at 08:45 A.M., resident laid in bed with grab bar on the right side of the bed. 4. Review of Resident #27's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent for bed mobility; - Assist of one staff for transfers; - Diagnoses of chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing problems), heart failure, diabetes mellitus, end stage renal disease (medical condition in which a person's kidneys stop functioning), anxiety, high blood pressure, major depressive disorder, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observation of the resident showed on [DATE] at 12:01 P.M., resident laid in bed with a grab bar on the left side of bed. During an interview on [DATE] at 12:01 P.M., the resident said he/she uses the grab bar for a boost to sit up on the side of the bed and doesn't really need it. 5. Review of Resident 44's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for bed mobility; - Limited assist of one staff for transfers; - Diagnoses of muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, pain in left hip and left knee, and need for assistance with personal care. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observation of the resident showed on [DATE] at 01:00 P.M., resident laid in bed with grab bar on the left side of bed. 6. Review of Resident 47's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for bed mobility; - Limited assist of one staff for transfers; - Diagnoses of muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, pain in left hip and left knee, and need for assistance with personal care. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observations of the resident showed: - On [DATE] at 12:53 P.M., resident laid in bed with grab bar on the left side of bed; - On [DATE] at 02:41 P.M., resident laid in bed with grab bar on the left side of bed. 7. Review of Resident #50's quarterly MDS, dated [DATE], showed: - Cognitively intact ; - Assist of two staff for bed mobility; - Assist of one staff for transfers; - Diagnoses included COPD, morbid obesity, anxiety disorder, major depressive disorder, and CHF. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observations showed: - On [DATE] at 1:49 P.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 8:44 A.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 10:22 A.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 3:17 P.M., resident laid in bed with grab bar on the right side of bed. During an interview on [DATE] at 3:19 P.M., the resident said he/she uses the grab bar to reposition in bed and sit upright in bed. 8. Review of Resident #58's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Assist of one staff for bed mobility; - Assist of one staff for transfers; - Diagnoses of diabetes mellitus, depression, muscle weakness, and reduced mobility. Review of the resident's medical record showed: - No documentation of quarterly side rail assessments; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observation of the resident showed on [DATE] at 10:41 A.M., resident laid in bed with a grab bar on the left side of bed. During an interview on [DATE] at 10:41 A.M., the resident said he/she uses the grab bar to reposition in bed. 9. Review of Resident #61's quarterly MDS, dated [DATE], showed; - Cognitively intact; - Impaired vision; - Impaired mobility with two person moderate assistance for transfers; - Diagnoses of hypertension, peripheral vascular disease, renal failure, obstructive uropathy (blockage of urinary pathway making urinating difficult), multidrug-resistant organism, diabetes mellitus (elevation of sugars in the blood), hemiplegia (paralysis of one side of the body), and depression. Review of the resident's medical record showed: - No documentation of quarterly side rails or trapeze assessments; - No documentation of informed consent for the use of side rails or trapeze; - Side rails and trapeze not addressed in care plan. Observations of the resident showed: - On [DATE] at 02:12 P.M., resident in bed with trapeze above head and quarter rail on the right upper side of bed; - On [DATE] at 02:30 P.M., resident transferred to bed per staff and resident instructed to use trapeze and right upper side rail to move over in bed; - On [DATE] at 02:32 P.M., resident pulled on trapeze to lift himself/herself into middle of bed. He/she pulled on the right upper side rail to roll over in bed; - On [DATE] at 08:40 A.M., resident in bed with trapeze above bed and right upper side rail in place. 10. Review of Resident #65's admission MDS, dated [DATE], showed: - Cognitively intact; - Impaired vision; - Independent for bed mobility; - Supervision or touching assistance for transfers; - Diagnoses of atrial fibrillation (abnormal heart beat), heart failure, falls, orthostatic hypotension (low blood pressure when moving positions), stroke, depression, and COPD. Review of the resident's medical record showed: - No documentation of quarterly trapeze assessments; - No documentation of informed consent for the use of trapeze; - Trapeze not addressed in care plan. Observations of the resident showed: - On [DATE] 01:21 P.M., resident in bed with gait belt on and trapeze in place; - On [DATE] 01:43 P.M., resident in bed with trapeze in place; - On [DATE] 08:20 A.M., resident in bed with trapeze in place; - On [DATE] 09:17 A.M., resident in bed with trapeze in place. 11. Review of Resident #68's admission MDS, dated [DATE], showed: - Cognitively intact; - Assist of two staff for bed mobility; - Assist of two staff for transfers; - Diagnoses included Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), peripheral vascular disease, non-pressure chronic ulcer to the left foot, muscle weakness, reduced mobility and history of repeated falls. Review of the resident's medical record showed: - Safety device evaluation, dated [DATE], showed no device present, in use or indicated; - No documentation of informed consent for the use of the side rails; - Side rails not addressed on care plans. Observations of the resident showed: - On [DATE] at 4:00 P.M., resident laid in bed with grab bars on the left and right side of the bed; - On [DATE] at 9:45 A.M., resident laid in bed with grab bars on the left and right side of the bed. During an interview on [DATE] at 9:47 A.M., the resident said he/she uses the bars to help reposition, as well as assist with positioning when staff provide care. During an interview on [DATE] at 10:43 A.M., the Administrator said side rail/enabler bar assessments have not been done as they should be and they are in the process of making an audit tool to correct this, but it has not been initiated at this time. 46460 47678 49152

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for 11 residents with side rails (Residents #6, #7, #8, #27, #44, #47, #50, #58, #61, #65, and #68) out of 18 sampled residents. The facility's census was 72. Review of the facility's policy titled, Bed Safety and Bed Rails, revised [DATE], showed: - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; - Maintenance provides a copy of inspections to the administrator and reports results to the quality assurance committee; - Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. The facility failed to provide a policy regarding Bed Rail Safety. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails or trapeze. Observations of the resident showed: - On [DATE] at 12:42 P.M., resident laid in bed with a grab bar on the right side of bed; - On [DATE] at 08:26 A.M., resident laid in bed with a grab bar on the right side of bed. 2. Review of Resident #7's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: -On [DATE] at 2:15 P.M., resident laid in bed with grab bar on the right side of bed; -On [DATE] at 3:48 P.M., resident laid in bed with grab bar on the right side of bed. 3. Review of Resident #8's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: - On [DATE] at 12:12 P.M., resident laid in bed with grab bar on the right side of the bed; - On [DATE] at 08:45 A.M., resident laid in bed with grab bar on the right side of the bed. 4. Review of Resident #27's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observation of the resident showed on [DATE] at 12:01 P.M., resident laid in bed with grab bar on the left side of bed. 5. Review of Resident #44's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observation of the resident showed on [DATE] at 01:00 P.M., resident laid in bed with grab bar on the left side of bed. 6. Review of Resident #47's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: - On [DATE] at 12:53 P.M., resident laid in bed with grab bar on the left side of bed; - On [DATE] at 02:41 P.M., resident laid in bed with grab bar on the left side of bed. 7. Review of Resident #50's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: - On [DATE] at 1:49 P.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 8:44 A.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 10:22 A.M., resident laid in bed with grab bar on the right side of bed; - On [DATE] at 3:17 P.M., resident laid in bed with grab bar on the right side of bed. 8. Review of Resident #58's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observation of the resident showed on [DATE] at 10:41 A.M., resident laid in bed with a grab bar on the left side of bed. 9. Review of Resident #61's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails or trapeze. Observations of the resident showed: - On [DATE] at 02:12 P.M., resident in bed with trapeze above head and quarter rail on right upper side of bed; - On [DATE] at 02:32 P.M., resident pulled on trapeze to lift himself/herself into middle of bed. He/she pulled on right upper side rail to roll over in bed. - On [DATE] at 08:40 A.M., resident in bed with trapeze above bed and right upper side rail in place. 10. Review of Resident #65's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails or trapeze. Observations of the resident showed: - On [DATE] 01:21 P.M., resident in bed with trapeze in place. - On [DATE] 01:43 P.M., resident in bed with trapeze in place. - On [DATE] 08:20 A.M., resident in bed with trapeze in place. - On [DATE] 09:17 A.M., resident in bed with trapeze in place. 11. Review of Resident #68's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: - On [DATE] at 4:00 P.M., resident laid in bed with grab bars on the left and right side of the bed; - On [DATE] at 9:45 A.M., resident laid in bed with grab bars on the left and right side of the bed. During an interview on [DATE] 10:43 A.M., the Administrator said side rail/enabler bar assessments have not been done as they should be and they are in the process of making an audit tool to correct this, but it has not been initiated at this time. Maintenance does not assess for entrapment. During an interview on [DATE] at 02:40 P.M., the Maintenance Director said he/she has not done entrapment assessments of bed rails. He/she said that he/she does not know who does the entrapment assessment information. 47678 49152

Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions for four residents (Resident #3, #7, #10, and #11) out of 17 sampled residents. The facility's census was 69. 1. Record review of facility's policy titled Comprehensive Person Centered Care Plan Policy dated 1/24/2019, showed: - Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. - The Comprehensive Person Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessment per the RAI manual. 1. Review of Resident #3's medical record, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Code status form signed/dated 5/5/21 for full code status (life saving measures to be performed in the event an individual's breathing and/or heart stops); -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive care plan, dated 8/5/21 and revision dated 2/3/22, showed the resident's code status not addressed with specific interventions and/or goals. 2. Record review of Resident #7's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - The code status form signed on 6/23/21 for full code status; - The February 2022 POS showed an order dated 11/3/21 for full code status. Record review of the resident's care plan dated, 2/8/22 showed the resident's code status not addressed on the care plan. 3. Record review of Resident #10's medical record showed: - An admitted [DATE]; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - The code status form signed on 8/19/19 and reviewed on 11/3/21 for full code status; - The February 2022 POS showed an order dated, 9/20/21 for full code status. Record review of the resident's care plan dated, 9/20/21 showed the resident's code status not addressed on the care plan. 4. Record review of Resident #11's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - The code status form signed on 8/19/19 for full code status; - The February 2022 POS showed an order dated, 8/19/19 for full code status. Record review of the resident's care plan dated, 10/15/21 and revised on 11/25/2021 showed the resident's code status not addressed on the care plan. During an interview on 2/9/22 at 9:25 A.M., the Administrator said she would expect the code status of the resident's to be on their care plans.

Based on observation, interview, and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 69. Record review of the facility's Medication Orders policy, revised August 2014, showed: - Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe; - Verbal orders for non-controlled medications are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber according to facility policy; - Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order; - The order is recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Observations of Resident #18 showed: - On 2/7/22 at 11:45 A.M., the resident sat in his/her wheelchair eating lunch with oxygen (O2) on at 2.5 liters per minute (2.5 LPM) per nasal cannula, (NC, a light weight tube that splits into two prongs on one end which delivers a mixture of air and oxygen); - On 2/8/22 10:30 A.M., the resident lay in bed playing games on his/her phone with O2 at 2.5 LPM per NC. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - No order in place for O2 therapy. During an interview on 2/16/22 at 9:30 A.M., LPN C said the resident has used oxygen at 2 to 2.5 liters as needed since his readmission from the hospital on 1/15/22 and that there should be a physicians order on the chart. 2. Observations of Resident #38 showed: - On 2/6/22 at 2:20 P.M., Resident set up in bed with oxygen on at two liters per minute (2 LPM) per nasal cannula; - On 2/7/22 at 11:11 A.M., Resident resting in bed with oxygen on at 2 LPM per nasal cannula; - On 2/7/22 at 4:05 P.M., Resident asleep in bed with oxygen on at 2 LPM per nasal cannula; Review of the Resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/7/22 at 11:11 A.M., Resident #38 said his/her oxygen saturation was down in the low 90's the past few days, so he/she asked the certified nurse aide (CNA) if they thought he/she should be using oxygen, and the CNA brought the oxygen concentrator in for him/her to use. During an interview on 2/7/22 at 4:05 P.M., LPN A said the resident is not on oxygen therapy that he/she knows of and will check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/8/22 at 9:18 A.M., LPN A said the Resident now has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She was unable to find out who provided the oxygen for the resident a few days ago. During an interview on 2/9/22 at 8:51 A.M., the Director of Nursing said he/she would expect that an order be written before any resident is given oxygen therapy, whether it be PRN or continuous.

Based on interview and record review, the facility failed to have a system to ensure that medication usage was evaluated on an ongoing basis, by not providing documentation of monthly medication regimen reviews by the pharmacy for one resident (Resident #3) out of 17 sampled residents. The facility census was 69. 1. Review of the facility's Medication Regimen Review Policy and Procedure, revision dated, August 2017, showed: -Policy: The AlixaRx (facility's pharmacy company) Clinical Pharmacist (ACP) performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record, to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities; -Procedure: B. The ACP reviews the medical record of each resident at least monthly; C. The routine monthly MRR are conducted on-site in the facility. 2. Review of Resident #3's medical record, showed: -admitted [DATE]; -Diagnoses included hypertension ([CONDITION(S)], high blood pressure), anxiety (persistent worry and fear about everyday situations) disorder and arthritis. Review of Resident #3's monthly pharmacy drug regimen reviews, showed: -MRR, dated 4/30/21, no recommendations and/or irregularities; -From May 2021 through October 2021, no MRR completed by the pharmacy and/or provided by the facility; -MRR's dated November 2021 through December 2021, no recommendations and/or irregularities; -MRR, dated January 2022, no recommendations and/or irregularities. 3. During an interview on 2/9/22 at 9:15 A.M. and 10:48 A.M., the administrator said prior to October 2021, the facility had a different pharmacy company and then obtained a different pharmacy company at the beginning of October 2021. The administrator verified the monthly pharmacy drug regimen reviews, gradual dose reductions and/or recommendations were not being completed prior to October 2021. The administrator said she expected nursing staff to follow the facility's policy/procedures regarding medication regimen review.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) when medications were administered. There were 29 opportunities with two medication errors made resulting in a medication error rate of 6.67%, This affected one resident (Resident #19) and had the potential to affect all residents. The facility census was 69. 1. Review of Resident #19's medical record, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 1/27/22 (stop date 2/10/22), to administer [MEDICATION(S)] (eye medication use to treat itching of the eye) 0.1% one drop to each eye twice daily (BID); -An order dated 11/30/21, to administer [MEDICATION(S)] (dietary fiber) one packet BID. Observation on 2/7/22 at 8:55 A.M., showed Licensed Practical Nurse (LPN) B prepared and administered the resident's scheduled medications through his/her gastrostomy (G-tube, a tube placed in the stomach for nutrition and medication administration) except [MEDICATION(S)] eye drop medication and [MEDICATION(S)] medication due to medications not available and not administered. The LPN verified the resident's [MEDICATION(S)] and [MEDICATION(S)] medications were not available on the medication cart and/or in the medication storage room. 2. During an interview on 2/7/22 at 10:19 A.M., the Director of Nurses (DON) said she expected the resident's medications to be available from the pharmacy to be administered as ordered. The DON said the pharmacy delivered medications daily to the facility. She expected nursing staff to contact the pharmacy regarding medications not available to be administered and should have contacted the pharmacy to have the resident's medications delivered. The pharmacy generally delivered medications to the facility several times daily and/or as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This deficient practice had the potential to affect all residents. The facility census was 69. Record review of the facility's policy on Nutritional Services Sanitation, dated 3/31/2021 showed: - Nutritional Services shall ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with Federal, State and Local regulations governing food sanitation and safety. - Personnel shall be responsible for daily, weekly, and monthly cleaning assignments as determined by the Dietary Manager and /or his/her designee; - Cleaning assignments shall include equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. Frequency of completion shall be in conjunction with food safety regulations and with consideration of manufacturer guidelines. - Cleaning of equipment condensers, lights, vents/fan, ceiling, ice machine, etc. shall be completed by the Maintenance Department as determined by the Administrator and in accordance to meet minimum standards of Federal, State, and Local guidelines and ordinances governing food service. Record review of the facility's policy on Pasteurized Eggs, dated 3/31/21 showed: - Eggs shall be prepared in a manner to prevent food borne illness and comply with state and federal regulations governing food preparation and food safety. - All eggs used for scrambled eggs, hard cooked eggs, fried eggs or as ingredients in recipes shall be purchased as pasteurized and prepared according to manufacturer instructions. Observation on 2/6/22 at 3:05 P.M. showed: - An area of 6 to 8 inches (in) of build up of ice at the top of both doors of the double door freezer; - Nineteen dozen, non-pasteurized eggs in the walk in refrigerator; - Four one in. by one in. brown/black areas on the air vent in front of the walk in freezer; - A fan attached to the wall with heavy buildup of lint and debris blowing directly on the clean dish area; - A 2 foot (ft) by 2 ft. return air vent on the ceiling above the drink area sink, at the entrance of the kitchen with buildup of debris; - A dented six pound (lb.) can of diced peaches. During an interview on 2/6/22 at 3:10 P.M. the Dietary Manager (DM) said the seal on the freezer had been reported to maintenance. During an interview on 2/6/22 at 3:20 P.M. the DM said she had ordered the non-pasteurized eggs by mistake and would re-order today. She said the eggs will not be served, they will use liquid eggs until new eggs arrive on Tuesday 2/8/22. The DM said staff did serve the eggs this morning at breakfast (2/6/22). During an interview on 2/9/22 at 9:45 A.M. Maintenance said the seal for the freezer is on order and thinks it should be in next week. The maintenance staff said the air return vent in the kitchen will be cleaned, and the other vent will be cleaned. During an interview on 2/9/22 9:55 A.M. the DM said the supplier has taken the non-pasteurized eggs off our order list so that mistake will not happen again. The dented cans should not be used. The DM said the fan blowing toward the clean dish area should be kept clean and will be unplugged until it is cleaned and maintenance will be given a work order when the vents need cleaned or with any other issues.

Based on interview and record review, the facility failed to prevent the misappropriation of an electronic portable tablet (ipad) for one resident (Resident #1) out of a sample of three residents when a staff member took possession of the resident's ipad without permission. The facility census was 59. The Director of Nursing and Administrator were notified of past non-compliance on 7/7/2021. The facility received information of the missing ipad on 6/14/21 and began investigating. The investigation found on 6/7/21 a community member dropped off an ipad at the facility saying it belonged to Certified Nurse Aide (CNA) A and that she had taken it from a resident. CNA A provided information that it was hers and she had bought at local retailer, and the ipad was returned to CNA A. The facility contacted the police and further investigation transpired resulting in CNA A admitting she had taken Resident #1's ipad. On 6/25/21, the ipad was returned to Resident #1 by the police. On 7/1/2021 the facility conducted an in-service to educate all staff on all facility policies and procedures related to the this matter. Record review of the Abuse Policy and Procedures dated September 17, 2019 showed: - It is the policy of this center to encourage and support all residents, team members, families, visitors, volunteers and resident representatives in preventing and reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property: - Misappropriation of resident property, including personal identifying information, means the deliberate or intentional taking, carrying away, using, transferring, concealing or retaining possession, misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings, movable property or of a negotiable security, instrument, paper or other negotiable writing of a resident without the resident's consent and with the intent to deprive the resident of possession of the property. 1. Record review of the Resident #1's Minimum Data Set (MDS), a federally required assessment tool to be completed by staff dated 4/23/2021 showed: - The resident is cognitively impaired; - The resident requires extensive assistance with all ADL's. Record review of the resident's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's investigation of possible misappropriation showed: - The Administrator received information on 6/14/2021 that Resident #1 had a personal ipad missing from the room; - The resident's room and previous rooms were checked; - Upon investigation, during interviews with staff, the Clinical Consultant said on June 7, 2021, an unknown community member brought an ipad to the facility and said it belonged to CNA A. The community member told the Clinical Consultant that CNA A had stolen the ipad from a resident and he/she wanted no part of it. The Clinical Consultant said he/she spoke with CNA A who denied any wrong doing and said she had bought it from a local retailer for personal use. The Clinical Consultant gave the ipad back to CNA A. - After further investigation the police were contacted and an investigation continued; - Staff were all interviewed again and CNA A denied ever having possession or owning an ipad; - The police interviewed the resident at which point CNA A confessed to taking the ipad and returned it to the police. The police contacted the facility and returned the ipad to the resident. Record review of the Police Report dated 6/23/2021 showed on 6/25/2021, CNA A returned the ipad and charger to the Police Department. During an interview on 7/7/2021 at 10:00 A.M., the Administrator (ADM) said Resident #1's family member reported to her that Resident #1's ipad was missing. The facility started an investigation and notified the Police. All staff were interviewed. CNA A was nervous and would not make eye contact. She informed the police and upon their investigation, CNA A confessed and returned the ipad to the police. The facility terminated the employment of the CNA and the family did not want to press charges. Complaint #MO 352

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatments and services to promote healing, prevent infection, and prevent new or worsening pressure ulcers for four sampled residents (Residents #2, #3, #7, and #8). The facility census was 62. The administrator was notified on 06/22/21 at 4:45 PM, of an Immediate Jeopardy (IJ) which began on 06/07/21. The IJ was removed on 06/24/21, as confirmed by surveyor onsite verification. Review of the facility's skin care pressure ulcer/wound management policy, undated, showed; -To promote healing of pressure ulcers, stasis ulcers and other wounds, the facility will use standardized protocols or follow physician's specific orders for wound care. -Optimal wound management will include: Assessment of the skin and wound daily, use of standardized protocols and regular reassessment to monitor effectiveness of interventions. -Treatment objectives to promote optimal wound healing are: Relieve pressure, treat infection (if present), protect healthy tissue, evaluate/correct nutritional deficiencies and treat consistently with appropriate products. -Standardized Protocols are: Based on currently accepted standards of practice, utilized consistently whenever possible and presented to physicians when obtaining orders for wound care. -Assessment of Pressure Ulcers include: Location, stage, size (length, width, depth), undermining, tunneling, drainage/exudate (amount, color), odor, slough, eschar, granulation, peri-wound and pain. -The Nurse will: 1) Do a complete skin assessment of each new resident upon admission (within 8 hours) to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, etc. 2) Document the size and description of the wounds in Point Click Care (PCC). 3) Initiate a Weekly Wound Assessment identifying the type of wound, the size, the location and the status of the wound. 4) Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .). If pain is present, implement pain relief measures. 6) Notify Wound Nurse and/or DON (Director of Nursing) of any resident admitted with pressure ulcers or other wounds. 7) Complete skin assessments on all residents weekly after showers or as assigned to check for new skin integrity impairment. 8) Following procedures 2-5 for any resident who develops a house acquired pressure ulcer. 9) Notify Wound Nurse and/or DON of residents who develop a house acquired pressure ulcer. 10) Perform treatments as ordered. Date and initial all dressing changes on the cover dressing or tape. The Wound Nurse will: 1) Do a complete skin assessment of each new resident upon admission to identify any wounds, present including pressure ulcers, stasis ulcers, surgical wounds, etc. (If the assessment has been completed by the admitting nurse, assess the resident and review the documentation for accuracy.) 2) Evaluate the treatment order and determine if it's appropriate. If not, establish whether the physician will allow order changes for treatment per facility protocols. 3) Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status. 4)Document the wound status on the Weekly Wound Assessment. 5) Record the wound on the Weekly Wound Report. 6) Contact physician when a pressure ulcer progresses from one stage to another (i.e. a stage II pressure ulcer becomes a stage III) or when there is any significant change in the condition of a wound. 7) Contact responsible party when there is a significant change in the condition of a pressure ulcer or any wound. 8) Contact the physician when a pressure ulcer or other wound fails to respond to treatment after 2-3 weeks. 9) Ensure that appropriate pressure ulcer prevention has been implemented including a dietary supplement to promote healing. If pain is present, ensure that proper pain relief measures have been implemented. 10) Follow procedures 2-9 for any resident who develops a house acquired pressure ulcer. -The DON will: 1) Review the reports; Weekly Wound Report. 2) Conduct a weekly Skin/Wound meeting with the IDT (Interdisciplinary Team). 3) Periodically observe pressure ulcers or wounds during treatment changes. 4) In-service nursing staff on wound management. 5) Contact Corporate Nurse Consultant (CNO) or vendor's wound care nurse to evaluate wounds that are difficult to manage. Review of the facility's Skin Report/Pressure Ulcer Report policy, undated, showed: -To assure proper monitoring of resident's skin condition including pressure ulcers, stasis ulcers, skin tears, abrasions, [CONDITION(S)], rashes, surgical wounds, open [CONDITION(S)] other than ulcers and other miscellaneous skin conditions, facilities will complete a weekly audit of all such conditions. All skin conditions will be documented on the Weekly Wound Report. - The Wound Nurse (or Designee) will: 1) Assess all residents with pressure ulcers, stasis ulcers, skin tears, or other skin conditions once weekly to monitor size and status. 2) Complete a Weekly Wound Assessment on each resident with a pressure ulcer, status ulcer, diabetic ulcer, etc. weekly in the assessments/forms in Point Click Care. A daily skin assessment is required with any resident who currently has a pressure ulcer. 3) Complete a weekly wound report for the facility. 4) Forward a copy of all reports to: DON, Care Plan Nurse, Food Service Supervisor, Administrator, Dietician and CNO and Director of Clinical Services (DCS). 5) Contact the physician when there is a significant change in the status of the skin condition. 6) Contact the responsible party when there is a significant change in the status of the skin condition. 7) Request new orders from the physician, when the current treatment method is no longer appropriate or when the wound or skin condition shows no progress in 2-3 weeks. 8) Consult with wound care specialists, as necessary. -The DON will: 1) Review the reports weekly. 2) Conduct a weekly Skin/Wound meeting with the IDT. 3) Consult with the Wound Nurse or designee regarding identified trends and address possible causes of any trends. 4) Review the reports with the administrator during the weekly Administrator/DON meeting. 5) File the weekly wound reports in the DON office by week/month. 1. Review of Resident #7's hospital discharge orders dated 3/12/21 showed: -[MEDICATION(S)] (antibiotic) 500 milligrams (mg) three times a day for 7 days; -[MEDICATION(S)] (antibiotic) 100 mg twice a day for 7 days; -[MEDICATION(S)] (antibiotic) 300 mg twice daily for 7 days; -Oral [MEDICATION(S)] (antibiotic) 125 mg every 6 hours for 21 days; -Infectious disease follow-up for further prescriptions/recommendations; -Urology service follow-up; -Primary care provider follow up; -Continue local wound care (no indication as to what specific wound care to continue). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -admitted on [DATE]; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 300 mg 2 capsules via G-tube three times a day every 7 days; -[MEDICATION(S)] 300 mg 1 capsule via G-tube two times a day every 7 days; -[MEDICATION(S)] 100 mg via G-tube two times a day every 7 days; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 300 mg 2 capsules via G-tube three times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 300 mg 1 capsule via G-tube two times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 100 mg via G-tube two times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Administered once on 3/13/21. Review of the resident's Treatment Administration Record (TAR), dated 03/21, showed no wound treatment orders documented on the TAR. Record review showed the facility did not transcribe the hospital discharge orders accurately to the POS and the MAR, all dated 3/12/21. The hospital orders said the [MEDICATION(S)], the [MEDICATION(S)], and the [MEDICATION(S)] were to be given, as ordered, daily for 7 days. As written on the POS and MAR, the medication would be given every seven days. In addition, the hospital order for the [MEDICATION(S)] showed it was to be given three times a day for 21 days. The order on the POS and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Licensed Practical Nurse (LPN) that took off the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nurses progress notes, dated 03/12/21 at 9:01 P.M. showed: -Resident needs a specialty mattress as soon as possible; -Resident admitted to the facility at 5:00 P.M.; -Resident has MS, contractures, and decubitus to left lower extremity, left heel, buttocks, and coccyx bandaged. Review of resident's admission skin assessment, which was not completed until 3/14/21 at 8:45 A.M. by Assistant Director of Nursing (ADON), showed the following: 1: Coccyx- Pressure- Stage III- Moderate serosanguineous drainage, no odor, epithelialization, open with surrounding red skin around periwound- Measurements 5. 5 x 5.5 x 0.1; 2: Coccyx- Pressure- Stage II- Small serosanguineous drainage, no odor, epithelialization, open with surrounding red skin around periwound- Measurements 6.5 x 5.5 x 0.1; 3: Right buttock- Pressure- Stage II- Small serosanguineous drainage, no odor, epithelialization, open with surrounding red skin to periwound- Measurements 2.5 x 2.0 x 0.2; 4: Left buttock- Pressure- Stage 2- Serosanguineous drainage, no odor, epithelialization, open with surrounding red skin around periwound- Measurements 3 x 3 x 0.1; 5: Left heel- Pressure- Stage 3- No description given as of wound bed- Measurements 4.0 x 3.5 x 0.2. Record review from the outside wound care clinic seen at the facility, dated 3/15/21 showed: -Wound #1: Left Heel- Stage 3 pressure- 1.5 x 1.0 x 0.1- Moderate serosanguineous drainage, no odor, 1-25% slough, 51-75% granulation and fat layer exposed. No infection present. -Wound #2: Left Lateral Buttocks- Pressure- Unstageable- 3.5 x 2.0 x 0.1- Moderate serous/green yellow drainage, 1-25% slough, 1-25% eschar, 51-75% granulation. S/S of infection present with culture and sensitivity (C&S) pending. -Wound #3: Left Medial Buttock (medial to wound #2)- Pressure- Unstageable- (cluster of 2 wounds) 6.3 x 4.0 x 0.1- Moderate serous/tan green drainage, 90% slough, 10% granulation. S/S of infection present with C&S pending. -Wound #4: Sacrum- Pressure- Stage 2- 6.0 x 1.0 x 0.1- Moderate serous drainage, 1-25% slough, 51-75% granulation. Limited skin breakdown. -Wound #5: Right Lateral Buttock- Pressure- Unstageable- 3.0 x 2.3 x 0.1- Moderate serous drainage, 76-100% slough. -Wound #6: Right Medial Buttock- Pressure- Unstageable- 10.0 x 6.5 x 0.1 (medial to wound #5)- Moderate serous drainage 100% slough. -Wounds #1, 2, 3, 5 & 6 were debrided. The wound care nurse wrote the following orders dated 3/15/2021: - Wound Orders for wounds 1, 2, 5, 6: Cleanse with Vashe wound cleanser, skin prep and [MEDICATION(S)] to periwound. To left hip, right hip and left heel apply alginate to the wound bed, cover with boarder foam dressing every 1-2 days and PRN. Encourage frequent position changes and offloading. - Wound Orders for wound 4: Cleanse with Vashe, apply skin prep and thick layer of barrier ointment twice daily and encourage frequent position changes and offloading. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/21, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Ulcer presents as a deep crater with or without undermining of the adjacent tissue); pressure ulcer of left heel, unstageable; -Cognition intact with Brief Interview for Mental Status (BIMS) score of 14; -Extensive assistance of 2 or more staff with activities of daily living (ADLs), total dependence of staff for dressing and supervision for eating; -Wheelchair for locomotion with staff to propel; -Indwelling urinary catheter (hollow tube inserted through the urethra into the bladder to drain the bladder of urine); -Frequently incontinent of bowel; -Two Stage 2 pressure ulcers; -Three Stage 3 pressure ulcers. (The MDS coordinator who entered the wound information was no longer employed by the facility so no interview is available to explain why the MDS does not match the pressure ulcer assessments.) Record review from the outside wound care clinic seen at the facility, dated 3/22/21, showed: -Wound 1: Left heel- Pressure- Stage 3- 0.8 x 0.5 x 0.1- Improving- Moderate serosanguineous drainage 1-25% slough, 51-75% granulation, fat layer exposed. No infection. -Wound 2: Left lateral buttock- Pressure- Unstageable- 4.5 x 3.5 x 0.1- No change- Moderate serous/green yellow drainage, 1-25% slough, 51-75% granulation, unknown deepest layer due to slough and eschar present in wound bed. Infection confirmed and local topical antibiotics prescribed. -Wound 3: Left Medial Buttock (medial to wound 2)- Pressure- Unstageable- 4.7 x 3 x 0.1- Improving- Moderate serous/tan green drainage, 76-199% slough, 1-25% granulation. Signs of infection with C&S pending. Systemic antibiotic prescribed. Topical antibiotic prescribed. -Wound 4: Sacrum- Pressure- Stage 2- Resolved. -Wound 5: Right lateral buttock- Pressure- Unstageable- 1.8 x 2.1 x 0.1- Improving- Moderate serous drainage, 76-100% slough. -Wound 6: Right medial buttock (medial to wound 5)- Pressure- Unstageable- 7.5 x 6.4 x 0.1- Improving- Moderate serous drainage 76-100% slough. -Wound 7: Buttock- Deep tissue injury related to pressure from Foley catheter tubing- 3.5 x 4.5 x 0.1 -Wounds 5 & 6 debrided during the visit. -Wound orders: Facility was instructed on daily dressing changes and advised to keep the wound clean and dry while showering. The wound should be cleansed only with normal saline or wound spray. Recheck immediately if any signs of infection such as redness, swelling or drainage arise. Wounds 1, 2, 5, 6: Every one to two days and PRN, cleanse wounds with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), skin prep and [MEDICATION(S)] to periwound, [MEDICATION(S)] to wound bed covered by [MEDICATION(S)], and cover with a bordered foam dressing. Encourage frequent position changes and offloading. Record review of Resident #7's March 2021 POS, MAR, and TAR showed none of the wound care orders from the 3/15/21 and 3/22/21 wound care clinic were written or carried out. (Per the wound policy and procedure, the wound nurse is responsible to communicate with the wound specialists.) Record review of the nurses progress notes, dated 3/23/21 at 4:12 P.M., showed: -Resident on telehealth visit with physician and showing signs of sepsis; -Resident complained of vomiting, chills and abdominal pain; -Resident sent to the emergency room . Record review of hospital admission record, dated 3/23/21 showed: -admitted with severe urinary tract infection and skin/soft tissue infection. Record review of hospital discharge record, dated 3/26/21, showed: -[MEDICATION(S)] (antibiotics) 750 mg daily for 10 days; -Continue course of [MEDICATION(S)] to complete the 21 days; -[MEDICATION(S)] 50 mg/ml administer 2.5 ml per feeding tube every 6 hours for 21 days; -PCP follow-up; -Wound Care: Cleanse left buttock, right hip and ulcers with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), wound cleanser, dry, cover with silver polymem wic (a multifunctional, antimicrobial wound filler that continuously cleanses absorbs and moistens), ABD pad (pads seal off the wound area, help prevent moisture seepage, and help reduce risk of infection) and secure with large [MEDICATION(S)] every other day and as needed (PRN) for soiling or saturation. Cleanse left heel ulcer with Vashe, dry and apply [MEDICATION(S)] and cover with dry gauze or ABD pad daily. Skin prep anterior top bend of foot and pad with ad pad prior to wrapping daily. Wear prevalon boots to bilateral feet and float heels. Cleanse right posterior leg with vashe, dry and cover with [MEDICATION(S)] AG, ABD pad and wrap with Kerlix every other day and as needed. Turn and position every 2 hours. Cleanse sacral ulcer and reddened excoriation to perirectal area and lower back with personal care spray, dry and apply antifungal skin barrier twice daily and PRN for incontinent episodes. Use absorbent pads underneath. Record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 750 mg daily for 10 days; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR, dated March 2021 showed: -[MEDICATION(S)] 750 mg daily for 10 days. Started 3/27/21 and completed 4/7/21; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Administered only one dose on 3/13/21; Record review of the TAR, dated March 2021 showed: -No wound treatment orders were transcribed to the TAR from the hospital discharge orders; -Weekly skin assessment every 7 days started 3/27/21; -Skin assessment for 3/27/21 not signed off as completed. The facility did not provide documentation of a readmission skin assessment or the weekly skin assessment for 3/27/21. Record review from the outside wound care clinic seen at the facility, dated 3/29/21, showed: Wound 1: Left heel- Pressure- Stage 3- 0.8 x 0.6 x 0.1- Improving- Moderate serosanguineous drainage, 1-25% slough, 51-75% granulation, fat layer exposure. Wound 2: Left lateral buttock- Pressure- Unstageable- Merged with wound #3- Measuring 5.2 x 7.0 x 0.1- Deteriorating- Serous green yellow drainage, 1-25% slough, 51-75% granulation, unknown deepest layer due to slough and eschar present in wound bed. Infection present with topical antibiotics prescribed. Wound 4: Sacrum (reopened 3/29)- Pressure- Stage 2- 6.5 x 2.4 x 0.1- Deteriorating, small serous drainage, 26-50% slough, 26-50% granulation. Wound 5: Right lateral buttock- Pressure- Unstageable- 1.8 x 2.1 x 0.1- Improving, moderate serous drainage, 76-100% slough. Wound 6: Right medial buttock (medial to wound 5)- Pressure- Unstageable- 6.8 x 4.0 x 0.1- Deteriorating, moderate serous drainage 76-100% slough. Wound 7: Buttock- Pressure- DTI from Foley tubing- Resolved. Wounds 1, 2, 4 & 6 were debrided during this visit. Wound orders: Facility instructed on daily dressing changes and advised to keep wound clean and dry while showering. Wound should be cleansed only with normal saline or wound spray. Recheck immediately if any signs of infection such as redness, swelling or drainage arise. Wounds 1, 2, 5, 6: Cleanse wounds with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), skin prep and [MEDICATION(S)] to periwound, [MEDICATION(S)] to wound bed cover with ABD then kerlix daily and PRN. Encourage frequent position changes and offloading. Please do not use depends or disposable chuck when patient in bed. Please use draw sheet and cloth chuck. Record review of the March 2021 POS and TAR, showed the facility staff did not transcribe orders from the wound care clinic. When on-site, the facility was only able to provide three wound care clinic records. Per the policy and procedure the facility wound care nurse is responsible to review the records and ensure the orders are carried out. Record review from the outside wound care clinic seen at the facility, 4/05/21, showed: -Wound 1: Left heel- Pressure- Stage 3- Resolved 4/5 with scab present. -Wound 2: Left lateral buttock (merged with wound 3)- Pressure- Unstageable- Deteriorating- 5.2 x 9.0 x 0.1- Moderate serous green yellow drainage, 1-25% slough, 51-75% granulation, 1-25% epithelialization. Infection present topical antibiotic prescribed. -Wound 4: Sacrum- Pressure- Stage 2 (reopened 3/29)- 7.0 x 5.0 x 0.1- Deteriorating- Small serous drainage, 26-50% slough, 26-50% granulation. -Wound 5: Right lateral buttock- Pressure- Unstageable- Deteriorating- 3.5 x 2.6 x 0.1- Moderate serous drainage, 76-100% slough. -Wound 6: Right medial buttock- Pressure- Unstageable- Deteriorating- 6.5 x 4.1 x 0.1- Moderate serous drainage, 76-100% slough. -Wound 7: Buttock- DTI related to Foley resolved. -Wound orders: Wounds 1, 2, 5, 6: Cleanse wounds with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), skin prep and [MEDICATION(S)] to periwound, [MEDICATION(S)] to wound bed cover with ABD then kerlix daily and PRN. Encourage frequent position changes and offloading. Please do not use depends or disposable chuck when patient in bed. Please use draw sheet and cloth chuck. Record review of the resident's April 2021 POS and TAR, showed the facility staff did not transcribe orders from the wound care clinic. Record review of nurses progress note, dated 4/8/21 at 2:11 PM showed: -Pharmacy review note: [MEDICATION(S)] order from 3/27/21 is not showing on any of the MARs to be signed off as given. (Called facility and spoke with Assistant Director of Nursing (ADON). Signed off by the pharmacist. Review of the resident's care plan, dated 4/16/21, showed: -Problem: Impairment to skin integrity related to mobility deficit and moisture; -Pressure injury areas noted on admit; -Goal: Skin injury to be healed by the review date. (Target Date: 07/13/21). Will have no complications related to pressure injury areas on left heel and buttocks through the review date (Target Date: 07/13/21); -Interventions: Elevate heels off the bed. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observe pain and administer pain medications/treatments as ordered and/or per pain problem. Observe/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician. Turn and position during rounds and as needed. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review from the outside wound care clinic seen at the facility, 4/19/21, showed: -Wound 1: Left heel- Pressure, Stage 3- Healed on 4/5 with scab present. -Wound 2: Left lateral Buttock- Pressure- Unstageable- Deteriorating- 5.5 x 8.3 x 0.1- Moderate serous green yellow drainage, 1-25% slough, 1-25% eschar, 26-50% granulation, 1-25% epithelialization. Infection present topical antibiotics prescribed. -Wound 4: Sacrum- Pressure- Stage 3 (reopened 3/29)- No change- 6.8 x 5.7 x 0.1- Small serous drainage, 26-50% slough, 26-50% granulation. Wound 5: Right lateral buttock- Pressure- Stage unstageable- Deteriorating- 5.7 x 4 x 0.1- Deteriorating- Moderate serous drainage, 1-25% slough, 51-75% granulation. -Wound 6: Right medial buttock- Pressure- Unstageable- Deteriorating- 6.5 x 4.1 x 0.1- Moderate serous drainage, 76-100% slough. -Wound 7: Buttock- Pressure- Resolved. -Wound 2 was debrided during this visit. -Wound orders: Wounds 2, 4, 5, 6: Cleanse wounds with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), skin prep and [MEDICATION(S)] to peri-wound, calcium with alginate with silver in areas of increased drainage to wound bed cover with ABD then kerlix daily and PRN. Encourage frequent position changes and offloading. Please do not use depends or disposable chuck when patient in bed. Please use draw sheet and cloth chuck. Record review of the resident's April 2021 POS and TAR, showed the facility staff did not transcribe orders from the wound care clinic. Record review of the resident's POS, dated 4/21, showed: -No order for [MEDICATION(S)] entered. The original [MEDICATION(S)] order was to start 3/13/21 and be given every 6 hours for 21 days. The order was to be continued after the resident was hospitalized from 3/23-3/26/21. Record review of the resident's MAR, dated 4/21, showed: -No order for [MEDICATION(S)] entered. Record review of the resident's TAR, dated 4/21/21, showed: -No treatment orders for wound care. -Weekly skin assessments every 7 days. Skin assessment on 4/3/21 and 4/24/21 not signed off as completed. -Skin assessments on 4/10/21 and 4/17/21 were signed off. -The facility did not provide any skin assessment forms. Record review from the outside wound care clinic seen at the facility, dated 5/03/21, showed: -Wound 1: Left heel- Pressure, Stage 3- healed 4/5. -Wound 2: Left lateral buttock- Pressure- Unstageable (merged with wound 3)- Improving- 5.5 x 7.3 x 0.1- Moderate serous green yellow drainage, 1-25% slough, 1-25% eschar, 26-50% granulation, 1-25% epithelialization. Topical antibiotic. -Wound 4: Sacrum- Pressure- Stage 2 (reopened 3/29)- Deteriorating- 5.2 x 6.5 x 0.2, Small serous drainage, 26-50% slough, 26-50% granulation. -Wound 5: Right lateral buttock- Pressure- Unstageable- Improving- 2.0 x 1.4 x 0.1- moderate serous drainage, 1-25% slough, 51-75% granulation. -Wound 6: Right medial buttock- Pressure- Unstageable- Deteriorating- 7.6 x 4.0 x 0.1- Moderate serous drainage, 76-100% slough -Wound 7: Buttock- Pressure- (DTI from Foley cath)- Healed. -Wound 8: Left medial interior buttock- Pressure- 0.5 x 0.5 x 0.1, small serosanguineous drainage, 76-100% slough, fat layer exposure. -Wounds 2, 4, 5, 6 debrided this visit. -Wound orders: Facility instructed on daily dressing changes and advised to keep wound clean and dry while showering. Wound should be cleaned only with normal saline or wound spray. Recheck immediately if any signs of infection such as redness, swelling or drainage arise. Encouraged frequent position changes to promote offloading to different areas. Dressings for left hip, sacrum and right hip: Cleanse wounds with Vashe (moisten gauze and apply wet gauze on wound bed and allow to soak for 7-10 minutes), skin prep and [MEDICATION(S)] to periwound, calcium with alginate with silver in areas of increased drainage to wound bed cover with ABD then kerlix daily and PRN. Encourage frequent position changes and offloading. Please do not use depends or disposable chuck when patient in bed. Please use draw sheet and cloth chuck. Review of the May 2021 POS and TAR, showed the facility staff did not transcribe orders over from the wound care clinic. Record review of nurses progress note dated 5/3/21 at 2:13 AM showed: -Resident's wounds on bilateral buttocks cleansed with wound cleanser. [MEDICATION(S)] (it acts as an osmotic engine to draw fluid from deeper tissues to the wound surface to promote removal of devitalized tissue) applied to wounds, non-adherent dressing followed by ABD pad applied with paper tape. Record review of skin assessment completed by facility, dated 5/5/21 showed: 1: Coccyx- Pressure- Stage IV- 10.5 x 10.5 x 1.0- moderate purulent drainage, slight odor, epithelialization, open, surrounding skin reddened, deteriorated. Current tx: cleanse with wound cleanser, place [MEDICATION(S)] on wound, cover and try to cover where fecal matter cannot get in wound. There is pain related to the wound. 2: Left trochanter (hip)- Pressure- Unstageable- 4.5 x 3.5 x 0.1- scant serous drainage, epithelialization, open with surrounding skin reddened. Cleanse with wound cleanser, apply [MEDICATION(S)], secure with dressing. There is pain related to the wound. 3: Left buttock: Pressure- Unstageable- 4.7 x 3.0 x 0.1- small serous drainage, slight odor, epithelialization, open with surrounding skin reddened. Cleanse with wound cleanser, apply [MEDICATION(S)] secure with dressing. 4: Left heel: Pressure- Stage 3- 0.8 x 0.5 x 0.5- No exudate, eschar, hardened wound edges, surrounding skin reddened. Cleanse with wound cleanser, apply silver alginate fiber sheet then gauze dressing. Record review from the outside wound care clinic seen at the facility, dated 5/10/21, showed: -Wound 1: Left heel- Pressure- Stage 3- healed on 4/5/21 -Wound 2: Left lateral buttock- Pressure- Unstageable (merged with wound 3)- Improving- 5.5 x 7.2 x 0.1- Moderate serous green yellow drainage, 1-25% slough, 26-50% granulation, 1-25% epithelialization, fat layer without necrosis. Topical antibiotic prescribed. -Wound 4: Sacrum- Pressure- Stage 2- Improving- 4.3 x 5.8 x 0.2- small serous drainage, 1-25% slough, 51-75% granulation. -Wound 5: Right lateral buttock- Pressure- Unstageable- Improving- 0.7 x 0.4 x 0.1- scant serous drainage, 76-100% slough, fat layer exposed. -Wound 5: Right medial buttock- Pressure- Unstageable- Improving- 5 x 3 x 0.1- moderate serous drainage, 1-25% slough, 51-75% granulation. -Wound 7: Buttock- Pressure- DTI from cath- resolved -Wound 8: Left medial inferior buttock- Pressure- No Change- 1 x 0.7 x 0.1- small serosanguineous drainage, 76-100% granulation, fat layer exposure. -Wound orders: Facility instructed on daily dressing changes and advised to keep wound clean and dry while showering. Wound should be cleaned only with normal saline or wound spray. Recheck immediately if any signs of infection such as redness, swelling or drainage arise. Encouraged frequent position changes to promote offloading to different areas. Dressings for left hip, sacrum and right hip: Cleanse wounds with Vashe, skin prep and [MEDICATION(S)] to periwound, Santyl and [MEDICATION(S)] to wound bed cover with ABD daily and PRN. Encourage frequent position changes and offloading. Please do not use depends or disposable chuck when patient in bed. Please use draw sheet and cloth chuck. Please order mattress for resident. A speciality mattress was not ordered until 6/9/21. Record review of the May 2021 POS and TAR, showed the facility staff did not transcribe orders from the wound care clinic. Record review from the outside wound care clinic seen at the facility, dated 5/17/21, showed: -Wound 1: Left heel- Pressure- Stage 3- healed 4/5. -Wound 2: Left lateral buttock- Pressure- Unstageable- No change- 5.5 x 7.5 x 0.1- moderate serous green yellow drainage, 1-25% slough, 26-50% granulation, 1-25% epithelialization. Topical antibiotic. -Wound 4: Sacrum- Pressure- Stage 2- No

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two residents (Resident's #1 and #4) of two sampled residents that required diabetic management and wound care. The facility failed to assess, monitor, and ensure the residents received treatment and care for diabetic ulcers. In addition, the facility failed to contact the physician for wound care orders, notify the physician of changes, and complete weekly skin assessments. The facility also failed to obtain and follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 62. Review of the facility's Skin Report/Pressure Ulcer Report policy, undated, showed: - To assure proper monitoring of resident's skin condition including pressure ulcers, stasis ulcers, skin tears, abrasions, [CONDITION(S)], rashes, surgical wounds, open [CONDITION(S)] other than ulcers and other miscellaneous skin conditions, facilities will complete a weekly audit of all such conditions; - All skin conditions will be documented on the Weekly Wound Report; - The Wound Nurse (or Designee) will: - Assess all residents with pressure ulcers, stasis ulcers, skin tears, or other skin conditions once weekly to monitor size and status; - Complete a Weekly Wound Assessment on each resident with a pressure ulcer, stasis ulcer, diabetic ulcer, etc. weekly in the assessments/forms in Point Click Care (an electronic health record); - Complete a weekly wound report for the facility; - Contact the physician when there is a significant change in the status of the skin condition; - Request new orders from the physician, when current treatment method is no longer appropriate or when the wound or skin condition shows no progress in 2-3 weeks and consult with wound care specialists as necessary; - The Director of Nursing (DON) will: - Review the reports weekly; - Conduct a weekly Skin/Wound meeting; - Consult with the Wound Nurse or designee regarding identified trends and address possible causes of any trends; - Review the reports with the Administrator during the weekly Administrator/DON meeting; - File the weekly wound reports in the DON office by week/month. Review of the facility's Skin Care Pressure Ulcer/Wound Management policy, undated, showed: - To promote healing of pressure ulcers, stasis ulcers, and other wounds, the facility will use standardized protocols or follow physician's specific orders for wound care; - Optimal wound management will include assessment of the skin and wound daily and regular reassessment to monitor effectiveness of interventions; - The nurse will: - Do a complete skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, etc.; - Document the size and description of the wounds in Point Click Care; - Initiate a Weekly Wound Assessment identifying the type of wound, the size, the location, and the status of the wound; - Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Notify Wound Nurse and/or DON of residents admitted with pressure ulcers or other wounds; - Complete skin assessments on all residents weekly after showers or as assigned to check for new skin integrity impairments; - Perform treatments as ordered. Date and initial all dressing changes on the cover dressing or tape; - The Wound Nurse will: - Do a complete skin assessment of each new resident upon admission to identify any wounds present; if the assessment has been completed by the admitting nurse, assess the resident, and review the documentation for accuracy; - Evaluate the treatment order and determine if it's appropriate; if not, establish whether the physician will allow order changes for treatment per facility protocols; - Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status; - Document the wound status on the Weekly Wound Assessment; - Record the wound on the Weekly Wound Report; - Contact physician when a pressure ulcer progresses from one stage to another or when there is a significant change in the condition of a wound; - Contact the physician when a pressure ulcer or other wound fails to respond to treatment in 2-3 weeks; - The DON will: - Review the reports; - Conduct a weekly Skin/Wound meeting; - Periodically observe pressure ulcers or wounds during treatment changes; - In-service nursing staff on wound management; - Contact Corporate Nurse Consultant or vendor's wound care nurse to evaluate wounds that are difficult to manage. Record review of the facility's Diabetes policy, dated September 2017, showed: - For resident's with confirmed diabetes, the nurse shall assess and document/report the dose and time of most recent anti-hyperglycemic (medication used to lower glucose levels in the blood) given and all other current medications; - For the resident receiving insulin who is well controlled; monitor blood glucose levels twice a day if on insulin; monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin; - Adjust monitoring frequency depending on glucose control and resident preference; - The physician will order desired parameters for monitoring and reporting information related to blood sugar management; - The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan; - The staff will identify and report issues that may affect or be affected by a patient's diabetes and diabetes management such as foot infections, skin ulcerations, increased thirst, or [CONDITION(S)]. Record review of the facility's Nursing Care of the Resident with Diabetes Mellitus policy, dated December 2015, showed: - The management of individuals with diabetes mellitus should follow relevant protocols and guidelines; - The physician will order the frequency of glucose monitoring; - Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation; - Assist the resident with his or her specific medication regimen, as ordered, and as needed. 2. Record review of Resident #1's Hospital History and Physical, dated 5/11/21, showed diabetic ulcer of the right heel since 5/29/20. Record review of the resident's Hospital History and Physical, dated 5/13/21, showed: - Diabetes; - Ulceration/eschar (dead tissue) on the feet; - Gangrenous necrosis (dead tissue caused by an infection or lack of blood flow) on both feet with right heel eschar; - Right foot heel eschar and great toe ulcerations; - Left foot great toe ulceration. Record review of the resident's Hospital After Visit Summary (discharge instructions), dated 5/10/21 through 5/17/21, showed: - Wound care: cleanse bilateral great toes and right heel with wound cleanser, pat dry, paint sites with [MEDICATION(S)], allow to dry, cover with bordered foam dressing, and change dressing daily; - New patient appointment on 5/24/21 at 11:30 A.M., for hyperbaric wound care; - [MEDICATION(S)] (insulin) 100 units/milliliter (u/ml): 55 units by subcutaneous (SQ) injection two times a daily: - [MEDICATION(S)] (insulin) sliding scale SQ three times a day with meals: - If blood sugar 0-60 give glucogel (used to treat low blood sugar); - 61-150 give no insulin; - 151-250 give 3 units; - 251-350 give 6 units; - Over 351 give 9 units, call physician. Record review of the resident's baseline care plan, dated 5/19/21, showed: - Resident communicates easily with staff; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Insulin not marked; - No skin integrity issues. Record review of the resident's Admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 5/21/21, showed: - The resident cognitively intact; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident received insulin injections two days out of the last seven days. - Required supervised to limited assistance with activities of daily living (ADL); - Impairment both lower extremities; - Diabetic foot ulcers. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - admitted to the facility on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - An order on 5/18/21 for [MEDICATION(S)] 100 u/ml 55 units SQ two times a day; order discontinued on 5/25/21; - An order on 5/23/21 for accucheck (blood sugar monitoring) before meals and at bedtime; - No order for blood sugar monitoring prior to 5/23/21; - An order on 5/25/21 for [MEDICATION(S)] (insulin) 25 units one time order; - An order on 5/25/21 with start date of 5/26/21 for Novolog (insulin) inject as per sliding scale SQ two times a day for elevated blood sugar: - If blood sugar 200-250 give 3 units; - 251-300 give 6 units; - 301-350 give 9 units; - 351-400 give 12 units; - 401-450 give 15 units; - 451 and above call the physician; - Hospital discharge instructions for [MEDICATION(S)] sliding scale not on POS; - No wound treatment orders. Record review of the resident's May 2021 Treatment Administration Record (TAR) showed no wound treatment orders or wound care documented. Record review of the resident's May 2021 Licensed Nurse Administration Record (LNAR), showed: - No blood sugar readings: - On 5/23/21 at 4:30 P.M., 5/27/21 at 8:00 P.M., 5/28/21 at 6:30 A.M., 5/29/21 at 4:30 P.M., 5/29/21 at 8:00 P.M., and 5/30/21 at 6:30 A.M.; - Blood sugar readings were not documented as completed 6 times out of 30 opportunities; - Resident's blood sugar readings over 351: - On 5/24/21 blood sugar at 8:00 A.M. 373; - On 5/25/21 blood sugar at 8:00 A.M. 498, at 11:30 A.M. 498, at 4:30 P.M. 519, and at 8:00 P.M. 367; -Resident's blood sugar reading 451 and over: - On 5/30/21 blood sugar at 4:30 P.M. 451. Record review of the resident's physician note, dated 5/18/21, showed: - Right heel wound; - Wound care, dry dressing every day at least; - Wound care appointment on 5/24/21. During an interview on 6/8/21 at 10:55 A.M., the Director of Nursing (DON) said the resident refused to go to the wound care clinic appointment on 5/24/21. The resident wanted to been seen by a different wound care clinic. She expected staff to notify the physician of the resident's request, obtain a referral to resident's clinic of choice, and make the necessary arrangements. Nurses should have documented in the resident's progress notes of him/her not wanting to go to the wound clinic appointment. Review of the resident's nursing admission/readmission evaluation, undated and unsigned, showed: - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident is complaintive about medications and change of insulin; - Bilateral lower extremity wounds; - Bilateral lower extremity [CONDITION(S)] with blistering to feet and legs. Review of the resident's May 2021 progress notes, showed: - On 5/18/21 at 3:53 P.M., resident here short term for rehabilitation and wound care; - On 5/24/21 at 7:08 P.M., resident has large blister on the top of his/her foot, covers entire top of left foot, stands about 3.5 inches tall clear, instructed resident to keep it up so not to rupture blister; - On 5/25/21 at 4:46 P.M., the resident verbalized being upset about insulin changes, blood sugar of 498 and medication given, resident has black toe on left foot, very large blister on top of left foot, and necrotic area on right heel; at 8:00 P.M. blister on left foot broke with large odorous fluid drained out, blood sugar reading was 518, contacted the Nurse Practitioner (NP) and new orders obtained; - On 5/25/21 at 7:00 P.M., [MEDICATION(S)] (insulin) 25 units given per NP order for blood sugar 519 and to implement sliding scale; - On 5/25/21 at 7:37 P.M., resident has sore on his/her left great toe questionable gangrene and will not keep it up, dressing changed, wounds cleansed; - On 5/25/21 at 8:05 P.M., 445 glucose now; - On 5/28/21 at 8:24 P.M., reviewed resident's medications with his/her home medications, notified physician via fax regarding medications, waiting for response. - No documentation of the physician notification of the resident's blood sugar readings when over 351 on 5/24/21 and 5/25/21 at 8:00 AM and 11:30 A.M. Record review of a fax sent to the resident's physician, dated 5/28/21, showed: - Request to reinstate [MEDICATION(S)] 100 u/ml 55 units SQ twice a day; - Blood sugar readings from 5/19/21 through 5/28/21 faxed. Review of the resident's May 2021 progress notes, showed: - On 5/29/21 at 7:37 P.M., diabetes mellitus and high blood sugars; - On 5/30/21 at 11:02 A.M., left heel dressing changed, very odorous, left leg very edematous and beginning to blister, right foot dressing changed, right leg very edematous with blister forming; - On 5/30/21 at 6:42 PM., resident called 911, resident's blood sugar 301, resident upset, resident wants insulin from prior admission, ambulance arrived, explained ambulance would take him/her to emergency room and then bring him/her back to facility, resident wanted to go to wound clinic where they knew him/her, resident refused ambulance, and signed himself/herself out against medical advice; - No documentation of physician notification of the resident's blood sugar readings of 451 on 5/30/21; - No documentation of sliding scale insulin administration. Record review of the facility's Weekly Wound Reports binder, showed no weekly reports for May 2021. The facility provided no documentation of ongoing wound assessments that included wound descriptions and measurements, ongoing monitoring, weekly skin assessments, and notification of the resident's physician for changes in the resident's skin condition. During an interview on 6/9/21 at 11:12 A.M., LPN C said the resident did have high blood sugar readings at times. The resident did not have any routine insulin orders. The resident only had an as needed insulin order. The resident was not having any symptoms of high blood sugar. He/she said the Director of Nursing (DON) told him/her she was taking care of obtaining routine insulin orders for the resident. LPN C said he/she did not contact the resident's physician because the DON was taking care of it. He/she did not know the facility's policy on when to contact the physician for a resident's elevated blood sugar readings. During an interview on 6/7/21 at 12:32 P.M., LPN A said he/she called the NP (unknown date and time) regarding the resident's elevated blood sugar of 518 per progress note The NP ordered a one-time dose of insulin to be given now, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she does not recall calling the physician or the NP for the resident's elevated blood sugar readings other than the one time. If the physician or the NP was contacted, it would be documented in the resident's progress notes. If a resident does not have a parameter to call the physician for an elevated blood sugar reading then he/she would notify the physician if the resident's blood sugar was over 300. LPN A was unsure of the facility's policy. During an interview on 6/7/21 at 2:40 P.M., the DON said he/she was not sure why the resident did not receive his/her [MEDICATION(S)] as ordered by the physician. She said if it is not documented then it was not done. The resident was upset regarding not receiving [MEDICATION(S)]. On 5/28/21, she talked with the resident and faxed the physician with a request to restart the resident's [MEDICATION(S)] along with the resident's blood sugar readings. The physician had not responded prior to the resident's discharge. She expects nurses to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She expects nurses to contact the physician if the resident's blood sugar is over the sliding scale limit or if blood sugar is over 300 and no sliding scale order. The facility does not have a policy on when to contact the physician for elevated blood sugar readings. She expects the admission nurse to contact the physician if a resident is diabetic and has no orders for blood sugar monitoring. During a telephone interview on 6/9/21 at 8:35 A.M., the NP said a nurse from the facility contacted him/her regarding the resident's elevated blood sugar reading, but was unable to recall the day. The nurse said the resident did not have any current insulin orders. On 5/25/21, he/she gave a one-time order for insulin to be given and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she expects to be contacted if the resident's blood sugar is over 300 unless the resident has a sliding scale order then the staff should follow the parameter set by the sliding scale. He/she expects nurses to follow sliding scale orders as directed. During an interview on 6/7/21, at 12:30 P.M., Licensed Practical Nurse (LPN) A said the resident admitted to the facility with an open area on right heel and black toes on both feet. The resident did not receive any routine wound care, because the resident did not have any wound treatment orders. LPN A did not contact the physician for orders because it is the wound nurse's responsibility. Later on, the resident developed a large blister on the top of the left foot that ruptured and had foul smelling drainage. After the blister ruptured, LPN A placed a non-adhesive dressing over the area even though the resident did not have any orders. It is the facility's policy to have physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound nurse was aware of the large blister and responsible for contacting the physician. LPN A contacted the NP on the day the blister ruptured for other concerns, but did not notify the NP of the resident's open blister or need for wound care orders. Nurses are responsible for documenting an assessment every time a dressing change is performed, but since the resident did not have any wound care orders no assessments would have been completed by the nurse. Nurses are also responsible for performing weekly skin assessments and documenting on the weekly skin assessment form. Any new skin issues, the nurse is to notify the wound nurse. LPN A did not recall performing any skin assessments for the resident. Any wound care that is performed should be documented on the resident's TAR or progress notes. The nurse should document in the resident's progress notes if the physician was notified. He/she relies on the resident's TAR to know when wound care is needed. The nurse who admits a new resident is responsible for the admission skin assessment, ensuring orders are transcribed onto the POS, MAR and/or TAR, and notifying the wound nurse if any wounds. The nurse who receives a new or change in orders from the physician is responsible for entering into the computer. During a telephone interview on 6/17/21 at 12:45 P.M., Registered Nurse (RN) B said he/she took care of the resident shortly after the resident admitted to the facility. The resident had black areas on both big toes and right heel with no signs or symptoms of infection. He/she did not see any orders on the resident's POS or TAR so reviewed the resident's discharge instructions and found a order for wound care. Wound care was provided according to the discharge instructions, but did not document a wound assessment or the wound care provided. He/she thought the Wound Nurse was taking care of getting the orders onto the resident's POS and TAR. The admission nurse is responsible for admission skin assessment and transcribe orders into the resident's POS, MAR, and TAR. RN B relies on the POS, MAR, and TAR being accurate in order to know how to care for residents. Nurses are responsible for weekly skin assessments and to notify Wound Nurse if a new or change to a wound. During an interview on 6/7/21 at 2:36 P.M., the DON said the resident did not have any wound care documented on his/her TAR because the resident had no wound care orders. If staff performed any wound care they would have documented on the resident's TAR or progress notes. She said if the care is not documented it is not done. The admission nurse must have missed the treatment order on the resident's hospital discharge instructions. The nurse who admits a new resident is responsible for completing an admission skin assessment including a description of any wounds, accurately transcribe orders onto the resident's POS, and contact the physician if wound care orders are needed. The DON said nurses are responsible for ensuring assessments and wound treatments are completed, however she said the facility currently did not have a system in place to double check orders. She expects nurses to perform weekly skin assessment and notify the physician of any changes. She expects nurses to perform wound care as ordered by the physician. The DON said she had not been reviewing residents' wound care orders or treatment records. During an interview on 6/7/21 at 2:48 P.M., the Assistant Director of Nursing (ADON)/Wound Nurse said the nurses are responsible for assessing and documenting including wound measurements on each resident's wounds. Nurses are responsible for monitoring and notifying the physician for any changes. Nurses are responsible for assessing if wound treatments are effective or need to be changed. She said she is like a consultant to the nurses if they have any questions or concerns. She does not routinely assess or review assessments for residents with wounds and has not been filling out any weekly wound reports. Resident #1 was admitted with wounds, but she never saw them. The resident did tell her that he/she was upset because the nurses were not performing wound care and he/she was supposed to have [MEDICATION(S)] on wounds. She told the nurses to start putting [MEDICATION(S)] on the resident's wounds, but did not check to see if the resident had any wound care orders. The nurses are responsible for performing weekly skin assessments and notifying the physician of any changes. During a telephone interview on 6/9/21 at 8:30 A.M., the NP said the facility did not notify him/her of any concerns with Resident #1's wounds. He/she was not made aware of any wound concerns until he/she received an after hours phone call from the resident's family member the weekend the resident discharged from the facility. NP was not made aware the resident had no wound care orders or had developed a large blister. He/she called the facility, but the resident was already discharging. He/She expects the nursing home to contact him/her for any changes in the resident's condition, for wound care orders, and to provide wound care as ordered. During a telephone interview on 6/17/21 at 8:59 A.M., the NP said he/she saw the resident at the facility one time and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she was not notified the resident refused the wound care appointment. During a telephone interview on 6/17/21 at 11:00 A.M., the ADON/Wound Nurse said she did assess the resident's wounds when the large blister formed on top of his/her foot. The blister was intact and did not require a dressing. She did not contact the physician, because she did not think the blister required any treatment. During a telephone interview on 6/17/21 at 1:10 P.M., the DON said until last week the weekly wound reports had not been completed by the wound nurse. She was unable to recall prior to last week when the last time the wound reports had been completed. It was the responsibility of the nurses to monitor each resident's wounds and contact the physician when needed. She expects the nurses to assess each wound, document a description, provide wound care as ordered, and notify the physician of any new or changes to existing wounds. 3. Record review of Resident #4's Hospital History and Physical, dated 4/29/21, showed the resident with diabetic foot ulcers. Record review of the resident's Hospital After Visit Summary (discharge instructions), dated 4/29/21 through 5/7/21, showed: - No wound care instructions; - [MEDICATION(S)] 100 u/ml 10 units SQ three times a day; - [MEDICATION(S)] 100 u/ml 25 units SQ two times a day. Record review of the resident's baseline care plan, undated and unsigned, showed: - Resident communicates easily with staff; - Resident diabetic; - Current skin integrity issues with no wound descriptions. Record review of the resident's Admission MDS, dated [DATE], showed: - Cognitively intact; - Diabetic foot ulcers; - Received insulin injections four days out of the last seven days. Record review of the resident's POS, dated 6/22/21, showed: - admitted to the facility on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - An order on 5/7/21 for [MEDICATION(S)] 10 units SQ three times a day; - An order on 5/7/21 for [MEDICATION(S)] 25 units SQ two times a day; - An order on 5/10/21 for weekly skin integrity assessments every day shift on Fridays; - An order on 6/1/21 for accucheck before meals and at bedtime. (No order for blood sugar monitoring prior to 6/1/21 and no guidelines for when to call the physician). - An order on 6/2/21 to cleanse left heel with wound cleanser, apply [MEDICATION(S)] (a topical medication to treat skin infections), skin prep (a protective wipe), and [MEDICATION(S)] (a moisture barrier cream) to periwound (area around wound); apply [MEDICATION(S)] and santyl (a topical medication used to break up and remove dead skin and tissue) to wound bed, cover with kerlix (gauze wrap) or kerracel AG (absorbent dressing) for heavy weeping every day shift and every 6 hours as needed. - An order on 6/2/21 to cleanse left lateral foot with normal saline or wound cleanser, apply [MEDICATION(S)] (a topical medication to treat wound infections) to wound bed, cover with calcium alginate (an absorbent dressing) for heavy weeping, if not place abdominal (abd) pad, secure with 4 x 4 (gauze pad), and gauze wrap every day shift on Mondays, Wednesday, and Friday and every 6 hours as needed when soiled; - An order on 6/18/21 to cleanse wound to right upper thigh above bend of knee with wound cleanser, apply skin prep to wound edges, apply duoderm, change every 3 days and as needed; - No order for the resident's five times a week hyperbaric (a decompression chamber to promote wound healing) therapy and the resident's weekly wound clinic appointments. Record review of the resident's May 2021 MAR, showed: - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - Assessment not performed on 5/14/21; - Assessment marked as completed on 5/21/21 and 5/28/21. Record review of the resident's medical chart, dates 5/7/21 trough 6/8/21, showed no documentation of assessments on skin integrity assessment forms or in progress notes. Record review of the resident's May 2021 LNAR, showed: - The resident's blood sugar readings over 300: - On 5/10/21 blood sugar at 6:00 A.M. 304, at 11:00 A.M. 333, and at 4:00 P.M. 443; - On 5/11/21 blood sugar at 4:00 P.M. 347; - On 5/12/21 blood sugar at 4:00 P.M. 357; - On 5/14/21 blood sugar at 4:00 P.M. 356; - On 5/18/21 blood sugar at 4:00 P.M. 362. Record review of the resident's June 2021 LNAR, showed: - No blood sugar readings: - On 6/3/21 at 6:00 A.M., 6/9/21 at 6:00 A.M., and 6/14/21 at 6:00 A.M., no blood sugar monitoring; - From 6/1/21 through 6/22/21, blood sugar not obtained 3 times out of 85 opportunities; - Resident's blood sugar readings over 300: - On 6/8/21 blood sugar at 8:00 P.M., 340; - On 6/19/21 blood sugar at 6:00 A.M., 378. Record review of the resident's May 2021 TAR showed no wound treatment orders or wound care provided. Record review of the resident's progress notes, dated 5/7/21 through 6/18/21, showed: - On 5/7/21 7:39 P.M., resident has [CONDITION(S)] on left lower leg and also has some ulcers on left foot; - On 5/12/21 at 12:31 A.M., diabetic foot wound; - On 6/6/21 at 5:58 A.M., resident's blood sugar 137, requested insulin be administered after breakfast, will report to oncoming day shift nurse; - On 6/9/21 at 2:58 P.M., resident wound present on right posterior thigh. Resident voiced began as psoriasis and then opened. Measured 3.5 cm by 3 cm, red macerated edges, yellow slough and 1 cm of eschar in center of wound, will contact physician for wound care; Record review of the resident's progress notes, dated 5/7/21 through 6/18/21, showed: - On 6/12/21 at 5:59 P.M., cleanse wound with [MEDICATION(S)], apply skin prep, apply duoderm, change every 3 days and as needed, wound care done, (location not noted); - On 6/16/21 at 1:43 A.M., left lateral foot wound care administration note; - No documentation of the resident's right posterior upper thigh wound; - No documentation of physician notification; - No documentation of skin integrity assessments completed; - No documentation of the resident attending hyperbaric therapy or wound clinic services; - No documentation the physician notified of blood sugar readings over 300 on 5/10/21, 5/11/21, 5/12/21, 5/14/21, 5/18/21, and 6/8/21. Record review of the resident's June 2021 TAR, showed: - An order on 6/2/21 for wound care to left heel, dressing change not performed on 6/16/21, 6/18/21, and 6/19/21(missed 3 times out of 20 opportunities); - An order on 6/2/21 for wound care to left lateral foot, dressing change not performed on 6/2/21, 6/4/21, 6/16/21, and 6/18/21 (missed 4 times out of 9 opportunities); - An order on 6/18/21 for wound care to right upper thigh, dressing change not performed on 6/19/21 (missed 1 out of 1 opportunities); - An order on 6/18/21, weekly skin integrity assessment every Friday, assessment not performed on 6/18/21 (missed 1 out 1 opportunities). Record review of the resident's physician note, dated 5/10/21, showed left heel wound and seeing wound clinic. Record review of the resident's wound care center note, dated 5/21/21, showed: - Left heel, diabetic ulcer, acquired on 8/5/20 (best known date), measured 4.6 centimeters (cm) by 7.5 cm by 0.4 cm; - Left lateral foot, diabetic ulcer, acquired on 9/22/20 (best known date), measured 2.8 cm by 2.9 cm by 0.3 cm; - Left middle lateral foot, diabetic ulcer, acquired on 5/14/21 (best known date), measured 0.8 cm by 1.0 cm by 0.1 cm; - Wound care order for left lateral foot cleanse with normal saline or wound cleanser, apply [MEDICATION(S)] to wound bed, cover with calcium alginate for heavy weeping, if not place abd pad every 2-3 days and as needed; - Wound care order for left heel cleanse with wound cleanser, apply [MEDICATION(S)], skin prep and [MEDICATION(S)] to peri wound, apply [MEDICATION(S)] and santyl to wound bed, cover with kerracel AG for heavy weeping, cover, and secure with kerlix change daily and as needed. Observation on 6/8/21 at 11:05 A.M. of the resident wound care, showed: - The resident

Based on interview and record review, the facility failed to ensure three residents (Resident's #1, #4, and #7) were free of significant medication errors when staff did not administer medications as ordered by the physician. The facility census was 62. Record review of the facility's Medication and Treatment Orders policy, dated July 2016, showed: - Orders for medications and treatments will be consistent with principle of safe and effective order writing; - Drug and biological orders must be recorded on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's Diabetes policy, dated September 2017, showed: - For resident's with confirmed diabetes, the nurse shall assess and document/report the dose and time of most recent anti-hyperglycemic (medication used to lower glucose levels in the blood) given and all other current medications; - The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. Record review of the facility's Nursing Care of the Resident with Diabetes Mellitus policy, dated December 2015, showed: - The management of individuals with diabetes mellitus should follow relevant protocols and guidelines; - Assist the resident with his or her specific medication regimen, as ordered, and as needed. 1. Review of Resident #7's hospital discharge orders, dated 3/12/21, showed: -[MEDICATION(S)] (antibiotic) 500 milligrams (mg) three times a day for 7 days. -[MEDICATION(S)] (antibiotic) 100 mg twice a day for 7 days. -[MEDICATION(S)] (antibiotic) 300 mg twice daily for 7 days. -Oral [MEDICATION(S)] (antibiotic) 125 mg every 6 hours for 21 days. -Infectious disease follow-up for further prescriptions/recommendations. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -admitted on [DATE]; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 300 mg 2 capsules via G-tube three times a day every 7 days; -[MEDICATION(S)] 100 mg via G-tube two times a day every 7 days; -[MEDICATION(S)] 300 mg 1 capsule via G-tube two times a day every 7 days; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Review of the Medication Administration Record (MAR) dated March 2021, showed: -[MEDICATION(S)] 300 mg 2 capsules via G-tube three times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 100 mg via G-tube two times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 300 mg 1 capsule via G-tube two times a day every 7 days. Administered on 3/13/21 and 3/20/21; -[MEDICATION(S)] 2.5 ml via G-tube three times a day every 21 days. Administered once on 3/13/21. Record review showed the POS and the MAR, all dated 3/12/21, did not match the hospital discharge orders. The [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were only given every seven days and the [MEDICATION(S)] was given every 21 days. Review of Resident #7's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/21, showed: -Cognition intact with BIMS (Brief Interview for Mental Status) score of 14; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Ulcer presents as a deep crater with or without undermining of the adjacent tissue); pressure ulcer of left heel, unstageable; -Extensive assistance of two or more staff with activities of daily living (ADLs), total dependence of staff for dressing and supervision for eating; -Indwelling urinary catheter (hollow tube inserted through the urethra into the bladder to drain the bladder of urine); -Two Stage 2 pressure ulcers; -Three Stage 3 pressure ulcers. Record review of the resident's progress notes dated 3/23/21 at 4:12 P.M., showed: -Resident on telehealth visit with physician and showing signs of sepsis; -Resident complained of vomiting, chills, and abdominal pain; -Resident sent to the emergency room . Record review of the hospital admission record dated 3/23/21, showed the resident was admitted with a severe urinary tract infection and skin/soft tissue infection. Record review of the resident's hospital discharge record, dated 3/26/21, showed: -[MEDICATION(S)] 750 mg daily for 10 days; -[MEDICATION(S)] 50 mg/ml - administer 2.5 ml per feeding tube every 6 hours for 21 days. Record review of the resident's Physicians Orders Sheet (POS) dated 3/26/21, showed orders which read: -[MEDICATION(S)] 750 mg daily for 10 days; -[MEDICATION(S)] 2.5 milliliters (ml), via Gastric (G)-tube, three times a day every 21 days. Per the hospital discharge orders, the [MEDICATION(S)] should have been administered four times daily for 21 days, not every 21 days. Record review of the resident's Medication Administrator Record (MAR), dated March 2021, showed: -[MEDICATION(S)] 750 mg daily for 10 days. Started 3/27/21 and completed 4/7/21; -[MEDICATION(S)] 2.5 milliliters (ml) via G-tube three times a day every 21 days. Administered only one dose on 3/13/21. Record review of the POS, dated April 2021, showed: -No order for [MEDICATION(S)]. Record review of the MAR, dated April 2021, showed: -No order for [MEDICATION(S)]. Record review of the resident's progress note, dated 4/8/21 at 2:11 P.M. showed: -Pharmacy review: [MEDICATION(S)] order from 3/27/21 is not showing on any of the MARs to be signed off as given. Called facility and spoke with Assistant Director of Nursing (ADON); - Signed off by the pharmacist. During an interview on 6/22/21 at 5:00 P.M., the ADON said if the [MEDICATION(S)] order was not on the POS or MAR and signed off then it was not given. He/she does not remember speaking with the pharmacist regarding the order not showing up on the MAR. During an interview on 6/17/21 at 3:23 P.M., the Director of Nursing (DON) said he/she would expect the nurse receiving the orders to enter them into Point Click Care (PCC). She expects admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's medication transcription errors from the hospital discharge summary should have been identified if two nurses verified the orders being entered. During an interview on 6/17/21 at 6:00 A.M., Registered Nurse (RN) E said he/she had provided care for Resident #7, but was unable to recall any orders for [MEDICATION(S)]. RN E said orders should be on the POS, MAR or TAR so that the nurse knows the resident is to receive medications or treatments. He/she said if orders are not signed off as completed then it was not done. During an interview on 6/17/21 at 3:45 P.M., Licensed Practical Nurse (LPN) said orders should be put in PCC and signed off or it would look like it was not done. If orders were not on the POS, MAR or Treatment Administrator Record (TAR), the nurse would have to rely on being told in shift report to perform the treatments and what the treatments are. Two nurses are expected to enter all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/18/21 at 2:17 P.M., RN F was unable to recall orders for [MEDICATION(S)] for Resident #7 from 4/05/21-6/1/21, as there were no orders on the POS, MAR or TAR at the time. RN F said sometimes orders get passed along during shift report, but it is the nurse's responsibility to enter the order into PCC. He/she said that orders should be signed off in the PCC so that it shows the order was completed. It is expected for two nurses to enter admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Record review of Resident #1's Hospital After Visit Summary (Discharge Instructions), dated 5/10/21 through 5/17/21, showed: - [MEDICATION(S)] (insulin) 100 units/milliliter (u/ml): inject 55 units by subcutaneous (SQ) injection two times daily; - [MEDICATION(S)] (insulin) sliding scale SQ three times a day with meals: - If blood sugar 0-60 give glucogel (used to treat low blood sugar); - 61-150 give no insulin; - 151-250 give 3 units; - 251-350 give 6 units; - Over 351 give 9 units, call physician. Record review of the resident's baseline care plan, dated 5/19/21, showed: - The resident can communicate easily with staff; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - The baseline care plan did not indicate the resident required insulin. Record review of the resident's Admission MDS, dated [DATE], showed: - The resident was cognitively intact; - Required supervised to limited assistance with activities of daily living (ADL); - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident received insulin injections two days out of the last seven days. Record review of the resident's POS, dated 6/7/21, showed: - admitted to facility on 5/17/21; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - An order on 5/18/21 for [MEDICATION(S)] 100 u/ml inject 55 units SQ two times a day. This order was discontinued on 5/25/21; - A one time order, written on 5/25/21, for [MEDICATION(S)] (insulin) 25 units; - An order on 5/25/21, with start date of 5/26/21, for Novolog (insulin) injection, to be given SQ per sliding scale, two times a day for elevated blood sugar: - If blood sugar 200-250 give 3 units; - 251-300 give 6 units; - 301-350 give 9 units; - 351-400 give 12 units; - 401-450 give 15 units; - 451 and above call the physician; - Hospital discharge instructions for [MEDICATION(S)] sliding scale not on POS. Record review of the resident's May 2021 Licensed Nurse Administration Record (LNAR), showed: - [MEDICATION(S)] 55 units twice a day was not documented as administered 7 times out of 15 opportunities - 5/19/21 at 8:00 P.M., 5/20/21 at 8:00 A.M. and 8:00 P.M., 5/21/21 at 8:00 A.M. and 8:00 P.M., and 5/22/21 at 8:00 A.M. and 8:00 P.M.; - Resident's blood sugar readings that met sliding scale criteria: - On 5/25/21 blood sugar at 8:00 A.M. 498, at 11:30 A.M. 498, at 4:30 P.M. 519, and at 8:00 P.M. 367; - On 5/26/21 blood sugar at 6:30 A.M. 389, at 11:30 A.M. 293, at 4:30 P.M. 364, and at 8:00 P.M. 437; - On 5/27/21 blood sugar at 6:30 A.M. 410, at 11:30 A.M. 420, and at 4:30 P.M. 387; - On 5/28/21 blood sugar at 11:30 A.M. 426, at 4:30 P.M. 432, and at 8:00 P.M. 324; - On 5/29/21 blood sugar at 6:30 A.M. 268 and at 11:30 A.M. 386; - On 5/30/21 blood sugar at 11:30 A.M. 386 and at 4:30 P.M. 451. Record review showed the sliding scale Novolog was not given as ordered 10 times out of 10 opportunities from 5/26/21 through 5/30/21. Record review of the resident's nursing admission/readmission note, undated and unsigned, showed: - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident is complaintive about medications and change of insulin. Record review of the resident's May 2021 progress notes, showed: - On 5/25/21 at 4:46 P.M., the resident verbalized being upset about the change in his/her insulin. At 8:00 P.M. the resident's blood sugar was 498 and insulin was given. The resident's blood sugar was rechecked at 8:00 P.M., with a reading of 518. The Nurse Practitioner (NP) was contacted and a new order was obtained; - On 5/25/21 at 7:00 P.M., [MEDICATION(S)] (insulin) 25 units was given, per NP order, for a blood sugar of 519 and orders received to implement sliding scale; - On 5/25/21 at 8:05 P.M., the blood sugar was repeated with a reading of 445; - On 5/28/21 at 8:24 P.M., the resident's current medication orders were compared with his/her home medications. The physician was notified, via fax, regarding medications, waiting for response; - On 5/30/21 at 6:42 P.M., the resident's blood sugar was 304 which upset the resident. The resident wants insulin from his/her prior admission. The resident signed himself/herself out against medical advice. Review of the resident's progress notes showed no documentation of the administration of sliding scale insulin as per order. Record review of a fax, dated 5/28/21, sent to the resident's physician, showed a request to reinstate the [MEDICATION(S)] Insulin 100 u/ml 55 units SQ twice a day and included the blood sugar readings from 5/19/21 through 5/28/21. Record review of a note written by the DON, dated 6/10/21, showed: - On 5/28/21 around 8:00 P.M., the resident was upset regarding his/her medications; - The resident believed his/her medications were not correct and was upset the hospital had changed them; - The resident provided a hand written list of medications he/she was taking prior to the hospital stay and wished for his/her medications to be returned to prior orders; - The DON reviewed and compared the home medication list with hospital discharge orders; - A fax sent to the physician with request to reinstate [MEDICATION(S)] 55 units SQ two times a day. During an interview on 6/7/21 at 12:30 P.M., LPN A said he/she called the NP regarding the resident's elevated blood sugar reading. The NP ordered a one-time dose of insulin to be given immediately, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A does not recall administering sliding scale after the order was received. If sliding scale was given, it would be documented on the resident's MAR or progress notes. He/she did not know why the resident's sliding scale had not been administered as ordered. The resident did not have any symptoms when the blood sugar was elevated. During an interview on 6/7/21 at 2:36 P.M., the DON said she was not sure why the resident did not receive his/her [MEDICATION(S)] as ordered by the physician or why it was discontinued. She said if it is not documented then it was not done. The resident was upset regarding not receiving [MEDICATION(S)]. On 5/28/21, she talked with the resident and faxed the physician along with resident's blood sugar readings. The physician had not responded prior to the resident's discharge. She did not know why the nurses did not document any administration of sliding scale insulin on the resident's MAR or progress notes. She expects nurses to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/9/21 at 8:30 A.M., the NP said a nurse from the facility contacted him/her regarding the resident's elevated blood sugar reading. The nurse said the resident did not have any current insulin orders. He/she gave a one-time order for insulin to be given now and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident is currently on a routine dose of insulin then he/she would use the sliding scale order to supplement the routine insulin order. He/she did not discontinue the resident's [MEDICATION(S)] order. It would not have made sense to discontinue a routine insulin order when the resident's blood sugar is high. The NP found out the resident had been on [MEDICATION(S)] when he/she received an after hours phone call from the resident's family member the weekend the resident was discharging from the facility. The family member was upset because the nurse at the facility had told him/her that the NP had discontinued the resident's [MEDICATION(S)] order. The NP called the facility and was unable to obtain accurate information from the facility regarding the resident's insulin orders. He/she was informed by the nurse the resident was discharging from the facility. The NP only recalls being contacted one time regarding the resident's elevated blood sugar readings. No other physicians or NPs in his/her practice had been contacted. He/she expects nurses to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/9/21 at 11:12 A.M., LPN C said the resident did have high blood sugar readings at times. The resident did not have any routine insulin orders. The resident only had an as needed insulin order. He/She said the DON told him/her, she was taking care of obtaining routine insulin orders for the resident. If he/she had given any as needed insulin, he/she would have documented on the resident's MAR. LPN C was unable to recall if he/she had given the resident any insulin. During an interview on 6/17/21 at 12:33 P.M., RN D did not recall if he/she administered any sliding scale insulin to the resident. If sliding scale insulin had been administered, it would have been documented on the resident's MAR. If the physician had been contacted, it would have been documented in the resident's progress notes. RN D did not know why the resident's [MEDICATION(S)] or sliding scale insulin was not administered as ordered, or why it was discontinued. 3. Record review of Resident #4's POS, dated 6/22/21, showed: - admitted to the facility on [DATE]; - An order on 5/7/21 for [MEDICATION(S)] 25 units SQ two times a day; - An order on 5/7/21 for [MEDICATION(S)] 10 units SQ with meals. Record review of the resident's Admission MDS dated [DATE], showed: - The resident cognitively intact; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident received insulin injections four days out of the last seven days. Record review of the resident's baseline care plan, undated and unsigned, showed: - Resident communicates easily with staff; - Resident diabetic; - The baseline care plan did not indicate the resident required the use of insulin. Record review of the resident's May 2021 LNAR, showed: - [MEDICATION(S)] 25 units was not initialed to show it had been administered: 5/9/21 at 6:00 A.M.; 5/20/21 at 6:00 A.M.; 5/25/21 at 6:00 A.M.; 5/26/21 at 6:00 A.M.; 5/28/21 at 6:00 A.M. [MEDICATION(S)] was not documented as administered 5 times out of 48 opportunities; - [MEDICATION(S)] 10 units was not initialed as administered: 5/9/21 at 6:00 A.M., 11:00 A.M., 4:00 P.M.; 5/20/21 at 6:00 A.M.; 5/25/21 at 6:00 A.M.; 5/26/21 at 6:00 A.M.; 5/28/21 at 6:00 A.M. [MEDICATION(S)] was not documented as administered 7 times out of 72 opportunities. Record review of the resident's June 2021 LNAR, showed: - [MEDICATION(S)] 25 units was not initialed as administered: 6/1/21 at 6:00 A.M.; 6/3/21 at 6:00 A.M.; 6/6/21 at 6:00 A.M.; 6/7/21 at 6:00 A.M.; 6/9/21 at 6:00 A.M.; 6/14/21 at 6:00 A.M. [MEDICATION(S)] was not documented as administered 6 times out of 43 opportunities. - [MEDICATION(S)] 10 units not initialed as administered: 6/1/21 at 6:00 A.M.; 6/3/21 at 6:00 A.M.; 6/6/21 at 6:00 A.M.; 6/7/21 at 6:00 A.M.; 6/9/21 at 6:00 A.M.; 6/14/21 at 6:00 A.M. [MEDICATION(S)] was not documented as administered 6 times out of 64 opportunities. During an interview on 6/17/21 at 11:24 A.M., LPN J said if a resident's MAR has a blank spot then the medication was not administered. If there is a reason for not giving a medication, then the nurse would mark a code and document in the resident's progress note. He/she did not know why the resident's insulin was not administered as ordered. During an interview on 6/17/21 at 1:10 P.M., the DON said she would expect nurses to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She would expect nurses to document on the MAR or progress note why medication not given. Complaint MO# 998

Based on observation, interview and record review, the facility failed to provide protective oversight by ensuring one confused resident (Resident #1) of four sampled residents at risk for elopement did not leave the facility without supervision. The facility identified five residents at risk for elopement. Resident #1 exited the facility through an alarmed door without staff knowledge. The resident walked across the facility grounds, through two neighboring back yards, crossed a street and went into a neighbor's house. The facility census was 73. 1. Record review of the Physician's Order Sheet (POS), dated 7/29/11, showed Resident #1 entered the facility on 1/14/11 and had [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated instrument required to be completed by facility, dated 7/20/11, showed the following: -[DIAGNOSES REDACTED]. -Long and short term memory problem. -Moderately impaired cognitive skills for daily decision making. -Wandered one to three days a week. -Wears glasses. -Sometimes understands-responds adequately to simple, direct communication only. -Uses a cane for mobility, but independent in all areas of activities of daily living. -One fall since admission. Record review of Resident #1's plan of care (POC), updated on 7/21/11, showed: -[DIAGNOSES REDACTED]. -The resident at risk to try and leave the building. -The nursing staff should involve the resident in activities. -The Wanderguard alarm should be on at all times and redirect the resident if elopement is attempted. Record review of a psychiatric progress note, dated 6/2/11, showed Resident #1 as markedly mentally ill, calm, not irritable, easily redirectable and compliant with medications and activities of daily living. Record review of the wandering/elopement assessment, dated 1/15/11, showed Resident #1 at risk for wandering and elopement. Review of the nurses' notes, dated 6/12/11 at 2:30 P.M., showed the resident exited the building through the front door. The Wanderguard alarm activated and staff brought Resident #1 back into the facility, diverted his/her attention and called the family. Review of the nurses' notes, dated 8/6/11 at 4:55 P.M., showed staff could not locate the resident. A search was initiated of the inside of the facility and out the exit doors. Staff walked the perimeter of the building. While still searching, the facility received a telephone call from a neighbor to inform them of seeing an elderly person in their backyard. The neighbor brought the resident into their house. A Certified Nurse Aide (CNA) was sent to get the resident. The resident said that he/she was going to find a relative. The resident returned to the facility willingly. The resident said he/she almost fell , but didn't. A head to toe assessment revealed no skin issues, no bruising, no scratches, no redness or swelling. Resident was pleasant, but upset. During an interview on 8/9/11 at 11:45 A.M., the Administrator said: -On the evening of 8/6/11, Licensed Practical Nurse (LPN) C was in charge of B and D Halls. -Resident #1 lived on B Hall. -On 8/6/11 at 4:45 P.M., the door alarm sounded on D Hall. -LPN C said she sent CNA D down to the D Hall solarium to check the door. LPN C said that CNA D had been assigned to the D-Hall. LPN C said CNA D told her that all of the residents from D-Hall were accounted for. -LPN C said other staff came to the desk and they all looked outside and did not see anybody. -LPN C said the alarm shut off on its own. -LPN C said ten minutes later CNA E, who had been assigned to B-Hall came to the nurse's station looking for Resident #1. LPN C said they began searching for Resident #1 at that time. -LPN C said a neighbor called five minutes later at 5:00 P.M. to tell them Resident #1 was at their house. -LPN C said he/she had not initiated a facility wide head count because the alarm shut off by itself. He/she assumed the alarm malfunctioned; they had looked around and did not see anyone outside. -LPN C said he/she had not been inserviced on how to handle a missing person situation. -There were two documents signed by LPN C, that he/she had been trained on the facility procedure to follow when the door alarms were activated. -All of the staff knows that if an alarm goes off, they are not supposed to stop looking until they know why the alarm sounded or if they cannot figure out why an alarm sounded, they should make sure all the residents are accounted for. During an interview on 8/9/11 at 11:00 A.M., the Director of Nursing (DON) said Resident #1 has early stage Alzheimer's. The DON said Resident #1 did not want to be admitted to the facility and often talked of leaving when he/she first arrived in the facility. The DON said the only time Resident #1 ever went out the door was on 6/12/11 and 8/6/11 and there were no new interventions implemented between 6/12/11 and 8/6/11. The DON said Resident #1 does like to walk around in the hallways of the facility, but usually does not attempt to go outside. During an interview on 8/9/11 at 4:30 P.M., CNA A said he/she had been assigned to B Hall. CNA A said on 8/6/11 he/she had last seen Resident #1 around 3:30 P.M., sitting in his/her rocking chair. CNA A said the resident did not appear to be upset about anything at that time. CNA A said around 4:45 P.M., the alarm sounded. CNA A said he/she walked out in the hall, looked toward the door on B Hall, didn't see anyone and proceeded toward the nurse's station. CNA A said he/she thought the alarm sounded like it was coming from the nurse's station. CNA A said he/she went toward the front door and out the door to look around and did not see anyone. He/She said after that, the alarm shut off and he/she went about his/her work. CNA A said 10 minutes later he/she could not find Resident #1 to walk to supper. CNA A said he/she went to the nurse's station and asked the charge nurse to check to see if Resident #1 was on leave of absence (LOA) with his/her family and they found out he/she had not been signed out on LOA. CNA A said that was when they all started checking rooms and some staff went outside. CNA A said five minutes later the neighbor called to say Resident #1 was over at their house. CNA A said he/she went to pick the resident up in his/her own car. CNA A said he/she made a point of asking the neighbor how long the resident had been over there and had been told 15 minutes. CNA A said that he/she knows to go toward the nurse's station whenever an alarm goes off. CNA A said none of the nurses told him/her to count the residents on his/her hall. During an interview on 8/10/11 at 3:30 P.M., LPN A said he/she was doing a tube feeding and giving medications when he/she was told that the D hall alarm sounded. LPN A said he/she did not hear the alarm sound. He/she said the intercoms are not in the patient's rooms and sometimes they can't hear what is said. During an interview on 8/10/11 at 3:45 P.M., CNA E said he/she never heard a door alarm sound because he/she was in a resident room. At 5:00 P.M., he/she was told a resident was missing, so he/she walked around the building, but did not see anyone. During an interview on 8/10/11 at 3:50 P.M., CNA D said he/she was taking a resident to dinner and the alarm sounded. CNA D went to the nurses' station to check the light panel and it showed the D hall door had alarmed. CNA D said she didn't see anyone go out that door. During an interview on 8/10/11 at 4:20 P.M., Graduate Practical Nurse (GPN) B said he/she is still in orientation and did not have a key to turn off any alarms. GPN B said he/she came to the nurse's station, looked out the front door and went down to the D Hall. No one could be seen outside. The GPN said when an alarm goes off the panel shows which door is open. He/she said they would call a code 10 over the intercom and announce which door is open. He/she said if they don't know who opened the door, staff is supposed to go to the nurse's station, they are given part of the census sheets and told to account for those residents in their area. Then code 10 is over when all the residents are accounted for. During a telephone interview on 8/18/11 at 9:00 A.M., LPN C said on 8/6/11 at 4:45 P.M., the alarm for D-Hall door went off. LPN C said he/she and CNA D were assigned to the D Hall and were at the nurse's station when the alarm sounded. LPN C sent CNA D to the D Hall to check the door. CNA D reported that all of the residents from D Hall were in the dining room waiting for supper. CNA D said no one was seen on that hall or outside. LPN C said the alarm shut off by itself. LPN C said CNA A, GPN B and CNA D all responded to the alarm. LPN C said he/she did not have a key to reset the alarm, LPN A had the key. She assumed that LPN A turned the alarm off. LPN C said she did not tell any of the staff to do a head count at that time. LPN C said he/she did not have a lot of time to think about it before CNA E came to the nurse's station looking for Resident #1. LPN C said once they figured out that Resident #1 wasn't in the building everyone started looking and five minutes later a neighbor called to say that Resident #1 was there. LPN C said he/she did not remember being trained on the alarms. LPN C said he/she had been a new graduate and did not know everything the seasoned nurse's take for granted. During a telephone interview on 8/24/11 at 10:00 A.M., the physician said he was aware the resident had eloped from the facility. He said the resident is a functional Alzheimer's patient and appropriately placed. He said the resident is very mobile and if the resident was placed on a secured unit his/her quality of life would deteriorate. He said the problem is with the facility not the resident. He said the resident needs supervision and can continue to live at the facility if the alarm system is fixed. Review of the facility elopement policy effective May 2001 showed the following: -Upon admission, each resident is assessed for the potential for elopement. -All residents at risk of elopement are assessed quarterly and as needed. -A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. -Door alarms are tested each shift at least once a month. -Testing of the system included not only that the alarms function, but also that staff respond appropriately to the alarms. -Only the executive director may authorize disabling the alarm system and is responsible for the method of monitoring for resident's safety and resetting the alarm. -All new employees are inserviced on elopement policy during orientation. -All new employees will be inserviced on elopement procedures annually. -The charge nurse is responsible for coordinating a building search followed by an immediate search of the facility grounds if a resident is discovered missing or an elopement is evident. Review of the facility policy for missing patients, undated, showed upon notification that a patient is missing the following procedures apply: -Notify the Administrator and the DON. -Assemble all department heads. -Organize and institute a thorough search of the nursing center and surrounding grounds and buildings. -Notify local law enforcement. -Recall off-duty personnel as needed. Review of a facility form, Preventing Elopement, signed by LPN C on 11/01/10 showed the following: -To help prevent elopement, you should know the facility's policy on activation and deactivation of the door alarms, how to report a suspected elopement and how to report resident behavior that may indicate they are risk for elopement. -If you suspect that a resident has eloped inform the charge nurse immediately. -The charge nurse alerts staff with an overhead page of Code 10. -The charge nurse initiates a search of the facility and grounds. -After the resident is located, the charge nurse uses an overhead page of Code 10 clear. Record review showed the facility policy and procedures for missing residents did not address what the staff was supposed to do when the door alarms activated. The policy starts upon notification a resident is missing, not with how to verify if a resident is missing after an alarm is activated. The policy did not include anything about the door alarms and verifying why the door alarms are going off. The policy did not address when the appropriate time would be to start accounting for all the residents. Review of the facility inservice book showed the facility inserviced staff on missing residents yearly. The inservices did not contain anything about how the alarms function and how staff would be expected to respond in a timely manner. During an interview on 8/9/11 at 11:00 A.M., the DON said she would expect for the nursing staff to know to do a head count if they did not know why a door alarm activated. The DON said they need to change the policy and procedure to include doing a head count immediately when staff do not know the reason an alarm is activated. The DON said all staff will be required to attend an inservice on door alarms and missing residents before they can start their next shift. The DON said the staff was inserviced yearly, but from now on they are going to have the alarm and missing resident inservice at least quarterly for all staff in the building. The DON said they need to turn up the volume on the alarms, so more staff can hear them from where ever they are working. Observation on 8/6/11, showed the resident exited out the D-Hall at the back of the facility. The resident travelled along a sidewalk that ran parallel with the facility building, he/she then walked through two neighboring back yards, crossed a residential street and entered a neighbor's yard. The resident then entered the neighbor's house invited. He/She travelled approximately two blocks and the temperature outside was 82 degrees. MO *The higher classification merited due to the extent of the violation and the impact on the resident. *NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility changed the policy to read when an alarm sounds, the charge nurse will take the central position at the main desk. Staff will immediately respond to determine the cause of the alarm. If the reason the alarm was activated becomes known, the charge nurse will be told immediately. If a resident is seen leaving the building, they will be escorted back into the building. If the cause of the alarm is unwitnessed, the charge nurse will announce a code 10 over the intercom. Each resident must be accounted for. The results of the head counts are communicated to the charge nurse. If all residents are accounted for, then the charge nurse will announce a code 10 all clear. All staff were to be inserviced by 8/12/11 on the changes. All existing policies and procedures pertaining to elopement were combined into one policy and procedure for clarity. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. The facility needs to ensure all staff receives the inservice training regarding monitoring and assessment of the residents who are at risk for elopement and utilize the new policies and procedures. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.