Every finding on record at Citizens Memorial Healthcare Facility

Based on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Nurse Practitioner (NP)) spoke disrespectfully and in a loud tone when interacting with one resident (Resident #1) in a selected sample of 14 residents. The facility census was 94.The Administrator was notified by the Director of Nursing (DON) and Social Service Director (SSD) on 09/23/25 of the incident regarding the resident and the NP. The NP was removed from the facility that day and the facility completed in-servicing of all staff by 09/25/25. The non-compliance was corrected on 09/25/25. Review of the facility's policy titled Patient Rights and Responsibilities, last revised November 2026, showed the following: -Personnel will be oriented and instructed in observing the patient rights and responsibilities within the capabilities and mission of the organization and complying with laws and regulations. Staff will receive a copy of the code of ethics and the facility's guiding principles during general orientation which provide expectations for professional conduct, mission, vision, and values;-Right to dignity and respect. Be treated with consideration, respect, and dignity, recognizing each resident's individuality.1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 05/21/20;-Diagnoses included nontraumatic intracerebral hemorrhage in hemisphere cortical (ICH - a stroke subtype that often present with sudden neurological deficits, headache, or seizures). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 01/19/26, showed the resident had cognitive skills intact.Review of the resident's care plan, revised on 01/20/26, showed the following:-Allow the resident ample time to absorb and respond to information;-Provide a calm, therapeutic environment and structured routine;-The resident had a diagnosis of anxiety. Use a calm reassuring approach, explain all procedures and provide reassurance and comfort. During an interview on 02/09/26, at 2:50 P.M., the resident said the following:-A few months ago, he/she was upset about his/her blood pressure medication;-He/she went to the nurses' desk to talk to the NP regarding his/her concerns;-He/she and the NP got into it and yelled at each other.During an interview on 02/09/26, at 2:39 P.M., Certified Medication Technician (CMT) B said the following:-Over a month ago CMT B was in the medication room next to the nurses' desk;-CMT B heard yelling at the nurses' desk and looked out the window to see who was yelling;-The resident and the NP were in a heated argument about the resident's medication;-The NP yelled at the resident and the resident yelled back;-Staff should not yell and/or raise their voice to residents;-A nurse and a charge nurse were at the desk while the yelling was going on and neither of them tried to intervene;-CMT B reported the incident to the Social Services Director (SSD) and told her the NP yelled at the resident.During an interview on 02/09/26, at 11:03 A.M., CMT C said he/she was in the bathroom by the nurses' station and heard loudness. A staff member told CMT C later that day that the NP and resident were loud with each other.Review of the SSD investigation, dated 09/23/25, showed the following: -The SSD and Director of Nursing (DON) met with the resident after his/her discussion with the provider;-The resident voiced he/she was frustrated because he/she felt the NP was not listening to him/her and understanding what he/she was trying to say to the NP;-He/she repeatedly voiced his/her frustration but did not feel as if the NP listened to him/her and voiced the NP was also frustrated and speaking to the nurse when he/she approached the NP.During an interview on 02/09/26, at 3:10 P.M., SSD said the following: -She heard loudness outside of her office, it was loud enough to get her attention;-The resident and the NP were loud with each other;-She spoke with the resident later who said he/she felt the NP was not understanding him/her;-The SSD expected staff to be respectful of residents. Residents should be comfortable in their own home. Review of the DON's investigation summary, dated 09/23/25, showed the following:-A nurse reported hearing loud voices coming from his/her office. The DON exited his/her office to investigate and observed the resident yelling at the NP;-The NP stood at the nurses' station and faced the nurse on duty;-They appeared to disagree over an order that the resident requested;-Shortly after the DON exited her office, the resident wheeled away, and the NP returned to his office;-The DON reported this interaction to the Administrator at the time of the incident with the SSD present;-The Administrator contacted the NP's supervisor, and NP was sent home for the remainder of the day. During an interview on 02/09/26 at 3:45 P.M. the DON said she was in her office, and the NP was at the nurses' station and his voice was loud. The NP and the resident were loud. She saw the NP facing the nurse when she walked out to the nurses' station. She reported the incident to the Administrator who instructed her to follow up with the resident and NP. The NP went home for the day. She thinks the NP talked to the nurse, the resident yelled at him and the NP got louder and frustrated.During an interview on 02/10/26, at 10:30 A.M., Certified Nurse Aide (CAN) F said the following;-If a resident was yelling or screaming, he/she would try to de-escalate the situation and offer the resident reassurance. If he/she were unable to calm the resident, he/she would notify the charge nurse;-A staff member yelling at a resident was not appropriate, and was an example of not treating a resident in a respectful and dignified manner;-He/she considered the facility to be the resident's home, and staff should treat residents with respect.During an interview on 02/10/26, at 10:23 A.M., Registered Nurse (RN) D said the following: -If he/she observed a staff member yelling or loud with a resident, he/she would ensure the resident's immediate safety and help the resident;-If a resident was yelling, he/she would attempt to intervene and offer the resident a snack and/or an activity;-If a nurse was unable to calm the resident, he/she would notify the DON or the Administrator;-Staff should not yell at any resident.During an interview on 02/10/26, at 10:25 A.M., RN E said the following:-If a resident yelled at a staff member, he/she would try to determine the cause of the yelling and would intervene;-A staff member yelling at a resident would be inappropriate and an example of not treating a resident with dignity/respect.During an interview on 02/09/26, at 3:50 P.M., the Director of Clinical said the following: -The Administrator called her and said the NP was acting out a little and not typical behavior, he got loud with a resident;-She understood that the resident had got after the NP about something, the NP tried to explain, and the resident got louder, and the Administrator said the NP matched the resident's tone;-The Director of Clinical spoke with the NP who said he was frustrated with the scenario. During interviews on 02/09/26, at 2:51 P.M., and 02/10/26, at 12:08 P.M., the Administrator said the following: -She expected staff to remain professional when working with residents;-The NP's tone matched the resident's tone;-She heard this through a third party. The DON heard it outside of her office.Complaint #2706770

Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as possible when staff failed to check the temperature of soup prior to serving and failed to ensure the resident was in an appropriate upright position prior to meal service for one resident (Resident #44) resulting in a burn from the hot liquid. The facility census was 95. Review of the facility policy titled, Event Reporting, approved 10/2025, showed the following:-The incident reporting system will be used to report possible errors, untoward events, and near misses to management, risk manager/administration;-To promptly document information relative to possible errors, untoward events, and near misses;-Definition of event is an occurrence that ideally should not have happened to a patient/resident, client, visitor, or other, whether or not an injury resulted;-An occurrence that is inconsistent with the desired outcome of the patient/resident, client or visitor;-An occurrence having an adverse effect on the patient/resident, client, visitor or other. Review of the facility's policy titled, Safe Food Handling and Preparation, approved 12/2025, showed the Director of Nutritional Services/Food Service supervisor is responsible for maintaining and establishing safe food procedures which meet the conditions set up by the Missouri Department of Health and Senior Services. Review showed the facility did not provide a policy regarding accident hazards or steps taken to prevent them or a policy regarding hot liquids. 1. Review of Resident #44's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 04/10/25;-Diagnoses included cerebral palsy (a group of neurological disorders affecting movement, posture, and coordination), chronic obstructive pulmonary disease (COPD -a lung disease that makes it difficult to breathe), and insomnia (decreased ability to fall asleep and/or stay asleep). Review of the resident's care plan, last reviewed 12/11/25, showed the resident required set up/clean up assistance with eating and the resident resident was able to feed him/herself. Review of the resident's quarterly Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 12/19/25, showed the following: -The resident was cognitively intact;-The resident had impairment on both sides of his/her upper extremities;-The resident requires setup or clean-up assistance with eating; -The resident used an electric wheelchair for mobility. During an interview and observation on 12/15/25, at 1:23 P.M., the resident said the following: -The resident had a sore on his/her left shoulder;-The resident spilt soup on his/her left side;-The resident had a bandage on his/her left shoulder. Review of the resident's medical record showed staff documented the following: -On 12/10/25, at 4:58 P.M., the nurse was called to the resident room by Domestic Care Technician (DCT) L. Staff had given the resident his/her hot potato soup and it had spilt over his/her left shoulder extending down his/her upper arm and to his/her elbow. The nurse cleaned off what he/she could of the hot soup, removed the shirt the resident was wearing, and cleaned off the resident's skin. The resident had a reddened area where the hot soup had landed and a blister had formed on his/her left shoulder, where the majority of the soup was stationed. The resident requested a cool rag on the areas;-On 12/10/25, at 5:06 P.M., staff notified the on-call doctor about the burn incident. The doctor suggested cool compresses to area until area is cooled for comfort, then apply Silvadene cream (a type of cream used to treat burns) for five days to burn area, and wrap lightly with gauze/Kerlex (a think gauze wrap) for comfort. During an interview on 12/22/25, at 8:31 A.M., the resident said the following: -The resident was sitting up in bed with the back of the bed in the raised position when DCT L brought in his/her dinner tray;-The resident picked up the bowl of soup with his/her right hand and was trying to get a better hold on it with his/her left hand when the soup spilt on his/her left shoulder and down his/her left arm;-DCT L immediately called for help after seeing the soup spill;-Staff came to the resident's room, cleaned up the resident, and took care of the burn. Review of a written statement, dated 12/10/25, showed DCT L said on 12/10/25, he/she was passing a tray to the resident, and he/she asked the resident twice if he/she needed to get a certified nurse aide (CNA) to help him/her sit up to eat. The resident told DCT L no and told DCT L to give him/her the soup. DCT L gave the resident the soup and told the resident to be careful. By the time DCT L realized the soup was slipping, he/she did not have enough time to grab the soup. DCT L yelled for a CNA. During an interview on 12/18/25, at 9:21 A.M., DCT L said the following: -He/she passed meal trays down the halls which come in a hot box;-He/she takes the meal trays to the resident's rooms;-The resident normally sits up in his/her chair. The resident was in his/her bed on the day he/she delivered the soup;-He/she sat the meal tray down on the resident's bedside table and asked if he/she needed a CNA to assist him/her to sit up in bed. The resident said no. He/she asked the resident again and the resident said no and to give him/her the soup;-He/she handed the resident the cup of soup and reached to get the resident a spoon, by this time, he/she saw the soup slipping in the resident's hand;-The soup went backwards on the resident's shoulder;-When the soup fell, the resident's body twitched, and he/she ran out of the door and screamed at a CNA;-He/she was not trained to obtain temperatures on food. During an interview on 12/17/25, at 6:12 P.M., Licensed Practical Nurse (LPN) K said the following: -He/she had gone to the resident's room after DCT L had requested an aide;-The resident was lying in bed and had spilt hot soup on her shirt and pillow;-LPN K cleaned up the soup and removed the resident's shirt;-The resident's left shoulder, arm, and left side of his/her neck were red in color;-The first layer of the resident's skin had sloughed off his/her shoulder;-Measurements were not taken of the burn. LPN K estimated that the burn was the size of a silver dollar;-LPN K staged the burn as first-degree burn, similar to a sunburn. During an interview on 12/18/25, at 10:27 A.M., the on-call physician said the following:-The physician was contacted after hours regarding a resident being burned;-LPN K reported that the resident had spilled hot soup on his/her left shoulder and that it ran down the resident's left arm and up the left side of the resident's neck;-LPN K described the resident as having red skin with a large blister on the left shoulder;-Based on the description of the wound the physician staged the wound as a partial thickness burn;-The physician gave orders for Silvadene treatment and a cold compress for comfort. During an interview on 12/17/25, at 4:36 P.M., the Director of Nursing (DON) said he/she was notified by the charge nurse that the resident had spilt hot soup on his/herself. LPN K reported that the resident's left shoulder was red in color and appeared to have been burned. During an interview on 12/17/25, at 4:29 A.M., the DD said the following: -The resident had ordered soup for dinner. The soup was being served off the steam table;-DCT L said he/she went to the resident's room with the dinner tray. When DCT L saw the resident in bed, he/she told the resident that they would get a CNA to help the resident up in bed;-The resident picked up the soup off the bedside table and spilt it on his/herself;-DCT L immediately called for a nurse. The resident was assessed by the nurse;-The resident told the DD that he/she picked up the soup off the table and it spilt;-The resident said DCT L asked the resident to wait for help sitting up in bed. During an interview on 12/17/25, at 4:24 P.M., the Administrator said the following: -The DON received a phone call that let her know that the resident had been burned by hot soup;-The DON and DD completed an investigation of the incident;-The responsibilities of the DCT were to deliver resident trays, fill water cups, and take resident food orders;-DCT L sat the resident's tray on the resident's bedside table. The tray contained hot broccoli and cheese soup;-The resident was lying in bed. The resident picked up the bowl of soup and spilt it on his/her left shoulder;-The DD spoke with the resident about the incident and the resident said he/she picked up the soup and tipped it over to far causing the soup to spill down the resident's shoulder and arm. During an interview on 12/18/25, at 8:50 A.M., Registered Nurse (RN) B said the following:-The resident sometimes eats in his/her room, but staff do try to have him/her go to the dining room;-The resident was independent and fed him/herself, but staff do open cartons and put straws in for him/her;-He/she did a treatment on the resident's shoulder;-This burn on the resident's shoulder looked like a typical burn the size of a silver dollar with red skin around it;-The burn was a blistered area;-He/she did not measure this because he/she did not have the equipment to do this and the resident was crying and was anxious about the burn. During an interview on 12/20/25, at 7:38 P.M., RN V said the following: -RN V worked the night that the resident was burned;-The blister on the resident's shoulder was no longer intact;-The open area of the burn was the size of a [NAME]. Observation on 12/17/25, at 10:42 A.M., of [NAME] Y showed the following: -Cook Y prepared four bowls of tomato soup and two bowls of chicken noodle soup;-Cook Y placed the bowls one at a time into the microwave and set the cook time for one and a half minutes;-When the soup was done cooking, [NAME] Y placed a plastic lid on the bowl of soup and put the soup in the warmer;-Cook Y did not check the temperature on the bowls of soup prior to placing them in the warmer. Observation on 12/17/25, beginning at 3:14 P.M., showed the following: -Cook Y heated a bowl of tomato soup in the microwave for one and a half minutes. [NAME] Y did not check the temperature of the soup, placed a plastic lid on the bowl and gave to the DD;-The DD carried the bowl of soup with the lid on it down to the end of A hall. The DD checked the temperature of the soup, and it was 183.4 degrees F. During an interview on 12/19/25, at 10:39 A.M., the DD said cooks are responsible for temping all food after preparing it and before serving it. The DD would expect the cook to check the temperature of items heated in the microwave before serving it. During an interview on 12/22/25, at 10:42 A.M., the Dietician said the following: -He/she would expect to be notified if a resident received an injury from hot food;-He/she was not notified of the resident's burn from the hot soup;-He/she would expect the cook to check the temperature of food heated in the microwave prior to serving it. During an interview on 12/22/25, at 11:39 A.M., the physician said he/she would expect kitchen staff to check the temperature of food prior to it being served. During an interview on 12/22/25, at 12:57 P.M., the Administrator he/she expected kitchen staff to check the temperature of all food prior to serving it.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and failed to follow proper hygiene practices when two staff failed to wear beard nets. The facility's census was 95.Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and failed to follow proper hygiene practices when two staff failed to wear beard nets. The facility's census was 95.1.Review of the facility's policy titled, Dry Storage of Food and Non-Food Supplies, approved 07/2023, showed the following:-Food items and non-food items are stored in compliance with regulations established by the Missouri Department of Health and Senior Services;-Purpose was to preserve quality and prevent contamination;-Opened products are covered, labeled, and dated before storing. Review of the facility's policy titled, Refrigerated storage of Perishable Foods, approved 09/2025, showed the following: -Food items and non-food items are stored in compliance with regulations established by the Missouri Department of Health and Senior Services;-Purpose was to preserve quality and prevent contamination;-Foods are to be covered, and if removed from original packaging clearly labeled with the common name of the food and dated prior to storage;-Use by labels are to be placed on covered foods with the opened date and use by date clearly marked and kept no more than three days.Review of the facility's policy titled, Safe Food Handling and Preparation, approved 12/2025, showed the following:-The Director of Nutritional Services/Food Service Supervisor (DNS) is responsible for maintaining and establishing safe food procedures which meet the conditions set up by the Missouri Department of Health and Senior Services;-Purpose was to prevent cross contamination and avoid conditions which might cause food borne illness;-Freshly prepared potentially hazardous foods are to be covered, labeled, and dated after preparation and immediately stored according to refrigerated storage of perishable foods guidelines or per state and federal regulations.Observation on 12/15/25, at 9:53 A.M., of the refrigerator labeled salad bar/resident freezer, showed the following: -Four clear hinged take-out containers that contained salad. The containers were not labeled or dated;-Two clear hinged take-out containers that contained cottage cheese. The containers were not labeled or dated.Observation on 12/15/25, at 10:01 A.M., of the refrigerator labeled cooks fridge, showed the following: -One gallon size zipper bag containing raw hamburger. The bag was not labeled or dated;-Twenty-two clear plastic bowls, covered with saran wrap that contained salad. The bowls were not labeled or dated;-Two clear plastic bowls, covered with saran wrap that contained cottage cheese. The bowls were not labeled or dated;-Two clear plastic bowls, covered with saran wrap that contained sliced tomatoes. The bowls were not labeled or dated.Observation on 12/16/25, at 9:30 A.M., of the refrigerator labeled cooks fridge, showed the following: -One gallon size zipper bag containing raw hamburger. The bag was not labeled or dated;-Twenty clear plastic bowls, covered with saran wrap that contained salad. The bowls were not labeled or dated;-One clear plastic bowls, covered with saran wrap that contained cottage cheese. The bowls were not labeled or dated.Observation on 12/16/25, at 10:33 A.M., of the refrigerator labeled salad bar/resident freezer, showed the following: -Nine clear hinged take-out containers that contained salad. The containers were not labeled or dated;-One clear hinged take-out containers that contained cottage cheese. The containers were not labeled or dated.Observation on 12/17/25, at 9:53 A.M., of the refrigerator labeled cooks fridge, showed the following: -One gallon size zipper bag containing raw hamburger. The bag was not labeled or dated.Observation on 12/19/25, at 9:44 A.M., of the freezer labeled cooks freezer showed the following: -Three 8-ounce Styrofoam containers with lids, not labeled or dated, sitting on tray labeled chocolate ice cream, with a made date of 12/14/25 and use by date of: 12/17/25;-Five 8-ounce Styrofoam containers with lids, not labeled or dated, sitting on tray labeled vanilla ice cream, with a made date of 12/14/25 and use by date of: 12/17/25;-Six 8-ounce Styrofoam containers with lids, not labeled or dated, sitting on tray labeled strawberry ice cream, with a made date of 12/14/25 and use by date of: 12/17/25;-Four 8-ounce Styrofoam containers with lids, containing an orange substance, labeled [NAME], with no date.During an interview on 12/19/25, at 9:51 A.M., Dietary Aide (DA) W said the following:-The DA making food was responsible for dating and labeling food before putting in refrigerator/freezer;-The night shift was responsible for discarding food after the use by date;-Food was good for three days after the prepared date.During an interview on 12/19/25, at 10:13 A.M., DA Z said the following: -All staff are responsible for dating and labeling food prior to putting in refrigerator/freezer;-Food was good for three days after it was prepared;-Kitchen staff are responsible for throwing away food passed the use by date.During an interview on 12/22/25, at 10:29 A.M., DA X said the following: -All staff are responsible for dating and labeling food before it was put up;-Food was good for three days after the made date;-All staff are responsible for discarding food that is past the use by date.During an interview on 12/19/25, at 10:39 A.M., the Dietary Director (DD) said the following: -Kitchen staff are responsible for dating and labeling food before putting in refrigerator/freezer;-All staff are responsible for pulling out of date food out of the refrigerator/freezer.During an interview on 12/22/25, at 10:42 A.M., the Dietician said the following: -He/she expected staff to follow facility policy regarding food storage;-He/she expected staff to discard food that was past the use by date.During an interview on 12/22/25, at 12:57 P.M., the Administrator said she expected food to be dated and identified prior to storing in the refrigerator/freezer.2.Review of the facility's policy titled, Nutritional Services, approved 06/2025, showed the following:-Employees shall follow good hygiene practices as described in the Human Resource Policy and procedure manual, in order to maintain an overall clean and healthy working environment;-Beards and goatees are not permitted in the department. Mustaches are to be neatly trimmed and groomed not to extend below the corners of the mouth;-Daily shaving is required as part of the employee uniform.Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following: -Food employees may contaminate their hands when they touch their hair;-A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair;-Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. Observation on 12/15/25, at 10:16 A.M., showed DA X with facial hair not wearing a beard net. Observation on 12/15/25, at 10:30 A.M., showed [NAME] Y with facial hair not wearing a beard net. Observation on 12/16/25, at 10:32 A.M., showed DA X with facial hair wearing a black surgical mask and no beard net.Observation on 12/17/25, at 10:01 A.M., showed DA X with facial hair wearing a black surgical mask and no beard net.During an interview on 12/17/25, at 3:14 P.M., [NAME] Y said staff with a beard, goatee, or mustache were required to always wear a beard net while in the kitchen.During an interview on 12/22/25, at 10:29 A.M., DA X said the facility policy states that staff must wear a beard net to cover the beard and mustache regardless of length.During an interview on 12/19/25, at 10:39 A.M., the DD said the facility policy stated that beards and goatees were not permitted in the Nutritional Services Department.During an interview on 12/22/25, at 10:42 A.M., the Dietician said he/she expected staff to follow facility policy regarding hygiene, including beard nets.During an interview on 12/22/25, at 12:57 P.M., the Administrator said he/she expected kitchen staff to follow facility policy regarding personal hygiene/beard nets.

Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during personal cares for one resident (Residents #5) who had a catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) and when the staff failed to complete proper hand hygiene during personal cares for two residents (Resident #5 and #57) and during wound care for one resident (Resident # 12). The facility census was 95. Review of the facility provided policy titled Enhanced Barrier Precautions for Long Term Care, dated September 2024, showed the following:-EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes;-EBP involved gown and glove used during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as those with increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices);-High contact activities included dressing, transferring, bathing, providing hygiene, changing linens, changing briefs, and device care or use; -Indwelling medical devices include, but are not limited to, central venous lines, indwelling urinary catheter, feeding tubes, and tracheostomy tubes. Review of the facility provided policy titled Hand Hygiene, dated April 2025, showed the following: -Preform hand hygiene on ungloved hands with approved alcohol-based hand rub (ABHR) or soap and water;-Preform hand hygiene before touching a patient, before a clean or aseptic procedure, after body fluid exposure or risk, after touching a patient, after touching a patient's surroundings;-Use ABHR before entering the patient's room, before donning gloves, before donning any personal protective equipment (PPE), before inserting invasive device, before moving from a contaminated body site to a different body site during the care of the same patient, after contact with the patients skin, body fluid, excretions, mucous, or dressing, after contact with objects in the patients immediate vicinity, after doffing sterile or non-sterile gloves, after doffing PPE, and upon exiting a patient room;-Use soap and water when hands are visibly soiled and before eating;-Gloves are not substitute for hand hygiene;-Change gloves during patient care if moving from a contaminated body site to a different body site of the same patient;-Preform hand hygiene between glove changes. 1. Review of Resident #5's face sheet showed the following:-admission date of 05/01/17;-Diagnoses included unspecified intracapsular fracture (a break in the upper part of the thigh bone) of the left femur (thigh bone). Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 9/30/25, showed the resident had moderately impaired cognitive skills. Review of the resident's current physician orders showed the following: -An order, dated 01/21/25, for a foley catheter with a urinary catheter size of 16 and balloon amount of 10;-An order, dated 09/09/25, for staff to clean bilateral groins and apply antifungal powder every shift. Review of the resident's care plan, dated 02/11/25, showed the following:-The resident had a foley catheter related to his/her diagnosis of a neurogenic bladder (a condition where the nerves that control the bladder do not function properly, leading to difficulty with urination);-Staff to use EBP per policy. Observation of resident care on 12/16/25, at 12:45 P.M., showed the following: -Certified Nurse Aide (CNA) G and CNA H entered the resident's room; -The CNAs washed their hands and donned gloves. The CNAs did not don gowns;-CNA H touched the resident's foley catheter bag with gloved hand and placed it the bag on the bed. With the same hand the CNA proceeded to touch the resident and assist him/her in turning over;-CNA G and CNA H then assist resident with removing a soiled brief;-CNA G touched the resident's hair with gloved hand and without performing hand hygiene;-CNA G held resident to his right while CNA H cleaned his/her buttocks with sanitary wipes. The CNA then turn the resident to the center of the bed and cleans the resident's peri area with new sanitary wipe with same gloved hands and without performing hand hygiene; -CNA G and CNA H then assist the resident with fastening new brief;-The CNAs collected trash, doffed gloves, and exited the room without performing hand hygiene. During an interview on 12/16/25, at 12:50 P.M., CNA H said the following: -Residents with foley catheters are on EBP. There is a sign on the door indicating EBP;-Staff were supposed to wear gowns while changing the resident. He/she and the other aide forgot;-Staff wash hands and put on new gloves whenever staff do patient care. Staff wash hands when changing gloves. During an interview on 12/16/25, at 12:55 P.M., CNA G said the following:-Residents with foley's are on EBP, which means staff are supposed to wear a gown and gloves;-The CNAs did not wear gowns during the resident care because they forgot;-Staff are supposed to wash hands and change gloves when going from one task to another;-Staff can use hand sanitizer in between if hands are not soiled. During an interview on 12/17/25, at 10:30 A.M. and 1:30 P.M., Registered Nurse (RN) A said the resident had chronic urinary tract infection (UTIs). If staff did not provide proper peri-care, it could cause infections. Staff should wash hands during peri care. For residents on EBP staff wear gowns and gloves when caring for the resident. Any resident with a foley catheter or wound would be on EBP. During an interview on 12/22/25, at 11:38 A.M., the physician said he/she expected all staff to wash hands before and after each patient encounter and staff to wear gown and gloves as needed by their EBP policy. During interview on 12/19/25, at 2:00 P.M., the Director of Nursing (DON) she expected staff to wear protective equipment, such as gown and gloves, for EBP for residents with a urinary catheter. 2. Review of Resident #57's annual MDS, dated [DATE], showed the following:-Severely impaired cognition;-Inattention and altered level of consciousness behavior that fluctuates (comes and goes, and changes in severity);-Dependent on staff for toileting and personal hygiene;-Required substantial/maximal assistance for eating, dressing, and transfers;-Always incontinent of bowel and bladder;-Diagnoses included anemia (low iron in the blood), high blood pressure, arthritis, stroke, and hip fracture. Review of the resident's care plan, reviewed 12/11/25, showed the following:-Required dependent assistance from staff with dressing, personal hygiene, toileting, and perineal care;-Required maximal assistance from staff with bed mobility and transfers.-Diagnoses of acute and chronic respiratory failure;-Wears oxygen, has an oxygen concentrator at the bedside, and uses an oxygen tank on the wheelchair. Observation on 12/19/25, at 10:50 A.M., showed the following:-The resident was on the bed and fully dressed;-CNA S entered the resident's room, put on gloves without performing hand hygiene, and then removed the resident's damp incontinence brief. The CNA then performed perineal care;-Without removing his/her gloves or performing hand hygiene of his/her hands, CNA S went to the resident's closet and took out a pair of pants and put the pants on the resident;-Without removing his/her gloves and performing hand hygiene, CNA S turned off the resident's oxygen concentrator, put a gait belt (belt used to transfer a resident) around the resident, and assisted the resident to stand and pivot to sit in a chair;-He/she then removed his/her gloves and washed his/her hands. During interview on 12/19/25, at 11:06 A.M., CNA S said the following:-Staff were to wash hands when they entered and left a resident's room;-Staff were to wash hands before applying gloves;-When staff change a resident's incontinence brief, staff were to remove their gloves and wash hands before they re-applied gloves;-He/she did not do wash hands and re-apply gloves after performing perineal care. 3. Review of Resident #12's face sheet (admission data) showed the following:-admission date of 8/07/25;-Diagnoses included fever. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Impaired cognitive skills;-Dependent on staff for toileting, showering/bathing and personal hygiene;-Had pressure ulcers;-The resident was at risk for developing pressure ulcers. Review of the resident's care plan, updated 10/03/25, showed the following:-The resident was at risk for impaired skin integrity with his/her history of falls and limited mobility;-Skin assessment every seven days;-Skin treatment daily. Review of the resident's Physician Orders showed the following:-An order, dated 09/27/25, for staff to cleanse the sacral area (triangular bone in the lower back), dry well, apply skin prep (creates a protective film on skin) to the skin and apply a mepilex (dry gauze dressing) patch for protection. Staff to check daily and change weekly unless soiled;-An order, dated 09/27/25, for staff to cleanse left heel with wound cleanser, dry well, apply skin prep to intact surrounding skin area, apply betadine (broad-spectrum antiseptic and antimicrobial) to wound bed only, cover with gauze, wrap with kerlix or kling and then secure with paper tape. Staff to change daily;-An order, dated 10/03/25, for staff to cleanse the resident's right heel with wound cleanser, dry well, apply skin prep to intact surrounding skin, apply Betadine to wound bed, cover with gauze, wrap with kerlex or kling (a type of bulky woven cotton gauze bandage) and secure with tape. Staff to change daily. Observation of wound care on 12/17/25, at 10:00 A.M., showed the following: -Registered Nurse (RN) A and Licensed Practical Nurse (LPN) D washed their hands and donned gowns and gloves;-LPN D assisted while RN A removed dressing from the resident. After removing the dressing, RN A doffed gloves and donned new glove. The RN did not complete hand hygiene during the glove change;-RN A cleansed the wound to resident's right heel. The RN then doffed gloves and donned new gloves. The RN did not complete hand hygiene during the glove change;-RN A applied a clean dressing to the resident right heel;-RN A and LPN D doffed gloves and gowns and washed their hands. During an interview on 12/17/25, at 10:30 A.M., RN A said he/she forgot to wash are hands when changing gloves. 4. During interviews on 12/19/25, at 8:42 A.M. and 2:00 P.M., the DON said the following:-She expected staff to wash and or sanitize their hands during personal cares such as incontinence care;-All staff are educated on infection control policies and procedures;-Management does frequent rounds to ensure compliance;-The facility utilizes a staff vision board in the break room with statics and education on EBP;-She expected all staff to be following infection control policies. During an interview on 12/22/25, at 11:38 A.M., the physician said the following: -I expect all staff to wash hands before and after each patient encounter;-Staff should be wearing gown and gloves as needed by their EBP policy. During interviews on 12/22/25, at 12:58 P.M. and 1:26 P.M., the Administrator said the following: -The facility educates all staff on infection control. She expected all staff to follow all infection control policies;-She expected all staff to wash their hands before and after patient care;-She expected all staff to wash their hands when changing their gloves.

Based on observation, interview, and record review, the facility failed to have a process in place to ensure food was served at a palatable temperature to all residents when food was below the optimal holding temperature before leaving the kitchen and was not routinely temped by all kitchen staff. This resulted in complaints regarding cold food from seven residents (Resident #55, #39, #72, #11, #83, #61, and #52.) The facility census was 95. Review of the facility's policy titled, Safe Food Handling and Preparation, approved 12/2025, showed the following:-The Director of Nutritional Services/Food Service Supervisor (DNS) is responsible for maintaining and establishing safe food procedures which meet the conditions set up by the Missouri Department of Health and Senior Services;-Purpose was to prevent cross contamination and avoid conditions which might cause food borne illness;-Hot prepared foods are to be fully cooked to proper temperatures and then held at a temperature of 140 degrees Fahrenheit (F) or above, not to exceed 4 hours;-Cold stops germs from growing and heat destroys bacteria. Prepared food should not be left standing at room temperature longer than four hours. Keep hot foods above 140 degrees F and cold foods below 41 degrees F; -Food service personnel shall use timers and metal tip thermometers to monitor the temperature of foods as a means of avoiding excessive shrinkage, overcooking foods, and to retain the nutritional value an appearance of foods prepared.1. Review of the Resident #55's comprehensive Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 11/21/25, showed the resident was cognitively intact.During an interview on 12/15/25, at 10:57 A.M., the resident said the food was cold by the time it was served to him/her in his/her room.2. Review of Resident #39's quarterly MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 12/15/25, at 11:35 A.M., the resident said that the waffle that he/she had for breakfast was cold. 3. Review of Resident #72's quarterly MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 12/15/25, at 11:20 A.M., the resident said he/she ate in the dining room and the food was cold when it was served.4. Review of Resident #11's comprehensive MDS, dated [DATE], showed moderate cognitive impairment.During an interview and observation on 12/15/25, at 12:06 P.M., the resident sat at a table in the dining room. The resident was not eating and stated that the food was cold.5. Review of Resident #83's comprehensive MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 12/15/25, at 12:11 P.M., the resident said the food was cold by the time it was served to him/her in his/her room.6. Review of Resident #61's 5-day scheduled MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 12/15/25, at 1:22 P.M., the resident said that he/she had to ask staff to reheat his/her food because it was cold when it was served to him/her.7. Review of Resident #52's quarterly MDS, dated [DATE], showed moderate cognitive impairment.During an interview on 12/15/25, at 2:12 P.M., the resident said there had been multiple times that the food was served cold when it should have been hot.8. Observation on 12/17/25, at 10:42 A.M., of [NAME] Y showed the following: -Cook Y prepared four bowls of tomato soup and two bowls of chicken noodle soup;-Cook Y placed the bowls one at a time into the microwave and set the cook time for one and a half minutes;-When the soup was done cooking, [NAME] Y placed a plastic lid on the bowl of soup and put the soup in the warmer;-Cook Y did not check the temperature on the bowls of soup prior to placing them in the warmer.Observation on 12/17/25, at 11:42 A.M., of the serve out process showed the following:-Cook Y prepared residents' trays and set them on top of steam table to be served;-The Dietary Director (DD) checked the temperature of the food on the plate before served to the resident. The baked ham measured 140 degrees F, the French fries measured 114 degrees F, the Philly cheese steak measured 132 degrees F, and the cooked carrots measured at 130 degrees F.9. During an interview on 12/19/25, at 9:51 A.M., Dietary Aide (DA) W said the following:-Cooks were responsible to checking the temperature of the food prior to serving;-When a resident stated their food was cold, DA W would heat the food up in the microwave, then stir the food to make sure it was warm enough;-DA W did not check the food with a thermometer. He/she would reheat it for two minutes and tell the resident the food was hot.During an interview on 12/19/25, at 10:13 A.M., DA Z said residents were to get a fresh, new tray if their food was cold when served to them.During an interview on 12/19/25, at 10:39 A.M., the DD said the following: -When a resident's food was cold, staff were to get the resident a new tray with fresh food;-Cooks were responsible for temping all food after preparing it, before serving it, and during serve out;-The DD was not aware that residents had complaints about cold food. During an interview on 12/22/25, at 10:42 A.M., the Dietician said the following: -The Dietician would expect for dietary staff to temp food at start of serve out and maintain that temperature during serve out.During an interview on 12/22/25, at 12:57 P.M., the Administrator said he/she expected kitchen staff to check the temperature of all food prior to serving and during serve out.

Based on observation, interview, and record review, facility failed to ensure all residents were free from significant medication errors when staff failed to administer the correct insulin dosage to one resident (Resident #42) and failed to prime the insulin pen prior to use for two resident (Residents #42 and #72). The facility census was 95.Review of the facility policy Medication Errors and Near Misses, dated 04/25, showed the following:-A medication error was defined as a preventable event that may cause or lead to inappropriate medication use or patient harm;-Example of medication errors would include wrong dose and omission of ordered medication.Review of the facility policy Medication Administration and Documentation, dated 03/25, showed the following:-For the safety of the resident, the provider will observe the right dose by comparing dosage on medication to dosage on Medication Administration Record (MAR);-Before administration, the licensed professional should check the dose, time, and route of administration;-Do a visual examination of the product to be administered noting particulates or discoloration. Review showed the facility did not provide the policy regarding a protocol for sliding scale insulin which was not included in the physician's orders for residents.Review showed the facility did not provide a policy regarding priming insulin pens. Review of the manufacturer's instructions for the Novolog (rapid acting insulin) Flex pen, showed the following:-Wash hands and gather supplies;-Attach new needle;-Dial the dose selector to two units;-Hold the pen with the needle pointing upwards and gently tap the cartridge holder to move any air bubbles to the top;-Press the push button all the way in until the dose counter shows 0;-A drop of insulin should appear at the needle tip. If no drop appears, repeat this step. 1. Review of Resident #42's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/26/25, showed the following:-Diagnoses that included diabetes mellitus (high blood glucose);-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/10/25, showed the following:-History of diabetes and takes routine medication;-Sliding scale for insulin administration;-Prefer the physician to be notified if blood sugar reaches a level outside the resident's sliding scale range;-Administer medications as directed by the physician;-Monitor signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar);-Accuchecks (device which reads the blood sugar levels) as ordered by the physician. Review of the resident's physician's orders showed the following:-An order, dated 01/21/25, for insulin aspart/Novolog flex pen. Staff to see protocol. Administer subcutaneous (SQ - under the skin) before meals (AC) and at bedtime (HS). (The protocol for sliding scale insulin was not on the physician's orders.)- An order, dated 04/02/25, for insulin aspart/Novolog Flex pen 10 units SQ three times a day (TID) with meals. Observation on 12/17/25, at 11:30 A.M., showed the following:-Licensed Practical Nurse (LPN) D reviewed the insulin order on the computer, noting there were two insulin orders for the Novolog insulin to administer for the noon dose;-LPN D said he/she checked the resident's blood sugar level which was 130 milligrams (mg)/deciliter (dL); -LPN D dialed up 13 units of Novolog insulin with the resident's Novolog flex pen, did not prime the pen, and then administered the 13 units of Novolog insulin in the resident's abdomen. During interview on 12/17/25, at 3:25 P.M., LPN D said the following:-He/she did not look at the resident's physician's orders correctly and read the resident's insulin order wrong on the computer;-The sliding scale level for blood sugar of 130 gm/dl would not have had any extra units of insulin to administer to the resident;-He/she did not prime the resident's Novolog insulin pen before administering the insulin to the resident. Review of the resident's progress notes dated 12/17/25, at 3:37 P.M., showed the following:-The resident's blood sugar at lunch was 130 mg/dL);-Staff administered 13 units of Novolog per Sliding Scale Insulin (SSI) and the scheduled insulin. The resident was only to receive was 10 units per scheduled insulin and no SSI;-Staff notified the resident, nurse practitioner, and Director of Nursing (DON). The resident's blood sugar was checked and was 152 mg/dl. 2.Review of Resident #72's quarterly MDS, dated [DATE], showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/10/25, showed the following:-History of diabetes and takes routine medication;-Administer medications as directed by the physician;-Monitor signs and symptoms of hyperglycemia and hypoglycemia;-Accuchecks as ordered by the physician. Review of the resident's physician's orders, dated 09/08/25, showed an order for insulin aspart/Novolog flex pen 16 units subcutaneously TID with meals for Type 2 diabetes mellitus. Observation on 12/17/25, at 11:26 A.M., showed LPN D took the Novolog insulin pen and dialed up 16 units of the Novolog insulin, did not prime the pen, and administered the insulin in the resident's right arm. During interview on 12/17/25, at 3:25 P.M., LPN D said he/she did not prime the pen by wasting two to three units before dialing up the Novolog insulin pen before administering Novolog insulin 16 units to the resident. 3. During an interview on 12/19/25, at 2:00 P.M., the Director of Nursing (DON) said the following:-The nurse was to read and follow the physician's order for insulin. When administering insulin using the Novolog flex pen, they were to dial two units of insulin to waste before they dial up the units to administer to the resident;-The nurse was to double check orders when there was additional insulin per sliding scale to administer. During interviews on 12/22/25, at 10:45 A.M. and 12:56 P.M., the Administrator said the following:-He/she expected staff to prime the insulin flex pens before administering insulin to the resident;-He/she expected staff to check the sliding scale order for proper dose of insulin based on their blood glucose (sugar) level;-There was no specific policy regarding staff priming the insulin pen before administration. During an interview on 12/22/25, at 12:25 P.M., the physician said she expected staff to prime the insulin pen prior to use. She expected staff to administer the correct amount of insulin.

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to ensure complete weekly skin assessments and wound assessments were completed and document for two residents (Resident #12 and Resident #84) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 95. Review of the facility policy titled Pressure Ulcer/Wound Assessment and Treatment, dated May 2025, showed the following: -The skin risk assessment score will be documented by nursing on the admission assessment and then weekly for the first four weeks;-Basic skin assessment is completed on the resident each week;-The Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), care plan, and changes in cognition, functional abilities, or health status may trigger extra skin risk assessments;-Long term care will obtain exact dressing change orders from the physician with the materials to be used and the frequency to be changed;-Document assessment in the patient's medical record; -Long term care setting document the assessment and treatment of wounds in the wound assessment intervention once per shift and as needed;-Long term care photos (of the wound) are taken on admission, weekly, and when newly acquired. 1. Review of the Resident #84 face sheet (document that gives the resident's information at a quick glance) showed the following: -admission date of 09/28/25;-Diagnoses included unspecified fracture of the right tibia, closed fracture. Review of the resident's nursing note dated 10/09/25, at 1:35 P.M., showed the resident has an air cast in place to right ankle. The resident's right lateral (outside) ankle noted to have a deep tissue injury (DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) and right medial (midline) ankle noted to have a pressure injury stage 1 (intact skin with a localized area of non-blanchable erythema (redness)). Staff notified physician in person and via message/task. New skin treatment orders received for both areas. Order for skin prep (used prevent damage from bandage) to area and apply Mepilex (soft foam dressing). The air cast has been reapplied after skin check and areas addressed. Air cast adjusted to ensure proper alignment and fit. Staff updated orthopedic office updated via message/task about new area of concern. Low air loss mattress has been noted for placement. Review of the resident's Wound/Pressure Ulcer Skin Assessment, dated 10/09/25, showed the following: -A facility acquired deep tissue pressure injury to the right lateral (outside) ankle identified on 10/09/25. The wound measured 2.9 cm (centimeters) by 2.8 cm by 0.0 cm;-A facility acquired stage 1 pressure injury to the right medial (close to midline) ankle identified on 10/09/25. The wound measured 1.5 cm by 1.7 cm by 0.0 cm. Review of the residents Wound/Pressure Ulcer Skin Assessment, dated 10/15/25, showed the following: -A facility acquired deep tissue pressure injury to the right lateral ankle identified on 10/09/25. Wound measured 2.7 cm by 2.5 cm by 0.0 cm;-A facility acquired stage 1 pressure injury to the right medial ankle identified on 10/09/25. -Wound measured 1.3 cm by 1.3 cm by 0.0 cm. Review of the resident's physician orders showed an order, dated 10/17/25, to cleanse (right ankle) well, dry well, apply skin prep to discolored area and surrounding intact skin, and apply 4x4 Mepilex. Check daily for placement and change weekly. Review of the resident's Wound/Pressure Ulcer Skin Assessment, dated 10/23/25, showed the following: -A facility acquired deep tissue pressure injury to the right lateral ankle identified on 10/09/25. The wound measured 1.7 cm by 2.51 cm by 0.0 cm;-A facility acquired stage 1 pressure injury to the right medial ankle identified on 10/09/25. The wound was listed as healed. Review of the residents' care plan, revised 12/03/25, showed the following:-Resident was at risk for skin breakdown and had a history of wounds and skin breakdown;-Weekly and as needed (PRN) skin monitoring by a professional nurse;-Weekly skin assessment;-Daily skin treatments. Review of the resident's MDS, dated [DATE], showed the following: -Resident was cognitively intact;-Resident was incontinent of bowel and bladder;-Resident at risk for pressure injuries with no current pressure injuries noted. Review of the resident's nursing notes, dated 10/10/25 to 12/15/25, showed staff did not document related to the resident's wound or wound assessments completed. Review of the resident's Wound/Pressure Ulcer Skin Assessment, dated 10/23/25 to 12/15/25, showed staff did not document an assessment completed. Review of the resident's Weekly Skin Assessments, dated 11/06/25 to 12/15/25, showed staff did not document skin assessments completed. Review of the resident's Wound/Pressure Ulcer Skin Assessment. dated 12/16/25, showed the following: -A facility acquired deep tissue pressure injury to the right lateral ankle identified on 10/09/25. Wound measured 1.5 cm by 1.7 cm by 0.0 cm;-A facility acquired stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure injury to the left heel. Wound measured 0.4 cm by 0.4 cm by 0.0 cm. Review of the resident's physician orders showed an order, dated 12/16/25, to clean and dry (left heel) with wound cleanser, apply calcium alginate (used to promote wound healing), and cover with Mepilex daily. 2. Review of Resident #12's face sheet (admission data) showed the following:-admission date of 8/07/25;-Diagnoses included fever. Review of the resident's care plan, dated 8/08/25, showed the following:-The resident was at risk for impaired skin integrity with his/her history of falls and limited mobility;-Skin assessment every seven days. Review of the resident's physician orders showed the following:-An order, dated 09/27/25, for staff to cleanse the area, dry well, apply skin prep to the skin and apply a Mepilex patch to the sacral area (a triangular bone in the lower back) for protection. Staff to check daily and change weekly unless soiled;-An order, dated 09/27/25, for staff to cleanse with wound cleanser to the left heel, dry well, apply skin prep to intact surrounding skin area, apply betadine (wound cleanser) to wound bed only, cover with gauze, wrap with Kerlix (gauze bandage) or kling (gauze bandage), secure with paper tape, and change daily;-An order, dated 10/03/25, for staff to cleanse the resident's right heel with wound cleanser, dry well, apply skin prep to intact surrounding skin, apply betadine to wound bed, cover with gauze, wrap with Kerlex or kling and secure with tape. Staff to change daily. Review of the resident's nurses note dated 10/14/25, at 2:25 P.M., showed a nurse documented staff updated the resident's family on wounds and skin concerns. The nurse spoke with the resident's family in person and reviewed the current treatment plan for the resident's bilateral heels and buttocks pressure injuries. Review of the resident's Weekly Skin assessment dated [DATE], at 1:00 P.M., showed the following:-Location: left heel. Staff did not document a description or size of area on left heel;-Location: left buttock, abrasion, warm, edematous (swollen), and skin texture fragile;-Location: right heel. Staff did not document a description or size of area on left heel. Review of the resident's Wound assessment dated [DATE], at 11:17 A.M., showed a the following:-Acquired right heel stage III (a deep wound that involves full-thickness skin loss) pressure injury, identified 9/27/25, measured 2.7 cm long by 2.9 cm wide by 0.1 cm in depth. Wound had granulation (new connective tissue), was reddened, and had slough (yellowish, stringy, dead tissue) with no undermining (destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface) or tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) present;-Acquired left heel stage III pressure injury, identified on 09/30/25, that measured 2.1 cm long by 1.8 cm wide by 0.2 cm in depth. Wound had granulation, was reddened, and had slough with no undermining or tunneling present with a small amount of serous (thin, watery drainage) with no odor;-Acquired stage III pressure injury measured 2.1 cm long by 2 cm wide by 0.2 cm in depth. Wound had granulation with no undermining or tunneling present and scant amount of serous drainage with no odor. Slough had decreased and less than 25% of wound bed. Review of the resident's Wound assessment dated [DATE], at 12:05 P.M., showed a the following:-Acquired right heel stage III pressure injury, wound identified 09/27/25, measured 2.5 cm long by 2.9 cm wide by 0.1 cm in depth with eschar (a dry, dark scab or falling away of dead skin), granulation, and slough. There was no undermining or tunneling present;-Acquired left heel stage III pressure injury, identified 09/30/25, measured 2.0 cm long by 1.5 cm wide by 0.2 cm in depth with granulation and slough. There was no undermining or tunneling present and a thin, small amount of drainage with no odor;-Acquired sacrum stage III, identified 09/27/25, measured 1.5 cm long by 1.5 cm wide by 0.2 cm in depth with granulation and slough. There was no undermining or tunneling present with scant amount of serous drainage with no odor. Review of the resident's Weekly Skin assessment dated [DATE], at 12:44 P.M., showed the following:-Location: left heel. Wound was cool, dry, with pallor (unhealthy pale appearance) with loose, thin, saggy, fragile, and wrinkled skin;-Staff did not document information for the resident's right heel and sacrum;-Skin comment: pressure areas to buttocks and bilateral heels. See wound assessment. Review of the resident's medication record showed staff did not document completion of wound assessment on 11/05/25. Review of the resident's nurses note dated 11/05/25, at 12:28 P.M., showed a nurse documented the resident had orders for medihoney (used to promote healing in wounds) to his/her bilateral heels. The nurse spoke with the nurse practitioner and physician about the concerns that the medihoney did not seem to work on the wounds. The nurse asked if Santyl (medication used in wound care to help remove dead tissue) would be appropriate due to dead tissue in both of the resident's wounds. The physician stated the wounds did not need debrided. The physician ordered betadine to be applied to the wounds and covered with bandage to 'dry out'. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderately Impaired cognitive skills;-Diagnoses included Alzheimer's disease and depression;-Had pressure ulcers;-The resident was at risk for developing pressure ulcers. Review of the resident's Weekly Skin assessment dated [DATE], at 5:10 A.M., showed the following:-Left heel was cool, dry, erythema (skin redness caused by inflammation, increased blood flow or irritation), loose skin; and boggy;-Left buttock was cool and dry;-Right heel was cool, dry, erythema, thin and boggy;-Skin comment: pressure areas to buttocks and bilateral heels. See wound assessment. Review of the resident's Wound assessment dated [DATE], at 7:20 A.M. showed a the following:-Acquired right heel stage III pressure injury, identified 09/27/25, measured 1.5 cm long by 0.7 cm wide by 0.1 cm in depth. Wound had granulation with no undermining or tunneling present and no wound drainage or odor. Wound had improved since last assessment;-Acquired left heel stage III pressure injury, identified on 09/30/25, measured 1.4 cm long by 0.4 cm wide by 0.2 cm in depth. Wound was granulation pink with no undermining or tunneling present and no drainage or odor. Improved measurements since last assessment;-Acquired sacrum stage III, identified 09/27/25, measured 0.5 cm long by 0.4 cm wide by 0.1 cm in depth. Wound was granulation pink with no undermining or tunneling present and no drainage or odor. Much improvement noted. Some shearing noted below area; -Staff will continue with treatment plan to all wounds. Observation on 12/17/25, at 10:00 A.M., of wound care showed the following: -Right heel had an open irregular shape wound with serosanguineous (watery red fluid that is a mix of blood and serum) fluid on the bandage;-Left heel had no open wounds;-Coccyx (tailbone) area had two small superficial wounds with no drainage. During an interview on 12/17/25, at 10:39 A.M., Certified Nurse Aide (CNA) G said the following:-The resident has an open area on his/her bottom and one sore on each of his/her heels. He/she did not think the areas were opened;-The resident's heels are wrapped and should float on two pillows when in bed and heel protectors on while up out of bed. During an interview on 12/17/25, at 1:30 P.M., Registered Nurse (RN) A said the following:-The resident has a little open area on his/her buttock area and below is a shearing with no signs of infection;-The resident's left heel had dry skin and a chunk pealed out, an indentation. The resident's right heel was open. During an interview on 12/19/25, at 12:46 P.M., the Director of Nursing (DON) said the following:-Staff did not complete the resident's weekly skin assessments from 11/05/25 through 12/16/25;-Staff did not complete a wound assessment on the resident for 11/05/25;-There were no wound assessments for the resident from 10/27/25 through 12/16/25. 3. During an interview on 12/17/25, at 8:40 A.M., Licensed Practical Nurse (LPN)s D said the following: -The nurses on the floor do the wound treatments and monitor all wounds;-Staff run a skin report that pulls all orders to see which treatments need to be completed each day;-New skin concerns are to be measured, photos taken, and the physician, DON, abd family would be notified;-Charge nurses complete weekly skin assessments and wound assessments. During an interview on 12/17/25, at 9:40 A.M., RN A said the following: -Certified Nurse Aides (CNA) and Shower Aides will report any new skin concerns to the charge nurse;-Nurses are to assess all residents skin weekly;-Wound assessments and interventions should be documented in the nursing notes;-He/she did not measure wounds when completing wound treatments;-Wounds should be assessed and documented weekly. During an interview on 12/19/25, at 10:00 A.M., the DON said the following: -The DON and RN B were responsible for ensuring all weekly skin assessments were completed;-Currently the charge nurse on the floor should be completing skin assessments and wound assessments weekly;-Staff have missed some assessments after the wound care nurse left. During an interview on 12/22/25, at 11:38 A.M., the physician said the following: -He/she expected nursing staff to provide all wound treatments and wound assessments as ordered;-He/she expected nursing staff to notify him/her of any wound concerns;-He/she would get a weekly wound list when they had a wound nurse, but they do not currently have one;-It was very important for nurses to assess the wounds every week and more depending on severity more often. During an interview on 12/22/25, at 12:58 P.M., the Administrator said the following: -The wound nurse was responsible for completing wound assessments and they do not currently have a wound nurse;-Charge nurses were responsible for completing wound assessments if they did not have a wound nurse;-Nursing staff should be completing all weekly skin and wound assessments.

Based on observation, interview, and record review, facility failed to ensure the facility maintained a medication administer error rate of less than 5% when staff failed to administer the correct insulin dosage to one resident (Resident #42) and failed to prime the insulin pen prior to use for two resident (Residents #42 and #72), resulting in two error out of 26 opportunities (a medication error rate of 7.69%). The facility census was 95.Review of the facility policy Medication Errors and Near Misses, dated 04/25, showed the following:-A medication error was defined as a preventable event that may cause or lead to inappropriate medication use or patient harm;-Example of medication errors would include wrong dose and omission of ordered medication.Review of the facility policy Medication Administration and Documentation, dated 03/25, showed the following:-For the safety of the resident, the provider will observe the right dose by comparing dosage on medication to dosage on Medication Administration Record (MAR);-Before administration, the licensed professional should check the dose, time, and route of administration;-Do a visual examination of the product to be administered noting particulates or discoloration. Review showed the facility did not provide the policy regarding a protocol for sliding scale insulin which was not included in the physician's orders for residents.Review showed the facility did not provide a policy regarding priming insulin pens. Review of the manufacturer's instructions for the Novolog (rapid acting insulin) Flex pen, showed the following:-Wash hands and gather supplies;-Attach new needle;-Dial the dose selector to two units;-Hold the pen with the needle pointing upwards and gently tap the cartridge holder to move any air bubbles to the top;-Press the push button all the way in until the dose counter shows 0;-A drop of insulin should appear at the needle tip. If no drop appears, repeat this step. 1. Review of Resident #42's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/26/25, showed the following:-Diagnoses that included diabetes mellitus (high blood glucose);-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/10/25, showed the following:-History of diabetes and takes routine medication;-Sliding scale for insulin administration;-Prefer the physician to be notified if blood sugar reaches a level outside the resident's sliding scale range;-Administer medications as directed by the physician;-Monitor signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar);-Accuchecks (device which reads the blood sugar levels) as ordered by the physician. Review of the resident's physician's orders showed the following:-An order, dated 01/21/25, for insulin aspart/Novolog flex pen. Staff to see protocol. Administer subcutaneous (SQ - under the skin) before meals (AC) and at bedtime (HS). (The protocol for sliding scale insulin was not on the physician's orders.)- An order, dated 04/02/25, for insulin aspart/Novolog Flex pen 10 units SQ three times a day (TID) with meals. Observation on 12/17/25, at 11:30 A.M., showed the following:-Licensed Practical Nurse (LPN) D reviewed the insulin order on the computer, noting there were two insulin orders for the Novolog insulin to administer for the noon dose;-LPN D said he/she checked the resident's blood sugar level which was 130 milligrams (mg)/deciliter (dL); -LPN D dialed up 13 units of Novolog insulin with the resident's Novolog flex pen, did not prime the pen, and then administered the 13 units of Novolog insulin in the resident's abdomen. During interview on 12/17/25, at 3:25 P.M., LPN D said the following:-He/she did not look at the resident's physician's orders correctly and read the resident's insulin order wrong on the computer;-The sliding scale level for blood sugar of 130 gm/dl would not have had any extra units of insulin to administer to the resident;-He/she did not prime the resident's Novolog insulin pen before administering the insulin to the resident. Review of the resident's progress notes dated 12/17/25, at 3:37 P.M., showed the following:-The resident's blood sugar at lunch was 130 mg/dL);-Staff administered 13 units of Novolog per Sliding Scale Insulin (SSI) and the scheduled insulin. The resident was only to receive was 10 units per scheduled insulin and no SSI;-Staff notified the resident, nurse practitioner, and Director of Nursing (DON). The resident's blood sugar was checked and was 152 mg/dl. 2.Review of Resident #72's quarterly MDS, dated [DATE], showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/10/25, showed the following:-History of diabetes and takes routine medication;-Administer medications as directed by the physician;-Monitor signs and symptoms of hyperglycemia and hypoglycemia;-Accuchecks as ordered by the physician. Review of the resident's physician's orders, dated 09/08/25, showed an order for insulin aspart/Novolog flex pen 16 units subcutaneously TID with meals for Type 2 diabetes mellitus. Observation on 12/17/25, at 11:26 A.M., showed LPN D took the Novolog insulin pen and dialed up 16 units of the Novolog insulin, did not prime the pen, and administered the insulin in the resident's right arm. During interview on 12/17/25, at 3:25 P.M., LPN D said he/she did not prime the pen by wasting two to three units before dialing up the Novolog insulin pen before administering Novolog insulin 16 units to the resident. 3. During an interview on 12/19/25, at 2:00 P.M., the Director of Nursing (DON) said the following:-The nurse was to read and follow the physician's order for insulin. When administering insulin using the Novolog flex pen, they were to dial two units of insulin to waste before they dial up the units to administer to the resident;-The nurse was to double check orders when there was additional insulin per sliding scale to administer. During interviews on 12/22/25, at 10:45 A.M. and 12:56 P.M., the Administrator said the following:-He/she expected staff to prime the insulin flex pens before administering insulin to the resident;-He/she expected staff to check the sliding scale order for proper dose of insulin based on their blood glucose (sugar) level;-There was no specific policy regarding staff priming the insulin pen before administration. During an interview on 12/22/25, at 12:25 P.M., the physician said she expected staff to prime the insulin pen prior to use. She expected staff to administer the correct amount of insulin.

Based on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to obtain an order for dialysis and routine assessment and monitoring of the dialysis site, failed to document ongoing communication with the dialysis center, and failed to provide a lunch meal timely for one resident (Resident #3) who received dialysis. The facility census was 95. Review of the facility's policy titled Assessments in Long Term Care, revised December 2025, showed the following:-Purpose to provide an initial assessment to use as a baseline and provide reassessments as needed if a change is indicated for the patient's response to care, condition changes, and/or diagnosis;-Hemodialysis assessment;-Dialysis communication report sent on dialysis days for center to fill out and return to facility and staff to scan into the electronic medical record (EMR);-Assess for bruit (an audible vascular sound associated with blood flow)/palpate thrill (indicates the fistula is working) at AV (arteriovenous - an abnormal connection between an artery and a vein) shunt site and document assessment in EMR;-Monitor weights and vital signs;-Assess for swelling;-Monitor for fatigue, vomiting, pallor, itching, chest pain, shortness of breath, changes in cognition or abnormalities, and notify provider;-Assessments will be completed according to the standard of care. 1. Review of Resident #3's face sheet (admission data) showed the following:-admission date of 10/20/25;-Diagnoses included end stage renal disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 10/20/25, showed the following information:-Moderately impaired cognitive skills;-Diagnoses included anemia, heart failure, and hypertension (high blood pressure);-Resident received dialysis.Review of the resident's care plan, last reviewed 12/15/25, showed the following:-The resident had end stage renal failure and went to dialysis every Monday, Wednesday, and Friday at 12:30 P.M.;-Dressing changes completed at the dialysis center every treatment;-Monitor the resident for changes in condition;-Coordinate the resident's transportation to the dialysis center as scheduled and any after care as directed by the dialysis center. (Staff did not care plan related to communication forms to and from the dialysis center, monitoring of the dialysis site, or meal provisions on dialysis days.) Review of the resident's current Physician Order Sheet (POS) showed staff did not document an order, for dialysis and staff did not have an order regarding assessment of the resident's dialysis site. Review of the resident's medical record showed staff did not have documentation of the dialysis communication forms between the facility and the dialysis center since 11/01/25. Staff did not document follow-up contact with the dialysis center after each dialysis visit. Staff did not document related to assessment of dialysis site. During an observation and interview on 12/15/25 at 10:14 A.M., the resident was in his/her bed. The resident said the facility did not send communication forms with him/her to his/her dialysis appointments. During an interview on 12/17/25, at 1:30 P.M., Registered Nurse (RN) A said the following: -The resident went to the dialysis center on Monday, Wednesday, and Fridays for his/her appointments;-The resident had a dialysis packet on the back of his/her chair, and the Director of Nursing (DON) reviewed the communication form before the dialysis appointment;-The resident has a port in his/her right upper chest and the dialysis center changes the dressings at the appointments. During an interview on 12/17/25, at 1:55 P.M., Certified Nurse Aide (CNA) G said staff should provide the resident a meal tray before the dialysis appointment on scheduled days. Today, the resident did not get a meal tray, the resident said he/she was fine with the ensure drink and did not want anything to eat. During an observation and interview on 12/18/25, at 10:58 A.M., the resident was in his/her bed. The resident said he/she would have lunch, but staff never deliver it to him/her in time before the appointment. He/she sometimes did not want to eat but asked if staff could bring the lunch meal early. When the van is ready, then his/her lunch comes. The staff bring him/her an ensure drink, but he/she wants something to eat so his/her dialysis procedure did not make him/her sick. During an interview on 12/19/25, at 10:22 A.M., Licensed Practical Nurse (LPN) C said the following:-The dialysis center called the facility with any reports of the resident's dialysis appointment. No communication form came back with the resident from the dialysis appointment;-Nurses should check the resident's dialysis site for any discoloration, drainage or discomfort.During an interview on 12/19/25, at 10:13 A.M., Dietary Aide (DA) Z said the following:-There was a list of residents who had doctor appointments/dialysis in the kitchen;-CNA's were responsible to notify the kitchen staff when a resident needed an early meal;-When a resident had an appointment during lunch staff would deliver lunch to that resident as soon as it was prepared;-The resident required lunch early on Monday, Wednesday, and Fridays. Staff should deliver lunch to the resident no later than 11:30 A.M.During an interview on 12/19/25, at 10:39 A.M., the Dietary Director (DD) said the following: -There was a weekly list printed and hung in the kitchen that showed which residents had doctor appointments and required an early meal;-The DD was not aware that the resident required lunch early until 12/17/25;-There was now a sign in the kitchen informing that the resident needed his/her meal tray by 11:00 A.M. on Monday, Wednesday, and Friday.During interviews on 12/19/25, at 1:48 P.M., and on 12/22/25, at 9:33 A.M., the MDS/Care Plan Coordinator said the following: -Staff discuss in morning meetings, by email, or verbally of any needed changes to a resident's care plan;-Staff should check the resident's dialysis site and have lunch before the resident's dialysis appointment and it should be on the care plan;-The resident stated in an interview that he/she was used to skipping lunch on dialysis days and it should be on the care plan;-He/she has called and spoke with the dialysis center manager to request the communication forms;-The communication forms inform staff about how the resident did at the appointment;-The resident takes the communication form and staff call the dialysis center if the form is not returned;-He/she did not see any of the communication forms uploaded in the computer that the facility sends with the resident for appointments During interviews on 12/19/25, at 9:40 A.M. and at 12:46 P.M., the DON said the following:-Nurses should monitor the resident for any change of condition;-Nurses should check the resident's dialysis site in his/her chest for any signs of infection, pain or swelling, and document in the resident's medical record;-There was no order for staff to monitor the resident's dialysis site;-There was no order for the resident's dialysis treatments, but the dialysis appointment days was in the resident's care plan;-Staff send communication forms with the resident to his/her appointments but the dialysis center did not always send the forms back with the resident;-She expected the MDS Coordinators to notify the dialysis center to obtain the communication forms;-She did not have any communication forms since 11/01/25 for the resident;-Staff should communicate with the dietary staff to provide an early lunch tray before the resident's scheduled dialysis appointments;-Dialysis procedure can cause low blood pressure and sugar;-The resident needed adequate nutrition before a scheduled dialysis appointment. During an interview on 12/22/25, at 12:57 P.M., the Administrator said she expected staff to send communication forms for dialysis to the dialysis center. She expected staff to have an order and check the resident's dialysis site and document it in the resident's medical record. She expected staff to deliver lunch to the resident before the dialysis appointments.

Based on interview and record review, the facility failed to ensure an effective pain management system was in place when staff failed to accurately assess and document pain levels, failed to document follow-up after a change in pain medication, and failed to update the care plan related to pain for one resident (Resident #80) resulting in the resident having continued pain that affected his/her desire to get out of bed. The facility's census was 95.Review of a facility policy titled Pain Management, dated April 2026, showed the following:-The facility will assist with establishing a mutual plan between caregiver and patient for the control of pain;-Pain will be assessed upon admission, with as needed (PRN) pain medication administration, and documented on a routine basis within the pain assessment intervention or more frequently as appropriate and care planned as appropriate for each individual resident; -Assessment of pain shall include the circumstance of onset, location, description of pain, aggravating factors, intensity on 0 to 10 pain scale, and the patient's individualized pain level goal;-Reassessment of pain shall be completed at appropriate levels not to exceed 60 minutes following pharmacological and non-pharmacological interventions;-Notify the physician for inadequate pain control, a rating of pain for which pain medicine is not ordered, or unacceptable adverse effects;-Develop a plan of care for the resident's pain management and update as needed. 1. Review of Resident #80's face sheet (facility form that shows basic resident information) showed the following:-admission date of 10/14/13-Diagnoses included diabetes (a chronic disease where your body cannot regulate blood sugar) and pneumonia (a lung infection). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 11/11/25, showed the following:-Cognitively intact;-Received scheduled pain medication;-Received no non-medical pain interventions;-Pain assessment indicated resident had no pain.Review of the resident's care plan, last reviewed 12/15/25, showed the following:-Potential for pain due to left hip pain, low back pain, and arthritis involving multiple joints on both sides of the body;-Pain assessment interviews every seven days and pain plan every 90 days.(Staff did not document related to non-pharmological pain interventions.) Review of the resident's Physician Orders Sheet (POS), dated 12/17/25, showed the following:-An order, dated 05/06/20, for baclofen (a medication used to treat muscle spasms, cramping, and stiffness) 20 milligrams (mg), by mouth, three times a day;-An order, dated 11/24/20, for Tylenol (a medication used to treat pain or fever) 1,000 mg by mouth every twelve hours; -An order, dated 01/23/24, for gabapentin (a medication used to treat types of nerve pain) 300 mg by mouth three times a day;-An order, dated 02/15/25, for duloxetine (a medication used to treat chronic pain) 60 mg by mouth, twice a day. Review of the resident's nurses' notes, dated 10/01/25 to 12/22/25, showed the following: -A note dated10/29/25, at 3:05 P.M., by the Director of Nursing (DON). The DON called the resident's sister who had expressed concerns with pain control. The DON consulted with the pharmacist and tramadol (used to treat moderate to severe pain) was recommended. The physician was contacted with the new recommendations;-Staff did not document any other notes related to resident's chronic pain. Review of the resident's care plan, last reviewed 12/15/25, showed staff did not update the care plan to reflect the pain concerns and request for new medication. Review of the resident's pain assessment interview, dated 11/03/25, showed the following:-The resident should be assessed for pain;-The resident has not had pain in the last five days;-The resident rarely or not at all experienced pain or hurting over the last five days;-The resident rarely or not at all had trouble sleeping because of pain;-The resident rarely or not at all had limitations to day-to-day activities because of pain over the last five days.(Staff did not address the resident's pain that warranted the request for the tramadol.)Review of the resident's Physician Orders Sheet (POS), dated 12/17/25, showed an order, dated 11/05/25, for tramadol (a medication used to treat pain) 50 mg by mouth as needed three times a day.Review of the resident's pain assessment interviews, dated 11/10/25, 11/17/25, 11/24/25, 12/01/25 and 12/08/25, showed the following:-The resident should be assessed for pain;-The resident has not had pain in the last five days;-The resident rarely or not at all experienced pain or hurting over the last five days;-The resident rarely or not at all had trouble sleeping because of pain;-The resident rarely or not at all had limitations to day-to-day activities because of pain over the last five days. Review of the resident's current pain plan, dated 12/08/25, showed the following:-Pain goal of a 0;-Pain scale of 1 to 10;-Medication/interventions included baclofen 20 mg three times a day and Tylenol 1000 mg every 12 hours.(Staff did not document regarding the PRN tramadol.) Review of the resident's pain assessment interview, dated 12/15/25, showed the following:-The resident should be assessed for pain;-The resident has not had pain in the last five days;-The resident rarely or not at all experienced pain or hurting over the last five days;-The resident rarely or not at all had trouble sleeping because of pain;-The resident rarely or not at all had limitations to day-to-day activities because of pain over the last five days. During an interview on 12/15/25, at 2:50 P.M., the resident said the following: -He/she had pain every day in his/her left hip;-The pain ranged from 2 to 5 on a 1 to 10 scale. This day the pain was a 5;-He/she did not like to get out of bed because it hurt to be up in the chair for very long;-He/she tells the nursing staff that he/she is having pain but states they won't give him anything for it;-He/she did not feel like nursing staff was taking his/her pain seriously.During an interview on 12/19/25, at 9:20 A.M., the resident said the following:-He/she had pain at a 2 to 5 level all morning, on a 1 to 10 scale;-He/she was not sure if he/she would get out of bed that day because he/she was scared of making the pain worse;-He/she tells staff what his/her pain is every day;-He/she was not aware of what his/her pain plan said or what was in their care plan. During an interview on 12/17/25, at 12:40 P.M., Certified Medication Technician (CMT) F said the following:-Residents or staff will tell the CMT if they are having pain;-If a resident complains of pain, staff will check their orders and let the nurse know;-Staff will administer PRN medications for pain if staff have an order. If not, staff will let the nurse know;-If a resident was still complaining of pain, staff will tell the nurse. During an interview on 12/19/25, at 10:50 A.M., Certified Nurse Assistant (CNA) E said the following: -The resident complained of pain to his/her left hip and shoulder all the time;-CNA's report the resident's pain to the CMT and the nurse;-He/she has reported the resident's pain to the CMT and to the nurse; -The resident's care plan was in their charting system and the CNA's could review it for information on how to help residents. During an interview on 12/19/25, at 11:10 A.M., Licensed Practical Nurse (LPN) C said the following:-CNAs and CMT's will inform the nurse if a resident was in pain;-Nursing staff will assess the resident's pain and administer medication if necessary;-If a resident's pain was not resolved, nursing staff should notify the provider; -The resident had chronic pain in his/her left hip and frequently told staff he/she was in pain;-Staff have PRN medication they can give him/her if he/she was in pain;-He/she was not sure when the resident last received a PRN pain medication. During an interview on 12/19/25, at 2:40 P.M., the MDS Coordinator said the following:-The resident had chronic pain, and this was included in his/her care plan;-The resident has two interventions in their care plan, the pain plan and weekly pain assessment;-Nursing staff completed the weekly pain assessments;-He/she had no reason to believe the resident's pain plan was not adequate. During an interview on 12/19/25, at 10:00 A.M., the DON said the following: -The resident had chronic pain;-He/she had a meeting with the resident's family over concerns related to the resident's pain;-Nursing staff complete weekly pain assessments on all residents taking pain medication;-These assessments appear on the nurse's worklist, so they are not missed;-MDS is responsible for care planning patient specific pain interventions for residents;-He/she expected the care plan would include non-pharmacological, resident specific goals and interventions;-He/she expected nursing staff to administer PRN medication to a resident who complained of pain and to notify the physician if a resident was having pain that was not relieved by PRN medication;-He/she expected nursing staff to document communication with the provider in the nurses' notes or message to provider task. During an interview on 12/22/25, at 11:38 A.M., the physician said the following:-The resident had chronic pain and several medications to help treat his/her pain;-He/she expected nursing staff to assess residents' pain using a pain scale, vital signs, and non-verbal signs of pain, and administer PRN medication based on that assessment;-He/she expected nursing staff to reassess pain after PRN pain medication and non-pharmacological interventions are used;-He/she expected staff to be using non-pharmacological pain interventions based on resident preference and that those would be in the resident's care plan;-He/she would expect to be notified if pain interventions are not working, and the resident was still experiencing pain. During an interview on 12/22/25, at 12:58 P.M., the Administrator said the following:-He/she expected nursing staff to complete pain assessments and reassess after interventions for any residents experiencing pain;-He/she expects nursing staff to document pain interventions used;-He/she would expect nursing staff to communicate with the provider when pain interventions are not effective;-He/she would expect the care plan to be individualized to the resident's pain plan and goals.

Based on observation, interview, and record review, the facility staff failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent and treat urinary tract infections when staff failed to notify the physician of and provide treatment for suspected urinary tract infections (UTI) for one resident (Resident #36). The facility also failed to ensure proper catheter (a thin, flexible tube inserted into the body to drain fluid) care when staff failed to keep the catheter tubing below bladder level and failed to keep the catheter bag off the floor for one resident (Resident #7). The facility census was 95.1. Review of the facility policy titled, Long Term Urinary Symptoms, revised January 2025, showed the following:-To provide for the immediate treatment for residents who screen positive in the infection screening tool for urinary symptoms;-Registered nurses (RN) and licensed practical nurses (LPN)s in long term care may order and initiate the following protocol;-This protocol may be utilized on residents who screen positive for urinary symptoms on the infection screening tool;-The RN/LPN may order the following items individually utilizing the protocol order source: urinalysis and urine culture;-Document vital signs and assessments as appropriate in the electronic medical record. Review of Resident #36's face sheet (admission data) showed the following:-admission date of 1/05/18;-Diagnoses included major depressive disorder. Review of the resident's care plan, updated 03/20/25, showed the following:-Resident had a history of occasional urinary incontinence and limited mobility;-The resident was at risk for infections due to residing in a nursing facility, his/her age, and underlying health conditions;-Monitor for signs and symptoms of infection;-Utilize the infection/sepsis screening tool;-Notify the provider and responsible party of changes or abnormal screenings. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/07/25, showed the following:-Cognitive skills intact;-Required partial to moderate assistance of staff with toileting and showering/bathing;-Occasional incontinent of urine; -Always continent of bowel. Review of the resident's infection screening assessment dated [DATE], at 10:14 A.M., showed the following:-Mental status change, acute onset;-Functional decline of personal hygiene and toilet use;-General illness, myalgias, or body aches;-UTI symptoms: Infection screening urinary pain/frequency;-Criteria met - yes. Review of the resident's physician orders showed an order dated 12/09/25, at 12:27 P.M., to obtain a urinalysis (UA) and urine culture and sensitivity if indicated. Staff noted it had been collected. Review of the resident's final urine culture results received on 12/09/25, at 1:16 P.M., showed the following:-Result of greater than 100,000 colony-forming units (CFU)/milliliter (mL) of Escherichia coli (a common bacterium found in the intestines of humans);-Result of greater than 100,000 CFU/ml of Klebsiella pneumoniae (a type of bacteria that can cause pneumonia, UTIs, wound infections and more);-An accompanying list of antibiotics for the bacteria with sensitivity and resistance listed. Review of the resident's medical record showed staff did not document notification of the physician regarding the urine culture results. Review of the resident's nurse's note dated 12/14/25, at 6:10 P.M., showed LPN C documented at 5:50 P.M. the resident was noted to continue to have tenderness in his/her lower abdomen and peri area when voiding as well as with palpation of the area. LPN C also noted resident to have some tenderness in the kidney area of the ribcage anterior and posterior. LPN C passed on this information to the night nurse for continued monitoring and notification of the physician regarding the UA results. During an interview on 12/17/25, at 1:30 P.M., Registered Nurse (RN) A said the following:-Signs and symptoms of a UTI include burning, increased frequency and change in confusion;-Nurses enter on a work list of the sepsis monitoring in the computer and it informs staff of qualifications to obtain a UA; -Nurses obtain the UA, send to the laboratory, notify the physician with the results, and enter the order for an antibiotic in the computer if ordered. During an observation and interview on 12/18/25, at 1:06 P.M. and 1:44 P.M., the Director of Nursing (DON) said the following: -She reviewed the 12/09/25 UA and culture and sensitivity results in the computer and said the resident had a UTI and it should be documented in the nurses' note. There should be a provider note regarding the UA results and the resident should be on an antibiotic; -The DON said she did not find the provider message, or a progress note of the resident's UA results and the resident was not on an antibiotic. During an interview on 12/19/25, at 9:56 A.M., Certified Nurse Aide (CNA) G said signs and symptoms of UTI include a burning sensation, increased urination, and decrease in appetite. Staff should inform the charge nurse if a resident has symptoms of a UTI. Observation and interview on 12/19/25, at 10:15 A.M., showed the resident sat in his/her wheelchair in his/her room. The resident said he/she had burning with urination a couple weeks ago. Staff obtained a UA, and he/she received an antibiotic yesterday (12/18/25). It took two weeks to get an antibiotic. He/she had pain while waiting for the antibiotic and it was uncomfortable. He/she was glad to have the antibiotic now. During an interview on 12/19/25, at 10:22 A.M., LPN C said the following:-Signs of a UTI include change in attitude, complaints of general discomfort, discomfort in the kidney and lower back;-Nurses complete the UTI criteria, contact the physician, and obtain an order for a UA and culture if indicated;-Staff deliver the collected specimen to the laboratory which is down the road;-Nurses obtain the results on the computer system within two to three hours;-Nurses inform the physician of the results and follow orders;-Preliminary culture and sensitivity results are within 24 to 36 hours and the final report within 72 hours;-Staff document notification of the physician in the nurses' notes or messages;-He/she thought the resident's antibiotic should had started before 10 days after the results were obtained. During an interview on 12/19/25, at 12:46 P.M., the DON said the following:-Staff should monitor for signs and symptoms of a UTI which include confusion, falls, pain with urination or a change in frequency;-Staff utilize an infection sepsis screening tool on the work list which is an intervention on the computer;-Nurses enter the symptoms and information on the infection screening tool which informs if criteria for further testing were met and it messages a task system to the provider;-If the infection screening tool shows criteria was met, a UA is ordered at that time;-Nurse enter the UA order and the provider notes it as agreed;-Nursing staff collect the UA and take it to the laboratory which is down the road;-The computer system did not notify the facility easily. Nurses should check the computer;-The laboratory results go to the provider which is in a queue;-The provider should receive it and initiate an order for treatment;-Nurses should communicate in shift report of the UA order and check for any outstanding laboratory reports;-The provider or the nurse can enter the antibiotic order;-The pharmacist looks to see if the antibiotic is correct;-Sometimes staff wait for the culture and sensitivity, but the initial results should return within 24 hours;-A culture and sensitivity can take up to 72 hours, but staff can treat for broad spectrum;-If the culture and sensitivity is not back to show resistant but a resident is symptomatic, staff want to start a treatment;-Nurses should message the physician or nurse practitioner who worked in the facility to determine what treatment until the culture and sensitivity results are received;-The physician ordered the UA for the resident. The administrator checked into this further and the physician was not set up in the system yet, so the physician did not receive the UA results in her queue;-She expected the nurses to monitor for UA results each shift and communicate during shift report. During an interview on 12/22/25, at 11:38 A.M., the physician said nursing staff had a protocol to obtain a UA. Sometimes the laboratory results did not come to her. She was not aware of the resident's 12/09/25 UA results. During an interview on 12/22/25, at 12:57 P.M., the Administrator said she expected staff to notify the provider with laboratory results and obtain the ordered antibiotic timely. The computer system was the fail safe, and it failed them. The computer system was designed to send laboratory results automatically to the provider to order any needed antibiotic. It was not turned on for the physician until Thursday (12/18/25).2. Review of the Cleveland Clinic article Urine Drainage Catheter Bags, dated 05/20/25, showed the following:-Try not to let the catheter bag or openings touch any dirty surfaces;-Do not place the catheter bag on the floor;-Keep the catheter bag below waist or hip when emptying it;-Keep the catheter bag below the bladder when walking;-When sleeping, keep the catheter bag below the bladder.Review of Resident #7's quarterly MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Dependent on staff for toileting;-Had an indwelling urinary catheter (tube that drains urine from the bladder) in the bladder;-Diagnoses included renal failure (kidney fail to remove waste and excess fluid) and neurogenic bladder (nerve damage that disrupts bladder control leading to difficulty urinating, leakage (incontinence), and incomplete emptying). Review of the resident's care plan, reviewed 11/21/25, showed the following:-Had a foley catheter related to neurogenic bladder and urinary retention;-Staff to monitor resident for complications of catheter and report to charge nurse;-Change catheter per orders.Review of the resident's physician's order showed an order, dated 03/26/25, for urinary catheter. Staff to insert urinary catheter every 30 days and continue foley catheter care. Review of the resident's progress notes, dated 8/27/25, showed the resident was incontinent of bowel and bladder at this time and had a foley catheter due to diagnosis of neurogenic bladder. Observation on 12/17/25, at 9:03 A.M., showed the resident up in the wheelchair in his/her room and the indwelling urinary catheter bag touched the floor beneath the wheelchair (potentially contaminating the catheter bag/system). Observation on 12/17/25, at 9:41 A.M. showed the following:-Nurse Aide (NA) T brought the sit-to-stand transfer lift (a mechanical lift to assist in transfers) into the resident's room;-The urinary catheter bag touched the floor beneath the wheelchair;-The CNA and NA transferred the resident with the sit-to-stand lift from the wheelchair to the bed. NA T put the catheter bag on the bed when they transferred the resident to the bed;-The CNA and NA removed the resident's pants where the tubing ran down his/her right leg. The resident wore an incontinence brief;-The catheter tubing ran up and over the incontinence brief and a dressing anchor apparatus was attached to the lower abdomen. There was urine was in the tubing from the resident's entry into the body/bladder to the bend in the tubing up on the lower abdomen (resulting in the urine not draining properly);-The CNA and NA did perineal care and attached the catheter bag to the side of the bed. The catheter bag touched the floor;-The CNA and NA removed left the resident's room. Observation on 12/17/25, at 3:40 P.M., showed the following:-CNA P and CNA Q entered the room. The resident's catheter bag touched the floor with urine in the tubing;-CNA Q drained the urine from the catheter into a graduated (measurement) container;-CNA Q noticed the anchor dressing apparatus for the catheter tubing up on the abdomen was loose;-The CNAs removed this anchor apparatus and placed another dressing anchor apparatus on the upper thigh for the catheter tube to run down the resident's pant leg and re-attached the incontinence brief;-The CNAs pulled up the resident's pants, changed his/her shirt, and then transferred the resident with the sit-to-stand lift with the catheter bag to the wheelchair and placed the dignity bag holding the catheter under the wheelchair which touched the floor;-CNA P opened the resident's door and pushed the resident to the dining room in the wheelchair with the bag touching the floor. Observation on 12/18/25, at 9:00 A.M., the resident sat in the wheelchair with urine in the catheter bag tubing under the wheelchair. The catheter bag touched the floor. Observation on 12/18/25, at 12:29 P.M., showed the resident in the wheelchair in the dining room with the catheter bag under the wheelchair. The catheter bag touched the floor. There was urine in the catheter tubing.During interview on 12/19/22 at 2:00 P.M., the DON said when a resident had a urinary catheter, she would expect staff to keep the catheter bag above the floor and not to touch the floor under the wheelchair or while they were in bed. During interview on 12/22/25, at 12:25 P.M., the physician said any urinary catheter bag was not to touch the floor. During interview on 12/22/25 at 12:56 P.M., the Administrator said she would expect the catheter dignity bag not to be on the floor at any time whether under the wheelchair or on the side of the resident's bed.

Based on observation, interview, and record review, the facility failed to provide care to all residents with a urinary catheter (a sterile tube inserted into the bladder to drain urine) in a manner that prevented possible infection when staff failed to follow proper infection controls practices, including proper handwashing, during wound and catheter care for one resident (Resident #2) with a history of urinary tract infections (UTIs). The facility census was 83.Review of the facility policy titled, Standard Precautions, IP0-05, revised October 2024, showed the following:-Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered;-Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings;-Hand hygiene includes both hand washing with soap and water and use of alcohol-based products that do not require the use of water;-During delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces;-Indications for hand hygiene from Centers for Disease Control and Prevention (CDC) include prior to entering a patient's room or care area; when exiting a patient's room or care area; before direct contact with patients; before inserting invasive devices that do not require a surgical procedure; after contact with a patient's intact skin; after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; before putting on gloves; and after removing gloves;-Gloves are used to prevent contamination of hands when anticipating direct contact with blood or body fluids, mucous membranes, non-intact skin and other potentially infectious material, or handling, or touching visibly or potentially contaminated patient care equipment and environmental surfaces;-It may be necessary to change gloves during care of a single patient to prevent cross contamination;-It will be necessary to change gloves if during the interaction you touch nonsterile objects such as computer keyboards, trash can, etc. Review of the facility policy titled, Urinary Catheterization, NUR08-13,. revised March 2024, showed the following:-The policy is to provide guidance for the placement of urinary catheters, maintenance techniques, and to assist in the prevention of catheter-associated urinary tract infections (CAUTI);-For maintenance, standard precautions should be used. Use gloves when manipulating the catheter site and drainage system and practice hand hygiene before and after;-A sterile, continuously closed drainage system should be maintained for indwelling and suprapubic catheter systems;-If there are breaks in aseptic technique, disconnection of tubing, or leakage from the bag, or if the catheter becomes contaminated, the catheter should be replaced;-Meatal care (hygiene practices for the urethral opening) is performed twice per day and includes cleansing of the peri area with soap and water or with organization approved chlorhexidine gluconate (CHG) wipes;-Cleansing the meatal surface during daily bathing is appropriate and can be included as part of the twice per day requirement and CHG wipes should be used daily for patients with an indwelling device;-Hand hygiene should be performed immediately before and after manipulation of the catheter site or collection bag. Review of the facility policy titled, Hand Hygiene, IP02-07, revised April 2025, showed the following:-Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting;-Perform hand hygiene before crossing the threshold/entering the patient's room, before donning sterile or non-sterile gloves, before donning any PPE (i.e. gown, mask, gloves), before inserting or handling invasive devices, before moving from a contaminated body site to a different body site during the care of the same patient, after contact with patient's skin, body fluids, excretions, mucous membranes or dressings, after contact with objects in the immediate vicinity of patients, after doffing of sterile or non-sterile gloves, after doffing of any PPE, and upon crossing the threshold when exiting the patient's room;-Gloves are not a substitute for hand hygiene;-Wear gloves when contact with blood or other potentially infectious materials, mucous membranes and non-intact skin is anticipated;-Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients;-Change gloves during patient care if moving from a contaminated body site to a different body site of the same patient;-Perform hand hygiene between glove changes;-Perform hand hygiene and change gloves if you suspect your gloves have been contaminated. 1. Review of Resident #2's face sheet showed:-admission date of 11/04/21;-Diagnoses included acute (short-term) urinary tract infections (UTI's), chronic neurogenic urinary bladder disorder (a condition in people who lack bladder control due to brain, spinal cord, or nerve problems), renal insufficiency (poor function of the kidneys), and sepsis (the body's extreme reaction to an infection). Review of the resident's Minimum Data Sheet (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/02/2025, showed the following:-Cognitively intact;-Dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, and moving from sit to lying;-Had an indwelling urinary catheter. Review of the resident's physician order, dated 01/20/25, showed direction for staff to insert a urinary catheter every 30 days and continue catheter care at 6:00 A.M. and 6:00 P.M. daily. Review of the resident's clinical laboratory report, dated 06/03/25, showed a urine culture positive for Pseudomonas aeruginosa (bacterial infection that typically occurs in a healthcare setting). Review of the resident's nurse's note dated 06/24/25, at 2:06 P.M., showed a nurse documented the resident was transferred to the emergency room (ER) due to marked decrease in response, diaphoretic (excessive sweating), and temperature of 102 degrees Fahrenheit (F). Review of the resident's care plan, reviewed on 06/27/25, showed the following:-Keeping skin clean and dry, providing peri-care after each incontinent episode;-Resident has a catheter due to his/her diagnosis of neurogenic urinary bladder disorder;-Required extensive assistance;-Would like the catheter bag emptied every shift and have a dignity bag over the catheter bag;-Is dependent with peri care;-The resident is at risk for infections due to residing in a nursing home, his/her age, and underlying health conditions;-He/she takes prophylactic medication to prevent infections;-His/her goal is to show no signs and symptoms of infection through the next review date;-Interventions include monitoring for signs and symptoms of infection, utilizing infection/sepsis screening tool, providing adequate hygiene practices, utilizing standard precautions, infection screenings, as indicated, per policy, and notifying the provider and responsible party of changes or abnormal screenings. Record review of the resident's hospital Discharge summary, dated [DATE], showed the following:-Resident admitted on [DATE];-Primary discharge diagnosis of sepsis;-Other active medical issues addressed during the hospital admission included urinary tract infection with hematuria (presence of blood in the urine)) and acute cystitis (inflammation of the bladder) with hematuria;-Noted to have sepsis from urinary tract infection (UTI);-Maxipime (cefepime - antibiotic) 2,000 milligrams (mg) intravenous (IV) injection every 8 hours for 14 days;-Hiprix (methenamine Hippurate, prescription antibacterial medication primarily used to prevent and control recurring UTIs) 1 gram by mouth two times per day. Review of the resident's nurse's note dated 07/01/25, at 4:59 A.M., showed a nurse documented the following:-The resident returned to the facility at 4:25 A.M. via ambulance;-Pharmacy notified of resident's arrival and stated no changes made to medications, except cefepime 2,000 (mg) IV every eight hours for 14 days;-The resident's indwelling catheter was removed at the hospital per the resident's request and an external catheter was used in the hospital instead;-It was explained to the resident that the facility did not use the external catheter;-The resident stated he/she did not want an indwelling catheter back in at this time. Review of the resident's nurse note dated 07/01/25, at 7:33 P.M., showed a nurse documented the following:-The resident stated after a large incontinence, that he/she still felt the need to void;-The nurse spoke to the nurse practitioner and received an order to reinsert a #16- 10 cc (size) catheter;-The nurse was unable to insert a normal 16-gauge catheter, so he/she inserted a #16- 10cc coude catheter (specifically designed to maneuver around obstructions or blockages in the urethra) with minimal difficulty;-The catheter drained well to gravity drainage. Observation on 07/01/25, at 10:52 A.M., showed the following:-The Wound Nurse and Certified Nurse Aide (CAN) I prepared to provide the resident's pressure ulcer care;-The Wound Nurse and CNA I did not perform hand hygiene prior to donning gloves and a gown;-The incontinence pad under the resident was saturated with a large amount of yellow urine and a large amount of stool;-Stool was present on the resident's buttocks and buttock wound dressing;-The Wound Nurse and CNA I cleaned the resident and the bedding up from the urine and stool;-The Wound Nurse completed wound care treatment for the resident;-With the same gloves and gown on, the Wound Nurse and CNA I placed new bedding on the bed and placed the soiled bedding in a trash bag;-The resident requested that CNA I adjust the room temperature in the room by using the thermostat beside the resident's bed;-CNA I did not complete hand washing, hand hygiene, or change his/her gloves prior to adjusting the thermostat;-After adjusting the thermostat, CNA I removed his/her gown and gloves, but did not use hand hygiene or wash his/her hands;-CNA I donned a new gown and gloves and proceeded to provide catheter care to the resident;-CNA I used one peri wipe to briefly clean the catheter tubing in a circular motion and one peri wipe to briefly clean the resident's perineal area;-The urinary meatus was not cleaned;-The Wound Nurse and CNA I doffed their gowns and gloves and completed handwashing in the resident room prior to exiting the room. During interviews on 07/01/25, at 10:35 A.M., and on 07/07/25, at 11:01 A.M., the resident said the following:-He/she returned from the hospital around 4:00 A.M. today after being admitted for a UTI;-He/she requested that his/her indwelling catheter be removed at the hospital, but the facility nurse had to put the catheter back in due to him/her feeling like he/she still needed to urinate;-He/she gets frequent UTI's;-The hospital staff said the facility staff should be cleaning his/her catheter two times per day and should clean it better than they have been,-Facility staff usually only complete catheter care on him/her one time per day. During an interview on 07/01/25, at 11:26 A.M., the Wound Nurse said the following:-He/she should wash his/her hands or use hand hygiene when he/she enters a resident's room;-If his/her hands are physically soiled, he/she should wash his/her hands and put on new gloves;-He/she should wash his/her hands any time he/she goes from a dirty environment to a clean environment;-If his/her hands are not visibly soiled, he/she would use hand sanitizer rather than wash his/her hands with soap and water;-He/she would physically wash his/her hands when the resident's care is all finished. During an interview on 07/02/25, at 10:25 A.M., CNA J said the following:-He/she normally provides catheter care two times per day during his/her 12-hour shift;-He/she documents catheter care under the work list/care item under the bowel and bladder diary;-The documentation process in the resident chart only allows him/her to enter the time the catheter care was completed, not the process or supplies used for catheter care;-If he/she has concerns with a resident's catheter, he/she tells the nurse, and the nurse would be responsible for documenting the concerns. During an interview on 07/02/25, at 11:35 A.M., CNA K said the following:-The aides provide catheter care when they empty the catheter bag and at least one time per shift;-He/she wears a gown and gloves for catheter care;-He/she empties the catheter bag prior to completing catheter care;-CNA K would wash his/her hands after catheter care is completed;-He/she would change gloves only if the gloves were visibly soiled or if the resident requested some kind of care non-related to the catheter care;-He/she charts catheter care in the resident's bowel and bladder diary located in the electronic health record;-CNA K would notify the nurse immediately if he/she had concerns regarding a resident's catheter. During an interview on 07/02/25, at 11:43 A.M., Registered Nurse (RN) D said the following:-The CNA's complete catheter care and document it in the resident's electronic health under the bowel and bladder diary;-Catheter care should be completed at least every 12 hours;-The CNA's are expected to let him/her know if they find anything abnormal regarding a resident's catheter;-Catheter care should be completed from top to bottom, around the opening, and then on down;-Gloves and a gown should be worn during catheter care;-If a resident was soiled with stool and staff had to clean the resident up and change their soiled bedding, staff would be expected to change their gown and gloves and complete hand hygiene prior to providing catheter care;-RN D said there would be a potential increased risk of infection of the catheter if staff clean a resident up from incontinent stool, change the resident's bedding that was soiled with stool, and then did not change their gown or gloves or use hand hygiene or wash their hands prior to providing catheter care. During an interview on 07/02/25, at 12:30 P.M., Licensed Practical (LPN) L said the following:-The CNA's and nurses provide catheter and peri care;-Staff are expected to use a foam soap with a wet rag for catheter care and clean in a downward motion, then rinse with a wet cloth and pat it dry;-Staff should clean around the catheter last;-Staff should use hand sanitizer or wash their hands before they enter the resident's room and don gloves and a gown for catheter care;-If gloves become soiled, staff should use hand sanitizer and apply new gloves;-If his/her gloves and gown are not soiled after he/she cleans a resident up after a bowel movement, he/she does not change his/her gown or gloves;-Sometimes he/she double gloves and removes the outer layer of gloves if they become soiled;-If he/she only has one pair of gloves on and they become soiled, he/she would remove the gloves and probably use hand sanitizer;-He/she would assume that there would be an increased risk for a UTI if staff did not change their gloves and wash their hands or use hand sanitizer after cleaning a resident up from a bowel movement, or after changing sheets that were soiled with stool prior to providing catheter care;-After cleaning a resident up after a bowel movement, he/she should don a new gown and gloves before starting catheter care;-Catheter care should be completed every shift and after every soiling;-The CNA's chart in the electronic health records every time they complete catheter care. During an interview on 07/02/25, at 2:37 P.M., the Assistant Director of Nursing (ADON) said the following:-He/she tracks antibiotics and has an infection screening tool that the nurses use;-He/she has noticed a trend in infections, specifically in residents with UTI's, but the facility has more indwelling catheters now;-He/she recently sent a huddle binder to all staff with instructions on how to take care of indwelling catheters;-The underlying cause of the increased UTI rate in the facility has not been determined;- He/she expected staff to empty catheter bags during rounding checks every two hours;-He/she expected staff to provide good peri care for resident's that have an indwelling catheter, which would include cleaning the crusting discharge from the catheter tubing itself;-Staff were expected to use hand hygiene prior to providing catheter care and wear a gown and gloves while providing catheter care;-He/she would expect staff to change soiled gloves;-He/she would expect staff to use hand hygiene or wash their hands and change their gloves before they enter a resident room or touch a resident, immediately after they complete resident care, and when they move from a dirty procedure to a clean procedure;-If staff clean up stool from a resident or their bedding, they are expected to wash their hands with soap and water and change their gloves and gown prior to providing catheter care;-Handwashing/hand hygiene and gloving up are important to help prevent the spread of infections between residents;-If staff are not properly washing their hands, using hand hygiene, or are not changing their gloves and gowns properly, it could place the residents at risk for UTI's and other infections;-Staff should be cleaning body parts from inside outward, front to back, and down rather than up;-If staff assist a resident with incontinent care, they are expected to wash their hands with soap and water and don new gloves and a gown prior to completing catheter care;-If the staff's hands are not soiled, it is acceptable for them to use an alcohol-based hand sanitizer prior to applying new gloves. During an interview on 07/02/25, at 4:29 P.M., the Wound Nurse said the following:-Staff should wash their hands or use hand sanitizer when they enter the resident's room;-When transitioning for cleaning a resident up from urine or stool, staff should take off their gloves, wash their hands and put on new gloves prior to starting wound care;-When providing peri care and catheter care, staff should wash their hands, put on gloves and a gown;-Staff should perform one swipe with a peri wipe, then throw the wipe away and get a new wipe to continue cleaning the peri area and catheter;-Staff should use an inner to outer process to clean the catheter;-Staff can use either peri wipes, foam and a washcloth, or soap and water for catheter care;-After completing catheter care, staff should wash their hands with soap and water prior to leaving the resident's room. During an interview on 07/07/25, at 10:20 A.M., the Director of Nursing (DON) said the following:-The resident has had multiple UTI's;-The ADON provides infection prevention training for staff by sending out daily education and offering daily huddles for staff;-The CNA's provide catheter care during peri care;-CNA's empty the catheter bags;-Catheter care is completed as many times as needed throughout the day, and for sure two times per day;-Catheter care is completed with incontinence care and every shift at a minimum;-If staff clean a resident up from stool, he/she would expect staff to use hand hygiene or hand washing if their hands are soiled and apply new gloves and a gown prior to starting another procedure process, such as catheter care, with the same resident;-Anytime staff go from a dirty process or procedure to a clean process or procedure, they are expected to use hand hygiene or wash their hands prior to putting on new gloves;-Staff should be using the soap in and soap out process or using hand hygiene when they enter and exit a resident's room;-It is not acceptable for staff to not use hand hygiene or wash their hands after cleaning a resident up from stool and prior to moving on to complete catheter care;-During wound care, when going from a dirty process to a clean process, staff should remove their gloves, complete hand hygiene, and put new gloves on;-Staff should not wipe towards the catheter insertion site in order to keep dirty content away from the catheter insertion site;-He/she would expect the catheter to be cleaned last in the catheter care process to avoid spreading dirty content to the catheter insertion site.Complaint #1775421, #1775424

Based on observation, interview, and record review, the facility failed to provide care for pressure ulcers per standards of practice when staff failed to follow-up regarding an intervention of an appropriately sized bed and when staff failed to follow-up with the physician in a timely manner regarding a wound culture for one resident (Resident #1) and when facility staff failed to utilize appropriate hand hygiene prior to and during pressure ulcer wound care for one resident (Resident #2). The facility census was 83. 1. Review of the facility policy titled, “Pressure Ulcer/Wound Assessment and Treatment”, revised June 2025, showed: -Nursing personnel will continually strive to maintain the skin integrity, tone, turgor, and circulation to prevent skin breakdown, injury, and infection; -Purpose to provide a consistent effective method or treatment for pressure ulcers/wounds; -Initiate the appropriate prevention intervention; -Positioning techniques: Use positioning devices (pillows, heel protectors, overlay air mattress) to raise a pressure off the support surface. Avoid utilizing donut-type devices; Establish a repositioning plan according to individual resident needs, care goals, tissue tolerance, and response to treatment. Avoid positioning on pressure ulcer/wound, when possible, to facilitate protection of uninvolved areas. Avoid positioning immobile individuals directly on their trochanters, bony prominences, or existing wounds. Use positioning devices to prevent direct contact between bony prominences. Maintain head of bed the lowest degree of elevation tolerated by the resident’s condition and limit the amount of time the head of bed is elevated more than 30 degrees. -Patient support systems: Protective padding, alternating pressure mattress, gel pads, low air loss therapy, air mattress overlay. Review of Resident #1’s face sheet showed the following: -admission date of 01/10/24; -Primary diagnosis of lumbar spine epidural abscess (a collection of pus that formed in the space between the spinal cord and the bones of the spine.) Review of the resident’s current care plan showed the following: -Resident had a history of peripheral vascular disease (PVD-a condition where the arteries and veins become narrowed or blocked resulting in reduced blood flow to and from the legs) and diabetes; -Resident has a history of skin break down; -Resident has had a right metatarsal great toe amputation due to a wound, resulting in greater high risk for skin integrity; -Interventions for pressure ulcer, start 01/18/24, Braden scale as needed, dietitian to evaluate resident nutrition as needed, keep nails trimmed and filed, encourage not to scratch as needed, keep skin clean and dry, use lotion on dry skin as needed, offer supplemental nutrition, if indicated, pressure relieving devices to bed (air mattress), provide peri-care after each incontinent episode, use caution during transfers and bed mobility to prevent shearing, and weekly and as needed skin monitoring; -Skin risk assessment scale every 90 days, starting on 01/10/24; -Skin assessment every 7 days, starting on 01/28/24; -Protective skin barrier at bedside, starting 05/30/24; -Resident has had a right metatarsal (mid foot bone) great toe amputation due to a wound resulting in a greater high risk for skin integrity. Review of the resident’s wound assessment dated [DATE], showed: -Wound location: Right great toe; -Present on Admit or Acquired: Acquired; -Wound type: Pressure injury; -Wound Staging: Stage 2; -Wound length: 0.4 centimeter (cm); -Wound width: 0.3 cm; -Wound appearance: Beefy red, pink, and shiny; -Wound surrounding tissue appearance: Bright red; -Surrounding tissue appearance: Cool; -Wound drainage description: Sanguineous (containing blood); -Wound drainage amount: Scant; -Wound drainage odor: No odor; -Wound details/comments: Resident acquired this pressure ulcer due to continuously sliding down in bed and his/her right great toe had contracture (stiffening and shortening of the muscles, tendons, ligaments) noted and pressed against the foot board. Sanguineous drainage was noted on the gauze, scant amount. Interventions and prevention measures have taken place as in a foam wedge placed between the mattress and foot board and heel/foot protectors are in place. Review of the resident’s nurse note dated 03/12/25, at 11:33 A.M., showed the wound nurse documented the following: -Right great toe wound open; -The resident states when he/she was getting up with assistance, he/she bumped his/her toe, and it started to bleed. The resident’s right great toe is open superficially. Review of the resident’s quarterly Minimum Data Sheet (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 4/04/25, showed the following: -Moderate cognitive impairment; -Did not reject care; -Required substantial/maximal assistance with upper body dressing, rolling left and right; -Dependent on staff for assistance with toileting hygiene, lower body dressing, putting on and taking off footwear, and transfers; -Functional limitation in range of motion to bilateral lower extremities; -Diagnoses of type 2 diabetes mellitus with polyneuropathy (impacts nerve function in multiple areas of the body, often characterized by numbness, pain, and muscle weakness, primarily in the distal arms and legs); -Mobility device manual wheelchair; -Presence of one stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer); -Pressure reducing device for chair and bed; -Application of dressings to feet. Review of the resident’s wound assessment dated [DATE], at 10:05 A.M., showed: -Wound location: Right great toe; -Present on Admit or Acquired: Acquired; -Wound type: Pressure injury; -Wound Staging: Stage 3 (full-thickness loss of skin); -Wound length: 0.9 centimeter (cm); -Wound width: 1.1 cm; -Wound Depth: 0.1 cm; -Presence of pain: No; -Wound appearance: Bleeding and reddened; -Wound surrounding tissue appearance: Granulated Pink; -Surrounding tissue appearance: Cool; -Wound drainage description: Sanguineous; -Wound drainage amount: Moderate; -Wound drainage odor: No odor; -Wound details/comments: Wound update and change from a stage 2 to a stage 3 pressure injury. Impeded wound healing with transfers. Review of the communication between the nurse and nurse practitioner (NP) showed the following: -On 04/09/25, at 12:51 P.M., the nurse wrote recommendation to get a wound culture on the resident’s right great toe wound related to stalled wound healing. Wound is slightly larger in size, there is edema (fluid retention/swelling) and erythema (redness of the skin) to the right great toe surrounding the wound. -On 04/09/25, at 1:54 P.M., the NP wrote please culture the drainage, if possible. Review of the communication between the nurse and nurse practitioner showed the following: -On 04/10/25, at 1:57 P.M., the nurse wrote resident was a sit to stand transfer (a mechanical transfer device that assists staff in lifting the resident to a standing position for transfers) and because of the location of the wound on the right great toe, the wound is being impeded. Recommendation for wound healing to use a Hoyer (a mechanical sling lift used to raise/transfer residents) to transfer the resident as he/she has in the past; -On 04/10/25, at 2:07 P.M., the NP wrote okay to use the Hoyer lift for skin protection, wound healing at this point. Review of the resident's Braden Scale (tool for predicting pressure ulcer risk completed by facility staff), dated 04/10/25, showed the following: -Sensory perception = Slightly limited; -Skin = Constantly moist; -Activity = Chairfast; -Mobility = Very limited; -Nutrition = Adequate; -Friction and shear = Potential problem; -Skin Risk = High risk. Review of the resident’s nurse note dated 04/10/25, at 10:54 A.M., showed the wound nurse documented the following: -Right great toe update: Wound to right great toe has worsened with size and moderate amount of serosanguineous drainage noted. The great toe is swollen and red. Recommendation to get a wound culture to rule out infection relating to the worsen appearance, size, swelling, and erythema noted. The physician noted to get a culture via messages. Obtained the culture on 4/10/25 at 10:48 A.M. and sent over to the laboratory. Review of the resident’s nurse note dated 04/10/25, at 1:43 P.M., showed the wound nurse documented the following: -Skin Team review; -Reason for review: Pressure ulcer; -Location: right great toe; -Measurements: See wound assessment; -Preventative measures: Continue all preventative measures set in place; -Current treatment: Silver alginate; -Progress: Wound has declined in healing with an increase in drainage and swelling to the toe; -Rehab: OT lymph massage; -Notes: Wound culture obtained today and pending results; -Team recommendations: To use Hoyer for transfers to assist in wound healing. Review of the resident’s nurse note dated 04/10/25, at 4:42 P.M., showed a nurse documented the following: -Resident complaining that he/she was “freezing to death.” The resident’s vital signs were stable and no fever at this time. -The resident was actively shivering, blankets applied. Staff notified the NP and the infection/sepsis tool completed. A urinalysis was ordered per the NP. Staff will continue to monitor. Review of the resident’s nurse note dated 04/10/25, at 9:31 P.M., showed a nurse documented UA obtained and taken to lab. Review of the resident’s laboratory report for wound culture of right great toe, showed the following: -Collected on 04/10/25 at 10:49 A.M.; -Received on 04/10/25 at 10:59 A.M.; -Preliminary results: 04/11/25 at 11:29 A.M., showed coagulase positive staphylococcus, sensitivity to follow. Record review of the resident’s nurse note, dated 4/11/25 at 5:34 A.M., showed a nurse documented the resident continued with chills. Review of the communication with the nurse and NP showed the following: -On 04/11/25, at 1:57 P.M., the nurse wrote: Please see wound culture results; -The NP did not reply. Review showed nurses did not document any further nurse notes between 04/11/25, at 1:57 P.M., and on 04/12/25, at 12:47 P.M., regarding the wound culture or follow-up with the NP. Review of the communication with the nurse and NP showed the following: -On 04/12/25, at 12:47 P.M., the nurse wrote: Notified of this day. -The NP did not reply. Review of the resident’s laboratory report for wound culture of right great toe showed the following: -Final results: 04/12/25 at 2:02 P.M., showed Methicillin Resistant Staph Aureus (MRSA - a bacteria that is resistant to several antibiotics). Review of the resident’s physician order showed an order dated 04/12/25, at 2:07 P.M., for ceftriaxone (a broad spectrum anti-infective medication) 1000 milligrams (mg) mixed with 1% lidocaine (used to treat pain) 2.1 ml, give intramuscular injection one time daily for diagnosis of MRSA infection of wound. Review of the resident’s pharmacy consultation note dated 04/12/25, at 7:00 P.M., showed the following: -Nursing infection screening completed on 04/10/25 at 4:38 P.M.; -Reason: Lumbar spine epidural abscess; -Overall symptoms: Mental status change not/applicable (N/A), functional decline N/A, vital signs N/A, and general illness N/A; -UTI Symptoms: Infection screening, new or marked increase in frequency, urinary pain/frequency; -Overall criteria met: Yes -Origin of infection: Infection acquired while at the facility? Yes; -Urinary tract infection: Appropriate empiric therapy ordered: Yes -Antibiotic medications ordered. Antibiotic ordered: Ceftriaxone; -Lab ordered: Urinalysis, urine culture. -On 04/10/25 UA showed: Clear, yellow urine with no protein, glucose, ketones, or nitrites, trace of blood, no bacteria, few white blood cells. Comment culture not indicated. -On 04/10/25, at 10:48 A.M. right great toe culture final showed MRSA. Review of the resident’s intervention documentation report showed staff did not document completion of a daily dressing change to the resident’s right great toe on 04/12/25. Review of the resident’s physician order dated 04/13/25, at 8:33 A.M., showed an order for doxycycline (an antiinfective medication) 1000 mg every 12 hours for diagnosis of MRSA infection of wound. Review of a communication form showed: -On 04/13/25, at 1:14 P.M., the nurse wrote: Orders were placed for Vibramycin (antibiotic) that started today. Upon inspecting his/her wound, it is exceptionally worse. The entire foot is now red, swollen and continues to enlarge. The wound is actively pouring blood of it. On call physician was contacted and gave approval to send the resident to the emergency room (ER) for further evaluation. Review of the resident’s nurse note, dated 04/13/25 at 1:17 P.M., showed a nurse documented upon inspection of the resident’s great toe wound, it was noted that the entire foot was now inflamed, red, and had excessive amount of blood coming from the wound. The nurse contacted the on-call physician who gave orders to send the resident to the emergency room. Family notified. Called report to the emergency room nurse and called the ambulance for transport. Review of the resident’s nurse note, dated 04/13/25 at 1:53 P.M., showed a nurse documented the following: -This nurse went in to do the resident’s wound care on his/her right toe. This nurse was alarmed when observing the blood-soaked bandage. Bandage removed and wound cleansed. Wound had a large amount of blood discharge. Cleansed again and pressure applied. Bleeding subsided and wound cleansed again. This nurse went to get a second opinion from the nurse manager. Both in agreement that the on-call needed to be contacted to send the resident to the emergency room for evaluation. Resident’s toe had considerable swelling, redness, and warmth that extended down into his/her foot. Resident’s family contacted and in agreement with the resident’s plan of care. Vital signs were stable at the time of transfer. During an interview on 07/01/25, at 3:00 P.M., Certified Nurse Assistant (CNA) A said the following: -The wound nurse told staff the resident’s right great toe pressure ulcer was caused from the resident being transferred using a sit to stand lift and due to the resident’s bed foot board; -The resident slid down in the bed; -The resident needed a longer bed; -He/she and other aides told the wound nurse, the charge nurses, and maintenance several times about the resident’s need for a longer bed; -Maintenance said the facility did not have any longer beds, because the resident was on a bariatric air mattress; -The resident required assistance to moved up in the bed and reposition; -The CNA said the resident slid down in the bed for approximately 2 months prior to going out to the hospital for a toe amputation. During an interview on 07/01/25, at 3:14 P.M., CNA B said the following: -He/she kept a pillow at the foot of the resident’s bed; -The resident developed a sore on his/her toe due to not wearing proper footwear while in the sit to stand and the resident slid down in bed; -The resident was not able to pull him/herself up in bed; staff needed to assist the resident in moving up in the bed; -He/she did not ask nursing for a longer bed for the resident, he/she was not aware the resident wanted a longer bed. Observation and interview of the resident on 07/01/25, at 10:50 A.M., showed the following: -The resident currently had a bariatric air mattress with no foot board; -The resident said he/she was too tall for his/her last bed, and he/she would slide down in the bed, and his/her toes would push against the foot board; -The resident said he/she told nursing staff, the wound nurse on multiple occasions that he/she needed a different bed, but they kept saying they did not have a different bed; -The resident said as a result of his/her toes pushing against the foot board, he/she developed a sore on the top of his/her right great toe, which became infected; -He/she talked to maintenance about his/her bed and maintenance said the facility did not have a longer bed at that time; -The facility tried to place pressure relieving boots on him/her, but they would slide sideways, and his/her feet would once again be pressing on the foot board. During an interview on 07/01/25, at 11:38 A.M., CNA C said the following: -The resident asked for a bed extender or padding for his/her toe; -The CNA said the resident thought his/her toe against the foot of the bed caused his/her toe ulcer, but the aide did not know for sure what caused the ulcer. During an interview on 07/01/25, at 12:30 P.M., CNA E said the following: -The resident’s bed was too short for him/her; -Staff tried to place pillows at the foot of his/her bed; -Staff tried to use pressure relief boots on the resident, but the Velcro straps would get caught on his/her bedding and the boots would twist, exposing the resident’s feet; -Staff tried different interventions, but these interventions did not matter, the resident always ended up with his/her feet against the foot board of the bed; -He/she was not aware foot boards would come off some of the beds; -He/she addressed with the nurses that the resident’s feet touched the foot board; -It took approximately two months for the resident to get a different bed; -The staff switched the resident’s bed with another resident’s bed. During an interview on 07/01/25, at 2:30 P.M., Occupational Therapist (OT) F said the following: -The resident was very tall and would slide down in his/her bed; -The resident needed a bed extender (to make the bed longer); -Staff tried a wedge at the foot of the bed and maintenance found a foam pad that they anchored to the foot board; -Maintenance said they did not think the resident’s bed would accommodate a bed extender; -After the resident had his/her toe amputated, the facility placed the resident in a different bed; -The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware the resident needed a longer bed; -The resident was on an air mattress and had a history of shoulder injury and both arms were impaired; -The resident was not able to pull him/herself up in the bed; -The resident has plantar flexion of both feet (feet point down) and his/her toes curl under, exposing the top of his/her toes to the foot board; -When staff placed boots on the resident, these boots would roll into the wrong position; -The resident had an issue with sliding down in the bed for months. Review of the resident’s medical record and care plan showed staff did not document regarding attempts address the resident’s need for a longer bed. During an interview on 07/01/25 at 3:36 P.M., the Maintenance Director said the following: -Nursing reported the resident was tall and his/her feet were hitting the bed when they raised the head of his/her bed; -Initially we got with therapy and placed a cushion at the foot of the resident’s bed, but the resident still slid down in the bed; -The facility ended up using a different resident’s bed for the resident with no foot board, and then the Administrator ordered a new bed; -Maintenance switched the resident’s bed within one week of being told the resident had an issue with sliding down in the bed. During an interview on 07/02/25, at 11:00 A.M., Registered Nurse (RN) G said the following: -The resident had a bed with a foot board; -He/she did the resident’s toe ulcer treatment at times on the weekend and the wound nurse did the treatment during the weekdays; -He/she observed one day in April (unsure which day) that the resident’s foot was reddened and edematous and had some drainage (he/she could not recall the appearance of the drainage) but the wound had no odor; -He/she notified the wound nurse of the change to the wound, but the wound nurse said he/she was aware of the changes and had changed the resident’s treatment order. During an interview on 07/02/25, at 12:33 P.M., Nurse Practitioner (NP) H said the following: -He/she did not recall seeing the resident’s toe ulcer; -He/she thought a wound care company was seeing the resident’s toe pressure ulcer; -He/she was not aware of an issue with the resident’s bed/foot board. During an interview on 07/02/25, at 3:50 P.M., the Wound Nurse said the following: -He/she completes weekly skin assessments on all residents, does weekly wound assessments on all residents with open wounds, and completes wound treatments on the days he/she worked; -The resident developed a pressure ulcer to the top of his/her right great toe; -The wound nurse said he/she thought the wound was caused from staff transferring the resident with a sit to stand lift; -The resident’s toes were contracted and therefore curled under, creating pressure to the top of the resident’s toes during transfers; -The resident developed the open area to his/her right great toe in January 2025, and the wound nurse began wound assessment on the area; -The resident’s feet were hitting the foot board on his/her bed; -The resident had an issue with sliding down in bed and he/she was a tall person; -The wound nurse showed the resident how to elevate his/her legs before raising the head of the bed, so he/she would not slide down; -The resident was able to move him/herself up in bed, but would continue to slide down; -Facility staff tried a wedge at the foot of the resident’s bed, as well as heel protectors; -The resident’s heel protectors did not cover the resident’s toes; -The resident continued to slide down in bed, despite the staff’s best efforts; -He/she talked with the Administrator, the DON and OT about the issue; -The resident’s foot board wound not come off and the bed was the longest bed we could get; -Initially he/she did not realize the resident’s foot board was causing the pressure ulcer, but eventually it was obvious the foot board was putting pressure on the top of the resident’s toes because the resident’s feet were against the foot of the bed; -In March 2025, the wound showed signs of healing; -On 04/10/25, the wound worsened with increased redness and swelling; -He/she asked for and received from the NP, orders for a wound culture of the resident’s right great toe ulcer; -He/she obtained the wound culture on 04/10/25; -On 04/11/25, the wound culture showed staph infection; -On 04/12/25, the final wound culture showed MRSA infection; -The nurse should contact the physician as soon as they received the wound culture results; -The wound treatment was not initialed as completed on 04/11/25, and he/she was unsure if the nurse completed the treatment that day or not; -The wound nurse did not see the resident’s wound again after 04/10/25. During interviews on 07/02/25, at 4:45 P.M., and on 07/07/25, at 10:15 A.M., the DON said the following; -The resident had a tendency to slide down in the bed and was prone to pressure ulcers; -The resident was on an air mattress because he/she was unable to reposition him/herself; -The resident required the help of staff with repositioning in bed; -Prior to the resident’s right great toe amputation, the DON and the wound nurse both talked with maintenance about the resident's need for a bed modification, such as an extender for the bed or a longer bed; -Maintenance said the resident was already in the biggest bed that the facility could obtain; -On 04/10/25, the resident was shivering, the nurse notified the NP, and the NP gave orders for a urinalysis; -On 04/11/25, the nurse received the initial wound culture results and should have called the physician or on-call physician immediately to notify of the results instead of sending a message through the message portal; -On 04/12/25, the NP asked for a pharmacy consult and the pharmacist recommended antibiotic; -The facility began administration of ceftriaxone (Rocephin) IM 1000mg to the resident daily on 04/12/25 and began administration of doxycycline on 04/13/25; -The DON was unsure if the nurses completed the treatment on 04/12/25 or not, but they did not document completion of the treatment, and the nurse should sign when completed; -The facility sent the resident to the hospital 04/13/25 and the resident returned to the facility on [DATE] after amputation of his/her right great toe. 2. Review of the facility policy titled, “Standard Precautions, IP0-05”, revised October 2024, showed: -Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered; -Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents; -Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings; -Hand hygiene includes both hand washing with soap and water and use of alcohol-based products that do not require the use of water; -During delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces; -Indications for hand hygiene from Centers of Disease Control and Prevention (CDC) include prior to entering a patient’s room or care area; when exiting a patient’s room or care area; before direct contact with patients; before inserting invasive devices that do not require a surgical procedure; after contact with a patient’s intact skin; after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; before putting on gloves; and after removing gloves; -Gloves are used to prevent contamination of hands when anticipating direct contact with blood or body fluids, mucous membranes, non-intact skin and other potentially infectious material, or handling, or touching visibly or potentially contaminated patient care equipment and environmental surfaces; -During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from “clean” to “dirty,” and confining or limiting contamination to surfaces that are directly needed for patient care; -It may be necessary to change gloves during care of a single patient to prevent cross contamination; -It will be necessary to change gloves if during the interaction you touch nonsterile objects such as computer keyboards, trash can, etc.; -Gloves are to be discarded immediately after removal and not reused. Review of the facility policy titled, “Hand Hygiene, IP02-07,” revised April 2025, showed: -Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting; -The term “hand hygiene” replaces “hand washing” to reflect the acceptance of waterless hand cleaning agents such as alcohol-based hand rubs (ABHR); -Gloves are not a substitute for hand hygiene; -Remove gloves prior to performing hand hygiene. Do not perform hand hygiene on gloves; -Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients; -Change gloves during patient care if moving from a contaminated body site to a different body site of the same patient; -Perform hand hygiene between glove changes; -Perform hand hygiene and change gloves if you suspect your gloves have been contaminated. Review of Resident #2’s face sheet showed: -admission date of 11/04/21; -Diagnoses included osteomyelitis (infection in a bone) of vertebra (back bones of the spine), sacral (bone at the bottom of the spine), and sacrococcygeal (bones at the bottom of the spine) region, chronic (long-term) decubitus ulcers (damage to the skin caused by constant pressure. Review of the resident’s MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, moving from sit to lying; -Always incontinent of bowel; -Had an indwelling urinary catheter; -At risk of developing pressure ulcers; -Had one stage four pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that was present upon admission/reentry. Review of the resident’s physician order, dated 05/23/25, showed an order to cleanse the wound bed with wound cleanser, pat dry, apply skin prep to the wound edges and surrounding intact skin, dampen Drawtex (dressing for a wound bed) and apply Drawtex to wound bed only, then cover and apply sacral mepilex (absorbent foam dressing) to secure. Change dressing daily. Review of the resident’s wound assessment documentation, dated 06/11/25 at 1:00 P.M. showed: -Wound location number one: Left buttocks; -Present on Admit or Acquired: Admit; -Wound type: Pressure injury; -Wound Staging: Deep tissue injury; -Wound length: 2 centimeter (cm); -Wound width: 1.6 cm; -Wound Depth: 0.1 cm; -Wound appearance: Granulation, pink, and reddened; -Wound surrounding tissue appearance: Pink; -Surrounding tissue temperature: Cool; -Wound drainage description: Serous; -Wound drainage amount: Scant; -Wound drainage odor: No odor. -Wound location number two: Left sacrum; -Present on Admit or Acquired: Acquired; -Wound type: Pressure injury; -Wound Staging: Stage four; -Wound length: 2.3 centimeter (cm); -Wound width: 3.2 cm; -Wound Depth: 0.2 cm; -Presence of pain: No; -Wound appearance: Bleeding, granulation, pink, and reddened; -Wound surrounding tissue appearance: Pink; -Surrounding tissue temperature: Cool; -Wound drainage description: Sanguineous; -Wound drainage amount: Small; -Wound drainage odor: No odor. -Wound details/comments: Hypergranulated tissue has decreased, silver nitrate was ordered within the past week as daily for two days. Review of the resident’s care plan, last reviewed on 06/27/25, showed the following: -Resident has a risk for skin breakdown with a long history of skin problems due to his/her mobility status and disease process; -He/she has a diagnosis and history of diabetes mellitus, cellulitis, and stage four decubitus ulcers on his/her sacrum and c

Based on interview and record review, the facility failed to ensure establish an accurate system of administration of narcotic pain medications when staff failed to accurately document administration of narcotic pain medications and administer them within the parameters of physicians' orders for two residents (Resident #1 and Resident #2). Ten residents were sampled out of a facility census of 100. Review of the facility's policy titled Medication Administration and Documentation, revised 06/2024, showed the following: -The facility maintains a standard procedure for admission of drugs by licensed personnel with a physician's order; -Purpose of the policy was to outline correct procedure for documentation of bedside medication administration utilizing the Medication Administration Record (MAR) in the Patient Care System (PCS). To provide a medication administration system that enhances patient safety by providing a means for the verification of the 5 Rights. To provide a framework for timing of medication administration based on the nature of the medication and its clinical application to ensure safe and timely administration; -Non-time critical scheduled medications are those for which a longer or shorter interval of time since the previous dose does not significantly alter the therapeutic effect or otherwise cause harm; -Medications not eligible for scheduled dosing times will have a time specified by the provider in the initial order such as stat doses (to be administered immediately or within 15 minutes); first doses or loading doses timed to bring plasma or tissue concentrations to an effective concentration quickly such as vancomycin (an antibiotic), digoxin (a medication used to treat heart failure and heart rhythm problems) and amiodarone bolus dose (a medication use to treat heart rhythm problems); one time doses such as those specifically timed for a procedure; doses timed for obtaining serum drug levels; and medications prescribed on an as-needed basis; -The medication should be administered as soon as possible after the dose has been prepared, particularly a medication prepared for parenteral administration (drugs given by injection or infusion). The medication dosage will not be removed from its packaging or labeling until immediately before administration of the drug; -For the safety of the patient, the provider will observe the following factors: right patient-ask patient/resident to verify name and date of birth, compare name bracelet and/or resident photo identification and MAR; right time-check MAR for proper time medication is to be given; right medication- compare medication packet to medication name on MAR and doctor's order sheet if indicated; right route-check MAR for correct route and site for injections; and right dose-compare dosage on medication packet to dosage on MAR; -As needed medications shall be charted in the MAR. Laboratory data and any subsequent re-assessment after the administration is to be completed through an assessment or nursing intervention in PCS. The patient's report of his/her experience of the medications effects must also be documented. Nursing may incorporate patient preference and administer a less potent or non-opioid product if ordered for a lesser pain scale. Documentation of patient choice must be included in the pain assessment. A more potent narcotic cannot be given without a provider's order regardless of patient preference. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed an admitted [DATE]. Review of the resident's current diagnosis sheet showed the resident had diagnoses that included chronic pain syndrome and other chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/20/24, showed the following: -The resident was cognitively intact; -The resident received scheduled and as needed (PRN) pain medications and non-medication intervention for pain; -The resident frequently had pain; -Pain occasionally effected sleep, interfered with therapy activities, and day to day activities; -The resident's pain intensity was 7 on a pain scale of 0 to 10 and the resident described it as moderate; Review of the resident's care plan, reviewed 10/02/24, showed the following: -The resident was at risk for pain due to paraplegia (loss of muscle function and sensation in the lower half of the body, including legs, feet and toes), lumbar spondylosis (degenerative disease of the lower back), chronic kidney disease and spinal compression fracture. -Consider pain assessment and develop pain management program with the resident. The resident had pain medication that he/she wished to ask for when in pain. He/she did not wish to be woken up during the night. Review of the resident's October 2024 Physician's Order Sheet (POS) showed an order, dated 07/23/24, for oxycodone (a pain medication), 5 milligrams (mg) PO (by mouth) every 4 hours PRN. Review of the resident's October 2024 Medication Administration Record (MAR) showed on 10/16/24, at 1:40 A.M., Licensed Practical Nurse (LPN) A administered PRN oxycodone 5 mg tablet to the resident. Review of the resident's Controlled Drug Record showed on 10/16/24, at 2:00 A.M. and 10:20 P.M., LPN A administered oxycodone 5 mg tablet to the resident. Review of the resident's October 2024 MAR showed on 10/17/24, at 2:18 A.M., LPN A administered PRN oxycodone 5 mg tablet to the resident. Review of the resident's Controlled Drug Record showed on 10/17/24, at 2:20 A.M., LPN A administered oxycodone 5 mg tablet to the resident. During an interview on 10/22/24, at 11:17 A.M., the resident said the following: -He/she took pain medications; -He/she took pain medications during the night once in a while when he/she needed one; -He/she normally fell asleep around 10:30 P.M. and slept until 5:00 A.M.; -He/she had not requested pain medications in the middle of the night for over a month; -When LPN A worked, the LPN documented the resident took pain medications in the middle of the night, but other nurses did not. He/she believed it was odd; -He/she did not take pain medications in the middle of the night on 10/16/24 or 10/17/24. He/she knew this because he/she would have to wake up and drink water when taking the medication. During an interview on 10/22/24, at 1:09 P.M., Certified Medication Technician (CMT) A said the following: -He/she noticed starting a couple months ago that twice nightly at the same or similar times, the resident received PRN oxycodone; -He/she asked the resident if the resident took this in the middle of the night and the resident said they did not ask for the medication in the middle of the night; -He/she told the Director of Nursing (DON) and a few days later, the DON said the medication pass was normal; -Approximately a week ago, he/she noticed the same trend start again with the resident; -He/she asked the resident and the resident said they did not take the oxycodone at night. During an interview on 10/23/24, at 1:23 P.M., LPN A said the following: -The resident sometimes asked for PRN oxycodone and when the resident asked for the medication he/she gave the medication; -He/she did not know if he/she gave the PRN oxycodone on 10/16/24, at 1:40 A.M., or 10/17/24, at 2:18 A.M.; -He/she did not know where the resident's medication went and he/she could have laid the medication down in another resident's room or thrown them in the trash with another cup. During an interview on 10/24/24, at 2:08 P.M., Registered Nurse (RN) E said the following: -The resident did not complain of a lot of pain to the RN; -The resident was cognitively intact and would know if he/she received pain medication during the night; -Unless the resident woke up and complained of pain, he/she would not wake the resident up to give a PRN pain medication. During an interview on 10/24/24, at 1:37 P.M., the DON said the resident said he/she did not receive pain medication during the night that was signed out by LPN A. 2. Review of Resident #2's face sheet showed an admitted [DATE]. Review of the resident's diagnosis sheet showed the resident had diagnoses that included low back pain and other chronic pain. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -The resident received scheduled and PRN pain medications; -At the time of the assessment the resident did not have pain. Review of the resident's current care plan showed he/she had pain related to his/her disease process, chronic psychosocial or physical disability, and musculoskeletal pain. He/she would have his/her pain relief maintained to a satisfactory level. Review of the resident's September 2024 POS showed an order, dated 06/06/22, for hydrocodone (a narcotic pain medication) 7.5/325 mg., one tablet by mouth every four hours PRN. Review of the resident's September 2024 MAR showed on 09/19/24, at 1:00 A.M. and 3:45 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident; Review of the resident's Controlled Drug Record showed on 09/19/24, at 1:00 A.M. and 5:00 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident. Review of the resident's September 2024 MAR showed on 09/24/24, at 12:15 A.M., 1:28 A.M., and 4:45 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg. tablet to the resident. Review of the resident's Controlled Drug Record showed on 09/24/24, at 12:00 A.M. and 4:00 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident. Review of the resident's October 2024 POS showed an order, dated 06/06/22, for hydrocodone 7.5/325 mg., one tablet by mouth every four hours PRN. Review of the resident's October 2024 MAR showed on 10/05/24, at 1:40 A.M., 3:43 A.M., 7:47 P.M. and 7:55 P.M., LPN A administered one PRN hydrocodone 7.5/325 mg. tablet to the resident. Review of the resident's Controlled Drug Record showed on 10/05/24, at 12:00 A.M. and 4:00 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident. Review of the resident's October 2024 MAR showed on 10/07/24, at 1:45 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg. tablet to the resident. Another staff member administered one PRN hydrocodone 7.5/325 mg. tablet to the resident at 2:54 A.M. Review of the resident's Controlled Drug Record showed on 10/07/24, at 2:55 A.M., a staff member administered one PRN hydrocodone 7.5/325 mg tablet to the resident. LPN A did not document the administration of one tablet that was signed out in the MAR at 1:45 A.M. Review of the resident's October 2024 MAR showed on 10/08/24, at 1:30 A.M. and 4:25 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg. tablet to the resident. Review of the resident's Controlled Drug Record showed on 10/08/24, at 1:50 A.M. and 5:50 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident. Review of the resident's October 2024 MAR showed on 10/10/24, at 1:20 A.M. and 3:56 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg. tablet to the resident. Review of the resident's Controlled Drug Record showed on 10/10/24, at 1:20 A.M. and 5:01 A.M., LPN A administered one PRN hydrocodone 7.5/325 mg tablet to the resident. During an interview on 10/22/24, at 1:28 P.M., CMT B said he/she noticed the resident received more PRN pain medication during the night when LPN A worked and reported this to the DON. During an interview on 10/22/24, at 2:49 P.M., the resident said he received pain medications sometimes in the middle of the night. During an interview on 10/23/24, at 1:23 P.M., LPN A said the following: -The resident always asked for pain medication when the resident woke up; -He/she told the resident to tell the other nurses when the resident was hurting; -He/she popped the residents medications and scanned them, but did not administer the medications at that time; -He/she sometimes forgot to go back and change the time he/she did administer the medications. During an interview on 10/24/24, at 1:37 P.M., the DON said the following: -The resident had an order for PRN hydrocodone 7.5/325 mg. every four hours; -The doses given to the resident by LPN A on 09/19/24 at 1:00 A.M. and 3:48 A.M. were not given as prescribed; -The doses given to the resident by LPN A on 09/24/24 at 12:15 A.M., 1:28 A.M. and 4:45 A.M. were not given as prescribed; -The doses given to the resident by LPN A on 10/05/24 at 1:40 A.M. and 3:43 A.M. were not given as prescribed; -The doses given to the resident by LPN A on 10/07/24 at 1:45 A.M. and 2:54 A.M. were not given as prescribed; -The doses given to the resident by LPN A on 10/08/24 at 1:30 A.M. and 4:25 A.M. were not given as prescribed; -The doses given to the resident by LPN A on 10/10/24 at 1:20 A.M. and 3:56 A.M. were not given as prescribed. During an interview on 10/24/24, at 2:08 P.M., RN E said the resident did not complain of pain throughout the day, but received PRN pain medications during the night. During an interview on 10/24/24, at 2:37 P.M., the Administrator said the doses given to the resident by LPN A on 09/19/24, 09/24/24, 10/05/24, 10/07/24, 10/08/24 and 10/10/24 were not administered as prescribed. 3. During interviews on 10/22/24, at 1:09 P.M., and on 10/24/24, at 11:36 A.M., CMT B said the following: -When he/she passed medications, he/she ensured the right medication, order, time, dose and resident; -He/she could administer PRN pain medications with an order for every four hours as needed if 3.5 hours passed since the last dose; -He/she did not prepare the medication until the medication was administered even for the residents who frequently asked for their medication. Staff should not assume a resident would need the medication and prepare it earlier than the order said; -He/she knew when he/she gave medications and watched the residents take the medication. 4. During an interview on 10/22/24, at 1:28 P.M., CMT C said when he/she passed medications, he/she ensured the right medication, order, time, dose and resident. 5. During interviews on 10/23/24, at 1:23 P.M., and on 10/24/24, at 12:33 P.M., LPN A said the following: -He/she should not prepare a resident's medication until he/she was ready to administer the medication to a resident; -When he/she administered medications, he/she checked right resident, dose, medication, frequency, time and route, but he/she did not always follow this; -If a resident had an order for PRN pain medication to be given every four hours, he/she could give every four hours or could give up to one hour early. He/she could not give that medication 2 to 2.5 hours early. 6. During an interview on 10/24/24, at 11:56 A.M., LPN E said the following: -When he/she administered medication he checked for right resident, time, medication and route; -He/she required a physician's order before he/she administered a medication; -He/she gave medications per the physician's order; -If a resident had an order for a PRN narcotic, he/she gave the medication when the resident requested and within the timeframe specified on the physician's order; -If a resident had an order for a PRN narcotic every four hours and four hours had not passed since the last dose, he/she contacted the physician to see if he/she could administer the medication early; -He/she did not remove medications from the cart unless he/she administered the medications. 7. During an interview on 10/24/24, at 2:08 P.M., RN E said the following: -He/she required a physician's order before giving a resident a medication; -He/she ensured the right resident, medication, route, dose and time prior to administration of a medication; -If a resident had a PRN pain medication ordered for every four hours, he/she administered when the resident complained of pain but not before 3.5 to 4 hours had passed since the last PRN dose; -Staff should not remove medication from the cart early because they know the resident would ask for the medication. The removed the medication when the resident complained of pain and the appropriate time passed. 8. During an interview on 10/28/24, at 1:46 P.M., the Director of Pharmacy Services said the following: -He/she did not believe the PRN pain medication orders could be liberalized; -He/she did not think it was appropriate for PRN oxycodone orders to be liberalized; -If the physician wrote an order for PRN hydrocodone every four hours then the physician meant the medication to be given no more than every four hours. 9. During an interview on 10/24/24, at 1:37 P.M., the DON said the following: -Staff informed her there were possible documentation errors with pain medications in the past, but LPN A worked six nights a week so she could not see a trend and the resident who received the medication made sense; -She expected staff to follow the right dose, time, resident and route when they administered medication; -PRN pain medication was given when the resident requested, or an appropriate assessment was made for a resident who could not ask for the medication; -Staff should not assume a resident would need medication and prepare the medication early. 10. During an interview on 10/24/24, at 2:37 P.M., the Administrator said the following: -Staff should not prepare medication early. They should remove them from the cart when the medication was due, or the resident requested medication; -Staff should administer medication as prescribed, but they could give medication one hour early or one hour late; -Nurses should know if they signed the medication out that they gave the medication. MO00243564

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to accurately and consistently monitor and document weights for three residents (Resident #37, #73, and #56). The facility census was 103. Record review of the facility's policy titled, Patient Weights. dated April 2022, showed the following: -In long-term care setting, weights will be done on admission, monthly, and as needed or ordered; -Upon admission to long-term care facility, an initial weight will be obtained; -Wheelchair weights: balance scales, patient may be rolled upon platform by placing scale side flaps down, receive weight, weight empty wheelchair, and subtract weight of chair from total weight of resident; -Document the weight in the electronic medical record. Review of the facility's policy titled, Documentation, dated December 2020, showed the following: -Consistent patient data will be maintained in the patient's medical record by authorized personnel; -Purpose to develop, implement, and evaluate the plan of care and response of treatment through communication to the health care team. To provide consistent data with the electronic medical record by personnel; -Entries will be made as close as possible to the time of occurrence of the event being documented; -Licensed personnel of a designated shift should do a 24-hour chart check. These personnel will review orders of the past 24-hour period. 1. Review of Resident #37's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE] with a readmitted [DATE]; -Diagnosis included anoxic brain injury (brain injury occurs when the brain is deprived of oxygen) and obesity (state or condition of being very overweight). Review of the resident's Annual Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility), dated 10/13/23, showed the following information: -Cognitively intact; -Use of wheelchair for locomotion; -Weight 366 of pounds. Review of the resident's documented weights showed the following: -On 06/01/23, the resident weighed 323 pounds and 4 ounces. -On 07/07/23, the resident weighed 334 pounds and 2 ounces; -On 08/04/23, the resident weighed 366 pounds and 6 ounces; -On 10/31/23, the resident weighed 323 pounds and 9.6 ounces; -On 12/07/23, the resident weighted 308 pounds and 9.6 ounces. Review of the resident's progress notes showed the following: -On 11/28/23, showed staff documented a nutrition note that said readmission assessment was completed. Recommendations include obtain current weight, monitor and evaluate intake, weight and lab value trends; -Staff did not document related to weight variations from 06/2023 to 12/2023. During an interview on 12/08/23, at 12:40 P.M., the Director of Nursing (DON) said the resident had some desired weight loss and was emotional about his/her weight. The resident will order pizza and then be very emotional if anyone talked about his/her weight. 2. Review of Resident #73's face sheet showed the following information: -admitted [DATE]; Diagnoses included anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Alzheimer's (progressive disease that destroys memory and other important mental functions), and cardiovascular accident (CVA - stroke). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Use of wheelchair for locomotion; -Weight of 236 pounds. Review of the resident's documented weights showed the following: -On 08/15/22, the resident weighed 468 pounds; -On 08/19/22, the resident weighed 423 pounds; -On 08/22/22, the resident weighed 225 pounds and 6 ounces; -On 09/09/22, the resident weighed 207 pounds and 0.2 ounces; -On 09/26/22, the resident weighed 229 pounds and 4 ounces; -On 10/10/22, the resident weighed 217 pounds and 0.2 ounces; -On 10/14/22, the resident weighed 229 pounds and 4 ounces; -On 12/12/22, the resident weighed 237 pounds and 6.4 ounces; -On 01/30/23, the resident weighed 249 pounds and 9.6 ounces; -On 02/10/23, the resident weighed 238 pounds; -On 04/03/23, the resident weighed 194 pounds and 6 ounces; -On 04/28/23, the resident weighed 236 pounds; -On 05/05/23, the resident weighed 215 pounds and 4 ounces; -On 06/09/23, the resident weighed 231 pounds and 14 ounces; -On 07/17/23, the resident weighed 220 pounds and 15 ounces; -On 08/04/23, the resident weighed 218 pounds and 2 ounces; -On 10/24/23, the resident weighed 235 pounds and 8 ounces; -On 11/02/23, the resident weighed 202 pounds. Review of the resident's care plan, dated 11/07/23, showed the following: -Resident intake usually 100% of meals. Encouraged to select meal options with staff. Resident had no chewing/swallowing problems noted. Resident eats meals at an assist table. Resident prefers finger foods. Resident had a stroke that affects right side. Resident had difficulty feeding self and required help. Review of the resident's progress notes showed the following information: -On 11/07/23, staff documented the resident's weight change nutritional review was completed. The resident was assisted with meals. The resident's nutritional needs are being addressed. Encourage staff to continue assist with meals to promote adequate intake. Staff should offer extra fluids in between meal to promote adequate hydration; -Staff did not document related to weight variations from 08/2022 to 11/2023. 3. Review of Resident #56's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should) stage 4 (severely damaged), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and congestive heart failure (CHF -a condition in which the heart can't pump enough blood to the body's other organs). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Weight of 297 pounds; -Use of wheelchair for locomotion. Review of the resident's care plan, dated 11/09/23, showed the following: -Resident on regular diet with no added salt for CHF diagnosis; -Staff should monitor weight as ordered. Review of the resident's documented weights showed the following: -On 11/07/23, at 9:29 A.M., with weight charted as 297 pounds; -On 11/15/23, at 9:37 A.M., with weight charted as 265 pounds and 6.4 ounces; -Staff did not document related to weight variations in 11/2023. 4. During an interview on 12/08/23, at 10:25 A.M., Registered Nurse (RN) I said that aides and nurses have a daily to do list and work list that shows the work to be done included getting residents weights. The staff should accurately document resident weight as scheduled. If the weight is significantly different from the last weight the resident should be re-weighed. 5. During an interview on 12/08/23, at 10:40 A.M., Certified Nurse Aide (CNA) K said that the nurses provide the aides with daily vitals sheet that include residents that need weighed. He/she said staff should accurately weigh the resident and provide the information to the nurses. 6. During an interview on 12/08/23, at 11:00 A.M., RN L said that the CNAs are able to chart resident weight into the electronic medical record. The RN said the charge nurse, nurse manager, and dietary manager should monitor residents for weight loss. If a resident's weight is way off, the nurse will have staff re-weigh the resident, and if still off staff should start the monitoring for weight loss process. The nutritionist is in the building on Tuesdays and the risk meetings is held on Thursdays. Residents should be re-weighed if there is an obvious discrepancy. Staff should make a nurse note about changes or discrepancies. Staff should document if a resident refuses to be weighed. 7. During an interview on 12/08/23, at 12:40 P.M., the Director of Nursing (DON) said the two restorative aides generally take the residents' weights. The staff document resident weights in two locations. They should document the total weight and the wheelchair weight. The DON said that staff should document resident refusals to be weighed and weight discrepancies. Staff should accurately document resident weights and ensure documentation related to variations of weights. 8. During an interview on 12/08/23, at 1:18 P.M., with the Administrator and DON, the DON said that ensuring staff are obtaining resident weights as ordered is something the staff are working on. The Administrator said that the documentation should be accurate, and staff should check if weighed accurately when there are large fluctuations.

Based on observation, interview, and record review, the facility failed to provide and accurately care plan one resident's reasonable accommodation of need for one resident (Resident # 48) who was unable to access the call light system. The facility census was 103. Review of the facility policy, titled General Physical Environment, dated June 2019, showed the following: -The facility considers the purpose of an equipped and functional environment to ensure adequate care and safety of residents, employees, and visitors; -The nurses' call system registers calls to the nurses' station from each resident's bed, toilet room, bathtub, and shower. Review of the facility policy, titled Nursing Safety, dated March 2021, showed the following: -The facility considered the purpose of nursing safety to ensure safety for the residents, employees, and visitors; -The nurse call light should be within reach of the resident; -Residents will be instructed on call light use. 1. Review of Resident #48's face sheet (a brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included quadriplegia (a form of paralysis that affects all four limbs, plus the torso), urinary tract infection, hypertension (high blood pressure), and diabetes (high blood sugar). Review of the resident's admission Minimum Date Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/12/23, showed the following information: -Cognitively intact; -Required two-person assistance for bed mobility and transfer; -Required assistance with all activities of daily living (ADL's) including dressing, toilet use, and personal hygiene; -Impairment of upper and lower extremity impairment on both sides. Review of the resident's care plan, revised 12/07/23, showed the following information: -Resident is currently unable to lift arms, but can use his/her hands to squeeze the call light; -Ensure call light is under his/her chin or under right hand so that he/she is able to utilize when needed; -Resident requires maximal assistance with all activities of daily living (ADL's). Observation on 12/06/23, at 10:43 A.M., showed the resident resting in bed with his/her eyes closed. His/her call light was clipped the resident's sock and laying on the air mattress next to his/her ankle. Observation on 12/07/23, at 3:30 P.M., showed the resident resting in bed with his/her eyes closed. His/her call light was clipped the resident's sock and laying on the air mattress next to his/her ankle. Observation on 12/08/23, at 10:41 A.M., showed the resident resting in bed with his/her eyes closed. His/her call light was laying on the air mattress next to his/her ankle on the bed. During an interview on 12/04/23, at 10:30 A.M., the resident said that he/she is not able to use his/her call light. He/she is not able to move his/her arms or hands and is therefore unable to press the call light. The staff have tried to put the flat round touch call pad under his/her chin, shoulder, and under his/her head, but that did not work. When he/she was first admitted to the facility he/she was able to use the call pad by touching with his/her foot, however, after the facility changed his/her bed to an air mattress he/she is now unable to press down on the touch pad because the pad goes down into the air mattress when he/she attempts to use. The staff are putting the touch call pad near her foot even though he/she is unable to use it. The resident said that he/she will ask his/her roommate to call for help, but said he/she tries not to be a nuisance. During an interview on 12/04/23, at 10:35 A.M., the resident's roommate said that he/she puts on his/her own call light when the resident needs assistance because the resident is unable to press his/her call light. During an interview on 12/05/23, at 1:15 P.M., the resident's spouse said that he/she is concerned that the resident is not able to use the call light and call for help when needed. The spouse said that the resident must rely on his/her roommate or just yell out for help if the roommate is asleep or not in the room. During an interview on 12/06/23, at 10:31 A.M., Registered Nurse (RN) J said that the resident is sometimes able to press his/her call light, but not always, and has been known to yell out for help. The staff check on him/her more often because of that. During an interview on 12/06/23, at 10:58 A.M., Certified Nursing Assistant (CNA) H said the resident is not always able to press his/her call light, but is able to yell out when he/she needs help. The staff check on him/her more often because they are aware he/she can not use his/her call light. During an interview on 12/07/23, at 2:27 P.M., CNA G said the resident had a hard time using the call light. He/she has tried clipping the call light to various areas of the resident's body, but because the resident can not use his/her hands or arms he/she is unable to press the button. CNA G said the facility got him/her the little flat pad and staff keep it close to his/her foot so that he/she can lift his/her foot and tap the call light. The resident does not have a lot of movement of his/her legs so sometimes he/she is not able to use it. He/she will also yell out for help. CNA G said that the resident can be heard yelling out for help only if staff are on the resident's hall. You cannot hear the resident yelling at the nurses' station. During an interview on 12/08/23, at 8:10 A.M., Certified Medication Technician (CMT) E said that the resident does not normally use his/her call light because he/she cannot move his/her arms. CMT E has heard the resident yelling out for help at different times. During an interview on 12/08/23, at 8:57 A.M., RN I said that the resident can sometimes put on his/her call light with his/her foot and if he/she cannot get the call light on the resident can yell out for help. RN I said that he/she was able to hear the resident yelling from the nurses' station and that the CNA's check on the resident more frequently because of this. During an interview on 12/08/23, at 1:47 P.M., with the Administrator and the Director of Nursing (DON), the Administrator said that upon admission it was realized that the resident was not able to use the call light, so they got the resident the round flat touch pad call light. The Administrator said that he/she would expect staff to notify him/her if the resident's condition changed so that they could readdress the resident's needs.

Based on observation, interview, and record review, the facility failed to ensure a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) was only inserted when needed and with physician orders for catheter insertion and management when staff place a catheter for one resident (Resident #56) without physician orders. The facility census was 103. Review of the facility's policy titled, Catheter Care, dated August 2022, showed the following information: -Urinary catheterization is to facilitate urinary drainage when medically necessary; -Urinary catheters should be placed only under the direction of a physician order; -Indwelling catheters should be removed as early as possible to help prevent catheter-associated urinary tract infections; -Obtain physician order for removal. Review of the facility's policy titled, Physicians Orders, dated September 2023, showed the following information: -Physician orders will be completed in a safe, effective, and timely manner; -Physician orders may be active and effective for up to one year. After one year a new order should be documented in the electronic medical record. Review of the facility's policy titled, Documentation, dated December 2020, showed the following: -Consistent patient data will be maintained in the patient's medical record by authorized personnel; -Purpose to develop, implement, and evaluate the plan of care and response of treatment through communication to the health care team and to provide consistent data with the electronic medical record by personnel; -Entries will be made as close as possible to the time of occurrence of the event being documented; -Licensed personnel of a designated shift should do a 24-hour chart check. These personnel will review orders of the past 24-hour period. 1. Review of Resident #56's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE] and readmitted [DATE]; -Diagnoses included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should) stage 4 (severely damaged), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and congestive heart failure (CHF -a condition in which the heart can't pump enough blood to the body's other organs). Review of the resident's progress notes dated 11/03/23, at 3:37 P.M., showed the resident arrived at the facility at approximately 3:15 P.M. The resident had a catheter due to urine retention. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/09/23, showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility and transfers; -Indwelling catheter; -Used electric wheelchair for mobility. Review of the resident's progress notes dated 11/11/23, at 7:46 A.M., showed the resident's catheter was clamped for the previous 24 hours per physician and removed at 7:40 A.M. this morning. No complaints from resident of pain. Staff will monitor for retention. Review of the resident's progress notes, dated 11/12/23 to 12/03/23, showed staff did not document regarding the resident's catheter. Review of the resident's current care plan, dated 12/04/23, showed the following information: -Resident had an indwelling Foley catheter, size 16 French, due to benign prostatic hypertrophy (BPH - enlarged prostate) and obstruction; -Resident goal is to have optimal urinary elimination and be free of infections; -Staff should monitor for complications of catheter and report to charge nurse; -Staff should change catheter per orders; -Staff should monitor for evidence of catheter blockage or leakage. Observations of the resident showed the following: -On 12/04/23, at 1:49 P.M., the resident seated in his/her room with an indwelling urinary catheter, with yellow urine in the tubing, and the catheter bag under the wheelchair was in a dignity bag; -On 12/05/23, at 12:35 P.M., the resident was in a wheelchair in the hallway returning to his/her room after lunch. A catheter was present under the wheelchair in a dignity bag, clear yellow urine was visible in the tubing. Review of the resident's physician's orders sheet, current as of 12/08/23, showed on active order for a catheter or catheter management. During an interview on 12/08/23, at 10:25 A.M., Registered Nurse (RN) I said that the nurses and aides have a daily to do list and work list that is on their computer program. The list will include residents with catheter cares and or changes to be completed. The list is populated from the physician orders. During an interview on 12/08/23, at 10:45 A.M., RN L said there should be physician orders for residents with catheters that should include when to change, the size of catheter, when to clean, and diagnosis for the catheter. During an interview on 12/08/23, at 1:18 P.M., with the Administrator and Director of Nursing (DON), the DON said there should be a physician order for residents to have a catheter and the order would include specific information about the catheter.

Based on interview and record review, the facility failed to ensure all residents received dialysis services per professional standards, when staff failed to have written physicians' orders related receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), failed to document monitoring the resident as care planned, and the failed to mark dialysis on the Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility) for one resident (Resident #62). The facility census was 103. Review of the facility's policy titled, Patient Weights, dated April 2022, showed the following: -In long-term care setting, weights will be done on admission, monthly, and as needed or ordered; -Upon admission to long-term care facility, an initial weight will be obtained. Record review of the facility's policy titled, Documentation, dated December 2020, showed the following: -Consistent patient data will be maintained in the patient's medical record by authorized personnel; -Entries will be made as close as possible to the time of occurrence of the event being documented; -Licensed personnel of a designated shift should do a 24-hour chart check. These personnel will review orders of the past 24-hour period. Review of the facility's policy titled, Physicians Orders, dated September 2023, showed the following information: -Physician orders will be completed in a safe, effective, and timely manner; -Physician orders may be active and effective for up to one year. After one year a new order should be documented in the electronic medical record. 1. Review of Resident #62's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included acute respiratory failure (the inability of the respiratory system to meet the oxygenation needs of the body) with hypoxia (not enough oxygen in the tissues), obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), and end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). Review of the resident's annual MDS, dated [DATE], showe showed staff did not mark dialysis as a special treatment on admission or while a resident. Review of the resident's care plan, dated 02/24/23, showed the following information: -The resident had stage 5 End Stage Renal Failure and went to dialysis three times per week; -The resident needed weighed before each dialysis; -The resident was at risk for infection due to dialysis treatment; -Staff should monitor AV shunt site (arteriovenous shunt (AV) is the most commonly used access for patients receiving regular dialysis) for signs and symptoms of infection and/or bleeding; -Staff should monitor and document an abnormalities and notify dialysis staff; -Resident was at high risk for fluid overload. Review of the resident's quarterly MDS, dated [DATE], showed staff did not mark dialysis as a special treatment on admission or while a resident. Review of the resident's weight record showed the following: -On 05/31/23, staff documented the resident weighed 198 pounds; -On 06/01/23, staff documented the resident weighed 200 pounds and 10 ounces; -On 07/06/23, staff documented the resident weighed 202 pounds and 14 ounces; -On 07/14/23, staff documented the resident weighed 203 pounds; -On 07/17/23, staff documented the resident weighed 204 pounds and 14 ounces; -On 08/04/23, staff documented the resident weighed 204 pounds and 12 ounces; -On 08/07/23, staff documented the resident weighed 204 pounds; -On 10/09/23, staff documented the resident weighed 167 pounds. Review of the resident's quarterly MDS, dated [DATE], showed staff did not mark dialysis as a special treatment on admission or while a resident. Review of the resident's weight record showed on 11/15/23, staff documented the resident weighed 194 pounds and 3.6 ounces. Review of the resident's medical record from 05/31/23 to 12/08/23, showed staff did not document any additional weights for the residents and did not document any resident refusals to be weighed. Review of the resident's physician orders sheet, current as of 12/08/23, showed no orders related related to dialysis treatment or monitoring. During an interview on 12/08/23, at 10:30 A.M., Registered Nurse (RN)L said that the resident should have his/her weight taken every Monday, Wednesday, and Friday morning before dialysis. The staff should monitor the dialysis site and monitor the resident for any changes. There should be a physician order with dialysis instructions and should be marked on the resident's MDS sheet. During an interview on 12/08/23, at 1:18 P.M., with the Administrator and the Director of Nursing (DON), the DON said residents that are on dialysis should have their weight monitored with each dialysis date and this should be documented under the weight notes in the electronic medical record . Staff should document if the resident refused to be weighed. The resident often refused to be weighed, but the staff should document that information. The Administrator said all treatments, including dialysis, should have a physician's order and that staff should make notations related to residents' cares accurately, including on the MDS.

Based on observation, interviews, and record review, the facility failed to ensure staff followed acceptable standards of practice for infection control at all times when staff failed to perform hand hygiene during a medication pass and failed to dispose of potentially contaminated medication for one resident (Resident #16) of two residents observed during medication pass. The facility census was 103. Review of a facility policy entitled Hand Hygiene, reviewed 07/21, showed the following: -Hand hygiene is the single-most effective method of reducing the transmission of microorganisms in a healthcare setting. The term hand hygiene replaced hand washing to reflect the acceptance of waterless hand cleaning agents such as alcohol based hand rubs (ABHR). Hand hygiene education is provided during orientation and annually; -Perform hand hygiene on ungloved hands with approved ABHR or soap and water before touching a patient; before a clean or aseptic procedure; -after touching a patient; and after touching a patient's surroundings. Review showed the facility did not provide a policy regarding infection control or hand hygiene specific to medication administration. 1. Review of Resident #16's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - breathing disorder), anxiety, diabetes mellitus, high blood pressure, depressive disorder, chronic pain, acid reflux, and allergies. Observation on 12/07/23, at 9:00 A.M. showed the following: -Certified Medication Tech (CMT) A exited a resident's room, approached the medication cart, and pushed the cart down the hall to position it close to the nurses' desk; -Without performing hand hygiene or sanitizing the top of the medication cart, the CMT punched pills from bubble packed cards into a medication cup (cup #1). The CMT picked up a pen from the cart, opened the controlled record logbook, and signed the administration of the narcotic; -CMT A dispensed medications from bubble pack cards into another medication cup (cup #2), then picked up and opened the capsules (potentially contaminating the capsule) to release the contents into medication cup #1 with the other pills; -CMT A retrieved stock bottles (used for any resident with orders for that medication or supplement) and dispensed medications into medication cup #1; -CMT A dispensed one medication into cup #2; -The CMT poured all pills from cup #1 into a plastic sleeve and used a pill crusher to crush the contents, pouring the crushed mixture back into the medication cup; -While setting down medication cup #1, CMT A accidentally bumped and tipped over medication cup #2. A medication fell from the cup onto the top of the medication cart (a contaminated surface). The CMT used the cup to scoop up the pill against the lip of the cart top, and poured it into medication cup #1 with the crushed medications; -CMT A dispensed one fish oil capsule from a stock bottle into medication cup #2. The CMT then picked up the capsule with his/her left hand (potentially contaminating the capsule) and picked up a push pin (a contaminated surface) from the top of the medication cart. The CMT pierced the capsule with the push pin and the CMT squeezed the liquid content into medication cup #1 with the other medications. -After mixing in applesauce, the CMT walked into the activity area and fed the combined medications to the resident, who sat in his/her wheelchair at a table with other residents; -The resident became anxious and tearful while taking the medications. The CMT handed tissues to the resident and then wheeled him/her to his/her room; -CMT A returned to the medication cart, did not perform hand hygiene, and dispensed one medication into a medication cup and mixed it with applesauce. CMT A poured some water from a pitcher on the cart into a small plastic drinking cup, then returned to the resident's room to administer the medication and sips of water to the resident; -Without performing hand hygiene, CMT A donned gloves and administered eye drops into the resident's lower eyelids. During an interview on 12/08/23, at 12:45 P.M., CMT B said the following: -During a medication pass, staff should wash their hands prior to starting, and they should use gloves to administer eye drops, inhalers, etc.; -Staff should not touch any of the pills, except when opening a capsule (then they should wear gloves in case it got on their skin); -Staff should wash hands or use sanitizer gel in between residents and wash hands if they are visibly soiled or if they touched the resident or their items; -If a dispensed pill lands outside of the med cup (floor, top of med cart, etc), staff should discard the pill and get a new one; -Capsules can be opened into a medication cup for residents who can't swallow them; -CMT B said it would be okay to [NAME] a gel capsule; staff could just use a tack or something - there is usually one in the cart. The staff should clean it off afterward with an alcohol swab. During an interview on 12/08/23, at 12:50 P.M., Licensed Practical Nurse (LPN) C said the following: -During a medication pass, staff should wash their hands in between every resident and should wash with soap/water if their hands are visibly soiled or splashed. Staff keep hand sanitizer on the carts; -Staff should never touch the pills to be given. Staff should discard a dropped pill and get a new pill; -The capsules may be opened into a medication cup, but staff should wear gloves to open capsules; -For a gel capsule, staff should use a sterile syringe needle to puncture. A thumbtack could be contaminated. During an interview on 12/08/23, at 12:55 P.M., CMT D said the following: -Staff should sanitize or wash their hands in between residents during a medication pass; -Staff should keep the top of the cart clean, but if a pill lands on the cart they should still discard it and retrieve a new pill to administer; -Staff can open capsules wearing gloves; -Staff can [NAME] a gel capsule with a tack and sanitize it before putting it back in the cart drawer. During an interview on 12/08/23, at 1:18 P.M., with the Administrator and the Director of Nursing (DON), the DON said staff should not touch the medications during administration, except to open capsules wearing gloves. If a pill is dropped onto the medication cart or floor, staff should discard the pill and retrieve a new one to administer. The DON said a gel capsule may be pierced using a sterile lancet; education had been given regarding not to use a thumbtack stored in the medication cart.

Based on interview and record review, the facility failed to notify all residents' families of changes in condition or an event that would require a change in plan of care when staff did not notify one resident's (Resident #1) family when the resident left the building out of an alarmed exit door in the early morning hours while it dark outside without staff knowing. The facility census was 93. Review of the facility's policy Changes in Resident Condition Notification Guidelines, dated 12/2022, showed the following: -Physicians, residents, hospice when applicable, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the resident; -Purpose to provide timely communication of condition and environmental changes to care providers, residents, and families; -When resident changes are noted, facility staff will notify the resident's physician, resident, legal representative (if resident is incompetent) and/or interested family member; -If multiple family members wish to be informed, they will designate a member to receive calls; -When a resident is a hospice patient, the hospice nurse should be notified first; -The hospice nurse will advise the long term care staff regarding whether hospice or long-term care will be responsible for notification of physician and family members; -Notification will occur as soon as possible when there is deterioration in health, mental, and/or psychosocial status in either life-threatening conditions or clinical complications. (The policy did not address elopements.) 1. Review of Resident #1's face sheet (admission information) showed the resident's admitted was 03/28/17. Review of the resident's care plan, reviewed 09/01/23, showed the following: -Cognitive impairment related to dementia (set of related symptoms which usually surface when the brain is damaged by injury or disease) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions); -Admission to hospice (end of life) care on 01/24/23 with diagnoses of Alzheimer's disease; -History of osteoarthritis of knee and gait abnormality and dementia; -Uses a wheelchair and a geri (geriatric) chair (a large padded chair that is designed to help seniors with limited mobility) when unable to safely walk. Use a wheelchair and was unable to move self around; -A high elopement risk (when a resident with a known history of altered mental status or intermittent mental status changes, leaves the facility, is missing, and could be at risk for serious harm when not adequately supervised). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 9/10/23, showed the following: -Severely impaired cognition; -The resident used a wheelchair; -Had no alarms or electronic monitoring devices. Review of the resident's nurse's note on 9/23/23, at 5:48 A,M., showed staff observed the resident outside in the parking lot in his/her wheelchair. Staff assisted the resident back into the building. (The nurse did not document he/she tried to notify the resident's family of the elopement). During interview on 09/26/23, at 10:32 A.M., Registered Nurse (RN) A said that staff were to call family for changes. If it was not an emergency and the resident was not hurt or in imminent danger, staff could leave a message for family. The family contact/attempt should be documented by staff. Licensed Practical Nurse (LPN) B tried to call the family and there was no answer. During interview on 09/25/23, at 2:45 P.M., LPN B, night nurse, said he/she worked from 6:00 P.M. to 6:00 A.M. on the night of 09/23/23 to the morning of 09/24/23. Another staff person coming in to work around 5:30 A.M., reported to him/her that a resident was outside the building. He/she and LPN D went outside, found the resident in his/her wheelchair sitting in the parking lot. LPN B told the resident to come on back inside and they wheeled the resident back inside the facility. He/she did try to call the family at 5:30 A.M. and could not reach them. He/she was unable to leave a message. He/she did pass this on in report to the day shift charge nurse that the resident got outside the building. The staff should have contact the family and documented the attempts. During interview on 09/25/23, at 3:24 P.M., LPN D said he/she worked on the east hall over the weekend when the resident got outside to the parking lot. He/she had gone outside with LPN B to bring the resident back inside. If one of his/her residents eloped he/she would do a head-to-toe assessment on the resident, notify the supervisor nurse on-call and look at the book at the nurse's desk for elopement protocols and procedures. He/she would notify the family and would document the contact. During interviews on 09/25/23, at 3:55 P.M. and on 09/26/23, at 11:24 A.M., LPN E said he/she worked the day shift (6:00 A.M.-6:00 P.M.) on Saturday, 09/23/23. He/she got the report from LPN B, night nurse that the resident got outside. The charge nurse, LPN B, said the resident was in the parking lot. LPN B did not say anything about calling the family, but did say he/she called the on-call nurse supervisor to report this. They were to notify the family when a resident had a change in condition of anything like if they have to send the resident to the hospital, or they had a fall, or put on an antibiotic, and when they get out of the building like the resident. It would have been appropriate to notify the family. LPN B said in report that morning, on 9/23/23, that he/she tried to call the family and there was no answer. LPN E was unsure if LPN B left a message. During interview on 09/25/23, at 5:15 P.M., the Associate Director of Nursing (ADON) said he/she was the on-call nurse supervisor last weekend on 09/23/23 to 09/24/23. He/she did not receive a call from the night or day charge nurse regarding the resident getting out of the building and found in the parking lot. She would have expected the staff to report this to him/her. Staff should have notified the resident's family and document the notification in the resident's record. During interviews on 09/25/23, at 9:55 A.M. and 2:21 P.M., and on 09/26/23, at 11:25 A.M., the Director of Nursing (DON) said he/she had just received a report from the hospice nurse. This was the first he/she had heard this about the resident going out of the building without staff knowledge, and found in the parking lot. Staff would need to call the family and/or power of attorney (POA) if it was a true elopement. Staff were to notify the family if the resident had a fall, a change in their condition, a medication change, and an incident like an altercation between residents, and if a resident eloped from the property. She did not notify the family about the resident getting out of the building. During an interview on 09/26/23, at 11:40 A.M., the Administrator said he/she would have expected staff to notify the family when there was a significant change in their condition, an injury, and it is case by case such as any other situations based on the family's preferences. It was important to have family dialogue to ask these questions and when (such as time) they should notify them. The family's preferences should be on the care plan. In this situation, staff should have notified the resident's family of him/her getting outside the building in the parking lot. Staff should document family notification. MO00224938