Every finding on record at Columbia Manor Health & Rehabilitation

Based on interview, and record review, facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) within two hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 44.1. Review of the facility's Abuse Prevention Program policy, dated 11/25, showed staff are directed to report any allegation of abuse within timeframes as required by federal requirements.2. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as moderately cognitively impaired and admitted to the facility on [DATE].Review of the resident's nurse's notes did not contain documentation staff reported an allegation of employee to resident sexual abuse.Review of facility provided documentation did not contain documentation staff reported to DHSS the allegation of sexual abuse to the resident. During an interview on 08/16/26 at 3:27 P.M., the resident said he/she felt Certified Nurse Aide (CNA) A was sexually abusive towards him/her by pulling on it, referring to the way he/she was touching his/her genitals and how long the aide was taking to clean his/her genitals. He/She said he/she told the CNA to stop providing care and he/she did not care about being left dirty. The resident said CNA A did stop when he/she asked him/her to stop.During an interview on 08/16/26 at 4:05 P.M., CNA A said he/she was providing the resident perineal care. He/She said while he/she was performing care, the resident made a statement he/she was being sexually inappropriate with him/her. He/She said the resident said the CNA just liked touching his/her genitals. He/She said he/she immediately went to the nurse and reported the allegation.During an interview on 08/16/26 at 3:53 P.M., the administrator said staff are directed to immediately report allegations of sexual abuse to her. She would investigate and report allegations of abuse to DHSS within two hours. She said she did not investigate or report the allegation of employee to resident sexual abuse because staff did not report it to her.During an interview on 08/16/26 at 4:31 P.M., Licensed Practical Nurse (LPN) B said CNA A reported to him/her the resident made an accusation of sexual abuse against and said the resident accused him/her of touching his/her genitals. Staff are directed to immediately report allegations of abuse to the Director of Nursing (DON) or the administrator. He/She believed he/she told someone, possibly the DON, but could not recall who.During an interview on 08/18/26 at 10:34 AM, the DON said staff are educated to report an allegation of sexual abuse immediately to him/her or the administrator. She said the facility was required to report an allegation of sexual abuse within two hours. LPN B did not report the allegation of employee to resident sexual abuse to her so she could not report it. 3159939

Based on interview and record review, facility staff failed to ensure one resident (Resident #2) out of five sampled residents, remained free from abuse, when Dietary Aide (DA) C provided the resident with methamphetamine (a powerful, highly addictive synthetic central nervous system stimulant). The facility census was 43.The administrator was notified on 8/24/26 of Past Non-Compliance which occurred on 08/20/26. The Administrator and Director of Nursing (DON) investigated the allegation, terminated DA C, notified the required parties and agencies, sent the resident to the hospital for resources on addiction and illegal drug use, and in-serviced staff regarding abuse and illegal drugs in the facility. Staff corrected the deficient practice on 08/20/26. 1.Review of the facility's Employee Handbook regarding a Drug Free Workplace, undated, showed employee will not be allowed to work who possesses, distributes, sells, offers to sell or distribute, or uses any illegal controlled substance, or alcohol, or who misuses or abuses prescription or over-the -counter drugs.2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Hypertension, and Congestive Heart Failure. Review of the facility's investigation report, dated 08/20/26, showed the administrator documented staff notified her staff found alcohol shooters and marijuana at the resident's bedside. The administrator spoke with the resident regarding alcohol and a burnt substance at his/her bedside. The resident admitted the substance on the burnt aluminum foil was methamphetamine and DA C gave him/her the methamphetamine. The administrator notified the police. The administrator, DON, and Human Resource Manager spoke with DA C and DA C refused a drug test and admitted to using methamphetamine while on duty. DA C denied providing methamphetamine to the resident. The administrator terminated DA C for having illegal drugs on the property.Review of the resident's plan of care, updated 08/20/26, showed staff documented the resident agreed to have personal belongings searched, and will always be free from illegal substances while on the facility premises.Review of the resident's nurse's notes, dated 08/20/26, showed staff documented the emergency services notified for a non-emergency transfer to the hospital for evaluation and treatment for drug dependency.During an interview on 08/24/26, at 9:30 A.M., the DON said staff found alcohol and a small piece of foil with an unknown substance in the resident's room. The resident told him/her, DA C gave him/her methamphetamine. The resident did not display any adverse effects of the methamphetamine, the physician directed staff to monitor the resident for changes in condition, and the resident requested to go to the hospital for resources for drug addiction. Staff have been in-serviced regarding abuse, and the policy regarding a drug free workplace.During an interview on 08/24/26, at 9:56 A.M., the resident said DA C gave him/her methamphetamine. He/She asked DA C if he/she had any methamphetamine because DA C was acting like he/she was under the influence of methamphetamine. DA C brought a small amount of methamphetamine to his/her room. He/She took the methamphetamine, but did not have any reaction to it because, It wasn't very good. The DON found a small piece of foil with an unknown substance in his/her room, and he/she told the DON DA C gave him/her the methamphetamine. Complaint # 3171739

Based on interview, and record review facility, staff failed to administer medications as ordered and failed to document a reason medication was on hold for one resident (Resident #30). The facility census was 44. 1. Review of the facility's Administering Medications policy, revised April 2019, showed the facility will ensure medications are administered in a safe and timely manner and as prescribed. Medication is administered in accordance with prescribers' orders, including any required time frame. If a dosage is believed to be inappropriate of 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 residents attending physician or the facility's medical director or discuss the concerns. 2.Review of Resident #3's quarterly Minimum Data Set, a federally mandated assessment tool, dated 3/4/26, showed staff assessed the resident as cognitively intact with diagnoses of hypertension, renal failure, hyperlipidemia and stroke.Review of the resident's physician order sheet (POS), dated January 2026, showed orders as follows:-Amlodipine Besylate Oral Tablet 5 Milligram (MG) one tablet by mouth one time a day for hypertension;-Atorvastatin Calcium 20 MG one tablet by mouth at bedtime for hyperlipidemia;-Cranberry Capsule 450 MG one capsule by mouth one time daily for supplement;-Melatonin Tablet 3 MG one tablet by mouth at bedtime related to insomnia;-Pantoprazole Sodium Tablet (Delayed Release) 40 MG by mouth one time daily for GERD;-Potassium Chloride tablet 20 (extended release) milliequivalent (MEQ) one tablet by mouth one time daily dietary supplement;-Spironolactone Oral Tablet 25 MG one tablet by mouth one time daily diuretic;-Thiamine HCl Tablet 100 MG one mouth one time daily dietary supplement;-Vitamin D3 Tablet 20 MCG (800 UNIT) one tablet by mouth one daily dietary supplement;-ZyrTEC Allergy Tablet (Cetirizine HCl) 5 mg by mouth one time daily allergies;-Eliquis Tablet 5 MG (Apixaban) five mg by mouth two times a day for prevention related to stroke;-House shake two times a day for nutrition;-Gabapentin Capsule 300 MG one capsule by mouth three times a day related to chronic pain;-Lactulose Oral Solution 10 GM/15ML 30 ml by mouth three times a day related to encephalopathy.Review of the resident's Medication Administration Record (MAR), dated January 2026, showed staff documented they held resident's medication, and they did not contain documentation of reason or new orders from physician to hold the medication for: -1/17/26- Atorvastatin Calcium 20 Mg, Melatonin Tablet 3 Mg, House shake, Gabapentin 300 Mg, and Lactulose 30 ml;-1/18/26- Amlodipine Besylate Oral Tablet 5 MG one daily, Cranberry Capsule 450 Mg one daily, Pantoprazole Sodium 40 mg one daily, Potassium Chloride, House Shake, Spironolactone 25 mg one daily, Thiamine HCl 100 Mg one daily, Vitamin D3 20 Mcg one daily, Zyrtec 5 mg one daily, Eliquis 5 mg one twice daily, and Lactulose 30 ml oral three times per day;-1/19/26- Atorvastatin Calcium 20 Mg;-1/22/26- Gabapentin Capsule 300 Mg.Review of the resident's POS, dated February 2026, contains orders as follows:-Spironolactone Oral Tablet 25 MG one tablet by mouth one time daily;-Gabapentin Capsule 300 MG one capsule by mouth three times daily.Review of the resident's MAR, dated February 2026, showed staff documented they held resident's medication, and they did not contain documentation of reason or new orders from physician to hold the medication for: -2/16/26 Gabapentin 300 Mg;-2/20/26 Gabapentin 300 Mg;-2/23/26 Spironolactone 25 Mg.Review of the resident's POS, dated March 2026, contains orders as follows:-Spironolactone Oral Tablet 25 MG one tablet by mouth one time a day;-Ondansetron HCl Tablet 4 MG by mouth three times a day.Review of the resident's MAR, dated March 2026, showed staff documented resident's medication , held and ,did not contain documentation of reason or new orders from physician to hold the medication for: -3/4/26 Spironolactone 25 MG one daily;-3/8/26 Spironolactone 25 MG one daily and Ondansetron HCl Tablet 4 mg. During an interview on 3/23/26 at 12:21 A.M., Certified Medication Technician (CMT) B said he/she does not recall why he/she used code 5 (hold medication / see progress notes for documentation) on the MAR for the resident multiple times. He/She said in some cases if blood pressure was low, residents had loose stools or were not feeling good medications would be held. He/She said it depends why the medication is being held if the physician needs to be contacted, he/she said he/she does not need orders to hold blood pressure medications or stool softeners, even if there are not parameters of when to hold in the orders. He/She said most of the medications at the facility do not have parameters. He/She said he/she does not recall notifying the physician to hold medication for Resident #3 because the charge nurse would need to do it. He/She said he/she does not know why he/she did not document why he/she held the resident's medications. During an interview on 3/17/36 at 10:30 A.M., the administrator said he/she expects all staff to follow physician orders and if a medication is held, they should have a physician's order to do so, he/she also expects if a medication is temporarily held with a physician order that the reason is documented. Complaint #2799285

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1. The facility census was 44.1.Review of the facility Administering Medications policy, revised April 2019, showed the facility will ensure medications are administered in a safe and timely manner and as prescribed. The individual administering the medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking the identification band, checking photograph attached to the medical record and if necessary, verifying the resident's identification with other facility personnel. Medication errors are documented, reported and reviewed by QUAPI committee to inform process changes and the need for additional staff training. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications. 2. Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 7/14/25, showed staff assessed the resident as cognitively intact with a diagnosis of anxiety and depression.Review of the resident's physician order sheet (POS) , dated February 2025, did not contain orders for Oxycodone. Review of the resident's progress notes, dated 3/17/26, did not contain documentation of a medication error. Review of the facility provided records, dated 3/17/26, did not contain documentation of a facility investigation for a medication error. Review of Certified Medication Technicians (CMT) A personal file, dated 2/23/26, showed CMT A was given a corrective action form for a medication error when staff gave the resident two oxycodone with no order, when the resident was ordered two Ativan. During an interview on 3/17/26 at 8:53 A.M., the administrator said they recently had one medication error for the resident, he/she said he/she was out on leave and does not know the details of the medication error. During an interview on 3/17/26 at 9:13 A.M., CMT A said he/she had one medication error when he/she gave Resident #1, Resident #2's Oxycodone. During an interview on 3/17/26 at 10:30 A.M, the administrator said the Director of Nursing (DON) gave CMT A his/her corrective action plan, another nurse in management who is no longer with us did the full investigation, but we have no proof of what he/she did. He/She said he/she expects all medication errors to be documented in the resident's chart, what happened, when it happened, corrective action taken and when family and physician were notified. He/She expects staff watch for and document all adverse reactions. He/She said Resident #1 is not ordered Oxycodone at all.During an interview on 3/17/36 at 10:46 A.M., Resident #1 said he/she is prescribed two Ativan, and he/she took two little white pills from CMT A but then started feeling really funny. He/She said the nurse told him/her that he/she was given 10 milligrams of Oxycodone instead of his/her Ativan. He/She said facility staff called the physician and continued to check his/her blood pressure. He/She said CMT A apologized to him/her for the medication error. He/She said he/she now uses a magnifying glass to check all his/her medications because he/she is so anxious to get the wrong medications again. Complaint #2799285

Based on interview and record review, facility staff failed to notify the physician and resident representative for one resident (Resident #1) out of one sampled resident, when staff assessed the resident with a lump to his/her forehead, and when the resident refused all his/her scheduled medications. The facility census was 41.1.Review of the facility's Change in a Resident's Condition or Status policy, revised 02/2021, showed staff are directed to promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition, and/or status. The nurse will notify the attending physician or physician on call when there has been a: -Discovery of injuries of unknown source;-Significant change in the resident's physical/emotional/mental condition;-Refusal of treatment or medications two or more consecutive times. 2. Review of Resident #1's Electronic Medical Record (EMR), dated 02/18/26 through 02/23/26, showed the resident with diagnoses to include Parkinsonism unspecified, essential tremors, and Atrial Fibrillation (AFib), admitted to facility from home on [DATE] with coordinated hospice services for a planned five-day stay, and had a documented resident representative. Review of the resident's incident report, dated 02/21/26 at 6:30 P.M., showed Licensed Practical Nurse (LPN) A documented Certified Nursing Assistant (CNA) B asked LPN A if he/she was aware the resident had a lump on his/her forehead. LPN A assessed the resident as alert and oriented, with a lump to his/her left forehead, no discoloration, denied pain or discomfort, and no identified injuries. The report did not contain documentation the nurse notified the physician or resident representative of the identified skin concern, or potential injury of unknown source. Review of the resident's Physician's Order Sheet (POS), dated 02/18/26 through 02/23/26, showed physician's orders as followed: -Aspirin Oral Tablet 325 milligrams (mg); Give 325 mg by mouth one time a day for pain;-Midodrine hydrochloride (HC)l Oral Tablet 2.5 mg; Give 2.5 mg by mouth one time a day for headaches;-DiazePAM Oral Tablet 2 mg; Give 2 mg by mouth two times a day for anxiety/tremors;-Propranolol HCl Oral Tablet 60 mg; Give 60 mg by mouth two times a day for hypertension related to essential tremors;-Senna-Plus Oral Tablet 8.6-50 mg; Give 1 tablet by mouth two times a day for constipation hold if has diarrhea;-Tamsulosin HCl Capsule 0.4 mg; Give 0.4 mg by mouth two times a day for Benign Prostatic Hypertrophy until 02/23/2026;-Carbidopa-Levodopa Oral Tablet 25-100 mg; Give 1 tablet by mouth three times a day related to Parkinsonism, unspecified. Review of the resident's Medication Administration Record (MAR), dated 02/23/26, showed staff documented the resident refused his/her Aspirin, Midodrine, Diazepam, Propranolol, Senna, Tamsulosin, and Carbidopa-Levodopa. During an interview on 02/27/26 1:03 P.M., the administrator said after thorough investigation, staff could not determine what caused the lump to the resident's forehead. The administrator said he/she would expect the nurse to notify the on-call physician, the hospice physician, and resident representative of the lump to the resident's forehead, and staff to also notify the physician and resident representative that the resident refused all his/her medications the day of discharge. During an interview on 02/27/26 at 1:17 P.M., LPN A said he/she did not know what caused the lump to the resident's forehead, and he/she should have notified the resident's physician and resident representative of the lump, but he/she got busy and forgot to notify anyone. During an interview on 02/27/26 at 3:31 P.M., the resident representative said he/she expected staff to notify him/her of any skin changes or if the resident did not take his/her medications. He/She said staff did not notify him/her about the lump to the resident's forehead, and the resident refused his/her medications on 02/23/26 prior to discharging home. During an interview on 03/02/26 at 9:56 A.M., the attending physician said he/she had not seen the resident during his/her stay at the facility but would have expected staff to notify him/her or the on-call physician of the lump to the resident's forehead, and that the resident had refused his/her medications. The physician said he/she would also expect staff to notify the Hospice Physician/staff as well. During an interview on 03/02/26 at 3:36 P.M., the Hospice Physician said he/she would expect facility staff to notify him/her of the lump/swelling to the resident's forehead, as well as the medication refusals prior to discharge so the hospice staff could better monitor and follow up at their next home assessment of the resident. Intake #2789733 & complaint #2786826

Based on interviews and record review, facility staff failed to report an allegation of bruises and injury of unknown origin for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the 24-hour required timeframe. The facility's census was 41.The administrator was notified on 2/27/26 of past Non-Compliance, which occurred on 02/25/26, when the resident representative called the facility and made a follow-up report of the allegations. Staff immediately started an investigation, contacted the resident's Hospice Provider, Regional Staff, in-serviced facility staff on the abuse and neglect policy which included to report injury of unknown origin within 24 hours, and reported the allegations to DHSS on 02/26/26. The resident's representative reported the concerns to the DON on 2/24/26 and called again on 2/25/26 to talk to the administrator, where he/she again reported the concerns. 1. Review of the facility's Abuse Investigation and Reporting policy, revised 07/2017, showed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. 2. Review of Resident #1's Electronic Medical Record (EMR), dated 02/18/26 through 02/23/26, showed the resident admitted to the facility from home on [DATE], had a documented resident representative, and discharged back to home on [DATE] after a planned five-day stay. Review of the facility's investigation, dated 2/25/26, showed staff documented: -On 02/24/26, the resident representative reported to the Director of Nursing (DON), allegations of bruises and injuries of unknown origin to the resident;-On 02/25/26 at 9:40 A.M., the resident representative made a second report to the administrator, that when the resident returned home from the facility, the resident had a lump to his/her left forehead, laceration above his/her left ear, bruising to his/her left side/underarm, and excoriation to his/her genitals. Staff began an investigation;.-On 02/26/26, residents were interviewed, staff were in-serviced on the abuse and neglect policy, and the administrator reported the allegations to DHSS. The report did not contain documentation facility staff contacted DHSS within the 24-hour required timeframe after the resident representative reported the allegations. Review of the DHSS complaint/facility self-report database did not contain a report facility reported allegations of bruises and injury of unknown origin for over 48 hours after the resident representative reported the allegations to facility staff. During an interview on 02/27/26 at 10:31 A.M., the administrator said staff should have probably made an initial report to DHSS within two hours after the resident representative initially reported the allegations on 02/24/26, but since there was no suspicion of abuse, and rather bruises and injury of unknown origin, staff should have notified DHSS within 24 hours (on 02/25/26). The administrator said he/she first became aware of the allegations on 02/25/26, and should have notified DHSS within 24 hours, but he/she got busy with the investigation and did not realize the 24 hours timeframe had passed before he/she submitted the report to DHSS. During an interview on 02/27/26 at 11:19 A.M., the DON said the resident representative reported to him/her on the morning 02/24/26 the resident had an abrasion to his/her left side, a laceration approximately 0.5 inches above his/her left ear, bruising under his/her left armpit, and a [NAME] to his/her back, but did not specify abuse/neglect or accuse anyone. The DON said the resident was no longer at the facility, and he/she immediately started to interview staff regarding any known incidents or falls, and none were reported. The DON said based on the information received from the resident representative, and interviews from staff, he/she should have notified DHSS within 24 hours of the allegations of bruises and injury of unknown origin. Intake #2789733 & complaint #2786826

Based on interview and record review, facility staff failed to meet professional standards of care when staff failed to document a skin assessment for one resident (Resident #1) out of one sampled resident, when staff assessed the resident with a lump to his/her forehead. The facility census was 411. Review of the facility's admission Assessment and Follow up: Role of the Nurse policy, revised 09/2012, showed staff are directed to conduct a physical assessment on admission, including the eyes, ears, nose, throat, head, neck, and skin. Conduct supplemental assessments (following facility forms and protocol) including skin assessment. The policy did not specify the frequency for which staff should complete a skin assessment. 2. Review of Resident #1's Electronic Medical Record (EMR), dated 02/18/26 through 02/23/26, showed the resident with diagnoses to include Parkinsonism unspecified, essential tremors, and Atrial Fibrillation, admitted to facility from home on [DATE] with coordinated hospice services for a planned five-day stay, and discharged back to home on [DATE]. Review of the resident's incident report, dated 02/21/26 at 6:30 P.M., showed Licensed Practical Nurse (LPN) A documented the resident had a lump on his/her left forehead, no discoloration, denied pain or discomfort, and no identified injuries. Review of the resident's EMR, dated 02/21/26 through 02/23/26, did not contain documentation staff completed a skin assessment after staff reported the lump to the resident's forehead, or a skin assessment prior to the resident's planned discharge on [DATE]. Review of the facility's investigation, dated 2/25/26, showed staff documented the resident representative reported to the administrator, that when the resident returned home from the facility on 02/23/25, the resident had a lump to his/her left forehead, laceration above his/her left ear, bruising to his/her left side/underarm, and excoriation to his/her genitals. During an interview on 02/27/26 at 11:19 A.M., the DON said it was standard protocol for the nurse to complete a skin assessment with any identified skin changes, and the day of a resident's planned discharge. The DON said he/she was not sure why LPN A or the nurse at discharge did not complete a skin assessment. During an interview on 02/27/26 at 12:07 P.M., LPN C said the nurse is expected to complete a head-to-toe assessment and document a skin assessment prior to a resident's planned discharge. LPN C said he/she was responsible to complete the resident's skin assessment prior to discharge but he/she did not. During an interview on 02/27/26 at 1:03 P.M., the administrator said although it is not specified in the facility policy, he/she expects the nurses to complete a skin assessment on admission, with any identified skin changes, and prior to a planned discharge as standard nursing protocol. During an interview on 02/27/26 at 1:17 P.M., LPN A said he/she should have completed a skin assessment to follow up on the incident report on 02/21/26, but he/she got busy and forgot. During an interview on 03/02/26 at 3:36 P.M., the Hospice Physician said he/she would expect facility staff to complete a skin assessment on the resident prior to discharge as standard procedure, particularly since he/she was only there for a short stay, to ensure there were no new skin concerns during his/her stay. Intake #2789733 & complaint #2786826

Based on interview and record review, facility staff failed to notify the facility attending physician following a change in condition of one resident (Resident #1) out of nine sampled residents when the resident fell and received a head injury. The facility census was 44.1.Review of the facility's Change in a Resident's Condition or Status policy, revised 02/2021, showed staff are directed as follows:- The policy states facility staff promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition, and/or status, including an accident or incident involving the resident;- A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions;- Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.2.Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/25, showed staff assessed the resident as cognitively impaired.Review of the resident's Care Plan, updated 08/07/25, showed the resident required extensive assistance with bathing/showering. Review showed staff directed to inform the resident of any changes in condition and benefits, risks, and possible choices of treatment. The care plan did not contain documentation staff assessed the residents fall risk or implemented interventions for falls.Review of the resident's nurses' notes, dated 11/24/25, showed the Director of Nursing (DON) documented a housekeeping staff member notified him/her of an emergency in the north shower room. The DON documented the resident on the floor in front of the shower chair with Hospice Aide A squatted down next to the resident. Vitals obtained. Resident hit head, purple raised area above right eye. Resident is conscious. Neurological checks initiated. Resident is not making sense verbally. Staff reported this is the resident's baseline this morning prior to fall. RN Hospice nurse in to see resident. Hospice RN called resident's family member. The nurse's note did not contain documentation staff notified the resident's attending physician. During an interview on 12/05/25, at 11:56 A.M., the administrator said if a resident falls, staff should notify the attending physician. During an interview on 12/05/25, at 11:59 A.M., the Corporate Nurse said if a resident falls, staff should notify the resident's facility attending physician. He/She said if a resident falls and hits their head, staff should initiate neurological checks, monitor for changes related to a head injury, check the resident's medication list for anticoagulants (blood thinners), and notify the facility's attending physician. The Corporate Nurse said the DON should not rely on the Hospice Nurse to determine if the resident should be sent to the emergency room. During an interview on 12/05/25, at 1:11 P.M., Hospice Aide A said he/she was assisting the resident with a shower, and when he/she turned halfway to get the soap, the resident's eyes rolled back, the resident leaned forward, and the resident fell and hit his/her head on the wall. He/She said the DON responded and assessed the resident. Hospice Aide A said he/she notified the Hospice RN. During an interview on 12/05/25, at 1:44 P.M., the Hospice RN said the Hospice Aide notified him/her of the resident's fall. He/She said he/she was five minutes away from the facility, and he/she went to the facility to assess the resident. He/She said the facility staff did not notify him/her of the fall, and he/she notified the on-call Hospice Nurse Practitioner. During an interview on 12/05/25 at 1:53 P.M., the Hospice Nurse Practitioner said if Hospice staff notify him/her a resident has a change in condition, he/she relies on the Hospice staff to tell him/her what the resident's family wishes to do before recommending sending the resident to the hospital. During an interview on 12/05/25, at 2:15 P.M., the DON said he/she responded when the resident fell in the shower room. He/She said the resident was awake and babbling, which the resident had done previously. He/She said the resident had a raised bruised area, like a goose egg. He/She said he/she initiated neurological checks, assessed the resident's vital signs, and assessed the resident for signs of pain. He/She said the Hospice RN came in to assess the resident, and the Hospice RN told him/her he/she notified the resident's family member and the hospice nurse practitioner, and the family member said to provide comfort measures only. The DON said if a resident has a change in condition, staff should notify the administrator, the facility attending physician, and the resident's family. He/She said if a resident is on Hospice, and has a change in condition, he/she notifies Hospice, and Hospice staff determine the next steps to take. The DON said facility staff are ultimately responsible for the oversight of all residents in the facility.Complaint # 2682541

Based on interview and record review, facility staff failed to provide a discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the hospital was unable to admit him/her and told the facility the resident was ready to return. The facility's census was 38.1. Review of the facility's Emergency Transfer or Discharge policy, revised 08/2018, showed emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s), and should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:-Notify the resident's attending physician;-Notify the receiving facility that the transfer is being made;-Prepare the resident for transfer-Prepare a transfer form to send with the resident;-Notify the representative or other family member;-Assist in obtaining transportation;-Others as appropriate or as necessary. 2. Review of Resident #1's Discharge-Return not anticipated Minimum Data Set (MDS), a federally mandated assessment, dated 08/27/25, showed an admission date of 08/21/25 and discharge date of 08/27/25.Review of the resident's nurse's note, dated 08/27/25 at 8:46 A.M., showed staff documented the resident transferred to the hospital. Review of the resident's nurse's note, dated 08/27/25 at 11:34 A.M., showed staff documented the resident was sent to the hospital for fluid leakage from his/her skin, the hospital staff reported to facility staff they did not have a reason to admit the resident, requested facility staff to arrange the resident's return to the facility, but the hospital staff would be told no because the facility cannot care for the resident's needs. Review of the resident's progress note, dated 08/27/25 at 1:12 P.M., showed the administrator documented the facility will not allow the resident to return to the facility as facility staff are unable to care for the resident's current needs. Review of the resident's electronic medical record, dated 09/03/25, showed the medical record did not contain a 30-day discharge or an emergency discharge notice. During an interview on 09/04/25 at 1:10 P.M., the Social Service Director (SSD) said the administrator said the resident will not be allowed to return to the facility. During an interview on 09/05/25 at 12:44 P.M., the administrator said the nurse sends a discharge notice when a resident is discharged to the hospital. The administrator said staff did not issue a discharge notice when he/she was discharged to the hospital because staff were busy trying to safely transfer the resident out of the facility and did not plan for the resident to return to the facility. The administrator said the resident will not be allowed to return to the facility because the facility staff cannot adequately meet the resident's care needs at the facility. Complaint# 2605768

Based on observation, interview and record review, facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. This failure has the potential to affect all residents. The facility census was 38.1.Review of the facility's policy titled Cleaning Dishes/Dish Machine, dated 2021, showed the policy directed staff to air dry washed dishes on dish racks and to inspect the dishes for cleanliness and dryness before they are put away. Review showed Dishes should not be nested unless they are completely dry. Observation on 08/05/25 at 10:10 A.M., showed wet six plates stacked together on a service cart in the mechanical dishwashing area. During an interview on 08/05/25 at 10:10 A.M., the Certified Dietary Manager (CDM) said he/she washed the plates that morning. The CDM said washed dishes should be air dried before they are put away and he/she did not realize they were still wet when he/she stacked them on the cart. Observation on 08/05/25 at 10:22 A.M., showed nine wet metal food service pans, 12 wet plastic service trays and 15 wet plastic plate covers stacked together in the service station. Observations on 08/05/25 at 12:04 P.M., during the lunch meal service showed the CDM used the wet stacked plate covers and trays to serve food to residents. During an interview on 08/05/25 at 1:09 P.M., the administrator said washed dishes should be air dried before they are stacked into storage or used. The administrator said the person washing the dishes is responsible to ensure the dishes are dry before they put them away and the CDM should monitor dish washing and storage periodically for compliance. The administrator said staff, especially the CDM who had worked at the facility for 30 years, were trained on the requirement to air dry washed dishes.

Based on observation, interview and record review, facility staff failed to ensure residents had complete, accurate and individualized care plans, to address the care needs for four residents (Residents #3, #7, #32, and #34) out of 12 sampled. The facility census was 38.1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan will incorporate identified problem areas. The care plan will incorporate risk factors associated with identified problems. The care plan will reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. The IDT must review and update the care plan when there has been a significant change in the resident's condition.2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/31/25, showed staff assessed the resident as cognitively impaired.Review of the resident's Physician Order Sheet (POS), dated August 2025, showed the physician ordered the resident to be a Full Code (desire to receive all possible life-saving measures in the event of heart or lung arrest). Review of the resident's care plan dated 08/07/25, showed the care plan did not contain guidance or direction for advanced care planning, to include the Full Code order. 3. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as cognitively impaired.Review of the resident's POS, dated August 2025, showed 0n 06/13/25, the physician ordered the resident to be a Do Not Resuscitate ((DNR) the desire to prevent staff or caregivers to perform resuscitative measures if a person's heart or breathing stops). Review of the resident's medical record showed a DNR order, dated 06/12/25, signed by the resident and/or family and physician.Review of the resident's care plan dated 08/04/25, showed the care plan did not contain guidance or direction for advanced care planning, to include the DNR order.4. Review of Resident # 32's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;-Diagnoses of aphasia, a brain disorder that affects how you speak and understand language; stroke, seizure disorder, and malnutrition;-Did not include the use of a percutaneous endoscopic gastrostomy (PEG) tube, a feeding tube inserted into the stomach through the abdominal wall to deliver nutrition -Did not include a therapeutic diet;-Did not receive antibiotics.Review of the resident's care plan, dated 06/27/25, showed staff documented is on Enhanced Barrier Precautions (EBP) related to PEG tube; is on Amoxicillin, (an antibiotic) for prophylaxis, (preventive care), for possible aspiration pneumonia.Review of the resident's POS, dated 08/07/25, showed the resident did not have orders for PEG tube management, therapeutic diet, EBP, or amoxicillin.Review of resident's nurse's notes, dated 07/10/25, showed staff documented the resident came out with his/her feeding tube site open holding his/her gastric tubing in his/her hands. During an interview on 08/07/25 at 11:00 A.M., the resident said he/she does not have a PEG tube anymore. During an interview on 08/07/2025 at 11:52 A.M. Certified Medication Technician (CMT) E said he/she reviewed the electronic medication record (eMAR) and the resident is not receiving Amoxicillin. It was discontinued a long time ago.During an interview on 08/07/2025 at 1:22 P.M., the MDS Coordinator said the resident's care plan had been reviewed in the past two months and the Amoxicillin and PEG tube were not removed because there was an end date. The MDS Coordinator said he/she is new in the role and did not know discontinued treatments with an end date should be removed from the care plan.During an interview on 08/07/2025 at 4:15 P.M. the Director of Nursing (DON) said the resident does not have a PEG tube, is not on EBP, and currently does not have an order for Amoxicillin. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired.Review of the resident's POS, dated August 2025, showed on 04/15/25, the physician ordered the resident to be a DNR. Review of the resident's medical record showed a DNR, dated 12/19/24, signed by the resident and/or family and physician.Review of the resident's care plan, dated 08/04/25, showed the care plan did not contain guidance or direction for advanced care planning, to include the order for DNR.6. During an interview on 08/07/2025 at 1:22 P.M., the MDS Coordinator said he/she is responsible to revise care plans, and he/she reviews them every two weeks. The MDS Coordinator said care plan changes are triggered by changes discussed in the daily clinical meetings, discussions with family and reported changes in condition; and should include cognition, diet, wounds, antibiotics, preferences, and medication risks.During an interview on 08/07/2025 at 4:15 P.M. The DON said it is the responsibility of the MDS Coordinator to revise care plans, but he/she is still learning and did not know to remove discontinued treatments. The DON said advanced code status should be included on the care plan per physician order.During an interview on 08/07/2025 at 04:43 P.M., the Administrator said care plans are the responsibility of the MDS Coordinator, who pulls information from assessments, referrals, and clinical meetings. The Administrator said PEG tube, EBP, medication changes, and code status should be care planned.

Based on observation, interview and record review, facility staff failed to follow infection control protocols for COVID-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) when staff did not wear eye protection while inside the room of two residents (Resident #10 and #24) of three sampled residents who tested positive for COVID-19. Facility staff failed to use appropriate hand hygiene during wound care for two residents (Residents #38 and #41) of two sampled residents. The facility census was 38. 1.Review of the facility's COVID-19 policies and procedures guide, dated 09/26/25, showed symptomatic residents, regardless of vaccination status, suspected or confirmed with COVID-19, are encouraged to stay restricted to their rooms and cared for by staff using a respirator, eye protection, gloves and a gown. Review of the Centers for Disease Control (CDC) Infection Control Guidance: SARS-CoV-2 (COVID-19), dated 6/24/24, showed:-This guidance applies to all United States settings where healthcare is delivered, including nursing homes;-The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency;-Health Care Providers (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 2. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/26/25, showed staff assessed the resident as cognitively intact. Review of the resident's medical record showed staff documented the resident tested positive for COVID-19 on 07/28/25.During an interview on 08/05/25 at 1:00 P.M., the resident said staff does not wear eye protection during his/her care. Observation on 08/05/25 at 2:13 P.M., showed Certified Nurse Aide (CNA) F applied a gown, gloves, and respirator mask and entered the resident's room to provide care. Observation showed the CNA did not wear eye protection. During an interview on 08/05/25 at 2:33 P.M., CNA F said he/she uses what PPE is available. He/She said eye wear is not available, so he/she doesn't wear it.3. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's medical record showed staff documented the resident tested positive COVID-19 on 07/28/25.During an interview on 08/05/25 at 1:17 P.M., the resident said staff does not wear any eye protection during his/her care. Observation on 08/05/25 at 2:13 P.M., showed CNA F applied a gown, gloves, and respirator mask and entered the resident's room to provide care. Observation showed the CNA did not wear eye protection. During an interview on 08/05/25 at 2:33 P.M., CNA F said he/she uses what PPE is available. He/She said eye wear is not available, so he/she doesn't wear it.4. During an interview on 08/07/25 at 3:18 P.M., Registered Nurse (RN) G said he/she would expect staff to wear eye protection during care of those residents who tested positive for COVID-19. He/she said he/she knew the face-shields and goggles were ordered but staff were just wearing gown, gloves and respirators. He/She said the eyes are very susceptible for germs and that is the reason staff should wear eye protection. Eye protection guards from flying germs. During an interview on 08/07/25 at 4:14 P.M., the Director of Nursing (DON) said staff caring for residents in COVID-19 positive rooms should wear gowns, gloves, booties, and goggles or a face-shield. The DON said he/she did know staff were not wearing face shields, because they had been ordered but he/she did not know if the face shields had been delivered. During an interview on 08/07/25 at 4:42 P.M., the administrator said staff caring for COVID-19 positive residents should wear booties, gloves, gowns, appropriate N95 mask and eyewear to protect from droplets. He/She did not know the eye wear was unavailable until staff asked about it. The Charge nurse and DON should double check the staff have the equipment they need. 5. Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2019, showed wash hands with soap and water when hands are visibly soiled. Use alcohol-based hand rub or soap and water before donning gloves, before handling clean or soiled dressings, gauze, pads, etc., before moving from a contaminated body site to a clean body site during resident care, after handling used dressings, and after removing gloves.Review of the facility's policy titled Wound Care, revised 10/2010, showed:-Wash and dry hands thoroughly;-Put on exam glove. Remove dressing;-Pull glove over dressing and discard. Wash and dry hands thoroughly;-After applying treatment and dressing, remove gloves and wash and dry hands thoroughly.6. Observation on 08/07/25 at 08:24 A.M. showed Licensed Practical Nurse (LPN) A touched the wound on Resident #38's left ankle with a gloved hand, applied ointment and a dressing to the wound, and did not change his/her gloves or perform hand hygiene from dirty to clean. 7. Observation on 08/06/2025 at 09:22 A.M. showed Resident #41's pannus (abdominal folds) with open wounds and sores. Observation showed LPN A entered the resident's room and applied gloves. LPN A applied powder and barrier cream to the resident pannus and with the same soiled gloves, placed the barrier cream on the bedside table. Observation showed the LPN removed his/her gloves and placed the treatment supplies in the resident's bedside table. Observation on 08/07/25 at 08:35 A.M. showed LPN A entered the residents room and applied his/her gloves. Observation showed the LPN removed a soiled dressing from the resident's right lower leg. With the same soiled gloves, the LPN touched the clean dressing and treatment supplies. The LPN removed his/her gloves, did not wash his/her hands and applied clean gloves. The LPN applied a clean dressing to the resident's right buttock wound, reached into his/her pocket for keys, handed Certified Nurse Aide (CNA) D the keys. With the same soiled gloves, the LPN applied the clean dressing to the resident's left leg. The LPN changed his/her gloves, cleaned the resident's pannus, applied the treatment to the resident and reached into his/her pocket and removed his/her keys. The LPN handed the keys to Certified Medication Technician (CMT) E, and removed perineal care supplies from the resident's drawer. 8. During an interview on 08/07/25 at 10:00 A.M., LPN A said hand hygiene and glove changes should be done when moving from a dirty site to a clean site. LPN A said he/she got nervous and did not perform good hand hygiene during care.During an interview on 08/07/2025 at 4:15 P.M. the DON said LPN A is the facility's wound care nurse. The DON said it is expected staff perform hand hygiene when moving from a dirty site to clean site during care. During an interview on 08/07/2025 at 4:43 P.M., the administrator said staff is expected to follow the facility policy for hand hygiene and wound care.

Based on observation, interview, and record review, facility staff failed to ensure the wireless call light system was fully operational twenty-four hours per day, seven days a week, and failed to ensure direct care staff always carried and utilized the wireless nurse call pagers for three residents (Resident #3, #10, and #24) out of five sampled residents when the call-light response time was greater than 30 minutes. The facility census was 38.1. Review of the facility's policy titled, Answering the Call Light, dated March 2021, showed be sure the light is plugged in and functioning at all times. The policy did not contain direction or guidance for the use of paging devices to audibly alert staff of a residents call for assistance.2. Review of the facility's Past Call's log dated 08/02/25 showed:-At 7:19 A.M., room [ROOM NUMBER] call light response time of 30 minutes and 37 seconds;-At 9:33 A.M., room [ROOM NUMBER] call light response time of 56 minutes and 47 seconds;-At 1:31 P.M., room [ROOM NUMBER] call light response time of 52 minutes and 16 seconds;-At 7:20 P.M., room [ROOM NUMBER] call light response time of 37 minutes and 45 seconds;-At 7;29 P.M., room [ROOM NUMBER] call light response time of 37 minutes and 13 seconds;-At 10:10 P.M., room [ROOM NUMBER] call light response time of 1 hour, 4 minutes and 10 seconds;-At 10:16 P.M., room [ROOM NUMBER] call light response time of 1 hour, 14 minutes and 15 seconds;-At 10:21 P.M., room [ROOM NUMBER] call light response time of 1 hour, 5 minutes and 35 seconds;-At 10:54 P.M., room [ROOM NUMBER] call light response time of 36 minutes and 59 seconds. Review of the facility's Past Call's log dated 08/03/25 showed:-At 6:38 A.M., room [ROOM NUMBER] call light response time of 1 hour, 53 minutes and 20 seconds;-At 6:47 A.M., room [ROOM NUMBER] call light response time of 40 minutes and 40 seconds;-At 7:15 A.M., room [ROOM NUMBER] call light response time of 1 hour, 1 minute and 29 seconds;-At 8:02 A.M., room [ROOM NUMBER] call light response time of 1 hour, 33 minutes and 29 seconds;-At 8:35 A.M., room [ROOM NUMBER] call light response time of 2 hours, 12 minutes and 37 seconds;-At 8:39 A.M., room [ROOM NUMBER] call light response time of 39 minutes and 36 seconds;-At 8:41 A.M., room [ROOM NUMBER] call light response time of 36 minutes and 41 seconds;-At 9:33 A.M., room [ROOM NUMBER] call light response time of 1 hour, 46 minutes and 44 seconds;-At 9:59 A.M., room [ROOM NUMBER] call light response time of 43 minutes and 33 seconds;-At 10:42 A.M., room [ROOM NUMBER] call light response time of 30 minutes and 32 seconds;-At 1:20 P.M., room [ROOM NUMBER] call light response time of 1 hour, 1 minute and 2 seconds;-At 1:30 P.M., room [ROOM NUMBER] call light response time of 47 minutes and 59 seconds;-At 5:19 P.M., room [ROOM NUMBER] call light response time of 45 minutes and 37 seconds;-At 5:26 P.M., room [ROOM NUMBER] call light response time of 31 minutes and 47 seconds;-At 9:30 P.M., room [ROOM NUMBER] call light response time of 46 minutes and 44 seconds.Review of the facility's Past Call's log dated 08/04/25 showed:-At 3:25 A.M., room [ROOM NUMBER] call light response time of 41 minutes and 52 seconds;-At 5:19 A.M., room [ROOM NUMBER] call light response time of 36 minutes and 59 seconds;-At 5:49 A.M., room [ROOM NUMBER] call light response time of 1 hour, 27 minutes and 33 seconds;-At 7:29 A.M., room [ROOM NUMBER] call light response time of 1 hour 1 minute and 47 seconds;-At 8:09 A.M., room [ROOM NUMBER] call light response time of 2 hours, 4 minutes and 40 seconds;-At 9:05 A.M., room [ROOM NUMBER] call light response time of 33 minutes and 55 seconds;-At 9:05 A.M., room [ROOM NUMBER] call light response time of 49 minutes and 8 seconds;-At 9:08 A.M., room [ROOM NUMBER] call light response time of 31 minutes and 35 seconds;-At 12:24 P.M., room [ROOM NUMBER] call light response time of 1 hour, 19 minutes and 47 seconds;-At 1:03 P.M., room [ROOM NUMBER] call light response time of 30 minutes and 34 seconds;-At 2:57 P.M., room [ROOM NUMBER] call light response time of 46 minutes and 3 seconds;-At 3:13 P.M., room [ROOM NUMBER] call light response time of 33 minutes and 23 seconds;-At 5:35 P.M., room [ROOM NUMBER] call light response time of 1 hour, 13 minutes and 34 seconds;-At 5:59 P.M room [ROOM NUMBER] call light response time of 42 minutes;-At 6:21 P.M., room [ROOM NUMBER] call light response time of 1 hour 2 minutes and 13 seconds;-At 6:34 P.M., room [ROOM NUMBER] call light response time of 52 minutes and 50 seconds;-At 10:50 P.M., room [ROOM NUMBER] call light response time of 32 minutes and 51 seconds.3. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/06/25 showed staff assessed the resident as cognitively intact.During an interview on 08/05/25 at 11:08 A.M., the resident said it can take up to one to two hours before staff answers the call light. He/she said he/she must lay in his/her waste for long periods of time. 4. Review of Resident #10's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/05/25 at 1:00 P.M., the resident said call light wait times are long and it bothers him/her. He/She said he/she cannot hold their urine and needs staff to help keep them clean. He/She said he/she does not like to smell of urine and its not good for the skin.5. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/05/25 at 1:15 P.M., the resident said he/she wears a depend and if staff take too long he/she has to sit in his/her urine and that's just not good. He/She said sometimes it takes up to and hour to an hour and a half to get help. 6. Observation on 08/05/25 from 12:56 P.M. to 1:58 P.M., showed the centralized call light monitor altered for room [ROOM NUMBER] and did not have an audible sound. Observation showed several staff passed by the monitor and pager noise could not be heard. 7. Observation on 08/05/25 at 2:06 P.M., showed Certified Nurse Aide (CNA) D did not wear a pager.During an interview on 08/05/25 at 2:06 P.M., CNA D said he/she forgot to get a pager. The pagers are kept in a drawer at the nurse desk. He/She said he/she usually just walks up the hall and checks the monitor at the desk. 8. Observation on 08/05/25 at 02:08 P.M., showed CNA F did not wear a pager. During an interview on 08/05/25 at 2:08 P.M., CNA F said he/she does not wear a pager and didn't know anything about the pagers. He/She walks up the hall to the desk to check for call lights. 9. During an interview on 08/07/25 at 4:14 P.M., the Director of Nursing (DON) said the nursing staff are expected to carry a pager, so they know if the resident needs something and has initiated a call light. A call light wait time of 20 minutes for a resident is unacceptable. He/She said it is his/her responsibility to ensure staff are wearing their pagers and did not know they weren't.During an interview on 08/07/25 at 4:42 P.M., the Administrator said when he/she started at the facility, staff were not wearing their pagers so a sign in and out sheet was set up. He/She said he/she just found out the staff were not doing it. The call lights do alarm at the monitor at the nurse station, but staff would have to walk down the hall to hear it and see what call light is sounding. He/She would expect staff to answer call lights within 20 minutes and was unaware call light times were longer than that. He/She said anything could happen to those who must wait.

Based on interview and record review, facility staff failed to maintain professional standards of practice when staff failed to provide access for qualified staff to the facility's emergency medication kit (E-Kit), in order to administer medications to three newly admitted residents (Residents #1, #2, and #3). The facility census was 38. 1. Review of the facility's Medication Pass Policy, undated, did not contain information related to administration of medications from the E-Kit. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/15/25, showed an admission date of 4/09/25. Review showed staff assessed the resident as cognitively intact, with diagnoses of high cholesterol and depression. Review of the resident's Physician's Order Sheet (POS), dated April 2025, showed the physician orders directed staff to administer Metoprolol Tartrate (a medication used to decrease blood pressure) 50 milligrams (mg) one tablet twice daily, Baclofen (a muscle relaxant) 10 mg one-half (1/2) tablet three times daily, Benzonate (a cough suppressant) 100 mg three times daily, and Clonidine (a medication used to decrease blood pressure) 0.1 mg one tablet three times daily. Review of the resident's Medication Administration Record (MAR), dated April 2025, showed Certified Medication Technician (CMT) A documented he/she did not administer the resident's evening doses of Metoprolol Tartrate, Baclofen, Benzonate, or Clonidine on 4/09/25. Review showed CMT A documented to see progress notes. Review of the resident's progress notes did not contain staff documented the resident's evening or bedtime medications were not administered. 3. Review of Resident #2's Quarterly MDS, dated [DATE] showed a re-admission date of 4/07/25. Review showed staff assessed the resident as cognitively intact, with diagnoses of hypertension and depression. Review of the resident's POS, dated April 2025, showed the physician orders directed staff to administer Febuxostat (a medication used to treat gout) 40 mg one tablet at bedtime, Sertraline (an antidepressant) 50 mg one tablet at bedtime, and Simvastatin (a medication used to decrease cholesterol) 40 mg one tablet at bedtime. Review of the resident's MAR, dated April 2025, showed CMT B documented he/she did not administer the resident's evening dose of Calcium Acetate, or the resident's bedtime doses of Febuxostat, Sertraline, or Simvastatin 4/07/25. Review showed CMT B documented the reason for not administering the resident's medications to see progress. Review of the resident's progress notes did not contain staff documented the resident's evening or bedtime medications were not administered. 4. Review of Resident #3's admission MDS, dated [DATE], showed an admission date of 4/10/25. Review showed staff assessed the resident as cognitively impaired, with diagnoses of cerebral vascular accident, and hemiplegia (paralysis of the muscles on one side of the body). Review of the resident's POS, dated April 2025, the physician orders directed staff to administer Atorvastatin Calcium (A medication used to decrease cholesterol) 80 mg one tablet in the evening, Ezetimibe (a medication used to decrease cholesterol) 10 mg one tablet at bedtime, Eliquis (an anticoagulant used to reduce blood clots) 5 mg one tablet twice daily, Hydrochlorothiazide (a medication used to decrease fluid retention) 25 mg one tablet twice daily, Lisinopril (a medication used to decrease blood pressure) 20 mg one tablet twice daily, Baclofen 5 mg one tablet three times daily, and Hydralazine (a medication used to decrease blood pressure) 10 mg one tablet three times daily, Review of the resident's MAR, dated April 2025, showed CMT A documented he/she did not administer the resident's evening doses of Atorvastatin Calcium, Eliquis, Hydrochlorothiazide, Lisinopril, Baclofen, or Hydralazine, or the resident's bedtime dose of Ezetimibe on 4/10/25. Review showed CMT A documented the reason for not administering the resident's medications as see progress notes. Review of the resident's progress notes did not contain staff documented the resident's evening or bedtime medications were not administered. 5. During an interview on 4/29/25 at 12:50 P.M., the Director of Nursing (DON) said if a new resident's medications are not available in the facility, staff should administer the medications from the facility's E-Kit. The DON said all residents' routine medications should be available in the E-Kit, unless it is an uncommon medication. The DON said he/she has been the DON at the facility for two days, and he/she did not know who is responsible for setting up access to staff for the facility's E-Kit. During an interview on 4/29/25 at 1:00 P.M., CMT A said he/she did not administer Resident #1's or Resident #2's evening or bedtime medications because corporate staff had not set up his/her access to the facility's E-Kit. CMT A said he/she started working at the facility in mid-February, and staff had not given her access yet. He/She said a staff member's fingerprint and [NAME] are needed to access the facility's E-Kit. During an interview on 4/29/25 at 1:05 P.M., the administrator said he/she did not know some CMT's did not have access to the facility's E-Kit. He/She said only the facility's corporate nurses have authorization to set up access for new nursing staff at this. During an interview on 5/01/25 at 8:12 A.M., the [NAME] President of Clinical Operations said if a resident is admitted to the facility after the last pharmacy delivery of the day, staff are to administer medications from the facility's E-kit. He/She said the pharmacist and DON have the ability to set up access to the E-Kit for new nurses and CMT's. He/She said he/she and the interim DON are responsible for setting up access to the E-Kit at this time. He/She said he/she did not know CMT A did not have access to the E-Kit, and did not know staff did not administer the residents' medications. He/She said he/she expects staff to notify him/her or the charge nurse on duty if a staff member was unable to administer medications. MO00252685

Based on observation, interview and record review, facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for two residents (Resident #1 and #2) of two sampled residents. The facility's census was 37. 1. Review of the facility policies showed it did not contain a Enhanced Barrier Precaution policy. Review of the Centers for Medicare and Medicaid Services, New CDC Guidance: Enhanced Barrier Precautions, dated 03/20/2024 showed: -Educate all staff on enhanced barrier precautions and use during high-contact resident care activities to include dressing, bathing, transferring, providing hygiene, changing linens and briefs, assisting with toileting, device care or use: central lines, urinary catheters, and feeding tubes, tracheostomy, urostomy, and wound care: any skin opening requiring a dressing. -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside or inside of each resident room, and alcohol based hand rub should be available for every room. 2. Review of Resident #1's Significant Change Minimum Data Set (MDS) a federally mandated assessment tool, dated 01/23/25, showed the resident admitted to the facility on [DATE]. The resident had one or more unstageble pressure ulcers. Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed a physician order to cleanse left hip wound with saline and gauze, moisten rolled gauze with saline and fill wound depth. Apply sure prep to peri wound and cover with silicone foam boarder. Change three times a week as needed when soiled. Review showed the physician ordered to cleanse right buttocks wound with soap and water, pat dry, apply sureprep to peri wound and cover with petroleum jelly, mesh and silicone foam boarder. Change every three days and as needed when soiled. Observation on 02/26/25 at 12:41 P.M., showed the resident room did not have PPE in close proximity. Observation showed Certified Nursing Assistant (CNA) A and CNA B entered the residents room to provide incontinence care and did not apply a gown. During an interview on 02/26/25 at 12:57 P.M., CNA B said he/she was informed less than an hour ago by the Administrator about the EBP and needing to wear PPE in the residents rooms with wounds. He/She said there is not a PPE cart outside of the residents room. He/She said a resident with wounds would require gloves and a gown. During an interview on 02/26/25 at 12:58 P.M., CNA A said no one communicated to him/her he/she needed to wear additional PPE in the resident rooms. 3. Review of Resident #2's Entry tracking record MDS, dated [DATE], showed the resident admitted to the facility on [DATE] and staff documented the resident did not have skin issues on admission. Review of the facility wound list showed staff documented they identified on 02/26/25, a new wound on the resident's coccyx. Observation on 2/27/25 at 1:03 P.M., showed the resident's room did not have PPE in close proximity. Observation showed the resident with a dime sized wound on his/her coccyx. Observation showed CNA A and CNA B provided incontinence care to the resident and did not wear a gown. During an interview on 02/26/25 at 1:20 P.M., CNA C said he/she does not know what EBP is. During an interview on 02/26/25 at 1:21 P.M., CNA D said he/she did not wear PPE because there is a lack of PPE carts and communication. The administrator came up early and spoke about it but he/she was confused and it was not clear exactly what he/she needed to do. 4. During an interview on 02/26/25 at 1:28 P.M., the Corporate Registered Nurse said facilities were well educated on the new EBP and the new administration has been fixing issues and had not yet educated and put out appropriate EBP and PPE. During an interview on 2/26/25 at 12:15 P.M., the administrator said he/she has only been in the facility for three weeks and is aware the facility must implement EBP. During an interview on 02/26/25 at 1:29 P.M., the administrator said EBP has been implemented and additional PPE carts have been ordered. He/She said he/she will have a more thorough inservice with all staff for clarification. MO00249971

45564 Based on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 37 with a capacity of 52. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Water management program, reviewed April 2024, showed facility staff identified ice machines and hot water storage less than 140 degrees Fahrenheit (F) as potential risk areas for the growth of Legionella. Review showed control measures included weekly visual inspections of ice machines, weekly temperature checks of water temperatures and monthly inspection and flushing of hot water storage tanks. Review showed the program instructed staff to document how the program status is monitored and when staff are to take corrective action. Review of the water management program records showed the records did not contain documentation of monthly water heater flushing. Observation on 05/29/24 during the Life Safety Code tour showed the facility contained two ice machines for resident use. Observation showed the dining room ice machine contained a black drainage tube which was inserted into a white plastic drain. The ice machine drain did not contain an air gap. Observation showed the ice machine filter was dated 12/21/22 and contained a label which directed the user to replace the cartridge no later than six months from installation date. Observation on 05/29/24 showed the facility contained two water heaters which provided hot water throughout the facility. During an interview on 05/30/24 at 9:05 A.M., the maintenance director said he/she should change the ice machine filter every three or four months and he/she did not know why the dining room filter was not changed. The maintenance director said he/she did not know about the requirement to have an air gap in the ice machine drain. The maintenance director said he/she kept the water temperature between 105 and 120 degrees F. The maintenance director said he/she released pressure from the water heaters for about 15 seconds every month, but he/she never flushed the water heater tanks. The maintenance director said he/she did not know about flushing the water heaters as a Legionella control measure. During an interview on 05/30/24 at 11:05 A.M., the administrator said the maintenance director was responsible for the ice machines and water heaters. The administrator said the maintenance director inspected the ice machines weekly but was not sure if the inspection included looking for an air gap in the drain. The administrator said he/she would expect the ice machine filter to be changed according to manufacturer's instructions. The administrator said he/she was not sure exactly what the water heater flush was so he/she relied on the maintenance director for expertise.

Based on observation, interviews, and record review, facility staff failed to maintain a clean comfortable, and maintained homelike environment. The facility census was 37. 1. Review of the facility's Work Orders, Maintenance policy, dated April 2010, showed maintenance work orders shall be completed in order to establish a priority of maintenance, work orders must be filled out and forwarded to the maintenance director and emergency requests will be given priority in making necessary repairs. Review of the facility's Cleaning and Disinfection of Environmental Surfaces, dated August 2019, showed environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. 2. Observation on 05/28/24 at 10:30 A.M., showed the occupied room [ROOM NUMBER] with build up of a dark substance on the room floor tile grout lines. Observation on 05/30/24 at 10:30 A.M., showed the occupied room [ROOM NUMBER] with build up of a dark substance on the room floor tile grout lines. 3. Observation on 05/28/24 at 10:40 A.M., showed the occupied room [ROOM NUMBER]'s bathroom floor with multiple areas of gouges. Observation showed bathroom wall tile around the toilet with a dark dried smear. Observation on 05/30/24 at 11:05 A.M., showed the occupied room [ROOM NUMBER]'s bathroom floor with multiple areas of gouges. Observation showed bathroom wall tile around the toilet with a dark dried smear. 4. Observation on 05/28/24 at 10:45 A.M., showed the occupied room [ROOM NUMBER] bathroom door with large gouges and rough edges. Observation on 05/30/24 at 11:45 A.M., showed the occupied room [ROOM NUMBER] bathroom door with large gouges and rough edges. 5. Observation on 05/28/24 at 10:58 A.M., showed the occupied room [ROOM NUMBER] with a large black build up between the room floor tile. Observation showed the bathroom door frame rusted. Observation on 05/30/24 at 1:58 P.M., showed the occupied room [ROOM NUMBER] with a large black build up between the room floor tile. Observation showed the bathroom door frame was rusted. 6. Observation on 05/28/24 at 11:05 A.M., showed the occupied room [ROOM NUMBER] contained a sink counter top that was cracked with rough edges down the side. 7. During an interview on 05/30/24 at 1:46 P.M., Certified Nurse Aid (CNA) L said staff are to tell the Maintenance Director when they find damaged areas in the resident rooms. Housekeeping are told about dirty areas or we clean then ourselves. During an interview on 05/30/24 at 2:00 P.M., Nurse Aid (NA) E said the maintenance department is informed about broken items in resident rooms and housekeeping is responsible for cleaning the resident rooms. During an interview on 05/30/24 at 2:40 P.M., The Maintenance Director said he/she was aware of some of the damage in the resident rooms. He/She said they attempt to patch damage like the counter tops, but the corporate office has to provide payment for the materials needed. He/She said the facility uses a computer based system to track repair request of staff tell them directly. During an interview on 05/31/24 at 10:38 A.M., Housekeeper N said he/she cleans all of the resident rooms daily. He/She said something like a smear on a toilet wall should be cleaned immediately. During an interview on 05/31/224 at 11:21 A.M., the Director of Nursing said damage in the resident rooms is the responsibility of the maintenance department and approval from the corporate office would be needed for the expense of making the repairs. He/She said housekeeping cleans the rooms daily and there should be no areas left uncleaned.

Based on observation, interview, and record review, facility staff failed to safely propel two (Resident #17 and #8) out of 15 sampled residents while in a wheelchair. The facility census was 37. 1. Review of the facility's polices showed staff did not provide a wheelchair propulsion policy. 2. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/28/24, showed staff assessed the resident as follows: -Cognition not assessed; -Uses a wheelchair for mobility; -Diagnosis of Alzheimers, and Parkinson disease. Observation on 05/30/24 at 11:40 A.M., showed Certified Nurse Aid (CNA) L propelled the resident from the hall to the dinning area without the resident's foot pedals. Observation showed the residents feet made contact on the floor. During an interview on 05/30/24 at 11:42 A.M., CNA L said he/she should have put the residents feet in the footrests but did not because the resident has contractor in both legs. 3. Review of Resident #8's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition not assessed; -Dependent for wheelchair mobility; -Diagnosis of stroke, dementia, aphasia, seizures, depression, and respiratory failure. Observation on 05/31/24 at 11:25 A.M., showed CNA K propelled the resident from the hall towards the dinning area without footrests on the wheelchair. The residents feet glided across the floor. During an interview on 05/31/24 at 11:27 A.M., CNA K said he/she should not push the resident in a wheelchair without footrest but forgot to put the footrests on because they were not with the wheelchair. 4. During an interview on 05/31/24 at 8:06 A.M., Licensed Practical Nurse (LPN) M said staff should use footrests to push residents in wheelchair. The resident might fall out and be injured if the staff don't. The staff are educated on this often. During an interview on 05/31/24 at 11:18 A.M., the Director of Nursing (DON) said staff should use footrests when propelling a resident and make sure the resident is secure. Staff have been educated on the risks of not doing so. He/She said staff and the administrator are responsible for resident safety. During an interview on 05/31/24 at 11:45 A.M., the administrator said staff should use footpedals when propelling a resident. Injury is a risk to any resident when pushed in a wheelchair without footpedals. He/She said the DON and themselves along with all nurses are responsible for oversight.

Based on interview and record review, facility staff failed to meet professional standards of care when nursing staff failed to obtain and document weights for five (Resident #1, #12, #17, #33 and #142) of nine sampled residents and failed to follow up on dietician recommendations for one (Resident #142) of one sampled residents with a weight loss. The facility census was 37. 1. Review of the facility's Weighing and Measuring the Resident policy, dated March 2011, showed: -The purpose to determine the weight, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident; -Weight is measured on admission and monthly during the resident's stay; -The following should be recorded in the resident's record: date and time the procedure was performed, name and title of person who performed the procedure, signature and title of person recording the data; -Notify the nurse supervisor if the resident refuses the procedure. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/16/24, showed staff assessed the resident as: -Cognitively intact; -Did not lose or gain weight or unknown; -Weight 120 pounds; -Diagnosis of anemia, kidney disease and lung disease. Review of the resident's Physician Order Sheet (POS), dated May 2024, showed an order with a start date of 9/2/23 to weigh the resident monthly on the second. Review of the resident's Treatment Administration Record (TAR) showed staff did not document the residents weight for the months of 01/2024 through 05/2024: Review of the resident's nurse notes, dated January 2024 through May 30, 2024, showed the nurses notes did contain the residents weights. 3. Review of Resident #12's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Did not have cognitive assessment; -Did not lose weight or unknown; -Weight of 150; -Diagnosis of thyroid disorder, arthritis, dementia, and anxiety disorder. Review of the resident's POS, dated 05/21/24, showed an order to weight the resident weekly after the admitted for four weeks, and then weigh the resident once monthly. Review of the resident's TAR, dated 03/2024, showed staff documented the residents weight on 03/06/24. Review showed the TAR did not contain documentation staff weighed the resident for the additional three weekly weights and did not document the resident's weight for April 2024. Review of the resident's medical record showed the record did not contain weekly weights after admission or monthly weights for April 2024. 4. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not lose or gain weight or unknown; -Weight 98 pounds; -Diagnosis of Alzheimer dementia. Review of the resident's POS, dated May 2024, showed the POS did not contain an order for weights. Review of the resident's medical record, showed the record did not contain a documented weight for April or May 2024. 5. Review of Resident #33's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not lose or gain weight or unknown; -Weight 132 pounds; -Diagnosis of pneumonia, septicemia (a body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), dementia, and respiratory disease. Review of the resident's POS, dated 02/02/24, showed an order to weigh the resident monthly. Review of the resident's medical record did not contain documentation of the residents mothly weights for March, April or May 2024. 6. Review of Resident #142's Admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognition intact; -Presence of a diabetic foot ulcer; -Did not lose or gain weight or unknown; -Weight 221 pounds; -Diagnosis of anemia, heart failure, diabetes and kidney failure. Review of the resident's census sheet showed the resident: -admitted to the faciity on 04/22/24; -hospitalized [DATE]; -readmitted to the facility 05/08/24. Review of the resident's POS, dated May 2024, showed an order with a start date of 05/08/24, to weigh the resident weekly after the admitted for four weeks, and then weigh the resident once monthly on the fifth. Review of the resident's medical record showed staff did not documented the resident weight on 5/9/24 and 5/13/24. Review of the residents nurse notes, dated April through May 2024, showed dietician documented recommendation as follows: -On 4/26/24, recommendation of multivitamin with minerals daily and one scoop of protein powder twice a day or 30 milliliters of protein liquid; -On 5/21/24, start house supplement 120 milliliters twice a day and monitor weight and intake. Review of the residents medical record, showed, the record did not contain follow up documentation to the dietician recommendations. 7. During an interview on 05/29/24 at 2:24 P.M., the DON said if the weights are not recorded in the electronic medical record, then they are not completed. He/She said it has been a struggle getting the weights as ordered but feels it is getting better in the past couple of weeks. The dietician comes in monthly and his/her assistant either comes in person or reviews the residents remotely. The registered dietician recommendations should be followed up on within 24 hours by the DON or the charge nurse. He/She was not aware of any dietician recommendations until 5/29/24. During an interview on 05/30/24 at 1:52 P.M., the Registered Dietician said he/she comes to the facility monthly and would like to have the weights during each visit so he/she could determine if there are nutritional issues with the residents. He/She said the weights are not always done for his/her visits. He/She would expect the facility staff to follow up on recommendations, especially those residents with wounds or other significant issues. He/She did not have an expectation of a timeframe when the recommendations should be followed up on. During an interview on 05/31/24 at 8:17 A.M., Licensed Practical Nurse (LPN) M said weights are the responsibility of the nursing staff but is not sure if they are up to date. He/She said if the weights are not done, then there is an opportunity to miss a potential problem. The dietary recommendations go to the DON for review and if an order or other follow up is needed, the DON will give them to the nurse working. He/She is not sure why the recommendations were not followed up on, but would expect they should have been. During an interview on 05/31/24 at 8:33 A.M., Nurse Aide (NA) J said weights are completed monthly as assigned by the DON. He/She said he/she does not know if they are up to date. 42484 43327

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three (Resident #9, #33 and #143) out of ten sampled residents The facility census was 37. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated December 2016 showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing the goals of care; -The comprehensive, person centered care plan will: include measurable, objectives and timeframe's, describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, psychosocial well-being, describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his/her right, including the right to refuse treatment, incorporate identified problem areas and risk factors associated with identified problems, build on the resident's strengths, reflect the residents expressed wishes regarding care and treatment goals, reflect treatment goals, timetables, and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, aid in preventing or reducing the decline in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program and reflect currently recognized standards of practice for problem areas and conditions; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/25/24 showed staff assessed the resident as: -Cognitively intact; -No behaviors or rejection of care; -Had pain; -Use an antidepressant, antipsychotic, antianxiety, antiplatelet, anticoagulant and opiod medication; -Diagnosis of stroke, dementia and anxiety. Review of the residents Physician Order Set (POS), dated May 2024, showed physician orders for: -Lithium 300 milligrams (mg) (used to reduce mania and manic episodes) daily for psychosis; -Lithium 150 mg at bedtime for psychosis; -Abilify (an antipsychotic) 20 mg tablet, give 0.5 tablet twice daily for depression, anxiety and obsessive compulsive disorder (OCD); -Buspirone (an antianxiety) 7.5 mg three times a day for anxiety; -Plavix (stop blood cells from sticking together) 75 mg daily for blood clot prevention; -Cymbalta (antidepressant and pain medication) 30 mg daily for depression; -Eliquis (blood thinner) 5 mg twice a day for hypertension; -Hydrocodone/acetaminophen (used to decrease pain) 5/325 1-2 tablets every 6 hours as needed for pain; -Lorazepam (antianxiety) 0.5 mg three times a day for anxiety; -Trazodone (antidepressant and sedative) 50 mg daily at bedtime for sleep related to anxiety; -Methylphenidate (stimulates brain involved with concentration) 5 mg tablet, give 0.5 mg daily for anxiety; -Namenda (reduces chemicals in brain that contribute to symptoms of Alzheimer's disease) 28 mg daily for depression, anxiety and OCD; -Banophen (used to temporarily relieve pain caused by minor cuts/burns/scrapes, insect bites, or skin irritations) 25 mg tablet, give 0.5 tablet every 24 hours for pain; -Myrbetriq (used for urinary incontinence and overactive bladder) 25 mg daily for spastic hemiplegia; -Sumatriptan (treatment for headaches) 25 mg every 6 hours as needed for headache. Review of the residents care plan, dated 1/25/24, showed the care plan did not contain interventions for dementia care, resident centered behaviors/behavior management, pain management, or risk of bleeding for anticoagulant and antiplatelet use. During an interview on 5/31/24 at 08:17 A.M., the MDS Coordinator said the resident does not have any behaviors except for some reported depression and anxiety so it is not included in the care plan. He/She said the resident does not show signs of dementia. 3. Review of Resident #33's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors or rejection of care; -All activities were somewhat important to the resident; -Diagnoses of pneumonia, septicemia (a body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), dementia, and respiratory disease. Review of the Care plan dated 1/25/24 showed the care plan did not address social, cognitive, or activity needs of the resident. 4. Review of Resident #143's admission MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Smokes; -History of falls prior to admission with a fracture; -Felt it was very important to have books, newspapers, and magazines to read, listen to music he/she liked, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. Review of the resident's smoking assessment, dated 5/13/24, showed the resident smokes two to three times a day with supervision. Review of the resident's nurse notes dated 5/9/2024 at 11:00 P.M., showed the resident on the floor in his/her room. Review of the resident's care plan, dated 5/28/24, showed the care plan did not contain activity preferences, smoking safety and use of cigarettes, or fall interventions for the fall on 5/8/24. During an interview on 5/31/24 at 08:17 A.M., the MDS Coordinator said the resident only participates in occasional smoke breaks and is a passive observer to other activities. The resident was hospitalized after the fall on 5/8/24 and is receiving therapy. He/She said the resident is still new to the facility and actively working on his/her care plan. 5. During an interview on 5/31/24 at 08:17 A.M., the MDS Coordinator said care plans should include resident specific behaviors and how to manage them, how a resident transfers, diet, goals of care, interventions for falls, if a resident is on hospice, side rail use, activity preferences and other triggers from the MDS assessment including psychotropic medication use. He/She said it is his/her responsibility to update the care plans when there are changes in the resident conditions, on admission and at least quarterly. He/She said the Director of Nursing adds new interventions for falls. During an interview on 5/31/24 at 10:16 A.M., Registered Nurse (RN) M said care plans should include things that trigger in the MDS assessment such as behaviors and should be updated on admission, quarterly and with changes in condition. Other things that the care plan should include are behavior problems, dementia care, anticoagulant medication use, smoking and activity preferences. He/She said the MDS nurse updates the care plans with changes in the residents care. During an interview on 5/31/24 at 11:13 A.M., the Director of Nursing (DON) said care plans should include triggers from the MDS such as code status, diet, mobility, transfers, activity of daily living, assistive devices, activity preferences and medication use. He/She said the managers and MDS coordinator update the care plans. The DON said all the nursing staff have access to care plans. He/She said if a resident has dementia there should be a goal and interventions specific to the person in the care plan and updated accordingly. 43327 50753

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate seven residents who tested positive for COVID-19 from residents who had tested negative for COVID-19. Residents (Resident #2, Resident #4, Resident #6, Resident #8, Resident #10, Resident #12 and Resident #14) were at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 37. The Administrator was notified on 3/8/23 at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on 03/03/23. The IJ was removed on 3/8/23 as confirmed by surveyor onsite verification. 1. Review of Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated Sept. 23, 2022, showed a patient with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated health care professional (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. Review of the facility's Coronavirus (COVID-19) Policy, undated, showed this facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility. This policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning and social distancing for COVID-19. Residents are screened daily for fever and symptoms of COVID-19. Residents with fever or symptoms of COVID-19 are provided a facemask, immediately isolated and placed on transmission-based precautions. Asymptomatic residents are provided face coverings (or facemasks) as supplies permit. Residents are encouraged to wear face coverings or masks when they leave their rooms or are around others during outbreak status. Residents are not required to wear face coverings when in their rooms. Residents are instructed on proper hand hygiene after touching or removing face covering or mask. Residents who are incapacitated, unconscious, have difficulty breathing, or cannot remove the face covering or mask without assistance are not asked to wear them. Standard precautions are utilized when caring for all residents. For a resident with known or suspected COVID-19: -Staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator; and -Resident is placed in a private room with a dedicated bathroom (if available) and close the door; OR -Resident is cohorted per national, state, or local public health authority recommendations. 2. Review of the facility testing report showed Resident #13 tested positive for COVID on 03/03/23. Review of the report showed Resident #14 tested negative for COVID on 03/07/23, 3/9/23, and 3/12/23. Observation on 03/08/23 at 11:20 A.M., showed Resident #13 in a room with resident #14. Resident #13 and Resident #14 did not have a face mask on. During a telephone interview on 3/10/23 at 10:34 A.M., Resident #14's relative said he/she expected staff to move a resident who tested positive for COVID-19 out of the room of someone who tested negative. 3. Review of the facility testing report showed Resident #5 tested positive for COVID on 03/03/23. Review of the report showed Resident #6 tested negative for COVID on 03/07/23, 3/9/23, and 3/12/23. Observation on 03/08/23 at 11:25 A.M., showed Resident #5 in a room with Resident #6. Observation showed Resident #5 and Resident #6 did not have a face mask on. 4. Review of the facility testing report showed Resident #11 tested positive for COVID on 03/05/23. Review of the report showed Resident #12 tested negative for COVID on 03/05/23, 3/7/23, 3/9/23, and 3/12/23. Observation on 03/08/23 at 11:30 A.M., showed Resident #11 in a room with Resident #12. Observation showed Resident #11 and Resident #12 did not have a face mask on and the privacy curtain was not closed. 5. Review of the facility testing report showed Resident #1 tested positive for COVID on 03/05/23. Review of the report showed Resident #2 tested negative for COVID on 03/05/23, 3/7/23, 3/9/23, and 3/12/23. Observation on 03/08/23 at 11:32 A.M., showed Resident #1 in a room with Resident #2. Observation showed Resident #1 and Resident #2 did not have a face mask on. 6. Review of the facility testing report showed Resident #7 tested positive for COVID on 03/04/23. Review of the report showed Resident #8 tested negative for COVID on 03/05/23 and 3/7/23. Review showed Resident #8 tested positive for COVID on 3/9/23. Observation on 03/08/23 at 11:34 A.M., showed Resident #7 in a room with Resident #8. Observation showed Resident #7 and Resident #8 did not have a face mask on. 7. Review of the facility testing report showed Resident #3 tested positive for COVID on 03/03/23. Review of the report showed Resident #4 tested negative for COVID on 03/03/23, 3/5/23, 3/7/23, 3/9/23, and 3/12/23. Observation on 03/08/23 at 11:36 A.M., showed Resident #3 in a room with Resident #4. Observation showed Resident #3 and Resident #4 did not have a face mask on. 8. Review of the facility testing report showed Resident #9 tested positive for COVID on 03/04/23. Review of the report showed Resident #10 tested negative for COVID on 03/04/23, 3/7/23, and 3/9/23. Review showed Resident #10 tested positive for COVID on 3/9/23. Observation on 03/08/23 at 11:39 A.M., showed Resident #9 in a room with Resident #10. Observation showed Resident #9 and Resident #10 did not have a face mask on and the privacy curtain was not closed. During a telephone interview on 3/10/23 at 10:36 A.M., Resident #10's relative said he/she expected staff to move a resident who tested positive for COVID-19 out of the room of someone who tested negative. 9. During a telephone interview on 3/8/23 at 11:52 A.M., the administrator said in order to protect residents who tested negative for COVID from their roommates who test positive, staff use personnel protective equipment (PPE), wash their hands and change gloves between taking care of the residents, and use the privacy curtain. The administrator said she did not know a resident who tested positive for COVID should not be in the same room with a resident who tested negative. During an interview on 3/8/23 at 12:07 P.M. the regional manager said he/she did not realize a resident who tested positive for COVID should not be in a room with a roommate who tested negative. During an interview on 3/8/23 at 12:56 P.M., the regional manager said in order to protect residents who tested negative for COVID from their roommates who test positive staff use PPE, wash their hands and change gloves between taking care of the residents, and use the privacy curtain. During a telephone interview on 3/13/23 at 9:17 A.M., the MDS Coordinator said she expected staff to separate residents who test positive for COVID-19 from residents who test negative for COVID-19. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E 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). MO00214948

Based on observation, interview and record review staff failed to properly assess/evaluate the care and treatment of [REDACTED].#1) of three sampled residents. The facility census was 42. 1. Review of the Facility's skin and wound management policy, dated 10/2010, showed instruction for staff to complete the following: Guidelines for wound care: - Notify and obtain physician order [REDACTED].>- Review resident's care plan, current orders, and [DIAGNOSES REDACTED]. - Check the treatment record; - Verify that there is a physician order [REDACTED].>- Notify responsible party; - Record all assessment data in the residents medical record(i.e.,wound bed color,size, drainage,etc.) 2. Review of Resident #1's care plan dated 6/19/15 showed staff identified the resident at high risk for development of pressure ulcers and planned the following interventions: -Reposition every two hours; -Apply a pressure reducing device in chair; -Utilize two people with repositioning; -Observe skin daily with routine care; -Complete a full skin evaluation weekly; -Float heels off bed; -Use pillows and other supportive/protective devices to assist with positioning. Review of the plan of care, dated 6/19/15, showed staff identified the resident had blisters over his/her trunk and arms due to an [DIAGNOSES REDACTED] disorder and planned the following interventions: -Provide wound care as ordered by physician; -Use two people to assist with repositioning; -Observe skin with routine care (wound nurse); -Complete a full skin assessment weekly with shower; -Adjust treatment plan if wound does not heal within 2-4 weeks (wound nurse); -Monitor for changes in skin status that may indicate worsening of open lesion and notify the physician; -Resident has regular dermatology appointments. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument used to plan care, dated 7/7/15, showed staff assessed the resident as follows: - Severely impaired cognitive skills for daily decision making; - Required extensive, two person, assistance with bed mobility, transfers, and personal hygiene; - Required total, two person assistance with toilet use and bathing; -Required total, one person assistance with locomotion and dressing; - Non-ambulatory; - Loss of functional use of one upper extremity; - History of stroke; - Incontinent: - At risk for developing pressure ulcer; - No current pressure ulcers; - Open [MEDICAL CONDITION], rashes, cuts; - Pressure reducing device in chair; - Dressings to feet; - Insulin dependent diabetic. Review of the resident's wound records showed on 7/17/15 staff documented they first identified an area on the resident's right heel measuring 1.6 centimeters (cm) x 2.1 cm x 0.1 cm centimeters. Staff did not document any description of the wound bed and did not stage the wound. Staff documented the treatment was pending. Staff did not document an assessment of the resident's right fourth toe. Review of the resident's physician order [REDACTED]. Review of the resident's plan of care, dated 7/17/15, showed staff documented they identified a [MEDICAL CONDITION] on the resident's right heel and an abrasion to right 4th toe. Staff did not document any new interventions. Review of the resident's wound records showed on 7/23/15 staff documented the area on the resident's right heel measured 1.0 cm x 1.6 cm x 0.1 cm and the treatment pending. Staff did not document an assessment of the resident's right fourth toe abrasion they identified in the plan of care on 7/17/15 to show ongoing monitoring for improvement or decline. Review of the resident's wound records, dated 7/27/15 showed staff documented the following: -The area to the resident's right heel measured 2.1 cm x 1.0 cm x 0.1 cm. Staff documented the wound status deteriorated and treatment pending. Staff did not document they staged the wound and did not document any wound base assessment; -Staff identified a new skin tear to the resident's right elbow unknown cause, measuring 0.60 cm x 1.50 cm x 0.10 cm with edges well approximated. Staff did not document any treatment; -Staff identified a new skin tear to the resident's left elbow unknown cause, measuring 0.50 cm x 2.60 cm x 0.10 cm with edges not well approximated, missing torn skin flaps. Staff did not document any treatment. - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of the resident's plan of care, dated 7/27/15, showed staff documented they identified a skin tear to the right and left elbow, and abrasion to right 5th toe. Staff did not document any new interventions. Review of the resident's wound records, dated 8/3/15, showed staff documented the following: - The wound to right heel measured 1.6 cm x 1.8 cm x 0.1 cm. Staff did not document they assessed the stage and did not document an assessment of the wound base; - The skin tear to the resident's left elbow from unknown cause, measured 3.10 cm x 1.20 cm x 0.10 cm with edges well approximated, wound deteriorated. Staff did not document any treatments; - Staff did not document an assessment of the residents right elbow; - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of the resident's wound records, dated 8/11/15, showed staff documented the following: -The wound to the right heel measured 1.5 cm x 1.8 cm x 0.1 cm with 80% eschar (dry dark scab or dead tissue). Staff did not document a stage of the wound or any treatment; -The lesion to the resident's right elbow from unknown cause, measured 2.20 cm x 3.80 cm x 0.10 cm with edges well approximated. Staff did not document any treatment. - Staff did not document an assessment of the residents left elbow; - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of the resident Physician order [REDACTED]. -Apply Clobestasol (medication used to treat skin disorders) ointment 0.5% to erosions on the trunk and extremities, place duoderm ([MEDICATION NAME] dressing) over erosions and ointment. Change every two days. - On 8/13/15 staff notified the physician and obtained an initial treatment for [REDACTED]. The physician ordered staff to cleanse the wound to right heel with wound cleanser, apply santyl ([MEDICATION NAME] ointment), Vaseline gauze, secure with roll gauze and tape. Change daily and as needed. Review of the resident's POS, dated 8/17-9/15/15 did not show an order directing staff to cleanse skin tear to left elbow with wound cleanser, apply Triple Antibiotic Ointment (TAO), Vaseline gauze, gauze roll, and secure with tape. Review of resident's Treatment Administration Record (TAR) dated 8/17 - 9/15/15 showed staff documented they completed the following treatments to the resident's skin: - Cleanse wound to right heel with wound cleanser, apply Santyl, Vaseline gauze, gauze wrap and secure Change daily and as needed; - Cleanse skin tear to left elbow with wound cleanser, apply Triple Antibiotic Ointment (TAO), Vaseline gauze, gauze wrap and secure. Change daily and as needed. Review of the resident's POS and the TAR, dated 8/16/15 through 9/15/15 showed staff did not document orders for and did not document completed treatments for the care and treatment of [REDACTED]. Review of the POS [REDACTED]. Review of resident's wound assessment report, dated 8/17/15, showed staff documented the following: - The wound on the resident's right heel measured 1.4 cm x 2.9 cm x 0.1 cm with 75% eschar. Wound deteriorated; -The skin tear to the resident's left elbow from unknown cause, measured 2.60 cm x 2.00 cm x 0.10 cm with edges well approximated. - The skin tear to the resident's right elbow unknown cause, measured 2.10 cm x 1.90 cm x 0.10 cm. - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of the resident's Braden Scale (assessment used to predict a person's risk of developing a pressure ulcer), dated 8/26/15, showed staff assessed the resident scored a 12 (at high risk for developing a pressure ulcer). Review of the resident's wound report, dated 8/28/15, showed staff documented the following: - The wound to right heel measured 1.5 x 2.0 x 0.1 cm with 50 % eschar; - The skin tear to the resident's left elbow unknown cause, condition unchanged, and measured 2.50 cm x 2.00 cm x 0.10 cm with edges not well approximated, all torn skin flaps present. - The skin tear to the resident's right elbow measured 2.50 cm 2.0 cm x 0.10 cm. - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of the POS [REDACTED] - Air mattress; - Turn resident every 1-2 hours; - Wound care team to treat wounds on elbows as pressure ulcers and not as blisters from bullae (fluid filled blister). Review of Wound care specialist report dated 9/3/15 showed the wound care specialist documented the following: - Unable to palpate right dorsalis pedis (artery of the foot) pulse and right posterior tibial (artery of the foot) pulse; - Open sores and fragile skin; - Identified wound to the lower right heel, acquired 9/3/15, measuring 2.0 cm x 1.0 cm x 0.02 cm; - Treatment orders included; apply santyl for enzymatic debridment(to remove dead tissue), Vaseline gauze, cover with gauze, and secure with gauze wrap. Change daily and as needed. Off-load right heel at all times. Turn and position every two hours. Please order arterial doppler (device to determine adequacy of circulation) on lower extremities including ABI (ankle brachial index-the ratio of the blood pressure in the lower legs to the blood pressure in the arms). -Wound specialist did not document assessments of the resident's elbows. Review of resident's wound assessment report, dated 9/7/15, showed staff documented the following: - The resident's right heel wound measured 1.0 x 2.0 x 0.1 cm with 75% eschar. Staff did not document further assessment or stage of the wound; - The skin tear to the resident's right elbow unknown cause, measuring 3.50 cm x 4.90 cm x 0.10 cm with 10% slough in wound bed. Staff documented they cleansed and dressed wound with Clobestasol ointment and Duoderm (wound dressing) patch, secured with gauze wrap. - The skin tear to the resident's left elbow measured 2.50 cm x 3.5 cm x 0.10 cm with edges not well approximated, all torn skin flaps present. - Staff did not document an assessment of the resident's right fourth or fifth toes. Review of Wound care specialist report dated 9/10/15 showed the wound care specialist documented the following: - Unable to palpate right dorsalis pedis pulse and right posterior tibial pulse; - Open sores and fragile skin; - Identified wound to the lower right heel, acquired 9/3/15, measured 2.0 cm x 1.0 cm x 0.07 cm with extensive slough present; - Treatment orders included apply santyl for enzymatic debridment, Vaseline gauze, cover with gauze, and secure with gauze wrap. Change daily and as needed. Off-load right heel at all times. Turn and position every two hours. Please order arterial doppler on lower extremities including ABI(9/3/15). 9/10/15 - told by nursing staff that arterial doppler is not available. - Review showed wound care team did not assess wounds on elbows to treat as directed by the dermatologist. Review of nurses notes dated 9/10/15 showed staff documented the wound care team was at facility and assessed resident's heel. The resident's family member reported to the nurse that the wound team was to evaluate and treat the elbows per orders of the the dermatologist on 9/3/15. Nurse that rounded with the wound care team was unaware of the order. Attempts to get the wound care team to return and evaluate the resident was unsuccessful as the doctor was returning to his/her home base. The resident's family member also asked about the air mattress the dermatologist ordered on [DATE]. Staff notified the supply vendor that day and would be delivered later in the day. Review of resident's wound assessment report, dated 9/14/15, showed staff documented the following: - The skin tear to the resident's left elbow accident/other cause, measured 4.00 cm x 5.30 cm x 0.10 cm with edges not well approximated, missing torn skin flaps. Staff did not document any treatment; -The lesionwound to right elbow measured 3.0 cm x 1.60 cm x 0.10 cm. - No assessment of right heel was documented as completed; - Staff did not document an assessment of the resident's right fourth or fifth toes. Observation on 9/15/15 at 10:58 A.M. showed Registered Nurse (RN) A completed treatment for [REDACTED]. Several areas, including both elbows were covered with a duoderm dressing. The observation showed the resident had a quarter size open area to the right heel. The RN cleansed the area, applied santyl and Vaseline gauze dressing, and wrapped with roll gauze. The observation showed resident with scabbed over areas across top of toes on right foot, treatment provided of TAO and gauze dressing. Observation on 9/15/15 at 1:30 P.M. showed RN A provided treatment to resident's left and right elbow. Observation showed the RN removed a duoderm treatment from both wound sites. The observation showed the area to left elbow was approximately one inch by 1/2 inch with with depth greater than 0.10 cm. Observation showed an irregular shaped area to right elbow was approximately 1 inch x 1/2-3/4 inches with greater than 0.10 cm depth. The observation showed the RN completed treatment of [REDACTED]. During an interview on 9/15/15 RN A said that the areas on the elbows are being treated as if blisters caused by bullae with Clobestasol and the left elbow was not treated as directed in TAR. The RN said she was not aware of orders to treat areas as a pressure ulcer area. The RN said he/she did fail to provide treatment to the left elbow as directed in the TAR. During a phone interview on 9/17/15 the wound care nurse, RN B, said they first identified the area on the heel on 7/17/15. She said the area was blackened, but closed. She said that she assumed the area was caused by pressure on the mattress and that is why we started floating resident's heels. Review of POS dated 9/16/15 showed orders obtained from wound care team to complete the following: - Off load right heel. Turn and position every two hours; - Apply santyl and Vaseline gauze to right heel wound, cover with gauze and secure with gauze wrap. Change daily and as need; - Arterial doppler on lower extremities including ABI. Review of the resident's POS dated 9/17/15 showed the following orders: - Cleanse right elbow wound with wound cleanser, apply xelofoam (pressure ulcer treatment) gauze, dry gauze, wrap with roll gauze and secure with tape. Change daily and as needed; - Cleanse left elbow wound with wound cleanser, apply xelofoam gauze, dry gauze, wrap with roll gauze and secure with tape. Change daily and as needed; - Cleanse abrasion to right 4th toe with wound cleanser, apply TAO, Vaseline gauze, cover with gauze and secure with tape. Change daily and as needed; -Cleanse abrasion to right 5th toe with wound cleanser, apply TAO, Vaseline gauze, cover with gauze and secure with tape. Change daily and as needed; - Cleanse abrasion to right metatarsal head with wound cleanser, apply TAO, Vaseline gauze, cover with gauze and secure with tape. Change daily and as needed. During an interview on 9/15/15 at 4:00 P.M. the administrator said that during this period their MDS coordinator was out on vacation. The wound care nurse had to cover for the MDS coordinator and staff nurses attended to wound care and monitoring which could have lead to areas of care not being addressed as she would expect. She said she was called on 9/10/15 regarding air mattress request and elbow wounds not being addressed by wound care team as directed. She instructed staff to notify appropriate vendor for air mattress and to call the wound care team to see if they could return to evaluate the resident's elbows. She said the air mattress was obtained on 9/10/15, but the wound care team could not return to evaluate the resident. During an interview on 9/18/15 at 1:45 P.M. the resident's responsible party/DPOA said that he/she had not been made aware of the ulcer on the resident's right heel until 8/13/15. He/She said that he/she was told by staff on 8/13/15 prior to leaving town that the resident would begin to be seen by wound care team. He/She said after returning on 8/27/15 discovered the resident had not been seen by the wound care team, and was told it was due to not having a signed consent which he/she was not asked to sign. The responsible party said facility staff did not attempt to call her during that time, and that another family member is co-DPOA and staff did not attempt to call them either. The DPOA said that he/she took the resident to a dermatology appointment on 9/3/15 and returned with orders for an air mattress and for the resident to have elbow wounds assessed and treated as pressure ulcer by the wound care team. The DPOA said he/she visited on 9/10/15 and the resident did not have an air mattress and the wound care team saw the resident earlier in the day and were not instructed to evaluate and treat elbows as directed by the dermatologist on on 9/3/15. During an interview on 9/18/15 at 2:15 P.M. the Director of Nursing (DON) said that treatment for [REDACTED]. She said the physician should have been contacted on 7/17/15 when the ulcer on the heel was identified and orders obtained to treat, generally off-loading heels and skin prep would be a typical treatment approach, family/responsible party should be notified, and when the wound opened it would require notification of physician and responsible party and a change in treatment. She said that the primary physician should have been notified of dermatologist order for specialty wound care of areas on elbows and air mattress when received and timely implementation of the physician recommendations should have occurred. The DON said that the facility has access to an arterial doppler through Mobile x-ray and should have been obtain when requested by the wound care team. During an interview on 9/24/15 at 3:15 P.M. the resident's physician said he/she thought the resident heel area was being treated through the dermatologist. Staff did contact the physician on 8/13/15 to request treatment for [REDACTED]. The physician ordered pressure ulcer treatment for [REDACTED]. MO 379

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for two of ten sampled residents (Resident # 1 and # 9). The facility staff failed to provide weekly skin assessments for resident # 9 to prevent the development of a stage III pressure ulcer (a wound that presents with full thickness tissue loss without ligament of bone tissue present, with or without slough-dead skin tissue). The facility failed to provide weekly skin assessments and failed to implement interventions to prevent the development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue making the ulcer unable to be staged) for Resident # 1. The facility census was 39 residents. Review of the facility's Pressure Ulcer Risk Assessment policy, dated October 2010, showed the following: - Pressure ulcers are often made worse by continual pressure; - Staff will conduct resident skin assessments on a weekly basis, or more frequently if indicated, to assess for the presence of developing pressure ulcers; - Staff need to identify residents at risk for pressure ulcers and have interventions implemented promptly to attempt to prevent pressure ulcers. 1. Review of Resident # 1's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/9/13, showed staff assessed the resident as follows: - Severe cognitive impairment; - Did not reject care; - Required extensive assistance from staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Did not walk; - Used a wheelchair; - Limited range of motion in his/her upper and lower bilateral extremities; - diagnosed with [REDACTED]. - At risk for pressure ulcers; - Had two Stage I pressure ulcers (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues). Review of the resident's Braden Scale (assessment used to predict a person's risk of developing a pressure ulcer), dated 7/10/13, showed staff assessed the resident scored a 13 (at moderate risk of developing a pressure ulcer). Review of the resident's medical record showed staff documented the following skin assessments: - 7/2/13 - The resident admitted to the facility. Skin assessment completed. (Staff noted no open areas or skin abnormalities to the resident's right outer ankle); - 7/15/13 (13 days from the last assessment) - Skin assessment done today and noted a small red spot on the resident's right outer ankle; - 7/16/13 - (Staff noted no open areas or skin abnormalities to the resident's right outer ankle); - 7/23/18 - (Staff noted no open areas or skin abnormalities to the resident's right outer ankle);; - 8/13/13 (21 days from the last assessment) - Open area on the resident's right outer ankle; - 8/20/13 - Open area on the resident's right outer ankle. Review of the resident's nurses' notes showed staff documented the following: - 7/17/13 - Wound to right ankle without signs or symptoms of infection. Area cleansed and new dressing applied; - 7/24/13 - Wound to right ankle continues to have yellowish slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy at times). Review of the facility's contracted wound physician's notes showed he/she documented the following: - 8/1/13 - The resident had an unstageable pressure ulcer on the right outer ankle, acquired on 7/23/13, that measured 1.8 centimeters (cm) long by 1.1 cm wide by 0.1 cm deep. The wound had a moderate amount of slough. The resident was to use/wear padded boots when in bed; - 8/8/13 - The resident had an unstageable pressure ulcer on the right outer ankle, acquired on 7/23/13 that measured 1.3 cm long by 1.4 cm wide with a depth that could not be determined. The wound had a moderate amount of slough. He/she debrided (removed dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) the wound with a curette (a surgical instrument that can be used to scrape dead tissue from a wound). The resident was to use/wear padded boots when in bed; - 8/15/13 - The resident had an unstageable pressure ulcer on the right outer ankle, acquired on 7/23/13 that measured 1.0 cm long by 1.2 cm wide with a depth that could not be determined. The wound had a moderate amount of slough. He/she debrided the wound with a wet then dry 4 x 4. The resident was to use/wear padded boots when in bed. Review of the resident's care plan, dated 7/15/13, showed staff identified the resident admitted to the facility with two stage I pressure ulcers to the buttock, had a [DIAGNOSES REDACTED]. Review showed staff did not update the resident's care plan to include the resident's unstageable pressure ulcer to his/her right outer ankle and did not include the intervention of pressure relieving boots recommended by the wound clinic physician. During tour on 8/27/13 at 10:00 A.M., Registered Nurse (RN) A said the following: - The resident had a facility acquired pressure ulcer on the bony prominence of his/her right outer ankle; - Staff did not implement any heel protectors or pressure relieving boots until after the resident developed a reddened area that opened up; - After staff informed him/her of the red area on the resident's ankle, he/she instructed them to apply heel protectors. The physical therapist later got the resident pressure relieving boots; - Staff are directed to place pressure relieving boots on the resident's feet to help the pressure ulcer heal. Observation on 8/27/13 at 11:12 A.M., showed the resident lay in bed on his/her back with his/her eyes closed and a leg brace on his/her right leg. Observation showed the resident had socks on but did not have pressure relieving boots on his/her feet. The resident's feet and ankles rested directly on the mattress. Observation on 8/27/13 at 1:40 P.M., showed the resident lay in bed awake on his/her back. The resident wore a leg brace on his/her right leg. Observation showed the resident had socks on but did not have pressure relieving boots on his/her feet. The resident's feet and ankles rested directly on the mattress. Observation on 8/27/13 at 3:05 P.M., showed the resident lay in bed on his/her back with his/her eyes closed and a leg brace on his/her right leg. Observation showed the resident had socks on but did not have pressure relieving boots on his/her feet. The resident's feet and ankles rested directly on the mattress. Observation on 8/28/13 at 9:50 A.M., showed the following: - Licensed Practical Nurse (LPN) B went into the resident's room to do a dressing change. The resident lay in bed with his/her eyes closed; - LPN B removed the resident's right sock. There was not a dressing on the resident's wound. LPN B looked in the resident's sock for the dressing but there was not one. LPN B said he/she did not know the resident's wound did not have a dressing on it; - LPN B said the wound was from the way the resident positions his/her legs. LPN B said the resident turned his/her legs outward so the bony prominence of the resident's outer ankle rests directly on the bed; - The resident's right outer ankle wound was an open area that measured approximately 1.0 centimeters (cm) in diameter and was covered in yellow slough. The wound was surrounded by a pink area approximately the size of a golf ball. Observation on 8/28/13 at 1:00 P.M., showed the resident lay in bed on his/her back with his/her eyes closed and a leg brace on his/her right leg. Observation showed the resident had socks on but did not have pressure relieving boots on his/her feet. The resident's feet and ankles rested directly on the mattress. Observation on 8/28/13 at 2:05 P.M., showed the resident lay in bed on his/her back with his/her eyes closed and a leg brace on his/her right leg. Observation showed the resident had socks on but did not have pressure relieving boots on his/her feet. The resident's feet and ankles rested directly on the mattress. During an interview on 8/29/13 at 9:10 A.M., the facility contracted Wound Care Physician said the following: - Staff are directed to put pressure relieving boots on the resident's feet when he/she is in bed to relieve pressure on the resident's wound and help the wound to heal; - He/she debrided the resident's right outer ankle wound today to get rid of the slough to help it heal. During an interview on 8/29/13 at 10:15 A.M., Certified Nurse Aide (CNA) F said when the resident lays in bed staff are supposed to keep his/her feet off the bed with pillows. CNA C said he/she did not know if the resident was supposed to wear any pressure relieving boots. During an interview on 8/29/13 at 10:50 A.M., the MDS/Care Plan Coordinator said the following: - The resident's care plan does include that the resident has a pressure ulcer on his/her outer right ankle or that staff are directed to put pressure relieving boots on the resident while he/she is in bed. He/she should have updated the resident's care plan to include this information. During an interview on 8/29/13 at 11:05 A.M., the facility contracted physical therapist said the following: - He/she use to provide the resident with physical therapy services. One day when he/she and an aide assisted the resident to bed, the aide told him/her that the resident had an open area on his/her outer right ankle. He/she provided the resident with pressure relieving boots on 7/23/13 because the heel protectors the staff were using for him were not completely covering the open area. During an interview on 8/29/13 at 11:10 A.M., the Director of Nurses (DON) said the following: - The resident's right outer ankle pressure ulcer should have been on the resident's care plan as well as the intervention for staff to put pressure relieving boots on the resident when the resident is in bed; - Staff are directed to put pressure relieving boots on the resident when he/she is laying in bed; - The resident's pressure ulcer was avoidable. Staff should have implemented the intervention of heel protectors as soon as the resident was admitted because the resident wasn't able to move his/her right leg well, spend a lot of time in bed on his/her back and often turned his/her legs outward so the bony prominence of the outer ankles rested on the bed. Staff should implement heel protectors or pressure relieving boots for any resident that is dependent on staff for mobility and likes to lay in bed on their back before skin breakdown occurs. 2. Record review of the resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument dated 08/09/13, showed staff assessed the resident as follows: - Cognitive, having no short or long term memory loss; - No behaviors or mood disorders, did not reject the provision of care provided by the staff ; - Independent with bed mobility; - Required limited to extensive assistance of one staff for transfers, dressing, eating and bathing; - No range of motion impairment in upper or lower extremities - Continent of bowel and bladder ; - At risk for the development of pressure ulcers; - Has one unhealed stage III pressure sore. Review of the Resident's Plan Of Care updated 08/09/13 showed staff identified the resident had a facility acquired stage III pressure sore (a wound that presents with full thickness tissue loss without ligament of bone tissue present, with or without slough -dead skin tissue) on the right buttock. Further review showed the facility reported the wound "healed" on 08/26/13, and the resident to be at risk for the development and/or pressure sore re -occurrence. Review of the resident's most current Braden Scale (an assessment tool to identify resident's at risk for skin breakdown and/or pressure sore development) dated 12/4/13, showed the resident was assessed by the staff with a score of 22 (at low risk for skin breakdown and /or pressure sore development. Review of nursing notes showed the following: - 07/25/13- Areas on buttocks cleaned [MEDICATION NAME] (a zinc- based barrier medication) applied. - 07/29/13 - Open areas on bottom have decreased. - 07/30/13 - Buttocks continue to heal. - 08/02/13 - Right buttock open area. - 08/08/13 - Wound physician here to see the resident. Buttock area measures 3.5 centimeters (cm.) long, 4.0 cm. wide, 0.2 cm. deep. The wound was further described, 10 percent slough (dead skin tissue), 5 percent eschar (dead skin tissue). Review of the facility's weekly skin assessment for the resident showed the facility staff failed to perform weekly skin assessments 07/17/13 to 08/14/13 (a period of three weeks). Review of the mobile wound clinic's wound care assessment report was as follows; - 08/1/13 - Facility acquired stage III pressure sore acquired on 07/30/13, right medial buttock measuring 3.0 cm. long, 2.1 cm. wide, 0.1 cm deep. The wound was further described as having minimal slough and a scant (small) amount of drainage. - 08/08/13 - Facility acquired stage III pressure sore acquired on 07/30/13, right medial buttock measuring 3.5 cm. long, 4.0 cm. wide, 0.20 cm deep. The wound was further described as having moderate slough and partial coverage of eschar, with a small amount of serous ( yellow and or clear colored) drainage. - 08/15/13 - Facility acquired stage III pressure sore acquired on 07/30/13, right medial buttock measuring 0.30 cm. long, 0.10 cm. wide, 0.10 cm deep. The wound was further described as having minimal slough and no drainage. - 08/22/13 - Facility acquired stage III pressure sore acquired on 07/30/13, right medial buttock measuring 0.0 cm. long, 0.0 cm. wide, 0.0 cm deep. The wound was further described as having 100 percent epithelium ( newly formed skin). Observation of the residents skin on 08/28/13 at 1:00 P.M., with facility staff Licensed Practical Nurse (LPN) B showed the resident with one healed stage III pressure sore on the right medial buttock. The skin was pink, intact, and had no drainage. During an interview on 8/28/13 at 1:00 P.M., LPN B said the following: - The resident is at a low risk for pressure sores, the resident can turn and reposition, is ambulatory with assist of one staff, and does not reject care from staff. - The facility staff are responsible for performing weekly skin assessments which began 7/3/13. - The resident acquired a stage III pressure sore while in the facility. During an interview 8/29/13 at 10:30 A.M., the Director of Nursing and RN A said the following: - Certified Nursing Assistants are responsible for reporting any skin issues to the licensed nurses. This may be done by written report sheet, and/or verbal report. - Licensed nurses (LPN, RN) are responsible for assessing the resident's skin, notifying the physician, obtaining and performing treatment orders, implementing/ updating interventions on the resident's care plan. - The mobile clinic's resident skin assessment does not replace the facility's skin assessment of the resident. - The resident should have had weekly skin assessments for the three week period 7/17/13 to 8/14/13. The resident acquired a stage III pressure sore on the right medial buttock while living in the facility during that time period.

Based on interview and record review, the facility failed to assess a change in one of three sampled residents (Resident #1) condition and failed to notify the resident's physician of the resident's condition. Therapy staff first recorded the resident experienced diarrhea on [DATE] and reported this to the nursing staff. Nursing staff failed to monitor the resident's condition, failed to notify the resident's physician of the diarrhea, and failed to implement measures to treat the diarrhea and prevent dehydration. The resident's facility physician did not learn of the resident's condition until [DATE] from the resident's previous primary care physician and ordered laboratory work and treatment for [REDACTED]. The resident continued to decline and staff sent the resident to the hospital on [DATE] at the request of the resident's family. The resident expired at the hospital on [DATE] with one of the final [DIAGNOSES REDACTED]. The facility census was 37. 1. During an interview on [DATE] at 9:00 A.M., Resident #1's family member said the resident was admitted to the facility for antibiotic therapy to treat an infection and also for physical, speech, and occupational therapy until he/she was strong enough for gall bladder surgery. Review of the resident's admission physician order [REDACTED]. Review of the resident's POS dated [DATE] showed orders for the following: - Occupational therapy five times a week for 30 days for self care management, therapeutic exercise, therapeutic activity and neuromuscular re-education; - Physical therapy five times a week for 30 days for therapeutic exercise, gait training, neuromuscular re-education, therapeutic activity and wheelchair management; - Speech therapy five times a week for 30 days for cognitive and language skills. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. and 4:00 P.M. Review of the resident's occupational therapy (OT) daily notes and weekly summary dated [DATE] showed OT C recorded the following information: "Resident complained of diarrhea and was reported to nursing." Review of the resident's nurses notes dated [DATE] showed the facility staff did not record OT C notified nursing staff of the resident's complaints of diarrhea. Staff did not record they notified the resident's physician of the resident's complaints of diarrhea or implemented monitoring or treatment. Review of the resident's MAR, dated [DATE], showed staff recorded they continued to administer the resident's Senna despite the resident's diarrhea. During an interview on [DATE] at 3:40 P.M., Licensed Practical Nurse (LPN) H said he/she did not recall therapy notifying him/her of the resident's diarrhea on [DATE]. LPN H said he/she remembered, at one point, hearing in report that the aides reported the resident had diarrhea. LPN H said he/she was off for a few days, and when he/she came back, he/she was told the resident's diarrhea "cleared up." Review of the resident's meal intake record dated [DATE] through [DATE] showed staff recorded the resident consumed an average of 980 cubic centimeters (cc) of fluid daily. Review of the resident's nutritional assessment dated [DATE] showed the registered dietitian recommended 1,970 cc of daily fluid requirements for the resident. Review of the resident's OT notes dated [DATE] showed OT C recorded, "The resident is not feeling well and has diarrhea." Additional review showed OT C recorded, "The resident was making mild progress. However his/her progress was impeded by stomach and diarrhea issues, decreased oral intake and general weakness." Review of the resident's nurses notes for the 7:00 A.M.-3:00 P.M. shift dated [DATE] showed staff recorded the resident had complaints of diarrhea and requested medication to control it. The staff recorded they sent a fax to the resident's physician requesting medication. The staff recorded the resident did not get up for lunch due to his/her diarrhea. The staff recorded the resident's family brought him/her [MEDICATION NAME] for his/her diarrhea. The staff recorded they would monitor the resident closely to prevent dehydration. During an interview on [DATE] at 8:45 A.M., the DON said she was the charge nurse on [DATE] on the day shift and sent a fax to the resident's physician about the resident's complaints of diarrhea and requested medication for it. During an interview on [DATE] at 3:00 P.M., the DON said when the nurses send a fax to the physician, they place the fax on the clipboard next to the fax machine. The DON said when the physician sent a response, the nurses removed the fax from the clipboard. The DON said if, by the next morning, there was still no response, the nurse should either re-fax it or call the physician. The DON said she could not find the fax she sent on [DATE] to the resident's physician concerning the resident's diarrhea Review of the resident's MAR, dated [DATE], showed staff recorded they continued to administer the resident's Senna despite the resident's diarrhea. Review of the facility's nursing shift report for the 7:00 A.M.-3:00 P.M. shift dated [DATE] showed facility staff recorded, "The resident complained of diarrhea." Review of the resident's nurses notes dated [DATE] showed the staff did not record information to show on-going monitoring of the resident regarding continued diarrhea or that they notified the resident's physician of his/her complaints of diarrhea. During an interview on [DATE] at 12:25 P.M., Registered Nurse (RN) F said he/she was not aware of the resident's complaints of diarrhea. During an interview on [DATE] at 1:25 P.M., RN F said he/she did not recall recording on the nurses shift report dated [DATE], the resident's complaints of diarrhea. RN F said he/she did not recall therapy staff notifying him/her of the resident's diarrhea. Review of the resident's MAR, dated [DATE], showed staff recorded they continued to administer the resident's Senna despite the resident's diarrhea. Review of the resident's speech therapy (ST) daily notes and weekly summary dated [DATE] showed ST A recorded the following information: "The resident complained of diarrhea." Review of the resident's MAR, dated [DATE], showed staff recorded they continued to administer the resident's Senna despite the resident's diarrhea. Review of the resident's MAR, dated [DATE] through [DATE], showed staff circled the 8:00 A.M. dose of Senna (indicating they did not administer the dose). Review of the back of the MAR indicated [REDACTED]. During an interview on [DATE] at 4:45 P.M., the DON said the circled 8:00 A.M. doses of Senna on [DATE] and on [DATE] indicated staff did not administer it. The DON said the staff should have recorded on the back of the MAR indicated [REDACTED] During an interview on [DATE] at 1:35 P.M. Certified Medication Technician (CMT) I said he/she worked the day shift on [DATE] and [DATE]. CMT I said he/she did not administer the resident's Senna (laxative) to him/her because the resident had complained to him/her of diarrhea. CMT I said he/she reported this to nursing. Review of the resident's physical therapy (PT) daily notes and weekly summary dated [DATE] showed PT B recorded, "The resident was leaning in his/her wheelchair to the left side. The resident reported he/she has the runs and does not have any energy. Nursing states the resident does not have diarrhea." Additional review showed PT B recorded, "The resident made significant progress through [DATE], then declined on [DATE]-[DATE]." Review of the resident's OT daily notes dated [DATE] showed OT C recorded, "PT reported the resident with increased weakness today. Nursing reported the resident had diarrhea and labs being done. Resident seen up in wheelchair at dining table. Resident required moderate assistance to drink from cup with straw. Maximum assistance for feeding, then requested toilet again. Instructed Certified Nurse Assistants (CNAs) the resident unable to get drink of water and needs fluids to decrease dehydration." Review of the resident's monthly bowel movement record dated [DATE] through [DATE] showed staff recorded the resident had one medium loose stool on [DATE], but did not record information to show the resident experienced diarrhea as therapy staff recorded starting on [DATE]. Record review of the resident's admission comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE] showed staff assessed the resident as follows: - Cognitive score of 14 out of a possible 15; - Required stand-by assistance of one staff for eating; - Required limited assistance of one staff for locomotion, bed mobility, transfers and toilet use; - Continent of fecal material; - Required extensive assistance of one staff for dressing and personal hygiene; - The resident did not walk; - [DIAGNOSES REDACTED]. - Required a wheelchair for mobility. Review of the resident's medical record showed a fax to the resident's physician, dated [DATE], requesting [MEDICATION NAME] as needed for an "upset stomach." Staff did not report the resident's diarrhea to the physician. Additional review showed the physician's response to the fax dated [DATE] for the following: - [MEDICATION NAME] 15 cc by mouth every four hours as needed; - If having diarrhea, send stool sample for fecal leukocytes (bowel mucosal inflammation) and [MEDICAL CONDITIONS]. - Obtain a Complete Blood Count (blood test used to evaluate overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]) and Complete Metabolic Panel (blood test used to evaluate the status of kidney function, liver function, electrolytes and fluid balance). Review of the resident's nurses notes for the 3:00 P.M.-11:00 P.M. shift dated [DATE] showed staff recorded, "The resident has had no complaints of this evening. New order for [MEDICATION NAME] as needed for upset stomach. Will continue to monitor." The staff did not record the resident complained of diarrhea. Review of the resident's Complete Metabolic Panel laboratory results dated [DATE] showed his/her Blood Urea Nitrogen (BUN-a blood test used to evaluate the function of the kidneys and liver) was 46 (normal range ,[DATE]). An elevated BUN suggests impaired kidney function or dehydration. Review of the resident's [MEDICAL CONDITION] laboratory results dated [DATE] showed the resident was positive for [MEDICAL CONDITION] (normal is none to be detected). Review of the resident's POS, dated [DATE], showed a physician's orders [REDACTED]. Review of the resident's MAR, dated [DATE] through [DATE] showed staff recorded they administered the resident's [MEDICATION NAME] as ordered. Review of the resident's Fecal Leukocytes laboratory results dated [DATE] showed Fecal Leukocytes present (normal is none to be detected). Review of the resident's nurses notes dated [DATE] at 6:00 P.M., showed facility staff recorded, "The family felt that the resident needed to go to the hospital for possible intravenous fluids. A call was placed to the resident's physician who gave his/her permission to send the resident to the hospital. The resident was sent to a local hospital emergency room by family car." Review of the resident's hospital admission notes dated [DATE] showed the hospital staff recorded they admitted the resident with the following Diagnoses: [REDACTED]. - Dehydration; - Diabetic ketoacidosis (the body fails to adequately regulate [MEDICATION NAME] which is produced when the [MEDICAL CONDITION] for energy or fuel); - Severe [MEDICAL CONDITIONS] (swelling and irritation of the large intestine, or colon from [MEDICAL CONDITION]); - Altered mental status; - [MEDICAL CONDITION] (inadequate oxygen in the blood); -[MEDICAL CONDITION] syndrome (a systemic response to infection). Additional review of the resident's hospital admission notes dated [DATE] showed the hospital staff recorded the following information: "The patient was admitted to the emergency room with recent [MEDICAL CONDITIONS] and [MEDICAL CONDITION] (high blood sugar). Laboratory results and clinical features are suggestive of dehydration, secondary to diabetic ketoacidosis and new-onset [MEDICAL CONDITION]. Most likely, the reason for diabetic ketoacidosis production is [MEDICAL CONDITIONS]. The hypoxemia could be explained because of dehydration, low perfusion and overall deconditioning. [MEDICAL CONDITION] Emboli (blockage in one or more arteries in the lungs) can not be ruled out. The patient will be admitted to the Intensive Care Unit with diabetic ketoacidosis, [MEDICAL CONDITIONS] [MEDICAL CONDITION] syndrome." During an interview on [DATE] at 11:00 A.M., ST A said he/she was the therapy department program manager. ST A said he/she was aware of the resident's complaints of diarrhea. ST A said he/she talked to the other therapists and directed them to make sure they documented all resident complaints of diarrhea and reported it to nursing. ST A said that on [DATE], the resident complained of diarrhea and he/she reported it to nursing. ST A said the three therapy disciplines (ST, OT and PT) discussed the resident's decline in his/her function the last week before staff sent him/her to the hospital. During an interview on [DATE] at 11:05 A.M., PT B said the first week when he/she worked with the resident, the resident did quite well. PT B said the resident was frail, but could participate in the therapy sessions. PT B said when he/she came back after being gone over the weekend, he/she noticed a decline in the resident's functioning ability. PT B said the resident appeared a lot weaker and did not have as much energy. PT B said the resident was also leaning in his/her wheelchair more to the left side than before. PT B said the resident complained of diarrhea. PT B said that on [DATE] the resident complained of having the "runs" and he/she reported it to nursing, but nursing told him/her the resident did not have diarrhea. During an interview on [DATE] at 11:10 A.M., OT C said that on [DATE] the resident complained of diarrhea. OT C said he/she reported this to nursing. OT C said that on [DATE] the resident complained of diarrhea. OT C said the last week before the resident went to the hospital he/she noticed a decline in his/her functioning ability. OT C said the resident leaned more to one side when in his/her wheelchair. OT C said when the resident did not feel good, he/she seemed to lean to the left more. During an interview on [DATE] at 11:15 A.M., Certified Nurse Assistant (CNA) E said he/she was aware the resident had diarrhea. CNA E said the resident had it for "several days" before staff checked the resident for [MEDICAL CONDITION]. CNA E said the diarrhea was "quite a bit....pretty bad." CNA E said he/she collected the resident's stool sample. CNA E said he/she reported the resident's diarrhea to the nurse. During an interview on [DATE] at 8:45 A.M., the Director of Nursing (DON) said she reviewed the medicare minutes notes from [DATE] and [DATE]. The DON said staff did not record the resident's complaints of diarrhea. During an interview on [DATE] at 9:00 A.M., Licensed Practical Nurse (LPN) G he/she was the nurse on duty [DATE] when they sent the resident to the emergency room . LPN G said the resident was "very weak" and had a decreased appetite. LPN G said the resident's family member was afraid the resident was becoming dehydrated and wanted him/her to go to the hospital. LPN G said he/she felt as though the resident should go too, so he/she notified the resident's physician who gave orders to send the resident to the emergency room . LPN G said the staff assisted the resident into the family member's car and the resident's family member transported the resident to the emergency room . During an interview on [DATE] at 10:50 A.M., LPN G said one CNA reported to him/her the resident was having diarrhea. LPN G said he/she did not remember who obtained the order for a stool sample, but he/she collected the stool specimen. LPN G said if a staff member reported a resident having diarrhea, staff should check how many times the resident had diarrhea and if it had an odor. LPN G said he/she worked 12 hours shifts, 7:00 A.M.-7:00 P.M., and if he/she had known of the resident having diarrhea, he/she would have reported it to the night nurse. LPN G said the resident was dependent on staff for toileting. LPN G said the staff would transfer the resident to his/her wheelchair, wheel him/her to the bathroom and then transfer him/her to the toilet. LPN G said the staff had to provide the resident with personal hygiene after toileting. LPN G said the staff had to encourage the resident to eat. LPN G said the staff had to assist the resident to eat and drink. LPN G said the resident could not even put a cup up to his/her mouth. During an interview on [DATE] at 2:50 P.M., CMT J said he/she was very familiar with the resident. CMT J said he/she often administered the resident his/her medication. CMT J said the CNAs and CMTs reported the resident's diarrhea to the charge nurses "a couple of weeks" before staff checked the resident for [MEDICAL CONDITION]. CMT J said the charge nurses just thought the resident had the flu. CMT J said he/she told the charge nurse about the resident's diarrhea, and asked the charge nurse about possibly getting an order for [REDACTED]. CMT J said he/she did not administer the resident's Senna (laxative) for a couple of days because of the resident's diarrhea, but after the aides told him/her the diarrhea stopped, he/she started giving it to the resident again. CMT J said when he/she was told again the resident was having diarrhea, he/she asked the charge nurse if he/she should not administer the resident the laxative. CMT J said the charge nurse told him/her that no one had reported the resident was having diarrhea, and directed him/her to administer the resident's laxative. CMT J said he/she gave the resident his/her laxative even though the aides had reported the resident having diarrhea. CMT J said the resident required complete staff assistance to use the bathroom and toilet. CMT J said at one point it took three staff to assist him/her to the toilet. CMT J said the resident could not even sit up on the toilet by him/herself and that he/she would lean to the side without support of staff. CMT J said the resident's diarrhea was reported "off and on" during CMT shift change report while the resident lived in the facility. During an interview on [DATE] at 4:10 P.M., LPN G said he/she questioned the aides if the resident was having diarrhea. LPN G said no one was able to tell him/her prior to [DATE] the resident was having diarrhea. LPN G said staff told him/her the resident was "possibly" having diarrhea. LPN G said if he/she had known "for certain" the resident was having diarrhea, he/she would have notified the physician. LPN G said CMTs did not ask him/her about not administering the resident's laxative. During an interview on [DATE] at 12:05 P.M., Physician D said staff did not fax a note dated [DATE] concerning the resident's diarrhea. Physician D said the facility staff "never" notified him/her of the resident's diarrhea. Physician D said the resident's family member e-mailed the resident's previous physician concerning the resident's diarrhea who then forwarded the e-mail on to him/her. Physician D said that was the reason he/she worded the order on [DATE] "if" having diarrhea, because he/she was not aware of the resident having diarrhea. Physician D said he/she was not aware of the resident's diarrhea until the stool sample came back positive for [MEDICAL CONDITION]. During an interview on [DATE] at 1:20 P.M., the DON said she expected the staff to report changes in condition to the physician. Review of the resident's hospital record showed the resident expired at the hospital on [DATE]. Review of the resident's certificate of death dated [DATE] showed the following underlying causes of death: - C [MEDICAL CONDITION], Chronic Antibiotics and [MEDICATION NAME] (gall bladder infection). During an interview on [DATE] at 1:00 P.M., Physician D said staff should have notified him of the resident's diarrhea on [DATE] when therapy reported it to nursing. Physician D said the delay in treatment of [REDACTED]. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. A monitoring visit was completed on [DATE]. 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 this time. The Director of Nursing and/or the administrator inserviced staff regarding facility policies and procedures related to emergency physician care, change in a resident's condition or status, charge nurse charting and nurse reporting, and is ongoing until all staff are addressed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D grid 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 the Class I violation. MO 531

Based on observation, interview and record review, the facility staff failed to provide appropriate care and services to prevent the development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy at times) and/or eschar (dead tissue that is thick, leathery, and frequently black or brown in color) in the wound bed), failed to accurately and consistently assess the resident's pressure ulcer, failed to provide appropriate treatment as ordered to an existing pressure ulcer to promote healing, and failed to apply the facility's skin and pressure ulcer protocols for one sampled resident (Resident #3) out of 3 sampled residents. The facility census was 37. 1. Review of the facility's "Specific Interventions based on the Braden Scale Score" policy, undated, showed the policy directed staff to immediately implement and place certain interventions on a resident's comprehensive care plan based on that resident's Braden score. Record review of Resident #3's Braden Scale assessment (tool used to predict a person's risk of developing a pressure sore), dated 1/6/12, showed staff assessed the resident scored an 18 (at a mild risk of developing a pressure ulcer). Based on the resident's Braden Scale score of 18, this policy directed staff to put in the care plan and perform the following: - Frequently turn, at least every two hours; - Maximize the resident's mobility; - Protect the resident's heels (or other areas identified at risk); - Manage moisture, nutrition, friction, and shear; - Use a pressure-reducing support surface if the resident is confined to bed or a chair. Review of the facility's pressure ulcer protocol, undated, showed the protocol directed staff to do the following: - Assess pressure ulcers location, size (length, width, and depth) in centimeters (cm), sinus tracts (a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound), undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), exudates (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic (dead) tissue, and the presence or absence of granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal) and [MEDICATION NAME] (healing process of the skin); - Determine a pressure ulcer's current stage of development; - Use positioning devices to raise a pressure ulcer off the support surface; - Perform dressing changes which keep the pressure ulcer tissue moist while keeping the surrounding intact skin dry; - Document on a pressure sore weekly and include interventions in place, treatment and response, measurements of the pressure sore, description of surrounding tissue, description of drainage, odor, and presence of granulation tissue; - The same nurse needs to be responsible for the weekly documentation and measurements to insure consistency in evaluation and if this is not possible, pictures must be taken when the ulcer is identified and monthly thereafter until the area is healed. Record review of the resident's admission nursing assessment, dated 1/6/12, showed staff documented the resident had intact skin upon admission. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/19/12, showed staff assessed the resident as follows: - admitted to the facility on [DATE]; - Moderate cognitive impairment; - Required limited assistance of one person for bed mobility and ambulation; - Required extensive assistance of one person for transfers, dressing, toileting, and personal hygiene; - Used a walker; - Occasionally incontinent of bladder; - Always continent of bowel; - At risk for developing pressure ulcers; - Currently had no pressure ulcers. Review of the resident's Care Area Assessment (responses to MDS items which assist the staff in the development of individualized care plans) dated 01/19/12 showed the resident at risk for pressure ulcers. Review of the facility's Wound Assessment binder showed staff first assessed the resident's pressure ulcer on 1/22/12. Review of the resident's wound report, dated 1/22/12, showed staff traced an outline of the right heel pressure ulcer which measured 7 cm by 4.5 cm. Staff did not include assessment of the depth measurement, staging, description of the pressure ulcer tissue, description of the surrounding tissue, description of drainage, or odor as directed in their protocol. Further review of the facility's Wound Assessment binder showed staff did not include any other assessments of the resident's right heel pressure ulcer. During an interview on 2/17/12 at 2:20 P.M., the MDS/Care Plan coordinator said the following: - She was responsible for implementing and updating the care plans; - If a resident developed a pressure ulcer, then she should update the care plan identifying the pressure ulcer as a problem with measurable goals and interventions; - She did not add a problem of pressure ulcer with measurable goals and interventions to the resident's care plan. Review of a fax sent to the resident's physician on 1/22/12, showed staff documented the following information on the fax: - A dark purple area on the resident's right heel measuring 7 cm by 8 cm which is fluid filled and appears to have an opening in the middle of the purple area; - Request for an order of [MEDICATION NAME] (topical skin care ointment designed to prevent infection, promote healing and relieve pain in many types of wounds) and steri strips (sterile adhesive strips used to secure, close and support small cuts, wounds and surgical incisions) as a treatment for [REDACTED]. Review of the 72 Hour Post Incident Follow-Up charting for the resident's right heel pressure ulcer, dated 1/22/12, showed staff documented; - There is an area on the resident's right heel that was bleeding; - Upon a nurse's assessment, the resident's right heel is dark purple in color with a fluid filled blister; - The blister measures 7 cm by 8 cm and has an open area in the middle; - Staff applied [MEDICATION NAME] and steri strips; - Staff notified the resident's physician by fax; - Staff left a message for the resident's family to call the facility. Review of the resident's physician's orders [REDACTED]. heel blister. Review of nurses notes, dated 1/23/12, showed staff documented: - The resident had a moon boot (device for the foot designed to prevent and treat heel pressure ulcers by taking pressure off the heel) on his/her right foot; - The resident's sock had bloody drainage from the resident's right heel; - Staff applied a protective dressing to the resident's right heel. Review of the resident's Treatment Administration Record (TAR) dated 1/23/12 through 2/15/12, showed facility staff documented they applied [MEDICATION NAME] spray and steri strips once daily 1/23/12 through 1/26/12. Review of nurses notes, dated 1/24/12, showed staff documented: - A protective dressing is on the resident's right heel; - Staff placed the resident's feet floating off a pillow to keep pressure off of the heels; - Staff educated the resident on the importance of keeping pressure off of his/her heels. Review of the resident's comprehensive care plan, dated 1/25/12, showed staff identified the resident at risk for skin breakdown related to occasional urinary incontinence. Staff planned the following interventions for the resident: - Assist to toilet before meals, after meals, at bedtime, and as needed; - Assess skin during care and report any changes in skin to the charge nurse; - Provide with briefs when up to protect dignity; - Give perineal care every shift and as needed; - Apply protective barrier cream as needed; - Licensed nurse to complete a weekly skin assessment; - Encourage the resident to shift weight and assist the resident with repositioning while in wheelchair or bed. Review of the resident's POS, dated 1/16/12 to 2/15/12, showed on 1/27/12 the resident's physician directed staff to perform a wet to dry dressing (placing a wet/moist gauze dressing on a wound, allowing it to dry, and wound drainage and dead tissue can be removed when you take off the old dressing) to the resident's right heel twice daily and discontinue the [MEDICATION NAME] spray and steri strip treatment. Review of the resident's TAR, dated 1/23/12 through 2/15/12, showed facility staff documented they performed the wet to dry dressing treatment twice daily on the resident's right heel 1/27/12 through 2/13/12 except on 2/5/12 on the 3:00 P.M. to 11:00 P.M. shift and on 2/11/12 on the 3:00 P.M. to 11:00 P.M. shift. Review of nurses notes, dated 1/28/12 on the 11:00 P.M. to 7:00 A.M. shift, showed staff documented the following: - The "busted blister" on the resident's right heel has old dried blood in some of the skin left over from the blister bursting; - The tissue is red; - There is no abnormal discharge, odor, or drainage; - The resident requested pain medication for right heel pain. Review of nurses notes, dated 1/29/12 at 10:00 P.M., showed staff documented the resident's right heel had minimal drainage and there was some skin sloughing (peeling) off from the heel. Staff did not record the interventions in place, treatment and response, measurements of the pressure sore, description of surrounding tissue, description of drainage, odor, and presence of granulation tissue as directed in their protocol to show on-going monitoring for improvement or decline. Review of a fax facility staff sent to the resident's physician on 2/2/12, showed staff requested to use a podus boot (a boot that offers protection for heel wounds) to decrease pressure to the right heel pressure ulcer. Review of the resident's POS, dated 1/16/12 through 2/15/12, showed on 2/3/12 the resident's physician directed staff to use a podus boot on the resident's right foot to decrease pressure to the right heel pressure ulcer. Review of the resident's TAR, dated 1/23/12 through 2/15/12, showed facility staff documented they used a podus boot for the resident's right foot to decrease pressure to the right heel pressure ulcer from 2/3/12 through 2/13/12. Review of nurses notes, dated 2/3/12, showed staff documented: - The resident's right heel was dark purple with the top layer of skin gone; - The pressure ulcer had a reddish drainage; - Wet to dry dressing were being done twice daily as ordered; - Staff is using a moon boot to keep pressure off the resident's right heel; - The resident's right heel has no signs or symptoms indicating infection. - Staff did not record the pressure ulcer's response to treatment, measurements of the pressure sore, description of surrounding tissue, odor, and presence of granulation tissue as directed in their protocol to show on-going monitoring for improvement or decline. Review of nurses notes, dated 2/9/12, showed staff documented: - Staff is administering the pressure ulcer treatment as ordered; - A podus boot is on the resident's right foot; - The resident complained of pain related to the right heel pressure ulcer and staff administered pain medication; - The pain medication was effective. - Staff did not record the pressure ulcer's response to treatment, measurements of the pressure sore, description of surrounding tissue, odor, and presence of granulation tissue as directed in their protocol to show on-going monitoring for improvement or decline. Review of a fax facility staff sent to the resident's physician on 2/13/12, showed staff informed the physician of the following: - The resident's right heel had eschar over the wound bed; - The wound had a slight odor and was tender to touch. Review of the resident's POS, dated 2/14/12 through 2/15/12, showed on 2/14/12 the resident's physician directed staff to apply [MEDICATION NAME] cream to the eschar tissue on the resident's right heel and cover with a dressing twice daily for one week and then to reevaluate the resident's wound. During an interview on 2/14/12 at 11:35 A.M., Registered Nurse (RN) F said Resident #3 was the only resident with a pressure ulcer. In addition, RN F said the resident was admitted with the pressure ulcer on his/her right heel. (The resident's admission skin assessment showed staff assessed the resident's skin was intact when admitted ). During an interview on 2/14/12 at 12:25 P.M., RN F said staff usually only completed the skin and wound assessments monthly. Observation and interview on 2/14/12 at 12:40 P.M., showed the resident lay in bed as RN F removed the resident's podus boot. RN F then started the dressing change on the resident's right heel. RN F removed the gauze wrapped around the resident's right foot which had 4 x 4's laid flat inside the wrap. The 4 x 4's contained brown drainage. The resident's right heel had 2 cm by 3 cm black eschar tissue in the middle of the pressure ulcer. Surrounding the eschar tissue was white peeling skin and reddened tissue. The entire pressure ulcer (necrotic, reddened, and white peeling tissue) was 6 cm in diameter. The resident asked, "What causes this?" The resident said he/she "never had sores at home". RN F then said he/she was mistaken and the resident acquired the pressure ulcer at the facility. RN F placed two 4 x 4's in saline and wrung some of the saline out of them. RN F then placed the two wet 4 x 4's on the resident's heel covering the eschar tissue as well as part of the the red and white peeling tissue surrounding the eschar tissue. RN F then wrapped gauze around the resident's wet to dry dressing, foot, and ankle and put a podus boot back on the resident's right foot. During an interview on 2/15/12 at 11:50 A.M., the DON (Director of Nurses) said the following: - The resident's right heel wound resulted from pressure; - The resident acquired the pressure ulcer at the facility; - The charge nurse was supposed to complete the wound assessments weekly on the resident and place them in the Wound Assessment binder; - She was the charge nurse on 2/1/12 and performed the resident's dressing change to his/her right heel and she observed the pressure ulcer to be almost healed on that day; - She had not seen the resident's pressure ulcer since 2/1/12. On 2/13/12, nursing staff reported to her that the resident's pressure ulcer had eschar tissue; - On 2/13/12 she looked at the resident's pressure ulcer and was unable to stage the pressure ulcer due to the eschar tissue present; - She faxed the resident's physician a notification of the change in the pressure ulcer and requested a different dressing/treatment; - She could tell by looking at the resident's right heel pressure ulcer that the staff were doing the wet to dry dressing changes incorrectly, that the staff were putting the wet gauze on the resident's healthy tissue surrounding the necrotic tissue and as a result, the healthy tissue surrounding the necrotic area became white (macerated-when skin is consistently wet, the skin softens, turns white, and can easily get infected with bacteria or fungi) and red and began to peel. During an interview on 2/17/12 at 2:10 P.M., the DON said she thought the resident's right heel pressure ulcer was avoidable. She said the resident preferred to lay primarily on his/her back when he/she is in bed and nursing staff should have implemented the use of moon boots to protect the resident's heels. The DON said if staff had done this, the resident would not have developed a pressure ulcer.

Based on staff interview and medical record review, licensed facility staff failed to follow recommendations from a swallow study for one resident (Resident #1) and did not follow their recipe for a mechanically altered diet for this resident. The resident was hospitalized with a [DIAGNOSES REDACTED].#2) in a timely manner and did not report the results to the resident's physician in a timely manner. The resident was admitted to the hospital for treatment of [REDACTED]. The facility census was 46. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 02/02/11, showed facility staff assessed the resident as follows: -History of aspiration pneumonia; -Short and long term memory problems; -Required the use of an indwelling urinary catheter; -Dependent on tube-feeding for nutrition and hydration; -Severely impaired cognitive skills for daily decision-making; -Totally dependent on assistance from at least two staff for Activities of Daily Living (ADLs) including bed mobility and transfers. Review of the resident's "Admission Plan of Care" dated 02/16/11, showed staff planned the following interventions: -Administer continuous tube feedings with auto flushes; -Nothing by mouth (NPO) do not lay flat, place head of bed up at all times. Review of the resident's swallow study results dated 02/25/11, showed recommendations included: -Nursing to initiate by mouth (PO) trials of mechanical soft food and thin liquids; -Monitor for changes in respiration status and resident's temperature; -One on one "total feed" with meals, medications and snacks; -Monitor for fatigue; -Use spoon sized presentations; -Use small bites; -Provide total assistance to the resident to eat for increased safety during meals. Review of the facility's guidelines (undated) directing staff how to prepare mechanically altered diets showed direction for staff to follow the "Regular Diet" with foods being "fork tender" or cut/chopped as needed at the table. Staff should grind meat and should serve meat with gravy, broth or mayonnaise. Staff should alter any food as indicated on the menu that they cannot adequately cut, chop or grind. Foods should be tender and moist. Staff should grind or finely chop raw fruits and vegetables. During an interview on 03/23/11 at 11:00 A.M., the Dietary Manager (DM) said they did not grind the breaded fish patty served to residents with orders for a mechanical soft diet because the fish turned into a paste-like consistency. She said the fish "flaked" into pieces easily and therefore did not need to be ground. Staff served the "tator tot" potatoes to residents with orders for mechanical soft diets in the same form as regular diets. Staff did not chop, cut, or grind the potatoes. The DM said the Director of Nurses (DON) trained the charge nurses about how to follow the swallow study recommendations and only charge nurses should assist the resident to eat. During an interview on 03/22/11 at 3:30 P.M., Licensed Practical Nurse (LPN) A said the resident wanted to feed himself/herself. LPN A said he/she handed the resident a breaded fish patty on a bun. He/She said dietary staff did not chop or cut the piece of fish into smaller pieces. LPN A said he/she served the food as dietary staff prepared it on the resident's plates. LPN A said the resident also ate "tator tot" potatoes with his/her hands. Staff did not chop or cut the potatoes before serving the resident. LPN A said he/she "swapped" sitting by the resident with a Certified Medication Technician (CMT) while he/she assisted other residents during the meal. Licensed staff did not monitor the resident throughout the meal as directed. The LPN said he/she saw the resident "a few days" later and the resident acted less alert and more lethargic than usual. During an interview on 03/25/11 at 10:00 A.M., the speech language pathologist supervisor said he/she expected facility staff to feed the resident small amounts of food with supervision. He/She said when he/she recommended a "trial", it meant staff usually served the resident less than four ounces of food to see how the resident tolerated the food. During an interview on 04/05/11 at 4:30 P.M., the resident's physician said she would expect staff to sit with the resident and introduce food in small bites and would not expect staff to hand the resident a whole fish patty on a bun to eat, but would expect staff to feed the resident. She said this was not the best choice for somebody who received tube feedings the previous six weeks. The resident's physician said staff should introduce fish slowly and in small flakes. She said she diagnosed the resident with aspiration pneumonia. 2. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/23/10, showed facility staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Dependent on one staff person to complete Activities of Daily Living (ADLs) including bed mobility, transfers, toilet use and personal hygiene; -Required set-up with supervision, oversight, encouragement or cueing to eat; -Continent of bowel and bladder. Review of the resident's nurse's notes from a recent hospital admission, dated 01/24/11, showed hospital staff documented "patient reported loose stool today" while at the hospital. Review of the resident's facility nurse's notes dated 02/01/11 through 02/06/11, show staff documented the resident experienced ongoing episodes of diarrhea. Review of the Physician's Progress note dated 02/01/11, showed the resident's physician wrote an order directing staff to obtain a blood and stool specimen to be sent to the laboratory for evaluation. Review of the documentation the laboratory sent to the facility showed staff did not obtain the blood specimen until 02/04/11. The lab faxed the partial results dated 02/04/11 to the facility, and showed the following critically high results: -White Blood Cells-26.55, normal- 4.00-12.00 (elevated WBC can indicate bacterial infections) -Blood Urea Nitrogen (BUN)-73, normal- 10-26 (Increased BUN levels suggest impaired kidney function. This may be due to acute or [MEDICAL CONDITION], damage, or failure.) -Creatinine-6.1, normal-0.4-1.5 (Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function.) Further review showed staff did not notify the resident's physician of the critically high results until 02/06/11. Review of the documentation the laboratory sent to the facility showed staff did not obtain the stool specimen until 02/05/11. The partial results the lab faxed to the facility, dated 02/07/11, showed a positive result for ,[MEDICAL CONDITION].-difficile (antibiotic-associated diarrhea). Review of the resident's nurse's notes dated 02/06/11, showed day shift staff documented the resident continued to have diarrhea with small amounts of bright red blood, vomited one time and continued to be pale and weak. Staff did not document they notified the resident's physician of the lab results or the resident's decline in condition. Review of the resident's nurse's notes, dated 02/06/11, showed the evening shift documented they reviewed the partial lab results from the blood work and paged the resident's physician with a request to send the resident to the emergency room due to "some of the partial labs being critical". During an interview on 02/17/11 at 1:00 P.M., Licensed Practical Nurse (LPN) B said the day following the order for lab work, a snow storm occurred to the extent most staff stayed at the facility for four days. He/She said lab staff would not come to the facility during this time to collect ordered blood or stool specimens. LPN B said the resident's stool smelled foul and he/she suspected [MEDICAL CONDITION], however, he/she did not obtain a specimen because lab staff would not pick it up. LPN B said he/she did not notify the resident's physician of their inability to obtain the ordered specimens, the resident's continued diarrhea or declining condition. Additionally, he/she said he/she would expect the charge nurse on duty when the results arrived, to notify the resident's physician of the results, especially if they are in the critical range. LPN B said he/she paged the physician as soon as he/she reviewed the results. He/She sent the resident to the emergency room for evaluation. During an interview on 02/25/11 at 1:18 P.M., LPN C said he/she usually worked the evening shift. He/She said the day shift charge nurse usually took care of the faxes received from the lab. LPN C said he/she did not recall reviewing the lab results for the resident dated 02/04/11. During an interview on 03/22/11, LPN A said he/she collected a stool sample on 02/03/11, however, the lab continued to refuse to come to the facility due to the snow. He/She said the directions regarding obtaining a stool specimen stated the lab must receive the sample within two hours of collection, so he/she disposed of the sample. Review of the fax sent to the facility from the lab dated 02/04/11, showed the facility received the fax in the facility at 8:43 P.M., during the evening shift. Review of the documentation obtained from the hospital dated 02/06/11, showed the resident's [DIAGNOSES REDACTED]. During an interview on 02/17/11, the resident's physician said staff did not notify him of the resident's results for the labs he ordered on [DATE]. MO 353, MO 529 and MO 818