Every finding on record at Cedar Pointe

Based on interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility staff failed to ensure indoor and outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 65.1. Observations on 02/10/26 at 10:15 A.M. and 1:15 P.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. Observation on 02/11/26 at 9:00 A.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. Observations on 02/12/26 at 9:15 A.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. During an interview on 02/12/26 at 12:05 P.M., the maintenance director said he/she usually checks the outside dumpster at least once a day, but all staff who use the dumpster are responsible to maintain it and the lids should be closed when it is not in use. The maintenance director said all staff are trained to cover waste containers when not in use and he/she reeducates staff when he/she finds the lids open, but there continued to be constant problems with staff leaving the dumpster lids open. During an interview on 02/12/26 1:06 P.M., the administrator said he/she could not locate policy for maintenance of waste containers or the outside dumpster, but he/she and the maintenance director are responsible to maintain the outside dumpster as required. The administrator said the dumpster lids should be closed when it is not in use and if the maintenance director finds the dumpster lids open, he/she should close them and educate staff. The administrator said all staff should be trained to close the lids on the dumpster and any staff who put trash in the dumpster are responsible to close the lids when they are done. 2. Observation on 02/11/26 at from 10:09 A.M.to 10:35 A.M., showed a large waste container, which contained waste, uncovered in the mechanical dishwashing station and not in use by staff. During an interview on 02/12/26 at 11:00 A.M., the Dietary Manager (DM) said waste containers should be covered when not in actual use. The DM said he/she knew that he/she had discussed the need to cover the waste container by the cook's station with staff, but he/she may have not specifically discussed the one in the mechanical dishwashing station. During an interview on 02/12/26 1:06 P.M., the administrator said he/she could not locate a policy for the maintenance of waste containers, but he/she and the DM are responsible to maintain the kitchen waste containers are required. The administrator said all kitchen waste containers should be covered when not in use and staff are trained on this requirement.

Based on observation, interview, and record review, facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, address, phone numbers of the State Survey Agency (SA) and the name, address and phone number for the for the Long-Term Ombudsman in an accessible location for residents and visitors to view in the memory care unit. The census was 65. 1. Review of the facility's policies showed staff did not provide a policy for the required postings.Observation from 2/9/26 at 10:00 A.M., through 2/12/26 at 12:00 A.M., showed the facility did not post the name, address, and toll-free telephone number for the Elder Abuse Hotline or the name, address, and phone number for the Long-Term Care Ombudsman in an accessible location on the memory care unit for residents or visitors to use if needed. During an interview on 02/12/26 at 11:42 A.M., Certified Nurses Aide (CNA) H said he/she thinks the hotline line is posted by the nurses station on the memory care unit. He/She said he/she does not see it though. He/She said it should be posted on the memory care unit for residents and visitors. During an interview on 02/12/26 at 11:37 A.M., Licensed Practical Nurse (LPN) G said he/she thought the posting was by the nurse's station. He/She said he/she does not see one on memory care unit now. He/She said the hotline posting should be available for residents and visitors. During an interview on 02/12/26 at 11:56 A.M., the Director of Nursing (DON) said there is usually always one hanging up. He/She said a resident may have taken it down. He/She said it's important to have the hotline number posted so residents and visitors have access if needed. During an interview on 02/12/26 at 12:27 A.M., the administrator said there should be a hotline number posted on the memory care unit. He/she said it must have got taken down when they did cabinet work in the memory care unit and never got put back up. He/She said its importance for residents and visitors can call if needed.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for three residents (Resident #2, #22 and #50) out of 24 sampled residents. The facility census was 65.1. Review of the facility's policy titled, Care Planning Policy and Procedure, revised 01/17/20, showed the following:-Standard is to perform quality of care that applies to all treatment and care provided to facility residents;-Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices;-A Care plan will be updated quarterly, and annually per Centers for Medicare and Medicaid Services (CMS) guidelines to ensure that there is a continuity of care and is in accordance with the individual's needs; -Care plan will also be updated with a significant change of condition;-As the resident's status changes, the facility must review and/or revise care plan goals and treatment choices.2. Review of Resident #2's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 12/25/25, showed staff assessed the resident as:-Severe Cognitive Impairment;-Diagnosis of Non-Alzheimer's Dementia;-Taking antipsychotic medication. Review of Resident's Physician Order Sheet (POS), dated February 2026, showed the following orders:-Buspirone (used to treat generalized anxiety disorder) 5 milligram (mg) tablet, 1 tablet by mouth two times per day;-Lexapro (used to treat major depressive disorder) 20mg tablet, one tablet by mouth one time per day;-Seroquel (used to treat schizophrenia, bipolar disorder, and major depressive disorder) 50mg tablet, one tablet by mouth three times per day. Review of the resident's care plan, revised 11/10/25, showed staff did not document resident's Dementia or the use of antipsychotic medications along with interventions. 3.Review of Resident # 22's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and had a diagnosis of Alzheimer's Disease.Review of the resident's care plan, revised 11/06/25, showed staff did not document resident's Alzheimer's Disease along with interventions.4. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely Cognitively impaired;-Required supervision or touching assistance for sit to lying position, lying to sitting on bed side, sit to stand position, and chair/bed-to-chair transfer;-One fall with injury since admission/entry or prior assessment.Review of resident's Incident/Accident report, dated 11/26/25, showed resident was found on floor next to bed wrapped in bed sheets on right side.Review of residents Incident/Accident report, dated 12/19/25, showed resident was found on the floor by the nurse's station on her right side.Review of resident's care plan, revised 11/03/25, showed staff did not document residents falls on 11/26/25 and 12/19/25 with new interventions. 5. During an interview on 02/12/26 at 11:37 A.M., Licensed Practical Nurse (LPN) G said care plans are important, so staff know how to care for the resident. He/She said falls, dementia/Alzheimer's should be included on care plan.During an interview on 02/12/26 at 11:45 A.M., the Care Plan Coordinator said he/she knows to update the care plan by attending morning meetings where falls and important updates are discussed. He/She said falls, Dementia/Alzheimer's, and antipsychotic medication should be in care plan with interventions. He/She said the residents above must have got missed when updating. He/She said care plans are important, so staff know how to care for residents.During an interview on 02/12/26 at 11:54 A.M., the Director of Nursing (DON) said care plans are important to ensure all resident needs are met and staff know how to care for residents. He/She said care plans are updated by the care plan coordinator after morning meetings, after falls, change in conditions, and behaviors. He/She said falls with updated interventions should be included in care plan. He/She said Dementia/Alzheimer's along with antipsychotic should be included on care plan. During an interview on 02/12/26 at 12:27 P.M., the administrator said care plans are important for staff to know how to care for residents. He/She said the Care Plan Coordinator is responsible for ensuring care plans are accurate. He/She said information is gathered during morning meetings to update care plan. He/She said falls, Dementia/Alzheimer's, and antipsychotic medication should be included on care plan along with interventions.

Based on observation, interview and record review, facility staff failed to use enhanced barrier precautions ((EBP) infection control intervention designed to reduce transmission of multi-drug-resistant organisms) and/or failed to have EBP signs posted for three residents (Resident #14, #63, and #77) out of three sampled residents. The Facility Census was 65.1. Review of the facility's policy titled, Enhanced Barrier Precautions, undated, showed EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition like residents with wounds or indwelling medical devices. The gown and gloves will be outside the resident room for the staff to dawn before entering the room and staff will doff inside the room before exiting.2. Review of Resident #14's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 12/25/25, showed staff assessed the resident as:- Moderate Cognitive Impairment;- Three stage three pressure ulcers;- One unstageable pressure ulcer.Review of resident's Physician Order Sheet (POS), dated February 2026, showed a treatment order for every AM shift cleanse area to left hip with wound cleanser, pat dry, apply leptospermum honey (to treat chronic and acute wounds, burns, and ulcers), cover with xeroform (non-adherent, petrolatum-impregnated gauze dressing) and gauze, secure with island dressing.Observation on 02/09/26 at 2:25 A.M., showed the resident's room did not contain a posted EBP sign or supplies available.Observation on 02/10/26 at 2:04 P.M., showed resident in bed, the resident's room did not contain a posted EBP signs or supplies available.Observation on 02/10/26 at 2:19 P.M., showed Licensed Practical Nurse (LPN) D performed wound care on the resident's left hip and did not put a gown on.Observation on 02/11/26 at 8:45 A.M., showed resident in bed, the resident's room did not contain a posted EBP signs or supplies available.During an interview on 02/10/26 at 2:30 P.M., LPN D said residents who require EBP are catheters, and wound cares with drainage. He/She said resident does not have any active drainage at this time, so he/she did not think about wearing EBP. He/She said staff know who is on EBP by a sign and supplies on their door, said resident does not have EBP sign on door currently. He/She the importance of wearing EBP is to protect yourself and the resident from getting any new infections.3. Review of Resident #63's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively Intact;-Dialysis;-Diagnosis of Renal insufficiency, Renal failure, or End-Stage Renal Disease.Observation on 02/09/26 at 3:53 P.M., showed resident in bed, resident's room did not contain a posted EBP signs or supplies available.Observation on 02/11/26 at 8:05 A.M., showed the resident's room did not contain posted EBP signs or supplies available.Observation on 02/11/26 at 8:10 A.M., showed Certified Nurse Aide (CNA) B and CNA C transferred resident to bed with the mechanical lift, performed peri care, and transferred the resident into his/her wheelchair. CNA B and CNA C did not place a gown on during direct resident care and during transfer.During an interview on 02/11/26 at 3:25 P.M., CNA B said residents who require EBP have catheters, wounds, or a port. He/She said staff are aware of who is on EBP by signs and supplies on door and it's mentioned in report during shift change. He/She said there was no EBP sign on resident's door, so he/she did not even think about needing to wear EBP during cares. He/She said EBP is used to keep from transferring germs and infections from staff to resident. He/She said EBP should be worn when in contact with residents when performing cares and even with transfers. He/She said because of residents' dialysis port EBP signs and supplies should be available.During an interview on 02/11/26 at 3:31 P.M., CNA C said EBP is used for residents with catheters, sores or open areas, and ports. He/She said staff are aware of residents with EBP by a sign on their door. He/She said because resident has a port, he/she should have used EBP, but did not see a sign on residents' door to remind him/her. He/She said EBP is used to protect the resident from infection from staff to them. He/She said EBP should be used when in contact with the resident.4. Review of Resident #77's Tracking (entry/death) record, dated 02/04/26, showed the resident was admitted to the facility on [DATE].Review of the resident's POS, dated February 2026, showed the following:- An order dated 02/05/26 for two times per day foley catheter (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) care;- An order dated 02/05/26 for foley catheter, 16 French every month on the 28th on day shift.Observation on 02/09/26 at 11:02 A.M., showed the resident's room did not contain a posted EBP signs or supplies available.Observation on 02/10/26 at 8:32 A.M., showed the resident in his/her room in a wheelchair with a foley catheter. The resident's room did not contain a posted EBP signs or supplies available.Observation on 02/11/26 at 9:59 A.M., showed the resident's room did not contain posted EBP signs or supplies available. During an interview on 02/12/26 at 9:08 A.M., LPN G said EBP should be used when dealing with wounds, foley catheter care and high contact activities. LPN G said if nursing staff had the orders, then the nurse would grab the signs and PPE from the Director of Nursing (DON), and he/she did not know why the sign and PPE had not been up this whole time, he/she said there has been a lot of new signs put up that he/she had noticed today. LPN G said the resident should have had a sign and PPE because the resident has a foley catheter.5. During an interview on 02/12/26 at 11:57 A.M., the Director of Nursing (DON) said residents who require EBP are ones with catheters, wounds, and ports. He/She said if a resident is admitted and requires EBP the charge nurse should know to get a sign and supplies for the resident's door. He/She said her/himself and the administrator try to ensure signs are posted on resident doors. He/She said the residents above must have just been missed. He/She said staff should wear EBP when in direct contact with residents and during transfers. He/She said EBP is important, so staff does not transfer germs to the resident reducing risk of transmission.During an interview on 02/12/26 at 12:27 P.M., the administrator said EBP is used when residents have catheters, wounds, and ports. He/She said EBP is used to prevent spread of organisms from staff to residents. He/She said EBP should be used during high contact care or when touching the resident. He/She said he/she was not aware the resident above were missing EBP signs and supplies. He/She said [NAME] and him/herself were trying to ensure EBP signs were being put up but understands that everybody should know how to get the signs and supplies posted.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) out of one sampled resident did not receive a chemical restraint (medications used to sedate or control behavior) as a convenience to treat behaviors. The facility census was 62. The administrator was notified on 04/04/25 of past Non-Compliance which occurred on 03/28/25. Staff immediately suspended Licensed Practical Nurse (LPN) A, assessed the resident for injuries, and notified the required parties and agencies. The administrator immediately in-serviced all staff on medication administration and abuse and neglect policies and procedures. The deficiency was corrected on 03/31/25. 1. Review of the facility's policy, Administering Medications, dated 03/07/22, showed medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director Nursing Services. Review of the facility's policy, Policy on Restraints, 04/01/25, showed staff are directed as follows: -Residents have the right to be free from chemical and physical restraints; -Chemical Restraint involves using medication, including prescribed, as needed, or over-the-counter drugs, to control a patient's behavior or restrict their movement, when the medication is not a standard treatment for their condition; -In Missouri nursing homes, as part of the Nursing Home Reform Act, chemical restraints are only permissible to treat a resident's medical symptoms and not for convenience or discipline and such use of medication must be documented in the clinical record and ordered by the physician or practitioner. Review of the facility's Investigation Report, dated 03/31/25, showed LPN A admitted to administering 0.25 milliliters (ml) of Lorazepam (medication used to treat anxiety) solution on 03/28/25 to Resident #1 without a physician order or contacting the physician. Staff documented LPN A administered the medication to calm the resident. Review of LPN A's signed statement showed he/she documented the resident was yelling and keeping others awake, so he/she used his/her judgment to administer 0.25 ml of Lorazepam to calm the resident. Review of Resident #1's Five Day Scheduled Assessment Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/21/25, showed staff assessed the resident as severely cognitively impaired. Review of the resident's Physician Order Summary (POS), dated 03/01/25 through 03/31/25, did not contain a physician order for Lorazepam 0.25 milligram/milliliter (mg/ml) oral concentration. During an interview on 04/01/25 at 9:51 A.M., LPN A said he/she heard Resident #1 yelling, checked on him/her, and an hour later, the resident was still yelling. LPN A said he/she administered a 0.25 dose of Lorazepam to the resident. He/She said the resident had a scheduled order for Lorazepam, but he/she gave the resident an additional dose. He/She took the medication from Resident #2. He/She said staff are directed to call the physician to get an order for a medication if a resident had behaviors. He/She did not contact the physician for an order because there was a sign in the facility, not to contact the physician after 7:00 P.M. unless it was an emergent situation. He/She took it upon himself/herself to administer the medication. He/She said nurses were not allowed to administer medications without a physician order. He/She did not document the administration of the Lorazepam in the resident's medical record. During an interview on 04/01/25 at 1:27 P.M., the Director of Nursing (DON) said staff are not allowed to administer medications due to behaviors without an order. He/She said staff were directed to contact the physician to obtain orders before administering medications to a resident without an order. He/She said it would be considered a chemical restraint to administer Lorazepam for behaviors. During an interview on 04/01/25 at 1:28 A.M., the administrator said administering medications to residents because of behaviors would be considered a chemical restraint. MO00252040

Based on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document the controlled substance administered for one resident (Resident #2) and failed to complete shiftly controlled drug counts on the memory care unit. The facility census was 62. 1. Review of the facility's policy, Narcotics Count Change of Shift Policy dated 01/04/23, showed staff are directed as follows: -Narcotics must be counted with the Nurse/Certified Medical Technician (CMT) at the change of shift. The Nurse/CMT must count the total number of cards/packages and note total on count sheet. Each card/package must be counted to ensure that the total number of narcotics is accurate and matches the total number of narcotics in the card/package. The Nurse/CMT arriving for their shift and leaving their shift must initial the change of shift count sheet; -If any discrepancies are noted at change of shift Nurse/CMT is to notify Director of Nursing (DON) or Nursing Management immediately. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/02/25, showed staff assessed the resident as: -Severely cognitively impaired; -Diagnosis of anxiety; -Received an anti-anxiety medication. Review of the resident's Physician Order Sheets (POS), undated, showed a physician order for Lorazepam two milligram/milliliter (mg/ml) oral concentration administer 0.25/1 ml sublingually (underneath tongue) every four hours. Review of the resident's Lorazepam's Count form, dated 03/31/25, showed staff documented 10.50 ml Lorazepam remained. Observation on 04/01/25 at 11:16 A.M., showed the resident's Lorazepam bottle contained 8.50 ml in the bottle. Review of the facility's Controlled Substance Shift Change Form, dated 03/01/25 through 03/31/25, showed: -03/04/25-03/05/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/06/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/07/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/10/25, one staff signature for the 6:00 P.M. shift; -03/11/25, did not contain staff signatures for 6:00 A.M. shift; -03/12/25-03/14/25, did not contact staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/15/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/16/25, did not contain staff signature for the 6:00 A.M. shift; -03/17/25, one staff signature for the 6:00 P.M. shift; -03/18/25, one staff signature for the 6:00 P.M. shift; -03/19/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/20/25, one staff signature for the 6:00 P.M. shift; -03/24/25, one staff signature for the 6:00 P.M. shift; -03/25/25, one staff signature for the 6:00 A.M. shift; -03/26/25, one staff signature for the 6:00 A.M., shift; -03/27/25 - 03/30/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -04/01/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift. During an interview on 04/01/25 at 10:10 A.M., CMT B said narcotic medications are counted each shift by two nurses. During an interview on 04/01/25 at 1:27 P.M., the DON said staff are directed to count narcotics at the end of the each shift or nurse change by two staff members. The DON said he/she was responsible to ensure the narcotic medications were counted and documented, but he/she had been busy with other responsibilities and was not told there was an issue. During an interview on 04/01/25 at 1:28 P.M., the administrator said two staff members should count the narcotic medications at the beginning and end of each shift and document they completed the task. MO00252040

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #1 and #2) out of five sampled residents. The facility census was 64. 1. Review of facility's Care Planning Policy and Procedure policy, dated 01/17/24, showed facility staff are directed as follows: -The facility's standard is to perform quality of care that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices; -To ensure individualized completion of the care plan, and family/resident participation in the resident's plan of care with admission, quarterly, annual update, and if there is a significant change of condition; -A care plan will be developed upon admission per the Centers for Medicare and Medicaid Services (CMS) guidelines. It will be updated quarterly, and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individual's needs. Care plan will also be updated with a significant change of condition; The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident's status changes, the facility, attending practitioner and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/04/25, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Physical and verbal behavioral symptoms directed toward others occurred one to three days during the look back period; -Did not exhibit wandering behaviors during the look back period. Review of the resident's care plan, dated 09/18/24, showed it did not contain documentation the resident had behaviors of wandering or physical aggression towards other residents. Review of the facility's investigation report, dated 12/31/24, showed the resident wandered into another resident's room, yelled at another resident, then pulled the other resident's hair and hit him/her in the head. Review of the facility's investigation report, dated 01/22/25, showed the resident hit another resident in the arm multiple times. During an interview on 01/23/25 at 10:07 A.M., Certified Medical Technician (CMT) A said the resident had a history of wandering and aggression towards other resident's. He/She said he/she did review other resident's care plans, but did not review Resident #1's care plan yet. He/She said he/she was educated to redirect the resident. During an interview on 01/23/25 at 10:20 A.M., Certified Nurse Aide (CNA) B said the resident has a history of wandering and aggression towards other residents. He/She said staff are educated to redirect to watch a tv show or another activity. During an interview on 01/23/25 at 10:28 A.M., Licensed Practical Nurse (LPN) C said the resident did have a history of wandering and physical aggression towards others. He/She believed the interventions were listed in the resident's care plan. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said the resident did have physical aggression towards other residents and wandering. He/She said he/she did not add the interventions to the care plan, even though the resident had behaviors of wandering and physical aggression. He/She said he/she just added interventions to the resident care plan. 3. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and wandering behavior occurred four to six days during the look back period. Review of the resident's care plan, dated 10/16/24, showed it did not contain documentation the resident had behaviors of wandering or physical aggression towards other residents. Observation on 01/23/25 at 9:56 A.M., showed Resident #2 wandered into Resident #1's room laid in Resident #1 bed. Observation on 01/23/25 at 10:16 A.M., showed a staff member assisted Resident #2 out of Resident #1's room. During an interview on 01/23/25 at 10:20 A.M., CNA B said the resident did have a history of wandering and staff are educated to redirect the resident. During an interview on 01/23/25 at 10:07 A.M., CMT said the resident did have a history of wandering and staff were directed to redirect the resident. He/She said the purpose of the care plan was to provide care and safety measure for the resident. During an interview on 01/23/25 at 10:28 A.M., LPN C said staff are educated to redirect the resident if he/she was wandering or becoming aggressive. He/She said the resident had a history of wandering, but had not noticed the resident wandering into other resident's rooms. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said he/she did not know the resident wandered. He/She said staff meet daily to discuss resident behaviors or changes. 4. During an interview on 01/23/25 at 10:28 A.M., LPN C said he/she would expect to see behaviors of wandering or physical aggression towards others addressed in the care plan by the Care Plan Coordinator. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said he/she updated care plans quarterly, when a resident had a change and new interventions were added to the care plan. He/She said the purpose of the care plan was to provide staff with direction to they type of care the resident required. He/She said if a resident had behaviors, including wandering or aggressive behaviors towards other residents, it should be added to the care plan. During an interview on 01/29/25 at 11:27 A.M., the administrator said the Care Plan Coordinator was responsible to update the care plans. He/She said staff discuss changes in resident conditions daily during meetings. He/She said the purpose of the care plan was to provide staff with direction to meet the resident needs. He/She said if the care plans were correct, then the concern is the staff may not be able to provide person centered care. He/She said staff were conducting random audits, but not currently. He/She said behaviors of wandering and aggression towards other resident's should be addressed in the care plan. During an interview on 01/29/25 at 11:28 A.M., the Director of Nursing (DON) said the purpose of the care plan was to provide staff with direction to meet the resident needs. He/She said if the care plans were correct, then the concern is the staff may not be able to provide person-centered care. He/She said behaviors of wandering and aggression towards other resident's should be addressed in the care plan. He/She said the Care Plan Coordinator was responsible to update the care plans. He/She said staff discuss changes in resident conditions daily during meetings. He/She said staff were conducting random audits, but not currently. MO00248408

Based on interview and record review, facility staff failed to prevent the misappropriation of three resident's (Resident #1, Resident #2, and Resident #3's) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 67. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated 12/14/18, showed the facility defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belonging or money without the resident's consent. 2. Review of the facility's investigation, dated 9/20/24, showed the ADON was notified LPN A displayed suspicious behavior on his/her shift. When the ADON arrived he/she observed the behaviors and issued LPN A a drug test with Human Resources (HR). The test was positive for oxycodone. The ADON notified the DON and performed a narcotic count with LPN C. During the count three narcotic log sheets with the cards could not be located on the medication cart. LPN A denied knowing what happened to the sheets or the medications. The ADON and LPN C found tops of the three medication cards and the cards in the trash with identified as Resident #1, #2, and #3. Staff called the police department. LPN A was arrested. Review showed staff were inservived on their controled drug policy and medication administration policies. Review of the police records, dated 9/20/24, showed the officer arrived to the facility at 6:12 A.M. and spoke to the ADON about the stolen narcotics. Review showed the office interviewed LPN A and LPN A said he/she used the record sheets to sign out medications for several patients but put the sheets back on the nursing station table where they belonged. LPN A said he/she did not steal any medications. Review showed the officer searched LPN A's vehicle and found several orange and white Oxycodone capsules opened, two straws with white residue, three cards with white powder residue, numerous narcotic record sheets from another nursing facility, and several medication packages for Oxycodone , Oxycotin (narcotic pain medication) and Hydrocone (narcotic pain medication). The officer placed LPN A under arrest. Review showed LPN A said he/she had the missing record sheets concealed in his/her pants. The officer retreived three missing record sheets from LPN A. LPN A told the officer he/she took five narcotic medications throughout his/her 12 hour shift the previous night. Review showed LPN A said most of the pills were Oxycodone and Hydrocodone. 4. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/23/24, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis unspecified pain; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain frequently. Review of the resident's Physician's Order Sheet (POS), dated October 2024, showed an order for Oxycodone five milligrams (mg) take one tablet by mouth every six hours as needed for severe pain. Review of the narcotic log book showed it did not contain the narcotic log sheet for the Oxycodone. 5. Review of Resident #2's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of arthritis in the bones of the left knee, and left knee pain; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain occasionally. Review of the resident's POS, dated October 2024, showed an order for Hydrocodone 5/325 mg take one tablet by mouth every six hours as needed for pain, moderate to severe (4-10). Review of the narcotic log book showed it did not contain the narcotic log sheet for the Hydrocodone. 6. Review of Resident #3's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of necrosis (death of body tissue) of amputation stump, right lower extremity; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain almost constantly. Review of the resident's POS, dated October 2024, showed an order for Hydrocodone 5/325 mg take one tablet by mouth nightly and take one table by mouth as needed daily for dressing change. Review of the narcotic log book showed it did not contain the narcotic log sheet for the Hydrocodone. 7. During an interview on 10/1/24 at 10:23 A.M., the Director of Nursing (DON) said he/she was made aware by the ADON and Human Recourses of a possible narcotic diversion. He/She said LPN A was drug tested by the ADON and Human Resource and was found to be positive for Oxycodone. He/She did the narcotic count with the ADON upon arrival to the facility. He/She said he/she was unable to find three narcotic count sheets and and blister packs for three separate residents. He/She said they searched the trash and shred bin and found the tops of the medication cards without the blister packs. He/She said the police were called and LPN A was escorted off the property and taken to jail. During an interview on 10/1/24 at 10:36 A.M., The Human Resource employee said he/she was notified by the ADON of LPN A having odd behaviors on his/her shift. He/She said it's their policy to drug test under suspicion. He/She said LPN A tested positive for Oxycodone. The human resouce employee said he/she was a witness to the drug testing and stayed with LPN A until the police arrived. During an interview on 10/1/24 at 2:12 P.M., LPN C said he/she was orienting LPN A and was told to let him/her take the lead. He/She said LPN A was not signing narcotics out as they were given and started noticing LPN A disappearing for extended periods of time to the bathroom. His/Her eyes appeared red and glassy. LPN C said he/she notified the ADON of the suspicious behaviors between 5:00-6:00 A.M LPN C said he/she and the ADON did a narcotic count and noticed three cards missing along with the narcotic log sheets for residents #1, #2, and #3. During an interview on 10/1/24 at 2:24 P.M., the ADON said he/she was notified by LPN C around 5:00-6:00 A.M. LPN A was having suspicious behaviors. ADON said he/she arrived at the facility and watched LPN A do the last medication pass. He/She said LPN A's eyes were red, glassy and he/she was not making sense. ADON said he/she and the Human Resource employee completed a drug tested on LPN A and his/her test came back positive for Oxycodone. He/She asked LPN A if he/she had a script for the Oxycodone and he/she said no. ADON said he/she did a narcotic count with LPN C and there were three missing narcotic count sheets and three pill cards for Resident #1, #2, and #3. The ADON said LPN A could not tell him/her where the sheets or medications were at. He/She said the tops to the pill cards were later found in the shred bin and the cards were found empty in the trash. MO00242385

Based on interview and record review, facility staff failed to contact one resident's (Resident #4's) responsible party when the resident passed away at the facility. The facility census 67. 1. Review of the facilty's Discharge of a Resident due to death policy, undated, showed staff are instructed to notify the family or the responsible party. 2. Review of Resident #4's Entry Minimum Data Set (MDS), a federally mandated assesment tool, dated 9/21/24, showed staff assessed the resident as: -admitted to the facility 9/21/24; -Diagnosis of skin cancer of scalp and neck, liver cancer with bile duct involved, rectal cancer, and throat cancer; -Received hospice services. Review of the residents nurses notes, dated 9/26/24, showed staff documented the resident passed away at 8:02 A.M. Review showed the nurses note did not contain documentation staff contacted the next of kin or family for the resident. During an interview on 10/1/24 at 10:15 A.M., Licensed Practical Nurse (LPN) B said staff are expected to contact the resident's family, doctor, administrative staff, and the coroner when a resident passes. LPN B said he/she worked the day the resisdent passed and he/she had not contacted the family because it had slipped through the cracks. He/She later asked hospice to contact the family since he/she had not done so. During an interview on 10/1/24 at 10:23 A.M., the Director of Nursing (DON) said staff are expected to notify the family, hospice, the doctor, and coroner in the case a resident passes. During an interview on 10/1/24 at 11:40 A.M., the administrator said staff are expected to notify the doctor, the family, hospice, and furneral home of the resident's passing. During an interview on 10/3/24 at 11:00 A.M., the resident's next of kin said he/she was not not notified by the facility of his/her spouses' passing. He/She said he/she was notified by hospice hours after his/her passing. MO00242752

Based on interview and record review, the facility staff failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. The facility census was 70. 1. Review of the Facility Assessment, dated 04/10/24, showed facility staff documented the staffing requirements needed on a 24-hour basis to meet the needs of their residents for an average census of 70-80 are as follows: -West Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift; -East Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift. 2. Review of the facility night shift staff schedule for the west and east area of the facility, dated 04/20/24 through 04/30/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 04/06/24-04/30/24 as directed in the facility assessment. 3. Review of the facility night shift staff schedule west and east area of the facility, dated 05/01/24 through 05/31/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 05/01/24, 05/02/24, 05/05/24- 05/09/24, 05/11/24, 05/12/24, 05/14/24- 05/31/24 as directed in the facility assessment. 4. Review of the facility night shift staff schedule the west and east area of the facility, dated 06/01/24 through 06/30/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 06/01/24 -06/03/24, 06/06/24, 06/08/24-06/30/24 as directed in the facility assessment. 5. Review of the facility night shift staff schedule the west and east area of the facility, dated 07/01/24 through 07/18/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 07/01/24-07/04/24 and 07/15/24-07/18/24 as directed in the facility assessment. 6. During an interview on 07/18/24 at 1:20 P.M., the Director of Nursing (DON) said the facility always has a licensed nurse scheduled at each shift but not always two. He/She said he/she questioned it when he/she first started because he/she was not sure of the guidelines. He/She said he/she was not aware the facility assessment says they should have two licensed nurses at night. During an interview on 07/18/24 at 2:18 P.M., the administrator said the facility always has a licensed nurse in the building, just not two. He was not aware the facility assessment said he/her needed two licensed nurses per unit, per shift.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 70. 1. Review of the facility's Resident Services Policy, dated March 27, 2017, showed the facility provides sufficiant licensed nursing and ancillary services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/01/24; -06/02/34; -06/08/24; -06/09/24; -06/15/24; -06/16/24; -06/22/24; -06/23/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on 07/06/24 and 07/07/24. 4. During an interview on 07/16/24 at 6:50 A.M., RN F said he/she is the certified nurse aide (CNA) instructor for the facility. RN F said, I am here every day, because I am the only RN on staff right now other then the DON, and I work Monday thru Friday. During an interview on 07/18/24 at 1:20 P.M., the Director of Nursing (DON) said the facility currently is short two RN positions. He/She said they do not have a full time RN to work weekends and their CNA instructor is working as their RN through the week. During an interview on 07/18/24 at 2:18 P.M., the administrator said he/she is trying to hire an RN. He/She said he/she currently doesn't have an RN scheduled every weekend and the DON and CNA instructor are the RN's who cover the eight hour shifts during the week.

45564 Based on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failured to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use a barrier when performing blood sugars for three (Resident #42, #51, and #53) of four sampled residents. The facility census was 70. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program - Legionella, undated, showed the members of the committee will ensure the inspections of the identified areas where Legionella could grow are completed and the results are within regulatory guidelines. Maintenance will ensure the areas where Legionella could grow in the equipment are inspected, cleaned and free of bacteria. Logs will be kept in the maintenance shed. Review showed the plan indicated the facility's water flow comes from the city. Water enters the building from the water main at the street level through the building's main line. Review showed the plan did not contain a description of the building water system using text or a flow diagram. Review of the plan showed water heaters, eye wash stations, faucets, flow restrictors, whirlpool tubs, water fountains and pipes/valves/fittings were identified as areas where Legionella could grow. Review showed the control measures for water heaters were visual inspection and maintaining proper temperatures. Review showed the plan did not include a description of the visual inspection or a temperature range. Review showed the plan did not contain control measures or interventions for the additional identified areas. Review of the plan showed maintenance logs and routine maintenance for equipment such as water heaters, ice machines, backflow preventers, etc. can be found with the maintenance director. Theses logs are kept up to date and filed in the maintenance office. Review showed the maintenance records did not contain water management program documentation. During an interview on 07/18/24 at 12:20 P.M., the maintenance director said he/she flushes the water heaters for 30 seconds every month. The maintenance director said he/she checks the eyewash station tags and performs a brief function check every month, but he/she had never deep cleaned or flushed the eye wash stations. The maintenance director said housekeeping staff cleaned the water fountains and flushed toilets and sinks. The maintenance director said the shower aides cleaned and sanitized the whirlpools. During an interview on 07/18/24 at 8:00 A.M., the administrator said he/she was not familiar with the CDC Toolkit or the requirement for a water system flow diagram, control measures or specific corrective actions to be taken if control measures were out of range. X. Review of the facility's policy titled, Blood Glucose Monitoring, revised 04/19/23, showed staff are directed to place glucometers on clean surfaces. Review of the facility's policy titled, Infection Prevention and Control Program, undated, showed equipment or items in the resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents (e.g. wear gloves for handling soiled equipment and properly clean and disinfect or sterilize reusable equipment before use on another resident). X. Observation on 07/17/24 at 11:47 A.M., showed Licensed Practical Nurse (LPN) D entered Resident #42's room to perform a blood sugar check on the resident. LPN D placed the glucometer on the resident's bedside table without a barrier and prepped the resident for the blood sugar test. LPN D tested the resident's blood sugar and placed the glucometer on the bedside table. LPN D removed the glucometer and placed it on the top of the medication cart without a barrier before he/she removed his/her gloves and performed hand hygiene. LPN D replaced his/her gloves and cleaned the glucometer with a wipe before placing the clean glucometer back on the medication cart without a barrier. X. Observation on 07/17/24 at 11:30 A.M., showed LPN D entered the dining room to perform a blood sugar check on Resident #51. LPN D placed the glucometer on the dining room table without a barrier as he/she prepped the resident for the blood sugar test. LPN D tested the resident's blood sugar and placed the glucometer on the dining room table. LPN D removed the glucometer and placed it on the top of the medication cart without a barrier before he/she removed his/her gloves and performed hand hygiene. LPN D replaced his/her gloves and cleaned the glucometer with a wipe before placing the clean glucometer back on the medication cart without a barrier. X. Observation on 07/17/24 at 11:38 A.M., showed LPN D performed Resident #53's blood sugar check in the East wing hallway and placed the glucometer on the medication cart without a barrier. LPN D cleaned the glucometer and then placed it back on the medication cart without a barrier. X. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said it is his/her expectation that staff do not place glucometers on dining room tables, bedside tables, or medication carts that are not sanitized. He/She said placing used glucometers on tables presents a risk for transmitting blood born pathogens or bacteria. He/She was not aware nursing staff were placing glucometers on these surfaces without a barrier. During an interview on 07/18/24 at 3:36 P.M., the administrator said it is his/her expectation staff do not place glucometers on any surface without a barrier because it is not sanitary. He/She said he/she was not aware staff were not using a barrier. During in interview on 07/26/24 at 3:52 P.M., LPN D said staff should use a barrier before placing the glucometer on surfaces. He/She said it is an infection control concern. He/She said he/she did not use a barrier because he/she did not have one at the time.

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility census was 70. 1. Review of the facility policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 07/18/24 at 3:50 P.M., the administrator said the Assistant Director of Nursing (ADON) is the facility's Infection Preventionist. He said the ADON started the required classes sometime last month, but he is not sure how much longer she/he has. The administrator said he was aware the training and certification needed to be completed before given the position or title of Infection Preventionist. During an interview on 07/23/24 at 10:15 A.M., the ADON said he/she was not aware he/she was the actual Infection Preventionist (IP) yet, due to he/she is enrolled in the Centers for Disease Control and Prevention Infection Preventionist training but is not certified. He/She said they are only about halfway through the modules. The ADON said he/she was aware the certification needed to be completed before they assumed that title of Infection Preventionist.

Based on interview, and record review, facility staff failed to review and revise the care plan after a fall for five (Resident #13, #21, #36, #44, and #52) out of eighteen sampled residents. Facility staff failed to document and update care plans in regard to pressure ulcers for two (Resident #5 and #44) out of seven sampled residents. Staff failed to address and update behaviors for one (Resident #4) of one sampled resident. The facility census was 70. 1. Review of the facility's Miniumin Date Set (MDS) Policy, undated, showed the care plans will be updated quarterly and with changes to the resident plan of care. Changes made to the care will be communicated to the interdisciplinary team. The staff member completing the care are assessment for the specified section will also compete the comprehensive care plan on the resident. 2. Review of the Resident #13's Quarterly MDS, a federally mandated assessment tool, dated 05/02/24, showed staff assessed the resident as: -Moderate cognitive impairment; -One fall since admission with injury; -Diagnosis of Quadriplegia (paralysis affects the body from the neck down. Can result in partial or total loss of function in the arms, legs, trunk, and pelvis). Review of the resident's medical record showed staff documented the resident fell on [DATE] in the dining room, resident was positioned straight up from eating and slid out of chair. Review of the resident's care plan, dated 06/18/24, showed the care plan did not contain documentation of the resident's fall on 6/11/24 or updated fall interventions. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -One fall with major injury since last MDS. Review of the resident's medical record, showed staff documented the resident fell on [DATE] in his/her room while ambulating to the bathroom and fractured his/her left arm. Review of resident's care plan, dated 07/01/24, showed the care plan did not contain documentation of the resident's fall on 06/26/24 or updated fall interventions. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -One fall with no injury since last MDS -Dependent with bed-to-chair transfer and bed mobility. Review of resident's medical record showed staff documented the resident fell on [DATE] in his/her room next to his/her bed. Review of resident's care plan, dated 07/01/24, showed the care plan did not contain documentation of the resident's fall on 04/24/24 or updated fall interventions. 5. Review of the Resident #44's Significant Chanage MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Documentation two falls since admission with injury; -Documentation of one stage 3 pressure ulcer, a diabetic foot ulcer, and other open lesions on foot; -Diagnosis of Alzheimer Disease, dementia, Peripheral vascular disease (is a slow and progressive disorder of the blood vessels) and Diabetes mellitus. Review of resident's medical record, showed a fall on 07/04/24 in his/her room, resulting in a hematoma to the left side of his/her face. -The resident had a stage III pressure ulcer on right ischium. Review of resident's care plan, dated 07/09/24, showed the plan did not contain the following: -Documentation of the resident's fall on 07/04/24 or updated fall interventions; -Documentation of the resident's stage III pressure ulcer on the right ischium (lower buttock) or interventions. 6. Review of Resident #52's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No falls since last MDS; -Dependent for sit to stand and bed-to-chair transfers. Review of resident's medical record, showed the resident suffered a fall on 07/06/24 out of his/her wheelchair landing on his/her face and right side. Review of resident's care plan, dated 05/31/24, showed the care plan did not contain documentation of the resident's fall on 07/06/24 or updated fall interventions. 7. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Documentation of a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle) and other open lesion on foot; -Diagnosis of diabetes mellitus. Review of resident's medical record showed staff documented the resident had a Stage IV pressure ulcer on right heal. Review of resident's care plan, dated 05/31/24, showed the plan did not contain documentation of the resident's Stage IV pressure ulcer or interventions. 8. Review of the Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -One physical behavior directed toward others; -Two verbal behaviors directed toward others; -One behavioral symptom not directed toward others; -Wandering daily; -Behaviors worse than previous review; -Diagnosis of Alzheimer's, dementia, anxiety, depression, and traumatic brain injury. Review of resident's medical record showed staff documented a resident to resident altercation on 06/22/24, in the diningroom. Review of resident's care plan, dated 06/17/24, showed the care plan did not contain documentation on how to care for the resident's behaviors. During an interview on 07/18/24 at 10:38 A.M., Certified nurse aide (CNA) H said the resident is an emotional person with behaviors daily. He/She said the resident will often swat at staff during care and is easily frustrated. He/She said he/she is not an aggressive person, that handling him/her is all in the approach. He/She said he/she rarely has issues with the resident because he/she knows how to redirect him/her. During an interview on 07/18/24 at 11:12 A.M., CNA I said did not received education after the resident altercation. He/She said the resident is easily agitated, but always easily redirected. He/She said the resident gets very emotional, at times likes to be in peoples faces and can get frustrated if others don't want to be near him/her. During an interview on 07/18/24 at 11:21 A.M., licensed practical nurse (LPN) E said he/she was not aware the resident had an altercation with another resident and did not receive education regarding interventions. He/She said the resident can be emotional, easily agitated, and often refuses to sleep. He/She said the resident is easily redirected. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said he/she it is the Care Plan Coordinators responsibility to update the care plans as needed with interventions and resident specific care. She would expect the residents frequent behaviors to be addressed on the care plan with interventions. 9. During an interview on 07/17/24 at 3:21 P.M., LPN G said he/she is responsible for care plans. The LPN said they took over the job in May of 2024, but there had not been a care plan coordinator since 2023. The LPN said resident information is shared in morning meeting or it can be placed in their box. LPN G said the care plan should be updated as needed with interventions, change in conditions and care information as soon as possible. During an interview on 07/18/24 at 3:54 P.M., the DON said gathered information, goals, and interventions are all included in the care plan. The The DON said he/she would expect any issues, changes in condition, medication changes, behaviors, wounds and falls with interventions to be updated in the care plan as needed. During an interview on 07/18/24 at 3:55 P.M., the Administrator said the expectation is the care plan to be updated as things come up and for resident's needs. The administrator said it is the Care Plan Coordinators responsibility to update the care plans as needed, he said he is not sure how quickly care plans should be updated after a change with the resident. 47193 50422

Based on interview and record review, facility staff failed to implement their Grievance Policy for two residents (Resident #7 and #25) out of 18 residents when reported missing items and failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 70. 1. Review of the facility's Grievance policy, dated 09/13/19, showed: -A grievance will be translated into writing, containing the name and address of the person filing it if permitted; -The administrator or his/her designee shall conduct an investigation of the complaint; -The Grievance official will complete a review of the grievance no later than 30 days after its filing. The Resident has the right to obtain a written decision regarding his/her grievance; -All written grievance decisions will include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, and corrective active taken or to be taken by the facility as a results of the grievance, and the date the written decision was issued; -Maintain evidence demonstrating the result of all grievances for a period of no less than three years from the issuance of the grievance decision. Review of facility's grievance binder, showed the binder contained two grievance forms completed in 2024. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/19/24, showed staff assessed the resident as cognitively intact. Review of resident's medical record did not contain a inventory list for the resident's property. During an interview on 07/16/24 at 9:47 A.M., the resident said three weeks ago he/she had abluetooth ear bud set go missing from his/her room. He/She said he/she reported it to the administrator but never received an update. He/She said the facility has not replaced his/her bluetooth ear buds. During interview on 07/17/24 at 2:20 P.M., the administrator said that he did not know about the bluetooth ear bud set that was missing by the resident. 3. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of resident's medical record did not contain a inventory list for the resdient's property. During an interview on 07/16/24 at 11:26 A.M., the resident said one month ago his/her cell phone went missing from his/her bedside table in his/her room. He/She said it was reported to the administrator and business office manager, but never received an update. He/She said the facility has not replaced his/her cell phone. During interview on 07/17/24 at 2:10 P.M., the Business Office Manager said the resident did report his/her phone missing. He/She said the facility has looked for it and it has not been found. He/She said he/she needs to talk with the administrator about what needs to be done next. During interview on 07/17/24 at 2:20 P.M., the administrator said the resident did report cell phone missing. He said the facility looked for it and the cell phone was not found. 4. During interview on 07/17/24 at 2:10 P.M., the Business Office Manager said when a resident reports something missing, he/she looks for the missing item. He/She said a grievance form is filled out and discussed with administrator what to do if unable to find missing item. He/She said he/she does not have any grievances from past years. He/She said the grievances he/she has is in the grievance binder. During an interview on 07/18/24 at 3:03 P.M., the Director of Nursing (DON) said if a resident reports something missing, a grievance form should be filled out and investigate the missing item. He/She said she expects the grievance form to be filled out within 24 hours of reporting to help keep track of grievance and to start investigating the missing item. During an interview on 07/18/24 at 3:38 P.M., the administrator said residents know to report missing items to him/herself or business office manager, a grievance form is filled out, and they investigate the missing item. He said the grievance form should be filled out as soon as possible once item is reported missing. He said if they are unable to locate missing item, they contact family to see if resident had the item or if they happened to take it with them, or if its money the facility will reimburse the resident. He said the grievance should be resolved as soon as possible. He said they try to resolve the grievance same day.

Based on observation, interview, and record review, facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 70. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated December 14, 2018, showed an injury of unknown source defined as not witnessed by any person and the source of the injury could not be explained by the resident, and the injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Review showed the charge nurse to complete the documentation, neurological flow sheet (if appropriate), notify the responsible party, medical directorm and clinical manager. Review showed staff are directed to: -Complete a Situation, Background, Assessment, Recommendation (SBAR) -Head to toe assessment; -Secure treatment orders if applicable/complete pain assessment; -Social Services intervention five times a week for two weeks, then reassess; -Residents on same assignment interviewed; -Staff Interviews; -72hr post incident observation; -Physical Therapy/Occupational Therapy (PT/OT) referral, if applicable; -Care plan review and revision, if applicable. 2. Review of Resident #15's Annual Minimum Data Set (MDS), a federally mandated assessment tool used by staff, dated 06/15/24, showed staff assessed the resident as follows: -Cognition intact; -Dependent on staff for toileting and lower body dressing; -Diagnoses of Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) or Hemiparesis (one-sided muscle weakness), Stroke (Damage to the brain from interruption of its blood supply). -Uses wheelchair. Review of the resident's plan of care, dated 06/03/24, showed staff assessed the resident speech unclear, at risk for falls and has a history of falls. The resident's care plan did not contain documentaion of a fall or bruise. Review of the resident's medical record, showed the record did not contain documentation of the resident's bruises, or a facility investigation of the injury of unknown origin. Observation on 07/15/24 at 1:45 P.M., showed the resident in his/her wheelchair with a bruise on the right side of his/her forehead and on lateral right eye area. During an interview on 07/18/24 at 9:25 A.M., Certified Nursing Assistant (CNA) J said the resident had the bruises on his/her face on 07/11/24 when he/she gave him/her a shower. CNA J said we only document skin issues on shower sheets if it is new, but the nurse already knew about this bruise so he/she did not put it on the shower sheet. During an interview on 07/18/24 at 10:45 A.M., the Nurse Practitioner (NP) said he/she seen the resident last on 07/11/24 and the bruises were there and appeared fresh. The NP said he/she did not talk to staff after his/her visit and figured they already knew about the bruises as they were obvious and in plain sight. During an interview on 07/18/24 at 3:54 P.M., the Director of Nursing (DON) said he/she was not notified in a timely manner of the incident. The DON said after he/she found out about it, he/she was not sure where to go with it, so there was not a complete investigation done. The DON said he/she would expect the CNA to notify the charge nurse, who would then report to him/her. During an interview on 07/18/24 at 3:55 P.M., the Administrator said this would be considered an injury of unknown origin, and the expectation it to investigate and find out what happened. The administrator said it was not reported earlier, he just found out when he walked in on Monday. The Administrator said he would expect the CNA to report something like this to their charge nurse, then that charge nurse should tell me and DON about it.

Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments for for three residents (Resident #7, #21, and #36) out of 18 sampled residents after unwitnessed falls. The facility census was 70. 1. Review of the facility's policy titled, Neurological Assessments, undated, showed when resident has an incident with a head injury/trauma, or an unwitnessed fall, the nurse is the perform neurological assessment. Review showed the nurse is required to: -Document the results on the neurological assessment flow sheet in the resident's chart; -Complete checks-Every 15 minutes for one hour, every 30 minutes for the next two hours, and every shift until the 72 hours are completed; -Neurological checks consist of level of consciousness, pupil size, hand grasps, extremities, pain response, and vital signs; -All items above must be completed on each neurological check. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/19/24, showed staff assessed the resident as: -Cognitively intact; -One fall with no injury since last MDS. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 05/06/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -One fall with major injury since last MDS. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 06/26/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -One fall with no injury since last MDS -Dependent with bed-to-chair transfer and bed mobility. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 04/24/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 5. During an interview on 07/18/24 at 2:42 P.M., Licensed Practical Nurse (LPN) A said with unwitnessed falls, the nurse should do a full skin assessment and vitals. He/She said a neurological exam should be completed for unwitnessed falls or if resident hits their head. During an interview on 07/18/24 at 3:06 P.M., the Director of Nursing (DON) said after an unwitnessed fall he/she expects neurological checks to be done for first 72 hours and an incident report to be completed. During an interview on 07/18/24 at 3:38 P.M., the administrator said for unwitnessed falls, he/she expects the nurse to complete an incident report, monitor the resident, and complete neurological checks for 72 hours.

Based on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner when staff failed to date the open multi-dose medication bottles, and placed non-medication in medication storage room refrigerator. The facility census was 70. 1. Review of the facility's Storage of Medication policy, undated, showed facility staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Medications require refrigeration must be store in a refrigerator located in the drug room at the nurses' station or other secured location. -Medications must be stored separately from food and must be labeled accordingly. Review of the facility's Administering Medications policy, dated 03/07/22, showed the facility staff are directed to record the open date on the container when opening a multi-dose medication container. 2. Observation on 07/15/24 at 9:30 A.M., showed the west wing medication cart contained: -One opened bottle of vegetable laxative, undated; -One opened bottle of diphenhydramine, undated and without a lid; -One opened bottle of ibuprofen, undated; -One opened bottle of calcium, undated; -One opened bottle of milk of magnesia, undated. 3. Observation on 07/15/24 at 9:50 A.M., showed the [NAME] wing medication storage room contained: -One opened bottle of dietary supplement, undated; -One opened bottle of Vitamin D3, undated. 4. Observation on 07/15/24 at 9:50 A.M., showed the medication refrigerator in [NAME] wing medication storage room contained: -One to-go container containing a cinnamon roll; -Two sandwiches; -One leftover box of pizza; -One container of butter; -One soda, -One bottle of chipotle ranch; -One bottle of lime juice; -One box of leftovers; -One cup of coffee. During an interview on 07/15/24 at 9:40 A.M., certified medication technician (CMT) C said he/she usually labels the lid of the medication bottle when he/she opens it. He/She said the CMT on the medication cart is responsible for maintaining the medication cart, labeling medications when opened, and help maintain medication storage rooms. During an interview on 07/15/24 at10:05 A.M., licensed practical nurse (LPN) A said the person on the medication cart is responsible for maintaining it for that shift. He/She expects staff to label and date bottles as they are opened. He/She said he/she is not sure what the policy is on the medication storage room refrigerator containing food in the same refrigerator as the medications. He/She said that fridge always ends up with food in it due to the staff refrigerator being full and staff not having a place to put resident food and leftovers. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said it is the responsibility of the nurse or CMT who is on the medication cart, to maintain it. He/She said he/she also does monthly audits of the medication carts. He/She said staff should be going over the carts at change of shift and signing off that they are good. He/She said he/she expects staff to label medications with an open date when they first open the bottle. He/She was not aware staff were not labeling the medications when opening them. He/She said it is his/her expectation that food is not kept in the same refrigerator as medications. He/She was aware there was an issue. He/She said he/she has cleaned out the fridge and staff keep refilling it. He/She said he/she has been looking for a solution. During an interview on 07/18/24 at 3:36 P.M., the administrator said it is his/her expectation that charge nurses, CMT's, should maintain the medication carts and the assistant director of nursing (ADON), and the DON should oversee them to ensure it is done. He/She said the nurses and CMT's should be checking medication carts daily per shift and the DON and ADON should be checking them weekly. He/She said he/she is not sure what the policy is for labeling mediations once they are opened.

Based on interview and record review, facility staff failed to ensure six (Resident #7, #8, #10, #21, #24, and #25) out of 18 residents have appropriate access to their trust fund account to include on the weekends. The facility census was 70. 1. Review of facility policy titled, Resident Funds/Money, dated 05/18/22, showed facility staff were to maintain a written account of all the resident's funds. Residents who have a trust account have access to their funds Monday through Friday, between 9:00 A.M and 4:00 P.M., excluding holidays. Residents who would like funds for the weekend can obtain funds on Friday before end of day. Depending on resident circumstances/financial necessity, staff may notify administration. If resident requests funs outside of normal baking hours and management will attempt to have manager local to facility go to facility to obtain funds for resident out of secured resident funds drawer. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/19/24, showed staff assessed the resident as cognitively intact. During an interview on 07/16/24 at 9:46 A.M., the resident said we are not able to get money on the weekends. 3. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 07/16/24 at 9:27 A.M., the resident said, I like to go out to eat or go shopping on the weekends with my family, but sometimes I don't have the money available. He/She said there is no one here on the weekends to give money. 4. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 7/16/24 at 8:50 A.M., the resident said, I am not able to get money in the evenings or weekends because there is no one here to give money. 5. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 07/16/24 at 1:57 P.M., the resident said if he/she needed money he/sh would ask the business office, but we do not get money on the weekends because there is no one here to give money. 6. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 07/16/24 at 12:35 P.M., the resident said there are only two people who can give you money at the facility, but neither are there often in the evenings or weekends. The resident said, Forget about getting money in the evenings or on the weekend. The resident said if they go with family or a friend on the weekend they must borrow money from that person and he/she said, I don't like that. 7. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 07/16/24 at 11:24 A.M., the resident said, We can not get any money on the weekends which sucks for us because if we do not like what is on the menu, we can not get our money to order something else. 8. During an interview on 07/18/24 at 2:42 P.M., License Practical Nurse (LPN) A said residents do not have access to money in the evenings or weekends. He/She said if the residents need money, they must request it Friday. During an interview on 07/18/24 at 11:38 A.M., the Business Office said the banking hours are posted on his/her door (Monday-Friday 9am-4pm, closed Holidays). He/She said the residents know that if they want money on the weekends that they need to request it on Friday. He/She said nobody is here on the weekends to give money, residents have to get money on Fridays. He/She said he/she was not aware that residents had to have access to money on the weekends. During an interview on 07/18/24 at 3:02 P.M., the Director of Nursing (DON) said there is no one in the facility on the weekends to give money to residents. He/She said he/she was not aware that residents had to have access to money on weekends. During an interview on 07/18/24 at 3:38 P.M., the administrator said residents can get money Monday through Friday from the business office. He/She said he/she was not aware that money had to be available on weekends. 50422

Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for three (Resident #10, #21, and #25) out of 18 residents. The facility census was 70. 1. Review of the facility's policy titled, Activity Department, dated 08/17/21, showed the facility to have an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities will provide one on one to any resident that do not want to participate in group activities or are not able to attend group activities. Review of the facility's Activity Calendar, dated June, 2024, showed: -Saturday, 06/01/24; did not contain a time, Bingo; -Sunday, 06/02/24; did not contain a time, game day; -Saturday, 06/08/24; did not contain a time, Bingo; -Sunday, 06/09/24 at 3:00 P.M., Church; -Saturday, 06/22/24; did not contain a time, Bingo; -Sunday, 06/23/24; did not contain a time, Game Day; -Saturday, 06/29/24; did not contain a time, Bingo; -Sunday, 06/30/24; did not contain a time, Game Day. 2. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/08/24, showed staff assessed the resident as follows: -Independent for decisions; -Very important to listen to music, do favorite activities, and go outside to get fresh air when weather is good; -Somewhat important to participate in religious services or practices. Review of the resident's care plan, dated 06/21/24, showed staff documented the resident will participate in three or more activities per week through next review. During an interview on 07/16/24 at 8:47 A.M., the resident said he/she loves activities, and the activities keep him/her busy. He/She said the facility does not have activities on the weekends. He/She said sometimes a helper will come in and do bingo once a month on Saturday. He/She said sometimes there is church on Sunday if they are lucky, but not every Sunday. He/She said he/she would love if there were activities on the weekends and he/she would play them if the facility had them. 3. Review of Resident #21's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Independent for decisions; -Very important to listen to music, do things with groups of people, do favorite activities; -Somewhat important to participate in religious services or practices, have books, newspapers, and magazines to read, and go outside to get fresh air when weather is good. Review of the resident's care plan, dated 07/01/24, showed staff documented the resident will participate in three or more activities per week through next review. During an interview on 07/16/24 at 1:56 P.M., the resident said he/she enjoys going to activities and loves to play bingo. He/She said the facility does not have activities on the weekends. He/She said he/she would love if there were activities on the weekends. 4. Review of Resident #25's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Independent for decisions; -Very important to keep up with the news; -Somewhat important to do favorite activities, listen to music, and have books, newspapers, and magazines to read. Review of the resident's care plan, dated 06/07/24, showed staff documented the resident will take part in preferred activity pursuits and demonstrate satisfaction with his/her ability to engage in preferred activities. During an interview on 07/16/24 at 11:20 A.M., the resident said he/she wishes the facility would do more activities. He/She said the facility does not have activities on the weekends. He/She said the weekends are boring without activities. 5. During an interview on 07/18/24 at 2:48 P.M., Certified Nurse Aide (CNA) B said the facility does not have anything scheduled for activities on the weekends. During an interview on 07/18/24 at 2:42 P.M., Licenses Practical Nurse (LPN) A said there are no activities on the weekends. He/She said no staff comes in to do activities on the weekends. During an interview on 07/22/24 at 1:01 P.M., the Activities Director said the facility has bingo on Saturdays and every second Sunday there is church service. He/She said he/she has an assistant that comes in one weekend a month to help with activities. He/She said on the other Sundays when there is no Church, there are games that the residents could play or watch church on tv. The activity director said said the assistant helps one weekend a month, otherwise its the receptionist if he/she is there or CNA's if they have time. During an interview on 07/18/24 at 3:02 P.M., the Director of Nursing (DON) said he/she is unaware of any scheduled activities on the weekends. He/She said he/she is unaware if staff comes in on Saturday or Sunday to do activities. During an interview on 07/18/24 at 3:38 P.M., the Administrator said the facility has some crafts on the weekends. He/She said one weekend a month the activity assistant comes in to play bingo. The administrator said staff working on the weekends are responsible for activities on the weekend. 50422

Based on observation, interview, and record review, facility staff failed to monitor one resident (Resident #220) they assessed as an unsafe smoker who used a vaping device (electronic cigarette/nicotine). Staff failed to plan and implement measures to ensure the resident's safety. Staff failed to prevent the resident from using a vape device while wearing oxygen and from keeping vape devices in his/her room. The facility census was 69. The administrator was notified on 4/4/23 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 4/4/23. The IJ was removed on 4/7/23, as confirmed by surveyor onsite verification. 1. Review of the facility's Smoking/Vaping policy, undated showed: -If a resident uses electronic cigarettes/vaping devices, they may do so in the designated smoking areas, or in their room if they are in a private room, or if in a semi-private room, their roommate must approve of the vaping within the room; -A resident may not vape in their room if they or their roommate are on oxygen; -Vaping is not allowed anywhere near supplemental oxygen usage; -Residents who wish to vape in their room will have a safe vaping assessment completed. -Review of the policy showed the policy did not address how to handle the devices, batteries and refill cartridges. Review of the Food and Drug Administration's (FDA) Tips to Help Avoid Vape Battery or Fire Explosions, showed one of the tips is not to vape around flammable gasses or liquids, such as oxygen, propane, or gasoline. According to the National Institute of Health (NIH) website, Hazards of E-Cigarettes in Current Smokers, dated Mar- April 2015, the basic components of most disposable or rechargeable e-cigarettes include a cartridge containing a liquid solution of propylyne glycol, a battery and a heating element. This latter component reaches high temperature and aerosolizes the e-liquid to be inhaled. Consequently, it can conceivably ignite in the presence of oxygen. Review of Resident #200's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/26/23, showed staff assessed the resident as: -Cognitively intact; -Had limited Range of Motion on one side of body; -Did not use tobacco; -Did not use oxygen; -Did not have shortness of breath; -Had diagnosis of Cancer. Review of the resident's most recent smoking assessment completed in July 2022, showed staff assessed the resident as an unsafe smoker, but did not list the reasons they assessed the resident was unsafe. Review of the resident's nurses notes showed staff did not document previous smoking or vaping incidents. Review of the resident's physician orders, dated 3/3/23, showed an order for staff to provide oxygen for the resident. Review of the resident's most recent plan of care, dated 3/21/23, showed staff did not document interventions regarding the resident's unsafe smoking/vaping, and supervision required for the resident while smoking/vaping, or use of oxygen. Observation on 4/4/23 at 11:08 A.M., showed the resident utilized a vape device while wearing oxygen turned on and set at 2 Liters via nasal cannula in his/her room. During an interview on 4/4/23 at 2:27 P.M., the resident said staff did not educate him/her on why he/she should not use a vape device when using oxygen. The resident said he kept his/her vaping devices in his/her room and had been using them in his/her room for a long time. During an interview on 4/4/23 at 12:36 P.M., Certified Nurse Aide (Q) said he/she was aware of all the residents who vaped and only one of those residents used oxygen which was resident #220. He/She was not aware of any issues with the resident using oxygen and using his/her vape device at the same time since there was no fire. CNA Q did not realize the resident was using oxygen while he/she used his/her vape device. During an interview on 4/4/23 at 2:45 P.M., the Director of Nursing (DON) said they did provide education to the resident regarding vaping while wearing oxygen. He/She said residents are educated on admission on the smoking policy and informed not to smoke or vape with oxygen on. During an interview on 4/4/23 at 11:36 A.M., the administrator said he/she was not aware the resident was using a vape device and oxygen in the room at the same time. He/she said would expect staff to report if a resident was using a vape device and oxygen at the same time. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 43327

Based on observation, interview, and record review facility staff failed to provide medications in accordance with professional standards leading to a significant medication error and decline in condition for one resident (Resident #1) of five sampled residents. Facility staff failed to ensure the medications were available for the resident. The facility census was 82. 1. Review of the facility's Reordering of Medications policy, undated, showed staff are directed as follows: - When a resident is down to seven pills in medication card, the medication is to be reordered; - If a resident receives liquid medications, when the resident is down to two bottles, the medication is to be reordered; - Certified Medication Technician's (CMT's)/nurses to check on Thursday for any medications that may need to be filled for the weekends; - If problems arise when ordering and or receiving medications, Director of Nursing (DON) is to be contacted immediately. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff for care planning, dated 05/06/16, showed staff documented the resident as: - Moderate cognitive impairment; - Requires extensive assistance of two or more staff members for bed mobility, transfers, dressing, toilet use and personal hygiene; - Requires extensive assistance of one staff member for eating; - Urinary indwelling catheter; - Occasionally incontinent of bowels; - Frequent pain; - Receives Hospice care. Review of the resident's Physician order [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Review showed staff did not administer one dose of [MEDICATION NAME] on 05/10/16. Further review showed staff documented the medication was unavailable. Review of the resident's physician's note, dated 04/29/16, showed the physician documented the resident was admitted to the facility under hospice for terminal care. Further review showed the physician documented the resident has problems with hepatic encephalopthy (loss of brain function when a damaged liver doesn't remove toxins from the blood) and requires sufficient [MEDICATION NAME] to keep him having about three bowel movements a day to keep him from having problems with the encephalopthy. Review of nurses notes, dated 05/07/16, showed staff documented the family reported the resident acting weird and every time the resident acts like this the resident needs to have double doses of [MEDICATION NAME]. The hospice nurse was called with the family's concern. Further review showed the nurses notes did not contain documentation between 05/07/16 and 05/12/16. Review of the resident's physician's note, dated 05/13/16, showed the physician documented the resident was seen due to an increase in lethargy and decreased mental status. Review showed the physician documented the resident is on [MEDICATION NAME] to keep his ammonia level down. The physician documented the facility ran out of the [MEDICATION NAME] and the resident missed four doses. It was reported to the physician the resident had diminished mental status and increased lethargy, by the hospice nurse. Review showed the physician ordered an ammonia level that came back significantly abnormal and it was elevated a little over 100. The physician documented a nasogastric (NG) tube (a tube inserted through the nose, down the esophagus to the stomach for medication or liquid nutrition administration), be inserted so the resident could get his [MEDICATION NAME]. Further review showed the physician documented an order to increase the [MEDICATION NAME] from 45 to 60 GM. During an interview on 06/03/16 at 1:30 P.M., CMT C said the facility CMT's order medications. He/She said he/she did not know why the resident's [MEDICATION NAME] was not available. During an interview on 06/03/16 at 1:45 P.M., Licensed Practical Nurse (LPN) A said the CMT's order medications. He/She said the nurses are responsible for contacting Hospice staff for medications. He/She said he/she was notified on a Monday the medication was not available. He/She contacted the pharmacy for refill but was not notified when the medication did not arrive. He/She said he/she should have followed up on the medication. He/She said as a result of the missing medication, the residents ammonia levels became elevated which caused mental status changes. He/She said when the physician was notified by Hospice, an NG tube was ordered to deliver the [MEDICATION NAME] to the resident. Additionally, he/she said after the medication was started again, the resident's mental status began to improve. During an interview on 06/06/16 at 12:30 P.M., the Director of Nursing (DON) said the medication was ordered from the pharmacy but did not come in. She said staff are expected to reorder liquid medications when two bottles remain. She said Resident #1's medications come from the pharmacy and staff are expected to call the pharmacy to receive the medications. Additionally, she said the pharmacy did not give a reason for not delivering the medication. She said staff are expected to call Hospice and notify the DON so another pharmacy could be contacted if the medication is not available. The DON said the resident's physician was not notified of the missed medications. She said staff are expected to notify the physician. She said she was not sure why the physician was not notified. The DON said facility staff were made aware the missing medication was the cause of the resident's mental status changes when the physician told them. The physician was notified by Hospice of the changes in the resident's mental status. The DON said the facility did not have a baseline ammonia level for the resident. MO 842

Based on observation, interview and record review the facility staff failed to provide one dependent and confused resident (Resident #1) with appropriate assistance while on the commode. Staff left the resident alone on the commode resulting in a fall from the commode. The resident hit his/her head on the floor resulting in a 3.5 inch laceration to his/her left forehead. The resident was transported to the emergency room where hospital staff placed seven sutures in his/her left forehead laceration. The facility census was 88. 1. Review of Resident #1's fall risk assessment dated [DATE] showed the staff scored the resident as a 14 (10 and above indicated the resident was a high fall risk). Review of the resident's occupational therapy notes dated 03/16/13 showed therapy staff recorded the resident's sitting balance was "poor" and he/she "leaned constantly to the left". Review of the resident's occupational therapy notes dated 03/26/13 showed therapy staff recorded the following information: - Resident displayed a poor safety awareness; - Fair sitting balance; - Poor standing balance; - Some confusion; - Required maximum assistance of two staff for toilet transfers. Review of the resident's nurses notes dated 04/01/13 at 8:05 PM, showed staff recorded the resident was on the commode with his/her call light in reach when his/her roommate immediately pulled his/her call light after the Certified Nurse Assistants (CNA) had just left the resident's room. Staff recorded the CNAs entered the resident's room and called for the nurse. Staff recorded upon entering the resident's room, Resident #1 was found laying on the left side of his/her head. Staff recorded a wound was noted to the left side of his/her forehead which measured approximately 3.5 inches above his/her left eye with a hematoma (localized swelling that is filled with blood caused by a break in the wall of a blood vessel). Review of the resident's emergency room report dated 04/01/13 showed hospital staff recorded the resident had sustained a scalp laceration which required sutures. Review of the resident's plan of care updated 04/01/13 showed staff recorded the resident was at risk for falls related to his/her unsteady gait and medication use. Staff recorded the resident had falls at home and was dependent on staff for transfers. Staff recorded the resident had a [DIAGNOSES REDACTED]. Staff recorded the resident had some problems with short and long term memory and his/her mental status varied throughout the day. The care plan directed staff to provide the following interventions for the resident: - Required assistance of two staff for transfers; - Do not leave alone unattended on bedside commode (added 04/01/13); - Ask yes/no questions when possible. Give him/her frequent reminders of daily activities. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 04/05/13 showed staff assessed the resident as follows: - Confused; - Required extensive assistance of two staff with transfers; - Required extensive assistance of two staff with toilet use; - Did not ambulate; - [DIAGNOSES REDACTED]. - Muscle weakness; - Not steady moving on and off toilet and only able to stabilize with human assistance; - Not steady moving from seated to standing position and only able to stabilize with human assistance; - Not steady transferring between bed and chair and only able to stabilize with human assistance. Review of the resident's treatment record dated 04/10/13 showed licensed staff recorded they removed seven sutures from the resident's left forehead laceration. Observation on 04/12/13 showed the resident sitting in his/her wheelchair. Further observation showed seven steri strips to his/her left forehead laceration. During an interview at this time, the resident said he/she was left alone sitting on the commode, slide off and hit his/her head. The resident said it probably took the staff 15 minutes to answer the call light. During an interview on 04/12/13 at 11:30 A.M., Physical Therapist (PT) A said staff should never leave the resident alone on the commode because of his/her poor balance and constant leaning to the left. PT A said when the resident was younger, he/she had polio which left him/her weak on the left side. PT A said the resident required the assistance of two staff for his/her Activities of Daily Living including transfers which was indicated by the pictures of two balloons on the outside of his/her room. During an interview on 04/12/13 at 12:55 P.M., Certified Nurse Assistant (CNA) B said the resident required two staff to transfer him/her to the commode. CNA B said because of the resident's poor balance and leaning forward, he/she has never left him/her alone, even before his/her accident. During an interview on 04/17/13 at 8:45 A,M., CNA C said he/she was working the evening of 04/01/13 when the resident fell . CNA C said he/she was instructed that if the resident did not wear a personal alarm or if they were alert and oriented enough to use a call light, then it was acceptable to leave the resident alone on the commode. CNA C said he/she and his/her hall partner had placed the resident on the commode and left the room when approximately one to two minutes later, the resident's roommate pulled his/her call light because he/she heard the resident call for help. During an interview on 04/17/13 at 8:30 P.M., Licensed Practical Nurse (LPN) D said he/she worked the evening of 04/01/13 when the resident fell off the commode. LPN D said if a resident had no history of falls and was alert and oriented sufficiently to use a call light, then it would be acceptable to leave the resident alone and unassisted on the commode; however if the resident did have a history of falls and was confused, then no, the resident should not be left alone on the commode. During an interview on 04/19/13 at 2:30 P.M., CNA E said said he/she worked the evening of 04/01/13 when the resident fell . CNA E said he/she was told if the resident was not a fall risk and alert and oriented, then it was okay to leave them on the commode unassisted. CNA E said to his/her knowledge, the resident did not have a history of falls and was alert and oriented. CNA E said he/she had left the resident on the commode alone before and had no problems. CNA E said the resident's roommate pulled his/her call light when he/she heard the resident calling for help. CNA E said he/she and his/her hall partner had not been gone maybe 15-20 seconds before the resident's roommate pulled his/her call light. During an interview on 04/28/13 at 7:30 A.M., Occupational Therapist (OT) F said the resident required moderate to maximum assistance of staff with his/her Activities of Daily Living which meant he/she could not do much for himself/herself. OT F said the resident required two staff for assistance with transfers and should not have been left alone on the commode. OT F said whenever the resident sat in his/her wheelchair, staff attached leg rests in an effort to keep him/her upright in his/her wheelchair. During an interview on 04/29/13 at 8:00 A.M., the Director of Nursing said she had nothing further to add and was in agreement with the resident's therapy evaluations. MO 335

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for four residents (Residents # 45, #62, #76, and #89) of 17 sampled residents. The facility failed to provide the necessary care and services to promote healing of pressure ulcers by not performing weekly wound assessments for one resident (Resident #89), and failed to administer wound treatments as ordered by the residents' physicians for four residents (Residents #42, #62, #76, and #89) out of 17 sampled residents. The facility census was 85. 1. Review of Resident #42's Admission Nursing Assessment, dated 5/3/11, showed staff assessed the resident as: - Alert to own name, confused- able to state needs; - Requires Limited assistance with bed mobility, transfers, toileting and grooming; - Currently has pressure ulcer, stage IV (full thickness tissue loss with exposed bone, tendon or muscle) to coccyx; - Bilateral heels soft. Review of the resident's Admission Nursing Assessment Skin Assessment Report, dated 5/3/11, showed staff were directed to: - Turn and/or reposition every two hours; - Toilet every two hours; - Pressure relieving mattress; - Positioning devices in bed; - Perineal care with toileting and/or repositioning; - Skin assessment with bathing. Review of the resident's Braden Scale (a tool used to determine a resident's risk for the development of pressure ulcers), dated 5/3/11, showed staff assessed the resident as "mild risk" with a score of 17. Review of the resident's POS dated 5/3/11, showed a physician's orders [REDACTED]. - Right heel ulcer- [MEDICATION NAME] (a wound dressing) with Opsite (a transparent adhesive dressing) to secure. Change daily; - Line wound bed with thin layer [MEDICATION NAME] gel (a wound healing ointment). Use 1/2 strength Dakins solution (used to prevent and treat skin and tissue infections) moistened 4 x 4's (gauze) stuffed and placed in wound to fill all of wound cavity, cover with Opsite, change BID (twice a day). Review of the resident's Treatment Administration Record (TAR), dated 5/3/11, showed the following: - A treatment for: Right heel ulcer- [MEDICATION NAME] with Opsite to secure. Change everyday; - Staff did not document they administered treatment to the resident's heel wound as ordered by the resident's physician on 5/4/11; - A treatment for: Line wound bed with thin layer with [MEDICATION NAME] gel. Use 1/2 strength Dakins solution moistened 4 x 4's stuffed and placed in wound to fill cavity, cover with Opsite, change BID(twice daily); - Staff did not document they administered treatment to the resident's stage IV pressure ulcer as ordered by the resident's physician on the following dates: 5/4/11, 5/5/11, 5/6/11, 5/9/11, 5/10/11, five days. Review of the resident's Pressure Ulcer Record showed the following: - 'Site A' right heel, 'site B' right gluteal, 'site C' left gluteal; - 5/3/11 site A- stage I (an observable, pressure-related alteration of intact skin) 3.5 centimeters (cm) by 5.2 cm, pink with brown scab; - 5/3/11 site B- stage IV, 5.5 cm by 8.7 cm by 4.5 cm deep, wound bed yellow, pink, slough (necrotic tissue in the process of separating from the viable portions of the body); - 5/3/11 site C- stage IV, 3.9 cm by 4.7 cm by 1.7 cm deep, wound bed yellow, pink, slough; - 5/10/11 site A- stage II, 0.5 cm by 0.5 cm, brown scab; - 5/10/11 site B- stage IV, 8.5 cm by 7.7 cm by 3.0 cm deep, wound bed red, yellow, sloughing; - 5/10/11 site C- stage IV, 3.7 cm by 4.7 cm by 2.0 cm deep, wound bed red, yellow, slough. Observation on 5/11/11 at 11:20 A.M., showed Licensed Practical Nurse (LPN) N provided treatment to the resident's pressure ulcers. LPN N measured the pressure ulcer on the resident's right buttock at 10.0 cm by 6.0 cm by 3.5 cm deep, with undermining at 6:00 at 3.5 cm, at 7:00 2.4 cm. The wound bed was pink with a small amount of yellow slough. LPN N measured the pressure ulcer on the resident's left buttock at 4.4 cm by 4.3 cm by 2.0 cm deep, with undermining at 1:00 at 1.9 cm. The wound bed was 100% yellow slough. During an interview conducted at the time of the intervention, LPN N said there was "a lot more slough" since last week. Further observation showed a 1.0 cm by 1.0 cm black scab on the back of the resident's right heel. During an interview on 5/12/11 at 1:30 P.M., the Director of Nursing (DON) said: - The facility's wound care nurses were performing wound assessments and measurements of wounds until last month, when the DON and Assistant Director of Nursing (ADON) took over; - When determining the stage of a pressure ulcer, the DON and ADON use the "standard of care", a stage II is the "first layer of skin", a stage III is "deeper"; - If staff did not document they performed a resident's treatment "it wasn't done"- "I have no defense for that." 2. Review of Resident #76's MDS, dated [DATE], showed staff assessed the resident as: - Able to repeat three words; - Able to recall one word after cueing; - Unable to state correct year, month, or day of the week; - Requires limited assistance of one person physical assist for bed mobility; - Requires extensive assistance of two plus persons physical assist for transfers and toileting; - Requires extensive assistance of one person physically assist with personal hygiene; - Always incontinent of urine and bowel; - At risk for pressure ulcers; - No pressure ulcers present at the time of assessment or prior assessment. Review of the resident's plan of care, dated 4/19/11, showed staff were directed to: - Keep skin clean and dry at all times; - Able to turn/reposition as needed, may need reminders occasionally; - Monitor skin during showers and inform nurse/physician. Review of the resident's Braden Scale (a tool used to determine a resident's risk for the development of pressure ulcers), showed staff assessed the resident on 9/10/10 as not at risk with a score of 20, and on 3/24/11 as "mild risk" with a score of 16. Review of the resident's POS, dated 5/1/11, showed physicians orders directing staff to: - Right gluteal (right buttocks): apply barrier paste to open areas TID (three times a day) and PRN (as needed); - Lay down after meals for pressure relief. May be up for favorite activities. Review of the resident's TAR, dated 5/1/11, showed the following: - A treatment for: apply barrier paste to open areas TID (three times a day) and PRN (as needed); - Staff did not document they administered treatment to the resident's wounds as ordered by the resident's physician on the following dates: 5/2/11, 5/5/11, 5/9/11, 5/11/11. Review of the resident's Shower Review sheets showed staff assessed the resident's skin condition on the following dates: - 4/27/11 -staff circled an area over the left buttock area on the body chart and documented "open"; - 5/4/11 -staff circled an area over the mid buttock area on the body chart and documented "open"; - 5/10/11 -staff circled an area over the mid buttock area on the body chart and documented "bottom open". Review of the resident's Pressure Ulcer Record showed the following information: - Date of onset Site 'A': 4/11/11, right buttock; - Date of onset Site 'B': 5/3/10, right buttock; - 4/11/11, site A, stage I (an observable, pressure-related alteration of intact skin) 3.4 centimeters (cm) by 3.5 cm; - 4/18/11, site A, stage II (partial thickness skin loss) 0.5 cm by 0.5 cm; - 4/27/11, site A, stage II, 1.8 cm by 1.0 cm; - 5/3/11, site A, stage II, 2.4 cm by 1.4 cm; - 5/3/11, site B, stage II, 2.0 cm by 1.5 cm; - 5/10/11, site A, stage II, 2.0 cm by 1.5 cm; - 5/10/11, site B, stage II, 1.0 cm by 1.2 cm. Observation on 5/11/11 at 10:45 P.M. showed LPN N provided treatment to the resident's pressure ulcers. The resident had two stage II pressure ulcers on the right buttocks, one approximately penny size, the other approximately one cm. in diameter. During an interview on 5/12/11 at 1:30 P.M., the DON said: - The resident had family from out of town stay for three weeks that wanted the resident to be "up and visiting"; - The resident's skin breakdown started during the time the family was here. - If staff did not document they performed a resident's treatment "it wasn't done"- "I have no defense for that." 3. Review of Resident #62's MDS, dated [DATE], showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - Long and short term memory problem; - Total dependence of two plus persons physical assist with bed mobility and transfers; - Total dependence of one person physical assist with personal hygiene; - Always incontinent of bowel and bladder; - At risk for the development of pressure ulcers; Review of the resident's plan of care, dated 2/24/11, showed staff were directed to: - Check and change during rounds and as needed. Perineal care with each incontinent episode; - Staff to reposition every two hours while in bed; - (updated 3/30/11) stoma powder (a protective skin powder that absorbs moisture)/barrier paste TID (three times a day)/PRN (as needed) Review of the resident's POS, dated 5/1/11, showed physicians orders directing staff to: - Stoma powder and barrier paste to open area on buttocks TID and PRN; - Remove Hoyer (mechanical lift) pad when up in wheelchair. Review of the resident's Braden Scale (a tool used to determine a resident's risk of developing a pressure ulcer) showed staff assigned the resident a score of '10' (high risk) on the following dates: 5/6/10, 11/17/10, and 3/24/11. Review of the resident's TAR, dated 4/1/11, showed a treatment for [REDACTED]. Staff did not document they administered the treatment as ordered on the following dates: 4/10/11, 4/11/11, 4/14/11, 4/20/11, 4/21/11, 4/22/11, 4/25/11 through 4/30/11, a total of 12 days. Review of the resident's TAR, dated 5/1/11, showed a treatment for [REDACTED]. Staff did not document they administered the treatment as ordered on the following dates: 5/4/11, 5/6/11, and 5/11/1, three days. Review of the resident's Shower Review sheets showed staff assessed the resident's skin condition on the following dates: - 3/28/11, staff marked an area on the body chart over the left buttocks and documented "open"; - 4/4/11, staff marked an area on the body chart over the left buttocks and documented "open"; - 4/7/11, staff did not document any open areas on the body chart over the buttocks; - 4/11/11, staff marked an area on the body chart over the right buttocks and documented "open"; - 4/14/11, staff marked an area on the body chart over the left buttocks and documented "open"; - 4/18/11, staff did not document any open areas on the body chart over the buttocks; - 4/21/11, staff did not document any open areas on the body chart over the buttocks; - 4/25/11, staff marked an area on the body chart over the left buttocks and documented "open"; - 4/28/11, staff marked an area on the body chart over the left buttocks and documented "open"; - 5/2/11, staff marked an area on the body chart over the right buttocks and documented "open"; - 5/5/11, staff marked an area on the body chart over the right buttocks and documented "open"; - 5/9/11, staff marked an area on the body chart over the right buttocks and documented "open". Further review of the resident's POS dated 3/1/11, showed staff did not obtain a physician's orders [REDACTED]. Further review of the resident's TARs dated 3/1/11 and 4/1/11, showed staff did not begin treatment to the resident's pressure ulcer, first noted on 3/28/11, until 4/1/11, three days later. Review of the resident's Pressure Ulcer Record showed the following information: - 3/30/11 date of onset, right coccyx, stage I, 0.5 centimeters (cm) by 0.5 cm; - 4/5/11 stage II, 0.8 cm by 1.4 cm; - 4/11/11 stage II, 1.2 cm by 1.0 cm; - 4/18/11 stage II, 0.5 cm by 0.8 cm; - 4/27/11 stage II, 0.9 cm by 0.5 cm; - 5/3/11 stage II, 1.1 cm by 0.4 cm; - 5/10/11 stage II, 0.8 cm by 0.4 cm. Observation on 5/11/11 at 6:55 A.M., showed Certified Nurse Assistant (CNA) T and CNA L transferred the resident to his/her wheelchair using the Hoyer lift. CNA T and CNA L did not remove the Hoyer lift pad from under the resident as ordered by the resident's physician. Observation on 5/11/11 at 7:50 A.M. showed the resident sat on the Hoyer lift pad in his/her wheelchair in the dining room for breakfast. Observation on 5/11/11 at 10:35 A.M. showed the resident lay in bed on top of the Hoyer lift pad. During an interview on 5/11/11 at 10:55 A.M., LPN N said: - The staff member that "finds" a wound notifies the DON and performs a wound assessment; - The licensed staff notify the resident's family and physician, and obtain a physician's orders [REDACTED]. - If an aide notes the wound first, the aid will notify the wound nurse; - If a treatment is not "working" after 48 hours, the wound nurse will notify the resident's physician for a new order. Observation on 5/11/11 at 11:52 A.M., showed the resident sat on the Hoyer lift pad in his/her wheelchair in his/her room. Observation on 5/12/11 at 11:00 A.M., showed LPN S provided treatment to the resident's pressure ulcer. The resident had a stage II (partial thickness skin loss) pressure ulcer on his/her right buttock. LPN S measured the wound at 0.8 cm by 0.9 cm by 0.1 cm deep. During an interview on 5/12/11 at 1:30 P.M., the DON said: - The ADON and DON do wound measurements weekly, and use the "standard of care" to determine the stage of the wound; - If staff did not document they performed a resident's treatment "it wasn't done"- "I have no defense for that"; - The resident is "prone to breakdown", the pressure ulcer "heals up and comes back"; 4. Review of Resident #45's MDS, dated [DATE], showed staff assessed the resident as: - Able to repeat three words, recall one; - Able to state correct year and month; - Requires limited assistance of one person physical assist for bed mobility; - Requires extensive assistance of one person physical assist for transfers; - Frequently incontinent of bowel and bladder. Review of the resident's plan of care, dated 4/7/11, showed staff did not include interventions to promote healing of the resident's pressure ulcer. Review of the resident's POS, dated 5/1/11, showed a physician's orders [REDACTED]. - Left gluteal wound: clean lightly, pack with normal saline saturated [MEDICATION NAME] Blue ([MEDICATION NAME] wound dressings) dressing, cover with 2 x 2 gauze dressing, secure with Opsite (a transparent adhesive dressing) dressing daily. Review of the resident's Braden Scale showed staff assigned the resident a score of '20' on 12/28/10 and 4/7/11. Review of the resident's TAR, dated 4/25/11, showed a treatment for: O/A (open area) R (right) gluteal: apply stoma powder (a protective skin powder that absorbs moisture)/barrier paste TID (three times a day)/PRN (as needed). Staff did not document they administered the treatment as ordered on the following dates: 4/26/11 through 4/30/11, five days. Review of the resident's Pressure Ulcer Record showed: - 4/27/11 date of onset- site 'A' right buttock, site 'B' left buttock; - 4/27/11 site A, stage II (partial thickness skin loss) 0.3 centimeters (cm) by 0.5 cm - 4/27/11 site B, stage II, 1.0 cm by 0.5 cm; - 5/3/11 site A, stage II, 0.5 cm by 0.5 cm; - 5/3/11 site B, stage II, 1.5 cm by 1.8 cm; - 5/10/11 site B, stage II, 1.2 cm by 2.0 cm by 1.0 cm deep. Further review of the resident's TAR, dated 4/1/11 and 4/25/11, showed staff did not obtain an order for [REDACTED]. Observation on 5/12/11 at 11:30 A.M., showed LPN S provided treatment to the resident's pressure ulcer. The resident's incontinent brief was removed and LPN S cleansed the resident's buttocks of bowel. Observation showed the resident had a Stage III (full thickness skin loss) on his/her left buttocks that measured 0.6 cm. by 1.0 cm. and the depth was 0.5 cm. LPN S packed the pressure ulcer with [MEDICATION NAME] Blue (moist wound dressing) soaked in normal saline and covered the wound with a barrier dressing. During an interview on 5/12/11 at 1:30 P.M., the DON said: - The facility's wound care nurses were performing wound assessments and measurements of wounds until last month, when the DON and Assistant Director of Nursing (ADON) took over; - The ADON and DON do wound measurements weekly, and use the "standard of care" to determine the stage of the wound; - When determining the stage of a pressure ulcer, the DON and ADON use the "standard of care", a stage II is the "first layer of skin", a stage III is "deeper"; - The resident's pressure ulcer was a stage II last week and is now a stage III (full thickness tissue loss); - Wounds are discussed at the facility's weekly wound meetings, and care plans are updated at that time; - The resident should have care interventions directing staff to promote healing of the resident's pressure ulcer in his/her care plan; - If staff did not document they performed a resident's treatment "it wasn't done"- "I have no defense for that." 5. Review of Resident #89's MDS, dated [DATE], showed facility staff assessed the resident as: - Severe cognitive impairment; - Extensive assistance for bed mobility, transfers, dressing, toilet use; - Limited assistance for personal hygiene; - Always incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - Stage I pressure ulcer (observable, pressure related alteration of intact skin); - Bed rails up times two and used daily. Review of the resident's plan of care, last updated 3/3/11, showed staff are directed to: - Air mattress (added 1/25/11); - Keep skin clean and dry at all times; - Stage II pressure ulcer (partial thickness loss) on his/her coccyx; - Barrier cream to coccyx three times a day and as necessary; - Check and change before and after meals and every two hours when in bed; - Check for incontinence every two hours at night. Review of the resident's Braden scale assessment showed staff assessed the resident on: - 12/9/10 - high risk for skin breakdown; - 3/3/11 - high risk for skin breakdown. Review of the resident's Pressure Ulcers: Comprehensive CNA Shower Review, dated 1/26/10, showed the resident had scabs on left leg. No other skin breakdown noted. The DHSS surveyor requested the Comprehensive CNA Shower reviews prior to the resident developing the skin breakdown and the facility provided a sheet, dated 1/14/11, and staff documented the resident refused the visual assessment. No other shower reviews were provided by facility staff. Review of the resident's Pressure Ulcer Record showed staff documented 1/18/11 as the date of onset for the resident's left gluteal pressure ulcer. Review of the resident's Pressure Ulcer Record showed staff documented on: - 1/19/11: Stage II (partial skin thickness loss) pressure ulcer on left gluteal, measured 0.5 centimeters (cm.) by 0.6 cm.,no depth and pink wound bed; - 1/27/11: Stage II pressure ulcer on left gluteal, measured 0.7 cm. by 1.0 cm., no depth and pink wound bed; - 1/31/11: Stage II pressure ulcer on left gluteal, measured 0.7 cm. by 0.7 cm., no depth and pink wound bed; - No pressure ulcer documentation week of 2/7/11; - 2/16/11: Stage II pressure ulcer on left gluteal, measured 0.3 cm. by 0.4 cm., no depth and pink wound bed; - No pressure ulcer documentation week of 2/21/11; - 3/3/11: Stage II pressure ulcer on left gluteal, measured 0.5 cm. by 0.8 cm., no depth and pink wound bed; - No pressure ulcer documentation week of 3/7/11; - 3/16/11: Stage II pressure ulcer on left gluteal, measured 0.3 cm. by 0.3 cm., no depth and pink wound bed; - No pressure ulcer documentation the weeks of 3/21/11, 3/28/11 and 4/4/11; - 4/11/11: Healed area to left gluteal. Review of the resident's POS, dated 1/2011, showed staff are directed to: - Pressure reduction mattress to bed; - Apply [MEDICATION NAME] (barrier cream) and Stoma powder (protects raw and weeping skin, absorbs moisture) to left gluteal (buttocks) three times a day and as necessary (PRN) (order started on 1/19/11). Review of the resident's TAR, dated 1/2011, showed staff did not document the resident's pressure ulcer treatment on: - 1/19/11 - no treatments documented; - 1/20/11 and 1/21/11 - day and evening shift; - 1/22/11 and 1/23/11 - night shift; - 1/28/11 - day and evening shift. Review of the resident's POS, dated 2/2011, showed staff are directed to: - Pressure reduction mattress to bed; - Apply [MEDICATION NAME] and Stoma powder to left gluteal three times a day and PRN. Review of the resident's TAR, dated 2/2011, showed staff did not document the resident's pressure ulcer treatment on: - 2/1/11 - no treatments documented; - 2/3/11 - evening shift; - 2/5/11 and 2/6/11 - day and evening shifts; - 2/8/11 - evening and night shifts; - 2/10/11- night shift; - 2/12/11 and 2/13/11 - night shift; - 2/14/11 - day and evening shifts; - 2/15/11 - evening shift; - 2/23/11 - night shift; - 2/24/11 and 2/25/11 - day and evening shifts; - 2/27/11 - night shift. Review of the resident's POS, dated 3/2011, showed staff are directed to: - Pressure reduction mattress to bed; - Apply [MEDICATION NAME] and Stoma powder to left gluteal three times a day and PRN. Review of the resident's TAR, dated 3/2011, showed staff did not document the resident's pressure ulcer treatment on: - 3/1/11 - evening shift; - 3/8/11 - day and evening shift; - 3/13/11 - day and evening shift; - 3/15/11 - evening shift; - 3/17/11 and 3/18/11 - evening shift; - 3/19/11 and 3/20 11 - day and evening shift; - 3/21/11, 3/22/11, 3/24/11, 3/25/11, 3/26/11 and 3/27/11 - evening shift. During an interview on 5/11/11 at 12:30 P.M., the DON said the resident used to slide down in wheelchair and after developing skin breakdown a cushion was put in his/her wheelchair. 6. During an interview on 5/11/11 at 12:30 P.M., the DON said the shower aides do weekly skin assessments and give to the treatment nurse. The treatment nurse reviews the assessments, looks at resident if needed, and if any breakdown noted gives to the DON. 7. During an interview on 5/12/11 at 1:10 P.M., the administrator said if staff did not document administering a treatment on the TAR she would think staff did not administer the treatment.