Every finding on record at Clinton Healthcare and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure all allegations of abuse were immediately and thoroughly investigated and steps were taken to protect all residents during the investigation when the facility began an investigation four days after staff reported witnessing the Director of Nursing (DON) had grabbed one resident (Resident #1's) face and yelled at him/her. The facility census was 73.Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 04/21, showed the following:-Residents have the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse;-Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property;-Investigate and report any allegations within timeframes required by federal requirements. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 11/04/25;-Diagnoses included diabetes, high blood pressure, and parkinsonism (a general neurological term for a group of movement symptoms- specifically slowed movement, muscle stiffness, tremors, and balance problems). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/20/26, showed the following:-Moderate cognitive impairment;-No verbal or physical behaviors exhibited toward others;-Requires partial to moderate assistance from staff for mobility. Review of the resident's care plan, revised 07/26/26, showed the following:-The resident was a prankster and liked to joke around with staff and other residents;-Encourage/remind the resident to keep his/her jokes appropriate;-Staff to redirect the resident if behavior is inappropriate with staff for other residents. During an interview on 08/04/26, at 10:41 A.M., the resident said the following information:-Most of the staff treat him/her well, with the exception of one gal, the DON;-The resident said he/she had a tendency to play around with the staff and pretended to grab a Certified Occupational Therapist Assistant (COTA) A by the breasts;-He/she did not actually make contact with COTA A's breast, he/she was pretending and did not mean any harm. While pretending to do so, the DON went off on him/her;-The resident showed the surveyor with physical movements of his/her hand, that the DON had grabbed him/her by/around the chin, turned his/her face toward her, and began yelling at him/her. The resident could not recall exactly what the DON had yelled at him/her, but recalled she was scolding him for acting inappropriately;-The resident wished not to elaborate any further as he/she indicated he/she had fear he/she would be kicked out of the facility. During an interview on 08/04/26, at 1:33 P.M., Resident #2 said the following:-He/she was further down the hall, behind Resident #1 when the incident occurred;-He/she saw the DON grab Resident #1's wheelchair and observed the DON talking terrible to him/her. He/she would not even talk to a dog the way the DON was speaking at Resident #1. The DON told Resident #1 that she was tired of his/her shit, and as soon as she had the time she would be getting rid of his/her ass;-From what he/she could see, the DON began pushing the resident in his/her wheelchair down the hall, very fast. The DON was visibly angry with Resident #1 and once she got him/her into his/her room, she yelled don't come back out!;-The DON was not professional and was always hateful to the residents;-The entire incident made him/her feel very uncomfortable. He/she was not great friends with Resident #1, but no one deserved the kind of treatment he/she witnessed. Review of facility records on 08/04/26, showed the facility did provide a documented completed abuse investigation or documented steps to protect residents during the investigation. During an interview on 08/04/26, at 11:27 A.M., COTA A said the following:-An example of physical abuse would be putting hands on someone else with any type of pressure;-He/she was present for the incident on 07/31/26;-He/she, the DON, and several residents walked down 100-Hall to the smoking area. The resident pretended to grab his/her breast, and the DON turned around, grabbed the residents face, by the chin, and faced him/her. The DON made the resident apologize for his/her behavior and then pushed the resident down to his/her room;-The tone the DON was using, was concerning. Right away after grabbing the resident by the chin, the DON said oh man and adjusted her grasp;-He/she felt the incident could be perceived as abuse;-It would not be okay for staff to put hands on a resident that way;-With any abuse allegations, the alleged perpetrator should be suspended pending an investigation. During an interview on 08/04/26, at 11:11 A.M., the Wound Nurse said the following:-She was aware of a recent abuse allegation as he/she was a witness to it;-The incident occurred on 07/31/26. All the smoking residents were heading down 100-Hall when Resident #1 wheeled up to COTA A pretending to grab their breasts. Immediately the DON started screaming and yelling at the resident, saying things like you aren't going to do that, you are not going to act like a child, and revoked the resident's smoking privileges;-While the DON was scolding the resident, the resident laughed and told the DON that he/she did not do anything wrong. At that time, the DON grabbed the resident's face by his/her chin and got in front of him/her;-The Wound Nurse immediately called and reported the incident to the Assistant Director of Nursing (ADON) and the ADON said she would report the incident to the Regional Nurse Consultant (RNC);-She felt what he/she witnessed was both physical and verbal abuse;-The expectation for abuse allegations is the alleged perpetrator should be suspended pending investigation and a complete investigation is to be conducted. During an interview on 08/04/26, at 11:20 A.M., the ADON said the following:-The Wound Nurse called and notified her of an incident on 07/31/26;-It was reported to her by the wound nurse that the DON yelled at the resident as if he were a child and grabbed ahold of his face during. She found both of those to be abusive behavior;-She reported the incident to the RNC, who said he would follow up and have a conversation with the resident the following morning. That is the last she heard of the incident;-She did not witness the incident, but if the allegations were true, she felt that it was both verbal and physical abuse;-There had not been any investigation to her knowledge. During an interview on 08/04/26, at 12:02 P.M., the RNC said the following:-An example of physical abuse would be any kind of touching that could leave a mark on a resident;-A resident's rights, such as smoking cannot be taken away from them for misbehaving, however the staff are expected to provide protective oversight and can take rights away if there is a safety concern;-He was not aware of any recent abuse allegations;-What was reported to him, was that there was an interaction in the hall on the morning of 07/31/26 where the resident was being sexually inappropriate toward staffing and that the DON had to redirect the resident. He did not obtain specifics of the redirection and was not told the DON grabbed the residents face or yelled at the resident;-He does believe the ADON sent him a text message regarding the allegations. She mentioned to him that there was more to the story than what the Administrator had told him. He instructed her to notify the Administrator, if she thought abuse had occurred;-If the DON did grab the residents face and yell at him, that would be considered abuse;-The allegations should have been investigated. During an interview on 08/04/26, at 12:51 A.M., Certified Nursing Assistant (CNA) B said typically when an allegation of abuse occurs, the alleged perpetrator is suspended pending an investigation. During an interview on 08/04/26, at 1:13 P.M., Dietary Aide C said when staff has an abuse allegation against them, they would normally be suspended and investigated. During an interview on 08/05/26, at 2:30 P.M., Licensed Practical Nurse (LPN) E said the following:-If a staff member grabbed a resident's face and yelled at them, that would be considered abuse;-Any abuse allegation should be investigated. During an interview on 08/05/26, at 1:00 P.M., the RN Supervisor said the following information:-If a staff member were to put their hands on someone, that was physical abuse;-If an incident occurred on the weekend, she, the ADON, DON, and Administrator were to be notified;-She was notified about the situation on 08/01/26 and was told that the DON yelled at the resident and grabbed his/her face on 07/31/26. COTA A expressed to her, that the incident had not been reported or investigated but he/she was in fear of retaliation so he/she did not report it his/herself;-Typically, when staff have an abuse allegation against them it would be investigated;-She asked the ADON if the allegations were even investigated, the ADON reported not to her knowledge. During an interview on 08/05/26, at 2:13 P.M., the Social Services Director (SSD) said the following:-If she were to hear or see something abusive, she would follow her chain of command and report it;-Any abuse allegations should have an internal investigation carried out and the alleged perpetrator should be suspended pending investigation. During an interview on 08/04/26, at 10:00 A.M., the DON and Administrator said the following:-Physical abuse would be any unwanted touching;-Verbal abuse would be something as simple as calling someone a word they didn't appreciate;-If a staff member reported any abuse allegations, they would start an investigation. During an interview on 08/04/26, at 10:20 A.M., the Administrator said the following:-She would consider unwanted physical contact abuse;-She would consider yelling at a resident, abuse;-Any staff accused of abuse were expected to be suspended pending investigation;-The DON had called and notified her shortly after the incident occurred but the DON did not tell her that she placed her hands on the resident, nor yelled at him/her. The DON said she had to redirect the resident due to behaviors. She did not believe it was an abuse allegation according to what the DON reported to her;-The DON was not suspended;-Knowing all of the details, she should have suspended the DON and completed a full investigation. Complaint #3132189

Based on observation, interview, and record review, the facility failed to ensure all allegations of abuse were reported immediately, but no later than two hours, to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when the facility failed to report allegations that staff witnessed the Director of Nursing (DON) grabbed the face of and yell at one resident (Resident #1's). The facility census was 73. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 04/21, showed the following information:-Residents have the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse;-Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents;-Investigate and report any allegations within timeframes required by federal requirements. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 11/04/25;-Diagnoses included diabetes, high blood pressure, and parkinsonism (a general neurological term for a group of movement symptoms- specifically slowed movement, muscle stiffness, tremors, and balance problems). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/20/26, showed the following:-Moderate cognitive impairment;-No verbal or physical behaviors exhibited toward others;-Requires partial to moderate assistance from staff for mobility. Review of the resident's care plan, revised 07/26/26, showed the following:-The resident was a prankster and liked to joke around with staff and other residents;-Encourage/remind the resident to keep his/her jokes appropriate;-Staff to redirect the resident if behavior is inappropriate with staff for other residents. During an interview on 08/04/26, at 10:41 A.M., the resident said the following information:-Most of the staff treat him/her well, with the exception of one gal, the DON;-The resident said he/she had a tendency to play around with the staff and pretended to grab a Certified Occupational Therapist Assistant (COTA) A by the breasts;-He/she did not actually make contact with COTA A's breast, he/she was pretending and did not mean any harm. While pretending to do so, the DON went off on him/her;-The resident showed the surveyor with physical movements of his/her hand, that the DON had grabbed him/her by/around the chin, turned his/her face toward her, and began yelling at him/her. The resident could not recall exactly what the DON had yelled at him/her, but recalled she was scolding him for acting inappropriately;-The resident wished not to elaborate any further as he/she indicated he/she had fear he/she would be kicked out of the facility. During an interview on 08/04/26, at 1:33 P.M., Resident #2 said the following:-He/she was further down the hall, behind Resident #1 when the incident occurred;-He/she saw the DON grab Resident #1's wheelchair and observed the DON talking terrible to him/her. He/she would not even talk to a dog the way the DON was speaking at Resident #1. The DON told Resident #1 that she was tired of his/her shit, and as soon as she had the time she would be getting rid of his/her ass; -From what he/she could see, the DON began pushing the resident in his/her wheelchair down the hall, very fast. The DON was visibly angry with Resident #1 and once she got him/her into his/her room, she yelled don't come back out!;-The DON was not professional and was always hateful to the residents;-The entire incident made him/her feel very uncomfortable. He/she was not great friends with Resident #1, but no one deserved the kind of treatment he/she witnessed. Review of the Department of Health and Senior Services records showed the facility did not self-report the allegation of abuse prior to DHSS entering the facility to investigate on 08/04/26. During an interview on 08/04/26, at 11:27 A.M., COTA A said the following:-An example of physical abuse would be putting hands on someone else with any type of pressure;-He/she was present for the incident on 07/31/26;-He/she, the DON, and several residents walked down 100-Hall to the smoking area. The resident pretended to grab his/her breast, and the DON turned around, grabbed the residents face, by the chin, and faced him/her. The DON made the resident apologize for his/her behavior and then pushed the resident down to his/her room;-The tone the DON was using, was concerning. Right away after grabbing the resident by the chin, the DON said oh man and adjusted her grasp; -He/she felt the incident could be perceived as abuse;-It would not be okay for staff to put hands on a resident that way;-He/she did not personally report what he/she seen as he/she was shocked and didn't believe the DON meant any harm;-Any abuse allegations should be reported to the state agency within two hours. During an interview on 08/04/26, at 11:11 A.M., the Wound Nurse said the following:-She was aware of a recent abuse allegation as she was a witness to it;-She was aware of a recent abuse allegation as he/she was a witness to it;-The incident occurred on 07/31/26. All the smoking residents were heading down 100-Hall when Resident #1 wheeled up to COTA A pretending to grab their breasts. Immediately the DON started screaming and yelling at the resident, saying things like you aren't going to do that, you are not going to act like a child, and revoked the resident's smoking privileges;-While the DON was scolding the resident, the resident laughed and told the DON that he/she did not do anything wrong. At that time, the DON grabbed the resident's face by his/her chin and got in front of him/her;-The Wound Nurse immediately called and reported the incident to the Assistant Director of Nursing (ADON) and the ADON said she would report the incident to the Regional Nurse Consultant (RNC); -She felt what he/she witnessed was both physical and verbal abuse.-The expectation for abuse allegations, is to report it going through the chain of command. The Administrator is supposed to report to the state agency within two hours. During an interview on 08/04/26, at 11:20 A.M., the ADON said the following:-The wound nurse called and notified her of an incident on 07/31/26;-It was reported to her by the wound nurse that the DON yelled at the resident as if he were a child and grabbed ahold of his face during. She found both of those to be abusive behavior;-She reported the incident to the RNC, who said he would follow up and have a conversation with the resident the following morning. That is the last she heard of the incident;-The interdisciplinary team would generally discuss things like this in morning meetings, but it was not brought up;-She did not witness the incident, but if the allegations were true, she felt that it was both verbal and physical abuse.-The incident was not reported to the state agency to her knowledge. During an interview on 08/04/26, at 12:02 P.M., the RNC said the following:-He was not aware of any recent abuse allegations;-The allegations were not reported to the state agency based on what was reported to him. He did not believe it met the level of abuse;-What was reported to him, was that there was an interaction in the hall on the morning of 07/31/26 where the resident was being sexually inappropriate toward staffing and that the DON had to redirect the resident. He did not obtain specifics of the redirection and was not told the DON grabbed the residents face or yelled at the resident. If those things had been told to him, he would of reported it;-He does believe the ADON sent him a text message regarding the allegations. She mentioned to him that there was more to the story than what the Administrator had told him. He instructed her to notify the Administrator, if she thought abuse had occurred; -The allegations should have been reported to the state agency and investigated, but he and others had to go off of what others were telling them and the way it was reported, did not seem like an abuse allegation. During an interview on 08/04/26, at 12:51 A.M., Certified Nursing Assistant (CNA) B said the following:-If he/she seen a staff member yell at or hurt a resident, he/she would report it to the ADON, DON, or Administrator; whoever she trusted to handle the situation at that time;-The state agency is to be notified within two hours of an abuse allegation. During an interview on 08/04/26, at 1:13 P.M., Dietary Aide C said the following:-He/she was present during the incident on 07/31/26;-He/she did report the incident to the Administrator immediately, but all the Administrator said was okay. He/she also reported the incident to the weekend Registered Nurse (RN) supervisor;-He/she knew this should be reported to the state agency. During an interview on 08/05/26, at 2:30 P.M., Licensed Practical Nurse (LPN) E said the following:-If a staff member grabbed a residents face and yelled at them, that would be considered abuse;-Any abuse allegation should be reported to the state agency within two hours. During an interview on 08/05/26, at 1:00 P.M., the RN Supervisor said the following information:-If a staff member were to put their hands on someone, that is physical abuse;-She told staff that the incident was reportable and someone should have reported it to the state agency;-She called the ADON and told her that this incident had to be reported and the ADON expressed that the Administrator was aware as the DON told her, herself. During an interview on 08/05/26, at 2:13 P.M., the Social Services Director (SSD) said the following:-If she were to hear or see something abusive, she would follow her chain of command and report it;-Any abuse allegations should be reported to the state within two hours. During an interview on 08/04/26, at 10:00 A.M., the DON and Administrator said the following:-Physical abuse would include any unwanted touching;-Verbal abuse would be something as simple as calling someone a word they didn't appreciate;-If a staff member reported any abuse allegations, she would report that to the state agency within 2 hours. During an interview on 08/04/26, at 10:20 A.M., the Administrator said the following:-She would consider unwanted physical contact abuse;-She would consider yelling at a resident, abuse;-Any abuse allegations are expected to be reported to the state agency, physician, and family members;-The incident was not reported to the state agency;-Knowing all of the details, she would have notified the regional staff. Complaint #3132189

Based on interview, and record review, the facility failed to ensure a complete pain management process was in place for all residents when staff failed to care plan regarding pain medications, failed to administer pain medications as ordered, and failed to document physician and pharmacy follow-up regarding missed doses of pain medication for one resident (Resident #3) whose medication was not received in a timely manner. The facility census was 73.Review of the facility policy titled Administering Medications, revised April 2019, showed the following information:-Medications are administered in a safe and timely manner, as prescribed;-Medications are administered in accordance with prescriber orders, including any required time frames;-Medication errors are documented, reported, and reviewed;-Medications are administered within one hour of their prescribed time;-If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR). 1. Review of Resident #3's face sheet (brief look at resident information) showed the following information:-admission date of 07/15/26;-Diagnoses included fibromyalgia (a long-term medical condition that causes widespread pain, tiredness, and sleep problems), depression, and pain in the right knee. Review of the resident's care plan, undated, showed staff did not care plan regarding the resident's medication prescribed for pain. Review of the resident's July 2026 Physician Order Sheet (POS) showed the following information:-An order, dated 07/16/26, for lidocaine (an anesthetic cream that prevents and treats pain) patch 5%- apply 2 patches to painful areas topically one time a day for pain;-An order dated 07/16/26, for gabapentin (medicine that calms overactive nerves to treat nerve pain and seizures) 300 milligrams (mg) by mouth (po) three times a day (TID) for pain. Review of the resident's July 2026 MAR showed the following information:-On 07/16/26, staff did not administer the Lidocaine patch 5%. Staff noted other/see progress note;-On 07/16/26, staff did not administer the morning dose of gabapentin 300 mg. Staff noted other/see progress note;-On 07/16/26, staff did not administer the noon dose of gabapentin 300 mg. Staff noted other/see progress note. Review of the resident's progress notes, dated 07/16/26, showed the following information:-At 9:44 A.M., staff documented nurse regarding the missed lidocaine dose;-At 9:46 A.M., staff documented on order regarding the missed morning gabapentin dose;-At 11:46 A.M., staff documented on order regarding the missed noon gabapentin dose.(Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) Review of the resident's July 2026 MAR showed the following information:-On 07/17/26, staff did not administer the lidocaine patch 5%. Staff noted other/see progress note;-On 07/17/26, staff did not administer the gabapentin 300 mg morning dose. Staff noted other/see progress note;-On 07/17/26, staff did not administer the gabapentin 300 mg noon dose. Staff noted other/see progress note. Review of the residents' progress notes, dated 07/17/26, showed the following information:-At 9:46 A.M., staff documented nurse regarding the missed lidocaine dose;-At 9:49 A.M., staff documented on order regarding the missed morning gabapentin dose;-At 10:20 A.M., staff noted a fax received from the physician related to the resident's lidocaine patches and received an order to change the dosage to 4%;-At 12:05 P.M., staff documented on order regarding the missed noon gabapentin dose.(Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) Review of the resident's July 2026 POS showed the following information:-An order, dated 07/17/26, to discontinue the 5% dosage of lidocaine;-An order, dated 07/18/26, for lidocaine 4% patch, apply 2 patches to painful area every morning. Review of the resident's July 2026 MAR showed on 07/18/26 staff did not administer the lidocaine patch 4%. Staff noted other/see progress note. Review of the resident's progress notes dated 07/18/26, at 7:58 A.M., showed staff documented not in stock regarding the missed lidocaine dose. (Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) Review of the resident's July 2026 MAR showed on 07/19/26, staff did not administer the lidocaine patch 4%. Staff noted other/see progress note. Review of the resident's progress notes dated 07/19/26, at 7:42 A.M., showed staff documented not in stock regarding the missed lidocaine dose. (Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) Review of the resident's July 2026 MAR showed on 07/20/26, staff did not administer the lidocaine patch 4%. Staff noted other/see progress note. Review of the resident's progress note dated 07/19/26, at 7:29 A.M., showed staff documented on order regarding the missed lidocaine dose. (Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) Review of the residents' July 2026 MAR showed on 07/21/26, staff did not administer lidocaine patch 4%. Staff noted other/see progress note. Review of the resident's progress note dated 07/21/26, at 7:18 A.M., showed staff documented no medication available regarding the missed lidocaine dose. (Staff did not document regarding physician notification of the missed doses or follow-up with the pharmacy.) During an interview on 08/04/26, at 12:51 P.M., Certified Nursing Assistant (CNA) B said physician orders were expected to be followed. During an interview on 08/05/26, at 1:55 P.M., CNA D said physician orders were expected to be followed. During an interview on 08/18/26, at 3:00 P.M., Certified Medication Technician (CMT) F said the following:-Physician orders were expected to be followed;-If a medication was not available for administration, he/she would notify the charge nurse, and call the pharmacy;-If a medication was available in the emergency kit, it should be pulled from there for administration;-If a medication was not at the facility within two days of the physician order, he/she would notify the physician;-All notifications and follow-up was expected to be documented in the progress notes. During an interview on 08/05/26, at 1:00 P.M., Registered Nurse (RN) Weekend Supervisor said the following information:-Physician orders were expected to be followed;-If a medication was not administered, the MAR should indicate reasoning why and there should be documentation in the progress notes with an explanation;-If a medication was not available, nurses were expected to call the pharmacy and/or physician and determine the reason for the medication not being available. The notification was expected to be documented in the progress notes;-The facility did have an emergency kit for medication that had yet to be delivered from pharmacy, but he/she did not believe it included lidocaine or gabapentin;-If staff would follow up on the medication that was not available, the problem would be solved timely;-He/she was not notified of any medications not being available. During an interview on 08/05/26, at 2:30 P.M., Licensed Practical Nurse (LPN) E said the following information:-Physician orders should be followed;-If a medication was not administered, the MAR should indicate reasoning why and there should be documentation in the progress notes with an explanation;-If a medication was not available, nurses were expected to call the pharmacy and/or physician and determine the reason for the medication not being available. The notification was expected to be documented in the progress notes;-Nurses and CMT pass medications at the facility. If a CMT runs into concerns of a medication not being available, they should notify the nurse;-He/she was not notified of any medications not being available. During an interview on 08/04/26, at 11:11 A.M., the Assistant Director of Nursing (ADON) said the following:-Physician orders should be followed;-If a medication was not administered, staff should document the reasoning on the MAR and progress notes;-She expected staff to follow up with the pharmacy and physician for any medication that is not available or administered. During an interview on 08/05/26, at 3:24 P.M., the Administrator said the following:-She expected all physician orders to be followed;-If medication was not available, she expected staff to notify the pharmacy and physician and follow up with the concern with documentation. Complaint #3105601

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff when the facility Director of Nursing (DON) grabbed a resident's (Resident #1's) chin, yelled at him/her, and did not allow the resident to smoke the rest of the day. The facility census was 73.Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 04/21, showed residents have the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 11/04/25;-Diagnoses included diabetes, high blood pressure, and parkinsonism (a general neurological term for a group of movement symptoms- specifically slowed movement, muscle stiffness, tremors, and balance problems). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/20/26, showed the following:-Moderate cognitive impairment;-No verbal or physical behaviors exhibited toward others;-Requires partial to moderate assistance from staff for mobility. Review of the resident's care plan, revised 07/26/26, showed the following:-The resident was a prankster and liked to joke around with staff and other residents;-Encourage/remind the resident to keep his/her jokes appropriate;-Staff to redirect the resident if behavior is inappropriate with staff for other residents. During an interview on 08/04/26, at 10:41 A.M., the resident said the following information:-Most of the staff treat him/her well, with the exception of one gal, the DON;-The resident said he/she had a tendency to play around with the staff and pretended to grab a Certified Occupational Therapist Assistant (COTA) A by the breasts;-He/she did not actually make contact with COTA A's breast, he/she was pretending and did not mean any harm. While pretending to do so, the DON went off on him/her;-The resident showed the surveyor with physical movements of his/her hand, that the DON had grabbed him/her by/around the chin, turned his/her face toward her, and began yelling at him/her. The resident could not recall exactly what the DON had yelled at him/her, but recalled she was scolding him for acting inappropriately;-The resident wished not to elaborate any further as he/she indicated he/she had fear he/she would be kicked out of the facility. During an interview on 08/04/26, at 1:33 P.M., Resident #2 said the following:-He/she was further down the hall, behind Resident #1 when the incident occurred;-He/she saw the DON grab Resident #1's wheelchair and observed the DON talking terrible to him/her. He/she would not even talk to a dog the way the DON was speaking at Resident #1. The DON told Resident #1 that she was tired of his/her shit, and as soon as she had the time she would be getting rid of his/her ass;-From what he/she could see, the DON began pushing the resident in his/her wheelchair down the hall, very fast. The DON was visibly angry with Resident #1 and once she got him/her into his/her room, she yelled don't come back out!;-The DON was not professional and was always hateful to the residents;-The entire incident made him/her feel very uncomfortable. He/she was not great friends with Resident #1, but no one deserved the kind of treatment he/she witnessed. During an interview on 08/04/26, at 11:27 A.M., COTA A said the following:-An example of physical abuse would be putting hands on someone else with any type of pressure;-He/she was present for the incident on 07/31/26;-He/she, the DON, and several residents walked down 100-Hall to the smoking area. The resident pretended to grab his/her breast, and the DON turned around, grabbed the residents face, by the chin, and faced him/her. The DON made the resident apologize for his/her behavior and then pushed the resident down to his/her room;-The tone the DON was using, was concerning. Right away after grabbing the resident by the chin, the DON said oh man and adjusted her grasp;-He/she felt the incident could be perceived as abuse;-It would not be okay for staff to put hands on a resident that way. During an interview on 08/04/26, at 11:11 A.M., the Wound Nurse said the following:-She was aware of a recent abuse allegation as he/she was a witness to it;-The incident occurred on 07/31/26. All the smoking residents were heading down 100-Hall when Resident #1 wheeled up to COTA A pretending to grab their breasts. Immediately the DON started screaming and yelling at the resident, saying things like you aren't going to do that, you are not going to act like a child, and revoked the resident's smoking privileges;-While the DON was scolding the resident, the resident laughed and told the DON that he/she did not do anything wrong. At that time, the DON grabbed the resident's face by his/her chin and got in front of him/her;-The Wound Nurse immediately called and reported the incident to the Assistant Director of Nursing (ADON) and the ADON said she would report the incident to the Regional Nurse Consultant (RNC);-She felt what he/she witnessed was both physical and verbal abuse. During an interview on 08/04/26, at 1:13 P.M., Dietary Aide (DA) C said the following:-He/she was present during the incident on 07/31/26;-The resident was coming out of the dining room and began going down 100-Hall. COTA A was in the hallway and the resident pretended like he/she was going to grab his/her breast. At that time, the DON grabbed the resident's arm, whipped him around in his/her wheelchair, and then grabbed the resident on the face by the chin and got nose to nose with the resident and begun yelling at him/her saying things like; you don't do that and that's disrespectful. The DON also threw in the F word multiple times. This occurred in front of other residents, and staff. The resident did not say anything and just seemed to be pulling back from the DON's grasp;-He/she did report the incident to the Administrator immediately. He/she also reported the incident to the weekend Registered Nurse (RN) supervisor;-The DON is generally abrasive and rude. He/she yells at staff and degrades residents often. During an interview on 08/04/26, at 12:51 A.M., Certified Nursing Assistant (CNA) B said the following:-Residents should not be reprimanded;-Residents have rights and those rights should not be taken away from them as a form of punishment;-Grabbing a resident's face, or yelling at a resident is considered abuse;-If he/she saw a staff member yell at or hurt a resident, he/she would report it to the ADON, DON, or Administrator;-He/she worked on 07/31/26 and did not witness the initial incident, but did hear a commotion in the hallway;-He/she heard the DON yelling things like; you will not try to touch a staff member's breast and you will not be smoking now. The yelling was very loud and abrupt;-He/she looked out into the hallway and saw the DON pushing the resident in his/her wheelchair without foot pedals to his/her room. The resident was capable of self-ambulating. The DON was pushing the resident so fast that if the resident had placed his/her feet down onto the ground, he/she would have fell out face first. The resident was not speaking during this scolding;-The way the DON talked to the resident was abusive;-He/she did not see the resident outside of his/her room the rest of the day;-The incident was reported to the ADON. During an interview on 08/04/26, at 11:20 A.M., the ADON said the following:-The Wound Nurse called and notified her of an incident on 07/31/26;-It was reported to her by the wound nurse that the DON yelled at the resident as if he were a child and grabbed ahold of his face during. She found both of those to be abusive behavior;-She reported the incident to the RNC, who said he would follow up and have a conversation with the resident the following morning. That is the last she heard of the incident;-The interdisciplinary team would generally discuss things like this in morning meetings, but it was not brought up;-She did not witness the incident, but if the allegations were true, she felt that it was both verbal and physical abuse. During an interview on 08/04/26, at 12:02 P.M., the RNC said the following:-An example of physical abuse would be any kind of touching that could leave a mark on a resident;-A resident's rights, such as smoking cannot be taken away from them for misbehaving, however the staff are expected to provide protective oversight and can take rights away if there is a safety concern;-He was not aware of any recent abuse allegations;-What was reported to him, was that there was an interaction in the hall on the morning of 07/31/26 where the resident was being sexually inappropriate toward staffing and that the DON had to redirect the resident. He did not obtain specifics of the redirection and was not told the DON grabbed the residents face or yelled at the resident;-He does believe the ADON sent him a text message regarding the allegations. She mentioned to him that there was more to the story than what the Administrator had told him. He instructed her to notify the Administrator, if she thought abuse had occurred;-If the DON did grab the residents face and yell at him, that would be considered abuse. During an interview on 08/04/26, at 10:15 A.M. and 10:30 A.M., the DON said the following:-On 07/31/26, she and smoking residents went down the 100-Hall. She turned around and noticed that the resident was grabbing the breast of COTA A;-She grabbed the resident's hands with her hands, placed the residents hands in his/her lap. Then she put her left hand on his/her face and turned his/her face toward her and told him/her to stop doing what he/she was doing;-She placed her hand in a grabbing manner onto the resident's chin, but quickly realized that was wrong and raised her thumb off his/her chin to release the grasp after pulling his/her face toward her direction;-It was not appropriate to put her hands on a resident, but it was a reaction to him/her grabbing a staff members breast;-She pushed the resident back to his/her room instead of letting him/her go outside to smoke, as scheduled, because he did not need to go smoke;-The resident did not come out of his/her room for the rest of that day. During an interview on 08/05/26, at 1:00 P.M., the RN Supervisor said the following information:-If a staff member were to put their hands on someone, that was physical abuse;-If an incident occurred on the weekend, she, the ADON, DON, and Administrator were to be notified;-She was notified about the situation on 08/01/26 and was told that the DON yelled at the resident and grabbed his/her face on 07/31/26. COTA A expressed to her, that the incident had not been reported or investigated but he/she was in fear of retaliation so he/she did not report it his/herself. During an interview on 08/05/26, at 1:55 P.M., CNA D said the following information:-He/she believes if a staff member were to grab a resident's face and yell, that would be abuse;-He/she was working on 07/31/26;-He/she did not witness the initial incident, but did hear the DON yelling at the resident. She observed the DON push the resident in his/her wheelchair down to his/her room and continued to rant and rave the entire way to his/her room;-He/she did tell his/her nurse, and the Administrator was aware of the situation;-The resident did not come out of his room the resident of the day. During an interview on 08/05/26, at 2:30 P.M., Licensed Practical Nurse (LPN) E said the following:-He/she was working during the time of the incident, but did not witness the entirety;-He/she heard the DON with a raised voice toward a resident, telling the resident that his/her behavior was not appropriate;-If a staff member grabbed a resident's face and yelled at them, that would be considered abuse. During an interview on 08/04/26, at 10:20 A.M., the Administrator said the following:-Unwanted physical contact was abuse;-Yelling at a resident was abuse;-The DON had called and notified her shortly after the incident occurred but the DON did not tell her that she placed her hands on the resident, nor yelled at him/her. The DON said she had to redirect the resident due to behaviors. Complaint #3022674, #3108543, #3132189

1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (chronic, autoimmune disease that affects the central nervous system (brain and spinal cord)), spastic hemiplegia (paralysis or severe weakness) affecting left dominant side on the left side of the body, chronic pain syndrome, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for showering, toileting hygiene, and lower body dressing; -Resident required substantial to maximal assistance of staff for upper body dressing and personal hygiene. Review of the resident's nursing progress notes dated 03/03/25, at 5:26 P.M., showed the resident was totally dependent on staff for toileting and bathing, and substantial assistance to dependent on staff for dressing and grooming. Due to his/her impairment the resident required total assistance for mobility in bed and transfers. He/she was unable to ambulate. Review of the resident's care plan, last updated 03/17/25, showed staff did not care plan regarding the resident's need for shower assistance and his/her shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review, showed the following: -On 03/05/25, staff documented resident received a shower, fingernail care, and shaved. Staff stripped off the resident's linen, wiped down bedding, and made bed with clean linen. Staff noted no new skin concerns. A CNA and licensed practical nurse (LPN) signed the form. -On 03/18/25 (13 days after prior shower), staff documented resident received a shower and shaved. Fingernail care was not needed. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:20 A.M., showed the resident was in his/her bed. He/she said Tuesday and Friday were his/her scheduled shower days. His/her last shower was over one week ago. Before last week it had been over two weeks since his/her last shower. He/she felt terrible, dirty, and worried about smell without a shower twice per week. 2. Review of Resident #2's face sheet, showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly), glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), need for assistance with personal care, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident required partial to moderate assistance of staff for showering, toileting hygiene, lower body dressing, upper body dressing and personal hygiene. Review of the resident's care plan, updated 12/20/24, showed staff did not care plan related the resident's need for assistance with showers or shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/02/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/05/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/12/25 (seven days after prior shower), staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:25 A.M., showed the resident was seated in his/her recliner. He/she said his/her last shower was over two weeks ago. He/she was offered a shower before his/her leg was broken, but it was going to be done by a man, and he/she did not want a man to complete the shower. He/she wrote dates down when he/she a shower, but was unable to find the last date. He/she felt dirty without being shower routinely. 3. Review of Resident #3's face sheet, showed the following: -admitted [DATE]; -Diagnoses included rhabdomylosis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, muscle weakness, pain, and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident was totally dependent on staff for toileting hygiene; -Resident required staff assistance for set up or clean up of personal hygiene; -Resident required partial to moderate assistance for upper body dressing; -Resident required substantial to maximal assistance for showering and lower body dressing. Review of the resident's care plan, updated 01/21/25, showed the following: -Resident required assistance with activities of daily living (ADL's) related to limited mobility and pain; -Resident required dependent to max assistant with shower transfers and full body showering; -Resident required max to dependent assist of two staff for transfer to/from toilet, dependent for toilet hygiene and clothing management, and incontinent care of bowels. Resident had Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and dependent for catheter care. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care was refused. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/13/25 (7 days after prior shower), staff documented resident received a shower and toenail care was not provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:52 A.M., showed the resident was in his/her wheelchair near the nursing station. The resident said he/she usually received a shower twice per week, but was unsure when he/she last received a shower. He/she really liked when he/she did receive a shower twice per week. 4. Review of Resident #4's face sheet, showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), hemiplegia (complete paralysis on one side of the body) and hemiparesis (milder form of weakness on one side) affecting unspecified side, anxiety disorder, and chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was totally dependent on staff for toileting hygiene; -Resident required substantial to maximal assistance for showers and lower body dressing; -Resident required set up or clean up assistance from staff for upper body dressing; -Resident required supervision or touching assistance from staff for personal hygiene. Review of the resident's care plan, updated 01/21/25, staff did not care plan regarding shower assistance or the resident's shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail and toenail care provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/10/25, staff documented resident received a shower and fingernail care not needed. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/17/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/24/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:00 A.M., showed the resident in his/her room in a wheelchair. The resident said he/she was only getting one shower per week, but preferred two per week. He/she a shower this Monday, 03/24/25, but felt it was only because he/she had a doctor's appointment. He/she was embarrassed when he/she had not received a shower and especially embarrassed to go to the doctor without a shower. The shower aide was frequently being pulled to work the floor. 5. During an interview on 03/26/25, at 10:00 A.M., CNA E said that there was only one shower aide that was not working this day. He/she said very few residents were receiving two showers per week. During an interview on 03/26/25, at 1:40 P.M., CNA C said that he/she was not told that any residents needed a shower. There was one shower aide and that he/she was not working this day. The shower aide had the shower schedule. During an interview on 03/26/25, at 11:20 A.M., LPN A said residents were not receiving showers twice per week. One shower aide recently quit and there was only one shower aide for the entire facility. During an interview on 03/26/25, at 11:35 A.M., LPN B said there was currently only one shower aide in the facility, but there was no one working as a shower aide this day. The residents were not receiving two showers per week. During an interview on 03/26/25, at 1:55 P.M., LPN D said he/she knew that residents were not receiving showers twice per week. There was only one shower aide for the facility and the aide was not working this day. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said there was a recent turn over and only one full time shower aide was working. He/she called in on this day. Until another shower aide could be hired or assigned, the home planned to start having the floor aides provide showers as well. During an interview on 03/26/25, at 2:20 P.M., the Director of Nursing (DON) said the expectation was for residents to receive two showers per week and if a resident refused a shower they would have to sign the shower sheet. MO00251410, MO00251648

1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations; -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe; -The Director of Nursing (DON) and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications; -Only authorized, licensed nursing and pharmacy personnel have access to controlled medications; -Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents; -The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident if the facility so desires; -Alternatively, the facility may utilize a bound book in place of count sheets; -The following information is completed up dispensing or upon receipt of the controlled substance: resident's name, prescription number, drug name, strength, and dosage for of medication, date received, quantity received, and the name of person receiving the medication supply; -If the facility uses a bound book in lieu of the pharmacy count sheets, all of this information will be completed by a licensed nurse at the facility; -At each change of custody (shift change or exchange of keys) all on-hand controlled medication quantities shall be counted by two nurses and reconciled with the count sheets; -This shall be documented by completing a Controlled Drug Count Form indicating the date and time the physical count was completed; -Any discrepancies shall be reported to the charge nurse and the DON immediately; -With the nurse supervisor present, the discovering nurse should place a signed entry on the resident controlled drug record where the discrepancy was detected; -If it is something other than a mathematical error, the DON should provide assistance with the investigation and resolving the discrepancy; -Controlled substance medications are stored at the facility under double lock on the medication cart or medication room separate from all other medications. 1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included rhabdomyolysis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, pain, muscle weakness, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of the resident's care plan, dated 10/18/24, showed the following: -Resident received as needed pain medication therapy related to rhabdoymyolysis, rib fractures, and occasional generalized pain; -Staff should administered analgesic (pain) medications as ordered by physician; -Staff should monitor and document side effects and effectiveness every shift; -Staff should notify physician if medication does not control pain to tolerable level. Review of the resident's Physician Order Sheet (POS), current as of 03/26/25, showed an order, dated 10/04/24, for morphine sulfate ER (drug used to treat moderate to severe pain), oral tablet extended release 30 milligrams (mg), give one tablet by mouth two times per day for multiple fracture of ribs. Review of the resident's March 2024 Medication Administration Record (MAR), showed staff documented administration of morphine sulfate ER 30 mg every day in the morning and at bedtime from 03/01/25 to 03/26/25. Review of the pharmacy consolidated delivery sheets, dated 03/10/25, showed morphine sulfate ER 30 mg tablets, quantity of 60 tablets, received for the resident. Review of the controlled medication logbook on the medication cart showed the following: -On 03/10/25, staff documented there was 9 tablets of morphine sulfate and the pharmacy delivered 60 tabs. The total at the end of shift was 69 tablets; -On 03/16/25, the resident had 57 tablets of morphine sulfate. When the evening shift completed the change of shift count there were only 27 tablets of morphine sulfate in the cart; -On 03/24/25, the pharmacy delivered 30 tablets of morphine sulfate; -On 03/26/25, at 1:55 P.M., there were 38 tablets of morphine sulfate in the cart when reviewed with nurse. Review of the facility's Investigation Report, dated 03/18/25, showed the following information: -On 03/16/25, at 10:10 P.M., the Administrator received a call from Licensed Practical Nurse (LPN) B that the narcotic count for the resident showed there was 30 tablets of morphine sulfate missing; -Staff searched the medication cart and medication room. The medication was not located; -Police department notified on 03/17/25; -Notified pharmacy to report and request they send replacement for the missing medication and to bill the facility; -LPN F's statement, dated 03/16/25, showed the LPN worked 4 1/2 hour shift, from 5:30 P.M. to 10 P.M. The nurse was rushing during the count at the beginning of shift and was unsure if the count was actually correct at that time; -LPN A's statement, dated 03/17/25, showed he/she counted medications on beginning of shift on 03/15/25 evening and end of shift on 03/16/25 morning. The count was correct at those time. When he/she worked the day shift on 03/17/25, he/she was informed by the night shift nurse that the count was off by 30 tablets. During an interview on 03/26/25, at 10:45 A.M., LPN A said the narcotic count was completed at the beginning and end of every shift. If the count was incorrect staff should notify the DON and administrator immediately. During an interview on 03/26/25, at 11:35 A.M., LPN B said the process for narcotics included the off-going nurse taking the narcotic book and the on-coming nurse taking the narcotic drawer to complete the shift count. Staff start by going through all of the tablets and then they count the liquids. If the narcotic count was not correct staff were to immediately contact the supervisor and staff do not leave the facility until the supervisor approved. During an interview on 03/26/25, at 1:55 P.M., LPN D said that if the log and tablets do not match during shift change, staff are to call management and have to stay at the facility until approved to leave. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said staff should complete a narcotic count during each shift change. If an error was found, staff were to contact management immediately. During an interview on 03/26/25, at 2:20 P.M., the DON said she expected the staff to follow facility policy. During an interview on 03/26/25, at 2:40 P.M., the Administrator said when she was notified of narcotic count discrepancy on 03/16/25 around 10:00 P.M. by LPN B. The medication cart and medication room were searched, and the narcotic was not located. The nursing staff did not have any knowledge of where the narcotics could be. The Administrator expected staff to complete narcotic counts accurately with every shift change. If the count was not accurate the staff were to notify the DON and Administrator immediately for further instructions. MO00251335

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to transcribe new admission orders correctly for one resident (Resident #1) resulting in staff administering two medications in excess of the ordered dosage amounts for five days. Once notified of the error, the staff did not document notification of the physician of the medication error to obtain further direction. The resident passed away on the day the medication error was discovered. The facility census was 74. The Administrator and the Corporate Nurse were notified on [DATE], at 4:10 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility policy titled Administering Medications, dated [DATE], showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions; - Medications are administered in accordance with prescriber orders, including any required time frame; -Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI -a data-driven approach to improving the quality of care and life for nursing home residents) committee to inform process changes and or the need for additional staff training; -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns; -Each nurses' station has a current Physician's Desk Reference (PDR - comprehensive reference book that compiles information about prescription drugs available, including details like dosage, side effects, and indications) and/or other medication reference; -Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. Review of the facility policy titled Adverse Consequences and Medication Errors, dated February 2023, showed the following: - The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects; - An adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: -The staff and practitioner strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; -Residents receiving medication are monitored for adverse consequences; -Adverse consequences are promptly identified and reported; -An adverse drug reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic and helpful effects of the drug; or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis or therapy.; -Adverse drug reactions are reported to the attending physician and pharmacist, and to federal agencies as appropriate; -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals providing services; -A significant medication-related error is defined as requiring medication discontinuation or dose modification; requiring hospitalization , or extending a hospitalization ; resulting in disability; requiring treatment with a prescription medication; resulting in cognitive deterioration or impairment; life threatening; or resulting in death; -Review the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis; -When a resident receives a new medication order, review to ensure the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. Document the clinical rationale for using the medication if prescribed outside the accepted standard of practice; -Monitor the resident for medication-related adverse consequences when there is an addition of a new medication; discontinuation of an existing medication; an increase or decrease in dose or frequency; -Addition or discontinuation of enteral feedings; significant changes in diet that may affect medication absorption; or an medication error; -In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare; -Promptly notify the provider of any significant error or adverse consequence; -Implement the provider orders and monitor the resident for 24 to 72 hours, or as directed; -Communicate the event to the oncoming shift as needed to alert staff of the need for continued monitoring; -The QAPI committee is responsible for conducting a root cause analysis of medication administration errors to determine the source of errors; creating and implementing process improvement steps; and comparing results over time to determine that system improvements are effective in reducing errors. Review of the facility's checklist titled Admission Checklist, undated, showed the following: -Admission medications verified by physician and pharmacy notified; -Orders entered correctly; -Admitting nurse and date; -Items requiring follow-up; -Nurse completing form and date. Review of the Diltiazem Prescribing Information, dated [DATE], showed the following: -Diltiazem belongs to a class of medications called calcium-channel blockers; -It works by relaxing the blood vessels, so the heart does not have to pump so hard; -Diltiazem also increases the supply of blood and oxygen to the heart; -Usual adult dose for hypertension (high blood pressure) initial dose of 120 milligrams (mg) to 240 mg orally once a day and increasing the dose as needed. Maintenance dose of 120 mg to 540 mg orally once a day; -Maximum dose per day of 540 mg; -Diltiazem may cause serious side effects including chest pain; fast, slow, or uneven heart rate; light-headed feeling; heart problems; swelling, rapid weight gain; feeling short of breath; liver problems; loss of appetite; upper right side stomach pain; tiredness; itching; dark urine; clay-colored stools; and jaundice (yellowing of the skin or eyes). -Overdose symptoms may include low blood pressure, slow heart rate, severe dizziness, or fainting. Review of the Eliquis Medication Guide, dated [DATE], showed the following: -Eliquis is a blood thinner medicine that reduces blood clotting; -Eliquis lowers the chance of having a stroke by helping to prevent blood clots from forming; -Most common side effects are bruising and may cause bleeding which can be serious and rarely may lead to death; -Take Eliquis exactly as prescribed by the doctor; -Take Eliquis twice every day with or without food; -The recommended dose for most patients is 5 mg taken orally twice daily; -The recommended dose of Eliquis is 2.5 mg taken orally twice daily for age greater than or equal to [AGE] years, body weight less than or equal to 132 pounds, or serum creatinine greater than or equal to 1.5 mg/deciliter (dL). Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute respiratory failure with hypoxia (not enough oxygen in the blood or body's tissues), influenza due to influenza A (contagious respiratory illness) with other respiratory manifestations (symptoms that affect the lungs and airways, such as coughing, shortness of breath, and chest pain), congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's baseline care plan, dated [DATE], showed the following: -Full code (resident wanted to receive cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) and other life-saving treatments if their heart or breathing stops); -Initial discharge goal to return to the community; -Alert and cognitively intact; -See physician orders for medications; -Functional goal to improve functional status with physical therapy. Review of the resident's hospital discharge summary, dated [DATE], showed the following medications to be continued on discharge: -Apixaban (generic for Eliquis) 5 mg orally, take one-half tablet two times per day to thin blood and stroke prevention; -Diltiazem (used to treat high blood pressure) 120 mg 24-hour capsule, take one capsule by mouth every morning to prevent arrhythmia (irregular heart beat). Review of the resident's facility Physician Order Sheet (POS), dated [DATE], showed the following: -An order, dated [DATE], for apixaban 5 mg, give one tablet by mouth two times a day for stroke prevention (twice the ordered amount on the resident's hospital discharge orders); -An order, dated [DATE], for diltiazem HCL (hydrochloride) ER (extended-release) beads capsule extended release 24-hour 360 mg, give one capsule two times a day for blood pressure (six times the ordered amount on the resident's hospital discharge orders). Review of the resident's [DATE] Medication Administration Record (MAR) showed the following: -On [DATE], staff did not administer the resident's apixaban 5 mg evening dose due to medication on order; -On [DATE], staff did not administer the resident's diltiazem ER 360 mg evening dose due to medication on order. Review of the resident's medical record showed the following: -On [DATE], at 1:59 P.M., a system order note showed the order you have entered is outside of the recommended dose or frequency. Diltiazem HCl ER Beads Capsule Extended Release 24 Hour 360 mg give 1 capsule by mouth two times a day for blood pressure. The dosing regimen of 1 capsule 2 times per day exceeds the usual dosing regimen of 0.33 to 1 capsule daily. The frequency of 2 times per day exceeds the usual frequency of daily Review of the resident's medical record showed staff did not document regarding the system generated warning on [DATE]. Review of the resident's admission summary dated [DATE], at 2:57 P.M., showed resident arrived via medical transport accompanied by driver. Resident required stand by assist. Lungs clear to auscultation (listening to the sounds of lungs using a stethoscope) and respirations even and unlabored. Abdomen soft and bowel sounds active times 4. Continent of bowel and bladder. Alert and oriented times 4 and able to make wants and needs known. Denied pain at this time. Review of the resident's Nursing Home Initial Physician Assessment, dated [DATE], showed the following: -Blood pressure ,d+[DATE] millimeters of Mercury (mm/Hg - normal is less than ,d+[DATE] mm/Hg) and pulse 70 beats per minute (bpm) (normal is 60 to 100 bpm); -Diagnoses included acute respiratory failure with hypoxia, influenza, and atrial fibrillation (irregular and rapid heart beat); -Physician review of systems showed no edema (fluid trapped in body's tissues); -Physician's plan showed to continue apixaban 5 mg twice per day and continue diltiazem 120 mgER on ce per day. Review of the resident's medical record showed staff did not follow-up to address the discrepancy between the discharge orders, orders entered, and the physician note on [DATE]. Review of the resident's [DATE] MAR showed the following: -On [DATE], staff administered apixaban 5 mg morning and evening doses; -On [DATE], staff administered diltiazem ER 360 mg morning and evening doses; -On [DATE], staff administered apixaban 5 mg morning and evening doses; -On [DATE], staff administered diltiazem ER 360 mg morning and evening doses. Review of the resident's facility POS, dated [DATE], showed the following: -The prior order for diltiazem HC was discontinued on [DATE]. -An order, dated [DATE], for diltiazem HCL ER Beads Capsule Extended Release 24-hour 360 mg, give one capsule two times a day for hypotension (low blood pressure) (six times the ordered amount on the resident's hospital discharge orders). Review of the resident's [DATE] MAR showed the staff documented the following: -On [DATE], staff administered apixaban 5 mg morning and evening doses; -On [DATE], staff administered diltiazem ER 360 mg morning dose; -On [DATE], staff administered diltiazem ER 360 mg evening dose and noted the resident's blood pressure was ,d+[DATE] mm/Hg with a pulse of 65 bpm; -On [DATE], staff administered apixaban 5 mg morning and evening doses; -On [DATE], staff administered diltiazem ER 360 mg morning dose and noted the resident's blood pressure was ,d+[DATE] mm/Hg with a pulse of 64 bpm; -On [DATE], staff administered diltiazem ER 360 mg evening dose and noted the resident's blood pressure was ,d+[DATE] mm/Hg with a pulse of 71 bpm. Review of the resident's medical record dated [DATE], at 12:31 P.M., showed a pharmacy consultant note documenting he/she completed the monthly drug regimen review and noted medication errors. The consultant called and spoke with Licensed Practical Nurse (LPN) D. The order for diltiazem should be ER 120 mg every day and Eliquis should be 2.5 mg twice per day. Consultant also emailed DON, Administrator, Assistant Director of Nursing (ADON), and MDS Coordinator to ensure error corrected and let them know they need to notify provider of medication errors. Review of the resident's facility POS, dated [DATE], showed the following: -The prior order for apixaban and diltiazem were discontinued; -An order, dated [DATE], for apixaban 2.5 mg, give 1 tablet by mouth two times a day for blood thinner; -An order dated [DATE], for diltiazem HCL ER oral tablet extended release 24-hour 120 mg, give 120 mg by mouth in the morning for blood pressure, with a start date of [DATE]. Review of the resident's [DATE] MAR showed the staff documented the following: -On [DATE], staff administered apixaban 5 mg morning dose; -On [DATE], staff did not administer the diltiazem ER 360 mg morning and noted the resident's blood pressure was ,d+[DATE] mm/Hg with a pulse of 69 bpm. Review of the resident's medical record showed staff did not document notification of the family or the physician of the medication errors. Review of the resident's medical record showed staff documented the following: -On [DATE], at 1:27 A.M., at approximately 9:50 P.M., the nurse went into the resident's room to administer medication. The nurse observed the resident lying in bed and was unable to arouse resident. The nurse checked the pulse apically (with a stethoscope at the bottom tip of the heart) for 1 minute with no pulse present. The certified nurse aide (CNA) on duty had seen the resident at approximately 7:30 P.M. alive and laying in bed. The nurse called for the other nurse on duty and told the CNA to move the resident from the bed to the floor and start CPR at approximately 9:55 P.M., while the nurse went to get the crash cart. The CNA contacted emergency medical services (EMS) at approximately 10:14 P.M. The LPN and CNA performed CPR on the resident until EMS arrived at approximately 10:22 P.M. and EMS took over CPR. EMS called the time of death at 10:42 P.M. During an interview on [DATE], at 1:15 P.M., the Pharmacy Consultant said he/she completed monthly drug reviews at the facility. He/she did not see all new resident medications at the time of admission. The review would happen at the time of the next monthly review. He/she would look at the hospital discharge when able to. When reviewing resident charts, he/she would send a fax with any non-urgent recommendations every month. He/she would call the facility with urgent recommendations. He/she noted on the resident's chart that the Eliquis dose was higher than recommended for the patient's age, but not out of maximum dosing. He/she noted the diltiazem was at an extremely high dose and the maximum dose of the medication for any diagnosis was 540 mg daily. He/she contacted LPN D about the urgent need to change the medication. The pharmacy consultant checked later that day to ensure the change was made. He/she said that side effects of that dosage could include edema, bradycardia (slow heart rate), heart arrhythmia, and decreased blood pressure. During an interview on [DATE], at 1:25 P.M., LPN D on the day the resident was admitted he/she transcribed the medications from the hospital admission history and physical instead of the hospital discharge orders. He/she did not know when the physician saw the orders. He/she did notify the physician of the resident admission orders. He/She was notified from the pharmacy consultant [DATE] of the medication order correction. He/she then corrected the orders. He/she did not notify the physician of the incorrect orders. He/she thought the DON verified the order entries, but there was currently only an Interim DON and he/she did not know if the Interim DON was auditing charts. During an interview on [DATE], at 11:00 A.M., Certified Medication Tech (CMT) A said if he/she had any concerns related to a medication order, he/she would talk to the charge nurse and the DON. If there was a medication error, it was to be reported to the charge nurse and DON. The nurse would contact the physician and the family. The resident was only at the home a short time. He/she took his/her medications without issue. When preparing and administering medications for residents he/she followed the orders in the MAR for medication administration. He/she was not aware of any medication error. During an interview on [DATE], at 11:40 A.M., LPN C said the charge nurse entered the physician orders from the hospital discharge summary and notified the physician for approval before the resident received medications. Chart audits were done by management, but he/she did not know when that was completed. The pharmacy completed a medication review at least once per month. The pharmacy would send recommendations by fax and the nursing staff notified the physician to review the recommendations and make changes according to the physician's order. If there was a medication error, staff were to complete the medication error sheet, notify the DON and the physician, and follow any physician orders. He/she was not aware of any medication errors. During an interview on [DATE], at 2:50 P.M., LPN E said that he/she usually was on the medication cart and the charge nurse was the one to enter orders for new admissions. Once the hospital sent the discharge summary the charge nurse would send it to the physician to review and to approve the orders. The nurse would enter the orders into the computer and he/she would help review the orders entered, when available. He/she said when entering orders a screen will pop up if there was a drug to drug interaction alert or other warning about the drug. The nurse had to sign off on that page when it popped up. He/she was not aware of any medication errors. During an interview on [DATE], at 11:25 A.M., Registered Nurse (RN) B said when a new resident was admitted , the charge nurse on shift should enter the hospital discharge medication orders into the computer system and notify the physician for review. He/she would send the list to the pharmacy to fill the medications. Once the admission was completed, the DON or ADON completed chart audits. If notified of a medication error, he/she would notify the physician for orders, and notify the DON and Administrator. The nurse was not aware of any medication errors. During an interview on [DATE], at 3:35 P.M., LPN H said that when he/she received a new admission, he/she would look for the hospital discharge final orders and go through the orders with the resident being admitted , if the resident was alert, and verify that they seemed familiar to the resident. He/she would then verify the orders with the physician. Once the orders were entered into the computer, he/she would put the admission packet in the medical records box and was told that a copy was given to the administration staff to verify. If he/she was aware of a medication error, he/she would notify the physician and the family. He/she would monitor the resident for 72 hours and notify the physician of any issues. He/she would complete a risk management form, like an incident report. When he/she worked, if a CMT told him/her that something looked inaccurate on the MAR, he/she would thoroughly check into and investigate. He/she said it was not uncommon for him/her to find and fix errors. He/she was not aware of the resident receiving incorrect medication doses until after the fact. During an interview on [DATE], at 4:30 P.M., LPN C and RN B both said the nurse getting the order from the physician would enter it into the electronic system in the POS. If the system detected a problem with the dosing amount/time, an allergy, or a conflict with another current medication, a warning message will pop up on the screen stating the information. The nurse should see the message before continuing. A warning symbol would then appear next to the medication on the POS. When administering medications, the warning does not pop up on the MAR, but the nurse or medication technician could check the warning box for the medication on the POS. During an interview on [DATE], at 11:50 A.M., the Interim DON said typically the charge nurse would put new physician orders into the computer and there would be a chart audit. The facility had gotten behind on chart audits. The nurse will now have the next shift nurse review the order entries because there had been some orders entered wrong. She was not aware of any outcome or medication errors due to the incorrect order entry. The resident was not expected to pass away, but was found unresponsive, CPR was initiated, and EMS contacted. She was not aware of any medication errors for resident. During an interview on [DATE], at 2:15 P.M., the Corporate Nurse said the best practice for new resident admissions would be for the charge nurse to enter the orders from the hospital discharge summary and then to reconcile once entered into the computer. Staff should ask someone else to check their data entry of the orders. The interim DON should be doing chart audits. During an interview on [DATE], at 2:40 P.M., the Medical Director said that was an awful lot of diltiazem, when told of the dose provided. He/she said that dose was not a good thing. The side effects of that dose could include showing signs of hypotension. During an interview on [DATE], at 1:55 P.M., the Administrator said when a charge nurse received a new resident admission he/she should review and enter the orders from hospital discharge summary. The physician visited with the new resident as soon as possible. She was not aware if staff were completing chart audits after new admission. The pharmacy consultant called the Corporate Nurse on [DATE] about the medication order entry for the resident. The Corporate Nurse came to the facility and went over the order entry process and medication error process with LPN D. The corrections were made to the resident's chart. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit [DATE], the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO00249050

Based on record review and interview, the facility failed to ensure a written transfer agreement with a hospital was in effect to ensure residents timely admission to the hospital when medically appropriate and that information would be exchanged between providers. This has the potential to effect all the residents. The facility census was 74. Review showed the facility did not provide a policy pertaining to written transfer agreements with a hospital or a written transfer agreement with a community hospital. During interviews on 02/10/25, at 1:30 P.M. and 2:10 P.M., the Regional Director of Operations said he/she was not aware of the federal requirement for the facility to have a written transfer agreement with a hospital. Staff could not locate a written transfer agreement with a hospital. During an interview on 02/10/25, at 2:00 P.M., the Regional Nurse Consultant (RNC) said he/she was unaware of the federal requirement for a written transfer agreement with one or more hospitals. The RNC said the facility made a determination on which hospital to send a resident to based on the specific medical condition and the hospitals had always accepted their residents. During an interview on 02/10/25, at 5:00 P.M., the Administrator said he/she had not been able to locate a written transfer agreement.

Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 07/22/20; -Diagnoses included multiple sclerosis (chronic, autoimmune disease that affects the central nervous system (brain and spinal cord)), spastic hemiplegia (paralysis or severe weakness) affecting left dominant side on the left side of the body, chronic pain syndrome, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for showering, toileting hygiene, and lower body dressing; -Resident required substantial to maximal assistance of staff for upper body dressing and personal hygiene. Review of the resident's nursing progress notes dated 03/03/25, at 5:26 P.M., showed the resident was totally dependent on staff for toileting and bathing, and substantial assistance to dependent on staff for dressing and grooming. Due to his/her impairment the resident required total assistance for mobility in bed and transfers. He/she was unable to ambulate. Review of the resident's care plan, last updated 03/17/25, showed staff did not care plan regarding the resident's need for shower assistance and his/her shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review, showed the following: -On 03/05/25, staff documented resident received a shower, fingernail care, and shaved. Staff stripped off the resident's linen, wiped down bedding, and made bed with clean linen. Staff noted no new skin concerns. A CNA and licensed practical nurse (LPN) signed the form. -On 03/18/25 (13 days after prior shower), staff documented resident received a shower and shaved. Fingernail care was not needed. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:20 A.M., showed the resident was in his/her bed. He/she said Tuesday and Friday were his/her scheduled shower days. His/her last shower was over one week ago. Before last week it had been over two weeks since his/her last shower. He/she felt terrible, dirty, and worried about smell without a shower twice per week. 2. Review of Resident #2's face sheet, showed the following: -admission date 05/08/23; -Diagnoses included atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly), glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), need for assistance with personal care, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident required partial to moderate assistance of staff for showering, toileting hygiene, lower body dressing, upper body dressing and personal hygiene. Review of the resident's care plan, updated 12/20/24, showed staff did not care plan related the resident's need for assistance with showers or shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/02/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/05/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/12/25 (seven days after prior shower), staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:25 A.M., showed the resident was seated in his/her recliner. He/she said his/her last shower was over two weeks ago. He/she was offered a shower before his/her leg was broken, but it was going to be done by a man, and he/she did not want a man to complete the shower. He/she wrote dates down when he/she a shower, but was unable to find the last date. He/she felt dirty without being shower routinely. 3. Review of Resident #3's face sheet, showed the following: -admission date 10/04/24; -Diagnoses included rhabdomylosis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, muscle weakness, pain, and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident was totally dependent on staff for toileting hygiene; -Resident required staff assistance for set up or clean up of personal hygiene; -Resident required partial to moderate assistance for upper body dressing; -Resident required substantial to maximal assistance for showering and lower body dressing. Review of the resident's care plan, updated 01/21/25, showed the following: -Resident required assistance with activities of daily living (ADL's) related to limited mobility and pain; -Resident required dependent to max assistant with shower transfers and full body showering; -Resident required max to dependent assist of two staff for transfer to/from toilet, dependent for toilet hygiene and clothing management, and incontinent care of bowels. Resident had Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and dependent for catheter care. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care was refused. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/13/25 (7 days after prior shower), staff documented resident received a shower and toenail care was not provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:52 A.M., showed the resident was in his/her wheelchair near the nursing station. The resident said he/she usually received a shower twice per week, but was unsure when he/she last received a shower. He/she really liked when he/she did receive a shower twice per week. 4. Review of Resident #4's face sheet, showed the following: -admission date 09/07/18; -Diagnoses included cerebral infarction (stroke), hemiplegia (complete paralysis on one side of the body) and hemiparesis (milder form of weakness on one side) affecting unspecified side, anxiety disorder, and chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was totally dependent on staff for toileting hygiene; -Resident required substantial to maximal assistance for showers and lower body dressing; -Resident required set up or clean up assistance from staff for upper body dressing; -Resident required supervision or touching assistance from staff for personal hygiene. Review of the resident's care plan, updated 01/21/25, staff did not care plan regarding shower assistance or the resident's shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail and toenail care provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/10/25, staff documented resident received a shower and fingernail care not needed. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/17/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/24/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:00 A.M., showed the resident in his/her room in a wheelchair. The resident said he/she was only getting one shower per week, but preferred two per week. He/she a shower this Monday, 03/24/25, but felt it was only because he/she had a doctor's appointment. He/she was embarrassed when he/she had not received a shower and especially embarrassed to go to the doctor without a shower. The shower aide was frequently being pulled to work the floor. 5. During an interview on 03/26/25, at 10:00 A.M., CNA E said that there was only one shower aide that was not working this day. He/she said very few residents were receiving two showers per week. During an interview on 03/26/25, at 1:40 P.M., CNA C said that he/she was not told that any residents needed a shower. There was one shower aide and that he/she was not working this day. The shower aide had the shower schedule. During an interview on 03/26/25, at 11:20 A.M., LPN A said residents were not receiving showers twice per week. One shower aide recently quit and there was only one shower aide for the entire facility. During an interview on 03/26/25, at 11:35 A.M., LPN B said there was currently only one shower aide in the facility, but there was no one working as a shower aide this day. The residents were not receiving two showers per week. During an interview on 03/26/25, at 1:55 P.M., LPN D said he/she knew that residents were not receiving showers twice per week. There was only one shower aide for the facility and the aide was not working this day. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said there was a recent turn over and only one full time shower aide was working. He/she called in on this day. Until another shower aide could be hired or assigned, the home planned to start having the floor aides provide showers as well. During an interview on 03/26/25, at 2:20 P.M., the Director of Nursing (DON) said the expectation was for residents to receive two showers per week and if a resident refused a shower they would have to sign the shower sheet. MO00251410, MO00251648

Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (chronic, autoimmune disease that affects the central nervous system (brain and spinal cord)), spastic hemiplegia (paralysis or severe weakness) affecting left dominant side on the left side of the body, chronic pain syndrome, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for showering, toileting hygiene, and lower body dressing; -Resident required substantial to maximal assistance of staff for upper body dressing and personal hygiene. Review of the resident's nursing progress notes dated 03/03/25, at 5:26 P.M., showed the resident was totally dependent on staff for toileting and bathing, and substantial assistance to dependent on staff for dressing and grooming. Due to his/her impairment the resident required total assistance for mobility in bed and transfers. He/she was unable to ambulate. Review of the resident's care plan, last updated 03/17/25, showed staff did not care plan regarding the resident's need for shower assistance and his/her shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review, showed the following: -On 03/05/25, staff documented resident received a shower, fingernail care, and shaved. Staff stripped off the resident's linen, wiped down bedding, and made bed with clean linen. Staff noted no new skin concerns. A CNA and licensed practical nurse (LPN) signed the form. -On 03/18/25 (13 days after prior shower), staff documented resident received a shower and shaved. Fingernail care was not needed. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:20 A.M., showed the resident was in his/her bed. He/she said Tuesday and Friday were his/her scheduled shower days. His/her last shower was over one week ago. Before last week it had been over two weeks since his/her last shower. He/she felt terrible, dirty, and worried about smell without a shower twice per week. 2. Review of Resident #2's face sheet, showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly), glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), need for assistance with personal care, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident required partial to moderate assistance of staff for showering, toileting hygiene, lower body dressing, upper body dressing and personal hygiene. Review of the resident's care plan, updated 12/20/24, showed staff did not care plan related the resident's need for assistance with showers or shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/02/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/05/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/12/25 (seven days after prior shower), staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:25 A.M., showed the resident was seated in his/her recliner. He/she said his/her last shower was over two weeks ago. He/she was offered a shower before his/her leg was broken, but it was going to be done by a man, and he/she did not want a man to complete the shower. He/she wrote dates down when he/she a shower, but was unable to find the last date. He/she felt dirty without being shower routinely. 3. Review of Resident #3's face sheet, showed the following: -admitted [DATE]; -Diagnoses included rhabdomylosis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, muscle weakness, pain, and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident was totally dependent on staff for toileting hygiene; -Resident required staff assistance for set up or clean up of personal hygiene; -Resident required partial to moderate assistance for upper body dressing; -Resident required substantial to maximal assistance for showering and lower body dressing. Review of the resident's care plan, updated 01/21/25, showed the following: -Resident required assistance with activities of daily living (ADL's) related to limited mobility and pain; -Resident required dependent to max assistant with shower transfers and full body showering; -Resident required max to dependent assist of two staff for transfer to/from toilet, dependent for toilet hygiene and clothing management, and incontinent care of bowels. Resident had Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and dependent for catheter care. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care was refused. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/13/25 (7 days after prior shower), staff documented resident received a shower and toenail care was not provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:52 A.M., showed the resident was in his/her wheelchair near the nursing station. The resident said he/she usually received a shower twice per week, but was unsure when he/she last received a shower. He/she really liked when he/she did receive a shower twice per week. 4. Review of Resident #4's face sheet, showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), hemiplegia (complete paralysis on one side of the body) and hemiparesis (milder form of weakness on one side) affecting unspecified side, anxiety disorder, and chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was totally dependent on staff for toileting hygiene; -Resident required substantial to maximal assistance for showers and lower body dressing; -Resident required set up or clean up assistance from staff for upper body dressing; -Resident required supervision or touching assistance from staff for personal hygiene. Review of the resident's care plan, updated 01/21/25, staff did not care plan regarding shower assistance or the resident's shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail and toenail care provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/10/25, staff documented resident received a shower and fingernail care not needed. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/17/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/24/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:00 A.M., showed the resident in his/her room in a wheelchair. The resident said he/she was only getting one shower per week, but preferred two per week. He/she a shower this Monday, 03/24/25, but felt it was only because he/she had a doctor's appointment. He/she was embarrassed when he/she had not received a shower and especially embarrassed to go to the doctor without a shower. The shower aide was frequently being pulled to work the floor. 5. During an interview on 03/26/25, at 10:00 A.M., CNA E said that there was only one shower aide that was not working this day. He/she said very few residents were receiving two showers per week. During an interview on 03/26/25, at 1:40 P.M., CNA C said that he/she was not told that any residents needed a shower. There was one shower aide and that he/she was not working this day. The shower aide had the shower schedule. During an interview on 03/26/25, at 11:20 A.M., LPN A said residents were not receiving showers twice per week. One shower aide recently quit and there was only one shower aide for the entire facility. During an interview on 03/26/25, at 11:35 A.M., LPN B said there was currently only one shower aide in the facility, but there was no one working as a shower aide this day. The residents were not receiving two showers per week. During an interview on 03/26/25, at 1:55 P.M., LPN D said he/she knew that residents were not receiving showers twice per week. There was only one shower aide for the facility and the aide was not working this day. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said there was a recent turn over and only one full time shower aide was working. He/she called in on this day. Until another shower aide could be hired or assigned, the home planned to start having the floor aides provide showers as well. During an interview on 03/26/25, at 2:20 P.M., the Director of Nursing (DON) said the expectation was for residents to receive two showers per week and if a resident refused a shower they would have to sign the shower sheet. MO00251410, MO00251648

Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations; -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe; -The Director of Nursing (DON) and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications; -Only authorized, licensed nursing and pharmacy personnel have access to controlled medications; -Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents; -The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident if the facility so desires; -Alternatively, the facility may utilize a bound book in place of count sheets; -The following information is completed up dispensing or upon receipt of the controlled substance: resident's name, prescription number, drug name, strength, and dosage for of medication, date received, quantity received, and the name of person receiving the medication supply; -If the facility uses a bound book in lieu of the pharmacy count sheets, all of this information will be completed by a licensed nurse at the facility; -At each change of custody (shift change or exchange of keys) all on-hand controlled medication quantities shall be counted by two nurses and reconciled with the count sheets; -This shall be documented by completing a Controlled Drug Count Form indicating the date and time the physical count was completed; -Any discrepancies shall be reported to the charge nurse and the DON immediately; -With the nurse supervisor present, the discovering nurse should place a signed entry on the resident controlled drug record where the discrepancy was detected; -If it is something other than a mathematical error, the DON should provide assistance with the investigation and resolving the discrepancy; -Controlled substance medications are stored at the facility under double lock on the medication cart or medication room separate from all other medications. 1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included rhabdomyolysis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, pain, muscle weakness, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of the resident's care plan, dated 10/18/24, showed the following: -Resident received as needed pain medication therapy related to rhabdoymyolysis, rib fractures, and occasional generalized pain; -Staff should administered analgesic (pain) medications as ordered by physician; -Staff should monitor and document side effects and effectiveness every shift; -Staff should notify physician if medication does not control pain to tolerable level. Review of the resident's Physician Order Sheet (POS), current as of 03/26/25, showed an order, dated 10/04/24, for morphine sulfate ER (drug used to treat moderate to severe pain), oral tablet extended release 30 milligrams (mg), give one tablet by mouth two times per day for multiple fracture of ribs. Review of the resident's March 2024 Medication Administration Record (MAR), showed staff documented administration of morphine sulfate ER 30 mg every day in the morning and at bedtime from 03/01/25 to 03/26/25. Review of the pharmacy consolidated delivery sheets, dated 03/10/25, showed morphine sulfate ER 30 mg tablets, quantity of 60 tablets, received for the resident. Review of the controlled medication logbook on the medication cart showed the following: -On 03/10/25, staff documented there was 9 tablets of morphine sulfate and the pharmacy delivered 60 tabs. The total at the end of shift was 69 tablets; -On 03/16/25, the resident had 57 tablets of morphine sulfate. When the evening shift completed the change of shift count there were only 27 tablets of morphine sulfate in the cart; -On 03/24/25, the pharmacy delivered 30 tablets of morphine sulfate; -On 03/26/25, at 1:55 P.M., there were 38 tablets of morphine sulfate in the cart when reviewed with nurse. Review of the facility's Investigation Report, dated 03/18/25, showed the following information: -On 03/16/25, at 10:10 P.M., the Administrator received a call from Licensed Practical Nurse (LPN) B that the narcotic count for the resident showed there was 30 tablets of morphine sulfate missing; -Staff searched the medication cart and medication room. The medication was not located; -Police department notified on 03/17/25; -Notified pharmacy to report and request they send replacement for the missing medication and to bill the facility; -LPN F's statement, dated 03/16/25, showed the LPN worked 4 1/2 hour shift, from 5:30 P.M. to 10 P.M. The nurse was rushing during the count at the beginning of shift and was unsure if the count was actually correct at that time; -LPN A's statement, dated 03/17/25, showed he/she counted medications on beginning of shift on 03/15/25 evening and end of shift on 03/16/25 morning. The count was correct at those time. When he/she worked the day shift on 03/17/25, he/she was informed by the night shift nurse that the count was off by 30 tablets. During an interview on 03/26/25, at 10:45 A.M., LPN A said the narcotic count was completed at the beginning and end of every shift. If the count was incorrect staff should notify the DON and administrator immediately. During an interview on 03/26/25, at 11:35 A.M., LPN B said the process for narcotics included the off-going nurse taking the narcotic book and the on-coming nurse taking the narcotic drawer to complete the shift count. Staff start by going through all of the tablets and then they count the liquids. If the narcotic count was not correct staff were to immediately contact the supervisor and staff do not leave the facility until the supervisor approved. During an interview on 03/26/25, at 1:55 P.M., LPN D said that if the log and tablets do not match during shift change, staff are to call management and have to stay at the facility until approved to leave. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said staff should complete a narcotic count during each shift change. If an error was found, staff were to contact management immediately. During an interview on 03/26/25, at 2:20 P.M., the DON said she expected the staff to follow facility policy. During an interview on 03/26/25, at 2:40 P.M., the Administrator said when she was notified of narcotic count discrepancy on 03/16/25 around 10:00 P.M. by LPN B. The medication cart and medication room were searched, and the narcotic was not located. The nursing staff did not have any knowledge of where the narcotics could be. The Administrator expected staff to complete narcotic counts accurately with every shift change. If the count was not accurate the staff were to notify the DON and Administrator immediately for further instructions. MO00251335

Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations; -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe; -The Director of Nursing (DON) and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications; -Only authorized, licensed nursing and pharmacy personnel have access to controlled medications; -Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents; -The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident if the facility so desires; -Alternatively, the facility may utilize a bound book in place of count sheets; -The following information is completed up dispensing or upon receipt of the controlled substance: resident's name, prescription number, drug name, strength, and dosage for of medication, date received, quantity received, and the name of person receiving the medication supply; -If the facility uses a bound book in lieu of the pharmacy count sheets, all of this information will be completed by a licensed nurse at the facility; -At each change of custody (shift change or exchange of keys) all on-hand controlled medication quantities shall be counted by two nurses and reconciled with the count sheets; -This shall be documented by completing a Controlled Drug Count Form indicating the date and time the physical count was completed; -Any discrepancies shall be reported to the charge nurse and the DON immediately; -With the nurse supervisor present, the discovering nurse should place a signed entry on the resident controlled drug record where the discrepancy was detected; -If it is something other than a mathematical error, the DON should provide assistance with the investigation and resolving the discrepancy; -Controlled substance medications are stored at the facility under double lock on the medication cart or medication room separate from all other medications. 1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admission date of 10/04/24; -Diagnoses included rhabdomyolysis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, pain, muscle weakness, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of the resident's care plan, dated 10/18/24, showed the following: -Resident received as needed pain medication therapy related to rhabdoymyolysis, rib fractures, and occasional generalized pain; -Staff should administered analgesic (pain) medications as ordered by physician; -Staff should monitor and document side effects and effectiveness every shift; -Staff should notify physician if medication does not control pain to tolerable level. Review of the resident's Physician Order Sheet (POS), current as of 03/26/25, showed an order, dated 10/04/24, for morphine sulfate ER (drug used to treat moderate to severe pain), oral tablet extended release 30 milligrams (mg), give one tablet by mouth two times per day for multiple fracture of ribs. Review of the resident's March 2024 Medication Administration Record (MAR), showed staff documented administration of morphine sulfate ER 30 mg every day in the morning and at bedtime from 03/01/25 to 03/26/25. Review of the pharmacy consolidated delivery sheets, dated 03/10/25, showed morphine sulfate ER 30 mg tablets, quantity of 60 tablets, received for the resident. Review of the controlled medication logbook on the medication cart showed the following: -On 03/10/25, staff documented there was 9 tablets of morphine sulfate and the pharmacy delivered 60 tabs. The total at the end of shift was 69 tablets; -On 03/16/25, the resident had 57 tablets of morphine sulfate. When the evening shift completed the change of shift count there were only 27 tablets of morphine sulfate in the cart; -On 03/24/25, the pharmacy delivered 30 tablets of morphine sulfate; -On 03/26/25, at 1:55 P.M., there were 38 tablets of morphine sulfate in the cart when reviewed with nurse. Review of the facility's Investigation Report, dated 03/18/25, showed the following information: -On 03/16/25, at 10:10 P.M., the Administrator received a call from Licensed Practical Nurse (LPN) B that the narcotic count for the resident showed there was 30 tablets of morphine sulfate missing; -Staff searched the medication cart and medication room. The medication was not located; -Police department notified on 03/17/25; -Notified pharmacy to report and request they send replacement for the missing medication and to bill the facility; -LPN F's statement, dated 03/16/25, showed the LPN worked 4 ½ hour shift, from 5:30 P.M. to 10 P.M. The nurse was rushing during the count at the beginning of shift and was unsure if the count was actually correct at that time; -LPN A's statement, dated 03/17/25, showed he/she counted medications on beginning of shift on 03/15/25 evening and end of shift on 03/16/25 morning. The count was correct at those time. When he/she worked the day shift on 03/17/25, he/she was informed by the night shift nurse that the count was off by 30 tablets. During an interview on 03/26/25, at 10:45 A.M., LPN A said the narcotic count was completed at the beginning and end of every shift. If the count was incorrect staff should notify the DON and administrator immediately. During an interview on 03/26/25, at 11:35 A.M., LPN B said the process for narcotics included the off-going nurse taking the narcotic book and the on-coming nurse taking the narcotic drawer to complete the shift count. Staff start by going through all of the tablets and then they count the liquids. If the narcotic count was not correct staff were to immediately contact the supervisor and staff do not leave the facility until the supervisor approved. During an interview on 03/26/25, at 1:55 P.M., LPN D said that if the log and tablets do not match during shift change, staff are to call management and have to stay at the facility until approved to leave. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said staff should complete a narcotic count during each shift change. If an error was found, staff were to contact management immediately. During an interview on 03/26/25, at 2:20 P.M., the DON said she expected the staff to follow facility policy. During an interview on 03/26/25, at 2:40 P.M., the Administrator said when she was notified of narcotic count discrepancy on 03/16/25 around 10:00 P.M. by LPN B. The medication cart and medication room were searched, and the narcotic was not located. The nursing staff did not have any knowledge of where the narcotics could be. The Administrator expected staff to complete narcotic counts accurately with every shift change. If the count was not accurate the staff were to notify the DON and Administrator immediately for further instructions. MO00251335

Based on record review and interview, the facility failed to provide care that met professional standards quality for one resident (Resident #2) from a sample of 13 residents. Facility staff failed to accurately transcribe the resident's physician orders on admission. The facility census was 74. Review of the facility policy titled Administering Medications, dated April 2019, showed the following: -The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions; -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns; -Each nurses' station has a current Physician's Desk Reference (PDR - comprehensive reference book that compiles information about prescription drugs available, including details like dosage, side effects, and indications) and/or other medication reference; -Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. Review of the facility's checklist titled Admission Checklist, undated, showed the following: -Admission medications verified by physician and pharmacy notified; -Orders entered correctly; -Admitting nurse and date; -Items requiring follow-up; -Nurse completing form and date. Review of Resident #2's face sheet (a brief information sheet about the resident), showed the following: -admitted [DATE]; -Diagnoses included aftercare following joint replacement surgery (post-operative care and monitoring that a patient receives after undergoing a joint replacement procedure), osteoarthritis (type of arthritis (painful inflammation and stiffness of the joints that occurs when flexible tissue at the ends of bones wears down) of left knee, and osteoporosis (condition in which bones have lost minerals-especially calcium-making them weaker, more brittle, and susceptible to fractures (broken bones)). Review of the resident's baseline care plan, dated 01/24/25, showed staff noted see physician orders for medications. Review of the resident's hospital discharge summary, dated 01/24/25, showed an order for alendronate (used to prevent and treat osteoporosis), 70 milligrams (mg) by mouth, one tablet every seven days. Review of the resident's Physician Order Sheet (POS), dated 01/31/25, showed an order, dated 01/24/25, for alendronate sodium oral tablet 70 mg, give one tablet by mouth in the morning for osteoporosis related to unilateral primary osteoarthritis, left knee. Review of the resident's medical record showed the following: -On 01/24/25, at 2:26 P.M., a system note showed alendronate sodium oral tablet 70 mg, give one tablet by mouth in the morning for osteoporosis related to primary osteoarthritis of left knee was outside of the recommended dose or frequency. The dosing regimen of 1 tablet daily exceeded the usual dosing regimen of 0.5 tablet every 7 days to 0.67 tablet daily. Review of the resident's medical record showed staff did not document addressing the system notice related to the medication dosage. Review of the resident's medical record showed an administration note date 01/25/25, at 9:45 A.M., showed alendronate 70 mg, give one tablet in the morning for osteoporosis related to primary osteoarthritis of left knee was not available and nurse notified. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -On 01/25/25, staff documented alendronate was not administered due to medication not available; -On 01/26/25, staff documented alendronate was not administered due medication not available; Review of the resident's Physician Order Sheet (POS), dated 01/31/25, showed the prior order for alendronate was discontinued. A new order, dated 01/27/25, with start date of 02/02/25, for alendronate sodium oral tablet 70 mg, give one tablet in the morning every one week on Sunday. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -On 01/27/25, staff documented the alendronate was administered. During an interview on 02/06/25, at 11:00 A.M., Certified Medication Tech (CMT) A said if he/she had any concerns related to a medication order, he/she would talk to the charge nurse and the DON. If there was a medication error, it was to be reported to the charge nurse and DON. The nurse would contact the physician and the family. When preparing and administering medications for residents he/she followed the orders in the MAR for medication administration. During an interview on 02/06/25, at 11:40 A.M., Licensed Practical Nurse (LPN) C said the charge nurse entered physician orders from the hospital discharge summary and notified the physician for approval before residents received medications. Chart audits were done by management, but he/she did not know when that was completed. The pharmacy completed a medication review at least once per month. The pharmacy would send recommendations by fax and the nursing staff notified the physician to review the recommendations and make changes according to the physician's order. If there was a medication error, staff was to complete the medication error sheet, notify the DON and the physician, and follow any physician orders. During an interview on 02/10/25, at 2:50 P.M., LPN E said that he/she usually was on the medication cart and the charge nurse was the one to enter orders for new admissions. There was a new admission checklist. Once the hospital sent the discharge summary, the charge nurse would send it to the physician to review and approve orders. The nurse would enter and he/she would help review the orders entered when available. He/she said when entering orders a screen will pop up if there was a drug to drug interaction alert or other warning about the drug. The nurse had to sign off on that page when it popped up. During an interview on 02/06/25, at 11:25 A.M., Registered Nurse (RN) B said when a new resident was admitted , the charge nurse on shift should enter the hospital discharge medication orders in the computer system and notify the physician for review. He/she would send the list to the pharmacy to fill the medications. Once the admission was completed the DON or Assistant Director of Nursing completed chart audits. If notified of a medication error, he/she would notify the physician for orders, and notify the DON and Administrator. During an interview on 02/11/25, at 3:35 P.M., LPN H said when he/she received a new admission, he/she would look for the hospital discharge final orders and go through the orders with the resident being admitted if the resident was alert, and verify that they seemed familiar to the resident. He/she would then verify the orders with the physician. Once the orders were entered into the computer, he/she would put the admission packet in the medical records box and was told that a copy was given to the administration staff to verify. If he/she was aware of a medication error, he/she would notify the physician and the family. He/she would monitor the resident for 72 hours and notify the physician of any issues. He/she would complete a risk management form, like an incident report. When he/she worked, if a CMT told him/her that something looked inaccurate on the MAR, he/she would thoroughly check into and investigate. He/she said it was not uncommon for him/her to find and fix errors. During an interview on 02/10/25, at 4:30 P.M., LPN C and RN B both said the nurse getting the order from the physician would enter it into the electronic system onto the POS. If the system detected a problem with the dosing amount/time, an allergy, or a conflict with another current medication, a warning message will pop up on the screen stating the information. The nurse should see the message before continuing. A warning symbol would then appear next to the medication on the POS. When administering medications, the warning does not pop up on the MAR, but the nurse or medication technician could check the warning box for the medication on the POS. During an interview on 02/06/25, at 11:50 A.M., the Interim DON said typically the charge nurse would put new physician orders into the computer and there would be a chart audit. The facility had gotten behind on chart audits. The nurse will now have the next shift nurse review the order entries because there had been some orders entered wrong. She was not aware of any outcome or medication errors due to the incorrect order entry. During an interview on 02/06/25, at 2:15 P.M., the Corporate Nurse said the best practice for new resident admissions would be for the charge nurse to enter the orders from the hospital discharge summary and then to reconcile once entered into the computer. Staff should ask someone else to check their data entry of the orders. The interim DON should be doing chart audits. During an interview on 02/06/25, at 1:55 P.M., the Administrator said when a charge nurse received a new resident admission he/she should review and enter the orders from hospital discharge summary. The physician visited with the new resident as soon as possible. She was not aware if staff were completing chart audits after new admission. There had been three DONs in the past four months. MO00249050

Based on interview and record review, the facility failed to maintain an effective infection control program including screening all staff for tuberculosis (TB - a contagious infection that usually attacks the lungs) as required when the facility failed to ensure the first and second step of the two-step tuberculin skin test (TST) was completed prior resident contact for three staff members (Registered Nurse (RN) A, Certified Medication Tech (CMT) B, and Licensed Practical Nurse (LPN) C), failed to ensure the TB test was read within 48 to 72 hours from placement for one staff (CMT B), and failed to complete a second step TB test for one staff (RN A), of 10 sampled staff members. The facility census was 67. Review of the facility policy Employee Screening for Tuberculosis, dated March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI - infected with TB but not active TB) and active tuberculosis disease, using tuberculin skin test or interferon gamma release assay (IGRA - blood test to determine if exposed to TB) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; -Screening includes a baseline test for LTBI using either a TST or IGRA, individual risk assessment, and symptom evaluation; -If the baseline test is negative and the individual risk assessment indicates no risk factors for acquiring TB, then no additional screening is indicated; -If the baseline test is positive, but the individual risk assessment is negative and the individual is asymptomatic, a second test is conducted; -The employee health coordinator will accept documented verification of TST or IGRA results within the preceding 12 months. Review of the Center for Disease Control (CDC) Guidelines, dated 04/10/24, title Tuberculosis Skin Test, showed the following: -The tuberculin skin test is one method of determining whether a person is infected with mycobacterium tuberculosis (the specific bacteria that causes tuberculosis); -It is performed by injecting 0.1 milliliter (ml) of tuberculin purified protein derivative (PPD) into the inner surface of the forearm; -The skin test reaction should be read between 48 and 72 hours after administration by a health care worker trained to read TST results; -A patient who does not return within 72 hours will need to be rescheduled for another skin test. Review of 19 CSR 20-20.100 showed the following: -Long-term care employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two)-step tuberculin test within one month prior to starting employment in the facility. -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 1. Review of RN A's personnel record showed the following: -Date of hire of 08/01/23; -The first step TB test was administered on 08/02/23 and read on 08/04/23 (three days after the RN's hire/start date). -Staff did not document a second step administered or a prior history of prior test in the prior two years. 2. Review of CMT B's personnel record showed the following: -Date of hire of 05/31/23; -The first step TB test was administered on 05/31/23 and read on 06/01/23 (24 hours later and after the CMT's hire/start date). -The second step TB test was administered on on 06/14/23 and read on 06/16/23. 3. Review of LPN C's personnel record showed the following: -Date of hire of 12/19/23; -The first step TB test was administered on 02/06/24 and read on 02/09/24 (a month and a half after the LPN's hire/start date). -The second step TB test was administered on 02/16/24 and read on 02/19/24. -Staff did not document other TB testing documented in the preceding two years. 4. During an interview on 09/17/24, at 12:45 P.M., LPN D said that newly hired staff have TB testing placed and read by the nursing staff. The TB test should be read 48 to 72 hours after placement for accurate results. 5. During an interview on 09/17/24, at 2:00 P.M., LPN E said that newly hired staff have TB placed and read by the one of the nurses. The TB test is read 48 to 72 hours after placement and a second step is then repeated 10 days after the reading of the first step. 6. During an interview on 09/17/24, at 2:15 P.M., the Director of Nursing (DON) and Regional Nurse Consultant (RNC), the RNC said that new hire TB testing should be started before staff can work on the floor with residents. The TB test is generally read 24 to 48 hours after placement and a second test is completed one to two weeks after the first step. 7. During an interview on 09/17/24, at 2:35 P.M., with the Administrator and Interim Administrator, the Interim Administrator said staff should have TB testing on hire, with the first step completed before working with residents. The TB test should be read 48 to 72 hours after placement and the second step should be done within 21 days. The facility did not have additional test results documented for the reviewed staff.

Based on interview and record review, the facility failed to implement an effective grievance process when staff failed to ensure all grievances included documentation of a full investigation, of a final decision, and of follow-up regarding findings with the resident who filed the grievance. Review of the facility policy Grievances/Complaints, Recording and Investigating, dated 2021, showed the following: -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. -The investigation and report will include the circumstances surrounding the alleged incident, the names of any witnesses and their accounts of the alleged incident, the resident's account of the alleged incident, and recommendations for corrective action. 1. Review of the Grievance/Complaint Report, dated 04/29/24, showed the following: -Resident stated the night shift Certified Nurse Aide (CNA) 4 was rough when doing cares and transfers. -Staff spoke to CNA 4 about his/her behavior and educated him/her on customer service. CNA 4 with issues at home. Explained that home problems must be left at the door. CNA 4 verbally agreed that he/she understood the education given. Staff will continue to monitor CNA 4 behavior with residents. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 2. Review of the Grievance/Complaint Report, dated 05/03/24, showed the following: -Resident stated that staff member, CNA 4, was rude and hateful on night shift. -Staff spoke to CNA 4 and reminded him/her that resident can often recognize and feel when they are rushed and have personal frustrations. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 3. Review of the Grievance/Complaint Report, dated 07/11/24, showed the following: -Resident stated that night shift CNA 4 was rude and rough and he/she did not want him/her in his/her room or providing cares for him/her. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 4. Review of the Grievance/Complaint Report, dated 08/09/24, showed the following: -Resident stated staff member CNA 4 was very rough when doing cares. -Director of Nursing (DON) educated staff on proper customer service and transferring technique when doing cares. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 5. Review of the Grievance/Complaint Report, dated 08/09/24, showed the following: -Resident stated staff (CNA 4) was very rough. Resident said he/she just jerks me around. Resident also stated that employee was rude and hateful. -Staff educated employee to announce to resident before he/she starts any cares and to practice good customer service skills. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 6. During an interview on 09/03/24, at 3:15 PM, the Regional Operations Director (ROD), Regional Nurse Consultant (RNC) 2 and the Administrator reviewed the grievance forms related to CNA 4. The Administrator said when education was completed it was completed verbally and nothing was documented. The RNC agreed the current documentation was not enough to ensure the grievance was resolved.

Based on observation, interview, and record review, interview, the facility failed to develop and implement complete and accurate care plans for all residents when staff failed to ensure five residents' (Resident #36, #42, #3, #1, and #4), of 27 residents reviewed, care plans addressed all appropriate care areas. Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated 03/2022, showed the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive person-centered care plan included measurable objectives and timeframes, resident's stated goals upon admission, and desired outcome. 1. Review of Resident #36's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 07/04/24 and located under the MDS tab of the EMR, showed the following: -The resident had no cognitive impairment; -The resident received antidepressant and antipsychotics on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR and dated 08/12/24, showed the following: -An active order for buspirone (an antidepressant medication) 15 milligrams (mg) tab, three times daily for anxiety disorder; -An active order for quetiapine (an antipsychotic medication) 50 mg, once daily for major depressive disorder. Review of the resident's Care Plan, located under the Care Plan tab of the EMR dated 03/14/24, showed staff did not care plan related to the resident's psychotropic medication use. During an interview on 09/05/24, at 12:35 P.M., the MDS Coordinator (MDSC)/Director of Nursing (DON) said the resident's medications should have been care planned. She said any type of psychotropic medication should have their own care plan with interventions. 2. Review of Resident #42's Face Sheet, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), alcohol abuse, and opioid dependence. Review of the resident's annual MDS, with an ARD of 09/18/23 and located under the MDS tab of the EMR, showed the following: -Resident had no cognitive impairment; -Resident received antidepressant and antianxiety medication on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR, showed an active order for fluoxetine (an antidepressant medication) 40 mg tab, once daily. Review of the resident's Care Plan, located under the Care Plan tab of the EMR and dated 03/14/24, showed staff did not care plan related to the resident's psychotropic medication use. During an interview on 09/05/24, at 12:35 P.M., the MDSC/DON said the resident's medications should have been care planned. She said any type of psychotropic medication should have their own care plan with interventions. 35690 3. Review of Resident #3's Admission Record, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included major depressive disorder, anxiety disorder, and Alzheimer's Disease. Review of the resident's MDS, with an ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident was severely cognitively impaired; -The resident received antidepressant and antipsychotic medication for seven of seven days during the look back review period. Review of the resident's Medication Administration Record (MAR), dated 09/2024, located in the EMR under the Orders tab, showed the following: -The resident received citalopram (an antidepressant) 10 mg, daily for major depressive disorder; -The resident received olanzapine (an antipsychotic) 2.5 mg, daily for an anxiety disorder. Review of the resident's comprehensive Care Plan, updated 08/17/24, showed the following: -Staff did not care plan related to the resident's diagnoses of major depressive disorder, anxiety, or Alzheimer's Disease; -Staff did not care plan related to the resident's use of an antidepressant. During an interview on 09/04/24, at 12:42 PM, the DON/MDSC said there should be a care plan for each psychotropic medication and each diagnosis the resident had. The DON agreed that the resident did not have a care plan for the use of an antidepressant, a major depression diagnosis, a diagnosis of Alzheimer's Disease, or a diagnosis of anxiety. 36246 4. Review of Resident #1's Admission Record, in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included of chronic allergic conjunctivitis (inflammation of the conjunctiva from infection or allergies). Review of the resident's Progress Note, dated 04/16/24 found in the EMR under the Progress Note tab, showed the resident had left side effect from previous CVA (cerebral vascular accident or stroke) that limited his/her range of motion (ROM) to his/her upper extremity. Review of the resident's quarterly MDS, with an ARD of 06/05/24, showed the resident had limited ROM to the upper and lower extremities on one side. Review of the resident's Physician's Orders, in the EMR under the Orders tab, showed the following: -An order, dated 07/29/24, for Pataday Ophthalmic Solution 0.1 % (olopatadine HCl), instill one drop in both eyes one time a day for chronic allergic conjunctivitis. Observation and interview on 09/02/24, at 4:14 P.M., showed the resident had a contracture of the left wrist. The resident said it was the result of a stroke. Review of the the resident's current Care Plan, in the EMR under the Care Plan tab showed staff did not care plan related to the resident's chronic allergic conjunctivitis or his left wrist contracture. During an interview on 09/04/24, at 4:37 P.M., the DON/MDSC said confirmed staff did not care plan the above concerns for the resident. 5. Review Resident #4's Admission Record, in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve) and dry eye syndrome. Review of the resident's annual MDS, with an ARD of 05/30/24 found in the EMR under the MDS tab, showed the following: -The resident had moderate difficulty with her hearing and was moderately impaired for her vision. -The resident received anti-anxiety and anti-depressant medications. During an interview on 09/02/24, at 4:08 P.M., the resident said he/she had a detached retina in the right eye making him/her blind in that eye and he/she was hard of hearing in the left ear. Review of the resident's Care Plan, in the EMR under the Care Plan tab, showed staff did not care plan related to the resident's hearing, vision, or for the use of anti-anxiety and anti-depressant medications. During an interview on 09/04/24, at 4:37 P.M., the DON/MDSC said confirmed staff did not care plan the above concerns for the resident. 6. During an interview on 09/05/24, at 12:35 P.M., the MDSC/DON said staff would let her know after a new care area was identified or if they noticed that something was not on the care plan. 7. During an interview on 09/05/24, at 3:57 P.M., the Administrator said that all regulations should be followed. She said the care plan should be specific to the needs of the residents and updated timely.

Based on record review and interview, the facility failed to provide effective pain management for all residents when the facility failed to ensure four of four residents (Resident #57, #32, #18 and #7) had pain medication available to be administered as ordered at all times. Review of the facility policy titled, Pharmacy and Medication Administration, undated, showed the following: -The emergency medication kit is refilled by the pharmacy; -The facility will have a clear practice about reordering of medication. lf the medication nurse or CMT (Certified Medication Tech) does not pull the labels to reorder the medications during their med pass, they may not be available when needed. Review of the facility policy titled, Emergency Kit System/With Controlled Substances (E-Kit), dated March 2015, showed the following: -The E-kit will be replaced after it has been opened and the pharmacy notified. -Replacement of the entire E-Kit will be done on the next scheduled delivery. -Remove the item/s needed. Remove enough of the medication to last until the order is filled and can be delivered. -lf for some reason the E-Kit is not exchanged at the next delivery, again call the pharmacy during regular business hours. -The facility is responsible to notify the pharmacy if the E-Kit is not delivered as expected. 1. Review of Resident #57's Admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included pain and fibromyalgia (musculoskeletal pain). Review of the resident's Minimum Data Set (MDS - a federally mandated assessment completed by facility staff ), with an Assessment Reference Date (ARD) of 05/15/24, located in the EMR under the MDS tab, showed the following: -The resident had no cognitive impairment. -The resident received scheduled and PRN (as needed) pain medications during the five day look back period, -The resident had occasional pain frequency and pain occasionally affected her sleep. -The resident rated the pain as a seven out of 10 (with one being no pain and 10 being the worse pain). Review of the resident's pain Care Plan, updated 11/11/23, showed the following: -Resident was experiencing the presence of occasional pain; -Interventions included teaching distraction techniques, resting after receiving pain medication, monitoring worsening of pain symptoms, notifying physician of changes, and assessing pain daily using the 1 to 10 scale. Review of the resident's August 2024 Medication Administration Record (MAR), located in the EMR under the Orders tab, showed the following: -A current order for tramadol (an opioid pain medication) 50 mg (milligrams), three times a day for pain; -A current order for acetaminophen 325 mg, two tablets every four hours as needed for general discomfort; -A current order to assessed for pain every shift. -The resident did not receive his/her tramadol or acetaminophen on 08/31/24 during the evening medication administration. The resident rated his/hr pain as a seven. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, dated 08/27/24,showed Licensed Practical Nurse (LPN) 1 notified the physician by voice mail that the resident was out of tramadol. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, dated 08/28/24, showed LPN 1 contacted the pharmacy to follow-up on the resident's tramadol. The LPN was informed the pharmacy was waiting for the order from the physician. Review of the resident's September 2024 MAR, located in the EMR under the Orders tab, showed the following: -The resident did not receive his/her tramadol on 09/01/24 during the evening medication administration. The resident rated his/her pain as a seven at 6:00 PM. -The resident did not receive all three doses of tramadol on 09/02/24. The resident rated his/her pain as an eight. -The resident did not received all three doses of tramadol on 09/03/24. The resident rated his/her pain as a seven. Review of the facility E-kit forms showed four tramadol 50 mg were removed for the resident on 08/27/24. Two tramadol were removed for the resident 08/28/24 and 08/30/24. The pharmacy was noted to have been sent a fax on 08/31/24. During an interview on 09/02/24, at 2:58 P.M., the resident the resident said he/she had not received his/her tramadol over the weekend because the facility ran out. The facility had called the doctor, but they had not received it yet. He/she had been taking Tylenol (acetaminophen) and gabapentin (can be used to treat neuropathic pain) which was somewhat effective. The resident said he/she noticed the difference between tramadol and Tylenol and he/she was hurting more without the tramadol. During an interview on 09/04/24, at 3:14 PM, LPN 5 said he/she would order medication when the medication card indicated the resident had seven days of medication left. At this time the physician should be notified. If he/she didn't get any results the day after calling the physician, he/she would call the next day. LPN 5 said medication was delivered at night, so nurses knew they needed to call by 4:00 P.M. to have it delivered that day. On 09/01/24, there was no tramadol on the medication cart or in the E-kit. There was also no one to call to receive more medication. He/she thought there was a backup pharmacy for the facility, but he/she was not sure who it was. He/she confirmed he/she had not called the physician to see if she could give the resident something else for pain. 2. Review of Resident #32's Admission Record, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnosis included chronic pain. Review of the resident's quarterly MDS, with ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident was severely cognitively impaired. -The resident received scheduled and PRN pain medications during the five day look back period. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the resident had an active order for tramadol 50 mg, two tablets two times a day for chronic pain syndrome. Review of the facility's E-kit forms provided showed four tramadol 50 mg were removed for the resident on 08/27/24. Four tramadol 50 mg were removed for the resident on 08/31/24. The pharmacy was noted to have been sent a fax on 08/31/24. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident had an active order for tramadol 50 mg, two tablets two times a day for chronic pain syndrome; -The resident missed his/her medication twice on 09/01/24, once on 09/02/24, and twice on 09/03/24; -Staff did not document notification of the resident's physician about the resident being out of tramadol, or of any non-pharmacological interventions were attempted. 3. Review of Resident #18's Admission Record, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included of chronic pain syndrome. Review of the resident's quarterly MDS, with ARD of 06/19/24, located in the EMR under the MDS tab, showed the following : -The resident was moderately cognitively impaired. -The resident received scheduled pain medications during the five day look back period. -A pain assessment interview should be conducted and the resident had pain constantly. The resident rated his/her pain as a eight out of 10. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident had an order for ordered Norco (narcotic pain medication) 5-325 mg, one tablet six times per day for pain; -The resident missed his/her medication twice on 08/31/24, six times on 09/03/24, and twice on 09/02/24; -Staff did not document notification of the physician that the resident was out of medication or that any non-pharmacological interventions were attempted. 4. Review of Resident #7's Admission Record, located in the EMR under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses included pain. Review of the resident's quarterly MDS, with ARD of 07/03/24, located in the EMR under the MDS tab, showed the following: -The resident was moderately cognitively impaired. -The resident received scheduled and PRN pain medications during the five day look back period. -The resident reported his/her pain was frequent and affected his/her sleep occasionally. The resident's pain intensity was seven out of 10. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident has an order for hydrocodone-acetaminophen (narcotic pain medication) tablet 5-325 mg, one tablet three times a day for pain. -The resident missed his/her medication once on 09/01/24, once on 09/02/24, and all three times on 09/03/24. -Staff did not document notification of the physician that the resident was out of medication or that non-pharmacological interventions were attempted. 5. During an interview on 09/04/24, at 2:38 P.M., Licensed Practical Nurse (LPN) 1 said if the medication was out on the medication cart then medication should be pulled from the E-kit. There was no tramadol in the E-kit on 09/02/24 and 09/03/24. He/she knew that Resident #57 and Resident #32 had run out of medication. He/she confirmed he/she had contacted the physician on 08/27/24 to order more medication and the pharmacy was contacted on 08/28/24 and they said they were waiting for the orders from the physician. This was the only time the physician and the pharmacy were contacted. He/she was not sure if the facility had a backup pharmacy, but it was difficult to obtain medication from the pharmacy or orders from the physician during a holiday weekend. 6. During an interview on 09/04/24, at 3:04 P.M., the Regional Nurse Consultant (RNC) 1 said the EMR System interfaced through the pharmacy and medication should automatically be reordered and delivered in timely manner. If the medication was not available, nurses should use the medication in the E-kit. The physician should be called daily. The pharmacy manager should be called to find out why the E-kit was not stocked. Since the facility ran out of pain medication, nurses should have asked the physician if there was another medication that was available that could be administered and non-pharmacological approaches for pain should have been attempted. Additionally, the backup pharmacy should have been called. 7. During an interview on 09/05/24, at 9:24 A.M., Registered Nurse (RN) 1 said if the medication card indicated the resident had seven days worth of medication, it would be time to notify the physician to reorder the medication. They should call sooner if a resident was running out of a narcotic for pain. They could also get medication from the E-kit and if the E-kit was out of medication they would call the pharmacy to determine when the medication would be delivered. RN 1 said there were risks if a resident did not receive their medication which included the potential for withdrawal. The physician should be notified every time a resident missed their medication. A nurse should also ask the physician if they could give the resident something else for pain and try non-pharmacological interventions. Occasionally a physician will not respond to the request then the Administrator, Director of Nursing (DON), and the Medical Director should be notified to get assistance to obtain the unavailable medication. He/she knew that Resident #57 had run out of tramadol and there was no tramadol in the E-kit. He/she also knew Resident #18 had run out of Norco. It was important that nurses always think ahead to ensure a residents' medication was ordered to ensure they did not run out. 8. During an interview on 09/05/24, at 9:39 A.M., the Regional Operations Director (ROD) 1 and Regional Nurse Consultant (RNC) 2 agreed that more should have been done to obtain the medication for the residents RNC 2 said that the physician should have been notified daily about the missing medication for each resident and should have been asked if there was another medication that could be provided in place of the missing medication. Residents should have also been offered and provided non-pharmacological interventions to assist with managing their pain. 9. During an interview on 09/05/24, at 9:54 AM, the Administrator said the physician should have been called to see if something else could have been given to the resident.

Based on record review and interview, the facility failed to ensure a system was in place to account for all controlled drugs and that allowed for accurate reconciliation when staff failed to routinely complete a documented narcotic count for each change of shift. 1. Review of the 200 Hall Narcotic Record Books, reviewed with Licensed Practical Nurse (LPN) 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/21/24 for 6:00 P.M. outgoing; -On 08/26/24 for 6:00 P.M. outgoing; -On 08/27/24 for 6:00 P.M. outgoing; -On 09/01/24 for 6:00 A.M. incoming; -On 09/01/24 for 6:00 P.M. outgoing. Review of the medication tech 100 Hall Narcotic Record Books, reviewed with LPN 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/20/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 P.M. outgoing; -On 08/26/24 for 10:00 A.M. incoming; -On 08/26/24 for 10:00 P.M. outgoing; -On 08/27/24 for 6:00 A.M. incoming; -On 08/27/24 for 6:00 P.M. outgoing; -On 08/30/24 for 6:15 A.M. incoming; -On 08/30/24 for 6:00 P.M. outgoing; -On 09/01/24 for 11:00 P.M. outgoing; -On 09/02/24 for 6:00 P.M. outgoing. Review of the nurse 100 Hall Narcotic Record Books, reviewed with LPN 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 A.M. incoming; -On 08/17/24 for 6:00 P.M. outgoing; -On 08/19/24 for 10:00 P.M. incoming; -On 08/20/24 for 6:00 P.M. outgoing; -On 08/21/24 for 6:00 A.M. incoming and outgoing; -On 08/21/24 for 7:00 P.M. outgoing; -On 08/22/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 P.M. outgoing; -On 08/26/24 for 10:00 P.M. outgoing; -On 08/27/24 for 6:00 A.M. incoming; -On 08/27/24 for 6:00 P.M. outgoing; -On 08/30/24 for 6:15 A.M. incoming; -On 08/30/24 for 6:00 P.M. outgoing; -On 08/31/24 for 6:00 A.M. incoming; -On 08/31/24 for 6:00 P.M. outgoing; -On 09/01/24 for 6:00 A.M. outgoing; -On 09/04/24 for 6:00 A.M. incoming. Review of the medication tech 200 Hall Narcotic Record Books, reviewed with Registered Nurse (RN) 1, was missing signatures for: -On 08/20/24 for 6:00 A.M. incoming; -On 08/20/24 for 6:00 P.M. outgoing; -On 09/03/24 for 6:00 A.M. incoming; -On 09/03/24 for 6:00 P.M. outgoing; -On 09/05/24 for 6:00 A.M. incoming. During an interview on 09/05/24, at 8:49 A.M., RN 1 reviewed the results of the review of the four Narcotic Record Books and confirmed the missing signatures. The RN said the Narcotic Record Books were supposed to be signed by the oncoming and outgoing staff, at the change of every shift, after the narcotics are counted by those two staff, acknowledging that the narcotic count was done and correct. During an interview on 09/05/24 at 11:19 A.M., the Administrator said the Narcotic Record Books contained empty signature areas indicating staff was not signing consistently at every change of shift, after the narcotic count was done.

Based on interview and record review, the facility failed to have a system in place to monitor for side effects and targeted behaviors for five of five sampled residents (Resident #48, #36, #42, #4, and #3) reviewed for unnecessary medications who received psychotropic medications. Review of the facility's Psychotropic Medication Use policy, dated 7/2022, showed the following: -Psychotropic medication management included .adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences. 1. Review of Resident #48's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety disorder, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 09/18/23 and located under the MDS tab of the EMR, showed the following: -The resident had severe cognitive impairment. -The resident received antipsychotics on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR, showed the following: -A current order for fluphenazine (an antipsychotic medication) 5 milligram (mg) tablet, twice daily for schizoaffective disorder; -A current order for risperidone (an antipsychotic medication) 1 mg, twice daily for schizoaffective disorder. Review of the resident's Medication Administration Record (MAR), dated 08/01/24 through 09/05/24, found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., Registered Nurse (RN) 1 reviewed the resident's Treatment Administration Records (TAR) and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the Regional Nurse Consultant (RNC) verified there was no behavior monitoring for the resident. 2. Review of Resident #36's Face Sheet, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's significant change MDS, with an ARD of 07/04/24 and located under the MDS tab of the EMR, showed the following : -The resident had no cognitive impairment; -The resident received antidepressant and antipsychotics on a routine basis. Review of of the resident's current Physician Orders, located under the Orders tab in the EMR, showed the following: -A current order for buspirone (an antidepressant medication) 15 mg tab, three times daily for anxiety disorder; -A current order for quetiapine (an antipsychotic medication) 50 mg, once daily for major depressive disorder. Review of the resident's MAR, dated 08/01/24 through 09/05/24 and found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., RN 1 reviewed the resident's TARs and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the RNC verified there was no behavior monitoring for the resident. 3. Review of Resident #42's Face Sheet, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder, alcohol abuse, and opioid dependence. Review of the resident's annual MDS, with an ARD of 09/18/23 and located under the MDS tab of the EMR, showed the following: -The resident had no cognitive impairment; -The resident received antidepressant and antianxiety medication on a routine basis. Review of the resident's Physician Orders, located under the Orders tab in the EMR, showed a current order for fluoxetine (an antidepressant medication) 40 mg tablet, once daily. Review of the resident's MAR, dated 08/01/24 through 09/05/24, found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., RN 1 reviewed the resident's TARs and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the RNC verified there was no behavior monitoring for the resident. 4. Review of Resident #4's Admission Record, found the EMR under the Profile tab, showed the following; ' -admitted [DATE]; -Diagnoses included anxiety disorder and depression. Review of the resident's annual MDS, with an ARD of 05/30/24 and found in the EMR under the MDS tab, showed the resident was on anti-anxiety and anti-depressant medication. Review of the resident's Physician Orders, found in the EMR under the Orders tab, showed the following: -A current order for lorazepam (anti-anxiety medication) oral tablet one mg, give one tablet by mouth at bedtime for anxiety; -A current order for paroxetine HCL (antidepressant medication) 20 mg, give one tablet by mouth in the afternoon for depression. Review of the resident's medical record showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 10:12 AM, RN 1 said behavior monitoring or side effect monitoring for these medications should be listed on a resident's Medication Administration Record (MAR) or the Treatment Administration Record (TAR). RN 1 confirmed this was not being completed for the resident. During an interview on 09/04/24, at 4:35 P.M., the Director of Nursing (DON) confirmed there was no behavior or side effect monitoring being completed for the resident's use of the anti-anxiety or anti-depressant medications. 5. Review of Resident #3's Admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following; -admitted [DATE]; -Diagnoses included major depressive disorder, Alzheimer's Disease, and anxiety disorder. Review of the resident's MDS, with an ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident had severe cognitive impairment; -The resident received antidepressant and antipsychotic medication for seven of seven days during the look back review period. Review of the resident's comprehensive Care Plan, updated 08/17/24, showed the following: -The resident was at risk for side effects of antipsychotic drug use; -Intervention included monitoring patterns of target behaviors. Review of the resident's MAR, dated 09/2024, located in the EMR under the Orders tab, showed the following: -A current order for citalopram (an antidepressant) 10 mg, daily for major depressive disorder; -A current order for olanzapine (an antipsychotic) 2.5 mg, daily for an anxiety disorder. Review of the resident's medical record showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. 6. During an interview on 09/05/24, at 9:06 A.M., Registered Nurse (RN) 1 said most of the residents on antipsychotic medications had a question on the Treatment Administration Record (TAR) that asked about behaviors. 7. During an interview on 09/05/24, at 12:13 P.M., the RNC verified said they were unaware there needed to be behavior monitoring for psychotropic medications because they have never monitored for anything other than anti-psychotic medications. 8. During an interview on 09/05/24, at 12:46 P.M. and 1:15 P.M., the DON said as a nurse she knew to look for and monitor for any change in a resident's condition that was on psychotropic medications. She agreed that if behavior monitoring was not on the MAR/TAR that not all staff would know what to look for or ensure they were monitoring for specific behaviors and there would not be any consistency in monitoring. Specific targeted behavior and potential side effects should be monitored for all psychotropic medications. 9. During an interview on 09/05/24, at 3:57 P.M., the Administrator said that all regulations should be followed, including behavior monitoring and monitoring side effects for anti-depressants and anti-psychotics. 35690 36246

Based on interview and record review, the facility failed to ensure all residents, or resident representatives, received written notice of transfer when staff failed to provide a written notice of discharge to one resident (Resident #56), of one sampled resident, or his/her representative, for a facility initiated emergent hospital transfers. Review of the facility's Discharge Policy, dated 2021, showed the policy did not address written transfers notice. 1. Review of Resident #56's face sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admitted [DATE]; -Diagnoses included chronic respiratory failure with hypoxia (low oxygen levels). Review of the resident's Progress Note, located in the EMR under the Progress Note tab, showed the following: -The resident was sent to the emergency room for increased anxiety, complaints of extreme back pain, and difficulty with breathing. -The resident was admitted to the Intensive Care Unit (ICU) for chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems). -Staff did document regarding, or have a copy of, a written transfer provided to the resident and/or representative. During an interview on 09/04/24, at 6:53 A.M., Licensed Practical Nurse (LPN) 5 said he/she did not complete a transfer/discharge summary to provide to the resident and/or representative when a resident discharges to the hospital. During an interview on 09/05/24, at 4:30 P.M., the Administrator agreed a transfer/discharge summary should be provided to all residents upon discharge. She confirmed the resident and/or the representative did not receive a transfer/discharge summary when she was sent to the hospital.

Based on interview and record review, the facility failed to ensure all residents were free from abuse when a staff member (Certified Nurse Aide (CNA) A) acted in an abusive manor by cursing at, and making contact with the face of, one resident (Resident #1) resulting in the resident being too upset to talk about the event initially without crying. The facility census was 65. Record review of the facility policy, titled Abuse Prevention Program, dated September 2021, showed the following: -The facility will not tolerate verbal or physical abuse by employees; -Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment; -Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of age, ability to comprehend, or disability. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/4/2022, showed the following: -The resident was cognitively intact. Record review of the resident's current care plan showed the following: -The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident will maintain his/her dignity, current level of ADLs, and have no injuries related to MS through the next review. Record review of the facility investigation, dated 8/26/2022, showed the following: -On 8/25/2022, at 10:20 A.M., the resident reported to the Administrator and Director of Nursing (DON) that CNA A made physical contact with his/her hand on the resident's face on 8/24/2022, between 3:00 P.M. and 3:30 P.M. CNA A said that during cares he/she did run the back of his/her hand jokingly over the resident's face, but denied striking the resident. Another staff member, CNA B was present in the room, and stated he/she overheard the resident say that CNA A smacked him/her, and CNA A said to the resident I barely touched you. Record review of the resident's written statement, dated 8/25/2022, showed the following: -The resident had just been put in his/her bed. CNA A and CNA B were the ones helping him/her. CNA A told the resident he/she was a nasty ass for refusing his/her shower earlier. The resident told CNA A he/she was a nasty ass. CNA A turned around to do something and when he/she turned back around, backhanded the resident. The resident then told CNA A he/she would be wearing this soda if he/she didn't shut up. CNA A said no, you will get what you just got. During an interview on 8/26/2022, at 10:06 A.M., the resident said on 8/24/2022, between 3:00 P.M. and 4:00 P.M., CNA A and CNA B were trying to get him/her to take a shower, and CNA A called him/her a nasty ass. He called him/her one back, and then CNA A backhanded him/her. CNA B was in the room at the time and heard the encounter. The resident said he/she was so angry at the time he/she could not report it to the Administrator or DON without crying, so he/she waited until the next day. The resident said if CNA came back to the facility, he/she would seek other placement due to the incident. Record review of CNA A's written statement, dated 8/25/2022, showed the following: -On 8/24/2022, CNA B asked for help changing the resident. CNA A asked the resident if he/she just sat there and didn't ask to be changed; -After changing the resident's pants, and pulling up the blankets, CNA A ran his/her hand up the resident's chin and nose; -As CNA A grabbed the bedside table, the resident said smack me in my face again, I will throw this Coke on you. CNA A replied no, you won't throw anything in my face, because I didn't smack you in the face. Don't say those lies for [OBSCENITY] 's sake; -CNA A told the resident to stop smoking a THC (the main psychoactive compound in marijuana) pen because he/she was being hateful. During an interview on 8/29/2022, at 10:25 A.M., CNA A said on 8/24/2022, CNA B asked for assistance changing and laying down the resident. CNA A said to the resident My God Resident #1, did you not ask for help? CNA A said the resident had an attitude when the CNAs changed him/her. They always played and joked, and CNA A had run his/her hand up the resident's chin and nose, in what he/she said was a joking manner. The resident said you slap me again and I will throw this Coke. CNA A said he/she said you won't, and did say [OBSCENITY] to the resident, but couldn't remember when. It is never appropriate to hit a resident, or curse at a resident. He/she would consider that abuse. Record review of CNA B's written statement, dated 8/25/2022, showed the following: -On 8/24/2022, CNA B and CNA A went to the resident's room to lay him/her down and change him/her; -As CNA B was bagging dirty trash and linens, he/she heard an argument between the resident and CNA A about CNA smacking the resident; -The resident said CNA A smacked him, and CNA A said to the resident, Resident #1, I barely touched you. During interviews on 8/26/2022, at 2:35 P.M., and on 8/29/2022, at 9:50 A.M., CNA B said on 8/24/2022, he/she and CNA A went in to change and lay down the resident, and he/she heard CNA A and the resident arguing. They had a relationship where they often joked around and played. CNA B said he/she never saw CNA A hit a resident, but he/she did hear the resident say don't slap me, I am going to call state. CNA A then said, I didn't slap you, I just popped you. CNA B said he/she would consider popping a resident abuse. During an interview on 8/26/2022, at 10:16 A.M., Resident #2 said Resident #1 told him/her he/she was hit in the mouth by CNA A. Resident #1 said CNA A backhanded him/her in the mouth. Resident #1 was upset when he/she told Resident #2 and did not immediately tell the Administrator or Director of Nursing (DON) because he/she didn't want to cry when he/she told them. During interviews on 8/26/2022, at 10:38 A.M., and on 8/29/2022, at 10:05 A.M., Certified Medication Technician (CMT) C said he/she would consider hitting or popping a resident abuse, and would consider cursing at a resident abuse. During an interview on 8/26/2022, at 10:55 A.M., Licensed Practical Nurse (LPN) D said he/she would consider cursing at a resident and hitting a resident abuse. During an interview on 8/29/2022, at 10:05 A.M., LPN E said he/she said it would never be appropriate to curse at a resident or pop a resident in the mouth, whether playing or not. Both would be considered abuse. During an interview on 8/29/2022, at 10:15 A.M., LPN F said he/she would consider hitting or popping a resident and cursing a resident abuse. During an interview on 8/29/2022, at 11:30 A.M., the DON and Administrator said they would consider popping a resident in the mouth abuse, and would consider cursing at a resident abuse. During an interview on 8/29/2022, at 11:30 A.M., the Director of Regional Consulting said he would consider cursing directly at a resident abuse. He would consider hitting or popping a resident abuse. MO 078

Based on interview and record review, the facility staff failed to ensure the safety of all residents when transport staff failed to properly secure one resident (Resident #1) in the transport van. This resulted in the resident suffering a fall causing a C-2 (the second bone down from the skull in the neck vertebrae) fracture. The facility census was 67. On 07/07/21 at 2:10 P.M., the administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 1/21/21. On 1/21/21, the facility notified the Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, terminated the employee involved, in-serviced the facility staff involved in transporting residents, and started utilizing only outside transport services for approximately four months. The IJ was removed and corrected on 1/23/21. Record review of the facility's policy titled Transportation and Diagnostic Services, dated December 2008, showed the following: -The facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. -The policy did not address resident safety during transportation. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted on [DATE]; -Diagnoses included a coccyx (tailbone) fracture, [CONDITION(S)] (an irregular and often rapid heart rate than can increase the risk of strokes), hypertension (high blood pressure), and cerebral infarction (stroke). Record review of the resident's care plan, dated 1/6/2021, showed the following: -Used a wheelchair and transferred him/herself to the wheelchair; -Fall risk. Record review of the resident's 5-Day Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 1/13/2021, showed the following: -Cognitively intact; -Used a wheelchair for mobility; -Required one person assist with transfers. During an interview on 7/7/2021, at 11:30 A.M., the Social Service Designee (SSD) said the facility procedure was to use four straps to secure a resident in the van for transport. He/she trained Certified Nurse Assistant (CNA) A for transports when he/she started at the facility. Record review of CNA A's written statement, dated 1/22/2021, showed the following: -CNA A was preparing to depart from an appointment at Hospital A with the resident; -CNA A loaded the resident into the transport vehicle, rear facing as normal, but opted to use only two of the four wheelchair tie down straps; -CNA A crisscrossed the tie down hooks at the middle base of the wheelchair frame and tightened them; -Procedure dictates a wheelchair be secured by four tie down straps to ensure resident safety, which CNA A chose to deviate from because of his/her self-imposed concern for timing; -After partially securing the resident's wheelchair, CNA A closed the lift and back doors to the transport vehicle and got in the front seat and started departure; -As CNA A approached the stop sign at the intersection, he/she applied the brakes. Before the vehicle stopped, he/she heard the resident yelling out. The CNA looked in the mirror in time to see the end of the resident's fall; -The downward slope of the road, the inertia created by the vehicle braking, and the lack of proper restraint caused the resident's wheelchair to tip backwards and fall; -CNA A pulled the van into a parking lot and exited the front of the van to assess the resident; -The resident's face and neck were under the bench seat that sat behind the driver and passenger seats; -The resident was kicking his/her feet and screaming for help; -CNA A unstrapped the wheelchair and pulled it from under the resident, and removed it from the van; -The resident expressed concern that his/her neck was broken; -CNA A called 911 to request an ambulance and medical attention for the resident. While on the phone with 911, the CNA asked the resident about his/her condition. The resident was able to move his/her limbs upon request; -The resident continued to speak of pain in his/her neck and his/her belief that it was broken; -EMS arrived and the resident was placed in a neck brace and on a back board; -CNA A called the facility and notified the Director of Nursing (DON) of the incident -The resident was transported via ambulance to Hospital A and CNA A went back to the facility. Record review of the facility investigation, dated 1/22/2021, showed the following: -Certified Nursing Assistant (CNA) A assisted the resident into the facility van to transport the resident back to the facility following an appointment; -During the investigation the facility staff determined CNA A used two straps to secure the resident and his/her wheelchair. According to facility procedure CNA A should have used four straps to secure the resident; -When CNA A began to stop at a stop sign, the resident's wheelchair tipped over; -CNA A stopped the facility van in a parking lot and began to assist the resident; -The resident said he/she had pain in his/her neck; -CNA A called 911; -The resident was transferred to the emergency room for evaluation and treatment; -The resident and CNA A were the only people in the van. Record review of Hospital A's emergency department provider notes dated 1/21/2021, at 5:14 P.M., showed the following: -The resident struck his/her head and back of his/her neck; -The resident complained of a headache and increased neck pain; -Lifeflight (helicopter) was launched to take the resident to Hospital B. Record review of Hospital B's physician history and physical dated 1/21/2021, at 11:10 P.M., showed the following: -The resident presented to the emergency room as a transfer from Hospital A for a higher level of care following a fall; -The resident was reportedly not secured in the vehicle, so when the vehicle accelerated, the patient fell backward from his/her wheelchair in the vehicle, striking the back of his/her head and neck; -CT imaging (a series of x ray images taken from different angles to create cross sectional images of the body) performed at Hospital A demonstrated a C-2 fracture, necessitating transfer to Hospital B. Record review of Hospital B's discharge summary, dated 1/30/2021, showed the following: -The resident was transferred to Hospital B for a C-spine (neck) fracture; -The resident fell out of a wheelchair while being transported; -The resident sustained a C-2 fracture; -The resident was discharged on [DATE] to a hospice facility. Record review of the SSD's statement, dated 1/22/2021, showed the following: -When CNA A was hired, the SSD trained him/her on the van lift and procedures; -CNA A expressed understanding and stated he/she had done transports for residents at another facility and stated he/she was comfortable with transportation duties; -The SSD accompanied CNA A on his/her first two appointments to give guidance and evaluate his/her understanding of the facility van and lift; -CNA A showed understanding of the procedure and followed protocol for the procedures needed for the lift, and securely fastened the belts, and used proper placement. Record review of CNA A's Corrective Action Form, dated 1/22/2021, showed the following: -CNA A was discharged from employment on 1/22/2021; -The reason for action was CNA A was transporting a resident and admitted that he/she did not buckle the resident's wheelchair in correctly; -The employee said he/she was aware how it should have been buckled and chose not to secure the wheelchair properly; -Due to not having the resident's wheelchair secured properly, the resident tipped over in the wheelchair and suffered injuries. During an interview on 7/7/2021, at 11:30 A.M., the SSD said CNA A had experience doing transports at another facility and was very conscientious. He/she paid attention, always used all the straps, and gave no cause for concern. The SSD accompanied CNA A on two transports and had no concerns. During an interview on 7/7/2021, at 11:55 A.M., CNA B said he/she was trained by the SSD and recently had an in-service on how to use the equipment properly. Staff should always use four straps to attach the wheelchair to the van. It would never be appropriate to use less than four straps to secure the wheelchair. If the wheelchair will not attach properly, the vehicle is not to be moved. CNA B said he/she was trained multiple times on how to properly attach the wheelchairs to the van and was given literature on how the equipment operates. During an interview on 7/7/2021, at 12:55 P.M., the Medical Director said he had been made aware of the incident, he believes the following day. He would have expected staff to use all four straps if the protocol was to use four straps to attach the wheel chair. During a combined interview on 7/7/2021, at 2:05 P.M., the DON and Administrator said he/she would expect staff to follow facility procedure and use all four of the safety straps when taking residents on transports. CNA A was terminated as a result of purposefully not using all four of the straps on the transport with the resident. He/she had worked at another facility doing transports and they had no reason to expect a problem. MO 774

Based on record review and interview, the facility failed to contact the physician at admission to obtain monitoring guidelines related to the International Normalization Ratio (INR - a blood test that measures how long it takes for blood to clot) levels and blood glucose levels for one resident (Resident #1) with a history of diabetes, unstable INR levels, and recent perforated intestinal repair. The staff failed to monitor INR and blood glucose levels during the resident's stay at the facility. The resident was admitted to the hospital with [REDACTED]. At the time of the resident's admission, the facility identified a total of three residents, including Resident #1, who received anticoagulation therapy. The facility's census was 72. Record review of the facility's policy titled Anticoagulation-Clinical Protocol, revised September 2012 showed: -The nurse shall assess and document current anticoagulation therapy, including drug and current dosage; recent labs, including therapeutic dose monitoring; other current medications and all active diagnosis; -The physician will identify potentially serious medication interactions with [MEDICATION NAME] (a medication that thins the blood to prevent blood clots). The physician should stop, taper, or change medications that interact with [MEDICATION NAME], and monitor the PT/INR very closely, while the individual is receiving [MEDICATION NAME], to ensure the PT/INR stabilizes; -The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications, for example periodically checking hemoglobin/hematocrit (tests to measure the volume of the red blood cells), platelets (a test to measure the part of the blood that makes it clot), INR and stool for occult blood (blood in the feces). The staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. According to the National Library of Medicine, National Institutes of Health, antibiotic medications are associated with an increased risk of bleeding among patients receiving [MEDICATION NAME]. [MEDICATION NAME] has a narrow therapeutic range and requires frequent monitoring to avoid potentially life-threatening complications from both under-and over-coagulation. Record review of the facility's policy titled Admission Assessment and Follow Up: Role of the Nurse, revised September 2016 showed: -Reconcile the list of medications from the medication history, admitting orders, the previous Medication Administration Record [REDACTED] -Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [REDACTED] Record review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus (a conditions that effects the way the body processes blood sugar), revised March 2015, showed: -The physician will order the frequency of glucose monitoring. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation; -Normal ranges for blood glucose are defined as 80-130 mg/dl before meals and greater than 180 mg/dl after meals. [MEDICAL CONDITION] is considered anything above target reference ranges. 1. Record review of Resident #1's Face Sheet (admission information) showed the following: -admitted to the facility on [DATE]; -Admitting [DIAGNOSES REDACTED]. Record review of resident's hospital discharge instructions dated 10/30/16, showed the following: -Ensure the resident's INR is monitored closely as patient is on medication that can affect [MEDICATION NAME] metabolism; -Follow-up with regular primary care physician (PCP) for [MEDICATION NAME] monitoring; -Recommended range for INR result is 2.0 to 3.0; -Blood drawn for INR level regularly. The result of the INR will be given to the physician and [MEDICATION NAME] dose may be adjusted; -Potential for Adverse Drug Reactions and Interaction: [MEDICATION NAME] decreases how fast the blood clots. If the dose is too high, it may result in increased bleeding. If the dose is too low, it may result in an increased risk of forming clots; -Follow up with PCP to review diabetes control; glucose was elevated while the resident was in the hospital. Record review of the New Admits Report Sheet, completed by facility staff prior to the resident's admission to the facility dated 10/30/16, showed the resident's INR was 2.6 (per hospital laboratory results). Record review of the resident's physician's orders dated 10/30/16, showed the following: -[MEDICATION NAME], 5 milligrams (mg), daily, for [MEDICAL CONDITION]; -Aspirin (mild pain reliever and blood thinner), 81 mg, daily, for [MEDICAL CONDITION]; -[MEDICATION NAME] (oral diabetic medication to treat diabetes), 10 mg, two times a day with meals for diabetes; -[MEDICATION NAME] (an antibiotic), 500 mg two times daily for 28 doses for helicobacter pylori (type of bacteria that lives in the intestinal tract); - The physician orders did not include orders for INR or glucose monitoring. During an interview on 12/01/16 at 4:45 P.M., the Director of Nursing (DON) said: -She faxed the medication orders to the physician when the facility admitted the resident on 10/30/16, and completed the physician's orders and Medication Administration Record [REDACTED] -It would have been logical for the admission nurse to call Resident #1's physician and ask if any labs were needed; -She expected the charge nurse to follow up with the physician regarding the need to monitor INR level since the resident was on [MEDICATION NAME]. The admitting nurse would be the person to follow up regarding labs; -Any nurse caring for Resident #1 should have recognized the need to find out if the physician wanted labs. During a phone interview on 12/2/16 at 9:32 A.M., Licensed Practical Nurse (LPN) B said: -He/she worked the day shift and worked over onto the evening shift when the resident was admitted on [DATE]. He/she did not know the resident was being admitted to the facility until he/she showed up because he/she did not work on that hall. The nurse said the DON had left for the day and he/she was the only nurse in the building at the time of the admission. He/she did not have much information about the resident; -When a nurse admits a resident who takes [MEDICATION NAME], he/she would see how often the physician wanted the INR level checked, usually the admission orders [REDACTED] -The nurse said the admission orders [REDACTED] -He/she did not contact the physician regarding the resident's admission. Record review of the resident's medicare charting guidelines showed nursing staff should document on the resident's anticoagulation therapy ([MEDICATION NAME] therapy) including the following: -Lab results; -Patient/family teaching. Record review of the resident's daily skilled nursing notes dated 10/30/16 through 11/25/16, did not show any documentation related to anticoagulant therapy, patient/family teaching related to anticoagulant therapy or need for labs. Review of the resident's initial care plan (completed by facility at the time of admission), dated 10/30/16, showed the following: -Resident on [MEDICATION NAME] therapy; -Staff to monitor for bruising and bleeding and report. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/5/16, showed the following: -Moderate cognitive impairment as indicated by a total score of 11 on the Brief Interview for Mental Status (BIMS - an assessment tool completed by facility staff used to determine the cognitive level of a resident); -[DIAGNOSES REDACTED]. Record review of the resident's pharmacy consulting review dated 11/15/16, showed the pharmacist documented: -A notation mark was made on the glucose and INR section for labs needed. During an interview on 12/01/16 at 3:00 P.M., the director of rehab (who is a certified occupational therapy assistant - COTA), said the following: -On admission the resident was alert and did great with therapy the first week, but by week two of his/her stay, the resident started to decline. The resident's family contacted her and requested a family meeting with facility staff and therapy to discuss concerns related to the resident's decline in function. The meeting was arranged and the Speech Therapist (ST), Physical Therapy Assistant (PTA), COTA, administrator and social services attended, along with the resident and multiple family members; -The family asked how the resident's blood sugars were. The social services designee - SSD) reviewed the resident's medical record (while in the meeting) and told the family staff did not check the resident's blood sugars. During an interview on 12/01/16 at 5:15 P.M., the SSD said she was present during the family meeting for Resident #1. The family wanted to know what treatment the resident was on for diabetes and what the resident's blood sugars were. The administrator represented nursing in the meeting and he reviewed the resident's medical record during the family meeting. During interviews on 12/1/16 at 1:17 P.M. and 6:15 P.M., the administrator said: -He attended a meeting with the resident's family to discuss concerns on 11/16/16 or 11/17/16. The family asked about the resident's diabetic medications and blood glucose check. When he reviewed the resident's medical record, during the meeting, he did not see an order for [REDACTED].>During an interview on 12/1/16 at 4:45 P.M., the DON said: -The family met with staff to discuss their concerns, but she did not attend the meeting. She did not recall any staff reporting the resident had a decline in function; -The physician saw the resident in his/her office on 11/18/16. The physician did not order any labs at that time; -The resident should have had a [MEDICATION NAME] Flow Sheet started on admission; -The [MEDICATION NAME] Flow Sheet should be part of the admission packet. Nurses should keep this flow sheet with the nurse MAR. Record review of the resident's November 2016, MAR indicated [REDACTED]. Record review of the resident's comprehensive care plan, last updated 11/22/16, showed staff did not identify the resident as receiving anticoagulation therapy or medication to control blood glucose levels. The facility did not develop interventions related to anticoagulation therapy or blood sugar monitoring. Record review of the resident's medical record, including physicians' orders, laboratory results, treatment administration record, MAR, and nurses' notes, from 10/30/16 through 11/25/16, showed no documentation staff was monitoring the resident's INR or blood glucose levels. During an interview on 12/01/16 at 3:00 P.M., the COTA said on 11/25/16, the resident's last day at the facility, she assisted a certified nurse aide (CNA) in transferring the resident onto the toilet. The resident passed out and was unresponsive for one to two minutes. The COTA informed LPN A who said the resident was probably just really tired. The COTA returned to the resident, he/she awoke and wanted a big glass of water. Staff assisted the resident to the family room where the resident's family was located. During interviews on 12/1/16 at 1:17 P.M. and 6:15 P.M., the administrator said on 11/25/16, a family member came to the administrator and asked him to look at the resident, as something was not right. The administrator told the family member he would get a nurse. Record review of a nurse's note dated 11/25/16 at 2:43 P.M., showed a nurse documented the resident had decreased alertness and complained of lightheadedness. The nurse checked the resident's blood sugar three times and each time the reading showed hi (high). Staff transferred the resident to the hospital for evaluation and treatment. During an interview on 12/1/16 at 2:15 P.M., LPN A said: -The resident was usually alert, and pleasant and went to therapy during the day. The resident did not have a physician's order for staff to check his/her blood glucose; -On 11/25/16, the resident was in the family room and was not responding. The LPN checked the resident's blood sugar level, which registered as high (greater than 600 mg/dl). He/she took the resident to the nurses' station and rechecked the resident's blood sugar; which also registered high. The resident was sluggish. LPN A called for an ambulance and notified the resident's physician. Record review of Hospital A's records for the resident dated 11/25/16, showed the following: -A laboratory report dated 11/25/16 at 4:52 P.M., showed the resident's INR was 13.62 (critically high). The resident's hemoglobin (a protein red blood cells that carries oxygen throughout the body) was 5.9, (normal range for men 13.5 to 17.5. Normal range for women 12.0 to 15.5.) and his/her blood glucose was 812 mg/dl; -The resident received blood on 11/25/2016; -The resident received Vitamin K (a fat soluble vitamin that helps blood clot); -The resident was transferred to Hospital B due to [MEDICAL CONDITION] (a condition when the blood does not have enough healthy red blood cells) and the availability of a higher specialized level of surgery care. During a phone interview on 12/3/16 at 10:45 A.M., the physician's medical assistant said: -Regarding a new admission, the facility usually gets the transfer records from the hospital and then the nurse calls the physician and asks if the physician is going to accept the resident for care. The nurse also sets up an appointment for the physician to see the resident; -He/she did not know the facility's protocol on how often to check INR levels for someone on [MEDICATION NAME]. He/she would usually check INR levels every week after surgery until the resident's INRs were stable. He/she did not know if the surgeon ordered INR level checked at the hospital; -He/she was not sure why staff was not monitoring the resident's blood sugar. During an interview on 12/6/16 at 11:00 A.M., the resident's physician said: -He did not recall if the facility called him on 10/30/16, to verify orders for the resident, but it was not normal for them to do so. The facility receives the admission orders [REDACTED] -He would expect INRs to be checked for a resident receiving [MEDICATION NAME]; -If a resident had just started taking [MEDICATION NAME], he would expect the INR to be checked one to two times each week until the level was stable, then every two to three weeks and finally monthly, if stable; -Blood sugar monitoring is a good idea for a resident with a [DIAGNOSES REDACTED]. -The physician was not aware of the resident's high INR or high blood glucose level when he/she was admitted to the hospital. During an interview on 12/06/16 at 5:45 P.M., LPN B said: -When a resident is admitted to the facility, it is dependant on the situation on who completes what regarding the admission paperwork. If the DON is at the facility, sometimes she will transcribe the discharge orders from the hospital onto the resident's physician's order sheets. Nurses' give each other report on which tasks needed completed. The night shift staff also completes a 24 hour chart check to ensure all required steps of the admission are completed. If LPN B noticed staff did not sign the chart indicating a 24 hour chart check was completed, he/she would check the the chart for new physician's orders and follow-up accordingly; -If a resident, who takes [MEDICATION NAME] or medication to lower blood sugars, is admitted to the facility without physician's orders to monitor those levels, like an INR or blood glucose checks, the nurse should call the physician to obtain those orders. During an interview on 12/6/16 at 7:05 P.M., the administrator said: -On 09/26/16, all staff attended an in-service on several issues, including the [MEDICATION NAME] protocol. The administrator gave the nursing staff a packet of forms to review and use, including a [MEDICATION NAME] flow sheet. The nursing staff should use the flow sheet for all residents who receive [MEDICATION NAME]; -The administrator found out the nursing staff was not using the [MEDICATION NAME] flow sheet, on any resident, after staff sent Resident #1 to the hospital (11/25/16); -On 11/28/16, the administrator gave another in-service to nursing staff about using the [MEDICATION NAME] flow sheet; -The nurse on the night shift is responsible for completing 24 hour chart checks. The nurse is to check every resident's chart for new orders, and confirm the nurse carried over orders accurately to the MAR. The DON is responsible for monitoring that the 24 hour chart checks are completed by staff; -For a newly admitted resident, the nurse should review physician's orders, including laboratory orders. For residents taking diabetic medications or [MEDICATION NAME], it is at the physician's discretion as to how often laboratory work is completed, however the nurse should ask the physician about needed labs if the physician does not order labs; -The resident's [DIAGNOSES REDACTED]. During an interview on 12/07/16 at 4:25 P.M., the MDS coordinator said she completed the MDS's as well as the care plans. After she completes the MDS, the computer generates a problem which then is used to create the care plan. The MDS created problem list is not all inclusive. She had not been including [MEDICATION NAME] therapy or glucose blood glucose monitoring on the care plan. During an interview on 12/8/16 at 3:10 P.M., the DON said: -When the facility admits a new resident, the nurse should get orders or take report from the discharging facility or admitting physician. The nurse should fax the physician's orders and face sheet to the resident's physician and ask the physician to review the orders, make any needed changes, and sign the orders. If the physician makes a change to the orders, the nurse should document the change on the physician's order sheet, and document in the nurses' notes the date, time, and changes made by the physician. The night shift nurse then verifies the admission orders [REDACTED] -The nurses should use the [MEDICATION NAME] Flow Sheet to track INR labs. At shift change, the nurse should report any needed labs and lab results to the oncoming nurse. The night nurse should verify that labs are completed and the physician reviewed the results. If there is no physician's order for lab work after a resident's dosage of [MEDICATION NAME] has changed, the nurse should follow up with the physician to find out when to obtain the next INR level. The nurse should take any new orders from this progress report and put the orders on the physician's order sheet. #MO 520 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included immediate in-servicing of staff on the facility's receipt of orders and monitoring labs and assigned staff for monitoring of these labs. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 12/08/16, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when water temperatures in the facility exceeded safe parameters greater than 120 degrees Fahrenheit (F) on the 100 corridor and at the hand-washing sink in the residents' dining room. The facility had a census of 65. 1. Record review of the Consumer Product Safety Commission information showed the majority of hot water accidents involve the elderly. Burns will occur after a 6-second exposure to 140-degrees Fahrenheit (F) water or after a 30-second exposure to 130-degrees F water. Even if the water temperature is 120 degrees F, a 5-minute exposure could result in third-degree burns. 2. Observations on 10/07/15, beginning at 11:10 A.M., showed the following hot water temperatures at the sink faucets in residents' rooms on the 100 hall, using a digital long stem thermometer: -Resident room 100, 127.4 degrees F; -Resident room 102, 127.2 degrees F; -Resident room 104, 122.4 degrees F; -The facility surveyors ran the water for two minutes and used a calibrated digital thermometer each time. Observations on 10/07/15, beginning at approximately 1:30 P.M., showed the following hot water temperatures at the sink faucets in residents' rooms on the 100 hall, using a digital long stem thermometer: -Resident room 100, 127.4 degrees F; -Resident room 102, 127.2 degrees F; -Resident room 104, 122.4 degrees F; -The facility surveyor ran the water for two minutes and used a calibrated digital thermometer each time. 3. Observations on 10/08/15, beginning at approximately 10:00 A.M., showed the following hot water temperatures at the sink faucets in residents' rooms on the 100 hall, and the residents' dining room, using a digital long stem thermometer: -Room 100, 126 degrees F; -Room 101, 126 degrees F; -Room 103, 126 degrees F; -Room 102, 126.2 degrees F; -Room 104, 126 degrees F; -Room 105, 126 degrees F; -The main dining room, 127 degrees F; -The facility surveyor ran the water for ten to 15 seconds and used a calibrated digital thermometer each time. 4. Observation on 10/7/15, beginning at 12:00 P.M., showed two certified nurse assistants (CNA) and a speech therapist took turns washing their hands at the sink in the main dining room. CNA C cautioned CNA D and the speech therapist that the water was very hot. CNA D said that would make them wash their hands very quickly. The residents in the dining room could access the hot water at the sink, but none attempted to during the meal observation. 5. During an interview and observation, on 10/09/15, beginning at 8:35 A.M., the maintenance supervisor said it was his responsibility to check the hot water temperatures weekly. He said the highest the water temperatures should be in a residents' sink was 125 degrees F. Observation of the maintenance closet showed two 100 gallon water heaters piggy backed into each other supplying hot water to the kitchen and 200 hall. There was one 80-gallon water heater draining hot water into a 119-gallon holding tank supplying hot water for 100 hall. The thermometer located on the outline on the holding tank measured 118 degrees F. The maintenance supervisor said if staff thought the water was too hot they should report it on the maintenance slip and turn into the maintenance supervisor for repairs.

Based on observation, interview and record review, the facility failed to ensure staff failed to prevent the development of pressure ulcers for two residents (Resident #4 and #11) whom staff assessed as being at risk for the development of pressure ulcers. Staff failed to consistently assess, accurately monitor, and document progress or lack of progress of the pressure ulcers. One resident (Resident #4) was admitted on [DATE] with no pressure ulcers and within three months developed one open area on his/her buttocks and a Stage III pressure ulcer on his/her heel. Staff failed to obtain a treatment order for another (Resident #11), who acquired a Stage II pressure ulcer on his/her buttock. Thirteen residents were chosen for review in a facility with a census of 67. Pressure sore staging according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines #15: - Stage I pressure sore (a persistent area of skin redness without a break in the skin, that is non-blanchable) - Stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) - Stage III pressure sore (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) - Stage IV pressure sore (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) Record review of the National Pressure Ulcer Advisory Panel Reference Guide 2014 showed the following standards for the assessment of pressure ulcers: -Assess the pressure ulcer initially and re-assess it at least weekly; -Document the results of all wound assessments; -Assess and document physical characteristics including: Location; Stage; Size; Tissue type; Color; Periwound (skin surrounding wound) condition; Wound edges; -Undermining (area open around and beneath the edge of the wound); -Tunneling (channels extending into the surrounding tissue); -Drainage; -Odor. -Address signs of deterioration (e.g., increase in wound dimensions measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time, change in tissue quality, increase in wound exudate/drainage or other signs of clinical infection) should be addressed immediately. Record review of the facility's Wound and Skin Care protocol and procedure, dated January 2012, showed the following information: -Staff should provide ongoing documentation by the charge/treatment nurse in the medical record to describe the effectiveness of the interventions and the resident's response to therapy; -Specific interventions such as position changes, incontinence care, and equipment use will be recorded no less then weekly in the medical record; -Staff assessment of wound at each dressing change. Document the site, stage, length, width and depth, color and treatment. 1. Record review and staff interview on 7/15/15 of the facility's pressure ulcer and wound tracking system showed staff used multiple forms: - The CNAs (Certified nursing assistant) complete a Skin Monitoring/Comprehensive CNA shower review sheet on each resident when the CNA bathes the resident. When CNAs identify any areas on the resident's skin during the bath, the CNAs are expected to report this information to the charge nurse or any other nurse (nurse completing the skin assessments, ADON (assistant director or nursing) or the DON (Director of nursing). The nurse will then follow up with the assessment and treatment of [REDACTED]. - During interview on 7/15/15 at 1:00 P.M. the ADON said the skin assessment nurse (not the treatment nurse) completes the facility form entitled Weekly Skin Integrity Review for each resident each week. The form is used to identify skin areas as new or old for each resident. The staff will inform the ADON of any newly identified skin areas; -The ADON documents weekly on the Wound Evaluation Flow Sheet. This form is used to track the progression of each wound; -The ADON completes the facility's form entitled Wound and Skin Status Report used to track all wounds and skin problems in the facility. The form contains stagable and unstagable wounds and skin problems identified by the staff. The form lists the date the wound was identified, last assessed, location, stage, appearance of the wound bed, if drainage is present, and the status of the wound. The ADON (who is also the wound treatment nurse) said she will add wounds to this form once the physician has staged the wound and identified it as either a pressure ulcer, stasis (due to poor circulation) or diabetic type ulcer/wounds. She will identify if there is tunneling (Tunneling is a narrow passageway resulting from destroyed tissue )or undermining (Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening) is present, the appearance of the surrounding skin and skin edges, pain associated with the wound, any infections associated with the wound and if the physician and the family have been notified; -The nurse completes a facility's form entitled Investigation of an Abnormality to the Skin on any newly identified skin areas. During interview on 7/15/15 at 12:58 P.M., the ADON said that registered nurse (RN) C was responsible for doing everything besides pressure ulcer treatments (skin assessment, completing forms, reviewing shower sheets and obtaining physician orders). During an interview on 7/15/15 at 1:40 P.M. , RN C said the following: -He/she completed skin assessments on all residents up until two weeks ago; -His/her duties increased and he/she stopped doing skin assessments two or three weeks ago; -RN C reviewed the CNA shower sheets and said he/she should complete the weekly skin assessments on each resident; -He/she is expected to sign all the shower sheets in the building and look for any areas to investigate on the residents; -RN C is expected to write, treatment in progresson the shower sheets and give the sheets to the ADON/treatment nurse. The ADON/treatment nurse will notify the physician and a treatment will be established; -The CNAs complete the shower sheet when a shower is completed. During an interview on 7/15/15 at approximately 3:05 P.M., the administrator and the DON said two weeks ago, they identified that RN C had not completed the skin assessments for several months (May and June 2015). The DON said RN C should have been documenting skin assessments. For the past two weeks, the DON appointed a night nurse (LPN B) to complete the skin assessments. During an interview on 7/17/15 at 3:26 P.M., LPN B said the following: -Up until two days ago he/she completed the weekly skin assessments. He/she works as the charge nurse from 10 P.M. to 6:00 A.M. (night shift); -The LPN said on 7/07/15, he/she completed the skin assessments (on the night shift) for the entire building ( approximately 67 residents); -The LPN, did not complete a full skin assessment on every resident on 7/14/15. The LPN said she completed as many as she could while also being the charge nurse for the night. The DON expects the staff to notify the ADON if any new areas were identified during the assessments. The nurse documented all newly identified areas on the Weekly Skin Integrity sheet. The ADON/treatment nurse measures and contacts the physician and the family. Record review on 7/15/15 of the Wound and Skin Status Report dated 7/10/15, showed the ADON identified seven residents with skin wounds, while the staff hand wrote a list of 14 residents identified as requiring skin treatments. During an interview on 7/16/15, at 3:48 P.M., the administrator, the DON, ADON, RN C and the MDS coordinator said the following: -The staff are expected to add wounds, skin tears or any bruises to an Investigation of an Abnormal skin sheet. The CNAs should complete a 'Skin Monitoring: Comprehensive CNA Shower Review sheet' and bring it to the DON for further investigation. The DON and the ADON will assess the skin for further treatment. No one is tracking the shower sheets. The nurse just signs the shower sheets and changes it if something is incorrect. -The DON said it is her responsibility to ensure that weekly skin assessments are being completed and she dropped the ball on this. Staff did not complete the May and June 2015 weekly skin assessments. -The Administrator and the DON discovered the CNAs did not complete shower sheets for every shower. -The staff all agreed they do not have a tracking system for skin and there is too many forms being used. 2. Record review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 04/15/15, showed the following information: -On 4/7/15, the resident entered the facility; -Cognitively intact; -Total dependence on staff for bed mobility, transfers, locomotion, dressing, personal hygiene and toileting; -At risk for developing pressure ulcers; -The staff did not identify any pressure ulcers upon admission to the facility; -No pressure reducing or relieving devices to prevent pressure on the skin. Record review of the resident's Care Plan dated 4/14/15 showed the following: -Able to verbalize his/her needs; -Cooperative with care and requires assistance from staff for transfers using a mechanical lift; -Staff should use positioning devices and/or pillows for the resident while in bed; -The resident is able to turn and reposition while in bed; -Requires assistance of staff during showers; -Requires assistance with an indwelling urinary catheter, occasionally incontinent of bowel; -Requires assistance with toileting and after incontinence episodes; -The resident has his/her own mattress for prevention of skin breakdown; -Identified as at risk for skin breakdown due to decreased mobility; -The facility staff did not identify any pressure ulcers at that time. Record review of the resident's Braden Scale (a score predicting risk for pressure ulcer development) dated 4/14/15 showed the following: -The staff scored the resident a 14, or at moderate risk. Staff assessed the resident as having sensory impairment that limits the ability to feel pain or discomfort over half of the body. The resident has an indwelling urinary catheter in which the skin is usually dry. -Staff did not identify any open areas at this time. Record review of the May 2015 Skin Monitoring: Comprehensive CNA Shower Review form showed the following: -On 5/04/15, the staff did not mark or identify any skin areas on the resident's skin; -On unknown date, the DON signed acknowledgement of the form. Record review of the physician's orders [REDACTED]. -On 5/08/15, the physician ordered [MEDICATION NAME] (antibiotic) ointment topically, twice daily to affected skin areas (staff did not identify the location of the areas). -The physician ordered warm moist packs as needed and [MEDICATION NAME] (antibiotic) 100 mg (milligrams) twice daily. Staff did not identify a [DIAGNOSES REDACTED]. Record review of the Skin Monitoring: Comprehensive CNA Shower Review form completed on 5/18/15 and again on 5/20/15 showed CNAs did not mark or identify any skin areas on the resident's skin. On an unknown date, the DON signed acknowledgement of both forms. Record review of the May 2015 POS showed on 5/28/15, the physician discontinued the [MEDICATION NAME] medication. Record review of the Skin Monitoring: Comprehensive CNA Shower Review form showed the following: -On 6/08/15, the CNA identified an area on the resident's left upper heel as being a sore. -On 6/8/15, the charge nurse signed acknowledgement of the form, but did not document an assessment or a treatment plan for the resident's left upper heel. Record review of the June 2015 POS showed on 6/09/15, the physician ordered [MEDICATION NAME] ointment and dressing daily to a burn on the right inner arm. The POS did not show any other skin treatment orders for the month of June. Record review of the nursing notes showed the following: -On 6/15/15 at 10:55 A.M. the staff applied a dressing to the resident's left elbow. The nurse did not document a description of the area. -The nurse did not identify any other skin areas. Record review of nursing notes dated 6/16/15 showed the following: -At 10:50 A.M. the staff applied a dressing to the resident's right elbow. The staff did not document a description of the injury. The staff did not identify any other skin areas; -At 10:05 P.M. the staff said the resident's dressing to the left elbow was dry and intact. The staff did not describe the injury. The staff did not identify any other skin areas. Record review of the physician's progress notes showed the following: -On 6/19/15, the physician prescribed the resident a custom powered wheelchair for mobility with a Roho Cushion (special cushion used for pressure relief). -The physician wrote the resident had gluteal (buttocks) atrophy (decrease in the muscle tissue in the gluteal area due to lack of use). Record review of nursing notes showed the following: -On 6/20/15, at 12:00 P.M. the nurse documented the resident's skin as warm, dry, and intact; -On 6/20/15, (evening shift, no specific time documented), the nurse documented the resident had an open, bleeding area to the right elbow. Record review of nursing notes showed on 6/30/15 at 9:00 A.M., the nurse documented the resident's skin as warm, dry and intact. Record review of the Facility's Wound and Skin Status Report (a tracking form that is not part of the resident's medical record) dated 7/03/15 showed the staff did not identify the resident as having any wounds or skin problems. Record review of the Weekly Skin Integrity Review form showed the following: -On 7/07/15, the nurse identified an old surgical site on the resident's buttocks that had drainage. The nurse did not document a description of the wound or the drainage. -The staff identified an old open area on the left heel. The staff did not identify any other skin areas. Staff did not document a comprehensive assessment of the left heel area with measurements or any other description of the wound bed and surrounding skin. Record review showed staff did not complete the Skin Monitoring: Comprehensive CNA Shower Review sheets on 7/09/15. Record review of the physician's progress notes, dated 7/9/15, showed the following: -The physician noted the resident did not have any other skin problems except for a calloused, excoriated (skin that has been stripped off or removed) left decub (decubitus/pressure ulcer) on the resident's left heel. -The physician ordered TAO (Triple antibiotic ointment) and Prafo boots (a device that is worn on the calf and foot similar to a boot and is often used to relieve pressure and for residents who spend the majority of their time in bed). Record review of the facility's Wound and Skin Status Report (a tracking form that is not part of the resident's medical record) dated 7/10/15 showed staff identified the resident as having no wounds or skin problems. Record review of the resident's Wound Evaluation Flow Sheet showed the following information: -On 7/10/15, the staff started the treatment to the wound on the resident's left posterior upper heel. The staff documented the resident's wound as a new area. (CNA staff identified an left upper heel soreon 6/8/15, approximately one month earlier) The staff measured the resident's wound as an area measuring 3.0 cm x 3.5 cm, the staff said the wound had a slight odor and scant amount of pale serous exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation). The staff identified the area as a Stage III pressure ulcer. Record review of the July 2015 POS showed an order on 7/10/15, for TAO and dressing to the left heel daily. The physician ordered the resident to wear a protective boot on his/her left foot. Record review of the resident's quarterly MDS, dated [DATE], showed the following changes: -The nurse did not identify any pressure ulcers. The nurse identified only a skin tear and moisture related skin damage; -Staff provided ointments to the resident's feet for prevention of additional skin breakdown. Record review of the Weekly Skin Integrity Review form showed the following: -On 7/14/15, the nurse identified an old surgical site on the resident's buttocks that had drainage. The nurse did not document a description of the wound or the drainage. -The nurse identified an old area on the resident's left heel as ongoing. The nurse did not identify any other skin concerns. Record review of the resident's Wound Evaluation Flow Sheet showed the following information: -On 7/14/15, staff completed the resident's dressing changes to be done on Monday through Friday only. -The staff identified the resident's wound as a Stage III pressure ulcer. Record review of the July 2015 POS showed the following information: -On 7/14/15, the physician ordered to cleanse the area on the left posterior upper heel with wound cleanser or normal saline, apply Xeroform dressing (fine mesh gauze impregnated with a blend of 3% [MEDICATION NAME] Tribromophenate, or Xeroform, and USP [MEDICATION NAME] ) daily, Monday through Friday. Discontinue previous treatment. -On 7/15/15, the physician ordered to treat the right lower gluteal fold with wound cleanser and dress with Xeroform and Alleyvn (dressing to keep each wound at the optimum moisture) and cover every other day (Monday, Wednesday and Friday) until healed. Left lower gluteal fold is to be treated with calmoseptene (Moisture barrier prevents irritation). Record review of the Skin Monitoring: Comprehensive CNA Shower Review sheet, dated 7/15/15, showed the CNA documented a draining area on the resident's buttocks and an open and draining area on the resident's left heel. During an interview on 7/15/15 at 4:20 P.M. with the DON and the ADON said the following: -They have been monitoring the resident's old surgical wound since admission. The resident reported to the staff the wound had an odor. Upon observation, the staff did not witness an odor coming from the wound. The staff provide a dry dressing to absorb the clear to occasionally yellow drainage from the site. The staff provide the dressing as a comfort to the resident; -They said the resident has had a spot on his/her right heel for two weeks. The DON and ADON said the physician saw the wound last week and referred the resident to the wound clinic and ordered the resident to wear heel protectors. During an observation and interview with the resident and two unidentified CNAs on 7/15/15 at 4:30 P.M. showed the following: -The CNAs assisted the resident on his/her right side. The CNA pulled the resident's brief down to expose an old surgical wound and dressing. The ADON removed the soiled dressing with gloved hands. The ADON sanitized her hands and applied clean gloves. The ADON applied a clean dressing to the old surgical site. The ADON pulled the resident's brief up and stepped away from the resident, washed her hands and exited the room. The CNAs pulled the resident's pants up and rolled the resident onto his/her back. The resident's pants became soiled and the aides removed them. The aides rolled the resident onto his/her back. The surveyor questioned the aides regarding an open area on the resident's right buttock. The aides repositioned the resident and exposed another reddened area on the resident's left lower buttock; - The aides said the resident probably got the open area from sitting in his/her chair; - The resident said he/she had been telling the staff there was something wrong with his/her bottom for weeks but the staff would not listen to him/her. The resident said he/she reported an odor to the staff; but, staff did not listen; - The CNAs said they will report the new areas immediately to the charge nurse for care. The aides said they did not know of any areas on the resident's lower bottom except for the old surgical site until today. Record review of the change in status note, dated 7/15/15, at 4:30 P.M. showed the CNAs notified the charge nurse of a reddened area on the resident's left lower gluteal fold and an abrasion (an area damage by tearing or breaking way) on the right gluteal fold. The staff documented the treatment areas on the TAR. Record review of the facility's form entitled Investigation of an Abnormality to the Skin dated 7/15/15 showed the following: -Right Gluteal fold with a 1 in. (inch) x 0.5 in. area with some scab formation and some bright red areas. No odor or drainage noted; -Left Gluteal fold with a 1.0 in. x 0.5 in. bright pink spot with no open areas. The staff treated the resident's skin with Xeroform, Alleyvn and Coversite until evaluated by the wound clinic on 7/16/15. Record review of the resident's wound clinic physician progress notes [REDACTED]. -Primary reason for the visit for evaluation of the resident's sacral wound; -Treating the resident for a left heel ulcer with necrosis-unstageable, a right gluteal wound-unstagable with necrosis, and a stage I-II right heel ulcer; -The physician identified a pressure area on the right buttock measuring 1.5 cm (centimeters) x 2 cm x 0 cm, a pressure area on the left heel measuring 3.3 cm x 3.5 cm x 0.2 cm, and a pressure area on the resident's right heel measuring 0.7 cm x 1.0 cm; -The staff to place heel protectors on the resident. Record review of the resident's care plan showed the following changes: -On 7/16/15, staff identified a single Stage III ulcer on the resident's left posterior ankle (left heel ulcer). The ankle ulcer is managed by a wound physician; -Monitor the resident's skin daily and weekly by the wound nurse and on his/her shower days; -The staff did not identify or include interventions for the newly discovered open areas on the resident's gluteal fold and the right heel ulcer. During an interview on 7/17/15, at 2:57 P.M., CNA D said the following: -During the resident showers, he/she is expected to document any new areas on a shower sheet and report these areas to a nurse. Resident #4 has had the wound area on his/her heel for several weeks and the area continues to get worse. The CNA said she has reported this area to the DON, RN C, and the ADON. On 7/15/15, the CNA said he/she saw an open draining area on the resident's bottom. The CNA did not know of any treatment provided to the resident for the wound on his/her bottom. During an interview on 7/17/15, at 3:26 P.M., LPN B (night nurse previously responsible for skin assessments) said the following: -The nurse said he/she did not know of any areas on the resident's buttocks other than an old surgical site that occasionally drained. The resident only had one area on his/her heel; -The LPN said that any newly discovered area would be treated by the ADON and he/she should complete a weekly skin assessment form. 3. Record review of Resident #11's care plan, dated 2/2/15, showed the following: -Long-term placement; -Staff assistance with repositioning in the bed and chair; -Staff assistance of two for transfers or a sit-to-stand (designed to assist in raising weight-bearing residents to a standing position without the need for manual lifting) mechanical lift; -A wheelchair for mobility; -Staff assistance for personal hygiene and toileting; -Incontinence of both bladder and bowel; -At risk for skin breakdown due to decreased mobility; -Staff monitor for skin breakdown daily; -The wound nurse monitors for skin breakdown weekly; -The care plan is reviewed every 90 days and as needed. Record review of the Braden scale (an assessment instrument used to predict pressure ulcer risk), completed on 3/3/14, showed staff determined the resident was at risk of developing a pressure ulcer. Record review of the facility forms titled, Skin monitoring: comprehensive CNA shower review sheets showed the following: -On 6/16/15, showed the CNA's visual assessment showed no skin concerns. The charge nurse signed and dated the form with the same date. The DON signed the form but did not date it. -On 6/19/15, showed the CNA's visual assessment showed the CNA noted an abnormal color and the CNA circled the buttock region of the body diagram. The charge nurse assessment noted the resident's buttocks were red and listed the intervention as protective cream applied. The DON signed the form but did not date it. Record review of the skin monitoring/comprehensive CNA shower review sheet dated 6/23/15, showed the showed the CNA's visual assessment showed the CNA circled on the body graph the resident's inner areas of both buttocks and identified as having an abnormal color. The charge nurse assessment noted the resident's buttocks were red and listed the intervention as protective cream applied. The DON signed the form but did not date it. Record review of the facility weekly skin integrity review sheet, completed by a RN, dated 6/23/15 and 6/26/15 showed the RN noted the resident's skin condition with redness and noted macerated area (the softening and breaking down of skin resulting from prolonged exposure to moisture) and the body graph showed the nurse circled the resident's buttocks with an inner circle to the residents inner mid buttocks area. Record review of the skin monitoring/comprehensive CNA shower review sheet dated 6/26/15, showed the CNA's visual assessment showed the CNA circled the body graph identifying the resident inner areas of both buttocks as [MEDICAL CONDITION]. The charge nurse assessment noted the resident's buttocks were red with dark areas on the inner lower buttocks. The nurse listed the intervention as protective cream applied and resident repositioned frequently. The DON signed the form but did not date it. Record review of the resident's skin monitoring/comprehensive CNA shower review sheets showed the following: -On 6/30/15, the CNA's visual assessment showed the CNA circled the resident's buttocks and identified the area as abnormal in color. The charge nurse assessment noted the resident's buttocks were dark red and listed the intervention as protective cream applied. The DON signed the form but did not date it. -On 7/3/15, the CNA's visual assessment showed the CNA circled the resident's buttocks area and identified them as abnormal in color. The charge nurse's assessment noted the resident's buttocks were red and listed the intervention as protective cream applied. The DON signed the form but did not date it. Record review of the resident's daily skilled nurse's note, dated 7/5/15 through 7/8/15 showed staff documented the resident's skin was within normal limits with no skin concerns or pressure ulcers were identified. Record review of a nurse's notes identified as a late entry for 7/8/15 showed the nurse inspected the resident's buttocks and noted no open areas but identified a patch of sloughing (outer skin shed) skin on right buttock and applied barrier cream. Record review of the skin monitoring/comprehensive CNA shower review sheet, dated 7/7/15, showed the CNA's visual assessment showed the CNA circled the resident's low back, buttocks and back of upper thighs area and listed these areas as abnormal in color. Additionally, the CNA circled the inner areas of both buttocks and identified them as macerated areas. The charge nurse assessment noted the resident's buttocks were red with small areas of maceration and listed the interventions as protective cream applied and repositioned. The DON signed the form but did not date it. Record review of the skin monitoring/comprehensive CNA shower review sheet dated 7/10/15 showed the CNA's visual assessment showed the CNA circled the resident's low back, buttocks and back of both upper thigh area and listed these areas as abnormal in color and labeled them red. The charge nurse's assessment noted the resident's buttocks were dark red and listed the intervention as protective cream applied and resident repositioned frequently. The DON signed the form but did not date it. Record review of the resident's medical record and other facility forms showed the nurses did not further assess the area to determine if the redness blanched or did not blanch which is the criteria for determining a Stage I pressure ulcer. Record review of the facility's Weekly Skin Integrity review sheets dated 7/7/15 and 7/14/15 showed the RN noted the resident's skin condition had an old open area and the body graph showed the resident's buttocks marked with an x to the mid buttocks area. Record review of the resident's medical record and other facility forms showed no evidence nursing staff notified the physician of the skin condition on the resident's buttocks to obtain a treatment order. During observation and interview on 7/16/15, at 9:51 AM, CNA E and CNA F transferred the resident from his/her bed to the wheelchair. CNA E said the resident had two small open areas on his/her bottom. During observation and interview on 7/16/15, at 11:19 AM, CNA E and RN G transferred the resident from his/her wheelchair to the commode. The RN said the resident's open area to his/her bottom was no longer open. Upon observation, the RN said the open area was better because there was no middle indented area and said the area had become granulated (formation of new tissue in a wound). Observations showed there was an open area to the resident's inner right buttock approximately 2.2 cm in length and approximately 1.0 cm in width at the widest part with an approximately 0.2 cm indentation, connecting area, midway on both sides (somewhat kidney-shaped) with a red beefy granulated wound base. During an interview on 7/16/15, at 11:35 AM, CNA E said the resident's open areas to his/her bottom were fairly new and healing quite well. During an interview on 7/16/15, at 11:40 AM, LPN H said the following: -The charge nurse or the wound nurse completed the residents' skin treatments. -The current treatment to the resident's buttock open area was extra protective cream each shift. -The treatment should have been written on the MAR/TAR. -The resident does not like to lay on his/her side and preferred to lay on his/her back. During an interview on 7/16/15, at 11:51 AM, RN G said the following: -The CNAs failed to report the open area to him/her. -He/She was not aware the resident's area to the buttock was open. -He/She just investigated the open area to the resident's buttock; -He/She checked the MAR/TAR and staff failed to write a treatment to the resident's buttock open area. -He/She would be completing the change of condition paperwork. -The CNAs should have reported any resident changes to the charge nurse. During an interview on 7/16/15, at 1:25 PM, CNA F said the area to the resident's buttock opened during the past month. The CNAs completed shift to shift report with the on-coming CNAs and it had been reported the charge nurse had been informed of the resident's open area. Complaint # MO 27 and MO 76

Based on observation, interview, and record review, the facility failed to ensure staff provided protective oversight and adequate supervision for two residents (Resident #1 and Resident #2) who had [DIAGNOSES REDACTED]. The residents had a public administrator as guardian. On 1/13/14, the facility failed to implement interventions to prevent another elopement attempt after the residents tried to memorize and input pass codes to exit the facility. The residents had multiple elopement attempts between 12/18/13 and 2/21/14, which included exiting through alarmed exit doors and enlisting the help of a visitor to transport the residents' packed belongings to their home on 2/18/14. The facility staff failed to assess, monitor, and accurately document the events of the elopement on 2/21/14, when the residents left the facility property, crossed a busy street, with Resident #1 almost being struck by a car. The facility failed to follow the facility elopement protocol following the incident. The facility failed to develop a care plan to address the residents' elopement risk, repeated attempts and vocalizations of wanting to go home. The facility failed to ensure one of three sampled residents (Residents #3), who was at a high risk for fractures due to a [DIAGNOSES REDACTED]. This failure resulted in a spiral fracture (bone fracture occurring when torque (a rotating force) was applied along the axis of a bone) of the resident's right leg. The facility failed to notify the physician of the incident and of the resident's complaint of pain which resulted in a delay of treatment for 11 1/2 hours before the resident was transported to the hospital. The census was 70. Record review of the facility's elopement policy dated March 2004, showed, in part, the following information: -Nursing personnel must report and investigate all reports of missing residents. -It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. -Should an employee observe a resident leaving the premises, he/she should: -Attempt to prevent the departure; -Obtain assistance from the other staff members in the immediate vicinity, if necessary. -Instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the premises; and -Be courteous in preventing the departure and in returning the resident to the facility. -Upon return of the resident to the facility, the director of nursing services or charge nurse should: -Examine the resident for injuries; -Contact the attending physician and report what happened; -Contact the resident's legal representative and inform him/her of the incident; -Complete and file an incident report; -Make appropriate notations in the resident's medical record; -Take appropriate action to try and prevent future elopements. Record review of the facility's elopement precautions/missing resident policy, dated 2001, showed, in part, the following information: -The objective is prevention of the resident from leaving the facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing. -The resident will be considered an elopement risk when unsafe to leave the facility without supervision. Examples of elopement risk: -1. They are admitted with a history of elopement, -2. They have made attempts to leave without supervision since admission, -3. They give verbal indicators that they have intent to leave,-4. They demonstrate elopement behavior or there is an elopement incident since admission. A resident will no longer be considered an elopement risk when there has been no demonstrated elopement behaviors during an annual comprehensive review period (12 months) or the resident's ambulation status declines to a point that elopement is not a possibility. -Any resident that demonstrates or verbalizes elopement will immediately be considered an elopement risk and immediate care interventions will be adopted to prevent unplanned elopement. -Residents who are considered an elopement risk are to have their whereabouts confirmed at least every 30 minutes. -Residents who are demonstrating agitation and demonstrating elopement attempts are to remain under constant surveillance until the period of agitation resolves. Increased whereabouts checks shall be maintained until staff is assured the resident is thoroughly redirected and it is safe to return to 30 minute checks. -Residents who continually demonstrate periods of agitation and elopement and do not suffer from dementia, who are able to manipulate the alarms and the exits, and who are unsafe to leave without assistance, shall be considered for discharge to a more secure environment pending consultation with physician, family, legal authority, case manager, and if appropriate, the interdisciplinary team of the facility. -The elopement precaution policy does not guarantee all elopements can be prevented. Residents who are assessed to be at such high risk that the facility is not able to keep them safe using the reasonable precautions provided for by this policy shall be subject to immediate transfer. -Residents who are assessed to be elopement risks shall have specific care plan interventions that identify how to manage the resident's elopement behavior. -Any identifiable indicators by the resident that an elopement episode is likely to occur is to be included. Such behaviors might include statements about leaving, i.e. "I'm going home today" or behaviors such as putting on hat and coat, looking outdoors, packing clothes, restlessness, or other indicators identified in previous elopement incidents that have been displayed before the elopement attempt occurred. -Interventions should include how the resident is best redirected, what works, various interventions that might have to be considered until the most effective intervention is identified. 30 minute whereabouts checks are to be included in all interventions and constant surveillance must be included when a resident is demonstrating elopement behavior. -An occurrence consisting of a resident leaving through an alarmed door, the door alarming, and staff responding in accordance with this policy and immediately returning the resident to the facility, shall be considered as having an effective system in place to manage elopement behavior and an unusual event incident and report are not required. Such behaviors should be reflected in the care plan and the nursing documentation and known by physician and family as an existing behavior and need not be reported each time it occurs unless it is reflecting a change in the usual functioning of the resident. Such incidents would be reported to the oncoming shifts to heighten alert. Record review of the (undated) facility protocol for any elopement or attempted elopement showed, in part, the following information: -Start 15 minute checks per form; -Start care plan; - Put large print elopement monitoring protocol in all nursing and nurse aide report books; -Nurse to fill out elopement risk assessment form; -Notify doctor and family. -Once the resident is secure you must read the policy and fill out the necessary paperwork: -Incident report; -Elopement monitoring sheet for 72 hours; -Elopement risk assessment; -Change in condition report; -Risk elopement review for the next four weeks. Charge nurse does the first one then hands it off to the DON to complete the next 3 weeks of follow up. -Staff also then start charting for 72 hours. 1. Record review of Resident #2's hospital neurological consultation, dated 12/16/13, showed the following information:-Resident has altered mental status, forgetfulness, delusions, and hallucinations. This appears to be longstanding. The resident most likely has underlying dementia with psychotic features;-His/her insight and judgment are impaired;-He/she is unable to make decisions about him/her self and it affects taking care of Resident #1 also as Resident #1 is dependent on Resident #2;-He/she is unable to take care of him/her self, requires supervision constantly, and placement in a long-term care facility appears to be medically necessary at this time. Record review of the initial care plan dated 12/18/13, showed the following information:-Wheelchair and walker for mobility;-Continent bowel and bladder;-Able to communicate;-Alert, poor short-term memory;-Poor decisions;-No known behaviors. Record review of Resident #2's nurse's notes showed the following information:-On 12/19/13:-At 3:00 P.M., alert and oriented times two. Resident #2 wants to know when this office is going to release him/her. -At 9:15 P.M., staff observed Resident #2 being pushed in the wheelchair by Resident #1 out the back door by the laundry entrance. Staff followed and returned the residents to the building. Resident #2 cursed and threatened staff. Staff did not document they notified the resident's physician, guardian, administrator or DON. Staff did not document they started the facility elopement protocol; -At 10:00 P.M., Resident #2 and Resident #1 were at the nurses' station on frequent checks. Resident #2 said he/she and Resident #1 wanted to go home;-On 12/20/13 at 3:05 P.M., the resident remained on frequent checks. The resident continued to make a "plan" with Resident #1 about leaving the facility;-On 12/21/13, staff checked the resident frequently due to the incident earlier in the week;-On 12/22/13, the resident used a cane and wheelchair to ambulate;-On 12/23/13:-At 12:00 A.M., Resident #2 kept saying, "Resident #1 and I are going home". Resident #2 had Resident #1's clothes in his/her room and would not let the nurse remove them.-At 2:00 P.M., in a weekly note, the DON documented the resident was mad and angry about being at the facility. The resident was hateful to staff. Staff kept frequent checks on him/her because he/she did make statements about going home. The DON did not document the elopement attempt from 12/19/13. Record review of the five day admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 12/24/13, showed the following information:-Severely impaired cognitive decision-making skills -Extensive assistance for mobility and transfers;-Used a walker, cane and/or wheelchair/ Record review of the nurses notes showed:-On 12/24/13:-At 2:25 P.M., Resident #2 sat in the wheelchair in the hall with Resident #1;-At 4:00 P.M., Resident #1 and Resident #2 exited through the door to the parking lot. Staff followed the residents and returned the residents to the building. Staff did not document they notified the resident's physician, guardian, administrator or DON. Staff did not document they started the facility elopement protocol. Record review of the comprehensive admission care plan dated 12/26/13, showed the following information: -Alert and oriented to person, place and surroundings;-The resident had a problem with adjusting to the facility; -Resident #2 and Resident #1 have come to live at the facility because Resident #2 was no longer able to care for self and Resident #1; -The resident was not happy about being here;-The resident often complained staff do not take care of him/her and he/she would be better off at home;-The resident would like to return home;-Staff did not develop problems, goals or interventions to address the resident's elopement risk, elopement attempts on 12/19/13 and 12/24/13, the resident's repeated comments of wanting to go home, and the packing of Resident #2's and Resident #1's clothes. Record review of Resident #2's nurse's notes showed the following information:-On 12/27/13, the resident wandered frequently, talking about leaving to go home;-On 12/28/13, Resident #1 and Resident #2 continue to "plot their escape from the facility" although no attempts have been made.-On 12/30/13, in a weekly note, the DON did not document regarding the 12/19/13 and 12/24/13 elopement attempt and the residents' plot to escape.-On 12/31/13 at 7:35 P.M., Resident #1 and Resident #2 have been exit-seeking this evening and requiring constant monitoring. The residents have clothes packed and concealed behind Resident #2 in his/her wheelchair. Staff did not document he/she notified the resident's physician, guardian, administrator or DON. Staff did not document they started the facility elopement protocol; -On 1/4/14 at 10:00 P.M., Resident #2 tried to talk Resident #1 into leaving the facility;-On 1/6/14, in a weekly note, the DON did not document regarding the 12/19/13, 12/24/13, or 12/31/13 elopement attempts or the residents packing and concealing their clothing.-On 1/13/14, the DON documented Resident #2 and Resident #1 have been sitting by the front door watching the code being entered and asking people to let them out. The Social service director (SSD) brought Resident #2 to his office. Resident #2 started calling everyone names. The DON told the resident his/her guardian had Resident #2's and Resident #1's best interest in mind. Resident #2 said the guardian was not "telling him/her what to do". Resident #2 threatened to hit SSD and his/her guardian with his/her cane. Staff called the physician and received orders to send the resident to a behavioral unit for an evaluation. Record review of the care plan between 12/26/13 and 1/13/14, showed staff did not develop problems, goals and interventions to address the resident's elopement risk, elopement attempts on 12/19/13, 12/24/13, 12/31/13, and 1/13/14 or the resident's repeated comments of wanting to go home, "plotting an escape plan", concealing clothes behind him/her in the wheelchair, and packing his/her and Resident #1's clothes. Record review of the hospital psychiatric evaluation, dated 1/13/14, showed, in part, the following information:-Resident #2 transferred from the facility due to increasing psychosis, agitation, and related behaviors;-Resident #2 was trying to elope;-The resident was alert and oriented to location, month and year;-The resident's thought process did show some confabulation (fabricated, distorted or misinterpreted memories ) but was generally goal directed. Record review of Resident #2's nurse's notes showed on 1/27/14, staff readmitted Resident #2. Staff did not document any behaviors at this time. Record review of the care plan dated 1/27/14, showed the following information:-Resident #2 was recently sent out to a behavior unit due to his/her behaviors. Since the resident's return from the behavior unit, the resident was calmer and more cooperative with staff;-Staff did not develop problems, goals or interventions to address the resident's elopement risk and previous elopement attempts. Record review of Resident #2's nurse's notes showed the following information:-Between 1/28/14 to 2/1/14, staff did not document regarding behaviors; -On 2/1/14, staff documented during the last three days in the evening, the resident was starting to have behaviors and refusing medications. Resident #2 still did not understand the purpose or need for oversight. Resident #2 was also influencing Resident #1 on taking his/her medications. The charge nurse informed Resident #2 if the behaviors continued, Resident #2 and Resident #1 would be separated;-On 2/11/14, Resident #2 was very agitated and upsetting Resident #1. Resident #2 demanded to know why Resident #2 and Resident #1 "can't leave". Resident #1 kept saying his/her family would come get them. Resident #2 said, "No one's gonna tell us what to do".-On 2/13/14, Resident #2 was combative and agitated. Resident #2 would not leave Resident #1's room;-On 2/18/14, charge nurse licensed practical nurse (LPN) A documented a visitor of another resident let Resident #2 out the front door. Staff found Resident #2 and Resident #1 packing items in boxes and putting the boxes outside the front door. Staff redirected the residents inside. LPN A did not document he/she notified the resident's physician, guardian, administrator or DON. LPN A did not document he/she started the facility elopement protocol and frequent checks.-On 2/19/14 at 10:20 P.M., Resident #2 was argumentative and refusing medications. Staff had to redirect Resident #2 several times away from the outside doors.-Between 2/19/14 to 2/20/14, staff did not document regarding the residents' behaviors and exit seeking. Record review of the monthly summary dated 2/19/14, showed the nurse documented Resident #2 continued to be an elopement risk. Record review of the care plan showed the following information:-On 2/20/14, staff documented Resident #2 still would like/wanted to go home. Resident #2 has been placed on elopement precautions due to his/her previous behaviors of getting upset and wanting to leave. Resident #2 was on elopement precautions per the facility protocol;-Staff still did not develop goals or interventions to address the resident's elopement attempts and risk. Record review of Resident #2's nurse's notes showed the following information:-On 2/21/14 at 10:15 A.M., the DON documented Resident #2 and Resident #1 left the building and headed to the store. The DON and administrator brought Resident #2 back to the facility. Resident #2 said they wanted to go to the store. The DON explained to Resident #2, they had to go with someone and could not go alone. Resident #2 was upset and cussing. Resident #2 was told staff were transferring Resident #1 to another facility. The DON did not document that Resident #2 and Resident #1 had eloped off the facility property.-On 2/22/14, the nurse documented Resident #2 had kept to his/herself most of the day. Resident #2 had been emotional, crying, and worrying about Resident #1. In the dining room during supper, Resident #2 told staff when he/she "got out, he/she would come back to this place and shoot it up". The nurse did not document notification of the physician, guardian or administrator of the resident's threats to staff. 2. Record Review of Resident #1's nurses' notes, dated 12/18/13, showed staff admitted the resident to the facility. Staff documented the resident said he/she would be getting married this month and leaving here. Record review of the initial admission care plan dated 12/18/13, showed the following information: -The resident walked independently, turned self in bed, continent of bowel and bladder, dresses and feeds self, alert and was able to communicate needs. The resident was alert.-The resident did not have any known behaviors;-Staff did not document the resident as an elopement risk. Record review of the nurses' notes showed the following information: -On 12/19/13:-At 10:30 A.M., Resident #1 said to the DON several times "I need to go home". -At 9:15 P.M., staff observed Resident #1 pushing Resident #2 (who is related to Resident #1) in a wheelchair out the door by the laundry room. The staff followed the residents and returned the residents to the building. Resident #1 became very loud and angry. Resident #1 continued to "wander" and said he/she "wants to go home". Staff did not document they notified the resident's physician, guardian, administrator or DON. Staff did not document they started the facility elopement protocol. Record review of the initial admission care plan dated 12/18/13, showed staff did not update the care plan on 12/19/13, to indicate the resident was an elopement risk. Record review of the nurses' notes showed the following information: -On 12/20/13, Resident #1 continued to "wander" pushing Resident #2 in the wheelchair. Staff instructed Resident #1 to stay out of rooms except his/her own room. -On 12/21/13, Resident #1 said to staff that he/she was leaving tomorrow. -On 12/22/13:-At 3:20 P.M., Resident #1 said repeatedly that he/she was going home on Tuesday and getting married. "Resident alert with periods of confusion, fixated on certain things. Was very determined that he/she was leaving tonight". -Night shift staff documented they found Resident #1 to have his/her clothes packed and would stand at the door "eyeing staff". Staff encouraged Resident #1 to get some sleep; Record review of the admission MDS assessment dated [DATE], showed the following information:-Severely impaired cognitive decision-making skills -Has the resident wandered?: staff documented "0" for behaviors not exhibited;-Section E1000: Wandering Impact:-Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of facility). Staff left this section blank;-Independent with transfers and mobility. Record review of the nurses' notes showed: -Between 12/23/13 to 12/26/13, staff did not document any behaviors or elopement attempts. (Record review of Resident #2's notes showed on 12/24/13 at 4:00 P.M., Resident #1 and Resident #2 exited through the door to the parking lot. Staff followed the residents and returned the residents to the building.) -On 12/26/13, the DON documented Resident #1's behaviors continued. Resident statements included, "I want to go home", and "why am I here?". The DON did not document the elopement attempts from 12/19/13 to 12/24/13. Record review of the comprehensive care plan dated 12/26/13, showed the following information:-Resident was alert and oriented to person and surroundings. -Resident has mental retardation and short-term memory problems;-Resident was able to verbalize needs with clear speech;-Resident would like to go back home because of his/her garage;-Resident tells staff, when he/she goes back home he/she is getting married. Resident has been telling this story for a very long time;-Resident asks staff everyday when he/she will get to go home; -Staff did not develop problems, goals or interventions to address the resident's elopement risk, elopement attempts on 12/19/13 and 12/24/13, or the resident's repeated comments of wanting to go home, and packing his/her clothes. Record review of the nurses' notes showed the following information: -On 12/27/13, at 10:00 P.M., Resident #1 said he/she was going home on Monday. -On 12/29/13, at 11:30 A.M., Resident #1 and Resident #2 talked to SSD about leaving. -On 12/30/13, at 9:00 P.M., Resident #1 "continues to talk about getting out of here". Record review of the monthly summary dated 1/1/14, showed the following information: -Resident #1 has inattention, disorganized thinking, short tempered, rejects care, delusions, and obsesses on going home. -Resident #1 constantly wanders the halls pushing Resident #2 in the wheelchair. -Resident #1 "Threatens to leave facility and walk home". Record review of the nurses' notes showed the following information: -On 1/3/14, the DON documented Resident #1 showed no change. He/she continued to want to go home and speaks of getting married. -On 1/4/14, at 9:50 P.M., Resident #1 and Resident #2 were at the nurses' station. The residents said they were "leaving this place!" -On 1/6/14, at 2:35 P.M., Resident #1 continues to wander around the building. -On 1/13/14, at 6:00 P.M., Resident #1 was upset by a phone call from a family member. Resident #1 was crying and said he/she wanted someone to take him/her home. Record review of the physician's notes, dated 1/18/14, showed the following information:-Present illness: Resident continues to ask nursing staff whether he/she could leave or not. Record review of the nurses' notes, dated 1/20/14, from 10 P.M.-6 A.M., the resident was in the room coloring and talking about fixing bikes and going home. Record review of the monthly summary dated 1/27/14, showed the following information: -Resident #1 has inattention, disorganized thinking, short tempered, rejects care, delusions, and is obsessed with going home. -Resident #1 constantly wanders the halls and talks about going home with Resident #2. Record review of the nurses' notes showed the following information: -On 1/28/14, at 5:35 P.M., Resident #1 continues to say he/she "can't wait to go home". -On 2/1/14, at 12:20 P.M., staff overheard the resident on the phone saying to a family member, "I don't like it here, I just want you to come get our stuff and take us out of here!". -On 2/18/14, at 7:00 P.M., LPN A documented staff found Resident #1 packing personal items and placing them outside the front door. Another resident's family member let Resident #1 and Resident #2 out the front door. Resident #1 asked a visitor of another resident to move his/her belongings to his/her house. The staff informed the visitor that it was not allowed to take residents out of the facility. Staff redirected Resident #1 to his/her room. LPN A did not document he/she notified the resident's physician, guardian, administrator or DON. LPN A did not document he/she started the facility elopement protocol and frequent checks.-On 2/19/14, Resident #1 non-compliant and argumentative. The resident was upset because he/she could not go home. Staff redirected the resident several times away from the outside doors. Record review of the monthly summary dated 2/19/14, showed the following information: -Resident #1 was inattentive with disorganized thinking. Resident #1 rejects care, is short tempered, delusional and continues to obsess about leaving and going home. -The resident is an elopement risk and needs to be monitored frequently. Record review of the care plan showed the following information: -On 2/20/14, staff documented Resident #1 was at risk for elopement due to wanting to go home. Staff placed Resident #1 on elopement risk with precautions in place per facility practice.-Staff did not develop goals and interventions to address the resident elopement attempts and risk. Record review of the nurses' notes, dated 2/21/14, at 10:15 A.M. showed staff observed Resident #1 leaving the building. Staff "intercepted" the resident. Resident #1 said he/she was going to the store to shop. Resident #1 said he/she was not aware that someone had to go with him/her. Resident #1 became upset saying, "I want to leave here! I am not staying! I want to go home!" Staff notified the resident's physician and court appointed guardian. The DON did not document that Resident #2 and Resident #1 had eloped off of the facility property. Record review of the physician's orders [REDACTED].#1 to a facility with a locked unit. 3. During an interview on 2/26/14 at 5:15 P.M., the assistant director of nursing (ADON) said: -Resident #1 was discharged to another facility because he/she was an elopement risk;-Resident #1 and Resident #2 (related to Resident #1) were trying to leave the facility and go out the doors. Resident #2 was getting Resident #1 upset more and more. Resident #1 and Resident #2 wanted to go home; -Resident #1 would pack his/her clothes for several days;-Resident #2 was trying to figure out the security code to the front facility entrance door; staff thought he/she was watching visitors enter the code and writing down different code combinations;-Resident #1 and Resident #2 had not been successful getting out of the facility;-The residents had suspicious and increased behaviors;-The ADON said she was not aware of Resident #1 and Resident #2 getting out of the building;-Staff did not have any in-services on elopement since Resident #1 was discharged . Observation and interview on 2/26/14, at 5:34 P.M., showed Resident #2's room at the end of the corridor, next to an exit door. The resident sat on the side of the bed. -Resident #2 said (on 2/21/14), he/she and Resident #1 were "going home, they just walked right out the door. We knew everyone was against us, so I said let's go". They left the facility and Resident #2 wanted to go the store (the store was across the main highway west of the facility approximately 0.08 miles or 423 feet away). Resident #2 told Resident #1, "Okay baby, you go to the store". Resident #2 said when Resident #1 tried to cross the highway, he/she "almost got hit by a car". Resident #1 made it into the store and "they (staff) did not like that". The DON and the administrator started "yelling and screaming at him/her from the car on the road. The maintenance man went into the store and got Resident #1".-Resident #2 said he/she and Resident #1 had gone out of the building before to get fresh air; but, they heard an alarm and staff made them come back inside;-Resident #2 said he/she had not tried to leave since Resident #1 was discharged , but "not saying that I won't try again". During an interview on 2/26/14, at 5:35 P.M., the DON and administrator said:-Resident #2 would get Resident #1 agitated and his/her behaviors escalated;-The administrator said on 1/13/14, staff documented Resident #2 and Resident #1 watched as visitors put the codes in at the front door. Staff had to direct the residents away from the door. Resident #2 became upset, cussing and threatening his/her guardian. Staff received orders to send the resident to the behavior unit for evaluation. The DON said when the facility readmitted Resident #2 he/she had seemed to improve. -On 2/21/14, the DON said Resident #1 and Resident #2 wanted to go to the store. They got out of the facility, down to the sidewalk, and staff stopped them at the sidewalk. Staff told the residents they could not go to the store. Staff got the residents back into the facility. The residents were "angry and wanted to leave". The DON said a visitor of another resident let Resident #1 and Resident #2 out of the facility. The DON and administrator did not say the residents had left the facility property and that Resident #2 had crossed the highway to the store. -The surveyor told the DON and administrator of the resident's interview and he/she and Resident #1 were off the facility property. The surveyor asked the DON and administrator at what point did Resident #1 and Resident #2 leave the facility property and at what point did staff go into the store to get Resident #1;-The DON and the administrator admitted Resident #1 and Resident #2 had eloped off the facility property. The administrator said the truth was that the maintenance director was coming up the facility driveway and saw Resident #2 off the facility property on the side of the highway;-After staff brought the residents back into the facility, the administrator and DON discussed interventions but did not document the interventions. The administrator considered placing a sign on the facility doors alerting visitors not to let residents out of the facility. The administrator said staff never made those signs. The staff did not change the code on the front door;-The administrator was aware of the 2/18/14 incident but was not aware the residents were outside the facility doors. The DON was not aware of the 2/18/14 incident; -The DON had LPN A come to the office to recall the 2/18/14 incident. LPN A said he/she walked down the hall and saw a bunch of staff by the front doors. A visitor of another resident had let Resident #1 and Resident #2 out the front doors. Resident #1 had his/her personal belongings outside the front door. Staff had a hard time redirecting Resident #1 back into the facility. Staff brought the resident's personal belongings back into the facility. LPN A did not complete an incident report but did start the frequent checks on Resident #1 and Resident #2 (staff could not locate documentation of the frequent checks from 2/18/14 to 2/21/14). During an interview on 2/26/14, at 7:15 P.M., LPN A said Resident #1 and Resident #2 had eloped from the facility. Resident #1 made it to the store and Resident #2 was on the opposite side of the road, waiting. LPN A was not sure how the residents got out of the facility. During an interview on 2/26/14, at 7:50 P.M., the administrator said:-An elopement was anytime a resident was off the facility property;-Resident #1 and Resident #2 "were just going to the store";-She could not recall what the facility policy was regarding elopement and could not recall if an elopement off the facility property was reportable to the state agency;-The new staff need more education about elopement;-Staff completed elopement risk sheets for all residents at risk for elopement. -The administrator retrieved a copy of the facility elopement protocol. She said the staff did not implement and follow the facility's elopement protocol. During an interview and record review on 2/

Based on record review and interview the facility failed to identify, assess and document pressure ulcers that one resident (Resident #17) acquired in the facility. The resident had two superficial areas, one on each buttock on admission on 7/13/12. By 08/23/12, the resident had acquired three unstageable pressure ulcers ( not stageable due to coverage of wound bed by slough and/or eschar, dead tissue), one on the resident's coccyx (tail bone), one on the resident's right foot (identified by the wound clinic and not facility staff) and the third as an unstageable blue blister on the resident's right heel. The resident also developed a pressure ulcer, in the form of a blood blister, on the left heel. The delay in identifying and assessing the pressure ulcers caused a delay in treatment. The facility also failed to notify and follow-up with the physician regarding abnormal laboratory showing infection in one of the pressure ulcers. This caused a delay in antibiotic treatment for [REDACTED]. Eight residents were sampled out of a facility census of 90. According to MEDSCAPE NURSING MEDPULSE (Nurses.Medscape.com) purple or maroon localized areas of discolored intact skin or blood-filled blisters are the result of damage to the underlying soft tissue from pressure and/or shear.* The affected tissue may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue. The evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (dead tissue). The progression of this type of injury can be rapid, exposing additional layers of tissue even with optimal treatment. *Shear occurs when friction holds the skin in place but the body is pulled by gravity, as when a patient slips down in bed from a semi-upright position. Although it looks like a deep bruise, deep tissue injury is sometimes mistaken for a category I pressure ulcer. This can happen if only the color and fact that the skin is intact are noted. However, these injuries are potentially extremely severe because they indicate deep subcutaneous injury occurring from the inside out. Despite the relatively mild appearance, these [MEDICAL CONDITION] can open up into full-blown pressure ulcers within days. Deep tissue injury usually advances rapidly despite proper care. 1. Record review of Resident #17's medical record showed [DIAGNOSES REDACTED]. Record review of the resident's admission evaluation and interim care plan, dated 07/13/12, showed the following information: -Braden score (a tool used to predict pressure sore risk) of 20 (a score of 15-18 equals a resident at risk); -The resident had a 1 centimeter (cm) to 2 cm open area on both of his/her inner buttocks. Record review of a nurses' note, dated 07/13/12, at 4:00 P.M., showed a nurse documented the resident had a 1 cm-1.5 cm open areas observed on both inner buttocks. Record review of the initial care plan, dated 07/13/12, showed the following information: -Required assistance of two staff for transfers and turning; -Required total assistance for dressing and personal hygiene; -Required staff assistance for eating. Record review of a physician's orders [REDACTED]. Record review of the weekly summary, on the back of the July 2012 treatment administration sheet (TAR) showed on 07/16/12 a nurse documented the resident had two skin shears, very superficial in depth. The left buttock skin shear measured 2 cm x 2 cm and the right buttock shear measured 5.5 cm x 2 cm. Record review of the admission minimum data set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 07/19/12, showed the following information: -Total score of 13 on the brief interview for mental status (cognitively intact); -Extensive assistance required for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Indwelling catheter; -At risk for pressure ulcers; -No pressure ulcers; -Pressure relieving device for bed; -Applications of ointments/medications other than to feet. Record review of the weekly summary, located on the back of the July 2012 TAR showed on 07/25/12 a nurse documented the resident's skin shears were very superficial in depth. The left buttock shear was healed and the right buttock had two areas measuring approximately 0.1 cm. Record review of the Resident Treatment Details (physical therapy/ PT progress notes), dated 07/22/12-07/27/12, showed on 07/25/12 the physical therapy aide (PTA) documented the resident complained of pain/ discomfort on his/her left heel; the area was very purple to deep purple in color. The PTA placed a rolled up blanket under the resident's heels and informed the wound care nurse and rehabilitation manager. Record review of the nurses' note, dated 07/25/12, showed all three shifts, the nurses' documented the resident had no skin concerns with no mention of the left heel identified by the PTA. Record review of the care plan, dated 07/26/12, showed the resident at risk for skin breakdown due to decreased physical mobility. He/she had two skin shears on his/her buttocks; treatment, as ordered, by wound nurse. Staff assisted the resident with repositioning in bed and chair as needed and used positioning devices and/or pillows as needed. Record review of a nurses' note, dated 07/28/12, at 4:30 A.M., showed the nurse documented the resident complained of left heel pain. The resident's left heel was "mushy" and light red but had no open areas. The resident had pressure reliving boots on his/her feet. Record review of PT's Resident Treatment Details dated 07/29/12-08/04/12, showed on 08/03/12, a late entry for 08/02/12, the PTA documented the resident complained of a sore bottom. The PTA noticed a "slit" on the upper buttocks area and a quarter-sized deep purple area on the resident's right buttocks. The certified nurse aide (CNA) said he/she will notify the charge nurse, however the PTA reported the area to the DON. Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/03/12 a nurse documented the resident's skin was fragile but intact. The nurse did not make any notations of the areas found by the PTA. During an interview conducted on 10/05/12, at 9:00 A.M., the DON said she did not remember the PTA telling her the resident had any areas on his/her heel or his/her buttocks. Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/10/12 (eight days after the PTA identified the wound) a nurse documented the resident had a 2.3 cm x 2.1 cm dark blue unstageable pressure area with 0.5 cm surrounding redness on the resident's right upper buttock, a 3 cm x 1 cm Stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough/dead skin. May also present as an intact or open/ruptured blister), with yellow and red wound bed, to the resident's mid-upper buttock crease. During an interview conducted on 10/05/12, at 9:00 A.M., the wound care nurse said when she completed the skin assessment on 08/03/12; she noticed the purple area on the resident's buttocks but did not document the observation because the skin was intact. Record review of a physician's orders [REDACTED]. change every three days and as needed. Record review of the resident's closed medical record, from 07/28/12-08/13/12; showed staff did not document an assessment of the resident's heels. During an interview conducted on 10/05/12, at 9:00 A.M., the director of nursing (DON) said when the nurses perform a treatment on a wound, they do not always document what the wound looked like. The wound nurse documents weekly, but maybe on the more difficult wounds they should document daily. Record review of a physician's orders [REDACTED]. with normal saline, apply skin prep (topical treatment that helps reduce friction on skin) and cover with Opsite (a transparent dressing). Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/14/12 a nurse documented the resident had a 0.5 cm x 2 cm unstageable blue blister with approximately 0.5 cm surrounding blanchable (a reddened area that turns white when pressure is applied, usually a sign of healthy tissue) redness on the right outer heel and a 1.5 cm x 1.5 cm blue blister with approximately 0.6 cm surrounding blanchable redness on the left outer heel. During an interview conducted on 10/05/12, at 11:00 A.M., certified nurse aide (CNA) M said if the aides notice a resident's skin condition getting worse or if they notice a new skin concern, they notify their charge nurse. The CNA said the resident had a wound on his/her buttocks and one on his/her heel. The wound on his/her buttocks was nasty and had an odor, even though the nurses' cleaned it. During an interview on 10/05/12, at 11:20 A.M., the DON said the shower aides complete a shower sheet with each resident's shower. If a resident has any skin concerns, the aides document it on the shower sheet and give it to the charge nurse. When staff, aides or nurses, first finds a wound, they complete a skin sheet and give it to the wound nurse. During an interview conducted on 10/05/12, at 10:50 A.M., licensed practical nurse (LPN) O said if he/she identifies a new wound, he/she assesses the wound and notifies the physician and obtains wound care orders. The LPN documents the assessment and notification in the nurses' notes. He/she does not always document a skin assessment after he/she completes a wound treatment. The wound care nurse documents a skin/wound assessment weekly. Record review of the physician's orders [REDACTED]. -On 08/21/12 instructions for staff to send the resident to the wound clinic for evaluation; -On 08/23/12 instructions for staff to apply silver alginate (a treated, absorbant gauze-type dressing) rope to the resident's coccyx (tailbone) ulcer every day and [MEDICATION NAME] CGF (an occlusive-type of wound dressing) to the resident's right foot every three days. Continue the thin film (skin prep) to his/her heels. Record review of the Patient Evaluation Report, completed by wound clinic staff, dated 08/23/12, showed the following information: -Midline coccyx: 3 cm x 4.5 cm x 2.5 cm, unstageable pressure ulcer ( not stageable due to coverage of wound bed by slough and/or eschar, dead tissue) with 5% red granulation tissue and 95% yellow slough; -Left outer heel: 1.5 cm x 2 cm blood blister; -Right outer heel: 2.5 cm x 3.5 cm blood blister; -Right plantar (bottom of the foot) ulcer: 2.3 cm x 1.5 cm x 0.1 cm, 5% granulation tissue and 95% slough. Record review of the resident's closed medical record showed facility nurses did not document any information regarding the resident's right plantar foot wound. Record review of the buttocks wound culture report, dated 08/30/12, showed the following information: -Moderate growth of Proteus mirabilis (a type of bacteria); -On 08/31/12 staff faxed the report to the physician; -On 09/04/12 the physician faxed back orders for staff to administer [MEDICATION NAME] (an antibiotic) one gram, to the resident, every day for seven days. During an interview conducted on 10/05/12, at 9:00 A.M., the wound care nurse said she usually faxes the laboratory reports to the physician. If she receives an abnormal laboratory report, she faxes and calls the physician. During an interview conducted on 10/05/12, at 10:50 A.M., licensed practical nurse (LPN) O said the wound care nurse usually faxes the laboratory reports to the physician but she tells the nurses when she does so they can follow up. The laboratory report is placed on the charge nurses' clipboard and given to the oncoming nurse in shift report along with if the physician had responded or not to the report. During an interview conducted on 10/05/12, at 9:00 A.M., the director of nursing (DON) said the laboratory faxes the facility the laboratory results. Staff reviews the results then fax the report to the physician. If staff faxes a laboratory report to the physician on Friday, they would wait until Monday to follow-up. The resident's physician can be difficult to get a hold of on the weekends. Record review of the nurses' notes showed the following information: -On 09/06/12, at 3:00 P.M., a nurse documented the resident and his/her family have decided on more intensive wound care at a hospital; -On 09/08/12, at 12:15 P.M., staff discharged the resident from the facility. Complaint #MO

A deficiencey was cited at F314. See the revisit event PEE112 for further information.

Based on record review and interview the facility failed to identify, assess and document pressure ulcers that one resident (Resident #17) acquired in the facility. The resident had two superficial areas, one on each buttock on admission on 7/13/12. By 08/23/12, the resident had acquired three unstageable pressure ulcers ( not stageable due to coverage of wound bed by slough and/or eschar, dead tissue), one on the resident's coccyx (tail bone), one on the resident's right foot (identified by the wound clinic and not facility staff) and the third as an unstageable blue blister on the resident's right heel. The resident also developed a pressure ulcer, in the form of a blood blister, on the left heel. The delay in identifying and assessing the pressure ulcers caused a delay in treatment. The facility also failed to notify and follow-up with the physician regarding abnormal laboratory showing infection in one of the pressure ulcers. This caused a delay in antibiotic treatment for [REDACTED]. Eight residents were sampled out of a facility census of 90. According to MEDSCAPE NURSING MEDPULSE (Nurses.Medscape.com) purple or maroon localized areas of discolored intact skin or blood-filled blisters are the result of damage to the underlying soft tissue from pressure and/or shear.* The affected tissue may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue. The evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (dead tissue). The progression of this type of injury can be rapid, exposing additional layers of tissue even with optimal treatment. *Shear occurs when friction holds the skin in place but the body is pulled by gravity, as when a patient slips down in bed from a semi-upright position. Although it looks like a deep bruise, deep tissue injury is sometimes mistaken for a category I pressure ulcer. This can happen if only the color and fact that the skin is intact are noted. However, these injuries are potentially extremely severe because they indicate deep subcutaneous injury occurring from the inside out. Despite the relatively mild appearance, these [MEDICAL CONDITION] can open up into full-blown pressure ulcers within days. Deep tissue injury usually advances rapidly despite proper care. 1. Record review of Resident #17's medical record showed [DIAGNOSES REDACTED]. Record review of the resident's admission evaluation and interim care plan, dated 07/13/12, showed the following information: -Braden score (a tool used to predict pressure sore risk) of 20 (a score of 15-18 equals a resident at risk); -The resident had a 1 centimeter (cm) to 2 cm open area on both of his/her inner buttocks. Record review of a nurses' note, dated 07/13/12, at 4:00 P.M., showed a nurse documented the resident had a 1 cm-1.5 cm open areas observed on both inner buttocks. Record review of the initial care plan, dated 07/13/12, showed the following information: -Required assistance of two staff for transfers and turning; -Required total assistance for dressing and personal hygiene; -Required staff assistance for eating. Record review of a physician's orders [REDACTED]. Record review of the weekly summary, on the back of the July 2012 treatment administration sheet (TAR) showed on 07/16/12 a nurse documented the resident had two skin shears, very superficial in depth. The left buttock skin shear measured 2 cm x 2 cm and the right buttock shear measured 5.5 cm x 2 cm. Record review of the admission minimum data set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 07/19/12, showed the following information: -Total score of 13 on the brief interview for mental status (cognitively intact); -Extensive assistance required for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Indwelling catheter; -At risk for pressure ulcers; -No pressure ulcers; -Pressure relieving device for bed; -Applications of ointments/medications other than to feet. Record review of the weekly summary, located on the back of the July 2012 TAR showed on 07/25/12 a nurse documented the resident's skin shears were very superficial in depth. The left buttock shear was healed and the right buttock had two areas measuring approximately 0.1 cm. Record review of the Resident Treatment Details (physical therapy/ PT progress notes), dated 07/22/12-07/27/12, showed on 07/25/12 the physical therapy aide (PTA) documented the resident complained of pain/ discomfort on his/her left heel; the area was very purple to deep purple in color. The PTA placed a rolled up blanket under the resident's heels and informed the wound care nurse and rehabilitation manager. Record review of the nurses' note, dated 07/25/12, showed all three shifts, the nurses' documented the resident had no skin concerns with no mention of the left heel identified by the PTA. Record review of the care plan, dated 07/26/12, showed the resident at risk for skin breakdown due to decreased physical mobility. He/she had two skin shears on his/her buttocks; treatment, as ordered, by wound nurse. Staff assisted the resident with repositioning in bed and chair as needed and used positioning devices and/or pillows as needed. Record review of a nurses' note, dated 07/28/12, at 4:30 A.M., showed the nurse documented the resident complained of left heel pain. The resident's left heel was mushy and light red but had no open areas. The resident had pressure reliving boots on his/her feet. Record review of PT's Resident Treatment Details dated 07/29/12-08/04/12, showed on 08/03/12, a late entry for 08/02/12, the PTA documented the resident complained of a sore bottom. The PTA noticed a slit on the upper buttocks area and a quarter-sized deep purple area on the resident's right buttocks. The certified nurse aide (CNA) said he/she will notify the charge nurse, however the PTA reported the area to the DON. Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/03/12 a nurse documented the resident's skin was fragile but intact. The nurse did not make any notations of the areas found by the PTA. During an interview conducted on 10/05/12, at 9:00 A.M., the DON said she did not remember the PTA telling her the resident had any areas on his/her heel or his/her buttocks. Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/10/12 (eight days after the PTA identified the wound) a nurse documented the resident had a 2.3 cm x 2.1 cm dark blue unstageable pressure area with 0.5 cm surrounding redness on the resident's right upper buttock, a 3 cm x 1 cm Stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough/dead skin. May also present as an intact or open/ruptured blister), with yellow and red wound bed, to the resident's mid-upper buttock crease. During an interview conducted on 10/05/12, at 9:00 A.M., the wound care nurse said when she completed the skin assessment on 08/03/12; she noticed the purple area on the resident's buttocks but did not document the observation because the skin was intact. Record review of a physician's orders [REDACTED]. change every three days and as needed. Record review of the resident's closed medical record, from 07/28/12-08/13/12; showed staff did not document an assessment of the resident's heels. During an interview conducted on 10/05/12, at 9:00 A.M., the director of nursing (DON) said when the nurses perform a treatment on a wound, they do not always document what the wound looked like. The wound nurse documents weekly, but maybe on the more difficult wounds they should document daily. Record review of a physician's orders [REDACTED]. with normal saline, apply skin prep (topical treatment that helps reduce friction on skin) and cover with Opsite (a transparent dressing). Record review of the weekly summary, located on the back of the August 2012 TAR showed on 08/14/12 a nurse documented the resident had a 0.5 cm x 2 cm unstageable blue blister with approximately 0.5 cm surrounding blanchable (a reddened area that turns white when pressure is applied, usually a sign of healthy tissue) redness on the right outer heel and a 1.5 cm x 1.5 cm blue blister with approximately 0.6 cm surrounding blanchable redness on the left outer heel. During an interview conducted on 10/05/12, at 11:00 A.M., certified nurse aide (CNA) M said if the aides notice a resident's skin condition getting worse or if they notice a new skin concern, they notify their charge nurse. The CNA said the resident had a wound on his/her buttocks and one on his/her heel. The wound on his/her buttocks was nasty and had an odor, even though the nurses' cleaned it. During an interview on 10/05/12, at 11:20 A.M., the DON said the shower aides complete a shower sheet with each resident's shower. If a resident has any skin concerns, the aides document it on the shower sheet and give it to the charge nurse. When staff, aides or nurses, first finds a wound, they complete a skin sheet and give it to the wound nurse. During an interview conducted on 10/05/12, at 10:50 A.M., licensed practical nurse (LPN) O said if he/she identifies a new wound, he/she assesses the wound and notifies the physician and obtains wound care orders. The LPN documents the assessment and notification in the nurses' notes. He/she does not always document a skin assessment after he/she completes a wound treatment. The wound care nurse documents a skin/wound assessment weekly. Record review of the physician's orders [REDACTED]. -On 08/21/12 instructions for staff to send the resident to the wound clinic for evaluation; -On 08/23/12 instructions for staff to apply silver alginate (a treated, absorbant gauze-type dressing) rope to the resident's coccyx (tailbone) ulcer every day and DuoDerm CGF (an occlusive-type of wound dressing) to the resident's right foot every three days. Continue the thin film (skin prep) to his/her heels. Record review of the Patient Evaluation Report, completed by wound clinic staff, dated 08/23/12, showed the following information: -Midline coccyx: 3 cm x 4.5 cm x 2.5 cm, unstageable pressure ulcer ( not stageable due to coverage of wound bed by slough and/or eschar, dead tissue) with 5% red granulation tissue and 95% yellow slough; -Left outer heel: 1.5 cm x 2 cm blood blister; -Right outer heel: 2.5 cm x 3.5 cm blood blister; -Right plantar (bottom of the foot) ulcer: 2.3 cm x 1.5 cm x 0.1 cm, 5% granulation tissue and 95% slough. Record review of the resident's closed medical record showed facility nurses did not document any information regarding the resident's right plantar foot wound. Record review of the buttocks wound culture report, dated 08/30/12, showed the following information: -Moderate growth of Proteus mirabilis (a type of bacteria); -On 08/31/12 staff faxed the report to the physician; -On 09/04/12 the physician faxed back orders for staff to administer [MEDICATION NAME] (an antibiotic) one gram, to the resident, every day for seven days. During an interview conducted on 10/05/12, at 9:00 A.M., the wound care nurse said she usually faxes the laboratory reports to the physician. If she receives an abnormal laboratory report, she faxes and calls the physician. During an interview conducted on 10/05/12, at 10:50 A.M., licensed practical nurse (LPN) O said the wound care nurse usually faxes the laboratory reports to the physician but she tells the nurses when she does so they can follow up. The laboratory report is placed on the charge nurses' clipboard and given to the oncoming nurse in shift report along with if the physician had responded or not to the report. During an interview conducted on 10/05/12, at 9:00 A.M., the director of nursing (DON) said the laboratory faxes the facility the laboratory results. Staff reviews the results then fax the report to the physician. If staff faxes a laboratory report to the physician on Friday, they would wait until Monday to follow-up. The resident's physician can be difficult to get a hold of on the weekends. Record review of the nurses' notes showed the following information: -On 09/06/12, at 3:00 P.M., a nurse documented the resident and his/her family have decided on more intensive wound care at a hospital; -On 09/08/12, at 12:15 P.M., staff discharged the resident from the facility. Complaint #MO